An excerpt from Healthcare Upside Down: A Critical Examination of Policy and Practice.
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.”
– Charles Dickens: A Tale of Two Cities
Setting: TV quiz show
Story participants: TV Host, Contestant, United States TV Audience
Host: Name at least two of the three NFL quarterbacks of all time with the highest career passer ratings up to 2020.
Contestant: All three have ratings over one hundred. They are Deshaun Watson, Aaron Rogers, and Russell Wilson.
Host: Correct! You got all three.
Audience: Response of millions—I knew that! I could have gotten that one!
Host: When did Dow Jones Industrials first exceed thirty thousand, month and year?
Contestant: November 2020
Audience: Response of millions—I knew that! Big day!
Host: What was Marilyn Monroe’s biggest box office hit?
Contestant: Some Like It Hot.
Audience: Response of millions—I knew that! Too easy!
Host: United States life expectancy among all nations ranks … I’ll accept an approximate answer.
Contestant: Not sure. I would say close to the top, within the top ten.
Host: Wrong! Not even close. It is 40 or lower out of 200, not even in the top quarter of all nations.
Audience: Response of millions – Wow!
With regard to health care in the USA, the quote from Dickens is twice correct. We are in the best of times for knowledge, capability, and potential. We also are in the worst of times with regard to the application of our knowledge and the outcomes achieved, especially when compared to other nations.
The USA has a proud history of medical firsts. We have the largest number of Nobel laureates in physiology or medicine, in technologic advancements, and in the highest quality of health care—for certain individuals. At the same time, we are not world leaders, not even close, when we examine the global statistics of life expectancy, mortality rate, potential life lost years, specific diseases mortality, infant mortality, derived amenable mortality to health care, health care access and quality index, and availability of health care. These are the parameters used to measure health care and in all of them, given our potential, we are failures, losers in comparison to comparable industrial nations. Yet, we pay much more in dollars per capita and in percentage of our gross national product (GNP) for health care than any other nation.
The best way to illustrate these facts that govern our lives is to examine available statistics. In looking at the numbers, it is essential to appreciate their real-life implications. Today’s newspaper articles, as well as some scientific articles, will make “statistically valid” claims—by a convention defined as the probability of being factual if something occurs 95 out of 100 times, a criterion fairly useless in the real world. In selecting the statistics for this section, I have used only meaningful real-life data where the numbers represent actual deaths, lives saved, and the quality of life experienced.
One often hears the statement that life expectancy at birth in the USA in the past 160 years has almost doubled from 39.4 years in 1860 to 79.1 years in 2020. So, however, has life expectancy from birth in the rest of the world, and the USA is not in the top quarter of all nations. According to the United Nations estimates, Hong Kong, the leading country, in 2020 had an overall life expectancy of 85.29 years (88.17 females, 82.38 males). The top ten countries in life expectancy in 2020 were in order: Hong Kong, Japan, Macao, Switzerland, Singapore, Italy, Spain, Australia, Channel Islands, and Iceland. The USA was ranked below Cuba and Estonia at 46 out of 193 (the US total 79.11 years, females 81.65, males 76.61). The USA ranked six years in life expectancy below Hong Kong, about three years below our neighbor, Canada, and about two years below Great Britain. The World Health Organization (WHO) ranked the USA at 40th, and the United States Central Intelligence Agency (CIA) Factbook ranked the USA at 46th out of 227 (30th percentile).
The mortality rate, or death rate, is defined as the number of deaths in a particular population during a particular period of time, usually calculated as the number of deaths per 1000 or 100,000 people per year. According to the WHO, the country with the highest mortality in 2020 was Bulgaria (15.4), and the country with the lowest mortality rate is Qatar (1.2). There are 227 nations on this list and the USA with a mortality rate of 8.7 is 150th from the bottom (the good end) and 77 from the top (the bad end); in fact, the USA is among the 35% of the nations with the highest annual mortality rate in the world. Annual overall mortality rate has declined over the past 40 years, primarily due to advances in cancer and heart disease therapy, but the USA consistently lags behind comparable industrial nations
Potential life lost years
A common statistic of premature mortality is the age-specific potential life lost years (PLLY) per 100,000 population, determined by subtracting the age of death from an arbitrary life expectancy of 70 or 75 years (at the discretion of the reporting agency). This statistic can be applied to specific disease categories for comparisons among nations. According to Health System Tracker, the USA has lower PLLY for all cancers than comparable industrial countries; however, the USA has higher rates for diseases of the circulatory system (including heart disease), the respiratory system, external causes of mortality (including accidents), mental and behavioral disorders, diseases of the nervous system, and endocrine, nutritional, and metabolic diseases, as well as total PLLY.
Henry Buchwald is a surgeon and author of Healthcare Upside Down: A Critical Examination of Policy and Practice.
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