Putting to Rest the Lie that U.S. Healthcare Rank's 37th in the World

Dec 2, 2014

          Over a decade ago, The World Health Organization (WHO) produced a report from which it tried to rank the health care systems of all the countries in the world. The report listed the U.S. health care system as 37th. The ranking was used by many as a means of attacking the U.S. system in favor of more socialistic systems. Although the 37th ranking still gets bandied about, even in advocacy events attended by students, it’s time put this flawed and erroneous ranking to rest

          What is little known is that soon after the WHO report was published it was met with accusations of being “unethical,” of “manipulating data,” and of being “meaningless.” What was startling about the accusations was that they came from the editor-in-chief of the report, Philip Musgrove. Although Musgrove was editor-in-chief, he was subordinate to other bureaucrats at WHO who were in charge of the study.

          Musgrove wrote an article in The Lancet in 2003 about lapses in scientific and ethical judgment on the part of those who put the rankings together. These are some of the statements from that article, with key words emphasized:

  • The attainment values in WHO’s World Health Report 2000 are spurious.”
  • Indices of composite attainment and performance are based on imputations and thus are also meaningless.” 
  • The attainment and performance estimates are of no use for judging how well a health system performs” (Philip Musgrove, “Judging Health Systems: Reflections on WHOs Methods,” The Lancet, vol. 361, issue 9371, pages 1817-1820, May 24, 2003, doi:10.1016/S0140-6736(03)13408-3).

          As Musgrove was writing one of the chapters for the report, it became evident that real data were not going to be used, but rather imputed. About this, he wrote:

          “I now think it was a mistake to have put these figures in the text” (see previous citation, p. 1817).

          Musgrove quoted one of those who participated in a pilot study when this participant found out how the information from the pilot study was going to be used by the various directors of the WHO report:

          “ranking countries based on this pilot study has been inappropriate and embarrassing” (see previous citation, p. 1817).

          While working on his contribution to the report, Musgrove discovered dubious substitutions in the data and emailed the following to one of the directors of the rankings, questioning the honesty and integrity of the substitutions:

          “if that doesn’t qualify as manipulating the data, I don’t know what does. . . At the very least, it gravely undermines the claims to be honest with the data and to report what we actually find” (see previous citation, p. 1818).

          Musgrove wrote the following about his attempt to persuade the directors of the rankings from using information in an unethical manner:

          “I regard these issues as not merely statistical or even political, but ethical. WHO insists that member governments should not misrepresent the data they send to the organization. It is important that WHO publications meet the same standards. My efforts to persuade [the directors] that publication of these numbers was unethical were in vain” (see previous citation, p. 1819).

          One sign of how arbitrary the rankings are is that if the amount a country spent on health care were not included in the calculations, and thus focused more on calculating the quality of care received, the U.S. could have ranked as high as 7th, doing better than Germany, Spain, Iceland, and Demark (see chart labeled “Questionable Diagnosis” in article by C. Bialik titled “Ill-conceived Ranking Makes for Unhealthy Debate” Oct. 21, 2009, available at http://online.wsj.com/article/SB125608054324397621.html, accessed Aug. 4, 2012).

          Before Musgrove published his article, another Lancet article written by 16 researchers called into question the ethics of the WHO report:

          “The measures of health inequalities and fair financing do not seem conceptually sound or useful to guide policy; of particular concern are some ethical aspects of the methodology for both these measures, whose implications for social policy are cause for concern” (Celia Almeida et al., “Methodological Concerns and Recommendations on Policy Consequences of the World Health Report 2000,” The Lancet, May 26, 2001; vol. 357, pp. 1692- 1697).

          Another Lancet article by another set of researchers also called into question the usefulness of WHO’s report in regards to its inequality index:

          “We found that the World Health Report index does not correspond with international variations in the size of socioeconomic inequalities in mortality. These findings indicate that the Index should not be interpreted as a reflection of socioeconomic inequalities in health, nor should the Index be used to replace the indices developed to monitor socioeconomic inequalities in health” (Houweing et al., “World Health Report 2000: Inequality Index and Socioeconomic Inequalities in Mortality,” The Lancet, May 26, 2001: vol. 357, pp. 1671-1672). 

          The report was generally considered a useless, unethical embarrassment by many experts in the field. The words “fraud” and “deceptive” were actually used as descriptors in an article titled “The Worst Study Ever?” by Dr. Scott Atlas (M.D.). Dr. Atlas is a professor of radiology as well as the chief of neuroradiology at the Stanford University Medical Center. This is how he summed up the WHO study:

          “In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all. The report’s true achievement was to rank countries according to their alignment with a specific political and economic ideal—socialized medicine—and then claim it was an objective measure of ‘quality’” (“The Worst Study Ever?” Commentary, April 2011, http://www.commentarymagazine.com/article/the-worst-study-ever/, accessed August 3, 2012) (emphasis added).

        The 37th ranking, then, comes from a document considered to be, by the chief of neuroradiology at Stanford University, an “intellectual fraud of historic consequence,” and by its editor-in-chief as “unethical,” and by another participant as “inappropriate and embarrassing.” Let’s hope that students will not be exposed to such false data at their advocacy events again. But if so, they will now be armed with the information to protect themselves from such propaganda.