- The Washington Times - Thursday, July 6, 2000

How timely that Elian Gonzalez has been allowed to return to Cuba exactly a week after the World Health Organization report ranked Cuba 39th in health care compared with the United States' 37th. At least he won't suffer any significant health consequences if you believe the report.

However, unlike last year's Institute of Medicine report on medical errors, the WHO report hasn't fooled many editors or medical reporters.

The World Health Organization carried out the first-ever analysis of the world's health systems. Using five performance indicators to measure health systems in 191 member states, it finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan.

In designing the framework for health system performance, WHO broke new methodological ground, employing a technique not previously used for health systems. It compares each country's system to what its experts estimate to be the upper limit of what can be done with the level of resources available in that country. It also tries to measure what each country's system has accomplished in comparison with those of other countries.

WHO ranks the health-care systems according to how well they perform on five measures. Among them is overall population health as determined by the number of years of good health that an average baby born in 1999 can expect in his or her lifetime. The U.S. health system spends a higher portion of its gross domestic product on health than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just 6 percent of GDP on health services, ranks 18th. Several small countries San Marino, Andorra, Malta and Singapore are rated close behind second-placed Italy.

In North America, Canada rates as the country with the fairest mechanism for health system finance, ranked at 17-19, while the United States is at 54-55.

Cuba is the highest among Latin American and Caribbean nations at 23-25.

Since Cuba outranks the United States, theoretically Elian will get fairer treatment at home.

According to WHO, it is more important that health care financing be "fair" than that it be adequate. It doesn't matter how much a country spends on health care or how it is used so long as the "financial burden is shared" fairly. The method of measuring life expectancy is an innovation in which the years a person lives after becoming disabled or sick are not counted as a positive value. So a country like the United States, which has done so much to extend the lives of cancer survivors, AIDS victims, and people with brain injuries or Alzheimer's disease, actually gets marked down for the effort. The international health bureaucrats at WHO must have had a ball with this monstrous report. Assigning numerical values to peoples' preferences across the great diversity of world cultures is an overwhelming enterprise.

The implication of WHO's scoring method is that people with disabilities and chronic disease should be euthanized as they really don't count.

In countries with public payment for medical services, a doctor who accepted direct payment for services would be considered a criminal guilty of accepting bribes. Health care services would be rationed out to the population according to the preferences of the bureaucrats and their bosses, whether dictators or elected socialists. The preferences of the WHO authors are for a combination of some of the worst elements of socialism, monopoly and managed care. The rankings reflect the authors' positive value of medical care under a Castro socialistic-style dictatorship and their disdain for human freedom and medical advances achieved in the United States.

To us as physicians and potential patients, the recent WHO report on the world's health systems is about as zany as the old Abbott/Costello routine, "Who's on first"? We still prefer choice of country that means even under for-profit-managed-care we choose to be treated in the United States rather than France or Cuba.



Michael Arnold Glueck, M.D., has written extensively on medical reform issues. Robert J. Cihak, M.D. is president-Elect of the Association of American Physicians and Surgeons.

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