January 1 will mark 60 years since Fidel Castro’s seizure of power. How are we to assess this long period, especially from the perspective of the average Cuban citizen? The fact that Cuba used to be one of the richest countries of Latin America at the time of Castro’s revolution and is now one of its poorest ought to settle the question. However, Cubans are significantly healthier than one would expect: life expectancy is quite high while infant mortality is quite low for a country that poor. Cuba also has high literacy rates relative to the rest of Latin America.
The latter facts have been the basis of much praise heaped upon Castro’s regime by a great number of scholars, public health experts, politicians, and pundits. In these praises, the blame for the apparent poverty of the country is simply shifted onto the American trade embargo. Some even suggest that we ought to find ways to adopt Cuba’s health care system without assuming the abuse of human rights that the regime has inflicted upon its population (i.e., sorting the wheat from the chaff). Even so, opinions are divided on what judgment to render upon Fidel Castro.
They ought not be divided, for three reasons. The first is that there is scientific evidence that while it did not help, the trade embargo cannot explain Cuba’s relative poverty. The second is that the regime’s ability to improve health outcomes is overstated. The third, and most important, is that the heavy-handed tools of dictatorship are quite well-suited to improving health outcomes even though this comes at heavy costs.
Economic Growth in Cuba Since 1959
A casual look at open-access data sources such as the World Bank’s Development Indicators shows that Cuban incomes more or less stagnated from 1959 to the mid-1990s, when Cuba was in a deep recession following the collapse of the Soviet Union. While there has been some growth since the early 1990s, income per capita is below the average level in Latin America.
Given that the most conservative assessment of Cuba’s economic welfare places it as one of the richest countries of Latin America in the 1950s (and probably richer than even the United States if you trust other economic historians), this should be sufficient to show that the effects of the revolution are important. However, the causes of the stagnation cannot be fully ascribed to Castro; there are other factors, such as the American trade embargo. We need to disentangle the factors; otherwise, one could argue that while true, the facts mentioned above result from American action, not Cuban policies.
Fortunately, recent research produced by Hugo Jales, Thomas Kang, Guilherme Stein, and Felipe Garcia Ribeiro and published in the journal The World Economy has disentangled these factors. They find that the trade embargo is not sufficient to explain Cuba’s economic divergence since 1959. First, they find no strong effect on income per capita of the 1962 implementation of a full embargo even though there may have been effects of the partial embargo which preceded it..
Second, they find that when the Soviet Union began to ramp up subsidies to the regime in the 1970s (by buying sugar above world prices), this mitigated the adverse effects. Finally, they attempt to disentangle the effects by considering the end of Russian subsidies at the collapse of the Soviet Union and find that while the embargo did have an effect, its amplitude was smaller than that of the revolution itself.
It is also important to note that Jales and his associates’ conclusions are probably understated because they rely on assumptions that trust the national income statistics produced by Cuba while many economists and economic historians are skeptical of the way some of the numbers are computed. If there are errors in the numbers, they would only make the conclusion stronger.
Health Outcomes Are exaggerated
In 1959, Cuba was not only one of the richest countries of Latin America, it was also one of the healthiest. It had a high level of life expectancy at birth and a relatively low rate of infant mortality. Accordingly, Cuba improved from an already pretty-good base. However, many researchers have pointed out important discrepancies in the data regarding infant mortality. They have showed that doctors often reclassified early neonatal deaths (before the 7th day of life) as late fetal deaths (before birth). Because late fetal deaths are not included in infant mortality calculations while early neonatal deaths are, this reclassification artificially reduces the infant mortality rate. Demographers have also observed this reclassification in the Soviet Union in the 1970s, when infant mortality appeared to be rising.
This type of reclassification also has an effect on measured life expectancy because late fetal deaths are not counted in the life tables that are used to calculate life expectancy at birth. In research recently published with Gilbert Berdine and Benjamin Powell in Health Policy & Planning, I show that, in Cuba, this practice has reduced life expectancy at birth for men by somewhere between 0.22 and 0.55 years.
Moreover, doctors also pressure women into having abortions if they believe the pregnancies are risky (and sometimes perform abortions without consent). Because Cuban physicians are penalized when health outcomes are poor, they have strong incentives to do so. This explains why Cuba has one of the highest abortion rates in the world. It also alters life expectancy figures. If only 5 percent of the abortions in Cuba are performed on unwilling mothers (a low estimate given ethnographic studies) to prevent births that would have led to infants’ death, the effects would add up to a reduction of between 1.46 and 1.79 years of male life expectancy at birth.
In the same research, I also argue that Cuba’s relative poverty has paradoxical effects on health outcomes. For example, Cubans cannot afford to purchase automobiles (whose importation is restricted anyway). Thus, they drive less, which explains why Cuba has one of the lowest rates of car ownership in Latin America. Driving less also means that they are less likely to die in car crashes. In Brazil, whose car ownership rate is eight times that of Cuba, road fatalities knock off 0.8 years of life expectancy at birth for males. The effect is compounded by the fact that the Cuban regime rations numerous items such as salt and cigarettes. Thus, some of Cuba’s health outcomes are accidental outcomes of its poverty and non-health-related policies.
Finally, along with Jamie Bologna Pavlik, I also show that within the first 15 years of the revolution, infant mortality increased relative to what it would have been without the revolution. Few people note that the improvements in infant mortality happened after circa 1970 and that there was a long hiatus from a previous downward trend that lasted until circa 1960. This means that from 1960 to 1970, there was a break in the trend, which, incidentally, was not shared by comparable countries. This hiatus, we find, implies that an extra 33,000 infants died between 1959 and 1974 because of Castro’s revolution.
Coercion Is a Key Ingredient
Nevertheless, even after adjusting for the fabrications of the regime, Cuba remains an outperformer and the initial adverse effect of the revolution faded as the country began increasing health outcomes. In this respect, it is important to note something crucial: most communist countries did well on health metrics.
For example, in the Soviet Union, life expectancy and height (a key indicator of nutrition) went up until the 1970s so that Russians were better off than they were before the end of tsarism. Literacy rates were also higher. There is similar evidence for Eastern European countries under Soviet rule.
Why would this be the case? Because rulers have an incentive to improve such outcomes as it solidifies their hold on power. First of all, education can be used for indoctrination, and it has been used to that end. True, Cubans are now more literate than in 1959, but they are reading information valuable to the regime’s survival. The same can be said of health care. Cuban physicians are also members of the army, and they are expected to report everything about their patients. Accordingly, they are the first line of information gathering for the regime and thus a key tool in the regime’s ability to continue in power. The heavy-handed tools that dictators use to maintain themselves in power accidentally improve health outcomes.
Moreover, dictators are also social planners, and like all social planners they are quite good at solving unidimensional problems. For example, they are quite good at improving one indicator (which they then vaunt about on the international scene) because they forcibly allocate resources to this end. However, everything comes with trade-offs.
The cost of the Castro regime’s laser-like focus on infant mortality is that other health outcomes are actually worsened. For example, Cuba has a much higher rate of maternal mortality and its ranking in life expectancy corrected for disabilities (adjusting for crippling diseases affecting adults) is quite different from its unadjusted figure (which places a heavy weight on infant survival).
Moreover, these outcomes come at a heavy cost economically because the regime allocates close to 11 percent of national GDP to health care and physicians constitute close to 1 percent of the labor force. These are resources that are not available to other sectors of economic activity. No other country in Latin America allocates as many resources, not even those that outpace Cuba in terms of outcomes.
Once all the elements mentioned above are taken into account, it is hard not to accept a bleak view of how Cubans have lived through the last 60 years. The road not taken by Cuba, that of not having the revolution, is one on which the country would have been healthier and richer than it is now. This denial of human flourishing makes Cuba just like any other Communist regime, and thus the regime deserves only scorn.
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