Comments for Boston University SPH — 10/24/2022

“They clarify our past, make livable our present and are certain to shape our future. And since the future is where our immortality as a race lies, no overview of the state of black people at this time can ignore some speculation on the only ones certain to live it — the children.”

Toni Morrison. A Slow Walk of Trees (as Grandmother would say), Hopeless (as Grandfather would say). New York Times Magazine (4 July 1976): 104+

I would like to thank the Boston University School of Public Health for inviting me to provide a simple framework I have been developing to assist people to begin having the same conversations. One huge limitation that we are seeing play out in the public health and clinical health services provision is a misalignment of conversations with values and resources. I believe this is one fundamental reason why we have not been able to make impactful change in resolving the Black maternal health crisis in the United States, COVID-19 and a whole host of other public health issues.

I, now never have to explain against others why it has been so difficult to fund prevention efforts neither in sexual and reproductive health or infectious disease — we have lived through almost 3 years of a stark example of this.

We are at a pivotal moment where everything we have ever valued in public health is up in the air. Many of the proxies we use to assess maternal and child health have been rendered almost meaningless by the Dobbs decision. For example, as my good friend Dr. Joia Crear-Perry has always pointed out, marital status is a useless proxy because when 2 poor people decide to parent, you now have 3 people attempting to live on the wages of 2 poor people. Similarly, early entry to prenatal care will need to be reimagined in the context of our current situation. It is not precise enough to capture that you may have spent a month or longer traveling across state lines to receive a wanted abortion that you were unable to obtain, so despite the fact that you may have had an ultrasound, seen a provider, talked to a counselor that somehow doesn’t count? This is one of many reasons why we need to operationalize reproductive justice alongside reproductive health and rights.

Therefore, I would like to take the opportunity to frame our discussion today such that we can have a shared discussion about what it will take to transform both public health and clinical health services provision toward improved reproductive health — including maternal health. As a reminder, let me provide the definitions of retrofit, reform, and reimagine from Merriam Webster.

Retrofit — transitive verb

1: to furnish (something, such as a computer, airplane, or building) with new or modified parts or equipment not available or considered necessary at the time of manufacture

2: to install (new or modified parts or equipment) in something previously manufactured or constructed

3: to adapt to a new purpose or need: MODIFY (retrofit the story for a new audience)

Reform — transitive verb

1a: to put or change into an improved form or condition

◦ b: to amend or improve by change of form or removal of faults or abuses

2: to put an end to (an evil) by enforcing or introducing a better method or course of action

3: to induce or cause to abandon evil ways (i.e., reform a drunkard)

4a: to subject (hydrocarbons) to cracking

◦ b: to produce (gasoline, gas, etc.) by cracking

Reimagine:

1: to imagine again or anew especially: to form a new conception of : RE-CREATE

Another way to think about this framework is as:

v Retrofit (Past)

v to adapt to a new purpose or need: MODIFY (retrofit the story for a new audience)

v Reform (Present)

v 1a: to put or change into an improved form or condition

v 1b: to amend or improve by change of form or removal of faults or abuses

v Reimagine (Future)

v : to imagine again or anew especially: to form a new conception of : RE-CREATE

So, I plan to walk you through three exemplars to get us prepare to answer the questions in the next section that are specific to private sector funding in maternal health and policy/investment ideas and/or business models that could be transformative. Before I provide these exemplars, I do want to make 3 important points that we remember as we brainstorm and get creative today.

1. Birth is an outcome of pregnancy, these are other outcomes. It will be very difficult to discuss this in a vacuum. First, most people will spend more time in their lives avoid pregnancy than being pregnant. Simple math shows that if the reproductive window for people is on average ages 15 to 44, and most people in the US have between 2 and 3 children. If you factor in the recommended 18 months in between births, at most people will spend 8 years in some state of pregnancy or immediate postpartum. The range of potential for pregnancy is 29 years. Which brings me to my second point:

2. Without a robust social safety net, we will either pay for health on the front end if you are lucky (babies) or on the back end if we are not (elderly/elder care). These things go hand in hand since to my knowledge immortality is not ethical or possible. That said, affording humans the things we need to lead a dignified and healthy life requires investments in health and human services. Which brings me to my third point:

3. Any solutions we consider must include an entire society. I say this as a person who has never been pregnant, never birthed, and never wanted to parent. There is a role for everyone in this work and any solutions we propose must be generated and led by people with lived experience — however, that does not let anyone off the hook for creating the future we all wish to build.

I will conclude by saying that I fully believe we have the tools, the brilliance, and the political will in our current time to address these issues without compromising on what people deserve. We have robust evidence to show that our health outcomes in the United States can be improved, particularly when we already know that even the outcome white pregnant capable people have are not the best we can get in the world. I am hoping this discussion will be grounded in the simple principle that curiosity will allow us to get beyond past ineffective solutions and retrofits as the only possibility! We can reform and reimagine with whom and how we do this work. I look forward to the discussion.