As part of my series of blog post reconsidering health outcomes in Cuba, I argued that other countries were able to generate substantial improvements in life expectancy even if Cuba is at the top. Then I pointed out that non-health related measures made Cubans so poor as to create a paradoxical outcome of depressing mortality (Cubans don’t have cars, they don’t get in car accidents, life expectancy is higher which is not an indicator of health care performance). Today, I move to the hardest topic to obtain information on: refugees.
I have spent the last few weeks trying to understand how the Cuban refugees are counted in the life tables. After scouring the website of the World Health Organization and the archives of Statistics Canada during my winter break, I could not find the answer. And it matters. A lot.
To be clear, a life table shows the probability that an individual of age X will die by age X+1 (known as Qx). With a life table, you will obtain age-specific death rates(known as Mx), life expectancy at different points and life expectancy at birth (Lx)(Where x is age). Basically, this is the most important tool a demographer can possess. Without something like that, its hard to say anything meaningful in terms of demographic comparison (although not impossible).The most common method of building such a table is known as a “static” method where we either compare the population structure by age at a single point in time or where we evaluate the age of deaths (which we can compare with the number of persons of each group alive – Ax). The problem with such methods is that static life tables need to be frequently updated because we are assuming stable age structure.
When there is important migration, Qx becomes is not “mortality” but merely the chance of exiting the population either by death of migration. When there are important waves of migration (in or out), one must account for age of the entering/departing population to arrive at a proper estimates of “exits” from the population at each age point that separate exits by deaths or exits (entries) by migration.
As a result, migration – especially if large – creates two problems in life tables. It changes the age structure of the population and so, the table must be frequently updated in order to get Ax right. It also changes the structure of mortality (exits). (However, this is only a problem if the age structure of migrants is different from the age structure of the overall population).
Since 2005, the annual number of migrants from Cuba to the United States has fluctuated between 10,000 and 60,000. This means that, on an annual basis, 0.1% to 0.5% of Cuba’s population is leaving the country. This is not a negligible flow (in the past, the flow was much larger – sometimes reaching north of 1% of the population). Thus, the issue would matter to the estimation of life tables. The problem is we do not know how Cuba has accounted for migration on both mortality and the reference populations! More importantly, we do not know how those who die during migration are measured.
Eventually, Ax will be adjusted through census-based updates (so there will only be a drift between censuses). However, if the Cuban government counts all the migrants as alive as they arrive in a foreign country as if none died along the way, it is underestimating the number of deaths. Basically, when the deaths of refugees and emigrants are not adequately factored into survival schedules, mortality schedules are be biased downward (especially between censuses as a result of poor denominator) and life expectancy would be accordingly biased upward.
Now, I am willing to reconsider my opinion on this particular point if someone indicates some study that has escaped my gaze (my Spanish is very, to put it euphemistically, poor). However, when I am able to find such information for other Latin American countries like Chile or Costa Rica and not for Cuba, I am skeptical of the value of the health statistics that people cite.
The other parts of How Well Has Cuba Managed To Improve Health Outcomes?