• Why Politics Should Be Kept Out of Miscarriages

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    Georgia’s much-discussed new law on abortion is one of the most restrictive in the nation. Abortion will be banned as early as six weeks into pregnancy — before many women even know they are pregnant.

    This law goes even further, though: Although the intent of the law is to block abortion, it has opened a vigorous debate about whether women who miscarry could be questioned or even prosecuted.

    The new law, which goes into effect Jan. 1, gives a 6-week-old fetus the legal status of a human being. One definition of second-degree murder in Georgia includes cruelty to children during which “he or she causes the death of another human being irrespective of malice.” This raises the question of whether a woman who miscarries because of what is perceived to be her conduct could be held liable for that conduct.

    “This suggests that women who ‘cause the death’ of a fetus, with or without malice, could be charged with second-degree murder,” said Eric Segall, a law professor at Georgia State University, and a supporter of abortion rights. He said the law would most likely be struck down in the lower courts.

    Even if the Supreme Court reverses course on abortion, law enforcement authorities with scarce resources may not investigate women this way. “One would hope,” he said, “that there would be a political cost if they did.” But, he noted, given the ambiguities in the new law and its complex interactions with other Georgia statutes, prosecutors would have a lot of discretion, and it would be “completely up to” them.

    Other Georgia criminal statutes may still protect women from prosecution for ending their pregnancies or for miscarrying. Even if that winds up being true, the new law says doctors who perform abortions will be prosecuted, and that could still have an impact on women who miscarry.

    Staci Fox, president of Planned Parenthood Southeast, told The Washington Post she didn’t think that the Georgia law could be used to successfully prosecute women, but that a woman who miscarried “could be pulled into an investigation looking at whether someone performed an illegal abortion on her.”

    It would be helpful, of course, if legislators and judges and prosecutors understood the basics of miscarriage. Early pregnancy loss is not uncommon. It occurs in about 10 percent of recognized pregnancies. Four out of five cases occur in the first trimester. Many women miscarry before they know they’re pregnant.

    About half of miscarriages are because of abnormalities in the fetal chromosomes. These defects are usually incompatible with life, and spontaneous abortions occur. The chance of an early pregnancy loss rises with age. While it is less common in younger women, about 80 percent of pregnancies in 45-year-old women can end this way.

    Without randomized controlled trials, which really aren’t possible here, we can’t know for sure what is causing many miscarriages not involving chromosomal abnormalities. We have a great deal of information about what is associated with them, but that is not the same.

    A woman who has health problems in general is more likely to suffer early pregnancy loss than one who does not. Women with high blood pressure, diabetes and thyroid disease are at higher risk. So are those who have hormone problems, immune disorders or infections.

    Circumstances at work can be associated with miscarriages. A 2013 systematic review found that working nights was a risk factor, as were things like working in a three-shift schedule, working 40 to 52 hours per week, and standing for six to eight hours per day.

    Smoking has been associated with an increased risk of miscarriage, according to a meta-analysis that included 98 studies. Obesity has also been linked to recurrent miscarriage.

    To be clear, there is no evidence that any of the factors I’ve mentioned causes a miscarriage. All of these data arise from observational studies that investigate associations, not causes. It’s easy to make an erroneous leap from one to the other. Smoking, obesity and night-shift work are each associated with being poorer and having fewer resources for health. This probably wouldn’t stop some people from quickly blaming women for their choices rather than considering their socioeconomic status.

    Ask almost any medical professional what caused a miscarriage, especially one early in pregnancy, and — other than chromosomal abnormalities — they will say that “we do not know.” If medical professionals cannot make that determination, it’s hard to understand how someone in law enforcement might.

    A bigger concern is that a fear of becoming part of an investigation may cause women to avoid medical care. Women who are bleeding or are heading toward septic shock may not come to the emergency room or doctor’s office. They could die. This would only increase America’s maternal mortality rate, which is already much higher than that of most other advanced nations.

    John Becker, a state representative in Ohio, recently sponsored a bill that would also change how pregnant women with unsustainable pregnancies are treated. He suggested that ectopic pregnancies, which are not viable, should in part be handled by “removing the embryo from the fallopian tube and then reinserting it in the uterus so that’s defined as not an abortion.”

    This procedure is not possible. It’s not clear that those who are writing many of these bills understand how pregnancy works.

    We do know some things about how miscarriage works: It’s a common, natural and unavoidable health outcome for many heartbroken people. Inserting politicians and the criminal justice system into the grieving process seems as if it could only cause further pain.


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  • The Potentially Lifesaving Difference in How a Gun Is Stored

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    Legislators and gun safety advocates often focus on how guns are purchased. But many lives could be saved, especially among children, if they looked more at how they are stored.

    In the last decade, guns killed more than 14,000 American children. A startling number of those deaths — more than a third — were classified as suicides, and around 6 percent as accidents. Many more children were injured.

    Nearly everyone agrees that children should not be able to buy guns, and no state lets them do so on their own. When children die by suicide in this way, it’s a result of being able to get hold of a gun that someone else already obtained — often legally.

    How guns are stored matters. A study published Monday in JAMA Pediatrics has found that even a modest increase in owners who lock up their guns would pay off in an outsize drop in gun deaths.

    Dr. Michael Monuteaux, an assistant professor of pediatrics at Harvard Medical School and an author of the study, said, “We need to communicate to parents that storing guns in a way that makes them inaccessible to children can reduce the number of children who die year after year, especially from suicide.”

    In 2010, researchers examined who owned the firearms used in youth suicides. In cases where this could be determined, three-quarters of the time the owner was a parent, and for a further 7 percent it was some other relative.

    In a 2005 study published in JAMA, researchers found that keeping guns locked and unloaded, and keeping ammunition locked and separate from guns, were significantly associated with lower levels of suicides and accidents among adolescents in gun-owning households. This held true for both handguns and long guns.

    But such safety practices aren’t common. If a recent New York bill is signed into law, it will make the state one of just a handful with comprehensive gun storage laws to protect children.

    Last year, a study based on a national survey in 2015 found that about one in three of all households in the United States owned at least one gun. Of those households with both guns and children at home, more than 20 percent reported storing them both loaded and unlocked — the least-safe way. An additional 50 percent stored them either loaded or unlocked.

    This meant that about 7 percent of all children in the United States lived in a house in which at least one gun was stored in an unsafe manner. This was about twice the number reported in the previous national survey, published in 2002. Other research suggests that many people in gun-owning households, typically not the primary owner of the gun, think they are safely stored when they are not.

    Critics of gun-storage laws say homeowners need to be able to act quickly if a criminal tries to enter a home. It’s not easy to measure how often guns are used in self-defense when someone attempts a break-in, but research suggests it’s a rare occurrence.

    Suicides are less rare than self-defense shootings and, along with accidents, they are more likely in children who have parents who abuse alcoholStudies have also found that children living with an adult who misuses alcohol were more likely to live in a house with a gun stored unsafely, and that heavy alcohol use was most common in those who store guns loaded and unlocked.

    “We know from prior studies that children who live with alcohol-misusing adults are at a greater risk of suicide attempt, bullying victimization and perpetration, and unintentional injuries,” said Dr. Ali Rowhani-Rahbar, an associate professor of epidemiology at the University of Washington’s School of Public Health.

    Critics also say safe storage laws are hard to enforce because of privacy concerns. As a model from Monday’s study in JAMA Pediatrics shows, though, even a modest intervention that motivates households to safely store guns could reduce youth firearm deaths by 6 percent to 32 percent.

    Last year, in the journal Injury Prevention, Dr. Rowhani-Rahbar and other researchers reported on the results of two community-based firearm safety events in Washington State. They found that presenting people with information and offering to sell them trigger guards or lockboxes resulted in an increase of about 14 percent of households that stored all guns locked and 9 percent more that stored them unloaded.

    In 2017, the Government Accountability Office reviewed 16 public or nonprofit programs that aimed to improve the storage of guns. It also reviewed studies of these programs. It found that distributing locks led to more safely stored guns. Few of these evaluations were rigorous, however. (Gun research, as with most things related to guns, is a politically divisive issue, and for many years research funding has been very low relative to other major causes of death.)

    Policy can make a difference, too. In 2004, a study examined how laws that focused on the sale of guns affected the suicide rates of children, compared with laws mandating safe storage of firearms. They found that between 1976 and 2001, minimum-age purchase laws and possession-age laws had no effect on adolescent suicide rates. Laws preventing children’s access to guns, on the other hand, were associated with significant reductions of suicides by guns, even when reductions were not seen in suicides by other methods.

    About two-thirds of gun deaths in the United States are suicides, and given political stalemates over gun rights, it seems an area in which policymakers could be more productive. Safer storage of guns, especially in households with children, might make more of a difference than many legislative and advocacy efforts that get more attention.


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  • The paperback version of The Bad Food Bible is available!

    I hope all of you have already bought a copy of The Bad Food Bible already, but if not – the paperback is out! It’s yellow and awesome! There’s a new (and better) subtitle. There’s also a great quote from Alex Beggs on the cover.

    I would really, really appreciate it if you would buy a copy. I think you will enjoy it. It’s chock full of research and wisdom on nutritional science which will make you feel calmer and better about food in general.


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  • Healthcare Triage: Aaron Becomes a Medical Tourist after a Monkey Mugging

    When Aaron went to Malaysia to learn about medical tourism, he became a medical tourist himself after he was mugged by a monkey. The monkey stole Aaron’s glasses, and he had to have new ones made. It turned out to be pretty easy! Malaysia and many other countries actually encourage people from outside their countries to travel there for care. While it’s probably not worth traveling internationally just to save on eyeglasses, there are a lot of arguments in favor of the practice generally. Aaron tells the story of his monkey encounter, and looks at the pros and cons of medical tourism.

    Lots of footage included!


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  • Healthcare Triage News: Infants and the Medicaid Expansion

    What can we do about infant mortality and disparities in health care? This week we take a look at a recent study in JAMA that may have an answer.


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  • JAMA Forum: The rural hospital problem

    [H]ospital closures in rural areas are both a source of concern and a perplexing challenge. Where populations are thin and in the context of changing patterns of care—shifting away from hospitals—what can be done to maintain adequate health care infrastructure for the most critical and urgent conditions?

    Go read my recent JAMA Forum post for more. (Research for it was supported by the Laura and John Arnold Foundation.)


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  • Two forthcoming concerts

    I’m in two concerts the weekend of May 18-19.

    8pm, Saturday, May 18 in Jamaica Plain, MA: I’ll be playing in Nocturno by Mendelssohn (here’s a recording). It’s part of a larger program by the Weston Wind Quintet & Friends. Details here.

    3pm Sunday, May 19 in Arlington, MA: I’ll be playing with the Mystic Brass Ensemble. There’s a lot to the program (details here), which ends with suites from Star Wars.

    If you come to either, please say hello. If you come to both, say hello twice!


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  • Would it be legal to block grant Medicaid?

    I don’t know, and I doubt the Trump administration does either. But we may soon find out.

    With the Trump administration’s encouragement, Tennessee is moving ahead with a waiver to block grant its Medicaid program under section 1115 of the Social Security Act.  “Currently,” as Stephanie Armour explains at the Wall Street Journal, “Tennessee, like other states, gets open-ended federal dollars because the government matches a percentage of state spending. A switch to block grants would essentially cap funding.”

    As I’ve explained before, the language of section 1115 is really broad. But it’s not infinitely elastic. A waiver has to be a genuine experiment that advances the Medicaid statute’s purposes. You might conceivably be able to squeeze block grants in there: for decades now, waivers have been used in expansive ways that would’ve shocked 1115’s drafters.

    But block grants are a big step past work requirements, which one court has already invalidated because they don’t advance Medicaid’s purposes. And work requirements are themselves a big step past prior waivers. Besides which, the whole point of block grants—if we’re being honest—isn’t to run an experiment or make Medicaid work better. The point, instead, is to give states the latitude to cut beneficiaries or benefits. That doesn’t sound to me like it’s consistent with Medicaid’s purposes.

    There may also be landmines in the Medicaid statute that would make it impossible to block grant the program. Section 1916(f), for example, says that you can’t use 1115 authority to tinker with the program’s general rules governing premiums and cost-sharing, except under really restrictive circumstances. That particular provision wouldn’t preclude block grants, but there may be some other explicit limitation on 1115 that I don’t know about. The Medicaid statute is a ferociously complex piece of legislation; if anyone can point me to other parts of the law that may pose problems for block grants, I’d love to see them.

    At a minimum, there will be lawsuits.


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  • Healthcare Triage: Doctors’ White Coats Can Host a Lot of Bacteria

    For a lot of doctors and patients, the physician’s traditional white coat is a big part of a doctor’s identity, and contributes to their authority. Those white coats can also spread disease! It turns out, fabrics in doctors coats can be a breeding ground for bacteria, and they probably don’t get cleaned often enough.

    This episode was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.


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  • Healthcare Triage Podcast: How New Drugs Are Developed

    Dan Skovronsky, President of Lilly Research Laboratories and Chief Scientific Officer for Eli Lilly and Company gives us a peek into the drug discovery and development process specifically focused on Alzheimer’s detection and research.

    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

    As always, you can find the podcast in all the usual places, like iTunes and Soundcloud.


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