Aren't we over-reacting to the maternal mortality rate?

 

From a brief zoom interaction with my colleague, Holly Mattix-Kramer, earlier today on maternal mortality rates:

Reacting to your posting in the chat, Holly, it is a source of great sadness that a woman should die becoming a mother.  If my wife, sister, daughter was the woman who died, this would be the biggest tragedy in my entire life. 

But thinking about this from the standpoint of the community as a whole, maternal mortality is a small blip on the screen of preventable deaths in the US.

In 2022, the MMR was 22.3/100,000.  That is a total of 817 deaths.  OK, so I picked a low year.  So in 2021 MMR was 32.9/100,000, which is 1204 deaths.  And the highest number I could find on how many of those deaths might be preventable was 80%.  That is 963 in 2021 and 654 in 2022.  Why the variability with MMR?  I am not a statistician, but I bet the fact that we are dealing with a small base of numbers is an important factor; wouldn’t this make slight differences look very large?

Motor vehicle accidents in 2022 were 42,514.  That is 65 times higher than maternal deaths that year.

Kidney disease deaths (hitting you where you live, Holly) in 2022 were 57,987.  That’s 89 times higher than maternal deaths.

And remember that, even though we are properly focused on the differential between white and Black moms, the number of Black moms who die is an even smaller number.  About 1/7^th of all births in the US are to Black moms.  Around 500,000.  If the Black MMR is 3 times the total MMR, then it is 66.9/100,000.  (I know that isn’t right, because we should multiply by the white births, but I don’t know that number.)  That means about 67 time 5, or 335 Black moms die.  Again, a terrible, unspeakable tragedy, but an even smaller number from a public policy standpoint, particularly if only 80% are preventable, which lowers the number to 268.

Yes, I know that every preventable death is worth saving, but I am not arguing we do nothing about this.  I am just arguing that we take into account that how much money and energy and attention we allocate to MMR should be at least roughly proportional to the size of the problem.  About 480,000 people in the US still die from smoking.  That’s 1,315 per day, higher than the maternal death number for the entire year of 2021.

Yet our colleagues in public health continue to rank MMR as a huge problem deserving of the designation of a “crisis.” 

I usually start this discussion in my classes by asking the class how many people have to die from a disease, condition or life event before we start really focusing on it and spending a lot of money to lower it.  The consensus is usually 10,000.  Maternal mortality isn’t anywhere near that.

I am not saying we shouldn’t put some focus on MMR.  And we should definitely focus on the disparities between Black and white mothers.  But in my opinion, we are over-reacting to the problem as a whole.  Beyond my opinion that we are over-reacting to this problem, there is also the point I tried to raise with the student today.  Something with a small “n” is not a very good thing to use as our outcome measure to address poor access to maternal care.  There will be too much variability, and at some point some one opposed to putting more money into caring for poor, Black moms, is going to do the math and say “this isn’t that big a problem.” 

So, we should look for more compelling measures to highlight the problem of maternal care deserts.  Numbers of primary care docs per population served?  Numbers of dollars spent on maternal care per population served?  Money spent on FQHC’s?  Maybe some measure of morbidity?  Extra money spent on intensive care?  I don’t know what would be best to use; this is not my expertise.  But the people with the expertise keep insisting this is a crisis!

That would have been a much more interesting and compelling result of the policy analysis presented. 

OK, thanks for listening.  I feel better now.

DS

PS, Don’t get me started on K-12 school shooting deaths.  Between 1999 and 2022, this number has peaked at 50, with most years well below that.  https://www.security.org/blog/a-timeline-of-school-shootings-since-columbine/.  Yet we have produced an entire generation of children, whom we routinely run through gun detectors to get to their classrooms, scared to death of going to school.  In some of those 23 years, more people died of lightening strikes than being shot at school.  I get that the media blows this sort of thing up, but too many public health experts are doing the same.  ds

 

This election showed the power of passion over reason

I am still processing this election, but I have a few preliminary thoughts.

Passion not reason

Overall, I don't think this was a fight over policy or rational positions.  Trump won because he stirred up passion among a lot of unhappy people, a lot of angry people, and among another group who wanted to believe passionately in "someone," maybe "anyone." The key is "passion," not raciocination.

My friend Sagar, a doctor and former student of mine, said this was an amygdala election, not a cerebral one.  Another friend, Alan, who is a psychologist, likened this idea to “the reflexive response seen in youth challenged by complex trauma.”  Simply put, we are not talking about executive function-like decision-making.  It is emotions, like anger and rapture, not reason.  Something more akin to spirituality, with the many associations between Trump and God as evidence.

So, if that is true, then Harris lost the election the day she announced, because nothing she did or could have done would have evoked greater passion than did Trump. He got people from around the country moving in his direction.  Best results for a Republican in Chicago in decades! All the recriminations against the Democrats are misguided. To use the old cliche, we brought a knife to a gunfight.  And if you scan the likely Democratic candidates for President, it seems clear that none of them could have beaten Trump this year.

It couldn’t have been reasoned analysis that led to his 75 million votes; Trumps biggest positions were patently refutable.

Undocumented immigrants

There aren't 25 million undocumented, and removing the ones who exist will sink agriculture, construction and hospitality. Plus he killed the bipartisan immigration bill.  And study after study shows, contrary to Trump’s dark scenarios, that undocumented immigrants are less likely to commit violent crimes than citizens.  But people who cared about immigration were passionate, and Trump incited that. Not reason. Passion.

Inflation

Inflation, caused almost entirely by the pandemic, peaked at 9.1% in July 2022. It started dropping soon thereafter and is down to 2.1% now (without a recession!). But prices didn't come down, on eggs or rents or a dozen other things people buy every month. So people blame the Dems for causing the high prices (they didn't) and not lowering them (no one knows how to do that). "Aaargh! Look at that grocery bill!"  First Biden, then Harris, talked sense on this, but were met with vivid anger and sadness, not thoughtfulness.

Tariffs

Raising tariffs has sounded simple for centuries, and people feel passionately about fighting economic wars with other countries, with "those goddamn foreigners."  

You can argue logically that high tariffs have never worked and have repeatedly caused severe problems, like more inflation. All you get is passionate shouting in return. Trump led those shouts.

Climate change

Climate change is good science, and that science has been presented by lots a calm discourse by our leaders and pundits. But "drill, baby, drill" is a battle cry. Trump led his followers in that passionate cry and they followed him, amygdalae aflamed.

The “good old days”

More than 1,000,000 Americans died because of Trump's failures in responding to COVID. And one of the very few things he positively championed was tax cuts for the rich, decidedly not in the interest of most of his voters. Yet many of his voters remember his first four years as a wonderful time in the country's history. What did we liberals do?  We offered rational arguments based on solid history, sound science and powerful economic analysis. And, of course, we utterly failed in the face of the passionate memories of that great first Trump term.

Nothing we could do

Nope, there was nothing we could do. Harris was a very strong candidate if this had been an ordinary election. But she was totally out of her league in a hard fought contest of passion over reason.  As would have been any other likely Democrat.

If all of this is accurate, and whoever comes after Trump is as good a rabble-rouser as he was, then we have to find our own purveyor of passion and then come together around a set of values we can champion to fight against the anger, selfishness, and resentment that Trump stoked. I am open to thoughts about who that might be. But I think it is a pretty short list.  

Maybe the next election (if we get to have one) will go back to the standard contest of a mix of emotions, values and reasoned policy discourse. But a roused rabble seldom settles quickly.

Death begets death

 After the despicable attack on southern Israel and the evil brutality that Hamas perpetrated, I was enraged.  I wanted Israel to fight back, I still do.  But I am coming to understand that the lust for vengeance is a cycle.  That killing, however justified, only results in more killing.

Death begets death.  Death does not beget life.  Death only begets more death.  It doesn’t lead to hope, to joy, to justice, to peace.  Just more death.

This is a lesson that Hamas will learn.  And it is a lesson that my fellow leftists need to learn before they champion the horrible deaths of thousands of innocent people.

And it is a lesson that the Israel government will have to someday learn.  If they kill large numbers of Gazans, aside from the moral problems of doing this, they will beget rage and anger which will result in more attacks, more rockets, more brutality.  More death.

But what if we could kill all of the Hamas fighters?  Well, that is probably not possible.  They aren’t wearing uniforms or badges.  They have had years to plan their hiding.  We will miss quite a few.  And they will organize more followers to come after us and kill us.  

But even if we could kill almost all of them, their fathers, their mothers, their brothers, their sons and their daughters will rage against us.  So will their grandchildren.  And they will all try to kill us.  More death.

And their rage and anger is useful to evil people in the world, who will support them, finance them, train them, equip them.  And derive power and treasure from their rage and the killing it produces.

Peace is not produced by the waging of war.  Centuries of war demonstrate that.  If we want peace, we will have to wage peace.  If we want justice, we will have to work towards justice. Both of those paths are hard.  Hard to see, hard to tred.  But killing only begets more killing.  Death begets death.

Isn't it time to exercise some control over young techies?

 [The following is a slightly expanded version of a recent tweet.]

Am I getting too old to have an opinion like this? Young techies, working in glass palaces w/ free lunches (we know better) & ping pong in the lobby, think they are helping the world. But they are just making it more and unnecessarily complicated, beyond our capabilities and our social systems to cope.

Driverless cars kill people in ways the techs didn’t foresee. They expect drivers to pay attention while the program runs!  Don’t they know any actual drivers? How many people will have to die before we accept that human consciousness is a necessary part of using machines safely?

I am a computer nerd. I bought my first computer in 1981, and I have been tinkering with the hardware and software of my desktops and laptops ever since.  I have been word-processing for 40 years. But I can’t intuit anymore how to make new software work. It does more than earlier versions and is certainly more complicated, but I can do less with it because I can’t figure out how to do the things I need to do.

These kids in Silicon Valley are fixated on artificial intelligence and machine learning, with only passing lip service to the potential negative consequences.  And it stands to reason, if there is artificial intelligence, there will be artificial stupidity.  Who will be responsible?  The companies ask to be relieved of liability in case something bad happens.  Isn’t the fear of losing lawsuits one of the few things that might keep us safe from their hubris?

Tech-obsessed youth, giddy about the profits they can make off of their addictive software, creating algorithms that they don’t fully understand, reaping billions of dollars, with no sense that our irresistible attraction to their lures ultimately will make us sad, sick, sleepless, lonely.

They hook little girls with Instagram posts that undercut self-esteem and maybe heighten the chances of suicide.  Many of their customers are hooked on social media programs, spending hours scrolling their lives away.  Do the techies care?  It makes them obscenely rich, as they sell our attention to the highest bidders.

We have let these children design our future, not for the betterment of our lives, but for their own immense greed. With no forethought, planning or oversight. Maybe it is too late.  Maybe the monsters they created are already eating us alive. No, we shouldn’t give up. We just need some grown-ups to step in and take away their toys.

Accepting the Lifetime Achievement Award from the Law Section of the American Public Health Association

 On October 24th I was honored with the Lifetime Achievement Award from the Law Section of the American Public Health Association.

Here is the nomination statement from Marjorie Jaski, JD, MPH:

Attorney Daniel Swartzman
Nominee for APHA Law Section Lifetime Achievement Award

My nomination of Dr. Daniel Swartzman is derived from my time as his student at the University of Illinois School of Public Health, my continued association with Dr. Swartzman, and witness to his extensive following and influence on some of our brightest leaders today in Public Health as well as his lifelong career in public health law.

Professor Daniel Swartzman became an environmental public interest lawyer in the 1970’s, after graduating from Northwestern Law School and serving as Director of Legal Services for the Chicago Lung Association, working on issues in Illinois and nationally.  Upon receiving his MPH in Environmental Health Sciences in 1978, he also joined the faculty of University of Illinois (UIC) School of Public Health.  

At the School of Public Health, Dr. Swartzman taught some of the earliest classes in the country on public health advocacy and public health ethics, and, today, he is the most awarded teacher in the School’s history in this area.  During his tenure at UIC, he also served as Associate Dean of the School, and his book on cost-benefit analysis and environmental regulations has been widely reviewed and sits in more than 350 libraries around the world.  He has presented widely in conferences, including 20 abstracts at APHA, and in international settings. He started a joint JD/MPH program between UIC and the Chicago-Kent College of Law, and is currently working on a similar program with Loyola’s Health Law program.  His academic work has focused on environmental law, public policy making and social justice.  

Concurrent with Dr. Swartzman’s academic work, he opened his own law practice in 1985 focusing on toxic torts and private brownfield reclamations.  His law firm has been the only Chicago firm that took a cigarette manufacturer to a federal jury verdict, and he has helped close brownfield sites worth hundreds of millions of dollars.  His legal work has been influential in implementing the Clear Air Act Amendments, the work of the National Air Conservation Commission and the National Clear Air Coalition.

Over many years, Dr. Swartzman has helped advise more than two dozen student dissertations and served as advisor to hundreds of MPH students, at least 20 of whom were lawyers or who went on to law school.  In 2017, a group of former students started a campaign raising an endowment of over $100,000 for the “Daniel Swartzman Lecture in Public Health Ethics” at UIC.  He continues his work at Loyola’s new Parkinson School of Health Sciences and Public Health, where he teaches both graduate and undergraduate students.  He advises undergraduate students on becoming lawyers.  He is busy developing teaching case studies focusing on social justice issues which Parkinson hopes to make widely available.

After a highly distinguished career in public health law, that continues to this day, I believe that Daniel Swartzman is an ideal candidate and highly worthy recipient of this award. 

And here are my remarks on accepting the award:

My remarks on receiving the Lifetime Achievement Award
from the APHA Law Section
October 24, 2021

    This is a humbling experience.  I look at the previous recipients of this award, and I think “It is their work that my work is built upon.  These are the shoulders on which my achievement, such as it is, stands.”  With us tonight is the first recipient of this award, Scott Burris, and I am honored to be here with you, Professor Burris.  And I think about a couple of dozen people in our field who deserve this award more than I do.  Of course, I am not going to tell you who those people are, because I don’t want you to change your mind.

    You know, when I graduated from law school, back in 1975, I realized that one can take pride in how well one does their work and in what the work actually is.  But for many lawyers, that second part is not all that easy.  I know so many lawyers who have worked for decades, and have taken pride in how well they lawyer, but not necessarily in what the lawyering accomplished.  But I wanted to be a lawyer for Good things.  And I am sure all of you here tonight know exactly how that feels, because you all want to be lawyers for Good things.  As a public interest lawyer and then as a lawyer for people harmed by toxic chemicals and as a lawyer who helped people clean up polluted land, what we call “brownfields,” I am proud of what I have done.  But there is always that question in the back of your mind, is it enough?  Have I contributed enough?

    Then, a few years later, I became a teacher, teaching public health graduates and undergraduates how to work towards Good things.  Many of you are teachers.  You see your students learning and you can see by the tests scores that they understand the material.  But have you really helped them build careers to achieve what we Jews call “tikkun olam,” repairing the world?  I know that the professors here tonight understand the doubt that I am expressing.

    But four years ago, a large group of my former students worked together to collect more than $100,000 to endow a lectureship on public health ethics in my name at the UIC School of Public Health.  OK, I thought, I probably was doing some Good with those folks.

    And tonight, by being recognized by you, my peers, for my 46 years of practice and teaching and writing, I am being offered an acknowledgment that, yes, maybe what I have been doing was worthwhile, that I really did achieve something.  

    For that statement from you, I am very, very grateful.  Thank you so much for this honor.

No one exists alone; liberty is embedded in community

President Biden is taking concerted action to increase the number of Americans who are vaccinated.  It looks like public opinion favors this move, but he is being criticized by a small but highly vocal minority saying that his actions are unconstitutional and against individual liberty.

It is long established law in the US that the government has the authority to mandate actions, including vaccinations, to achieve public health goals.  This power lies mostly with the states, under the “police power,” the state’s responsibility to protect the “health, safety, welfare and morals” of the community.  This is why the President is only encouraging governors to act, since he does not have the power to force them to do so.  But the federal government does have the power to control the conditions of its own employees, and OSHA has the power to regulate health and safety in the workplace.  These actions will likely be challenged in court, but unless the courts decide to change more than a century of strong, legal public health protections, the President’s actions should be upheld.

But what of that small and noisy minority who insist that this is a violation of their personal liberty?  I think the key is to ask about the context of liberty. We have for a very long time treated liberty as something that is separate from the community. The two are presented as opposing positions, inevitably at odds.  This has become so pronounced over the last forty year that I have taken to calling this a “fetishization” of individual liberty.

I think this view, that liberty is somehow removed from community, is not useful or accurate. Individual liberty does not exist without a community that supports individual members in their individual choices. What keeps us from being a battle-royal of every individual against every other individual is the presence of an overarching community that provides a safe and respected place for individual action.  I believe there is no society of individuals that exists without a healthy community. I said this in a tweet a couple of months ago:

"Freedom is not separate from the needs of the community. It is a right that is protected by, empowered by the community. Individuals enjoying their freedom must respect the community that protects it. A healthy community guarantees freedom, within limits of the community's needs."

Some people say that the individual is the basic unit of analysis within a society. But this makes little sense in arranging the affairs of social animals such as humans.  Who keeps the commons open to individual thought and actions?  I think we were all members of a community before we ever realized that we were individuals. There is no history of individual humans wandering alone in the grasses or forests fending for himself or herself. Our history starts with hearths, kinship, mutual protection and, most of all, caring for “the other.” Going off on one’s own only happens after the community raises you to the point of being ready to try that.  And it is probably waiting behind you when you return, helping you in bad times or sharing in your successes.

We are all inevitably embedded in community, either one present in our lives today or one that operated in the past to support our families and allowed us to get to the point of “striking out on our own.”  If we perpetuate the illusion that all of our successes are due only to our own efforts, we will neglect the communities that are just as responsible as we are for our achievements.  And not being vaccinated and not wearing masks are exactly that neglect.

The ACA is up for grabs; how did we get here?

A bit of history 

The ACA requires that insurers cover anyone, even if they have a pre-existing condition.  That is an expensive requirement for the insurance companies.  After all, you are agreeing to cover someone whom you know will be incurring costs.

In return for this, the ACA requires that everyone has health insurance, the “individual mandate.”  That way, people who are not currently sick or are unlikely to get sick will pay for insurance, and the insurance companies will make money to compensate them for paying out to those with pre-existing conditions.

In order to make sure that people buy the health insurance, the ACA established a penalty for not having insurance, to be collected by the IRS when we do our taxes.

In 2012, the US Supreme Court found that the individual mandate was not constitutionally valid under the Constitution’s “interstate commerce” clause, but that it was valid under the “tax” clause.  Was this a penalty or a tax?  The Obama administration admitted it was a tax, and the Supreme Court said that that was acceptable.  The ACA was constitutional.

However, in 2017, Congress passed a major tax cut law.  And in that law, it set the value of the tax on the individual mandate to zero.  So, it eliminated the penalty for not having health insurance. 

In spite of that, people still signed up for insurance under the ACA.

A Texas judge

But in 2018, a group of state Republican attorneys-general brought suit in a Texas court, in front of a judge known to be conservative, claiming that if the individual mandate tax was eliminated, then that eliminated the constitutionality of the mandate.  And if the individual mandate was unconstitutional, then that meant that the entire ACA was unconstitutional.  The judge threw out the entire ACA.

Is that right?  Does an entire law fall if one part of it falls?  No, not automatically.  There are rules for determining whether an entire law is unconstitutional if a court finds that one part of it is unconstitutional.  Most legal scholars (most of whom, admittedly, are liberals) found that the judge in Texas did not come close to following these rules.  A number of Democratic attorneys-general appealed the judge’s decision.

The Trump Administration’s first response to this ruling was to not get involved.  However, just in the last couple of days, the Administration has changed its position, and recently filed a brief with the Circuit Court of Appeals hearing this case taking the position that the ACA was now completely unconstitutional. 

We liberal scholars still think that the Texas judge’s decision was flawed.  But having the Administration come out in favor of the ruling is a big deal.  And ultimately this is going to go to the US Supreme Court.  In my view, any reasonable decision by SCOTUS would throw out the judge’s faulty decision.  But my view of what is reasonable and what five conservative judges on the Supreme Court think is reasonable do not always coincide.  They may very well throw the whole thing out.

The New York Times coverage

Hence the review by the New York Times this morning:

https://www.nytimes.com/2019/03/26/health/obamacare-trump-health.html

But that is not all.  Back in 2017, Congress decided that it was going to repeal and replace the ACA.  The Republican controlled House, after a lot of back and forth, passed the American Health Care Act, which sort of repealed and sort of replaced the ACA.  The Republican controlled Senate couldn’t find any language they could agree upon.  Late one night, a poorly drafted law was put up for a vote, to at least keep the discussion going.  Whether it would pass came down to one vote, to be cast by Sen. John McCain, who entered the “well” of the Senate chamber and dramatically extended is hand and indicated “thumbs down.”  (In case you were wondering why Trump has been so focused on the now deceased Arizona senator, this is part of that anger.)

The Republican Congress ended up not passing anything.  Why?  Because it is very, very hard for conservatives to come up with the replacement that was promised.  Keep in mind that the ACA is the conservative approach to healthcare reform, published many years ago by the very conservative Heritage Foundation.  And the President and most Republicans in Congress had agreed to keep the ban on refusing insurance to those with pre-existing conditions, a very popular position amongst the electorate, given that more than 100 million Americans have a pre-existing condition.  But if you want to make insurers cover people with pre-existing conditions, you have to make everyone buy health care. . . .  Congress could never figure out a way around this.  And both Congress and Trump had also promised to lower healthcare costs, which no one knows how to do.  (Short of passing a single payer system, which will give the federal government extraordinary bargaining power over the healthcare providers.  This is one of the main reasons why healthcare is much cheaper in the other rich countries around the world.)

Healthcare in the 2020 election

The President has sworn to make this one of the big issues in the 2020 campaign.  He vows that the Republican Party will become “the party of healthcare.”  At the exact same time, the Democrats in the House have submitted legislation to bolster the ACA, increasing the subsidies, and strengthening other parts of the law.  And it is widely viewed that healthcare was one of the big winning issues for Democrats as they took back the House in 2018.  They will likely be delighted to have this debate in 2020.

So, here we are.  The courts shouldn’t throw out the ACA, if they follow established rules, but they well might.  And one house of Congress is making the ACA stronger, while the other house wants to get rid of it. 

And the Times has let us know exactly what is at stake.  Lots of people’s lives and livelihoods.
Quite a moment!