James W. Collins, Jr., MD, MPH, joins In Pursuit to discuss how his exploration of disparities in neonatal health outcomes has expanded over the course of his career to include race, education, socioeconomics, paternal acknowledgment and other social influencers of health. Hosted by Patrick Seed, MD, PhD, FIDSA.
Guest: James W. Collins, Jr., MD, MPH, Medical Director, Neonatal Intensive Care Unit, Lurie Children's; Attending Physician, Neonatology; Zeisler Family Neonatology Leadership Chair; Professor of Pediatrics (Neonatology), Northwestern University Feinberg School of Medicine.
Host: Patrick C. Seed, MD, PhD, FIDSA, Attending Physician, Infectious Disease; President & Chief Research Officer, Stanley Manne Children’s Research Institute; Children’s Research Fund Chair in Basic Science; Professor of Pediatrics (Infectious Disease) and Microbiology-Immunology, Northwestern University Feinberg School of Medicine.
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Journey to Neonatology
Early on in his medical training, Collins was intrigued by observations in the disparities in newborn survival rates. These observations led him to a deeper investigation into the factors affecting health outcomes, particularly focusing on racial disparities in premature births. He says “one of the biggest risk factors for not doing well is if you're born too small, too soon. And, unfortunately, there seems to be a racial disparity in that with African American women having a higher risk.” He has dedicated much of his research to trying to understand why such disparities exist so with that understanding, the disparity can be eliminated.
Chicago Shaped Collins’ Research
Chicago’s diverse population and access to generations of data on neighborhoods, race and income has influenced his research. Collins says the city's demographic mix provided crucial insights into racial and socioeconomic disparities in neonatal health care.
Education, Generational Poverty and Other Factors
Collins has investigated many factors that could contribute to neonatal health differences such as access to prenatal care, a genetic link and upward economic mobility. For example, he found when moms who were “born in poverty had some upward economic mobility, preterm birth rates came down and infant mortality rates also came down. But for those moms who stayed in poverty their entire life, those rates did not change. But something that was a surprise in the research was “ if you were born in poverty and you were born small and you had upward mobility, your risk of preterm birth did not go down at all. It remained elevated.” This research shows that there is likely a potential link to epigenetics or developmental programming at play.
The Immigration Paradox and the Role of Race
Collins also discusses how certain immigrant populations, such as the Mexican-American population in Chicago, often display superior birth outcomes compared to native-born minorities and the general white population, despite significant challenges such as language barriers, lower socioeconomic status and limited access to healthcare. He hypothesizes that subsequent Mexican-American generations may experience worse birth outcomes and similar to African Americans, “it's something about being a minority your whole life is a risk factor for poor outcome in itself.”
Another topic Collins has investigated is paternal acknowledgement or “dads who are acknowledged on the birth certificate.” In white children, paternal acknowledgement doesn’t seem to impact pregnancy outcomes. In African Americans it does. “If dad was acknowledged, preterm birth rates went down. If dad was acknowledged and married, preterm birth rates came down even more. But if dad was not acknowledged, preterm birth rates did not decline at all.” Collins says dad non-acknowledgement may be a proxy for structural racism. “We know that incarceration rates are sky high for African Americans compared to Whites. We know that college graduation rates are abysmally low for African-American men compared to white men. So maybe there are structural processes that are going on here that really underlie paternal non-acknowledgement,” he says.
Future Studies and Interventions
Collins is continuing his research journey into the impact of generational poverty on birth outcomes by establishing a third-generation data set of Chicago births to observe whether the observed elevated risks start to diminish, providing insights into the persistence or fading of these disparities across familial lineages and societal changes. He thinks with access to healthier neighborhoods we may start to see birth outcomes improve. Based on historical data from the Dutch famine of the 1940s, he says it takes two-to-three generations of safe livin, in a safe living environment in order to help improve outcomes.
Read the transcript
[00:00:00] James W. Collins, Jr. MD, MPH: This is In Pursuit, research perspectives from Ann and Robert H. Lurie Children's Hospital of Chicago. I am your host, Dr. Patrick Seed, President and Chief Research Officer of Stanley Manne Children's Research Institute, one of the nation's largest freestanding pediatric research centers. Our guest today has dedicated his research career to understanding factors that affect the health outcomes of newborns, including a particular focus on how race and other social influencers of health are tied to birth outcomes in the U. S. and globally. He's an attending physician in neonatology, the medical director of the neonatal intensive care unit and the Zeisler Family Neonatology Leadership Chair at Lurie Children's. He's also a professor of pediatrics at Northwestern University's Feinberg School of Medicine. Jimmy Collins, welcome to the podcast and thanks so much for joining us. Thank you very much for having me, Pat. Looking forward to it.
[00:00:58] Patrick Seed, MD, PhD: So I'm going to start by just saying and I hope this isn't too fanboy, but I'm going to cast back to the Pediatric Academic Societies meeting that was actually quite a few years ago now. But I remember you giving a talk there and I really remember how impressed I was with your work and how easy and confident your speaking style was. So I'm going to admit that I see today's podcast as a real treat. So I'm excited about getting into it and learning more about you and the work you've done.
[00:01:25] James W. Collins, Jr. MD, MPH: Thank you very much.
[00:01:26] Patrick Seed, MD, PhD: Let me just start with a straightforward one because I'm always interested in how people see what they do. So, you're with new friends around the table and they say, so remind me what you do, what's your answer to that, that you typically give?
[00:01:39] James W. Collins, Jr. MD, MPH: Usually I focus on the clinical aspect. But then usually the follow up question is: what is it you do the rest of your time that you're not taking care of babies? And then I usually delve into the research interest and passion that I have. And usually what I say is that one of the biggest risk factors for not doing well is if you're born too small, too soon. And, unfortunately, there seems to be a racial disparity in that with African American women having a higher risk and my passion has been really trying to understand that with the hope that with that understanding, we can actually eliminate that with time.
[00:02:08] Patrick Seed, MD, PhD: What was your journey to being a neonatologist, but particularly, really investigating in the depth that you have in social determinants of health. How'd you get there?
[00:02:18] James W. Collins, Jr. MD, MPH: I think back to when I was a resident. And one of the clinical observations that was going around at that time was that African American babies, particularly if they were girls, had a higher chance of surviving to go home than white babies, particularly if those white babies were boys. So I thought, why is that? And my mentor said well, maybe we should do a study to look at that. So we did a study and he gave me some hypothesis that he thought that babies being born who are African American, they were actually more robust because of the stresses that their moms went through that led them to being born early, but also made it so if they were born early, they were more likely to survive. Make a long story short, we found that indeed that observation that had been made clinically was indeed true, but it wasn't because of the hypothesis that we thought. But more than that, when I went to my mentor, I go, African American moms are twice as likely to have a small baby. That is the primary determinant of outcome, not so much what your outcome is if you're born small. And my research mentor Richard David was like, " you got it." I go, "I got what?" He goes, " you've come to the realization of what's really important." I go " I go why didn't you tell me that before I did this study?" He goes, " you had to figure it out on your own." And that was like one of those monumental moments during residency, and about that same time, I was trying to decide which field to go into in terms of career, and I love neonatology clinically, and it kind of dovetailed with this interest that I had in public health. But at that time, anything in public health would require more education, which would require more time, and I just wanted to get in and get out. So I thought this would be a good way to maybe mix those two passions together, public health and also the clinical aspect, and this kind of emerging research interest.
[00:03:52] Patrick Seed, MD, PhD: A lot of this journey happened for you in Chicago. How did Chicago shape the way you've investigated social determinants and the role of race and ethnicity in prematurity in perinatal events?
[00:04:06] James W. Collins, Jr. MD, MPH: One of the beautiful things of Chicago is the diversity. We have a broad mix of ethnicities, a broad mix of socioeconomic status. And unfortunately healthcare tends to parallel that. And that's one of the observations that we made early on was that African American babies were more populous in the NICUs than what white babies were. I really thought that this disparity was going to be driven by the lack of education for African Americans compared to whites. But one of the conclusions that we came to is we looked at data for Chicago which had a fairly large African American population. We compared it to a very large white population. We found that for moms who are college graduates, 16 more years of education, so that equates to PhD, doctorate levels of education, we found in that very small cohort that the racial disparity was actually wider than what it was for women who didn't complete high school. And that was one of those things that just struck me. It was just so pertinent. And about that same time we had a African American mother who was highly educated, who had a preterm infant and she was struck with why she had this risk of having a preterm infant, because she was highly educated, didn't do the things that we know contribute to preterm birth, didn't smoke, got good prenatal care. So it kind of hit me at both levels, the clinical level speaking with a mother, but also the academic level of using data which we obtained from Chicago Department of Public Health that showed that in the city that I live in that this disparity was real.
[00:05:31] Patrick Seed, MD, PhD: What's your current hypothesis? Where are you now in terms of thinking about those disparities that create that gap?
[00:05:39] James W. Collins, Jr. MD, MPH: Sometime in the mid nineties, late nineties, there was a realization that education didn't explain it. Prenatal care didn't explain it. And all these events that we know are important didn't explain the disparity. So there was a big body of literature speculating that this was a genetic abnormality And this is about the time that genetics is becoming more in vogue contributing to a lot of disease processes that we see going on. We really thought that this was still going to be a socially driven process, but if it was, we really weren't seeing it in the data that we had. So one of the studies that we thought would be interesting that if it was a genetic phenomena, we should see it more prevalent among women who themselves were born in Africa, given the way that African- Americans have a genetic admixture with European women. But we found that African women themselves, when they come to the United States, their birth outcomes is actually similar to the general white population. So it really put the kibosh on the whole genetic phenomena, but it still had not moved us forward in terms of what is it about the social process. So one of the things that we're trying to figure out, what is that social process? One of the things that we've always thought is , it's not really so much what happens to you during pregnancy, but maybe what happens to you through your entire life, maybe what happens to you a generation or two prior to that. And one of the unfortunate realities for African- Americans in this country is that race and ethnicity are really bound to poverty. And that it's a good probability that if you don't live in poverty well, maybe your parents did, or your grandparents did, or your great grandparents did, and that legacy is what's contributing to this poor outcome. So we decided to actually try to look at that. And to do that, we acquired a bigger data set, not just one generation, but actually in a perfect world, two or three generations. And we actually created a two generational data set where we had moms who were born in Illinois and their offspring were also born in Illinois. So we had two generations and we also had where they lived. Chicago is very nice to look at outcomes because as you know, Chicago is very neighborhood specific and very neighborhood driven and neighborhoods actually mean something. So we actually looked at neighborhood income, and we can have neighborhood income when moms were born themselves. We have neighborhood income when moms actually delivered their babies some 20 or 30 years later. And we found that for moms who were born in poverty, and they had some upward economic mobility, preterm birth rates came down. And infant mortality rates also came down. But for those moms who stayed in poverty their entire life, those rates did not change. But even something that struck us even more was that if you were born in poverty and you were born small and you had upward mobility, your risk of preterm birth did not go down at all. It remained elevated. So we thought, why is that? And we thought that there's something going on maybe with epigenetics, maybe with programming that somehow that's making it so even with upward mobility, you still have this risk of poor outcome. And that kind of takes us to where we are now, cause we're in the process of actually trying to create a third generation of data set of Chicago births, actually to see if that second or third generation, we start to see that start to pale and fall away.
[00:08:43] Patrick Seed, MD, PhD: The other angle that you've taken that's really fascinated me, I'd love to couple with this line of discussion, is really what you've described. the immigration paradox. Can you just help everyone understand, what's the paradox? And then tell me a little bit about the recent work you've done and some of the ideas, the hypotheses that have come from that to explain the paradox.
[00:09:04] James W. Collins, Jr. MD, MPH: Again, it's the beauty of Chicago because we're so ethnicity diverse that it lends itself to looking at these issues and actually confirming observations that other people have speculated. The interesting thing is we have a large Mexican-American population in Chicago. Mexican-Americans despite having a very low education attainment, despite maybe not receiving as much prenatal care as they're supposed to, their birth outcomes are actually better than the general white population. And that's kind of a paradox because based on their social demographic risk status, they should be at risk of poorer outcome. And we found that persists, again, even among women who are uneducated, even among women who do not receive prenatal care, even among women who smoke cigarettes, even among women who have many babies in a short period of time, they still have a low overall risk of having a preterm infant. And that's kind of the paradox. And one of the things that we thought, what drives this? And there were two hypotheses that have been put out there. One is that if you stay here for a long period of time, here being the United States, and that second generation starts to come to fruition and starts to have babies, their birth outcomes tend to deteriorate. So it was a thought that maybe it's something about acculturation to the United States lifestyle that has somehow predisposed you to have a preterm infant. There may be a small component of truth in that, but that hasn't made a lot of sense to me because we have the general white population, which has a United States lifestyle by definition, and you don't see that same deterioration in outcome. So we really thought that maybe it's really driven, similar to what happens with African-Americans, maybe what's happened is it's something about being a minority your whole life is a risk factor for poor outcome in itself. So we said well how can we disentangle the acculturation phenomena versus the being poor your whole life phenomena. And one of the interesting things that we're looking at right now is the contribution of race to the Latinx population. They're a very homogeneous population, but there's a fair percentage that self-identify as Black. And if you look among the various subgroups of Latinx people, particularly Mexican-Americans, Puerto Ricans, Cuban-Americans, those of South American descent, and we asked those women who self-identify as Black, and they record that on the birth certificate. It gave us the ability to look at what impact race has for that group of women. And we're finding that those who self-identify as Black have a higher risk of poor outcome than those who self-identify as White.
[00:11:38] Patrick Seed, MD, PhD: So, one of the conclusions that we're coming to is that race seems to be having a more important negative impact in overriding the positive impact of ethnicity, such that really race itself is a risk factor for poor outcome. And we believe race is a proxy for racism. So that's something that we're putting our heads around to try to actually examine that academically. Thanks for illuminating us on the paradox. And I think it really does bring home, leaning into the issue of race and racism to improve birth outcomes clearly is becoming more and more prescient and important. I really would not be doing the job of this host well and having Jimmy Collins on if I didn't ask you about a really intriguing topic around paternal acknowledgement. Can you just tell us what is that? And then what got you interested in the role of the father being present or acknowledged? And what kind of data do you have right now? What are the results of your study so far?
[00:12:37] James W. Collins, Jr. MD, MPH: Yeah, that's something that we're passionate about looking at as we speak. Paternal acknowledgement is basically acknowledging dad's involvement on the birth certificate. Just check it off, yes or no. As I think back, we were looking at a study trying to look at the outcome of women who were born in the United States who are Black compared to women who were born in the United States who are White. And we also looked at the same thing, except this time we made the comparison between foreign born Blacks and U.S. born blacks. And we wanted to quantify The impact of individual risk factors. We really wanted to see what impact mom education was having. And we just kind of looked at paternal acknowledgement only because there had been a few articles out there saying paternal acknowledgement may be important. There's a whole body of literature that says marital status is important. So we thought, let's just look at paternal acknowledgement. And we were surprised to find that using some fancy statistical modeling, that paternal acknowledgement actually had a greater contribution to the disparity than paternal education. And it was explaining the disparity between US born and foreign born Blacks, and also between US born Blacks and US born Whites. And it was one of those moments where you're just like, the data can it be wrong? But it's national data, huge data set. So then we said what is it about paternal acknowledgement that is having such a major contribution? What do fathers bring to the plate? And one of the things that they bring to the plate is obviously income. So we looked at individual contribution of dad's income independent of mom's income. And we couldn't really get a good measure for dad's income, but we do have a measure for dad's education. We also had a measure for dad's economic status based when he was born and back when he had his child. And we found that dad's income does indeed make a contribution, which is kind of what you expect. But more than that, we want to say, well, what is it about dad's income? What is it about dad's being acknowledged that actually leads to improve birth outcome, as defined by preterm birth and infant mortality? And we found that dads who are acknowledged on the birth certificate, those moms are more likely to stop smoking if they smoke. They're more likely to receive more prenatal care than if dads aren't acknowledged. They're more likely to have appropriate weight gain. So those are three points of potential intervention that we see dads are having a positive impact on in terms of looking at pregnancy outcomes. The other side of the coin is if dad is not acknowledged, why is that a risk factor? And that is exceptionally important. we did a study, which is not published, we're trying to get it published. and we see that if you look among the general White population, as mom's education goes up, preterm birth rates go down. If we look among African-Americans, mom's education goes up, preterm birth rates come down, but they don't come down as much. So we thought ,what impact does dad acknowledgement have on this? We found that for Whites, paternal acknowledgement didn't make a difference. So even if your dad was not acknowledged, preterm birth rates still came down as your education went up. Makes sense. But for African- Americans, we found if dad was acknowledged preterm birth rates went down. If dad was acknowledged and married, preterm birth rates came down even more. But if dad was not acknowledged, preterm birth rates did not decline at all. That was really strange. So we think, why is that the case? It could be the case that if dad is not acknowledged, it could uncouple the potential contribution of generational wealth, which is missing among African-Americans. That if data is not acknowledged, you don't have that other potential source of generational income, and maybe that's what's driving it. But dad non-acknowledgement may also be a proxy for structural racism. We know that incarceration rates are sky high for African-Americans compared to Whites. We know that college graduation rates are abysmally low for African-American men compared to white men. So maybe there are structural processes that are going on here that really underlie paternal non-acknowledgement.
[00:16:40] Patrick Seed, MD, PhD: Some of these findings are somewhat mesmerizing, right, in the sense that acknowledgement, which is a checkbox on a birth certificate, there's so many interpretations of what happens after that. But it has this clear association with better outcome. But a lot of the things you described that then are the hypotheses why: generational wealth. Long standing poverty and epigenetics. And they're historical, right? And they're not easily rectified. What are you thinking are some of the top interventions that that you might test to see whether there's at least a signal of reversing what otherwise is unerasable history?
[00:17:16] James W. Collins, Jr. MD, MPH: That is a tough question. And I think the first thing that I would try to get across, because anything that you have to do requires funding, is get across to the funders that this is not a quick fix. So I really would try to encourage funders to look at the end game. I think if we looked at birth outcome in isolation, it gets hard. But I think if we look at the other outcomes. I think if we look at obesity. I think we look at childhood asthma. I think if we look at handgun violence and youth. I think if we look at high school graduation rates. All these things that are related to ultimate health outcome as adults really start to signal themselves to be socially driven. So instead of looking at birth outcome in isolation, I would try to partner and measure five or six outcomes. And then look at the contribution of neighborhoods. I think neighborhoods are the most important thing. And somehow if you had Bill Gates money and you could build a Bill Gates neighborhood, and it was safe. In that neighborhood, you had access to healthy foods. In that neighborhood, you had access to high quality schools, public schools. And I think in that context, you'd have a more healthier neighborhood, healthier community, and then you start to see all those health outcomes that I mentioned at the initial start of the question, get better each subsequent generation. But if we look back historically and just look at the Dutch famine we know that that happened, World War II, 1940s, and we know those birth outcomes were abysmal. And we know that for those women who got pregnant during that first or second trimester of the Dutch famine , it took two to three generations before that was reversed. I think it's going to take two or three generations of safe living in a safe living environment that will help improve outcomes.
[00:19:03] Patrick Seed, MD, PhD: While the scale to many would seem long, and it's certainly, as you said it's a longer scale than often we think about projecting research initiatives and things, it's really not that long, actually. You know, two, three generations is something that one could see in one's own lifetime, which I think to put it on scale is a pretty short scale. Boy, Jimmy, it's been really terrific having you on the podcast today. Thanks for joining me.
[00:19:26] James W. Collins, Jr. MD, MPH: My pleasure. Thank you very much.
[00:19:28] Patrick Seed, MD, PhD: For more information on Stanley Manny Children's Research Institute at Ann and Robert H. Lurie Children's Hospital of Chicago, visit our website, research.luriechildrens.org.