Part 1.You are considering shifting resources from maternal-child health programs to programs for more members of the community. If black-white disparities in birth outcomes continue, but the overall health of the community improves, have you met your ethical obligations as a health department?Is there something about infant mortality that makes it special in consideration of fairness? Do we need to think about what is fair in a different way because infants are involved?Should the role of race and racism in infant mortality impact how we set priorities and allocate resources? Why or why not?Part 2There are 3 choices suggested in this case study:1. Maintain funding for maternal-child health care2. Shift funding from maternal-child health care to programs that impact the health of the larger community3. Involve the community in deciding what the priorities are and how resources should be allocatedWhat are the ethical dimensions of each option? If the community gets involved, who should speak for the community?Read this case study then answer above questions.Case Study3.8 Case 4: Black-White Infant Mortality: Disparities,Priorities, and Social Justice Erika Blacksher Department of Bioethics and Humanities University of Washington Seattle , WA , USA e-mail: eb2010@u.washington.edu Susan D. Goold Department of Internal Medicine and Department of Health Managementand Policy Center for Bioethics and Social Sciences in Medicine University of Michigan Ann Arbor , Michigan , USAThis case is presented for instructional purposes only. The ideas and opinions expressedare the authors’ own. The case is not meant to refl ect the offi cial position, views, orpolicies of the editors, the editors’ host institutions, or the authors’ host institutions.3.8.1 Background Preterm births, the leading cause of infant mortality, are increasing annually worldwide(World Health Organization 2012 ). The United State s shares company with Nigeria,India, and Brazil among the top ten countri es with the highest numbers of preterm birthsand ranks 31st among Organisation for Economic Co-operation and Development (OECD)nations in infant mortality (OECD 2010 ). Within the United States, racial and ethnicdisparities in infant mortality remain entrenched and have increased (MacDorman andMathews 2009 ). U.S. health policy leaders have made the elimination of health disparities a top public health priority (Centers for Disease Control and Prevention 2011 ;U.S. Department of Health and Human Services 2011 ). Infant mortality is an importantarea of focus for eliminating disparities, both in its own right and because the rate ofinfant mortality serves as an indicator of the nation’s health due to its association withmaternal health, social and economic conditions, racial discrimination, access to healthcare, and public health practices (MacDorman and Mathews 2009 ). During the twentieth century, U.S. infant mortality declined 93 % (MacDorman 2011 ). In 1900, about 100 infants died per 1000 live births. By 2000, that numberfell to 6.89. During the last half of the twentieth century, the rate of black infantmortality dropped dramatically. In 1950, black infant mortality was 43.9 deaths per1000 live births compared with 26.8 deaths per 1000 live births among whites(Mechanic 2002 ). But by 1998 black infant mortality fell to 13.8 deaths per 1000live births compared with 6.0 deaths per 1000 live births among whites. As thesenumbers show, both groups made signifi cant absolute gains, with blacks gainingmore in absolute terms—a reduction of 30.1 for blacks and 20.8 for whites. Yet,black infant mortality still remained about twice that of whites.N. Daniels85 These disparities have persisted in the twenty-fi rst century. In 2006, non- Hispanicblack women experienced the highest rate of infant mortality, with 13.4 infantdeaths per 1000 live births, while non-Hispanic white women had a considerablylower rate, with 5.6 infant deaths per 1000 live births. Citing a 2006 report from theNational Healthy Start Association, MacDorman and Mathews ( 2009 ) report thatprogrammatic efforts to reduce disparities in black-white infant mortality have hadsome successes at local levels, but eliminating the disparities is diffi cult. The U.S. Centers for Disease Control and Prevention and the U.S. Department ofHealth and Human Services have prioritized both the elimination of health disparities and improvement in overall population health. These twin goals—one distributive, the other aggregative—are separate and sometimes confl ict (Anand 2004 ).Increases in health disparities often accompany advances in aggregate gains in population health (Mechanic 2007 ). Although this case is specifi c to the United State s, thedilemma is not. Data show that signifi cant progress on child mortality has been madein many countries but that this overall success is often coupled with increasedinequalities between advantaged and disadvantaged groups (Chopra et al. 2012 ). InChina and India, for example, disparities in mortality persist between boys and girlsyounger than 5 years, a function of entrenched gender discrimination (You et al. 2010 ). These examples raise challenging questions about how ethically to assesssuch cases and set priorities for the allocation of scarce public health resources.3.8.2 Case Description You serve as the director for the local health department in a racially segregatedurban city in the Midwest with one of the greatest concentrations of AfricanAmericans in the United States. The city has a long history of civil rights activismthat led to protests and marches that ultimately empowered and mobilized blackcommunities and organizations. Your health department has a history of prioritizingmaternal-child health and the elimination of black-white disparities in infant mortality in its programs, an investment of resources affi rmed by the city residentsthrough the department’s community outreach program and planning processes. Chronic underfunding of public health, made worse by the economic downturn,has resulted in drastic and unprecedented reductions in the public health budget. Inconsultation with your staff and community board of health, you have raised thepossibility of redirecting resources from maternal-child health into other programsbased on a number of practical and ethical considerations. As with national statistics, the city has seen signifi cant declines in black infant mortality, even as blackwhite disparities remain. You note that although the maternal-child health programsare cost-effective, their impact on reducing black-white disparities seems to havestalled. Other programs appear to meet targets more consistently. To help supportthese other programs, you note that allocating resources to more effective programsprovides more “health” per dollar, thus meeting the utilitarian demand to maximizeoverall health, which many view as the primary goal of public health and health policy (Powers and Faden 2006 ). In addition, although black-white disparities in3 Resource Allocation and Priority Setting86infant mortality persist, blacks have made signifi cant gains, declining more thanwhites in some decades. You note that remaining inequalities could be deemed ethically acceptable by some standard s of equity , such as the “maximin” principle .Although this distributive principle is subject to interpretation (Van Parijs 2003 ), itis generally understood to require that social and economic inequalities work tobenefi t society’s least advantaged groups. Thus, inequalities (even signifi cant ones)are morally acceptable as long as the least advantaged have signifi cantly benefi ted(Powers and Faden 2006 ). The director of community outreach proposes that the health department notmake this decision unilaterally, but instead listen to community opinions on thesequestions of priorities and fairness. He suggests that the health department collaborate with community partners to host a series of public forums. He insists that atopic of such historic and contemporary concern to the community must be subjectto public deliberation. Despite having a history of supporting community discussions, you are concerned about the cost of community forums, noting that they willdrain resources from an already slim budget.