COIN - Collaborative Improvement and Innovation Network addressing infant mortality

When I arrived in Minnesota in 1980, the issue of infant mortality was beginning to rise in importance in our state and nationally. Analysis of linked birth and death records along with fetal and infant death reviews were giving us new information about the causes of infant deaths. The data were also pointing out the huge racial disparities in this major health indicator. However, by 1991, with a change in priorities at the federal level, these efforts waned with the result that the US ranking on infant mortality declined and racial disparities in infant mortality rates remained at an unacceptably high level.

When I left the Minneapolis Health Department in 1995 for the University of Minnesota, my attention to the issue of infant mortality declined just like that of the federal government. Fortunately, just as I joined the Minnesota Department of Health, the Health Resources and Services Administration (HRSA) began to refocus its attention on reducing infant mortality in the United States. As part of that effort, HRSA has established something they call a COIN – Collaborative Improvement and Innovation Network with the goal of reducing infant mortality. The COIN focuses on five issues:

• Improving regional perinatal care systems
• Expanding smoking cessation efforts for pregnant women
• Reducing Sudden Infant Death Syndrome/Sudden Unexpected Infant Deaths (SIDS/SUID)
• Expanding inter-conception care, especially among high risk women and women on Medicaid
• Reducing elective deliveries before 39 weeks gestation

As a State Health Official and the Region V representative to the Association of State and Territorial Health Officials (ASTHO) Board, I was invited to a meeting in D. C. to discuss the COIN. It’s been satisfying seeing some familiar faces from the past and getting re-immersed in an issue that was formative in my public health career - an issue that is core to public health throughout the world.

Sitting through the sessions today made me think about all the things that have been tried in our state to reduce this devastating event. Being here also brought back memories of some of the infants I cared for who didn’t make it to age 1. And it made me think of the parents whose lives changed dramatically because of the death of their infant. I vividly remember the story of one particular mother who I met in clinic during my first month as the Maternal and Child Health Director of the Minneapolis Health Department. Her story highlights the devastating and long-lasting impact an infant death can have.

People said I’d get over it. They said it might take a few weeks or even a few months -- maybe a year, but I’d get over it.

They said I had a good family, a good husband, a good home, good friends. That’s all I’d need to get over it.

I tried, I really tried, but I couldn’t get over it. My life began to fall apart. I dropped out of school, I saw a counselor, I went to some support groups but I still couldn’t get over it.

Finally, we decided to leave town. Maybe a new place would help me get over it. My husband quit his job; we packed up and moved to Texas. But that didn’t help. I still couldn’t get over it.

To make things worse, neither of us could find jobs. My husband then started to drink -- so did I. That helped us get over it at least for a little while, but it didn’t last. Then we started to fight -- a little at first but it got steadily worse. Soon we couldn’t talk to each other without fighting.

In one of our sober and saner moments we decided to move again. Maybe another new start would help me get over it. It didn’t.

We moved to Idaho. But things continued to go downhill. There were no jobs for us there either and we were soon out of money. Just as we were nearing rock bottom, I got pregnant. I thought a new baby might help us get over it, but it didn’t. My husband continued to drink and to become more and more distant from me. Finally, he became so distant that he just disappeared.

I was now alone, except for the baby. I had no job, no money, no insurance, no hope and I still wasn’t over it. My life was in shambles. I had no place to go. I decided to come back to my home here in Minneapolis and go back to school. But I found that I can’t even go back home. My mother won’t talk to me. After all these years she still blames me. She still thinks it was all my fault.

But, it was just as much her fault as mine. She’s the one who gave me the crib. It was the one that I used when I was a baby and I never got hurt. How was I to know that it would be the cause of my baby’s death?

Do you think I’ll ever get over it?

According to an April 4, 2012 report on infant mortality by the Congressional Research Service, Minnesota’s 2008 infant mortality rate is 6.0. That ranks us 20^thin the country. Our 2009 rate has improved to 4.5 but still pales in comparison to Luxembourg, Slovenia, Iceland, and Sweden who have infant mortality rates of 1.8, 2.1, 2.5, and 2.5 respectively. Our vital statistics unit has shown that, using a 3 year moving average, the Minnesota infant mortality rate has actually increased from 4.8 in 2003-2005 to 5.6 in 2006-2008 and that racial disparities have remained unacceptably high. We are not making progress and are far from where we should be.

32 years ago my patient asked, do you think I’ll ever get over it? Today we should ask ourselves a similar question, should we ever divert our attention from addressing this major public health problem? I hope our answer will be no because one of the greatest gifts we can give a family is never having to be confronted with the death of an infant and that unanswerable question.

Ed

Greetings from D. C.

As I waited in line to go through airport security, I sensed that Terminal 1 (Lindberg) at MSP was more crowded than usual for a Sunday afternoon.  It was certainly noisier.  Looking around, I realized that many of the participants from the just-completed USA Cup were there preparing to fly home.  Throughout the terminal, groups of athletic-looking kids from various countries and states were massing one last time.  One mass of boys just in front of me was part of a Mexican team that was gleefully passing around a huge trophy.  A team of girls from Japan was right behind me.  They were more sedate but no less proud of their championship trophy.  Although it took longer to get through security, the energy and joy in the lobby made the wait less onerous. 

On the plane, I was seated next to a U-16 girl from Maryland, whose team lost in the semi-finals.  Even though her team didn’t go home with a trophy, her experience of being around 958 teams from 22 states and 16 countries made it one of the most memorable experiences of her young life.  “Just being here was exciting.  Even though we didn’t win, I felt like I was part of a bigger world – something big and important.  I’ll be back.”  

On the other side of me was an 80 year old engineer who for many years worked on and ran critical components of the Intercontinental Ballistic Missile Program and who is now consulting with the Nuclear Regulatory Commission on nuclear reactor safety.  As I asked him about the length of his career, he admitted, “I promised my wife that I’d retire when I reached 80, but I can’t quit quite yet.  My work is too important.  I’m no longer in charge of some of the big projects but my input is essential if we are going to get it right.”

After our initial conversations, I settled into my seat for the two hour flight to Washington D.C. where I will be part of a 3-Region “Infant Mortality Collaborative Meeting” sponsored by the Health Resources Services Administration (HRSA).  I’m anticipating that there may be 30 – 50 people at our infant mortality meeting.  At the same time, tens of thousands of people will be in D.C. for the International AIDS Conference.  I have no doubt that the AIDS meeting will get lots of media attention while our meeting will get none. 

That made me think, which issue is more important in our efforts to improve the health of people throughout the world?  Obviously, that is not the proper question because addressing both issues is essential in our public health work.  Yet, the media does ask that question and it’s hard not to feel slighted when one’s important work on an important issue fails to capture the interest and attention of the media and the public. 

This is a real dilemma faced on a daily basis and MDH is not immune.  Currently, the department is in the process of finalizing the Healthy Minnesota 2020 plan.  With the hope of limiting the size and keeping the plan manageable and useable, a decision was made to not specifically list all possible problems, diseases, high-risk groups and populations, or risk factors.  Instead, an attempt was made to create broad categories that would be inclusive of all of these issues, many of which already have a comprehensive plan of action that’s been developed and were articulated in the needs assessment that accompanies the Healthy Minnesota 2020 plan.  Yet, how does one develop a plan that provides some focus without dismissing the importance of essential public health problems, populations, and programs?

At the same time, the department is in the early stages of developing its 2014-2015 Budget.  After years of budget cuts, every program within the department is essential in protecting and improving the health of Minnesotans. Yet, there is also a recognition that limited resources and time-limited opportunities will necessitate some prioritization of activities.  How does one set budget priorities without dismissing the importance of every other departmental program that is essential for the success of MDH?

Those questions kept bringing me back to the perspectives of my seatmates on the flight.  One didn’t win the soccer tournament but knew she was part of something bigger.  The other no longer was the visible head an agency but valued his continuing contributions to an important effort.  Both recognized a larger frame in which they existed and were comfortable with their place within that frame. 

For public health, that larger frame is social justice – everyone should get basic needs met and no one should benefit at the expense of someone else.  This frame of social justice assures efforts to create health equity and the inclusion of high risk population in all public health efforts. 

That broader public health frame is also one that is much longer than the next news cycle, the next planning cycle, or the next biennium.  It is a frame that includes multiple generations.  This long-term frame helps assure (I’m an optimist) that, at some point, all public health issues will become a visible priority and get the attention they deserve.

And that larger frame acknowledges that all parts of public health are connected to and influenced by every other part of public health.  Successful action depends on that interconnection.  A healthy community cannot happen without the efforts of everyone in public health.  We must work to help assure the success of every one of our public health colleagues and they must reciprocate.  After all, it’s what “we do collectively that assures the conditions in which people can be healthy.”

After we landed, seat D, E, and F all headed in different directions.  Yet, because of our conversations, we knew that we all had something in common and it wasn’t just Row 34 – it was something much bigger than that.

Ed

Data are the coins of the public health realm

Greetings,

Last Monday, June 4^th, I had the opportunity to welcome the attendees of the joint annual meeting of the National Association for Public Health Statistics and Information Systems (NAPHSIS) and the National Center for Health Statistics (NCHS). Hundreds of people from around the country were here to learn about the latest advances in the field of vital statistics, electronic health records, and various other aspects of collecting and using population-based data. From the title of their conference, “Shooting for the North Star: Our Journey from Good to Great” and from the focus of many of the scheduled sessions, it was obvious that they were also here to find out how to navigate their field through this time of major change in health and health care. 

In welcoming attendees to the North Star State, I mentioned the usual things like the fact that Minnesota has more shoreline than California, Florida and Hawaii combined; that we really are all above average; and that Minnesota is truly becoming a land of many cultures – and not just throat. I also mentioned the many public health firsts that have occurred in Minnesota like: the first clean indoor air act; the first Great American Smokeout (aka D-Day); the first study linking dietary fat, serum cholesterol and heart disease; and the first reliable diagnostic test for typhoid fever. 

I then acknowledged that in preparing for this short presentation, I realized that this year we are celebrating the 100th anniversary of the establishment of the Children’s Bureau in the U. S. Department of Labor. The mission of the Children’s Bureau was “to investigate and report...upon all matters pertaining to the welfare of children and child life among all classes of our people and shall especially investigate the questions of infant mortality, the birth rate, orphanage, juvenile courts, desertion, dangerous occupations, accidents and diseases of children, employment, and legislation affecting children…”

The establishment of the Children’s Bureau is of particular relevance for people attending this conference because the first major initiative of the Children’s Bureau was the development of a National Birth Registry and institution of compulsory birth registration. With compulsory-birth-registration, not only could a state generate accurate birthrate and infant-mortality statistics as well as providing children with accurate proof of age, it could also begin to identify the medical, social, and economic conditions leading to high rates of infant mortality. 

I also pointed out to the audience that June 4th (the day of my talk) was the day in 1919 when Congress passed the 19th Amendment to the Constitution giving women the right to vote – one of the greatest public health achievements of the 20th century. Women’s Suffrage was crucial to the passage of the Sheppard-Towner Act in 1921, an act promoted by the Children’s Bureau. Among other things, the Sheppard-Towner Act established a partnership with federal and state governments around maternal and child health, it created the first public grants-in-aid program in the U.S., it established MCH programs in all state health departments, and it expanded birth registration from 30 to 46 states. With funding from the Sheppard-Towner Act states were able to build a state-level infrastructure for birth registration, appoint local registrars, and train doctors and midwives to register births. 

Although I didn’t mention it in my speech, there are some interesting parallels between the Shepard-Towner Act and the Affordable Care Act. It was a state/federal partnership which required enabling legislation by the states for some (but not all) portions of the Act. It was also not universally supported because it was considered “socialism” and an overreach of the federal government.

Despite its detractors, the data that came available through the work of the Children’s Bureau and the Sheppard-Towner Act had a tremendous impact on the health of mothers and children. Vital statistics data were made available in ways never before imagined and they were the key to the initiation and implementation of multiple programs and policies. The results were dramatic; maternal mortality began to plummet shortly after the implementation of the Act and the rate of decline in infant mortality rates accelerated. 

In concluding my remarks to the conference attendees, I suggested that, in many ways, our situation today is similar to the early days of the Children’s Bureau. In the last decade we have gained access to an incredible amount of old and new quantitative and qualitative data. We’ve developed methods to analyze those data and turn them into useful information. We have found ways to link data so that we can see the interactions of many of the genetic, social, environmental, behavioral, and medical determinants of health. And we have new partners to work with who help us gain a broader perspective from these data. 

I ended by opining that the need for good data has grown in importance. Given the magnitude of the problems in our communities and the rapid and dramatic changes that are occurring in the realms of medical care, social service, and public health, the need for good data is unprecedented. Also unprecedented are the opportunities that exist to link our data capabilities with programmatic and policy initiatives that will benefit everyone in our society. 

Although I gave this challenge to a group of statisticians and registrars attending last week’s conference, it is a challenge that all of us in public health need to embrace. Data are the coins of our public health realm. We need good data to accomplish our public health mission. Not since the 1920s have we had such an expansion in our data capabilities. Fortunately, this expansion has come at a time when we most need good data to help transform our health systems. Let’s not waste this magnificent opportunity.

Ed

If it’s not fun, it’s not public health. If it’s not public health, it’s not fun.

Those were the days, my friend
We thought they'd never end
We'd sing and dance forever and a day
We'd live the life we choose
We'd fight and never lose
For we were young and sure to have our way...
Those were the days, oh, yes, those were the days.”

Lyrics by Gene Raskin popularized by Mary Hopkin in 1968.

Once I got beyond the range of the Twin Cities, “oldies” stations were the only ones that came in clearly on my car radio, as I drove to Madison for my 40^thmedical school class reunion.  I thought that was quite appropriate, so for three hours the sound track of the 60s and 70s filled my ears and my mind and my soul as I reminisced about the “good old days.”  The nostalgia increased as I turned onto Madison’s East Washington Avenue and saw the Wisconsin State Capitol in the distance, drove by Ella’s Deli, and headed to the Madison Club on the shores of Lake Monona.  All the hopes and dreams I had as a medical student welled up in my consciousness and gave me pause as I considered how well I had taken advantage of the opportunities that were before me in 1972.  I had mixed emotions because my actions have been a mixed bag.

(As an aside, the first person I ran into upon entering the Madison Club was not one of my classmates but our gross anatomy professor, Jim Pettersen, who was one of our favorite faculty members and who has attended most of our reunions over the years.  When I told him what I was currently doing, he asked, “Do you know my uncle George who used to be the Minnesota Health Commissioner?”  George Pettersen was the health commissioner when I came to Minnesota and George and I worked together on several projects in the early 80s.  I discovered that he is doing well and living in the Crosby-Ironton area.  What a small world.)

It wasn’t long after entering the reception room and getting reintroduced to former classmates before we were sharing stories and catching up on 40 years of life.  However, among the laughter about the quirks of old professors and the silly things we did as students, there was a palpable sense of underlying dissatisfaction among many of my classmates.  Eighty percent had already retired and among those still practicing, most were looking forward to retirement.  Besides me, the only one who seemed to be still enjoying himself in his profession was Henry Anderson, who happens to be the state health officer in Wisconsin. 

Our class had started to practice right at the beginning of a major transition in medicine.  In our conversations it became evident that the advent of managed care and HMOs and the evolution of medicine as big business had negatively affected their enjoyment of medicine.  They articulated that what they ended up doing was not what they had anticipated.  They felt like the rules had changed in a way they didn’t like, yet they weren’t able to get out of the game.  Most enjoyed many parts of their practices but they did not have the passion they thought they would have had. 

In pursuing this discontent a bit further, I got a sense that the parts of their practices that they didn’t like were when they functioned as technicians or when they treated the same conditions over and over again with little impact or when the business of medicine overwhelmed the profession of medicine.  What gave them joy, however, was when they were making a true difference in the lives of families and their community.  They lit up when talking about their work with scouts or other community groups, their volunteer time with high need or underserved populations in their communities, their teaching and mentoring of future physicians and other health care workers, or their advocacy around policies that affected their practice or the health of their communities.  It struck me that they were most energized and most satisfied when their medical training and practice could be linked with public health outcomes.

Yesterday, I shared this story during the “Heritage Lecture” that I had been invited to give to a group of radiologist who were attending the annual meeting of the Minnesota Radiological Society.  After my presentation, several physicians of much younger vintage than I, approached me and shared that the disenchanted feelings are not unique to my 1972 classmates; they are prevalent even among today’s early and mid-career practitioners.  This made me think of a quotation of Rudolf Virchow, a noted physician of the 19^th century and the father of pathology. 

“Medical education does not exist to teach individuals how to make a living, but to empower them to protect the health of the public.”

These experiences with my classmates and physicians in Minnesota have convinced me that our efforts to integrate medicine and public health and to use a public health as a framework for health reform are not just essential to improve population health and control healthcare costs; they are necessary to restore meaning and enjoyment to the provision of healthcare.  Public health is an integral part of the values of being a physician (and probably every other healthcare profession).  If that part is absent, meaning and satisfaction are easily lost.  Integrating medical care and public health are essential to truly reforming our healthcare system.

You have all heard me say that “If it’s not fun, it’s not public health.”  I still believe that but the experiences of the last week have also convinced me that in the field of healthcare “If it’s not public health, it’s not fun.” 

Ed