Fifty-Million-Dollar Baby

A Skeptic's Eyes on Economics, Ethics, and Health

Premature Infant with CPAP. Photo by Brian Hall, September 1998. In public domain at Wikimedia Commons.

NOTE: I’m posting excerpts from my not-yet-published book, “Fifty-Million-Dollar Baby: A Skeptic’s Eyes on Economics, Ethics, and Health.” The goal is to edit the manuscript in plain view—to seek your comments, corrections, and suggestions. [Note: I’ve changed the subtitle slightly since posting this piece .]

In our era, medical and public health authorities issue uncountable advisories and fiats over all aspects of American civic life—not only over realms that are clearly medical, but also over peripheral fields, such as bullying, climate, crime, employment, gentrification, guns, higher education, human trafficking, identity theft, incarceration, juvenile justice, online poker, policing, property law, racism, terrorism, transportation, voting laws, and wages. It is true that all of these areas indirectly or directly impact health, but it does not necessarily follow that medical and public health personnel are positioned to offer authoritative advice or meaningful expertise. Moreover, even in areas directly related to health, medical and public health authorities have often erred grievously, as I described here, here, here, and here. One of the most visible examples of unscientific hubris our time was Anthony Fauci’s comment that his critics were “criticizing science, because I represent science.” My book is a plea for experts to maintain humility and for the rest of us to maintain a healthy dose of skepticism. Below is a draft of my opening chapter.

The value of a life is not infinite; but neither is it finite. Rather, it is some distance to the southwest of both. No objective metric exists or can exist. For this reason, credulity is a constant danger, with informed skepticism the only salvation.

The alarm clock slips from 5:59 to 6:00 a.m. and fills the darkened room with, “I Got You Babe”—Day One of a new semester. At 8:11, a student asks the Eternally Conjoined Questions: (1) “Why does the United States spend more than any other country on healthcare?” and, (2) “Given that level of spending, why is our healthcare worse than that of so many other countries?” This precise sequence of events also occurred the previous semester. And the one before that. And so on back through the decades. Asking a question is not the same as stating a truth, although sometimes it can be.

According to World Bank data, in 2019, the United States spent 16.77% of GDP on healthcare—higher than any country other than tiny Tuvalu. The lowest figure for any country, at 1.53%, is Monaco, though that number tells you far more about Monégasque income than it does about their healthcare spending. For countries belonging to the Organisation for Economic Co-operation and Development (OECD), the figure is 12.53%. For the European Union, 9.92%. For the world, 9.83%.  

Why, I ask the questioner, do you suppose that the United States has worse healthcare than other countries? The response is almost always, “We have shorter lifespans and higher rates of infant mortality. And the World Health Organization (WHO) ranked the U.S. as #37—just below Costa Rica and just above Slovenia and Cuba.”

Statistics versus Political Statistics

In 1945, Winston Churchill sought to pummel the ruling Labour Party over its healthcare policies. A young Conservative Party researcher, Iain Macleod, brought Churchill voluminous, accurate statistics. In his speech, Churchill made only one vague reference to this statistical armamentorium. Seeing Macleod afterward, he advised him:

I gather, young man, that you wish to be a Member of Parliament. The first lesson that you must learn is that, when I call for statistics about the rate of infant mortality, what I want is proof that fewer babies died when I was Prime Minister than when anyone else was Prime Minister. That is a political statistic. (Fairlie, pp.203-204)

Macleod apparently learned his lesson, as he did, in fact, enter Parliament five years later. In 1952, Churchill appointed the 38-year-old Macleod Minister of Health. The Tory Chief Whip said he was too young to be eligible for the position. Churchill fired back that Macleod was “too eligible to be too young.” He seemed destined to become prime minister when he died unexpectedly at 56.

That “WHO says America is #37 in healthcare” trope comes from the World Health Report 2000—a gigantic collection of political statistics, whipped up by dint of ideology and incompetence. Some editors of the publication (which we shall revisit in later chapters) soon renounced it, but it has plagued healthcare discourse ever since. At its inception, the WHO’s country rankings were a chowder of fetid clams. To cite those rankings today is even worse, as the tureen has putrified on the countertop for 23 years.

But let us focus in on that question of infant mortality. According to the Centers for Disease Control and Prevention (CDC), out of every 1,000 children born in the United States in 2020, 5.4 died within one year of their birth. In that year, the Swiss rate was in the neighborhood of 3.5. (The reason for singling out Switzerland will become clearer below.)

For much of history, infant mortality was perhaps 250 for every 1,000 births (with another 250 dying before adulthood). World Bank data suggest that in 2020, the highest rate on earth was Sierra Leone, at 80, and the lowest was Iceland at 2. In that year, infant mortality per person was 50 for Sub-Saharan Africa, 27 for the entire world, 6 for the OECD countries, and 3 for the European Union. Those data listed the U.S. at 5 and Switzerland at 4 (presumably rounded versions of the numbers described earlier). The key is that the data show infant mortality higher in the U.S than in Switzerland and in most developed countries.

What is the worth of a child? One of my students, Dr. S―, a brilliant and renowned child psychiatrist, mentioned that her child had been born extremely prematurely, weighing only 1 pound, 3 ounces. His survival was dramatic enough to make the medical record books. More than twenty-five years later, he was an attorney and an officer in the U.S. Marine Corps. "We thought the $500,000 it cost to save him was well worth it," said Dr. S―. I asked what his chances of survival were at birth, and she said "less than 1%."

In that case, I noted, it cost $50,000,000 to save him, not $500,000. This, I explained, is because, actuarially speaking, saving him meant treating 100 desperately ill children at $500,000 apiece, with full knowledge that, on average, only one would survive. Her son won this grim lottery. The other 99 (hypothetically) did not. Of course, I added, we can all be thankful that her son survived to flourish and to serve his country.

How should one feel about spending $50 million to save a single infant?

• A first impulse is exhilaration. America had the resources to wrench her child away from the hands of death, chose to do so, and succeeded. The Babylonian Talmud (Tractate Sanhedrin 4:5 says, “He who saves one life it is as if he saved an entire world, and he who destroys one life it is as if he destroyed an entire world.” (Telushkin, p.239)

• A second impulse is despair. Economics tells us that the cost of something is what we give up to get it—a concept known as “opportunity cost.” With little doubt, the $50 million, allocated differently, could certainly have saved many more than a single life. One can wonder who those lost souls were and who their progeny might have been.

• A third impulse is terror. This is because so many people—and so many in positions of power—think that science or data alone or some soulless algorithm can clearly answer the question, “How should one feel about spending $50 million to save a single infant?”

To Be or Not to Be

Above, it was noted that in 2020, the infant mortality rate in the United States was 5.4 per 1,000, while, in Switzerland, the number was around 3.5 per 1,000. Or to go by the coarser World Bank numbers, US=5 and Switzerland=4. But the skeptic rightfully asks whether this difference is real or a statistical artifice. In 1993, Nicholas Eberstadt addressed this question. In its more rigorous work, the WHO establishes reporting guidelines that, in Eberstadt’s words:

stipulate that all births evidencing any signs of life be included for purposes of defining infant mortality, regardless of the duration of pregnancy or the size of the newborn. In principle, U.S. procedures conform to these guidelines. In 1988, for example, U.S. vital statistics registered almost 24,000 infants weighing less than 1 kilogram (about 2.2 pounds). … Although the group accounted for just over one-half of 1 percent of the year’s registered births, it may end up accounting for nearly a third of its registered infant deaths.

In Switzerland, by contrast, an infant must be at least 30 centimeters long at birth to be counted as living; the restriction effectively excludes most infants weighing less than a kilogram. The country’s relatively low reported rate of infant mortality reflects in part the categorical exclusion of these high-risk births.

Eberstadt addressed similar underreporting concerns in various other countries. He noted that had these countries been as fastidious as the U.S. in following the WHO’s reporting guidelines, America would have risen in the infant mortality rankings. He was careful to note, however, that consistent reporting would not eliminate America’s inferior performance on infant mortality vis-à-vis other developed countries. Nevertheless, this one case is indicative of the myriad methodological problems that plagued the WHO’s country rankings.

Thus, the perception that underlies my students’ question: “[W]hy is our healthcare worse than that of so many other countries?” is partially negated by an accounting of such statistical failings. And perhaps, just perhaps, it offers a response to the students’ other question: “Why does the United States spend more than any other country on healthcare?”

Consider the hypothetical 100 babies on which America spent $50,000,000 to save only life. In America, my student’s son would be recorded as a live birth, while the other 99 would enter our infant mortality statistics. In Switzerland, under the same circumstances, my student’s son would be recorded as a live birth, but the other 99 would be registered as stillbirths rather than entering the infant mortality statistics. They would be rumors, figments, phantasms.

But this raises a further question—one for which I do not have an answer: Does an ethic that denies the existence of a brief life on the basis of a tape measure make that country’s medical system less likely to treat such a child in the first place? Would Swiss medical personnel have engaged in the heroic attempts to save those 100 infants, with the resulting one life saved? Again—I don’t know the answer, but if not, we also find a partial explanation for America’s unparalleled expenditures on healthcare. Monetarily and ethically, the two situations would yield radically different scenarios.

• 100 infants cling barely to life in America. The healthcare system devotes $50,000,000 to saving them. One survives and triumphs in life. The other 99 soon die. Their hearts beat faintly and then are heard no more. Each becomes a memory. And a certificate of live birth. And a death certificate. And an infant mortality statistic. To become an infant mortality statistic, one must first live and then die. And however pitifully brief, that child’s life and death are known and acknowledged and recorded and entered as a tiny mark in American history and medicine.

• 100 infants cling barely to life in Switzerland. The healthcare system makes no heroic effort toward saving any of them. None survives. In each, a heart beats faintly and then is heard no more. Each becomes a memory. But not all—and perhaps none at all—become certificates of live birth. Or death certificates. Or infant mortality statistics. They are merely “stillborn.” By the standard of Switzerland’s grim census, those infants never lived and never died. They were never residents of Switzerland, but merely ghosts, consigned to oblivion.

I reiterate: I can’t ascertain whether these reporting standards actually alter the course of medical treatment, though I suspect they would. If a life is deemed nonexistent, then I suspect the impulse to save that life atrophies. (But, I am a skeptic, so I could be wrong.)

There is much that is right and inspiring about American health care; there is much that is not. American health care is an enormous jigsaw puzzle of countless pieces. In assembling them into a picture, we discover bright blue patches over here, gray stretches over there, and precincts of utter darkness. Somewhere toward the center, some pieces come together in the image of a fragile newborn who barely survives the neonatal intensive care unit and then, decades later, successfully undergoes the rigors of Marine Corps training. And that is why we continue to assemble the puzzle.

If one wishes to lower healthcare spending and record better results, there are two easy paths available: stop treating those who are most in need of medical attention, and structure the data to minimize unwanted results. There are other paths, but they are far more expensive and difficult to implement. They are, however, far more satisfying, as well. Many problems of American healthcare are not illusory. Many criticisms are not fallacy. America can learn much from other countries, as other countries can learn much from America.

In the 19^th Century, humorist Josh Billings said, “I honestly beleave it iz better tew know nothing than two know what ain’t so.” A corollary often attributed to Will Rogers said, "It ain't so much the things we don't know that gives us trouble, but the things we think we know that just ain't so." The idiom and eye dialect seem antiquated. The sentiments should not.

When I hear that America’s healthcare system is only 37th best—just below Costa Rica and just above Cuba and Slovenia—I recall an iconic conversation in Casablanca (1942).

Captain Renault: “What in heaven's name brought you to Casablanca?”
Rick: “My health. I came to Casablanca for the waters.”
Captain Renault: “The waters? What waters? We're in the desert.”
Rick: “I was misinformed.”

Lagniappe

Recently, I learned to perform Astor Piazzolla’s impossibly lovely and haunting tango, “Oblivion.” Given the content above, this piece seemed an appropriate with which to reflect and gather one’s thoughts.

Robert F. Graboyes is president of RFG Counterpoint, LLC in Alexandria, Virginia. An economist, journalist, and musician, he holds five degrees, including a PhD in economics from Columbia University. An award-winning professor, in 2014, he received the Reason Foundation’s Bastiat Prize for Journalism. His music compositions are at YouTube.com/@RFGraboyes/videos.