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Monday, March 19, 2007

Wow does this guy get it wrong
I have been alerted to this article in slate blaming the United States' high infant mortality rate on fertilization treatments and emphasis on neonatal care rather than healthcare inequality between the rich in the poor. Dr. Singhavi argues that it is these interventions, and not the absence of a single-payer health system that explains our exceedingly high rate for a developed country.

Comparing infant mortality rates between countries is fraught with uncertainty—after all, it's hard to argue that every country's figures are reliable. But it's still worth asking what more we can do to stop babies from dying. Defined as death before one year of age, infant mortality frequently gets framed in the United States as a problem of insufficient health-care funding. In December, for example, a New York Times column blamed it on the lack of a single-payer health insurer. However, a closer look reveals the counterintuitive possibility that high infant mortality in the United States might be the unintended side effect of increased spending on medical care.


Uh oh, beware the inversion, that most insidious of emotionally appealing arguments because they make you feel as though you have privileged or special knowledge that no one else knows about. Inversions are arguments which appear to upset the consensus view that is supported by most of the data. Sometimes they are correct, and the consensus view or what appears to be "common sense" is incorrect, but usually inversions are just bullshit (remember the George Bush is good for science inversion? or worse, the H2 is more environmentally sound than a Prius inversion?).

Infant deaths in poor nations are roughly six times more common than in developed areas and result mainly from easily treated infections like diarrhea in the first few months. By contrast, the majority of deaths in developed countries result from extreme prematurity or birth defects that kill a newborn in the first few days or weeks of life. According to a 2002 analysis by the Centers for Disease Control and Prevention, at least a third of all infant mortality in the United States arises from complications of prematurity; other studies assert the figure is closer to half. Thus—at the risk of oversimplifying—infant mortality in the United States principally is a problem of premature birth, which today complicates just over one in 10 pregnancies.

To reduce infant mortality, then, we need to prevent premature births, and if that fails, improve care of premature babies once born. (Prematurity is also linked to other problems; for example, it's the leading cause of mental retardation and cerebral palsy in children.) But modern medicine isn't good at preventing prematurity—just the opposite. Better and more affordable medical care actually has worsened the rate of prematurity, and likely the rate of infant mortality, by making fertility treatment widespread. According to a 2006 Institute of Medicine report, the numbers of women using assistive reproductive technology doubled from 1996 to 2002. At least half of their pregnancies culminated in multiple births (twins or more), which are at high risk of premature delivery.


This is really a bizarre conclusion based on an incomplete read of the available data with several misleading and factually incorrect statements. First I'd point out, that our infant mortality rates are not being compared to the poorest third world countries, in his own article he says we're comparable to Malta and Slovakia, we're not exactly talking about Mozambique here in which his dysentery argument would actually be valid. So, in warning us away from and apples to oranges comparison, he makes an egregious apples to oranges comparison.

Next I'd like to point out this map:



from this previous post. Here's how I originally wrote about the problem.

Infant mortality rate (deaths per 1000 live births) by state 2000-2002. To put the numbers in perspective, Mississippi, with its stunning rate of 10.5 deaths per 1000 live births (or 1 in 100), has more than double the infant mortality rate of Massachusetts at 4.8, and places it somewhere between Macedonia and Uruguay on an international scale.

...

When you compare states with the highest infant mortality rates (Alabama, Arkansas, Delaware, Georgia, Louisiana, Michigan, Mississippi, North Carolina, South Carolina and Tennessee all have rates of 8 deaths per 1000 live births or greater), and the states with the lowest infant mortality rates (California, Maine, Massachusetts, Minnesota, New Hampshire, Oregon, Washington, and Utah all have rates of infant mortality in the range of 4.8- 5.5 deaths per 1000 births) you see that a certain portion of America actually enjoys comparable or lower infant mortality than the combined average for the EU or countries like Great Britain and the Netherlands.

...

Source: National Center for Health Statistics. Health, United States, 2004 With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2004.


Now, think about this. The states in our country with the highest infant mortality have the highest birth rates, the highest teen pregnancy rates, the poorest hospitals, the highest rates of venereal diseases, and the highest poverty rates. Dr. Singhavi argues that it's not these problems, it's not the absence of equality in health care, it's not the poor overall health of these citizens, it's fertility treatments! It's neonatal intensive care! Hmmm, not likely, these are things far more available in rich states and for rich people with insurance.

Beware inversions people, they lead to sloppy, sloppy thinking. This is very poor analysis from Dr. Singhavi.

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2 Comments:

Anonymous said...

His article certainly is a bit tough to make heads or tails of, but I think you may be a little harsh on the guy. I know that you probably just used the article as an excuse to bring out your red state blue state map of infant mortality (which, like all of your other maps, is excellent and very effective). However if can get through Sanghavi's contradictions (such as complaining that only 50% of pregnant mothers get the steroid shot, which undermines his "we're spending too much" claim), I think the main focus of his article is on the increase in premature births in the US today, which, and I have to agree with him, probably has more to do with modern prenatal care than we give credit. On the whole, I agree with you and I think it is fairly obvious that a single payer health care system more concerned with the child's well being than any sort of profits would be the best solution (and serve the same purpose as his plan of consolidating neonatal intensive care centers), however he does bring up an important issue with the ramifications of the increase in the number of premature births

1:58 PM, March 19, 2007

 
Rev. Dr. said...

I was perhaps a bit harsh, but that is partly because this is a bit of a canard that comes up a lot. Infant mortality is often explained away by those who would rather not see the problem as being due to better medical care, and a lot of people like the idea because it's an inversion and makes them feel happy about the old US of A.

However, once you see Mississippi has a rate of 10.5, and all these other poor states with very high rates, it becomes clear that prematurity can't begin to explain the increase in mortality. It might make the numbers a little higher, but the generalized correlation with poverty, ignorance, poor health and disease can't be dismissed.

3:49 PM, March 19, 2007

 

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