“Let’s go see the sunrise! Let’s go see the sunrise!” yelled 10-year-old Caleb. We were in the rural town of Viñales in western Cuba. It was pitch-dark at 6:30 am and Caleb, Caleb’s cousin Jose, our host Juan, my wife Hyejung and I were headed to the hills to see the sunrise. After walking through fields and up hills for about 15 minutes, we reached our vantage point. Although we still had about 15 minutes until the sunrise, our surroundings were quickly being illuminated. Roosters were crowing loudly. Caleb looked at the massive rock formations to our left and said, “They look like an elephant!” His cousin Jose countered, saying “They look like giraffes.” Juan gently told them both that “it all just depends on where your imagination takes you.”
Our host Juan, who rented us a room in his home for two-nights, was Caleb’s abuelo, or grandfather, despite never having children himself. Caleb slept at Juan’s house every night, which was down the street from his parents. Caleb was close to both his mom and dad but felt a special closeness to his non-biological grandfather.
After returning from the sunrise, Juan took us to meet his 90-year-old father, older brother, and sister-in-law who were all living in the same house which was a two-minute walk from Juan’s. We talked for 20 minutes about Cuban history, what each person did for a living, and then returned to Juan’s. On the way, a group of neighbors had just slaughtered a pig. Juan and his neighbors raised pigs together. When we arrived back at his home, his twin sister was waiting for him along with his sister’s daughter and two grandchildren.
The previous evening at dinner, Juan boasted to me that almost everyone knew each other in Viñales and were very helpful during challenging times. In the early 1990s, Cuba suffered through shortages of all types of goods. As a community, people learned how to use a special type of seed to wash their clothes. Viñales is also frequently hit by hurricanes, and Juan is proud of how people in sheltered areas house those from exposed, more dangerous areas. “Cubans are at their best during a crisis, always helping each other and coming together,” Juan proudly stated.
Juan is 52 years-old and divorced. Despite loving children, Juan biologically cannot have children, nor can his two brothers. In the United States, it is possible he would be lonely or – at the very least – not as physically and emotionally close to so much family. As a middle-aged man in the United States without an immediate family, he could be a high suicide-risk. Despite his age and lack of immediate family, in Viñales he is surrounded by a loving family whom he sees multiple times a day. His village and its support network is a point of immense pride and central to his identity as a citizen of Viñales. His high degree of familial and social connectedness makes him an unlikely suicide risk.
The CDC states that "theory and research addressing the association between connectedness and suicidal behavior date back to Durkheim [in 1951], but later evidence continues to support the association."
In a politically closed, one-party state reliable suicide and health statistics in Cuba are difficult to find. When I was in Havana, I tried to visit both a polyclinic and a large hospital and was told the entrance of foreigners was prohibited without written permission from the Ministry of Public Health. In the central Cuban city of Trinidad, however, I encountered a nurse in the street who was finishing house to house check-ups. She was very happy to speak (I will keep the nurse anonymous to protect her given the government’s lack of openness to showcasing their medical system).
Typical of the paternalistic Cuban healthcare system, this nurse was assigned to a specific neighborhood and knew all the families well. She went to their houses regularly to check up on families even if they did not have reported illnesses. Every Cuban neighborhood also has a general practice doctor assigned to it and they are intimately acquainted with the families as well, according to a doctor who spoke with me outside the Havana polyclinic to which I was denied entry. This nurse in Trinidad has 30 years of experience. I asked her if there was a problem with suicide in Cuba. She did not know the statistics. She said that there were cases here and there but it was by no means an out of control problem. She said that psychiatrists monitor mentally ill patients in their homes through regular check-ups. Patients who had attempted suicide were also visited often by psychiatrists or placed in a mental health hospital for a period. A patient simply cannot avoid care. The nurse I spoke with also claimed that basic psychiatric medicine was available in Cuba, although I could not verify the extent to which this was true.
In societies like Korea, elderly suicide is a major issue because of loneliness and cultural dislocation. In Cuba, however, not only does there appear to be a strong familial network but the government provides Casas de Abuelos. Elderly, retired citizens can go to a Casa de Abuelos during the day for very little money to spend time with and do activities with others their age, as shown in the picture I took at a Casa in Havana. This provides crucial social connection between others of the same age and prevents loneliness while younger family members are working. As the CDC writes, “one case-control study estimated a 27 percent reduction in elderly suicide if limited social interaction was available for that group.”
Is Juan a typical Cuban with a typical Cuban support network, or is he just a special case? Is Juan’s village of Viñales itself just a special case? Havana, the polluted capital where everyone seems in a free-for-all to make money and escape poverty shows that Cuba is far from uniform. That said, once I scratched the surface of Havana I found evidence of very strong family structures. A worker at a state-owned soda factory said that while her pay was minimal, her family’s solidarity made life possible. Everyone pooled their money to help each other and together they were able to survive despite the poor wages.
Cuba is famous for its contradictions of poverty, quality medical care, education access, and repressive communism. I witnessed all of these pieces first hand, but the most impressive part of the trip, however, was the way people cared for each other. Families are solidly together, nurses and doctors are part of the community, and the old are not left to be alone.
Are Cuba’s mental health outcomes better that other countries? Impossible to say, for reasons of transparency I discussed. Given what research and experience shows creates good mental health outcomes – connectedness to family and friends, access to care – it is a safe bet that Cuba has the fundamental elements of a suicide-safer nation.