Title: “When the Bough Breaks” from the California Newsreel Documentary
Series Unnatural Causes: Is Inequality Making us Sick?1 – A Discussion Guide for
Health Professional Students
Prepared by: Olivia Carter-Pokras Ph.D., Alexander Fischer, Sonja Williams, Sylvia
Bereknyei, MS, Ana E. Núñez, MD; Candace Robertson, MPH
Acknowledgements: The authors gratefully acknowledge funding from the National
Heart Lung and Blood Institute’s Cultural Competence and Health Disparities Academic
Award grant program (Carter-Pokras, Fischer, Bereknyei), and the University of
Maryland College Park School of Public Health (Williams) as well as comments by
dental, medical, and nursing students at the University of Maryland Baltimore, and
public health students at the University of Maryland College Park.
(For students)
Session Goals(s):
This small group discussion is intended to acquaint health professional students with
examples of specific health disparities that affect communities in the United States,
bring to their attention the role that social determinants of health play in these
disparities, and foster discussion regarding solutions and action that can be taken to
eliminate these health disparities.
Learning Objectives:
1. Describe the nature, extent, and type of health disparities in the United States.
2. Describe and assess health disparities in infant mortality as they relate to
minority populations.
3. Evaluate social determinants of health and other underlying factors related to
disparities in infant mortality
Session Summary:
This is a 28 minute film segment entitled “When the Bough Breaks” from the California
Newsreel documentary series Unnatural Causes: Is inequality making us sick?, followed
by a 30 minute small group discussion to explore examples of health disparities and
pathways by which social conditions affect physiology. The video focuses explores why
infant mortality rates among African Americans remain more than twice as high as white
Americans. Researchers are shown discussing a provocative hypothesis: that the
chronic stress of racism can become embedded in African American mothers’ bodies
and take a toll on their children even before they leave the womb. The small group
case discussion will be facilitated by medical, health professional, and/or epidemiology
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UNNATURAL CAUSES: Is Inequality Making Us Sick? Produced by California
Newsreel with Vital Pictures. Presented by the National Minority Consortia.
www.unnaturalcauses.org; www.newsreel.org
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faculty or graduate students. Faculty may wish to use this documentary segment to
supplement curriculum materials on infant mortality, low birthweight or premature
delivery, and/or as a case study for eliciting pertinent social and environmental risk
factors in history taking. Facilitators will have familiarized themselves with material in
the video and readings as well as the provided Unnatural Causes Discussion Toolkit.
Facilitators may also have completed “A Physician’s Practical Guide to Culturally
Competent Care” and/or “Culturally Competent Nursing Care: A Cornerstone of Caring,”
training programs designed for providers to increase cultural competence through case
studies about awareness of racial and ethnic disparities in health, and through curricula
about accommodating increasingly diverse patient populations and improving the quality
of health care services given to diverse populations (available at:
http://www.thinkculturalhealth.org). Students will be provided the background readings
at least one week in advance of discussion.
Readings:
1. Behrman RE, Butler AE (Editors). Committee on Understanding Premature Birth
and Assuring Healthy Outcomes. Preterm Birth: Causes, Consequences, and
Prevention. National Academy of Sciences. 2007. Available at:
http://www.nap.edu/catalog.php?record_id=11622#toc
2. Jackson FM. Race, Stress, and Social Support: Addressing the Crisis in Black
Infant Mortality. Joint Center for Political and Economic Studies. September
2007.
3. David R, Collins J. Disparities in Infant Mortality: What’s Genetics Got to Do With
It? American Journal of Public Health 2007;97(7):1191-1197.
4. Howell EA, Hebert P, Chatterjee S, et al., Black/White Differences in Very Low
Birth Weight Neonatal Mortality Rates Among New York City Hospitals,
Pediatrics 2008;121(3):e407-e415.
Additional information on trends over time in disparities in infant mortality:
5. Alexander G, Wingate M, Bader D, Kogan M. The increasing racial disparity in
infant mortality rates: Composition and contributors to recent US trends.
American Journal of Obstetrics and Gynecology. 2008;198(1):51.e1-51.e9
6. Harper S, Lynch J, Burris S, Davey Smith G. Trends in the Black-White Life
Expectancy Gap in the United States, 1983-2003. JAMA. 2007;297:1224-1232.
Available at: http://jama.ama-assn.org/cgi/reprint/297/11/1224
Discussion Questions:
1. High infant mortality rates are a major problem for the United States, with
America ranking 34th internationally, below even third world countries.
Why is that? What can we do to change this?
2. What are the factors that the video explores to explain why AfricanAmerican women have low birth weight babies at twice the rate of white
women? Can you think of possible contributing factors?
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3. The video mentions that rates of infant mortality in African-American
women with a college degree are higher than rates in white women
without a high school diploma. What can we attribute that to?
4. Are certain racial groups predisposed genetically to low birth weight
babies or premature delivery? The study mentioned in the video suggests
that this is not the case. What do you think? How can we account for
this?
5. During the time of the civil rights and anti-poverty movements (1960’s1970’s), health outcomes improved among African Americans compared
to whites, including slowly lowering infant mortality rates. What has
happened since then and why?
6. What is the phenomenon of living as a “life-long minority”? Do you think
this is a relevant issue? How do you think it affects overall quality of life?
7. Does racism take a toll on the body? How might racism do this?
8. What is the “Life-Course Perspective” that Dr. Lu refers to? How does it
relate to women and the children they give birth to?
9. Now there is some evidence that racism as a stressor does affect health
outcomes, how can we further study it?
10. Dr. Fleda Jackson, Dr. Mona Phillips, and Dr. Carol Hogue are studying
the effects of racism on African-American women. How will their studies
be able to help women in African-American communities?
11. How do you feel about this theory of racism being a major stressor on
African-American women and its effects on their pregnancies? Did the
video show any innovative methods for fixing the problem? What if
anything can be done about it?
12. How can we as future health care professionals fix this apparent problem?
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