JayB

BC or Calgary?

I always thought it was "Fah-vrey."

Where are you thinking of heading? Colorado, Utah, Canada? Overseas?

Would you say that they are nearly identical in ethno-cultural terms as well? If the proximity between Canada and Mexico were the same as between Mexico and the US, and Canada had been absorbing the same number of immigrants (in percentage terms) from Mexico and other locales south of the border for the same amount of time, are you certain that this would have no bearing whatsoever on the aggregate behavior in Canada, or wouldn't present some challenges with regards to neonatal/maternal health that the system there doesn't currently have to contend with? I couldn't actually find the report that they were referring to, but hopefully someone can dig it up. With regards to Ireland, here's a partial explanation for the difference between Ireland and, say, Canada, from the Irish Medical Journal: "Maternal Mortality Statistics in Ireland: Should They Carry a Health Warning? C Murphy, C O Herlihy University College Dublin and National Maternity Hospital Holles Street ,Dublin 2 Sir, Maternal mortality statistics are the most important indicators of reproductive women’s health care. Ireland has experienced a gratifying progressive decline in maternal deaths for over 60 years; rates cited by the Central Statistics Office (CSO), and taken up by the news media, suggest that this is one of the safest countries in the world in which to deliver a baby. Nevertheless, closer inspection of maternal death rates in the Republic indicate significant under-reporting by the CSO thus casting considerable doubt on any comparative conclusions, and in fact, on the overall reliability of figures in recent years. Each of the three chartered Dublin maternity hospitals (National Maternity, Coombe and Rotunda) publish Annual Clinical Report 1-3 of their activity before the end of the following year. In five of the fifteen years from 1990-2004, these reports have indicated that more maternal deaths have occurred in Dublin than have been reported in the National birth cohort (see Table 1). These repeated discrepancies are consistent with persistently defective case ascertainment by the current mechanisms used by the CSO. This should be addressed as a matter of priority." As far as the discrepancy with the rest of the world is concerned, it would be interesting to see a breakdown of the statistics concerning who dies of what. My understanding - which may be incorrect - is that most deaths associated with childbirth in developing countries these days are a consequence of something that occurs during the delivery or shortly thereafter, which suggests that they're likely to occur within a hospital environment. I could be wrong about this, but if that's the case, I have a hard time believing that a woman haemorrhaging after delivery is more likely to die in a US delivery room or hospital than in, say, Italy - but perhaps this is the case. As far as maternal mortality in the US is concerned, I think that we actually keep reasonably good records of this, at least when someone's doing a study. I think that this study may address your question to a certain extent: "1: MMWR Surveill Summ. 2003 Feb 21;52(2):1-8.Links Pregnancy-related mortality surveillance--United States, 1991--1999. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, Syverson CJ. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, USA. PROBLEM/CONDITION: The risk of death from complications of pregnancy has decreased approximately 99% during the twentieth century, from approximately 850 maternal deaths per 100,000 live births in 1900 to 7.5 in 1982. However, since 1982, no further decrease has occurred in maternal mortality in the United States. In addition, racial disparity in pregnancy-related mortality ratios persists; since 1940, mortality ratios among blacks have been at least three to four times higher than those for whites. The Healthy People 2000 objective for maternal mortality of no more than 3.3 maternal deaths per 100,000 live births was not achieved during the twentieth century; substantial improvements are needed to meet the same objective for Healthy People 2010. REPORTING PERIOD COVERED: This report summarizes surveillance data for pregnancy-related deaths in the United States for 1991-1999. DESCRIPTION OF SYSTEM: The Pregnancy Mortality Surveillance System was initiated in 1987 by CDC in collaboration with state health departments and the American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provide CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death certificates) of all deaths occurring during or within 1 year of pregnancy. State maternal mortality review committees, the media, and individual providers report a limited number of deaths not otherwise identified. Death certificates and relevant birth or fetal death certificates are reviewed by clinically experienced epidemiologists at CDC to determine whether they are pregnancy-related. RESULTS: During 1991-1999, a total of 4,200 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 11.8 deaths per 100,000 live births and ranged from 10.3 in 1991 to 13.2 in 1999. The pregnancy-related mortality ratio for black women was consistently higher than that for white women for every characteristic examined. Older women, particularly women aged >/= 35 years and women who received no prenatal care, were at increased risk for pregnancy-related death. The distribution of the causes of death differed by pregnancy outcome. Among women who died after a live birth (i.e., 60% of the deaths), the leading causes of death were embolism and pregnancy-induced hypertension. Interpretation: The reported pregnancy-related mortality ratio has substantially increased during 1991-1999, probably because of improved ascertainment of pregnancy-related deaths. Black women continued to have a 3-4 times higher pregnancy-related mortality ratio than white women. In addition, pregnancy-related mortality has the largest racial disparity among the maternal and child health indicators. Reasons for this difference could not be determined from the available data. PUBLIC HEALTH ACTIONS: Continued surveillance and additional studies should be conducted to monitor the magnitude of pregnancy-related mortality, to identify factors that contribute to the continuing racial disparity in pregnancy-related mortality, and to develop effective strategies to prevent pregnancy-related mortality for all women. In addition, CDC is working with state health departments, researchers, health-care providers, and other stakeholders to improve the ascertainment and classification of pregnancy-related deaths." (Incidentally, using figures generated by measuring the actual number of deaths (11.8) and multiplying that by the average number of births-per-woman in the US (2.13) and dividing 100,000 by this number actually gives figures that are higher(worse) than the figures from the WHO.) I would guess that in summary - I would say that -I'm not convinced Ireland or any other stats are completely accurate, and that when the overall incidence is low across the board, minor variations in standards for reporting can have significant impacts on the values that show up in the statistical record. -More pregnancies in high risk groups where neither the mother nor the baby receive adequate pre-natal care. I'd wager that quite a bit of this is correlated with teen-pregnancy rates in the said groups. I'll leave it to others to speculate as to the effect that changing to a single-payer plan would have on outcomes in these cases.

I think the idea with respect to savings accounts isn't that those who held them would no longer need insurance, but that they would be used to cover non-catastrophic medical expenses in conjunction with high deductible insurance plans that would kick in when and if the expenses exceeded the annual deductible. The idea here is that by increasing the deductible you decrease your premiums enough that you are actually reducing your total expenditures on health care each year, and a greater percentage of the money that you do spend goes directly to providers rather than to insurance companies. As far as the endpoints under discussion are concerned, I'm not convinced that the intercountry comparisons are completely valid, and that a baby born at a particular gestation point, birthweight, etc is more likely to die in the US than in another country, I'd like to see it. The study that Murray cites for maternal mortality may be valid, but I'd need to see the study before conceding that a pregnant woman in the US is more likely to die before, during, and after giving birth than than in other countries. That's possible, but I'd like to see the data. As far as your frustrations are concerned, I share them, but mine are the inverse of yours. In my opinion, when you compare data across countries you have to be very careful when attempting to determine which outcomes are due to differences in the manner that the country provides health care, and which are due to cultural factors and lifestyle choices that are unlikely to vary much from one health-care delivery model to the next, and I rarely see much enthusiasm for this task.

If there's one thing that you can trust in this world, it's third hand statistics. (And yes, do lecture me on this point, ye champion of the "Fat Virus.") I could be incorrect, but I also think it's possible that the methodology they used for their rankings may not produce an accurate result. It's hard to say without seeing the study. Just for that, I'm going to force you to do some scrolling: " Maternal mortality in 2000 Estimates developed by WHO, UNICEF and UNFPA Maternal mortality: The measurement challenge Definitions The Tenth Revision of the International Classification of Diseases (ICD-10) defines a maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.4 The 42-day limit is somewhat arbitrary, and in recognition of the fact that modern life-sustaining procedures and technologies can prolong dying and delay death, ICD-10 introduced a new category, namely the late maternal death, which is defined as the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy. According to ICD-10, maternal deaths should be divided into two groups: * Direct obstetric deaths are those resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. * Indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy. The drawback of this definition is that maternal deaths can escape being so classified because the precise cause of death cannot be given even though the fact of the woman having been pregnant is known. Such under-registration is frequent in both developing and developed countries. Deaths from “accidental or incidental” causes have historically been excluded from maternal mortality statistics. However, in practice, the distinction between incidental and indirect causes of death is difficult to make. To facilitate the identification of maternal deaths in circumstances where cause of death attribution is inadequate, ICD-10 introduced a new category, that of pregnancy-related death, which is defined as: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In practical terms then, there are two distinct approaches to identifying maternal deaths, one based on medical cause of death following the ICD definition of maternal death, and the other based on timing of death relative to pregnancy, that is, using the ICD definition of pregnancy-related death. This has important implications for the approaches to measurement described below. Measures of maternal mortality There are three distinct measures of maternal mortality in widespread use: the maternal mortality ratio, the maternal mortality rate and the lifetime risk of maternal death. The most commonly used measure is the maternal mortality ratio, that is the number of maternal deaths during a given time period per 100,000 live births during the same time period. This is a measure of the risk of death once a woman has become pregnant. The maternal mortality rate, that is, the number of maternal deaths in a given period per 100,000 women of reproductive age during the same time period, reflects the frequency with which women are exposed to risk through fertility. The lifetime risk of maternal death takes into account both the probability of becoming pregnant and the probability of dying as a result of that pregnancy cumulated across a woman’s reproductive years. In theory, the lifetime risk is a cohort measure but it is usually calculated with period measures for practical reasons. It can be approximated by multiplying the maternal mortality rate by the length of the reproductive period (around 35 years). Thus, the lifetime risk is calculated as [1-(1-maternal mortality rate)35]. Why maternal mortality is difficult to measure Maternal mortality is difficult to measure for both conceptual and practical reasons. Maternal deaths are hard to identify precisely because this requires information about deaths among women of reproductive age, pregnancy status at or near the time of death, and the medical cause of death.4 All three components can be difficult to measure accurately, particularly in settings where deaths are not comprehensively reported through the vital registration system and where there is no medical certification of cause of death. Moreover, even where overall levels of maternal mortality are high, maternal deaths are nonetheless relatively rare events and thus prone to measurement error. As a result, all existing estimates of maternal mortality are subject to greater or lesser degrees of uncertainty. Broadly speaking, countries fall into one of four categories: * Those with complete civil registration and good cause of death attribution – though even here, misclassification of maternal deaths can arise, for example, if the pregnancy status of the woman was not known or recorded, or the cause of death was wrongly ascribed to a non-maternal cause. * Those with relatively complete civil registration in terms of numbers of births and deaths but where cause of death is not adequately classified; cause of death is routinely reported for only 78 countries or areas, covering approximately 35% of the world’s population. * Those with no reliable system of civil registration where maternal deaths – like other vital events – go unrecorded. Currently, this is the case for most countries with high levels of maternal mortality. * Those with estimates of maternal mortality based on household surveys, usually using the direct or indirect sisterhood methods. These estimates are not only imprecise as a result of sample size considerations, but they are also based on a reference point some time in the past, at a minimum six years prior to the survey and in some cases much longer than this (see below). WHO, UNICEF and UNFPA have developed estimates of maternal mortality primarily with the information needs of countries with no or incomplete data on maternal mortality in mind, but also as a way of adjusting for underreporting and misclassification in data for other countries. A dual strategy is used that adjusts existing country information to account for problems of underreporting and misclassification and uses a simple statistical model to generate estimates for countries without reliable data. Approaches for measuring maternal mortality Commonly used approaches for obtaining data on levels of maternal mortality vary considerably in terms of methodology, source of data and precision of results. The main approaches are described briefly below. As a general rule, maternal deaths are identified by medical certification in the vital registration approach, but generally on the basis of the time of death definition relative to pregnancy in household surveys (including sisterhood surveys), censuses and in Reproductive Age Mortality Studies (RAMOS). Vital registration In developed countries, information about maternal mortality derives from the system of vital registration of deaths by cause. Even where coverage is complete and all deaths medically certified, in the absence of active case-finding, maternal deaths are frequently missed or misclassified.5,6,7,8,9 In many countries, periodic confidential enquiries or surveillance are used to assess the extent of misclassification and underreporting. A review of the evidence shows that registered maternal deaths should be adjusted upward by a factor of 50% on average. Few developing countries have a vital registration system of sufficient coverage and quality to enable it to serve as the basis for the assessment of levels and trends in cause-specific mortality including maternal mortality. Direct household survey methods Where vital registration data are not appropriate for the assessment of cause-specific mortality, the use of household surveys provides an alternative. However, household surveys using direct estimation are expensive and complex to implement because large sample sizes are needed to provide a statistically reliable estimate. The most frequently quoted illustration of this problem is the household survey in Addis Ababa, Ethiopia, where it was necessary to interview more than 32,300 households to identify 45 deaths and produce an estimated MMR of 480. At the 95% level of significance this gives a confidence interval of plus or minus about 30%, i.e. the ratio could lie anywhere between 370 and 660.10 The problem of wide confidence intervals is not simply that such estimates are imprecise. They may also lead to inappropriate interpretation of the figures. For example, using point estimates for maternal mortality may give the impression that the MMR is significantly different in different settings or at different times whereas, in fact, maternal mortality may be rather similar because the confidence intervals overlap. Indirect sisterhood method The sisterhood method is a survey-based measurement technique that in high-fertility populations substantially reduces sample size requirements because it obtains information by interviewing respondents about the survival of all their adult sisters. Although sample size requirements may be reduced, the problem of wide confidence intervals remains. Furthermore, the method provides a retrospective rather than a current estimate, averaging experience over a lengthy time period (some 35 years, with a midpoint around 12 years before the survey).11 For methodological reasons, the indirect method is not appropriate for use in settings where fertility levels are low [total fertility rate (TFR) <4] or where there has been substantial migration, civil strife, war, or other causes of social dislocation. Direct sisterhood method The Demographic and Health Surveys (DHS) use a variant of the sisterhood approach, the “direct” sisterhood method.12 This relies on fewer assumptions than the original method but it requires larger sample sizes and the information generated is considerably more complex to collect and to analyse. The direct method does not provide a current estimate of maternal mortality but the greater specificity of the information permits the calculation of a ratio for a more recent period of time. Results are typically calculated for a reference period of seven years before the survey, approximating a point estimate some three to four years before the survey. Because of relatively wide confidence intervals, the direct sisterhood method cannot be used to monitor short-term changes in maternal mortality or to assess the impact of safe motherhood programmes. The Demographic and Health Surveys have published an in-depth review of the results of the DHS sisterhood studies (direct and indirect methods) and have advised against the duplication of surveys at short time-intervals.13 WHO and UNICEF have issued guidance notes to potential users of sisterhood methodologies, describing the circumstances in which it is or is not appropriate to use the methods and explaining how to interpret the results.14 Reproductive Age Mortality Studies The Reproductive Age Mortality Study – RAMOS – involves identifying and investigating the causes of all deaths of women of reproductive age. This method has been successfully applied in countries with good vital registration systems to calculate the extent of misclassification and in countries without vital registration of deaths.9,15,16,17,18 Successful studies in countries lacking complete vital registration use multiple and varied sources of information to identify deaths of women of reproductive age; no single source identifies all the deaths. Subsequently, interviews with household members and health-care providers and reviews of facility records are used to classify the deaths as maternal or otherwise. Properly conducted, the RAMOS approach is considered to provide the most complete estimation of maternal mortality but can be complex and time-consuming to undertake, particularly on a large scale. Verbal autopsy Where medical certification of cause of death is not available, some studies assign cause of death using verbal autopsy techniques.(19) However, the reliability and validity of verbal autopsy for assessing cause of death in general and identifying maternal deaths in particular, has not been established. The method may fail to correctly identify a proportion of maternal deaths, particularly those occurring early in pregnancy (ectopic, abortion-related), those in which the death occurs some time after the termination of pregnancy (sepsis, organ failure), and indirect causes of maternal death (malaria, HIV/AIDS). Census There is growing interest in the use of decennial censuses for the generation of data on maternal mortality. A high-quality decennial census could include questions on deaths in the household in a defined reference period (often one or two years), followed by more detailed questions that would permit the identification of maternal deaths on the basis of time of death relative to pregnancy (verbal autopsy). The weaknesses of the verbal autopsy method have already been noted. Nonetheless, the advantages of such an approach are that it would generate both national and subnational figures and that it would be possible to undertake analysis according to the characteristics of the household. Trend analysis would be possible because sampling errors would be eliminated or greatly reduced. However, data obtained from enquiries into recent deaths in the household in a census require careful evaluation, and often adjustment. A number of countries have used the census to generate maternal mortality figures, and work is under way to assess the extent to which such approaches may prove of value in measuring maternal mortality. (2"

In the case of infant mortality - it's quite likely that the "quibbles" account for the vast majority of the variation between the US and other countries, so reallocating resources on the basis of the said variations could very well result in more spending where it's not needed, and less spending where it is. In the case of the child, that was tragic, but I think the story is more complicated than a simple lack of resources.

I find that hard to believe, but of course that doesn't mean it can't be true. It would be interesting to see the study and look at the study first hand. My hunch is that the figures are not as straightforward as they might seem at first glance, and don't actually capture the risk associated with each pregnancy in one highly developed country (where the risk of dying during or because of complications associated with childbirth is relatively low) versus another terribly well, and that within these subgroups, the variations in the fertility rate will skew the statistics. E.g., in developed states where the women have relatively few children, this distorts the maternal mortality risks downward relative to the average, and distorts the risks upwards where fertility is highest. Maybe you can post a link to the story when you get a chance. In the meantime, here's a link that might have some bearing on this discussion: http://www.who.int/reproductive-health/publications/maternal_mortality_2000/challenge.html My larger point isn't that we should dismiss all data - statistical or anecdotal - that reveals shortcomings in the American healthcare. However, it's incumbent upon anyone who cares about improving healthcare in to insure that both the data and the interpretations of it are as accurate as possible. That is, if the goal is to draw attention to and allocate resources towards the resolution real problems. I don't personally think that the odds of a baby born with a given risk - be it a congenital defect, low birthweight, premature birth, or any other condition - dying ins a US hospital are any greater than those of the same baby dying in Canada, France, etc. I'd make the same claim with regards to mothers, and I think that allocating more resources to neonatal ICU's, and the like would do little to help either newborns or women who've just delivered babies in this country. The area where I do think that the US can improve is with regards to pre-natal care in poor and minority communities, especially recent immigrants. To the extent that women in these groups aren't getting care for their unborn children for for a lack of resources - this is indeed a problem, but I don't think it's reasonable to conclude that socializing all of medicine would be more effective in addressing these problems than other approaches that could be undertaken by selective changes in government spending, insurance regulations, etc. However, I also think in these groups, that there are dimensions to this problem that go beyond the mere availability of resources.

I'm all for improving the health care system, but am not sure that what you propose would actually do that any better than modifying the existing system to remedy that problems associated with it. But that's an old discussion. Dmjua: With regards to infant mortality rates - are you confident that all of the nations are using the same set of criteria to classify pre and post natal mortality? If a baby is born premature, is under a certain weight, and dies before a specified period after birth - the death will show up as an infant death, rather than a stillbirth in all countries? If so, you may wish to consult the literature, and then ponder what effect national differences such as these may have on the statistical record.

The North Face of Shuksan might be worth looking into as an alternative if the snow conditions are favorable. Probably a more pleasant outing than LR this time of year for most parties, I'd imagine. You might also want to consider taking a look at Mount Hood.

Do you serve up this diatribe when handing over the espresso, or do you just smile and say "Have a nice day" and hope they'll toss another quarter in the tip jar?

I think you'd rather enjoy figuring this one out on your own, comrade, and I'd hate to deprive you of that opportunity. If there's any place that's conducive to reading, it's Bellingham in the winter. Bon chance.

Did he have any particularly relevant insight into this collection of turds as it relates to the actual historical record?: meddling socialist engineers always trying to "solve" some problem with big gov't and only creating more problems... which of course they will "solve" with big gov't. repeat. meanwhile Archie pays more taxes Recognizing of course that: A. He's dead B. We're talking about the US. The oblivio-irony of this post issuing forth from the personification of his central thesis amuses..

You burn quite a few more calories chasing down a whale than you do chasing down a cheeseburger or a brick of welfare cheese. Death by starvation wasn't terribly uncommon. http://query.nytimes.com/mem/archive-free/pdf?_r=1&res=9D01E7DD173CE433A25752C1A9639C94649ED7CF&oref=slogin

Adding skiing/climbing towns to the database would be my first suggestion. Lacking that - folks should feel free to chime in with post climbing/skiing bars/pubs/restaurants for the benefit of their fellow climbers. The Tav in Ellensburg, and The Brick in Roslyn (or maybe it's Cle-Elum) have been pretty sweet. -Alternatives to Gustav's in Leavenworth would also be worth compiling. -How about places on the way to/from Tieton? -Heading to/from Mt. Rainier and/or Crystal?

Raymond Aron is sighing wearily in his grave....

"High Five'n White Guys" and "The Lame List," also get high marks.

Nothing can match the genius of "Sluggy..."

My goal is to insure that's all that gets broken. I'm sure that Halford would approve of the studded tires I'll be installing at the end of the month, if not sooner...

The burned hand teaches best...

"It's been eight years since a new episode of "Almost Live" came out. Up-down-up-down monorail, drunken driving council candidates, the Sonics owner's feet of Clay and civic paralysis -- all became vital local issues. But they also represent something more. They are missed opportunities, unwritten bits. Here was the target-rich environment where "Almost Live" made its mark for 15 years. Even so, Keister isn't so sure that the issues today -- as good as they remain -- could prop up the show once famous for its parodies of local politics, neighborhood stereotypes, Seattle quirkiness and anything regarding Renton or Kent. The city has lost its oddball manner and its regional distinction, he said, in ways that have muted much of "Live's" local flavor. Former "Live" cast member Nancy Guppy agreed. "I don't know if it could exist now," she said. Everything is becoming more homogeneous, with condos stacked on Subways, luxury markets, Pottery Barns. Said Guppy: "I'm not sure who cares about the local thing -- the Seattle thing." Or as Keister put it: "Ballard was old Scandinavians. Fremont was hippies. Capitol Hill was gay. Kent was where whites of modest means moved to escape Seattle school busing. Bellevue was the same for the rich. "Today, you can make a joke about Ballard but it's a bunch of wealthy people who work in the information industry. You make a joke about Wallingford and it's a bunch of wealthy people who work in the information industry. Fremont? That would be a bunch of wealthy people who work in the information industry. "And Belltown is a bunch of wealthy people who live in luxury condos ... who work in the information industry."

I run red lights, ride the wrong way on one way streets, cross at random places and commit a gazillion other violations so long as doing so doesn't force motorists to change their speed or direction.

Is this just a change that you've wanted to make for a while, or because the job-market for life scientists in Seattle is just so incredibly abysmal and will be for the indefinite future?

Thanks, that's useful information, but unfortunately for me I think that the Edge Card is limited to residents of BC/WA. Are the gas coupons on the table this year for sure. With the value of the Dolero being what it is relative to the Loony, that'd be pretty important when deciding whether to hit Whistler or Utah.

There's also the issue of striking targets where you know there will be civilians. If all of AQ's leadership were sitting in a building, and had five or six of their family members with them, then striking that building means passing an immediate, trial-free death sentence on people that are not guilty and by themselves pose no threat. Seems like this morally worse than torturing people who you have even the slightest reason to suspect are or have been engaged in acts of terrorism. Seems to me like our distaste for using painful interrogation techniques is significantly greater than our distaste for ordering an airstrike on a compound full of terrorists that may or may not have civilians in it. I wonder why this is.