All children should be safe in the water

Where structural racism and drowning intersect

May is National Water Safety Month with the goal of engaging the public and raising awareness about water safety. It is also meant to highlight the importance of public education regarding safer practices for children and adults in and around water.

According to the Centers for Disease Control and Prevention (CDC), every year in the United States there are an estimated 4,000 fatal, unintentional drownings, including boating-related drowning—an average of 11 drowning deaths per day. In addition, there are 8,000 non-fatal drownings. For every child under 18 who dies from drowning, another seven receive emergency department care for non-fatal drowning. 

Drowning and race

Injury death rates for African American and American Indian/Alaska Native children are disproportionately higher than those for White children. According to the CDC, American Indian and Native Alaskan children are two times, and African American children are 1.5 times more likely to die from drowning than White children. 

In swimming pools, Black children aged 10-14 drown at rates 7.6 times higher than White children. Black children and youth are more likely to drown in public pools, and White children and youth are more likely to drown in residential pools. In natural water, American Indian and Alaska Native people have the highest drowning death rates, with rates 2.7 times higher than White people. 

In the United States, the past several years have been marked by a renewed focus on the pervasiveness of racism and its effects. An important aspect of this focus has been the understanding that the high rates of the most common cause of death for children and adolescents, intentional and unintentional injuries, are rooted in the history and consequences of structural racism in the nation. 

The notable differences in injury and death rates across pediatric age groups and disparities across ethnicities do not occur in a vacuum. These differences are best seen within the context in which they occur. 

Structural racism creates an environment that affects the risk of injury and death for children who are vulnerable by virtue of race, ethnicity, poverty, or where they live, which places some youth at greater risk of injury and injury death than others. 

These disparities have a historical and current context rooted in systemic racism. The historical denial of access to public swimming pools, the lack of municipal pools in marginalized communities, and the expenses associated with swimming lessons are reasons these disparities persist. 

What is drowning?

Drowning is the process of experiencing respiratory impairment from submersion or immersion in a liquid. Fatal drowning happens when the drowning results in death. Non-fatal drowning occurs when a person survives a drowning incident with a range of outcomes, from no injuries to severe injuries or permanent disability.

According to the CDC, children ages one to four have the highest drowning rates. Most drownings of these children happen in home swimming pools. However, drowning can happen anytime, including when children are not expected to be near water, such as when they gain unsupervised access to pools, ponds, or in natural waters. 

Certain factors make drowning more likely:

• Not being able to swim. Many adults and children report that they can’t swim or are weak swimmers. Structural racism and the legacy of Jim Crow has meant that many Black families have grown up with less access to swimming pools and swimming lessons.
• A lack of representation in swimming competition and myths surrounding people of color and swimming have also led to restrictions in performance and limited participation in swimming.
• Missing or ineffective fences around water. Barriers such as pool fencing prevent young children from gaining access to the pool area without caregivers’ awareness. 
• Lack of close supervision. Drowning can happen quickly and silently anywhere there is water, especially to unsupervised children. It happens in lakes and oceans, pools, bathtubs, and even buckets of water. Drowning can occur even when lifeguards are present.
• Not wearing life jackets. The U.S. Coast Guard reported 613 boating-related deaths in 2019, and 79 percent of these deaths were drowning-related. Of those who died from drowning, 86 percent were not wearing life jackets.
• Using drugs and certain prescription medications can increase the risk of drowning. 
• Drinking alcohol. Among adolescents and adults, alcohol use is involved in up to 70 percent of deaths associated with water recreation, nearly one in four emergency department visits for drowning, and about one in five reported boating deaths. 
• Certain medical conditions, such as epilepsy, autism, and heart conditions, are also associated with a higher risk of drowning.

Location of drowning

The highest risk locations for drowning vary by age. Among infants under one-year-old, two-thirds of all drownings occur in bathtubs. Most drownings happen in home swimming pools among children ages one to four. More than half of fatal and non-fatal drownings among people 15 years and older occur in natural waters like lakes, rivers or oceans.

Drowning prevention

The American Academy of Pediatrics (AAP) and the CDC point to several ways to prevent drowning deaths. These include:

• Teaching school-age children basic swimming, water safety, and safe rescue skills. Learning to swim can reduce the risk of drowning by 88 percent for one- to four-year-olds who take formal swimming lessons.
• Ensuring equitable access to swimming pools and expanding swimming pool access in communities and schools that serve children of color. 
• Strengthening public awareness of drowning and highlighting the vulnerability of children.
• Ensuring close adult supervision whenever children are around water. The AAP recommends assigning a Water Watcher, an adult who will pay constant attention to children in the water. Close supervision is required when kids are in or near water (including bathtubs), always. Drowning happens quickly and quietly, so adults watching kids in or near water should avoid distracting activities like playing cards, reading books, talking on the phone, and using alcohol or drugs.
• Placing four-sided isolation fences, with self–closing and self–latching gates, around backyard swimming pools can help keep children away from the area when they aren’t supposed to be swimming. 
• Learn CPR. These lessons can help save a life. 
• Make sure kids wear life jackets in and around natural bodies of water, such as lakes or the ocean. Life jackets can prevent drowning during water activities, especially boating, and swimming. Life jackets can be used in and around pools for weaker swimmers too. 

Swimming is a fun activity and sport that can and should be enjoyed safely by all. We should work towards a society where all children can learn how to be safe in the water.

Dr. Kiragu is an associate of the Children’s Respiratory and Critical Care Specialist’s group and provides pediatric critical care at Children’s of Minnesota. Dr. Kiragu is a passionate advocate for children and is a past president of the MN Chapter of the American Academy of Pediatrics. He is also a past president of the Minnesota Association of Black Physicians. He is an associate professor of pediatrics at the University of Minnesota.