How to make childbirth safer for mothers and infants (hint: not by spending more money)

"American Way of Birth, Costliest in the World." 

That's the headline of an article by Elisabeth Rosenthal in yesterday's New York Times. The article includes a chart comparing childbirth costs in seven countries. In the United States, the average amount paid for a conventional delivery in 2012 was $9,775; for a Caesarean section, it was $15,041. Those are the highest prices for childbirth anywhere in the world.

To get an idea of just how high, I made a chart using the figures in the NYT chart. Childbirth costs in the other six countries range from 21 to 43% of US costs, even though American women typically spend far less time in hospital.

This chart is based on prices that are actually paid, whether by individuals, insurers, or the government. [Chart by L. Neff; data from the International Federation of Health Plans 2012 Comparative Price Report]

You'd think America's higher costs would mean that American women and infants get better care. Not at all. "Despite its lavish spending," Rosenthal writes, "the United States has one of the highest rates of both infant and maternal death among industrialized nations." And among lots of other nations as well: according to the CIA's World Factbook, 50 countries have a lower infant mortality rate than the US, and 47 countries have a lower maternal mortality rate.

 Here's some comparative data in graph form. The longer the line, the more dangerous the country is for mother and child.

South Africa is so dangerous for childbirth that its graph line would not fit on this blog page. For every 1,000 births, there are 56 infant deaths. For every 100,000 births, there are 400 maternal deaths. [Chart by L. Neff; data from WHO]

Rosenthal mentions one reason that high costs often do not translate into low death rates: "The fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures." I decided to use the Gini Index - a scale that measures "the degree of inequality in the distribution of family income in a country" - to compare the seven countries in the NYT graph. Here are the results:

South Africa's red line is missing because for every 100,000 births in that country, there are 400 maternal deaths. The chart would have had to be six times wider to accommodate the data. [Chart by L. Neff; data from CIA and WHO]

Wow. I didn't expect the results to line up so neatly, but there you have it: The more inequality in a country's  distribution of family income, the more mothers and babies die in childbirth. Of the 136 nations reported by the CIA, South Africa is #2 on the inequality list. Chile is #15, the United States is #41 (that means that 40 countries have less income equality than the US, while 95 countries have more). Britain, France, the Netherlands, and Switzerland, at numbers 60, 101, 111, and 117 respectively, all have significantly more income equality than the US.

Number 136, the nation with the least inequality of all, is Sweden. Swedish infant and maternal mortality rates are even lower than Switzerland's - in spite of the fact that Sweden spends about 1/3 less per capita on healthcare.

COOKED by Michael Pollan

Eat food.
Not too much.
Mostly plants.

--Michael Pollan, In Defense of Food

In The Omnivore's Dilemma (2006), science journalist Michael Pollan looked at how food is produced. In his next two books, In Defense of Food (2008)and Food Rules (2009), he told us what we should eat (see above). In his most recent book, Cooked (April 2013), he investigates the methods, biology, and philosophy of food preparation.

I loved Omnivore: it's one of those rare books that can get a person fascinated by a topic that previously held no interest whatsoever. The two Food books were thin but full of wise advice, such as Pollan's now-famous seven-word guide to good eating.

Cooked, at 480 pages, should have been thinner.

I enjoyed Pollan's introduction, which is essentially the speech I heard him give at a nearby college a couple of months ago. Cooking, he says, is what separates humans from all other species--or at least so wrote the Scottish biographer Boswell in the 18th century, the French gastronome Brillat-Savarin in the 19th, and the French anthropologist Lévi-Strauss in the 20th. In fact, numerous writers suggest, cooking (rather than hunting and gathering) made civilization possible.

Unfortunately, Americans in the 21st century seem to be devolving: we now spend less time than people of any other nation preparing our meals, though we watch an incredible amount of cooking-related TV. "The premise of this book," Pollan writes, "is that cooking--defined broadly enough to take in the whole spectrum of techniques people have devised for transforming the raw stuff of nature into nutritious and appealing things for us to eat and drink--is one of the most interesting and worthwhile things we human beings do."

Pollan explores four of these techniques in the book's four sections, "Fire" (grilling: barbecue), "Water" (braising: stews), "Air" (baking: bread), and "Earth" (fermenting: sauerkraut, cheese, wine, beer). In each section he observes and often works alongside masters of the particular craft, not only describing each process but also telling how to reproduce the ancient methods today, how they work biologically, what they offer nutritionally, and how the results taste.

Part of the fun of a book by Pollan is the way he interacts with his topic. My favorite story in Cooked is about the night he and his son, Isaac, decided to "cook" a meal using only convenience foods bought at Safeway. It's not exactly a spoiler to let you know the outcome: more time, more expense, and less family time at table than when they cooked meals from scratch. And besides, after the first three bites everything tasted alike.

Still, 480 pages turned out to be more than I wanted to know. I found myself skimming though many descriptive pages that needed to stop circling and come in for a landing. Pollan could have condensed his material into one fantastic magazine article, or maybe even four of them. His book-length treatment, however, seemed excessive.

Besides, I wondered, why was the guy who told us to eat "mostly plants" devoting maybe three-quarters of his book to meat and dairy?

If you haven't yet read a book by Pollan, don't start here: you are more likely to be entranced by The Omnivore's Dilemma. If you already love Pollan's writing (or his frequent commentaries on TV), go ahead and read Cooking. Skim if you need to: just as you're thinking, he does go on, doesn't he, you'll hit a trenchant observation that keeps you reading. Like this, for example, on the role of alcohol in religion:

Alcohol has served religion as a proof of gods' existence, a means of access to sacred realms, and a mode of observance, whether solemn (as in the Eucharist) or ecstatic (as in the worship of Dionysus or, in Judaism, the celebration of Purim). The decidedly peculiar belief that, behind or above or within the physical world available to our senses, there exists a second world of spirits, surely must owe at least a partial debt to the experience of intoxication. Even today, when we raise and clink glasses in a toast, what are we really doing if not invoking a supernatural power? That's why a glass of water or milk just doesn't do the trick.

I'll drink to that.

J. Alfred Prufrock contemplates retirement

There will be time, there will be time

To prepare a face to meet the faces that you meet;

There will be time to murder and create,
And time for all the works and days of hands
That lift and drop a question on your plate;
Time for you and time for me,

And time yet for a hundred indecisions,

And for a hundred visions and revisions,

Before the taking of a toast and tea.
 T.S. Eliot 

Wednesday is my husband's last day at the office.
We've been looking forward to this next phase of our lives for a long time. For some 25 years we've been sending a large percentage of our modest incomes to retirement accounts. We joke that our retirement plan is to live on so little that we won't miss it when it's gone.

For the last several months we've been crunching the numbers. When exactly should he retire? Would a reallocation of our retirement resources make them last longer? Which of our two highly professional, fee-based, but disagreeing financial advisers should we follow? When should we take Social Security? When can we start getting Medicare benefits? Which work-based health-insurance plan should we sign up for in order to stay covered until Medicare kicks in? Which of the many Medicare supplemental insurance plans is best? Which of the many insurance companies offering such plans is most likely to stay solvent and keep its rates low? Which Medicare Part D prescription drug plan will best suit our needs?

We've also been looking at lifestyle questions. Should we stay in the place that has been home for 25 years, or should we move to be closer to family? We know about living too far from our kids - 1100 miles from one daughter's family, 800 miles from the other's - but is it possible to live too close? If we move, how do we find good realtors, here and there? What do we need to do to get our place ready to sell? We already live in a townhouse - should we downsize even further? When thinking about a place to live, what factors are most important to us? Will we need a place without stairs?

And then there's the question everybody asks: What will you do in retirement?

"First," my husband says, "I'm going to clean the garage." I hope he's not joking.

CATASTROPHIC CARE: HOW AMERICAN HEALTH CARE KILLED MY FATHER--AND HOW WE CAN FIX IT by David Goldhill

This week the company my husband works for unveiled the health-insurance plans available to us beginning July 1. If we chose the plan closest to our current plan, our premium would nearly double and our office visit co-pays would increase 25-50%.

I am so glad we are going on Medicare in August.

Medicare isn't perfect, by any means. It isn't even cheap. Just the insurance (Medicare medical, Medicare supplement, prescription) is going to cost us more than $500 a month, and that doesn't include the deductible or the prescription co-pays. And that's for this year. Who knows what it will cost 10 years from now?

I was so ready to read a book that would solve America's health-care crisis.

Besides, David Goldhill's title is irresistible: Catastrophic Care: How American Health Care Killed My Father - And How We Can Fix It.

First the bad news. Goldhill, who is president and CEO of the Game Show Network, got interested in health care when his physician father "died from a hospital-borne infection he acquired in the intensive care unit of a well-regarded New York hospital." In his early chapters, he piles up statistics about how truly dreadful our health-care system is. Wherever you are on the political spectrum, you need to read his "eleven strange things we all believe about health care." (Goldhill is a Democrat who thinks Obamacare will not work.)

After the bad news, Goldhill gives all kinds of wonky explanations about why our approach to health care doesn't work. This section will probably appeal most to free-market-loving Republicans. Despite being a lefty who distrusts the market, I found it very helpful.

Finally what we're all waiting for: Goldhill's solution. My daughter Molly should have written this book: she recommended an almost identical solution to me a couple of months ago when we had a long discussion about health care. (Molly and I do not agree about a lot of political issues, but we have respectful and helpful discussions. We don't see the point in today's political polarization: differing opinions can increase clarity and come up with better solutions than either side could do on its own.)

In a nutshell: Insurance should be reserved for catastrophes - unforeseen big-ticket expenses like major surgery or cancer treatment. Anticipated health-care expenses should come from health-care savings accounts. And there needs to be some kind of safety net.

What Republicans will like: Consumers need to have control of their own health-care dollars. There's no reason to siphon off 20% or more to insurance companies. Besides, when we pay for things ourselves, we tend to be a lot more careful about what we buy. We comparison shop. We avoid unnecessary expenses. And to get our money, providers compete with one another to provide good care at low prices.

What Democrats will like: Everyone must have a health-care savings account - no exceptions. Most people will build up a good-sized balance when they are young. As they age, they will start to draw from it. People whose emergencies cost more than their savings can borrow to cover the additional expenses. At a predetermined level, they need borrow no more: the government will make up the difference. Nobody will be left without health care: the government will provide the safety net (though not by running the program).

What everyone except certain industries and lobbyists will like: Prices must be completely transparent and equal for everybody. The market isn't free if people don't have the information they need to make smart decisions.

What nobody will like: There will be limits. Just because something sounds good in the TV ads doesn't mean everyone should have access to it. Some treatments (especially those that have little proven worth in lengthening lives) will not be available. Some will be too expensive and most people will choose to forgo them. Some will be available, but only to people who have lots of money to spend.

My favorite health-care book is still T.R Reid's The Healing of America. (See my review on this blog or in Christian Century, if you subscribe.) The fact is that a lot of other developed nations have much better health-care programs than America's. They get better results. People live longer. And they do this for about half our cost. Before we do anything else about health care, we need to lay aside our prejudices and study what these other countries are doing.

But if Reid should be required reading for legislators, Goldhill should be too. As Goldhill points out, America's politicians are unlikely to accept a lot of features that make perfect sense in other countries. We need a program that fits with our own weird beliefs and behaviors--one that combines vigorous free-market competition with a safety net for everybody.

Someday we may actually come up with such a program. But probably not until we understand, as Goldhill says, that "at some point, we will have to decide whether our attachment to the idea of helping people is more important than actually helping them--a decision that will require a rethinking of our assumptions."

MIDNIGHT AT MARBLE ARCH by Anne Perry

Some 20 years ago a friend lent me a stack of Anne Perry novels--all in the Charlotte and Thomas Pitt series, as I recall--which I eagerly devoured.

At the time I had no idea that Perry at age 15 conspired with a friend to murder the friend's mother, or that she at age 30 became a Mormon because of her commitment to morality. Until today I didn't know that since 1979 she has published more than 60 novels and novellas--almost two a year. No wonder, as her biographer points out, Perry's books deal with the themes of "miscarriages of justice, family secrets exposed, punishment, redemption and forgiveness."

Her newest book, Midnight at Marble Arch (number 28 in the Charlotte and Thomas Pitt series), is especially strong in the first two themes. The year is 1896. Thomas Pitt is now in charge of Special Branch, similar to the U.S. Department of Homeland Security. No longer a policeman, he does not normally get involved in assault cases, even when he learns that a prominent businessman's wife has died after being brutally raped.

But when it appears that the 16-year-old daughter of the Portuguese ambassador has been raped by a sociopathic but exceedingly rich young man, Pitt decides to act. His reason may be to satisfy his wife's sense of justice, but his excuse is that Britain's international relations will be endangered if foreign diplomats fear to bring their families to London--and whoever the rapist is, he is likely to strike again.

Meanwhile, the widowed businessman has asked Pitt's former superior, Lord Victor Narraway, to help him find the man who raped his wife. Narraway eagerly takes the case, partly to make himself feel useful in retirement, and partly because he is very fond of Charlotte Pitt's formidable great-aunt-by-marriage, Lady Vespasia Cumming-Gould.

And then a couple more women are raped, and Pitt and Narraway find themselves working together once again.

Perry adeptly portrays late 19th-century society with its fancy dress, incessant parties, and suffocating superficiality. She chillingly shows how most Victorians regarded rape, how it ruined women, and why it was rarely prosecuted. Somehow, however, the four sleuths at the center of the story--Thomas and Charlotte, Narramore and Vespasia--have escaped the attitudes of most of their contemporaries, which somewhat strains the story's credibility. But as long as you can handle 21st-century consciences in a few 19th-century people, you will likely enjoy this addition to the Charlotte and Thomas Pitt collection.

In fact, I think Midnight at Marble Arch might make a good movie.

Perry's plotting is full of surprises, and yet not too complex to follow easily. In a film, action and conversation would replace the book's incessant and sometimes tiresome inner questioning ("How many men feared for their sons?... What would Pitt do if Daniel ... should be wrongly accused of such a violent and repulsive crime?... How would Pitt know what Daniel thought of women who perhaps teased him, provoked him, with little or no idea of what tigers they were awakening?... How would he prevent Daniel from becoming a young man who treated women as something he had the right to use, to hurt, even to destroy? Where did such beliefs begin?... How would he ever make certain his son could lose an competition with the same grace as when he won?... Would it be Pitt's fault if Daniel grew up arrogant, brutal?"--and all of these questions come from just one page). With its faster pace and--minus the internal monologues--reduced opportunity for anachronism, the film might be even better than the book.

I haven't figured out who should play three of the four good guys, but Lady Vespasia Cumming-Gould, with her elegance, steel-trap mind, and late-life sexual allure, is Helen Mirren.

THE MOONLIGHT SONATA AT THE MAYO CLINIC by Nora Gallagher

Ten years ago Nora Gallagher wrote Practicing Resurrection, a memoir involving her brother's death, her Episcopal parish's response to their recently uncloseted gay priest, and her own process of deciding whether or not to prepare for priesthood. Publishers Weekly's anonymous reviewer loved it: "With a poet's ear for language and a novelist's eye for essential detail," she wrote, "Gallagher offers a compelling story of her journey toward 'a wholeness bought at the cost of suffering.'"

OK, I confess: I wrote that review. And I also loved Gallagher's earlier memoir, Things Seen and Unseen (1998), about her brother's cancer and her own coming to faith, all taking place within the framework of the church calendar with its major feasts and fasts.

So I was twice happy to learn from Gallagher's website that "Moonlight Sonata at the Mayo Clinic is part three of a quartet on modern faith as it is lived out"--once because this new memoir is about her journey into what she calls the Land of the Sick, or Oz (a land I know better than I'd like to), and twice because if this is part of a quartet, there's yet another book coming.

Let me say right up front that you should read Gallagher's other two memoirs first. They reach out to a broader audience. They are more finely crafted. They will allow you to befriend Nora before going with her on this darker journey where both physical and spiritual health are challenged.

The story begins in November 2009 when the vision in Gallagher's right eye goes blurry. She hasn't been feeling well anyway--headaches, queasiness, fatigue--so she schedules an appointment with her doctor. He doesn't like what he sees, and for the next two years Gallagher goes from specialist to specialist trying to find out, and hopefully to fix, whatever is wrong.

There's an element of medical mystery about her story, and I'm not going to spoil it by telling you the eventual diagnosis. Suffice it to say that it will not raise your opinion of American medicine in general: "Doctors were often baffled; the system of specialists who did not follow up on patients made it worse." The Mayo Clinic comes up smelling like roses, however. (Personal note: My experience at Cleveland Clinic, where I had open-heart surgery in 2011, was similar to Gallagher's at Mayo. Both have stellar reputations for the quality of their health care, and both have found ways to keep costs below the national average.)

Gallagher is a spiritual writer, and a person facing a major health crisis tends to have major spiritual concerns. I'm not going to spoil the account of her spiritual journey by telling you how her illness affected her faith, either. I'll only say that she and I--two women of about the same age, both of us having spent years in the Episcopal Church, both of us living with scary health conditions--look for peace in somewhat different places.

You may not identify with this memoir if you are young, or if you have never faced a life-threatening illness, or if you are a conservative evangelical. You'll probably want to read it if you prefer questions to answers, if you've faced serious illness or are caring for people who do, or if you work in health care and wonder how it feels to be the one on the examining table.

I'll finish by quoting a few paragraphs, one of Gallagher's many asides, that I particularly enjoyed:

I once interviewed Jews who had recently emigrated from Russia in one of the openings in the Cold War in the 1980s. Many of them had survived the siege of Leningrad. They were living in a retirement home in Denver. One of them took me aside after I had been there for a few days and said, "Tell me, Nora. Is everyone in America always fine? I ask someone how they were doing and they reply, always, 'Fine.'"
     I explained to her that this was a commonplace; a custom, it meant nothing. Relief showed all over her face.
     "Ah," she said. "That's good. Because I am rarely fine." (Later, whenever they saw me, they would chorus: "How are you? We are fine!" and then laugh uproariously.)
     I missed them, I thought. These were people who understood not fine.

Money: The God of This World

This week Pope Francis spoke out against the cult of money. Here is how Catholic News Service's Carol Glatz summarized his remarks:

Pope Francis called for global financial reform that respects human dignity, helps the poor, promotes the common good and allows states to regulate markets.

"Money has to serve, not to rule," he said in his strongest remarks yet as pope concerning the world's economic and financial crises.

A major reason behind the increase in social and economic woes worldwide "is in our relationship with money and our acceptance of its power over ourselves and our society," he told a group of diplomats May 16.

"We have created new idols" where the "golden calf of old has found a new and heartless image in the cult of money and the dictatorship of an economy which is faceless and lacking any truly humane goal."

His words reminded me of one of the most significant books I've ever read, Protestant French philosopher Jacques Ellul's Money and Power.

First published nearly 60 years ago as L'Homme et l'argent ("Man and Money"), new French-language editions appeared in 1979 and 2007. I translated the English-language edition in 1984 and have been grateful ever since for the opportunity to immerse myself in this paradigm-bending book.

Money, Ellul argued, is not morally neutral. It is "Mammon, a demigod, a demon, an idol, a power from which we need liberation" (I'm quoting from David Neff's review of Money and Power in the February 15, 1985, issue of Christianity Today--and yes, he may have been biased, but damn, his review was good).

The problem isn't money, we say. The problem is that we don't have enough. Or that somebody else has too much.

No, says Ellul. Money is not neutral. "Jesus personifies money and considers it sort of a god. He does not get this idea from his cultural milieu. … This personification of money, this affirmation that we are talking about something that claims divinity . … reveals something exceptional about money, for Jesus did not usually use deifications and personifications" (p. 75).

Ellul explains that in Matthew 6:24 and Luke 16:13 Jesus shows that money is a power, a law unto itself that acts in the material world but with a spiritual orientation. In the Bible, power is never neutral. And it is often personal. Just as Scripture often portrays death as a personal force, so it also portrays money.

In the 60 years since Ellul wrote Money and Power (and even more in the 30 years since I translated it), the love of Money has taken root throughout the world in ways even Ellul might never have imagined. We fight wars to keep it, and to gain more of it. We damage the earth, deny social services to the poor, and pay ever smaller wages for ever longer hours, because to do otherwise would be bad for business. We don't enforce safety regulations or we outsource production to places with no regulations, so we can make higher profits on cheaper goods. And we have developed a theology of money in which the "free market" is the giver of every good and perfect gift - never mind the evidence.

Perhaps this is nothing new. It's been 2000 years since Jesus identified money with Mammon. But whether our love of Money is worse than ever before in the history of the world, or whether it is just business as usual, Pope Francis joins Jacques Ellul in reminding us that Money is a powerful false god.

If you like to get your reminders straight from Scripture, read Revelation 18, a gorgeously dark and dreadful poem about the fall of Babylon, surely Mammon's capital city, for she has deceived "all nations." As Babylon falls, so do the political leaders who "committed fornication with her" and the business tycoons who "have grown rich from the power of her luxury" and the multinational merchants whose ships "grew rich by her wealth."

The good news in Scripture is not that our stock portfolio has doubled or that our taxes have been cut or even that our nation's GDP is in recovery. The good news comes through an unmarried pregnant teenager: The Mighty One

has brought down the powerful from their thrones,

and lifted up the lowly;

he has filled the hungry with good things,

and sent the rich away empty.

                                                  Luke 2:52-53