Weekly Pulse: The Swine Flu Postgame Show

Lindsay E. Beyerstein

Vermont senator Bernie Sanders is arguing that the new Democratic super-majority in the Senate, created by Arlen Specter’s party switch, is a golden opportunity to achieve national healthcare.

So far, swine flu hasn’t developed into the deadly global pandemic that many feared. Was it all media hype, as Cervantes argues for AlterNet?
Or did all that quarantining and hand-washing actually help? While
we’ll never know what might have been, perhaps we should consider the
relatively mild swine flu as a cheap lesson–a dry run, if you will.

The swine flu scare underscores the need for strong public health infrastructure, writes Amitabh Pal in the Progressive:

When the flu began taking its toll,
Mexico didn’t have a single facility to test for the virus, and so
samples had to be sent to the United States and Canada. Mexican health
officials were slow to pick up on the initial outbreak of the disease,
and, by the government’s own admission, still have not been able to
reach out to the public in an effective manner.

Pal argues that Mexico’s healthcare system is in disarray in part
because of international pressure from to decrease the government’s
role in healthcare in accordance with the prevailing free-market
ideology.

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Laura Carlsen of New America Media also worries about the health fallout from globalization, arguing that NAFTA
helped swine flue. According to Carlsen, globalization created a
perfect storm for the development and spread of an epidemic flu in
Mexico–a rapid shift to factory farming, the breakdown of public health
infrastructure, and accelerated flow of people and goods across the
border.

Americans shouldn’t be smug about our own state of readiness. In the American Prospect, Harold Pollack takes “moderate” senators to to task for pinching pennies on public health:

Throughout, our key opponents were
moderate senators who had no problem supporting the usual giveaways to
powerful constituencies, yet who balked at spending small amounts on
useful but unsexy measures to prevent sexually transmitted infections,
promote family planning, help people quit smoking, finance
substance-abuse treatment, and, yes, prepare to fight pandemic flu. In
a $2.4 trillion health-care economy dominated by personal medical
services, it once again proved nearly impossible to channel public
investments into population-level activities that are often much more
cost-effective.

Just because this particular epidemic didn’t spread, that doesn’t
mean that a deadly influenza virus couldn’t emerge in the future. In
fact it’s a virtual certainty that such outbreaks will continue to
happen, as they have at unpredictable intervals throughout human
history.

Vermont senator Bernie Sanders
(I) argues that the new Democratic super-majority in the Senate,
created by Arlen Specter’s party switch, is a golden opportunity to
achieve national healthcare. “Clearly the United States needs to join
the rest of the industrialized world with a real national healthcare
program that guarantees comprehensive healthcare to every man, woman
and child–and we save money as we do that,” Sanders told Ed Schultz.
Watch the clip, via Chelsea Green:


 

Finally, Stephanie Mencimer of Mother Jones raises questions about the safety of NuvaRing,
a novel contraceptive technology from Schering Plough that promises the
benefits of hormonal birth control without the hassle of taking a pill.
However, more than 100 lawsuits blame Nuva for serious side effects,
including deadly blood clots:

Making birth control easier is, of
course, a good thing. But for years there have been serious safety
questions about the “third generation” hormones used in NuvaRing and
several other contraceptives on the market—questions that NuvaRing’s
labeling sidesteps by saying that it is “unknown” how the device
compares to other hormonal birth control.

It’s been an eventful week in healthcare. We failed to beef up
public health earlier this year because some legislators lacked a sense
of urgency, but prevention seems a lot more pressing in light of our
brush with swine flu. Before Specter’s defection, it seemed like
healthcare might never pass the Senate, but now there’s at least a hope
of breaking a filibuster if the Democrats can hammer out their internal
differences. We’ve got a long way to go on public health and healthcare
reform, but we passed some important milestones this week.

Commentary Maternity and Birthing

‘Born in the Wild’? The Problems With Lifetime’s New Reality Show

Martha Kempner

Women should be free to choose their childbirth experience, whether it be in a hospital or in the woods. But I fear that Born in the Wild will be a disingenuous attempt to suggest that modern medicine ruined childbirth.

Lifetime Television, once known for its melodramatic movies of the week, has been bringing us reality shows for many years—from Dance Moms, to Preachers’ Daughters, to True Tori, the network has given us the opportunity to watch both regular people and the rich and famous in their natural habitats.

Now the cable channel is taking on childbirth, and it too will be done in a natural habitat.

The new show, Born in the Wild, will follow couples who eschew hospitals and doctors for babbling brooks and fields of wildflowers. As the press release announcing the show teased: “What happens when the craziest experience of a woman’s life becomes truly wild, and soon-to-be parents decide to take on an unassisted birth in the outdoors?”

Women should be free to choose their childbirth experience. If you want to give birth at home or in the backyard or in the woods, you should be free to do so. If you want a camera crew to watch as you give birth, go ahead. But this show strikes me as a step too far. It is capitalizing on the misperception that modern medicine ruined childbirth, and that childbirth was better in the “old days” when women trusted their bodies and did it the way nature intended. Moreover, the show’s premise is disingenuous at best; trading modern medical equipment for a camera crew and a satellite van does not take us back to nature.

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Modern Medicine Did Not Ruin Childbirth

The complaint about childbirth having become too medicalized is a common refrain among a certain group of new parents today. The argument suggests that women have been having babies for most of human history without pain medication, fetal monitors, and emergency C-sections, and that we should go back to the day when childbirth was run by the woman herself and not an army of doctors and nurses and specialists.

Yes, women have been having babies without intervention for centuries, but a hell of a lot of them died while doing it.

As part of her 2013 series on longevity for Slate, Laura Helmuth took on death in childbirth. She notes that in the United States today, about 15 women die in pregnancy or childbirth for every 100,000 live births. That’s quite high—in fact, for a developed country, we should be ashamed of our maternal mortality rate—but nowhere near as high as it has been in the past. In the 1600s and 1700s, between 1 and 1.5 percent of births ended in maternal deaths, which meant that women (who had a lot more children at the time) had about a 4 percent lifetime chance of dying in childbirth. Even in the early 1900s, childbirth was a dangerous proposition, with nearly 600 women dying for every 100,000 live births in the United States.

Interestingly, Helmuth explains that 100 years ago the medicalization of childbirth may have in fact make it more dangerous in some ways. As physicians tried to lure patients away from homebirths and midwives, they often offered unnecessary medical procedures designed to prove that women needed to be in a hospital setting. Moreover, they failed to take some easy steps—such as washing their hands between patients—that could have saved many lives.

But a lot has changed in medicine in the past century. The advent of antibiotics has meant that the most common killer of new mothers—post-birth infections—is no longer a big threat. And prenatal care is now able to detect many potentially life-threatening complications before they occur. What Downton Abbey viewer can forget when Lady Sybil died while delivering her baby? Eclampsia—the condition that likely killed that character—is now screened for throughout a woman’s pregnancy, through the use of frequent urine tests and blood pressure monitoring.

The primary complaint about births in hospitals today is that too many women undergo unnecessary cesarean sections, which are major surgeries and carry more risks than vaginal delivery. This is in many ways a legitimate concern, as C-section rates rose dramatically between 1996 and 2009. In the past few years, however, major medical organizations have put out guidelines aimed at reducing C-sections that are not medically necessary, and the rates have stabilized. Although I agree that many obstetricians may still be too quick to order a C-section for reasons that may not be medically necessary, I do think we have to remember that in many instances this surgery can save both mother and child, and that women today are lucky it’s available.

My fear with the new Lifetime show is that it will tout the mantra of the over-medicalization of childbirth without ever challenging its legitimacy. Furthermore, as I mentioned in an article I wrote for Rewire a few years ago, there is a lot of judgment swirling around women’s childbirth choices. Many proponents of natural childbirth (often used to mean a birth without any pain medication) seem to suggest that it is the only “real” or “legitimate” birthing experience, and some in the home birth movement have suggested that getting out of a hospital setting is the best option for those who want a meaningful childbirth experience. Given that the women who will be featured on Born in the Wild have all had at least one hospital experience in the past (it’s one of the requirements to be on the show) and are choosing something radically different, I worry that the show will perpetuate the idea that “real” women give birth without modern medicine.

The Wild or “The Wild”?

Even worse about the message that “real” women have their babies in a field without any help is that when it comes to this reality show, that is not what is happening. The women featured on the show will be surrounded by a production team, there will be an emergency medical professional on set, and though the couple can choose the location, the producers will only agree to it so long as they are within a certain radius of a hospital in case complications arise. You can’t tell me that that’s really the wild, or that it’s these births are truly unassisted.

There are women around the world who have no choice but to give birth without any medical care because they have no access to care or they can’t afford it. Their risk of complications and death is certainly higher than for women who have access to care. Women in areas like South Sudan, which has been in conflict for years, have no access to medical institutions. The last available maternal death rate in that country (from 2006) showed that 2,045 women died per every 100,000 live births. In Chad, where two-thirds of the population lives in poverty, more than 1,000 women die for every 100,000 live births. The rates throughout many regions in Africa hover near 500.

Here in the United States, the maternal death rate is also closely linked to poverty, race, and access. A report by the Department of Health and Human Services looked at maternal death from 1935 through 2007. It notes:

Compared to women in the low poverty group, women in the middle poverty and high poverty groups had 90 percent and 220 percent higher maternal mortality risks in 1969-1971 and 58 percent and 102 percent higher maternal mortality risks in 2003-2007, respectively.

The report also notes that the risk of maternal death over the last six decades has been four times higher for Black women than for non-Hispanic white women. Within racial groups, too, poverty continues to play a role. The report found that Black women in the high-poverty group had a 35 percent higher maternal death rate than Black women in the low-poverty group. Similarly, non-Hispanic white women in the high-poverty group had a 50 percent higher maternal death rate than non-Hispanic white women in the low-poverty group. Much of the disparity here is based on access to high-quality health care.

Born in the Wild has not yet aired, and I cannot claim to know the socioeconomic background of the couples who will be featured. We do know, however, that they will need to have had one hospital-based birth in the past, so it seems likely that their decision to forego medical intervention during delivery is a philosophical one rather than a financial one. I must admit it’s hard for me to get behind such a choice when so many women in the world die because they don’t have access to what these women could have had.

The likelihood, however, is that all of the births on this show will go smoothly and end in healthy infants. The show is taking precautions to choose only mothers at low risk for complications, and there is back-up medical care if need be. In addition, though these women are choosing to go it alone during delivery, unlike low-income women in this country and around the world, these women will likely have had prenatal care, which can predict and prevent many complications. And research has shown that for low-risk mothers who have access to emergency medical care should problems arise, home births can be as safe as hospital births.

So, as my grandmother would say, “Gai gezunterhait.” Go in good health. Do what you will.

I can only hope that when the show airs, the choice these women have made is not presented as morally superior, healthier, or more “real” than those of women who—like me—felt far more comfortable surrounded by fetal monitors, obstetrics nurses, and specialists than we would have surrounded by trees.

Analysis Law and Policy

The New Front in the Legal Fight Over Obamacare

Jessica Mason Pieklo

A lawsuit filed by the State of Indiana shows conservatives' evolving legal strategy in trying to undermine health-care reform.

Click here for all our coverage of the health insurance exchange rollout as part of the Affordable Care Act.

It’s been well over a year since the Supreme Court declared much of the Affordable Care Act constitutional, but that’s hardly stopped conservatives from trying to litigate health-care reform to death. In addition to the now over 70 federal lawsuits challenging the law’s birth control benefit, conservative attorneys general in red states that refused to set up their own health insurance exchanges are targeting the power of the federal government to operate exchanges on their behalf. It’s the latest iteration of a multi-faceted strategy with one goal in mind: to make Obamacare so politically unpopular the law sinks from the weight of its own opposition. If you listen to conservatives, they’ll tell you this is a winning strategy. The evidence, however, suggests otherwise.

The latest lawsuit targeting health-care reform comes from Indiana, where last week attorneys for the state filed a federal lawsuit arguing a new IRS regulation governing the employer mandate in Obamacare is unconstitutional. The IRS poses hefty fines on employers that don’t offer health insurance coverage and whose employees use federal premium subsidies to buy coverage through any public insurance exchange. Under the IRS rules, if employers do not offer health insurance coverage to at least 95 percent of its full-time employees and even one employee uses a federal premium subsidy to buy coverage in either a federal or a state exchange, the employer is liable for a $2,000 penalty for each full-time employee, minus the first 30 employees. The penalty is slated to take effect in 2015.

The lawsuit, filed by Indiana Attorney General Greg Zoeller and 15 Indiana public school districts, claims the Affordable Care Act employer mandate is unconstitutional because Congress never gave the IRS authority to impose penalties for not complying with the individual or employer mandates in states that did not create their own health insurance exchanges and that the financial penalties for not complying with the employer mandate cannot be applied to government employers, like public schools.

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Indiana’s lawsuit follows a similar suit filed by Oklahoma’s attorney general this summer. Oklahoma’s lawsuit, which was originally filed in January 2011 but remained pending until a resolution of the lawsuit challenging the individual mandate was made, cleared its first legal hurdle this summer when a federal district court refused to grant the Obama administration’s motion to dismiss the lawsuit.

The motion, brought at the initial stage of the lawsuit, challenged Oklahoma’s standing to sue and not the merits of the claims, a point mostly overlooked by conservatives who heralded the August ruling as more proof the law would ultimately fail. And like the other conservative legal challenges to health-care reform, the legal claims sound sophisticated, but in reality they are more smoke-and-mirrors.

According to the states challenging the employer mandate and IRS rule, unless insurance subsidies are administered by exchanges created by the states, the subsidies are forbidden by the ACA. Therefore, states that have not set up their own exchanges, including Indiana and Oklahoma, effectively cut their residents out of affordable health insurance. That’s because, the red states argue, if the federal government comes in and sets up an exchange after a recalcitrant state refuses to, those exchanges can’t offer subsidies to make coverage affordable because the law only explicitly empowers state-run exchanges, and not the IRS, to offer those subsidies. The result is apparent: It create no means of affordable coverage in most of the red states for those who need it most. And thanks to the Roberts Court ruling that the individual mandate is constitutional, people who struggle to get coverage but are not so poor as to meet the exemption would be stuck with a penalty and no health-care coverage, increasing support for a repeal of the law.

But, that hasn’t quite happened. In August, while the federal court refused to dismiss Oklahoma’s claims outright, it hardly gave an enthusiastic support of the merits of the claims either, noting that at the beginning of a lawsuit, plaintiffs are entitled to very “lenient” standards in coming up with viable legal claims.

More importantly, though, the August order, while allowing the lawsuit to proceed, largely dismisses the main theoretical premise of Oklahoma’s lawsuit and the suit advanced by Indiana—the premise being that the states, vis-a-vis the Tenth Amendment, have legal interests to pursue claims against the federal government on behalf of their constituents. The law calls this idea parens patriae, which roughly translates to the state “acting on behalf of” someone unable to act in their own interests. It’s a theory that shows up in some juvenile proceedings, for example, where the state steps into a “parental role,” so to speak, to assert rights and legal challenges on behalf of someone who is, for whatever reason, unable to assert them on their own. But courts have long rejected the idea that states can pursue such claims, because they typically don’t contain an actual injury—a loss of rights or an injury to a person or property sufficient to justify legal action. It’s a fundamental procedural concept—before anyone can sue, even the state, they have to have something legitimate to sue about. The Supreme Court made this clear in 1923, when it said “the naked contention that Congress has usurped the reserved powers of the several States by the mere enactment of a statute” is not enough to establish a state’s standing to challenge the law and sue the federal government.

Enter, then, the newest wave of conservative legal ideologues. Like the evolution of corporate religious exercise claims to challenge the contraception benefit, this latest iteration of the power of the states under the Tenth Amendment would have been widely dismissed a decade ago. But that was before conservatives made it their mission to defeat Obamacare at any cost. Now, with the federal government shutdown dragging into its second week and conservatives refusing to back away from demands that if the entire health-care law doesn’t go then at least the contraception benefit must, it’s clear that these lawsuits are simply a part of their war on the poor and their political crusade to make health-care reform too costly for the Obama administration to maintain. And while so far polling suggests this is a strategic misfire for the Republicans, that hardly matters for the tens of thousands who have been blocked by their own states from most of the benefits of health-care reform and now face the end of federal benefits as those same conservatives hold their lives hostage in the shutdown games.

Naturally, that’s now how conservatives see it. “This case is about the fundamental relationship between the State and federal government,” Indiana Attorney General Zoeller said in a statement announcing the lawsuit. “We contend the ACA improperly regulates sovereign states and does not authorize the IRS to do what it is doing in treating the State as a taxable entity. We are raising this respectful challenge for the federal courts to decide these questions.”

Zoeller’s statement is disingenuous at best. The legal theory, advanced by both Indiana and Oklahoma in their challenges to the employer mandate, was first cooked up by legal scholars at the libertarian Cato Institute, the same scholars that concocted the original legal challenge to Obamacare. These are not “respectful” challenges as much as they are political challenges disguised as legal arguments, and it’s time for the courts to recognize them as such.