Sport for a lifetime [full issue]

sport for a lifetime WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • NOVEMBER 1978 • USA $ 1.25 IX ISSN 0043-8502 Sport for a lifetime. Cover design by Peter Davies. ' III World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. • Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Sport and Health by F.J. Tomiche 3 Mountaineering : the athletic approach by C. Bonington . 7 Under medical supervision by V. Nikolayev ......... 10 Sports medicine by J.G.H. Refshauge 14 Eating well to perform better by M.-L. Bargues 18 Testing the limits by N. Willard 22 Good for the heart by R. Masironi . ......... 27 The Declaration of Alma-Ata 28 News Page 30 Sport and Health There can be no doubt about it : sport offers the best antidote to the tensions and stress that are everyday hazards as our lives become increasingly competitive by F. J. Tomiche avid, a' 15-year-old adolescent of athletic build and cheerful disposi- tion, was growing up with no par- ticular problems. His class marks were very good, he got on well with his schoolfriends, and he was always full of beans. Then one day his father announced that his boss was transferring him to an- other town; he had no choice about it— in two months' time the family would have to move house. David, who was deeply attached to his neighbourhood, took the news very hard and withdrew completely into his shell. He loved his school, his friends, his way of life; so now he was quite firm about it—he just didn't want to leave home. There were family rows one after the other amid an atmosphere of growing tension. Eventually David seemed to give in, and his parents thought that in a few weeks everything would be back to nor- mal. In fact quite the opposite took place. The young boy had been seriously disturbed, his school marks went steadily downhill, and he shut himself away in al- most complete silence, communicating with no-one. He began to put on weight, his character turned sour and he became aggressive towards those close to him. His anxious parents went to see his teacher. "Don't worry", he told them. "I have often seen cases like this. Try to get the boy interested in sport." It took a great deal of diplomacy, but David's mother succeeded in taking her son to a sports Club where he could run, jump, swim and play volleyball. Within three months a second transformation had taken place. David became commu- nicative again, recovered his good Until recently a sufferer from leprosy, this young footballer in Burma was helped towards recovery by his interest in sport. (Photo WHO) humour and lost the excess weight he had put on. And even his school marks improved. David's story, with variations, is being repeated thousands of times every year. This all goes to show that health and sport are closely linked, and that physi- cal exercise is every bit as important to the mind as it is to the body. There can be no doubt about it : sport offers the best antidote to the tensions and stress that are everyday hazards as our lives become ever more competitive. It offers a respite from our daily cares and contributes a vital element of bal- ance and relaxation. Individual sports, such as swimming, athletics or gymnastics, offer a school for character formation, where self- discipline and stamina can be developed. Individuals exert themselves to im- prove their own performances, however modest these may be, and to set them- selves new goals. Team games like foot- ball, rugby, hockey or water-polo, on the other hand, encourage another set of qualities, among them coordination with colleagues, the team spirit and a sense of belonging. What we call the sporting spirit combines fair play, dexterity, self- control and good manners. It was in this context that Baron Pierre de Coubertin, re-founder of the modern Olympic Games, commented : "The essential thing in life is not so much to win as to fight fair." On the physiological level the benefits of sport are too well-known to need repeating here. All the same it is worth recalling that sport has a beneficial effect on general hygiene. There is nothing bet- ter than a good shower after the sweat of physical effort, and it is just what tired muscles cry out for. Besides all this, athletes noticeably smoke and drink less than those who take no regular physical exercise, and the roles played by alcohol and tobacco in respiratory diseases, lung cancer and cirrhosis of the liver have today been clearly established. It follows that a heal- thy sporting life is in itself an excellent way of preventing quite a number of kil- ler diseases. It has even proved effective in curbing accidents at work; workers in Soviet factories are called upon to do five or ten minutes of exercise every day and this, according to the specialists, has both reduced the number of accidents and increased productivity. Beneficial at any age At whatever age a person starts, sport has a health-giving effect, although ob- viously the intensity and the nature of the effort involved varies with age. The consumption of oxygen determines the intensity of effort in the human body; that consumption reaches its maximum around 20 years of age, and then pro- gressively decreases as the years pass by. Women in general absorb 25 to 30 per cent less oxygen than men do. But regu- lar training can increase the absorption 3 Above: Boxing is among the most violent of sports. A protective helmet would guard box- ers' skulls from damage. Left: Kenyan runner Henry Rono, holder of several long-distance world records. Right: A tennis star delivers a fierce forearm drive. In beginners, a mistake could result in "tennis elbow". (Photos Len Sirman ©) of oxygen in both women and men by as much as 20 to 30 per cent compared with a person who is not in training. Around the age of 35, the heart rate decreases in men and this in turn reduces the maximum consumption of oxygen. People at this age should ease up their ef- forts, resist the temptation to go flat out in competitive sports, and stop racing against the clock. Beyond the age of 45, sport is the best antidote to a sedentary life and over-in- dulgence in food—two leading charac- teristics of the affluent society. And in the "Third Age", physical exercises help to keep limbs supple and to avoid such accidents as fractured hips to which the elderly are particularly prone. At all ages, countless invalids, heart cases and disabled persons have managed to restore themselves to normal activity, thanks to having embarked on the right sort of physical activity. There are some detractors of physical exercise who claim that the benefits which may be derived from sport fall very far short of compensating for the risks entailed. No human activity, whether it is merely boiling an egg or mending an item of clothing, is totally free from potential danger. Even walking on a lonely path, with no likelihood of ice about, can carry certain risks; you could be stung by a wasp or you could twist an ankle. But to set the benefits of sport on the same level as the dangers that can quite easily be avoided is to deny all the evidence—or merely to put up a lame excuse for not doing any phys- ical exercise. Boxing is among the most violent of sports. Yet nothing prevents those who practise it from wearing a protective hel- met to keep the skull from damage. Most of the accidents which do unfortunately occur are the result of blows on the head, 4 such as detached retina or concussion. After all, fencers don't consider it un- usual to wear a protective face-mask! A pathology of its own Sport is sometimes blamed for having developed its own pathology. Take for instance that painful affliction "tennis el- bow", or "athlete's foot", caused by a skin fungus, or the broken legs that are an all-too-frequent hazard on the ski slopes. Tennis elbow is caused by con- stant repetition of a faulty movement in making a forearm drive. It occurs most often among beginners who have not been taught the right action, which con- sists of stretching the arm while pivoting on the shoulder. The consequent pain becomes increasingly worse as, day after day, the player goes on mis-hitting the ball with a forearm stroke. It is just as if someone who has had a knock on the el- bow goes on banging its sensitive point. Athlete's foot affects many individuals who take no part in any sport, and par- ticularly afflicts those who go about barefoot. This skin condition is badly named and creates confusion in the pub- lie's mind, since many people wrongly believe that it is a problem strictly reserved for athletes. Finally ski equipment, and in particu- lar the boots and the bindings which hold the skis, have been tremendously improved in recent years, so that the number of accidents proportional to those who take up skiing is steadily on the decline. This total could be reduced still further if skiers took the trouble, before launching themselves down the snow slopes, to warm up their muscles with a few preliminary exercises—and if beginners at the game did not simply hurl themselves full-tilt down ski-runs that are too difficult for them. In every sport there is a natural progression from easy to difficult and there is simply no point in trying to skip some of the stages. Again, the opponents of sport criticize it on other grounds. According to them it has become a spectacle comparable to that of the circus. They claim that pro- fessionalism has invaded all forms of sport and corrupted its original spirit. It encourages rigged matches, doping and other irregular behaviour, and it panders to the worst kind of nationalism. What is certainly true is that sport, blown up by television and the other mass media, has come to occupy a prime place in the social activities of our age. Some people com- pare its standing to that of the circus games in Ancient Rome or to the joust- ing of knights in the Middle Ages. In fact the number of professional sportsmen and women is tiny today if compared with the total of amateur ath- letes. Those few thousands of footballers who are paid fabulous sums, or the hun- dred or so tennis players whose game merges into "show-business", represent a negligible total of individuals compared with the millions of teenagers who ex- press their joy of living by kicking a ball about. The big difference between these two categories of athletes is that the first mentioned lay claim to newspaper headlines and television interviews, while the others play their games in simple anonymity. In any event, the sports authorities in every part of the world are doing their best to combat irregularities. Doping, for instance, is subject to more and more 5 These fencers avoid unnecessary risks. Their bodies are well padded and their faces protect- ed by a wire mask. ( Photo Len Sirman ©) frequent checks. At the Olympic Games, the International Olympic Committee obliges the first three winners in each event to undergo tests to ensure that they have not taken anabolizing steroids or other stimulants. Several individuals were disqualified during the last Games at Montreal in 1976. The Olympic Committee hopes by taking this tough line to discourage any cheating. A famous racing cyclist who was leading the field in the Tour de France this year, and therefore was the proud wearer of the leader's symbolic yellow jersey, was eliminated from the race after a dope test. As for nationalism, it is quite true that there have been incidents of a deplorable kind. But who are those who form the ranks of these chauvinist hooligans? Pri- marily they are the spectators, those who are rather scornfully dismissed as "pas- sive sportsmen". What's more, these people are themselves influenced by the existing political systems, and it is those that ought really to be blamed for a state of mind for which competitive games are only the trigger and not the cause. School manuals and teachers also share a heavy responsibility for the sur- vival of extreme nationalism, as a num- ber of studies made by UNESCO have shown. Sport itself brings people togeth- er regardless of social origin, race or reli- gion. Prejudices of all kinds stand little chance amid the close-knit camaraderie of the big sports stadiums. Lower priority In the world's industrialized countries, sport is becoming more and more orga- nized, winning over more adherents and cutting across the lines of class. Unfortu- nately the same is not yet true in develop- ing countries where urgent needs—for food, work or housing—relegate sport to a lower priority. Cases such as that of Rono the Kenyan champion runner who has set world records in the 10,000 metres, 5,000 metres and 3,000 metres hurdles cannot hide a deeper reality : the fact that the level of a country's development al- most always governs the practice of sport. Can one really take pleasure in running, jumping or swimming when one is hungry or when there are doubts about what tomorrow will bring? Yet WHO has underlined time and time again the close relationship that exists between health and development, and as we have seen—sport is an essential factor for good health and well-being. All those who want to participate in sport ought to be able to do so. It is pre- cisely this that UNESCO has affirmed by drawing up a Charter proclaiming the right of children, teenagers, women and men of all countries in the world to take part in sports and to have access to sports installations. Let us hope that this UNESCO Charter will be rapidly and universally put into practice. Once it has been, we shall un- doubtedly find we live in a better world; more sport means more friendship and more brotherly love. ■ UNESCO SPORTS CHARTER A draft international charter of physical education and sports being submitted to UNESCO's General Conference proclaims what amounts to a new right for every human being: "The right to access to physical education and sport, which are essential for the full development of his personality"". An Interim Intergovernmental Com- mittee on Physical Education and Sport approved the draft at a Paris meeting last May. The draft calls for sport to be "ensured throughout life" as part of a global, lifelong and democratized educa- tion. It also asserts that "co-operation and the pursuit of mutual interests in the field of physical education and sport, which constitute a universal language, may help to promote the preservation of lasting peace. . . and create a propitious climate for solving international pro- blems." The draft says that UNESCO does not aim to concern itself in the staging of sporting events but would seek ways of overcoming problems in co-operation with the international sporting organiza- tions. 6 Mountaineering :the athletic approach The only way for today's climber to venture into new fields of exploration and adventure is to train both body and mind with the self-discipline of an athlete by Chris Bonington limbers have always considered their game to be very different from any of the organized sports, such as athletics or football. There seems, however, to be a move amongst some climbers towards a more athletic approach to their sport. In at least one country this has already taken on a more formalized aspect in the sense that its devotees hold competitive climbing meetings, the contestants being timed up a stretch of rock, and losing points for falls or lack of style. A rope from above is used in this type of event, so that the element of risk is removed and the climb becomes a form of gymnastic track-event in the vertical. Elsewhere, climbers have almost un- animously shunned this approach to climbing on the grounds that it seems to them to introduce a number of unsavou- ry ingredients to the climbing "mix". Formalized competition must inevitably mean a set of written rules for the game; it also entails a high level of control, with the exact position in the championship table being widely announced and inevi- tably becoming all-important to the con- testants. The effect could be to submerge the basic love of climbing and the moun- tains, which should be the real basis of the sport. Although many climbers have spurned the concept of climbing competitions, it would be hypocritical to assert that climbing was free of a competitive ele- ment. In fact an informal competitive- ness adds spice to it, whether it be amongst a small group trying to work out a boulder problem or between teams going for a major unclimbed problem in the Alps or the Himalayas. There was intense competition to be the first team up the North Wall of the Eiger, to be the first man to stand on the highest point on earth, or to be the first to climb the South-West face of Everest. On the Continent particularly there is an unspoken individual competition to bag as many 8,000 metre peaks as possible. At the moment the brilliant Italian climber Reinhold Messner leads the field with four. But all these forms of competi- tion lack formalized rules, and to my mind are simply a manifestation of man's innate competitiveness. This is something that has always been present in climbing. Back in 1865 there was a race to conquer that splendid Al- pine spire, the Matterhorn, but the level of competition was fairly casual and of course there were many mountaineers who denied it even existed. In parallel with this attitude, many climbers ap- proached their activity with a deliberate- ly dilettante attitude, spurning all forms of training other than that of the right arm, for lifting a beer mug. When I start- ed to climb in the early 1950s, and for that matter in many circles to this day, climbing and boozing in the pub were closely interlinked; I certainly don't feel I have completed my day's climbing until I have had a well-earned pint on the way home. But inevitably climbing standards have steadily risen, both because of each generation's natural desire to stretch it- self a little further than the previous one and also because there is only a finite amount of unclimbed rock. Inevitably climbers are forced on to progressively steeper and more holdless lines, as the easier ones are "climbed out". The sheer increase in difficulty has necessitated a more disciplined and more gymnastic ap- proach. The actual advance in rock climbing techniques has developed in a series of bounds. Immediately after World War II, with increasing prosperity, climbing in Britain became available to a much wider cross-section of people. Before the war it had tended to be a pre- serve of the middle classes, but in the late 1940s and early 1950s, using ex-War Department gear, any young lad living in the North of England could have a go on the rock outcrops that lie close to many Northern cities. Two young Manchester plumbers, Joe Brown and Don Whillans, made a climb- ing breakthrough, pushing up the stan- dard of routes to such a degree that it was 10 years before the bulk of the climbing world caught up and managed to repeat their routes regularly. 7

Left: Chris Bonington within sight of victory last year on the 23,900 foot Himalayan peak, the Ogre. (Photo C. Bonington ©) Above: A routine climb up the Matterhorn in the Swiss Alps. But this climber is managing with only one leg. (Photo Len Sirman ) Brown and Whillans were brilliant natural climbers who tackled their climbs in a very innovative manner with great determination, but they didn't train for their climbs and would have laughed at anyone who did. It was 20 years before another major breakthrough was made in climbing standards. It started with a group of Leeds climbers, one of whose leading lights was Pete Livesy. He had come to climbing comparatively late, in his late twenties, with a background in athletics and "pot-holing"—exploring the vertical shafts and caverns cut by rivers in lime- stone areas. He and his fellow climbers began applying athletic disciplines to their climbing, going to the gym, weight- lifting and doing exercises to increase their strength and agility. Most impor- tant of all, in a country like England, where the weather is so bad for most of the time, indoor climbing walls were introduced into sports centres. On these artificial walls, climbers would work out specific moves, pushing themselves to ever greater limits. Even climbers' dress is today showing athletic associations; instead of breeches or jeans you often see tracksuits. In warm weather, shorts and tee-shirts are favoured, and gymnasts' chalk is being increasingly used on the hard new routes. In the greater ranges of the Alps and particularly in the Himalayas, a more athletic approach is also becoming essen- tial. On the pre-war Everest expeditions, the dignified British mountaineer rarely carried a load and the team depended on a host of local porters. Today there is a trend away from big expeditions relying on porter-power and towards small, self- sufficient expeditions moving swiftly up the world's highest peak. Messner, from the Italian Tyrol, has led this trend, firstly with his very im- pressive two-man ascent with Peter Habler of Hidden Peak, an 8,000 metre tower in the Karakoram, and then, in 1978, the first ascent of Everest without using oxygen. They prepared for their ex- peditions with an athlete's thoroughness and discipline, running every day in the Austrian Alps, making a height gain of 1,000 metres and then pushing them- selves to the limit on Mount Kilimanjaro in Tanzania, shortly before going out to Everest. This summer I met the French climber Janic Seigneur on his way for a two-man attempt on Broad Peak in the Karakoram. Each day, at the end of their march, he and his companion would climb 1,000 metres up the moun- tain side beside the valley or glacier, to build up altitude acclimatization. On reaching Base Camp, they didn't pause, and climbed the 8,000 metre peak in three days. They were only able to do this because they had trained hard and systematically before setting out. There is still a school of thought that deplores this approach as unsporting, over-professional, escaping from the easy freedom of mountaineering. I think this is false thinking, for the added fitness as well as the use of modern equipment and aids enable the mountaineer to move more swiftly and pleasurably in increas- ingly wild and testing situations. Climb- ing, like every human activity, is con- stantly evolving, and today the only way that the climber can venture into new fields of exploration and adventure is to train his body and mind with the self- discipline of the athlete. ■ 9 Under medical supervision Physicians who work at the Soviet Union's sports clinics are often called "trainers in white". They are frequently credited, justifiably, as "co-authors" of new track records by Vyacheslav Nikolayev atiana Kazankina is one of the Soviet Union's leading sports- women. The claim is a justifiable one, since she captured two gold medals at the 1976 Montreal Olympics, in the 800 metre and 1,500 metre track events. Canadian sports commentator D. Gilbert wrote in the Montreal Gazette at the time that Tatiana Kazankina had accomplished a feat thought by many people to be impossible; here was a sportswoman of extraordinary talent and rare courage. Back in 1971, when Tatiana was begin- ning to approach record timings in the middle-distance track events that most appealed to her, doctors noticed some deviations from the normal in her heart- beat. They discovered that a serious in- fluenza attack in childhood had left her with heart trouble. As her sport activities put an increasing load on her heart, this weakness was beginning to tell. There was an apparent risk of danger to her health, so the doctors imposed a firm ban on over-strenuous training. Only after lengthy consultations with leading specialists in sports medicine, and following an all-round study of her functional capabilities, did the doctors and her trainers reach the conclusion that reasonable physical strain would do her no harm, could indeed be permit- ted—and might even improve her health. All the same, Tatiana and her chief trainer had to set aside their dreams of achieving world track records. A battle began against the effects of her child- hood illness, and it was conducted under close medical supervision. The physical load put on her was strictly limited, she undertook special exercises to improve her cardiovascular system, courses of vitamins and special pharmaceutical preparations were prescribed to strength- en her heart muscles, and her training took place only in the open air—mostly in a densely forested area. All this bore fruit. By 1972 Tatiana was already show- ing the sort of track results that won her a place in the national squad. She began training with the Olympic team. And four years later came Montreal. Was it possible that so much attention was paid to Tatiana Kazankina simply because she lives in Leningrad, one of the Soviet Union's largest cultural and sporting centres, or because she had Above: Soviet runner Tatiana Kazankina. Heart trouble following a childhood illness did not prevent her winning two Olympic gold medals at the 1976 Montreal Games. (Photo Len Sirman ) Facing page: Without close contact be- tween coach, doctor and athlete, the supreme effort required to break world records could entail serious risks to health. (Photo WHO/K. Henzo) already made a hit in the sports arena and was firmly in the public eye? I am fully convinced that this is not the case, particularly since I made a business trip to Murmansk, within the Arctic Cir- cle, where as usual I called in on the regional medical office for athletes. There are now more than 350 such of- fices in the country, as well as several thousand special departments at poly- clinics in cities and rural hospitals. I hap- pened to be present during a discussion between Felix Norkin, the chief physi- cian—who incidentally has a master's rating in fencing—and Vladimir Klimov, the trainer of the local athletics team. The coach complained that the results returned by his pupil, star athlete Alexei Baskakov, were getting progressively worse. He asked for an explanation. The athlete was duly given a thorough medical examination, using the most up- to-date equipment. The results showed that he had a low oxygen consumption; he had little capacity for work and his weight was on the increase. His body reacted by slowing down his speed in running heats. The physician offered an appropriate set of recommendations. This was a typical example of the close contact that is maintained between coach, doctor and athlete throughout Soviet sport. Without this relationship it is broadly speaking impossible to aim for record-breaking results without risk- ing dangers to health because of the strains imposed. The work loads have to match each individual's physical capaci- ty, and that in turn can only be deter- mined by doctors with access to the very latest in investigative equipment. Soviet physicians who work at the sports clinics are often referred to as "trainers in white", and they are frequently credited quite justifiably as "co-authors" of new track records. Nobody in the Soviet Union may take part in a sports contest without getting 10

• _ 4 , 44 , Left : A woman athlete tenses for the effort of putting the shot. Work loads have to match each individual's physical capacity, and this in turn can only be determined by doctors with access to the very latest in investigative equip- ment. (Photo WHO/L. Almasi) Right : Well within the Arctic Circle, a group of Soviet "walruses" warm up with a snowball fight before breaking the ice on a nearby pool and going for a swim. (Photo WHO/Novosti) the go-ahead from the doctors. Leading athletes undergo a full medical check every year, carried out as a rule at the local sports clinic. It is considered perfectly nor- mal for a physician to specialize in sports medicine in this way, since the prime goal of the Soviet physical education system is to boost the health of millions of individuals. As for track records— they are just one of the incidental by-products. Not only Tatiana Kazankina but also such world-famed sportsmen as weight- lifter Rudolph Plyukfelder and figure- skater Irina Rodnina were far from enjoying good health during their child- hood. Thanks to sport, and rational training sessions under medical supervi- sion, they have managed to achieve im- pressive results. It goes without saying that incidents involving overtraining or injuries cannot always be avoided. In such cases other health workers in the polyclinics, specia- lizing in remedial physical treatment, come to the athletes' aid. They have at their disposal a rich arsenal of clinical medical weapons : physiotherapy, reme- dial gymnastics, all kinds of massage, hydrotherapy, swimming pools, oxygen and vitamin therapy. Such remedial treatment is particular- ly popular among people of the older generation who do not practise active sports but who turn to different forms of health promotion in the open air. This too is one of the regular concerns of the sports clinics. In Murmansk, for in- stance, the clinic doctors act as advisers and organizers for the "walruses"—peo- ple who delight to plunge into ice-cold water during the winter and swim about. Although the eldest of this group is aged 67, its members also include several children. Swimming in icy water the whole year round is very beneficial to the health— but not everyone is capable of trying it. The fact that there has never been a sin- gle case of serious illness or complica- tions is a tribute to the daily supervision maintained by the clinic's doctors. This is what 56-year-old Vera Ivanova, a resident of Murmansk, says about the training sessions, which she has attended for some years at the municipal swimm- ing pool as a member of a general physi- cal training group : "Like many people of my age, I was constantly going to doc- tors, but the treatment they suggested did not seem to make any improvement. My blood pressure did not go down and I found it hard to breathe. Then I was advised to join a group for general physi- cal fitness—we call it a health group. After a medical check-up, I received a voucher to attend at the sports clinic. After a year's regular attendance, I can now get along without any drugs. They have been completely replaced by physical exercises and remedial swimming." Only a few of the many activities of the sports clinics have been touched upon here. But special mention goes to the work of sports physicians among young athletes in our schools, and among those whose poor health temporarily prevents them taking normal exercise. It is partic- ularly interesting work, and certainly not lacking in variety. And it is carried out on the same principles that characterize all Soviet sport : lessons in physical edu- cation, no matter what form they take, are seen as a means towards the harmo- nious development of mankind which will improve the health of millions of individuals. ■ 13 Sports medicine There is growing determination in many developed and developing countries today to set in motion formal post-graduate courses in sports medicine by Jack Refshauge ports medicine is not a new or modern practice. Ever since man- kind has existed the human body has been submitted to study. Early man, in order to survive, found he must employ only the required energy and technique needed to overcome his diffi- cult moments in hunting. Equally basi- cally, it is probable that supreme or max- imum performance was required only for survival in attack or defence, or in com- petition with his fellows. Nowadays, sport is an effective means of obtaining measures of work capacity, speed and execution of manoeuvres, power potential and physical endurance. In fact, these studies have made us aware that we must not only evaluate the rela- tive degrees of excellence that the body can obtain, but we must also define the limits that effort and performance must not exceed. The conviction that health is linked with physical and mental activities goes back to antiquity. Greek literature of the sixth century B.C. indicates these bene- fits, and in the virile and well-recorded Greco-Roman era remedial therapy was practised and extolled. In modern times, it is only during the last two to three decades that the worth and role of sports medicine have been recognised, and even now in some of the more developed countries the academic establishments still ignore its value and its inevitable development as a discipline. In the more affluent countries, press, radio and television give increasing expo- sure to the alarming escalation in health costs devoted to treating cardiac diseases, psychiatric problems, metabolic and neuro-muscular ailments, industrial and traffic injuries, social diseases and inju- ries due to violence. While highlighting spectacular and severe sports injuries, the media also lament the lack of knowledge in many countries of the numbers of people par- ticipating in sport and the number of in- juries sustained, as well as the type and severity of the trauma. At the same time, the press gives generous exposure to countries which are successful in interna- tional competitions, attributing their success to adequate financial backing, excellent medical and allied health sup- port, as well as to increasing excellence in training facilities and coaching expertise. This media exposure, combined with the explosion in medical technology, par- ticularly in the fields of work physiology, human movement studies, prevention, treatment and rehabilitation of injury, has led both to the increasing recognition of sports medicine as an essential part of the health spectrum and to its develop- ment as a discipline. It has been said that it is easier to de- scribe the discipline of sports medicine than to define it. In some countries it is confined to medical graduates only, while in others it is composed of a single professional specialty. Some see it as a combination of both medical and paramedical professionals. There is in- creasing acceptance around the world that suitable and regular physical activi- ties are generally beneficial, but it must also be appreciated that programmes for elite competitors and programmes for "fun sport" participants must be individ- ually designed, while the inherent risks in any such programmes must be calculated and covered to the best of the organisers' ability. The "descriptive definition" I propose is that put forward by the Australian Sports Medicine Federation. This Feder- ation in its present form is 16 years old This sturdy athlete was a competitor in the World Medical Games staged recently in the South of France. Doctors from many countries of Europe took part, to prove that the corol- lary of "Physician, heal thyself— is "Physi- cian, keep thyselffit"! (Photo Mediphot ©) 14 • • NO,{ a• 1111111.1111111111k 11111111111 11111111111111111 and rapidly expanding in numbers and activities. It is a multi-disciplinary organ- ization with representation from many different specialties, including general and specialist medical practitioners (team physicians), psychiatrists, psychol- ogists, exercise physiologists, physio- therapists, physical educators, podia- trists (specialists in the care of the foot), nurses, sociologists and coaches. This varied membership offers a team approach to sports medicine, and en- ables us more adequately to practise our aims and principles. These are : to supervise the medical care of or- ganizations which promote and conduct physical activities in sport and recrea- tion. Such medical care should help to safeguard and improve the physical and mental health of the community; to foster the scientific study of both the normal and harmful aspects of physi- cal activity and to encourage research into such matters; to promulgate information of use to sporting bodies; to co-operate with kindred national and international bodies such as the In- ternational Federation of Sports Medi- cine (Fills) ; to act in liaison with the Australian Olympic Federation and similar national sporting bodies; to act as an advisory body in matters pertaining to sports medicine and in mat- ters relating to national health and fit- ness; to act as a co-ordinating body for all the Australian State groups, to promote policy and undertake such tasks and re- sponsibilities as may be incidental to the Federation's aims. The Federation also produces the Australian Journal of Sports Medicine and the Australian Sports Medicine Newsletter. Wide involvement If it is to fulfil its role in its environ- ment, a sports medicine association has to be involved in many areas. It must provide the appropriate sports medicine personnel for full medical and paramedi- cal support at any international sporting event, at home or abroad. It must pro- vide similar sports medicine personnel at national, State, regional and community sports venues. It should offer guidelines for selecting medical and paramedical personnel for these occasions, and should be available to advise national, State, regional and local governments or sporting bodies upon sport and recrea- tional matters. It might, for instance, prepare medical guidelines for legislation to cover such sports as boxing or other martial arts, or it might lay down medi- cal guidelines for health care in sports sponsored by government or industry. Without this advice many such sponsor- ships could result in heavy casualties, all of which could be minimised if simple and fundamental sports medicine princi- ples are followed. An association might also investigate the suitability of certain sports to be registered as a parent body. Its medical opinion might be called for on such controversial matters as mixed- sex body contact sports, such as football, the registration of females as profes- sional boxers, or problems associated with competitive sport in the young. It would be required to make regular presentations at national, State, regional and community sports medicine con- gresses, seminars, lecture series and demonstrations. There is a vast range of potential themes for such meetings. They might deal with the effects of exercise, both beneficial and harmful; the scientif- ic basis for fitness and training in sport; or cardiac function in sport including such elements as electro-cardiography, the circulation and so forth. Sports psy- chology and psychiatry, genetics, the ef- fects of environment on sport (altitude, for instance), doping in sport, the role of team physicians, and sports trauma- tology with emphasis on prevention as well as treatment and rehabilitation—all these may figure on the agenda at such meetings. 16 sports medicine Left : Siamese boxers use legs as well as arms to overcome their opponent. A sports medicine association might be called upon, for instance, to prepare medical guidelines for legislation to cover such sports as boxing or other martial arts. (Photo Len Sirman ) Right: Not all who practise sports are young and fit. All the indications are that physical ex- ercise is beneficial at any age ; in some circum- stances it may even prolong life. (Photo WHO/T. Farkas) Some subjects will be governed by geography; thus some countries put em- phasis on skiing and others on aquatic sports. Then there are physical activities in the disabled, women in sport, sport and the aged, the effects of social habits such as smoking, alcohol and sex on per- formance, nutrition in sport, fitness tests and assessments, and even sudden death in sport. All these topics and many more have already featured at international congresses held under the auspices of FIMS sponsorship between 1928 in Amster- dam and 1974 in Melbourne. Post -graduate courses So far, only a few formal post-grad- uate courses in sports medicine have been recognised by national governments and national medical associations. The most outstanding of such courses is the six-year sports medicine study held in East Germany. The United Kingdom and the United States hold various courses and FIMS has basic programmes available. These are probably suitable for any countries that may wish to in- itiate studies of this kind. There is growing determination in many developed and developing coun- tries to establish such courses, and un- doubtedly this has in part been stimulat- ed by increased media coverage of inter- ....11111116. national and national sporting events, where naturally the greatest emphasis is accorded to the successful countries. Governments too are anxious to pro- mote health orientation by physical ac- tivity, and in affluent countries where health insurance covers medical costs, the health percentage of the gross national income has escalated to such a degree that governments are being forced to take measures to contain this expendi- ture. One aspect of this escalation has been the growth of numerous "Sports Medical Clinics", in many cases staffed by medical and paramedical graduates without any sports medicine experience. If governments are to control such clinics they must have some means of in- troducing an accreditation system, and it would be natural for them to turn to their sports medicine association for guidance. It seems logical that the most acceptable form of accreditation would be the completion of an appropriate course in sports medicine which would meet the requirements of the National Medical Association. In Australia, the Australian Sports Medicine Federation proposes to initiate such a course next year, in conjunction with the Royal Australian College of General Practitioners. It will initially be developed for medical practitioners, but the Federation hopes later to establish such courses for physical educationalists and physiotherapists in consultation with and under the auspices of their own educational authorities. Courses for coaches are already in action and are be- ing upgraded. A further stimulus to the initiative of the Australian Sports Medicine Federa- tion has come from our Asian neigh- bours, who would like to see such a course made available for their gradu- ates, which they could adapt to their own needs as their sports medicine associa- tions develop and consolidate. The proposed course to be set up for general practitioners in Australia would incorporate such topics as basic sports anatomy and kinesiology, exercise physiology and biochemistry, fitness tests, including methods and interpreta- tion for athletes and non-athletes, train- ing and conditioning for sport, exercise and disease—the preventive and therapeutic effects of exercise as well as medical contra-indication to sports, nutrition and drugs in sport, and the ef- fects of environment on sports perfor- mance. The course will also deal with paediatrics and adolescent sports medi- cine, the effects of age on sports and recreation, the prevention and treatment of injury in sport, the psychology and sociology of sport and recreation, and the role of the team medical officer. ■ 17 Eating well to perform better by Marie-Lise Bargues t would somehow tmwargoicnagl magical , t aosthifi nckertoaf i nfooi ndg rfeodr ieanthtsletoeffseares if da it I j instant formula for record-breaking performances. There is no miracle food. What really matters is to maintain the right balance, or to recover it once it has been lost. Certainly it can be said that food is vested with a degree of symbolism, but there is no point in adding some extra in- gredient and attributing to it powers that it does not have. But just as education can open doors for the child—if the child so wishes, so a healthy and balanced diet can help the athlete to realise his or her full potential if the athlete is willing to try it. Those who practise sport are not crea- tures apart, and their needs are not really any different from other people's. But those needs are multiple; they have to meet a demand for energy, while re- sponding to differences in metabolism and in bodily reactions. A correct diet has to take care of everything, so let us look at the situation both quantitatively and qualitatively. All foodstuffs contain a certain amount of energy which is expressed in calories; they also have a variety of other properties. These can be divided sche- matically into three main groups : the proteins which are body-builders, the carbohydrates which supply energy in immediately usable form, and the lipids which constitute our reserves. Beside these main groups there are the vitamins and the mineral salts, whose presence in minute quantities is essential to health. Finally we must not forget the body's liquid needs. To evaluate our quantitative require- ments, research has evolved various sophisticated methods which enable us to understand more fully what happens when our bodies are at rest or during strenuous exercise. Various informative studies have been made of the foods that athletes eat. Besides indicating the quantities con- sumed, they offer a basis for a public education campaign about food. And knowing what is actually being eaten, we can more easily determine what is lack- ing or on the other hand what is surplus to requirement. In practice, an individual's weight reflects very precisely how the body's needs for calories are being met. An ath- lete who puts on weight is eating too much and one who loses weight is not eating enough. But of course intense ef- fort also entails a considerable loss of liquid content, which is recorded by the weighing scale. In the long term, a con- sistent body weight is an excellent yard- stick of nutritional balance and a useful means of control. One gram of lipids will give the body nine calories, one gram of carbohydrates four calories, and one gram of proteins also four calories. But there is no such thing as an exclusively carbohydrate or protein diet. Broadly speaking, the diet should comprise 50 to 55 per cent of car- bohydrate, 13 to 15 per cent of proteins and 27 to 33 per cent of lipids. The proteins are the building materials. It is often said too that "eating proteins builds muscles". This is in fact not the case, since the proteins that are absorbed in too large quantities are sim- ply eliminated from the body. However intense effort involves a certain degree of muscular use, so it makes sense to in- crease the protein intake—though only slightly—particularly in the form of pro- teins of animal origin. These include meat, fish and eggs as well as milk and other dairy products. Proteins of plant origin are found in certain vegetables, es- pecially exotic and "dry" ones, to a lesser degree in dry fruits and flour-based 18 Powerful Sumo wrestlers in Japan may strug- gle for five hours at a stretch; afterwards they replace the energy with a no less powerful meal. A sportsman's needs are multiple, meet- ing a demand for energy while responding to differences in metabolism and bodily reaction. (Photos WHO/E. Schwab) foods, and still less in bread and pota- toes. Except in the most disadvantaged areas, mankind's protein needs seem to be adequately met everywhere in the world, and the proportions contained in our foodstuffs are relatively constant. Only their nature and origin—whether vege- table or animal—varies. As for the ath- lete, the main thing is to remember that it is pointless to step up his or her protein intake above the indicated level of one gram per kilogram body weight per day. But it is worth varying the source of these elements, and not neglecting ani- mal proteins; these are sometimes the only ones which provide certain amino- acids that are essential to cell-formation. The body fuels Carbohydrates and lipids are fuels; they supply us with energy. However the body does not use them at a steady rate. During intense effort, one burns carbo- hydrates, but as exertion falls off, the amount of lipids used increases, and is particularly important during prolonged effort. Moreover our reserves of these ele- ments differ widely. The adipose tissues contain about 8,000 calories in the form of fats. The sugar reserves (primarily in the liver and muscles) are in the order of 1,800 to 2,000 calories. Certain organs, including the brain, are glucose-dependent because they derive their energy only from glucose, that is, sugars that can be used by the various metabolic processes. The supply of carbo- hydrates has therefore to cover not only exertion but also the renewal of the carbohydrate "pool" which maintains the constant refuelling of the brain. Generally speaking, these carbo- hydrates form 50 per cent of the total diet; during competitive sports the intake ought to be increased. But it is essential to avoid overdoing it. Excess carbo- hydrates are stocked in the form of fat, and this padding affects performance and can have other long-term harmful con- sequences. These carbohydrates can be regrouped in another way. There are refined sugars (contained in jams or sweet pastry) that are rapidly absorbed and therefore serve as the fuel for sudden exertion. In much of the industrialised world today their consumption has become too excessive and has led directly to diseases of over- indulgence. There are also "slow" sugars, so called because the body takes longer to assimi- late them. They are valuable because throughout the day they keep us supplied with energy. Finally there is cellulose, a constituent of vegetable membrane, which is not strictly speaking a food; only partly affected by our digestive juices, it is not absorbed but forms an important element in our food disposal system. Very often, changes of habit or of life style in the athlete result in a kind of laziness of the bowels. Cellulose should not be neglected as a precaution against constipation. Avoiding abuse Like the proteins, lipids are of animal or vegetable origin. Cooking oils contain 100 per cent, butter and margerine 83 to 84 per cent. They are also found mixed with proteins; pork contains about 30 per cent and beef 10 per cent. These useful components, which are vital when we un- dertake prolonged effort, form our reserves and are also the agents which help us to assimilate certain vitamins. Here again we must beware of over- consumption. As in the case of refined sugars, it is easy to include too much in our food, but a super-fat diet slows down performance and inhibits the metabolic 19 rate. Depending on their origins, the nature of these fatty particles varies; vegetable fats give us first and fore- most certain fatty acids which are essen- tial, but also some polyunsaturated acids which encourage diseases of over- indulgence. These fatty sources need to be varied and it is wise not to overlook the fats. One millilitre of water is the equivalent of one calorie. So an athlete who uses up 3,000 calories ought to drink three litres of liquid ! Fortunately a great deal of this water is contained in other foodstuffs (about 1.5 litres), so it is still necessary to drink at least 1.5 litres. Furthermore the athlete has to make good the consider- able losses that result from strong physi- cal exertion. It is quite common for foot- ballers to lose one kilogram in weight, that is, one kilogram of water, in the course of a single match. In order to determine this loss, all that is needed is to weigh players before and after the sporting event. Thirst is the physical expression of the body's need for water but this alarm signal is trig- gered too late. Athletes should not wait until they are thirsty before they drink and should adopt the habit of drinking regularly during training as well as during competitions. A shortage of water content means a poorer performance. The nature of the foods we ought to eat is very varied, and depends on each person's habits and tastes. It is well to remember that milk, taken in too large quantities, can cause diarrhoea. All the same, milk and milk products should not be neglected since they are practically the only sources of calcium. Alcohol is not recommended, since it slows down the reflexes and its long-term toxicity can last for a considerable time. Athletes gen- erally prefer to stick to the two most desir- able drinks—water and tea! Poise, energy and concentration as Soviet gymnast Zinaida Drujinina runs through a dazzling performance. There is no miracle food for athletes; what really matters is to maintain the right balance in diet. (Photo WHO/Novosti) During competitions it may , be worth trying slightly sweetened water, with less than 50 grams of sugar to the litre; stronger concentrations can cause sto- mach troubles. A lot of water is lost through perspiration, and so are mineral salts, tiny quantities of which are essen- tial to health. But a balanced and varied diet normally meets all these needs. Need for vitamins Proteins, lipids and carbohydrates form the basis of our food, and the essen- tial mineral salts are provided by a varied 20 eating well to perform better diet. But we also need vitamins. Vita- mins B and C and niacin are soluble in water and vitamins A, D, E and K are soluble in fats. Vitamin C is well known for helping to fight infections, and it has been boosted, perhaps wrongly, as the vitamin of ef- fort. But just as there is no miracle food, so there is no miracle vitamin. An over- supply of vitamins is useless and may even be harmful. The nature of the food- stuffs that we eat can itself affect our vitamin needs, and for instance too many carbohydrates step up the need for vita- min B just when these may be in short supply. Don't forget that for a diet of 3,000 calories the right quantities are 150 to 200 milligrams of vitamin C, 3 to 5 milligrams of Bl, and 4 to 5 milligrams of B6; and this is about what one finds in a diet that offers a balance of the dif- ferent categories of foodstuffs, provided it varies a little from day to day. What we eat is important, but we should also guard against eating at any time of the day. Commonsense suggests an evenly spaced distribution of meals, perhaps three or four a day. In France, sports competitors ought to give some thought to their breakfast which is as a rule rather meagre. One study showed that three out of four athletes started their days badly by eating too little. This first contact with food after the night's sleep should be a meal like the others. The timetable has to be adopted to the times of training sessions and competi- tions. It is well to remember that evacua- tion from the stomach starts some five to 20 minutes after the start of a meal and continues for one to six hours. After a meal without too much fatty content, one can reckon on three hours during which it is best to avoid intensive exer- tion. Emotional upsets are not to be overlooked; they may interfere with gas- tric elimination and certainly affect the appetite. Above all it is a good thing to be flexible about diet, meal times and so forth; there are no hard and fast rules but each individual has to strike the right balance. Carbohydrates, mineral salts and vita- mins—it is difficult to work out the best levels. What is often recommended to athletes is "Rule CPL-421". What this means is that each of three meals a day should consist of four portions of car- bohydrates, two of proteins and one of lipids. The four carbohydrates might take the form of a raw vegetable which is filling and contains vitamin C; a cooked dish whose starch helps to keep the bowels moving; a starch or flour dish with slow sugars and also mineral salts; and the last C can be a sweetened food such as young people like and containing immediately usable energy. Of the two Ps, one protein at least will be milk-based and the other will proba- bly be of animal or vegetable origin. Finally one L—a single item of fat; preferably half of animal and half of vegetable matter. Don't forget there is some lipid content in proteins, and in the ingredients used in the cooking. And don't overlook the drinks. Children and adolescents should fol- low the same rules as adults. But the fact that they are growing means they have certain specific needs, particularly for proteins and calcium. These three groups ought to eat respectively one, five and two grams of proteins per kilogram body weight each day. Adolescents should really be offered about 30 per cent more food than the others; ideally they should have four "CPL-421" meals. There is much talk, in the context of high-level sport, about the so-called "dis- sociated diet". This Scandinavian or Scandinavian-American diet is based on a complete physiological examination. As energy is released, our muscles use up the glycogen that they contain—that is, the chief sugar storage material in men and animals. It has been shown that the quantity of muscular glycogen present depends on the diet. So the principle un- derlying this diet is simple : it plays on the sequence of depletion, repletion, compensation. It is rather as if one were to empty the muscular cell of all its sugar content so as to make it greedy for more sugar. In practice there are various possible regimes, all of which follow roughly this cycle : first of all, physical exercice to use up reserves, then two or three days of lipid-protein foods, and finally two or three days on a carbohydrate diet. This system is said to give excellent results in competitive sports and helps to avoid the "90 minute gap" experienced by mara- thon runners after they have covered about 35 kilometres. However this is not a system to be used on a regular basis, and ought not to be undertaken without medical control or guidance. By sport we do not mean solely com- petitive games. The term also includes the normal physical exercise that is indis- pensable for everyone who wants to enjoy a balanced and healthy life. Sport is not the preserve of the few who are particularly gifted or who happen to be offered the chance of special training. It is a need of every individual, of whatever age and physical condition, and is an essential factor in a balanced existence. So when we speak of food for athletes, we are really talking about the sort of simple rules that everyone can apply. Sport is not something additional to or outside of normal life, and similarly food for sportsmen and sportswomen is not some inaccessible ideal that may only be contemplated from afar with envy and frustration. Every individual should be able to find through sport the total fulfil- ment of his or her capability; all we need to know is the kind of food that will be most conducive to that full realisation of self. ■ 21 Testing the limits by Nedd Willard o one had said much while we drank coffee in the café on top of the mountain; they said even less as we climbed up the wet slope of the last hill that hid the precipice. Laying the pieces out on the wet grass, the group began assembling them into the brightly coloured wings of the hang- gliders. Each man was very absorbed as he fitted battens into the wings or tight- ened the struts. No one else was going to be there to help him in a few minutes when he launched himself from the mountain out into the cold air. The air was cold that day. Rain had been chasing sunny spells all afternoon and it was about five o'clock before we all crowded into the mini-bus and started up the Saleve, the mountain wall that broods over Geneva. This is where all the local people first try their legs at climb- ing, and where those who want to make their first real flight with a hang-glider go. The road to the top makes a series of sharp curves, running between forested slopes of fir and beech. Only when you arrive on top and stand at the edge do you see Geneva and all of its countryside laid out flat as a map, 3,000 feet below. "I was scared when I made my first real flight", confessed Marcel the in- structor, "scared stiff, but I jumped any- way". "You have to overcome fear", Yves, a flyer standing nearby had said, "and it is this conquest each time that gives you some great private dividend". By now most of the men were strapped into their harnesses. Marcel looked at the sky, tested the wind and pronounced conditions good. With an awkward walk, almost a hop at times, the men in their flying machines moved to the edge of a green meadow that slanted down steeply and, just how and when I don't know, they began to fly. They were actu- ally flying ... without a sound, and, after a few seconds, were whipped by the wind around the edge of the mountain and out of sight. Like most people, the first time I had seen hang-gliding was one day when I became aware of dark shapes floating overhead, too big to be birds, and rea- lized that they were men and in full flight. It looked improbable. It still does. Flying, on your own, so high that you of- ten look down on hawks soaring below, seems almost sacrilegious. I keep referring to the pilots as men because it is still largely a man's sport, though women are beginning to take it up. Hang-gliding, or Delta as it is called in French, is a new sport and one that raises the whole question of what sports are about. There is a vast difference between the solitary, long-distance runner fight- ing fatigue as his throat burns, the ar- dent, combative tennis player with his eyes glued on his opponent, the stocky member of a heaving scrum in rugger, the swimmers and the sprinters, the foot- ball players and those who prefer golf. There are solitary sports and team sports, competitive sports and group sports, gentle sports and endurance sports. Finally, there are the specialised sports like motor racing, parachuting and hang-gliding which seek out stress and test the limits. Sports are a form of exercise but also a means of self-discovery so that it is natural to note that they appeal to dif- ferent sorts of people. Anyone who has seen a long-distance runner is aware of the silent monologue he carries on with himself, the intense withdrawn conversa- tion going on as a counterpoint to the total effort. Sociologists, psychologists and others have already begun studies to analyze the differences between these sports and be- tween those who practise them. The free- falling parachutist is worlds away from the back-slapping garrulous horseplay that accompanies American football or the nervous tight ballet of basketball. Yet one conclusion about the stress-risk sports that is worth stating right away is that none of those who practise them are stupid or secretly seeking death or injury. Johnsgard, Ogilvie and Merritt, in their study entitled "Stress-seekers, a psychological study of sports parachu- tists, racing drivers and football players" published in the Journal of Sports Medi- cine and Physical Fitness, were formal: "None of the data suggest that these men who seek such high stress-risk sport are neurotic, self-destructive, uncontrolled or stupid". Down to earth I had plenty of time to think this over as I drove back. Before flying off the mountain in his own rig, Marcel had tossed me the keys to the bus and said "Take it down. You can meet us at the landing field". And that was that. As soon as you meet those who prac- tise a sport you get a feeling for them and for the sport. Hang-gliders have their own tight world, casual and even cool to the outsider, comfortable for those who belong. Yves had mentioned that those who did hang-gliding had usually done a lot of other things first ... especially danger- ous things. He himself had done cross- country racing with motor bikes, where ...Hang-gliders have their own tight world, casual and even cool to the outsider, comfort- able for those who belong... (Photo Len Sirman ©) 22 s.1 kJ • AIP _ $ P4A0. 4 ‘trt '443k* 411 'it• 4 e; ,#44 , ft "us •0,310- A: fit Cr'N sit• ! -741. AIA'...4•12t you weren't supposed to touch either foot to the ground, hot-dog (acrobatic) skiing and skiing "hors piste"—blazing mountain trails that no one else has been on. And then he had found hang-gliding. Marcel, the instructor, a big man and a professional athlete who teaches other sports in addition to hang-gliding, doesn't give the impression of one who scares easily, which fits someone who has flown down from the Matterhorn. He mentioned shrewdly, "Before we started hang-gliding, a lot of us used to race around in huge sports cars, tearing around corners and burning up rubber, but now a little old car just tooling along a country road is enough". In other words, these men have found a sport—or an activity, because the word sport seems too weak to stretch from :11 /111411t, pitching quoits to driving a racing car— that allows them a sort of inner peace. That may be another reason why some people prefer sports that test the limits. But there are other reasons too. Every- where more people live in cities than in the country. Everywhere more people have routine office jobs and find them- selves limited, cramped and confined. There must be some way to find freedom again. There must be something outside of work that doesn't involve crowded beaches, spectator sports, and following someone else's rules. So those who are stress-seekers begin experimenting, for there is more than one way to practise the same sport. Skiing is a good example. Many peo- ple ski, but you can ski in a crowd and wait in a slowly moving line to reach the ski-lift surrounded by talk and even the noise of cheap music from an amplifier as well, or you can strike out alone through the woods, in silence, cross- country. There is snow that no one else has trod on but you have to find it. Still others prefer to crouch into an eggshell position and thunder down the ski track in an attempt to shave off the quarter of a second that separates them from a prize. Again there are sports that award prizes and other that do not. Paradox- ically a sport like free-fall parachuting or hang-gliding which began as a solo non- competive sport can eventually drift into competition, where jumpers try to land on a square of cloth the size of a hand- kerchief or gliders try for precision or the longest time aloft. 24 testing the limits Left : ...With an awkward walk, almost a hop at times, the men in their flying machines moved to the edge and, just how and when I don't know, they began to fly ... (Photo Len Simian ©) Right : ... "You can't just land where you want to," said Marcel. "Only certain places are allowed by the authorities as landing grounds"... (Photo WHO/N. Willard) There are now hang-gliding clubs and competitions. "You can't just land where you want to", said Marcel. "Only certain places are allowed by the authorities as landing grounds". Someone has flown over Geneva from the Saleve mountain to Lake Geneva, crossing the city streets and traffic. But they won't do it again—it is not allowed. There are limits and res- trictions. Thus the Swiss Federal rules state: "No one may pilot a vehicle while under the influence of alcoholic beverages, nar- cotics or psychotropic substances". And "When two aircraft meet at about the same level, the one coming from the right has priority. There are however excep- tions : motorized vehicles will give way to dirigibles, gliders and free-floating bal- loons, dirigibles will give way to gliders and free-floating balloons" and so forth. The arguments are always the same. "We must cut down on the unacceptable risk." There is a need for rules and for training. Perhaps most of us rationalise our reluctance to drop out of a plane with a parachute or to take a long soft Hang-gliding Lift-off occurs at about 19-24 kilo- metres an hour (12-15 miles per hour) Kites weigh about 16-18 kg (35- 40 Ibs) each. Flight speed is about 24-56 kilo- metres an hour (1 5-35 miles per hour) Most serious accidents occur during the first five months of flying or during the first 40 flights; after that the acci- dent rate drops off sharply. glide in a hang-glider by thinking "They will all break their necks? No one but a fool would risk his life and limbs that way". Yet some sports are less danger- ous than they seem; there are many fac- tors that can cut down on accidents and when they do occur, they often seem to happen in such foolish trivial ways. "He had his camera fixed out on the wing to take photos of Geneva as he came down but he couldn't get the shut- ter to work. First he tried jiggling it with his right hand. No go. Then he took his left hand off the frame to steady the camera and went right into a nose-dive. He has been in a coma for two months now". Accidents so often seem so stupid, afterwards. "Another time one of my friends was aloft and ready to coast down when he 25 testing the limits remembered that he had left his keys in the car. He tried going back up over the edge of the cliff, hit a turbulent spot and broke his left leg coming down. All that to avoid having to hitchhike back to pick up his keys". Equipment has improved tremendous- ly. Most hang-gliders today will right themselves from a stall and don't nose dive. Yves is experimenting with a rig which will enable him to carry a para- chute with him but, as he confessed, "We don't have all the bugs (problems) out yet". One thing is sure. Training does cut ...Some skiers prefer to crouch low and thun- der down the track in an attempt to shave a quarter second off the time ... (Photo Len Sirman ©) down on accidents, provided one has good equipment and a fair amount of horse-sense. As Dr G. M. Yuill, a neu- rologist who is himself a member of the British Hang-gliding Association, states : "I believe that this sport is no more dangerous than horse riding, rock climbing, potholing or motor cycle racing, and with training may probably be rendered less hazardous than any of these sports". However if Dr Yuill is right, there is still the paradox that restrictions take out of a sport the very thing that was first sought for, freedom. Sports like hang- gliding begin because of the terrible thirst for freedom, for doing something on your own, without supervision or rules; yet to become acceptable to the community on a large scale, there is need for careful training, forethought and dis- cipline. That is why there are now "rules of the road" for the air. You can't just land anywhere anymore; there are ap- proved sites with a wind-sock flying. Freedom spells danger but with safety come restrictions. Sports evolve, change and grow. A few are just passing fads, but some, like hang-gliding, parachuting or motor rac- ing, are going to stay with us for a long time. Hang-gliding will probably join other stress-sports in becoming "accep- tably" risky and more of a group effort than before. But still as you walk a mountain path, you may find an awk- ward silhouette in front of you as a flyer hoists his equipment on his back in search of an ever-higher mountain, there to launch himself into the air and leave behind what someone has called "foot- prints in the air". ■ 26 Good for the heart by Roberto Masironi lthough there is no clear-cut proof that physical activity prevents car- diovascular disease and prolongs life, regular physical exertion of a certain intensity is needed for the human body to function at its best. This conclu- sion emerged from the International Conference on Sports Cardiology held earlier this year in Rome. The 300 participants from nearly 40 countries also agreed that physical activi- ty ought to be considered within the framework of healthy life habits. It should not be aimed only at, or restricted to, im- proving cardiovascular health, but should envisage better health in general. It is very likely that, in so doing, life ex- pectancy too will be increased while the risk of developing myocardial infarction (heart attack) will decrease. Organised by the Giovanni Lorenzini Foundation, in collaboration with the Italian National Olympic Committee and the Italian Federation of Sports Medicine, the Conference had two aims. It sought to assess the present state of knowledge on work physiology in athlet- ic performances, and at the same time to study the role of physical activity in maintaining cardiovascular health. Delegates agreed that physical activity should be carried out within the limits of good common sense, otherwise it might even prove dangerous. Depending on a person's age, health status and training status, it might be advisable for someone planning to undertake fairly strenuous physical exercise particularly if it is competitive in nature—to undergo a medical examination. Exercise should be of such a kind that it can be practised throughout a lifetime, the Conference suggested. The beneficial effects that physical training can have on cardiovascular and other functions do not persist for a long time. Thus it is not enough to have been an athlete in youth; much more valuable is to remain physi- cally active at a later age. There was general agreement that the actual mechanism whereby exercise im- proves health is not fully understood. However, physical activity ought to be maintained above a certain threshold, for instance, about 2,000 calories (8.4 megajoules) per week should be ex- pended in strenuous exercise, during which the heart rate should reach 130- 150 beats per minute. Physical activity has been found to increase HDL (high- density lipoproteins), although it takes several months to do so. These lipopro- teins are beneficially involved in the Above: Cardiac patients in Finland enjoy a game of volleyball—under supervision. (Photo WHO/D. Henrioud) transport and elimination of blood cholesterol. Similarly, the Conference found that the alleged beneficial effects of physical rehabilitation in patients who had suf- fered a myocardial infarction had not been definitely proved. But a 15-year fol- low-up study of such patients showed that 29 per cent of those who did not un- dertake physical rehabilitation pro- grammes died, compared with only four per cent of those who did. However, the most important finding was that myocardial patients who are physically rehabilitated benefit from a more balanced emotional stability, an in- crease in self-confidence, and a decrease in-fear and anxiety. In the case of borderline hypertension (slightly raised blood pressure), physical activity programmes are to be encou- raged. Of course, people with severe hypertension should not undertake stren- uous exercise. Physical exercise is good in patients with diabetes as it increases the rate of glucose utilisation. Physical activity itself is not a way of reducing body weight in obese people, but it can do so in association with dietary restric- tions. The body weight might not change, because of the building up of larger and stronger muscles, but excess body fat would decrease and this, the Conference concluded, would be beneficial. ■ 27 Declaration of Alma-Ata The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration: .. 7:_.3__ -4.-a . -,.2 a - i 4 -taa4t-.... -t -, t r_-.44 -i .- - --=a, ..--+.7•-• it - 4 st ". -)dfflir -.5711' , ...-, 4,314045A, '1 , , 1 ■ ■ I The conference strongly reaffirms that health, which is a state of complete phys- ical, mental and social wellbeing, and not merely the absence of disease or infirmi- ty, is a fundamental human right and that the attainment of the highest pos- sible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people, particularly between developed and developing coun- tries as well as within countries, is politi- cally, socially and economically unaccep- table and is, therefore, of common concern to all countries. III Economic and social development, based on a New International Economic Order, is of basic importance to the ful- lest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace. IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. V Governments have a responsibility fcr the health of their people which can be fulfilled only by the provision of ade- quate health and social measures. A main social target of governments, inter- national organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to at- taining this target as part of development in the spirit of social justice. VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally acces- sible to individuals and families in the community through their full participa- tion and at a cost that the community and country can afford to maintain at ev- ery stage of their development in the spi- rit of self-reliance and self-determina- tion. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic develop- ment of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a con- tinuing health care process. VII Primary health care : 1. reflects and evolves from the eco- nomic conditions and socio-cultural and political characteristics of the country and its communities, and is based on the application of the relevant results of 28 gy p action to launch and sustain primary health care as part of a comprehensive national health system and in coordina- tion with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally. IX 40, --711rlorm 1170Ple. "411111141110*' " f 4 ' 1.1! 4'. • ommer Jointly sponsored by WHO and UNICEF, the International Conference approved the Decla- ration in the V.I. Lenin Palace at Alma-Ata, in Soviet Kazakhstan. (Photo WHO) social, biomedical and health services research and public health experience; addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly; includes at least : education concern- ing prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition ; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; ap- propriate treatment of common diseases and injuries; and provision of essential drugs; involves, in addition to the health sec- tor, all related sectors and aspects of national and community development, in particular agriculture, animal husban- dry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated ef- forts of all those sectors; requires and promotes maximum community and individual self-reliance and participation in the planning, organ- ization, operation and control of pri- mary health care, making fullest use of local, national and other available resources, and to this end develops through appropriate education the ability of communities to participate; should be sustained by integrated, functional and mutually-supportive referral systems, leading to the progres- sive improvement of comprehensive health care for all, and giving priority to those most in need; relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and com- munity workers as applicable, as well as traditional practitioners as needed, suit- ably trained socially and technically to work as a health team and to respond to the expressed health needs of the com- munity. VIII All governments should formulate national policies, strategies and plans of All countries should cooperate in a spirit of partnership and service to en- sure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this con- text the joint WHO/UNICEF report on pri- mary health care constitutes a solid basis for the further development and opera- tion of primary health care throughout the world. X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and bet- ter use of the world's resources, a consid- erable part of which is now spent on ar- maments and military conflicts. A genuine policy of independence, peace, detente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. The International Conference on Pri- mary Health Care calls for urgent and ef- fective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Eco- nomic Order. It urges governments, WHO and UNICEF, and other international or- ganizations, as well as multilateral and bilateral agencies, non-governmental or- ganizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and finan- cial support to it, particularly in develop- ing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintain- ing primary health care in accordance with the spirit and content of this Declaration. ■ 29 ••• ••• ••• ••• ••• ••• ••• ••• ••• OOOOOO ••• •• • ••• ••• ••• •• • • •• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• •• • ••• ••• 4o414, omil m 4, 415... •*ow ••• ••• ••• 0 •• ••• 00. • •• ••• •• • ••• ••• ••• ••• ••• December 10, 1978 is Human Rights Day On 10 December this year will be observed the Thirtieth anniversary of the Universal Declaration of Human Rights, adopted by the United Na- tions just three years after the world had emerged from the holocaust of World War II. The document proclaims that "all human beings are born free and equal in dignity and rights" and that "every- one has the right to a standard of living adequate for the health and well-being of himself and his family, in- cluding food, clothing, hous- ing and medical care and necessary social services...". The gulf that separates the right and the reality is wide indeed, but that does not take away from the im- portance of the Declaration as a milestone in the march of civilization. Ideas that change society appear by a logic of their own at certain points in history and under the pressure of events. Then, over a period of time, they enter the norms of civilized thought and behaviour, and make their impact felt. The rights proclaimed by the UN are still denied to countless millions but already this denial is no longer con- sidered, as it was in earlier times, justifiable on grounds of divine dispensation or the "inherent" superiority of cer- tain races or social classes. Social injustice in man's world is seen for what it is—an anachronism and a stumbling block to any efforts to alleviate the human condition. This new awareness of human rights and social justice is voiced time and again when the nations of the world—the "haves" and the "have-nots" among them —come face to face with the serious questions of peace, international trade, resource- sharing, poverty, hunger and disease. It is in keeping with this trend that WHO and its (hieww111:(mu4nlinanfitutill - Member nations have adop- ted the goal of Health for all by the Year 2000, and the Organization's policies reflect a growing concern for the social purpose of health development and for the role of health as a lever to raise social and economic stan- dards. The most recent example is the Declaration adopted by 140 nations during a conference on primary health care in Alma- Ata, USSR. It reaffirms that health is a fundamental human right and regards the "gross inequality in the health status of the people" as "politically, socially and economically unacceptable". A suspected case of Lassa fever Details now available of the treatment of a Lassa fever suspect hospitalized in Wash- ington, DC., last May offer a perfect example of the difficulties of making an early diagnosisof this disease. It is an example also of the dilemma of health authorities in this age of speedy travel: they must be alert to the possibilityof a serious disease being transmitted from one part of the globe to another undiagnosed, and at the same time not over-react if a traveller is reported ill on arrival. The patient, a 42-year- old man, who had lived for the past seven years in Kenema, Sierra Leone, left that country at the end of April last to embark on a journey that took him to France, Switzerland, Sri Lan- ka, the UK and the USA. In Sri Lanka, where he stayed from 1-5 May, he was taken ill on 4 May with symptoms of cough, pharyn- gitis and inflammation of the mucous membrane of the nose. He was fit enough to travel, however, and left Colombo for London on 6 May. After a 4-day stay in London, he arrived in Washington on 10 May. On 15 May, he had chills, his sore throat worsened and he felt feverish. A physician who saw him the next day recorded a temperature of 39°C (102° F) and a severe in- flammation of the pharynx with plaque-like lesions on the gums, tonsils and poste- rior pharynx. The same day the patient was placed in strict isolation in hospital as a Lassa fever suspect. The suspicion was natural. The man had lived long in an area where the disease is known to be endemic and his symptons were similar to those asso- ciated with Lassa fever. Besides, his wife had sur- vived confirmed Lassa fever about one year before, and his driver in Sierra Leone had died a victim of Lassa fever in March this year. While tests were carried out on the patient, the family members with whom he had been staying in Bethesda, Maryland, were placed under daily surveillance. Names of other contacts who were believed to be at high risk were also compiled. However, the patient began to recover. His fever came down and his oral lesions began to fade. Serum specimens taken on 17, 18, 19 and 22 May were found negative for Lassa antibody or virus. No Lassa virus was found in conjunctival cells, either. The interpretation of sero- logical results presented a problem because of the difficulty in determining the date of the onset of the illness, since it would be two weeks after that that Lassa antibody would be expected to be present. Did the disease start on 4 May in Colombo when the first symptoms appeared or on 15 May in Washington when the patient's condition wor- sened? Ruling out the diag- nosis demanded both careful clinical follow-up of the patient as well as negative virological studies, which required 3 to 5 days to complete. On receipt of the negative results, the patient was dis- charged, and surveillance of his family members ter- minated. Lassa fever does not now appear to be a highly com- municable disease. Since the disease was first recognized in 1969, at least 5 patients with confirmed Lassa fever have travelled aboard com- mercial airliners, but no secondary cases among air- line passengers have been detected. However, until more is learned about the trans- mission of this disease, it is recommended that confirmed or suspected Lassa fever cases do not travel by commercial airliner. According to the US Center for Disease Control, persons who have recently arrived from parts of the world known to be endemic for Lassa fever and who present symptoms of pharyn- gitis and fever should be considered suspect cases. Such patients should be immediately hospitalized in strict isolation. Specimens, including throat swab, clotted blood, and urine, should be collected by a physician wearing a maskand protective clothing. High risk contacts (those known to have face- to-face, conversational, or other intimate exposure to the patient or exposure to his/ her blood or other bodily secretions) should be iden- tified, and placed under surveillance immediately or on laboratory confirmation of the diagnosis. Nobel Symposium on cholera control "Cholera and related diar- rhoeas—molecular aspects of a global health problem" was the subject of a sym- posium held in Stockholm last August under the aus- picesof the Nobel Foundation and its Nobel Symposium Committee. WHO was co- sponsor of the Symposium and was represented on its organizing committee. Some 30 scientists attend- ing the week-long meeting 30 discussed the very rapid progress made recently in understanding the mecha- nisms of cholera and related diarrhoeas and the develop- ment of immunity against them. Proposals were made on further lines of research that might facilitate appli- cation of this new basic knowledge in the prevention and control of these diseases. During discussions on epi- demiology, it was pointed out that new techniques of iden- tifying the causative agent in diarrhoeal diseases were being applied with con- tinuing success in well- equipped laboratories. Thanks to these techniques, it is today possible to pinpoint the cause of a diarrhoeal disease in 80 per cent of the cases, when only a few years ago it could be done with precision in no more than 20 per cent. Many participants stressed the need for new and simple tools suitable for laboratories with limited facilities to improve epidemiological investigation and techniques of determin- ing the interaction between the host and the bacteria. The participants took note of the latestadvances in gene- tic and biochemical tech- niques that can be applied to produce safe and potent vac- cinesagainst cholera. Reports were presented on two avi- rulent mutants of the cholera vibrio which have been shown to multiply in the gut of experimental animals with- out causing disease. The potential of these strains being used for live oral vac- cination created much in- terest. The scientists agreed, however, that a great deal of work had yet to be done in the laboratory and on animals and volunteers be- fore the strains could be recommended for public health use. Development of a new vaccine consisting of killed cholera vibrio combined with a component (B-subunit) of the cholera toxin was also reported. In animal experi- ments this vaccine has been found to be much more effective than the vaccines now in use. The participants strongly supported the promotion of oral rehydration therapy, which is one of the most important activities in the diarrhoea! disease pro- gramme of WHO. A good deal of the dis- cussion focussed on the possibility of developing new drugs that might interrupt the chain of bio-chemical events induced by the action of diarrhoea -producing toxins on the intestines. In the light of recent findings about the biochemical pathway of the action of intestinal toxins, a number of new anti- diarrhoeal compounds have been tested in animal experi- ments, some with promising results. The advent of these new drugs will go a long way in simplifying treatment of diarrhoea! diseases, a major cause of death and sickness among children in developing countries. (Photo WHO/D. Henrioud) Cholera camp. The recommendations and deliberations of the Nobel Symposium will be taken into account in developing the research component of WHO's programme for diar- rhoea! disease control. Legionnaires' disease: UK reports 30 cases In the summer of 1976, a mysterious illness broke out among persons who had been in or near a hotel in Phila- delphia, the site of a well- attended American Legion convention. The disease which, in the initial stages, offered no clue as to its origin or mode of spread struck 181 people, 29 of whom died after a brief pneumonia-type illness. Labelled simply "Legion- naires' disease", the pheno- menon abated as suddenly as it had appeared. Six months later, scientists of the US Center for Disease Control resolved the mystery. A type of bacteria—never before identified—was found to be the cause of the disease. The germ has since been linked to other unexplained outbreaks of pneumonia, and is known to exist in other parts of the world. The UK, in a recently published study, reported 30 cases between 1 976 and the first quarter of 1978. Most of the cases (25) occurred in 1977 against one in 1976, and 4 until April of this year. In seven of the eight fatal cases, it was possible to demonstrate the causative bacterium in post- mortem lung tissue by im- munofluorescent staining. The mean age for all cases was 45 years and the range 26-27 years. Over a third (12) of the cases were residents of the city of Nottingham, with dates of onset ranging between June 1 976 and February 1978. There were two cases in Preston, two in Bath and one each in 14 towns widely distributed throughout England and Wales. The presence of the bac- terium in Australia was de- monstrated following a sero- logical survey carried out in a Melbourne hospital on stored serum from patients who were treated for pneu- monia in 1 976 and 1 977 and whose disease had in some way been unusual. Of 32 specimens examined, 3 con- tained evidence of Legion- naires' disease. The US Center for Disease Control in Atlanta, Georgia, has convened a symposium this month, at which sci- entists, clinicians and public health officials on a world- wide scale will share the growing body of knowledge about Legionnaires' disease. In the next issue Nurses have long been recognized as forming an integral part of any coun- try's health services. Within today's concept of primary health care, they play a no less essential role as members of the health team. The December issue of World Health will look at the work of nurses in different countries around the globe. Authors of the month Mr F.J. TOMICHE was until 1977 the Director of WHO's Division of Public Information. Mr C. BONINGTON, mountaineer and author, led the successful team which conquered the fear- some South-West Face of Mount Everest in 1975. Dr V. NIKOLAYEV is a Soviet sports physician. Dr J.G.H. REFSHAUGE was until recently the Federal Secretary/ Treasurer of the Australian Sports Medicine Federation. Dr M.-L. BARGUES is a staff writer for the medical journal "Le Quoti- dien du Medecin", Paris. Mr N. WILLARD is a member of WHO's Division of Public Informa- tion in Geneva. Dr R. MASIRONI is a scientist with the Cardiovascular Diseases unit at WHO headquarters in Geneva. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows : US$* Swir.* One year 12.50 25.— Two years 22.50 45.- Three years 30. 60. One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency . World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland The access of every individual to sport may soon be formally accepted as a new human right. (Photo WHO) Sw itz er la n d Im p ri re or ia s R eH n ie s S. A , La us an ne