Is Cuban healthcare actually good?

Is Cuban healthcare actually good?

Better than average for such a poor country, but hardly a huge success story

Matthew Yglesias

 Aug 23 

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(YAMIL LAGE/AFP via Getty Images)

The New York Times recently ran a story about Covid-19 overwhelming the hospital infrastructure in Cuba, as it has whenever it’s hit lower-income countries who simply have fewer resources to dedicate to this kind of thing.

The headline describes this as “Overwhelmed by Coronavirus, Cuba’s Vaunted Health System Is Reeling,” and the lede of the story alludes to the fact that the healthcare system was “long a source of national pride” so there’s a kind of particular resonance to these problems. But the story doesn’t really evaluate the claim of whether that national pride is warranted or not, and a reader asked what I think about that. Is the Cuban healthcare system actually impressive?

I think the short answer is “no,” at least if by “healthcare system” you mean what people normally talk about when they talk about the healthcare system in the United States. Cuba does not have, like, tons of secret cures or advanced treatments or lots of great medical equipment. It’s not at all surprising that Covid-19 is posing a big problem for them because the disease spreads very efficiently, and the most widely used treatments involve a lot of capital-intensive hospitalization. When people praise Cuban healthcare, they are really praising Cuban health outcomes and attributing those outcomes to Cuban public health policy. That may be right (though I’m a bit skeptical), but it really is worth saying that it’s a different thing.

Everyone agrees, I think, that the social and behavioral determinants of health are a big deal. Everyone is aware that junk food, between-meal snacking, sugary drinks, alcohol, and tobacco are bad while fresh vegetables and daily vigorous exercise are good.

If we all did more of the good stuff and less of the bad stuff, our population health indicators would improve. If we became a communist dictatorship that had no McDonald’s, there might be some health upsides. But a democracy could ban fast food, too. We don’t do it because people enjoy their unhealthy snacks. This is different from healthcare questions like “if you have a routine medical problem, can you get it treated quickly, efficiently, and affordably?” and “if you have a severe medical problem, can you be restored to health at all?” It would be very misleading to say that American healthcare improved drastically between 1988 and 2008 when the smoking rate dropped or that it got worse when people started overdosing on fentanyl. These are important public health trends, but they’re not what we talk about when we talk about healthcare.

The question of why Cubans are in relatively good health is interesting, though they’re far from the best in the world or even the best in Latin America, so nothing about it warrants extraordinary praise. What’s unusual about Cuba is the role bragging about its healthcare system plays in the regime’s domestic and international politics. Because it’s such a major point of emphasis, they deliver well on certain heavily emphasized index points — so well that they are probably lying about it — and they also export medical services as a major industry.

Castrophiles like to portray this as a quasi-miraculous policy success story: here’s this relatively poor country doing high-end service exports, but it’s really just a policy failure. Cuba successfully exports doctors because its doctors are so poorly paid. Countries normally don’t pursue that as a development strategy because it doesn’t really make sense, and Cuba is now beyond the 60th year of this not working. If the regime was brand new, you might say they pulled together an impressive public health service with meager resources. But the Cuban Revolution happened generations ago. The most generous possible assessment you could give is that the effort to develop a specialization in medical services has given Cuba unusually good public health infrastructure for a country at its stage of development while failing as a development strategy. And it’s not even really clear how good that infrastructure is when you subject it to scrutiny.

The mystery of low infant mortality

The core claims to fame of the Cuban healthcare system are the linked facts that the country has a low infant mortality rate (4.1 per 1,000, which is below the high-income country average of 5 per 1,000) and a high life expectancy for a relatively poor country.

These facts are linked, however, because infant mortality exerts a strong statistical influence on life expectancy at birth. And precisely because this one statistical indicator is such a major regime talking point, there’s reason to ask whether it’s being manipulated in an authoritarian context. Indeed, Roberto Gonzalez shows that the flip side of Cuba’s abnormally low neo-natal fatality rate is an unusually high late-fetal death rate. There are a few possible explanations for this, but the most likely is that they are simply misclassifying the early-life deaths of premature infants as lost pregnancies. The other possible explanations would reflect even worse on the Cuban healthcare system: basically that they may be deliberately mismanaging pregnancies to generate late-fetal deaths rather than risky births. Either way, if you look at late-fetal and early-neonatal deaths as a combined phenomenon, Cuba’s performance drops to well below that of rich countries as well as Chile and Costa Rica, though still good relative to Latin America as a whole.

The broader issue is that there is more to healthcare than infant mortality. Even on a closely related issue like maternal mortality, Octavio Gómez-Dantés reports that “maternal mortality ratio in Cuba is 39 per 100 000 live births, compared with only 27 in Barbados, 28 in Belize, 22 in Chile, 25 in Costa Rica, 27 in Grenada and 15 in Uruguay.”

Cuba also undertakes public health measures that would not be considered acceptable by most Americans, including those who praise Cuba’s results, such as forcibly quarantining HIV-positive individuals in prison camps. This has been very successful in keeping HIV infection rates low, and high Cuban state capacity is something we should return to. But it’s a reminder that in general, reliance on cheap, non-pharmaceutical interventions as a public health strategy can have high costs in terms of human rights and other things that don’t happen to be priorities for the Cuban government.

Okay-but-not-great life expectancy

According to the WHO’s 2020 data, life expectancy at birth in Cuba is 77.8 years, just a hair behind the United States despite being a much poorer country and good for 46th place in the overall rankings. But some of this is driven by the potentially faked low infant mortality, and if you look at life expectancy at age 60, they drop down to 55th place.

But even using the more Cuba-friendly life expectancy at birth numbers, they are still below Ecuador, Colombia, Panama, Peru, Chile, and Costa Rica along with every European country, Japan, Korea, Singapore, the U.S., Australia, Canada, and New Zealand. This is to say that while Cuba’s public health outcomes are pretty good considering how poor the country is, you’d be better off health-wise living in a more economically successful Latin American country. And you’d also have more consumer goods.

What’s more obviously healthcare is not the only determinant of life expectancy.

One area where Cuba genuinely does do well and Latin America and the Caribbean struggle, as a region, is with high levels of crime and high homicide rates. Cuba’s numbers, according to the UN, are low compared to other countries in the region.

Cuba also has a relatively low number of traffic fatalities, estimated at 7.5 per 100,000 per year, which is a lot better than the United States at 12.4 per 100,000. Now a willfully blind person might chalk that up to amazing safety engineering on Cuban roads, but realistically, Cubans simply don’t have cars. In the United States, we have 14.2 traffic fatalities per 100,000 vehicles, whereas in Cuba it’s 133.7 per 100,000 — at least in part I assume because they are stuck with older, less-safe cars. Chile and Mexico both have traffic fatality rates per person that are similar to the United States, but less than half of Cuba’s traffic fatality rates per car.

Now recall there’s no Havana Metro and the capital city only accounts for two million of the island’s 11 million residents anyway. It’s not that people are living in an urbanist paradise, they’re just poor. I do think it’s an interesting fact that as long as you’re not so poor that people are dying of malnutrition, there are certain health benefits to being on the low side of middle-income status. The kind of diet you’re forced into when people struggle to afford basic staple foods and definitely can’t put much meat on the table may be healthier than what Americans eat.

Nobody wants to emulate this

You can kind of squint at all these numbers funny and try to make it sound good, but absent some strong motive toward ideological ax-grinding, I have a hard time understanding why anyone would.

Such non-obscure countries as France, Germany, Italy, Denmark, and the Netherlands all have fewer traffic fatalities than Cuba without being so poor that nobody can afford a car. Those countries also have excellent mass transit systems rather than “people ride the bus because nobody can afford a car.” The typical diet eaten in Japan seems to be much healthier than the standard American diet, again without people being forced into it by poverty.

Back to the core subject, I think if you’re an American of progressive sensibilities, you have to find something appealing about any system of universal healthcare. But if you want to admire that, you could admire Canada; there’s no need to go all-in on communism. The only metric on which the Cuban healthcare system really stands out is that it’s extremely cost-effective. That’s because they pay their domestic doctors very little money. Canada could try poverty wages for medical doctors, but that would make it very hard to attract quality people into medicine. It works for Cuba because everyone is poor. You also have the option as a Cuban doctor to earn a higher salary working abroad. The way this works is that the Cuban government basically leases you out to a foreign government, then keeps half the money, and then you get $1,000 a month — a lot by Cuban standards because the country is so poor.

It’s obviously not unusual for a poor country to develop an economic model based on low-wage exports, and that’s essentially what Cuba is doing with its doctors.

But note that one can name a whole series of countries that started out doing low-wage export-oriented manufacturing and successfully moved up the value chain to become rich. That’s Japan, Korea, Taiwan, and Singapore. China has walked a good way down that path. Closer to Cuba, the Dominican Republic has done this with some success. The doctor-exporting thing, by contrast, only works if the country stays poor — there’s no development model here, and really no success that even a middle-income country could seek to emulate, much less a rich one.

Say what you want about the tenets of communism….

I think the best thing you can really say about Cuba is what you can say about the track record of Communist Bloc states in general, which is that they tend to have a decent amount of state efficacy. It’s a repressive dictatorship, but it succeeds in repressing people and controlling the island. The HIV quarantine camps are cruel, but they function. The state monopolizes the use of force and there is not a lot of crime.

Countries like this usually manage to find something or other that they execute well.

Both Prague and Hungary are great models for how to build a high-ridership mass transit system in a relatively small city, and that work was done by communist regimes. The USSR was really good at rockets.

In other words, while communist eastern Europe had lower living standards than western Europe, the reduction was not uniform across all aspects of life. Cuba has put a lot of effort into maintaining its public health infrastructure, in part because exporting doctors is critical to the central government’s quest for hard currency reserves, so the health situation is better than you might expect for another country with a comparable GDP per capita.

But into the 60th year of the revolutionary regime, it doesn’t really make sense to relativize the public health outcomes to the country’s poverty; the question is whether the Cuban development model works, and the answer is that it doesn’t. In 1968 you might have said, “hey, the new gang took over and made these big investments in public health and I think it’s really gonna pay off.” But they haven’t paid off — they’ve actually failed so badly that Cuba can recruit people to be doctors for pathetically low salaries.

We should talk more about actually successful countries

I first saw this in reference to the comparison with Haiti, but if you’re looking for an island nation in the western hemisphere where something interesting and praiseworthy has happened, it seems like it would be worth talking about the Dominican Republic.

I’ve been trying to research what people say about the Dominican development success story on and off for the past month or so, and unfortunately, it seems to defy any past easy-to-summarize answers. That’s probably why you don’t hear so much about the Dominican Republic — it’s not a great ideological talking point. But it’s a once-authoritarian political system that transitioned into a pretty shaky democracy and then got less shaky over time rather than tipping back into authoritarianism. Given political stability, they then pursued some pretty boring strategies like “get foreign investors to build hotels” and “do some low-end manufacturing.”

I was covering politics back when the CAFTA trade deal was swiftly revised to be DR-CAFTA so the Dominican Republic could get in on the action, and that seems to have helped them too. They also lucked into literally a gigantic gold mine, which helps, but of course we have dozens of examples of natural resource wealth not translating into economic success so I don’t want to say it’s all good luck based on gold.

Everything people say about the Dominican Republic seems very sensible. My struggle, as a journalist, is that their successes all seem so sensible that it’s not like nobody in Jamaica has ever heard of these ideas. The question is why the Dominican Republic was able to successfully apply banal development advice that Jamaica was not. For Cuba, at least, the answer is pretty clear. But the world would benefit from more and more detailed consideration of actual success stories rather than special pleading about outliers designed to address various ideological fantasies. Even where Cuba is doing well, like on homicides, nobody is going to suggest “build a repressive communist dictatorship” as a crime control strategy. At least I hope not!

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