Midwives and the U.S.

As a childfree/childless adult, giving birth is not something that I think about a lot on a personal level, but it is something that most of my clients, many of my friends and family will at some point do, if they have not already.

In college, my friends and I watched The Business of Being Born one night (a wild college rager!) and it made a really big impression. Birth outcomes in the United States are not great. Other countries, with robust cultures of midwives, have much better birth outcomes. What is the relationship there?

I think this video from Vox does a great job showing the racist roots of the decline of midwifery practice in the United States. If you want to learn more – I suggest Barbara Ehrenreich and Dierdre English’s text Witches, Midwives and Nurses: a History of Women Healers (link to PDF), to see how culture has shaped the way women’s health is practiced.

Flint is Still Dealing with the Impact of Poisoned Water

The state of Michigan has just ended the free bottled water program for residents in Flint, Michigan although the process of replacing old lead pipes for thousands of residents continues. Testing shows that lead levels have dropped beneath the federal action limit, but for residents who lived through the state’s mismanagement of the Flint Water Crisis, concerns obviously remain.

Clean, accessible water is essential for human life. Adding to the frustration is that companies like Nestle were granted permission by the state to pump water near Flint:

[T]he governor of Michigan, Rick Snyder, announced on Friday that city residents would no longer receive free bottled water from the state.

Instead, residents will have to pay some of the steepest tap water prices in the country: around $200 per month for water they aren’t even sure is safe to drink.

To put all of this into perspective, Nestle pays around $200 per year to pump almost 100,000 times the amount of water that the average Michigan resident uses.

And now, the company has been given the go ahead to pump nearly double that amount – with no additional cost, of course.

I have a hard time putting my frustration and anger about this into words. Devaluing human life and suffering while promoting corporate profits… This is not the best that we can do.

“In 21st-Century America, no woman should die in childbirth.” … But they do

“Maternity care desert is is where there is limited access for women who are pregnant.” 

Access to health care is not just as simple as facilities being open. The distance someone has to travel to get to that facility also matters. The people who live in “Maternity Desert” in Washington , D.C. are predominantly African American, making this not just an issue of access but also racial inequality in health care access.

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Screenshot via youtube.com

This video does a great job showing the effects of this unequal access on one woman, Amber, whose story demonstrates how the distance she needs to travel for health care impacts her health care and her employment. All of these issues intersect, and make it more difficult to carry a healthy pregnancy. This is unfortunately an issue that women all over the country face, not just in D.C. We should do better for families.

Sesame Street Tackles Adverse Childhood Experiences

A special initiative from Sesame Street, called Sesame Street in Communities, has created videos, worksheets, and educational tools to help children deal with trauma.

A study that began in 1995, the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study, established that trauma experience, particularly repeated or multiple sources of trauma, can have long-term health impacts on one’s physical and mental health, and even contribute to shortened life expectancy. Addressing the impacts of trauma early, building resilience, and changing the context to remove children and families from traumatic environments, can really make a big difference in making sure people who have experienced traumatic events can bounce back and live the healthiest lives they can.

I can’t remember when I first heard about the ACEs study, I may have been in high school or college, but it immediately made so much sense to me. I have family members who grew up with a lot of trauma, and it gave so much context to the ways they had learned to cope with the effects of those traumatic events. Now that I work with (mostly adult) survivors of domestic violence, I have an even deeper appreciation for the ACEs research and how research on ACEs can get translated into resources for people who have experienced a lot of trauma.

Whether you work with people who children who have experienced trauma or not, I think the whole resource from Sesame Street in Communities is worth looking at because it does a really good job at explaining how trauma works and really easy, tangible coping mechanisms adults can do with children who have experienced trauma. Often children and adults have experienced trauma together, and the adults may need some coaching themselves on how to best help their kids.

This video in particular, meant for adults, is a good, short and impactful demonstration of how children of different ages may react to traumatic events different, and ends with a positive example of how adults can step in to help children.

Sesame Street in Communities included this information along with the video:

As you watch this video of two children’s different responses, consider these questions: What do you notice that is the same in the children’s responses to the traumatic experience? What is different? How does the grandfather make a difference in the end?

The symptoms of having experienced trauma can be different at every age and for every individual child. Every child’s response is unique. Some children “bounce back” after adversity; others show intense distress. Responses can go beyond immediate reactions to traumatic events and damage the child’s brain and nervous system, as well as overall physical health, creating long-term social, emotional, and physical problems. Trauma affects the whole body and the entire emotional world of the person experiencing it.

It can be very difficult to identify trauma in young children, so it’s important to watch for behavioral changes.

I haven’t looked at the site on a mobile device yet, but it is something I’m really interested in from an academic perspective, but also I think it will be really helpful for families and caregivers who have children who have experienced trauma and will definitely be referring people to this website.

Good Ratings ≠ Good Debate

“Looking back, it’s bananas that anyone included the Tobacco Institute in public health debates.”

While I stand firmly in the camp of gun control, I understand (some) of the reasons why others may want to own guns. However, it is bananas that when gun control debates are presented on television, they’re presented generally between victims of gun violence or advocates against gun violence and a lobbying group for guns. This skewed presentation of opinion influences the way people perceive the debate on gun control. How many times have you faced someone on the opposite side of an issue and felt like there was no possible middle ground?

Americans, including gun owners, have different opinions from the NRA! In fact, the majority of Americans are in favor of common sense gun control measures.

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60% of people polled said they supported more strict laws about firearm sales in October 2017 (From Gallup)

Much like public opinion on abortion, public opinion on gun control is more nuanced than than it is presented in the news. And it’s changed through time!

Going back to the comparison of the tobacco lobby and public health debates on smoking, public opinion and knowledge about the harms caused by smoking changed as people’s awareness changed. I think it is helpful to think about the (former) power of the tobacco lobby when thinking about the current power of the gun lobby because these things do change in time, but there are some key cultural and demographic differences. From a Harvard Political Review article:

In contrast to tobacco—which was used across all of America by all Americans—only a certain subset of Americans owns guns and cares about gun rights. The majority of gun owners fall within specific demographic categories. According to a 2013 Pew Research Center Study white Americans are much more likely to own a gun than Americans of other races… Overall, 61 percent of all gun owners are white men, who comprise just 32 percent of the general population. Gun rights advocates tend to be conservative and vote Republican… Guns don’t cut across socioeconomic, gender, and racial boundaries like tobacco did before 1964; rather, they exist within demographic boundaries.

Unlike tobacco, where the relationship between use and harm was unknown, there are readily available studies linking guns to homicides and violence. Studies have proven a nearly linear relationship between the level of gun ownership and a number of gun deaths…

There is an abundance of material to shock gun owners in the same way that smokers were jolted, revealing the damage that guns can cause… Between 1966 to 2012, nearly a third of the worlds’ mass shootings occurred in the United States, a country with just 5 percent of the world’s population…  gun-owners cannot be shocked like smokers were. The equivalent of the Surgeon General’s report—the mass shootings and research—have only caused gun owners to dig in their heels further.

The interpretation of the second amendment that is currently championed by the NRA and many people who are against gun control reform is also relatively new. Legal interpretations of the Second Amendment have changed, and the culture of gun ownership has as well. The Harvard Political Review article also explains [Emphasis mine]:

Prior to the late twentieth century, the Second Amendment was never interpreted as conferring an individual right to bear arms, but rather the right to keep a well-regulated militia. From 1888 to 1959 not a single law articlewas passed advocating such a right. However, in the 1970s, libertarian scholars, often funded by the NRA, began a revisionist history on the Second Amendment, publishing troves of articles arguing that it conferred an individual right to bear arms. Public opinion followed. According to a Gallup Poll, by 2008, 73 percent of Americans believed that the Second Amendment “’guaranteed the rights of Americans to own guns’ outside a militia.” That same year, in District of Columbia v. Heller, the Supreme Court agreed.

The power of the NRA to spend money on political campaigns and advertising also cannot be ignored. Their power to use the media and control how politicians feel obligated to vote is influenced by their spending, and in turn, their priorities are reflected in the way laws are created (or not created), even though their opinions do not match those of the general public. 

Since the Supreme Court’s ruling on Citizens United v. Federal Election Commission, special interests like the NRA have been able to flood our elections with money. It’s given them outsized influence and taken the voice away from the American people, who overwhelmingly support commonsense gun safety measures, such as comprehensive background checks or blocking terrorists from buying guns.

The NRA’s political spending has tripled since the Citizens United decision in 2010. In 2014 alone, the NRA spent nearly $30 million to influence elections.

Worse, Citizens United has allowed a handful of billionaires to funnel millions of dollars to groups like the NRA for them to spend in elections. For example, the Koch brothers’ network has given the NRA more than $10 million since 2010.

When lobbies like the NRA have that much power, what is the point of allowing them to debate on national television? Their priorities are connected to their financial interests, not the interests of real citizens.

If we want to experience real debates between people on opposite sides of issues, particularly when they are public health issues, we should stop inviting lobbies to the table and just speak to the people.

Links Roundup: Racial Disparities in Maternal Mortality

Higher rates of maternal death among Black women in the US have been evident in research for a long time but have lately gotten a lot more mainstream coverage. The increase in coverage is important to raising awareness and implementing changes in health care that would improve outcomes, but it has unfortunately come out of tragic deaths and near misses among new mothers, including Erica Garner and Shalon Irving.

 Serena Williams’ Birthing Experience Highlights The Danger Of Being Black And Postpartum (1.10.18 via Essence) Serena Williams, one of the greatest athletes of all time, experienced a near-fatal blood clot shortly after giving birth. Her own knowledge and self-advocacy helped clue medical professionals in to save her life.

Black mothers are dying: the toll of racism on maternal health (1.11.18 via STAT) This is an op-ed, so it doesn’t go quite as depth as some of the other articles I’m linking, but I think it’s a good one because it gives an overview of many of the factors that contribute to the racial disparity in maternal deaths, from preventative care and the policies that dictate accessibility, to institutional racism in medical professions.

Too many black women like Erica Garner are dying in America’s maternal mortality crisis (1.10.18 via Vox) Activist Erica Garner died within months of giving birth. Her death, particularly in light of her anti-racist activism, highlights the relationship between experience of racism and poor health outcomes for women of color. Vox writes:

Research has shown that a number of factors, including poor access to pre- and postnatal care, chronic stress, and the effects of racism, and inadequate medical treatment in the years preceding childbirth are all likely to play a role in a black woman’s likelihood to suffer life-threatening complications in the months that come before and after childbirth.

These issues might appear to suggest that the disparity between black women and white women dying from pregnancy-related causes is due to economic differences, but research has found that black women in higher economic brackets are still more likely than white women to die from pregnancy- and childbirth-related problems.

How Hospitals are Failing Black Mothers (12.27.17 via ProPublica) This is a really fascinating analysis by ProPublica (an organization that does really fascinating, in-depth reporting, support them!) into the differences in outcomes of maternal hemorrhage at hospitals in New York, Florida and Illinois. They found “that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related. When we looked at data for only the most healthy women, and for white women at black-serving hospitals, the pattern persisted.”

Nothing Protects Black Women from Dying in Pregnancy and Childbirth (12.7.17 via ProPublica and NPR) This is one you should sit down for and grab a box of tissues. Shalon Irving, a 36 year old CDC epidemiologist studying structural inequality and its relationship with poor health outcomes, died weeks after giving birth in 2017. There’s no pull quote I can find that really captures it, you really should just read the whole thing.

 

Get a Flu Shot!

It seems like everywhere I go right now, people are talking about the flu. There are definitely years where it seems like it takes out more people than others, but it does actually seem to be pretty bad this year. Regarding flu deaths this year, the CDC says:

The proportion of deaths attributed to pneumonia and influenza (P&I) was 6.7% for the week ending December 16, 2017 (week 50). This percentage is below the epidemic threshold of 6.9% for week 50 in the National Center for Health Statistics (NCHS) Mortality Surveillance System.

A 0.2 difference between the actual proportion of deaths and the epidemic threshold seems pretty small.

Even if you never get the flu and feel like the 15 minutes of hanging around at Walgreens is a waste of time, your immunocompromised friends, family, coworkers, and public transportation sharers will appreciate your having a shot.

Evidence is a Downer – But We Need It

In a season 6 episode of Parks and Recreation, City Councilwoman Leslie Knope decides to champion adding fluoride to the drinking water to prevent endemic cavities. Leslie, in her usual way, provides ample evidence in large binders supporting her position and expects everyone to join her side. However, her rival on City Council, a corrupt dentist, starts sowing uncertainty in the fluoride plan. He goes on a local news show and calls it a dangerous chemical, and when that doesn’t work to sway opinion, recruits the local candy company, Sweetums, to take over the city water system and replace the water supply with basically… gatorade.

What’s Leslie to do? Arguing against the sugary tap water is nearly futile because no one wants to listen to the evidence-based science she has supporting fluoride-treated water. In the end, Leslie reads the ingredients of the sugar-water to the town in a monotone, while her co-worker, Tom Haverford, introduces a re-branded fluoride as T-Dazzle, “which makes your teeth stronger and … starts a party in your mouth.” Constituents swayed to the newly-sexy fluoride and against the newly-boring sugar-water, Leslie wins.

So what does this have to do with public health?

Well, evidence is not so sexy in the real-world, either. Often the people who are tasked with creating laws about health (politicians) are not experts on health and ill-equipped to understand research about best practices in health policy.

A study on barriers and facilitators to use of evidence-backed research for policymakers found that many policymakers, particularly state politicians who are part-time, have little time and few resources to actual research issues that they’re making laws about. On top of that, many were unable to critically analyze research and tell what sources were reliable or not. One particular quote that hurt me to read was:

One official observed that in assessing the effectiveness of a new medical procedure, “I just did exactly what…everyone…is hoping I’m not. I talked to my brother-in-law and I Googled it” (Jewell & Bero, 2008, p. 184). (Emphasis mine.)

This is really bad for the rest of us – who have to live with hasty and ill-informed decisions made by politicians! In health sciences, evidence-based medicine is when specific decisions about the best available evidence are made to influence decisions for patients. Research is being done all the time to find out what the best types of therapy are for certain populations, or what screenings should be done for certain types of cancer, or what helps people stick to a diet or exercise plan. This information is useful, but can sit on a shelf unless medical professionals adopt it and communicate it to their patients, and in the legal realm, if policymakers don’t care to understand the latest and best available information, they’re not able to make informed decisions on what kind of legislation is going to bring the most benefit.

Making evidence easy to understand and accessible is important. We probably don’t have to go to T-Dazzle lengths to communicate benefit, but taking into consideration confirmation bias and general antipathy toward evidence and preference toward the familiar is important for making your case. As most people who have had arguments with a political opposite have experienced, throwing facts at someone usually does little to change their mind. We need evidence, but we need to push for better ways to communicate it so it can reach the people who need to hear it.

Pop Public Health: “The Pill”

Country legend Loretta Lynn married at 15 and had 4 children before age 20. (And a few years later had twins!) Her musical success in the 1950s and 60s was a triumph for women, who had few country icons. Many of Lynn’s most successful songs discussed her family life, motherhood, and being a real country woman. “The Pill,” recorded in 1972 and released in 1975, blasted conversation about birth control in rural communities into the mainstream.

Oral contraceptives, known as “The Pill” have not been available for that long. The 1965 Supreme Court case, Griswold v. Connecticut, decided that married couples had a right to use the pill to prevent contraception and Eisenstadt v. Baird decided that single people had a right to use the pill in 1972.

In ‘The Pill,” Lynn proudly sings in the chorus: “This old maternity dress I’ve got / Is goin’ in the garbage / The clothes I’m wearin’ from now on / Won’t take up so much yardage / Miniskirts, hot pants and a few little fancy frills /Yeah I’m makin’ up for all those years /Since I’ve got the pill.” In total, she sings that she’s “got the pill” 7 times in a song that’s just about two and a half minutes.

When Lynn’s label released “The Pill” in 1975, it immediately caused controversy and many country radio stations refused to play it. A 1975 People magazine article noted:

From his pulpit, a preacher in West Liberty, Ky. recently denounced country singer Loretta Lynn and her new song The Pill. The effect was to send much of the congregation scurrying out to buy the record. More than 60 radio stations from Boston to Tulsa have banned the song, but through word of mouth and the FM underground The Pill is selling 15,000 copies a week. For Loretta Lynn, the most honored woman in country music, it is her biggest hit ever.

Lynn’s response to critics of her song was as frank and cavalier as the lyrics: “If I’d had the pill back when I was havin’ babies I’d have taken ’em like popcorn. The pill is good for people. I wouldn’t trade my kids for anyone’s. But I wouldn’t necessarily have had six and I sure would have spaced ’em better.

Lynn later stated in an interview with Playgirl that she’d spoken with several rural doctors who told her that “The Pill” had been especially helpful in communicating the benefits of oral contraceptives to women in rural communities.

Mainstream acceptance of contraception was and is still a huge issue for people of reproductive age. Just last week, The Trump administration “moved to expand the rights of employers to deny women insurance coverage for contraception.” The 55 million women who had the right to copay-free birth control are now at risk of employers using personal religious beliefs to deny access to contraceptives. Without insurance, birth control pills can cost $50 per month, a birth control implant can cost up to $800, and intrauterine devices can cost up to $1000. Certainly all of these are less expensive than pregnancy, giving birth, or raising a child, but the cost of preventing pregnancy can be significant enough that women may not be able to afford reliable methods of contraceptives.

Sexually active people of all ages, religions, and race are all very likely to use or have used contraceptive methods to prevent unintended pregnancy. It’s unfortunate that the current political administration is attempting to curtail access to reliable and safe contraceptive methods. (Call your senator!!) It seems like, in 2017, we could also use a few new popular songs about birth control, right?

A Prescribed Epidemic

Prescription opioids (aka painkillers) like morphine, OxyContin, Percocet, and Vicodin (to name just a few) peaked in 2012, with 81.3 prescriptions per 100 persons. The rate of prescriptions has since fallen, but the United States still represents 80% of world opioid prescriptions (via 2015 data), and has high rates of opioid prescriptions among people under the age of 65 (i.e. the population that is younger and should be healthier). This problem of prescription is deeply embedded in how the United States (fails to) regulate the pharmaceutical industry:

Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.

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Image via postsecret.com

Opioid abuse is rampant, and is frequently cited as one of the “gateway” drugs to heroin . Opioids are highly addictive drugs because they target parts of the brain that are susceptible to feeling pleasure. Since opioids are more intense than the natural endorphins that humans produce, users of pharmaceutical opioids or illegal opioid drugs (like heroin) feel pulled to chase the high, continue using opioids (and use in increasing amounts), and may become addicted.

Prescriptions for opioids have fallen since an all-time high in 2012, but are still above CDC recommendations. Additionally, length of prescription was found to have actually increased between 2006 and 2015, meaning patients are exposed to the affects of prescription opioids for longer periods, against CDC recommendations. Prescriptions are also doled out unevenly, and a CDC report found that  “the places with the largest number of prescriptions filled tended to have more white residents and higher rates of poverty and unemployment…” See the maps below. On left, rates of opioid prescriptions by state in 2012, on the right, poverty rate by state in 2013. States with higher rates of poverty also have higher rates of opioid prescription.

Just about this time last year, Last Week Tonight did a segment on opioid prescriptions that highlighted the role of aggressive marketing from pharmaceutical companies to influence doctors’ prescriptions of opioid painkillers. [Note: There are some things I find grating in the format of Last Week Tonight but I think this does really quality work at communicating the history of opioid marketing and prescription in the US.] In sum – big pharma played fast and loose with marketing, many doctors fell for it, and now we have huge rates of opioid abuse.

It takes time to change trends in medical practices. It took time for the prescription rates to reach the 2012 highs! So it tracks that it’s going to take some time, even with increased surveillance, research, and awareness before doctors really change opinions about what pain management strategies should look like.

Most articles that I see in local news focus on the opioid epidemic in population health – through interviews with people affected by the opioid crisis and investigations into the areas where opioid addiction is most prevalent. I think many of these articles are great, but they do obscure the macro-level issue of how opioids have come to saturate the medical industry. Fortunately, now more attention is being paid to the source: big pharma. 

41 States of Investigate Pharmaceutical Companies over Opioids (9.19.17 via NPR) – A coalition of state attorneys general have come together to investigate potential impropriety in pharmaceutical companies’ role in the opioid crisis.

“Our subpoenas and letters seek to uncover whether or not there was deception involved, if manufacturers misled doctors and patients about the efficacy and addictive power of these drugs,” New York Attorney General Eric Schneiderman said during his press conference announcing the investigation. “We will examine their marketing practices both to the medical community and the public.”

Are Pharmaceutical Companies to Blame for the Opioid Epidemic? (7.2.17 via The Atlantic) – “Big Tobacco” faced lawsuits in the pursuit of improved public health and has been required to make changes – this article examines the legal possibility of states attorneys general pursuing these cases.

With the tobacco-industry lawsuits, customers were using the product as instructed and got sick. With opioids it’s a different story: Customers are not using the pills as directed, and so it is harder to blame the pharmaceutical companies for the effects of that misuse, according to Lars Noah, a professor of law at the University of Florida. In addition, doctors, not consumers, were the ones targeted by the aggressive marketing campaigns undertaken by pharmaceutical companies, so it can be difficult to link consumer deaths with aggressive marketing.

Whether suits against pharmaceutical companies will be successful is to be determined – already cities and states that have been hit hard by the opioid crisis have taken steps to sue pharmaceutical companies, and it’s possible that in the next year or so we could see court decisions go one way or another. I’m definitely interested to see what happens — but hopeful that this increased attention on the issue of opioid prescriptions will ultimately result in better treatment for those facing addiction and helpful changes made in medical care to prevent exacerbating an already unfortunate epidemic.