the best of times and the worst of times


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 madness, it was the age of belief, it was the time of unbelief was the season of light, it was the season of darkness, it was the springtime of hope, it was the winter of despair.
– Charles Dickens: A Tale of Two Cities

Setting: TV quiz show

Story participants: TV host, contestant, US TV audience

Host: Name at least two of the three all-time NFL quarterbacks with the highest career passer ratings through 2020.

Competitor: All three have marks above one hundred. They are Deshaun Watson, Aaron Rogers and Russell Wilson.

Host: Right! You have all three.

Audience: Response from millions – I knew it! I could have had that one!

Host: When did Dow Jones Industrials first surpass thirty thousand, month and year?

Competitor: November 2020

Host: Right!

Audience: Response from millions – I knew it! Big day!

Host: What was Marilyn Monroe’s biggest box office success?

Competitor: Some like it hot.

Host: Right!

Audience: Response from millions – I knew it! Too easy!

Host: Life expectancy in the United States among all nations ranks… I’ll accept a rough answer.

Competitor: Not sure. I would say near the top, in the top ten.

Host: Wrong! Not even close. It is 40 or less out of 200, not even in the top quarter of any nation.

Audience: Response of millions – Wow!

When it comes to health care in the United States, Dickens’ quote is twice correct. We are in the best of times for knowledge, ability and potential. We are also going through the worst times in terms of the application of our knowledge and the results achieved, especially compared to other countries.

The United States has a proud history of medical firsts. We have the most Nobel Prize winners in physiology or medicine, in technological advancements and in the highest quality health care – for some people. At the same time, we are not world leaders, not even close, when we look at global statistics on life expectancy, death rate, potential years of life lost, mortality from specific diseases, infant mortality, mortality attributable to health care, health care access and quality index, and health care availability. These are the parameters used to measure health care and in each of them, given our potential, we are failures, losers compared to comparable industrialized countries. Yet we pay far more in dollars per capita and as a percentage of our gross national product (GNP) for health care than any other country.

The best way to illustrate these facts that govern our lives is to look at the available statistics. When looking at the numbers, it is essential to appreciate their implications in real life. Today’s newspaper articles, as well as some scientific papers, will make “statistically sound” claims – by a convention defined as the likelihood of being factual if something happens 95 times out of 100, a rather useless criterion in the real world. In selecting statistics for this section, I have used only meaningful real data where the numbers represent actual deaths, lives saved and quality of life lived.

Life expectancy

One often hears the claim that life expectancy at birth in the United States over the past 160 years has nearly doubled, from 39.4 years in 1860 to 79.1 years in 2020. However, the life expectancy at birth in the rest of the world, and the United States is not in the top quarter of any nation. According to United Nations estimates, Hong Kong, the leading country, in 2020 had an overall life expectancy of 85.29 years (88.17 female, 82.38 male). The top ten countries in terms of life expectancy in 2020 were in order: Hong Kong, Japan, Macau, Switzerland, Singapore, Italy, Spain, Australia, Channel Islands and Iceland. The US was ranked behind Cuba and Estonia at 46 out of 193 (US total 79.11, women 81.65, men 76.61). The United States ranked six years in life expectancy below Hong Kong, about three years below our neighbor Canada, and about two years below Britain. The World Health Organization (WHO) ranked the United States 40th and the United States Central Intelligence Agency (CIA) Factbook ranked the United States 46th out of 227 (30th percentile).

Mortality rate

Death rate, or death rate, is defined as the number of deaths in a particular population during a given time period, usually calculated as the number of deaths per 1,000 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 United States with a death rate of 8.7 is 150th from the bottom (the good end) and 77 from the top (the bad end); in fact, the United States is among the 35% of countries with the highest annual death rate in the world. The annual global death rate has declined over the past 40 years, primarily due to advances in cancer therapy and heart disease, but the United States consistently lags behind comparable industrialized nations.

Potential years of life lost

A common statistic of premature mortality is the number of potential years of life lost (PLLY) by age 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 between nations. According to Health System Tracker, the United States has a lower PLLY for all cancers than comparable industrialized countries; however, the United States has higher rates for diseases of the circulatory system (including heart disease), respiratory system, external causes of death (including accidents), mental and behavioral disorders, diseases of the nervous system and endocrine, nutritional and metabolic diseases. diseases, as well as the total PLLY.

Henry Buchwald is a surgeon and author of Healthcare Upside Down: A Critical Examination of Policy and Practice.

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