Dr. Ali H.
Mokdad has spent much of his career educating others
about health. He is currently the Director of Middle
Eastern Initiatives and Professor of Global Health at the
Health Metrics and Evaluation (IHME) and Head Faculty
Member of U.S. Studies at the University of Washington.
Prior to joining IHME in 2009, Dr. Mokdad worked at the
U.S. Centers for Disease Control and Prevention.
One of the major health issues IHME covers is maternal
and infant mortality. Since the 1980s, infant mortality
rates have decreased in the United States; however, the
rates are still high in comparison to other developed
countries. The U.S. is also among only eight other
countries that experienced an increase in maternal death
rates since 2003. In one of the most medically-advanced
countries in the world, it leaves us wondering,
“what's the issue?” Dr. Mokdad took
some time to speak with me about some reasons behind this
reality from a rural perspective.
What are some factors that contribute to the high
rates of infant and maternal mortality in the United
What we see are many health indicators related to infant
and maternal mortality that contribute to us not
performing at the same level of our competitors. Our rank
of life expectancy at a global level is about 39 or 40.
It's a combination of things that also explains why we
have a variation of these disparities between rural and
urban, but there are four risk factors that lead to these
disparities – infant and maternal, as well as overall
mortality – within our country:
The first is socioeconomic factors. If you take
somebody's education and income, these are important
factors in health achievements. To give you an example,
if a woman is educated, she is more likely to know the
health danger signs and seek medical care, she is more
likely to adhere to the message of medical care, et
cetera. If you look within the U.S. between rural and
urban and compare education levels and income levels as a
nation, we also fall short of some of our competitors.
The second factor is access to medical care, meaning
health insurance, financial means, and distance. Now many
people have insurance, but before many didn't. Even with
health insurance, you can still be underinsured. It may
only allow coverage for an emergency or accident, but it
may not allow coverage for preventive care.
The third factor contributing to mortality in the U.S. is
quality of medical care. This is very important,
especially when you put it in a rural compared to urban
context. The timing of injury related to the timing of
intervention is also important. For example, in Seattle,
Washington, it would take 15 minutes to receive first
line of defense treatment to prevent mortality. Whereas,
in a rural area, it may take much longer.
The fourth one, which is the most important risk factor
that makes us fall behind other countries and makes rural
areas here perform at a lower level than urban areas, is
preventable risk factors. These include smoking, obesity,
physical inactivity, and drug and alcohol abuse. We know
that rural areas have a higher profile of these risk
factors. One thing in particular that is really impacting
rural areas is the drug abuse epidemic. Many babies are
born with a mom who is an addict, and there are
complications with these babies. There is a rise in
infant mortality because of drug use.
How many of these deaths are due to preventable
diseases, illnesses, and situations versus hereditary or
Most of the risk factors I mentioned, we call them
preventable risk factors for a reason. The leading causes
of infant and maternal mortality are smoking, obesity,
alcohol, and physical inactivity. There is no reason for
any one of us to deal with the diseases, such as diabetes
and cardiovascular diseases, that are results of these
risk factors. We have the medication and know-how to
prevent them, but we can do better.
The leading causes of infant and maternal mortality are
smoking, obesity, alcohol, and physical inactivity.
Smoking is a good example. You look at poor, rural areas
in the U.S. and you have high levels of smoking and
tobacco use. Smoking has a direct correlation to infant
mortality in rural areas. Moms who are smokers put their
newborns at higher risk of death during and after
If you look at infant mortality, for any pregnant woman
or one considering getting pregnant, her medical doctor
will put her on a multivitamin. During pregnancy, that
woman is recommended to seek regular medical care to
check on the baby and herself. If there is a sign of
danger during pregnancy, the doctors will advise the
woman to deliver in a hospital, in a certain way. That
automatically is a preventive measure that leads to a
lower chance of the woman dying during pregnancy and
leads to lower infant mortality because the woman and
infant are being taken care of.
If you are in an urban area, have more education or
insurance, live near a doctor or hospital and can get
there in 15 minutes rather than 2 hours, happen to be a
nonsmoker, are physically active, aren't overweight,
don't drink alcohol, and are not on drugs, then the baby
has a better chance as well. So the four risk factors
play into everything.
What are some solutions that would help these
high infant mortality rates decrease, especially in rural
The best return on investment is to attack these factors
– drug use, alcohol, obesity – and start preventive
programs to address them.
We are in a day and age with technology where the world
is becoming smaller and smaller. The solution has to be
several things. First, we need to address risk factors. I
know many small, rural counties don't have money or
resources. A good example is a recent story of the
couple who overdosed in Liverpool, Ohio and almost
died with a young boy in the back of the car. The sheriff
essentially said, “We have a big problem from
overdoses, but we don't have the resources to deal with
it.” The best return on investment is to attack
these factors – drug use, alcohol, obesity – and start
preventive programs to address them. Many big cities have
developed programs that are successful and working. But
you need to add a new twist to apply them to rural areas.
Second, have ongoing experiments to test them out in
rural areas. For instance, there are different programs
out there to prevent smoking and reduce obesity in
schools and communities. Public health departments need
to help their rural counties by saying, “We are
going to give you some money to try these four or five
programs that we know have worked in other places. As you
experiment with them, we will work with you as you adopt
a program to make your own success story.” It's
like with a retirement plan or 401(k): the investor puts
the funds in different stocks and monitors them,
investing more in the one that is making the best return.
In rural health, we should take the same approach. There
are many possible solutions out there; we just need to
Other countries have one factor that we aren't as strong
in – maternity leave. For working moms in the U.S., many
don't have paid maternity leave or enough of a maternity
leave to nurture their growing infant. In places like
France and Sweden, maternity leave is for six months, up
to one year in some places. There is more financial aid
after the delivery and more social programs that help a
woman balance between her work and child. Unfortunately,
during pregnancy and right after her child is born, many
working moms in the U.S. try to juggle between working
and taking the time to go to a doctor for regular
You mention on your site that some
key drivers to reducing
infant mortality include maternal education, medical and
public health innovations, and rising income. How is this
possible for rural America where resources to achieve
these things are often scarce?
Education is one of the biggest drivers, but we're not
talking college education or higher education; we're
talking about high school education. In many rural
counties, I wouldn't say we have the best education
compared to that of other rural Western countries, but we
have a decent one in that everyone has access to free
education. The challenge is how to make sure everyone
graduates from high school and is able to attend and
Once you have a high school and college degree, you are
more likely to make money than those who don't. When
young people delay pregnancy, they are more likely to
have a healthy child. If a woman is educated, she is more
likely to be financially independent. So, education has
been proven, through different studies, to have a strong
protective effect against infant and maternal mortality
in many countries.
Many sectors of our society have to be involved in order
to make it a success story.
Unfortunately, in the U.S., we debate health and
education more than any other country in the world. When
it comes to making all the ingredients for a success
story, we are not good at that. Many of the problems of
infant mortality are not the problems of the medical
system or educational system alone. Many sectors of our
society have to be involved in order to make it a success
story. If you look at the majority of the diseases that
we are facing right now, in order to take action, you
need the healthy diet to be available at a reasonable
price – that's not the health system, that's agriculture.
You need roads to be safe so people can access hospitals
– that's not the health system, that's urban planning. So
there are a lot of issues that need to play together in
order for a person to make a right decision. In this
country, we haven't done a comprehensive job at making
these players come together.
How can rural healthcare providers contribute to
this community-wide effort you are talking
There have been several studies that show when a provider
is the one to suggest that a patient quits smoking or
loses weight, the patient is more likely to adhere to it.
Physicians in rural areas have a bigger role to play, not
only to look at the immediate medical care that the
patient is seeking, but also to screen for other risk
factors ongoing in his or her community. Doing a little
bit more preventive care will be valuable.
…we need a system change in order to have success. In
rural areas, there are others who may need to take a role
in health interventions.
Now, after saying that, sometimes this is a big
aspiration for a rural physician because, first, they
don't have enough time and, second, they are not paid to
do so. Because of this, we need a system change in order
to have success. In rural areas, there are others who may
need to take a role in health interventions. But all of
these methods require resources, money, and time.
Opinions expressed are those of the interviewee
and do not necessarily reflect the views of the Rural
Health Information Hub.