50 [Fifty] years of making people healthier [full issue]

{.) r ~ iJJ \ ~ IJ ~ THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION I ,J I I _J ,JJ__r- _J 51 st YEAR, No. 2, MARCH-APRIL 1998 50 YEARS F MAKING EOPLE LTHIER W.,-~RLD ~ I . ~ ~ ~ii THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION Theme articles SO years of making people healthier 3 Hiroshi Nakajima 1948: a new health organization is born 4 Bock to basics: the shift to primary health core Essential drugs save lives 8 Building on success 10 The mother of fevers 12 DOTS: a breakthrough in TB control 14 A gift from the twentieth to the twenty-first century 16 Victory over leprosy draws nearer 18 Coping with chronic conditions 20 Promoting health locally, notionally and globally 22 Globalization and public health: a new challenge for WHO? 24 Ageing: the surest demographic reality of the next century 26 Features Healthy genes in a healthy body 28 Bob Williamson Health futures at Expo 2000 30 WHO publications 31 Contributors to this issue are: Douglas Bettcher, WHO John Blond, WHO David Bromley, WHO Shedo Dovey, freelance writer Angelo Haden, freelance w riter Alexandre Kalache, WHO Ilona Kiekbusch, WHO Mondy Mikulencok, WHO Jacqueline Sawyer, freelance writer Bob Wilriamson, guest author World Health • SlstYeor, No. 2 Morch-April 1998 IX ISSN 0043-8502 Correspondence should be oddressed to the Editor, World Health Magozine, World Heolth Organizotion, CH-1211 Geneva 27, Switzerland, or directly to outhors, whose addresses are given at the end of each article. for subscriptions see order form on page 31. HEALTH Cover: Photo WHO/ PAHO 5 Of MAKING PEOPLE HIAlTHIER World Health is the officio! illustrated mogazine of the World Heolth Orgonizotion. It oppeors six times a year in English, French and Spanish, ond four times o year in Arabic and Forsi. The Arabic edition is ovailable from WHO's Regional Office for the Eastern Mediterronean, P.O. Box 1517, Alexandria 2151 1, Egypt. The Farsi edition is obtoinoble from the Public Heolth Committee, Iron Univer~ty Press, 85 Park Avenue, Teheron 15875-47 48, Islamic Republic of Iron. © World Health Organization 1998 All rights reserved. Articles ond photographs that are not subject to separate copyright may be reproduced for non-commercial purposes, provided thot WHO's copyright is duly acknowledged. Signed articles do not necessarily reflect WHO's views. The designations employed ond the presentotion of material published in World Health do not imply the expression of any opinion whatsoever on the part of the Organizotion concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. World Health • Sl stYeor, No. 2, Morch-April 1998 3 Editorial 50 years of making people healthier Dr Hiroshi Naka;ima, Director-General of WHO. Photo WHO/H Anenden As we celebrate our 50th an-niversary, we can look back with legitimate pride at the many health gains WHO and its Member States have achieved for the benefit of the peoples of the world. To many it seemed self-evident in the early days of the Organization that science and technology meant progress, and that progress was irreversible. The resounding success of the campaign to eradicate small- pox, which was formally completed in 1980, reinforced this view. It led to the launching of other vigorous campaigns, such as those against poliomyelitis, leprosy, guinea-worm disease, river blindness, Chagas disease, measles and tetanus. In all these areas WHO has supported the development of global coalitions, and the results have been impressive. Meanwhile, a different approach was developing and gathering strength, with the strategy of health for all through primary health care, launched with the Declaration of Alma-Ata in 1978. Building up integrated health services at local level continues to be a major strategy, and has been the key to success in many areas. It has played a leading role in improving health status and increasing life expectancy. In recent years, the Organization has moved to broader family health approaches, to provide people with a continuum of essential care at all stages of their lives and in their communities. These approaches can be traced back to the inclusive definition of health adopted in our Constitution, as well as to the pri- mary health care strategy. But our new policy reflects a change in focus: attention now centres not so much on structures as on the people they exist to serve. In the future an even greater effort will be needed to I understand users ' needs, expecta- tions and potential to contribute to the definition and implementation of health priorities and interventions. This change in perspective re- flects a growing awareness of the importance of developing an open and mutually respectful dialogue between health professionals and the public. Empowering people, espe- cially women, in all cultures and segments of society with the neces- sary information and opportunities for health development is both an ethical and a technical imperative. With regard to technology and progress, simplistic assumptions have been called into question by the emergence of drug resistance, new environmental health hazards, and new infectious agents. Old scourges such as plague, cholera, meningitis, malaria and tuberculosis, as well as new diseases such as HIV/AIDS , Ebola haemorrhagic fever and transmissible spongiform encephalopathies, have called for new methods of surveillance and control, and demonstrated the need for coordination at global level. To meet these challenges, WHO is increasing its capacity to respond to countries ' requests for emergency support. These developments, to- gether with the increase of noncom- municable diseases and an ageing population in virtually all countries of the world, have brought about a radical change in perceptions of health and its determinants. Health can no longer be seen as separable from issues such as lifestyle, sustain- able development and justice. Public health strategies have to be multisec- toral if they are to be effective. The health services of the future will continue to carry out disease prevention and control activities, but this will be done in closer collabora- tion with other sectors, and will include the public health applications of new knowledge and technology such as genetics, molecular biology, immunology and diagnostic imaging. It is of the utmost importance to ensure that these developments are guided by sound technical and ethi- cal principles. WHO provides a forum within which international consensus can be built with regard to the many crucial issues that arise in these areas. The articles in this issue of World Health touch on some of the great achievements of the last 50 years, and show how they have prepared us for the equally great challenges the coming years will bring. • Hiroshi Noka;ima, M.D., Ph.D. 4 1948: a new health organization is born World Health • 51 st Year, No. 2, March-April 1998 Held each year, usually in Geneva, in May, the World Health Assembly enables Member States ta reach a consensus an ma;ar health issues. Photo WHO The World Health Organization came into being on 7 April 1948. Its Constitution had al- ready been approved in July 1946 when the representatives of 61 coun- tries met at the United Nations ' International Health Conference in New York. Before the new organiza- tion could exist officially, however, the Constitution had to be ratified by 26 of the 51 states that belonged to the United Nations at that time. When the 25th and 26th ratifications arrived on the same day in April 1948, WHO was born. Of course, the 20 months between the International Health Conference and the birth of WHO were not spent waiting for letters of approval to arrive. An Interim Commission was set up in 1946 to start the work and prepare the structure of the new organization. Operating first from New York and then fro m Geneva, the Interim Commission began fostering the international cooperation for health that was to become the hall- mark of WHO. The first World Health Assembly met for a month from 24 June to 24 July 1948. The representatives of 53 Member States and 12 observers chose a president (Dr Andrija Stampar of Yugoslavia), appointed a Director-General (Dr Brock Chisholm of Canada), agreed on a structure of six regions with a head- quarters in Geneva, chose an em- blem, and cut the budget from the proposed 7 million dollars down to 5 million . Early priorities The Health Assembly called for special priority to be given to four concerns - malaria, tuberculosis, venereal diseases, and the need to improve the poor health of mothers and children. The importance of environmental hygiene and nutrition was also stressed and a list of 33 further topics was drawn up for WHO's attention. The priorities of 1948 are still priorities today. Other concerns have come and gone and new problems have arisen but the four singled out by the first World Health Assembly continue to kill and debilitate mil- lions. WHO has had many successes in combating disease and ill-health over the half-century of its existence - and some are described on other pages of this issue of World Health - but some serious health problems remain that require more than medical interventions. The broader context of health was certainly recognized by WHO's founders. The Organization's Constitution with its definition of health as "a state of complete physi- cal , mental and social well-being and not merely the absence of disease or infirmity" is as relevant today as it ever was. The WHO Constitution World Health • 51 st Year, No. 2, Morch-April 1998 states that "the highest attainable standard of health" is a fundamental right of everyone and that govern- ments are responsible for providing the means to achieve it. Brock Chisholm, the Canadian delegate on the United Nations committee that drew up plans for WHO (and who became the Organization's first Director- General), described why its Constitution took such a broad view of health. "The microbe" he said, "was no longer the main enemy: science was sufficiently advanced to be able to cope with it admirably, if it were not for such barriers as supersti- tion, ignorance, religious intolerance, misery and poverty." The growth of international concern The adoption of WHO's Constitution at the International Health Conference was the culmina- tion of a movement towards interna- tional cooperation in health that had been gaining momentum for decades, even centuries. When the city of Venice turned away ships coming from areas infected by the plague in 1348, thereby reducing infection in the city and saving lives, it started a trend towards the use of quarantine in preventing disease. As interna- tional travel and trade increased over the following centuries, disease spread more rapidly than before. Quarantine was widely used as a preventive measure, disrupting the travel and trade that many people relied on for their livelihood. Concern for trade was the main motive behind the first International Sanitary Conference of 1851 at which 12 countries signed an interna- tional convention on quarantine for cholera, plague and yelJow fever. Nine more International Sanitary Conferences followed, each with its own convention. By the second half of the 19th century it was widely recognized that only international cooperation could combat the world's deadliest diseases effec- tively. Appearing in six languages at the main entrance to the WHO building in Geneva, the name "World Health Organization" was chosen in 1945 by a groundbreaking conference on health held in San Francisco . Photo WHO Economic development brought with it general improvements in living standards and education, reducing death rates and increasing life expectancy in Europe. Health came to be seen as an essential part of social and economic progress and even as an individual's right. The founding of the Red Cross in 1864 symbolized the growth of concern for the health and well-being of others. The first health agency to work on behalf of several governments was the Pan American Sanitary Bureau, founded in 1902. In 1907 it was joined by a European counter- part, the Office International d'Hygiene Publique (OIHP) based in Paris. When the League of Nations came into being after the First World War a new health organization was set up under its auspices. The new organization was intended to absorb the OIHP but some of the League's members had not signed the treaty that established the OIHP so the two bodies continued side by side. The League of Nations' health organization appointed commissions of experts to give advice on control- ling diseases or organizing health services, and held courses and study tours on various aspects of public health. It colJected epidemiological information from governments and shared data with the OIHP. The League of Nations and its health organization were never fully inter- national, however. 5 The Second World War put an end to the health organization of the League of Nations and to the OIHP. As destruction, food shortages and the numbers of displaced persons increased, the allied powers set up the United Nations Relief and Rehabilitation Administration (UNRRA) in 1943 to provide med- ical relief and health care to countries that had been liberated. Then at the May 1945 conference in San Francisco which founded the United Nations, the delegates of Brazil and China proposed setting up a "world health organization" as part of the UN. The proposal was approved unanimously, a preparatory commit- tee was set up and over the course of 22 meetings in early 1946 drafted the constitution that was approved at the International Health Conference. In the 1940s the aspirations for WHO were high, as they are today. Reflecting the post-war mood, WHO's first Director-General Brock Chisholm commented, "Groups will not again survive at the expense of the lives of other groups. We shall survive as a human race or not at all." There is little doubt that many people who are alive today would not have survived without the international efforts to prevent disease and pro- mote health led by WHO. Yet for large numbers of the world's popula- tion, life is still precarious. WHO's first 50 years represent just a short stretch of the road to global health. The rest of the journey still lies ahead ofus. • 6 World Health • SlstYeor, No. 2, Morch-April 1998 Back to basics: the shift to primary health care The founders of WHO took special care that health should be seen from as broad a per- spective as possible. According to WHO's Constitution, "the enjoy- ment of the highest attainable stan- dard of health is one of the fundamental rights of every human being". One commentator described the first World Health Assembly in 1948 as "charged with idealism". Certainly the representatives of Member States looked far beyond the doctor's surgery in their discus- sions on health. "Disease is not brought about only by physical and biological factors," Assembly President Andrija Stampar said. "Economic and social factors play an increasingly important part in sanitary matters, which must be tackled not only from the technical but also from the sociological point of view." The Philippine delegate reminded the Assembly not to over- look the role of the community in health, while Canada's delegate stressed that WHO's fundamental task was to "stimulate and facilitate in every appropriate way the devel- opment of national health organiza- tions in each country". WHO was not intended to be a global health service but rather an agency that would help countries develop their own health care systems. For the first three decades of the Organization's life, however, it was the global health service approach that predominated, attracting both publicity and funds. Mass cam- paigns were started against tubercu- losis, malaria, yaws, syphilis, smallpox, leprosy, typhoid, onchocerciasis and other diseases. Some of them are described else- where in this issue of World Health. Between 1950 and 1965, 46 million Villagers in Zimbabwe construct a water pump which will improve and protect health by making safe water available to their community. Photo WHO/L. Taylor yaws patients were treated in 49 countries and the disease ceased to be a significant public health prob- lem. Smallpox was declared eradi- cated in 1980 and leprosy should be gone as a public health problem by the end of the century. Not all mass disease-eradication campaigns were so successful, however. Organisms evolved, be- coming more resistant to antibiotics, disease carriers such as mosquitos changed their behaviour to avoid pesticides, and new diseases emerged. By the 1960s it was be- coming clearer, not just from the words of WHO's founders but also on the basis of experience in the field, that better health needed to be built on something more lasting than an occasional visit by a medical specialist. In 1973, as WHO celebrated its 25th anniversary, retiring Director- General Marcolina Candau stressed that much of the improvement in health worldwide was due to social and economic change. Acknowledg- ing that where health services ex- isted they were often little used, he pointed out that in many cases they had been imposed on developing countries and were "unlikely to function properly in the conditions obtaining there". He called on WHO to "turn more directly to the con- sumer and the small communities - the smallest units" in an effort to develop health services that would "visibly deal with the people's priorities, and not act as agents of outside forces , however benevo- lent". The move towards primary health care was under way. Four years later the World Health Assembly called for "the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life". World Health • SlstYeor, No. 2, Morch-April 1998 And a year after that (1978) the International Conference on Primary Health Care, in Alma-Ata, declared that primary health care was the key to reaching that target by the end of the century. Primary health care refers to the kind of care that is provided at the first point of contact with the health care system. Thus it has more to do with the community in which people live than with high-technology hos- pitals. It means ensuring certain basic . elements - nutrition, water and sanitation, maternal and child care, immunization, health education, prevention and treatment of common local diseases, and provision of essential drugs. Wherever this much is provided it will certainly make more people healthier than will expensive medical treatment that benefits only a few. Healthy living standards and universal access to affordable health care were the basis on which the campaign for "health for all by the year 2000" was to be built. Although disease-oriented programmes have continued to the present, it has been increasingly recognized that these are not enough by themselves to ensure general good health. The drive for primary health care has been a drive to provide a network of basic health services that are both available and accessible to everyone. It has also meant a shift from the earlier view that health could be achieved through medical science alone to a recognition of the very real impact of social, economic and cultural factors. The implications are far-reaching. As WHO Director- General Halfdan Mahler asked dele- gates to the Alma-Ata conference in his opening presentation: "Are you ready to address yourselves seriously to the existing gap between the health 'haves' and the health 'have nots ' ... ?" 7 A village health worker undergoing training in India. Given a basic knowledge of health practices, people from the local community can dispense the primary health care that can raise the health status of the population. Photo WHO/) & P Hubley Twenty years after Alma-Ata it has to be admitted that there are still far too many people who do not have access to basic health care. But there can be no doubt of the enormous impact that primary health care has had the world over. Nations , commu- nities and individuals are far more aware of the need for better nutrition, clean water supply and adequate sanitation, social support, immuniza- tion, and a healthy environment - and they are more willing to act to provide these things. Recent moves towards "health-promoting schools", "healthy cities" and even "healthy islands" are a direct result of the primary health care approach; they represent a recognition of the impact that the environment has on the physical and mental health of human beings. The earlier focus on disease became a focus on the community and is now evolving into a focus on the individual within a sociocultural context - with as much emphasis on the context as on the individual. As we try to visualize health care in the future we see two trends. One is to increased medical specialization and greater use of sophisticated technology to return the sick individ- ual to good health and to overcome disability. The other is to increased informality of health care as individ- uals, families and communities take more responsibility for improving the standard of health generally and caring for the sick. These two trends may appear to be headed in opposite directions but in fact they are com- plementary. Primary health care in an environment that supports and en- courages health, backed up by spe- cialist care for those who need it, is a combination likely to mark the health systems of the future . • 8 World Health • SlstYear, No. 2, March-April 1998 Essential drugs save lives Drugs being prescribed in Nepal. Proper prescription practices help ensure that drugs ore used effectively. Photo W HO/) Schytte Economic recession and rising health care costs have led to demands in the industrialized countries for beffer value for money through the use of a smaller range of generic drugs. It is estimated that countries can save up to 50% of their drugs budget through establishing an essential drugs list. Millions of people in develop-ing countries - many of them children under five - die needlessly every year from diseases that could be easily treated with safe, inexpensive drugs. Millions more are prescribed inap- propriate, often expensive, drugs which deplete foreign currency reserves and prevent investment in other public health priority areas. Elsewhere, people resort to self- medication with over-the-counter antibiotics - cutting short the treat- ment and increasing the global spread of drug-resistant organisms. Today, more than a third of the world's population lack regular access to essential life-saving drugs. In Africa, where many of the poorest countries have no more than US$ 1 per capita to spend on drugs, fewer than half have access to the basic drugs they need. In some cases, essential drugs may be unavailable or unevenly distributed throughout the country. Even where there is no shortage of drugs - in the new mar- ket economies of east and central Europe, for example - they may remain beyond the pockets of most people. To make matters worse, drugs may be ineffective due to poor quality control or improper prescrib- ing. WHO estimates that at least a third of all countries have no effec- tive regulatory agency to control the quality, procurement, and appropri- ate use of drugs. More than 110 countries are signatories to WHO's Certification Scheme on the Quality of Pharmaceuticals moving in International Commerce, but many countries are not using the scheme to verify whether a supplier meets WHO requirements. Elsewhere, efforts to assist peo- ple affected by war and natural disasters are often hampered by misguided donations of inappropri- ate drugs - prompted, in some coun- tries , by commercial incentives to donate. Aid workers are often on the receiving end of unwanted, poor quality, or badly labelled drugs, already beyond their expiry date. In the aftermath of the Armenian earth- quake in 1988, it took 50 people six months to sort out the 5000 tonnes of drugs and medical supplies received. Eight per cent had already expired on arrival and 4% were destroyed by frost. Of the rest, only 30% were easy to identify and only 42% of any use in an emergency situation. More recently, during the war in the for- mer Yugoslavia, some drugs more than 50 years old were sent to Mostar and aid workers were faced with the task of disposing of 340 tonnes of expired drugs. But all this is steadily changing. Today, over 120 countries have developed national essential drugs lists and about 60 countries have adopted, or are now drawing up, comprehensive national drug poli- cies. The WHO Action Programme on Essential Drugs is currently helping over 60 countries to develop new strategies for the financing , supply management, rational use, and quality control of drugs. And in a major breakthrough in 1996, WHO issued guidelines for drug donations in emergencies - a voluntary agree- ment reached in collaboration with the major international agencies involved in humanitarian relief work. They include stipulations that, in future, all drug donations should be made in response to a clearly expressed need, that donated drugs should be clearly labelled and have a shelf-life of at least one year, and that they should be obtained from a reliable source and comply with World Health • 51 st Year, No. 2, Morch-April 1998 Checking the arrival of drugs in Papua New Guinea. A national drug policy is a key to controlling the supply, promotion and use of drugs. Photo WHO/E. Lauridsen quality standards in both the donor and the recipient country. In addition, all donated drugs - or their generic equivalents - should appear on the national list of essential drugs or on WHO's Model List of Essential Drugs. The Action Programme on Essential Drugs was established in 1981 to ensure that all people have access to high quality essential drugs, at an affordable price, and that drugs are appropriately prescribed and used. The first Model List of Essential Drugs was drawn up by WHO 20 years ago, in 1977. It com- prised 200 items, all with generic names and most no longer patented. It was designed for adaptation to the health needs of individual countries and comprised the essential drugs needed to ensure a reasonable level of health care for as many people as possible. The list has undergone minor changes over the years and currently contains about 300 drugs. It is revised every two years . In 1978, the Declaration of Alma-Ata identi- fied access to essential drugs as one of the basic elements of primary health care. However, the idea of essential drugs was never intended to be restricted to developing countries. Today, economic recession and rising health care costs have led to demands in the industrialized countries for better value for money through the use of a smaller range of generic drugs. In Australia, for example, a list of essential drugs approved for reimbursement through a health insurance scheme contains about the same number of drugs as Zimbabwe's essential drugs list. It is estimated that countries can save up to 50% of their drugs budget through establish- ing an essential drugs list. Daphne Fresle, Editor of WHO's Essential Drugs Monitor, says the concept is based on universal princi- ples of equity, common sense, and sound, evidence-based medicine. "Every recommended drug has a weight of scientific evidence behind it and is the best product a country can afford" , she points out. "This is good, evidence-based medicine - not cheap, inferior medicine. It is as valid for the treatment of cancer, cardiovascular diseases and meta- bolic disorders as it is for malaria, acute diarrhoea, and pneumonia." But there is a lot more to it than drawing up a list of essential drugs. A comprehensive national drugs policy requires the enactment of new legislation to control the supply, promotion, and use of drugs. A supply and distribution network must be established, together with systems for the selection, procurement, fi- nancing, quality control , safe storage, and distribution of essential drugs. 9 Education and training are needed - for medical students, doctors , and consumers - to ensure that drugs are both prescribed and used correctly. And monitoring systems must be put in place. Failure to halt the growing resistance to first-line antibiotics, caused by overprescribing and pa- tient misuse of drugs , will force governments to switch to more expensive alternatives instead. Today, three-quarters of the world 's population live in developing countries, but they represent less than 20% of the global drug market, now valued at over US$ 200 OOO million. Spending on drugs accounts for one- third to two-thirds of total health .care costs in developing countries and transitional economies, with 60-90% of drug costs paid for out-of-pocket by those least able to pay. The trends are not encouraging. The cost of new drugs is rising - fuelled by higher research and development costs and by intellectual property rights . At the same time there is a growing demand for essential drugs in developing countries: to treat opportunistic infections, including tuberculosis, in the millions of people infected with the AIDS virus, for example, and to treat chronic diseases associated with changing lifestyles and ageing. And all this is happening against a back- drop of increasing privatization of cash-strapped health services. WHO maintains that if the goal of health for all is to be achieved, the supply of essential drugs cannot be left to market forces. Dr Hiroshi Nakajima, WHO 's Director-General, points out that the concept of essen- tial drugs is driven by the need for equity and meeting real health needs. "National drugs policies and essen- tial drugs programmes are now, and in the foreseeable future , the best means we have of pursuing and eventually attaining the dual objec- tives of rational management of drug resources and better health for all." • 10 Building on success The world's lost case of smallpox wos recorded in Somalia in 1977. Ali Mao/in suffered only a mild form of the disease and quickly recovered. Later, when his little sister died of measles, he trained as a health worker and devoted himself lo the immunization of children. Photo WHO/). Wickett The story of the eradication of smallpox and WHO's continuing fight against preventable diseases Twenty years after winning the battle against smallpox, WHO is still fighting the war against disease. Are the lessons learnt from the smallpox eradication campaign still relevant today? Smallpox is dead Ali Maalin of Merka town, Somalia, is the last recorded case of smallpox in the world. The onset of his rash on 26 October 1977 led to a veritable military operation - tracing contacts, quarantine and vaccination. National staff and WHO officers combined forces to make sure that the variola virus - the virus that causes small- pox - did not escape. Then came a time for everyone to hold their breath and hope. Would smallpox spring up somewhere else? It is easy enough to identify the virus, but much more difficult to prove that it does not exist any- where. WHO offered a reward of US$ 1000 to anyone who could identify a case of smallpox. Claim after claim was made. All were thoroughly investigated. None were smallpox. On 9 December 1979, the mem- bers of the Global Commission for the Certification of Smallpox Eradication solemnly affixed their signatures to the statement that "smallpox has been eradicated from the world". Battle campaign The only way to eradicate smallpox was to make sure that every single World Health • 51 st Year, No. 2, Morch-April 1998 case was found and isolated. Otherwise, the virus could spread. There is no treatment for smallpox. A method for preventing smallpox has been known from ancient times. In this method, called variolation, a healthy person is deliberately scratched with substance taken from an infected scab. A person who survives variolation is immune, but use of the live virus can spread the disease. The breakthrough came in 1796 when Edward Jenner took material from a cowpox sore on the hand of a milkmaid and inoculated it into the arm of an eight-year-old boy. When he tried to inoculate the boy with smallpox two months later, the infec- tion did not take. The findings were announced in 1798 and thousands of people were subsequently vacci- nated. In 1801, Jenner predicted the annihilation of smallpox. Why did it take so long to achieve that goal? With hindsight, the answer is clear. While some populations were protected by vaccination be- cause the knowledge and means were available to provide the necessary public health care, other populations remained at risk. The smallpox virus can only survive in a human host. If one person in the whole world has smallpox, the disease can spread, and anyone who has not been vaccinated is at risk. The problem of smallpox was raised at the very first meeting of the World Health Assembly in 1948. Ten years later, at the instigation of the Soviet delegation, the Assembly decided to step up efforts to eradicate smallpox. Mass vaccination cam- paigns were launched in many coun- tries, but the goal of eradication remained elusive. Millions were still dying from the disease. In 1967, a unit set up at WHO headquarters in Geneva started to work with WHO Regional Office teams and national programmes in an intensified effort to eradicate small- pox. By 1971, endemic smallpox had been cleared from South America World Heolth • Slst Year, No. 2, March-April 1998 following a huge programme of mass vaccination and case searching, in particular covering the vast Amazon basin. In Asia, the campaign strategy was refined to include improved case investigation and the containment of outbreaks, and the last case was seen in 1975 - a three-year-old girl in Bangladesh. The final stage of the campaign was in the Hom of Africa, the last remaining foothold of the disease. The total cost of the smallpox eradication campaign was some US$ 330 million. In economic terms, its benefit has been around US$ 1000 million annually. But the human benefit of averting needless suffer- ing, disfigurement, blindness and death is immeasurable. Know-how and expertise The smallpox eradication campaign brought governments, health workers and ordinary people throughout the world face to face with a successful health intervention. A heat-stabilized vaccine was developed. Cold chains were set up to bring the vaccine safely to remote areas. The inocula- tion technique was simplified - bifurcated needles replaced syringes. Alongside these technical advances, success enhanced the credibility of preventive health care. As the Director-General of WHO said at the time: "Victory over smallpox ... reasserts our ability to change the world around us for the better." Has WHO capitalized on its success? Do the specifics of small- pox - absence of asymptomatic carriers, no animal reservoir, ease of identifying former cases because of characteristic scarring - make the eradication of smallpox a unique event? Smallpox eradication created a demand for immunization. Governments could see that it was cost-effective and people could see that it worked. In 1974, before the goal of the eradication of smallpox had been reached, and at a time when fewer than 5% of infants in developing countries were protected against the vaccine-preventable diseases of childhood, WHO estab- lished a programme to expand its immunization efforts. Today, some 80% of children throughout the world are immunized against diph- theria, pertussis (whooping cough), tetanus, tuberculosis, poliomyelitis and measles. Work continues on vaccine development, and the Health Assembly has set goals for the eradication of polio and the control of other diseases. What next? Following the certification of the eradication of smallpox, the World Health Assembly in 1981 struck Vaccination for everyone living in endemic areas formed the backbone of the smallpox eradication drive. Photo WHO/). Mohr II smallpox from the International Health Regulations. The disease has gone, but the virus still exists - in two carefully guarded laboratories at the Centers for Disease Control and Prevention, Atlanta, Georgia, USA, and the Russian State Research Centre of Virology and Biotechnol- ogy, Koltsovo, Novosibirsk Region, Russian Federation. In 1996, the Health Assembly recommended that all stocks of variola virus should be destroyed. The escape of the virus would be a serious risk, because of the propor- tion of the population lacking immu- nity to smallpox. Extensive studies have been made of the virus. Se- quence information on the genome of several virus strains and cloned DNA fragments of genome allow for further research, as well as for the diagnosis of suspected smallpox. It is reassuring to know that the destruction of the virus stocks would not affect the capacity to produce smallpox vaccine, which - as in the time of Jenner - is still derived from cowpox. Nor would it prevent the reintroduction of vaccination in response to the recent change in the pattern of monkeypox infection in humans, with greater person-to person transmission than previously. (Vaccination against smallpox also protects against monkeypox.) The smallpox vaccine seed virus ( vac- cinia virus strain Lister Elstrea) will be maintained at the WHO Collabo- rating Centre on Smallpox Vaccine at the National Institute of Public Health and Environmental Protection, Bilthoven, Netherlands. The little sister of Ali Maalin was not as lucky as her brother: she died of measles. She had not been immu- nized. Shocked, Ali Maalin trained as a health worker so that he could help to protect other children against that disease. WHO, through its Global Programme on Vaccines and Immunization, is striving to protect humanity against preventable dis- eases. As the story of smallpox shows, an international strategy is needed to vanquish these diseases. Who better to lead it than WHO? • 12 The mother of fevers I n ancient Chinese it was known as "the mother of fevers". Today, it accounts for 300-500 million cases of sickness a year globally and kills over 1.5 million people - possi- bly as many as 2.7 million - includ- ing one million children under five. And it is costing Africa alone an estimated $2000 million a year in direct costs and lost earnings. Malaria occurs today in about 100 countries or territories. Most cases (90%) occur in sub-Saharan Africa, but the disease is also preva- lent in parts of Asia, the Western Pacific, and Central and South America. Elsewhere, there has been a resurgence of malaria in Tajikistan and Azerbaijan, where the disease had been eradicated. Epidemics have also occurred in Iraq and Turkey, where malaria had been under con- trol. In Afghanistan, an estimated 2-3 million cases a year are now occurring following the displace- ment of populations and the break- down of malaria control. Overall, about 40% of the world 's population ( over 2 billion people) are today at risk. World Health • SlstYeor, No. 2, Morch-April 1998 Efforts by WHO to help coun- tries tame malaria have had ache- quered history. The earliest attempts, from the mid-1950s, to eradicate the disease through the use of DDT ended largely in failure. Malaria was eradicated from all developed coun- tries, and parts of subtropical Asia and Latin America were also liber- ated from the disease. But initial successes in many countries led to complacency and a drop in funding. Without a good health infrastructure, it was impossible to maintain the necessary surveillance, and hard- won gains were quickly lost. In Sri Lanka, for example, the number of cases was slashed from two million in 1946 to 17 by 1963, as the mos- quito succumbed to insecticides and the parasite to antimalarial drugs. But before long, the mosquitos became increasingly resistant to insecticides, and populations be- Preparing medication for a malaria patient in Sudan . Photo WHO/Gibson & Hosfeld came more vulnerable to malaria than before. To make matters worse, by the early 1960s, there were re- ports of parasite resistance to first- line antimalarial drugs along the Thai/Cambodian border and the Venezuelan/Colombian border. In 1969, WHO announced the end of the malaria eradication cam- paign - although eradication re- mained the ultimate goal - and its replacement by an interim strategy of malaria control. Most African countries south of the Sahara had never been included in the eradica- tion effort because it was not consid- ered feasible at the time. The launch in 1978 of the concept of primary health care created a new framework for malaria control, but the switch- over evolved slowly in many coun- tries. In 1985, the World Health Assembly registered concern at the resurgence of malaria and the appar- ent failure of existing control strate- gies. In 1986, WHO's Expert Committee on Malaria concluded that there was no standard approach or "magic bullet" that could be used everywhere. This conclusion was based on the lessons of the eradica- tion campaign. Malaria patterns were determined by a variety of socioeconomic, political, environ- mental, and biological factors. In future, malaria control measures would have to be tailored to local situations. The problem is that epidemio- logical patterns of malaria are con- stantly changing. Mosquito habitats, parasite resistance to drugs, and human susceptibility to the disease are influenced by factors such as World Heolth • SlstYeor, No. 2, Morch-April 1998 internal conflict and the collapse of health services, mass population movements, rising poverty, intensifi- cation of agriculture, changing weather patterns, and economic exploitation of land. In South-East Asia, for example, the most rapid increase in drug-resistant cases of malaria has occurred in border areas plagued by internal conflict, refugee movements, and illicit gem mining. In the Amazon rainforest in Brazil, up to 500 OOO malaria cases occur every year - largely among non- imrnune settlers and miners. In countries such as Azerbaijan, Iraq, Tajikistan, and Turkey, epidemics of malaria have been sparked off by conflict, displacement of popula- tions, and by the intensification of agriculture. In 1996, exceptional rains and population movements were blamed for epidemics of malaria in southern Africa. In urban areas in Africa, malaria deaths have risen - the result of poor sanitation, inadequate health services, and drug resistance due to over-prescribing and improper self-medication. In 1992, a new strategy for the global control of malaria was adopted at a Ministerial Conference in Amsterdam. It calls for : early diagnosis and treatment of malaria; selective and sustainable preventive methods, including vector control; prevention or early response to epidemics; and strengthening local capacity to analyse the malaria situa- tion, especially ecological and socio- economic factors involved. Meanwhile, a new WHO global action plan stipulated that, by 1997, at least 90% of malaria-endemic countries should have appropriate control programmes in place (a target that has been met) and that, by the year 2000, deaths from malaria should be at least 20% lower than in 1995 in at least 75% of countries affected. Efforts to ensure the early diag- nosis and treatment of malaria have been backed up by a new WHO training programme. Between 1994 and 1996, WHO trained about 10 OOO health workers at district and com- munity levels - mainly in disease management, especially for cases of severe and complicated malaria. Elsewhere, research is continuing on the development of new tools to improve the prevention and control of malaria, mainly spearheaded by the World Bank/UNDP/WHO Special Programme for Research and Training in Tropical Diseases (TOR). These include vaccine devel- opment, trials of new antimalarial treatments, and the development of quick dipstick tests to speed up diagnosis of malaria and ensure early treatment with appropriate drugs. A worrying trend, amid mount- ing concern at the increase in multidrug resistance, is the Jack of commercial interest in developing new antimalarial drugs - a high-cost venture which relies on the lucrative travellers ' market to offset low returns from the developing coun- tries . Yet another major pharmaceu- tical company recently abandoned the development of new antimalari- als - after earlier axing its malaria vaccine development programme. However, Glaxo Wellcome has announced plans to establish a donation scheme to supply a new antimalarial drug, Malarone, free of charge for controlled use in areas of multidrug resistance. The new approach to malaria control has already produced some encouraging success stories. In China, the Philippines, and Vanuatu, 13 the number of malaria cases was slashed by 60% between 1992 and 1996. And in Viet Nam, where drug resistance is high and 144 epidemics of malaria were recorded in 1991 , malaria deaths were reduced by 92% and malaria cases by 40% between 1992 and 1996. Throughout Viet Nam, about 12 million people are now protected by house spraying and insecticide-impregnated bed- nets, and effective antimalarial drugs are available through the health service. In China, about 6.5 million people are protected by bednets - more than 10% of the population at risk. The challenge now is to apply the new strategy successfully in high- risk areas - especially in Africa. In 1997, the Director-General , Dr Hiroshi Nakajima, announced a US$ 10 million "shot in the arm" for 1997 and again in 1998 to boost the prevention and control of malaria in Africa. Today most African coun- tries are already implementing national action plans for malaria control. In the meantime, there is no prospect of a "quick fix" for malaria. For the foreseeable future at least, malaria control will continue to be a race to stay one step ahead of the emergence of drug-resistant forms of the disease. • Bednets impregnated with insecticide protect sleepers in the Solomon Islands from the mosquitos which transmit malaria. Photo W H0/5. Yoboo 14 World Health • SlstYear, No. 2, March-April 1998 DOTS: a breakthrough in TB control There exists a proven, inexpen-sive treatment strategy that has the potential to prevent millions of deaths over the next ten years. Diverse countries such as Bangladesh, China, Peru, and the Unjted Republic of Tanzania are reaping its benefits. The World Bank ranks it alongside immunization as one of the most cost-effective public health interventions. DOTS - short for Directly Observed Treatment, Short-course - is the strategy recommended by WHO for the detection and treatment of tuberculosis (TB). Hailed by some as the biggest health breakthrough of the decade, DOTS remains the most effective way of preventing the spread of the disease. Today, it is also the last line of defence against an alarming increase in multidrug- resistant tuberculosis - a form of the disease that is equally infectious and extremely difficult to cure. The strength of the strategy lies in its five critical components whjch work in tandem - detection of infec- tious cases through sputum smear microscopy, a dependable supply of powerful anti-TB medicines, obser- vation of patients taking their med- ication for at least the first two months of treatment, a reliable man- agement and record-keeping system to track treatment progress, and political and financial commitment. A TB patient receives her medication at home in Peru. Through direct obseNation and careful record-keeping, health workers ensure that the right doses are taken at the right inteNals. Photo WHO/). Davenport Inconsistent or partial treatment is one of the major causes of mul- tidrug resistance. The elements of DOTS, used together, are designed to prevent development of resistance to any one of the essential drugs. An important element of the strategy is direct observation of patients taking the appropriate combination of drugs on a regular basis until they are cured. Observers can be health workers, locally re- cruited health promoters or volun- teers . Peru's national TB programme illustrates that community volun- teers are a valuable resource in case detection and treatment. Dr Guillermo Suarez, who heads Peru's tuberculosis control programme, says volunteer health promoters are crucial to the success of DOTS. For every new patient identified and cured, an estimated 15 cases a year are prevented- among family mem- bers, friends, and workmates. "There is no strategy or public health policy that could function without community support," he says. "They support our work for two reasons - they are the ones who benefit from the results and there is a long tradition of community work." In China, which in 1990 ac- counted for almost a quarter of the world's TB cases, the launch of a one-year DOTS pilot project raised cure rates from below 50% to over 90%. Today, with a US$ 58 million loan from the World Bank, China has expanded the original scheme to reach over 500 million people. Although the effectiveness of DOTS in curing patients is unques- tionable, DOTS is still a strategy waiting to be used extensively. Only about 15% of all TB patients were treated by DOTS in 1996. A recent assessment showed that 89 out of 212 countries had adopted the DOTS strategy by the end of 1997. Of those 89, only 62 had implemented DOTS countrywide. World Health • Slst Year, No. 2, March-April 1998 Now, more than ever, it is impera- tive that DOTS reaches more of the world. Every year, tuberculosis kills up to 3 million people, and 8 million people develop the disease. An estimated two billion people - a third of the world's population - are al- ready infected with the TB bacillus, although only about one in ten go on to develop the disease. In India, one of the worst-affected countries, over 2 million people a year develop active tuberculosis and up to half a million people die from the disease. Globally, it is estimated that more people are dying of tuberculosis today than in the first half of this century when·it claimed the lives of one in seven in Europe and the United States. In 1993, WHO declared the worsening epidemic a global health emergency. The re-emergence of the disease on a global scale has been fuelled by a false sense of security, rising poverty, economic recession, and a massive increase in refugee movements and economic migration. Meanwhile, the emergence of AIDS in the 1980s helped push the inci- dence of tuberculosis even higher, as tuberculosis is the most significant opportunistic infection among people with AIDS and the only one which can be spread through the air to others. Persons infected with tuber- culosis are 30 times more likely to develop an active form of the disease if they are infected with HIV as well. In African countries such as Malawi, up to 50% of people with AIDS are also infected with tuberculosis. In Asia, where nearly one in two people are infected with tuberculosis, the rate of TB/HIV co-infection will rise as HIV infection rates increase. During 1997, two alarming re- ports bolstered the case for global implementation of the DOTS strat- egy, raising the spectre of a tubercu- losis epidemic that could otherwise spiral out of control. In September, officials from the US Centers for Disease Control and Prevention (CDC) announced that they had identified a new highly contagious strain of the TB bacillus in an out- break involving about 200 patients in Tennessee. The new strain grew 1 OOO IS A village practitioner in China checks the blood pressure of a woman TB patient as part of his responsibility For her directly observed treatment. Photo WHO/ J Mullins times faster in laboratory cultures than normal tuberculosis bacteria and by the time patients with this strain had been diagnosed, they had already infected over 70% of the people they had been in contact with. By then, eight of the area's 13 health care workers had also been infected. Fortunately, it was a treatable form of the disease. A month later, a major report on anti-tuberculosis drug resistance revealed the existence of tuberculosis "hot zones" around the world where the disease is resistant to the com- monly prescribed drugs. Unless checked, the report warned, this could ignite a wave of tuberculosis that is extremely difficult to cure. Already, multidrug resistance is tantamount to a death sentence in the developing world. Elsewhere, in the industrialized countries, it can cause a 100-fold hike in treatment costs - raising them up to US$ 250 OOO a patient. Even then, successful treat- ment cannot be guaranteed. The study was conducted by WHO and the International Union Against Tuberculosis and Lung Disease, with support from USAID and the Australian Agency for International Development. The hot zones identi- fied were: Argentina, Cote d'Ivoire, Dominican Republic, Estonia, India, Latvia, and the Russian Federation. Worst affected was Latvia, where 22% of TB patients had multidrug resistance. "No one can afford to ignore the growing incidence of drug-resistant TB," said J. Brian Atwood of USAID. "An epidemic of drug- resistant TB will have global impli- cations that all countries must immediately recognize." The problem is that tuberculosis is an airborne disease which is virtually impossible to avoid. It is transmitted by bacteria sprayed into the air by coughing or sneezing. Today large-scale population move- ments and a massive increase in airline travel have helped to bring tuberculosis out of oblivion to every- one's doorstep. Dr Arata Kochi, Director of WHO's Global Tuberculosis Programme, says it is alarming that many countries still do not have effective TB control programmes in place despite warnings of the global spread of drug-resistant tuberculosis. "We have the medicine and know- how to control TB," he says. "Unfortunately we don ' t have the magic potion to wake up the world's governments to the seriousness of the TB crisis and get them to take action." • 16 World Health • SlstYeor, No. 2, Morch-April 1998 A gilt from the twentieth to the twenty-first century The threat of polio to young lives and limbs will shortly be consigned to history. Photo WHOl).-F Chretien I t all began in a test-tube 50 years ago - the year the World Health Organization began its work. It is a story of international cooperation on a global scale, of a race to develop a vaccine against an incurable dis- ease that has paralysed millions of children, of efforts to broker a cease- fire in the midst of war so that chil- dren on both sides could be immunized, and of record-breaking efforts to immunize hundreds of millions of children on a single day. Its driving force has been a determi- nation to ensure that all children - rich or poor - are protected against polio. The first major breakthrough was in 1948. In the United States, a Harvard Medical School research team, headed by physician John Enders, succeeded in growing poliovirus in cell culture - paving the way for development of a vac- cine against polio. At the time, polio was a little understood and much dreaded disease. In the pre-vaccine era over half a million people were paralysed by polio every year- most of them children under three years old. The turning point came in 1955, when the first polio vaccine - Jonas Salk's inactivated polio vaccine - was licensed for use in the United States. From then on, the number of polio cases began to fall in the indus- trialized countries, where the vaccine was mainly used. But it was another 25-30 years before polio vaccine became widely available to children in developing countries. By then the Salk vaccine had long ago been overtaken by Albert Sabin's live oral polio vaccine, now used in virtually all national immunization programmes. In the 1950s, WHO was quick to recognize the potential of live oral polio vaccines as a global public health tool and played a key role in the development of Sabin's vaccine. Unlike the Salk vaccine, a live atten- uated vaccine could induce not only serum immunity but secretary immu- nity as well. By limiting multiplica- tion of "wild" poliovirus inside the gut, and reducing faecal excretion of the virus, it could provide an effec- tive barrier against circulation of wild polioviruses. With a live vac- cine, it might one day be possible to eradicate the disease. An added advantage was that an oral vaccine would be much easier to administer than the injectable Salk vaccine. From 1952 onwards, WHO steered the development of polio vaccines - establishing international standards to control the manufacture and safety of live attenuated polio- virus vaccines. In 1957 WHO spon- sored the first clinical trials of these vaccines and by 1961 the Sabin vaccine was licensed for use in the World Health • SlstYear, No. 2, March-April 1998 United States. The vaccine (like Salk's) was never patented, and in 1972 Sabin entrusted his seed vac- cines to WHO - together with an exclusive licence to distribute the strains to vaccine manufacturers free of charge, subject to stringent con- trols over the manufacturing process and vaccine safety. His aim was to ensure the continued availability of safe, effective, and affordable polio vaccines for every child - a goal which WHO today pursues for all vaccines through the Global Programme for Vaccines and Immunization and the Children 's Vaccine Initiative. During the 1970s, WHO-spon- sored lameness surveys in develop- ing countries shook the widely held belief that children in the industrial- ized countries carried a larger burden of polio paralysis - revealing that polio was equally widespread among children in developing countries. The need for polio vaccines was universal. In 1974, WHO launched the Expanded Programme on Immunization - one of the major global public health achievements this century. Within two decades, global immunization coverage dur- ing the first year of life against origi- nally six diseases - diphtheria, tetanus, pertussis, measles, tubercu- losis, and polio - soared from 5% to 80% and the number of child deaths was reduced by three million. Buoyed by these achievements, and by the success of efforts to eradi- cate polio in the Americas, the World Health Assembly in 1988 set a global target of polio eradication by the year 2000. In the words of the resolution, it would be "an appropriate gift, together with the eradication of smallpox, from the twentieth to the twenty-first century". WHO launched a polio eradica- tion strategy comprising: high rou- tine immunization coverage with oral polio vaccine; supplementary immu- nization in the form of national immunization days (mass cam- paigns); effective surveillance; and, in the final stages, door-to-door immunization in areas where the virus persists. To carry this out, WHO forged a global alliance in- cluding Rotary International, the United Nations Children's Fund (UNICEF), the US Centers for Disease Control and Prevention (CDC), nongovernmental organiza- tions, donor governments, and min- istries of health in the polio-endemic countries. Over the past decade their support has included not only fund- ing but technical expertise, advocacy, and volunteers. At the outset in 1988, there were about 350 OOO cases of polio world- wide. By 1996 (the latest year for which complete data are available at the time of writing) there were about 40 OOO cases - a reduction of almost 90%. In the Americas, where the last case of polio occurred in 1991 , an international commission certified in 1994 that polio had been eradicated throughout the Western Hemisphere. By the end of 1997, national immunization days had been carried out in almost every country in the world - establishing world records for immunization. During 1996, 400 million children - almost two-thirds of the world 's children under five - were immunized against polio during mass campaigns. In addition, 80% of babies were fully immunized against polio before their first birthday, through routine immunization. In December 1996, and again in January 1997, over 250 million children were immunized against polio during coordinated national immunization days in Asia. In India, which until recently accounted for over half the world's polio cases, 127 Immunization: the universal defence against polio. Photo WHO/H Anenden 17 million children were immunized on a single day in January 1997 - the largest public health event ever organized by a single country. Polio immunization has even been carried out in countries at war. Internationally brokered truces have been negotiated both for routine immunization and mass campaigns - mainly under the aegis of UNICEF - in Afghanistan, El Salvador, Lebanon, the Philippines, Sri Lanka, and Sudan. Elsewhere, unofficial ceasefires have been secured for national immunization days in areas of conflict in Cambodia, India, Iraq, Myanmar, Turkey, and elsewhere. It is too early to say whether polio will be eradicated on target by the year 2000. The countries where polio is still endemic include some of the poorest in the world. In some, health infrastructures have been destroyed by war and neglect, and immunization programmes sus- pended. To make matters worse, many of the almost 60 countries which reported - or failed to report - polio cases during 1996 are still not meeting WHO criteria for adequate surveillance. Elsewhere, donor fatigue and the competing need for funds to combat other infectious diseases - some both more life-threatening and more widespread than polio - pose contin- uing threats. In addition to what governments are spending, an esti- mated US$ 1000 million donor funding is needed up to the year 2005. Without both adequate re- sources and firm political commit- ment to polio eradication in the poorest developing countries, po- liovirus will continue to circulate - both in those countries and beyond. The danger is that, as the number of polio cases continues to fall, people will become complacent - allowing routine immunization coverage to slip and enabling the disease to stage a come-back. It would be a tragedy if the gift of polio eradication turned out to be an empty promise for the children of the 21st century. • 18 World Health • SlstYeor, No. 2, Morch-April 1998 Victory over leprosy draws nearer As early as 1914, the Office International d'Hygiene Publique (OIHP) - a forerun- ner of WHO - ordained that there should be compulsory notification, as well as surveillance or isolation, of cases of leprosy. The disease was very clearly an international public health problem, and in the year of WHO's founding, 1948, the International Leprosy Association was among the first nongovernmen- tal organizations to be brought into official relations with the infant organization. Shortly afterwards, an expert advisory panel was estab- lished whose members helped to prepare for the first meeting of the Expert Committee on Leprosy, held in Rio de Janeiro and Sao Paulo in 1952. That Expert Committee con- firmed two important points: "that leprosy is not in most cases a highly infectious disease, and that, with the introduction of sulfone therapy, a good proportion of cases can be cured". The experts also "accepted that temporary isolation might still be necessary, though for infectious cases only, but it was suggested that ambulatory and domiciliary treat- ment could be safely and satisfacto- rily given to most patients". The First Ten Years of WHO, published in 1958, reported that the clinical results of treatment with diaminodiphenylsulfone - also known as dapsone - "tend to confirm the favourable results already re- ported in medical literature on the treatment of leprosy patients in specialized institutions". Over- optimistically, it claimed that "lep- rosy patients no longer tend to avoid treatment because of its possible association with segregation. They now come forward spontaneously." There was also a mention of trials with BCG vaccination (the anti- tuberculosis vaccine) and of vaccines prepared with other myco- bacteria, This leprosy patient in Sudan has just received the blisterpack of drugs she needs to cure the disease. Photo WHO "which appear to offer a certain degree of protection against lep- rosy." In 1968 The Second Ten Years of WHO reported: "Participants in the seminar on leprosy control orga- nized at Belo Horizonte, Brazil, in 1958 were agreed that compulsory isolation of patients should be abol- ished and replaced by effective control of foci through the treatment of all patients and surveillance of their contacts - hospitalization being restricted to cases in need of special medical or social care." Later that year, the Seventh International Congress of Leprology, held in Tokyo, stressed that, from the epi- demiological point of view, "it is more advantageous to reduce infec- tiousness in many patients than to ~liminate infectiousness in a few." Poor patient compliance The Second Ten Years struck a gloomy note. "Poor follow-up and attendance of out-patients for regular treatment continue to be a main obstacle in leprosy control programmes. Leprosy control has been based primarily on chemother- apy with sulfones, and surveys have shown that 73% of lepromatous patients require more than three years to become bacilli-negative. Unfortunately, the longer treatment continues, the less regular it tends to become." It went on: "The special- ized leprosy control services need the active cooperation of the general health services, and leprosy control should be progressively integrated into the work of the health centres at the local level." All this was remarkably farsighted. There was the insistence that leprosy patients should not be segregated or isolated from their communities. There was the tantaliz- ing vision of a drug that would actu- ally cure leprosy without requiring many years of treatment. And there was the problem of maintaining patient compliance with drug regi- mens. Above all, there was the strong recommendation that leprosy control should be integrated with general health services, in fact with what was later to be called primary health care. Certainly the drug dapsone seemed to offer some light at the end of the tunnel. Its use spread around the world in the next decades, thanks largely to the work of WHO and of its partner nongovernmental organi- zations, many of them members of what was to become the Interna- tional Federation of Anti-Leprosy Associations (ILEP). But then dap- sone ran into trouble. The long duration of treatment made patient compliance a big problem; it was World Health • 51 st Year, No. 2, Morch-April 1998 rather a lot to expect a possibly disabled person to travel several miles every month to a health post to obtain the drugs. A patient who noticed an improvement - perhaps the disappearance of skin lesions - saw no further point in going on taking the pills. Worse still, Mycobacterium leprae - like so many other agents of disease that plague our planet - began to develop resistance to the drug. It looked as if mankind 's only safe weapon against leprosy was about to become use- less. Better drugs needed The WHO Expert Committee on Leprosy, in its fifth report published in 1977, struck a note of alarm when it declared "there is an urgent need for controlled clinical trials of com- bined chemotherapy in multibacil- lary leprosy" and called for research into alternative drugs to dapsone, with the cooperation of research institutes and the pharmaceutical industry. In due course, newer and better drugs came on the scene, in particular rifampicin and clofaz- imine, which proved to be both highly effective and well-tolerated by patients. As a result, a WHO Study Group which met in Geneva in October 1981 proposed a multi- drug regimen consisting of these two drugs in combination with dapsone, since they did not merely kill M. leprae in quick time but also prevented the bacillus from develop- ing resistance to any of the three. It was this multidrug therapy or MDT which provided the break- through that at last made it possible to envisage putting an end to lep- rosy. Today, even people with the more severe form of the disease, multibacillary leprosy, can be guar- anteed a total cure within the space of 12 months. Relapses - the recur- rence of the disease after stopping treatment- are very rare, constitut- ing well under 1 % of cases. One unexpected result of the amazing success of MDT has been to put the never very hopeful quest for a viable vaccine on the back burner. At the World Health Assembly in May 1991, the Member States of WHO made a formal commitment to bring about the elimination of lep- rosy as a public health problem by the year 2000. This means reducing the number of cases to less than 1 case per 10 OOO people. A full account of how WHO and its part- ners are prosecuting the war against leprosy appeared in the May- June 1996 issue of World Health. In the mid-1980s, there were an estimated 12 million cases (and 5.4 million registered cases) in the world. Today that estimate has been revised to only around one million, while the number of registered cases - there- fore receiving MDT - stands at around 800 OOO. Where there were 122 countries with prevalence rates above 1 per 10 OOO in 1985, there are today fewer than 50. So the goal of elimination is not far away - but neither is the target date of the year 2000. Aside from the purely medical aspects of the drive against leprosy, there is the human and social side. While the cure is certain for every person with leprosy who comes forward for MDT, many still face "I want it eliminated" 19 ostracism from their own communi- ties, even from their own families . The social suffering lingers on and, together with the totally unjustifiable loss of human rights, adds a heavy psychological burden to the physical damage that they have undergone. So it is essential for everyone con- cerned in public health to spread the word that leprosy is curable, that it is extremely hard to "catch," and that sufferers need not and must not be shunned. Unless this message reaches every patient in every vil- lage, and unless they come forward for the drugs - which should be available at every clinic and primary health care centre in the leprosy- endemic countries - the disease will still lurk in isolated and dangerous pockets. It is important to avoid triumphalism and the tendency to count our chickens before they are hatched. But provided the impetus is maintained and provided there is no shortfall in the human and finan- cial resources required we should be able to put paid to this age-old dis- ease and ensure a leprosy-free world in the 21 st century. • In his novel A Burnt-Out Case, set in a " leproserie" in cen tral Africa , the noveli st Graham Greene invented the word " leprophil " for people w ho appeared to prefer the disease to the people who suffered from the disease. The phys ic ian in charge, Doctor Colin, says : "You remember that li ttl e leproserie in the bush tha t the nuns ran. W hen DDS [da psone] w as discovered to be a cure, they were soon reduced to half a dozen patients . Do you know what one of the nuns said to me? ' It's terrible, doctor . Soon we' ll have no lepers at al l.' There surely was a leprophil. " Another character comments : "A ll the same, doctor , you 've said it yoursel f, leprosy is a psycholog ical problem. It may be very valuable for the leper to feel loved ." Doctor Colin replies : "A patient can always detect whether he is loved or whether it is only his leprosy w hich is loved . I don't wan t leprosy loved . I want it eliminated. " Greene dedicated his novel, published in 1961 , to Dr Michel Lechat w hose leprosy hospita l at Yanda in the Congo he had vis ited. The foreword expressly says: "I hope you wi ll accept the ded ication of this novel , w hich owes any merit it has to your kindness and patience .... Doctor Coli n has borrowed from you his experience in leprosy and noth ing else." Professor Michel Lechat \s a di st inguished leprologist. Formerly President of the School of Publ ic Health, Cathol ic Un iversity of Louvain in Brussels , he is Presiden t Emeritus of the Internationa l Leprosy Asssociation (ILA) and President of the International Leprosy Union (ILU). (Read his article "History of a Disease" on page 8 of the M ay-June 1996 issue of World Health. ) 20 World Health • SlstYeor, No. 2, Morch-April 1998 Coping with chronic conditions Balanced nutrition during childhood is a powerful defence against such chronic conditions as cardiovascular diseases in later life. Photo WHO/ H. Anenden In the case of infectious diseases, it has long been recognized that an ounce of prevention is worth a pound of cure. But as regards non- communicable diseases, recourse to curative treatment and palliation has only recently been complemented by more systematic primary prevention efforts. Still, health promotion is playing an increasing role in alerting the general public to possible ways of avoiding or mitigating chronic conditions whose causes may lie in the province of unhealthy lifestyles or environments. "The greying of mankind" was a phrase that first emerged in the 1980s as it became evident that people are living longer, thanks to the many advances in medical science and social living conditions. Smallpox eradication, the expansion of anti- biotics, the routine immunization of children and major breakthroughs in surgery contributed to raising life expectancy at birth, globally, by 4.6 years (4.4 years for men and 4.9 years for women) between 1980 and 1995. This demographic change has meant that more individuals are living long enough to fall victim to such chronic noncommunicable conditions as cancer, cardiovascular disease, Alzheimer disease, osteo- porosis and diabetes. During the first decades of WHO's existence, most of the health problems now coming under the heading of noncommunicable dis- eases were dealt with by various expert committees within the general context of public health. The in- creasing importance of cancer, for instance, was first underlined by an Expert Committee on Health Statistics in 1949, while the associa- tion of diseases of the circulatory system with obesity was stressed by a joint Expert Committee on Nutrition formed by WHO and the Food and Agriculture Organization of the United Nations in 1951. Not until the early 1970s were these ailments assembled under the umbrella of the Division of Noncommunicable Diseases. Since then, there have been impressive advances in basic, pathological, clinical, epidemiological and opera- tional research, encouraged through the expanding network of collaborat- ing centres under WHO's aegis. Noncommunicable disease pro- grammes now issue guidelines on As we discover ways to live longer, chronic conditions are crowding in to coexist with communicable diseases or take the place of those that have been controlled or eliminated. Preventing and controlling chronic diseases is often a matter of choosing wiser /if estyles and creating better environments. classification and nomenclature, diagnostic criteria and treatment methodologies, and the norms and standards of disease management. Cause and eff ed Epidemiological and laboratory research has shown that there are cause-and-effect relationships be- tween certain chronic conditions and hereditary predisposition, unhealthy lifestyles and the human environ- ment. The new findings on the pathogenesis of these conditions have paved the way for innovative approaches to disease control. In 1961 , a WHO Expert Committee warned of the potential threat of cardiovascular diseases, yet it took more than three decades to dispel the myth that these only concerned rich industrialized coun- tries. The World Health Report 1997 made it clear that roughly two-thirds of deaths caused worldwide by noncommunicable diseases occur in developing countries - and cardio- vascular diseases account for nearly half of the total deaths. A decline in these diseases is apparent in some World Health • SlstYeor, No. 2, Morch-April 1998 countries with established market economies and it seems possible that healthier lifestyles and improved environments are responsible. Several international networks have been formed in an effort to control cardiovascular diseases through "a risk factor modification approach". The North Karelia pro- ject in Finland has become a model for such initiatives; after intensive health promotion over many years, focused particularly on non-smoking, regular exercise and reduced con- sumption of calories, animal fat and salt, the mortality from coronary heart disease in the age group 35 to 49 was practically zero. Future generations As long ago as 1964, the scope of the Human Genetics Programme was determined by the notion that "ge- netic considerations add a new di- mension to public health work; a concern not only for the health and well-being of persons now living but also for the genetic endowment of generations yet to come." This had implications over the years for such priority areas as thalassaemia and sickle cell anaemia, cystic fibrosis and haemophilia. Dr M. S. Tsechkovski, Director of WHO's Division ofNoncommunicable Diseases, explains: "WHO is now well placed to watch the widening perspectives being opened up by the huge International Human Genome Project. Indeed, some experts pre- dict that we are on the threshold of a new era in the use of genetic ap- proaches and technologies to radi- cally improve prevention and control of chronic diseases." Another prominent noncommuni- cable disease, diabetes mellitus, was first reviewed as a public health problem by WHO in 1964, when it fell within the planned activities of the Social and Occupational Health Programme. Since the Second Expert Committee on the disease was convened in 1980, diabetes has no longer been thought of as a disease of the affluent and industrialized world. Developing countries today account for about 75% of all cases. In 1965 certain leading industrial- ized countries decided to set up the International Agency for Research on Cancer, in Lyon, France. This insti- tution has won a deservedly high reputation in the fields of cancer epidemiology surveillance and regis- tration, as well as research into the environmental causes of certain cancers. The Cancer Programme at WHO headquarters launched a new slogan in 1980: "Cancer is a Third World problem too", and helped to bring in new attitudes towards cancer pain relief and palliative care. Oral health is a good example of a field where major improvements can be brought about provided the mes- sages about dental care and healthy nutrition reach the public. Such messages, combined with the fluori- dation of water, have proved to be highly effective. WHO's Global Oral Data Bank System, set up in the late 1960s, now contains information on dental caries in 178 countries and serves as a practical tool to monitor progress towards the global goal of decreasing the average number of "DMFT" (decayed, missing and filled teeth) at 12 years of age. Mental health Some mental conditions can neither be prevented nor readily cured, so it is a question of treating the symp- toms and attempting to mitigate A school for mentally handicapped children. One of the goals of WHO is to ensure the integration of disabled people into the everyday life of the community. Photo Keystone/ B. March © 21 them. New types of drugs are being developed to treat such ailments as schizophrenia, depression and alco- holism, and WHO is closely follow- ing research into mental conditions linked with ageing, such as Alzheimer disease and other demen- tias. The Mental Health Programme works closely with the Programme on Substance Abuse. Although the latter programme is primarily con- cerned with illicit drugs such as cocaine and heroin, increasing attention is being given to the abuse of prescribed drugs, which stems in part from over-prescribing by physi- cians. Rehabilitation Efforts to help people with mental disorders rest heavily on the promo- tion of community-based rehabilita- tion in all parts of the world, and this is equally the approach taken by WHO's Rehabilitation unit. When the unit was first created in the late 1970s to meet the needs of the dis- abled, rehabilitation was viewed as a technological challenge. But it soon became apparent that for many millions around the world, it is not a question of supplying prostheses or wheelchairs. It is much more a matter of establishing relationships of mutual support within the com- munity. The goals of the rehabilitation programme are therefore multisec- toral and include empowering dis- abled people to demand greater independence and a better quality of life while at the same time making each community - in rich countries as well as poor - knowledgeable about their human rights and alert to their physical needs. A series of debates with concerned nongovern- mental organizations have been launched in all WHO Regions under the title: "Rethinking Care" and are expected to result in a set of recom- mendations to put before an eventual international conference on rehabili- tation for disabled people. • 22 World Health • 51 st Yeor, No. 2, Morch-April 1998 Promoting health locally, nationally and globally Calls are increasingly heard for more frequent and consistent assessment of health outcomes and impacts, not just of health care systems, but of decisions taken in non-health sectors. Living in a "supportive environ-ment for health" means that our physical, economic and social surroundings are conducive to good health. So in answering the ques- tion, "How is health protected and promoted?", attention is increasingly focused not only on models of disease, curative services or the consumption of medical care, but on the health potential inherent in the social and institutional settings of everyday life. The quality of the environment into which an infant is born, for instance, exerts a powerful influence on whether that infant lives until his or her first birthday. Countless examples exist of what can be done in each type of environ- ment to make it more supportive of health. In schools, parents, teachers and children can participate in pro- jects to improve hygiene, school playgrounds and classrooms. In workplaces, education can be pro- vided for workers on assessing risks and ensuring safe procedures. In marketplaces, the health conditions of stallholders and food-handlers can be promoted through provision of safe water, clean toilets and health services. And on a larger scale, city inhabitants - recognizing the physi- cal, mental and social aspects of health - can work together to ensure that urban conditions promote healthy living. Obstacles to securing health There are numerous obstacles to the creation of health-supporting envi- ronments, not least of which is the fragmentation of sectoral responsi- bilities at national level. In many countries, health remains the con- cern of a single ministry rather than At school in Niger. Children ore very open to ideas and can readily be encouraged to create a health-promoting environment in their school. Photo WHO/UNICEF/ Pirozzi a goal to which each sector or min- istry contributes in a conscious and coordinated manner. Similarly, traditional boundaries between government and nongovemmental organizations, and between the public and the private sectors, hinder the development of strategies and policies informed by an awareness of health and health needs. This fragmentation can reduce the impact of health-promoting activities, particularly those under- taken at the local level. It is of only very limited benefit, for instance, if teachers, pupils and parents work together to create a healthy school environment only to find that nearby industrial and transport pollution is getting worse because of decisions taken at national level, which paid no heed to the health effects of emissions. Integrated action is needed but the complex interactions and grow- ing international interdependence of our world can also work against the creation of supportive environments for health. For instance, the integra- tion of the global economy, financial markets and trade has in many cases resulted in the further marginaliza- tion of poor populations whose health status is already low. It is also contributing to the production of and trade in inherently harmful goods and substances such as tobacco, and the encouragement of marketing practices that are detrimental to health. Concurrently, large-scale environmental mismanagement, itself often linked to the demands of international trade, is a major con- tributor to global environmental problems such as climate change, destruction of the ozone layer and loss of biological diversity. Such problems tend to undermine both national and local efforts to ensure that the environments in which we World Health • Sl st Year, No. 2, Morch-April 1998 Enjoying o meal with colleagues of a works canteen. These settings afford excellent opportunities for health-promoting activities. Photo Keystone © live, work and play sustain our well- being. Failure to protect or promote health is partly the result of the failure of policies and decisions to take this responsibility into account. Efforts to counteract this situation are gaining ground, however. WHO and other international agencies are beginning to meet with some success in their efforts to put health on the agenda of all policy- and decision- makers, and to encourage them to tackle health issues using an inte- grated approach. Meanwhile, health advocacy groups and the media have played a major role in interpreting complex health policy issues for wider audiences. As a result, calls are increasingly heard for more frequent and consistent assessment of health outcomes and impacts, not just of health care systems, but of decisions taken in non-health sec- tors. Additionally, governments and all those who control or distribute resources are being asked to answer for the health consequences of their policies or lack of policies. In these ways it is becoming widely recog- nized that human health can be assured only in an environment that conserves resources through local, national and global ecological strategies. Education, empowerment and equality Increased accountability is brought about by education - in its broadest sense. It usually requires some "health literacy" to question deci- sions taken pertaining to health and evaluate the responses. Similarly, knowledge and skills are needed for active participation in sustainable health promotion efforts. Ability to participate means empowerment: the power of individuals, organizations and communities to support ap- proaches that promote or improve 23 health and counteract those that destroy it. Furthermore, participa- tion and empowerment to realize the potential for health that is inherent in society's many settings are more and more urgently required. This is amply demonstrated by the number and range of upcoming health threats. New and re-emerging infec- tious diseases, social changes such as those leading to lack of exercise, civil and domestic violence, and the apparent increase in mental health problems are just some of these. In many instances, responses will be effective only if they are imple- mented at several levels and with the support and participation of different "stakeholders". Participation and empowerment are also the key to reducing the gaps between the "haves" and the "have- nots". This inequality not only results in disparities in health status but also prevents groups such as women, elderly people, children and indigenous peoples from playing a full role in creating health-support- ing environments. Ensuring that our surroundings are conducive to good health thus means directing effort at all levels, within and between all sectors of society. In so doing we can make the healthier choice the easier choice and lay the foundations for true social and economic development. • Market scene in India. Health y marketplaces can make a marked contribution to improving the general health status. Photo WHO/). & P. Hubley 24 World Health • 51 st Year, No. 2, March-April 1998 Globalization and public health: a new challenge for WHO? Communication technology con be harnessed in mony woys to the fight against diseases and the improvement of health. Photo Keystone© l arge claims are made these days about globalization and how it is changing the entire structure of the world. As the World Health Organization reaches its 50th year, many analysts argue that globaliza- tion and global change are major challenges for the Organization in the 21st century. What are these international public health chal- lenges? Is the world really so differ- ent from what it was 50 years ago? Is globalization a fact, or just jargon? Globalization means different things to different people. On the one hand, it can simply refer to increasing financial and trade inter- dependence between countries. On the other, it suggests a much broader and more complex process of eco- nomic, political, social and cultural integration which takes place as capital, traded goods, persons, ideas, images, values, environmental toxins , and even microorganisms move across state boundaries. The concept of the globalization of public health takes this broader view, and refers to the threats and opportunities for health which transcend national boundaries. Advocates of this model argue that many health issues cannot be re- solved by national policies alone since such issues do not respect the geographical confines of sovereign states. The most commonly cited exam- ple of a transnational health threat is that of infectious disease spreading between countries. This is not a new problem. In mediaeval times the expansion of trade routes between Europe and East Asia was accompa- nied by epidemics: for example, plague spread across Asia and reached Italy in 1347. The threat of epidemics prompted European states to convene the first International Sanitary Conference in 1851 as a collective response to infectious diseases. In the late 20th century the risk of infectious disease trans- mission has been magnified by the increased volume and speed of travel. In the past 200 years the average distances travelled and the speed of travel have increased by a thousandfold. The massive volume of international traffic, with over one million persons crossing national boundaries each day, facilitates the "globalization" of infectious agents. With the emergence of new infec- tious diseases such as the Ebola virus and HIV I AIDS, and the re- emergence of old diseases such as tuberculosis, the transnational threat of communicable disease should not be underestimated. Global trade liberalization is also associated with transnational public health risks . Although the roots of globalized trade can be traced back to the industrial revolution and laissez-faire economic policies of the 19th century, the marketing and promotion of commodities have been enhanced by modem technol- ogy and by global trade agreements such as those reached by the World Health • SlstYeor, No. 2, Morch-April 1998 The gl~balization of information is bringing precious knowledge about health within the reach of those most in need. Photo Still Pictures/) Schytte © Uruguay Round of multilateral negotiations. Increased trade liber- alization has facilitated multina- tional food production, processing and distribution. The value of food trade, US$ 266 OOO million in 1994, was more than 300% greater than it was 20 years ago and continues to grow rapidly. The mass production and extensive distribution systems in the food industry favour the spread of infectious diseases across wide areas. The cross-border trade in psy- choactive drugs, tobacco, and alco- hol also poses a major threat to health in the 21 st century. For in- stance, the liberalization of world trade has accelerated the spread of tobacco products globally. The growth in tobacco consumption has been magnified by the aggressive advertising methods of multinational tobacco conglomerates which have targeted women, adolescents, and developing economies. If present trends continue there will be 10 million tobacco-related deaths in 2020, as compared with about 3 million deaths a year in the early 1990s. Global communication links have the power to enhance the pro- motion of harmful lifestyles. Trade in health services is an- other transnational health concern, although data on the extent of such trade are incomplete. In particular, the brain-drain of health profession- als from developing economies to industrialized ones threatens the quality of care in many countries. Although the negative effects of labour migration are partially offset by the foreign currency sent back to home countries, this does not com- pensate for the lower quality health services there. Structural adjustment policies, which have played a major role in liberalizing finance and trade, have important implications for public health. Structural adjustment pro- grammes aim to reduce the role of state institutions in national economies, and to open up these economies to international competi- tion by the reduction of trade barri- ers, and market deregulation. The globalization of adjustment policies in the health sector has resulted in a global culture of reform within health systems. Though the empiri- cal evidence is not conclusive, several studies have correlated adjustment policies with an increased burden on the health of vulnerable groups such as children, and a deterioration in the welfare of the poor in rural and urban areas. In many countries, economic adjustment is also associated with the deregulation of labour markets in favour of competition, resulting in erosion of basic labour rights and health and safety regulations, as well as access to services such as child care and maternity leave. The evolu- tion of flexible labour markets is linked to new employment and production patterns. For example, 25 employment in the "Maquila indus- tries" in the Americas and the "ex- port processing zones" in other parts of the world is characterized by low pay, poor working conditions, short- term tenure, and a primarily female workforce. Protection of employee well-being under these circum- stances is a matter of public health concern. It is important to note, however, that the implications of globalization for public health are not all nega- tive. The diffusion of modern tech- nologies and ideas between countries presents promising oppor- tunities for improving global health in the future. Recent advances in telecommunications technology, for example, have resulted in global communications links which are unprecedented in world history. Communications technology can be exploited for health purposes, which include: telemedicine, interactive health networks, disease surveil- lance systems, communication links between health workers, human resource development and continu- ing education, and distance learning. In summary, a strong case can be made that the globalization of public health represents an important trend for the 21st century. Although some transnational health problems have historical precedents, many new issues are emerging which are unique to our time. The 1997 Kyoto conference on climate change under- scored the fragility of the world's ecosystem, and showed how interde- pendent the health of all of humanity has become. Shared global prob- lems transcending state borders call into question conventional para- digms which divide countries into North and South, or developed and developing. The WHO Constitution of 1948 provides a rationale for global ac- tion. The cross-border issues con- fronting the world in 1998 can only be resolved by global cooperation. Transnational health threats and opportunities call for collective action. WHO could play a pivotal role in facilitating such action on transnational policy issues in the 21 st century. • 26 World Health • SlstYear, No. 2, March-April 1998 Ageing: the surest demographic reality of the next century WHO's mission is to maintain, protect and promote health throughout the entire human life cycle, including the closing years. Good health at every stage of our lives should be a universal opportunity, available to all. Ageing has become the leading demographic issue as we approach the new millennium. As such, it is an achievement to be celebrated. At the beginning of the 20th century, life expectancy at birth even in the richest countries was no more than 50 years . Today it has risen to more than 75. Countries such as China, Honduras, Indonesia and Viet Nam have added 25 years to their life expectancies at birth in just four decades. This has been largely due to improvements in living conditions - sanitation, con- trol of environmental hazards, better nutrition - to which public health (e.g. immunization) and clinical interventions (e.g. antibiotics) have acted as contributing factors . A recent phenomenon But while ageing is one of the major achievements of this century, it is often seen not as a reason for cele- bration but as a problem - a "tidal wave" of old people that will swamp us all. Ageing as a norm rather than an exception is a recent phenomenon to which humanity is still trying to adapt. Adapting to this new demo- graphic situation requires both commitment and determination. All parts of society are influ- enced by the ageing process. Let us look at the example of Japan - the country that today shows the highest life expectancy at birth in the world for both men and women. At the end of the Second World War Japan lagged well behind countries in Europe and North America. In the 25 years up to 1996, the percentage of people in Japan aged 65 and over doubled from 7% to 14%. Achieving the same increase in France took 115 years (from 1865 to 1980). By 2025 nearly one in three people in Japan will be aged 60 years or over, mak- ing Japan 's population the oldest in the world. In that year, nearly 15% of Japan's population will be 75 and over, and two-thirds of these people in their fourth quarter-century of life will be female (see figure) . How is it possible for a country to change its demographic profile so rapidly? Part of the answer is to be found not in greater longevity but in lower fertility. Rather than looking only at the top of the age pyramid, we need to see the fuller picture. A declining birth rate is the main determinant of increased ageing in a population. The speed of this de- cline in Japan is the main reason why the population has aged so rapidly. Since 1995 the Japanese population of "productive" age (those aged 15-64) has begun to decline. By 2050 the total population in Japan is expected to fall to llO million. Birth rates reflect social attitudes and practices. Today in Japan cou- JAPAN 1995 2025 MALES 6 5 4 3 2 0 M iiiions FEMALES 2 3 4 5 6 This graph superimposes tvvo oge distributions. The red one shows the situation in Japan in 1995. The grey one is a pro;ection of how the population will be distributed by age in 2025 if birth rates conform to current predictions for the next 30 years and if the trend towards longevity continues . Women aged 80 and over will form the largest segment of the population and will be l. 6 as many as men. Such a demographic perspective calls for radically new approaches to health planning Graphic by WHO. Source: World Population prospects, 1996 revision, New York, United Na tions (forthcoming). World Health • Slst Year, No. 2, Morch- April 1998 pies are choosing to have fewer children, with the result that the number of births does not replace the population lost through death. This contrasts with the situation in places with high birth rates, where the size of the population is going up as more babies are being born than the num- ber of people dying. Shrinking fertility rates Japan is not the only country with a falling birth rate. The table lists countries and areas where total fertility rates have now fallen below replacement levels. Those countries that joined this group after 1975 - mostly developing countries or economies in transition - are shown in red. As in Japan, the implications are far-reaching for society as a whole and are crucial for the health sector as it draws up policies for the future, allocates resources and de- velops services - from child care to the full range of care needed for older people. The debate on population con- cerns has often ignored the issue of ageing. The overwhelming feeling is that limiting the number of births is a good thing to do. Of course, unre- stricted population growth brings all manner of problems and hampers sustainable development. But, while it is clearly essential to provide family planning opportunities to all, the issues raised by exceedingly low birth rates are more complex than is usually realized. Healthy ageing There is mounting evidence that in many countries around the globe people are living not only longer but healthier lives. For instance, in the USA, the number of persons with chronic disorders such as arthritis, dementia, hypertension, stroke and emphysema is falling. Today there are at least 1.4 million fewer dis- abled older persons in the USA than there would have been if the health status of elderly people had not Total fertility rates in selected countries and areas where rates were at or below replacement level, 1990- 1995 Italy 1.2 Bulgaria 1.5 Hungary 1.7 China 1.9 Spain 1.3 Estonia 1.5 France 1.7 Yugoslavia 1.9 Germany 1.3 Netherlanas 1.6 Barbados 1.7 Thai Ian a 1.9 Hong Kong 1.3 Macau 1.6 Canaaa 1.7 Bahamas 2.0 Slovenia 1.4 Cuba l.6 Denmark 1.8 Sweaen 2.0 Greece 1.4 Belgium 1.6 Lithuania 1.8 Ireland 2.0 Austria 1.5 Ukraine 1.6 Unitea Kingaom 1.8 Martinique 2.1 Japan 1.5 Latvia 1.6 Singapore 1.8 United States 2.1 Bosnia ana Herzegovina 1.5 Republic ol Korea 1.7 Finlana 1.8 Malta 2.1 Former Yugoslav Romania 1.5 Croatia 1.7 Slovakia 1.9 Republic of Macedonia 2.1 Portugal 1.5 Luxembourg 1.7 Norway 1.9 Georgia 2.1 Democratic People's Switzerland 1.5 Belarus 1.7 Poland 1.9 Republic of Korea 2.1 Russian Feaeration 1.5 Czech Republic 1.7 Australia 1.9 Source: United Nations Demographers speak of the "replacement level" when each couple's fertility can replace one generation by another of the same size. These calculations are based on the female population. The replacement level is reached when each woman has, on average 2. 1 children in the course of her rer)(oductive life. The figure 2 means that there will be two children for each couple. The fraction 0. 1 has to be added to this figure to compensate for the death of women before they reach menopause [marking the end of their reproductive life), and for childhood deaths . In countries where the general mortality rate is low, the replacement level is 2. 1 :: any lower figure would not ensure replacement of the population. In high mortality countries, the fraction would need to be still higher to achieve replacement. The table lists the countries which are below the replacement level and will eventually have a declining population unless there is compensation from external factors such as immigration. The countries marked in blue were already below replacement level before 1975. Those marked in red have fallen to or below the 2. 1 figure at some time between 1975 and 1995, which means that their population structure has changed during the last two decades. improved since the early 1980s. Why is that so? 27 The answer is clearly not related only to advances in medical technol- ogy. There is much more to healthy ageing than prevention, postpone- ment and treatment of particular diseases. Healthy ageing is also related to the interaction of a wide range of "social" factors, such as maintaining or enhancing physical and cognitive functions, being fully involved in society, leading a stimu- lating and productive life, living in a stable social environment, and having meaningful personal relation- ships. WHO's role In any society, health is likely to be the most valued aspect of quality of life as persons grow older. WHO's mission is to maintain, protect and promote health throughout the life cycle, including the closing years. Good health at every stage of our lives should be a universal opportu- nity, available to all. For older persons to continue to be a resource for their families, their communities and the economy, it is essential that they be active - physi- cally, socially and mentally. The best possible foundation on which to build a long and fulfilling life is good health. In many developed countries, large numbers of older persons are already enjoying a healthy prolonged life and seeking ways to continue to contribute to their society. In developing coun- tries, healthy ageing is even more important. In the absence of univer- sal social security and within severe socioeconomic constraints, a longer and more productive life will depend on vigour, vitality and health throughout childhood, youth and middle age. • 28 World Health • Slst Year, No. 2, March-April 1998 Guest Author Healthy genes in a healthy body Bob Williamson The human genome is our her-itage from our ancestors and our legacy to our children. By the end of this century, scientists will have identified, isolated and se- quenced most of the human genome. The Human Genome Project is a cooperative international effort to understand the way in which these genes work in health and disease. It is appropriate that thjs great and positive effort is going on at the same time as WHO's efforts to achjeve health for all. Medical genetics has focused on gene mutations whjch cause diseases such as sickle cell anaerrua, thalas- saemia, cystic fibrosis and phenyl- ketonuria. Now it is clear that an equally important medical role of genes is to deterrrune whether an individual is at rugh or low risk of common health problems such as cancer, heart disease, diabetes or Alzheimer disease. Most genes do not act in isolation, but interact with environment. Some people are at higher risk of cancer than others, but those at high risk can protect them- selves by their lifestyle (not smok- ing, a healthy diet, low exposure to viral infection), while those who are fortunate enough to be at low risk can squander that genetic inheritance by environmental abuse. However, even the healthiest genes will not protect the heavy cigarette smoker from lung cancer! The gene mutations that cause most Mendelian diseases - those which are responsible for the genetic disorders of childhood such as thalassaemia and cystic fibrosis - have been identified. Where the disorders are common, this knowl- edge has been used for prevention. Carriers may be advised by religious or community leaders not to marry. More often, carrier couples are offered early prenatal diagnosis and A photograph of a set of human chromosomes, or karyotype, with two od;ocent cell nuclei. Lobe/led gene probes mark the X-chromosomes (seen here as minute green spots) and Y-chromosomes {in red). Norma/ males have a single Y-chromosome; the second red spot (seen both in the karyotype and the nuclei) is caused by an extra copy of Y, which in this case causes developmental deloy. Photo WHO/ Murdoch lnstitute/ L. Voullaire the option of terrrunating an affected pregnancy. In countries where these choices are available, the majority of informed couples choose to have healthy cruldren rather than face the problems and loss of quality of life associated with severe handicap. Geneticists stress that thjs choice must be free and rest with the cou- ple, and not be imposed by govern- ment. Protecting this freedom of choice also involves ensuring that good care of the handicapped is freely avrulable. Somatic gene therapy Scientists eventually hope to use healthy copies of genes to substitute for those that do not work in the tissues of affected children. This approach, known as somatic gene therapy, has been speculated about for the past 10 years. Somatic gene therapy would not change a person's egg or sperm cells, or involve changes that could be transmitted to children, as thjs would not be ethical at a time when there are still so many unknowns in genetics. Unlike gene testing, which is a simple and widely used procedure, somatic gene ther- apy has so far only been of value to a tiny number of children suffering from very rare diseases. The thera- pies that deliver healthy genes often use viruses, and therefore safety concerns loom large. Currently, there are no diseases for which gene therapy is a proven therapy. I believe that somatic gene therapy will come of age during the next l O to 20 years, as safe and effective ways of targeting healthy genes to affected tissues are devel- oped. When trus happens, it will be possible to use healthy genes for prevention of diseases such as can- cer and coronary artery disease. World Health • Slst Year, No. 2, March-April 1998 The human fetus developing in the womb already possesses all its future genetic characteristics. One day, these may make it possible to estimate each individual's potential risk of falling victim to certain diseases. Photo Keystone/Science Photo Library/G. Watson © This coincides with the view ex- pressed by WHO, that the real future for medicine is the preservation of health rather than the treatment of disease. Along with DNA sequences, the Human Genome Project generates other knowledge. The di scovery of the cystic fibrosis gene led to other approaches to treat the disease apart from gene therapy, such as using a human gene to make DNase to break down the mucus in the lungs, and new human peptide antibiotics to increase natural resistance. Such advances are as much a result of the Human Genome Project as are the more publicized gene tests and therapies. The property of us all investment, which will only be made if a financial return is likely. I do not pretend to know the answer to this conundrum, but it is not confined to genetics, and is equally apparent in many other fie lds of research. There are other ethical issues which arise from the rapid progress in human genetics. Can we always remember that the fami ly is our 29 concern, and that some members of a family may be more vulnerable than others? Can we ensure that the information is used to empower and not to disadvantage? We hope gene testing will never be used to deprive people of basic insurance, for in- stance, or the right to employment, or the hope of having children. The Human Genome Project is often seen as something different, "high-tech", "first world", and not suitable for or available to develop- ing countries. These are misconcep- tions. The techniques involved are si mple and can be introduced into any laboratory; the skills are within the grasp of any science graduate or doctor. Of course, the problems of ownership must be solved, and there may be room for WHO to work towards agreement that a set of useful gene tests should be available to all, without hindrance, in every country in the world, as for the world list of essential drugs. The human genome belongs to us all. It has taken a great deal of work over many years to unravel its se- crets. We must now work to use this information with responsibility and justice. • Professor Bob Williamson is Director of The Murdoch Institute for Research into Birth Defects, Royal Children's Hospital, Flemington Road, Parkville, 3052, Melbourne, Australia. Tel.· (3) 9345 5045; Fax (3) 9348 1391. As for all new technologies, issues of cost, patents and profits intrude. These issues are as complex in human genetics as in any field. In one sense the human genome is the property of us all, yet we know that developing a proven diagnostic tool or a gene pharmaceutical requires All those involved in human genetic investigation and treatment should be highly conscious of ethical issues which intimately concern the individual and the family. Photo Still Pictures/M Edwards© 30 World Health • Sl stYear, No. 2, March-April 1998 Event Health futures at EXPO 2000 In a new initiative, WHO is charting Health futures in a 10 OOO m1 exhibition which is expected to reach more than 40 million people worldwide. The exhibition will be part of EXPO 2000, the World Exhibition which is set to take place from l June to 31 October 2000 in the city of Hannover, Germany. Health futures will describe health in the early 21 st century in six areas: youth, older people, infectious diseases, noncommunicable diseases, health-promoting environments, and technology for health. Four of these are ou~ined as priority action areas in chapter 6 of Agenda 21 - the United Nations programme of action for sustainable development which resulted from the 1992 Earth Summit in Rio de Janeiro, Brazil. Planning for a positive tomorrow The exhibition will portray health challenges in these six areas and tell visitors about realistic, practical, cost-effective and sustainable approaches that are available now or will be in the next few years to create a positive future. It will challenge visitors to play a more active role in protecting their own health. Health futures is a new form of outreach, combining approaches used in theatre, multimedia events and science centres to make the visit unforgettable. The .,.,Island of we/I-being" Visitors will be able to establish a personal health appraisal that they can use on a personalized Web page at home. On the "Island of well-being", visitors will explore activities that enhance physical, social and mental well-being by means of virtual reality. Virtual reality technology will also enable them to simulate the ageing of their faces and hands. A life-size model of a plane will simulate the travel from Japan to Sierra Leone in a few hours, yet symbolizing the gap of 40 years of life expectancy between the two countries. The Observatory Up on the Observatory, visitors will be invited to play a computer game which simulates an outbreak of an infectious disease. Their task will be to set up a WHO Task Force, mobilize human, material and financial resources worldwide, and maintain the communications flow between all partners involved. The Observatory, a giant tower, symbolizes the vision for the 21 st century which is one of a world on the alert and able to contain infectious diseases. One of the health themes illustrated at Expo 2000 - "the globol teenager" - will highlight the important contribution that young people con make to a heolthier world in the 2 l st century. Photo WHO/) & P Hubley If you can't be there ... The exhibition also opens up opportunities to bring the messages of Health futures to "virtual visitors" - people who will not be able to attend EXPO 2000 physically. We envisage the production of multimedia tools that include educational CD-ROMs, a virtual walk through Health futures on the Internet, and the development of on-line systems that will give individuals constant access to health information from anywhere in the world. Do you have something to say? If you have comments, ideas o r suggestions on any of the topics covered in thi s issue , please write to the Editor, World Health , World Heal th Organization , 1211 Geneva 27, Switzerland. Letters should be not more than 250 words in length. Letters wi ll not necessarily be acknowledged. The Editor reserves the right to edit materia l selected for publication. World Health • 51 st Year, No. 2, Morch-April 1998 WHO publications Publications can be ordered from Distribution ond Sales, WHO, 1211 Geneva 27, Switzerland. Reporting on the future - The World Health Report 1998 What will life be like in the 21 st century? Will the world continue to grow healthier, with ever more diseases conquered by scientific advances, and life expectancy extending even longer? Or will new diseases and failing drugs cancel out these gains? If populations live longer, will these extra years be healthy and productive or merely an extended sentence of suffering? Will we conquer malnutrition, obesity, drug abuse, poverty, depression, and the common cold? Will we eradicate polio, leprosy, measles and other ancient foes? Will deaths from heart disease and cancer finally begin to decline? And when science surely delivers spectacular new therapeutic tools, who will be able to afford them? Will the gaps between the health of rich and poor grow ever wider? These are some of the mony questions addressed in The World Health Report 1998 which hos the theme "Life in the 21 st century- a vision for all". Issued as WHO marks its SOth anniversary, the report takes an expert look at health trends over the past five decades, assesses the current global situation, and predicts how health conditions, diseases, and the tools for managing them will evolve up to the year 2025. Using the latest data gathered and validated by WHO, the report paints a picture of a world poised to achieve unprecedented good health · if the lessons learned during recent decades are understood and heeded. The World Health Report 1998. Life in the 21 st century- a vision for all (ISBN 92 4 156 189 OJ costs Sw. fr. 17-/US $ 15. 30 (Sw. fr. 10. · in developing countries). Mortality map reveals inequalities in health 31 Anew arias from WHO's Regional Office for Europe gives death a geographical perspective. Not only does the Arias of mortality in Europe show national averages for all the main causes of death in WHO's European Region, but it also gives data on mortality in areas within countries between 1980/1981 and 1990/1991 . Through informative maps and charts, the arias presents vivid pictures of health in different parts of Europe. By showing differences in mortality from various causes, it raises the question of why these differences occur, and pinpoints areas where action is needed to reduce the death toll. The arias derives from the work of four main partners - the WHO Centre for Environment and Health, the United Nations Economic Commission for Europe, and the Central Bureau of Statistics and National Institute for Public Health and the Environment in the Netherlands. WHO's European Regional Office stresses that the arias reveals "inequalities in health between and within countries" - inequalities that have to be eliminated. In the next issue M alaria affects hundreds of millions of people in th e world today, ma in ly in tropical countries, w here it is a ma jor source of public health and economic problems. The M ay:lune 1998 issue of World Health w ill be o n the global strategy for malaria control now being carr ied out by WHO in partnership w ith other Un ited Nations agenc ies. The issue will present high lights of the startegy and of nationa l efforts to control this d isease. • Atlas of mortality in Europe: subnational patterns 1980/1981 and 1990/1991 (ISBN 92 890 1339 7 ) costs Sw.fr. 150 ·/US $1 35.00 (Sw. fr. 105. 00 in developing countries). Did you enjoy this issue? Why not toke out o subscription to World Health and enjoy read ing obout the world's mojor health issues six times o year. 1998 subscription prices are listed below. W HO also offers its popular 'Health Horizons' subscription, a combined subscription lot a reduced role) lo World Health and the quarterly World Health Forum. Order form O World Health 11998 subscription) al Sw. fr. 30 - /US $25.00 O Health Horizons 11998 subscription) al Sw. fr. 90-/US $72 .00 O Payment enclosed O Please charge lo my credit card O Visa O American Express O Eurocard/Maslercard/ Access Card number _________ _ Expiry date ___ Dote of order __ _ Signature _________ _ Nome __________ ~ Address _____ _____ _ World Health Organization, Distribution and Soles, 1211 Geneva 27, Switzerland. Printed in Great Britain by GreenShires Print limited, Kettering, Northamptonshire, England. SINCE 1948, WHO AND ITS MEMBER STATES HAVE WORKED TO BRING THE BENEFITS OF GOOD HEALTH TO MILLIONS AROUND THE WORLD, PARTICULARLY TO THE MOST VULNERABLE. WITHOUT THIS DYNAMIC PARTNERSHIP, FAR GREATER NUMBERS OF PEOPLE WOULD STILL BE EXPOSED TO DISEASE AND PREMATURE DEATH. Photo Keystone/ HOA-QUl/ de Wilde ©