Q&A with Nathanael Johnson: The side effects of too much health care

Radio reporter and freelance writer Nathanael Johnson followed his fascinating story on maternal mortality for California Watch with a piece about a few of the families left behind when women died from pregnancy-related causes.

As he writes on his blog, "Their stories had been squeezed out under the restrictions of newspaper writing." The story ran on the front page of newspapers up and down the coast and was featured on public radio's California Report. The talk show Forum interviewed Johnson about it. And, outlets all over the country have used the story as a touchstone for more reporting on the issue. (Jennifer Block's recent article in Time Magazine was particularly interesting.)

I reached Johnson at his home office in the Bay Area. The first part of my interview with him was posted last week. The second part is below. It has been edited for space and clarity.

Q: Was there ever a point in reporting the story where you felt that the story wasn't worth the effort? That the numbers were too small? When you're talking about 95 deaths in California out of 500,000 live births, that's lower than the death rate from lightning strikes or ladder falls.

A: Certainly the numbers are too small to merit a lot of effort if you are just focused on numbers. If I, as an investigative journalist, wanted to save lives, there would probably be better ways to spend my time. But that's not what interested me about the story. It was the fact that an increase in health care looked like it was killing people. That counter-intuitive twist was really intriguing. And it seems like pointing that out might be helpful at this moment in the national conversation. The entire health care debate seems to be about how much health care we can get? Or how can we force insurance companies to stop depriving us of health care? Or how do we stop the evil pharmaceutical companies from charging us too much? I thought it might be good to point out that maybe more isn't always better.

Q: Because the numbers were low, how did you talk with your editors about framing the story so that it would still catch people's attention without being misleading?

A: By saying this is really a sociological story. We're talking about a change in the way that birth happens in this country. This also as a canary in the coal mine, a barometer for all kinds of women's health issues.

Q: When did you pitch it to California Watch?

A: I did a piece for KALW about this report, and my editor there, Holly Kernan, is this awesome, Ben Bradlee type of editor who really cares about getting a good story out there. She said, "You should really pitch this to California Watch." She knew Bob Salladay, and she put us in touch with each other. He was the first editor to really go through the story and have me explain everything that I had found.

Q: So how did you interest California Watch?

A: At California Watch, they were willing to sit down and let me show them how I could back up the story. They wanted to see the proof. And they were willing to be a little more edgy and investigative. The fact that the state was kind of dragging its feet was part of why California Watch was interested. There was this implication that someone in the state didn't want this report out there. For me, though, the most interesting part of the story was the science and the implication that we are doing more for women who are giving birth but getting worse results.

Q: Had you written investigative pieces in the past?

A: Not really. My work has been picked up by magazines more because of the strength of the writing or taking stuff that's already out there and recasting it. Maybe that's why when I went back to those same editors but they didn't get it. The explanation for why this is a story gets very technical very quickly, and that's hard to capture in a one-page pitch.

Q: In writing the story, you took care to make it clear that, as you say, "despite the increase in the mortality rate, pregnancy is still safe for the vast majority of women". Was that something you felt strongly about, or was it something that came out in the editing?

A: I felt strongly about it from the beginning, and so did Mark Katches at California Watch. I am married. My wife and I are talking about having kids right now. It would have been a really easy story to blow up, and it just seemed like that wouldn't have been responsible.

Q: You didn't give as much weight to voices such as Dr. Jeffrey C. King at the American College of Obstetricians and Gynecologists, who said that better counting was leading to a rise in maternal death numbers. Why not?

A: First of all, there certainly is a numbers issue, and I tried to make that clear in the story. I have a ton of respect (for) Jeffrey King and I think that nationally we are vastly underreporting maternal mortality. The reason that I didn't delve into that more and say this just could be better reporting and write a story about underreporting was that these researchers were really confident that there was more to the trend than that. And they were looking specifically at California and comparing apples to apples. What's unique about this study is that because maternal mortality is relatively rare, most states don't have the population size to get statistically significant information. California is just big enough that it does. California is the size of a European country. But when researchers try to do the national numbers, it's difficult because every state has different definitions. The margins of error or the confidence intervals are way too large.

Q: California sort of provided a nice, isolated example where the science seemed to make sense, right?

A: What this group had done was looked at a really big population in a comprehensive way. And then they went down to the granular level of detail and compared birth certificates to death certificates. It wasn't just them counting the number of certificates that had the "pregnancy-related" box checked. These scientists actually checked to see if the mother showed up on a birth certificate and then checked to see if there was a death certificate, too. I really trusted these researchers, and one of the challenges I had was that I needed to have someone from outside comment on these findings but nobody had actually seen the report.

Q: This is a common problem for investigative reporters. You have a discovery and you are revealing something for the first time and yet you need those outside voices to give your story context and balance.

A: Every time, I would call someone, they would take me back to square one. "You don't understand the math." And I would have to say, "I actually know more than you about this at this point." Of course, experts don't like to be told that at all.

Q: So how did you keep them from hanging up on you?

A: Not everyone wanted to talk to me at first, and so I just kept making phone calls and would listen to them explain everything that they knew. Then I would say, "I hear everything that you are saying, and I think I have something new here." I would send them the data that had been made public.

Q: You're talking about that one chart that California had released.

A: Right. I would send them the chart, and almost none of the people I went to ask for outside comment had seen it.

Q: You compared California to Kuwait and Bosnia? Where did you get the data to make those comparisons, and why did you choose those countries?

A: It's World Health Organization data. You have identified something that I feel a little uncomfortable with. I have great respect for WHO's numbers, but the problem is, how much can you trust a nation's data and how well can you compare those datasets? England does an amazing job. They publish reports about mothers dying. Tajikistan is probably telling us something  based on their best guess, but who knows if they are actually collecting the right data? Typically, the more authoritarian a government is, the less likely their numbers are to be totally correct. So, that comparison to Kuwait and Bosnia is like the pull quote that a lot of people Tweeted and got a lot of people's attention. Researchers had pointed out that comparison to me as well. Originally it was a quote from Debra Bingham in the story and then we decided to put it up top.

Q: In some ways, I'm not sure the comparison makes California look bad. I wouldn't assume that Kuwait and Bosnia would have really high numbers. I just don't know enough about their health care systems.

A: Kuwait probably has a good medical system. It's a wealthy country. But everybody in the United States only has the U.S. as a frame of reference. We should have the best health care in the world, right? With Bosnia, you think of people getting shot in the streets. It's rhetorically effective, but if I were a scientist, I wouldn't have made that same comparison. I do think that it is a valid point that this country is far behind where we should be in comparison to other countries.

Q: What sort of reaction did you get to the story?

A: Tons of people commented. I got tons of emails through the Web site. We did an hour on a forum on KQED, and they said it was one of their heaviest influxes of calls. That was good because, sadly, it was me and these two other doctors and the host. Four men sitting around talking about women's health, which was a little unfortunate. There were some comments on the Web site saying that Kuwait has one of the best medical systems in the world. There also was some negative reaction from some people saying "Shouldn't you just be pointing the finger at the corrupt medical system and talking more about the safety of home births?" And, actually, I agree with them that those are interesting questions to pursue, but you can't get into everything in one story.

Q: What was the reaction from the California health department?

A: There wasn't a lot they could say. I called them up after the story ran and said, "Is there anything you want to talk about?" They said, "No. Here's our statement." They just restated that there was no attempt to slow this down. And that the report is just under review.

Q: What has surprised you the most about the reaction?

A: It surprised me there was such a big reaction at all after so many editors had just yawned and taken a pass on the story. My wife is more likely to die in childbirth in California than my mom was. I think that's interesting. But they would yawn and say, "Tell me something new." It took California Watch stepping forward and putting their credibility behind it to persuade editors that they should run the story.

Q: Does it feel like this model is going to work in the long run? The nonprofit reporting team working with for-profit outlets to publish stories?

A: I used to work at a newspaper, and if I had a story idea I could just do the story. It didn't have to be a home run. I would just know that I had a spot in the paper for that story. As a freelancer, I am finding more and more of these stories that are sort of just lying around that nobody else has picked up on. There are fewer reporters working for big organizations, so these stories are being missed. And, at the same time even though I'm finding these stories, it's harder to get them published. It's not like I can just go to an editor who knows me and trusts me and say give me a couple of days to look into this. I almost have to have the story completely reported to sell it. The California Watch model is certainly useful and laudable.

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Q&A with Nathanael Johnson: Why more California mothers are dying in childbirth