- Hayekian evolutionism and omitting the nation-state Scott Boykin, JLS
- Progress by consent: Adam Smith was right all along William Easterly, RAE
- Greater Britain or Greater Synthesis? Imperial debates (pdf) Daniel Deudney, RIS
- Bloodletting Whitney Curry Wimbish, North American Review
health
Health policy is a less mature field in India
The raging second wave of Covid-19 hasn’t just collapsed the Indian healthcare, it has devastatingly uncovered preexisting public health policy deficits and healthcare frailties.
In India, there is a need to revive a serious conversation around public health policy, along with upgrading healthcare. But wait, isn’t the term ‘public health’ interchangeable with healthcare? Actually, no. ‘Public health’ is the population-scale program concerned with prevention and not cure. In contrast, healthcare essentially involves a private good and not public good. Most public health experts point out, the weaker the healthcare system (such as in India), the greater the gains from implementing public health prevention strategies.
India focused its energies on preventing malaria by fighting mosquitoes in the 1970s and then regressed to treating patients who have malaria, dengue or Zika ineffectively. A developing public health policy got sidelined for a more visible, vote-grabbing, yet inadequate healthcare program. Why? Indian elites tend to transfer concepts and priorities, from the health policy debates of advanced economies, into Indian thinking about health policy without much thought. As a result, there is considerable confusion around terminologies. There is a need for a sharp delineation between: ‘public good,’ ‘public health’ and ‘healthcare.’ The phrase ‘public health’ is frequently misinterpreted to imply ‘healthcare.’ On the contrary, ‘healthcare’ is repeatedly assumed as a ‘public good.’ In official Indian directives, the phrase ‘public health expenditure’ is often applied for government expenditures on healthcare. It is confusing because it contains the term ‘public health,’ which is the antonym of ‘healthcare.’
Many of the advanced economies of today have been engaged in public health for a very long time. As an example, the UK began work on clean water in 1858 and on clean air in 1952. For over forty-five years the Clean Air Act in the U.S. has cut pollution as the economy has grown. Therefore, the elites in the UK and US can worry about the nuances of healthcare policy. On the other hand, the focus of health policy in India must be upon prevention, as it is not a solved problem. Problems such as air quality has become worse today in India. Can the Ministry of Health do something about it? Not much, because plenty of public health-related issues lie outside the administrative boundaries of the Ministry of Health. Air quality—that afflicts North India—lies in the Ministry of Environment and internal bureaucracy—“officials love the rule of officials”—deters the two departments from interacting and working out such problems productively. Economist Ajay Shah points out, Indian politicians who concern themselves with health policy take the path of least resistance—to use public money to buy insurance (frequently from private health insurance companies) for individuals who would obtain healthcare services from private healthcare providers. This is an inefficient path because a fragile public health policy bestows a high disease burden, which induces a market failure in the private healthcare industry, followed by a market failure in the health insurance industry.
In other words, Ajay Shah implies that the Indian public sector is not effective at translating expenditures into healthcare services. Privately produced healthcare is plagued with market failure. Health insurance companies suffer from poor financial regulation and from dealing with a malfunctioning healthcare system. No matter the amount of money one assigns into government healthcare facilities or health insurance companies, both these routes work poorly. As a consequence, increased welfare investment by the government on healthcare, under the present paradigm of the Indian healthcare, is likely to be under par.
The long-term lessons from the second wave of COVID-19 is that inter-departmental inefficiencies cannot be tolerated anymore. Public health considerations and economic progress need to shape future elections and the working of many Indian ministries in equal measure. India deserves improved intellectual capacity in shaping public health policy and upgrading healthcare to obtain a complete translation of higher GDP into improved health outcomes. This implies that health policy capabilities—data sets, researchers, think tanks, local government—will need to match the heterogeneity of Indian states. What applies to the state of Karnataka will not necessarily apply to the state of Bihar. The devastating second wave is not arguing for imposing more centralized uniformity in the working of healthcare and public health policy proposals across India, as it will inevitably reduce the quality of executing these proposals in its diverse states with various hurdles. Instead, Indian elites need to place ‘funds, functions and functionaries’ at the local level for better health outcomes. After all, large cities in India match the population of many countries. They deserve localized public health and healthcare policy proposals.
The need to address the foundations of public health and healthcare in India around the problems of market failure and low state capacity has never been greater.
Life expectancy at birth is not a predictor of health care efficiency…
This is going to be a short post to argue that pundits (and some economists) need to stop quoting life expectancy figures to argue for/against a particular health care system. This belief is best exemplified in a recent paper in the Journal of the American Medical Association where Papanicolas et al. (2018) point out that the United States “spent nearly twice as much as 10 high-income countries (…) and performed less well on many population health outcomes”. While the authors make good points about administrative costs, they point out that the US has a low level of life expectancy.
Sure, that is actually true – but Americans tend to die in greater proportions from homicides, drug overdoses and car accidents (Americans drive more than Europeans) than in other rich countries. While these factors of mortality are tragic (except car accidents since Americans seem to prefer the benefits of mobility to the safety of not driving), they are in no way related to the efficiency of health care provision. How much of a deal are these in explaining differences with other industrialized countries? A pretty big deal. For example, these three factors alone account for 64% of the male life expectancy gap between Austria and the United States (see table reproduced below). For women, 26% of the gap between Austria and the United States is explained by these three factors.
The study I cite here only includes three factors. If you add in other factors like drownings among youths (Americans tend to have more drownings than several industrialized countries) which is a result of the fact that Americans are richer and can afford pools (while Europeans tend not to), then you keep explaining away the difference. This is not to say that American health care is great. However, this says that American health care is not as bad as life expectancy outcomes suggest.
In health care, expenditures to GDP may be misleading!
In debates over health care reform in the US, it is frequent for Canada’s name to pop up in order to signal that Canada is spending much less of its GDP to health care and seems to generate relatively comparable outcomes. I disagree.
Its not that the system presently in place in the US is so great, its that the measure of resources expended on each system is really bad. In fact, its a matter of simple economics. Imagine two areas (1 and 2), the first has single-payer health care, the other has fully-private health care.
In area 2, prices ration access to health care so that people eschew visits to the emergency room as a result of a scraped elbow. In area 1, free access means no rationing through price and more services are consumed. However, to avoid overspending, the government of area 1 has waiting lists or other rationing schemes. In area 2, which I have presented as an ideal free market for the sake of conversation, whatever people expend can be divided over GDP and we get an accurate portrait of “costs”. However, in area 1, costs are borne differently – through taxes and through waiting times. As such, comparing what is spent in area 1 to what is spent in area 2 is a flawed comparison.
So when we say that Canada spends 10.7% of GDP on health care (2013 numbers) versus 17.1% of GDP in the US, is it a viable comparison? Not really. In 2008, the Canadian Medical Association produced a study evaluating the cost of waiting times for four key procedures : total joint replacement surgery, cataract surgery, coronary artery bypass
graft (CABG) and MRI scans. These procedures are by no means exhaustive and they concern only “excessive” waiting times (rather than the whole waiting times or at least the difference with the United States). However, the CMA found that, for the 2007 (the year they studied), the cost of waiting was equal to 14.8$ billion (CAD). Given the size of the economy back in 2007, this represented 1.3% of GDP. Again, I must emphasize that this is not an exhaustive measure of the cost of waiting times. However, it does bring Canada closer to the United States in terms of the “true cost” of health care. Any estimate that would include other wait times would increase that proportion.
I know that policy experts are aware of that, but it is so frequent to see comparisons based on spending to GDP in order to argue for X and Y policy as being relatively cheap. I just thought it was necessary to remind some people (those who decide to read me) that prudence is mandatory here.
On the paradox of poverty and good health in Cuba
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 Conclusion
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.
Aggregate measures of well-being, England 1781-1850
I went in the field of economic history after I discovered how much it was to properly measure living standards. The issue that always interested me was how to “capture” the multidimensional nature of living standards. After all, what weight should we give to an extra year of life relative to the quality of that extra year (see all my stuff on Cuba)?
However, I never tried to create “a composite” measure of living standards. I thought that it was necessary, first, to get the measurements right. However, I had been aware of the work of Leandro Prados de la Escosura who has been doing considerable work on this in order to create composite measures (Leandro also influenced me on my Cuba reasoning – see this article).
A year ago, I discovered the work of Daniel Gallardo Albarrán from the University of Groningen at the meeting of the Economic History Society (EHS). Daniel’s work is particularly interesting because he is trying to generate a composite measure of well-being at one of the most important moment in history: the start of the British industrial revolution.
Because of its importance and some pieces of contradicting evidence (inequality, stature, amplitude of real wage increases, amplitude of income increases, urban pollution leading to increased mortality risks etc), the period has been begging for some form of composite measure to come along (at least a serious attempt at generating it). Drawing on some pretty straightforward microeconomic theory (the Beckerian in me likes this), Daniel generates this rich graph (see the paper here).
The idea is very neat and I hope it will inspire some economic historians to attempt an expansion upon Daniel’s work. I have already drawn outlines for my own stuff on Canada since I study an era when (from the early 1800s to the mid-1850s) real wages and incomes seem to be going up but stature and mortality are either deteriorating or remaining stable while inequality is clearly increasing.
The Heights of French-Canadian Convicts, 1780 to 1830
A few days ago, it was confirmed that my article with Vadim Kufenko and Alex Arsenault Morin on the heights of French-Canadians between 1780 and 1830 was accepted for publication in Economics and Human Biology. In that paper, we try to introduce French-Canadians before 1850 to the anthropometric history literature by using the records of the prison of Quebec City. Stature is an important measure of living standards. As it is heavily related to other aspects of health outcomes, it is a strong measure of biological living standards. More importantly, there are moments in history when material living standards and biological living standards move in opposite directions (in the long-run, this is not the case).
We find three key results. The first is that the French-Canadians grew shorter throughout the era when living standards did not increase importantly (and were very volatile). This puts them at odds from other places in North America where increases in stature were experienced up until the 1820s. Furthermore, stature stops falling around 1820 when economic growth picked up. This places the French-Canadians in a unique category in North America since it seems unlikely that they experienced a strong version of the antebellum puzzle (decline in stature with increases in material living standards which is what the US experienced). The second key result is that the French-Canadians are the shortest in North America, shorter even than Black Americans in slavery. However, they are considerably taller than most (save Argentinians) Latin Americans. More importantly, they are considerably taller than their counterparts in France. The third key result is related to the second key result. Today, French-Canadians are noticeably shorter than other Canadians. However, the gap was more important in the late 19th century and early 20th century. Pegged as a “striking exception” within Canada, we do not know when it actually started. Thanks to our work, we know that this was true as far back at the early 19th century.
The working paper (dramatically different than the accepted version) is here and I am posting key results in tables and figures below. Moreover, I will be talking about anthropometric history and economic history with Garrett Petersen of Economics Detective Radio this Tuesday (I do not know when the podcast will be made available, but you should subscribe to that show anyways).
Is Trump So Old? Its all relative really!
Today is inauguration day. Donald Trump will officially be the 45th President of the United States of America. Many have pointed out that Trump is the oldest president (slightly above 70 years of age). I disagree.
Old is not a “purely” absolute concept. Advances in living standards mean advances in our ability to live longer lives. Not only do we live longer lives than in the past, but at any point in our life, our health is better. Someone who reached 65 years of age in 1900 probably did not have the same health prospects as someone who reaches that age today. Basically, the “quality” of old age has increased over time (see this great book on the economic history of aging). So, when people say “old”, I ask “old as compared to what”.
To meet that test, I took the CDC data on life expectancy as well as soon historical database from 1900 to today. I combined it with David Hacker’s work on life tables in the US from 1790 to 1900 which can be found in this article of Historical Methods. Hacker’s data concerns only the white population. I took only the age expectancy at birth of males. Then, I plotted the age of the president at the time of inauguration as a share of the life expectancy at birth (E0). This is the result:
As one can see, the age of presidents as a share of life expectancy is falling steadily since the early 1900s. In this light, Donald Trump is not the oldest president. In fact, the oldest president is …. drumroll…James Buchanan (1.85 times the life expectancy of white males at birth). Moreover, in this light, the youngest president at inauguration is not Teddy Roosevelt (Kennedy was the youngest elected). Rather, the youngest is Barack Obama followed very closely by Bill Clinton and John F. Kennedy.
I find this post to be interesting as it shows something more important in my eyes: how the poorest in society have done. Presidents have generally stemmed from the top of the income distribution. Over time, the ages of presidents at inauguration (in absolute terms) has not followed any clear trend. The drop seen in the graph above is entirely driven by increases in the life expectancy of the “average” American. In a certain way, it shows that the distance between that “Joe the Plumber” and the “Greatest Man in America” (huh…Lord Acton anyone?) seems to be diminishing over time.
How Well Has Cuba Managed To Improve Health Outcomes? (part 2)
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)
How Well Has Cuba Managed To Improve Health Outcomes? (part 1)
Since the passing of Fidel Castro, I have devoted myself to researching a proper assessment of his regime’s achievements in matters of health care. The more I dig, the more I am convinced that his regime has basically been incredibly brilliant at presenting a favorable portrait. The tweaking of the statistics is not blatant or gigantic, it is sufficiently small to avoid alerting demographers (unlike when Davis and Feshbach, Eberstadt and Miller and Velkoff found considerable evidence of data tweaking in the USSR which raised a massive debate). Indeed, a re-computation of life expectancy based on life tables (which I will present in the new few weeks) to adjust for the false reclassification of early neonatal deaths as late fetal deaths (raising the low infant mortality rate by somewhere 28% and 96%) suggests that somewhere between 0.1 and 0.3 years must be knocked off the life expectancy figures. Given that the variations between different measurements available (WHO, World Bank, MINISAP, CIA, FAO) are roughly of that magnitude, it falls within a very reasonable range of errors. This statistical tweaking is combined with an over-dramatization of how terrible the situation was in 1959 (the life expectancy figures vary from 63.9 years to 65.4 years at the beggining of the Castrist regime). But that tweaking is not sufficient to invalidate the massive downward trend. As a result, the majority of public health scholars seem confident in the overall level and trend (and I tend to concur with that statement even if I think things are worse than presented and the slope of the downward trend is too steep).
Those little tweaks have been combined with the use of massive coercive measures on the local population (beautifully described by Katherine Hirschfeld in what should be an example of ethnographic work that economists and policy-makers should rely on because it goes behind the data – see her book Health, Politics, and Revolution in Cuba: 1898-2005) that go from using doctors as tools for political monitoring to the use of abortion against a mother’s will if it may hinder a physician’s chance of reaching the centrally-decided target without forgetting forced isolations for some infectious patients. Such methods are efficient at fighting some types of diseases, but they are associated with institutions that are unable to provide much economic growth which may act as a palliative counter-effects to how choices may make us less healthy (me having the freedom to eat too much salt means I can die earlier, but the type of institutions that let me eat that much salt also avoid infringing on my property rights thus allowing me to improve living standards which is the palliative counter-effect). With such a trade-off, the issue becomes one of the ability of poor countries to improve in the absence of extreme violence as that applied by the Castrist regime.
Over the next few weeks, I will publish many re-computations of health statistics to sustain this argument as I write my article. The first one I am doing is the evolution of life expectancy from 1960 to 2014. What I did is that I created comparatives for Cuba based on how much living standards (income per capita). Cuban living less than doubled over that 49 years period (82% increase) from 1959 to 2008 (the latest available data from the high-quality Maddison data). Latin American and Carribean countries that saw their living standards less than double (or even decline) are Argentina (+90%), Bolivia (+87%), El Salvador (+68%), Haïti (-33%), Honduras (+71%), Jamaica (+51%), Nicaragua (-17%) and Venezuela (+7%). This forms the low income group. The remaining countries available are separated in two groups: those whose income increased between 100% and 200% (the mid-income group composed of Brazil, Colombia, Mexico, Peru, Uruguay, Ecuador, Guatemala, Panama and Paraguay) and those whose incomes increased more than 300% (the high-income group composed Chile, Costa Rica, Dominican Republic, Puerto Rico and Trinidad & Tobago). I also compared Cuba with a group of countries that had incomes per capita within 20% of the income per capita of Cuba. So, how did Cuba’s life expectancy increase?
Well, using only the official statistics (which I do not fully trust although they are from the World Bank Development Indicators Database), Cuba life expectancy (which was already pretty high by Latin American standards in 1959) increased 24%. However, all other countries – which were well below Cuba – saw faster increases. The countries that had the least growth in Latin America saw life expectancy increase 38% and the countries that were equally poor as Cuba saw life expectancy increase an impressive 42%. Chile, whose life expectancy was only 57.5 years against Cuba’s 63.9 in 1960, also increased more rapidly (also 42%) and it has now surpassed Cuba (81.5 years against 79.4 years) and what is more impressive is that this rate has increased in a monotonic fashion regardless of changes in political regimes (democracy, socialism, Pinochet, liberal democracy) while Cuba’s rate seems to accelerate and decelerate frequently. Now, this is assuming that the figures for 1960 are correct. I have surveyed the literature and it is hard to find a way to say which of the estimates is the best, but that of the World Bank for 1960 is the lowest. There are other rates, contained in McGuire and Frankel’s work – the highest stands at 65.4 years for 1960. That means that the range of increase of life expectancy in Cuba is between 21.4% and 24.2%. Its not earth-shattering, but it makes Cuba’s achievements less impressive (although it is impressive to keep increase life expectancy from an already-high level). But as you can see, more important improvements could have been generated without recourse to such violent means. In fact, as a post that I will publish this week shows, the decline in car ownership from 1959 to 1988 probably played moderately in favor of the increase in life expectancy while the massive increase in car ownership in all other countries played (all else being equal) in favor of slowing down the increases in life expectancy (but being too poor or making it illegal to import a foreign car is not health care and I deem it improper to consider that this accident from misfortune should be praised).
In a way, what I am saying is that the benefit is not as impressive as claimed. Given the costs that Cubans have to assume for such a policy, anything that makes the benefits look more modest should make more inclined to cast a damning judgment on Castro’s regime.
Coming up (I will add the links as they are published) :
- 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)
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).
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.
Castro: Coercing Cubans into Health
On Black Friday, one of the few remaining tyrants in the world passed away (see the great spread of democracy in the world since 1988). Fidel Castro is a man that I will not mourn nor will I celebrate his passing. What I mourn are the lives he destroyed, the men and women he impoverished, the dreams he crushed and the suffering he inflicted on the innocents. When I state this feeling to others, I am told that he improved life expectancy in Cuba and reduced infant mortality.
To which I reply: why are you proving my point?
The reality that few people understand is that even poor countries can easily reduce mortality with the use of coercive measures available to a centralized dictatorship. There are many diseases (like smallpox) that spread because individuals have a hard time coordinating their actions and cannot prevent free riders (if 90% of people get vaccinated, the 10% remaining gets the protection without having to endure the cost). This type of disease is very easy to fight for a state: force people to get vaccinated.
However, there is a tradeoff to this. The type of institutions that can use violence so cheaply and so efficiently is also the type of institutions that has a hard time creating economic growth and development. Countries with “unfree” institutions are generally poor and grow slowly. Thus, these countries can fight some diseases efficiently (like smallpox and yellow fever), but not other diseases that are related to individual well-being (i.e. poverty diseases). This implies that you get unfree institutions and low rates of epidemics but high levels of poverty and high rates of mortality from tuberculosis, diarrhea, typhoid fever, heart diseases, nephritis.
This argument is basically the argument of Werner Troesken in his great book, The Pox of Liberty. How does it apply to Cuba?
First of all, by 1959, Cuba was already in the top of development indexes for the Americas – a very rich and healthy place by Latin American standards. A large part of the high levels of health indicators were actually the result of coercion. Cuba actually got its very low levels of mortality as a result of the Spanish-American war when the island was occupied by American invaders. They fought yellow fever and other diseases with impressive levels of violence. As Troesken mentions, the rate of mortality fell dramatically in Cuba as a result of this coercion.
Upon taking power in 1959, Castro did exactly the same thing as the Americans. From a public choice perspective, he needed something to shore up support. His policies were not geared towards wealth creation, but they were geared towards the efficient use of violence. As Linda Whiteford and Laurence Branch point out, personal choices are heavily controlled in Cuba in order to achieve these outcomes. Heavy restrictions exist on what Cubans can eat, drink and do. When pregnancies are deemed risky, doctors have to coerce women to undergo abortion in spite of their wishes. Some women are incarcerated in the Casas de Maternidad in spite of their wishes. On top of this, forced sterilization in some cases are an actually documented policy tool. These restrictions do reduce mortality, but they feel like a heavy price for the people. On the other hand, the Castrist regime did get something to brag about and it got international support.
However, when you look at the other side of the tradeoff, you see that death rates from “poverty diseases” don’t seem to have dropped (while they did elsewhere in Latin America). In fact, there are signs that the aggregate infant mortality rates of many other Latin Americans countries collapsed toward the low-levels seen in Cuba when Castro took over in 1959 (here too). Moreover, the crude mortality rate is increasing while infant mortality is decreasing (which is a strong indictment about how much shorter adult lives are in Cuba).
So, yes, Cuba has been very good at reducing mortality from communicable diseases and choice-based outcomes (like how to give birth) that can be reduced by the extreme use of violence. The cost of that use of violence is a low level of development that allows preventable diseases and poverty diseases to remain rampant. Hardly something to celebrate!
Finally, it is also worth pointing two other facts. First of all, economic growth in Cuba has taken place since the 1990s (after decades of stagnation in absolute terms and decline in relative terms). This is the result of the very modest forms of liberalization that were adopted by the Cuban dictatorship as a result of the end of Soviet subsidies. Thus, what little improvements we can see can be largely attributed to those. Secondly, the level of living standards prior to 1990 was largely boosted by the Soviet subsidies but we can doubt how much of it actually went into the hands of the population given that Fidel Castro is worth 900$ million according to Forbes. Thus, yes, Cubans did remain dirt poor during Castro’s reign up to 1990. Thirdly, doctors are penalized for “not meeting quotas” and thus they do lie about the statistics. One thing that is done by the regime is to categorize “infant deaths” as “late fetal deaths” – its basically extending the definition in order to conceal a poorer performance.
Overall, there is nothing to celebrate about Castro’s dictatorship. What some do celebrate is something that was a deliberate political action on the part of Castro to gain support and it came at the cost of personal freedom and higher deaths from preventable diseases and poverty diseases.
Forget income, the greatest outcome of capitalism is healthier lives!
Yesterday, James Pethokoukis of the American Enterprise Institute posted, in response to Bernie Sanders’ skepticism towards free market, that capitalism has made human “fantastically better”.
I do not disagree – quite the contrary. However, Pethokoukis makes his case by citing the fact that material quality of life has increased for everyone on earth since the early 19th century. I believe that this is not the strongest case for capitalism. The strongest case relies on health. This is because it addresses an element that skeptics are more concerned about.
Indeed, skeptics of capitalism tend to underline that “there is more to life than material consumption”. And they are right! They merely misunderstand that the “material standard of living” is strongly related to the “stuff of life”. For them, income is of little value as an indicator. Thus, we need to look at the “quality of human life”. And what could be better than our “health”?
The substantial improvement in the material living standard of mankind has been accompanied by substantial improvements in health-related outcomes! Life expectancy, infant mortality, pregnancy-related deaths, malnutrition, risks of dying from contagious diseases, occupational fatalities, heights, the types of diseases we die from, quality of life during old age, the physical requirements of work and the risks related to famines have all gone in directions indicating substantial improvements!
My favorite is the case of height. Human stature is strongly correlated with income and other health outcomes (net nutrition, risks of disease, life expectancy, pregnancy-related variables). Thus it is an incredible indicator of the improvement in the “stuff of life”. And throughout the globe since the industrial revolution, heights have increased (not equally though). Over at OurWorldInData.org, Max Roser shows this increase since the 1800s (in centimeters)
However, the true magnitude of the increase in human heights is best seen in the data from Gregory Clark who used skeletal remains found in archaeological sites for ancient societies. The magnitude of the improvement is even clearer through this graph.
The ability of “capitalism” to generate improvement in material living standards did leak into broader measures of human well-being. By far, this is the greatest outcome from capitalism.
Are GMOs Bad For Me?
I am vaguely perceiving that there is a battle brewing someplace about labeling food containing genetically modified organisms (GMOs). It happened in California before. The initiative lost by referendum.
Of course, I am almost always in favor of more information for the public (even when it’s likely to be used for mischief). However, I can’t avoid wondering why sellers of food products don’t just do it on their own to gain a marketing advantage over their competitors. Not getting an answer to this question, I am wondering whether this is not just another case of a minority using the power of the state to impose its views (by force) on the indifferent majority. Keep in mind that this is what the word “law” means: If you break it, you expose yourself to official violence.
I honestly don’t know what’s wrong with GMOs. I only know that they (one?) allowed for a reduced use of pesticides. This has to be a good thing because exposure to large amounts of pesticides is bad for the health of producers and handlers. (I doubt today’s pesticides cause much harm to consumers but I always wash fruits and salad components.) I invited a local libertarian who addressed the topic on Facebook to write an essay for this blog explaining the answer. That was only a couple of days ago. He has not responded. I repeat the invite, to anyone.
What am I supposed to do, I, simple citizen and consumer not especially well equipped to ascertain if GMOs are a threat or not to my beloved? As I keep telling you, fortunately, I don’t necessarily have to go to graduate school yet three or four more years to get an idea. Instead, I look at the proponents I know.
In my area, the people who fight GMOs are mostly (but not only) foofoo heads who overlap a great deal, I think, with those who cancel erotically promising dates on the basis of astrology. They are largely the same people who advocate policy which, taken together, would take us back to what Karl Marx called, “the idiocy of village life,” with a life expectancy hovering around thirty five and a 30% infant mortality They, themselves, wouldn’t survive there more five weeks or less, by the way, because they are too coddled, too self-indulgent, and not alert enough. The wolves about which they keep crying now and here really lived then on the outskirts of such villages. They would gobble up anti-GMOist for a snack.
All the same, I keep an open mind. Anyone who wants to post a comment on GMOs can be sure it will not be censored or modified in any way. I will also consider with great interest any essay on this topic for this blog. Anyone can also send me reading assignments. I will post them but I will not read them unless the sender explains clearly why I should, beginning with the source. (See the standards I apply here)
Notes On Liberty 