- Egypt banned the sale of yellow vests. Are the French protests spreading? Adrián Lucardi, Monkey Cage
- Castro’s Revolution on Its 60th Anniversary Vincent Geloso, AIER
- Americans Are Losing Faith in Free Speech. Can Two Forgotten Philosophers Help Them Regain It? Bill Rein, FEE
- Do Congresswomen Outperform Congressmen? Tyler Cowen, MarginalRevolution
One of the most interesting (in my opinion) paradox in modern policy debates relates to how Cuba, a very poor country, has been able to generate health outcomes close to the levels observed in rich countries. To be fair, academics have long known that there is only an imperfect relation between material living standards and biological living standards (full disclosure: I am inclined to agree, but with important caveats better discussed in a future post or article, but there is an example). The problem is that Cuba is really an outlier. I mean, according to the WHO statistics, its pretty close to the United States in spite of being far poorer.
In the wake of Castro’s death, I believed it necessary to assess why Cuba is an outlier and creates this apparent paradox. As such, I decided to move some other projects aside for the purposes of understanding Cuban economic history and I have recently finalized the working paper (which I am about to submit) on this paradox (paper here at SSRN).
The working paper, written with physician Gilbert Berdine (a pneumologist from Texas Tech University), makes four key arguments to explain why Cuba is an outlier (that we ought not try to replicate).
The level of health outcomes is overestimated, but the improvements are real
Incentives matter, even in the construction of statistics and this is why we should be skeptical. Indeed, doctors are working under centrally designed targets of infant mortality that they must achieve and there are penalties if the targets are not reached. As such, physicians respond rationally and they use complex stratagems to reduce their reported levels. This includes the re-categorization of early neonatal deaths as late fetal deaths which deflates the infant mortality rate and the pressuring (sometimes coercing) of mothers with risky pregnancies to abort in order to avoid missing their targets. This overstates the level of health outcomes in Cuba since accounting for reclassification of deaths and a hypothetically low proportions of pressured/coerced abortions reduces Cuban life expectancy by close to two years (see figure below). Nonetheless, the improvements in Cuba since 1959 are real and impressive – this cannot be negated.
Health Outcomes Result from Coercive Policy
Many experts believe that we ought to try to achieve the levels of health outcomes generated by Cuba and resist the violations of human rights that are associated with the ruling regime. The problem is that they cannot be separated. It this through the use of coercive policy that the regime is able to allocate more than 10% of its tiny GDP to health care and close to 1% of its population to the task of being a physician. It ought also be mentioned that physicians in Cuba are also mandated to violate patient privacy and report information to the regime. Consequently, Cuban physicians (who are also members of the military) are the first line of internal defense of the regime. The use of extreme coercive measures has the effect of improving health outcomes, but it comes at the price of economic growth. As documented by Werner Troesken, there are always institutional trade-offs in term of health care. Either you adopt policies that promote growth but may hinder the adoption of certain public health measures or you adopt these measures at the price of growth. The difference between the two choices is that economic growth bears fruit in the distant future (i.e. there are palliative health effects of economic growth that take more time to materialize).
Health Outcomes are Accidents of Non-Health Related Policies
As part of the institutional trade-off that make Cubans poorer, there might be some unintended positive health-effects. Indeed, the rationing of some items does limit the ability of the population to consume items deleterious to their health. The restrictions on car ownership and imports (which have Cuba one of the Latin American countries with the lowest rate of car ownership) also reduces mortality from road accidents which, in countries like Brazil, knock off 0.8 years of life expectancy at birth for men and 0.2 years for women. The policies that generate these outcomes are macroeconomic policies (which impose strict controls on the economy) unrelated to the Cuban health care system. As such, the poverty caused by Cuban institutions may also be helping Cuban live longer.
Human Development is not a Basic Needs Measure
The last point in the paper is that human development requires agency. Since life expectancy at birth is one of the components of the Human Development Indexes (HDI), Cuba fares very well on that front. The problem is that the philosophy between HDIs is that individual must have the ability to exercise agency. It is not a measure of poverty nor a measure of basic needs, it is a measure meant to capture how well can individual can exercise free will: higher incomes buy you some abilities, health provides you the ability to achieve them and education empowers you.
You cannot judge a country with “unfree” institutions with such a measure. You need to compare it with other countries, especially countries where there are fewer legal barriers to human agency. The problem is that within Latin America, it is hard to find such countries, but what happens when we compare with the four leading countries in terms of economic freedom. What happens to them? Well, not only do they often beat Cuba, but they have actually come from further back and as such they have seen much larger improvements that Cuba did.
This is not to say that these countries are to be imitated, but they are marginal improvements relative to Cuba and because they have freer institutions than Cuba, they have been able to generate more “human development” than Cuba did.
Our interpretation of Cuban health care provision and health outcomes can be illustrated by an analogy with an orchard. The fruit of positive health outcomes from the “coercive institutional tree” that Cuba has planted can only be picked once, and the tree depletes the soil significantly in terms of human agency and personal freedom. The “human development tree” nurtured in other countries yields more fruit, and it promises to keep yielding fruit in the future. Any praise of Cuba’s health policy should be examined within this broader institutional perspective.
In light of what we see today, this is hard to believe. However, as a result of Castro’s death, I accidentally became interested in the history of this fascinating island and the more I discover, the more shocked I am at “the path” that Cuba has taken. One of these reasons is provided below by Victor Bulmer Thomas in his Economic History of Latin America since Independence. Now, Thomas uses a different approach than the commonly used Maddison data (he believes the assumptions are too heroic). He uses indicators correlated with GDP per capita to fill in the gaps and he finds that Cuba was generally richer than the United States for most of the 19th century (see below):
Now, I am not convinced by the figure Thomas presents. However, I am also skeptical of the levels presented by Maddison (where Cuba is roughly 60% as rich as the US in 1820). In between are some more reasonable estimate (see this great discussion in this book as well as this discussion by Coatsworth). Moreover, there is the issue of slavery which distorts the value of using GDP per capita because of high levels of inequality (however, it distorts both ways since the US was also a slave economy up to the Civil War).
Nonetheless, this tells you about the “path not taken” by Cuba.
Is it possible for two equally rich countries (on a per capita basis) to have different level of output per worker? The answer is obviously yes, and it matters in the case of measuring growth in Cuba since the revolution.
A country with a very young population will tend to have fewer workers than one with an older (but not too old) population. Let’s say that countries A and B have a median age of 22.5 in year one. However, in year ten, country A has a median age of 35 but country B has seen a more modest increase to a median age of 25. This will bias any estimates of growth comparison between both country. The increase in the median age suggests that there are more and more workers in country A (people of prime age) than in country B. As a result of that, output per capita will increase faster in country A than in country B even if both countries have equal rates of growth in output per worker.
Well, countries A and B are basically Cuba and most of the rest of Latin America. Since the 1950s, Cuba’s population has aged rapidly but birth rates have plummeted so fast that families shrunk. With fewer kids in the population, it means that the share of the Cuban population that are of prime working age increased rapidly. This is what biases the comparison of Cuban living standards with other Latin American countries.
In the figure below, I took the GDP (the Maddison data) of Cuba since 1950 (indexed at 1960 to see the arrival of Castro) and divided it by the total population, the population above 15 years of age and the population between 15 and 64.
As one can see, with the GDP per capita series, Cubans saw a 50% increase in their incomes between 1960 and 2005 (the Maddison data stops at 2008). However, when you look at GDP per working age adult in order to capture the growth in productive capacity, you get moderately different results whereby the cumulative increase is three-fifths to half as small.
In light of this, it seems like Cuba’s living standards are less and less impressive.
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?
In a recent post, I pointed out that life expectancy in Cuba was high largely as a result of really low rates of car ownerships. Fewer cars, fewer road accidents, higher life expectancy. As I pointed out using a paper published in Demography, road fatalities reduced life expectancy by somewhere between 0.2 and 0.8 years in Brazil (a country with a car ownership rate of roughly 400 per 1,000 persons). Obviously, road fatalities have very little to do with health care. Praising high life expectancy in Cuba as the outcome Castrist healthcare is incorrect, since the culprit seems to be the fact that Cubans just don’t own cars (only 55 per 1,000). But that was a level argument – i.e. the level is off.
It was not a trend argument. The rapid increase in life expectancy is undeniable, so my argument about level won’t affect the claim that Cubans saw their life expectancy increase under Castro.
I say “wait just a second”.
Cuba is quite unique with regards to car ownership. In 1958, it had the second highest rate of car ownership of all Latin America. However, while the rate went up in all of Latin America between 1958 and 1988, it went down in Cuba. During that period, life expectancy went up in all countries while there were substantial increases in car ownership (which would, all things being equal, slow down life expectancy growth). Take Chile and Brazil as example. In these countries, the rate went up by 6.9% and 8.1% every year – these are fantastic rates of growth. During the same period, life expectancy increased 25% in Chile and 19% in Brazil compared with Cuba where the increase stood at 17%. In Cuba, the moderate decline in car ownership (-0.1% per annum) would have (very) modestly contributed to the increase of life expectancy. In the other countries, car ownership hindered the increase. (The data is also from the WHO section on Road Safety while the life expectancy data is from the World Bank Database)
This does not alter the trend of life expectancy in Cuba dramatically, but it does alter it in a manner that forces us, once more, to substract from Castro’s accomplishments. This increase would not have been the offspring of the master plan of the dictator, but rather an accidental side-effect springing from policies that depressed living standards so much that Cubans drove less and were less subjected to the risk of dying while driving. However, I am unsure as to whether or not Cubans would regard this as an “improvement”.
Below are the comparisons between Cuba, Chile and Brazil.
The other parts of How Well Has Cuba Managed To Improve Health Outcomes?
- Life Expectancy Changes, 1960 to 2014
- Car ownership trends playing in favor of Cuba, but not a praiseworthy outcome
- Of Refugeees and Life Expectancy
- Changes in infant mortality
- Life expectancy at age 60-64
- Effect of recomputations of life expectancy
- Changes in net nutrition
- The evolution of stature
- Qualitative evidence on water access, sanitation, electricity and underground healthcare
- Human development as positive liberty (or why HDI is not a basic needs measure)