Newborn Nest, or Baby in a Box

November 18, 2016

CHW LogoThere are a number of striking features of the American healthcare system compared with those of other developed countries: the huge percentage of our GDP that goes to health (currently at 17.5%); the enormous gap between our spending and health outcomes (i.e., the apparent lack of value); and the tremendous health disparities in this country compared with others.  We have recognized these disparities as a particular problem in Milwaukee, and one of our strategic priorities is to address those disparities in our community.

One area we are addressing is safe sleep.  In Wisconsin, an average of one baby dies each week in an unsafe sleep environment, and while these tragic deaths are spread across the state, they disproportionately affect the underserved.  Children’s Health Alliance of Wisconsin has a safe sleep program that includes a variety of media, hospital, and community-based educational efforts. The ABCs recommendations for safe sleep from the American Academy of Pediatrics include:

  • Sleeping alone
  • Sleeping on the back
  • Sleeping in a crib
  • Non-smoking environment

For disadvantaged families, availability of cribs can be a barrier.  So one intriguing element of the CHAW program is the Newborn Nest.  It is essentially a cardboard box for the baby to sleep in.  For real.

Now, lest you think the idea of a baby in a box is crazy, it’s actually based on an extremely successful program from Finland.  Basically, all new mothers in Finland receive a maternity package.  Unlike in the US, where kits may be given out by hospitals but vary widely, it’s the same for all Finnish moms.  The kit comes in a box and includes breast feeding information, along with bodysuits, a sleeping bag, outdoor gear, diapers, bathing products for the baby, as well as bedding and a small mattress – the mattress is designed to go into the box, which serves as a crib!   And the culture is such that everyone uses it.  Mothers have a choice between the kit and a 140 euro cash grant; 95% choose the kit.

This baby box therefore not only provides a safe sleep environment, it levels the playing field.  Imagine how things might be different if all babies in the Milwaukee area, whether they live in Lindsay Heights or Whitefish Bay, napped in the same type of box.  Of course, that would require a cultural change that could be even harder to achieve than income redistribution.  The Finns note that part of the appeal of the maternity kit is the fact that it symbolizes equality.  But when it comes to children, there is a strain of American culture that supports that: for example, the traditional commitment to universal public education dating back to the first years of the Republic.

Our health disparities are a daunting problem.  Could the answer lie in a box?


Letter to My Nieces on the Election of President Trump

November 10, 2016

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I’ve been thinking about you two a lot recently, especially when I saw the election results.  It’s probably always challenging to be an almost 11 year old girl, but especially now.  Living in Florida, you’ve certainly seen a lot that was said during this election campaign, no matter how hard your mom might have tried to shield you from it.  And a lot of what was said was ugly, on all sides.  Now, this isn’t about Mr. Trump per se, and I don’t want to talk about what kind of president he might be (you also certainly know that there are many widely varying opinions about that, including within our own family).  I want to talk about what I think this election means for girls and women.

When your mother and I were growing up, it was the era of “women’s liberation.”  Since the early days of this country, there have been laws oppressing women: keeping them from voting, owning property, and in general participating fully in society.  By the 1960s and 70s, many of those legal barriers were gone.  But it was still generally assumed that women were simply not as qualified as men.  (We were lucky to have a mother – your Nana –  that defied those stereotypes.)   And just because women were no longer legally second-class citizens didn’t mean they were treated the same.  Liberty is not the same as freedom; attitudes can hold people back as effectively as laws.  So many women, and many men, worked to change those attitudes.  They also worked to enact laws to counteract the discrimination that came from those attitudes.  For example, even though many people thought sports were only for boys, Title IX meant that schools couldn’t only invest in boys’ sports – they had to provide equal opportunities for girls.  And gradually, things got better.  Not perfect – women still earned less than men, were less likely to be leaders in government and business, and frequently judged by different and stricter standards – but better.  Or so I thought.

A few things became clear during the past year or so.  First, when a woman (Hillary Clinton) and a man (Donald Trump) try to do the same thing, they are still judged very differently.  In particular, Americans still have a very “masculine” view of leadership and strength.  People can be strong in many, many ways.  (Just look at your grandmother.)  But it seems when we are electing a leader, we focus only on the kinds of strength – being pushy, brash, in-your-face – that are traditionally associated with boys and men.  It’s another one of those attitudes that is holding women back.  And I’m not sure that’s actually the right kind of strength for a leader.  Look at Vladimir Putin versus Angela Merkel – I’d take Merkel any day.

What’s more disturbing is that not only is the attitude that women are not as qualified as men still quite common, but so is the attitude that women aren’t as good as men, not worth as much.  That they are in many ways simply objects for men.  During the recent campaign we heard people say things about women that I didn’t think many people actually thought, much less said out loud, much less did.  And worse, we heard so many stories from women who said yes, they had heard it and seen it and experienced it.  The leers, the comments, the put-downs, the touches.  As a man I have never had to put up with what all the women I know say has happened to them.  And as a man I am ashamed for those other men.

Now, very few people actually said this sexual harassment was a good thing (though shockingly some did), and I know that most people who voted for Mr. Trump don’t believe it’s good.  Some people dismissed it as “just talk.”  Others said that’s just what guys do.  And many said yes, it’s bad, but we’re going to ignore it because nobody is perfect, and there are more important issues like security or the economy that we agree with him on.  It’s true no one is perfect – certainly Ms. Clinton isn’t – and we have to view people as a whole package of traits, some admirable and some not.  But there are some things that you can’t ignore: sexual harassment and assault is one of them.  You can’t minimize it, or trivialize it, or excuse it, or rationalize it because at least the trains are running on time.  By doing that, it sends the message that it’s only a little bad.

Which is why I was thinking of you on election night.  Obviously, if Ms. Clinton had won, that would have been a strong positive message for girls and women.  I worry that the message in Mr. Trump’s election is that mistreating , demeaning, and even abusing women is not so bad.  In fact, it may even be good – after all, it shows the kind of strength you need to lead.  Which means things are worse for women than I thought, and that makes me sorry and scared for you.

So know a few things.  First, degrading women is not OK.  It’s wrong.  Always.  Period.

Second, everyone has inherent worth and dignity.  Everyone deserves to be respected.  Don’t ever let anyone deny you that.  Be strong.

Third, it’s not something that all guys do or talk about.  I don’t, your cousins don’t, and most men don’t.  Sexism and misogyny are not carried on the Y chromosome.  They are learned, and they can be unlearned (or better, prevented).

I’m not going to send you this yet.  I wanted to get it off my chest, but I’m going to save this until I think you’re ready.  My sincere hope is that when I send it to you in 10 years or so, things will be better.  That no one will assume what you can and can’t do because you’re a girl.  That you’ll be treated fairly and with respect.  That you won’t have to deal with a demeaning boyfriend, or a creepy boss or colleague.  That no guy will brush up against you or press up against you or grab you.  That you won’t ever be a victim of “date” rape.  I hope that board rooms and legislatures and other halls of power will look like America, and not like an NHL hockey team.  I hope all those things.  But hope is not a plan.  So also know that you have people – women and men, like your aunt and your cousins and me –  who are going to fight like hell to make it so.


October 28, 2016

CHW LogoUnqualified success or unmitigated disaster?  If we’re talking about my attempts at home repair, that’s an easy question.  But I meant the Affordable Care Act, aka Obamacare.  The battle lines have certainly been sharply drawn.  It’s pretty clear that with regard to expanding coverage, the answer is qualified success.  Currently, the focus is on costs.  Many opponents of the law are now claiming that Obamacare has caused health care costs – actually meaning health insurance costs – to skyrocket, citing increases in the high double digits.  That sure sounds bad.  How bad is it, really?

To answer that question, we need to distinguish between health care costs and health insurance costs, and between the cost of insurance actually purchased under the ACA and employer-sponsored insurance.  Only about 12 million people actually purchased individual plans on the insurance markets established under Obamacare (an additional 10 million or so got coverage through the expansion of Medicaid.  The vast majority of Americans under the age of 65 continue to get coverage through their employer.  The good news is that for those folks, premium costs are actually going up more slowly than before the law.  Yes, Obamacare has actually decreased health insurance inflation for the 154 million people with employer-sponsored insurance.  As cited in a Commonwealth Fund study released today: “Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia.”  The rub is that at least some of this is due to employers shifting more of the costs onto workers via high deductible plans (a trend that predates but was accelerated by the “Cadillac tax” provision of the ACA).  And the increase in out-of-pocket costs hurts, even if it’s offset in part by the absence of cost-sharing for preventive services.  But it’s impossible to argue that overall Obamacare has made health insurance more expensive.

So what about those 70% increases being thrown around.  Well, for the plans purchased on the Obamacare marketplace (formerly known as the exchange), premiums are going up steeply next year – an average of 22%, and in some areas much higher.  Doesn’t this prove the law is a failure?  Yes and no. First of all, given lower than expected premiums in the first years of the marketplace, the actual premiums for 2017 are pretty much in line with what was forecast when the law was first drafted. (Full disclosure: Doug Elmendorf, the director of the Congressional Budget Office who produced that forecast, was a college classmate.)

More importantly, let’s look at the reasons for the huge jumps in marketplace premiums for 2017:

  1. Many companies have withdrawn from the exchanges, leaving less competition
  2. The reason companies have pulled out is they were losing money, due to:

a. Too few healthy people signing up

b. Setting too low a price in the past to attract more people

In other words, the free market – which despite the rhetoric is exactly what Obamacare established, a market for insurers to compete for customers – is doing exactly what the free market does.  Insurers are charging as much as they can in a non-competitive environment.

As originally envisioned, the ACA sought to mitigate this by requiring everyone to buy insurance, no matter how healthy (the individual mandate), and be ensuring competition by providing a public option.  The former was watered down by insignificant penalties for not complying, and the latter was eliminated.  In place of a public option, a number of co-operatives were formed, with substantial government subsidies, but these have generally not had the scale to compete successfully with large insurers the way Medicare could.

Those who are complaining about the rate increases “caused” by the ACA propose to…further unleash the market, and thus make the problem worse.  Donald Trump, for example, proposes eliminating the individual mandate (see 2.a. above), increasing the tax deductibility of health insurance premiums (which would decrease the incentive to shop on price), and allow insurers to sell across state lines (which by some analyses would decrease premiums for healthier people but increase those for people with higher utilization by a greater amount).  Paul Ryan’s plan similarly depends on those market-based elements that are driving the current increases.

It’s important to remember that despite the name and despite the administration’s claims, the Affordable Care Act was not primarily about health care costs.  It was about expanding coverage – which it has done, by addressing insurance costs.  Which it has done.  Both Democrats and Republicans worried that the bill did little to address overall costs.  Indeed, market forces would suggest that if there are more people with insurance demanding services, there would be upward pressure on the price of those services.

So yes, people continue to pay more for health care, as for almost everything else.  For most people – those with employer-sponsored insurance –  that rate of increase for insurance has actually slowed.  For others, those who benefited directly by getting new coverage from the market-oriented reforms known as Obamacare, the sticker shock is real.  But let’s not pretend that turbocharging the market is going to fix the problem.  That would be like buying me more power tools.  Bad idea.

53206 Decimated

October 14, 2016

CHW LogoSome words don’t mean what we think they mean.  Consider the word “decimate,” often used to mean “destroy completely,” as in “Hurricane Matthew decimated entire communities in Haiti.”  Yet decimate literally means to destroy one-tenth; it refers to a Roman military practice of killing one in ten men in a unit to punish mutiny or rebellion.  It has come to have a more global connotation because, well, the loss of one in ten people strikes most of us as pretty catastrophic, nearly inconceivable.  Think of how much worse a greater loss would be.  What if the Romans had killed one in two, or more?

That’s the level of devastation in the northside Milwaukee neighborhood in zip code 53206, one of the poorest areas in the state.  It also has one of the highest incarceration rates in the world.  (Yes, you read that right.)  62% of the men in that neighborhood are incarcerated or under correctional supervision (probation or parole).  The rate for the US as a whole is 2.8%.

Last week Children’s hosted a screening of a moving new documentary called Milwaukee 53206 which portrays the effect of mass incarceration on the people in this neighborhood.  The film does not take a political stance on the issue of mass incarceration.  Specifically, the high incarceration rates among African-American males (the population of 53206 is 97% black) is not portrayed as intentionally racist.  Rather, for a variety of reasons, policies enacted from the 1970s through today have caused the incarceration rate to skyrocket, with a disproportionate impact on African-American communities.  Take the war on drugs.  Currently, more people are arrested for marijuana possession than for all violent crimes combined.  Rates of arrest, prosecution, and sentencing for drugs are higher for blacks than whites despite similar rates of drug use.  In Wisconsin, “truth in sentencing” legislation has resulted in people serving terms far longer than originally intended.  And while over the course of American history the correctional pendulum has swung between emphasis on harsh punishment and meaningful rehabilitation, the system is more punitive than restorative at present, leaving those who have been imprisoned at some point at a long term disadvantage when they are released.  No matter how well intended these policies might have been, the detrimental effects are no less real.

We had the added bonus of a panel discussion featuring three of the individuals in the film after the showing.  What struck me the most after seeing the film was the impact on children.  Dennis Walton, Outreach Coordinator for the Milwaukee Fatherhood Initiative, described a prison class he recently ran.  Among the 50 men in his group, they had 210 children.  210 children who have therefore suffered one of the most devastating adverse childhood events you can imagine, the loss of a parent, with all of the attendant short- and long-term consequences.  Indeed, in 53206, more than half of all children can expect to experience the same loss.  Thanks to mass incarceration, that community is worse than decimated.

Get The Lead Out

September 23, 2016

CHW LogoRemember the game of Clue?  “Colonel Mustard, in the Billiard Room, with the Lead Pipe.”  What if the lead pipe is dangerous even if it’s not being wielded by the vicious colonel?  Since the story about severe lead contamination in Flint, Michigan surfaced, there is growing concern about lead in drinking water.  While lead isn’t actually good for anybody, it’s particularly a concern for children and pregnant women because of the effect of lead on brain development.  How much of a problem is it?

First, some context.  Lead was used for centuries as a material for water pipes (indeed, the word plumbing comes from the Latin plumbum, meaning lead.)  After the mid-1940s this was largely phased out in favor of copper, but through the 1980s lead-based solder continued to be used.  Thus, most homes and buildings built before 1990 have at least the potential for a problem with lead in the water, as do most cities where the water distribution infrastructure is that old.  Like Milwaukee.

Now, for the most part lead likes to stay in the pipe, rather than getting into the water.  It mainly becomes a problem if the water is corrosive, leaching the lead out.  In 1991, the EPA issued the Lead and Copper Rule, pursuant to the Safe Drinking Water Act of 1974.  This rule requires water utilities to control the corrosivity of its water, which is the simplest way to mitigate the problem.  In Flint, the water utility changed its water source to one that was much more corrosive, and failed to add the required treatment agents.  That is what created the crisis there.  (There was a similar problem in Washington DC in the early 2000s due to inadequate corrosion control.)  If the proper procedures are being followed, the risk is considerably reduced throughout the water system.  Water systems in Milwaukee and surrounding communities follow the procedures and meet the requirements for lead levels. (If you have a question about the quality of your water, you can get the annual Consumer Confidence Report for your water utility.)

Another vulnerability is when the pipes are physically disrupted, such as when a segment is damaged or replaced. This disruption can release lead into the water, an effect that is usually transient.  In homes with lead pipes or solder, it is recommended that when repairs are needed, all the piping should be replaced at once.  Since this is very expensive, few homeowners or landlords do that.  So for the most part, lead in water is not a widespread problem in this community, but it can be for an individual home.  Or school.  Or day care.

So how much should residents of Milwaukee worry about lead in the water?  Toxicologist Dr. Mark Kostic, of the Wisconsin Poison Center, urged a balanced perspective in an interview on WUWM.  He correctly notes that the much bigger concern remains other environmental sources of lead, including paint and soil.

However, for those in older homes who are concerned about the potential for lead in the water, parents can take a number of steps to protect their children.

  • Have their child screened for lead poisoning according to guidelines from the American Academy of Pediatrics. This includes a risk assessment starting at age 6 months, with blood lead testing for children identified as at risk.
  • If a child is found to have elevated lead levels, the public health department should investigate to identify the causes, which should be addressed.
  • For infants being fed formula reconstituted with tap water (a group particularly at risk), consider having home lead water levels tested through the local health department. Alternatively, run cold water (not hot) for 5 minutes before using it to mix with formula.  Filters are available, but these need to be replaced regularly and the cost can add up.  Bottled water is an alternative, but while the risk of lead is lower, it does not provide fluoride which is important for infant dental development.

Natural Healing

August 8, 2016

CHW LogoJust thinking about my upcoming vacation to Acadia National Park, I can feel my stress-induced canker sores melting away.  It’s partly about the time off, and partly about being with family.  Yet there’s something about being in a beautiful natural environment that is especially relaxing.  And healing.  In fact, the health benefits of nature are now sufficiently well understood that in some countries it is becoming common for physicians to prescribe “forest bathing.”

While extended periods in the woods provide even greater benefits – lower blood pressure, decreased levels of stress hormones, higher natural killer cell activity – even a brief stroll can be good for you.  I am grateful to work on a campus that includes green space, including some beautiful woods that used to be part of the county sanitarium.  (Woods that I hope will continue to be preserved in the face of regional development.)  Some days I simply wander over during lunch for a 20-30 minute walk.  It’s amazing how quickly one can forget you are in an urban area, in the midst of a major medical and research center.  And how quickly you can forget the looming deadlines, or the upcoming budget discussions, or the last person who pissed you off.

OK, off to Maine.  For those of you staying home, try the woods across the street.

Kids Deserve The Best

July 25, 2016

CHW LogoSimple.  Declarative.  Forceful.  This isn’t just a fluffy, sentimental, feel-good statement.  This four word sentence is a point of advocacy, a recognition that for too long, and still too often, kids don’t actually get the best. It calls attention to ongoing disparities for kids in health care and other areas of society.  For example, while the overall poverty rate is 14.5%, it’s 22% for children. Only 60% of medications used in both children and adults are approved for and have information on pediatric usage. And payment rates for Medicaid, the primary government insurance for children, are lower than for Medicare, which covers adults.

Few people would disagree with the notion that kids deserve at least as good as adults get.  So why do society’s results fall so short of its ideal?  In many ways, the deck is stacked against children’s issues.  Kids don’t vote.  (And they don’t make campaign contributions.). And because they are basically healthy, while children are 28% of the population, they represent only 13% of all health care spending.  So it makes sense that politicians and policy-makers, and health business leaders, are focused more on adult issues.

Now, saying kids deserve the best doesn’t mean adults don’t, too.  Advocating on behalf of kids to bring them to par doesn’t mean I’m advocating against adults.  I’d love for everyone to have a lower poverty rate, or universal access to medications.  But saying “everyone deserves the best” obscures the message that kids have been missing out.  So with all due respect to my fellow adults, I’ll continue to work to ensure kids get what they deserve.   The Best.

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