All the wonks are chirping in on infant mortality studies that has engaged in some impressive decomposition of international differences between the US and other wealthy nations.
We combine comprehensive micro-data on births and infant deaths in the US from 2000 to 2005 with comparable data from Austria and Finland to investigate this disadvantage. Differential reporting of births near the threshold of viability can explain up to 40% of the US infant mortality disadvantage. Worse conditions at birth account for 75% of the remaining gap relative to Finland, but only 30% relative to Austria. Most striking, the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality. This postneonatal mortality disadvantage is driven almost exclusively by excess inequality in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe.
Aaron Carroll at the Incidental Economist looks at the paper and makes the following comment:
Reporting differences (the favorite explanation of those defending the US healthcare system from the infant mortality metric attack) explained up to 40% of the disadvantage in US infant mortality. But that would only get us closer. It would still leave us way worse….
More concerning, though, is that our neonatal mortality (or the mortality in the first month of life) wasn’t so different than the other countries. What accounted for the real disadvantage was postneonatal mortality, or mortality from one month to one year of age. That difference was almost entirely due to excess inequality in the US.
In other words, most of the infant mortality difference between the US and other countries was due to really high postneonatal mortality in less advantaged groups. If differences were due to neonatal mortality, then you would want to try and reduce preterm births. That’s often what we’ve been trying to do. But this study shows us that this isn’t where the lesion is. It’s in the postneonatal period. (This point is consistent with Austin’s latest post about NICUs on the JAMA Forum.) It’s possible that the inpatient care is excellent right after birth, but once babies go home, their access to care is different along socio-economic lines. To fix that, you likely need to improve the health care system, or inequality in the US.
The first take-away that I get from this is that the US healthcare system is extremely fragmented and is technological heroism inclined. Every few years there is a wave of articles about face to face contact as the next paradigm buster in public health. And then nothing happens but massively capital intensive machines and systems are readily bought. We have a bias towards heroism and not towards maintaining good health.
My second thought was to pull the recent data on infant mortality within the United States to see if the international comparison has relevance to inter-state comparisons. The Kaiser Foundation has fifty four states or territories listed for the 2007-2009 time period. There is one state that was in the Confederacy(Texas) that had a lower Kaiser calculated infant mortality rate than the national average. Seven of the ten worst states were Confederate states.
Oh me, oh my, I must be making a spurious correlation to public health, race and class and states rights advocacy.
John N
Interesting data. It’s more evidence in favor of the moral argument surrounding income inequality. It’s wrong to let poor babies die because they don’t have enough money. That’s a pretty inarguable moral position, IMO.
JPL
One of Jason Carter’s ads discusses hospital closures. Maybe he’ll point at the infant mortality rate in GA. Since rural hospitals are closing, that number is not going down.
JPL
@John N: hmmm… The pro life group only worries about life in the womb. Once outside the womb, they really don’t care.
RSR
yup. Going to get on my usual public education soapbox and say this concept is borne out with pro ed reform propaganda movies like “Waiting for Superman” and “Won’t Back Down.”
Citizen_X
Oh come on. It’s not like those brats were precious babies or something. That’s only true while they’re still in the womb.
scav
@Citizen_X: Lolling about in cribs, pretending to be helpless and all. Superior babies with real ‘mercan grit are out earning their keep as paperweights at prestigious firms, or failing that, taking multiple low-paying jobs as doorstops in fast food restaurants or as speed-bumps in grocery parking lots.
Cacti
Is there any indication of what effect our robust anti-vaccination movement has played on infant and early childhood mortality rates vs. other developed nations?
piratedan
@JPL: I can only imagine the numbers in Arizona, while not in the same population based model, small towns are lucky to have urgent care clinics rather than the small 10-20 bed hospitals that they used to maintain. Just another reason that small town America is dying because folks keep electing people who cut taxes with nary a thought to the actual consequences. If the model keeps being used, I would imagine that education is the next to go as being perceived as a non-essential service.
Mnemosyne
@Cacti:
Ironically, at least in California, lower vaccination rates for upper-class people mean that working-class (mostly Latino) babies die, because their family members bring pertussis and measles home with them and infect babies who are too young to be vaccinated. There is probably also a correlation with pregnant women not getting prenatal care — a pertussis booster is recommended in the third trimester, but if you’re not seeing a doctor, you won’t know to get the vaccine.
big ole hound
@piratedan: Right you are plus these “urgent care” places are usually open from 8am to 11pm and send you too a distant ER for anything worse than a sprained ankle.
Tommy
@piratedan: Do small towns even have doctors anymore? My grandfather was a small town doctor. He had an office where he did “doctor” stuff. One time at his house I cut my leg with an axe (long story) and he took me in and sowed me up. My town doesn’t have any place like that anymore.
Arclite
Hawaii might have its first Ebola case.
piratedan
@Tommy: yeah, but think of all the money these places save in taxes!
shelley
@Arclite: Swell, now Tweety can have another on-air meltdown today.
Anoniminous
@Tommy:
No.
If the town is lucky, like mine, there is a Nurse Practitioner or Physicians Assistant available during office hours.
@piratedan:
Most small towns do not have the tax base to support a doctor. They depend on county or state funding, in most cases the latter.
RaflW
If those who say “choose life” mean it, they’ll do something about poverty and access. I don’t even care if they do it with charity or with taxes, but if they don’t put up, then they are full of shit.
Saving a pregnancy so that it can become a 9 month old who dies from lack of resources is utterly ungodly and inhumane. But that’s what low-tax freedom! get’s ya. Dammit.
Trentrunner
@Mnemosyne: This sounds like total horseshit. Link?
Gin & Tonic
@Tommy: A friend of my daughter’s, a physician, lives in NYC and practices somewhere in rural Maine. Not sure of the care environment, I think it may be a small regional clinic, but they fly her up and back for a 7-on/7-off schedule. I wonder how widespread that is.
Tommy
@piratedan: Not sure how taxes play into it. My grandfather made more money then I can spend in a lifetime. Seems being a good doctor was a nice business idea. I just wonder if there are anymore out there.
Tommy
@Gin & Tonic: I as well wonder how widespread it is. Why I asked. My grandfather was known as the “baby doctor” because he helped give birth to more than 3,750 kids (including myself). I go back to that town and people when they hear my name hug me. He birthed the entire town.
piratedan
@Anoniminous: that is exactly what I mean by taxes, they go to folks to provide those services, but in the GOP takeover in the Mountain West, those services are being reduced to medical coverage being handled by an urgent care center (if they’re lucky) or the local fire department (staffed with EMT’s) and the closest hospital being 50-100 miles away.
srv
Austria doesn’t have eleventy-billion anchor babies.
JustRuss
I’d say we ave a bias towards not maintaining anything. Exhibit A: Infrastructure. Maintaining is boring and involves paying competent people a decent wage. And if you screw it up, everybody knows it because they know how it’s supposed to work.
New and shiny is exciting and sexy, and since no one knows exactly what to expect or what it should cost, there are endless opportunities for grifting. Welcome to our world.
John N
@scav: Haha, paperweights! Nicely done.
Mnemosyne
@Trentrunner:
Sonoma County Has Highest Whooping Cough Rate in Statewide Epidemic
Sonoma County median income: $63,565 (California median: $61,400)
Hold for more links …
Mnemosyne
@Trentrunner:
CDC Pertussis Report for California 9/15/2014 (PDF):
You will also note on the PDF that the counties with the highest pertussis rates are also the highest-income counties, especially Marin, Sonoma, and Napa counties.
Mnemosyne
@Trentrunner:
So far we’ve only had one infant death in 2014. 2010 was our worst year, with 10 infant deaths with Hispanic infants under 3 months old making up the majority of the deaths.
Anything else?
Another Holocene Human
I work in essentially a service industry, and in my sector and across the municipal government I work for, they seem to think they can do without “the people” but buy expensive equipment annually. (It’s “non-recurring”.)
This is because equipment dealers have very effective lobbies. It’s pervasive across society.
Never, ever spend the money on personnel, but blow millions on shiny new equipment which will be junked before the end of its projected service life.
New cop cruisers, new fire trucks, new street sweepers, new MRI machines, new laboratory toys … funny, they say they’ll catch up on rape kits with a new DNA testing robot… we can spend millions to develop and purchase a robot, can’t spend thousands to train and hire more lab techs. That makes sense.
I would argue that the low clearance rate of homicides (a clearance rate which includes a lot of false convictions) as compared to the past (before DNA!) is because of the major drop in police manpower, so they don’t have dozens of uniform to go door to door and identify witnesses right after it happens. All the technology has NOT got us back to an early 20th century clearance rate. Surprise, surprise.
Another Holocene Human
To be clear, this is class warfare. The petty bourgeois and the billionaire allied against the slob who has to sell the sweat off her back for a roof over her head.
Another Holocene Human
@JustRuss: This, too. Americans are constitutionally incapable of maintaining anything. You’re right about the army of skilled laborers (unionized and working for the same outfit that operates, rather than working for the manufacturer … in the US just try to do repairs within the warranty window yourself).
I went to Germany, on every window of every train there was a remind to put a drop of lubricant in a hole annually. Mom’s german sewing machine had one of those lubricant holes. US just runs till it breaks, if you’re lucky there’s a back shop to just replace shit entire. So fucking wasteful.
Villago Delenda Est
@John N:
Not if you’re a 1% asshole.
The 1% needs to be culled. Start with the Kochs, move on to the Waltons and DeVos, and continue with Pete Petersen, etc.
Another Holocene Human
@srv: Hahahaha, I guess you haven’t been to Austria
in the last 50 yearsever.You haven’t lived until you’ve tried to get directions in broken German from someone whose German is even worse.
Villago Delenda Est
@Another Holocene Human: If you maintain equipment, you’re damaging the profit margins of the already obscenely wealthy by not replacing equipment outright every few years.
Another Holocene Human
@Tommy: Good bad or indifferent doctors in grandpa’s era made a lot of money. You probably do NOT want to know the details.
Another Holocene Human
@Mnemosyne: That’s pretty gross but not surprising.
Roger Moore
@Cacti:
I don’t think you can pin this one on the anti-vaxxers. For one thing, this is only for children who are under the prime vaccination age, so they haven’t had a chance to be vaccinated yet. More importantly, the anti-vaxxers have been working in Europe, too, so plenty of countries there have similar or lower rates of vaccination than the US. The figures I could find most quickly show the US with a 91% vaccination rate for measles, which is higher than Austria (76%!), Denmark (89%), France (89%), Italy (90%), or San Marino (74%). There are plenty of other countries (e.g. Belgium) that are roughly comparable to the US.
Lee
@big ole hound: Not around here. They are open 24 hours.
Mnemosyne
@Roger Moore:
I don’t know about that. In those links I have above, they think that one of the reasons for the now annual pertussis outbreaks in our home state is that pregnant women aren’t getting vaccinated against it in their third trimester as is recommended. But it’s not clear from the statistics if that’s because women are refusing the vaccination or if they’re not getting prenatal care.
karen
@RaflW:
Feature, not bug.
Villago Delenda Est
@karen: Mainly because “pro-life” isn’t about life. It isn’t about babies.
It’s about fucking. Always has been and always will be.
Anoniminous
@piratedan:
Ack. I misread the snark in your comment.
Villago Delenda Est
@srv: You mean like Michelle Malkin?
gvg
Why is texas above average? I would have predicted otherwise.
People know about budget cuts. That is part of why they fear to commit to salaries. At this University the fund raisers found out long ago that they could get lots of donations for buildings or even sidewalks but they couldn’t get many endowments for a chair or any paid position (clerk). They are afraid they can’t meet it in the future but a onetime payout can be obtained. Plus the fundraiser say somehow people want to see something tangible-a building with their name or a specific brick in a wall. They do not think its fun to pay someone a salary. But we’d be better off with more teachers and even more clerks…this is a University. We teach. We need people. We have so much ornamental brickwork it’s almost coming out our years but we don’t get raises much and the legislature is always cutting funds it seems. It sometimes gets called MBA mindset but in business school I was actually taught you had to spend a certain amount for expertise and even service…examples were given of false economy, businesses that died. Seemed like most of my classmates didn’t hear that. The mindset is currently everywhere.
JGabriel
Richard Mayhew @ Top:
Hmm, this actually makes an interesting, although perhaps unintended, point. We know that Republicans, racists, and the conservative 2/3rds of the 1% are all pretty much advocates for state’s rights. Since they get upset and offended when we point out their racism or self-interested classism, then resort to a state’s rights defense, maybe we should focus on correlating all of the former Confederacy’s current faults with their advocacy of state’s rights instead. If we can’t kill the racism & classism beasts – we haven’t had much luck at reducing either of those for the past 3 or 4 decades – then maybe we can at least kill the state’s rights defense by pointing out correlated bad outcomes.
Just a thought.
pluege
good thing republican/conservatives (including ubber religious Christian righties) could give a crap about postneonatal children and in fact avidly mock, denigrate, and route for their demise, or this would be a really big problem and an horrific indictment of “The American Way”
AA+ Bonds
Infant mortality, you say?
Mmm, that’s good public health policy . . .
Mnemosyne
@AA+ Bonds:
So low-income babies in the US deserve to die of preventable disease because of the actions of the US government?
Lovely.
AA+ Bonds
@Mnemosyne:
Nah, it’s more that Obama thinks Syrian kids need to die because of . . . the existential threat Syria poses to the United States? He doesn’t like how they look with their beady little baby eyes? I can’t look into his soul.
Anyway, announcing that the standards he just imposed that we shouldn’t bomb babies don’t apply whenever we want to bomb babies, that’s a hell of a way to fight infant mortality. Actually murdering children and all.
AA+ Bonds
For the record, I am for full on double scoop socialism, which means nationalizing all doctors and putting the President of the United States in jail. Obama and Bush can share a cell, that’d be about right for all their various wars on Middle Easterners and North Africans, destabilizing their governments, destroying their cities, sending in CIA death squad goons and complaining when the people in the countries fight back against them (Benghazi), and so on.
pluege
high mortality rates of the 47% moocher babies is a feature of repug nation, not a bug.
Mnemosyne
@AA+ Bonds:
And the reason for bringing this up in a thread decrying infant mortality in the United States is … what, exactly? I mean, other than to say you don’t actually give a shit about babies except to use them as a rhetorical weapon against people you hate.
Eric U.
I love to drink the blood of purity unicorns
Spike
Compounded with a bias toward enriching the Ferengi on Wall Street and in corporate boardrooms. Paying doctors and nurses to provide “face to face contact” with mere patients is much less efficient at achieving this goal than is spending on “massively capital intensive machines and systems”.
catclub
@Spike: I heard on NPR about Proton treatment centers, which apparently is a proton beam rather than the usual radiation for radiation therapy. Only approved for rare cancers, up to $200M for a Center. Not necessarily more effective treatment, but massively more expensive. But the notable thing was that one Center was being closed,
presumably for lack of paying customer. While the others were whistling in the dark that it would not happen to them.
scav
@srv: Well, Austria don’t have nearly the coastline we do so they really don’t need the full complement of eleventy-billion anchor babies — who, by the by, make especially fine paperweights and speed bumps for the jobs lazy moocher un’mercan ‘mercan babies won’t take.
AA+ Bonds
Hey, I understand that from time to time the tree of liberty must be watered with the blood of patriots. 12-year-old Syrian patriots, mind you.
Mnemosyne
@AA+ Bonds:
It’s always fascinating to see the left-wing version of the right-wing meme that American feminists can’t complain about any treatment they get in the US as long as girls in Egypt are undergoing female genital mutiliation. I guess all of those grieving Latino families in California should just STFU about their dead babies and be grateful they’re not being bombed, amirite?
Tommy
@Roger Moore: I got vaccinated as a kid. Just something that was done. I guess today somebody would protest but not when I was a kid it just happened. I don’t like needles. I can recall exactly 4 times getting stuck with them.
Tommy
And this happened:
Yes, yes, yes …..
Oh link: http://www.usatoday.com/story/news/nation/2014/10/02/ferguson-vote-registration/16572305/