We’re No. 37? Or Maybe Not …


Phil Musgrove, now at Health Affairs, was an editor at the World Health Organization when it compiled its international comparison of nations’ health status that ranked the U.S. 37th in the world, largely because of its poor performance on infant mortality and longevity. In a letter to the editor in today’s New England Journal of Medicine, he points out that the U.S. had no statistics for nearly half the measurements used in the rankings and that most of the national rankings were inputed from data from 30 of 191 countries in the survey who fully reported their health outcomes.

He concludes:

The number 37 is meaningless . . . Analyzing the failings of health systems can be valuable; making up rankings among them is not. It is long past time for this zombie number to disappear from circulation.

Fair enough. But the U.S. ranking in infant mortality and its lagging longevity are cause for alarm because they show that the U.S. lags in health status. There’s many factors well beyond the quality of the health care system that contribute to these lagging indicators: persistent poverty in certain parts of the country and among certain subpopulations; chronic un- and underemployment; high levels of income and status inequality; and high levels of social stress and insecurity, for instance.

Someone should update the rankings and stress that they measure health status, not the quality of health care systems. If not WHO, who?

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7 replies »

  1. Lots of discussion about infant mortality statistics, but silence on longevity. To use the logic above from JonD, since the U.S. spends more on end of life care, logically the longevity numbers should be better, but they aren’t. You have to use both sides of the argument.
    I’m also not sure that measuring ‘healthcare” or “medical systems” is where we should be. Shouldn’t we be interested in health and wellness – in which case macro-statistics can be very useful in establishing certain societal attributes in which we should all be very interested.

  2. Infant mortality is indeed a flawed measure due to the lack of a standard way to count it and other factors. I have seen multipled articles on the topic over the years that explored the flaws. Basically, we count as live births what other nations do not. As such, we will always be at a disadvantage when compared using this measure.
    Wikipedia actually explores the variances a bit:
    “The World Health Organization (WHO) defines a live birth as any born human being who demonstrates independent signs of life, including breathing, voluntary muscle movement, or heartbeat. Many countries, however, including certain European states and Japan, only count as live births cases where an infant breathes at birth, which makes their reported IMR numbers somewhat lower and raises their rates of perinatal mortality.”
    We also must be careful in a tendency to ascribe 100 percent linking medical care and infant mortality rates. For example, it is logical that countries where there is a low rate of dangerous drug abuse by pregnant women would likely have lower infant mortality rates. Counties with higher rates of drug abuse would see the opposite. Yet, under the simple cause-effect (+- infant mortility = +- medical care) linkages typically on display — this variation would be wholly attributed to the respective medical systems. Yet, can any medical system totally compensate for the law enforcement and culteral aspects that in play with regard to drug abuse by pregnant women?
    It is also a scientific fact that there are variations in infant mortality rates by race. For reasons not yet understood, black women are much more at risk. It apparently isn’t povery, as the tragic consequence afflicts upper-income black women at rates greater than their lower-income white counter-parts. If you have a greater population of black women of child-bearing age, you will see some increase in your overall infant mortality rates. It will also be for reasons that apparently have little to do with available medical care.
    The wide variances between infant mortality by race and its disproportionate impact on black women are widely known among health care researchers. A quick Google search will bring up multiple articles on the topic.
    Infant mortality rates can have their place as a measure, but they are a crude one that may obscure as much as they illuminate.

  3. “not on our health care capabilities and knowledge”
    Not sure what JonD refers to here “The author also shows his political leanings”, but Chris’ point is accurate as are the points made by Mr. Goozner.
    Gross measures of health status in particular longevity at birth and infant mortality no matter how imprecise the reported figures are (under the assumption that the statistics are at least the best and most accurate available) do in fact measure the efficacy of any healthcare system for a given population.
    The healthcare system obviously includes the part of the system that reflects most of the cost – medical services and its financing – but also social and public health policies/actions, governmental regulation of massive and misleading advertising from private interests whose purpose is increasing the economic value of those interests, not public well-being, cultural factors, etc.

  4. To Chris: If a population has more predisposition for certain diseases, then a health care system can only do so much. An incredibly diverse populace like the US should not be compared directly to a tiny, homogenous population like, say, the Netherlands.
    The author also shows his political leanings: if the US were more *fair*, like Europe, everyone would be healthier. But that’s an attack on the US’ political and social leanings, not on our health care capabilities and knowledge.
    I agree with Zietzew–if the US measures differently (and on infant mortality, it does), then direct comparisons are meaningless. Or, they’re simply used for political purposes.
    Ultimately, the US spends more on heroic measures near and at the end of life than other countries. This skews our costs without doing a whole lot for mortality–because developed nations as a whole have already done so much to beat the easy diseases.

  5. Any time you try to perform an analysis and attempt to reduce a myriad of data complexities down to a single value, the exact result will be meaningless. This is because the choice of measurements used can dramatically affect the overall ranking. However, it is important to keep in mind that in a more general qualitative way, the ranking value is still important because it shows that despite very high US spending on health care, the US still ranks nowhere near the top.

  6. Isn’t this both a question of data quality and a question of access to care? I have read elsewhere that US infant mortality statistics are not equivalent to those in other countries who do not count some premature births as live births, although the US does count them. In addition, and perhaps more importantly, it does not matter how high the quality of a system is to a patient who does not have access to it. As Wayne Gretzky once said: “You miss 100% of the shots you never take. Similarly, former US Surgeon General C. Everett Koop once said:”Drugs don’t work in patients who don’t take them.”
    In order to achieve high quality outcomes we will need a high quality of access to a high quality system. In order to measure quality accurately we will need access to accurate data.

  7. How is population health status not a measure of the quality of health care *systems*?

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