WORLD HEALTH The magazine of the World Health Organization July 1972 UK: 20p USA: 0.50 81)011S 0(1 le WORLD HEALTH vorls iittvlir illy Cover picture by E. Mandelmann Contents The urge to excel 3 Sports medicine: more than just first aid, by Professor M. J. Karvonen 4 Soviet sports formula: accent on fitness, by Galina Tarasova 14 Sunshine and surf: joys and hazards, by Professor F. Pages 18 The water babies, by Paul Almasy 24 Health requirements for carefree camping, by Aaron Sternfield 26 Around the world 30 World Health appears in Arabic, English, French, German, Hindi, Japanese, Portuguese, Russian and Spanish. 2 THE URGE TO EXCEL S ince the dawn of history, man has sought to improve his physical strength, his muscular co-ordination and also his competitive prowess. Primitive man hunted and fished and fought to provide food for himself and his family, and at the same time he may have felt the need to earn a reputation for bravery and skill. Ritual dances and endurance tests mixed with magic are perhaps also among the origins of sport today. However that may be, fleetness of foot and quick reactions—the qualities required of the primitive hunter— are also required of the 20th-century sportsman. Though the setting and the activities have changed over the ages, the physical demands have remained the same. The origins of competitive games of skill are obscure. Forerunner of the modern Olympic Games, taking place in Munich next month, was the competition held in Olympia, Greece, from 776 B. C. onwards. Athletes competed in running, boxing, wrestling and many other events which are part of the modern Olympic programme. Competition is the cornerstone of many sports, but competition does not merely mean besting your opponent. It is often a personal affair. The skier who tries to improve his performance on each descent or the child juggling a rubber ball against a wall is competing against himself. The record books will not chronicle his prog- ress, but he will know, and knowledge of progress will provide satisfaction. The mountaineer who succeeds in a difficult and strenuous climb has conquered not only the mountain but also himself. Then there is the joy of controlled, purposive, physical movement for its own sake as in diving, the common endeavour and comradeship of group activities such as a cross-country hike, and the non- competitive spontaneity of many children's games, leap-frog for example. The benefit of sport is not confined to the physical arena. Athletic competition can be the great leveller. Race, creed, colour, national origin and social back- ground should mean nothing in the 100- metre dash or on the football field. Per- formance and grace are all that count. The athlete learns to judge his adversaries and team-mates on their merits and not on the prejudices he may have acquired as a child. Games and athletics play an important role in today's world. Not so long ago, tennis and skiing were the province of the rich. Today millions of people in moderate circumstances participate in these acti- vities. Only a few decades ago, man had to spend most of his waking hours on the job. Today, the shorter work week and longer holiday periods allow the working man and woman to play golf and football, to hike and swim. Sport is woven into the fabric of modern life and provides a counter-weight to the often excessive comforts and indulgences of today. National health programmes and phys- ical rehabilitation programmes promote sport as an aid to both physical fitness and mental well-being. A WHO scientific group has pointed out that leisure-time physical activity is associated with a lower risk of ischaemic heart disease and that physical exercise has an established place in the treatment of several diseases and disorders, and plays a major role in medical and occupational rehabilitation. At the 1972 World Health Assembly in May, during the technical discussions, sports medicine, and the contribution it can make to physical fitness of large numbers of people, was mentioned as one of the factors contributing to economic devel- opment. Sports medicine is a relatively new field. The current issue of World Health deals with the pleasures and pitfalls of games and athletics, and tells what is being done—and should be done —to en- courage the widest possible participation in sports together with the least danger of injury. ■ 3 SPORTS MEDICINE MORE THAN JUST FIRST . by Professor M. J. Karvonen, Director, Institute of Occupational Health, Helsinki Tennis elbow is an accepted medical term describing "lameness of the elbow due to a strain incurred in playing lawn- tennis". It is not the only sport-connected ailment. Punch-drunkenness among box- ers is known to neurologists, and a fungal infection of the skin of the feet is called "athlete's foot"—often unjustly, as many non-athletes also suffer from it. Some deca- des ago, an enlarged heart in sportsmen in endurance events was considered a sign of ill health, but recently it has come to be regarded as evidence of physiological adaptation. Obviously, sports offer enough health problems to deserve their own medical speciality, and in hazardous sports there are of course many practical applications. The flourishing orthopaedic clinics of alpine ski resorts and the many young and old legs in plaster casts tell it eloquently: downhill skiing is, per unit of time spent, the most hazardous sport. It is particularly dangerous for the newcomer, who has not exactly mastered the required sensomotor co-ordination of body movement in time and space. There are other hazards in athletics. American football is a frequent source of damage, among other things, to the ligaments of the knee-joint. Its more internationally practised counterpart, soccer, taxes hard the cartilaginous menisci that function as buffers between the bony surfaces within the knee-joint. Many a football-player propels the ball with a knee from which a meniscus has been surgically removed. Among contact sports, boxing has a unique place; a match may be won by damaging the adversary, by hitting his head so hard that he loses consciousness. A knock-out by a blow to the head is equal in potential brain injury to a concussion. Where accidents occur, first aid should be available. The doctor enters the sports field or the gymnasium with a first-aid kit, places it in the dressing-room of the athletes, and takes his place where he can AID have a good look at the match. The ringside doctor may have boxed himself in his youth, and the doctor of the ice-hockey team may have been a former amateur player. Their work with the sports club is most often carried out in the very same sense of amateurism, as a hobby to bring a busy doctor for a moment from his patients into the midst of an active, vigorous young crowd. Most current sports medicine is practi- sed by the non-specialized doctor, who may be anything from a GP to a professor of gynaecology. But he is being replaced by sports specialists. In many countries, sports medicine is regarded as a serious 1' The photo clearly shows the usefulness of wearing a hehnet. (Photo PublifotoIWHO) Tennis elbow is the term for the painful elbow- joint so common among tennis-players. Constant shots with arm extended as in the photo are likely to produce it. For powerful shots, experienced players make use of their shoulder. (Photo L. Sirman (D) Serious bodily injury and concussion are -> common in boxing. (Photo Publifoto1WHO)
In American football, injuries to the ligaments of the knee joints are common. (Photo USIA C)) speciality. Chairs of sports medicine exist in universities and medical schools; re- search is carried out; the subject is taught to medical students, physical educators and sports coaches; and regular facilities for postgraduate training and education have been created. The modern practitioner of sports medi- cine still takes care of the first-aid kit. He must know his traumatology: both the sportsman and the general public make great demands on his skill. Sometimes, in the limelight, he must take medical deci- sions that are not popular with his audience. He should be able to judge when the risk of competition can be taken in the presence of a minor injury and when not. He should be an expert in applying ban- dages of adhesive plaster to support a strained knee ligament or a sprained ankle. A skilled orthopaedic surgeon will in due course become a favourite with sports- men and their doctors. It is not sufficient just to have a knee and to be able to walk with it; the sports surgeon must provide a knee good enough for international football, and quickly. When the sports doctor gets his injured patient back to the field, he generally takes over responsibility for rehabilitation of his patient. The sports doctor must known how to mobilize joints, to strength- en muscles, and to avoid the development of unwanted scar tissue. If he has a team of assistants, a physiotherapist certainly is one of its principal members. Prevention is better than cure also with regard to the hazards of sports. The ap- proach is quite similar to that of occu- pational medicine: preventive measures may be directed to the athlete himself, to his tools and to his "work-place", and ultimately to his "methods of work", the conduct of the sport. Prevention at the individual level includes regular medical examinations, with appropriate laboratory tests. For an endurance athlete in training, the blood haemoglobin level and the blood-cell count must be checked fre- quently, since training causes an increase of the blood volume and hence taxes the iron stores of the body for blood-cell formation. Medical checks should also be made prior to tough competitions, to exclude athletes with any acute illness or recent injury. For boxers and marathon runners such examinations are mandatory. A thorough baseline examination and subsequent regular check-ups help to reveal any changes in health and fitness. A sportsman needs strong muscles and good control of them. A carefully consid- ered and systematic training programme contributes much to the prevention of sports injuries. Practice of the sport itself is often not sufficient. The soccer-player, for instance, should strengthen his big thigh muscles, the quadriceps femoris, with special gymnastics before the playing season, to achieve kicking strength and protection of the knee-joint ligaments by the strong muscle. Prevention through improvement of sporting gear and of places of performance calls for a joint effort by experts in several fields. Sports medicine contributes epi- demiological information and understand- ing of the biomechanics. Protecting a boxer from hitting his head when he falls to the canvas raises problems similar to the construction of a safer motor-car. In both situations the shock of impact against a hard surface must be reduced by dece- 4— Soccer places great stress on the cartilaginous meniscus which functions as a 7 buffer between the bony surfaces within the knee-joint. (Photo K. Hemzo !WHO) Sports medicine Sports doctors in Moscow completely rest- ored Viktor Klimenko's Achilles tendon after the European gymnastics champion was injured in Madrid. He was soon back in training. (Photo Novosti1WHO) In terms of co-ordination, the high hurdles is one of the most demanding of track and field events. (Photo L. Sirman ©) lerating the moving object over distance and time. In the motor-car, this is provided by a gradually compressible frame, and in the canvas, by a special thick material which on impact compresses, but does not give an immediate elastic rebound. With a perfectly elastic material, the head of the poor boxer would, of course, receive two sudden jolts instead of only one. The automatically released ski is another com- plex biomechanical problem. The ski must be firmly connected to the boot until a critical limit of tearing force is reached, related to the mechanical strength of the structures of the leg. The ski should be released before any damage to the skier has occurred. The way in which a sport is conducted may cause hazards. Throwing the javelin- is probably the most complex performance among all track and field events. Just before the grip is released, the elbow-joint becomes forcefully hyperextended. This easily causes damage to the elbow-joint, and has in fact seriously affected the careers of many prominent javelin- throwers. To understand the mechanism of the trauma, it is necessary to make a careful analysis of the movements. Only then will the coach be able to advise the sportsman on how to avoid the trau- matizing part of the movement. In preventive efforts, doctor and coaches must become members of one and the same team. Once they start to work together they will, no doubt, consider whether the knowledge and techniques of sports medicine might be applied to improve performance. The cardinal determinant of perfor- mance is training, Innate ability, of course, is also necessary, but no sportsman ever excelled without hard training. Even today, training is an art; some coaches and athletes master it by intuition, some by trial and error. However, sports medicine already shows promise of being able to help in the measurement of training prog- ress. The strength of muscles can be observed with the aid of dynamometers. In sports like running, which require a sustained effort from the large muscles, the ability to take oxygen from air and to pump it to the muscles becomes a decisive factor. The measure of this ability in litres of oxygen maximally taken up per minute is called aerobic power. For many years, the famous Swedish skier Sixten Jernberg had the highest aerobic power recorded: 5.88 litres per minute, with a body weight Renato Dionisi pole-vaults to a height of 5.36 metres in the European Games in Helsinki. (Photo L. Sirman C)) of 72 kg. The present "world record" is reported to be 6.24 litres per minute. Aerobic power may also be expressed as millilitres for each kilogram of body weight. The average aerobic power in young men is approximately 40 millilitres per kilogram of body weight per minute, and in young women slightly less. In athletes, particularly long-distance run- ners, skiers, cyclists and rowers, it may increase to up to twice that level. It is determined in the laboratory with the aid of a bicycle ergometer or a treadmill mov- ing uphill, by measuring the amount of oxygen actually taken up from the respired air. The bicycle ergometer is, indeed, becoming a standard tool both for the sports doctor and for the coach. The ergometer tests have their main use in following the progress of training in an individual. During one training season, aerobic power does not change much, but heart response to submaximal loads of exercise is a valuable measure of changes in fitness. However, among top athletes a laboratory test does not predict the winner. Competition, the real event, still has its place. The hard school of failure and success demonstrates that even a well-trained athlete requires special preparation before a major competition. Good sleep, rest and the right amount of relaxation may not be the only ingredients needed. The training regimen and even dietary habits may play an important role. Studies in recent years have shown that muscle glycogen is the crucial source of energy in sustained hard exercise. Once a muscle has used up all the sugar from its glycogen stores, it is no longer capable of working at its maximum energy output, and the sportsman must stop because he feels himself quite ex- hausted. The amount of muscle glycogen may be studied simply by taking small samples of muscle tissue through needle biopsy. Such studies have indicated that the amount of glycogen stored in a muscle may be considerably increased within a few days by using a diet rich in carbo- hydrates. However, an even higher glyco- gen content is achieved if the glycogen stores are first depleted with the aid of hard exercise and then kept low for some days on a protein-fat diet, before they are built up again with a carbohydrate diet. Such trickery is, of course, irrelevant for most types of sports, but if a sustained effort lasting for more than two hours is Many world-famous javelin-throwers have had to drop out of top-class 10 competitions because of damage to the elbow-joint. (Photo K. Hemzol WHO) Sports medicine An enthusiastic footballer in Burma who used to suffer from leprosy. Sport, -÷ widely used in rehabilitation programmes, helped him regain his physical condition. (Photo WHO) Young Swedish girls in training for a school competition. Sport at school favours physical well-being and is being more and more widely practised under medical supervision. (Photo WHO/E. Mandelmann) **, ' 417:71 ".1;• : 'jrill:al Iti".,„..* ' • :A. - 41....40.. r,.., *.?.... "C.`e. . ...i. .....'", required, the team doctor should be up-to-date in nutrition and dietetics. The rich armamentarium of drugs pro- mises easy success, and many sportsmen are grateful believers in the magic of the medicine-man. Doping has become a serious problem, foreign though it is to the very nature of sport. In gruelling competition the athlete must stand on his own. The strategy of the run may have been discussed the pre- vious evening with the coach and the doctor. They should have spent time together previously learning to gauge the individual performance characteristics of the athlete. How far from the goal to start the sprint, and how to respond to the sprint of others, depends also on the indi- vidual's anaerobic power, as indicated by the levels of lactic acid in his blood. In protracted events, the loss of water and salt through sweating causes a gradual dehydration, with consequent deteriora- tion of performance capacity. Replenishing the loss during competition is another subject in which the sportsman may benefit from expert planning and advice. Physical fitness may be a fashion for the playboy or for the not-so-young executive. However, for the sedentary, for the obese and for the disabled, more physical activity generally also means better health. For the human product of industrial civilization, for whom the richness of experience is a measure of the level of life, physical fitness serves as a door to active recreation. The clients of sports medicine are no longer all top athletes. Some sports doctors work in rehabilitation teams for patients who have had a myocardial infarction. Others are consulted by municipal recreation leaders in planning exercise programmes for citizens of all ages. ■ 4-- The ability of an athlete to take oxygen from the air and pump it to the muscles is a decisive factor in sports. Here the amount of oxygen actually taken up from the respired air—the aerobic power—is measured. The average aerobic power in young men is approximately 40 millilitres per kg bodyweight per minute, and in young women slightly less. (Photo Comet ©) Ron Clarke of Australia receives oxygen after -+ the 10,000-metre run at the 1968 Olympics in Mexico City in which he finished sixth. The world record holder collapsed after crossing the finishing line. (Photo L. Sirman ©)
A Soviet schoolboy works out on the punching bag. More than 20 million schoolchildren in the Soviet Union are enrolled in athletic pro- grammes. (Photo Novostil WHO) Bicycle racers start young in the Soviet Union. Boys and girls aged five and six compete on three-wheelers near Novosibirsk in Siberia. (Photo Novostil WHO) 1 SOVIET SPORTS FORMULA ACCENT ON FITNESS by Galina Tarasova The sports programme of the Soviet Union is geared not only to athletes but to millions of citizens who might other- wise lead sedentary lives. Sports societies flourish, and factories and offices maintain extensive athletic activities for their em- ployees. An array of playing-fields, swim- ming-pools and camping areas are at the disposal of the casual sportsman. It's exercise for all—but there's more to it than that. To enrol in one of the activities, the Soviet citizen must obtain a certificate that he is fit to participate in sport, and he must undergo periodic physical examina- tions. The first certificate is issued by the local doctor at the district health centre. A visit to the Moscow Physical Culture Polyclinic No. 1 reveals how the system works. A gymnastics team is being examined. The athletes have already taken various medical tests, have had X-rays, and now await examination by various specialists. Most of them are not too happy about examinations. They feel hale and hearty, and regard the visit to the health centre as an unnecessary formality. But the law requires these examinations, and the law must be observed. Before the day is out, the athletes will be examined by an ear- nose-and-throat specialist, a neuropatho- logist, an oculist, a dentist and various other specialists. On the basis of their examinations, the athletes are told whether or not they can continue training. Functional diagnostics are all-important in Soviet sports medicine. Both equipment and methods are the latest, thus enabling the doctors to measure accurately the sportsman's functional condition and fitness. While one of the gymnasts pedals the cycling ergometer, the doctor checks him with a stop-watch, and an electrocardio- gram, a heart phonogram and sphygmo- gram are recorded. When the stop-watch clicks, the young man dismounts, hops on to a bed, and the nurse attaches wires to his hands, feet and chest. Each wire leads to a different apparatus. Pulse and blood pressure are measured at time intervals to determine the restorative capacity of his organism. His oxygen consumption and exhalation of carbon dioxide are also measured. The basic examination varies for differ- ent sports. For the track athlete, a stationary run of three minutes, with the pace speeded up in the last thirty seconds, replaces the cycle ride on the ergometer. Boxers are tested with the punching bag. Swimmers swim a number of laps in the pool. Each battery of tests is designed to determine the athlete's ability to perform a specific sport. While athletes are required to take physical examinations at the health centre twice a year, they are encouraged to report there any time they do not feel well. Then, additional tests are conducted, and the patient can be hospitalized at the health centre if the doctors think it necessary. The centre has a ward with 75 beds, 50 of which are reserved for injury cases. Paradoxically, though the object of sport is to promote health, injuries are not uncommon. The surgeons at the health centres deal with all sorts of injuries and seek to get the athletes back on the playing field with a minimum of delay. When Viktor Klimenko, the European gymnastics cham- pion, tore his Achilles tendon after execu- ting a double somersault at the European championships in Madrid, he was sent to the Moscow Physical Culture Polyclinic. The surgeons were able to restore the tissue completely, and Klimenko was soon back in training. While the physical culture centres pro- vide medical services for sports-related ailments, their scope is actually much broader. Sports doctors supervise remedial treatment in hospitals, maternity homes, day-nurseries and kindergartens. They have developed new methods of treatment and rehabilitation. For example, the phy- sical exercises for myocardial infarction patients were developed by sports doctors. Sports surgeons have successfully treated osteochondrous ailments common among sportsmen, and some have built up a reputation for treating damage to the hands and feet and the spinal cord. Children come in for special attention. Sports doctors have developed special exercises for healthy children, for children with physical handicaps, and for children recovering from illnesses. In the Soviet sports programmes, children just as adults are required to take regular physical examinations. In all Soviet factories, workers must do 15
Poetry in motion on the bar: Zinarda Drujinina, one of the top women gymnasts in the Soviet Union. (Photo Novostil WHO) exercises for 5 to 10 minutes every day. This boosts productivity and cuts down industrial accidents. Instructors are trained at physical culture institutes and medical schools, where remedial gymnastics are also taught, Every Soviet doctor thus has some background in this field. At the Moscow Physical Culture Poly- clinic No. 1, many of the doctors have graduated not only from medical school, but also from the Physical Culture Insti- tute, and many hold a master's title in sports. Head doctor Lev Markov is a sports master in skiing, and his assistant, Vyacheslav Romanov, is an international sports master in mountaineering. Sports doctors are generally active athletes. Recently, the doctors at the Polyclinic made a Moscow-Leningrad ski run, co- vering 115 kilometres a day. Moscow has 12 sports health centres. Centre No. 2, located in Moscow's largest stadium, the Lenin Central in Luzhniki, is home base for the USSR national and Olympic teams. Throughout the Soviet Union there are 300 physical culture health centres and 6,000 special depart- ments attached to hospitals and other health centres. Soviet sports medicine started some 25 years ago. Initially, veteran athletes were sceptical about the training pro- grammes introduced by the sports doctors. They questioned the authority of the doctor to play a role in the selection of a team, for example. But the success of the programme has now erased these doubts. Before a football game, each team- member is required to make a total of 50 sprints of 30 and 40 metres. The doctor, applying a variety of tests, then deter- mines which players will appear in the starting line-up and which players will be in reserve. This method, devised by Valentina Kuzmina, senior scientific staff member of the USSR Physical Culture Institute, has now been adopted in several countries. The USSR Ministry of Health adminis- ters all the sports health centres. Doctors and scientists belong to the Sports Medi- cine Federation. Research involving the USSR national teams comes under the wing of Professor Nina Grayevskaya of the Federation. The Federation has committees on children's sports, injuries, mass sports, scientific research and medical control of the national and Olympic teams. Every four years the Federation holds a general conference, and every two years it holds scientific conferences. ■ Victor Leontiev, USSR gymnastics champion, displays his form. Athletes must undergo 17 periodic physical examinations before they are allowed to compete. (Photo Novostil WHO ) SUNSHINE AND SURF JOYS AND by Professor F. Pages HAZARDS The fashion of taking summer holidays by the sea, which started among the leisured classes in the industrialized coun- tries, dates from the second half of the nineteenth century. The taste for the seaside rapidly spread to other classes of society, and came to be widely accepted as a means of obtaining rest and relaxation. In countries where the high standard of living is rising even further the desire to escape and enjoy leisure constantly in- creases. So there are massive seasonal migrations, in which men and women, tired of city life and the constraints of work, flock to the beaches with their children, eager to enjoy physical and mental freedom combined with the bene- ficial effects of the sun and the sea. The seaside presents a great variety of scenery to satisfy many tastes. Some seas are blue and transparent, others are green and turbulent; shores may be constant or ever changing with the tide; there are the fine sandy beaches and rocks pounded by ocean-waves; there is the long straight coastline stretching as far as the eye can see and the indented coast where one hidden creek follows another. The sea exerts its beneficial effects be- cause of the special nature of the coastal climate; at all latitudes the local climate is influenced by the presence of a huge mass of water. One may thus speak, in broad terms, of a maritime climate, which has the following features: a characteristic state of electrical ioniz- ation of the atmosphere, rich in chlorine, iodine, and ozone; air that is pure, and free from dust and germs ; a diffuse, intense luminosity, due to reflection from the surface of the sea and a fine suspension of water particles; relatively little variation in temperature; a humidity that is often high despite a lower rainfall than inland. Conditions, of course, vary from region to region, and are modified by prevailing winds, by sea-breezes and land-breezes, by the strength, temperature, direction and force of sea currents, and by the na- ture of the coast. There is no doubt that sunshine is nowadays one of the most highly valued aspects of the maritime climate and ex- plains the preference most people have for seaside areas where it is generally possible, on account of brilliant sunshine, to bathe all the year round. In such favoured areas, new hotels and holiday villages appear along the coast and are catering each year to an increasing number of visitors. 19 Sunshine and surf Sun-bathing is not without dangers. Before the skin tans, it can burn. Sun should be taken in short doses. (Photo J. Mohr/ WHO) Paddle-boaters off the Spanish coast. An easy and amusing sport for all ages. (Photo J. Mohr/WHO) 20 The effect of sunlight on the body relates to the various components of the solar spectrum: visible radiation, as split by a prism into colours, from violet to red; and invisible radiation, both infra-red and ultra-violet. The penetrating power in- creases from the infra-red to the ultra- violet end of the spectrum. Exposure to the sun, by its effects on the circulatory system, the respiration and the nerve endings can have a beneficial effect on some of the body's major func- tions. In addition, ultra-violet rays, by converting ergosterol in the skin into vitamin D, help the body to assimilate phosphorous and calcium, which are necessary for bone growth and repair. The most obvious and fashionable effect of sunlight, however, is tanning of the skin; the brown coloration is due to an increase in melanin, which is a black pigment secreted by special cells in the skin, known as melanocytes. At the beginning of a stay by the sea, this pigmentation is preceded by two phases of redness of the skin, or erythema. The first phase, which begins immediately and is transitory, results from a rise in skin temperature due to the red and infra-red parts of the solar spectrum; the second phase is of later onset and is accompanied by desquamation (peeling). The second erythema and the pigmentation are due to separate components of the ultra-violet radiation. Sea enthusiasts are familiar with the feeling of well-being and exhilaration expe- rienced under the double caress of sun and sea. In the case of illness, a medical opinion may be necessary in deciding whether a stay by the sea is desirable, taking into account the season and the region to be visited. When one is on vacation, the physio- logical effects of the sea are accompanied by a pleasant feeling of complete detach- ment. On remote beaches there is the added sensation of being removed from one's usual surroundings, plus the plea- sures of discovering new places and people, and the delights of tasting new foods, whether in the solitude of a primitive camping site or in hotels and holiday clubs. For those who are not content with simply bathing and enjoying the sun, the sea offers a range of activities, such as swim- ming, fishing, diving, water-skiing, and sailing. Surfing and underwater archaeo- logical exploration too have their enthu- siasts. Cruises that include visits to socially attractive places combine the pleasure of the high seas with fashionable pursuits. More and more people are discovering the strange world of the under-water fisherman. (Photo L. Sirman C))
A holiday by the sea may, however, lead to disorders and accidents, which are often of a minor nature but occasionally serious. At the beginning of one's stay, particularly in the tropics, there is a risk of certain temporary upsets due to the change of climate, changes in diet, or disturbance of biological rhythms follow- ing a long journey by air. A more serious occurrence is heat-stroke, which is fa- voured by a high temperature, humidity, the absence of wind, and a stormy, over- cast sky. Climate and lack of immunity to certain germs, combined with poor hygiene in some resorts, account for the high frequency of acute gastroenteritis with diarrhoea. Young children are very susceptible to heat-stroke and digestive upsets. On the shores of the Caribbean and in Oceania there occurs an intoxication known as "ciguatera", caused by the con- sumption of fish that feed on certain toxin- containing seaweeds. There are still many resorts where hygiene leaves much to be desired. A widespread problem, which becomes more disturbing each year, is the pollution of beaches and coastal regions. The pol- lution accumulated by streams and rivers is added to the sewage and industrial waste that are discharged directly into the sea from coastal towns. In addition, dust and smoke from factories may be blown onto the coast by the prevailing winds. It may be inadvisable to bathe near large cities or industrial areas. On much-frequented beaches the high density of people also leads to pollution. The discharge of petroleum products from ships at sea, either intentionally or by accident, gives rise to the notorious black patches on the surface of the water. Radioactive wastes, dumped far out at sea, may also one day constitute a danger. The practice of sunbathing and the desire to acquire a deep tan may give rise to mishaps. Some people, who are not sufficiently careful and have too much of a good thing too soon, develop reactions that may include burns, fever, and general malaise. Others, who are incapable of becoming brown, merely achieve a per- manent redness of the skin. Abuse of sunlight is one cause of premature aging of the skin, which becomes dry, rough, and wrinkled, with patches of pigmenta- tion and varicosities; the extreme con- dition is known as "sailors's skin". These degenerative changes are seen mostly on the face and neck, while the face is often the site of skin cancers. The pigmentation caused by sunlight is occasionally irreg- ular, with paler areas that are due to dermatosis, the lesions of which act as a barrier to the sun's rays. The effect of sunlight may be increased by photosensitization phenomena, of ex- ternal or internal origin. Lipstick, make- up, and perfumes occasionally provoke the formation of local areas of pigmentation, which are both unaesthetic and persistent. This type of photosensitization is also seen with hair dyes, soaps, cleaning liquids, sulfonamide powders, and even with cer- tain medicinal creams. Various drugs act as internal sensitizers, for example certain antibiotics, sulfonamides, antihistamines, local anaesthetics, and tranquillizers; the list grows longer every year. The cuta- neous prophyrias, which are caused by a complex metabolic disorder, are mani- fested by blisters and areas of pigmentation on the face and the back of the hands. Finally, numerous pathological reactions to light come into Duke's category of "physical allergy" ; they include the ecze- mas, the urticarias, and the sunlight prurigos. Light sensitivity can be reduced by means of barrier creams, and in some cases by the administration of nicotinamide or chloroquine, a synthetic antimalarial agent. Sea-bathing involves a risk of injury or poisoning as a result of contact with animals and plants. Occasionally, a serious accident may occur due to sudden immer- sion in cold water whose temperature is much below that of the skin. This provokes a state of shock, which in some subjects is severe enough to cause loss of conscious- ness, apnoea (prolonged cessation of respiration), and, by a reflex action on the heart, cardiac arrest. If respiration begins again, it may in turn lead to drowning through secondary asphyxia. Among the various causes of hydrocution, one of the most frequent appears to be sensitivity to cold. Various disorders occasionally interfere with the pleasures of diving. Water pres- sure increases with depth, and thus reduces the volume of the gases in the body. Although the soft organs can adapt themselves to this increased pressure, the same is not true of the cavities of the bones and the facial and cranial sinuses. During a dive, there may be pains in the ears, sinuses, or teeth, haemorrhages, and possibly even rupture of the ear-drums. Because of such accidents, which occur most often during free diving with the breath held, it should be forbidden to practise this sport while suffering from an infection of the sinuses or of the ear cavity. Skin-divers carrying their own oxygen supply are especially liable to accidents of decompression, which causes gases that have become dissolved during the descent suddenly to be released into the blood and tissues in the gaseous state. This pheno- menon of gas embolism manifests itself shortly after the diver has returned to the surface, and requires immediate treatment in a special decompression chamber. Such accidents are usually caused by ignorance or carelessness on the part of the diver, in diving too deeply, remaining underwater for too long, or ascending too rapidly and failing to observe the various safety rules. The risks that can spoil the pleasure of a seaside holiday should be neither under- estimated nor exaggerated ; they can usually be avoided by physical fitness and the taking of adequate precautions. Sea- sickness, the most common mishap to occur on a boat journey, can be prevented or at least relieved by anti-emetic drugs. The safety of beaches and swimming- pools depends on the maintenance of adequate standards of hygiene, on the technical quality of the available facilities, and on the presence of qualified and adequately equipped lifeguards. ■ Sailing is increasingly popular. 23 (Photo J. Mohr/WHO) THE WATER BABIES Photo report by Paul Almasy All mammals but the monkey swim naturally from birth. For man, like the monkey, it is by no means instinctive not to sink in water. Deaths by drowning are common everywhere. In the United States alone, about 7,000 children under four drown each year. Everything possible is done to prevent such tragedies. One solution is particularly effective—teaching children to swim while they are still babies. Most large towns in Florida and California already run lessons for babies and infants. The idea has spread to Europe, where in several countries spe- cial courses are now arranged for children from 7 to 24 months. The first step is to eradicate the child's fear of the water. Next, he is taught to float. Once he can do this naturally and without fear, the teacher can move on to breathing, and arm and leg movements. Before long, the child grasps the technique and can propel himself through the water. Babies still too young to talk are taught to swim by imitation. "The method is very simple", says Catherine Grojean, moni- tress at the municipal pool in Rouen, France. "I go into the water with the child in my arms. First I raise my head a little above the water and open my mouth, then I close my mouth again and put my head under a little way. After watching me a• few times, the child understands that he must have his head out of the water to breathe in and that he must close his mouth and not breathe if his head is below the water. We repeat this until the child has mastered the movements. "Usually it takes about 15 to 20 lessons, though some children are exceptional and need less. I have a little boy of 10 months at the moment who learned to breathe properly after only 12 lessons. Since then we can't keep him out of the water! He comes with his mother and shouts with delight as soon as he sees the pool. Some- times I dive down to about seven feet with him He never swallows any water and never has the slightest trouble breathing." The child's mother should always stay close at hand during a lesson. A sudden separation, particularly in unfamiliar sur- roundings, is terrifying for very young children and leads only to tenseness and tears. It takes far longer to teach an appre- hensive or insecure child, and the results are never satisfactory. When his mother stays with him, how- ever, the child is happy and relaxed. He looks upon the teacher as his mother's friend, and trusts her accordingly. In an atmosphere of confidence he makes rapid progress. For such a child, the swimming- pool will always remain, throughout his life, a place to have fun. ■ A nine-month-old boy (above) learns to swim with the help of a grown-up. The first step is to overcome any fear of water. The youngster below has complete confidence as he swims under water on the back of his instructor. Unlike almost all mammals, man does not swim spontaneously but must learn. (Photos WHO /P. Almasy) ,_ T I HEALTH REQUIREMENTS FOR CAREFREE CAMPING by Aaron Sternfield Caravaning provides millions with the opportunity of tasting the joys of the open road, exploring the wilderness and escap- ing the humdrum monotony of life in the industrial city. As man's leisure time increases at the same time as his income, the pressure to get away from it all increases also. The sale of caravans has accordingly boomed in the last decade. The search for the sylvan retreat where a man and his family can commune with nature is one of the features of 20th- century life. Unfortunately, the caravaner often fails to get away from it all. The paradox is that people, in their rush to escape the crowded housing of the cities, often create equally crowded conditions by the seaside, in the mountains, and in the wilderness. Whether they are actually yearning to re-create the milieu they have left behind is a point for psychologists to decide. Nevertheless, the sight of caravans parked side by side in dreary rows can be as oppressing as the sight of a complex of high-rise apartment buildings—the same lack of privacy, the same impression of regimentation... The popularity of many caravaning sites has led to overcrowding and overtaxing of facilities. When large groups of people congregate in a limited area, sanitation problems can be expected to increase. Water supplies must be adequate, and they must be protected and closely watched. The entire gamut of waste dis- posal—solid and liquid—must be control- led. Protective measures must be applied by the local authorities, not only to safeguard the tourists, but to preserve the health of the local population. According to an expert committee of the Council of Europe, a caravan camp should be limited in size to 10 hectares, with a capacity of not more than 2,000 persons. The density per hectare (10,000 square metres or about 2.5 acres) should not exceed 62 caravans, or 200 persons. This works out to 50 square metres per per- son. No caravan should be closer than three metres to any other caravan or structure. Also, at least 8 per cent of the camp area should be set aside for recreational purposes. WHO, in a comprehensive study of the subject, has outlined the necessary sanitary measures for camping and caravaning sites. In selecting a site for a caravan area, drainage is an important consideration. Low marshy areas should be avoided because of possible insect problems. The site should be beyond the flight range of insects from potential breeding areas. The soil should be porous to facilitate drainage. Heavy clay soils create problems in the disposal of liquid wastes. Wooded sites, in addition to providing shade and some protection from the elements, also facilitate drainage. Excessive growths of underbrush should be destroyed to prevent infestation by harmful insects. Reptiles and poisonous plants should be removed from the grounds. A safe water supply is essential to the caravan camp. Generally, the deeper the source of water, the safer it is. Water passing through three metres of undistur- bed earth is usually free of pathogenic organisms, though viruses and chemical pollutants are not removed. Generally, ground water should be at least six metres below the surface to provide a margin of safety against its pollution. Also, wells should be located at least 15 metres from septic tanks, and twice that distance from latrines. While many caravan camps near cities are provided with modern sewerage systems and flush toilets, proper disposal of sewage and other domestic water presents a problem in wilderness sites. For the more primitive caravan sites, latrines may offer a temporary solution. But at best, their suitability for recre- ational facilities is questionable. They are difficult to maintain in a sanitary condition and are subject to misuse. Latrines should be located at least 30 metres from the nearest well and if possible at a lower location. A compromise between the flush toilet and the basic latrine is the aqua privy and water seal latrine. When properly designed and operated, it meets the basic criteria regarding health hazards. The aqua privy 26 Caravaning here, there, everywhere, in any season. (Photos Comet and L. Sirman C)) consists of a watertight tank which receives the discharge through a pipe that extends below the level of water in the tank. The solid wastes undergo anaerobic decomposition which reduces them in volume. The development of caravans with waste-holding tanks has created a public health problem. Many caravan owners are not too careful about where they dump the contents of these tanks. To alleviate this problem, low-cost caravan sanitary sta- tions have been provided in many areas. Petrol stations in some countries have installed such units as a free service. More and more caravan camps are also install- ing them. The device consists essentially of a concrete platform with a drain and flushing hose. The drain is protected by a foot-operated, self-closing cover which seals the inlet when not in use. The caravan is placed over the platform; the drain hose is connected to the sewer; and the tank is drained. Refuse handling and disposal is another major consideration in the caravan site. Improper refuse practices contribute to the multiplication of rodents and insects. Strict surveillance of the area must be maintained to ensure placing of refuse in the containers provided for this purpose. 27 A safe water supply is essential. The ground water at this Italian caravan site is a safe six metres below the surface. (Photo Publifotol WHO) Rigid containers should be of durable, watertight, rust-resistant, non-absorbent and easily cleanable materials. Plastic containers, which are being used more and more, have the advantage of reducing noise. Refuse containers should be located no more than 45 metres from each caravan site. Each container should have a capacity of between 75 and 110 litres. A facility for washing containers should be located centrally. If possible, containers should be steamed after cleaning. The use of dis- posable plastic bags or paper liners is recommended, since this greatly reduces the need for cleaning the containers. Where a collection service for waste is not available, the caravan site owner can dispose of waste by incineration, sanitary landfill or trucking to an approved dis- posal site. Because of the danger of air pollution, the incinerator should be placed downwind from the caravan site. Control devices and careful incineration operation practices can reduce air pollution. The sanitary landfill method requires spreading and compacting of the refuse in thin layers of not more than 45 to 60 cen- timetres. The last layer should be cover- ed at the end of the day by a 15-cen- timetre layer of earth. The success of insect and rodent control measures on caravan sites is largely depen- dent on prior establishment of a basic sanitation and environmental programme. For example, the draining or filling of mosquito breeding areas will eliminate the mosquito problem. Chemicals can be used as larvicides and adulticides. Poison baits can be used for rodent control. In pest control it is well to use a combination of physical, biological and educational meas- ures which will give the best results with the least amount of a selective chemical poison and a minimum hazard to man, domestic animals and wildlife. Many caravan sites are located near streams, rivers, lakes, tidal areas or the sea. The quality of the water A normally beyond the control of the site operator. Therefore, before any bathing beach is opened to the public, certain steps must be taken. These include a sanitary survey of the area, comprising identification of pollution sources, water circulation and dilution. The bacteriological, physical and chemical quality of the water should be studied. Most of the health requirements for caravan sites do not entail large expen- ditures of money, and most of them are relatively simple to put into force. A little money and effort put into caravan sites today will pay major health dividends tomorrow and increase the enjoyment of holidaymakers. ■ 28 This kind of sylvan retreat is increasingly difficult to find. (Photo Comet C)) Public authorities have a clear responsibility for "holiday slums", becoming more and more numerous. (Photo Publifotol WHO / ‘st: 7 , - s , '• • Out of two million Indians with infectious tuberculosis, only about five per cent fail to recognize the symptoms. (Photo WHO/A. Kochar) AROUND THE WORLD Massive health outlay in Malaysia Health development projects under the Second Malaysia Plan will cost the country 230,660,000 Malaysian dollars (about US$ 82,000,000). Mr. S.Y. Lee, Minister of Health, told delegates to the 25th World Health Assembly in Geneva that his government believes good health to be the birthright of every Malaysian and the basis of economic productivity. Expansion of rural and urban medical services over the period 1971-75 takes high priority in Malaysia's national and economic devel- opment plan. In Malaysia, communicable diseases are still a major cause of illness and death. With WHO assistance, the Health Ministry is building up an epidemiological service to prevent or at least attenuate major epidemics. General practitioners and hos- pital doctors throughout the country will form the backbone of this national disease intelligence network. Rapid industrialization, land spoilage by mining, deforestation for agricultural expansion, widespread use of fertilizers and pesticides, urbanization and increas- ing motorized transportation—each of these is contributing to environmental pollution in Malaysia. Aware of the risks and anxious to minimize the effects, the government plans a central unit for pol- lution control and has requested expert advice from WHO consultants. India fights the white plague India, with its population of over 550 million, has about two million infec- tious cases of TB. Under ideal conditions, 90 per cent could be cured by modern drug treatment in about a year. The problem is to reach the large number of men, women and children who live scattered through the remoter areas of India. At least 190 million of them have been infected with TB at some time. At the moment, an estimated two million are actively spreading TB in the 3,000 towns and urban areas and 600,000 villages. Though a communicable disease, tuber- culosis is not so highly infectious as small- pox, cholera or measles. Simple sputum tests can detect it. With modern drugs it can be successfully treated. BCG vaccina- tion can prevent it. Ignorance of the disease is less than was supposed. Only five per cent of infectious TB patients are unaware of any symptoms. The majority are aware of their illness and 50 per cent will receive treatment at one time or another. With conventional methods, no more than 10 per cent of India's population could be treated, mostly in the cities. The National Tuberculosis Institute in Ban- galore and the Chemotherapy Centre in Madras, in collaboration with wHo and UNICEF, have pioneered simple methods which make diagnosis and treatment possible everywhere. If a patient admits to having a cough for more than three weeks, his doctor can order a sputum test on the spot. This quick test reveals most contagious cases. TB can now be treated at home, provided the patient takes his drugs regularly. BCG vaccination holds promise for the future. It can cut down the incidence of TB by 80 per cent. wHo helped to develop BCG vaccine production in India, due to reach a height of 15 million doses in 1972. Production will be stepped up to a target of 30 million doses in 1973. Freeze-dried vaccine is the most effective under tropical conditions. India has a nation-wide TB programme rivalled by few other developing countries. In its 340 districts, 247 programmes are in operation. The National Tuberculosis Institute intends to offer to the entire population case-finding, treatment, BCG vaccination and prevention. Health evolution in Malta Malta has succeeded in eliminating practically all of the traditional infectious diseases from its territory. In the last few 30 „ WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to World Health as follows: US$* £ • Sw. fr.* One Year 5.- 1.20 12.— Two Years 8. 2.20 22.— Three Years 10. 3.— 30.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: • or equivalent in local currency. years, not a single case has been recorded of polio, diphtheria or any of the quaran- tinable diseases. Infant deaths have fallen to about 25 per 1,000 live births, from almost 100 per 1,000 only twenty years ago. The other side of the coin is that the mortality rate for cancer and cardio- vascular diseases is slowly but steadily rising, as in other European countries. Together, these two account for about 66 per cent of all deaths. Diabetes is more common here than in any other part of WHO's European region. These facts and figures were cited by Dr. A. Cuschieri, Chief Government Medical Officer, speaking at the 25th World Health Assembly held in Geneva in May. Better health and medical care have resulted in a higher percentage of older and handicapped people in the population, So far as possible, both groups are looked after at home. Malta and its neighbouring islands are experiencing the effects of increased industrialization, including prob- lems of occupational health. Legislation is being enacted to protect the health of workers, and in the field of hygiene new laws are before the Maltese parliament to control food and drugs and to ensure water safety standards. Egypt international In 1971, over 250 non-Egyptian phy- sicians graduated from Egyptian univer- sities. They were of 20 different nationa- lities and constituted 12 per cent of all the graduates of that year. Over 200 non- Egyptian health workers have also been trained in Egyptian training centres and institutes in the last two years. Some of these non-Egyptian trainees studied with the aid of WHO fellowships. Since 1970, the Egyptian authorities have seconded more than 1,500 physicians and 2,000 other health staff to 35 Arab, African and Asian states. They are help- ing energetically to build up the health services of these countries. At the request of various governments, Egypt has donated cholera, smallpox and other vaccines. The amount of cholera vaccine alone donated by Egypt over the last two years has exceeded 42 million doses. ■ Football is all the rage in this village in Zambia. (Photo WHO/J. Mohr)