
Infants May Be More Likely to Die in America Than Cuba - pseudolus
https://www.nytimes.com/2019/01/18/opinion/sunday/cuba-healthcare-medicare.html
======
bhawks
"Cuba does have a very low infant mortality rate, but pregnant women are
treated with very authoritarian tactics to maintain these favorable
statistics," said Tassie Katherine Hirschfeld, the chair of the department of
anthropology at the University of Oklahoma who spent nine months living in
Cuba to study the nation's health system. "They are pressured to undergo
abortions that they may not want if prenatal screening detects fetal
abnormalities. If pregnant women develop complications, they are placed in
‘Casas de Maternidad’ for monitoring, even if they would prefer to be at home.
Individual doctors are pressured by their superiors to reach certain
statistical targets. If there is a spike in infant mortality in a certain
district, doctors may be fired. There is pressure to falsify statistics."

[https://www.politifact.com/truth-o-
meter/statements/2014/jan...](https://www.politifact.com/truth-o-
meter/statements/2014/jan/31/tom-harkin/sen-tom-harkin-says-cuba-has-lower-
child-mortality/)

Can we base our universal healthcare proposals on countries that have done it
without the authoritarianism and human rights violations please? There are a
few other examples.

~~~
blindwatchmaker
The 'pressure to undergo abortions in case of fetal abnormalities' sounds the
only potentially troubling part of that, but I don't exactly get what's
'authoritarian' about insisting women with complications stay and be be
monitored in the hospital, or firing people based on poor performance?

Am I missing something here?

~~~
rmrfrmrf
The only group of women who would feel oppressed would be the CEOs that can
afford fully-staffed private hospitals in their own homes and wouldn't be
caught dead resting alongside the unwashed masses.

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gnicholas
The data regarding infant mortality is collected differently in different
countries, so this is like comparing apples and oranges. In the US, more
events are included in the umbrella of "infant mortality" than in most other
countries, which use narrower definitions. Neither way is more "correct" than
the other, but the varying definitions mean that it is very difficult to make
meaningful cross-country comparisons, as Mr. Kristof is trying to do here.

[https://www.forbes.com/sites/physiciansfoundation/2016/04/12...](https://www.forbes.com/sites/physiciansfoundation/2016/04/12/infant-
mortality-not-a-true-measure-of-a-successful-health-care-system/#1829290631f0)

~~~
refurb
Similar issues comparing crime statistics across countries. What falls under
"assault" can vary quite a lot.

------
refurb
I at least have the author credit for stating that the statistics should be
taken with a grain of salt.

 _How is this possible? Well, remember that it may not be. The figures should
be taken with a dose of skepticism._

The US actually has very generous social services when it comes to medical
care for pregnant women and their babies. CHIP and Medicaid cover pregnant
women up to 200% (~$30K) or sometimes 300% (~$50K) of the federal poverty
level.[1] Waiting lists are non-existent for most states as they have an
exemption for pregnant women or newborns..[2]

[1][https://www.medicaid.gov/chip/eligibility-
standards/index.ht...](https://www.medicaid.gov/chip/eligibility-
standards/index.html) [2][https://www.medicaid.gov/chip/eligibility-
standards/waiting-...](https://www.medicaid.gov/chip/eligibility-
standards/waiting-periods/index.html)

~~~
TaylorAlexander
Very generous compared to what? Don’t most other wealthy nations also offer
this kind of care, along with continued free at point of service care for
life?

~~~
pseudolus
In the US there's a patchwork of programs that vary according to the state and
even the city you live in. The tragedy of the situation is that prenatal care
is literally a case of spending pennies and recouping many, many dollars down
the line in health costs for both the mother and the child. When you ponder
the situation, it's truly a WTF moment.

------
danielvf
When we were getting ready for our first child, looking for a hospital, I went
deep diving on infant mortality rates in the US in general, and specifically
in our area's hospitals.

At least in my area of the country, the higher infant mortality (outside birth
defects) rates are almost entirely driven by a tiny percentage of the overall
population - extremely young mothers with substance abuse problems. The
biggest portion of the effect is not a result of medical care differences.
According to the CDC, "Asians" in the US have almost a quarter the infant
mortality rate of "Blacks".

[https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf](https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf)

\--

The article mentions that the US infant death rate is 5.9, and the Cuban
infant death rate is 4.0. However, according to the CDC report, Cuban
ancestry, living in the US, has an infant death rate of 3.0!

------
adolph
_All this [these prenatal home visits] is possible because Cuba overflows with
doctors — it has three times as many per capita as the United States — and
pays them very little._

 _The country has an unusually high rate of late fetal deaths, and skeptics
contend that when a baby is born in distress and dies after a few hours, this
is sometimes categorized as a stillbirth to avoid recording an infant death._

------
corporateVeal27
Skeptical of these numbers:

1\. "4 (Cuban) vs 6 (American) deaths per live birth."

Are we sure they're measured the same? Are we sure that the count for deaths
starts at the same time? Could easily be that Cuban mothers are more likely to
lose a baby at an earlier stage of pregnancy (for example Cubans measure it
from 2nd trimester on, Americans measure it from conception so Cubans fail to
count early stage deaths).

2\. "7500 deaths per year in US".

The author does not seem to have his figures correct. Approximately 3.8
million american babies are born per year. If 0.6% of them die that's 228,000
total deaths and a differential of about 60,000 between US rates and Cuba's.
Not to nitpick here but if you can't get these objective facts right how can I
take you seriously about other things you're saying?

~~~
falsedan
> _Americans measure it from conception_

A pre-birth death can't be counted among the 'per live birth' deaths, and
would have to include estimates of miscarriage rates since those are woefully
underreported everywhere. Pretty sure every country starts the clock at birth.

~~~
corporateVeal27
I wasn't implying they DO measure it from conception I'm just an example that
could explain a discrepancy that is not indicative of better results

Agree on the point about underreporting everywher

------
nkurz
_The country has an unusually high rate of late fetal deaths, and skeptics
contend that when a baby is born in distress and dies after a few hours, this
is sometimes categorized as a stillbirth to avoid recording an infant death.
... I’m not in a position to judge who’s right, but any manipulation seems
unlikely to make a huge difference to the reported figures._

What are we to make of that last sentence? The author seems to be saying "I
don't know enough to judge" but then immediately follows that with a strong
opinion as to who must be wrong. How are we as an audience supposed to gauge
whether Kristof (the author) is right that the effects will be inconsequential
even if the accusations of manipulation were true? The implication would seem
to be that because he's writing his (clearly labeled) opinion in the New York
Times, we should trust him as an expert, despite his disavowals.

While we can't easily answer the question as to whether the statistics are
manipulated, it turns out that there are at least clear answers to what the
effect of the manipulation would be. In a 2015 article entitled "Infant
Mortality in Cuba: Myth and Reality", Roberto Gonzalez runs the numbers and
shows that the effect of reporting Early Neonatal Deaths as Late Fetal Deaths
would be enough to completely change our interpretation of the statistics.
Here's a summary of the paper's conclusions: [https://thecubaneconomy.com/wp-
content/uploads/2014/02/Infan...](https://thecubaneconomy.com/wp-
content/uploads/2014/02/Infant-Mortality-in-Cuba.pdf)

What should we make of this? Certainly a problem with a small detail like this
doesn't mean the overall question isn't worth asking, and the "human interest"
aspects of the story are certainly interesting, but it sure make me wonder how
much we should trust the author's intuitions about other details in the story.

------
rjf72
This article is extremely misleading. One of the main causes of infant
mortality is parental obesity. [1] As America becomes more and more obese
we're going to see more and more of these sort of consequences. For instance
our declining life expectancy is also related to this. Diseases ranging from
cardiovascular to cancer had been steadily retreating, but as our waist lines
expanded the frequency and mortality of these sorts of things have once again
begun rising. Better healthcare is not a magic pill for unhealthy lifestyles.

In other words, this is about a healthier people - not about a comparable
people with better access to healthcare. I'd expect to see these numbers level
out in time. Cubans have also been thickening up as the article does mention,
but they're still quite far behind us.

[1] -
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2674328/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2674328/)

~~~
TelmoMenezes
> One of the main causes of infant mortality is parental obesity. [1]

The article you cite does not say that it is a main cause. It says it is a
cause, and that it doubles the chance of infant mortality in obese mothers,
but it makes no comparisons with other causes.

> In other words, this is about a healthier people - not about a comparable
> people with better access to healthcare.

We can test your hypothesis. Let's compare two countries that happen to have
female populations with the same average BMI, with similar cultures and
dominant ethnicity (both former colonies of the British Empire):

* USA -> Female mean BMI: 28.8; Under-five mortality rate: 6.5

* Australia -> Female mean BMI: 28.8; Under-five mortality rate: 3.7

For Feamle Mean BMI I used World Health Organization data from 2015:
[https://en.wikipedia.org/wiki/List_of_countries_by_body_mass...](https://en.wikipedia.org/wiki/List_of_countries_by_body_mass_index)

For Under-five mortality rate (deaths/1,000 live births) I used World Bank
data from 2016:
[https://en.wikipedia.org/wiki/List_of_countries_by_infant_an...](https://en.wikipedia.org/wiki/List_of_countries_by_infant_and_under-
five_mortality_rates)

While obesity clearly plays a role in increasing infant mortality, it fails to
account for the big discrepancy in infant mortality rates between the USA and
the other western nations. One compelling explanation remains: the USA is the
only one of these countries without some form of universal healthcare.

~~~
rjf72
You need to compare maternal obesity rates, not mean BMI. The two are not
correlated because there are major biases in maternal demographics. For
instance in the US most children born are now non-white and there is a strong
inverse correlation between income and fertility rates. Both those
characteristics (non-white, low income) in turn correlate strongly with
increased obesity rates. There are an immense number of studies on this topic.
Without link bombing an easy way to find more data is to check out google
scholar:
[https://scholar.google.com/scholar?q=US+infant+mortality+obe...](https://scholar.google.com/scholar?q=US+infant+mortality+obesity)

Something that might help clarify matters most is this [1] paper. It not only
gives specific figures but is over an extremely large and comprehensive
sample, most of the data is from a ethnically homogeneous sample, and is in a
region with nationalized healthcare (Sweden). So it helps remove confounding
variables. And there too we find that infant mortality for normal weight women
was 2.4/1000 while it was 5.8/1000 for those with obesity grade 3. There was a
linear scaling of risks and mortality that mapped directly against obesity.
Interestingly enough even being just overweight also corresponded to a
slightly increased rate of infant mortality.

Crucially, what obesity tended to lead to was preterm deliveries, congenital
birth defects, pregnancy complications, and sudden infant death syndrome. The
reason I say crucially is that these [2] are the leading causes of infant
death from the CDC. Those issues that arise from obesity are literally the top
4/4 causes of infant death.

[1] -
[https://www.bmj.com/content/349/bmj.g6572.full.pdf+html](https://www.bmj.com/content/349/bmj.g6572.full.pdf+html)

[2] -
[https://www.cdc.gov/reproductivehealth/maternalinfanthealth/...](https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm)

------
gandalfian
"the infant mortality rate in Cuba is only 4.0 deaths per 1,000 live births.
In the United States, it’s 5.9. In other words, an American infant is, by
official statistics, almost 50 percent more likely to die than a Cuban
infant."

Is that right? Or is it 0.19% more likely to die in the USA. This is why I
never win on the horses.

So perhaps the answer is that they are both pretty safe? I would think more
elective caesarians and traffic accidents could account for much of the
differences but it must be getting pretty close to the margin of error?

~~~
AnIdiotOnTheNet
No, you may consider the statement misleading, but it is correct. 100% of
4/1000 is 4/1000, 50% of 4/1000 is 2/1000, so 50% more likely than 4/1000 =
4/1000 + 2/1000 = 6/1000.

------
davidivadavid
How reliable are the Cuban statistics?

~~~
manfredo
Regardless of reliability it's important to mention that mortality rates isn't
the be all end all of healthcare quality. Many people contrasting Cuban
mortality and life expectancy statistics against the US have a political axd
to grind, and they fail to mention key nuances. Chief among them, the fact
that it's drastically easier to curb obesity when the government rations food.

~~~
mdpye
The government provides _a ration_ , you can buy more food.

I'm not saying food in Cuba was available in the same kind of quantities and
choices as in the states, but portions were almost on par (which is to say,
enough to floor a European for several hours after a meal!)

The article even states that the primary weight problem faced in Cuba is over,
not underweight people.

~~~
manfredo
Buy more food with what money? Average wage is $18-20 a month from 2008 to
20015, as per some quick googling. Even if we trust the Cuban government's
states wage, that's still $25 per month. Some make more on the black market,
but for the most part the government rations dictates your diet. Apparently
wages have risen after slightly more normalized relations with the US and
greater tolerance of private enterprise on behalf of the Cuban administration,
but it's still pretty poor.

I come from a family of Cuban immigrants, and have some distant relatives
still in Cuba. Some of my family has visited over the last few years. It's a
tacit understanding that the visiting relatives will bring money or valuables
to sell on the black market to help pay for the feast that Cubans will
inevitably throw for visiting relatives, because otherwise several months
worth of income will be spent on food (which would only cost maybe a few days
wages for the person coming from abroad).

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andrenth
Cuban statistics cannot be trusted.

[https://academic.oup.com/heapol/article/33/6/755/5035051](https://academic.oup.com/heapol/article/33/6/755/5035051)

Key quote: “(...) evidence that physicians likely reclassified early neonatal
deaths as late fetal deaths, thus deflating the infant mortality statistics
and propping up life expectancy.“

------
maccio92
thanks anti-vaxxers

~~~
spamizbad
Actually it's likely our broken healthcare system and poverty. But they
certainly aren't helping.

~~~
antepodius
Don't forget obesity.

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antepodius
They state themselves the figures aren't to be trusted. This makes me unsure
how to feel about the subject. If Cuba's just lying about infant mortality (I
don't know how feasible that would be) it invalidates a lot of things.

I find the point about local, conveniently-accessible doctors leading to
earlier diagnoses interesting, too. That seems like a fair point: I've heard a
lot about the automobilised nature of america, where cities are built for cars
rather then people. If you can't just walk over to the local doctor you've
known for the last 5 years to ask about the lump on your back because going to
the doctor is seen as a big deal- you can imagine this leading to fewer check-
ups.

I've heard a point that the US is in a hellish middle-ground between
socialised healthcare ala euroland and hypothetical free-er market healthcare:
you can't actually shop around for cheaper treatment, because the government's
teamed up with big pharma to reduce competition and obscure pricing.

edit: Just read a comment mentioning obesity as a factor. That makes a lot of
sense, as well. Of course a country as fat as america's going to be in a worse
health state than one like cuba where people are only starting to bloat up
after starving a while back.

------
isolli
Infants are definitely more likely to die in the USA than in any almost any
other OECD country (the exceptions being Chile, Turkey, and Mexico).

[https://data.oecd.org/healthstat/infant-mortality-
rates.htm](https://data.oecd.org/healthstat/infant-mortality-rates.htm)

~~~
pitaj
Are these statistics standardized in methodology? Many countries don't count
certain types of infant mortality that the US does.

