February 2017        

Mental health: Lessons from Cuba

David Hartery

When attempting to create a comparison between the Irish and Cuban health systems’ attitudes to the treatment of mental illness, it’s important to remember that there is a structural and a philosophical difference between the two that is more than just about how a communist and a neo-liberal system is funded.
     In attempting to create a communist health system we must look at how Cuba categorises illness, and not fall victim to Cartesian notions of sickness, separating mind and body.
     Like all the other elements of Cuba’s health system, Cuba attempts to deal with mental health issues primarily through prevention and community care. While this may seem intuitively a better focus for a health system, this care approach requires a level of co-ordination and co-operation that is anathema to an individualised and atomised system of care, as is the model that the Irish system is increasingly tending towards.
     The backbone of the Cuban system is its primary care system. Integrated in communities, these holistic care teams often visit patients at home, especially high-risk patients, to ensure that they’re given the correct information to live healthily and also to check in for the early signs of illness.
     The mental health element of these check-ups goes hand in hand with the physical check-ups. This is an active and interventionist approach, one that places a large premium on making patients feel supported within their communities, minimising their risk of progressing to in-patient care. The point of such intervention is to reduce cost but also to ensure that patients are given the tools to take care of themselves. In the individualist neo-liberal system we are to be our own diagnostician and, increasingly, our own physician.
     Above the primary care facilities there are of course hospitals and institutional care facilities. However, even here mental health is not seen as different from physical health. Psychology and psychiatry are integrated in the care of all patients, particularly in the case of cancer or other illnesses with a heavy psychic toll. Physicians are trained alongside psychologists and other specialities from their first year in university to foster integration and interdependence. This is extremely different from our neo-liberal system, where health is departmentalised and mental health is increasingly exceptionalised.
     Driving the exceptionalism of mental health is the question of resources. As access to health becomes ever more difficult for the majority of people in advanced capitalist countries, cheap alternatives to care are more and more popular. Think of it: a heavily publicised drive to improve mental health is much cheaper than a new oncology ward for a public hospital. Then, if there is no improvement in outcome for patients, it can be blamed on the fact that stigma still exists, or that patients didn’t treat themselves well enough.
     That is the crux of Ireland’s mental health system, as now constituted. Primary care is atomised, often delegated to the charity sector or absent altogether. Advice like “Have a cup of tea and a talk” is seen as a substitute for proper public expenditure on health. By separating mental health from physical health and deciding to concentrate on improving “mental health,” the government can simultaneously provide cover for systemic underinvestment in the entire health system. By being seen to take action on mental health, it can then not take action on health.
     Cuba’s mental health system is not perfect. Suicide rates are high for its population. Because of the embargo there is a difficulty in obtaining psychiatric medication, which, while perhaps over-prescribed in capitalist counties, has definite therapeutic value. However, by treating health holistically—and caring for patients within their communities—Cuba has a mental health system far in advance of similar-sized countries. Their priority on aggressive early intervention and caring for the whole patient is something that Ireland should model itself upon.
     After the revolution, the lengths taken to include mental health in the wider public health framework is something that should be studied by anyone striving for a socialist health system.

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