Cuban infant mortality and longevity: health care or repression? Por Gilbert Berdine, Vincent Geloso e Benjamin Powell.
Cuban healthcare statistics are flawed.
The health achievements are in part the result of repressive methods.
The health achievements are in part the result of policies that are unrelated to health care provision.
Ongoing political changes in Cuba following Fidel Castro’s death offer an opportunity to evaluate his regime’s legacy with regards to health outcomes. The common assessment is that Cuba’s achievements in lowering infant mortality and increasing longevity are among the praiseworthy outcomes of the regime—a viewpoint reinforced by studies published in US medical journals (Campion and Morrissey 1993; Cooper and Kennelly, 2006)1 We argue that some of the praise is unjustified. Although Cuban health statistics appear strong, they overstate the achievements because of data manipulation. Moreover, their strength is not derived from the successful delivery of health care but rather from the particular repressive nature of the regime which comes at the expense of other populations.
(…) Centralized planning has disadvantages. Physicians are given health outcome targets to meet or face penalties. This provides incentives to manipulate data. Take Cuba’s much praised infant mortality rate for example. In most countries, the ratio of the numbers of neonatal deaths and late fetal deaths stay within a certain range of each other as they have many common causes and determinants. One study found that that while the ratio of late fetal deaths to early neonatal deaths in countries with available data stood between 1.04 and 3.03 (Gonzalez, 2015)—a ratio which is representative of Latin American countries as well (Gonzalez and Gilleskie, 2017).2 Cuba, with a ratio of 6, was a clear outlier. This skewed ratio is evidence that physicians likely reclassified early neonatal deaths as late fetal deaths, thus deflating the infant mortality statistics and propping up life expectancy.3 Cuban doctors were re-categorizing neonatal deaths as late fetal deaths in order for doctors to meet government targets for infant mortality.
(…) Misreporting to meet fixed targets is not the only reason for the low infant mortality rate. An ethnographic study of the Cuban health system showed that physicians who worried that a mother’s behavior might lead to missing the centrally established targets will prescribe the forceful internment in a state clinic (casa de maternidad) so that they may regulate her behavior.4 Physicians often perform abortions without clear consent of the mother, raising serious issues of medical ethics, when ultrasound reveals fetal abnormalities because ‘otherwise it might raise the infant mortality rate’ (Hirschfeld 2007b:12).5
Coercing or pressuring patients into having abortions artificially improve infant mortality by preventing marginally riskier births from occurring help doctors meet their centrally fixed targets. At 72.8 abortions per 100 births, Cuba has one of the highest abortion rates in the world.6 If only 5% of the abortions are actually pressured abortions meant to keep health statistics up, life expectancy at birth must be lowered by a sizeable amount. If we combine the misreporting of late fetal deaths and pressured abortions, life expectancy would drop by between 1.46 and 1.79 years for men.