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Infants May Be More Likely to Die in America Than Cuba (nytimes.com)
59 points by pseudolus 35 days ago | hide | past | web | favorite | 81 comments

"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."


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.

Hospital stays for pregnancy complications is incredibly common in the US (and you have to pay for it!) Acting like this is coersion is disingenuous, especially when pregnant women in the US are forced to go home without monitoring when they can't afford an extended hospital stay.

Edit: I should also add that these complications are things that can cause both maternal and fetal death. No one wants to be further than arms-length from medical care when the risk is that high (note the use of "may" in the quote from the parent comment, as if this is a theoretical discussion because they couldn't actually find anyone who was begging to leave).

Why did you choose to gloss over the forced abortions?

Because women aren't forced to have abortions in Cuba. If that were the case, there would be no Cubans with birth defects. No Cubans in wheelchairs. Etc etc etc.

I think the article definitely gave the impression that the abortions were "forced". But to be fair, the article never actually said that. I think the word they used most often was "pressure".

It's been a while since I was last in Cuba, but when I was last there abortion was given on a list of the various options that could be taken in such cases. And just like everywhere, the option that the doctor would recommend would depend on the doctor and his/her motivations. For instance, some might recommend abortion, another might recommend an experimental treatment that he came up with etc. Again, in fairness, you see this in the US as well. Let's say you go in and they find a tumor. Doctors conversant with radio-therapy will likely recommend radiotherapy. A surgeon, nine times out of ten, will recommend surgery. Etc etc etc.

So yeah, not much difference between the two systems in this regard. At least, when I was last there the doctors in the US and Cuba behaved similarly in this regard.

I will say though, that abortion seems like the only option if, say, 9 out of 10 doctors are all advising the same thing. Or if 9 out of 10 doctors are all saying your child will need 24/7 care for the rest of her life, and her life will be short. So how you're presenting the option, even though it is only an option, can make the whole thing feel forced.

The source does not go into the abortion side other than that quote, and it's hard to judge what actually happens. There's a big difference between "your child is going to require 24/7 attention until they likely die before adulthood, we advise an abortion" and "your child is unlikely to survive childbirth but is healthy otherwise, we're going to abort the foetus against your will".

The only other source I can find from a brief Google is from a predominantly pro-life org.

Politifact is a trustworthy source, if you want to argue that they are being disingenuous find a source that proves them wrong.

Because it was clearly bait meant to rile up Evangelicals in the US. Abortions due to fetal abnormalities are just and humane.


(For the sake of argument) Yes. Now you explain to me why we should allow pastors to force women to give birth to babies in chronic pain and suffering, using all interventions possible to maintain a heartbeat, even when there's no chance for the baby to experience life free of misery.

They shouldn't, and they aren't (not in Cuba at least)

Because that wasnt what their reply was about?

I dont really get this style of steering a discussion: the idea that every reply needs to include a disclaimer about every differences and some insight into how the poster agrees or disagrees with those things as if checking a box. “Oh darn we cant villify the messenger now what are we going to do... well we can discredit them by highlighting why we cant question their stance on anything”


They didnt address it at all. They added an addendum distinctly about a US policy.

Your concern is that they were normalizing something that they didnt even talk about, solely because it didnt join in villifying Cuba just so you would continue reading. I dont really get that train of thought

I've been to Cuba many times over the last 10 years and have seen how pregnant women are treated up close and personal. The difference between Cuba and the U.S. is that Cuba has a greater sense of urgency when it comes to pregnancy. No one is coerced, but there is a community-driven sense of urgency and importance when it comes to following up with your pregnancy.

>>Can we base our universal healthcare proposals on countries >>that have done it without the authoritarianism and human >>rights violations please?

You're entirely correct there are many other examples of western democracies that can stand as models. However, I believe the reason Cuba was chosen was precisely to elicit a reaction. A story comparing mortality rates in the US to those in Canada, the UK or France would have fallen by the wayside. For one reason or another, the mention of Cuba generates attention and reactions - as attested to by this post itself.

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?

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.

Patients have the rights to chose their treatment, and this includes the right to make unwise choices about their treatment.

(I have no idea what actually happens in Cuba).

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.


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

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... [2]https://www.medicaid.gov/chip/eligibility-standards/waiting-...

Lol try having kids and see for yourself how "generous" it is. We've been "fully-covered" for pregnancy and delivery for both kids and still had to go on payment plans to cover the costs.

Are you on Medicaid or CHIP? Because that's what I was referring to.

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?

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.

Generous compared to what the author is suggesting - pregnant women being left out in the cold.

Infant mortality in the USA is high relative to other developed countries:


At around 6 per 1000, compared to 4.3 for the UK (or 2.7 for Japan) for example.

I would imagine, infant mortality isn’t just about a function of healthcare available during pregnancy, but also for the parent before pregnancy. There could of course be multiple other confounding factors (such as life style issues)...

How countries count infant mortality is not the same. So it's very hard to compare numbers.

Would life style issues be a major difference between here and the UK or Japan?

Does chip and Medicaid cover absolutely everyone who might need it? Are there people who, despite the coverage, are still left with outstanding costs they can't meet?

My understanding is that in Cuba, there is no applying to services like Chip, or Medicaid. Theres no chance you won't get coverage, as everyone, by default, gets the care they need. Wait times are non existent for the pregnant or disabled across the country, not just in certain regions.

It doesn't seem totally unlikely that the people that """"fall through the cracks"""" in the American systems are enough to swing infant mortality rates.

>The US actually has very generous social services when it comes to medical care for pregnant women and their babies.

Only if you're white:


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".



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!

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.

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?

According to the CDC, in 2013, there were 3,932,181 live births and 23,446 infant deaths (from birth to age one). That checks out with a 6 in 1000 ratio.

> 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.

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

Edit: I meant 22.8k not 228k. Type on my part. Good thing I don't publish articles :)

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...

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.

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/

> 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...

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...

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.

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...

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

[2] - https://www.cdc.gov/reproductivehealth/maternalinfanthealth/...

"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?

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.

How reliable are the Cuban statistics?

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.

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.

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).

Not reliable at all.

Cuban statistics cannot be trusted.


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.“


> Eschew flamebait. Don't introduce flamewar topics unless you have something genuinely new to say. Avoid unrelated controversies and generic tangents.


I think there's quite a few Cubans who would disagree with your assessment.

And there are tons of people in capitalist countries who disagree with what goes on there too.

That explains the droves of people jumping on homemade boats to sail from Florida to Cuba.

There's a similar percentage of people who left cuba that left mexico. A countries wealth has little to do with it being communist or capitalist as much as it does with it's ability to integrate into the broader global economy and develop internal industrial infrastructure.


zjaffee 35 days ago [flagged]

I'm not a communist by any means, I just dislike that the collective community in liberalized, capitalist first world countries diss socialism in countries that would otherwise have been exploited by their own country without it.

The issue here isn't so much that America has bad healthcare, but the fact that Cuba has one of the best medical systems in the entire world while still being a far less developed country. Both capitalist and socialist countries can learn a lot from each other, and it's this diversity of approach that has resulted in the greatest improvements to the living standards of people all over the world.

andrenth 35 days ago [flagged]

> but the fact that Cuba has one of the best medical systems in the entire world

This is a lie.

No. There is nothing good to take from socialism. It's all about making stateman rich and the population poorer with disrespect for private property and human beings.

Do you care about people without access to goods in capitalist countries? I bet you don't, so just drop this argument.

BTW, are you claiming BRAZIL is a socialist country? Good grief.

United States currency is the base currency for the world, so yeah, if you're sore that you're don't live in the richest country on earth or of Humanity History then just move there. Don't blame made up stuff. You wouldn't go live in a Panama slum, right? So that's not the matter.

Don't be silly. Just because I said that I could travel to the United States and pay way less on everything it doesn't mean that the US is a role model or the only place possible.

Brazil is indeed a socialist country. Heck, just go see what happened in the past 90+ years here and in the rest of the developed world. High tax everywhere, dictatorship, no respect for private property, famine on the poorest areas in the Northeast, inflation, a large amount of state-owned companies and its de facto (by the very nature of itself + subsidies paid by taxation and inflation) or de juri monopoly, policies against importation, etc.

Only commies can't see it.

You're obviously completely blinded by ideologies so think whatever you want, it doesn't change, at all, the academic and historical definitions of the terms you use as if you knew what they meant. Taxation, state-owned companies, inflation, protectionism, famine, none of these are alien to any other liberal democracy in the entire world, nor of modern history, not even to ancient history, or whatever, in fact they are or have been present in almost every country in the world.

As this is just closed-loop thought(e.g.: thing = bad, I label anything I don't like as thing, therefore thing bad, thus I right) and not actually knowledge, or philosophy, or a proper tool to make sense of the world, to me it's worthless, but have fun with it!

A friendly warning: you sound like a crazy person.

Also recommended: https://news.ycombinator.com/newsguidelines.html

It must be compared with other caribean small poor post-colonial countries. Against that, they're obviously better off. One can only wonder what would be of it without the sanctions. This is not to claim their system is good or etc, what really pisses me off is that most examples we use, of people starving, of poverty, of misery, etc, in a "ideological-enemy" is proof that they suck, while we are full of it in our "other side" societies, slums, crime, misery, what this leads us to is that, actually, all those other suffering are irrelevant unless they serve as pretext for some political interest, in other words they're nothing. And let's face it, there's much more post-colonial people in capitalist societies living in hell than else, there's just more people.

US is propping up a war with Venezuela right now because of "humanitarian blablabla" at the same time there's children starving because of the Yemen's war the US is a sponsor.

There's absolutely no morals in geopolitics. If you hear about it, be confident it's bullshit. Sad but true.

This is my exact view on the matter, the comparison being made here is completely unfair as Cuba punches far above it's weight when it comes to healthcare outcomes and the west can learn a lot from their approaches here.

If people in a free and open vote want to choose communism as the basis for their economic system, as Europeans had the opportunity to do with various Eurocommunist parties, that's fine. But a system imposed by one party without accountability or the opportunity to push for change is a system that doesn't work. As others have noted, the rafts are heading in just one direction as was the traffic over the wall in Berlin.

One study that notes that it may be very flawed about one topic doesn't prove anything relative to:

"Yet people continue to argue how communism doesn't work"

The your scale and what this news story says are just totally on different planets.

"Yet people continue to argue how communism doesn't work."

Perhaps because there's a long parade of examples of it not working, and Cuba is not an unqualified success story -- not now nor for the decades it was propped up by the Soviet Union.

Cuba punches far above it's weight when it comes to healthcare outcomes however which is a huge achievement and it's approaches are likely one of the best bets for improving health outcomes in developing countries.

It's obviously not as simple as one system being dominant over another, but both systems clearly do work just fine, as it's unfair to ignore the substantial reforms that happened in capitalist countries due to work of socialist organizers pushing for higher labor standards.


We've banned this account for repeatedly violating the guidelines. We're happy to unban accounts if you email hn@ycombinator.com and we believe you'll start using the site as intended.



I can afford my medication just fine, thankfully, because my family was able to escape the complete and utter despair of socialist utopia and now completely uninformed morons are trying to bring that poison here.

Also, the soviet union got to space faster. Capitalism is good enough until it creates too much waste and uses all resources. The only reason capitalism is still "nice" is that the continuous growth has not been stopped yet. However, we live on a planet with limited resources and capitalism will hit a wall soon enough. I'm not in favor of communism and gulags, but definitely free healthcare, education, true effort by government to solve climate change and wealth redistribution.

> However, we live on a planet with limited resources and capitalism will hit a wall soon enough.

Scarcity is a necessity for capitalism. Do you even understand how capitalism works beyond "big corporation bad"?


> Canada has a drain problem of doctors leaving the country to go work in the US for exactly this reason.

This used to be true in the 1990s, but it is not true anymore.



Now it has hallway medicine and 18 month wait times - not really sure which is preferable to be honest, both are just shortages in unsustainable systems.

> There might be some good doctors in Cuba but you bet your ass that only Castro and his goons have access to them.

A minor correction, neither the late Fidel Castro nor Raul Castro are currently the leaders of Cuba. Cuba is currently led by Miguel Diaz-Canel.

My point still stands.

thanks anti-vaxxers

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

Don't forget obesity.

Do you have a source of infants dying from vaccine preventable diseases? I was under the impression that some vaccines aren't even administered to infants and the diseases become a problem a little later in life.

Infants are generally not vaccinated in the first few month but would have most common shots by the age of 1, with refreshers up to the age of 2.

However they do get protected by what’s called “herd immunity” If a sufficient fraction of all other people are vaccinated, diseases cannot spread. So basically the toddler in the family gets protected because the older kids/parents cannot be disease carrying. So yes, anti-vaxxers are a problem for toddlers (and other people that cannot be vaccinated due to other reasons)

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.

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).


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

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