The Norm Chronicles (4 page)

Watch her now in the loo, with thighs of iron, paisley skirt hoisted to her armpits, hovering. See how vigorously she then washes her hands. Meanwhile, notice Prudence in the pushchair reach out with infant curiosity to touch …

‘No, no, no! Dirty Prudence. Don’t … ever … Over here …’

‘Mama.’

‘Hands …’

‘Huh …’

‘Oh you haven’t? You have. All right. Legs up. Nappy … don’t touch. Whoops. Where are the wipes?’

Wipes. Trusted companions. First line of defence in the war with
dirt. Prudence would learn from an early age never,
never
to take peanut butter sandwiches onto school premises,
never
to mix the knives used for raw chicken. Just as her mother worried for the unaware, pitied them their lack of foresight and the risks they ran. Invited to join a book club, she nailed instantly the danger others missed – that if she lay awake to read at night, her husband might think she had the energy for sex.

The headline in her morning paper, ‘20 physical signs that you are seriously ill’, meant Prudence’s Weetabix must wait while she read it, twice, and self-diagnosed. Was that a new mole on Prudence’s leg? No, a spot of mud. Where were the wipes?

Follow mother and daughter now as they emerge from the loo into the coffee shop, where an old friend sneezes. See how the mother leans back from the table, lips zipped, breathing as if air hurts, trying to disguise the sweep of her hand over Pru’s mouth and nose. She’s thinking of disinfectant hand-wipes.

‘You need perspective,’ a male friend once told her, and offered to show her some probabilities.

‘Thank you,’ she said, ‘but numbers aren’t the point.’

‘What?’

Bad things happened in the world, unspeakable things. The thought of ‘what if?’ – what if the worst happened – beat the numbers game every time. ‘What if’ turned any risk, however small, into Prudence … screaming.

‘What if I show you it’s one in a million?’ he said.

‘No good.’

‘What?’

‘The problem’s the one.’

‘One in a million is good.’

‘Not to the one. Not to the one.’

Especially if the one was Prudence. Was her childhood home child-friendly? It was. Including the garden ponds or water features? They were dug up. Did her mother know how to react in an emergency? She learned. Had she chosen safe equipment and furniture? She had. There was safe and healthy eating, safety on holiday, sleep safety, bath safety, safety on stairs and sofas, little objects and little bones (easily broken),
scalds and burns, suffocation and drowning. Parenting magazines kept her alert. ‘Neglect’ was almost the worst word she knew.

She also knew that some terrible twist of nature, an undiscovered illness, say, might still take Prudence. But short of that, and with proper care, she would grow up healthy, to outlive the reckless and misguided who drove too fast, ate badly, ignorant of cholesterol and acrylamide, grew fat and, careless of gender-bending pollutants out there, left electromagnetic devices switched on in bedrooms and even had their children vaccinated. Or was it that they didn’t have their children vaccinated? Bugger, what was the latest? And Prudence was due a jab. Sometimes the threat seemed to come from both sides at once, like two-way traffic.

Children on a winter’s day meant a slip hazard; summer meant wasps and sunburn, with an eye for jellyfish on the beach and tsunamis on the horizon, when even restful moments with the
Mail
and a mint tea required a watchful eye over Pru’s play, which certainly ought not to stray beyond the line of the deckchairs. An advertisement on the train, ‘Don’t risk bad breath!’ was on an all-embracing continuum with terrorists: ‘In these times of heightened security, please ensure you keep all your belongings with you. If you see a suspect bag or package …’

This was the world Prudence would inherit, a world of hazards, threats, risks or symptoms, in which numbers hardly mattered but a scary story might, in which fear was the price she paid for love, in which Prudence, hurt, was an infinity of pain and guilt for her mother too – as she felt again on the way home after accidentally banging her daughter’s head on the car door.

PRUDENCE’S MOTHER IS RIGHT
to this extent: being a baby is high-risk – relatively. The hazard in the first tender year of life is roughly that of riding 30,000 miles on a motor bike, once around the world.
*
Imagine your baby on a Harley. Feel safe?

Those who survive won’t face the same level of annual hazard again until their mid-50s. Under-1 is a dangerous age, comparatively.

But you probably knew that. Children’s vulnerability is a cliché. First helpless, then a dicey mix of naive and curious, they’re asking for it, aren’t they? It’s easy to see them all on the same high wire until they grow up.

Easy, but misleading. This splurge of fear is too crude. It masks a stark difference in risks that change radically in only a few years. Prudence’s first year is relatively risky all right, but most of the risk is squashed into the first few weeks, and if she makes it to her first birthday, as the vast majority do, her annual risk plummets – from 4,300 MMs in the first year to fewer than 100 MMs a year for a seven-year-old, or about a quarter of a MicroMort a day from all causes. Believe it or not, this makes seven the safest age of all to be alive – far safer than life for mum and dad.
²

So infancy and childhood go in short order from one extreme of life’s acute risk to another. Babies don’t do much, but they do live dangerously, briefly, compared with others. As soon as they become young children, they get up to all sorts, safer from death than anyone.

This is only fatal risk, and there’s plenty of damage you can experience short of the big one. Even so, the change in fortune is stark. Anxious parents have something to worry about in year 1, most of it in the first weeks, and then …

But does their anxiety fall with the risk? Or do they worry away anyway, like Prudence’s mother? If so, maybe it’s watchfulness that keeps children safe, in which case worry works. Certainly, she thinks so. A danger foreseen is half avoided, an old proverb says. Or maybe once parents start to worry, they can’t stop, and it takes about a fortnight for paranoia to set in.

But there’s another reason her mother is frightened: not just love but also fear of blame. Danger can feel worse if you think someone is at fault when things go wrong, if someone else ‘did it’. Then there’s an innocent victim, and an accident is more than bad luck, it can become a grievance. If you are the one doing the looking after, when protection is your duty as well as your care, if you are not just loving but also the one who’ll be blamed, then danger is darker – and guiltier. ‘And where was the mother …?’ someone will ask.

So if something happened to Prudence, how would her mother feel? Amidst everything else, rightly or wrongly, she’d feel she hadn’t been there. You could tell her it was bad luck all you liked. She wouldn’t hear. Probabilities don’t mention this – the human pain.

But don’t judge them too harshly. This indifference can be a virtue. Probability is uncaring, it’s true, but by the same token it is often un-blaming. Not all the feeling in stories is benign – and so probabilities can be kinder than stories, more forgiving, less eager to find human agency (a particular person who ‘did it’) and happier to admit their uncertainty about exactly how the accident happened.

That’s partly what probability is – a statement of uncertainty about cause-and-effect or naming the guilty. So, being an emotionally challenged number can have its humane side too, if only by omission.

What the numbers primarily say is that the most serious risk of death in infancy is brief, as we say, and also that it has plunged. Infant mortality is a good indicator of the change in social conditions, and strongly influenced by transient famine and epidemic. It tells its own story of breath-taking progress.

Throughout ancient history perhaps 30 to 40 per cent of babies would die before their first birthday, what we might call the natural rate of infant mortality. By about 1600 in England, the figure had roughly halved, and remained at about 15 per cent from the mid-1800s.
³
If this were the rate today, it would mean well above 100,000 infant deaths a year in the UK.

Fortunately, it improved again, dramatically. By 1921 the rate had almost halved for the second time, but this time the leap took just one generation. Soon after the Second World War, it had halved again. By 1983 even that rate had halved again and then halved again, and then by 2012 it more than halved again to stand now at about 4 per thousand.
*
The change has been nothing short of astonishing, death slashed back, again and again. In much of the world the biggest historical cause of
early death has been so reduced that what was once ordinary is now exceptional. Has there ever been a more radical reduction of risk in human history than the risk of infant mortality in developed countries?

How do those numbers make you feel? Privileged by progress and reassured for your children? Or still anxious?

For though the risks have reduced massively, they are still around. By 2010 in England and Wales there were 723,165 live births, more than one a minute, or close to 2,000 a day: enough to fill a very large and very noisy cinema.
*
Think of Prudence as one of them. So far, so good. But she had to survive several scary moments along the way.

The first came before the first breath. If you look around that cinema, you notice ten empty seats. These represent the stubborn toll of still births, around 1 for every 200 live births, a rate unchanged since the early 1980s. While other countries have continued to make progress, the UK has not. This is a puzzle, and it is disturbing.

Next comes survival in life. Of the 2,000 live babies born each day, around 5 die in the first week, another 1 before a month is out, and 3 more before they reach their first birthday.
⁴
The total risk during that first year from a variety of causes is, as we say, 4,300 MicroMorts. That is how we arrive at the 30,000–miles-on-a-motorbike equivalent. If 1MM equals riding a motorbike for about 7 miles, then 4,300 MMs x 7 miles = 30,100 miles.

We’ll take the dangers to Prudence that make up this total one at a time. First, the largest single category: congenital disease or prematurity. Very tiny babies struggle. Of the 4,000 babies born in 2010 who weighed less than 1kg (a bag of sugar), 1,200, or 30 per cent, did not make it to their first birthday.

As Prudence was not premature or congenitally ill, the 30,000-mile motorbike equivalent risk falls sharply to about 16,000 miles, from 4,300 MM to about 2,300 MM.

But then comes the next danger: 202 babies, four a week, who died after the birth went wrong. It is a continuing controversy whether it’s safe to have your baby at home or in hospital (at least, since hospitals
learned the lessons of hygiene; see
Chapter 11
, on giving birth). People who give birth at home are generally better off financially, and that tends to be associated with higher rates of survival. They also tend not to be having their first baby, which should also be safer. Even so, the infant mortality rate is the same for home births and hospital births in England and Wales.

Figure 2:
Causes of death in infancy, England and Wales, 2010
⁵

A recent study of 65,000 ‘low-risk’ births showed that women giving birth in a unit run by midwives were just as safe as in hospital but had far fewer caesareans and more ‘normal births’. If it is not your first child, then giving birth at home is as safe as in hospital, but for first-time mothers there was around double the risk of a serious problem, and nearly half had to be transferred to hospital.
⁶

The final big danger to Prudence – and everyone else – is the 136 Sudden Infant Deaths (192 MicroMorts) added to those cases that are ‘unascertained’, to leave a distressing group that is officially called ‘Unexplained Deaths in Infancy’. Since the launch of the Reduce the Risk campaign in 1991, which overturned the received wisdom of leaving babies to sleep on their front, the number has dropped by 70 per cent. But there were still 279 in 2009 in England and Wales (400 MicroMorts in the first year), around 1 of the 2,000 babies born each day.
⁷

These mysterious deaths are around 50 per cent more common in
boys, more common in winter, and the risk is five times higher for children of mothers aged under 20 (1,230 MicroMorts in the first year) than over 30 (250 MicroMorts). So all in all, as a girl, not premature and with a mother in her 30s, Prudence was among the safest at this – relatively – dangerous age. Not that her mother would have been reassured.

That is in a developed country. What if she had been born elsewhere? International comparisons for infant mortality are tricky. Some countries don’t include in their infant mortality data the tiny premature babies that we have seen are at such high risk. Lack of good registration also means that the rates have to be estimated from surveys that ask households if they have had a child under five who has died, then use statistical models to estimate infant mortality.