In Cuba, not having a car might save your life

My two blog posts on the health statistics of Cuba have convinced me to try to assemble a research article on the topic of assessing health outcomes under Castro’s regime. My first blog post was that there is a trade-off (the core of the article) that Castro decided to make. He would use extreme coercive measures to reduce some forms of mortality in order to shore up support abroad. The cost of such institutions is limited economic growth and increased mortality from other causes (dying from waterborne diseases or poverty diseases rather than dying from measles).

When I thought of that, I was inspired by Werner Troesken’s Pox of Liberty on the American constitution and the disease environment of the country. I was mostly concerned by direct medical interventions. However, the extent of coercive measures used by Castro go well beyond simple medical care (or medical imposition). Price controls, rationing and import restrictions on many goods could also help improve life expectancy. Indeed, rationing salt at 10g (hypothetical number) per person per day is a good way to prevent dietary diseases that emerge as a complication from overconsumption of salt. That will, by definition, raise life expectancy.

And so will bans on importing cars.

There is an extensive literature on the role that car fatalities has on life expectancy. This paper in Demography (one of the top demographic journals) finds that male life expectancy in Brazil is lowered by 0.8 years by traffic deaths. And traffic has very little to do with the quality of health care services. Basically, the more you drive, the more chances you have of dying (duh!). But, people don’t care much because the benefits of driving outweigh the personal risks.

In Cuba, people don’t get to make that choice. As a result, the very few drivers on Cuban roads have few accidents. According to WHO data, the car fatality rate is 8.15 per 100,000. There is also only 55 cars per 1,000 persons in Cuba. The next closest country is Nicaragua at 93 cars per 1,000 and the top country is Uruguay at 584 cars per 1,000. When you compute reported (rather than WHO estimated) car fatalities per 1,000 cars (rather than persons), Cuba becomes the unsafest place to drive in Latin America (1.46 fatalities per 1,000 cars) after El Salvador (2.22 fatalities per 1000 cars but only 129 cars per 1000), Ecuador (1.78 fatalities per 1000 cars but only 109 cars per 1000) and Bolivia (1.53  fatalities per 1000 cars and only 113 cars per 1000).

The graph below shows the relation between car fatalities per 100,000 inhabitants and life expectancy. Cuba is singled out as a black square. Low rate of car fatalities, higher life expectancy. Obviously, this is not a regression and so I am not trying to infer too much. However, it seems fair to say that Cuba’s life expectancy can easily be explained by the fact that Cubans face stiff prohibitions on the ability to drive. Those prohibitions give them a few extra years of life for sure, but would you really call that a ringing endorsement of the health outcomes under Castro’s regime? I don’t…


On Cuba’s Fake Stats

On Monday, my piece on the use violence for public health purposes in Cuba (reducing infectious diseases through coercion at the expense of economic growth which in turn increases deaths from preventable diseases related to living standards) assumed that the statistics were correct.

They are not! How much so? A lot! 

As I mentioned on Monday, Cuban doctors face penalties for not meeting their “infant mortality” targets. As a result, they use extreme measures ranging from abortion against the mother’s will to sterilization and isolation.  They also have an incentive to lie…(pretty obvious right?)

How can they lie? By re-categorizing early neonatal (from birth to 7th day) or neonatal deaths (up to 28th day) as late fetal deaths. Early neonatal deaths and late fetal deaths are basically grouped together at “perinatal” deaths since they share the same factors. Normally, health statistics suggest that late fetal deaths and early neonatal deaths should be heavily correlated (the graph below makes everything clearer).  However late fetal deaths do not enter inside the infant mortality rates while the early neonatal deaths do enter that often-cited rate (see graph below).

Death Structures.png

Normally, the ratio of late fetal deaths to early neonatal deaths should be more or less constant across space. In the PERISTAT data (the one that best divides those deaths), most countries have a ratio of late fetal to early neonatal deaths ranging from 1.04 to 3.03. Cuba has a ratio of more than 6. This is pretty much a clear of data manipulation.

In a recent article published in Cuban Studies, Roberto Gonzales makes adjustments to create a range where the ratio would be in line with that of other countries. If it were, the infant mortality of Cuba would be between 7.45 and 11.16 per 1,000 births rather than the 5.79 per 1,000 reported by the regime – as much as 92% higher. As a result, Cuba moves from having an average infant mortality rate in the PERISTAT data to having the worst average infant mortality in that dataset – above that of most European and North American countries.

So not only is my comment from Monday very much valid, the “upside” (for a lack of a better term) I mentioned is largely overblown because doctors and politicians have an incentive to fake the numbers.