Cuban anonymous professional. The integrality of the concepts behind the statistics. Some broad questions. [Comment to a NEJM perspective--No way to send an anonymous letter to the NEJM Editor. Posted on Jan. 8, 2010]
To the Editor: Ranking 37th — Measuring the Performance of the U.S. Health Care System, by Murray and Frenk,(1-2) reflects a tremendous conceptual and operational work in the WHO-HQs a decade ago, and a good revisited analysis, but still limited to the physical health wellbeing and intra-sectorial health care concepts, without any specific weight in the public health analysis of the individual liberties and living standards.
It is a pity that measuring human development, living and health systems, the individual freedoms and living levels, are always absent of the last decades U.N.’s equations. These main psychosocial and economic components --according to the U.N. definitions of human rights (1948)(3) and standards of living (1954)(4)--, help give framework to the WHO health definition (1946)(5) in terms of physical, mental and social health wellbeing.
If the US health care from 1974 to 2010 does not show the best indicators of premature mortality, life expectancy, disease preventability, equality and efficiency of care;(1-2,6-7) Why are so few US emigrants to the first 36 countries under the US ranking 37th of performance? (1) Instead, there are much more immigrants in the US from those first 36 countries --obviating all the immigrants in the US from all the other countries ranking 38 to 191.
Are those indexes estimating in some measure some of the magnitudes of mental, spiritual and social health, quality of life, social equality, wellness, happiness, satisfaction, which the people of the world seems to appreciate more their meanings and to be more interested in accomplishing?
The US is the biggest multi ethnic and religious country in history, with 308 millions of people, natives and immigrants from all the richest, medium and poorest countries, dynamically increasing their average equality, based on the most advanced universal principles and values.(8) They live with great transparency without captivity, oppression, and restriction to any of the U.N. human rights’ 30 articles, and living standards’ 12 factors, with no coercive healthism to their personal lifestyles and cultures. Yes, the system needs reforms, but without compromises its unique achievements, which tends to be usually ignored in intra-national and international comparisons.
Never should be forgotten that the US is annually improving the limited liberty, living, and health levels of millions of people worldwide, through the acceptance of great refugees-emigrants inflows without exception of any country, and of huge public, private and family subsidies-remittances outflows,(9) as any other country in the world has ever done.(10)
The US healthcare system has top increasing costs, not only because of its freest-market economy, but also due to a political will to invest highest funding in the world leading scientific-technological most serious and expensive research in hardest sciences for evidence-based medicine-and-health policy. Health promotion and preventability of sub-clinical and clinical chronic diseases’ progression have less and softer evidence, though most of it has been found in the US. Health promotion and disease preventive successes depend also of education, culture, freedom of choice, and personal responsibility for health. They could only be assumed by a primary health care, but with more scientific research support, while, diseases and complications’ therapeutics, are being optimally controlled in the hospital care.
The US health care system functions under a complex equilibrium achieved by the freest partnership of the strongest world private sector with the public one, very successful but extremely difficult to regulate yet. It has all those needs of improvement mentioned,(1) but it cannot be forgotten that thanks to the 200-years US research results, at least the non-poorest 5.8 billions of the today world 6.8 billion population, are fully enjoying, and the poorest billion is increasingly enjoying, a great proportion of the top scientific and technological achievements in medicine, public health, and living standards and levels of all the times.
References
1. Murray CJL, Frenk J. Perspective: Ranking 37th — Measuring the Performance of the U.S. Health Care System. NEJM Jan 6, 2010;362:1: http://healthcarereform.nejm.org/?p=2610&query=TOC
2. World Health Organization. The world health report 2000 — health systems: improving performance. Geneva: WHO, 2000. http://www.who.int/whr/2000/en/
3. United Nations. (1948). Universal declaration of human rights. New York: UN Pub, 1948. Available in: http://www.un.org/en/documents/udhr/index.shtml (Accessed 22 July 2009).
4. United Nations. Report on international definition and measurement of standards and levels of living. New York: UN Pub, 1954.
5. World Health Organization. Definition of health. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York: WHO, 1946.
http://www.who.int/about/definition/en/print.html
6. Preston SH, Ho JY. Low Life Expectancy in the United States. Is the health care system at fault? Working Paper 15213. Cambridge, MA: National Bureau of Economic Research, 2009 http://papers.nber.org/papers/W15213
7. Peltzman S. Mortality Inequality. J Econ Perspect. 2009 Fall;23(4):175-90
8. Fogel RW. The escape from hunger and premature death, 1700–2100: Europe, America, and the third world, 1st edn. New York: Cambridge University Press, 2004. 191 pp.
9. Clark G. A Farewell to Alms. A Brief Economic History of the World. 1st ed. Princeton, NJ: Princeton University Press, 2007. 420 pp.
10. Maddison A. Contours of the World Economy, 1-2030 AD. Essays in Macro-Economic History. 1st ed. Oxford: Oxford University Press, 2007. 418 pp.
Rodolfo J. Stusser, M.D., MSc., MPH.
Freelance PHC GFM Research Consultant (Retired from Havana University, MINSAP, Scientific Pole)
International Member of AAFP & NAPCRG.
Home: Calle F # 256 apt. 2 interior / 11-13, Vedado, Havana 10400, Cuba.
Primary Care e-Research Collaboration Center http://havanacenter.familydoctors.net
[email protected], [email protected]
Comments written at Havana, Cuba, on Jan. 8, 2010; re-edited on Jan 14, 2010.