If you are reading this in a way that does not display pictures, you will want to click to the original to see the image. Yes, that is a real anti-public-service poster/ad from the city of Milwaukee’s department of health, intended to inflict emotional violence on mothers who make the possibly maybe slightly risky (bear with me — I discuss the evidence and other specifics of the message below) lifestyle choice to co-sleep with their babies, a radical behavior that is practiced by crazy cultists like… well, like the majority of humans alive today or who have ever lived.
Most of my regular readers who are familiar with my writings about tobacco harm reduction and its extremist prohibitionist opponents (and the related issue of the free-choice rights of smokers or other drug users) will find this hauntingly familiar. Those who are not familiar (and I have been told that writing on this topic will draw some new readers even though I am late to the story) need a bit of background:
Anti-smoking started as a legitimate and properly modest public health effort to educate people about risk and try to persuade them to reconsider their choice to smoke. But by the late 1990s, anti-tobacco had transformed into a multi-billion-dollar extremist industry, bent on eliminating not just smoking, but low-risk smokefree alternatives (which are about 99% less harmful), and willing to use any tactics, no matter how destructive. It became the tail waving the dog of public health, and the result has been terrible for public health’s social and scientific reputation. Even though smokers in Western countries are well aware of the risks (indeed, most of them actually overestimate the risk) the extremists push for inflicting more and more emotional violence on them, in the form of general abuse and denigration, as well as disturbing ad campaigns and labels. If people will not choose to quit if they know the truth, the extremists will pursue other avenues to make them so miserable that they have to quit. For their own good, of course.
To those of you, dear new readers, who may be adamantly anti-smoking and may not have thought this through before, and so perhaps are thinking “yeah, that sounds reasonable”, think about the classic “first they came for…” warning. As soon as it became acceptable, as well as a comfortable career path, to exaggerate risk and inflict emotional violence on people who do not conform to the demands of the “public health” community, it was no longer just about smoking. It metastasized.
There is little doubt that the authors of the nasty anti-co-sleeping poster drew their inspiration and got their tutelage from anti-tobacco propaganda. As anti-tobacco has trained a generation of activists who believe it is ethical to do whatever it takes to “improve” people’s behavior, they have moved into other areas of what used to be public health. Various observers have done a good job of showing how anti-tobacco extremists are actively and openly tutoring anti-alcohol extremists to aid their prohibitionist efforts, and it is trending toward overweight and fast food. But even if you are not an aficionado of nicotine or alcohol or junk food, and so you do not feel like speaking up, because you are not among the targeted, they might well be coming for you if you do anything they do not approve of. Like eating salty food, or not exercising, or choosing to raise your baby in a particular way. So far, the decidedly dangerous act of transporting your baby by car, or crossing the street with him, is not in their crosshairs. So far.
In terms of justification for the cleaver graphic, every news story (examples) seemed to quote only one statistic, in various forms:
“Is it shocking? Is it provocative?” asked Bevan Baker, the Milwaukee health commissioner. “Yes. But what is even more shocking and provocative is that 30 developed and underdeveloped countries have better infant death rates than Milwaukee.”
Should we be impressed? Center-city Milwaukee is a pretty awful place, as America goes. I would guess that 50 countries have higher average income and better health outcomes in general, and probably 100 have better educational attainment. So on a propensity score basis, the city might actually be doing better than expected on infant deaths.
But the biggest issue is that hyping the magnitude of a problem, the typical tactic of public health activists, is a fundamentally dishonest method of trying to justify a particular intervention. The intervention needs to be defended based on whether it will meaningfully contribute to solving a problem, not whether there is a problem. (Readers who are familiar with tobacco policies will be finding this to be quite familiar.) The high infant death rate in Milwaukee is mostly due to premature births to young poor mothers. Even if one accepts the morally dubious “ends justify the means” claims, there actually need to be some ends.
So, does proper co-sleeping increase infant deaths? The evidence supporting that claim is, at best, weak. There are definitely infant deaths that are directly caused by being in an adult bed. These seem to most often involve a parent who is passed out from drugs (be they FDA approved, legal, or illegal), or piles of fluffy bedding. That is where the “proper” in the previous sentence comes in; all advice about safe co-sleeping makes clear that these situations are bad. If we take out those cases — which should be blamed on parents not knowing how to be safe or not being competent to follow advice, which bodes ill for their babies wherever they sleep — it is not entirely clear what the net effects are. There are still some identifiable deaths caused by co-sleeping, even absent a stoned mother or inappropriate blankets. But there is also evidence that mysterious sudden infant death (crib death, cot death) is reduced by co-sleeping. The data is so poor (the stigma created by anti-co-sleeping campaigns makes it very difficult to find out the prevalence of incident-free co-sleeping) that it is difficult to be sure. But it is pretty clear that the worst that can be said about co-sleeping is that it creates a small risk, in the same range of such risky behaviors as running errands with the baby in his car seat. The only obvious candidate for the title of America’s leading scientifically competent source of advice about raising babies, Barry Sears and company, recognizes co-sleeping as a very reasonable option and offers some recommendations for keeping it safe.
“But,” gasp and sputter the self-appointed masters of our health-affecting decisions, “if even a single life can be saved, this is justified” (to paraphrase statements in many of the stories about this). Really? Would saving a single life justify a strict nighttime curfew for everyone in the violent city of Milwaukee? How about banning driving for a month — that would almost certainly save some lives, including kids. Oh, what’s that you say? There are other considerations that mean we should not blindly attack any freedom that might cause one person to die? Oh, I see. So the “if even a single life” game only applies when someone is doing something that you personally would not choose to do, Mr. Public Health Official.
Co-sleeping — like nicotine use, drinking, other drug use, playing sports, travel, eating junk food, etc., or having a baby in the first place — is a major lifestyle decision that involves health risk. Different people make different decisions, and some find that making one particular choice is extremely important, and worth the small risk. In the case of co-sleeping, there is not only the important choice about how to relate to one’s child, but for some babies and mothers there are important health benefits (better feeding, mother or baby able to get enough sleep, etc.). Providing misleading information, like claiming co-sleeping is as dangerous as a baby cuddling with a sharp knife, will result in suboptimal decisions. Moreover, telling parents that they are being criminally irresponsible by making a particular (common, reasonable, culturally acceptable) choice will often not change their behavior, but might make them feel bad about what they have done, thereby inflicting gratuitous emotional harm. And in those rare cases where a death seems to be attributed to co-sleeping, this messaging starts to seem a lot like those who tell parents that their decision to vaccinate caused their infant’s death — nothing but harm comes from such lie-based sensationalism.
Moreover, there is the classic prohibitionist problem: If you try to prohibit something it becomes very difficult to regulate it. One result is that banned drugs are often contaminated or used in needlessly dangerous ways. In the present case, by staking out a position that co-sleeping is an unacceptable evil, it is impossible to offer the nuanced advice about how to do it most safely.
How did the unhealthful news handle this story? Badly, of course. As is typical, the health reporters presented random useless claims on both sides of the issue, typically the claims above from the “public health” people and the equally useless counter quoting one mother who co-slept with her babies without incident. Worse, many reported the story of one recent death in Milwaukee that was attributed to co-sleeping without ever mentioning whether the mother was stoned. Accompanying these uninformative factoids was absolutely no mention of the evidence of whether there was net risk, or even an acknowledgment that such evidence might be a bit useful in the discussion. This absence was glaring even in the few good articles about the incident and issue, like those in Time Magazine’s health blog (which has somehow become one of the most complete sources of health news out there, exemplifying both the good, like these, and the bad, as in the link about overweight above).
The worst unethical behavior from anti-tobacco activists often traces to funding of the anti-tobacco industry by Big Pharma, which profits from selling their (almost useless) quit-smoking products. Could there be a Big Crib that is (ir)responsible for these ads? Strangely enough, the answer is sort of yes. The phone number printed on them rings to a QUANGO called “Cribs for Kids”, which offers to provide cribs for those who cannot afford them (as if that lack is the main reason for co-sleeping!). Gee, I wonder who is paying for such giveaways and who profits from it (kidding of course — there is no need to wonder). Presumably the Big Knife industry, though prominently featured, contributed nothing, since if we take away the misleading words we can just interpret the posters as suggesting “do not sleep with an armed baby“. That seems like good advice.
[Update: The first comment by KMN and my reply have some content that I wish I had included in the original post.]
EP-ology 
