Technology in the defense sector has advanced rapidly over the years, and looks to shape the future of modern warfare
Many new capabilities are disrupting the defense sector, bolstering operations across the world.
Niels Bohr – the father of the atomic model – once remarked that “prediction is very difficult, especially if it is about the future.” This is a dictum with which the founder of Intel, Gordon Moore, might well have disagreed. Moore’s 1965 forecast about the future of computational power was possibly one of the greatest technological predictions of the last century. His projection, which has become known as Moore’s Law, states that we can expect the speed and capability of our computers to increase incrementally every couple of years. The rule has been shown to be unerringly prophetic and it has become famous as a metric for the rapid technological progress of the last 60 years.
This growth still seems inexorable. The first two decades of the 21st century have witnessed an explosion in technological advances that have affected cultures, economies, and governments around the world. Militaries – and the realm of warfare – have been no different. Technological innovation has been slowly modifying the way armies are engaging with each other, and in doing so, re-mapping the boundaries of how conflicts are fought. Much impetus for this has come from the private sector: as civilian information technologies have become more sophisticated they have gradually percolated into the defense industry; a growing number of startups, for example, are seeking new commercial opportunities for their technology in defense contracting.
While the 20th century has witnessed seismic changes to war – from the horse-drawn 1910s, through the mechanized 1930s and jet-propelled 1940s, to the nuclear age – the gathering pace of present-day technology is foreshadowing another era altogether. This new state of affairs will be increasingly defined by digital capabilities. General Richard Barrons – a former head of Britain’s Joint Forces Command – summarized this well in The Times last November: “We’re seeing changes on the battlefield as profound as anything in the past 150 years as data, artificial intelligence and connectivity become the new , key components of warfare. But we’re still in the foothills of what’s coming. ” Indeed, there is little doubt that there will be more radical development on the horizon.
This necessity to evolve is nothing new: for centuries, armies have had to upgrade their weaponry to preserve battle worthiness. Those that fail to modernize forfeit their advantages in theaters of war. Today, however, this focus on physical equipment has begun to make room for a growing preoccupation with innovative capabilities.
What exactly are these? In short: data, artificial intelligence, increased connectivity, and automation. These are all elements that will underpin the digital weapons of the future. It is important, however, to point out that these advances are radically different from anything ever fielded before: they are tools that are for the most part intangible. It is possible, for example, to touch the armor plating of a tank, whereas the latest machine learning algorithms are immaterial, existing only in the interior of a command center’s computer.
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This digital revolution points to a new kind of hyper-modern warfare. Artificial intelligence is a good example of this. If AI can read more data in a minute than a human can read in a year, then its value to militaries is immeasurable. In a recent interview with The Daily Telegraph, the current Chief of General Staff, General Sir Mark Carleton-Smith, has acknowledged that “we are already seeing the implications of artificial intelligence, quantum computing and robotics, and how they might be applied on the battlefield ”. Machine learning, for instance, has already been used to harvest key grains of intelligence from the chaff of trivial information that usually inundates analysts.
All this is not to say, however, that there will be a complete obsolescence of traditional equipment and means. The British Army remains an industrial age organization with an industrial skill set, but one which is confronted by innovation challenges. Conventional threats can still materialize at any time. The recent stationing of Russian troops along the Ukrainian border and within the Crimea – in addition to the manoeuvring of its naval forces in the Sea of Azov – is a case in point. This overt display of hard power is a timely reminder that militaries are still fundamentally made up of hardware and manpower, and that the manoeuvring of these pieces on the strategic board is still of utmost importance.
To this end, many theorists powerfully argue that military doctrine and tactics are far more important to battle outcomes than technological prowess, a basic doctrine they say has changed little since WWI. The Taliban’s immanent victory in Afghanistan – once the American-backed government has capitulated, as only seems inevitable – shows that an organized, disciplined, and motivated insurgency can still defeat one of the world’s premier military powers with all the cutting-edge resources at its disposal.
And yet, there is little doubt that the onset of digitalization has marked the advent of a new type of warfare. This is predominantly defined by a hybridity between established and emerging technologies, or in other words, the fusion of industrial hardware with new electronic developments. Recent conflicts have accentuated this, with “small wars” in countries like Libya and Syria being notable for the decisive involvement of this “hybrid” weaponry.
One such example was the short war in Nagorno-Karabkh – a disputed region in the South Caucasus – between the armies of Azerbaijan and Armenia. It was notable for Azerbaijan’s use of “kamikaze” drones to secure a rapid victory over the Armenian forces. These drones – also known as “loitering munitions” – were able to automatically locate their own targets and then eliminate them through self-destruction. Launched at the press of a button, and a fraction of the cost of any traditional air force, they neutralized Armenian tanks, air defense systems, and personnel, forcing the country to accept punishing ceasefire conditions. Some analysts have gone so far as to say that this particular use of drones in time and space has signaled the death of the tank, with heavy armor becoming, they argue, as obsolete as cavalry in the First World War.
Ethics and regulation
Drones are typical of the recent paradigm of increased automation, a digital capability whose importance has become apparent in the last few years. The rise in military robotics – or Lethal Autonomous Weapons Systems (LAWS) as they are known in military circles – has seen nations around the world engaged in an arms race to furnish their militaries with weapons that are self-functioning. The Chinese, for example, observing the effectiveness of Azerbaijani drones, have rushed to test and develop their own “drone swarm” technology. This would see drones being launched from multiple tubes on the back of a truck, or helicopter, that then relentlessly zero in on their targets en masse. Similarly, American scientists have been experimenting with pocket-sized battlefield devices – some modelled on insects, including a “mechanical cockroach” – that could be used to spy or kill enemy troops. These “biomimetic”, or nature-imitating, weapons will soon make an appearance in combat zones – what once could only have existed in the pages of science fiction is now beginning to spill into the realm of the possible.
There are growing fears about the extent to which this automation might be developed. Weapons systems that act, and kill, on their own remove human agency from the equation; this has raised troubling moral dilemmas that are unlikely to be resolved soon. Indeed, the international architecture of treaties and protocols that regulate the world’s weapons are now looking out of step with the recent acceleration of scientific progress. From the exploration of space to cyber attacks, nuclear arms controls, and AI weapons, the speed of innovation is outpacing our attempts to police it.
In the past, nation states have agreed to prohibit particularly horrifying new weapons. By the mid-20th century, for example, international conventions had banned biological and chemical agents. There are as yet, however, no rules governing the ethics of information-age military technology. Take assassination: the cache of futuristic tools now available to nations – AI, sophisticated tracking of potential victims, remotely-controlled precision weapons – has irreversibly changed the assassin’s art. It is now an easy and gratuitous option that can be chosen at will. Officers, intelligence chiefs, and elected officials should be meeting with ethicists and lawyers to discuss the limits of assassination in this new era. The fact is they’re not.
The ascendance of digitalisation has also affected the nature of warfare in other, less obvious, ways. In particular, the militaristic use of newfound information capabilities (including cyber, propaganda, and psychological tactics) is becoming more and more apparent. This is an area where Britain’s adversaries are increasingly operating below the threshold of traditional conflict. In recent years, countries like China and Russia have been harnessing technology to further their omnivorous geo-political ambitions. While Britain and its allies have been trapped in counter-insurgency operations for the last 20 years – draining their strength in interventions such as Iraq and Afghanistan – these countries have won a succession of strategic successes, aided and abetted by digital means.
Russia, for example, has been perfecting information warfare through its subversive campaigns which aim to undermine the cohesion of their enemies’ societies. Through the funding of troll farms, state-endorsed cyber-criminality, election interference, the spread of disinformation, and assassination attempts, they have been quietly working to destabilize Western democracies and recalibrate the balance of power in important regions back to their favor.
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In a rapidly evolving world, the integration of digital capabilities into military affairs has resulted in warfare becoming more asymmetrical and harder to define. Recent conflicts have been characterized by mismatches between belligerents, with countries that can afford state-of-the-art technologies emerging victorious. Nations are now driven by a logic of deterrence: they fear a fait accompli on the battlefield if they are not able to equal, or surpass, their enemies’ martial technology. This new arms race has meant that many new capabilities are unknown quantities; future conflicts are likely, as a result, to be more amorphous and uncertain.
Battles are now also increasingly taking place in the shadows, more often than not in the “gray zone” between war and peace. This has seen technology playing a small, but important, role in the tectonic shifts currently taking place in geo-politics, as long-entrenched fault lines of the international order are slowly being repositioned. Hostile countries are turning to technology as an offensive means beyond traditional warfare to expand their spheres of influence. War is, after all, merely “the continuation of politics by other means”, as Carl von Clausewitz once observed.
Written by Archie Phillpotts, freelance journalist
Column | Troubled ‘turbantor’ Harbhajan and his aggressive instincts
The retirement of Harbhajan Singh from all forms of competitive cricket in December 2021 brought to close the career of a gifted cricketer who courted controversy at every turn of his career. During the first years of the 21st century, he was arguably the best spin bowler in the world and though his wicket-taking abilities hit a plateau after that, he sustained himself by the versatility that saw him play all formats of the game at the highest level with reasonable success. He was a regular in the national side and part of the team that won the International Cricket Council (ICC) T20 World Cup in 2007 and the ICC World Cup in 2011. Though he lost his place in the national squad in 2015, he continued playing in Indian Premier League (IPL) till he chose to hang up his playing boots last month.
Harbhajan kickstarted his career during the 1997-98 season when he found himself playing for the national side in March 1998 within four months after making his debut for Punjab in Ranji Trophy. His performances at the junior level and the absence of top quality off-spin bowlers were factors that prompted the selectors to try out this rookie bowler, then still in his teens. He did not set Kaveri on fire on his Test debut, which took place against Australia at Bangalore. Within one month, he made his bow in One Day Internationals (ODIs) as well but a string of below-par performances saw him lose his place in the side soon thereafter.
After going through a period of near oblivion when he was also thrown out of a training programme in National Cricket Academy on charges of indiscipline, Harbhajan staged a comeback to the national side in the winter of 2000-2001 with a performance that will be remembered by followers of the game in India for all times. Australia, led by Steve Waugh, had landed in India to conquer the “final frontier”. The visitors were on a high, having won the previous 15 matches on the trot and looked forward to creating a new world record with 17 consecutive triumphs in Tests, while also winning the series. And when they won the first Test at Mumbai by a margin of 10 wickets, everyone thought that they were on their way to attaining both their goals.
The Kolkata Test against Australia in February 2001 is known as “Laxman’s Test”, for his knock of 281 runs in the second innings which helped India to script a magnificent turnaround and win this game, after trailing in the first innings by 274 runs. Harbhajan also had a crucial role to play in this victory as he took 13 wickets (7 for 123 in first innings and 6 for 73 in the second), including a hat-trick on the first day. In the last Test at Chennai, Harbhajan again played a stellar role, bagging 15 wickets for 217 runs (7 for 133 in first and 8 for 84 in second innings) to finish the series with a tally of 32 wickets. Aussie batsmen did not have any answer for his wiles and even such accomplished performers as Rickey Ponting and Adam Gilchrist appeared shell-shocked while facing him. Australian media nicknamed him as “Turbanator”- a tribute to his destructive capacity with the ball.
Harbhajan’s career did not ever attain the stratospheric heights that this performance promised. The surfeit of limited overs’ cricket made him focus more on restricting runs than on “buying” wickets. This resulted in bowling a flatter line without “giving the ball air”; the classic loop which is the hallmark of a top-class off-spinner also disappeared. This made him a less destructive bowler except on helpful surfaces and the returns also started growing thinner. When Anil Kumble returned to the side after recovering from an injury, Harbhajan moved into the slot of support spin bowler.
A finger injury caused Harbhajan to return home during the tour to Australia in 2003-04. He returned to the side the next season and was amongst wickets with most of the games being played at home. However, the arrival of Greg Chappell as coach and the exit of Sourav Ganguly as captain of the national side in 2005 caused hiccups in Harbhajan’s career. He was the first Indian cricketer to publicly criticise Chappell and his methods and said that the coach was “instilling fear and insecurity” in the side. Though his explanation was called for, Harbhajan managed to escape action and issued a statement lauding Chappell soon thereafter!
Harbhajan found himself in the midst of one of the biggest controversies in cricket when India toured Australia in 2007-08. In the second Test at Adelaide, Australia lodged a formal complaint that he indulged in racial abuse against Andrew Symonds. The relations between the two sides were at a low ebb and this incident even threatened to disrupt the conduct of the remaining part of the tour. Harbhajan vehemently denied the charges and the Indian team management supported him. But Mike Proctor, the match referee, found him guilty and slapped a punishment. India promptly appealed against this verdict and got a stay, which allowed the tour to go on. Eventually, the ICC appeals Commissioner Justice John Hansen overturned the verdict of the match referee and absolved Harbhajan.
Controversy continued to dog Harbhajan even after the closure of this episode. During the Indian Premier League (IPL) matches in 2008, he slapped fellow India teammate S Sreesanth after the game between Kings XI Punjab and Mumbai Indians, which the latter side, led by Harbhajan, lost. The slapping of a national player in full view of television cameras drew widespread criticism and Board of Control for Cricket in India (BCCI) moved fast and initiated action against Harbhajan.
Incidentally, this was not the first time that Harbhajan had got physical with Sreesanth. During the Champions Cup trophy match in 2007, he had shoulder charged the fast bowler when he was walking to the top of his bowling mark. BCCI had chosen to ignore this incident despite it being witnessed across the country. But the “slapgate” was too serious to be brushed under the carpet and Harbhajan was barred from playing the remaining matches of that season of IPL, besides a five-match suspension from ODI’s.
Harbhajan’s international career took a severe reverse when he was injured during the tour to England in 2011. He was not selected for the tour to Australia in 2011-12 and his appearances in international matches became sporadic after that. He played his last Test in August 2015 and his final appearance in an ODI took place two months later, though he continued to play domestic first-class cricket till 2017. Since then, his appearances on the cricket field were limited to playing in IPL, where he picked up 150 wickets in 13 editions.
A tally of 417 wickets in Tests and 269 scalps in ODI’s makes Harbhajan the second most successful off-spinner to play for India, after Ravichandran Ashwin. He could also wield the willow effectively as evident from a total of 2,224 runs in Tests with 2 centuries and 9 fifties. He was also the first spin bowler from India to adjust to the demands of all versions of cricket effectively. But his tendency to create controversies and lack of amenability to discipline cast a cloud over his career which could have reached much greater heights given the prodigious talent he was blessed with.
Followers of the game from Kerala could be forgiven for not harbouring a soft spot towards this highly competitive cricketer as he is considered to be the bugbear of Sreesanth and the source of all troubles that the Kochi born pacer found himself in. News reports indicate that the two cricketers subsequently spoke to each other and resolved their differences. But it would be difficult for the fans to forgive so easily as the bad taste created by those incidents does not vanish quickly. The same is the case with cricketers and cricket-loving public of Australia, as could be understood from the observations in the autobiography of Gilchrist, despite Harbhajan and Symonds sharing the same dugout in IPL.
In retrospect, one is forced to conclude that it would have been better for Indian cricket if the aggressive instincts of Harbhajan Singh were channelled properly on the cricket field and outside.
(The author is a former international umpire and a senior bureaucrat)
Sports Betting’s Next Big Election Battles Are in California
TEMECULA, Calif. — Legal sports betting in the United States accelerated in 2021 as a flurry of states either overcame legislative logjams, as Ohio did just before Christmas, or signed off on online wagering, as New York did just after Election Day.
But those efforts are likely to pale in comparison to the all-out lobbying, campaigning and legal jousting in 2022 involving what a DraftKings executive recently called “one of the holy grails” in sports betting: California.
By November, Californians may be asked to vote on as many as four sports betting initiatives. That’s why deep-pocketed interests, including national sports books and Native American casinos, have been gearing up to spend $200 million to persuade voters in California to support their particular proposal — or to reject the others.
One measure that has already qualified for the state ballot, sponsored by powerful tribes in California, would add sports wagering, but only in person, at tribal casinos or horse racing tracks. Online betting initiatives, now gathering signatures, dangle the prospect of making bets anywhere through the internet. Others offer a middle ground.
If one of the measures passes, nearly two-thirds of Americans will live in states that allow or regulate sports betting. And with California and New York on board, sports wagering would essentially be national in scope, fueling a market that Goldman Sachs recently estimated could grow to $40 billion in revenues in a decade from $900 million now.
Yet gambling expansion in California has often fallen short or been torpedoed by competing interests. Indeed, California’s card rooms, which primarily operate around larger cities and offer a more limited range of games, just filed a lawsuit to invalidate the qualified tribal measure.
“We’re never going to get sports betting figured out at any level unless California comes on board,” Jason Giles, executive director of the National Indian Gaming Association, said at a recent sports betting conference at the Pechanga Resort and Casino in Temecula. “That will be the game changer for the United States.”
Since the Supreme Court’s decision in 2018 to strike down a federal law banning commercial sports betting in states other than Nevada, more than 30 states have authorized sports wagering, including about a dozen in the last year. More than 20 states have gone live.
New York just started mobile sports betting after awarding licenses for it to two coalitions featuring marquee names, Caesars Sportsbook and Bally’s Interactive. Gov. Mike DeWine of Ohio signed a bill legalizing sports betting in late December. And legislators in Wyoming and Arizona, among others, quickly approved sports betting.
“Look at this massive expansion across the country and where we are — it’s becoming very mainstream,” said Brandt Iden, a former state representative in Michigan who pushed to legalize sports betting in his home state. Iden is now head of government affairs for Sportradar, which collects and analyzes data for sports books. “I talk to legislators who say, you know what, I don’t support gambling, but everybody is doing it.”
Of the holdouts, Texas considered several bills in 2021, and some lawmakers expect momentum when the legislature reconvenes in 2023. Florida, meanwhile, is a mess: A federal judge recently blocked the Seminole Tribe’s new sports betting app, and DraftKings and FanDuel are racing to gather enough signatures to get a referendum on the 2022 ballot.
In California, gambling — mostly on slot machines and blackjack — has been legal for two decades on tribal lands under compacts negotiated with the state. The state also permits gambling at horse racing tracks, which was legalized in 1933, and card rooms, which trace their lineage to poker-playing miners during the Gold Rush.
Any changes would require constitutional amendments through a voter referendum, or legislation backed by the voters.
Previous attempts have bogged down; online poker, for instance, failed in part because the tribes themselves were split. But now there appears to be less resistance on moral and philosophical grounds.
“If we think about progressive legislation, or legislation to protect consumer welfare, California lies at the forefront, whether we want to talk about minimum wage or privacy protection,” said Marc Edelman, a law professor at Baruch College who has written extensively on sports gambling. “If California legalizes sports gambling it becomes very unlikely that another state would arise as the consumer-oriented opposer of sports gambling.”
This time, the push to expand gambling began before the pandemic, from a coalition of 18 tribes that have dominated casino gambling in the state.
Across the United States, tribal gambling generated $27.8 billion in revenue in its fiscal year from Oct. 1, 2019, to Sept. 30, 2020, despite the pandemic. California is the biggest state, with 66 tribal casinos on federally recognized lands, mostly far from the coast, yielding about $8 billion, with much of that coming from slot machines.
Under the tribes’ initiative, which is backed by a political action committee that has raised more than $13 million, sports wagering would be permitted at tribal casinos and horse tracks. Roulette and games played with dice, such as craps, would also be allowed under the proposal, which qualified for the ballot in May 2021 after collecting more than one million valid signatures.
One thing that is not included is online betting, because the initiative is intended to be “a very measured, incremental step,” said Mark Macarro, tribal chairman of the Pechanga Band of Luiseño Indians in Riverside County.
“We think this is the right thing to do for tribes and tribal sovereignty,” he said at the conference here. “There’s enough skittishness out there about what could happen to brick-and-mortar facilities.”
The initiative would also create a new civil enforcement tool allowing anyone suspicious of any illegal gambling operations to file lawsuits. It is this provision that has fueled two separate but related efforts by California’s card rooms to defeat the tribes, and to get their own sports betting measure passed.
California has more than 80 card rooms ranging from pub-like places with a few poker tables to sleek behemoths with 270 tables accompanied by restaurants and plentiful A.T.M.s. Collectively, they employ 23,000 people in urban areas, many of them Asian, Black and Hispanic, and pump in $300 million in federal, state and local tax revenues each year, according to the California Gaming Association, a trade group.
Many municipal budgets rely heavily on the card rooms to finance vital services and bolster juvenile justice and other programs, said Mayor Tasha Cerda of Gardena, which has two card rooms. She has backed an initiative that would permit sports betting at the card rooms, tribal casinos and racetracks, as well as allow for internet sports betting. That initiative has raised $450,000 to date. Meanwhile, some of the bigger card rooms have poured more than $24 million into a “No” campaign against the tribes’ initiative.
During a recent tour of Hollywood Park Casino in Inglewood, adjacent to SoFi Stadium, the host of the Super Bowl next month and the College Football Playoff national championship in 2023, Deven Kumar, the casino’s general manager, estimated sports betting could increase revenues — already hurt by the coronavirus pandemic — by 20 percent to 25 percent. He and James T. Butts Jr., Inglewood’s mayor, warned that the tribes’ civil enforcement provision could drain their existing business by up to 75 percent, compounded by the inevitable legal costs.
“They are attempting to make gambling a monopoly at the expense of others,” Butts said. “They are not the disenfranchised group they once were. The minority majority cities deserve the opportunity for equity as well.”
In the city of Hawaiian Gardens, where the Gardens Casino supplied 68 percent of the tax revenues in the 2019-20 municipal budget, Keith A. Sharp, the casino’s general counsel, said sports betting could transform Sundays at the casino — now mostly empty — into bustling periods where customers could wager on N.F.L. games while also playing baccarat or other games.
If the card rooms were hobbled, however, Nary Chin, a longtime card dealer and single mother of four, said she feared for her future.
“I learned English in the card room, not school,” said an emotional Chin, who immigrated from Cambodia in 1984. “I am very grateful. This is my home. If I didn’t have this job, I don’t know what I’d do.”
The third initiative comes from online sports books, including DraftKings and FanDuel, that want to enter California for the first time and offer online betting.
The measure requires those companies to partner with tribes, and its supporters say voters can pass both their initiative and the tribes’ in-person one. Most of the state’s profits would be dedicated to homelessness measures, and to the tribes themselves. It would also allow betting on nonathletic events, like award shows and video game contests, but not youth sports or elections, according to the nonpartisan Legislative Analyst’s Office.
“We view brick-and-mortar as very complementary to mobile,” Jonathan Edson, FanDuel’s senior vice president for business development, said at the sports betting conference.
“California is one of the holy grails in sports,” added Jeremy Elbaum, senior vice president for business development at DraftKings.
The supporters, buffeted by an initial $100 million from seven sports books, have lined up mayors in Long Beach, Oakland, Fresno and Sacramento, plus advocates working to combat a homeless crisis. They are confident they will collect enough signatures to be certified by the June ballot deadline.
“We are focused on ongoing stable revenue to fund the key programs that we know we need,” said Tommy Newman, vice president for engagement and activation at the United Way of Greater Los Angeles. “If we’re honest, this is regulating and capturing value from something that is happening, for people in communities that absolutely need the investment.”
In November, a fourth initiative arrived supporting both online and in-person betting, backed by a different group of tribes, including the Rincon Band of Luiseño Indians and the San Manuel Band of Mission Indians.
“Out-of-state and international gaming operators want to rewrite the balanced system California has created so that the future belongs to them, paying a pittance to serious local and statewide social problems, and trying to divide the Tribes by offering temporary riches to a few while taking future growth opportunities away from the rest,” the tribes wrote in their application to the California attorney general.
A lawyer for the tribes, Scott Crowell, did not respond to messages seeking comment.
Some gambling analysts believe that a plethora of initiatives may confuse voters, who may just say no to everything. Another wild card is a lawsuit filed in December by two card rooms claiming that the qualified tribal initiative violates the state constitution, which says initiatives can focus only on one subject, because the tribes are trying to add retail sports betting as well as add more table games.
Still, no matter the outcome of the lawsuit or the ballot measures, many sports and technology companies are building audiences through free-to-play games, contests, fantasy sports and national marketing campaigns, even in states where sports betting has not yet been cleared, said Rob Phythian, founder and chief executive of SharpLink Gaming, a technology company.
Teams like the Minnesota Vikings have hired companies like SharpLink to build fantasy games. That could be consequential in California, where there are 19 teams in the N.F.L., M.L.B., N.B.A., N.H.L. and W.N.B.A. — by far the most of any state.
“We’re just a bridge to betting,” Phythian said. “It’s sort of like training the muscle.”
Addressing maternal health inequities | AAMC
Kysha Shaw lives with a lot of uncertainty. Among other things, the 42-year-old single mother of three worries about COVID-19, schools closing, and drug use and crime in her West Baltimore neighborhood.
“I love this community, but it can be really sad,” she says. “You see people begging for shoes and clothes. You might see someone slumped over with a needle in their arm. People sell drugs in front of the convenience stores.”
But Shaw is determined to keep herself and her children healthy, which she’s done thanks in part to an innovative effort called B’more for Healthy Babies Upton/Druid Heights (BHB U/DH). Founded in 2011, the program is part of a citywide initiative and is a partnership between the local community, the University of Maryland Medical Center, and the University of Maryland, Baltimore.
BHB-U/DH supports mothers and babies in West Baltimore, where 92% of residents are Black and 66% of children live below the federal poverty level. It provides prenatal education, support groups, smoking cessation, some rental assistance, and connection to a range of social services. Among other achievements, the effort has reduced infant mortality by 75%.
Experts believe that programs like BHB U/DH are essential if the United States hopes to address the inequities in maternal health found in so many crowded cities and remote rural towns.
The statistics are striking: Black and American Indian/Alaskan Native women are two to three times more likely to die from pregnancy-related causes than White women. Black women are twice as likely to experience serious perinatal complications. And early indicators suggest that COVID-19 is only exacerbating such inequities.
What’s more, advanced degrees and full bank accounts don’t close the gap. In fact, a college-educated Black woman faces a 60% greater risk of maternal death than a White woman with no high school diploma. Why is that? Experts point to the effects of subtle and explicit racism as well as weathering, the biological fallout of ongoing stress that can cause premature aging and related health problems.
Faced with this worrisome reality, researchers and providers are working to improve the health of vulnerable pregnant people before, during, and after childbirth.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking.”
Kamilah Dixon-Shambley, MD
Medical director of Moms2B
“Inequities are so pervasive and persistent that they require multisector efforts,” says AAMC Health Equity Research Analyst Funmi Makinde, MPH. “We need to address transportation, employment, and housing as well as physician shortages, and we need more diverse providers. We need high-quality data that are shared publicly to ensure accountability. The list goes on.”
Throughout all this work, it’s crucial to include the perspectives of patients who are often overlooked, experts say. In one recent survey, 20% of Black, biracial, and Latinx people felt their medical requests were refused or ignored, compared with 11% of White people.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking,” says Kamilah Dixon-Shambley, MD, medical director of Moms2B, an Ohio State University Wexner Medical Center program that provides yearlong supports and health education to low-income new and expectant mothers. “It’s crucial that patients and the community can trust their providers.”
Below, AAMCNews profiles multifaceted efforts to address maternal health inequities across the country.
Data that save lives
In 2006, California officials noted a worrisome trend: Maternal mortality was on the rise, even as the state recorded the most births nationwide.
Hoping to reverse the disturbing death rate, they turned to Stanford University School of Medicine to co-found the multistakeholder group that became the California Maternal Quality Care Collaborative (CMQCC).
Serious number-crunching has fueled much of the CMQCC’s work. For one, it collects and analyzes hospitals’ raw data to quickly identify areas ripe for improvement, including racial and ethnic disparities.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. They may see that their Black patients have 6 percentage points higher C-section rates than Whites,” says CMQCC Medical Director Elliott Main, MD. “That really spurs them on to look at addressing racism in labor and delivery.”
CMQCC experts also use data to identify the need for and then create step-by-step provider toolkits on key causes of birth-related complications. One on postpartum hemorrhage, which covers such crucial moves as measuring and effectively treating blood loss, reduced disparities between Black and White patients by nearly 80%.
“The standardized protocols in toolkits take away a lot of provider subjectivity,” Main says. “Subjectivity is the entrée for biases that impact patient care.”
And hospitals in the collaborative — there are more than 200 of them — can receive training on implementing the toolkits. “A toolkit that sits on the shelf does nothing,” he adds.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. … That really spurs them on to look at addressing racism in labor and delivery.”
Elliott Main, MD
Medical director of the California Maternal Quality Care Collaborative
All of these efforts have borne fruit: Since the launch of the collaborative, California’s maternal deaths have dropped by 65%.
Now, the CMQCC is crafting additional equity-related recommendations, such as handing expectant patients a staff-signed commitment promising to treat every patient with dignity and engage them in all birth-related decisions.
Also high on the CMQCC agenda is assessing the approaches of maternal mortality review committees, the bodies that study every pregnancy-related death.
“Often a problem is that review materials are medical-centric, and obviously the patient can’t tell her own story,” says Main. “We’re now exploring interviewing family members who lost a relative for their perspective. I think that’s going to be the future of committee reviews.”
Pregnancy always brings some stress, but the tension is much higher for patients who struggle to understand English and the intricacies of the U.S. health care system.
That’s why Crista Johnson-Agbakwu, MD, founded Valleywise Health’s Refugee Women’s Health Clinic in Arizona in 2008.
Since then, the Phoenix-based center has served more than 16,000 patients, many from countries across Africa. Arizona, which ranks high on the list of states resettling refugees, is now integrating evacuees from Afghanistan, says Johnson-Agbakwu.
“These are people who have escaped war and gender-based violence and other human rights atrocities,” she notes. “It’s important to understand the communities’ needs and meet the priorities they identify.”
To help do that, the clinic hires cultural health navigators (CHNs) — lay health care workers steeped in the culture and language of those they serve. “CHNs deeply understand patients’ background, religion, and lived experience and can interpret their health care through those lenses.”
CHNs offer patients ongoing supports, from accompanying them to prenatal visits to facilitating a smooth hospital discharge. And they can chart all interactions in electronic health records so that physicians know what’s been done or discussed.
“These are people who have escaped war and gender-based violence and other human rights atrocities. It’s important to understand the communities’ needs.”
Crista Johnson-Agbakwu, MD
Founder of Valleywise Health’s Refugee Women’s Health Clinic
Like Baltimore’s BHB, Ohio’s Moms2B, and similar programs, the clinic’s supports are accompanied by classes on perinatal health. But its offerings include a tour of the hospital labor and delivery unit — a crucial support for participants unaccustomed to Western, medicalized births.
“Things like IV lines and beeping noises and blood pressure cuffs can be very scary for this population,” says Johnson-Agbakwu. “They’re used to being mobile in labor and can interpret what we do as tying them to the bed. The tour helps demystify a lot of this.”
In all its work, the clinic strives to honor patients’ perspectives. “We try to go beyond checking the boxes of ensuring medical care,” she says. “We are engaging in care that’s anchored in mutual respect. That’s a piece that can be missing in achieving maternal health equity.”
Reaching rural patients
Many of the patients treated by Vidant Health in eastern North Carolina face significant pregnancy-related risks. More than half are overweight or obese, and many have diabetes or hypertension. The poverty rate of this population is twice the national average, and nearly all live in remote rural areas.
Black people — who comprise roughly a third of Vidant’s birthing patients — often fare the worst. In one recent nine-year period, they represented nearly 70% of maternal deaths in the region.
And Vidant Medical Center, based in Greenville, is the only large hospital in an expanse covering 29 counties.
Since 2017, Vidant has been working to support providers throughout the region in efforts to ensure high-quality care during obstetrical emergencies.
One major focus is drills in birth-related crises. These simulations — hundreds have been held in 18 hospitals over the past three years — cover emergency cesarean sections, maternal resuscitation, and more.
The scenarios unfold realistically: A Vidant staff member assumes the role of a patient, and the local team races to save her — calling for emergency assistance, rushing to get instruments, and suggesting necessary maneuvers.
“In a small hospital, these emergencies happen maybe once every two or three years,” which makes it tough to keep skills fresh, says James deVente, MD, PhD, medical director of obstetrics at Vidant Medical Center. “We give them a chance to practice skills over and over so that when something actually happens, they’re ready.”
Traveling to provide training is not always the best option, though. So Vidant providers have also logged thousands of hours advising local providers on how to handle their toughest perinatal cases.
Now, in an effort launched in July 2020, Vidant experts also remotely treat high-risk patients, working in collaboration with 15 local obstetricians.
“Patients often need to drive 60 miles or more each way to be seen [at Vidant],” says Alan Sacks, MD, who heads the Maternal Outreach Through Telehealth for Rural Sites (MOTHeRS) Project. “Appointments can be a costly ordeal in wages lost for a day off from work, child care, and transportation. The project is patient-centered. We basically go to them.”
In addition to telehealth services like remote ultrasound, the effort screens all participants for food insecurity. Those in need immediately receive a food package and are connected to a local food bank. All patients with diabetes or obesity also receive ongoing nutrition counseling.
Sacks highlights another key component of the program: mental health care.
“Mental health disorders carry a 50% increase in severe maternal morbidity and mortality. Nearly 9% of maternal deaths are attributable to mental health disorders. All of these figures are higher in African American patients. The situation and statistics are tragic and can fuel a worrisome intergenerational cycle.”
Looking ahead, Sacks hopes to expand the MOTHeRS Project to additional remote locations. Meanwhile, Vidant’s efforts so far have made a difference. For example, the infant mortality rate in the region dropped by 24% in recent years.
“There’s more work to be done,” says deVente. “But we set out to make this region a better place to give birth and be born, and I think we’ve succeeded in doing that.”
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