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Remember that word? Unless you’re studying for a spelling bee, it probably doesn’t ring a bell. But when you hear the much-bandied about question in the current political arena, “are you better off than you were four years ago?”, that bell ought to ring. Because that’s where we were four years ago. There’s a human tendency to put a pleasant gauze over the past, emphasizing the positive and minimizing the negative. So, when considering the lay of the land four years ago, one might vaguely recall a couple of contact points with the economy, the price of gas and price of food, were better. One might not recall that four years ago employment fell by a combined 22.4 million in March and April. That decline of 15 percent was unprecedented in modern times. (The decline in the Great Recession of 2007 was 6 percent). That’s because four years ago we found ourselves in the grip of the COVID pandemic. That’s where hydroxychloroquine comes in. The Trump administration's chaotic response to the pandemic included promoting unproven treatments like hydroxychloroquine and even suggesting the use of bleach as a potential cure. Misinformation spread like wildfire, leading to confusion and fear among the populace. There was plenty of magical thinking – that it would go away with the coming of warmer weather, etc. There was plenty of pin-the-blame game, with Trump and media allies insisting that COVID be called the Wuhan Virus or Chinese Virus. Above all there was a push to reopen the economy, despite the fact that ramped up testing and other safety measures weren’t in place. There was also a push to split a frightened populace even further, with Trump delivering tweets railing against lockdown measures in the states with Democratic governors – Virginia, Michigan and Minnesota all got the “LIBERATE!” treatment. Misinformation was running rampant and conspiracy theorists were having a field day. Over in Britain, they were burning cell towers, as somehow someone came up with the idea 5G technology was spreading COVID. Similarly, messages coming from the White House briefings were all over the board. When masking was recommended Trump watered down the message by saying the recommendation wasn’t really a mandate and he couldn’t see himself wearing one. As to hydroxychloroquine, well, it’s been around as a malaria treatment for decades. Somehow it got touted as a COVID treatment, and Trump picked up on it. On several other treatments that weren’t really treatments as well. A paper called the “Impact of Trump's Promotion of Unproven COVID-19 Treatments and Subsequent Internet Trends: Observational Study’’ at the National Library of Medicine reported “From March 1 to April 30, 2020, Donald J. Trump made 11 tweets about unproven therapies and mentioned these therapies 65 times in White House briefings, especially touting hydroxychloroquine and chloroquine. These tweets had an impression reach of 300% above Donald J Trump’s average. Following these tweets, at least 2% of airtime on conservative networks for treatment modalities like azithromycin and continuous mentions of such treatments were observed on stations like Fox News. Google searches and purchases increased following his first press conference on March 19, 2020, and increased again following his tweets on March 21, 2020. The same is true for medications on Amazon, with purchases for medicine substitutes, such as hydroxychloroquine, increasing by 200%.” During White House briefings Trump mentioned hydroxychloroquine 37 times in total; chloroquine 12 times; azithromycin 8 times; and remdesivir 8 times in total. April of 2000 also gave us the tale of Trump and bleach. Contrary to popular belief, Trump didn’t actually say folks should drink bleach, but he did muse about whether disinfectants could be used to treat coronavirus infections inside human bodies. It was close enough to saying “drink this stuff’’ that Lysol issued a statement essentially saying “don’t do that.’’ Trump’s comments came after Department of Homeland undersecretary for science and technology William Bryan presented a study finding sun exposure and cleaning agents like bleach could kill the covid virus on surfaces. "So, supposedly we hit the body with a tremendous, whether it’s ultraviolet or just very powerful light,” Trump said, “and I think you said that hasn’t been checked, but you’re going to test it. And then I said supposing you brought the light inside the body, which you can do either through the skin or in some other way. (To Bryan) And I think you said you’re going to test that, too. Sounds interesting, right?" Four years ago, we were frightened of losing our jobs and our lives. Against this backdrop people were looking to their government for leadership. That’s what we were getting. Despite the challenges we faced four years ago, it's hard to deny that things have improved since then. The current situation may not be perfect, but we are in a much better place today than we were back then. Jim Buchanan is a longtime mountain journalist and author.

On October 7, 2023, the world changed.  Hamas attacked innocent Israeli citizens enjoying a concert.  Women were raped and senior citizens were kidnapped along with children, women and men.  A terrible, horrible, cowardly act against the Israeli people.  The world was outraged with this act of terrorism.  President Joe Biden was quick to offer unequivocal support for Israel.  Most Americans supported the comments and position of the American President. The world was outraged and supported Israel’s counter attack against Hamas, formally known as Harakat al-Muqawama al-Islamiya.  More than 1,200 Israeli citizens were killed on October 7, 2023. No one would argue with Israel’s right to defend itself and target Hamas for this horrendous act of terrorism.  More than 270 hostages were taken, with over 134 still being held by Hamas. As the war enters its fifth month; there is no end in sight.  What we do know is that more than 30,000 Palestinians have been killed and over 70,000 wounded; with reports that more than half of those killed or wounded are women and children.  Not to mention the recent shooting of starving Palestinians surrounding food trucks. Does President Biden make a mistake by continuing to offer unequivocal support to Israel? I believe he does, considering Israel’s brutal military response, which most Americans, likely including the President, could not have anticipated. Daily photos, video, and commentary from Al Jazeera show the devastation of Gaza.  The displacement of over 2 million Palestinians, who are without food, water, electricity, and the basics of human life.  When you see complete residential areas demolished, along with hospitals, schools, churches, warehouses and any place where civilians gather, it turns your stomach.  Gaza is considered the worst place for children now in the world.  Keep in mind the population of Palestinian children is close to half of the population in Gaza.  It stands to reason when you drop 2,000-pound bombs that you are going to kill children. The United States is being called complicit in this indiscriminate attack on Palestinians in Gaza. The United States has vetoed three (3) UN security council resolutions calling for humanitarian aid to Gaza.  Moreover, when the US rightfully points the finger at Russia’s aggression into Ukraine, we as the world leader for peace and democracy need to be careful with our international policies; or risked being accused of hypocrisy. This commentary began with the atrocious attack on October 7th and Israel’s rightful duty to respond militarily and to gain the release of their blameless hostages.  Moreover, Prime Minister Benjamin Netanyahu has stated his goal of eliminating Hamas and freeing the hostages.  The families of hostages want the primary objective to be bringing their family members’ home. It seems to me, Netanyahu has another agenda: the genocide of all Palestinians in Gaza.  You tell people to leave the northern sector of Gaza and go south, and then you bomb them.  You bomb hospitals, you shoot at ambulances, you bomb schools; and then you blame Hamas. This does not add up; and begs the question, who are we as Americans? I stand with the Arab Americans who voted “uncommitted” during the Michigan primary in February.  I cannot support the policy of Israel killing civilians and blaming it on Hamas. What happens to the Palestinians after the Israel-Hamas war?  Who will rebuild their schools, hospitals, homes and infrastructure?  It cannot be built on the revenge seeking of Netanyahu. Some military experts believe it is not possible to eliminate Hamas.  Retired Lt. Gen. Ben Hodges, former Commanding General of U.S. Army Europe says: “To ‘eliminate’ or destroy Hamas, Israel will have to destroy the root cause of Hamas, its reason for existence. That means Israel will have to accept progress towards a two-state solution and Palestinian statehood for Gaza and the West Bank. Prime Minister Netanyahu is on record in January 2024, stating, he is opposed to a Palestinian state because it would constitute “an existential danger to Israel.” To resolve this terrible situation, it is time for American leadership to do what is best for Palestinians and Israelites to prevent the ongoing genocide. Many say we are hesitant to do the right thing, because we are politically supportive of Israel. Who are we as Americans?  As Americans, we are a diverse group of individuals who come from different backgrounds, beliefs, and experiences. We have a long history of standing up for what is right and fighting for justice. It is our nature to lead and take action when faced with challenges. By taking a leadership role in resolving these conflicts, we can work towards creating a more peaceful world.  By supporting our allies, such as Israel, and holding them accountable when it is necessary. Let us remember the values that define us as Americans—compassion, unity, and freedom. It is up to us to lead positive change and create peaceful solutions. Virgil L. Smith formerly served as president and publisher of the Asheville Citizen-Times and Vice President for Human Resources for the Gannett Company. He is the principal for the Smith Edwards Group and the author of "The Keys to Effective Leadership.” He is the founder and a writer for Carolina Commentary. Photos from US News and Al Jazeera

The grievous decline in the quality of care provided by Asheville’s Mission Hospital during the past five years incites outrage and frustration on multiple levels. Failed leadership and corporate shortsightedness and greed have turned one of the nation’s premier health systems into one where substandard care may have resulted in patient deaths. There was a time, not so long ago, when Mission and its integrated region-wide network ranked as one of the nation’s Top 15 Health Systems. The rating meant Mission performed better on six measures - fewer deaths, fewer complications and infections, shorter length of stay, shorter emergency department wait times, lower costs and higher patient satisfaction - than hundreds of other health systems evaluated. That was before, in a surprise announcement in March 2018, the not-for-profit Mission’s Board of Directors revealed its intent to sell Mission to HCA Healthcare, the nation’s largest hospital chain, for approximately $1.5 billion. The sale was completed in February 2019. The announcement shocked virtually everyone – local leaders, Mission employees, associated medical professionals, patients and the larger community. Five years later, Mission is in “immediate jeopardy” of losing Medicare and Medicaid reimbursements as a result of nine deficiencies related to incidents that happened between April 2022 and November 2023. The U.S. Centers for Medicare & Medicaid Services (CMS) defines “Immediate jeopardy” as noncompliance that “has placed the health and safety of recipients … at risk for serious injury, serious harm, serious impairment or death….” In early February, CMS informed Mission that it has 23 days to fix the problems or risk losing Medicare and Medicaid funding, thereby threatening the financial viability of the hospital. CMS cited Mission’s failure to meet standards in six areas: governing body, emergency services, nursing services, patients’ rights, quality assurance and laboratory services. Accountability for this precipitous decline in quality of care rests with multiple entities. First, there’s North Carolina’s Republican-dominated legislature which, for a decade, refused to approve expansion of Medicaid to hundreds of thousands of uninsured North Carolinians under the Affordable Care Act. The fact that 90 percent of the expansion would be paid for by the Federal government failed to overcome their stubborn partisan opposition. Lawmakers finally approved the expansion in 2023, too late for a number of struggling rural hospitals, and too late to provide a critical income stream for Mission before it was sold. After selling Mission Hospital to HCA, according to reporting by Asheville Watchdog, Mission board members acknowledged that Mission was profitable and financially strong, but they were concerned about falling reimbursements from Medicare and Medicaid. Given lawmakers' refusal to expand Medicaid, there was no reason for them to expect that to change. They worried that Mission would face a future of cost-cutting that would ultimately degrade the quality, access and affordability of care, a concern that turned out to be ironic. Second, there’s the failure of Mission’s not-for-profit board and then-CEO Ronald Paulus to involve the community in the decision to sell one of its most valuable and essential assets, one critical not only to the health of Western North Carolinians but to the region’s economic strength. By failing to do so, they denied the community an opportunity to engage in a dialogue that might have changed the outcome. Third, there’s a serious question about whether the board performed adequate due diligence before selling Mission. Because everyone involved had to sign non-disclosure agreements, much of the circumstances surrounding the sale remain a mystery. But public record documents obtained by Asheville Watchdog suggest that HCA courted Mission directors and executives months before Mission’s board authorized CEO Paulus to start looking for potential partners. It appears HCA had an inside track from the beginning. Mission’s directors invited only a few companies to make proposals and quickly dismissed other suitors besides HCA. They invited only one other bidder to make a formal presentation and speedily rejected that bid, which came from a nonprofit, it was later disclosed. The board chose HCA, despite the fact that in 2017, HCA paid more than $200 million to settle lawsuits related to its purchase of a nonprofit hospital in Kansas City and that in 2003 HCA paid the government more than $1.7 billion in restitution, fines and penalties to settle fraud cases. By contrast, New Hanover County Commissioners recently sold their publicly owned regional hospital to Novant, a non-profit associated with the UNC Health and UNC School of Medicine, after ample opportunity for public comment, for approximately $2 billion. Fourth, and most outrageous, is the way HCA has systematically dismantled one of the nation’s premier regional health care systems. Western North Carolinians have long relied on Mission for advanced, high-quality health care. But for decades, Mission has also been an economic engine, making the area attractive to retirees and digital nomads and providing a hub for peripheral health related businesses. “This is a four-level problem, “Dr. Clay Ballantine told an audience of about 350 people who attended an Asheville Watchdog sponsored event titled “HCA-Mission at Five Years: What Can We Do to Restore Better Healthcare in WNC?” “You’ve got Mission Hospital,” Ballantine said. “You got satellite hospitals, but you’ve also got all these primary care and subspecialty practices that are under Mission’s purview and they are throughout the region. And then at the fourth level is patient services like rehab, low-cost pharmacies, and medical equipment that people need. HCA has impacted every single level of this system.” As of 2022, Ballantine said, 3,500 Mission employees had left, including at least 200 doctors. HCA has gutted staff, failed to provide adequate supplies and shutdown laboratory facilities, Ballantine said.  World class cancer and cardiology departments have been devastated. The situation is so bad, N.C. Attorney General Josh Stein is suing HCA and Mission for violating its asset purchase agreement regarding cancer care and emergency services. In its response, HCA insists the agreement is “silent as to the quantity or quality of services required.” And even though HCA pledged to maintain the same level of charity care that had been in place before it purchased Mission, Asheville Watchdog reported that a draft report of a study by a Wake Forest professor of law and public health found that “genuine charity care has diminished in systematic and extensive ways … with unfortunate effects on access to health care in western North Carolina.” It was multiple complaints from Mission nurses to the NC Department of Health and Human Services about policies, staffing levels, and quality of care that finally resulted in the inspection that brought about the CMS order to fix problems or lose Medicare and Medicaid funding. Those nurses’ persistent advocacy on behalf of their patients brings hope for improvement. State Sen. Julie Mayfield, D-Buncombe, organized a Feb. 6 news conference to allow Mission nurses, local elected leaders and other advocates to respond to the CMS finding. Mayfield and others voiced their outrage over the decline in care. In her opening remarks, Mayfield said, “If HCA is unable or unwilling to put the health and safety of our people first, then it’s time to find a company that will. Let me be clear, this community will not stop our advocacy and we will not quiet our voices until Mission Hospital once again provides world class care and the public’s trust and confidence in our hospital has been restored.” While it may be possible for HCA to accomplish such a reversal, it should be remembered that HCA’s first obligation is to its stockholders, who are likely pretty satisfied. Net income attributable to HCA Healthcare in the fourth quarter of 2023 totaled $1.607 billion, or $5.93 per share. Improvement adequate to meet an acceptable level of care shouldn’t be tolerable when we know a much higher standard has been and can be provided by Mission Hospital. Whatever it takes, our voices should not go quiet until that standard has been achieved again. Joy Franklin is a journalist and writer who served as editorial page editor of the Asheville Citizen-Times for 10 years. Prior to that she served as executive editor of the Times-News in Hendersonville, N.C. Franklin writes for Carolina Commentary.

Inflation has cooled since the 9% Covid-related spike in 2022, to around 3.4 %, as consumer spending and supply chains have “normalized.” The Federal Reserve’s anti-inflation interest-rate hikes helped, too. Though this rise in the ‘real interest rate’—calculated as interest rates minus the rate of inflation—could temporarily slow growth, North Carolina is one of the top five states where people are moving. A flood of federal spending on infrastructure, microchips, and electrification boosted North Carolina’s construction sector, and the nationwide housing shortage hasn’t hurt either. Low inventory is keeping home values high and rising. This gives homeowners confidence to spend, which helps prevent recession. Weirdly, though this economic news these days seems “good,” national consumer polls show disagreement with the healthy assessment. Fewer than one-quarter of registered voters in a Wall Street Journal poll, for instance, agreed the economy was “headed in the right direction.” Ben Harris and Aaron Sojourner of the Brookings Institution designed a model to study this perception gap. Their findings suggest biased sources of information play a role— that it’s not the economy, it’s the economic news that’s to blame. That news has become systematically more negative, starting in back in 2018. The negative bias has grown over the past three years. But maybe the respondents’  circumstances haven’t changed. We the people are the economy. Our spending behavior drives economic health, but we need confidence in the elected officials who answer to voters. Those officials can’t set interest rates, of course, but they do make policy. Rules governing electoral systems—think about North Carolina’s recently gerrymandered election maps, drawn unfairly and in secret—can be manipulated to create an electorate that tilts policy to richer, whiter districts. Those rules can also create barriers to voting that disenfranchise low-wage workers, young people, and others who rely on absentee or voting by mail. Senate Bill 749 is another insult. The bill would change the composition of elections boards and lead to gridlock, even election chaos, and threaten early voting. Both are being challenged in court. Recent research shows that the Voting Rights Act of 1965 reduced the Black-White wage divide; conversely, the recent judicial decision rescinding parts of the act has aggravated economic inequality. Studies link smaller differences in the turnout rate between low and high income voters with more generous state income support programs, higher minimum wages, and lower income inequality. As economic inequality worsens, frustrated citizens see the economy as “rigged” and turnout lags, especially in poor communities. This may explain the way citizens are interpreting today’s news about the economy’s health. Maybe survey respondents are distracted by global events in Israel or Ukraine, or maybe they only watch biased news channels. Or maybe, nothing has changed for them. Their wages haven’t gone up, but inflation has eroded purchasing power. They still can’t find child care. They don’t own a house. The strong construction sector hasn’t put them into affordable housing. Maybe they’re not buying these reports of a strong economy because they’re not feeling that strength or seeing evidence that their elected officials are working for them, no matter what the numbers say. Or maybe they don’t believe the good economy is sustainable, given today’s political climate. Since we are the economy, citizens’ beliefs will influence what we buy, literally, and figuratively, in our minds, and with our pocketbooks. That surely influences economic outcomes.

Public policy is, in many regards, akin to steering a supertanker. It takes a long time to change direction. Here in North Carolina, we've embarked on a major public policy change that likely has flown under the radar of many, if not most of our citizens. A decade ago, the state legislature included something called the Opportunity Scholarship program as part of the state budget. It was pitched as a way to help poor children escape public schools that were below par. North Carolina isn't the only state with a voucher program. Once a bit of fringe theory, the voucher movement has over the last couple of decades gained steam in many parts of the country. It's not merely gaining steam in North Carolina; it's downright turbocharged. This year's budget calls for about a billion dollars in new spending over the next decade, going from $176.5 million this year to more than half a billion each year by the 2032-33 budget. The argument remains that parents deserve a choice if their children are in failing public schools. That's hard to argue with. On the other hand, if public schools are failing and we don't have the money to fix them, it's sort of hard to argue that we have the money to fund scores of new schools through such a boom in voucher spending. Despite the fact that most parents are happy with their public schools, there's a cottage industry out there saying they aren't . Public schools have long been under attack but not with the level of fury that has been seen in recent years. From Commom Core to Critical Race Theory to a variety of LGBTQ controversies to the catch-all of "wokeism,'" public schools have been a punching bag. The uncertainity of the COVID era, a new pandemic few of us knew anything about sparked a whole new round of criticism when schools were, at the bottom line, trying to figure out how to keep kids alive. Were some mistakes made? Certainly. We were on an entirely new playing field when it came to a new disease. More than 1 million dead Americans later, it's safe to say public schools probably made fewer mistakes than other public sectors. Regardless, COVID helped spur a new push toward vouchers and provatization. And that push certainly has some hallmarks. In North Carolina, the top 71 recipients of the state's $134 million vouchers were religious schools, mainly Christian schools with a scattering of Islamic schools. Church and state separation arguments aside, there are some problems here. Private schools, unlike public schools, don't have to take everyone. Public schools have to provide services to students who need special services or accomodations under the Americans with Disabilities Act. Experiments with vouchers elsewhere have been...instuctional. Billed as a way to get kids out of failing public schools, in Arizona three-quarters of initial applicants for vouchers had never been in a public school in the first place. In Wisconsin, more than 40 percent of voucher schools have closed since that state's program begain in 1990. A person with a cynical eye might think some schools were started just to collect voucher money. A person with a synical eye might also note that education budgets are the largeest outlays for state govenrments. Ome of the biggest concerns of all about our fracturing educatiron system boils down to E. Pluribus Unum: Out of many, one. "An education system is the reproductrive organ of every culture,' worte Kenneth R. Conklin, Ph.D., back 2004,'...a society's culture is a living entity which transcends all the society's individual members. A society's culture can survive far longer than the lifespan of any of its members, because its educational system passes down the folkways and knowledge of one generation to subsequent generations. A culture changes over time, but has a recognizable continuity of basic values and behavioral patterns that distinguishes it from other cultures. That continuity is provided by the educational system." But the educaiton systemn itself needs continuity. A public education system mixes kids from differrent backgorunds and social statuses and, ideally, lets them learn how to deal with those who are different. "If a school system provides a basic curriculum which is the same for all students, the adults who emerge will hold the same basic knowledge and atitutdes as one another," Conklin continued. "Certainly, there will be great differendes of individual ability and outcome; but there will be an underlying cohesiveness. However, if some schools admit only certain kinds of students and give them an educational program significantly different from other schools, it can be expected that the emerging adults will hold fundamentally different attitudes and beliefs." "The easiest way to break apart a society long-term without using violence is to establish separate educational systems for the groups to be broken apart." Is that the path we're on in North Carolina - indeed, in much of Americaa? That remains to be seen. But one thing's for sure: This shoip has left the dock. And if we're on the wrong course, it will take us a very long time to turn it around. Jim Buchanan is a longtime mountain journalist and author.

The news gathering business is not what it used to be. That is especially true in local communities where there is a lack of investigative reporting to hold the powerful accountable, to record history, to celebrate and to inform. Bill Kovach and Tom Rosenstiel in The Elements of Journalism, tells us that journalism “is not defined by technology, nor by journalists or the techniques they employ.” Rather, “the principles and purpose of journalism are defined by something more basic: the function news plays in the lives of people.” Unfortunately, newspapers in particular have been on a downward spiral for more than 40 years. Meanwhile, digital news sources are on the upswing, as people are using their mobile devices to stay informed of breaking news alerts. The breaking news alerts have value, but they don’t replace the in-depth investigative reporting that provides the type of coverage needed to keep the general population informed. Fortunately in North Carolina a handful of online investigative news sources, such as The Assembly, Carolina Public Press and Asheville Watchdog, are working to fill the void. It’s no secret that technology and lifestyle changes contributed to the consistent decline of traditional newspapers, a decline that impacts democracy in the United States and North Carolina. News organizations such as the New York Times, Washington Post, the Wall Street Journal and national cable news networks such as CNN, Fox News, and MSNBC continue to provide in-depth national and international coverage. However, they are not providing the in-depth coverage needed at state houses, including the North Carolina Legislature. An initiative called Press Forward, coordinated by the MacArthur Foundation in cooperation with 20 nonprofit organizations plans to invest $500 million over the next five years in local media organizations. That is a significant infusion of dollars to address the predicament of local news. The initiative will invest in nonpartisan efforts to provide access to news that is important to residents and voters. It is crucial that news organizations hold elected officials accountable for their policymaking. A case in point is House Bill 259, the appropriations bill that funds state agencies, departments and institutions, that became law in October 2023. The Republican-controlled legislature inserted language into the bill that gives them the authority to appoint special Superior Court Judges to eight-year terms without oversight and exempts them from the state public records law, allowing them withhold their documents from public view. They also inserted language that empowers the Joint Legislative Commission on Governmental Operations, or GovOps, to investigate state and local government agencies, as well as private companies and charities that received taxpayer funding. Public employees contacted by investigators would be required to keep those communications and requests for information confidential. One Democratic lawmaker compared the new powers to setting up a new government “Gestapo,” a comparison to Nazi Germany. There will be severe penalties for not cooperating with an investigation, which could cost jobs and result in criminal charges. The role of newspapers and other media is to shed light on this type of legislation by keeping the public informed. While some state news organizations covered these add-ons to the budget bill, local news outlets don’t have the staff or resources to provide their readers with adequate coverage of the legislature and how the laws they pass affect them. The decline of newspaper readership gives legislators and government officials the freedom to enact legislation that is often not in the best interest of the public. Rather it is in the best interest of the politicians and their desire to remain in power and control the state for their political party. This has been clear with gerrymandering, a strategy that disenfranchises voters, and with the attack on public education, with the push for more charter and private schools. Voters have to do their own due diligence to find out the potential impact of laws passed by state lawmakers . Unfortunately, they cannot count on newspapers, as times have changed forever. The investment by the MacArthur Foundation and other foundations is an important step in reshaping the news and information landscape. Here are other strategies voters can utilize: 1. Follow reliable online news sources: While traditional newspapers may be declining, there are still many reliable online news sources available. Readers can follow reputable news websites. 2. Check the legislature's website: The North Carolina General Assembly's website provides access to bills, committee meetings, and other information related to the legislative process. Readers can check the website to find out what is happening in the legislature. 3. Follow legislators' social media: Legislators often post updates and information on their social media accounts. By following their accounts, readers can stay informed about their actions and positions. 4. Attend public hearings: The legislature holds public hearings on bills, and attending these hearings provides an opportunity to learn more about proposed legislation and provide input. Readers can find information on hearings by checking the legislature's website or contacting their representatives. 5. Engage with advocacy groups: There are many advocacy groups working to hold legislators accountable and promote transparency in government. Readers can engage with these groups to stay informed and get involved in advocacy efforts. Stay informed to make sure legislators serve their constituents’ interest, not their own. If not, use the power of the ballot box to replace them. Virgil L. Smith formerly served as president and publisher of the Asheville Citizen-Times and Vice President for Human Resources for the Gannett Company. He is the principal for the Smith Edwards Group and the author of "The Keys to Effective Leadership.” He is the founder and a writer for Carolina Commentary.

North Carolina’s hit parade of voter suppression marches on, now that the GOP has overridden Gov. Roy Cooper’s veto of Senate Bill 749, with tight ballot-receipt deadlines and extra signature scrutiny for mail-in voting, plus extra identification for same-day registrants. Both rules especially affect people of color and young voters who register on voting day and vote by mail at higher rates. Maybe politicians who become legislators don’t want deliberate debate and democratically-determined decisions. Or maybe even actual democracy. Rather than an election-day postmark, ballots must be received by poll-closing, which could invalidate many votes, due to delivery variation. New rules about same-day registration—extra identification and throwing away ballots of registrants whose mail comes back as undeliverable—make it harder to register during an early voting period. These rules especially affect the young and people of color. Tight turnarounds for mail-in voting make no sense, when there’s little to no evidence of electoral fraud. The practice dates from the Civil War, but Republicans seem to think it’s a scam, a partisan ploy designed to steal their votes. But even before the 2020 election, during Covid, absentee voting was on the rise. The only scam afoot is the GOP’s systematic efforts to undermine democracy. Mail-in voting includes signature verification, drop boxes in safe locations, and address confirmation. A Washington Post analysis found few (0.0025 percent) possibly fraudulent votes in the 2016 and 2018 elections. And, according to The Hill, in 20 years and 250 million mail-in votes, there were 143 criminal convictions. Significantly, the law also shifts county and state election board appointments from the governor to legislators; House speaker, Senate leader, and minority party leaders in each chamber would each appoint two members, replacing the current five-to-three, governor-selected appointees. Such deadlocked,bi-partisan boards are a gridlock guarantee. Deadlocked boards are figuring as prominently in partisan politics as in corporations. Corporate deadlocked boards are designed to keep a CEO entrenched. What should we infer from the GOP’s political move? Maybe gridlock is the goal. Suppose members deadlock on election certification; if legislators are called to decide, the Republican majority rules. District maps, currently being re-drawn, may also be GOP-gerrymandered. Theoretically the new configuration could avoid partisan advantage, through healthy debate and compromise. In reality, the deadlock ensures tied votes on decisions, with legislators stepping in to make the call. Is that what we want? One-party rule? Republicans have veto-proof majorities as well as a N.C. Supreme Court majority of 5-2 after last year’s election. Compromise and democratic deliberation seem forgotten and forsaken; certainly they seem like pre-Trump notions. Maybe some legislators have forgotten such skills and why they matter to voters. Or, maybe politicians who become legislators don’t want deliberate debate and democratically-determined decisions. Or maybe even actual democracy. Betty Joyce Nash reported for the Greensboro News & Record and the Hendersonville Times-News before moving to Virginia where she worked as an economics writer for the Federal Reserve Bank of Richmond. She co-edited Lock & Load: Armed Fiction, an anthology of literary short stories that probe Americans' complicated relationship to firearms. (University of New Mexico Press, 2017.)

On Aug. 28, Muhsin Mahmud, an exchange student from the UK, was making a video as he walked through the idyllic campus of my alma mater, the University of North Carolina. “You can have a little picnic here,” he said, panning around to show the tall trees and crisscrossed sidewalks with students leisurely walking to class. That was the ironic moment when air raid style sirens abruptly began blaring throughout Chapel Hill, shattering the peace. “I have no idea what the hell that is,” Mahmud said right before loud speakers announced an "armed, dangerous person." That was also the moment my daughter, a current student, called me. We were on a video call for two hours as we both sifted through online rumors about what was going on. The lockdown continued for an hour more as police methodically ruled out the possibility of a mass shooting like the one that occurred at our sister school, UNC-Charlotte. Thankfully, the terrifying incident turned out to be “only” a single murder. Outside North Carolina, it didn’t even get a lot of news coverage since it didn’t qualify as a mass shooting event. That changed, however, on Aug. 30 when The Daily Tar Heel — the student run newspaper published every Wednesday — appeared in newsstands. Instead of the football edition the editorial staff had already completed, the front page of the paper was covered with bold black and red text messages that students had exchanged during lockdown: HEY — COME ON SWEETHEART — I NEED TO HEAR FROM YOU. CAN YOU HEAR ANY GUNSHOTS? I’M IN CLASS EVERYONE IS LOSING IT PEOPLE ARE LITERALLY SHAKING. GUYS I’M SO FUCKING SCARED. The front page was such an authentic encapsulation of the moment that it immediately went viral. That evening President Biden posted an image of his hand holding his cell phone as he read the page. In the coming days, the young editors were being interviewed by NPR, NBC and other national press. As my own social media filled up with posts and reposts of the page, most parents and other adults were supportive, proud, and frankly in awe of what these student journalists had accomplished; however, a small but vocal minority had perplexing reactions like these: “Please remove this post…it contains foul language and just needs to be deleted.” “This language is inappropriate. Take it down or blur the words." “This post needs to come down because of the language.” That group of adults was more outraged by F-bombs being used in college students’ texts than they were by a gun being used to commit murder and spread terror throughout the UNC campus. I think it’s important to note that these people weren’t online trolls whose purpose is to bait people into reacting emotionally. They were real people who probably believed they were being virtuous. I imagine many of them were earnest conservative Christians speaking out for their values. I am an unaffiliated voter, part of the largest voting group in the state. While I tend to vote Democratic, I have voted for multiple Republicans and have been satisfied with several Republican officials I’ve known over the years. However, I doubt I will vote for a Republican in a partisan race for at least ten years, and the reason is related to the “outrage” reactions I witnessed on social media after the shooting. I’ve been watching closely and from what I see, the Republican Party is no longer interested in governing or solving problems or doing anything constructive. They don’t think it’s the government’s role to provide a safety net for the vulnerable or to ensure communities have safe water or to provide public education for all children. The only thing they seem to care about is the outrage of the week, which often makes no sense to anybody else. So instead of talking about ways to prevent terrorist-style events from happening on our college campuses, they were talking about how offended they were by strong language. Other things they are outraged about? Books with same-sex parents. (Not my family’s values!) The separation of church and state. (There should be prayer in school!) And anything they label as woke. (Removing Confederate statues! The anti-patriarchy of the Barbie movie! The footwear on the Green M&M!) It is ridiculous. It’s ridiculous but it’s also terrifying. The flash-in-the-pan outrage parade serves to manipulate a large voting bloc of evangelical Christians who strive to put their faith first. I believe these people are sincere and well-intentioned, but from my perspective, in recent years the vast majority tend to support any politician who makes a lot of noise about Christian values, even as that person is advocating legislation that harms Americans, the Earth we share, and global stability and often behaving in most un-Christian ways. From what I was taught growing up in a Southern Baptist church, many of the actual policies pushed by these extremely religious-sounding politicians directly oppose the foundational teachings of Christ. Also, from what I see, these leaders are exclusively Republicans. My parents were Republicans and I have been an engaged voter for more than 40 years. I feel confident in saying the Republican Party of the past does not exist today. I find this upsetting because I believe a healthy two-party system in which ideas can be debated is important, but I know we can’t pretend that today’s Republicans are working to create anything other than chaos to achieve an authoritarian right-wing state in which they control everything and everybody. It is not hyperbole to say they are following a fascist playbook. The outrage of the week is fundamental to their effort. The outrage of the week is the Pied Piper of the radical right-wing movement, causing a huge voting bloc of people to elect legislators who will make drag shows illegal but not child marriage, who argue that a microscopic embryo has more rights than a ten-year-old rape victim, who will deliberately make it more difficult for people of color to vote, who will criticize college students’ text messages rather than challenge the gun lobby. To have a choice in future elections we have to defeat authoritarians who have co-opted the Republican label. I’m asking other unaffiliated voters to re-examine the idea that we currently have two legitimate parties to choose from. I’m asking them to think about joining a coalition of people — including many former leaders in the Republican party (Stuart Stevens, Jennifer Rubin, Steve Schmidt, Justice Michael Luttig, Tom Nichols, Nicolle Wallace, Christine Todd Whitman, and many others) — in voting Blue. From my perspective, the faster we elect Democrats in a landslide, the faster we can put guardrails back in place (such as passing the Voting Rights Act) and the faster we can rebuild a two-party system that reflects the will of the people. I am cautiously optimistic. I have to believe that most Americans are in favor of limiting the proliferation of AK-15s in our communities. I have to believe that most people support our public education system. I have to believe that most people want voting to be accessible for all eligible Americans. I have to believe that most people will come to see beyond the outrage of the week and realize we have to address issues that affect people’s lives rather than made-up offenses. Elizabeth Gibson is a freelance writer who learned to meet deadline using black manual typewriters at the University of North Carolina at Chapel Hill. She has lived in the mountains of Western North Carolina for more than 30 years.

In early September, N.C. Superintendent of Schools Catherine Pruitt told the State Board of Education that school systems need more time to comply with the controversial Parents Bill of Rights that became law in August when the Republican-led legislature overrode Gov. Roy Cooper’s veto. The law requires educators to alert parents if their child changes his or her name or uses a different pronoun at school, restricts instruction about gender identity and sexuality in K-4 classrooms, requires parental consent for providing health care to children, requires parental permission to opt into surveys that ask questions about sexual behavior, illegal activity or mental health issues and requires school systems to more fully inform parents about how to object to materials or curriculum topics. Except for the provision about providing health care, which doesn’t kick in until Dec. 1, the law went into effect Aug. 15, days before school started on Aug. 28. Developing policies and procedures to comply will take hours of meetings and significant resources at a time when many school systems are still trying to find teachers to fill vacancies. If this were a law that promised to better prepare North Carolina students to navigate a world where those with nimble discernment and critical thinking skills will be best positioned to thrive, implementing it would be a good investment of time and resources. But, to the contrary, it’s a law that’s unnecessary, intrusive, likely disruptive and potentially harmful. It’s hard to see how this law furthers the primary function of public schools, which is to educate students and provide them with the skills they need to be contributing members of society. It’s even harder to think of a praise-worthy reason GOP lawmakers would spend the 2023 session, which began in January, hashing out divisive bills like this one and another one that denies treatment to young people with gender dysphoria, when they couldn’t be bothered to pass a 2023-2024 budget, the most fundamental thing their constituents send them to Raleigh to do. There can be little doubt, both these laws are an attempt to marginalize a very small number of vulnerable young people. Tamika Walker-Kelly, president of the NC Association of Educators, the state’s largest teachers’ group, told WRAL news in Raleigh that teachers are most concerned with the effect the new Parents Bill of Rights law will have on LGBTQ+ students and families, especially the provision that requires schools to inform parents if a student is questioning their own gender. “We know that not every student who comes to us at school has a caring adult, and sometimes the educator or the school personnel is that caring adult for that student,” she said. “It is our responsibility, part of our professional standards and code of ethics, to think about first the priority of the student, their health and safety. We will continue to navigate that as educators, but this provision in the law does make that a lot more difficult.” In the fall of 2022, the news agency Reuters worked with the health technology company Komodo Health Inc. to identify the number of young people, ages 6 to 17, in the United States who sought and received gender-affirming care between 2017 and 2021. Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients, including those covered by private health plans and public insurance like Medicaid. The data included roughly 40 million patients annually between ages 6 and 17. In 2021, the total number of young people diagnosed and/or treated for gender dysphoria, which is defined as distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth, was about 42,000. The total U.S. number over the five-year period was 121,882. Putting that into context, during the 2020-2021 school year, approximately 1.6 million students attended North Carolina public and charter schools. North Carolina makes up about 3.2 percent of the total U.S. population of about 340 million. That means there are likely less than 1,500 students in the entire state of North Carolina, where there are 2,500-plus public schools, who experience gender dysphoria. Why would state lawmakers spend time targeting such a small and vulnerable number of students instead of passing a budget that will hopefully give the state’s poorly paid teachers a raise? It is especially concerning given the evidence that youth who suffer from gender dysphoria are at high risk of severe depression and suicide. A study published by the Journal of the American Medical Association found that receipt of gender-affirming care in one small cohort of transgender and nonbinary youth was associated with 60 percent lower odds of moderate or severe depression and 73 percent lower odds of suicidality over a 12-month follow-up. There can be little doubt that decreased social support and increased stigma likely to result from legislators meddling in very private matters will almost certainly lead to increased mental health problems for this small group of young people. Meanwhile the calendar rolled toward mid-September with the state’s citizens still waiting for a budget that should’ve been passed with the start of the fiscal year July 1. Will teachers get a hefty raise? Will per pupil funding for schools increase significantly to give them the resources they need to prepare North Carolina students to navigate a world of evolving technology? A report published by the Education Law Center found that per-pupil funding in North Carolina ranked lower than any other state, when compared to the state’s wealth. In terms of total funding per pupil, the state fell from 46th in 2008 to 48th in 2020, according to the report. Will these metrics change as a result of the 2023-2024 budget? If not, it’s pretty clear that GOP lawmakers think fighting a manufactured culture war against a small vulnerable group of young people is more important than providing an adequate education for the state’s entire student population. Joy Franklin is a journalist and writer who served as editorial page editor of the Asheville Citizen-Times for 10 years. Prior to that she served as executive editor of the Times-News in Hendersonville, N.C. Franklin writes for Carolina Commentary

The Supreme Court of the United States is quickly changing the culture and rule of law for future generations. Historically, justices have been nominated and approved to honor and interpret the Constitution to make fair decisions that impact American society. Given their lifetime appointments, justices affect American life more than Congress or the Executive Branch, led by the president. As we all know, the decisions made by Supreme Court justices set precedent; the court has made historical decisions that have changed the direction of the nation. Some of the more influential Supreme Court cases were decided this year. Democracy prevailed in two decisions. In Allen v. Milligan, five justices, including Chief Justice John Roberts, agreed that Alabama’s gerrymandered congressional maps must be redrawn. And in Moore v. Harper, which originated in North Carolina, the court rejected the “theory” that the Constitution gives legislatures power over federal elections with no checks and balances from state constitutions, courts, governors, or voters. But the Court also repealed Roe vs. Wade, the law of the land for the past fifty years. The justices took away a woman’s right to decide the fate of her pregnancy and delegated states the power to determine abortion laws, to the detriment of women. Also, the Court overturned affirmative action for college admissions, causing deep concern in communities of color, especially the African-American community. Many have benefited from affirmative action, and may not have been accepted into colleges such as Harvard and the University of North Carolina without the decision. But this court found affirmative action in violation of the equal protection clause of the 14th Amendment. Supreme Court Justice Clarence Thomas attended Yale Law School, but voted against affirmative action. He had previously told employees at the Equal Employment Opportunity Commission: “God only knows where I would be today,” if not for the legal principles of equal employment opportunity measures such as affirmative action that are “critical to minorities and women in this society.” My, my how things have changed from Justice Thomas’s decades-old quote to the present, when he voted to eliminate and close the door on affirmative action for many students of color. All is not lost because historically Black colleges and universities stand to benefit from students who are seeking a college education. Justice Thomas stated: “Our Constitution is colorblind, and neither knows nor tolerates classes among citizens.” Unfortunately, we do not live in a colorblind society in America. Race and skin color still matter, given the United States’ history of slavery that has strongly influenced the generational wealth, or non-wealth, for white and Black families. When Supreme Court Justices are nominated and affirmed based on their ideological and political affiliations, all Americans lose. The conservative appointments by then-President Donald Trump illustrate the point. Supreme Court justices serve for life. Recent appointments of youthful justices, Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett mean that all could serve for the next 40 years. The conservative justices have demonstrated their commitment to a conservative ideology that will shape life for Americans for years to come. As President Obama once said, “elections have consequences.” Senator Mitch McConnell, a Republican, understood this when he blocked Obama’s Supreme Court nominee, District Court Judge Merrick Garland, with an unprecedented act denying Judge Garland a Senate hearing. McConnell subverted the will of the people, who elected Obama, to prevent the appointment of a Supreme Court justice he did not consider to be ideololigically aligned with his own party. It matters who nominates the Supreme Court justices in the United States. The Justices will rule our lives for generations. The decision on race-based criteria for college admission affects people of color, and benefits white college students in legacy admissions, according to an Associated Press survey of the nation’s most selective colleges. The survey found that legacy students in the freshman class ranged from 4% to 23%. At four schools — Notre Dame, USC, Cornell and Dartmouth — legacy students outnumbered Black students. "Legacy preferences have become an easy target in the wake of a Supreme Court decision that hinged on questions of merit in the college application process. Instead of getting in on their own merit, legacy students are standing on their parents’ shoulders." said Julie Park. Park studies college admissions and racial equity at the University of Maryland. “Let’s be clear: affirmative action still exists for white people. It’s called legacy admissions,” Rep. Barbara Lee, a California Democrat, said on Twitter. If a case challenging legacy admission makes its way to the Supreme Court, will the court decide to maintain this form of affirmative action for primarily white students? In North Carolina, Duke University and UNC Chapel Hill have taken action in response to the U.S. Supreme Court Affirmative Action decision. Both schools will target students based on income criteria. However, there is pushback from some at UNC Chapel Hill and further discussion on the financial admissions policy. This is a proactive approach to providing an opportunity for students from lower income families a chance to change the direction of their life and that of their family. This strategy is not race based and does not award students of families that attended a particular school. Access to a quality education is a game changer for many college students. A college education is valued and impacts who gets ahead in our society. If we citizens of the United States want a nation that is less polarized, based on fairness and equity, we need to vote for representatives who place the good of the nation first, regardless of political affiliation or loyalty to a political party. We should elect presidents who will nominate and senators who will affirm Supreme Court justices who make decisions that, instead of reflecting political ideology, provide equal justice under the Constitution. Virgil L. Smith formerly served as president and publisher of the Asheville Citizen-Times and Vice President for Human Resources for the Gannett Company. He is the principal for the Smith Edwards Group and the author of "The Keys to Effective Leadership.” He is the founder and a writer for Carolina Commentary.

For someone living in a rural county like Rutherford where the name of the Republican candidate is the only one on the ballot in most local races, it’s not news that the state Democratic Party has been largely missing in action during the past several election cycles. At the state level in 2022, Republicans were unopposed by a Democrat in one-fourth of House and Senate races. Even though it wasn’t news, it was gratifying to hear a Democratic Party official acknowledge it, as Vice Chair Jonah Garson did during a recent event at Henderson County Democratic Party headquarters. Thankfully, the party shows promising signs of coming to life again. Garson filled in for N.C. Democratic Party Chair Anderson Clayton, who stayed in Raleigh to participate in demonstrations associated with Gov. Roy Cooper’s veto of legislation that will ban nearly all abortions in North Carolina after 12 weeks. The New York Times recently profiled Clayton who, at 25, is the youngest state party chair in the U.S. After a friend invited me to the event, I looked forward to hearing her speak. But in her stead, Garson didn’t disappoint. An energetic, enthusiastic and engaging speaker, he told the gathering that a reform-minded board took over state party leadership a few months ago and plans to recruit and support candidates in every N.C. county. That’s good news. Voters deserve a choice when it comes to governing philosophy. But at the local level, where voters often have more direct knowledge of candidates, being able to choose the more capable one, no matter party affiliation, in terms of temperament, knowledge of the community and record of service should arguably carry even more weight. When there’s no competition, even the most incompetent or temperamentally unsuitable candidate can prevail. Garson, 36, is a civil litigation attorney who worked in the N.C. General Assembly for the late Rep. Paul Luebke, a Greensboro Democrat, before attending law school. He acknowledged that Democrats face an uphill battle. He quickly summarized how Republican strategic planning helped the party gain control of state legislatures, including North Carolina’s, through project REDMAP, by pumping huge amounts of money into swing state races aided by the Citizens United decision that allowed corporations and labor unions unlimited spending in support of candidates. Republicans outmaneuvered Democrats at a time when advances in computer software make it possible to surgically draw district lines to their advantage. Now that the Republican majority on the state Supreme Court has reversed precedent and declared it has no role in determining whether district boundaries disenfranchise voters, you can bet the Republican majorities in both chambers will draw maps that virtually guarantee noncompetitive districts. But Garson said N.C.’s new Democratic Party board has a six-year strategy to turn things around with four major goals. The first is to elect a Democratic governor in 2024. The second is to break the Republican’s supermajority in at least one General Assembly body, making it possible to sustain a gubernatorial veto. The third focuses on the courts, with a goal of replacing retiring Justice Michael Morgan, a Democrat, with another Democrat, and winning a full term for Judge Allison Riggs on the Court of Appeals. Gov. Roy Cooper appointed Riggs to the appeals court in 2023 to fill a vacancy left by Republican Richard Dietz, who was elected to the N.C. Supreme Court in November. The fourth goal is to win North Carolina for Joe Biden in 2024. In addition to putting resources into recruiting candidates and urging candidates and volunteers to go out into the community to talk to voters about their concerns, the party plans to employ 12 to 13 regional directors whose job it will be to support local candidates and to make sure the insights they gain from that voter interaction are integrated at the state level. “In so many of these communities that we need to win, the state Democratic Party has been like wall flowers at a middle school dance, dickering over the line that’s going to get the person we want to dance with us out on the floor and not saying anything at all,” Garson said. “I think that as Democrats we have great values and great policy. Policy is a terrible pick-up line. We really need to start just by talking to folks and having some variation of ‘Hey, we’re are fighting for freedom for you to retire with security, for having a town that your kids want to stay in, for the future of this place, for public education, for safe water, for you to do what you want when it comes to having a family.’” There is no motto or slogan that will move people, he said. Garson’s point is well taken. Until local Democrats develop a coherent and authentic response to Republican messaging, there can be no real debate about the role of government in solving the problems that confront us. And without that, there can be no consensus, no common-sense middle ground. We need civil debate about issues, not harangues that demonize those with a different point of view. Republicans have claimed the mantle of the party of freedom, but Garson talked about N.C. Democrats adopting Biden’s campaign theme that Democrats are in fact the party of freedom – freedom to decide what to do with your body, freedom to be safe in public spaces, freedom to vote. A vigorous debate about what exactly it means to be free seems a good place to start. North Carolina needs a vibrant, energetic Democratic Party, one that’s peeled off the wall, found its voice and walked onto the dance floor. Joy Franklin is a journalist and writer who served as editorial page editor of the Asheville Citizen-Times for 10 years. Prior to that she served as executive editor of the Times-News in Hendersonville, N.C. Franklin writes for Carolina Commentary.

Reprint from Carolina Public Press and KFF Health News BAMBERG, S.C. — Years before the Bamberg County Hospital closed in 2012, and the next-closest hospital in neighboring Barnwell shut its doors in 2016, those facilities had stopped delivering babies. These days, there’s not even an ultrasound machine in this rural county 60 miles south of Columbia, much less an obstetrician. Pregnant women here are left with few options for care. Federally qualified health centers offer prenatal services in nearby Fairfax and Barnwell, but only when a pregnancy is uncomplicated and only through about 34 weeks of gestation. During the final weeks of pregnancy, women must transfer their care to the nearest obstetrician, often in Orangeburg, which can be 20 miles away or more, depending on where they live in Bamberg County. Some women travel farther to hospitals in Aiken or Beaufort, where health outcomes are better. “Most of our women are driving an hour or more from their homes to an OB provider,” said Tracy Golden, a doula and senior program manager for the South Carolina Office of Rural Health. Although the regional hospital in the city of Orangeburg delivers babies, the birth outcomes in the county are awful by any standard. In 2021, nearly 3% of all Black infants in Orangeburg County died before their 1st birthday. Nationally, the average is about 1% for Black infants and less than 0.5% for white infants. Meanwhile, Orangeburg County’s infant mortality rate for babies of all races is the highest in South Carolina, according to the latest data published by the South Carolina Department of Health and Environmental Control. By 2030, the federal government wants infant mortality to fall to 5 or fewer deaths per 1,000 live births. According to annual data compiled by the Centers for Disease Control and Prevention, 16 states have already met or surpassed that goal, including Nevada, New York, and California. But none of those states are in the South, where infant mortality is by far the highest in the country, with Mississippi’s rate of 8.12 deaths per 1,000 live births ranking worst. Even in those few Southern states where infant mortality rates are inching closer to the national average, the gap between death rates of Black and white babies is vast. In Florida and North Carolina, for example, the Black infant mortality rate is more than twice as high as it is for white babies. A new study published in JAMA found that over two decades Black people in the U.S. experienced more than 1.6 million excess deaths and 80 million years of life lost because of increased mortality risk relative to white Americans. The study also found that infants and older Black Americans bear the brunt of excess deaths and years lost. That makes Black infant mortality in the South a complex regional crisis that should alarm everyone, not just future parents, said Georgina Dukes-Harris, senior director for social care at Unite Us, a national technology company focused on societal needs. Birth outcomes for mothers and infants are a leading indicator of population well-being and they run much deeper than health care: They reflect politics. They’re a direct product of generational poverty and racism. They reveal our priorities, Dukes-Harris said. Often, babies die under circumstances that states, communities, and parents can help control, like making sure infants don’t suffocate in beds or in unsafe cribs, or extending health coverage so that young women can afford to see a doctor before they become pregnant. In many of these respects, the South is failing. “This is something that has to change,” Dukes-Harris said. ‘An urgent problem’ with no easy solution Public health officials are still trying to parse the long-term impact of the covid-19 pandemic, but infant death rates in South Carolina were higher than the national average long before the health care landscape changed in 2020. And a report published by the South Carolina Department of Health and Environmental Control in April shows the rate for non-Hispanic Black babies — who died at a rate nearly 2½ times that of non-Hispanic white infants in South Carolina in 2021 — is growing worse. The death rate among infants born to Black mothers in the state increased by nearly 40% from 2017 to 2021. “That’s just not acceptable,” said Edward Simmer, director of the South Carolina health department. “It’s absolutely an urgent problem to me.” It’s a problem, though, without an apparent solution. Multimillion-dollar programs to improve South Carolina’s numbers over the past decade have failed to move the needle. To make things more complicated, separate state agencies have reached different conclusions about the leading cause of infant death. The state Department of Health and Human Services — which administers Medicaid, the health coverage program for low-income residents, and pays for more than half of all births in South Carolina — claims accidental deaths were the No. 1 reason babies covered by Medicaid died from 2016 to 2020, according to Medicaid spokesperson Jeff Leieritz. But the state health department, where all infant death data is housed, reported birth defects as the top cause for the past several years. Accidental deaths ranked fifth among all causes in 2021, according to the 2021 health department report. All but one of those accidental infant deaths were attributed to suffocation or strangulation in bed. Meanwhile, infant mortality is a topic that continues to get little, if any, attention, especially in the South. A group called the South Carolina Birth Outcomes Initiative meets regularly to talk strategy, but this consortium of the state’s top doctors, nurses, health insurers, and hospital leaders can’t solve fundamental problems, like teaching parents safe sleep habits or connecting all pregnant women to basic prenatal care. According to the Medicaid agency, nearly half of Medicaid-enrolled babies who died before their 1st birthday in 2021 were born to mothers who received no prenatal care. “There’s good work going on. It’s just in little patches. It’s just not spread out enough to change our overall numbers,” said Rick Foster, a retired physician and former chairman of one of the Birth Outcomes Initiative’s working groups. Expanding access to maternal care South Carolina and several other states recently extended postpartum Medicaid coverage for women who give birth, which means their coverage remains in place for one year after delivery. Historically, Medicaid coverage was cut off 60 days after having a baby. Some experts believe expanding Medicaid coverage to single, working adults who aren’t pregnant and don’t have children — something most Southern states have failed to do — would also help curtail infant deaths. A woman who is healthy when heading into pregnancy is more likely to give birth to a healthy baby because the health of the mother correlates to the health of the infant. But many women don’t qualify for Medicaid coverage until they become pregnant. Even when they become pregnant and are newly eligible for Medicaid, it isn’t unusual for women in South Carolina to put off seeing a doctor until the third trimester, physicians told KFF Health News. These women can’t afford to take time off work, can’t find child care, or don’t have a car, among other reasons. Telehealth could improve access if the state’s broadband network were better, said Simmer, the state health department director. The department could also invest in a fleet of mobile vans that provide prenatal care. Each costs just under $1 million, he said. Ultimately, South Carolina needs more doctors willing to practice in rural areas. Fourteen of its 46 counties lack a single OB-GYN, Simmer said. “We don’t have providers where we need them,” he said. To that end, he added, the state might consider using student loan forgiveness programs as an incentive for new medical school graduates to practice in rural areas of the state, where obstetricians are scarce. Meanwhile, two programs aimed at improving infant mortality in South Carolina, which were backed by millions of dollars in public and private funding over the past decade, were unsuccessful in hitting the goal. The Nurse-Family Partnership, for example, which pairs expectant South Carolina mothers with nurses for at-home visits, didn’t have a statistically significant effect on birth outcomes, according to an analysis of the multiyear project, published by the Harvard T.H. Chan School of Public Health. CenteringPregnancy, a separate program that offers small-group prenatal education to pregnant women, also failed to improve birth outcomes, said Amy Crockett, a maternal-fetal specialist in Greenville and one of the lead investigators for the state initiative. Crockett said she recently returned about $300,000 in grant funding to the Duke Endowment, a nonprofit that funds health, faith, and education initiatives in the Carolinas, because the evidence to support ongoing CenteringPregnancy projects simply wasn’t there. “It’s not the silver bullet we thought it would be,” Crockett said. “It’s time to move on.” Birth outcomes experts agreed that racism and poverty lie at the heart of this difficult problem, which disproportionately threatens Black infants and mothers in the rural South. Research shows that white doctors are often prejudiced against Black patients and minimize their concerns and pain. In South Carolina, the maternal mortality rate increased by nearly 10% from 2018 to 2019, according to the latest data, which found that the risk of pregnancy-related death for Black mothers was 67% higher than for white mothers. Upon review, the state health department determined 80% of those pregnancy-related deaths were preventable. Disparities related to both infant and maternal deaths deserve urgent attention from both the federal and state governments, said Scott Sullivan, division chief of maternal-fetal medicine at Inova Health System in Northern Virginia. Hospitals also bear a huge responsibility as doctors and health care providers must learn how to fairly and adequately take care of Black women and children. “The idea that we’re going to solve 400 years of racism in an hour’s worth of bias training is a cruel joke. Systems have to remodel their approach,” Sullivan said. “It’s going to take funding, and it’s going to take a sustained effort.” Have a question about this story? Do you see something we missed? Send an email to news@carolinapublicpress.org. _____ KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF. This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.