Comments in US infant mortality plateau to the CDC/CCHIS/NCHS

 

 

 

 

The paper of MacDorman MF, Mathews TJ. The challenge of infant mortality: have we reached a plateau? Public Health Rep. 2009 Sep-Oct;124(5):670-81, is a very interesting paper, which I commented to the first author Marian F. MacDorman by email from 10/28/09 to 11/08/09.

 

Sadly for the Cuban people, our propagandistic system has demonstrated with very short-term and cheap selective living and health care of pregnant (9 months), births and babies (12 months), in total 21-months per-baby, including top rates of abortions, in eleven-million inhabitants, that infant mortality rates (IMR) trend from 1900-1957 can be maintained decreasing and life expectancy at birth increasing (after the silenced worsening of both indexes 1959-69 due to first socio-economic disaster), while worsening the very long-term overall children, adults, and elder living and health levels and standards, more difficult to monitor by one specific age mortality rate. 

 

Since 1900 to 1957, the US maintained the first place in the Americas in infant mortality reduction, but that place was took in the 1990s by Canada, and in the mid-2000s by Cuba, if our figures had not been much more manipulated than in 1959-1989 in both, the numerator and denominator, in the period of Cuba’s second socio-economic disaster 1990-2008.

 

In my opinion, the immigration to the US of very low educated of Latin Americans, Africans, Asians, and even Eastern Europeans, could be a key variable to include in your study too.

 

In my view, the variations in infant mortality rates among the US and the countries of lowest IMR of the Table 4 may also reflect differences in another four key variables not mentioned by you. These are as follows:

 

Early attraction to pre-natal care of the pregnant; social support for the pregnant with more hunger and of highest social risk --which will reduce the US percentage of pre-term and low birth weight births; institutional delivery of high risk births, and 6-month breast-feeding for every baby.

 

Since the 1990s, our Cuban PHC system attracted early most of the pregnant. Some of them with sound hunger (representative of the 99% of the population) received complementary food supply in state enterprises dining rooms in or around the pregnant neighborhood, as well as in Maternal Homes for the most critical social cases. In this selective way, socialist Cuba controlled the percentage of low birth weight births that were rising in the 1990s again (as well as they had risen from 1959 to 1969 once), and maintain the IMR decreasing. Institutional deliveries of critical pregnant cases at high risk, guarantee to save the low birth weight babies, and the long-term breast-feeding, the healthiest first six months of highest risk of the babies’ life.

 

Until 1958, democratic Cuba used to well cared at the world state of the art pregnant, babies, children, young, adults and elder with mutualist and private care, and under cared in general those with not enough access to public services, but with a high network of midwives, reaching in 1957, the world 14^th  place in lowest IMR. (United Nations. Demographic Yearbook 1966, 18th Issue. New York: United Nations Publ., 1967.). I have studied this Cuban figure of IMR of 32 x 1000 l.b., and it showed all the problems of sub-registering and not standard registering of baby deaths and live births of France and other developed countries struggling in the 1950s with the WHO definition of baby deaths and live births. 

 

In 1957, the US used to well care at the world state of the art pregnant, babies, children, young, adults and elder, with insurance and private care and under cared in general those with not enough access to public services as both Canada and Cuba. Then the US showed the world 10^th  place in lowest IMR (26), with of course better care than Cuba in most public medical services, but with less midwives. (United Nations. Statistical Yearbook 1960, 12th Issue. New York: United Nations Publ., 1961.)

 

Since 1959-2009, socialist Cuba selectively have over cared pregnant, births, and babies, at the top state of the art in the West and under cared all the rest --children, young, adults and elder--, thanks to UNICEF-WHO support, with only public services, with the state of the art of the 1950s. This selectivity have been accentuated since 1990-2009 that the government lost the Russia-USSR huge subsidy, and have had a silenced cost in elder and adult mortality rates and quality of life that some day will be known.

 

The US care from 1958 on, seems to me to have well or over cared all the pregnant, babies, children, young, adults and elder with insurance, and all institutional deliveries and emergencies of all the US patients, even of those without insurance, but to have under cared the non-insurance patients, including pregnant pre-natal period and first months of baby life.

 

If the US health care system would include pre-natal care of pregnant, institutional birth care, and post-natal care of babies (an lying-in woman, to decrease the more difficult maternal mortality rate) for one year, the US would not have to reform anything more of crucial importance, in its healthcare system. Other thing will be, to put a limit to the poorest mothers with many children to have more subsidies for more than two or three children, to avoid the possible business now to give births in excess.

 

Nevertheless, with these simple measures, the US will observe at a 100%, the Article 25. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family; including food, clothing, housing, and medical care and necessary social services, […]; Motherhood and childhood are entitled to special care and assistance. United Nations. Universal declaration of human rights. New York: UN Pub. 1948. Available in: http://www.un.org/en/documents/udhr/index.shtml

 

I have read today that the US has reported a higher rate of premature births (12.4%).

 

I have not access from Havana to the US journal of your article, so I cannot send any comment to them. Nevertheless, I would like to make other comment to you. I am also a researcher, but have been obliged to research in policy development to understand what has happened in Cuba in the last 50 years. Yes, there are things that socialist Cuba has done well, even at the high price of let in the worst situation the overall living and health standards of the whole Cuban population, excepting mothers and babies for about 2 years per-pregnancy.

From the draft of an article I am writing for the EOLSS of the UNESCO on “Research challenges of human primary health care medicine”, I am reproducing for you a part about Cuba as follows: 

 

By Maddison, U.N. statistics and international works, Cuba in 1951 was a nation of immigrants advancing in liberties, longevity, education, wealth, and equality. In 1959 a revolution spread Sovietization in America and Africa, arrested Cuba’s balanced self-growth, urban civilization and living standards. In 1957, Cuba’s GDP per-head (1990-int-$) was $2406, double that South Korea's $1206, Taiwan’s $1314, over Singapore’s $2318, fourfold that of China’s $636, two-thirds of USSR’s $3576. Yet on 2006, Cuba’s $3214 was one-fifth of South Korea's, one-sixth of Taiwan’s $19860, one-eighth of Singapore’s $26162, a half of China’s $6048 and of Russia’s $7831.

 

In 1957, Cuba had the world 14^th lowest IMR [32 x 1000 live births (l.b.)], 36% of the South Korea’s (90); yet on 2007, it had the world 21^st lowest rate (5), over South Korea’s (4). Cuba having 65-year life span, 12-years more than South Korea (53), now has 78, one less than South Korea’s (79). Cuba having 80% of adult literacy, nearly twofold the South Korea’s (46%), now both are alike. Cuba since 1991 deepened its 1959-90 chronic malnutrition, weakening a 49-year subsistence sugar/rice rationing card.

 

Cuba from 1900;1957 to 2007 worsened its GDP per-capita growth % and place from 5^th;11^th to 18^th in America and 28^th;48^th  to 113^th worldwide; but improved its IMR reduction % and place in America from 5^th;3^rd to 1^st, but not enough finally, worsening its worldwide place from 19^th;14^th to 24^th.  Cuba’s U.N. HDI in 1951 could rank anyway around the 25^th place in the world. However, today, if the HDI was complemented with individual liberties, Cuba would worsen its current 51^st place at least over the 100^th.

 

In 1958, heart and cancer diseases were Cuba’s 1^st;2^nd  leading causes of death. Cuba having America and world, 5^th;26^th highest physicians’ densities in 1957, now has the world 1^st, but 30^th caring its own people, because half of them are state-contracted abroad. It also had America and world 3^rd;16^th places in dentists; 3^rd;14^th in midwives; 5^th;26^th in pharmacists; and America’s 6^th in nurses. Community midwives work disappeared, changed to obstetric nurses. Cuba’s percent of GDP for health was 11.3% (1909), 7.2% (1957) and 6.3% (2007). Healthcare expenditures count weakest Cuban pesos, as if they were US dollars in physicians’ wages (now less than $1 USD daily) --2^nd world underpaid services after North Korea.

 

Cuba “socialist paradox” with wealth-health strong-direct countries’ correlation is much more than low 1990s GDP per-head and premature mortality. It can be explained by late accumulative synergistic effects of integral-balanced improved living, working, education, health standards and infrastructure from 1500 to 1958; USSR huge billionaire subsidy 1959-89; and US-West medical advances 1959-2009 acquired via U.N.-WHO, applied exclusively in pregnant, birth, and baby cares. Military tasks abroad, repression and self-depressed economy, have forced overall children, adults and elder life and health levels’ regression. For non-pregnant/baby cares, Cuba guarantees access to physicians, but no to procedures and medicines.

 

As you can see, there is nothing new in our much rationed health system. Hope these comments could be interesting and of some help for your analysis and measures to suggest.

 

I would like to receive some day from you, if possible, your same Table 4 of the article, but with the addition of a first column with the IMR and places of the same countries for the year 1900 too. This is very important for me.

I have read with pleasure your interesting report on IMR international rankings on http://www.cdc.gov/nchs/data/databriefs/db23.pdf, and would like to make you some comments again.

 

I was remembering that in May-June 2001, I could not go to an exchange in infant mortality reduction and primary care medicine invited by Aurora Health Care system authorities in Milwaukee and the Dean of the Medicine School of the University of Wisconsin. Vicky George heard me talked openly at Havana to her PtP APP Delegation about our Cuban experience, but my Cuban government did not let me go to talk there. 

 

In 40 years of practice and research, I always have had personal evidence and heard Cuban experts saying that our difficulties to reduce the Cuban IMR were more in the prenatal care than in the postnatal care. In the 1990s, on a Havana health area we developed two research priorities in primary health care: pregnant women risk of low-birth weight and with other reproductive risks.

 

I am sending you the data of a paper in Spanish about low birth weight. Stusser R, et al. Low birth weight risks in the Area Plaza of Havana. PAHO Bull 1993;3:229-40. Afterwards, I could not publish in our GP journal a SILOS local program in my specific health area of 40,000 inhabitants, to reduce low birth weight, because the MINSAP authorities were afraid to contradict the fossilized centralized national program on the matter. In the 1990s, our birth-rates were more lowered than ever with UNFPA aid with all class of classic and modern contraceptives, apart to continue compulsive sterilization of extreme social cases of women potentially fertile. 

 

There is something clear after reading your two papers. The US health care system of pregnant women is the one in the world more spontaneous, with more degrees of freedom and freedom of choice for the pregnant woman, and with more transparency in the national report of all live births and deaths. In this case, or you try to improve the WHO, UNICEF and UNFPA standards for pregnant health care in the whole world and for the report of live births and deaths or you modify your system, or both, if you are feeling affected with international comparisons.

 

Are there problems with increased birth rates in your underserved areas, to use contraceptives, to access menstrual regulation by aspiration and classic abortions, and with excess of free will of pregnant women at high risk of preterm births, of pre-natal, and even of post-natal infant deaths in the US?

 

I do not know how many countries with IMR under the US IMR have highest abortion rates and lowest birth rates. I do know that Cuba is one of those countries of the most liberal and highest abortion rates since before socialism. Moreover, in the 1990s and 2000s Cuba has reduced its birth rate to 9.9 x 1000 in 2006.

 

I would like to read some international ranking reports on the matter, if possible. I am not suggesting you to reduce your IMR with overall lowest birth rates and high abortion rates, but maybe with more voluntarily contraceptives and abortions on very selected social cases of pregnant women at very high risk of preterm births or infant deaths will improve your current difficulties in underserved areas.

 

I imagine the US health care system trying to avoid the worst extreme of our Cuban totalitarian and selective coercive healthism to only pregnant and newborn to make ideological propaganda in the UN World Assemby, but there is the peril to go to the other extreme of letting all pregnant women in underserved areas to their free will... increasing unnecessarily the US infant mortality.

 

Cuba and other smaller countries which promote abortions in any case of pregnancy of any age or weight, and that very especially “suggest” compulsory abortions in pregnant women who are classified by the primary care social workers, nurses and GPs as social cases, to avoid preterm births, are not comparable with the excess of freedoms in the rules of the US health pregnant care and report of all live births in a 300 million inhabitants country.

 

In Cuba, most abortions are made very easy in the maternal and rural hospitals, and the fetuses die abandoned in the trash basket of the baths besides the scrape rooms. If Cuba would report all live births (including supposedly abortions from 12 to 20-22 weeks and even later, and from all weights), would worsen its ranking position much more and its IMR would be near the double that is reported. 

 

The US huge and powerful country could improve primary care contraceptive use and early attraction of pregnant women social cases at high risk, with public education, social workers, nurses, midwives, and GPs, in underserved areas to improve this situation with concrete preventive health measures.

 

Hope some of these comments and suggestions can be of help to analyze and improve your situation.

 

I am pleased to tell you our procedures to help the US decreases its IMR under ours again, because you conduct your health care system with transparency and not looking for ideological propagandistic gains as our last 50-year totalitarian government.

 

If you want to publish my comments, feel free to make a summary of them and send them as a correspondence letter to your paper in the Public Health Reports, under an Anonymous Cuban doctor sign, if this is possible for you and the journal.

I invite you to read my papers under my retirement in http://rational.fortunecity.com/retirementlist.htm in special my last research paper on the matter in: http://rational.fortunecity.com/papertablerrh.htm

 

If you want to know more insights about our health system, just tell me and will send more information analyzed in the last four years of retirement.

 

Best wishes,