Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
MARY RIMSZA: Thank you very much. First I have to say I’m greatly honored to be asked to speak here. I’m usually talking to my own colleagues in Pediatrics and it’s a little challenging to talk to a whole different kind of audience, and I hope what I have to say will be of interest to you. Basically, I’m just a pediatrician with a strong interest in child health advocacy and has led me in a number of different directions in the course of my career. What I’m going to talk today about is the specific issues related to children’s health in the southwest, and it’s interesting that all the speakers have really touched on some of the same areas that we see as special challenges for us, including the ethnic diversity of our populations. A large number of Native American and Hispanic population here, which adds such rich and historic culture, but also creates special challenges. The fact that in the southwest we are dealing with populations that live in widely different settings from urban, rural, to even frontier regions. There’s already been some discussion about the issues we have as a border state, and situations associated with having a lot of foreign-born mothers, as well as undocumented children. And probably not unique to the southwest, we have a huge, but certainly a big problem here.
We have a huge population of uninsured and underinsured that we have to deal with. And lastly, one thing that maybe isn’t brought up very much, but comes up for me as somebody who tries to advocate for children, is we have a very anti-government culture in the southwest, quite different than other parts of the country. When I have to tell my colleagues in pediatrics at national meetings that we had a big fight in our state about whether or not children could carry guns in public and there was a big fight about that, they kind of look at me aghast and say, “You mean people thought it was okay for children to have guns?” And I said, “Well, in Arizona they thought that was okay.” So the last two I’m not going to discuss because mostly what I want to do is share with you some of our data from the Child Fatality Review programs and how it relates to those first three issues, and there really isn’t enough time to go through all of these areas.
Let me begin by telling you a little bit about the Arizona Child Fatality Review Program. It’s been in existence now for 10 years. It provides an ongoing multidisciplinary review of all child deaths in the state. The death of every child under the age of 18 is reviewed as part of our Child Fatality Review Program. One of the unique things about it is we don’t just collect the data and report it, we really look at every single death and we make an assessment of whether or not we thought that death could have been prevented, which I think is very important. And we use that data. And when we talked earlier about data versus practice and conflicts, there’s no conflict within what we do. We gather the data and we also try to use the data to make recommendations for prevention statewide. We share this data with our legislators, community, policymakers, and the media each year when we produce an annual report. I think it’s also very unique in that it’s really a locally driven program. Local teams in each of Arizona’s counties meet to look at each of these deaths and to assess the preventability. It’s not done by somebody else in the Capital. It’s done by the who live in the same community where the death occurred.
The mission of the Child Fatality Review Program is to reduce preventable child fatalities by reviewing the child deaths and make data driven recommendations for community based prevention, education, legislation, and public policy. I need to mention for you how we define a preventable child death. The team uses as a definition a child’s death is considered preventable if an individual or the community could reasonably have done something that would have changed the circumstances that led to that child’s death. The process is as follows: each time a child dies, a death certificate is sent to the local teams on that death. If the child was under one year of age, the birth certificate is also sent by the vital records. Then the team meets--and I’ll tell you the constitution of the team in just a minute--and a standard data form is completed. That data is then entered into a state database and from that we produce an annual report. I’m not going to go through in detail the composition of our teams. I want to just show you who is on our teams just so you could get an idea of the breadth of the individuals involved. There’s representatives of the pediatric community, medical examiner’s office, CPS, DES, Department of Health Services, the courts, the Native American community. With the Inter Tribal Council of Arizona, the Navajo Nation, military family advocacies, our Sudden Infant Death Review. So we try to have a very broad group of people on the teams. This is at the state level. The local teams have a similar diversity, but they’re people who actually live in that county.
Let me discuss some of our data from the Child Fatality Team as it relates to some of these special challenges. The first one I want to discuss with you is the ethnic diversity. The ethnic disparities in total death rates are quite striking, I think, in Arizona. The data here shows you that--and this is for the 2002 deaths, and it represents all the deaths, not just the preventable ones--that black children had a much higher mortality rate than other ethnic groups: 86.5 compared to 51.8, and you can see from the data there that the Hispanics were second, and then American Indian children, third. Now what I’m going to show you next is some information from a article our group wrote that was published in “Pediatrics.” It is available on the ADHS website if you want to know more details about it. But summarizes the data from 1995 to 1999 on our Child Fatality Review Team, and it’s the first five full years of data that we had available. During that period of time, there were 4,800 death reviewed by the Child Fatality Review Team. We tried to make it 100 percent, but sometimes we miss a few because death certificates come in too late for the report or other reasons.
In that period time, our team found that almost a third of all deaths in our state could have been prevented, and that number has been consistent from year to year. Maybe go up a percent or two, but it’s basically been consistent from year to year. When you look at the ages of the children who died, there’s quite a difference in whether or not the death was preventable. For example, in the neonatal period, only five percent of deaths were preventable, and that makes sense when we consider the causes of death in that age group. Most children in that age group die of prematurity or congenital anomalies, and we haven’t found cures for most of those yet. The older age groups, the other children in the first year of life are older children, 26 percent of those deaths are preventable, and the two most common causes of death we see in that age group are Sudden Infant Death Syndrome and congenital anomalies and infectious diseases. And most of the preventable deaths are Sudden Infant Death Syndrome deaths when a child was not positioned appropriately for sleep. We seen a big decrease in that as other states have over the past 10 years, but that’s been really helpful. Thirty-three percent of the deaths in children one to 9 were preventable, and 56 percent of children over 9. Leading categories of deaths that were preventable: motor vehicle crashes, similar to what you might expect nationwide. But the second one is drowning, which is certainly a much bigger problem here than other parts of the country.
This information is pretty striking in terms of preventable deaths as well. Although they didn’t have the highest death rate among American Indian children, they do have the highest preventable death rate in our state. So we have many more opportunities to prevent Native American deaths in the other groups. Among American Indian children, we found that they have the highest preventable motor vehicle crash deaths. This has to do with the nature of living in rural environment, lots of travel on the roads. They have the highest preventable intentional injury death rates, unfortunately. But look at infant mortality: they have the lowest infant mortality. Hispanic children: they have the second highest motor vehicle crash death rate preventable in our state. The lowest preventable medical deaths, which relates to what Michael said previously regarding healthier populations and maybe not picking up the bad habits of our culture yet. Highest death in adolescence. Black children, unfortunately, have the highest infant mortality and the highest preventable medical deaths of any age group. In terms of urban, rural, and frontier regional factors, we have some real special issues we need to deal with because we have different governance in tribal areas that affect our ability to conduct public health.
We have limited health resources in rural areas, as has been discussed previously. We have children in rural areas much more likely to be living in injury prone environments, I think. A lot of reliance on automobiles and more time you spend in the car, the more likely you are to have an automobile crash. And ubiquitous guns. Guns in the old west: in Arizona we have found with our child fatality review that six percent of all deaths in our state are due to guns. These are highly male adolescents: 71 percent of them, usually a handgun. And from 1995 to 1999, we had 317 children die in our state due to guns. In the urban areas we also have our problems. Limited health resources, especially for the uninsured. Presence of backyard swimming pools. Swimming pools are the most common injury cause of death in our state for children one to four. It’s the most common cause of death, and these are largely related to the backyard pools. From 1995 to ’99, 187 Arizona children died due to drowning, and 70 percent of these children, unfortunately, were less than five years of age. Most of them drown in a backyard pool. Again, we have the reliance on automobiles and the access of guns.
We have border state issues, which I think are very important. Last year our Child Fatality Review Team reported that for the first time, we lost seven children in our state due to border crossings. These were children 11 to 17 years of age. While we hear about the hundreds of adults who die crossing the borders, we also have a problem with child death from this. In addition, they have the lack of healthcare resources, unwillingness oftentimes for undocumented people to cooperate with public health, and the issues of transporting public infectious diseases across borders. See, I’m trying to get you back on time. Let me just conclude by saying I think we have multiple unique challenges for U.S. in improving child health in the southwest, and programs such as the Child Fatality Review Team can be very helpful in meeting these challenges. By providing an ongoing review of every child death in the state, particularly with a focus on preventability, we can bring the community involvement into the public health arena. In addition, since the approach we use starts and ends at the local level, you already have the investment of your local community in coming up with prevention solutions. If you’d like to ask me questions later, I’ll be around as long as I can this morning. I’ve got a lot of flu to deal with in my practice situation, so I may not be able to stay for too long. And I’d be happy to answer any questions if we have time later.