Restoring the Infant Mortality Rate as a Measure of Societal Health

The infant mortality rate (IMR) — deaths in the first year of life per 1000 live births — has long been considered a central measure of public health. A recent New England Journal of Medicine article by Harrison, Ndulue, and Ojikutu revisits the IMR’s role as an indicator of societal well-being and equity.

Historical context

• At the end of the 19th century, IMR disparities in Boston and other U.S. cities were stark, with Black infants dying at nearly twice the rate of White infants.
• Early debates alternated between attributing differences to “innate” racial traits versus structural and socioeconomic conditions. Figures like W.E.B. Du Bois emphasized that high Black infant mortality reflected social conditions, not biology.
• Although overall IMR dropped dramatically in the 20th century (from 327 deaths/1000 live births in 1885 to 6.9/1000 in 2000), racial gaps widened. By 2022, IMR was 141% higher among Black infants compared to White infants.

Lessons from Boston

Boston serves as a case study showing how structural determinants — housing, economic mobility, education, and systemic racism — have shaped disparities. Even in a state with one of the lowest overall IMRs, the city still shows profound racial gaps (in 2021, 9.7 vs 3.2 deaths/1000 among Black vs White infants).

Key insights from the authors

1. IMR remains a powerful societal indicator — especially in mobilizing responses where other data may be lacking.
2. Narrow focus on clinical care and individual needs has historically overshadowed structural determinants.
3. Effective programs must integrate clinical, social, and structural interventions, addressing systemic drivers alongside patient-level needs.
4. Physicians play a critical role: in framing IMR disparities, building structural competency into medical education, and supporting community-based initiatives.
5. History matters: understanding the recurring neglect of structural causes can help counter arguments that resist systemic change.

Conclusion

The article calls for revitalizing the IMR not only as a measure of infant outcomes but as an index of societal health equity. Addressing disparities requires shifting policy frameworks from individual-level interventions to comprehensive structural reforms that foster environments where all infants can thrive

Editorial note: This content was developed with the support of artificial intelligence technologies to optimize the writing and structuring of the information. All material was carefully reviewed, validated, and supplemented by human experts prior to publication, ensuring scientific accuracy and adherence to good editorial practices.

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