WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • DECEMBER 1980 Cuba's health care revolution Enjoying an ample supply of trained doctors, Cuba has chosen not to follow the "barefoot doctor" pattern. But its primary health care system relies heavily on popular participation in health activities by Paul Harrison y any standards, Cuba's achieve- ments in the health sphere are im- pressive for a developing country. Life expectancy at birth has reached the European level of 72 years. Infant mortality is on a par with Eastern Europe, at 22 per 1,000 live births. The great Third World scourges of malaria, polio, diphtheria and tetanus were all eradicated by 1973. Not satisfied with this performance, in 1976 Cuba began in- troducing a new system of community medicine that holds as many lessons for developed as for developing countries. From the earliest days of the revolu- tion in the 1950s, when Che Guevara car- ried a surgeon's kit in his knapsack side- by-side with his rifle, health has been ac- corded the highest priority in Cuba. But two major setbacks followed the acces- sion to power of Dr Fidel Castro in 1959: almost half of the country's stock of 6,300 doctors emigrated, and the economic blockade imposed by the United States cut off supplies of pharma- ceutical products. Both these two reverses have now been turned to advantage. The doctors who remained behind were those more dedi- cated to service and less concerned with personal rewards. They were happy to serve in the long-neglected rural areas, where new hospitals and clinics were now built. Thanks to an immense effort of training, the supply of doctors reached 15,000 in 1979, one for every 674 people, a ratio better than that of several ad- vanced Western countries. The drug em- bargo launched the country on a pro- gramme of self-sufficiency in drugs, so that the long list of 40,000 proprietary medicines—many of them overpriced, 2 Cover: Every Cuban adult receives routine vaccinations 1, against tetanus and typhoid. i y' (Photo WHO/ , , i.c. P Harrison) I IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. 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. Cuba's Committees for the Defence of the Revolution are powerful agents for change, and each one designates a member who is responsible for a long list of health activities. (Photo WHO/P. Harrison) superfluous or duplicated—has today been reduced to 700 essential drugs, most of which are manufactured in Cuba. By the early 1970s, success in fighting the major Third World diseases such as malaria and tuberculosis gave Cuba's health planners time to consider how to remedy other deficiencies of the health service. A special commission on the health service reported in 1976 that med- icine was still too oriented towards cure rather than prevention. Primary care was still inadequate: hospital and specialist services were being overloaded with un- necessary referrals because primary level doctors did not have enough expertise. Nor did they have sufficient knowledge of, or concern for, individual patients, because the same patient might be seen by a different doctor at every visit. No single doctor was responsible for each individual patient. To remedy these defects, a new system of community medicine was introduced in 1976, and by the beginning of 1980 had been extended to two-thirds of the country's polyclinics. Four major fea- tures of the new system hold lessons for other countries : a heavy emphasis on high quality specialised care at the pri- mary level; a thorough system of preven- tive care; a very high level of popular participation in health; and a new push to democratise the health service and make it more human and more respon- sive to patients' needs. In Cuba, all primary health care is delivered by specialists who work in teams, rather than—as -in most countries —by individual general practitioners covering all types of medicine. Doctors are based in polyclinics serving some 4,000 people in scattered rural areas, and up to 30,000 people in the cities. The basic polyclinic has four specialists with their own lists of patients for whom they Contents Cuba's health care revolution by Paul Harrison ....... 2 Thirty years on— the Palestine refugees by Jean Poutaraud .... 9 Tower of Babel by Toma Strasser 12 The hospital—a breeding ground for disease? by R.T. Mayon-White 14 One man's meat... by Nedd Willard 18 The fight against famine by Etienne Berthet ... 24 A global view: WHO's Sixth Report on the World Health Situation 28 World Health Index for 1980 31 are personally responsible : a paediatri- cian, with 2,000-3,000 children under his care; a gynaecologist-obstetrician, dealing with up to 4,000 women ; an inter- nal medicine specialist, looking after everyone else; plus a dentist with 10,000- 20,000 patients. When a doctor encoun- ters a complaint he cannot deal with in one of his patients, he consults his specialised colleagues and can call on further expertise during the weekly visits of specialists in other disciplines such as skin ailments, ear nose and throat problems, psychology or cardiology. The amount of specialised knowledge that is routinely available at primary level has dramatically cut down the pro- portion of cases unnecessarily referred to hospital, from one in six before the reform to one in 25 after. Primary health care has been given a new status in Cuba. In most countries, hospitals are the main or only focus of training and research, and the places where high-level teaching doctors and consultants are based. This hospital monopoly means that medical training usually puts too much emphasis on cure rather than prevention, on dealing with the complaints that bring people to hos- pital rather than preventing them coming there in the first place. In Cuba, doctors have to spend at least one year of their training in one of the country's 15 teaching polyclinics. This must be one of the few countries in the world where you can meet a professor of medicine permanently based at primary level. The result is that health care now reaches into the remotest rural areas, providing them with a standard of care not far short of the best urban facilities. A typical polyclinic is El Cangre, which serves a population of only 4,500 and has its own laboratories, short-stay beds and an ambulance to take patients to hospital Above: A night-school course for sanitary brigade workers who undertake health educa- tion and other duties among members of the Federation of Cuban Women. Right: The preventive programme includes regular checks on child growth. Even the clinic's performance itself is carefully measured—how much waiting time, how many complaints... ( Photos WHO/P. Harrison) in Guines 12 kilometres away. Transport to get sick people to the clinic in an emergency is provided by cooperative farms, factories or community organ- izations. Cuba has chosen not to follow the "barefoot doctor" model, whose popu- larity is still growing in the Third World. There are, in the furthest rural areas, medical posts staffed by a single doctor and sanitary posts with only a nurse. But doctors remain in firm control of almost 4 "S every medical function except polio im- munization. In most poorer countries, to follow the Cuban model would result in leaving large sectors of the population without proper service, because of the lack of trained doctors and the large dis- tances people would have to travel. But Cuba now has an ample supply of trained doctors, and distance is less of a problem in a densely populated island that is only 100 kilometres or less from coast to coast. Prevention is now as much a part of the polyclinic's job as cure, thus putting an end to the fatal division between med- ical care and public health that afflicts so many health systems in the world. Clin- ics are responsible for sanitation and hygiene at home, at work and at school. Every adult gets a full course of vaccina- tions against tetanus and typhoid, and everyone over 45 has a blood pressure check every two years. Prevention and surveillance are especially strong in maternal and child health. Pregnant and nursing women and children under seven get an extra ration of one litre of milk per day. There is a programme of 13 check- up visits during pregnancy and 12 in the first year of the baby's life; working mothers are allowed time off for these visits. The network of 60 rural maternity homes has made it possible for 98 per cent of births to take place in hospital. Expectant mothers come and live in the home for the last week or two before the birth is due, and receive lessons in nutri- tion, child care and relaxation. In most developed countries, such pre- ventive facilities are available for those who want to make use of them. In Cuba, almost 100 per cent of the population does make use of them because, if they don't, voluntary health workers will come knocking on their door urging them to keep their appointments and ex- plaining the importance of doing so. This is the third secret of Cuba's success in health—her unparalleled level of popular participation in health, organized mainly through the island's two biggest grass roots organizations, the street-level Committees for the Defence of the Revo- lution and the delegations of the Federa- tion of Cuban Women. Both organiza- tions are ideal vehicles. They have almost universal membership, and perform a wide range of functions that give them a high credibility in everything they do. The Committees for the Defence of the Revolution (cDR) were set up in 1960 to prevent counter-revolution, at that time Above: Medical students taking a course in obstetrics. One year of every doctor's training is spent at primary level. Right: Eye-inspection for a young patient at a Havana polyclinic. One of four specialists at the clinic, the paediatrician has between two and three thousand children under his care. (Photos WHO/P. Harrison) a serious possibility. In 1961, they mobi- lised mass support to help repel the Bay of Pigs invasion. Gradually, they took on a whole range of functions, now totalling over 200, from controlling ration books and saving water and energy to salvaging wastes, as well as policing and organizing street cleaning and voluntary work— many Cuban hospitals have been built with volunteer labour. Every Committee has a health officer, who will often be a housewife or a pen- sioner who can put in the six to eight unpaid hours of work that are involved each week. At Calle Principe CDR in cen- tral Havana, for example, the health of- ficer is 64-year-old Maria Varona Miran- da. She carries out a long list of health activities. She organizes blood donations from her street, and one day each year administers polio vaccine to local chil- dren. She chases people up to make sure 6 they keep their clinic appointments for injections or check-ups. Once a month, she organizes a meeting of local residents around a popular health theme. The Federation of Cuban Women counts 81 per cent of women over four- teen years of age in its ranks. Its primary aim is to integrate women into social and economic life. Local delegations have many functions, from organizing volun- tary helpers for schools and for farms at harvest time, to political education and handicrafts. Each grass roots delegation has a sanitary brigade worker (brigadista sanitaria), many of whose functions are similar to those of the CDR health officer. The sanitary brigades persuade women to go for cervical smears every two years. They fumigate potential mosquito breed- ing sites once a month. And they lead the monthly debate on health topics (includ- ing nutrition, family planning and child care). The subjects and material for the debate are provided by the monthly women's magazine Mujeres (Women). These regular debates are usually attend- ed by nine out of ten members, since del- egations win prizes for the attendance record of their members. The amount of, voluntary work done is prodigious. Every qualified doctor is backed up by at least ten voluntary workers. Volunteer leaders and profes- sionals meet together regularly in Public Health Commissions, at clinic, regional and national levels, so the work of the two sides can be coordinated. Perhaps the most revolutionary inno- vation of Cuban medicine is its new drive to improve the way patients are treated by medical staff, and to give the users a much greater degree of control over the services. Bureaucratic or professional ar- rogance is all too common in the medical professions, and patients are frequently treated to suit the doctor's convenience. Offhand receptionists, brusque examina- tions, long waits at clinics, or cancelled appointments can create a feeling that the doctor does not care much about the patient's health. This feeling can delay recovery, just as the feeling that medical staff really care can help recovery along. In Cuba's programme to optimise ser- vices, each clinic's performance is care- fully measured : recording the number of case-notes lost, the number of cancelled appointments, the average waiting time, the number of complaints from patients. Going one step further, the new Cuban system of People's Power (Poder Popular) has handed over the control of local health facilities to elected represen- tatives. Every four months these repre- sentatives must hold public meetings with the entire adult population of the neighbourhood. They are expected to channel complaints to the appropriate institution, and to report back to the next meeting on any action that was taken. Staff at some clinics, on their own initiative, hold meetings with their com- munities to hear complaints and sugges- tions. At the Plaza de la Revolucion polyclinic in Havana, a People's Health Council has been created, on which the patients too are represented; it has powers to control the actual running of the clinic. Now that Cuba has conquered the typ- ical Third World complaints, the indus- trialized world's maladies of cancer and heart disease loom larger—especially since the Cubans are heavy consumers of their island's chief products, tobacco and sugar. But Cuba may be well placed to overcome these problems too. The close cooperation of mass organizations, vol- untary workers, state-controlled mass media and health professionals provide channels not available in most "Western" countries to mobilise and educate people into new habits. ■ 7 Above: The first camps which sheltered the refugees who fled from their homes in Palestine as a result of the Arab-Israeli conflict of 1948 were tented settlements. This was the scene in 1952 at Nahr-el-Bared Refugee Camp, against a backdrop of the mountains of Lebanon, which are snow-covered for several months of the year. Left: Decades later the camps are still there, but now have a much more settled appearance, as at this community in Jordan. Besides having drains, latrines and rubbish disposal systems, the camps have registered a slow but steady increase in the refugees' living conditions and health standards. ( Photos WHOIUNRWAI M. W. Chaumeny) Thirty years on the Palestine refugees Two United Nations agencies exist to deal with the worldwide problems of refu- gees. They are UNRWA—which marks its 30th anniversarythis year—and UNHCR. UNHCR, the Office of the UN High Commissioner for Refugees, was established by the General Assembly with effect from 1 January 1951. Its statute defines refugees as "persons outside their country of nationality because they have well-founded fear of persecution by reason of race, nationality or political opinion". UNHCR replaces the national protection which refugees no longer enjoy, provides legal protection and, at the request of a government or of the UN, offers them material assistance. But that organization of the UN was preceded, in 1950, by the UN Relief and Works Agency for Palestine Refugees in the Near East—UNRWA. It was estab- lished by the General Assembly as a subsidiary and temporary organ to help the refugees who, as a result of the Arab-Israeli conflict in Palestine in 1948, had left their homes in the territory which became Israel, and who now found themselves in need. It operates in Jordan, Lebanon, Syria and the Gaza Strip. Thirty years after it started work, this "temporary" body still exists. The article that follows explains why this is so and how it operates today. by Jean Poutaraud o be a refugee means automati- cally to live in an extremely pre- carious u health situation, and to be a Palestinian refugee imme- diately after the exodus of 1948 meant living under particularly catastrophic cir- cumstances. In most of the places where some 750,000 Palestinians settled after quitting their homes and land as a result of the first Arab-Israeli conflict there was, according to Count Folke Berna- dotte, then the UN mediator for Pales- tine, not a single health centre. He noted at the same time that the lack of water supply represented a threat to the health of the refugees, and that the hospital services available were well below the most elementary norms. The spectre of such contagious diseases as typhus, cholera, smallpox, dysentery, diphtheria or tuberculosis loomed over the hastily erected camps and over-popu- lated settlements where the refugees had gathered, and posed an equal threat to the people of the host countries. Count Bernadotte promptly called for a pro- gramme of protection against endemic and epidemic diseases to be started as a matter of urgency. The international community reacted immediately to his appeal. While the charitable organizations rushed in emergency aid, the World Health Organ- ization sent an expert to the Near East to assess the health situation of the Pales- tine refugees and determine what mea- sures to take. All this time, more people continued to flood into the regions or countries bordering what had now become the State of Israel namely Lebanon, Syria, Jordan, the West Bank of Jordan, the Gaza Strip. It was under these circumstances that officials appointed by WHO, at first under the responsibility of the Director of UN Relief for Palestine Refugees (uNRPR) and later, from 1950, of the newly creat- ed UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), organized health services in an effort to avoid the worst hazards. WHO and UNRWA signed an agreement to work closely together, which was to have effect until the Agency was dis- solved, then foreseen for the end of 1951. Thirty years later, UNRWA still exists, pending a final settlement of the Palesti- nian problem, and the collaboration between the two organizations goes on. These 30 years have been profitably used 9 Thirty years on the Palestine refugees Left : Refugee children in UNRWA schools are checked regularly by the Agency's health staff Infantile mortality has been reduced by half in the last 20 years but, despite every effort, the diarrhoeal diseases still constitute the principal danger for small children. (Photo WHO/UNRWA/J. Madvo) Right : A network of modest health centres grew up in the camps over the years, and made possible the systematic coverage of 80 to 90 per cent of the residents from the earliest age upwards. Today the refugee population effectively takes care of its own health. (Photo WHO/UNRWA/M. Nasr) to develop and diversify a health policy at the service of the Palestine refugees—a policy inspired by the broad principles recommended by wHo : prevention of disease, primary health care, community participation. This experience has been to a certain extent unique, since the WHO experts, who would normally play a con- sultative role, have in the case of the Agency's health services assumed direct responsibility for the programme. Prevention given priority The first task for those responsible for the health services of UNRPR, and later of UNRWA, was to evolve a two-fold policy of preventive medicine: on the one hand, a systematic vaccination programme, and on the other unremitting efforts to clean up the environment, both policies being reinforced by health education among the refugees. The launching of a maternal and child health programme enabled special atten- tion to be devoted to the most vulnerable sections of the community. The UNRWA schools also offered particularly good vantage points for putting into effect immunization campaigns and keeping communicable diseases under surveil- lance. In the course of the years, a net- work of modest health centres grew up in the camps and in localities where there was a high concentration of refugees. This made possible the systematic cover- age of 80 to 90 per cent of the refugee population from the earliest age up- wards. More serious cases were sent to regional hospitals. From the outset, this determined will to favour prevention and primary or secondary health care for all, while put- ting the accent on the most critical stages of life, has borne fruit. Infantile mortali- ty has been reduced by half in the last 20 years. With the exception of a small- pox epidemic in Jordan at the end of 1949 and start of 1950, the Palestine refu- gees have not had to face serious epidem- ics. The frequency of contagious diseases against which effective vaccines exist has decreased considerably, even though the refugee population has more than dou- bled. Between 1961 and 1978, the num- ber of cases of measles, for example, dropped from 8,654 to 2,683, and that of typhoid cases from 817 to 71. A notable decline in the incidence of eye and skin diseases is mainly due to the efforts made to improve hygiene and clean up the environment. Training in personel hygiene has been integrated into the programme of the UNRWA schools from the first year of instruction, while health education for adults is undertaken by the medical staff and by specially picked educators in the larger camps. Environmental health means ensuring supplies of safe drinking water—a matter which requires close attention in a part of the world where water is the source of many infections; it means constructing latrines—and today most of the homes in the camps have one; it means creating a network of drains, arranging rubbish disposal, waging war against insect pests. The situation today Despite every effort, the diarrhoeal diseases—against which there are no vac- cines—constitute the principal danger for children in their early years. UNRWA has consecrated particular attention to this sphere, as the main cause of infant 10 mortality. The Agency encourages moth- ers to breastfeed their babies as long as possible, and distributes supplies of pow- dered milk until the child reaches the age of six. Besides this, a warm meal is served daily to children aged under nine. A net- work of special nutrition centres ensures that children suffering from diarrhoea can receive oral rehydration treatment. As for the health of adult refugees, this is quite comparable today to that of the people living in the host countries. A slow but steady improvement in living conditions in the camps and, broadly speaking, an increase in the living stan- dards of the refugees since most of those who are of employable age now have a job—these factors together with the ac- tivities of UNRWA'S health services have made it possible to discount any danger from the classical contagious diseases. These have instead given place little by little to "modern" diseases, characteris- tic of urban settings where the major part of the refugee population is con- centrated. Chronic diseases such as car- diovascular disorders or cancer have obliged the Agency to appeal for help from specialists in such fields as cardiolo- gy, rheumatology and psychiatry. For serious cases, UNRWA continues to subsi- dise the cost of hospital beds. Refugee participation These encouraging results, if one con- siders the distressing conditions of the early years and the fact that one-third of the population registered with UNRWA are still living in the camps, could not have been brought about without the active participation of the refugees themselves, encouraged and motivated by health ed- ucation. They have in particular assumed responsibility for and carried out many projects to improve their own living con- ditions : their own homes of course, but also the network of drains and water- ways, the main road and streets, and garbage collection in the camps. UNRWA itself has always been careful to associate the refugee population as much as possible with the functioning of the health services, as well as with the other services which are under its control such as education and first aid. Almost all the doctors, nurses, midwives and health service staff of the Agency are themselves Palestine refugees. At the same time it has encouraged the use of health agents with only a modest degree of training: "dayahs" or traditional mid- wives, specialised nurses comparable to some extent with the "barefoot doctors" of China, and health educators. Health agents such as these are generally mem- bers of the refugee community which they serve. They have proved to be effec- tive auxiliaries and have helped to make the refugees understand the ins and outs of the Agency's health policies. This is what Dr Jean Puyet, Director of UNRWA'S health services, has to say on this subject: "Little by little the refugees, and particularly the women, have come to understand the meaning of the health care which we make available to them, and the reasons for our recommenda- tions. This greater understanding has considerably improved their spirit of co-operation. Today the Agency finances the services and lays down the broad policy lines, but the refugee population itself, thanks to its high level of educa- tion and its sense of community, takes care of its own health." ■ 11 Tower of Babel by Toma Strasser he parable of the Tower of Babel, where the tongues of the world's people became mixed up, is today as topical as ever—in medicine as in all other human relations. One of the commitments of WHO is to seek in every way to overcome obstacles in interna- tional communication. All of us who work for the Organization hope that better communication in the health field will catalyse international understanding, bringing the United Nations closer to its ideal; after all, health workers of East and West and North and South can cer- tainly all speak the same language. WHO's role in improving health com- munication is manifold. Its most impor- tant contribution in this respect is stan- dardization, in the widest sense of the term. Standardization includes terminol- ogy, methods of data collection, mea- surement, analysis and classification, as well as reporting on the findings. Unless it is standardized, the information pro- duced by any one laboratory or centre or country may remain unintelligible to the rest of the world. Let me illustrate a Tower-of-Babel- like situation with an example of termi- ological confusion. Here are a number of synonyms, found in the English medical literature, for myelofibrosis, a condition in which fibrous tissue is replacing the bone-marrow, leading to severe and often fatal anaemia. Osteosclerotic anaemia Chronic non leukaemia myelosis Leuco-erythroblastosis Leuco-erythroblastic anaemia Myelonecrosis Megacaryocytic myelosis with osteosclerosis Myeloid metaplasia Non leukaemic myeloid splenomegaly Myeloid megacaryocytic hepatosplenomegaly Atypical myelosis Myelosclerosis Splenomegaly with sclerosis of the bone marrow Thus, there are 12 synonyms which apply to a single condition. Should this seem to be exaggerated, I wish to point out that there are 13 synonyms in German and 31 in French, all of them designating the same condition. The obvious way out is to agree on a preferred or standard term, the one that figures in WHO's International Classifica- tion of Diseases. This is not only a list of terms, but also a standard classification of diseases and related conditions, backed up by a standard nomenclature, including definitions, published jointly by the Council for International Organ- izations of Medical Sciences (ctoms) and WHO. Let us consider how this aspect of ter- minological standardization would apply to a science such as lipidology—the study of body fats. In 1970, WHO con- vened a working group of prominent lipidologists from different schools of thought and speaking different lan- guages, in order to agree on a common nomenclature of lipoproteins and on a standard classification of hyperlipidae- mias. The memorandum issued by this group (it adopted, with some modifica- tions, the classification of Donald T. Fredrickson) has since then become the reference publication in the field of hyperlipoproteinaemias. This happened, however, a decade ago. Since then, lipi- dology has evolved tremendously and there is a need today to update the stan- dard nomenclature with much more details on such substances as the apo- lipoproteins, their names, definitions, and classification. A further example from a related field is standardization of lipid analyses. Serum-lipids (blood fats) play an impor- tant role in the origins of heart disease. Information collected by WHO and the experience of numerous lipid-epidemio- logists have shown that when the same serum sample was sent to different labo- ratories with a request for a simple bio- chemical analysis, such as cholesterol determination, amazing differences among the laboratories were obtained. The differences were so big that any in- ternational comparison—even inter-cen- tre comparison within a single country— became virtually meaningless, unless the performance of the laboratories partici- pating in such a comparative study had first been assessed. In order to cope with this problem, WHO began collaborating in 1962 with the Center for Disease Control (cDc) in Atlanta, USA, where a cooperative cholesterol standardization programme had been started two years earlier. The Atlanta laboratory was designated the wHo International Collaborative Centre for Lipid Standardization, and since then it has covered with its standardization programme a very impressive number of laboratories in all parts of the world. As awareness of the need for standar- dization was steadily growing in Europe too, in 1972 a WHO Regional Collaborat- ing Centre for Lipid Standardization was set up in Prague. Since its inception, this laboratory has covered some 135 labo- ratories with its lipid standardization programme, and is of course closely coordinated with the Atlanta centre. Observer error Let us look at another field altogether. Nothing is simpler in medicine than the measurement of blood pressure. It is therefore a particularly shattering experience to participate in a group experiment demonstrating observer error in this commonplace measurement in medicine. A film is projected to a group of physi- cians showing the scale of a blood pressure measuring instrument. Simul- taneously, the blood pressure sounds are audible. The physicians are invited to put on paper their findings. The usual result is that the tested subjects are amazed by the unexpected divergencies in their findings, which may range from 120 to 180 mmHg systolic or from 60 to 100 mmHg diastolic pressure, even though all of them were observing the very same audio-visual phenomenon. Observer error can be diminished by vigorous training. There are, however, From the Tower of Babel to the Round Table. Painted by Pieter Brueghel in the 16th century, "The Tower of Babel" is reproduced by cour- tesy of the Museum Boymans-van Beuningen, Rotterdam. Lower picture : Strategies for the future health of the world are thrashed out during a meeting at WHO's headquarters in Geneva. (Photo WHO) 12 , "frififfiliff jiff 1 Wulf , ... ....... numerous other sources of error due to instrumentation such as the width of the cuff (the inflatable band constricting the blood flow above where the measure- ment is read), the accuracy of the manometer, the amount of physical ac- tivity undertaken by the patient before the measurement, or the room tempera- ture. These variables can and have been standardized by wHo ; they appear in WHO Technical Report Series No. 628 (1978) on Arterial Hypertension. However, in order for such standardiza- tion to become effective, there must be awareness of the great extent of variability and of the importance of being standardized. Another vital key to better communi- cation is standard reporting. Laboratory values are now expressed in si (Systeme international) units, whenever possible— for instance, in millimoles rather than milligrams in the case of compounds whose molecular weight is known. These units are described in "The si for the health professions", published by WHO in 1977. It is also important, however, to adopt a standard way of reporting the results of measurements in populations (as contrasted with such values in indi- viduals). Mean values have a limited in- formation content, even if standard deviations are given. So, for describing lipid levels in populations, blood pres- sures or, for that matter, body heights and weights, the use of distributions in quantiles (percentiles) has been suggest- ed by WHO. In epidemiology (that is, the study of the various factors determining the fre- quency and distribution of diseases in a human community), "the importance of being earnest" is synonymous with the importance of being standardized. Since comparisons between populations are by necessity based on findings from a num- ber of investigators (in different institu- tions, laboratories, countries), the aware- ness of standardization problems became acute with the advent of comparative epidemiological studies some 25 to 30 years ago. This happens to coincide with WHO's age, since the Organization's Constitution was first endorsed on 7 April 1948. Of course lipid standar- dization, from which I have drawn exam- ples here, is only one among the many elements of standardization in the field of health, and standardization itself is only one among the many activities of WHO. But any item that promotes inter- national communications is important, since it may be a step forward on the road leading from the archaic Tower of Babel to the modern concept of the round table. ■ 13 _ The hospital a breeding ground for disease? In some circumstances, hospitals may foster the transmis- sion of diseases. Precautions by the staff can minimise the risks, but the past history of hospitals as hot-beds of infection is a salutary warning against complacency A by R. T. Mayon-White t4 II 4 • I $ 114 1 $ la a it I 1 11 4 I s • 1 7-1 4 lh 4 4 VI 4 communicable disease depends on the conjunction of three main factors : the presence of a micro- organism which can cause dis- ease, the presence of people who are sus- ceptible to that disease, and a mode of transmission whereby the causative micro-organism reaches the susceptible people. If the conjunction of these three factors occurs in a hospital, then the hos- pital can be deemed to be the breeding ground for the resultant outbreak of dis- ease. Let us look at some of the diseases in which this conjunction of factors may occur in hospital, and classify them according to which factor is the most critical. I should first of all point out the distinction between "colonisation", meaning that micro-organisms exist on or in a person without causing harm, and "infection", meaning that the micro-organisms are causing (or are likely to cause) disease. A source of infectious agents Even before the microbial nature of infection was known, hospitals were regarded as places where communicable diseases could be acquired as well as treated. Part of this fear, which was once justified for diseases like puerperal (or "childbed") fever, remains today. A hos- pital can act as a source of infection in two ways : either it can provide the spe- cial conditions needed for the survival of a micro-organism or it can be, by reason of its existence, the place where patients with infectious diseases are concentrated. Once the principles of infection were understood, the main problems arising from the special conditions in hospitals were due to practical difficulties in apply- ing aseptic techniques and to the evalua- tion of organisms that resist antimicro- bial drugs. At the time of the discovery of penicillin, nearly all strains of Staphy- lococcus aureus, an important cause of surgical wound infection, were sensitive to penicillin. However, within ten years of the widespread use of penicillin, peni- cillin-resistant staphylococci emerged to cause outbreaks of wound infection in hospital. It was feared that this might lead to an uncontrollable epidemic, but the discovery of new variants of penicil- lin and other antibiotics effective against penicillin-resistant bacteria, plus a more rational use of antibiotics and antiseptic methods, have contained the situation. No sooner had the threat of penicillin- resistant staphylococci subsided than a fresh problem arose with gram-negative bacteria, including Escherichia coli, Kleb- siella spp and Enterobacter spp, which are either part of the normal flora of the human bowel, or can easily colonise the bowel. These gram-negative bacteria were resistant to the original penicillin, and have shown a greater ability to 14 Hospital conditions are not always as hygienic as modern medical care demands. (Photo WHO/D. Henrioud) develop resistance to newer antibiotics. Part of this ability stems from the transfer between bacterial species of genetic material conferring drug resistance. This means that the antibiotic resistance ac- quired by a harmless bacterium could be transmitted to a more virulent organism. Hospitals in which antibiotics are heavily used are an environment where antibiotic-resistant bacteria are in effect selected for survival. In this way, hospi- tals have truly been the breeding ground for communicable diseases. Fortunately for the human host, there has been little spread of antibiotic-resistant bacteria from hospitals out into the community. This is possibly because antibiotic-resis- tance is a factor acquired at the expense of some other property which promotes the survival of bacteria in antibiotic-free environments. Where antibiotic resis- tance has appeared in infections acquired in the community, there has been widespread use of the antibiotic in the community as well as in hospital. Another recently discovered infection for which hospitals can provide special conditions enabling the causative orga- nism to survive is Legionnaires' disease. It is too early to be sure why this is so, but the evidence points to water pipes, taps and tanks in modern hospitals and similar buildings as the source of infec- tion. Modern hotels, too, have been associated with Legionnaires' disease. Indeed, the similarity between hospitals and hotels extends to other communi- cable diseases. In the past, both types of institution were places at which external parasitic infestations could be acquired, and even today both are places in which outbreaks of food poisoning and salmonellosis may occur. The admission into hospital of a patient with a communicable disease creates a potential source of infection in that hospital. Usually the risk is mini- mised by nursing the patient under con- ditions of isolation, but if the infectious nature of the patient's illness is unrecog- nized, the danger is increased. The dis- ease may be so rare as to seem an im- probable diagnosis : for instance, small- pox in Britain in 1973, which spread from an undiagnosed hospital patient to two visitors of a patient in the adjacent bed; or viral haemorrhagic fever in a Middle Eastern hospital which spread to nursing and medical attendants of the index case. The circumstances of the patient may confuse the clinical diagnosis : typhoid fever in a pregnant woman may lead to early labour, congenital infection of her 15
The hospital—a breeding groundfor disease ? infant and transmission to other women and babies in a maternity unit before the cause of the first woman's fever is dis- covered. Debility from tuberculosis may be ascribed to old age, alcoholism or oth- er illness until it is too late to prevent the patient's death and spread of infection to hospital staff. Rarely, the nursing and medical staff themselves are the source of infection to patients, but streptococcal pharyngitis, influenza and other respiratory infec- tions are examples of this. Hospital staff should take care to be immunized against communicable disease to reduce their chances of acting as sources of infection; they should take every precaution to avoid becoming infected and should report their own illnesses to their medical advisors. Hospital microbiology labora- tories are very rarely the source of direct infection to patients or the community, but indirect infection via laboratory staff to their families and friends has occurred in cases of tuberculosis and hepatitis B. Susceptible patients A consequence of many illnesses is to make patients more susceptible to infec- tion. In leukaemia, Hodgkin's disease, aplastic anaemia and hypogammaglobu- linaemia this effect is very marked, because the body's immunological defences against infection are themselves diseased. In hospital units where groups of such patients are nursed, an otherwise mild disease like chickenpox or measles can be very serious. The skin is an important defence against infection, so it is obvious that ac- cidental and surgical wounds that cause a break in the skin create a risk of infec- tion. The risk is increased if patients are more susceptible because they are very young or old, or because they are already ill. Damage to the tissues around wounds will diminish the blood supply to the wounds and make them more liable to anaerobic infections, including the organisms that cause gas gangrene and tetanus. All these points are well known to surgeons. Burns also damage the in- tegrity of the skin and underlying tissues, so that burnt patients have a special risk of serious infection. Medical treatment, too, may make patients more susceptible to infection. This is the case with anti-cancer drugs Hospitals may encourage communicable dis- eases simply because this is where susceptible patients and infectious agents are brought together. (Photo WHO/D. Henrioud) and drugs that act against the immune system (steroids and drugs given to or- gan transplant patients). Even those anti- biotics which inadvertently kill the nor- mal harmless bacteria living in peaceful symbiosis with us at the same time as they kill one dangerous pathogen can make a patient more liable to infection ; another pathogen can step into the place left by the harmless bacteria. Catheters draining the bladder, endotracheal tubes for assisted respiration and intravenous catheters for fluid replacement all offer to pathogenic micro-organisms some routes to invade the body. Again, these dangers are generally well appreciated by hospital staff, and the small risks entailed by therapeutic measures must be weighed against the advantages. Gastro-enteritis provides another ex- ample of the increased susceptibility of hospital patients. Salmonellae are an im- portant cause of gastro-enteritis in any community. Outside hospital, disease is caused by eating foods in which these micro-organisms have multiplied to high concentrations (a million organisms per gramme of food), and low concentra- tions do not usually cause clinical infec- tion. On the other hand, the infective dose for hospital patients is lower; this means that salmonellae causing gastro- enteritis can be transmitted not only by poorly prepared food, but also by nurses and medical instruments. Young babies, especially premature infants, in materni- ty units show this special susceptibility to gastro-enteritis from rotaviruses, pathogenic Escherichia coli and certain types of Staphylococcus aureus as well as salmonellae. Finally, hospital patients have a sus- ceptibility to infection from organisms that rarely cause infection in the commu- nity. Lung infections and septicaemia due to yeasts and fungi are examples which are difficult to treat effectively because of the toxicity of anti-fungal drugs. Some gram-negative bacteria like Pseudomonas aeruginosa can live and multiply harmlessly in wet places (such as kitchen sinks), but occur in hospital intensive-care units as harmful infectious agents. However, these infections are so confined to the hospital patient that it may be incorrect to count them amongst the communicable diseases bred in hospital. Opportunities for transmission The previous sections have contained examples in which the hospital may be a place in which infections are transmitted, simply because this is where susceptible patients and infectious agents are brought together. But in some cases the hospital provides a special opportunity for transmission. The best example is the transmission of hepatitis B infection by blood transfu- sion. The greatest risk is in patients like haemophiliacs who receive many trans- fusions. The identification of the causa- tive virus has resulted in the screening of blood donors, and this has reduced this route of transmission. This success has lead to the recognition that there are oth- er hepatitis viruses transmitted by blood or serum, but these are overshadowed by the marked increase in the transmission of hepatitis B outside hospital through drug abuse. There have been very rare occasions when malaria has been trans- mitted by blood transfusion, and hepati- tis B by surgical operation. Another un- usual route is the transmission of cyto- megalovirus by renal transplantation, but it has to be remembered that the reci- pients of organ transplants are highly susceptible to infection. Cytomegalo- virus can also be transmitted in blood. Medical drugs have occasionally been the vehicles of infection. Intravenous fluids contaminated by bacteria are the most serious hazard, but are very un- common. Eye drops have also been a problem when dispensed from large con- tainers which become contaminated after sterilization; the modern practice of us- ing small individual bottles avoids this. Finally, drugs prepared from heat-labile natural substances, such as pancreatic enzymes, have been known to transmit enteric infections. Any discussion of the possibility that hospitals are breeding grounds for com- municable diseases risks appearing as a catalogue of hazards which portrays hos- pitals as hot-beds of infection. This im- pression should be dispelled. In devel- oped countries, about half the infection seen in hospital is acquired in the com- munity before the patient is admitted. In developing countries, the proportion of community-acquired infection is often higher. Much of the infection that is acquired in hospital is caused by the patient's own colonising bacteria, which take the opportunity of the illness or treatment to become invasive and cause overt infection. Few, if any, of the dis- eases that can spread between healthy people depend on hospitals as their source or method of transmission. Nevertheless, the past history of hospi- tals as places where once infection was rife should serve to warn us against becoming complacent. ■ 17 One man's meat... Provided they eat enough of it, people who live on traditional cereal and legume diets receive sufficient protein. Although meat products may deliver plenty of amino acids, vegetables too can be combined to give an ideal diet by Nedd Willard I deas are powerful things. They give shape to the reality around us and can change the way we live. But wrong ideas are often as strong as right ones, and today they are helping to starve, sicken and destroy the health of millions of people in our world. Wrong ideas come in two kinds, old ones and new ones. And what we eat to stay alive is determined in large part on what we think we should eat, while this in turn rests on a series of ideas, traditions, assumptions, ideals and—often—blatant propaganda. During the past decades, for example, evangelists of a "Western" way of life have, in good faith, helped spread a false gospel to the rest of the world. This in- cluded the belief that only a diet based on meat and animal products could en- sure health and growth. In some remote villages in Asia and Africa, educators today still unroll faded nutrition charts which proudly show a piece of red meat, a chalky white glass of milk and all the other vegetables and food groups that can easily be found in a European store but are often unobtainable, and usually unaffordable, elsewhere. For centuries in many traditional cul- tures, mothers have been deprived of the basic foodstuffs they need to remain healthy (especially during pregnancy) and to help their children grow, because of twisted ideas that in effect starve them and their children. The idea that wom- en's diets needed "cooling", for example, relates to certain views about women's sexuality and the fear of it, and it is a poor guide to what women should eat during and after pregnancy. Food taboos But if we are to change wrong ideas we also have to understand how they arise. Taboos about food are connected with religious belief and the erroneous notion that you are—even mentally and spiritu- ally—what you eat. Therefore, eating rabbit or chicken will make you timo- rous, eating red meat will make you brave or warlike, spices will excite sensuality, and so on. Again, some foods are supposed to be more "spiritual" than others. Although most of these ideas have no basis in physiology, they are widely held and would be hard to change. Taboos are ritualized warnings. West- ernized over-simplifications, of the "let them eat the sacred cows" variety, over- look the fact that simply destroying a belief would not necessarily add anything to the well-being of the people, and might even make them feel more dis- oriented and lost in this changing, imper- sonal, industrializing world than they are today. Probably the best solution is to leave all those ideas, taboos and cultural practices alone that are not actually dangerous to health. However, thousands of children are still dying, being stunted physically and mentally or losing their sight each year because they are deprived of the food they need during the crucial first years of life. Good food may well be available locally, but the diets they are fed are related to wrong and often dangerous beliefs about nutrition. Starving a child to stop its diarrhoea is a killing practice, yet it seems logical to stop all food except gruel when a child is weak with "the runs". If that child is to develop, if it is to be able to protect its system against the assault of many other ailments, including the inevitable child- hood diseases, it needs food. Although every mother knows, and this time is correct in knowing, that diarrhoea is a killer, especially of babies and young children, it is often hard to persuade her that she should give nutritious foods to her child who suffers from diarrhoea. She must in addition be taught how to stop diarrhoea through the use of simple oral rehydration fluids, and how to feed her child adequately to get it past the dangers of childhood. But who will spread this life-saving information and how will it be made convincing? In the long run, only a rise in the status of women will allow informed young moth- ers to take the necessary steps to break the bondage of traditional beliefs that are weakening them and helping to kill their children. At the same time, simply giving im- ported food supplements and vitamin pills to all the children in a community and doing nothing about such underly- ing causes of diarrhoea as a bad water supply would be, at best, a palliative measure. Since most of these children are also likely to be severely weakened by childhood diseases, that is yet another problem that must be tackled. Dangerous trends If many old ideas deserve to be over- turned, it is equally vital to stop the flow of unwholesome new ones and to reverse dangerous modern trends in nutrition. The human being is omnivorous and can thrive on a wide variety of diets, yet Most "Western" diets include meat as a matter of course. But a well-balanced vegetarian diet can provide humans with as much muscle, ener- gy and drive as one based on animal products. (Photo WHO/Spooner) 18 ,
An Indian villager preparing chappatis, un- leavened bread which is often more nutritious than "Western" bread made from over-refined white flour. Left : Rice is an important part of the daily food eaten by these Vietnamese boys. It is tradi- tional food, and in combination with sufficient quantities of vegetables, it is the right food. (Photos WHO/ UN and WHO/P. Almasy) most nutritionists in the past made little effort to understand the value of tradi- tional diets in the Third World. The common European diet makes bread the "staff of life" accompanied by meat, eggs, milk and locally available vege- tables and fruits. With the rise of nutri- tional science, such a diet came to be ac- cepted everywhere in the world as the "ideal" one. This was only natural since many nutritionists themselves were Eu- ropean. When others came from deve- loping countries, they usually received their training in Europe or the United States, using textbooks developed in and for those countries; on returning home, they too became advocates for the Euro- pean diet. Such a diet just did not work in Third World countries, for many reasons. First of all, most people in these countries sim- ply could not afford such foodstuffs even if they wanted to and even if these foods were available. Moreover, there was a strong cultural resistance to change, and in this case it was a good thing it was so strong. The only people who did adopt the European diet were members of the ruling classes, of the elite, who also adopted much of that life-style as well. What made things worse was that they often came to represent the ideal that poorer people strove, unsuccessfully, to follow. Today's nutritionists everywhere in the world feel that the European diet is too high in total energy, too high in pro- tein, too high in fat, too high in refined sugar, too low in fibres and probably too high in salt. Because of its emphasis on food of animal origins, such a diet places the heaviest strain on the world's limited food supplies and resources. Food that could nourish human beings is given to animals; and it usually takes seven times as much food to produce the same amount of energy by passing it through an animal first than it would if consumed directly. Dr Moises Behar, Chief of the Nutrition unit at WHO headquarters in Geneva, says: "The European diet not only is not the best diet from the health point of view, but it is absolutely impractical in economic terms for the world population under present circumstances." 21 One man's meat ... Above: A European supermarket piled high with brightiv packaged, highly flavoured pro- cessed foods. Today, the developing countries too are seeing the deliberate promotion of "convenience" foods and drinks, as erroneous ideas take root that are helping to:i prevent the world from eating wisely. (Photo WHO) Left : Not cow-milk but buffalo-milk jets into the pail'in South-East Asia. Whole civi- lizations have developed and flourished in which cow-milk was unknown, and many cultures today have perfectly valid substitutes. (Photo WHO/P. Almasy) Traditional diets in the Third World are based mainly on cereals and legumes, with a small amount of food of animal origin. Now though meat products can deliver a high concentration of essential amino acids, vegetables can be combined to provide an excellent balance. Corn and beans, rice and beans, wheat with green peas or lentils can provide enough proteins to satisfy human needs when eaten in adequate proportions and amounts. "If populations living on tradi- tional diets, such as those based on cereals and legumes combined, have enough to satisfy their needs for energy, they will also have enough protein", says Dr Behar. The question of quantity is vital and is frequently overlooked. Most undernou- rished people in the world simply do not get enough to eat. Affluent people have to be careful not to salve their con- sciences about hunger by taking refuge behind the idea that "these people don't eat the right kind of diet". With few exceptions, where people in traditional cultures eat enough they are well fed. Furthermore, merely ensuring more food production does nothing to reduce malnutrition if the poor can't buy it or if the food doesn't reach them. Promoting bad habits Ideas are changing as ways of life change. The deliberate promotion of a new wave of "convenience" foods and drinks and ideas is helping to prevent the world from eating wisely. Infant foods, powdered milk and bottled soft drinks (along with cigarettes) are gaining ground as a result of massive hard-sell advertising campaigns. As a result, a number of crucial changes have been taking place in the eating and drinking habits of the poorest people on the planet. There has been a rapid decline in breastfeeding, which has been replaced by desperate attempts to feed children with powdered cow-milk preparations that are expensive and dangerous to pre- pare under the real-life conditions of developing countries. Local unrefined food products, such as grains and fruits, are being increasingly replaced by manufactured and, often, imported products. In a poor tropical country, soft drinks, tinned fruits and tinned juices may compete successfully with fresh fruits. Imported flour may replace local grain. Such imports act as a drain on the fragile national economy, and the result is that local farmers grow poorer and people eat less and less well. Imported cereals may actually be nutritionally poorer than those they replace; locally made tortillas, chappatis, local corn breads, sorgums and legumes are giving way to European breads made with imported, over-refined, white wheat flour. Even the fad for taking manufac- tured vitamin pills has begun to catch on, when what is needed is more food and more of the right food. Fortunately, food habits tend to change slowly, and there is still time to retain what is best in traditional foods, to bolster local agriculture and to improve traditional foods habits. It is certainly easier and better to build on existing food patterns than to try to impose new ones. This would also help people solve their own food problems rather than relying on others. Education is necessary but it must be pertinent and not condescending. Poor people, rural people, illiterate mothers are not as ignorant as many urban plan- ners believe. Once they are convinced of the sincerity of the message they will lis- ten to better ways of using their food ... always provided there is enough of it. A change in the status of women may prove to be the best long-term invest- ment in nutrition that a society can make. Young mothers no longer subju- gated by older members of the society, free to learn and to take initiatives, can be shown how to prevent deaths from diarrhoea by simple oral rehydration techniques. They can learn to feed their child in a way that will protect its health, provided they receive the right support; and they too can benefit from a better diet. And diets can be improved without overturning all the traditional values of rural societies. Firstly, those in positions of responsibility must be clear in their own minds. What is needed is not more pill hand-outs or more pious sermons on "nutrition", but better distribution of food, a healthier agriculture to produce it and a more equitable system of distribution that makes sure everyone gets a share. The fact that wrong ideas can be sown and take root should make us more opti- mistic. After all, weeds grow best in fer- tile soil and if wrong ideas can be sown so can right ones. Men, women and chil- dren everywhere want to be healthy. The human mind can discard ideas that are useless and acquire more positive ones that will make life easier. The world community has no higher task than that of seeing to it that each of its members has enough food to grow up on, to live on, to furnish energy for making the world a better place. ■ R. I. P. Let us lay some nutritional myths to rest Vegetarian diets keep you weak and are unsuitable for growth. Wrong: A well-balanced vegetarian diet can provide as much muscle, energy and drive as one based on animal products. There just has to be enough of it. Women during pregnancy need "low" or "cooling" diets. Wrong: During this crucial period, with its extraordinary demands on her system, a mother needs more food, rich in protein and truly nourishing. Milk is needed by all children and most adults. Wrong: Milk is fine, but civilizations have deve- loped and flourished in which cow-milk was unknown. Commercialized baby foods represent an improvement on traditional weaning foods. Wrong: Baby foods or traditional home-made weaning foods can do the job but there must be enough of them. Moreover, high cost may make adequate quantities of baby food inaccessible to poor families. Also, locally produced foods for weaning help local agriculture and don't waste resources on packag- ing, advertising and so forth. For those who can afford them, baby foods can be convenient. For those who can't, local foods can do the job just as well. There is a protein shortage in most of the traditional diets of developing countries. Wrong: With few exceptions malnutrition is caused by too little food. In most parts of the world, enough of the traditional diet provides enough protein as well. Grandmothers always know best what a child should be fed. Not always true: Grand- mothers can be the vehicle for con- veying dangerous, outdated ideas about what young mothers and babies should be fed. Being older, having lost children of your own, doesn't necessarily equip you to give good advice to young parents. An appropriate diet in Europe is an appropriate diet in Asia, or anywhere else. Wrong: This makes no more sense than saying that a heavy wool suit would be the best clothing to wear in India in July. Foods must suit local conditions and needs. -)3 The fight against famine by Etienne Berthet A single national council of food and nutrition to coordinate assistance would obviate the kind of anarchy that prevailed when large numbers of public and private charities intervened after the 1973 famine in the Sahel 3 espite all the efforts of govern-ments and international organ-izations over the past years, despite the spectacular scientific and technical progress made in the fields of agriculture and of health, despite the many international conferences that met during the 1970s, malnutrition and famine still represent a bitter scourge of our times. In the words of Joseph Klatzmann, Professor at the National Institute of Agronomy in Paris : "Is it really easier to go and collect pebbles from the surface of the moon than to feed the hungry masses of Bombay and Calcutta?" Equally, is it an impossible task to pre- vent malnutrition and famine, which are among the leading causes of mortality in the countries of the Third World? Famine and communicable diseases have decimated humanity throughout the centuries. The two were closely linked, since periods of famine were fre- quently followed by terrible plagues. Spectacular results have been achieved in the struggle against communicable dis- eases in the course of the recent decades. These are due partly to successes in the treatment of disease, but even more to the measures taken to prevent them. Yet the prevention of famines has scarcely been studied up to now. Nevertheless it is possible since, aside from periods of armed conflicts, famines generally only affect communities which suffer chroni- cally from malnutrition and poor living conditions. Natural catastrophes, in so far as they are the determining factors of famines, don't arrive dramatically like a thunder- clap from a clear sky. They simply emerge from some break in the pre- carious biological balance that exists be- tween mankind and the environment. A consequence of the aridity of certain parts of the world, famines are no new phenomenon, and the cycle of the fat and the lean cattle has been recorded since ancient times. What is new is the intru- sion into poor countries of techniques that have been tried out in rich countries, and which, crudely imposed upon popu- lations who have not been trained to Hungry and angry, this small boy was a victim of a famine in Northern India which resulted from devastating floods followed by drought. (Photo WHO! UNICEF/T. S. Satyan) use them, have interrupted that natural balance. On the one hand, the progress made in human and veterinary medicine has led to a spectacular growth in human and animal populations. On the other, a great many sociological factors have added to the risks of malnutrition—fac- tors such as the spread of industrial en- terprises at the expense of farm land, the impoverishment of the soil and increas- ing deforestation, the effects of huge in- creases in the cost of energy, mushroom- ing urbanization and the inadequacy of social infrastructures in rural areas. The health situation among people of the Third World offers proof of this unfortunate state of affairs. The great efforts expended over more than half a century in the prevention of epidemics have enabled us, if not to eradicate dis- eases (apart from smallpox) at least to control the worst scourges that have stricken mankind throughout history, and to make an appreciable improve- ment in people's health. Despite these ef- forts, infant mortality rates have stayed basically the same in recent years. For children aged under one year they are ten times higher in Third World countries than in the industrialized world, and for children aged between one and five years, 30 times higher. These Third World countries are therefore in no position to undertake the preventive actions that are needed, particularly in matters of nutrition. A study carried out in Africa has shown that 90 per cent of deaths among children aged under five could be laid at the door of three factors, all of them preventible by quite simple measures : communicable diseases, an unhealthy environment, and malnutrition. Pious hopes It will be long before the decisions taken at the World Food Conference in Rome in 1974 become a reality. In the course of those discussions, many fine resolutions were adopted, many pious hopes were expressed, many ambitious solutions were proposed. Specifically there was a call "to eliminate hunger and malnutrition in the next ten years ... Governments should set as their target that no child should go to bed at night feeling hungry, that no family should live with the dread of lacking food the next day, and that the future and the capability of no single human being should be put at risk by malnutrition." From 1974 to 1980: six years after the Conference of Rome, we are very far from attaining these objectives. At the last session of the UN Economic and Social Council (Ecosoc) held last July in Geneva, the risks of worsening famine in Asia and in Latin America were empha- sized. It was reported that the crucial shortage of cereals was all the more diffi- cult to overcome because most of the poor countries suffered from galloping over-population, drought and other natural calamities, as well as from serious armed conflicts which made it impossible to build up the vital infrastructure of transport and food distribution. So what can we do in a concrete, prac- tical and effective way under present conditions? "Remember they cannot eat your words", one British journalist wrote at the time of the Rome Confer- ence. What can we do tomorrow with the technical means available, while we wait and hope that human wisdom will one day enable us to channel the crazy expen- diture on armaments (US $480,000 mil- lion dollars in 1979) not into destroying people but into helping them to live? Must we passively wait for famines to appear and only then mobilize all the in- ternational charitable aid that is offered in order to take some kind of temporary action? Malnutrition and famine can be pre- vented. It will not be a simple matter. There are no vaccines such as exist to prevent most communicable diseases, and there are no universal, easily applied remedies. But there are some measures that can be taken at once which, when suitably combined and coordinated, can appreciably improve the nutritional level, the health and the living standards of the most deprived populations. Thirty years of international work by WHO, by the International Children's Centre and by the International Union for Health Education enable us to pin- point three important lines of action that can help to prevent malnutrition and famine. These are : better coordination of the efforts made by governments and the international institutions to fight against under-development, of which famine is 25 The fight against famine Left : The desperate face of starvation. Emergency rehydration may just save this little boy's life in a Bangladesh hospital. But when coupled with chronic malnutrition, acute diarrhoea' diseases are child-killers. (Photo WHO/A. S. Kochar) Right: Bare hands and a primitive wooden hoe are feeble agricultural imple- ments in the harsh lands of the high Andean plateau. To ensure that social and economic development reach "the poorest of the poor" this is the challenge of our time. (Photo WHO/ILO) only one of the more dramatic symp- toms ; greater participation by village communities themselves in activities aimed at improving their living condi- tions; and finally, thorough training in the problems of nutrition and health for all personnel responsible for govern- ment-sponsored economic and social development. Better coordination We have been only too ready to believe that the problem of nutrition could be solved simply by increasing food production, whereas this problem is just one of the more dramatic aspects of the under-development that still afflicts three-quarters of humanity all over the world. All the problems of economic and social development that communities face are complementary and interdepen- dent, and none can be resolved without the others. They have to be tackled by a global approach which takes into ac- count not only the whole range of human personality but also all the challenges of a constantly changing environment. Such an approach will only work if we can somehow coordinate all our efforts in the various sectors of human activity, whether in food production, health pro- motion, education or social demographic and economic action. Too often in recent years, economists and planners have tended to consider nutritional and health problems as secondary compared with the more ob- vious projects that economic develop- ment calls for, since such development must automatically result in improving people's living conditions. This concept has turned out to be erroneous; econom- ic growth is by no means always followed by social development and may even ag- gravate social inequalities, since progress has been known to enrich the rich and impoverish the poor. Thus the "green revolution", which enabled spectacular progress to be made in farming techni- ques, proved to be available only to those farmers who were well-provided with water, fertilizer, pesticides and technical equipment. The countries of the Third World must assume responsibility for resolving their own food and health problems, and for coordinating their campaign against the root causes—there is very rarely one sin- gle obvious cause—of nutritional lack. They can count on the support of a num- ber of international bodies. The Food and Agriculture Organization (FAO) deals with agricultural policy, those aspects of nutrition that are linked with foodstuffs, and the planning of food distribution; vnio deals with all aspects of nutrition that have a bearing on health; UNICEF oversees the health and diets of mothers and children; the World Food Pro- gramme looks after food supplies within the framework of development projects; and UNESCO deals with nutritional educa- tion and the training of technical person- nel. Besides this, the World Bank has for some years had a special interest in mal- nutrition in so far as strategies for rural or urban development can help to over- come it, while UNDP takes care of global development programmes and coordi- nates the whole range of activities under- taken by the specialised institutions of the UN system. All the same, the lack of coordination often seen at the national level also exists at the international level, as witnessed by the anarchy which resulted from the in- tervention of a great many public and private charitable organizations follow- ing the 1973 famine in the Sahel. In view of the large number of international and non-governmental bodies who are anx- ious to collaborate with countries in the fight against malnutrition, there ought to be an effective mechanism to ensure the sensible use of resources and avoid con- flicts of interest between the different sectors. The simplest thing would be to integrate all the collaborative assistance that is offered under a single national council of food and nutrition. Community participation It has been rightly said that the ancient Sumerian, Egyptian, Greek and Roman civilizations were built on an immense sea of misery out of which emerged tiny 26 islands of culture. The situation is not so very different in the Third World coun- tries, where one can still see an enormous contrast between the development of the towns and the poverty of the rural com- munities. Aid offered by the interna- tional institutions, particularly for nutri- tion and health, has too often been directed towards the towns, while 90 per cent of the population lives in the coun- tryside. Of course it may be hard to reach the dispersed and isolated villages in dis- tricts where there are neither communi- cating roads nor means of transport. Yet these are the very "poorest of the poor" who must be reached. Trying to reach the unreachable, the most numerous and the poorest—this is the challenge of our time. Whatever is done at the national level ought not to let -us forget that many small things undertaken in a lot of little places by a lot of humble people can make a very sizable improvement in peo- ple's well-being. In fact it is only in the field, at the grassroots level, that the grand theories can be tested, to see whether they respond to the real needs of the people. Simply transferring to the Third World the sophisticated techniques that are appropriate in the industrialized countries will not bring about progress in health and nutrition; instead what are needed are simple methods that are easi- ly adaptable. We have to change people's outlook, and motivate them afresh to work out for themselves all the possibili- ties for progress that exist. All human behaviour aims at satisfying a need or an aspiration, and people will only agree to change their habits when they are con- vinced that it will be to their advantage. So it is through informing, motivating, and encouraging the people in the rural communities that we can best hope to improve their living condition. Training personnel The safeguarding of valuable human resources is a fundamental condition for economic and social progress. Yet this idea has not yet sufficiently penetrated the minds of many economists, planners and politicians, who accord only a lim- ited space in their development plans to the protection of human resources, whether in the field of nutrition or that of health. Lack of personnel staff is the first and most•important stumbling-block to con- front governments as they plan their struggle against famine. They know per- fectly well what has to be done, but are brought up short by the bottleneck in the supply of technically trained personnel and material means. Such complex problems call for a multidisciplinary solution, to which concerned people at all levels must apply their technical skill and understanding. The education and specialised training of all responsible staff engaged in economic and social development are absolutely essential if worthwhile results are to be obtained; this is true whether they are politicians, administrators, agronomists, nutritionists, meteorologists, demograph- ers, sociologists, teachers, economists, planners, doctors or health workers. All these people should receive prac- tical instruction in how to tackle malnu- trition, how to recognize nutritional needs, what are the causes of famine, and how to prevent them. In short, what is needed is a simple, practical and easily adaptable training course that could be introduced in universities, teacher training schools, agricultural and rural development col- leges, and in schools of public health, national administration and journalism. Moreover, if this training is to be fully effective it should start in the first years of primary school: In the process of organizing various courses on "health, nutrition and devel- opment" in different parts of the world, particularly in Africa and the Eastern Mediterranean, I have become quite con- vinced that this is the first priority for developing countries. The most fruitful investments are not in material supplies, but in efforts undertaken to train men and women who, through their own in- itiatives, can in turn transform people's outlook and change their behaviour in favour of a better life-style. ■ 27 p rovided satisfactory progress is made in all those social, eco-nomic and political areas that influence mortality, the present gap in life expectancy at birth between developed and developing countries will be almost halved by the end of this century. With less than two decades to go before that date, this guardedly optimis- tic forecast is put forward in WHO's "Sixth Report on the World Health Situ- ation". Five years ago, life expectancy at birth in the developed countries was esti- mated at 72 years, while in the develop- ing countries it was only 55, a difference of 17 years. The situation has already improved, but the present gap is still estimated at between 15 and 18 years. A recent WHO survey of national mortality projections, however, estimates that, in the developed countries, by the year 2000 life expectancy will be in the range of 75 to 80 years and infant mor- tality will be 10 per 1,000 liveborn, or less. Most of these countries expect no significant improvements at ages other than infancy. In developing countries, on the other hand, "barring unforeseen develop- ments", it is anticipated that by the year 2000 the majority of their popula- tions will have a mean life expectancy at birth of at least 65 years—closing the gap to around 10 years—and the infant mor- tality will only rarely be in excess of 50 per 1,000 liveborn. But the Report warns that there is today a life expectancy gap of some 10 years between the least devel- oped countries and the remainder of the developing countries, and comments: "The least developed countries will, therefore, have to achieve much greater gains if current inequalities are to be drastically reduced." With the progressive reduction of pre- mature deaths the numbers of people in special morbidity and disability risk groups will increase, particularly those of the disabled, the mentally retarded and the chronically ill. In developing coun- tries, the proportion of those who are go- ing to live to be 65 in the year 2000 can be estimated at approximately 70 per cent (compared to about 45 per cent now) and one out of three can be expect- ed to celebrate his or her eightieth birth- day, as compared to one out of seven under 1975 mortality conditions. The figures emphasize that providing social services for the elderly can no longer be considered as an issue for the distant future and already require urgent attention. If the overall and long-term picture is bright, the Report is at pains to show that two decades of fearsome and toil- some struggle lie ahead if WHO's ambi- tious objective of "Health for all by the year 2000" is truly to be attained. It has this to say of the outlook for the future so far as morbidity is concerned : "In the coming decades, many of the developing countries will continue their struggle against infectious and parasitic diseases and accord them first priority. However, health problems now typical in the devel- oped countries—such as cancer, cardio- vascular diseases, mental health and ac- cidents—may well become of major concern to the developing countries as they move along the path of socioeco- nomic development. In addition, envi- ronmental health problems which will arise with rapid urbanization and indus- trialization will have to be tackled... "The lessons of the recent past have impressively demonstrated that the dangers posed by certain infectious and parasitic diseases should not be underes- A global view Newly published by WHO, the "Sixth Report on the World Health Situation" finds a gleam of hope in the pattern of our planet's health, but foresees decades of struggle ahead against the forces of disease and malnutrition 28 No significant breakthrough in improving the world's health status can be expected so long as poverty and underdevelopment remain. (Photo WHO/A. S. Kochar) timated. The conquest of diseases such as malaria, schistosomiasis and onchocer- ciasis will be a long and arduous task, challenging personal ingenuity and polit- ical determination. Success will depend very heavily on changes in the socioeco- nomic setting and in the political cli- mate; a significant breakthrough in im- proving the health status of the world's population cannot be expected unless the main causes of poverty and underdevel- opment, such as obsolete socioeconomic structures, can be removed. "An important part will be played by national and international efforts to at- tain the goals set by the United Nations Water Conference in Mar del Plata in 1977, and by WHO's Expanded Pro- gramme on Immunization, namely to provide by 1990 (a) safe drinking-water and sanitation for the entire world popu- lation; and (b) immunization for all the children of the world against the main infectious diseases. "Last but not least, changes in beha- vioural patterns, eating habits, smoking, alcohol consumption, use of drugs, phys- ical exercise and driving have an impor- tant bearing on health prospects; much will depend on whether health education can reach the public more effectively than in the past." The Report recognizes that malnutri- tion continues to be one of the leading causes of illness and death among young children in most developing countries. It quotes an estimate made during the World Food Conference in Rome in 1974 that the world's undernourished population was not less than 400 million, a great majority of whom would be young children. Specific nutritional deficiencies still pose alarming problems in much of the Third World and, of these, three have at- tracted attention, not only as health problems but also because they have grave socioeconomic implications. They are vitamin A deficiency and xerophthal- mia, endemic goitre and cretinism, and nutritional anaemia. Each year about 100,000 children aged under five become blind as a result of vitamin A deficiency in many countries of Africa, Eastern South Asia, the Middle East and Latin America. Endemic goitre and cretinism caused by iodine deficiency and associat- ed with mental retardation are wide- spread in various African, Asian and Latin American countries, and in certain mountainous areas the incidence of goi- tre is as high as 95 to 100 per cent of the population. Nutritional anaemia caused by iron deficiency, folate deficiency, or both, affects pregnant and lactating women and young children, not only in the developing world but to a lesser extent in the industrialized world as well. The Report rates "malnutrition of affluence"—that is, disorders due to overnutrition as one of the major health, social and economic problems in the industrialized countries today, being found especially in Western Europe and the USA. The main manifestations are obesity, cardiovascular diseases, diabetes mellitus and dental caries. To quote just one other theme that is treated in depth, smoking receives eight entries in the index, and in a four-page account under the heading "Health- related behavioural factors" the com- ment is made that "the smoking habit has spread like an epidemic. Although 29 the developing countries have not yet had time to experience the grim increase in smoking-related mortality that has taken place in the industrialized coun- tries, they must expect it unless they halt and reverse the increase in cigarette con- sumption. In many less developed coun- tries, the epidemic of smoking-related diseases is already of such magnitude as to rival even infectious diseases or mal- nutrition as a public health problem." The tone of this Sixth Report is set in the Preface by the Director-General of WHO, Dr Halfdan Mahler, who describes the years 1973 to 1977 as a period when the international social and political climate underwent dramatic changes in response to the clarion call for a new economic order and for social justice. He writes : "A fundamental reorientation in our thinking and action has thus taken shape. Development goals are no longer defined exclusively in terms of economic growth. Today development is inter- preted as a process aiming at the promo- tion of human dignity and welfare and at the radical elimination of poverty as the greatest obstacle to national and interna- tional progress and peace ... "The declaration contained in WHO's Constitution, now almost 35 years old, that 'the enjoyment of the highest attain- able standard of health is one of the fun- damental rights of every human being' and that 'governments have a responsi- bility for the health of their peoples which can be fulfilled only by the provi- sion of adequate health and social mea- sures' has thus acquired a new meaning and a contemporary significance. "However, health is not only a desir- able social goal by itself; it is also in- creasingly being recognized as a means and, indeed, an indispensable com- ponent, if not prerequisite, of social and economic development. Consequently, there is now an ever-increasing insistence on having health policy and health strategy fully integrated with national and international development plans." Covering specifically the years 1973 to 1977, the "Sixth Report on the World Health Situation" consists of two sep- A child strides purposefully through an Indo- nesian rice paddy—one child at least who will not go hungry this year. (Photo WHO/P. Almasy) 30 arate volumes, with the format reduced to a handy 18 by 24 cm. The first is a global analysis, with sections on all the main fields of health action from country health programming through primary health care to coping with disasters. There are also chapters on the problems of measuring and defining health status of countries, on research and its implica- tions for the future of world health, and—as we have already seen—on the broad outlook for the future. There are 30 pages of tables, graphs and charts, including some projections up to the year 2000. The second volume is a review by country and area of the health situation in some 120 Member States of WHO. These are grouped under the six Regions of the Organization and then listed al- phabetically. Varying in length since they depend on the amount of information furnished by governments, the reviews World Health Index 1958-1980 We propose to publish very shortly —and at present in English only—a cumulative Index of subjects dealt with in World Health magazine since it was launched in 1958. The last such Index, published at the end of 1975, proved particularly popular with librarians, health personnel, training schools and medical journalists. The Index will be available, free of charge, on request to: The Division of Public Information, World Health Organization, 1211 Geneva 27, Switzerland. list the major health and health-related problems of each country, the action taken, the health resources available, an appraisal of the progress taken in the years under consideration, and the future outlook. The report will be of particular value to public health policy-makers, planners and administrators who are engaged in initiating strategies for attaining the goal of health for all by the year 2000, and represents a unique and comprehensive source of information for all concerned with the wider aspects of social and eco- nomic development. The two volumes are already available in English and will shortly be published in Arabic, Chinese, French, Russian and Spanish. They may be ordered, price 20 Swiss francs and 28 Swiss francs respectively, from : Distribution and Sales, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland. JHB In the next issue The United Nations has declared 1981 the International Year of Dis- abled Persons (IYDP). To mark the opening of the Year, the January issue of World Health will be devoted to the theme of the physically and mentally handicapped. In particular, the maga- zine will look at the problems of dis- abled children in the Third World, the integration of handicapped persons into society, and the steps WHO is taking to advise its Member States on rehabilitation. WORLD HEALTH ISSUES IN 1980 January The message of health Blindness – New strategies PHC in the Philippines, the South Seas, Hong Kong February - March Smoking or Health – the Choice is Yours! World Health Day issue April A Revolution in Research May Smallpox is dead! June Women, Health and Development 119108 Mead. 1861.1980 AUGUST- SEPTEMBER . July Village health care Kazakhstan – Laos Psychosocial dimensions Eye diseases – Mental ward August - September Water Decade 1981 - 1990 October WHO's Six Regions November Communicable Diseases December Cuba – UNRWA Terminology – Hospitals Diet – Famine FEBRUARY- MARCH Authors of the month Mr Paul HARRISON i s a freelance journalist and photographer specialising in stories on economic development. He is the author of "Inside the Third World" and "The Third World Tomorrow". Mr Jean POUTARAUD is the Information Attaché for the Relief and Works Agency for Palestine Refugees in the Near East (t_NRwA). Dr Toma STRASSER works at WHO head- quarters in Geneva on the control and prevention of cardiovascular diseases. Dr R. T. MAYON-WHITE is an epidemiol- ogist with the Public Health Laboratory Service at the John Radcliffe Hospital, Oxford, UK. Mr Nedd WILLARD is an Information Officer with WHO'S Division of Public Information in Geneva. Dr Etienne BERTHET is the Honorary Director-General of the International Children's Centre, Paris, and Secretary- General of the International Union for Health Education, also based in Paris. WORLD HEALTH for readers everywhere 1980 Subscription Rates US$ Sw. fr. One year 15. 25. Two years 27.— 45.- Three years 36. 60. ORDER FORM Please enter my subscription to World Health as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque / international postal order in the amount of: Name: Street: City: Country: World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national currencies, please contact your usual bookseller. Even the stoniest ground some:73w prov'otes food for human settlements. See "The fight against famine", page 24 (Photo WHO/ P. Almasy)