Wednesday, January 12, 2005

Time to be the heartless guy 

Nicholas Kristof tells us today about a "wrenching fact": "If the U.S. had an infant mortality rate as good as Cuba's, we would save an additional 2,212 American babies a year." He then runs the same math through infant mortality statistics around the world and can find lots of places with lower infant mortality than we do. These places include Singapore, Japan, Iceland, China and Cuba. Kristof's conclusion:
It's simply unacceptable that the average baby is less likely to survive in the U.S. than in Beijing or Havana.

This appears to be as fine a sentiment as any other, but before loyal TigerHawk readers adopt it as their own they should consider how arrestingly unnuanced it actually is.

My principal objections do not turn on my suspicions about the underlying data, which are legion. For example, how does anybody really know what Cuba's infant mortality rates are? Cuba's government is incompetent at virtually everything other than stamping out any flicker of dissent within its own society, so why should be any good at collecting statistics? Indeed, there are even sources that show that the infant mortality rate in Cuba is higher than the United States. No matter. Since Kristof used the CIA World Factbook and I generally think the CIA is cool, let's take Kristof's data as is and instead examine the real basis of his concluding opinion.

The first and most obvious assumption buried in Kristof's opinion is that this is a problem we should do something about. I say it is not. And not because I don't care about infant mortality. I just don't care about it more than other things.

Virtually all human activity results in some quantifiable loss of life, and the application of sufficient data and statistics can generate global rankings in almost any category. Looked at this way, child birth is a cause of death as well as life, not unlike working in a factory, driving a car, eating a cheeseburger, or skiing down a mountain. All of these activities and countless others drive our national life expectancy, which is even worse in its global ranking than our infant mortality rank.

So the United States has done a better job with infant mortality than with grown-up mortality. Candidly, if you want to take the point of view that managing mortality rates is the government's or "society's" responsibility at all, I would prefer that we scratch where we itch. Let's do more to prevent unnecessary or premature deaths among adults. Why should we work harder at dealing with infant mortality, when we have the more consequential problem of dying adults?

Told you I was the heartless guy.

Of course, you might say that deaths among adults are in some fashion their fault or at least the result of their choices, whereas the dead babies are innocent. Even if we were to accept that dubious proposition, does this mean -- as Kristof implies -- that we should have some sort of government intervention to prevent these infant deaths because the babies are innocent? Dare I snark that the people most in favor of government intervention to prevent infant deaths are, in all likelihood, overwhelmingly in favor of lawful and accessible abortion (in fairness, I do not know Kristof's position on abortion)? Innocence, to those people, is apparently only compelling when there is the possibility for socialized medicine. (For the record, I am in favor of lawful and accessible abortion, so I do not denigrate those who support that position. But my heart isn't bleeding over infant mortality, either.)

So should we be doing more to prevent early or unnecessary deaths generally? Don't we want to get that ranking above 49th? It depends what it takes. There are certain types of interventions that are cheap, both in terms of their burden on our freedom and their economic cost per year of life saved. Keeping sewage out of the water supply is an excellent such example. Others are both expensive and totalitarian: no doubt, we could prevent some loss of life by banning all firearms, but only at a significant cost to our freedom and our wealth. Indeed, we could probably extend American life expectancy significantly by banning all sorts of food and requiring the consumption of other food (cheeseburgers are out, broccoli and kale are in), but that would make life dull and oppressive. But we would save lives! Why isn't it appalling that countless millions are dying early because we haven't taken away their right to eat what they want to eat?

The hidden assumption in Kristof's argument is that it is government's responsibility to prevent infant mortality. Do Americans really think this? I submit that there is no national consensus that it is in fact the government's responsibility to lower infanty mortality rates. Like most other forms of mortality, infant mortality is presumably a function of many considerations, including the competence and affluence of the parents both during the pregnancy and the infancy. Do we all agree that state intervention to redress these considerations is warranted to save a few thousand lives? I don't think so. It would take an enormous amount of intervention to improve the competence and affluence of American parents sufficiently to move the infant mortality meter.

Kristof, in the habit of many on the left, spotted a social problem in some statistics and declared it "simply unacceptable" that the United States should fare worse in the matter of infant mortality than the authoritarian societies of Singapore, China and Cuba. But why is it unacceptable? We pay an enormous price in lives for most of the freedoms that we enjoy (and I'm not referring to lives on the battlefield). Do we really want to suffer the tyranny of Singapore, China or Cuba, or even a tiny fraction thereof, just to save a few infants? To me the answer is obvious.

But then, I'm a heartless guy.

UPDATE: Captain Ed ably and heatedly fisks the facts and morality in Kristof's column.


By Blogger Fausta, at Wed Jan 12, 10:55:00 AM:

It's simply unacceptable that the average baby is less likely to survive in the U.S. than in Beijing or HavanaIt takes a special type of intellect to believe totalitarian regimes' health statistics.  

By Blogger Pile On®, at Wed Jan 12, 12:10:00 PM:

The best health care in the world can be accessed in this country by anyone, without intervention by the government. Period. If your infant dies there was nothing that could be done or shame on you.  

By Blogger TigerHawk, at Wed Jan 12, 12:18:00 PM:

Perhaps. I'm not willing to go that far, but I am willing to say that there is no consensus that government should remedy that state of affairs. That is, there are a lot of problems in the world to be solved, and I see no reason why this should be one of them, even if you are somewhat overstating the ability of all parents to gain access to good obstetrical care. (Remember, a low infant mortality rate does not begin with the moment of childbirth. It requires a lot of attention prior to the onset of labor, and it is probably not the case that everybody can get access to great medical care for the entire duration of an apparently normal pregnancy.)  

By Anonymous Anonymous, at Wed Jan 12, 04:06:00 PM:

Pile On:
I do not think it is true that any family can get access to an NICU under any circumstances. I think particularly of some Indian reservations.

However, you are right that many U.S. poor families have been able to get NICU care and save their children's lives. This is a very good thing. It happens because of a program called MEDICAID. Some people, however, denounce this as 'socialized medicine.'
Bill Gardner (http://childhealth.typepad.com)  

By Blogger Pile On®, at Wed Jan 12, 08:22:00 PM:

I may have overstated a tad but I stand by the assertion that the best health care in the world is available in one way or another here in the US. The poorest of the poor at the Pine Ridge Indian reservation in South Dakota can find a way to get to Rapid City. It may not be John Hopkins but the care will be pretty good. Can the same be said for a peasant living in Mongolia?  

By Anonymous Anonymous, at Wed Jan 12, 09:07:00 PM:

Pile on:
Let's agree that some people have a better chance of getting access to an NICU than others. If you find yourself suddenly giving birth prematurely, you may not have *time* to get to an NICU unless there is one near by.

There is no question, of course, that we have much better prenatal / obstetric / perinatal care than in Mongolia. Is that what the discussion is about? To me, it is more interesting that we have about twice the infant mortality rate of developed, democratic countries such as Japan or Norway. I think those are better benchmarks than Mongolia, Cuba, or China.

I was hoping that you would comment on the role of MEDICAID. You do understand that without this program, the poor would not receive NICU care?
Bill Gardner (http://childhealth.typepad.com)  

By Blogger Pile On®, at Wed Jan 12, 11:13:00 PM:

I used Mongolia as an example because I presumed those stats would be included in China's, if they are not the example could have easily been any rural China location. Where I would presume if a premature infant died it would likely not be reported or recorded anywhere.

The differences with other developed nations could probably be chalked up to our level of immigration, a high percentage of which is illegal and uneducated and likely will would not access NICU even if it were right accros the street. That is not a good thing, but it can't be chalked up to a failure of our healthcare system.

I am not going to be drawn into a discussion of MEDICARE, because we already have that, so it is not really germaine to the discussion of why our infant mortality rate is higher, unless you are making the case that the program is not extended to enough people than currently qualify for it.  

By Blogger Pile On®, at Wed Jan 12, 11:16:00 PM:

I mean MEDICAID, if you are on MEDICARE and you need prenatal care, well that would be amazing and deserving of further study. :)  

By Anonymous Anonymous, at Thu Jan 13, 07:48:00 AM:

Pile On:
I appreciate the time you've invested in this argument. Thanks.

I do not think that high U.S. infant mortality rates (relative to other developed countries) can be blamed on immigration. Nancy Hessol and Elena Fuentes-Afflick recently published an article on "Ethnic differences in neonatal and postneonatal mortality" (Pediatrics, 2005, 115, 44-51). They looked at the birth and death certificates for 1995-1997 in California (over a million live births). They found no difference between white and Latina mothers in rates of neonatal and postnatal mortality. The latter women are much more likely to be immigrants (see today's post at http://childhealth.typepad.com).

You are right, I do not think that MEDICAID explains why we have high infant mortality rates. It's possible that extending MEDICAID eligibility would reduce those rates, but I wouldn't assert that without more study.

Here is the point I was trying to make. I think there was some truth in your assertion that anyone can get first class medical care in the U.S., including NICU care. If you think that is important, I agree with you. However, this medical care is available to the poor largely because of MEDICAID, a socialized medicine component. I find that many conservatives oppose MEDICAID. I want to make the point that there is no free lunch: If, as I do, you are proud that the U.S. takes care of poor infants, you should support the institution that makes this possible.  

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