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 first birthdays.
The community had been incorporated, just decades earlier, as a regional steel and railroad hub. Like many industrial cities of its day, East Chicago struggled with overcrowding, lack of sanitation, a spoiled food supply, contagious diseases.
"Infant mortality last year in East Chicago was six out of 10," a Mrs. A.T. Cox said at a 1915 meeting of the state Child Welfare Round Table, according to a newsletter from the time. "(T)here is only one place in the world that has a worse record. That is somewhere in Russia."
Back then, Indiana's infant death rate was 87.7 per 1,000 live births. East Chicago's was 600.
By 1916, at the insistence of Cox and fellow members of her local women's club, East Chicago had hired its first health inspector. Her club also solicited local businessmen for donations to hire a visiting nurse.
At a subsequent meeting of the child welfare group, Cox gave an example of the work the visiting nurse did. The nurse had gone to a home where the child had an infected bone that had been neglected for a year and a half. The nurse insisted that the mother clean up the house, but the woman resisted.
"You will either take care of this child, or I will come with proper authority to take the child from you and place it in a home with proper sanitation," the nurse told her, according to Cox. The woman cleaned the home.
Fast forward to 100 years later.
In late December 2016, visiting nurse Djenaba Shine stopped by the East Chicago apartment of April Allen, a 21-year-old college student who was seven months pregnant with her first child. The public housing building where Allen lives with her boyfriend, mother and brother stands in the shadows of the smokestacks of the massive ArcelorMittal steel plant.
Shine, who works for Nurse-Family Partnership, took Allen's blood pressure. It was high. Shine called Allen's midwife at a local safety-net clinic.
"They want you to go the hospital," Shine said, after hanging up the phone. "Go straight to labor and delivery."
Allen and the child's father, Orlando Graves, got ready to leave. Graves teased his girlfriend about her salt intake, saying her high blood pressure was the result of all that bacon and Flamin' Hot Cheetos she'd been eating lately. They had no idea what was about to happen.
A few days later, Amari Lee Graves was born, six weeks early, at a local neonatal intensive care unit. He had a low birth weight of 4 pounds and 7 ounces.
Over the past 100 years, public health improvements like clean drinking water, vaccinations and food inspections have decreased the East Chicago infant mortality rate dramatically. But other things haven't changed. Home visiting nurses and social workers are still on the front lines of saving babies. And this city still has the highest infant death rate in Indiana.
The state's infant mortality rate is 7.3 per 1,000 live births. East Chicago's is 16.3.
Most at-risk in state
An African-American woman living in East Chicago is more at risk of losing a baby than anyone in the state. The black infant mortality rate in East Chicago (27.3) is on par with such developing nations as Zimbabwe or Guatemala.
If you're an African-American born in East Chicago, you have a 1 in 36 chance of dying before your first birthday. To compare, if you're a white person born in wealthy Hamilton County, your odds improve to 1 in 286.
"What we really have here are health disparities," said Rise Ratney, chairwoman of the Lake County Maternal Child Health Network.
East Chicago has a shortage of primary care providers, including OB-GYN specialists. Much of the city is classified as a food desert. Nearly 36 percent of East Chicago residents, including about half of children younger than 5, live in poverty. The unemployment rate is the highest in Indiana. The city has an economic distress score — based on factors like jobs, education and housing — of 97.9 out of 100, according to the Economic Innovation Group. The violent crime rate is the fifth-highest in the state.
"Education and poverty together play a role," noted Dr. Rajaraman Iyer, an East Chicago pediatrician.
Iyer has a high rate of no-shows at his office, and holds parenting classes that are sparsely attended. That's because of the fleeting nature of his patient base.
"These populations constantly move, change their address, change their phone," he said. "When you go to the physician routinely, you learn how to take care of a situation before it turns really bad."
Prenatal care lacking
Only half of pregnant women in East Chicago receive prenatal care during their first trimester, compared to 68 percent statewide, according to a 2011 study by the Indiana State Department of Health.
Part of that is due to lack of transportation, said Paulette Maxie, director of Lake County Nurse-Family Partnership, noting that Medicaid's transport system only picks up women at home, a barrier for pregnant teens.
"Some of it is fear. Some are trying to hide it. They don't want to let people know they're pregnant, so they hold out on getting prenatal care," she said.
"Some is financial and lack of knowledge about insurance. They think if they go they have to pay out of pocket and they don't have the money to pay for doctors' visits. Many are struggling to make ends meet as far as rent, utilities, groceries."
Mental Health America of Lake County has a teen parenting program that partners with five area schools. Its biggest program is at East Chicago Central High School. The initiative has been successful: Only 2 percent of enrolled teens go on to have another baby within two years (compared to at least a fourth nationwide), and all the participants have gotten their high school diploma or equivalent.
The programs help teens overcome the influence of family members. For instance, the teens might live in a household of people who smoke. Or their parents might have different ideas about child-rearing. "I've had girls say, 'My mom said I slept on my stomach and I was fine,'" said Heather Himes, a social worker at E.C. Central.
Alarming statistics in NWI
Northwest Indiana, the region where East Chicago is located, has among the highest rates of babies dying in the nation. Most of the infant deaths happen in the northern, largely minority communities near Lake Michigan, an area that is home to some of the most concentrated industry in the world.
"That's not a coincidence," said the Rev. Marie Siroky, a local community activist who works as a hospital chaplain, noting that pollution is a risk factor for birth complications. "I think it's the industry. I also think it's the water quality."
East Chicago had the highest infant mortality rate of any Indiana ZIP code between 2010 and 2014. A ZIP code in neighboring Hammond (46324) had the third highest. ZIP codes in nearby Merrillville, LaPorte and Michigan City were also in the top 25. The city of Gary, which has been economically devastated by the decline in U.S. manufacturing, had an infant death rate of 11.7 per 1,000 live births during that time period, 50 percent higher than the state average.
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"We rival Third World nations," said Tracy Lewis, executive director of the Lake County Minority Health Coalition.
Lake County ranks in the bottom quartile in America for diabetes deaths, adult smoking and annual average concentration of fine particulate matter, all risk factors for infant mortality, according to the Centers for Disease Control and Prevention's Community Health Status Indicators.
"Our infant mortality rate reflects the general health of our population," said Mary Pintillo, neonatal nurse clinician for St. Catherine Hospital in East Chicago.
"As a whole community, this is something we have to address because it affects the well-being of all of us. And the bottom line is it dips into all of our pockets when babies are sick."
Lake County also has above-average rates of low birth weights, teen births, adult obesity, food insecurity, physical inactivity, sexually transmitted diseases, children in poverty, income inequality, children in single-parent households, violent crime and severe housing problems, according to the Robert Wood Johnson Foundation.
Another factor: A legacy of lead
East Chicago was founded as a base for manufacturing and shipping along the heel of Lake Michigan, so it's been hit hard by the forces of globalization and technology. The population of 28,699 is half its peak level of 1960. Closed-down factories litter the landscape, posing a health risk for adjoining neighborhoods. This is exemplified by the former USS Lead plant in the southeast part of town. The lead smelter ceased operations in the mid-1980s after federal, state and local environmental officials found lead particles downwind of the facility.
In spring 2016, the city advised residents of a local public housing project to relocate after high levels of lead and arsenic were found in its soil. Pregnant women exposed to lead are at an increased risk for premature birth and low birth weight, two of the leading causes of infant death.
Michael and Katie Jacobi, who are expecting their first child this summer, live in one of the lead-contaminated neighborhoods in East Chicago. Despite the fact the Environmental Protection Agency has cleaned their home, declaring it lead-free, and provided them with a water filter, they intend to eventually move to the nearby suburb of Crown Point.
"I don't want my children raised here and contaminated with lead, arsenic and whatever else they love to put in the land," said Michael, 31, a dental student.
At community meetings about the lead crisis, he has encountered several local women who have had birth complications, leading to preterm births, miscarriages and abortions.
He was asked what he would recommend to people thinking about having children here. "Don't. Don't," he said. "Or figure out the best way to get out." He acknowledged that he has means to move, while many East Chicago residents don't.
Katie, a 27-year-old nurse, tested negative for lead but doesn't fully trust the results, because the East Chicago Health Department was only able to extract a minimal amount of blood.
"There's only so much you can do to avoid it," she said of the lead. "Because it's in the dust particles, you can breathe it in and you're risking being exposed to it."
Unsafe sleep deaths
The city health department keeps death certificates for infants who died at East Chicago's only hospital. Four of the 16 babies who died there from 2010 to 2014 lived in the housing project at the center of the lead crisis. Four of the 16 deaths were due to respiratory conditions. The majority (six) were caused by positional asphyxia, including bed sharing with parents or siblings.
"It's heartbreaking for our staff when it happens, when babies come into the emergency department and they've suffocated from sleeping with a family member," said Paula Swenson, chief nursing officer for St. Catherine Hospital. "It breaks your heart. It's a life-changing event for everyone involved."
Nonprofits in the community disperse portable cribs, infant sleep sacks and sleep education — "the ABCs of safe sleep" are that babies should always be alone, on their backs, in a crib.
HealthLinc, a federally qualified health center in East Chicago, also gives moms the book, "Sleep Baby, Safe and Snug," which is distributed by a safe-sleep organization called Charlie's Kids Foundation. That group, based in Louisville, Kentucky, was founded by the family of a 3-week-old boy who died after falling asleep on the couch with his dad, a pediatrician.
"This is not a socioeconomic issue. I'm just amazed my children lived. When my kids were little, we had bumper pads, pillows and stuffed animals in the crib," said HealthLinc CEO Beth Wrobel. "We can do this for Northwest Indiana. The numbers I saw were that about 40 percent of infant lives could be saved if there was safe sleeping."
Indiana is not among the states that require hospitals and birthing centers to educate parents on safe sleep.
A triumphant homecoming
Earlier this month, Amari Graves and his parents were reunited. The baby had spent a week in the neonatal intensive care unit. Now he was back in his family's modest East Chicago apartment, which had white brick walls, a fish tank full of family photos, basketball trophies and Three Stooges bobbleheads on the radiator. A Yorkie named Ace paced around the living room.
April Allen hadn't gotten over the fact that she already had given birth. Her baby shower wasn't for another two weeks.
"How are you feeling now that you got him home?" asked nurse Djenaba Shine, who was back for her first home visit since the high-blood-pressure incident.
"Excited. Happy," Allen said.
Allen was watching her diet, trying not to eat as much salt as before. She returned to college four days after giving birth (she's studying human development). She said she's noticed a change in her boyfriend.
"He's overprotective over Amari," she said. "When we went to pick him up, he wanted to sit in the back seat with the baby. I said, 'You get in the front seat.'"
She brought the baby out from his crib — his father was sleeping — so Shine could weigh him. A week after his birth, Amari had gained a pound. He was wrapped in a snug sleep sack, wore a knit baby cap and sucked intensely on a green pacifier.
"I couldn't believe everything went down the way it did. I'm still shocked from it all," Shine said. "What do you think would have happened if you didn't have a nurse come here to see you?"
Allen said she probably would have had a C-section. If her blood pressure had gotten any higher, she could have had a stroke. She could have lost the baby.
"You would have never known. You would have never known," Shine said. "So, thank God."
This series was produced as a project for the University of Southern California Center for Health Journalism's National Fellowship.