National Health Outcome Rankings: It’s the Culture Stupid!

Deciphering That 2000 WHO “Zombie Number” Ranking the U.S. 37th in the World

Philip Musgrove, PhD, who was editor-in-chief of the 2000 World Health Report, Health Systems: Improving Performance, says the report, published under his editorship, ranking the U.S. 37th in the world was a mistake (“Health Care Rankings, “ Letter to the Editor, New England Journal of Medicine, April 22, 2010). “It is long past time,” he says,” for this zombie number to disappear from circulation.”

Musgrove was responding to a New England Journal article critical of U.S. health care by two medical academics, Murray, C;l. and Frenk, J.: Ranking 37th – Measuring The Performance of the U.S. Health Care System,” N Engl J Medic 2010, 362:98-88.

Mosgrove argues that 37 is a”zombie number”because it predisposes national health outcomes depend only on access and ignore cultural, geographic, and historical factors.

I’m with Mosgrove. These examples supporting his position spring to mind.

• Medical care accounts only for about 15 percent of the health status of any given population (Leonard Sagan, The Health of Nations: True Causes of Sickness and Well-Being, 1987). Life style accounts for 20 percent to 30 percent, and income differences, and lack of social cohesion for the other 55 percent(D. Satcher, and R, Pamies, Multicultural Medicine and Health Differences, 2006).

• If one were to eliminate violence and accidents from the statistics, the U.S. would rank near the top in longevity. John Holcomb, M.D., the U.S. Army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s a useful statistic to keep in mind when comparing national health systems. If one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. Civilian trauma and deaths are largely beyond the health system’s reach.

• The U.S. is the number one destination for the world’s immigrants. The U.S. receives some 85 percent of the world’s immigrants. Because of such things as poverty, cultural differences, poor prenatal care, and discrimination, the non-white population, a disproportionate number of whom are immigrants, have lower life expectancies as follows; whites 81.0 years, black 63.6 years, Hispanic 74.0 years, Asian 75.2 years. (Abstract of the United States, 200-2004). From 1993 to 2003, the U.S. population exploded by 12.3 percent, due in large part to newly arrived immigrants with and their subsequent fecundity. This unexpected growth contributed to the physician shortage, lack of access to care, and dismal statistics.

• Life expectancy in the United States, a vast continental nation, depends on where you live . If you are black man in Harlem, your chances of surviving past 40 are less than if you lived in Bangladesh or other third world countries. If you live in Minnesota, you will live on average to 80.5 years. If you live in Mississippi, you are likely to die by 73.9 years. These various statistics are largely due to socioeconomic factors beyond the reach of health care professionals, who do not control what goes on in the streets or immigration patterns.

Top-down health care social engineering is a fine and wonderful bundle of good intentions worth pursuing, but it has its limitations - such as achieving uniform improved outcomes across all cultural groups.