THE RIGHT TO HEALTH
A. GENERAL OBSERVATIONS
1. The American Declaration establishes:
Article XI. Every person has the right to the preservation of his health through sanitary and social measures relating to food, clothing, housing and medical care, to the extent permitted by public and community resources.
2. The Universal Declaration of Human Rights, for its part, refers indirectly to the right to health and medical care in Article 25. However, the International Covenant of Economic, Social and Cultural Rights contains an explicit provision with respect to the right to health. Article 12 of the Covenant establishes:
1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; (b) The improvement of all aspects of environmental and industrial hygiene; (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; (d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.
B. LEGAL FRAMEWORK
3. Article 8 of the Constitution of Cuba establishes that “The socialist state guarantees that every sick person shall have medical attention”. Article 42, for its part, provides that “The state consecrates the right achieved by the Revolution that all citizens, regardless of race, color or national origin” be given medical care in all medical institution” Finally, Article 49 of the Constitution establishes:
Article 49. Everybody has the right to health protection and care. The State guarantees this right:
- by providing free medical and hospital care through the rural medical service network, polyclinics, hospitals and preventive and specialized treatment centers;
- by providing free dental care;
- by promoting the health publicity campaigns, health education, regular medical
examinations, general vaccinations and other measures to prevent the outbreak
of disease. All the population cooperates in these activities and plans through
the social and mass organizations.
4. It is broadly acknowledged that before 1959, the health of the Cuban people was reasonably good. A recent study states that the country enjoyed “relatively high health levels” before the revolution. Another study upholds this vies, stating that “pre-Revolutionary Cuba had made significant progress in both public and private health services”. Indeed, it may be affirmed that the mortality rate was low while the number of doctors and hospital beds per capita was quite high. Nevertheless, the characteristics of the real distribution of health services, human resources and diseases were such that further description is warranted.
5. Thus, it has been stated that:
Medical services were however, relatively unavailable to the inhabitants of the rural areas; medical skills and facilities were concentrated in the large cities. More than 60% of all physicians in 1958 lived and worked in Havana.
The trend toward concentration in the city of Havana (was) also visible among dentists. (In 1957, 62% of the total were in the capital) Nurses followed a similar pattern.
In 1958 there were 88 hospitals in Cuba, with one bed for every 300 people. But the distribution was irregular and completely inadequate when density and morbidity rates of the population were taken into account. The urban areas received preferential treatment, with 80% of all beds to be found in the city of Havana. For the entire rural population, there were only 10 beds in one single hospital.
6. Because available information is limited, the true health situation in the country prior to 1959 is not known with certainty.
7. It should be pointed out, however, that health services were generally obtained through financial payment, as free medical attention was limited. The quality of services was lower in public institutions and although clarity and mutual health organization made a contribution to the urban population’s health, they sometimes charged for their services. Likewise, it should be pointed out that administration of the provision and supervision of health services was not centralized, which tended to further the inequality of access to those services and efficiency in the provision thereof.
8. In 1958, Cuba had a gross annual mortality rate (deaths per thousand people) of 6.5. This rate was quite close to that of the developed countries. Nevertheless, this figure should be regarded with some reservation, since less than 90% of all deaths were recorded (the deaths of children were not recorded if they died before their births had been registered). The official infant mortality rate was 33/1000 live births. Infectious and parasitic diseases were the principal diseases that affected children. Gastroenteritis, e.g., was responsible for the death of 41.1 of every 100,000 children. It has been said that:
Of the main communicable diseases in Cuba has been intestinal parasitism. The International Bank for Reconstruction and Development reported in 1951 that between 80% and 90% of children in rural areas suffered from the illness. In 1956, a survey of rural families showed that at least 36% of them were aware that they had parasites. In 1957, a study of infants for whom medical aid was sought in public health centers revealed that 55% of those who were examined had parasites. And 1959, an exhaustive study made by public health authorities throughout the country disclosed that 71.96% of all Cubans were afflicted with parasitism; in rural zones the percentage was 86.54%”.
9. In 1956, approximately 14% of the rural population suffered or had suffered from tuberculosis. Deaths related to diarrhea came to nearly 7,000 in 1958, resulting in a rate of 103 deaths for every 100,000 inhabitants. The hospitals and other health centers in the country had a total of 380 beds for every 100,000 people and for the same number of Cubans there were 92 doctors and 31 dentists. Cuba, in 1958, spent $3.25 per capita to improve the mental and physical health of the people. The Economic Commission for Latin America (ECLA) has considered that large sectors of the marginal urban population and “practically all of the rural population” was not covered by the medical system.
10. In general, it may be concluded that prior to 1959 the Cuban health system was: (a) uneven with respect to provision of services, since it depended on the area of residence (rural areas received fewer services and less care than urban areas), or income (the poor showed lower health levels); (b) the system was not coordinated at the national level; private, charity and public institutions existed independently of each other to the detriment of coverage and quality of service; (c) there was no national program aimed at systematically reducing communicable diseases; (d) the State did not guarantee that every person would have equal protection as a recognized human right; (e) any improvement in the health field was rather the result of secular trends in modernization than the direct result of measures adopted by the government; (f) prevention, treatment and control of diseases was not a national objective; (g) coverage by the public sector of the health needs of the population was deficient and insufficient; (h) quality of public medicine was below that of the private sector.
11. Since 1959, the Cuban State has recognized the right of every person to receive health and medical services at no direct cost. This has been defined by Cuban authorities as a “biological right”. The State has assumed responsibility for providing the resources and means to ensure observance of this right, which was formally recognized in the Constitution of 1976.
1. Health Services
12. A number of administrative measures were taken in 1959 in order to set up a broader and more comprehensive medical care system, and these measures radically changed the health care system in the country. The Ministry of Public Health was authorized to centralize all authority, to supervise the operations of institutions and the country’s medical personnel, and to standardize procedures. The Ministry was also authorized to exercise full control over financial resources. In 1963, private hospitals and clinics were nationalized (community service clinics continued to function until 1969). With that measure a uniform plan was put into effect throughout the country, and planning became an essential part of health care.
13. Hospital services are distributed at four different levels: national, provincial, regional and local. The Ministry of Public Health supervises every level but manages only the national level. There are 14 provinces in the country, each of which (as well as the Isla de la Juventud) has a provincial hospital with approximately 600 beds. The provincial units provide specialized services to an area with approximately 500,000 inhabitants.
14. Each province is divided into medical regions, according to geography and population density. In 1974, there were 44 regions (the number apparently changed with the administrative reorganization of 1976). Each region has an urban hospital with a capacity of 350 patients each, and in which general surgery can be performed. Regions were further subdivided into health areas (there were 334 areas in 1974), each having at least one polyclinic. The polyclinic is the heart of the Cuban health system. “The polyclinic, an institution for outpatients that performs preventive and social functions, has a gynecologist, dentist, a pediatrician, an epidemiologist, nurses and a resident medical student. They also have health workers, who teach neighborhood communities the basic principles and methods of hygiene. Each rural polyclinic has from 20-30 beds and is equipped to deal with problems in general medicine, obstetrics and pediatrics. Cases requiring surgery are sent to regional hospitals”.
15. The polyclinics, rural hospitals and rural medical services are responsible for providing basic medical treatment, carrying out a number of activities related to the “promotion, protection and reestablishment of health, as well as to carry out activities aimed at protecting and improving the environment”. Each health area provides services to 30,000 inhabitants, and at the same time, each area is subdivided into health sectors. In 1974, there were 334 areas with 2,267 sectors; each sector covers an area with approximately 3,000 people. Doctors and nurses at the area level are assigned a certain number of people, whether or not they are in good health. The medical staff must carry out this personalized medical/community service as a preventive medical service.
a. Growth of health facilities
16. To ensure adequate medical care for the entire population, in 1959, the government initiated a program to increase the number of hospitals. In 1959, there were 79 hospitals in the country as a whole (54 public and 25 private hospitals), and in 1982 the number had reached 326, i.e., an increase of 3132%.
17. The greatest growth in health facilities took place from 1959-1969, with the construction of 128 new hospitals. In 1978, there were 13 different kinds of hospitals, by specialty; the majority provided services in general medicine (34.7%), followed by those specializing in maternity (22.1%), rural matters (19.8), child care (8%), psychiatric care (4.9%), etc.
18. The growth in rural hospitals has been significant. In 1958 there was one rural hospital in the country, representing 1.8% of the total. Throughout the 1960s, this ratio rose, reaching a maximum of 24.8% of the total number of hospitals. Since 1966, however, the ratio of rural hospitals to the total number of hospitals declined progressively until 1978. Since then, the State of urban and rural hospitals. For 1982, there were 117 rural hospitals in Cuba, i.e., 35.8% of all the hospitals in the country.
19. As mentioned earlier, the polyclinic is the cornerstone of the Cuban health system. In 1958 there were 52 polyclinics, and 22 years later that number had reached 389, or an increase of 648%. It should be pointed out that the function of rural polyclinics for medical service and of rural hospitals is to provide services in general practice medicine; they do not provide intensive care since there are other institutions for that purpose. As a result, these facilities do not have the number of beds per patient that might be expected.
20. In addition to increasing the number of hospitals, the authorities also augmented the total number of beds in hospitals. This effort was intensified during the first 10 years of the revolutionary government. In 1958, there were 25,745 beds, and in the next 11 years, 19,498 more beds were added. From 1969 to 1982 there was an increase of only 926 beds. Therefore, while the total number of hospitals rose, the number of beds remained constant and the rate of hospital beds for every 1,000 inhabitants changed little: in 1958 it was 3.8 and in 1982 only 4.7. Taking 1976 as the point of comparison with 1958, it can be noted that despite an increase of 65.3% in the total number of beds, certain provinces had enjoyed a greater increase than others. Taking 1976 as the point of comparison with 1958, it can be noted that despite an increase of 65.3% in the total number of beds, certain provinces had enjoyed a greater increase than others. For example, in Havana where most beds were concentrated prior to 1959, the rate of increase was only 10.8% during those seventeen years. The provinces which in the past had lagged behind saw notable increases: Las Villas (87.9%), Pinar del Río (161.1%), Matanzas (159.8%), Oriente (179.7%), and Camagëy (189.2%). There has been a basic inversion of the distribution of beds in hospitals; in 1958, the city of Havana monopolized approximately 62% of all beds, while the rest of the country had only 38%, whereas 20 years later the capital had 39% of beds while the rest of the country had 61%.
21. With 6,286 doctors in 1959, the doctor/population ration in Cuba was 11.107; twenty-two years later, there were 16,193 doctors, i.e., a ration of 1:600. Although unequal distribution among the provinces persists, differences have been reduced by more than half in the curse of the revolution. In 1980, the rations were as follows: Isla de la Juventud (1:611), Matanzas (1:615), Havana (1:862), Villa Clara (1:923), Pinar del Río (1:1500), Guantánamo (1:1520), and Granma (1:1855). Information on the other provinces could not be obtained.
22. Distribution of doctors among the provinces has improved, since prior to the revolution approximately 33% of all doctors were located outside the capital, while 1978 the exact opposite was true: 36% of all doctors lived in Havana while 64% resided in the rest of the country.
23. At this time, the Ministry of Health has a staff of 157,933 people of whom 16,193 are doctors, 14,156 nurses, 4.087 dentists, and the rest are pharmacists, technicians, administrators and support service personnel. The Ministry also supervises 326 hospitals, 389 polyclinics, 115 dental clinics, 37 health laboratories, 60 maternity homes, 67 homes for the physically or mentally retarded, 22 blood banks and 10 homes for the elderly.
24. The public health budget in 1958 was 22 million pesos ($3.30 per capita), which rose to $236 million in 1969 ($29.50 per capita) and to $388 million in 1978 ($40 per capita). From 1958 to 1969, the public health budget increased 10.7 times, while between 1970 and 1978 it grew only 1.6 times.
2. Health Situation
25. There are a number of indicators that can be used to determine the health level of a population. One of the is the gross annual mortality rate or the mortality rate (the number of deaths for every 1,000 inhabitants). In this respect, it should be pointed out that there was a significant increase in Cuba in the number of reported deaths in the period from 1959 to 1962; it was in the latter year that the highest rate for the entire revolutionary period was recorded. Since then, the rate declined until 1967, with the exception of a brief interval (1968-1969), when it again began to rise. Since 1970, the mortality rate has fallen to the lowest level in Latin America; while the mortality rate has fallen, life expectancy has increased from 61.8 years for the 1955-1960 period to 73.5 for the 1980-1982 period.
26. The distribution of death by age group has changed markedly in the last decade. Between 1959 and 1966, the infant population accounted for 19% of all deaths, but by 1978 the figure had fallen to 6%. The same is true of minors from 1 to 14 years of age. Until the mid 1960s, children and adolescents accounted for 5.7% of all deaths, but for 1978 they represented only 3.3%.
27. Analysis of infant mortality serves as a more exact indicator of health conditions in a country. Infant mortality (deaths of children under one year of age for every 1,000 births) tends to be higher in poor countries. An author has written in this regard that “the underdeveloped nations have a high infant mortality rate due to the lack of services, low income, inadequate nutrition of parents, and poor hygiene. With improvement in these conditions, infant mortality falls”.
28. In a recent study, a team of urban epidemiologists stated that before 1959 and during the first years of the revolution existing data on infant mortality in Cuba was not reliable, since there was a marked tendency not to report deaths and live births. At that time there was no clear definition of live births or of infant mortality, and in addition, records were rarely kept in rural areas. It was in 1965 that Cuban officials adopted the definition and differentiation of live births proposed by the World Health Organization (premature birth, late birth and postnatal). Since that time, data collection has become more reliable, but it was only after 1968 that careful records of the causes of infant mortality began to be kept.
29. From 1959 to 1969 the number of reported cases of infant mortality progressively increased. Thus, in 1969 the highest infant mortality rate was recorded, reaching 46.7/1000 live births. Furthermore, infant mortality which accounted for 13.8% of total deaths recorded in 1958 rose to 20.6% eleven years later (the rate in 1964 was even higher, at 21%). In a large number of cases (80%), there were six principal causes of death: perinatal disease, enteritis, acute diarrheaic illnesses, influenza, pneumonia, and congenital defects. Although poor nutrition cannot be regarded as a direct cause of death, it apparently complicates the situation. In that year, furthermore, the country was affected by an influenza epidemic, which given the critical situation of infant health, led to a systematic campaign to improve health. The campaign produced positive results, since from 1970 to 1979 the infant mortality rate fell from 38.8/1000 live births to 19.3/1000, or a reduction of 50%.
30. Cuba reorganized its political and administrative system in 1976, establishing 14 provinces instead of 6. The new provinces as a general rule were rural areas with fewer hospitals or other medical resources, and consequently showed a higher incidence of infant mortality (In particular in the provinces of las Tunas, Guantánamo, Granma, Sancti Spiritus y Ciego de Avila). Allocation of supplementary resources to these provinces in the course of the 1970s successfully reduced their infant mortality rates.
31. The shift in the principal causes of death has been notable. Prior to 1959, most of the illnesses responsible for deaths in Cuba were those that have traditionally been associated with underdevelopment: diseases of the digestive system, disease in early infancy, respiratory problems such as tuberculosis, etc. At present, the principal causes of death in Cuba are basically the same as those in the developed world: congenital defects, injuries that affect the central nervous system, diabetes, etc. In other words, the principal causes of death have changed from communicable diseases to degenerative diseases.
32. Furthermore, the general morbidity picture has changed markedly. Cuba has eradicated poliomyelitis, diphtheria, malaria, tetanus and yellow fever. The number of cases of typhoid fever has become statistically insignificant; poliomyelitis disappeared in 1963, followed by malaria in 1967, diphtheria in 1970 and tetanus in 1976.
33. A significant aspect of health care in Cuba is that it has succeeded in breaking the long-standing tie between morbidity and mortality. Despite the increase in the incidence of some diseases, death as a result of illness is much less frequent. The rates of acute diarrhea for example, rose from 5.707/100,000 in 1965 to 8.286 in 1973, but at the same time the mortality rate for this disease fell from 25.8/100,000 to 9.9; and in 1980 the mortality rate was 3.1.
34. Reported cases of tuberculosis for every 100,000 inhabitants increased by 261% from 1958 to 1965. However, although 60.1% of tuberculosis patients died as a result of the disease in 1959, the number of deaths at that time, when the illness was at its highest point, fell to 24.4%. Since the mid-1960s, the morbidity and mortality rate has fallen to its lowest point in the recorded history of the country.
35. With the passage of years, Cuban authorities have placed greater emphasis on preventive medicine. The cornerstone of that policy has been vaccination of possible victims against communicable diseases. Since the campaign was undertaken in 1960, Cuban children have been regularly vaccinated. For example, in 1974, 1.1 million children received oral vaccinations, representing the highest number reached in one year. The number of vaccinations has declined in absolute terms, following the demographic characteristics of the population.
36. Tuberculosis has also been co batted through a vaccination program. In 1959, only 10,000 people received BCG vaccinations; since then an annual average of 300,000 people have been vaccinated (in 1969, the number was 649,296). As part of the preventive campaign against tuberculosis, the Ministry of Health took chest x-rays of 5.8 million people between 1960 and 1970. At present, the BCG is administered to approximately 95% of the newborn and is later repeated for school-age children. Vaccination against tetanus has been widely distributed; between 1967 and 1978, 17.6 million vaccinations were administered. The same is true of typhoid fever, although not of measles, since the campaign against the latter was initiated only in 1972. Between 1971 and 1978, slightly more than 1.7 million people were vaccinated. Incidence of the disease has consistently fallen over the course of the 1970s, reaching its highest point of 264.5/100,000 inhabitants in 1977. Since then it has fallen drastically to 50.5 cases out of every 100,000 inhabitants, and the mortality rate per 100,000 has been less than 1 since 1972.
37. Leprosy cases have declined from 4.2/100,000 in 1965 to 3.3 in 1980. The Ministry of Health closely controls 98% of recorded cases. For their part, infectious hepatitis, venereal diseases and respiratory diseases have increased. The mortality rate caused by syphilis, however has been reduced in 21 years since 19600 from 95/100,000 to 2/100,000. Concern should be expressed with regard to the rising suicide rate, which went from 17.2 per 100,000 inhabitants in 1975 to 21.3 in 1980, and which is apparently “among the first causes of death in the age group of 15-49”.
38. It should also be stated that all vaccinations are administered free of charge to the population through the mass organizations.
39. Basic medical care in the current social system in Cuba is aimed at treating and preventing disease among all Cubans. In the first five years of the revolutionary regime (1959-1964), efforts were concentrated on treatment and on providing access to medical care to the greatest possible number of people; i.e., equal access and treatment progressed at the same pace. Efforts have been systematically concentrated since 1965 to prevent contagious diseases. Disease prevention and promotion of equality have become the dominating principle, and the growth of medical facilities and human resources are testimony to the country’s current policy with respect to medical care.
40. The number of medical and dental visits has increased consistently in the last 23 years. There is no information on the number of patients who received medical treatment in 1958, but for 1963 that number reached 13.8 million; 18 years later, it was 49 million. To put this figure in perspective, it should be pointed out that the pan American Health Organization established the goal of two medical visits per capita as of 1980. In 1981, Cuba attained a frequency of 5.04 visits per capita. The absolute number of medical visits has increased 276% between 1963 and 1981. The same is true of dental visits: in 1963 only 700,812 visits were made, but in 1981, that figure had reached 10.5 million.
4. Environmental Hygiene
41. To preserve and care for a healthy population, an environment conducive to that goal is essential. Certain factors have a significant impact on environmental hygiene: water supply, disposal of industrial or human waste, and the garbage collection system.
a. Water Supply
42. In 1953, over three-fourths of rural families in Cuba obtained their water from rivers, wells or springs, many of which were polluted. Only 6.6% of the population had indoor plumbing, although the national average was 55%, whereas in contrast, this figure rose to 79.5% in the cities. A housing census carried out in 1970 revealed that 66.7% of Cubans have access to plumbing (the figure for cities was 88.2%, although for the country it was 26.7%).Therefore, there has been a slight improvement, in particular in rural aras, although growth there has been less marked than in other areas. The absolute number of people without access to plumbing has risen from 508,000 inhabitants in 1953 to 628,000 in 1970.
43. The water has been treated with chlorine. In 1959, only 21% of the water supply to the public was treated, but in the decade of the 1970s, it had risen to 98% Even so, cases of water pollution are not infrequent. For example, in 1977 typhoid fever struck the oldest section of Havana, when human waste leaked into the water supply system. In the same year, there were 302 cases reported in the capital alone of water pollution, and in the following year 120 cases were reported. Due to the frequency of such cases, the Ministry of Public Health urges the public to boil whatever water it uses.
44. Water shortages have been a persistent and difficult problem. The water supply system has numerous leaks through which a considerable quantity of water is lost, and in addition, they create the risk of pollution. A government report indicates that in 1980 approximately 50% of the water supply was lost due to leaks. In general, water supply pipes are very old, as are the pumps, which are over 45 years old. The system has not been improved, received maintenance, or been extended because the country’s limited financial resources have been allocated to other priorities. As a result, the situation is deteriorating with the passage of time, and at present approximately 300,000 people receive little water in certain neighborhoods of the capital. Furthermore, the hydrostatic level in cities such as Havana and Santiago is becoming progressively lower, while salinity is increasing. Water scarcity has become a persistent complaint throughout the country.
45. Because Cuba has so many rivers, it is logical to think that they would be used as a source of water supply. Unfortunately, most of them have been polluted by industrial waste. Around the city of Havana, the Martín Pérez, Cojimar, Almendares, Luyano, Quibus and Arroyo Tadeo rivers are unusable or nearly unusable due to pollution, as they contain a high number of toxic chemicals as well as hydrocarbons from use for drainage.
46. Pollution of the rivers has in turn led to pollution of bays and coastal waters. The Antonio Nico López oil refinery in Havana, for example, has destroyed nearly all marine life in the port of Havana. Chemical wastes are discharged into the port of Nuevitas, in the beautiful Bay of Cienfuegos, and in the marsh of Zapata, whose ecosystems are at the point of total collapse. There is no longer any marine flora or fauna in the bay of Moa. A Soviet environmental specialist declared “The bays of Havana and Moa are practically dead regions today. It is impossible to obtain any natural resource from them, but they continue to pollute the floating in the water¼ in Santiago de Cuba¼over 60% of the water volume is highly polluted¼ In Moa, over 450 cubic meters of processed nickel waste is dumped daily into the water”.
47. Despite the enactment of several laws in recent years to solve the problem, little progress has been made.
48. It is well known that a population’s health may be affected by the system used for elimination of human waste. In the 1950s, the existing system was unquestionably inadequate. An author has written that “28% of homes had toilets with running water, and 13.7% were located outside the homes. Over one-third of families had latrines and 23.2% of housing (54.1% in the country) had no sanitary facilities”.
49. At present, while a small pat of the population enjoys the benefit of proper disposal of human waste, the sewerage system is in such a deplorable condition that it frequently affects the country adversely. The city of Havana is an example of this: its sewerage system was built between 1908 and 1913, and was designed for a maximum population of 600,000 people, who, it was thought, would live within a radius of 25 square miles. At present, the capital has over one million inhabitants and covers over 100 square miles. The sewerage system, to put it mildly, is overloaded; it handles 1.5 times its processing capacity. It is estimated that approximately one million cubic meters of liquid enters the system daily, i.e., approximately six cubic meters per second, but the sewerage system can only efficiently absorb one cubic meter per second. The result is that the pipes burst frequently.
50. It is estimated that the city of Havana requires 300 kilometers of sewerage alone to satisfy demand, but there is little planned to remedy this situation.
51. Garbage collection also represents a serious problem. In connection with this subject, there is no public information on the situation of the country as a whole, but the situation in the city of Havana may serve as an indicator.
52. In 1980, the city of Havana produced approximately 1,000 tons of garbage per day (an annual amount of 373,200 tons), i.e., approximately one pound per person. However, the city had only 30 trash collection trucks, a situation which improved slightly in 1981 with the purchase of more trucks. Collection trucks made an average of 92 trips per day, working 24 hours a day. Collection could take place in any neighborhood every fourth day, resulting in a highly unhealthy urban environment, given the tropical climate in which waste decomposes rapidly. Rats, cockroaches, and a number of insects infested the sidewalks where the trash was placed.
53. Garbage was left uncovered in front of homes until recently. In the mid-1980s, however, authorities purchased 92,000 garbage receptacles that were distributed to the population. This was a positive but insufficient measure since for every 100 residents in Havana there were 4.6 garbage receptacles. Resource scarcity has led to a proliferation of trash receptacles in neighborhoods. The situation became so critical that the ministry of Health coordinated a major effort to clean them. In 1981, “operation clean-up”, was launched for which six hundred trucks taken from various sectors of the economy were used, and which made over 40,000 trips to remove accumulated garbage. This kind ofmeasure is a beginning, but illustrates the limitations of the system due to lack of resources. The city cannot be kept clean in a systematic and daily fashion with current resources.
54. Between 1959 and 1981 the state constructed 235,047 housing units, a number which is still far from being sufficient. If one takes into account population growth (3 million since 1959), the establishment of new families, deterioration of old housing, etc., the resulting deficit would be 1.4 to 1.9 million units for 1985. According to the housing census carried out in 1970, 9.4% of the population lives in poorly-maintained housing, 15.5% in homes built with thatched roofs, and 0.1% in temporary housing. In other words, 2.1 million people lived in inadequate housing. This is an extremely deficient situation both in rural and urban zones. People often attempt to solve the problem on their own, and as a result marginal neighborhoods have sprung up throughout the provincial capitals. In Havana, for example, there are 94 poor neighborhoods (that the Cubans call “unhealthy neighborhoods”); there is no data on the total number in the country as a whole.
55. The State’s priorities with respect to housing have changed since the beginning of the 1970s. Until that time, almost half of new housing was built outside of Havana, in particular in rural zones. Housing repair receives scant attention. However, this has changed; now a good deal more resources are allocated to Havana, in particular for the maintenance of existing housing. Between 1978 and 1980, approximately 55% of the homes in Havana needed immediate repair. The population density in available homes grew parallel with the increasing acuteness of housing scarcity. As a result, in Old Havana, approximately 100,000 people lived in an area of 3.2 square kilometers, or 32,250 inhabitants per square kilometer. In fact, there are approximately 22, 750 buildings in Havana that shelter approximately 800,000 inhabitants, an average of 35 people per structure. Most of the buildings are in truly unhealthy conditions.
56. Housing scarcity is a problem that has yet to be solved. The same is true of home repairs and with respect to the cleanliness of neighborhoods and buildings.
57. It may be concluded from the above presentation that health services in the form of medical and dental care are a universal right in Cuba, that they are provided free of charge and under the responsibility of the State. Numerous positive measures have been adopted to extend this right to all sectors of society, without regard to sex, age, color, belief, income or place of residence.
58. Considerable progress has been made in reducing the rates of stillbirths, infant mortality and the healthy development of children. Prevention, treatment and control of epidemic diseases has improved over the years, in particular in terms of mortality, although morbidity rates have risen for some diseases. Nevertheless, the increase in the suicide rate is a matter of concern and it would be important to explain the above-mentioned increase.
59. Preventive medicine and participation of the community are the cornerstone of the health policy of the country. Prevention, treatment and control of diseases and job accidents leave a great deal to be desired, since sufficient efforts have not been made nor have the necessary resources been allocated to this area.
60. Environmental and industrial health practices require a great deal more attention. Housing, sewerage and water supply require radical improvement. Due to the scarcity of resources, preferential treatment is given to those who are deserving and have the greatest need.
61. Pollution of the soil, air and water is increasing at a dangerous rate, and unless methods are adopted to control it, it could undermine the successes that have been achieved in the health field.
 Mesa-Lago, C., “The Economy” op. Cit., p. 166.
 Domínguez, J., Cuba: Order and Revolution, Cambridge, Harvard University Press, 1978, p. 223.
 Valdés, Nelson P., “Health and Revolution in Cuba”, Science and Society, Vol. 35, No. 3, Fall 1971, pp. 321-322.
 Ibid, p. 334.
 CEPAL, “Cuba” op. Cit., p. 122
 Valdés, N.P., “Health” op. Cit., p. 323.
 Pan American Health Organization, Extension of Health Service Coverage Based on the Strategies of Primary Care and Community participation, Summary of the Situation in the Americas, Washington, D.C., 1978, Official Document, No. 156, p. 28.
 Leyva, Ricardo, “Health and Revolution in Cuba”, in rolando E. Bonachea and Nelson P. Valdés, eds., Cuba in Revolution, New York: Doubleday, 1972, p. 478; Comité Estatal de Estadísticas, Anuario Estadístico de Cuba 1978, Havana, Cuba, p. 246; Congreso del Partido Communista de Cuba, Informe Central, Havana: Editora Política, 1980, p. 24; Comité Estatal de Estadísticas, Cuba en cifras 1979, Havana, 1980, p. 75; Granma Resumen Semanal, October 31, 1982, p. 12. The figure of 326 hospitals was obtained by adding the 61 new rural hospitals built in 1982 to the 265 that existed two years earlier.
 Comité Estatal de Estadísticas, Anuario Estadístico de Cuba, 1975, Havana, n.d.; Anuario Estadístico de Cuba, 1978, Havana, n.e. pg. 246; Cuba en cifras 1979, Havana, n.d., p. 75.
 CEPAL, Cuba: op. Cit., p. 139; Bohemia, (Havana), February 16, 1979, p. 68.
 RL, p. 479; Anuario 78, p. 247; Cuba 79, p. 76; Speech by Fidel Castro, December 9, 1981; Bohemia, December 10, 1982, p. 58; March 12, 1982, pp. 46-47.
 Bohemia, October 2, 1981, p. 39; October 9, 1981, p. 13; October 16, 1981, p. 12; October 23, 1981, p. 12; October 30, 1981, p. 10; November 6, 1981, p. 10; November 13, 1981, p. 12, November 20, 1981, p. 10; November 27, 1981, p. 11; December 4, 1981, p. 12; December 11, 1981, p. 14, December 18, 1981, p. 12; December 25, 1981, p. 15; January 1, 1982, p. 10.
 Same sources as in footnote 12.
 Same sources as in footnote 12.
 Leyva, Ricardo, op. Cit., p. 486; Bohemia, February 16, 1979, p. 68
 Granma Resumen Semanal, December 5, 1982, p. 12.
 Leyva, Ricardo, op. Cit., p. 492; Anuario Estadistica de Cuba, 1979.
 Ibid., p. 489.
 Riverón, Ricardo, et al, “Salud materno0infantil: situación actual y perspectiva”, Revista Cubana de Pediatría, No. 50, 1978, pp. 407-423.
 CEPAL, op. Cit., Table 24; ESC, Table 44; Granma Resumen Semanal, December 7, 1980, Supplement, p. 5; Granma, January 19, 1969, pp. 2-4; Pan American Union, America en Cifras 1967, Washington, 1969, pp. 81-82; Comité Estatal de Estadísticas, Anuario Estadístico de Cuba 1975, Anuario de Estadístico de Cuba 1978.
 Informe Annual del Ministerio de Salud Pública, Cuba, 1981, and for 1981-82, see footnote 12.
 CEPAL, p. 142; Anuario 78, p. 253.
 Granma Resumen Semanal, December 5, 1982, p. 12. For the suicide rate, Ministry of Public Health, Annual Report 1980, p. 9.
 Pan American Health Organization, Annual Report of the Director 1979, Washington, D.C. August 1980, Official Document No. 171, p. 33; Bohemia, (Havana), December 10, 1982, p. 58.
 Ministry of Public Health, Cuba: la salud en la revolución, Havana, 1975, p. 78; Bohemia, December 10, 1982, p. 58.
 Figures from the census of 1953 and 1970, and United Nations, Economic Commission for Latin America, Statistical Yearbook for Latin America, New York, 1980, p.111.
 Información al Delegado (Havana), No. 3, 1980, p. 8.
 Gugler, Josef, “Un Mínimo de urbanismo y un máximo de reuralismo: la experiencia cubana”, Revista Mexicana de Sociología, Vol. 43, No. 4, October-December, 1981, p. 1473.
 Información al Delegado, No. 8, February 1979, p. 6.
 Granma, (Havana), January 25, 1980, p. 2.
 Domínguez, Jorge, “Cuba” op. Cit., pp. 284-285, 408, 488, 495.
 Hernández, Gregorio, “Detener la contaminación de nuestras aguas marinas”, Bohemia, April 30, 1982, pp. 28-31. See also: Hernández, Gregorio, “La contaminaci”on de la bahía de Cienfuegos Bohemia, August 20, 1982, pp. 28-30.
 Leyva, Ricardo, op. Cit., p. 466.
 Hernándes, Gregorio, “La contaminación en la bahía de La Habana”, Bohemia, August 20, 1982, pp. 28-30.
 Bohemia, June 13, 1980, p. 7.
 Bohemia, July 24, 1981, p. 46.
 Mesa-Lago, C., “The Economy” op. Cit., Table 46; “Del Informe del Comité Central del PCC al II Congreso”, Economía y Desarrollo, No. 62, May-June, 1981, p. 183; Pérez, Humberto, “La Plataforma Programática y el Desarrollo Económico del Cuba”, Cuba Socialista, No. 3, June 1982, p. 24.
 Estimates of carmelo Mesa-Lago in “The Economy” op. Cit., p. 173, and Sergio Días-Briquets, Demographic and Related Determinants of Recent Cuban Emigration, paper prepared and submitted at the Annual Meeting of the Latin American Studies Association, Washington, D.C., March 4-6, 1982, Table 3, p. 51.
 Bohemia, April 23, 1982, p. 48; June 19, 1981, p. 53.
 Bohemia, January 25, 1980, p. 2; February 15, 1980, pp. 52-53.
 información al Delegado, September 1979, p. 12; Bohemia, June 5, 1981, pp. 56-57.