Health
State health rankings find rise in infant mortality
■ The annual state of the states report notes a disturbing trend and finds that the United States may be stalled in its journey to better health.
By Victoria Stagg Elliott — Posted Dec. 6, 2004
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Deaths among children younger than 1 year old increased for the first time in more than 40 years, according to a report, "America's Health: State Health Rankings," published in November. The rate increased from 6.8 per 1,000 in 2001 to 7 per 1,000 in 2002 -- a far cry from the Healthy People 2010 goal of 4.5 per 1,000.
"It's only a little blip, but it's very concerning," said John Kattwinkel, MD, professor of pediatrics at the University of Virginia, Charlottesville.
The state health rankings report has been published annually for the past 15 years by the United Health Foundation in conjunction with the American Public Health Assn. and the Partnership for Prevention, using data collected from the Centers for Disease Control and Prevention and other public health agencies.
Experts acknowledged the possibility that the infant mortality uptick could be a fluke, but most believe that it could be the beginning of a true increase, because other related indicators have been headed in the wrong direction for several years, particularly prematurity and low-birth-weight rates.
"It's very consistent with the way the data have been trending," said Marie McCormick, MD, ScD, professor of maternal and child health at Harvard University School of Public Health in Boston. "Those numbers have to catch up with you at some point."
A commentary in the report attributed the increases to the growing number of multiple births caused by improvements in assisted reproductive technology. Improvements in neonatal intensive care lead many more sick newborns to survive initially. This advance, however, has not necessarily translated to survival through the first year of life.
"It's not just a matter of delivering care to sick babies better, and we may have done all we can in that area," Dr. Kattwinkel said. "We need to go back earlier than that to prevent babies from being sick."
Other indicators
But infant mortality is not the only health marker that has public health experts and many physicians worried. The report found that after years of significant improvement, most health indicators are still moving upward, but less so than before. For example, in the 1990s, the overall health of the United States improved an average of 1.5% per year. In the past year, it only improved 0.6%.
Leaders of the organizations that supported the report blamed factors beyond these slowing numbers, such as the increasing rate of obesity, a growth in the number of children living in poverty and an upward trend in the number of people who do not have health insurance.
"The data clearly indicate that we as a nation still have a lot more work to do in improving risk factors that result in disease," said William McGuire, MD, board chair of the United Health Foundation and CEO of UnitedHealth Group, the HMO that backs the foundation.
The report also ranked states. Minnesota was declared the healthiest state, a position it has held nine times in the past 15 years during which the report has been issued. Its successes include a low rate of deaths from cardiovascular disease, high rates of insurance coverage and strong support for public health. But even in this healthiest state, obesity is increasingly an issue, and access to prenatal care is also problematic.
"Minnesota has its share of health care problems, but Minnesota does very well in a number of areas," said J. Michael Gonzalez-Campoy, MD, PhD, medical director and chief executive officer of the Minnesota Center for Obesity, Metabolism and Endocrinology in Eagan. He is also president of the Minnesota Medical Assn.
Louisiana, with its low number of people having insurance, high death rate from cancer, and significant incidence of infectious disease, was declared the least healthy state -- a position it has held 14 out of the past 15 years. The report did, however, praise the state's efforts to address the obesity epidemic, which have resulted in a dip from 25.5% of the population being obese to 24.8%.
"We're not where we need to be, but we're making strides," said Fred Cerise, MD, MPH, head of the Louisiana Dept. of Health and Hospitals.
Physicians working in both states accounted for their success or failure on their patients' ability to access primary care. Some Louisiana doctors, for instance, complained that much of the public health-related funding pays for treatment in the state's unique charity hospital system, while very little supports prevention.
"A big chunk of the money from the Medicaid program goes to facilities like charity hospitals and nursing homes," said Michael Ellis, MD, a clinical professor in otolaryngology at Louisiana State University School of Medicine and a former president of the Louisiana State Medical Society. "That's the last place it ought to be going. It ought to be going to outpatient care where people can be prevented from having to use those facilities."
Minnesota, however, has the opposite approach. Physicians praised state government efforts to ensure that much of the population has at lease some access to preventive care.
"From a public policy perspective, we do a lot to support the uninsured and provide access to health care," said George Schoephoerster, MD, a family physician from St. Cloud and president-elect of the Minnesota Academy of Family Physicians.
Public health officials in both states, though, said the issue was far from simple and that many factors, particularly nonmedical ones, play a role.
"If you look at Medicare data, Louisiana spends more per beneficiary than any other state, and our quality outcomes are the worst," said Dr. Cerise. "This is not strictly an issue of who has coverage and who doesn't. We've got a lot of work to do with our existing system of care to get better outcomes for the dollars we spend."