WASHINGTON, Ind. — "He's growing great, by the way," Dr. Norma Kreilein said of the underweight baby suckling on a pacifier in his mother's arms.
"I thought so," said Angel Riggle, as her husband changed their other son's diaper during a pediatric checkup in November. "It's good to see the numbers."
"Oh, yeah, he wakes up every three hours to eat."
The baby, Matthew, and his twin brother, Mark, entered the world Oct. 4, six weeks ahead of schedule. Matthew weighed 3.5 pounds, Mark 4.4.
Matthew had a hole in his heart and a narrowing of his aorta. He was flown by helicopter to an Indianapolis children's hospital.
His mother and brother stayed behind here in southwest Indiana. "It was hard. I felt torn about where you were supposed to be," said Angel, 35, who lives in this small town, the county seat of Daviess County.
Ten days before the birth of the twins, an air quality warning went out in her part of the state. Her husband, Allan Riggle, remembers their older sons being sick and using an allergy spray, and that he had "crud" in his eyes and lungs.
"I remember there was something going on around the time they were born," said Riggle, 41. "It's been a problem for years. It seems to be getting worse. You definitely see the discoloration coming out of the power plant all the time."
Matthew was in the neonatal intensive care unit for 19 days. He underwent heart surgery. It was touch-and-go for his first few weeks.
Kreilein, the Riggles' pediatrician, is convinced the environment played a role in the twins' preterm birth. Not only that, she believes it causes infants to die in her county. Twins, however, are more likely to have birth complications than single babies.
From Oct. 31 to Nov. 7, a few weeks after the air quality alert, there were seven premature births at the Washington hospital, she said. In an average week, there would be less than one.
"We're basically downwind from some of the largest concentrations of industrial pollution in the country," Kreilein said.
"And there are too many women delivering premature babies and sick babies with no obvious risk factor other than the fact they live here."
Whatever the reason, from 2010 to 2014, this rural county of 32,407 had the highest rate of babies dying of any county in the state, with 10.6 deaths for every 1,000 live births. Health officials were largely taken aback by the news, and are just now trying to get a grip on why it happened.
"In the last few months, this has come to our attention," said Kathy Sullender, public health nurse for the Daviess County Health Department. "We're still in the early stages of digging down and finding out what's going on."
Indiana's infant mortality rate for African-Americans is 2.5 times that of whites. But Daviess County statistics suggest it's not strictly a racial issue. In a county that is 95 percent white, all 28 babies who died between 2010 and 2014 were white.
The leading causes of infant death in Daviess County were birth defects (36 percent) followed by premature birth (27 percent) and sudden unexplained infant death (14 percent), according to the county health department.
In Daviess County, more children died in the postneonatal period (after 28 days) than before. Nationally and statewide, the opposite is true.
County struggles with health
Daviess County ranks in the lowest percentile for the following infant mortality risk factors, according to the Centers for Disease Control and Prevention's Community Health Status Indicators: diabetes, adult overall health status, preterm births, cost barriers to care, primary care provider access, uninsured, adult smoking, inadequate social support and poverty.
Every year, about 600 Indiana babies die before their first birthdays.
"We at one point had a lot of teen pregnancies," noted Susan Moulden, program manager for Healthy Families of Daviess County, a home visitation program. "We also have a big drug issue." (Meth is the county's drug of choice, officials say, though opioids are quickly catching up.)
In 2013, Daviess Community Hospital surveyed residents to determine the community's greatest health concern. Respondents chose teen pregnancy. In response, local health and education officials started a teen pregnancy prevention program called Advocates for Smart Teen Choices. The group found that teen pregnancy is a symptom more than anything else.
"We realized very quickly that you could not address teen pregnancy without also addressing drug and alcohol abuse, mental health issues, bullying, peer pressure and antisocial behaviors," said Margaret Anderson, of Advocates for Smart Teen Choices.
At the high school, students in the TV and radio class create public service advertisements about teen pregnancy. Brochures on alcohol and sexual behaviors are handed out at prom activities. A local doctor gives an annual talk to freshmen about sexually transmitted diseases. A speaker talks to sophomores once a year about depression and suicide. Teen moms speak to the Life Skills class.
This programming goes above and beyond Indiana's typical abstinence-only sex education.
Daviess County's teen birth rate has decreased from 49 per 1,000 females between ages 15 and 19 in 2012 to 43 in 2016, according to the National Center for Health Statistics. The county is still above the state average of 37.
Daviess County, like many rural communities in America, has a shortage of primary care physicians, with just one for every 2,030 residents. The nearest federally qualified health center is more than 50 miles away, in Olney, Illinois.
"We do have a significant amount of poverty in the community," said Shawna O'Kelley, a nurse manager in the Women's Health Center at Daviess Community Hospital. "We do have some drugs in the community, and there aren't many resources for pregnant moms."
The county also has a large Amish population, who have unique genetic disorders that can lead to birth defects, she said.
Air pollution is a deadly problem
In the CDC study, Daviess County also ranked in the worst percentile for annual average concentration of fine particulate matter, or air pollution. Numerous academic studies have proven a link between pollution and infant mortality.
Research in Environmental Health Perspectives has found that particulate matter increases the risk for postneonatal mortality, and outdoor air pollution causes low birth weights and prematurity, two of the leading causes of infant death. A 2003 Quarterly Journal of Economics study determined that a 1 percent reduction in total suspended particulates leads to a 0.35 percent decline in infant mortality.
Southwest Indiana is home to some of the largest-polluting power plants in the country. An investigation by the Center for Public Integrity found that of the 22 sites on the top 100 lists for both toxic-air and greenhouse-gas emissions, four are in southwest Indiana, more than anywhere else in the country. The news outlet labeled these facilities "super polluters."
Washington, Indiana, is 15 miles downwind from one of those facilities, a coal plant in Petersburg, owned by AES Corp., that released 4.5 million pounds of toxic compounds and 11.1 million metric tons of greenhouse gases in 2014, according to the Center for Public Integrity. The U.S. Environmental Protection Agency found the plant in violation of the Clean Air Act in both 2015 and 2016.
In a statement, the company said the plant is installing environmental controls to reduce air emissions and wastewater discharge, including a project last April it says reduced mercury emissions by 80 percent compared to 2013 levels. The company also said it intends to eliminate wastewater discharge of coal combustion residuals at the plant next year.
The state of Indiana gets 85 percent of its energy from coal, widely considered the dirtiest energy source, and burns the second most coal of any state behind only Texas. By comparison, the United States generates just a third of its energy from coal and another third from natural gas, which emits half as much carbon dioxide as coal. Indiana derives just 8 percent of its energy from natural gas.
Indiana also produces the eighth most coal of any state. All the coal mines are concentrated in the southwest part of the state, including six surface mines and a processing facility in Daviess County. A 2011 study in the Maternal and Child Health Journal found that women who live in coal-mining areas have a 14- to 16-percent increased chance of having a low birth-weight baby.
Meghan Fahey Willoughby, 25, of Washington, gave birth to her daughter, Laura Christine Willoughby, on Dec. 6, three weeks before her due date, because of hypertension. She believes it was caused by air pollution.
"I worked outside a lot this past summer and I remember the air being so heavy and humid, making it hard to breathe," said Fahey Willoughby, a home health aide. "I remember my blood pressure shooting up pretty high in August, and it continued throughout the remainder of my pregnancy. I swelled up to the point I couldn't wear any shoes."
She said she had three previous pregnancies, in the central Indiana town of Greencastle, and never had any issues.
Lack of programs
Unlike larger cities in Indiana, Washington lacks programs that aim to prevent infant deaths. The Pregnancy Care Center, on the lower level of a Baptist church on the south side of Washington, is a rare exception. The organization provides free pregnancy testing, education and baby supplies, in hope of persuading women not to have abortions.
One day in late November, a mother and father of two small children, along with the mom's boyfriend, watched a video about shaken baby syndrome. Afterward, volunteer educator Peggy Pinkham quizzed them about what they'd learned.
"When you start to feel frustrated or angry with your baby, what should you do?" Pinkham asked.
"There are plenty of times I had to walk away, and there are plenty of times she has to, too," said the boyfriend, John O'Harah, 23.
Pinkham asked what often leads to shaken baby syndrome. "It's because the baby won't stop crying," said Amber Stone-Hall, 24, of Washington. Her daughter, Sklya, 9 months, sat on the floor, while her son, Noah, 1.5 years, wobbled around the room like he wasn't so sure about this walking thing. "You can call it stress," Pinkham said.
"Watching kids does get stressful," O'Harah said.
For completing the class, Stone-Hall got "mommy money," which she could use to purchase baby supplies from the Pregnancy Care Center. On that fall day, she got diapers and wipes. She said she's learned a lot about safety from the courses. She now uses electrical-outlet covers and baby gates at home.
Stone-Hall, who is studying to be a certified nursing assistant, got a ride to the class from a nonprofit that provides home-based services. She has also enrolled in First Steps, an early intervention program that helped Noah learn how to walk and talk.
"There's a lot of poverty and lack of education in Daviess County," said Yolanda Taylor, executive director of the Pregnancy Care Center. "We don't have as many factories as we used to."
Taking a page from Finland
Thirty-odd miles north of Washington, a small county hospital is trying to reduce the high number of deaths in southwest Indiana by borrowing a strategy from Finland.
The Scandinavian country has one of the lowest rates of infant deaths in the world. In 2015, in a country of 5.4 million, only 97 Finnish kids died before reaching their first birthdays. That same year in Indiana (population 6.6 million), 613 babies died.
EAST CHICAGO, Ind. — A hundred years ago, this city on the south banks of Lake Michigan had a problem: Most babies died before reaching their …
For the past 80 years, Finland has given every mother who goes to a prenatal visit in her first trimester a cardboard box filled with baby supplies and a mattress. The box ensures that every baby in the country has a safe place to sleep. Accidental suffocation or strangulation during sleep is the third-leading cause of infant death in Indiana.
In October 2015, Greene County General Hospital in Linton, Indiana, (population 5,343), started giving out its own version of the Finnish baby boxes, called Sweet Dreams Baby Bundles, to moms who went to at least three visits with a pregnancy coach.
Each bundle costs about $100, and so far the hospital has distributed about 30 of them. The hospital received a $250,000 grant from the Indiana State Department of Health late last year to expand the program.
"I know some women have definitely used them," said obstetrics manager Teresa Hutton, showing some of the supplies they contain: lotion, a parenting book, a sleep sack, diapers, baby wash. "They're so portable, much more than a Pack 'n Play. You can take it over to Grandma's."
No 'smoking gun'
Infant mortality is a hard problem to solve because there is no one cause. Babies die because of any number of compounding factors that are difficult to untangle. "You're never going to have a smoking gun," said Kreilein, the Washington pediatrician.
Pollution isn't the sole cause, she said, but she believes the state is being negligent in not acknowledging the role it plays.
"I've actually asked the state health department directly: Is pollution and infant mortality something we're not allowed to talk about? They said they were not allowed to talk about it," she said. "The trails for that lead directly to (former) Gov. (Mike) Pence and no one else. If it looks like a duck and quacks like a duck, it's a duck.
"The health department is very interested in fighting infant mortality, but the agenda is determined by the person they work for."
The Indiana State Department of Health said it has no authority over outdoor air quality.
"Our efforts to reduce infant mortality focus on issues such as smoking cessation, prenatal care, breastfeeding and safe sleep, because our research has shown those to be the largest contributing factors to infant mortality in Indiana," said Ken Severson, a spokesman for the state health department.
"Outdoor air quality is beyond the scope of the ISDH and falls to the Indiana Department of Environmental Management."
Barry Sneed, a spokesman for the state Department of Environmental Management, said the agency has no information about infant mortality.
Mary Weber, the former director of maternal and child health for the Indiana State Department of Health, said that when she worked for the agency earlier this decade, she acknowledged poor air and water quality as contributing factors in infant deaths.
"If the leadership's goals are more related to politics than the health of our state, I think it’s going to be very difficult for the State Department of Health to make a difference in infant mortality," she said.
Kreilein is outraged the state isn't examining more closely one of the potential causes of infant deaths in her county. She pointed out that there are only air quality monitors in about a third of Indiana counties and none in Daviess.
"This is my home," she said, starting to cry. "I have looked these people in the eye for 27 years. I have gone to the funerals. I get up in the middle of the night and take care of these children. Somebody's got to do something about this."
This series was produced as a project for the University of Southern California Center for Health Journalism's National Fellowship.