Water decade 1981-1990 [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JANUARY 1979 • USA $ 1.25 The Water Decade 1981-1990 BY IAIN GUEST sk someone from an affluent city suburb to characterize wa- ter and you would probably get a curious stare and something along the lines of "colourless, tasteless—and abundant". But ask the same question of a villager in the Third World, and the answer might well pro- vide a web of insights into a life of ex- traordinary hardship. For here water does not come from the ubiquitous tap. It has to be carried—usually by wom- en—from a well or a river up to a mile away, several times a day. It is usually in- sufficient, and what there is may be so badly contaminated that it risks causing severe diarrhoea. The fact that safe drinking water and its corollary, proper sanitation, are taken for granted in the more affluent coun- tries but are a matter of life and death in the developing world has been moni- tored with increasing concern by WHO in recent years. This concern expressed it- self in the UN agencies' own way of generating a sense of political urgency— the large international conference. The Habitat Conference, held in Van- couver in 1976, stated as a goal—"fresh water for all by 1990". The UN Water Conference, at Mar del Plata, Argentina, in 1977, made this more specific and des- ignated the period 1981-1990 as the In- ternational Water Supply and Sanitation Decade, while 1978-1980 would be the years for collecting data and evaluating the dimension of the crisis. Thirdly, the 1978 Alma-Ata Confer- ence on Primary Health Care spelt out in broad outline some of the ways and means of incorporating the decade into a new two-part strategy for health : more "relevant" health services, and more em- phasis on preventive health with all- round social and economic development. Sanitation is closely related to drink- ing water—indeed the rows of defecating children that are a common sight in much of the Third World are a more dra- matic reminder of the problem than the absence of fresh water. Several studies have stressed that providing only safe drinking water or only facilities for dis- posing of excreta—without the other half of the solution—will be unlikely to lead to an improvement. How serious is the crisis? WHO carries out regular surveys on the coverage of community water supply and excreta dis- posal services in the developing coun- tries. The most recent, published in 1975, found some 1,230 million people without adequate water supply and 1,350 million without sanitation. More specifically, by the end of 1975 the total population of the developing world, excluding China, was roughly 2,000 million people; of these, 70 per cent lived in the rural areas and the rest in cities. While 57 per cent of the city population had access to com- munity water through house connec- tions, and another 21 per cent through public standposts, in the rural areas only 22 per cent had access. A total of 38 per cent of the Third World's population had access to safe drinking water. In the cities, 25 per cent of the popula- tion had house connections to sewerage systems and an additional 50 per cent were served by household systems. In the rural areas, only 15 per cent had any ac- cess to sanitary latrines. Of the total number of people estimated to be 2 A tubewell in Bangladesh. Plentiful supplies of clean water save lives, particularly among babies, as well as making life easier for women. (Photo WHO/I. Guest) without these most essential of services, more than 700 million are children—an important and alarming figure, particu- larly as 1979 has been designated Inter- national Year of the Child. The first consequence of the lack is dis- ease. WHO estimates that as much as 80 per cent of all disease in the world is as- sociated with water. It can take several forms. Firstly, there are germs ingested through drinking contaminated water: these cause typhoid, gastro-enteritis, cholera. Then, communicable diseases such as scabies and trachoma, transmis- sion of which is favoured by chronic water shortage or poor quality of water. Thirdly, diseases caused by parasites that inhabit water and burrow through the skin—like schistosomiasis, which is car- ried by snails, or dracunculinsis, carried by the guinea worm. Finally, there are the carriers (vectors) of disease which breed in bodies of water. The most serious of these are mosquitos, responsible for the current alarming upsurge of malaria, and the flies which cause river blindness (onchocerciasis). In round figures an astonishing num- ber of people suffer from these water- related diseases at any one time : 400 mil- lion with gastro-enteritis, 160 million with malaria, 30 million with river blind- ness, 200 million with schistosomiasis. This connection between the lack of clean, piped water and disease is now well established. In one case, in a cholera outbreak in the Mulange district of Malawi, the families who escaped the disease were those with piped water which, though untreated, was coming from upstream and was therefore uncon- taminated. Those who suffered were those without piped water. WHO surveys have noted another characteristic of fresh water—it comes with money. One 1970 survey found that in countries with a per capita income of less than US$ 110 a year, over 80 per cent of the population still lacked ex- creta disposal services and fresh water. For most countries with incomes within the range of $110 and $1,000, the pro- portion is considerably smaller and ranges from 20 to 70 per cent. Within countries, the disparity in ser- vices between urban and rural areas is of- ten accounted for by the higher income of town dwellers, and their ability to apply greater political pressure in order to get services. Slums, however, stand Cover design by Peter Davies MI 41•110 IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents The Water Decade — 1981-1990 by I. Guest 2 Cholera in the Gilberts by Tin Maung Maung 6 The locust war by S. Baron 1 0 Women-power in Korea by J.C. Abcede 16 Which medium for the message? by D. Gibson ........ 20 Saving lives at Savar by P. Harrison ......... 24 News Page 30 out as an important exception—particu- larly since they are expected to expand dramatically in the next 14 years. In a limited sense, the situation is im- proving. WHO's 1975 mid-decade survey showed that the number of urban dwel- lers served by drinking water had in- creased from 316 million in 1970 to 450 million in 1975—from 67 to 77 per cent. In rural areas, the increase was from 182 million to 313 million-14 to 22 per cent. For excreta disposal, the increase was from 71 to 75 per cent in urban areas, and from 11 to 15 per cent in the coun- tryside. But this is still far below the rate of increase called for by the International Decade. In addition, the UN Fund for Population Activities (uNFPA) estimates that, irrespective of the success of family planning, the world's population is cer- tain to double by the end of the century. Furthermore, bare statistics can be fal- sely optimistic or may mask deficiencies. No water system can be entirely leak- proof, even in an advanced industrialized country. Where water can leak, contami- nation can enter. In one survey of 401 cities in the United States, two resear- chers found that in one out of ten cities, 25 per cent of the water was being lost. As with food lost during storage from rodents, water lost from leaky pipes in the developing world can amount to as much as 50 per cent. Water supply is often intermittent. This is serious, because when the pres- sure falls off there is no resistance to the intrusion of pollutants from the outside. An estimated 27 per cent of the water supplies in Africa south of the Sahara are intermittent, and as much as 91 per cent of the water supplies in South-East Asia. Again, many cities employ two systems of water—one safe for drinking, and the other for washing streets and watering gardens. When they run side by side, there is a serious risk of contamination. The 1981-1990 water decade concerns only safe drinking water and sanitation. It does not directly concern water management, which was discussed dur- ing the Desertification Conference held in Nairobi in 1977, nor the challenge of increasing and mobilizing water resources so as to meet food require- ments. But clearly, all are interconnect- ed, and it will be one of the aims of the decade to stress this. Malnutrition and a lack of fresh water are interrelated. Malnutrition under- mines the individual's resistance to such diseases as diarrhoea. Diarrhoea itself further reduces the intake of food and causes loss of body fluids, resulting in further malnutrition. Just as the need for food is greatest in the developing coun- tries, so is the need for water: in a dry cli- mate the body requires, on average, up to twice as much water (5 litres) a day. The Mar del Plata Conference in Argentina called for an unparalleled ef- fort to be made by governments and the international community—a call that was reiterated by last year's WHO/UNICEF Conference on Primary Health Care held at Alma-Ata in Soviet Kazakhstan. In a joint report to the Conference, the heads of the two agencies noted that "Plentiful supplies of clean water help to decrease mortality and morbidity, in particular among infants and children, as well as making life easier for women. Country- wide plans are required to bring urban and rural water supplies within easy reach of the majority in the shortest pos- sible time." That conference ended with 22 recom- mendations and the Declaration of Alma-Ata. In broad terms, these said that the best form of preventive health care is social and economic development. They stressed the need for increased in- vestment, and underlined that the form of technology and manpower to be in- volved must be relevant to the needs and resources of the countries involved. Of course, this is more easily said than done, as with all conference clarion-calls. What are the obstacles? In 1970, 88 countries were asked precisely this ques- tion in a WHO survey. The replies were il- luminating; 48 gave lack of internal finances as the first problem; 10 cited the lack of external resources, 11 said they lacked a proper administrative structure, and 19 said the chief concern was the lack of trained personnel. It is not hard to see why money looms so large. Be- tween 1970 and 1975 the amounts invest- ed on water throughout the world were As much as 80 per cent of all disease in the world is associated with water; and the connec- tion between the lack of clean, piped water and disease is well-established. ( Photo L. Solmssen, League of Red Cross Societies) on average $ 67 per person in urban areas, and $ 17 in rural areas. The World Bank and WHO reported to the Mar Del Plata Conference that $ 140,000 million would be needed to reach the target of "clean water for all by 1990". For this to be achieved, invest- ment on water supplies in urban areas would have to be increased one-and-a- half times and in rural areas four times, while eight times as much would have to be spent on sanitation. Where will it come from? On past per- formance, from the countries themselves. External aid from donors in the indus- trialized world has been falling behind the two targets set by the UN : one per cent of all net flows, or 0.7 per cent of the GNP for official development assistance. In 1970, net aid from the 17 western member-countries of the Development Assistance Committee (DAC) was $ 17,400 million instead of the target of $ 22,000 million. Of the money invested on water in 1971, only 12 per cent in ur- ban areas was met by aid and nine per cent in rural areas. In the same year, $ 710 million of aid went to community water and $ 142 million to sanitation. But even these figures disguise the fact that more than half the aid went to Latin America, and only two per cent to South- East Asia, where the need is even greater. It is not, of course, simply a question of money. It is a question of political will and priorities. The Alma-Ata Declara- 4 The Water Decade 1981-1990 tion talks of the need to involve the com- munity—almost a catch-phrase by now, but essential if the Water Decade targets are to be met. Community development starts with the family. Since women are usually the carriers of water, and often control the family's hygiene and health, they are the first obvious target. In Kenya, for instance, the Women's Asso- ciations are actively promoting basic family health and sanitation. Third World mothers cope marvellously well with their family's health in trying cir- cumstances, but they probably need to be told about the benefits of fresh water and sanitation. They may not be aware that diarrhoea (which, according to the 1975 World Bank report, was the leading identifiable cause of death in Paraguay, Guatemala, and El Salvador) can be cured by administering a simple sugar and salt solution to replace lost body fluids, and that there is no need for ex- pensive drip treatment in hospitals. Again, people may have to be encouraged to act together to construct a simple tubewell pump, since the only pumps in operation may have been ones owned by rich farmers. "Community development" implies appropriate tools or technology—anoth- er catch-phrase. But the acid test of tech- nology is whether villagers will in fact use it. Well-meaning aid programmes have introduced latrines into villages, only to find that they are not used— because they are malodorous, have to be emptied, are uncomfortable to use, and draw public attention to a bodily func- tion which many prefer to perform at night. The British development agency OX- FAM has designated a latrine currently in use in Viet Nam as one of the best avail- able in the Third World. It cuts down disease, and also turns human excreta into organic manure, producing some 600,000 tons a year. After 45 days, when the excreta has been rendered bacteria- free, it can be removed from a hole in the back of the latrine. In the Republic of Korea, human excreta is turned into methane gas, for use in 50,000 rural households. One reason why the community should be involved from the earliest time in decision-making is the problem of maintaining pumps and latrines. These services, in fact, again raise the dilem- ma—who should pay? WHO's policy is in general that the communities should share the costs, partly in order to in- crease their sense of responsibility. And yet, having the poorest pay for the ser- vices which should ideally be free seems to be a contradiction. This problem had to be overcome in one of UNICEF'S most successful pro- grammes—to install tubewells in Ban- gladesh, a country where more than 60 per cent of all disease is caused by pol- luted water. Bangladesh is peculiarly vul- nerable. It is washed by three huge rivers, and in the monsoons 70 per cent of the country lies under water. Too much wa- ter means flooding, yet too little means drought. And because the country is so flat, there is no possibility of preserving the water for use in the dry season. Changing priorities In most countries at the most senior level—the government it is not so much a question of the amount of money as a question of priorities. Even though the benefits stemming from having a healthy population are now well-estab- lished, it is as difficult for a government to direct sanitation and water services towards the poor as it is to change health priorities from city-based hospitals to rural health centres. Their difficulties may increase if government economists regard such services as "pouring good money after bad", and suspect that "community development" is another way of saying they will have no further control over how the money is used. Then there are the problems of admin- istration. Whose responsibility is wa- ter—that of the health ministry or of agriculture, or of a separate department? If water is going to be shared by several ministries, there will clearly be problems of coordination. But if it is going to be under a separate administration, other concerned ministries may well argue that they should no longer be involved. Yet most countries which have rated water and sanitation a priority are setting up separate administrative systems. One fact stands out: where govern- ments have committed themselves to the objectives of the Water Decade, particu- larly with the active collaboration of vil- lage communities, improvements have been substantial. In the Dominican Republic in 1961, 43 per cent of the ur- ban, and 83 per cent of the rural popula- tion lacked safe drinking water. The government set up a National Drinking Water Institute and the situation began to improve.. "There was no single factor involved," says one WHO official. "It had a proper institutional structure; proper training of staff; built-in flexibility; cooperation between ministries and coordination of resources; tight techni- cal supervision; dynamic community or- ganization." Similarly, Brazil has created a national sanitation plan and the National Hous- ing Bank has been given the task of pro- viding funds. The target is to provide 80 per cent of running water for the urban population by 1980. In the old crowded streets of Ibadan, Nigeria, a "family group" of between 100 and 1,000 people makes an applica- tion to the Ibadan sewerage authority, and undertakes to provide land, labour, and running costs. The Government then constructs "comfort stations", with one toilet and shower for every 25 people. But governments by themselves can- not be expected to carry the burden of in- creased investment. Part of the contribu- tion to the Water Decade from interna- tional agencies will take the form of greater coordination. With WHO and the UN Development Programme taking the lead, collaborative action will involve the World Bank, UNICEF, the Food and Agriculture Organization, the UN and the ILO. This in turn will seek to mobilize external cooperation for the Decade from bilateral and multilateral agencies. Within each country the UNDP resident representative will coordinate the needs. Each agency will continue to perform its special function, but the net results will be a much greater degree of coordi- nation. One other important form of coopera- tion was recommended by the Mar del Plata Conference, and that was regional cooperation. This will take the form of strengthening the water commissions in the various regional UN economic com- missions, and also making greater efforts to share common water. Whether such sharing actually hap- pens could determine whether govern- ments have the will to make the Water Decade a reality. Countries downstream argue that they are at the mercy of those upstream, which can turn valuable water on and off at will (by closing dam sluices), or may cause pollution and con- tamination which is beyond their con- trol. Countries upstream argue that they cannot be constrained by considerations outside their own frontiers. Agreements such as that between Bangladesh and India over the Farraka Dam across the Ganges, or between Brazil and Paraguay over the Parana River, suggest that international cooperation is indeed possible. ■ 5 Cholera in the Gilberts This outbreak opened the eyes of many health authorities in the South Pacific and started them thinking. More emphasis may be placed on good sanitation and water supplies in the future BY TIN MAUNG MAUNG 1111=11111 t was a pleasant morning when the doors of the Tungaru Central Hospi- tal in Tarawa, Gilbert Islands, were thrown open to the public on 3 Sep- tember 1977. An open day for the hospi- tal meant that the staff were busy wel- coming their guests and showing them around the wards. Food and drinks were served and the staff collected some dona- tions to improve the hospital. The au- thorities never realized that a dramatic event had begun—the first epidemic of cholera to affect the South Pacific— which would keep everybody much busier than the festivities they were wit- nessing that morning. Four days earlier, on 30 August, an adult woman from Teaorareka Village, Tarawa, was admitted to the hospital. She was in a very dehydrated condition, but nobody suspected cholera. The dis- ease had never been known in the South Pacific Islands. By Monday, 5 September, the first sus- picion of an epidemic of some sort arose. Seven patients with similar symptoms had been admitted to the hospital. Dr Teimone Flood, Chief Medical Officer for the Gilberts, Dr Tawita Tira, Senior Medical Officer for Public Health, and Dr Adrian Roberts, the Physician Spe- cialist at Tungaru Central Hospital, all considered cholera for the first time. However, the more common illnesses such as food poisoning or fish poisoning were still in the minds of the medical authorities. By chance, Mr Ah Yew Eng, WHO Laboratory Technical Officer, happened to be in the Gilberts to follow up the tuberculosis situation. Mr Eng and Mr Mantaia Tebuae, a National Labora- tory technician, began examining the stool specimens. All the established tests (including morphological studies of colo- nies grown on different culture media, agglutination tests using chicken blood, and indole motility tests) gave positive results suggestive of Vibrio cholerae. However, no final conclusion could be made because there was no available stock of anti-cholera sera for specific ag- glutination tests. Specimens sent to Guam and other places later reported V. cholera, biotype El Tor, serotype In- aba. South Tarawa has an estimated popu- lation of 20,000. It is composed of a string of atolls all connected by cause- ways, except for Betio (estimated popu- lation 8,000) which lies at the extreme west end of the atolls and is separated by approximately a mile of shallow sea. The Government reacted by imposing a ban on inter-island travel to the other 15 island groups as soon as the epidemic was recognized. However, Tabiteuea North and the two smaller islands of Abemama and Abaiang were presently affected. The spread of cholera usually cannot be stopped by a travel ban. Moreover, an international travel ban would be in excess of the International Health Regulations. In these territories strung from north to south across the Equator, the general sanitation is poor, especially in such densely populated areas as Betio and Bikenibeu. (One small village—Tangin- tebu—which has very good sanitation and a private water supply did not have a single case of cholera.) Local councils are responsible for gar- bage collection but this tends to be poor- ly organized. Garbage remains uncollect- ed for days, and unsupervised dumping of rubbish is frequently done in order to reclaim land along the coast. There are a few water-seal latrines connected to septic tanks. These are mainly in government quarters and a few dwellings. Public latrines, most often along the lagoon side rather than the ocean side of the atoll, are often to be found stationed over shallow water. As a result, in some places there is no water below the latrine at low tide. To make matters worse, many people do not use the toilets but defecate along the edges of the lagoon. Gastroenteritis has been pre- valent in the past and about 50 stool spe- cimens a month used to be sent to the laboratory for examination—though not for cholera. Fly breeding was uncon- trolled and fly density was very high at the start of the epidemic. In addition, this period coincided with the season for the ripening of breadfruit and pandanus fruits. The water supply is inadequate. Water from shallow wells is pumped through a reticulated water main. In South Tara- wa, the water flows from east to west, ending at Betio atoll, off the main island chain. It is supposed to be treated along the way, and at Betio before re-distribu- tion, but the treatment is poor at best or non-existent at times. The lagoon is greatly polluted by rubbish and sewage. Water samples taken from the lagoon water during the epidemic showed the presence of V. cholerae. People swim in the lagoon but usually a little distance away from the public latrine. All in all, the environment in the Gil- bert Islands was ripe for the spread of an organism like V. cholerae. How was it introduced ? Not one of the severe diarrhoea cases reported at the outset of the epidemic The nurses worked devotedly and without any rest, preparing oral rehydration fluids and tending patients. (Photo WHO/Tin Maung Maung) 6 g-101p4:, A ‘ +•-` 1" , - '' .kkl‘ili A4,:1144ki tttt SAL had travelled abroad. The organism may have been brought by an innocent and unsuspecting carrier or by a mild case. Who they were or where they came from will never be known. They may have been local residents returning from abroad. Gilbert Island men work as seamen on ocean liners plying through the South-East Asian ports and frequent- ly return by air when on home leave from any port in the world. It is quite likely that the suspected carrier or carriers came from among them. Once such a carrier or mild case enters the islands, there is no way of knowing until an explosive outbreak occurs. This could happen when considerable num- bers of cholera organisms enter the water main, resulting in the simultaneous oc- currence of cases—some mild, some even symptomless, but some like the adult woman who was admitted to hospital for severe diarrhoea and dehydration as de- scribed earlier. How many symptomless or mild cases occurred before the first case was admitted is not known and will never be known. Meanwhile, contamination of the en- vironment had occurred as was seen by the presence of V. cholerae. As usual, the water supplies were investigated first and cholera vibrios were found. A check on the lagoon water located cholera vibrios near the public toilets and as far as a hundred meters away from them. There was no doubt that not only the water in the lagoon was contaminated but also the marine life in it. It was therefore hardly strange that those who ate raw shellfish from the lagoon were infected. However, this does not mean that only the eating of raw shellfish will cause the disease. People who swam in the lagoon were also at risk, and infection could take place even without visiting the lagoon or eating raw fish. It was spread on land by the insanitary environment, contaminated water and food, and the swarms of flies. Everyone was exposed; why some got the infection while others did not may have been due to the num- ber of infective organisms ingested, the virulence of the organism, and the sto- mach acidity at the time of infection. Controlling the outbreak The Gilberts Government immediate- ly formed a Cholera Co-ordination Committee at the highest level, with the Chief Medical Officer as its chairman. Assistance came from the South Pacific Above : Mass vaccination against the cholera outbreak did take place but not much emphasis was placed on it. Right: Public latrines were frequently sta- tioned over shallow water, so that often there was no water below the latrine at low tide. ( Photos WHO/Tin Maung Maung) Commission, the New Zealand Govern- ment, the Australian Government and the World Health Organization. Doctors already in service carried out round-the- clock duty, led by Dr Adrian Roberts, who treated the incoming patients at the Tungaru Central Hospital. Gilbertese doctors and nurses worked devotedly and without any rest to tend the patients at their bedside, preparing oral rehydration fluids and treating con- tacts in the villages. Besides oral rehydra- tion, intravenous infusion was available as the need arose. Patients received tetracycline in doses of 500 mg. at six- hourly intervals for five days. A cholera surveillance unit was orga- nized and took responsibility for collect- ing all data. It also followed up the con- tacts of all patients and ensured that they were treated with a prophylactic dose of 8 tetracycline—half that for the patients but lasting for the same duration. Improvement of sanitation was the main aim of the control programme, which found better methods of rubbish disposal and instituted controlled dump- ing. A health education campaign urged the public to be more hygienic in its habits, especially during the epidemic. Water should be boiled before drinking, people were told, and they received ad- vice about better food sanitation. One of the first actions was to take wa- ter samples from many sources to test their chlorine content and potability. The authorities spared no effort to im- prove sanitation and prevent pollution. Public toilets were cleaned and disinfect- ed. Everybody was advised not to eat anything raw, particularly seafood and raw shellfish from the lagoon. Mass inoc- ulation did take place but not much em- phasis was placed on it. The epidemic that appeared to have started at the beginning of September reached its peak in South Tarawa on 16 September (45 cases) and declined thereafter. Observing the data further on a weekly basis, it can be seen that the largest number of cases were admitted to the South Tarawa hospital during the weeks ending 14 September and 21 Sep- tember (174 cases and 189 cases per week, respectively). The highest number of cases within any seven-day period was 232 cases during the week commencing 12 September. The total number of cholera-like cases admitted between September and the end of December 1977 was 902 cases, of which 270 were confirmed as being caused by V. cholerae. There were 11 deaths in Tarawa that seemed very likely due to cholera as shown by the clinical signs, although none of them were proved by laboratory diagnosis. Of the other islands in the Gilbert IS- land group, Abaiang had 39 cholera-like cases of which seven, all from the same household, were positive for V. cholerae. In Abemama, with a population of 2,300, 18 cases were notified, of which 12 were confirmed. Cholera spread to Abe- mama through school children returning from South Tarawa before the ban on inter-island travel. Tabiteuea, a large island 300 miles (500 km) south of Tarawa, was affected with cholera on 25 September, probably as a result of illegal travellers landing by canoe. Among a population of 3,942, a total of 110 cases were notified, of which ten were bacteriologically confirmed. Throughout the Gilbert Islands, by the end of 1977, a total of 1,102 cholera-like illness cases had been admitted for treat- ment. There were 299 cases confirmed and 21 deaths were attributed to cholera. Although 327 more cases were notified during the first quarter of 1978 and 46 were confirmed, there were no deaths. On 4 May 1978, the authorities in the Gilbert Islands, in accordance with In- ternational Health Regulations, declared the Gilberts to be free of cholera. This followed the third successive ten-day period without any confirmed case. Three more cases occurred up to 12 May, but none thereafter. Cholera in the Cilberts has opened the eyes of many health authorities in the South Pacific and started them thinking of being prepared against this disease. Poor sanitation frequently rates a men- tion in association with diseases, but many authorities ignore it or neglect to give it the priority it deserves. The out- break in the Gilberts should help to change the priorities, and more emphasis may be placed on good sanitation, sew- age disposal and water supplies in the future. ■ 9 The locust war BY STANLEY BARON inpointing the origins of a locust plague is rather like locating the proverbial needle in a haystack—if you can imagine a haystack mea- suring a third of the world's circumference in length and a few thousand kilometres in width; in other words, the area of the great belt of deserts where this insect breeds. The affected area stretches from the Western Sahara to the Nile, from the Nile to the Horn of Africa and the Red Sea, across all the Arab kingdoms, sheikdoms and republics (and also Is- rael) to Iran and thence on through Afghanistan, Pakistan and Northern India. These gigantic wilder- nesses, consisting of sand, bare rocks, arid moun- tains and seemingly endless gravel plains punctuat- ed by rare oases and a few stunted trees, have formed a retreat through the centuries for one of the world's most indomitable creatures Schistocerca gregaria, the Desert Locust. Within this hostile harbourage, wherever scant rains have produced ephemeral greenery, it is able to bide its time for years, barely surviving from gen- eration to generation, until Nature turns in its favour. All it needs then are three good seasonal rainfalls at the right times and places. Among the dormant plants which now burgeon it will find its food and shelter. Searching the sands for sufficient moisture, the females will lay their eggs, a hundred or more to a pod, and leave them to hatch out when they have gone. Within a year, allowing for preda- tors and other natural decimations, the original population will have multiplied a thousandfold, and this will see the beginning of the great swarms which, if uncontrolled, will overfly the desert mar- gins to sow disaster to the cultivated lands beyond. 1 0 Left: Enemy number one in the Sahel: the desert locust. Below left : A resting swarm clusters around a telegraph pole. Right: The gaunt corpse of a camel raises the spectre of famine in the land. Below right: Locusts fill the air as far as the eye can see, threatening both beast and man. ( Photos FAO/WHO) 11 SOW The locust war With hindsight, it can now be guessed that this is what happened in Southern Arabia two years ago. Small swarms es- caping from relatively minor spraying operations in the Saudi Arabian coastal deserts found fresh rains in Oman beyond the Empty Quarter. There they remained undetected until a British ento- mologist, Ken Guichard, taking part in the Oman Flora and Fauna Study near Salalah during the autumn of 1977, was surprised to discover the body of a pink- winged insect about five cm long with a ten cm wingspan. Though not a locust expert, he was knowledgeable enough to realize that pink in the cuticle could only mean that it had recently fallen out from an immature swarm. Boxing up his specimen, he airmailed it to Jeremy Roffey, chief of the Desert Locust Information Service at the Centre for Overseas Pest Research in London. To Roffey it signalled an immediate alarm—one he had half-expected since earlier reports had told of a midsummer cyclone pouring torrential rain on to the Oman coast and hinterland. The pink locust in the matchbox confirmed that this must have been followed by further heavy breeding. He warned the Locust Office of the Food and Agriculture Or- ganization (FAO), which co-ordinates control and information in Rome, that the resulting swarms could be expected to move westward. Around the same time there was also news of breeding in Yemen and Demo- cratic Yemen, and again in Saudi Ara- bia, as well as on the western side of the Red Sea, where locusts invading Western Sudan are suspected by Roffey to have originated in Tripolitania, far away across the Sahara. There was thus, so to speak, a pincer movement on two fronts; one from the east, the other—possibly more significant—from the west, both converging on the southern end of the Red Sea and the Gulf of Oman. It was the Oman swarms, migrating on the winds of a second cyclone, this time blowing up the Gulf, which were to prove disastrous. Having reached Soma- lia, they found not only good rainfall en- couraging further breeding but a war raging which made effective control im- possible. In Eritrea, torn by rebellion, there had also been heavy rain followed A long grim battle is in prospect, affecting the welfare of some 300 million people. ( Photo FAO/WHO) by upsurges of locusts, some probably from across the Red Sea, others local. In normal times these would have been counter-attacked by the highly efficient Desert Locust Control Organization for Eastern Africa, a regional body serving Djibouti, Ethiopia, Kenya, Somalia, Sudan, Tanzania and Uganda. But the fighting had compelled this body to with- draw from its good strategic base at As- mara to Addis Ababa, too far away to be effective. Since this part of the Red Sea basin is notoriously an epicentre for a locust pla- gue, almost irrespective of where it starts, it was no surprise when reports began coming in of swarming on a night- mare scale. Single swarms in Ethiopia were stated to be veiling the sky for 100 square miles. Since one square mile (2.6 kilometres) of a swarm contains a weight of 200 tons of insects (each weigh- ing only two grams and eating its own weight of vegetation daily) the size of the threat posed can be imagined. Not all the vegetation consumed would consist of crops, but wherever they did land on farmland the ruin would be total. (In Ethiopia in 1959, swarms which ulti- mately combined to form a single one of 400 square miles ate food enough in six weeks to feed a million people for a year). Again on the move By June the plague had developed in strength in Pakistan and India and by late summer the Somalian locusts which had been temporarily checked by adverse winds were again on the move out of the Horn of Africa toward Kenya. In all these regions there had been good rains (good, that is, for the locusts). Signifi- cantly, also, there had been above aver- age rain in the Air district of Niger, just south of the Sahara and there, too, breeding had started. Are we, then, in the same situation as occurred in the past, when the swarms proved unstoppable and plagues raged on for years? The cautious answer must be "Not necessarily". Much more about the ways of the insect has been learned since the last great plague ended 15 years ago, and techniques of control have been im- proved. Nevertheless, a long grim battle, dur- ing which the welfare of upwards of 300 million people will at various times be at stake, is in prospect. Certainly dur- ing the coming year a great deal will depend on whether or not the weather over this vast zone continues to be in the locusts' favour. Rains like those which brought floods and reported cholera to Northern India last autumn could tip the balance if repeated elsewhere. Nor need they be so heavy, for Schistocerca gre- garia is Nature's supreme opportunist among insects, able to fly 5,000 kilome- tres in a single swarming migration and capable of keeping going for long spells without food at all. The control of so well-endowed an insect enemy is there- fore abnormally difficult. Yet for its numbers to be significantly dented a kill of at least 95 per cent is necessary. Other species of locust are to be found in all except the wetter parts of the trop- ics and sub-tropics and in some temper- ate parts of the world. Compared with the Desert Locust, most of them can be fairly easily controlled. Two of the most damaging species in Africa, the Red Locust and the Migratory Locust, have been held in check since it was dis- covered that they bred in certain well- defined flood plains. The story of the pre-war discovery of the Red Locusts' breeding area among the headwaters of the River Niger is in particular an unsung saga of triumph over adversity by a young British ento- mologist, 0. B. Lean, who came near to dying in his search. Lean later joined FAO as a Locust Officer and it was he who, with Sir Boris Uvarov, the "Grand Old Man" of the locust world, laid the foun- dations of the present control system: seek, observe and, at the right tactical moment, spray. Among all species, the most serious in its economic harm, and certainly the most difficult to combat, is the Desert Locust. As well as having no specific breeding place, it has, so to speak, a second line of defence—a virtually uni- que ability to present extreme changes of coloration, behaviour and even body dimensions, depending on which phase it is in. During the "solitarious" phase of the recession periods, the most a recon- naissance team may see is an occasional flash of wings of an insect disturbed in a thicket of annual flowering plants or perennial grasses. Its colour, if a team member catches sight of it, will be green or neutral, between grey and brown. Its flight, not much more than a long hop, will be short during daytime, as though it were saving its energies for the longer flights, made mostly by night, which will be necessary when the vegetation dies. 13 Mating appears to be largely a matter of chance encounters. Otherwise when they come face to face, most desert locusts in the solitarious phase will in- stinctively recoil. For a long time it was thought that locusts in this phase were of a different species to those found swarm- ing, when they are not only hideously gregarious but have changed colour, through pink and brick-red, to bright yellow. Recognizable changes are equally clear in the pre-fledging stage, when bands of gregarious hoppers, sometimes miles wide, can do much damage. It was Uvarov who cracked the mystery of the phase change, and it is thanks largely to his work that control teams now seeking the enemy know with some precision what they are looking for, where to look for it and when and where to strike. Studies of the prevailing desert winds have also played a significant part by clarifying the seasonal patterns of swarm movements and this too has made con- trol easier in theory if not always in prac- tice. Unfortunately, human nature being what it is and since other agricultural problems loom larger when recessions of the plague occur, it is easy for even the best-contrived control system to break down, especially in poor countries with small resources. Experienced operatives are called away to other jobs, vehicles and planes equipped for spraying deteriorate and are not replaced, stocks of expensive pesticides like dieldrin and malathion (the most effective killers) run down and, most important, the need for perpetual vigilance is sometimes forgot- ten. This is clearly what happened in some regions during the 1963 to 1977 recession. Not surprisingly, the new outbreak caught a number of nations unprepared. Yet the cost of an uncontrolled plague is enormous not only in direct losses of crops, which can be measured, but also in terms of health, which cannot. Histor- ical accounts linking locust plagues with famine and pestilence are not the sort to satisfy a statistician. Nevertheless the de- scriptions of the Eighth Plague in Ex- odus, as in other chapters of the Bible de- scribing the events of 3,500 years ago, are extraordinarily precise, even to saying what the insect looked like and how it behaved. There can be little doubting the validity of other reports given by many later historians. Saint Augustine's ac- count of a plague in Roman Africa is one of the earliest in which pestilence is stat- ed to have been a consequence. The air having, he said, been "putrified" by the rotting bodies of drowned locusts piled 14 The locust war Left: The armaments that can be deployed against the insect pest vary according to the location. Where the spraying of insecticides from low flying aircraft or from ground level is not appropriate, anti-locust poison may even be scattered by hand. Unfortu- nately, whatever method is used, the need for perpetual vigilance is sometimes for- gotten. Right: Mating appears to be largely a matter of chance encounters; otherwise most desert locusts in the solitarious phase recoil from each other. But when they swarm, they are not only hideously gregarious but they change their colour from pink and brick-red to bright yellow. (Photos FAO/WHO) in masses along the coast, 800,000 people died. The phenomenon of swarming locusts blown offshore to drown, proba- bly at the end of long migrations, then piled up by the waves to a height of sev- eral feet along a front of many miles, has been noted on the Red Sea coast in mod- ern times. Although Saint Augustine's estimate of the dead populace seems sen- sationally high, it is not impossible nor even out of line with some modern famine figures. The probability is that the true cause of death was typhus fol- lowing famine. Other writers, describing other pla- gues, have said that the dead locusts caused an epidemic among animals feed- ing on them and that many people died of eating infected meat. Here again there is a modern parallel. In India, local famines caused by locust outbreaks have in the past been exacerbated by the pre- mature death of livestock for which there was no normal feeding stuff except sparse pastures containing sodium ars- enate, formerly used against hopper swarms. The belief that water-borne epidemics have originated in wells and springs, con- taminated by the rotting bodies of locusts has been repeatedly reported. Bubonic plague and typhus have both been associated, in the minds of people throughout the ages, with locust plagues which immediately preceded them. To sort out the truth is impossible without direct evidence. What is certain is that people weakened by famine are highly susceptible to epidemics and that locusts have often been an indirect cause. In its hazards to health, as in other fields, the possible long-term effects of the present plague are virtually impos- sible to assess. One can only say that they will be great. Much money is now being poured in with the object of strengthen- ing national and regional control efforts. FAO has used an emergency reserve. The Arab Bank for Economic Development in Africa has signed an agreement to pro- vide US$ 15 million to 11 African coun- tries. Bilateral assistance in the form of pesticides, planes, trucks and spraying vehicles will be coming into increasing use, but whether on a sufficient scale for an early turning of the tide has yet to be seen. The truth is that the Desert Locust provides a litmus-paper test of man's wil- lingness and ability to cooperate not only during emergencies like this but after them. Without sustained cooperation and vigilance, it will always be the enemy at the gate for the 60-old nations on whose territories it preys. ■ 15 19 Women-Power in Korea Founded only ten years ago, mothers' clubs in the Republic of Korea now have more than two and a half million members, and are helping to change age-old social attitudes towards women BY JOSE C. ABCEDE popular proverb, invoked for centuries to silence women and keep them out of community affairs has now been discred- ited in the Republic of Korea, thanks to effective village development work on the part of rural women during the past ten years. "Misfortune falls upon the house in which the hen crows like the rooster", says this proverb and, as an old folk say- ing, it has finally shaped attitudes and beliefs. In the male-dominated Korean society, it contributed in no small way to perpetuating the rather low status of women in the country. By tradition, Korean women were considered "inside persons". They were discouraged from taking part in any out- side matters. However, they had their own informal and co-operative activities, the most important of which was the kae or money club. Since 1961, several at- tempts have been made to organize vil- lage women and encourage them to take part in development activities. The year 1968 was considered a turning point when the Planned Parenthood Federa- tion of Korea (PPFK), with the backing of the Ministry of Health and Social Af- fairs, began transforming traditional women's groups into official family plan- ning Mothers' Clubs. In a manner of speaking, women in Korean villages have been "crowing" more than the "roosters" since 1968, and no misfortune or ill wind has fallen upon the households of the land. Instead, prosperity and good fortune have become apparent in many homes all over the country. The PPFK started the mothers' clubs mainly to expand family planning activi- ties, and the immediate purpose was to facilitate the distribution of oral con- traceptive pills. By mid-1977, nearly 70,000 clubs had been organized in com- bination with the New Village Move- ment, with a total membership of over 2,500,000 women. Their activities have covered the full range of village improve- ment, from family planning, nutrition and sanitation to village banks and elec- trification. A visit to some of the villages offered a clear view of the significant changes brought about by the women's groups. Mrs Kim In Sook, Mothers' Club leader at Chultongwon li, in Chunsong county, explained that the club provides opportunities for village women to get together to talk about health, children's education and improving the environ- ment. The club helps in family planning, vaccination and treatment of emergency cases, as well as organizing group labour during planting or harvest time. Savings union The women of Chultongwon li were able to start a savings union and a village co-operation store where they sell food and such household items as cooking utensils and soap. With their earnings, they were able to put up enough funds to bring electricity to the village. Commu- nal cooking for village affairs or group labour is now done in a screened, white- tiled communal kitchen. In less than two years' time, all the 22 mothers' clubs in Chunsong township had their own club banks, with deposits totalling more than US$ 24,000, each club averaging about US$ 1,100 and the most successful one having $ 5,000. The funds have been used to improve village amenities and provide water supply, vil- lage kitchens and electricity. With the participation of the Institute of Public Health at Seoul National University, the mothers' clubs in the Chungson area have also collected infor- mation on births, sickness and deaths, and have started operating a community- based health insurance scheme. Like other active rural leaders, Mrs Kim In Sook devoted about ten days a month to club activities. The women—whose average age is 36 years— do not receive compensation, but they consider the social recognition and pres- tige as an adequate return for their invol- vement in community work. Mrs Kim goes about the village on a bicycle, which one Korean male doctor based in Seoul described as a "revolu- tionary change". Ten years ago, he com- mented, it was not socially acceptable for women to ride bicycles. "Usually most Korean husbands think of family planning as a woman's job", Mothers' Club members at Chultongwon li now do the catering for village meetings in a clean, white-tiled communal kitchen. (Photo WHO/J. Abcede) 16 ,, r Mrs Kim said. The flow of information on family planning was therefore from the women to the men. In her case, she was the one who introduced the idea of family planning to her husband. This probably accounted for the quick accep- tance of the club when it was set up in October 1975. Only six out of the 22 members had to ask their husband's per- mission to join, but "no husband can ob- ject now". To enlist the support of the older peo- ple, the club organized a community gathering where they provided entertain- ment and food for the old folks. Group pressure and the obvious benefits derived by the community eventually broke down any resistance to the women's organization. The story of Chultongwon li is repeat- ed in almost all the 30,000 clubs in the Republic of Korea. From purely family planning activities, mothers' clubs branched out to home improvement, nutrition, sports and athletic competi- tions, village fairs, agriculture and other village development efforts. Positive recognition Mothers' club programmes have pro- liferated, until today almost all Korean Government agencies have their own sort of women's organization in the vil- lages. This is viewed as positive recogni- tion of women-power in the country. In order to harmonize all these various rural undertakings, the Government started to group them all under the Sae- maul or New Life Improvement pro- gramme. Two conclusions from well-document- ed studies on the Korean mothers' club deserve mention here. Writing in "Studies in Family Plan- ning", a publication of the Population Council, Dr Hyung Jong Park says : "It would be incorrect to suggest that the Mothers' Club Programme 'caused' rural mothers to adopt family planning and lower their fertility. It is more realis- tic to conclude that the clubs supported, complemented and enhanced the psycho- logical, social and economic changes that were already in process. The mothers' clubs were organized when they were most needed by both village women and the family planning programme. " . . . We should not expect rural fami- lies to have smaller families by merely promising them it will improve the quali- 18 Women-Power in Korea Milking the cows (left) and listening to a lec- ture on health care (right). From purely family planning activities, the mothers' clubs of the Republic of Korea branched out into home im- provement, nutrition, agriculture, village fairs, sports and athletic competitions, and other community development efforts. ( Photos WHO /J. Abcede) ty of their lives. The order in which change occurs is crucial. People first need to experience some improvements in the quality of their lives, ideally through their own efforts, and then see for them- selves the potential for more improve- ment if they have smaller families . . . "Beyond supplying basic services, one of the primary tasks of family planning programmes should be to provide the support and opportunity for such a chain reaction of changes to take place more easily. The Mothers' Club Programme has made a significant contribution in this respect to the family planning pro- gramme of the Republic of Korea." July El-Bushra and Susan Perl, writing about the programme for the Interna- tional Planned Parenthood Federation (IPPF), concluded that "the mothers' clubs have made significant impact on the gen- eral understanding and practice of family planning in rural Korea by demon- strating in practical ways how family planning is inseparably linked with planning and working for the future well- being of the community. This has been possible, essentially, because the mothers' clubs, though linked to national pro- grammes, are a genuinely grass-roots community network which owes little to outside administrators or planners. "The growth of women's clubs in Korea has coincided with considerable changes in social attitudes towards wom- en. The trend is towards greater recogni- tion of women's contribution to the com- munity, better communication between husband and wife, and more open dis- cussion of family planning matters. Whether the mothers' clubs have helped to make changes possible, or the reverse, is difficult to assess, but it seems clear that the enhanced status of women and the growth of mothers' clubs have gone hand-in-hand and are contributing signi- ficantly to the development of rural com- munities in Korea." Dr Lee In Ho, a professor of history at Korea University, commented that the growth of women's clubs is very signifi- cant. "The phenomena appears nation- wide and is coming from what is consid- ered to be the more conservative segment of the nation—the rural areas", she told me, and added that she sees women's clubs as very important "because they can be utilized effectively in breaking down the built-in prejudice against the female." ■ 19 Which medium for the message? BY DIANA GIBSON Press, radio, television and other media could be used much more advantageously to promote better health, and to encourage greater use of the existing health services ass communication media make little contact with most of the people of our world. Health information in particular cannot penetrate to where it is most needed because of poverty, illit- eracy, technical barriers, language prob- lems, and a wall of mistrust and suspi- cion dividing doctors and journalists. These were some of the findings at a workshop on "Medicine and the Mass Media" attended by 19 doctors and four radio and television producers from 20 countries of Africa, Asia, the Middle East and Latin America. Organized by the Carl Duisberg Gesellschaft in coop- eration with the Medical Women's Inter- national Association and the German Medical Women's Association, and financed by the Federal German Minis- try for Economic Cooperation, the workshop took place in Berlin (West) just prior to the MWIA congress on the same subject. According to the doctors and journal- ists present, the communication picture is equally grim in many parts of the deve- loping world. The press, television and even radio are city luxuries rarely en- joyed by that vast majority who live far from the bright lights. To take some ex- amples, 70 per cent of Bolivians live in localities of fewer than 200 people. In the Philippines, two-thirds are rural. In Sier- ra Leone, the majority live in remote areas where modern communications are only developing. In Lesotho, most wom- en and children are subsistence farmers (the men work away from home in South African mines) and 15 per cent of them must walk 14 hours or more to reach a health facility. The workshop included an exercise on how to use radio, television and the press to support a health campaign. Televi- sion, with its visual punch, was agreed to have the greatest potential for health in- formation. Yet with possible exceptions such as the Republic of Korea, where there is a large TV screen in many vil- lages, television sets are few and far be- tween in most developing countries. They are usually restricted to the towns, Vivid posters advertise popular films in an In- dian city. The cinema has not yet been Ally exploited as a vehicle for health information. (Photo Claire Minnaert (0) and their high cost puts them way beyond the pocket of most people. Even newspapers and magazines, also basical- ly a town medium, cost too much for the poor to buy them on a regular basis. Of the three main media, radio pene- trates furthest. In Malaysia, there is a radio in every rural house, often the only form of contact. But in other countries even radio has its limits. In Bolivia it reaches only 40 per cent, in Thailand 70 per cent. In Ghana there are few sets in the rural areas, in Sierra Leone the poor don't have them. A third of the rural population in Sri Lanka do not listen to the radio because even transistors are too expensive. In Lesotho there is a problem of reception. Some people can't get radio broadcasts at all, either because there is no electricity to power relay stations or because the high hills and deep valleys act as an effective natural barrier. "You don't have to be literate to listen to the radio", said some workshop par- ticipants, a point of great importance. In Guatemala, Senegal and Sierra Leone, the majority are illiterate in the rural areas. Sri Lanka is better off, with only 20 per cent unable to read and write. Certainly all this gives an advan- tage to radio as well as to information media that rely on pictures, such as pla- cards and posters, slides or filmstrips with commentaries, folk dramas and puppet plays. Ghana uses travelling cine- ma vans in the rural areas, though these suffer from technical troubles in the form of bad roads and the lack of spare parts. Person-to-person Illiteracy is also a reason why several participants felt that person-to-person contact—"word of mouth communica- tion by people in their immediate envi- ronment whom they know and re- spect"—was best for rural areas, though this is not strictly speaking a mass medium in the usual sense. Many of the doctors present had personal experience of this: they try to begin every consulta- tion with a few minutes of health educa- tion, even if they see 500 people a day. In some countries health questions are dis- cussed in groups in religious or commu- nity centres. Demonstration is another person-to-person method. The cultural background of media au- diences varies enormously, even within individual countries. In Brazil, reported one participant, some people still live in the Stone Age. "Modern civilization problems are of no interest to them", she said. "They understand that their life still has values which others have lost total- ly." Sometimes there are cultural taboos on discussing certain health subjects in public. In Kenya, for example, it is not acceptable to discuss pregnancy or venereal diseases openly on the radio or TV. Respecting the culture is a delicate matter that poses a special challenge to the media. Side by side with differences of culture go differences of language. In Bolivia, most of the people are Aymara or Que- chua and speak those languages, but oth- ers speak Spanish. Guatemala uses Span- ish and five dialects. Sri Lanka has three languages, Sierra Leone several. In Sene- gal, radio programmes given in Wolof are repeated by regional stations in the local dialect. In Ghana, announcements over the radio in English are followed by translation into the eight other officially recognized languages. Lesotho is a rarity in that its people, the Basotho, are united by one language, Sesotho. Medical terms can be difficult to trans- late satisfactorily into everyday words in a vernacular language. This is linked with another prickly problem, the jour- nalist/doctor conflict. On the one hand, journalists anxious to promote health in- formation in the media complain that doctors use an incomprehensible jargon, don't know how to express themselves in simple language, and are "too busy" to answer questions. The doctors for their part claim that they are tremendously busy just doing their work, and that tele- vision producers are liable to keep them waiting around in studios, away from needy patients, for hours. Too many journalists don't bother to check the ac- curacy of what they write or broadcast, they say, and give conflicting viewpoints that confuse the public, without verifying their sources. Publishers or broadcasting companies rarely bother to employ or train specialists on health subjects. An interesting aspect of the workshop was that it began with much mutual mis- trust between physicians and broadcas- ters, yet it was not long before dialogue and willingness to listen to others' prob- lems produced an atmosphere of friendly cooperation. A practical lesson that might be emulated by doctors and jour- nalists elsewhere, perhaps. The group defined three purposes for health information through the media: to encourage people to make more use of health services, to motivate them to bet- 21 ter health practices (particularly preven- tion), and to build up public opinion that will influence the authorities to provide better services. Many of those present lamented a general lack of coordination between isolated efforts at health infor- mation by either government, media or individual doctors, which leads to much wasted effort. Without coordination not only is there no continuity of effect on the audience, so that the initial impetus is lost, but the health problems dealt with are not necessarily the most relevant. In her analysis of a leading daily news- paper, an Indian delegate showed that the three most often reported problems over a year were hypertension, cardiac surgery and cancer, the preoccupations of an urban elite. "It is ironic", she said, "that in a country where malnutrition, infectious diseases and communicable diseases are by far the biggest health hazards, there is minimum reference made to these problems." Clearly the media as well as health officials bear a re- sponsibility to their audience to dwell on people's real needs. Some countries do attempt coordina- tion, however, and tackle widespread problems in a systematic way. Egypt has a High Committee for Health Education and Information chaired by the Minister of Health. Local health education branch offices organize public meetings, exhibitions, demonstrations and publica- 22 tions, and provide facilities to the mass media. They are considered to have played an important part in the success- ful 1977 polio immunization campaign. Senegal also has an office of Health Education, within the Health Ministry, which uses mainly the cinema, radio and flanellograph. In Lesotho, the Ministry's Health Programme Committee directs the twice-weekly radio health broadcast. In the Philippines, the bulk of health in- formation is done by the Government using Government-run radio and TV, as well as comics and illustrated material, particularly for the rural areas. There is a School-of-the-Air using "radio-print" : the radio lessons are supplemented by written material in the vernacular lan- guage. For subjects not covered by the Government, the medical associations' health education committees step in and fill the "information gaps". Malaysia's system is similar to that of the Philip- pines, but works on a regional basis. Feedback from the consumer and con- stant evaluation of the media's impact were heavily stressed during the work- shop as part of the two-way process of communication. "The media are the step-ladder of the people to good health", said a Lesotho delegate. But if this is to be so, people need to take an ac- tive part, and anything which stimulates a reaction from them is likely to be more effective. With radio-print, for example, the teacher or group leader can use the programme and its printed material to start a discussion. Or the audience can be encouraged to enter into a dialogue at public meetings. Whoever has led the discussion then reports back on what the reactions have been, so that producers can evaluate health information projects or revise them if they turn out to be poorly adapted to the audience or flawed in some other way. People have a natural tendency to pass on information to each other. "The 180 million literates to whom the press reaches out are after all potential health educators themselves", said an Indian delegate. So are the illiterates, said oth- ers. An Egyptian doctor told how wom- en attending demonstrations at maternal and child health centres go home after- wards and repeat the entire lecture to their neighbours. Though there are more illiterate wom- en than men, women are keen learners and respond practically to information, exerting by their example a great in- fluence on the health habits of families, friends and neighbours. Yet women, as the underprivileged among the under- privileged, are often not reached by the media. The sheer amount of work many of them have to get through in a day leaves them little time to relax and listen to the radio or read a magazine, even if they can afford them. Sometimes Which medium for the message ? Left : The silver screen flickers in the Indian night. Television can convey a particularly vivid health message, but in most developing coun- tries television sets are rare outside the large towns. (Photo WHO/UNESCO) Right : A Liberian studies a photo display about yaws. Women respond to information and in turn ex- ercise a tremendous influence on health prac- tices. But illiteracy, a heavy workload and tra- ditions that limit their social participation fre- quently prevent information from reaching them. (Photo WHO/P. Almasy) cultural practices determine what women may or may not do. In some Indian vil- lages there may be a community radio in a club; but only men can go to the club. Or women elsewhere may be excluded from attending public discussions. It is also a fact that the media cater mainly to masculine interests. This failure to reach women with health information of benefit to them and their community represents a valuable opportunity lost. "My question to this workshop", said a Malaysian rural broadcaster, "is what will be the best approach or alternatives to tackle health programmes besides always informing or teaching?" Many others asked the same question : how to entertain rather than lecturing, which bores people. In any medium the health message faces stiff competition. People who have done a hard day's work in the market or on the farm are so tired by the evening that they go to bed early. All they want to listen to is the news or mus- ic, or possibly the "soap-operas", a favourite in rural areas in the Philip- pines. In Ghana, the rural people can only be reached on a Tuesday, their day off from fishing or farming. Wherever the media are commercially sponsored—as is often the case in Latin America, for example—advertisers with their money and sophisticated techni- ques have the edge on would-be health educators. Everywhere the best pro- gramming time goes to political broad- casts, not to health. Doctors in one coun- try, who had agreed to contribute weekly articles to a Sunday newspaper, found that if something considered more "in- teresting" came up their column was rel- egated to the weekday issues and people missed it. All this means that health messages require not only better exposure but a better format if they are to attract the at- tention—and hold it. They should be simple and accurate, participants agreed, and for TV and radio short messages or slogans, often repeated, are probably best. Longer programmes are likely to hold the attention only if they are really entertaining. "Mini-dramas" make the message come alive, and local folk- dramas and puppet-plays can be used in the rural areas. Sri Lanka has used posters, bus adver- tising, banners, poster competitions, loudspeaker announcements, dramas, calendars, leaflets and printed table-mats that teach children preventive health at mealtimes. All these give an idea of the numerous possibilities still to be ex- ploited in many countries. Participants also called for the development of new low-cost methods—appropriate infor- mation technology—more suited to the pockets of the poorer societies. Other recommendations of the work- shop were that health information should be treated as an essential element of development, and that countries which have not already done so should set up some form of national institution, to define national health information priorities, devise campaigns, stimulate innovative techniques, conduct research and ensure feedback and evaluation. These institutions would comprise peo- ple from the media, the health ministry, the health professions, and other minis- tries and national organizations concerned with either health or connect- ed aspects of development. Developing countries should not concentrate their resources on privileged minorities, as the developed countries have, said the participants in this highly successful workshop. Instead, health in- formation activities should be relevant to the needs of the majority and should aim seriously to improve the lives of poor and rural people and to reach women. Yet certain governments maintain a vast gulf between the life-styles of the power- ful elite to which they belong and the poverty-stricken masses. They know that the dissemination of information, either on health or on other matters, carries with it the double danger of a growing awareness among people of their rights and a resulting demand for better ser- vices. Will those who thrive on the ignor- ance and deprivation of others dare to take this risk? ■ 23 .. s. . ., _. ., .. ' ▪ Pa.' •''''''., "*. 144. s'h - 17,•■ L 4.4. V- r - , • s . , .... .-- 141'7' 46 — I t rzt IZ— N.tiiii; '‘ :. eia.... • A."' . 4' SA '.11.14■,...' ‘ ' ....14.4thrk4514e$ ‘r-1-• ,..k... /.. , ,#. / .',.... .17-4,°. ": • r ' ' 1 .. - 4! 4#■•• ' ' , ........ ,...„ ,i .A Gonoshashthaya Kendra was founded in 1972 by a radical young Bangladeshi doctor, Zafrullah Chowdhury, now aged 37. After taking a medical degree from Dacca University, he spent five years in Britain and was within a month of taking his final exams for the Royal College of Surgeons when, in March 1971, civil war broke out in what was then East Pakis- tan. Dr Chowdhury dropped everything and rushed back to set up a field hospital to treat wounded freedom fighters. Trained doctors and nurses were in short supply. Forced to rely on girl volunteers with no previous medical training, he soon discovered the potentialities of the paramedic. After a couple of months of learning on the job, the girls were very Saving lives at Savar BY PAUL HARRISON he farmer staggers along the village path under his burden. His wife's emaciated body, draped in a coarse blue sari, is arched backwards in the rigor of tetanus. He is heading for Gonoshash- thaya Kendra, the People's Health Centre at Savar in Bangladesh. On the bed at the clinic, the wom- an's face grimaces in the familiar risus sardonicus of lockjaw. She had said she did not cut herself: but on the calloused, grimy sole of her foot, sure enough, is the tell-tale nick where the germ pene- trated. She will have the benefit of a new treatment for tetanus. Instead of pumping more than 100 am- poules of tetanus anti-toxin into the veins, just two ampoules will be injected directly into the spinal column (after excluding serum hypersensitivity), so the life-saving fluid can reach the nervous system more quickly. A female staff member makes the del- icate lumbar puncture that is required: a few drops of spinal fluid oozing out confirm her success. That staff member, astonishingly, is a para- medic, working under the supervision of a doctor. This People's Health Centre, which was one of the first projects outside China to make wide use of paramedics, or rural health workers, remains today one of the boldest experiments in bringing health care to the rural poor of the Third World. Few "barefoot doctor" programmes have dared to en- trust to modestly educated, briefly trained workers the range of functions that are routinely performed by the paramedics of Savar, from clinical pathology to minor surgery and tubectomy (excision of part of the uterine tube). And the health care they provide is financed by a pioneering village-level insurance scheme. 24 soon competent at all duties, ranging from giving injections to assisting in the operating theatre. The health situation in the new nation of Bangladesh is still in some respects reminiscent of wartime scarcity. Doctors and nurses are still scarce—even today the country has only some 8,000 doctors for its 80 million inhabitants. Three- quarters of the doctors work in the towns, but nine out of ten people live in the rural areas. The use of cheaply and rapidly trained paramedics was quite simply the only way to bring health care to the villages. Dr Chowdhury estab- lished GK, as its workers call it, on land donated by a friend's father, 22 miles north of the capital, Dacca, and set about proving that the concept could work. Today Savar's full time staff of 114 provide a comprehensive health service to a still expanding population of over 100,000. Under a three-tiered system, each level offers increasingly sophisticat- ed expertise and equipment. At the cen- tre is the health complex at Savar, with a 15-bed hospital, operating theatre, full scale pathology laboratory, a large phar- macy and a small staff of trained doc- tors. Below that come four sub-centres, each one serving about 15 villages with a population of 15,000 to 20,000. Each sub-centre too has a small operating theatre for minor surgery and tubecto- A frightened farmer carries his wife, stricken down with tetanus, to the People's Health Centre in Savar—a boldly pioneering complex that is bringing health care to the rural poor of Bangladesh. ( Photo WHO/ P. Harrison) my, the basic equipment to carry out its own pathology examinations, a small pharmacy and two in-patient beds. Working out of each sub-centre are five or six paramedics, the solid base of the pyramid. Each one spends most of his or her week in two or three villages, with a total population of around 3,000 and a radius of about five miles, easily covered on foot or by bicycle. Each paramedic works together with a trainee, who 25 watches, practises and learns from his experienced partner. To get an idea of the range of village work, I went on a day's rounds with Joseph Das, a 23-year-old paramedic with nine month's experience and 12 years of education behind him. With him was his "apprentice", Rafiq-ul-Islam, 19, a local village boy who failed his matric- ulation and was previously unemployed. Our first stop was the home of a 35- year-old mother of seven children. She had been getting three-monthly shots of the injectable contraceptive Depo- Provera for the past two years, and was suffering menstrual irregularities and spotting that were interfering with her marital life. Das gave her an iron supple- ment. On then to a house where the daughter was to be married the following week— all potential mothers in the area get an anti-tetanus injection. Islam adminis- tered it in a businesslike fashion. We passed through to the bari (compound) of a landless peasant whose only son's body was blistered with an ugly heat rash. Das had advised them to grow green vegetables, rich in iron and vita- min A, on the small garden plot around their home. At the next house one of the boys had diarrhoea. Das took time to show the mother how to make Savar's patent vil- lage formula for rehydration, devised for maximum cheapness and ease of prep- aration : just as much salt as can be picked up between two fingers and a thumb, enough gur or raw sugar to fill four cupped fingers, thoroughly mixed in a glass of water. He mixed the formula on the spot and gave it to the boy to drink: "If I tell them, they will not do it. If I show them, they will do it." Finally, we checked on the progress of a mother-to-be. Das measured the girth of her calf two inches above the ankle. He was looking for signs of the watery swelling that indicates pre-eclampsia—a condition of high blood pressure and loss of protein in the urine that can lead to premature labour and unnecessary peri- natal deaths. The calf measured nine in- ches—well above the safety level of six to seven inches. Das told her to stop taking salt (to bring down the blood pressure) and to eat more bread (for protein). On her record card he noted her expected day of delivery so he can visit her once a week in the last month, and attend the birth if need be. Simple curative medicine and first aid; motivation and provision of family plan- Above: A woman -paramedic" tests the teta- nus case for serum hypersensitivity before starting the emergency treatment that will save her life. Right: Joseph Das shows the mother of a child with diarrhoea how to prepare a rehydration solution. (Photos WHO/P. Harrison) ning; immunization; practical instruc- tion on health, nutrition and sanitation; surveillance of mothers and children at risk : these are the functions of the paramedics on their door-to-door visits. But they are also trained to make routine pathological examinations of blood, urine, stool and sputum samples; this is essential so that the sub-centres can screen out serious cases which need refer- ring to the health complex at Savar. Many of the paramedics are also adept at mini-laparotomy tubectomy (a small incision in the abdomen), menstrual reg- ulation and even abortion. Tubectomy is usually performed by female paramedics, who are preferred to male doctors in purdah-conscious Bangladesh. Savar's paramedics have carried out nearly 4,000 tubectomies since August 1974. They learn about sterilization, assist in the 26 operating theatre, and perform 10 to 15 operations under the eye of a doctor before being trusted on their own— though a doctor always has to be avail- able just in case. The infection rate in op- erations done by paramedics, at just over 5 per cent, is a good deal lower than that recorded by doctors, at 8.7 per cent. X-ray technology will soon be added to the list of skills the paramedics will ac- quire. The target is for there to be at least one auxiliary at each sub-centre prac- tised in each specialist skill. As there are not enough doctors and other specialists to go around, teaching paramedics to do these things is simply the only way to en- sure they are available within reach of the village. Under the Savar approach, therefore, the paramedic becomes a widely capable "doctor of delivery", while the trained physician becomes a doctor of information, providing techni- cal advice, supervision, and clinical con- sultancy for referred patients. "Paramed- ics are not second-best to doctors", says Dr Chowdhury, "any more than the pri- mary school teacher is second-best to the university lecturer." Yet most of the paramedics have at most ten years of education—indeed, Savar has now reduced the requirement to six years, or effective literacy in Ben- gali, as it proved impossible to find enough local girls with ten years schooling. So how does the People's Health Cen- tre work the transformation, with a basic training period of only six months? The secret seems to lie in the no-nonsense approach of learning by doing. New recruits spend their day tailing an old hand, first watching what he or she does as he explains it, then practising it under supervision, until they are finally skilled enough to do it themselves—and teach others. "The location of training should be the place where service is given", Chowdhury comments. "Reliance on hospital bedside training or training in urban institutions for nurses and aux- iliaries who will spend their time in vil- lages and shanty towns is wasteful tradi- tionalism." Savar physician Kamal Islam, who laments that no-one, during his year at medical college, ever taught him how to do an injection, says "Classes in theory take place in the evenings, and here con- cepts are simplified to their essentials, using familiar words instead of technical terminology. We want to teach them how to make a damn good injection, not what the fancy names are for the different needles." Perhaps the major problem in training, Savar has found, lies not with the trainee but with the "expert". The doctor who has been reared on high jargon with little understanding of the health needs of the majority has to re- educate himself or herself so as to make ideas and procedures understandable to less sophisticated pupils. At the end of the training period the paramedic is assessed not just for theo- retical knowledge and practical skills, but also for teamwork, sense of responsi- bility to work and patients, and reaction to frustration and emergencies. Gonoshashthaya Kendra never seems to stand still, and new ventures are con- tinually being planned. One of the most significant of these will be the opening, this year, of a US$ 2 million factory to manufacture a list of some 60 generic drugs—all of them free of patents—to supply the basic health care needs of Bangladesh. Experiments are going on, too, with a new type of latrine widely used in Viet Nam, which allows human excreta to be used as fertilizer; it is much cheaper than a bio-gas plant, which is unsuitable for poor peasants since it requires at least four cows to fuel it. Health forms only a part of the work at Savar. The People's Health Centre is quietly battling on a wide front against 27

Left: Checking the ankle of a mother-to-be for signs of the watery swelling indicating pre- eclampsia—which could result in premature labour. Right: Trainees at Savar are assessed not just for theoretical knowledge and practical skills but for teamwork and a sense of responsibility. ( Photos WHO/P. Harrison) the major causes of rural poverty and hence of malnutrition and disease. The oppressed status of women contributes to maternal and infant mortality and high fertility. Savar offers local women employment, independent income and training in jute handicrafts, carpentry and even metal work. Working with landless and marginal peasants, GK has offered low-interest loans in an attempt to break the hold of moneylending land- lords on the rural poor. And in 1977 a People's School was opened for the chil- dren of the poor who did not attend government school, offering them a practical, down-to-earth education rele- vant to their real needs. Because of its radical approach, Gonoshashthaya Kendra has not always had a smooth run. Local imams (Mos- lem priests) have railed against the eman- cipation of women, landlords against cut-price loans, quacks and doctors against paramedics and preventive medi- cine. One Savar worker, Nizamuddin, was brutally murdered in November 1976 in the village of Shimulia, at the instigation—Dr Chowdhury is con- vinced—of a coalition of powerful, local, vested interests. But patient work and effectiveness have clearly won the allegiance of the vast majority. Maternal deaths and diarrhoeal diseases are now extremely uncommon in the Centre's catchment area. The proportion accepting family planning is double the national average of 15 per cent. Death rates, birth rates and population growth rates are all ap- preciably lower. Several of Savar's lessons have been applied by the Bangladesh Government, which now uses women widely as family planning and multipurpose health work- ers. Last year it began a scheme to train 9,000 "village doctors", in a one-year course, to provide a level of health care intermediate between the village health worker and the physician concentrated in administrative centres. For other countries, Savar offers an object lesson in the bold training and use of paramed- ics, and in the need for administrators to be aware of the social and economic con- text in which health care takes place. ■ 00• 000 0.• 000 000 000 00 0 OOOOOO 000 000 *00 *00 00.000 *00 **0 00• 00* 00* 04100** 000 ro se 000 : :: :::**• 00..5 5 00• 000 00 * 000 000 *00 000 000 000 000 00* 00* ". 00* 000.0• *00 000 00* 0 0 0 0 0 • 000 *00050 000 0** 000 0.• 000 000 00• 000 000 000 000 1979: International Year of the Child Looking ahead Photo WHO A new year dawns Nineteen -seventy-nine—the International Year of the Child (IYC) is here. Since the year was formally proclaimed by the UN General Assembly—on 21 December 1976—prepara- tions have been made in various parts of the world to develop projects for advocacy and action on behalf of the child. These efforts are being coordinated by an IYC secretariat set up by UNICEF, designated as the UN system's "lead agency" for the Year. As it was decided right at the start, no such event as a world conference or world plan of action will mark the Year. Instead, the focus will be on strengthening or initiating actions of direct benefit to the child with full community par- ticipation and coordinated by National IYC Commissions. Of the 144 governments that have agreed to take part in the Year's activities, 106 have set up National IYC Commissions, and UNICEF has allocated $3 million to help the commissions to orga- nize, to survey children's needs and the services already avail- able, and to plan programmes and projects. More than 100 international non-governmental organizations have united in an NGO/IYC committee with secretariats in Geneva and New York. Projects planned by the NGOs relate to such fields as: children in disad- vantaged communities, the handicapped child, the rights of the child, harmful effects of the environment, the role of parents as educators, and education for peace. Twenty UN agencies or units have drawn up plans for the Year, focussing on the well-being of the child as it relates to their own areas of work. WHO's efforts in relation to IYC attempt to emphasize the interrelationship between child health, education and welfare, and socio-economic develop- ment, highlighting the role of the child not only as the beneficiary of, but also as the future contri- butor to the development process. Children's health needs and health care have always received priority in WHO's work. "The promotion of maternal and child health and welfare" is among the main functions of the Organiza- tion as laid down by its Consti- tution. One of the basic principles of the Organization, the preamble to the Constitution says, is that "healthy develop- ment of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development". WHO's commitment to this principle has led to the adoption of a main social target for the coming decades: Health for All by the Year 2000. The goal is to be achieved through the primary health care approach, which views health promotion as an integral part of social develop- ment. The approach lays stress on the importance of the family as a unit of care, and of family and community self-reliance as fundamental to the healthy growth and development of children. The aim of WHO's activities in child health is to cooperate with Member governments in their efforts to reduce maternal, peri- natal, infant and childhood mor- tality and morbidity; the im- provement of reproductive health; and the promotion of physical and psychological development of children and adolescents. The WHO plan of activities for IYC represents both the strength- ening of ongoing activities of the Organization and specific acti- vities related to the occasion, such as workshops, seminars, symposia, and exhibitions in support of country activities. In keeping with the spirit of the Year, the slogan chosen for World Health Day this year is: A healthy child, a sure future. Tetanus: results of Bangladesh survey A simple and relatively inex- pensive investigation by the Bangladesh health authorities has shown tetanus to be the leading cause of death in infants in the 0-1 age group, accounting for 27 per cent of all infant deaths. The survey, conducted in March 1977, covered a random selection of 120 groups of 100 houses each. Parents and other relatives of patients were inter- viewed in each household to confirm diagnoses and identify causes of death over the previ- ous 12 months. Questions on morbidity were limited to tetanus, whooping cough, resid- ual paralysis and blindness —conditions that can be relati- vely easily recognized—in the 0- 14 years age group, and causes of death for all ages were chosen from a list of 59 conditions. Photo WHO/J. Mohr Vaccination of mother protects baby. The significance of tetanus in the 0-1 age group was vividly demonstrated-78 per cent of all patients being less than one year of age. Presumably nearly all of these cases occurred in the neo- natal period—the first four weeks of life. Tetanus accounted for 27 per cent of all infant deaths and was shown as the leading cause of death in this age group. Extrapolation of these results to the entire country suggests that about 75,000 newborn ba- bies contract tetanus annually in Bangladesh, and 70,000 of them die. Recognizing the importance of neonatal tetanus, Bangladesh has decided to give special emphasis to the vaccination of pregnant women. A feasibility study was initiated in Septem- ber 1978, and by 1983 it is plan- ned to have tetanus vaccine available to women throughout the country. 30 The results of the Bangladesh survey are closely approximate to those arrived at through a WHO- devised method . to estimate morbidity and mortality due to tetanus in developing countries where reliable surveillance data may not be available. This method takes into con- sideration socio-economic fac- tors (F1 = proportion of non- immune women of child-bearing age; F2 = proportion of live- birth deliveries without medical assistance; F3 = annual per capita income; F4 = proportion of rural population), environ- mental factors (F5 = predicted findings of C/. tetani, the caus- ative organism, in soil samples; F6 = climate), and a biological factor (F7 = case fatality rate). Applying this method to the situation in Bangladesh, one arrives at a neonatal attack rate of 2,025/100,000 live births and a mortality rate of 1,721/100,000 live births. The survey shows an attack rate of 2,126/100,000 and a mortality rate of 1,988/ 100,000. An assumption made in analysing the survey data was that all cases recurring in the 0-1 age group were in the neo- natal period. If the assumption is made—which is probably more accurate—that only 95 per cent of the cases were neonatal, there is a difference of less than one half of 1 per cent in attack rates calculated by the two methods. The comparison has admirably demonstrated the possibility of obtaining useful and reliable morbidity and mortality data even in the absence of a refined sur- veillance system. Tetanus is among the six target diseases of childhood under the Expanded Programme for Immu- nization, in which WHO has been collaborating with a number of Member countries. * Bytchenko, Cvjetanovic, and Grab— "Factors determining mortality due to tetanus", Proceedings of the Fourth Inter- national Conference on Tetanus, Dakar, Senegal, 6-12 April 1975, pp. 43-66. Chart to monitor baby's growth A model growth chart for inter- national use, which can easily be adapted to local needs, has been developed by WHO to help mothers and health workers as- sess the growth and the nutri- tional status of children. The model was drawn up after a survey of growth charts ob- tained from 55 countries in dif- ferent parts of the world. The survey provided preliminary in- formation to appraise country needs and preferences. The model was then tested on 4,856 children in Algeria, Guatemala, India, Jamaica, Lebanon, Mexico, Thailand and Togo. The chart was well received by the health workers who used it, and some suggestions made by them were incorporated in the final version. Full-size reproductions and in- structions for use, along with an account of the chart's develop- ment, are contained in a recently released WHO publication entitled A Growth Chart for In- ternational Use in Maternal and Child Health Care. A variety of graphic models are used by countries to monitor weight and height. "This proli- feration of charts, standards and systems of classification" the WHO publication says, "has given rise to confusion in health services as to which is the most desirable for local use, as well as for regional and international comparisons." The prototype chart proposed by WHO is aimed at providing a model for adaptation in countries that do not have a growth chart. It can also offer an alternative where existing charts have proved unsatisfactory. A simpli- fied version of the chart is in- tended to be kept at home to give the mother a visual record of the nutritional and health status of her child. The chart carries two draw- ings. One shows a mother nurs- ing a baby, to indicate the impor- tance of breast-feeding, prefer- ably for a year but at least for six months; and the other, a bowl and a spoon, to indicate that the baby needs solid food to supple- ment breast milk beginning from the fourth month. On the reverse side of the chart, immunizations against childhood diseases are recorded along with other information, such as dates of appointments at the clinic, to ensure continuity of care. According to field tests, the time taken to instruct health workers in the use of the model chart varied from 15-30 minutes to 2-4 hours. The chart is ex- pected to become an important tool that primary health care workers can effectively use for the early identification of malnu- trition and for the education of mothers. Ten years of health development in S.-E. Asia The dark spots and bright areas in the health scene in South-East Asia have been high- lighted in a new publication of the WHO Regional Office for South-East Asia in New Delhi. Entitled WHO: A Decade of Health Development in South- East Asia, 1968-1977, the 418- page book is a sequel to WHO: Twenty Years in South-East Asia, 1948-1967. Photo WHO/K. Frucht Malaria team in Nepal Packed with a wide variety of health information about the 10 countries comprising WHO's South-East Asia Region (Bang- ladesh, Burma, Democratic People's Republic of Korea, India, Indonesia, Maldives, Mongolia, Nepal, Sri Lanka, Thailand), and illustrated with a number of telling photographs, the book offers a clear insight into the health situation in the Region. The reader senses the formidable nature of the task and the determination of the coun- tries of the Region in tackling their health problems. WHO's collaborative role and the shifts in emphasis over the years in developing appropriate health strategies for specific local needs are also brought out clearly. Priced at Sw. Fr. 52.—, the book may be ordered from the Regional Office. There is a dis- count of 50 per cent on all orders from the countries of the Region. In the next issue A healthy child —a sure future. The February-March issue of World Health will commemo- rate the World Health Day theme for 1979—the Inter- national Year of the Child. Authors of the month Mr lain GUEST is a freelance jour- nalist, based in Geneva, who spe- cializes in development topics. Dr TIN MAUNG MAUNG iS a Medi- cal Officer (epidemiologist) at ma-10's Western Pacific Regional Office in Manila. Mr Stanley BARON is a freelance journalist, and the author of "The Desert Locust". Mr J. C. ABCEDE is Public Infor- mation Officer for wtto's Western Pacific Region, based in Manila. Ms Diana GIBSON is a Public In- formation Officer at wit() Head- quarters in Geneva. Mr Paul HARRISON is a British freelance journalist and photo- grapher, specializing in develop- ment. He is the author of "Inside the Third World", and of "The Third World Tomorrow" to be published shortly. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* One year 12.50 25.- Two years 22.50 45.— Three years 30.— 60.— One year: Two years: Three years: 0 I enclose cheque/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland r. z CC CC in te d in S w itz er la n d Im pr im Primary health care in action in Bangladesh. A local health worker vaccinates a fellow-villager. (Photo WHO/P. Harrison)