WHO Regional Office for the Eastern Mediterranean
1968-69
WORID HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN
ENR0/69/725
ANNUAL REPORT
of the
REGIONAL DIREG'TOR
to the
NINETEENTH SESSION OF '!HE REGIONAL COMMITI'EE
1 July 1968 - 30 June 1969
EM/RC19/2
TABIE OF CONTENTS
INTRODUCTION ••••••• . . . . . . . . . . . . . . . . . . THE REGIONAL COMMITTEE FOR THE EASTERN MEDITERRANEAN EIGHTEENTH SESSION •••••••••••••••
PART I - GENERAL REVIEW
I ADVISORY AND TECHNICAL SERVICES
1. EDUCATION AND TRAINING
. . . . .
Medical Education Fellowships Programme . . . . . . . . . .
2 • . MALARIA .ERADICATION
.Stat1..:.s of Malaria Eradication Activities and General Progress • • • • • • • • Training and Fellowships •••••• Staffing and Financing ••••••• Technical .Problems and Research
. . . . . . Co-ordination
·Future Prospects . . . . . . . . .
. . . . . . . . . . . . . 3. ·cOMMUNICABIE DISEASES
Viral Diseases (Smallpox - Conrnunicable Eye Diseases - Yellow Fever) •••••••••• Bacterial Diseases (Tuberculosis - Leprosy - Gastro-enteritis - Cerebrospinal Meningitis -
. Cholera) . . . . . . . . . . . . • . . • • • • • Parasitic .Diseases((Schistosomiasis)
.Epidemiol ogical Surveillance •••••••••••• Meat Hygiene ••••••••••••
4. PUBLIC HEALTH .SERVICES
·Public Aealth.Administration (General - Rural "Health) . • • • ••••.••• Health Laboratory Services • • • Nursing • • • • • • • • • • • • Heaith Education •••••••••••••• Maternal and Child Health •••• Pharmacy and Medical Stores · Vi tal and Health Statistics
. •. . .
. •. . .
EM;RC19/2 page i
19
23 27
29 32 34 35 38 41
44
51 57 58 59
6o 65 68 71 74 75 77
EM;RC19/2 page ii
5. HEALTH PROI'ECTI ON AND PROMOTI ON
Capcer Control • • . • Radi ation Heal th . Nutrition Occupational Health Rehabilitat ion.
6 . ENVIRONMENTAL HEALTH AND COMMUNITY WATER SUPPLIES .
II
III
PUBLIC INFORMATI ON
ADMINISTRATION AND FINANCE
General. Personnel. Budget and Finance Medical Supplies and Equipment
PART II - PROJECT LIST
FOREWORD . . . . . ..
ANNEX
Cyprus Ethiopia French Territory of the Afars and the Issas . Iran Iraq Isr ael Jordan Kuwait Lebanon . Libya • Pakistan Qatar . Saudi Arabia Somalia .
.. ..
Southern Yemen (People' s Republic of) Sudan. Syrian Arab Republ ic Tunisia · . United Arab Republ i c Yemen Arab Republic •. Inter-Country Projects
Agreements signed between 1 July 1968 and 30 June 1969
. .
.
.
79 81 84 86 87
92
96 97 98 99
102
103 104 111 112 121 128 131 137 138 142 153 165 166 170 176 179 189 195 200 207 210
INTRODUCTION
UUlUU fll U H uu
I_ m rnn111m1 m
18TH SESSION OF THE W HO REGIONAL COMMITTEE
Ill u i urn Ill uuh ·nm Ill uuu.uu:u 1111 ,111,zi; , ~i ,· ,2s
I I m
A group of country rep reser.tat1ves at Sub-Committee A of the WHO Reg io nal Comm ittee in Nicosia. wit h th e Acting Pres iden t of t he Repu blic . The meeting was pres ided over by Dr. V. Vassilo poulos, Director-General of Hea lt h (Cyp rus), with Dr. Morshed, Und er-Secretary of State (Iran ), and Dr . A. Nabilsi, Under-Secretary of State (Jordan) , acting a1; Vice-Cha irmen .
< Right) H. E. Dr. Abdou Sal la m, Minister of Public Health 1UAR), visited the WHO-assisted schistoso miasis contro l project in _. t he Beheira Province. He. is seen here discussing a technical poin t w ith Dr. A. H. Taba, WHO Regiona l Di rector, and experts assig ned to the project.
(Left) Pictured with H.I.M. Empe ror Hai le Se lassie are participants to t he Seminar on Nut ri tion Problems in the W eaning Period , spon sored by WHO in Addis A baba from 3-15 March : 969.
Lead ing paediatricians, child experts and nutrition ists fro m 14 countr ies attend ed the Semi nar.
- (Right ) A Seminar on A11 Pol lution , With part icular reference to conditions in the Eastern Med ite rranean Region, was held in Tehe ran, fro m 21-29Aprtl 1969, under WHO sponsorship. Doctors, san itary engineers and publ ic health specialists from 11 cou ntries attended th e Seminar.
HO-SPONSORED MEETING S IN 1968-69
Senior public he;ilth administra cors from 19 countries attended the Seminar on Health Serv ices in Rural Areas, held in Tun is from 7 to 16 October 1968. Parti ci pancs are photographed here w ith H. E. Mr. Hedi Khefacha, Minister of Health (Tunisia) .
1 Right 1 H. E. Mr. Omar Jaouda, Minister of Public Health ( Libya), opening the Benghazi School of Nursing on the occasion of the inauguration ceremony of th e nursing education project.
Medical faculty deans from Iran, Iraq , Lebano n, Libya. Pakistan, Sudan Syria. Tu nis ia, Turkey and the United Arab Republic attended the Special Group Meeting on Med ical Education held in Khartoum , from 9 -13 Decem ber 1968, under WHO sponsorship. Particioants are oictured with the thPn PresiclPnt of thP RPn11 hl ic- :1nri Mini<tPr r.f HP~lrh
INTRODUCTION
In July 1969, our Regional organization completes its first twenty
years 01 activity. This ,·;oulct appear to be an appropriate time to sum
up what has been achieved 2..nd the progress made against the background
of the problems met. This, too 1 is the moment to assess the unresolved
issues facing us, many of them ~evealed in our past twenty yearsi en
deavours, with no illusion as to the magnitude of the tasks ahead.
The twelve countries that together in July 1949 set up our regional
co-operativ:e for health, have since been joined by nine others, bringing
WH01 s membership in thi3 -Region to twenty-one. . They have come a
long way "toward::. i:nternational co--operation in the epic fight against
diseas·e.- · · They· have joined in health-promoting and .training projects·,
which hold promise of lifting this Region to new heights of well-being·.
A:pd the past .twenty yea;rs I achievements, shared in many instances with , ,, . . . . . ..
W¥.O, bear witness to our Region1_s capacity to make furt,her headw<1:Y:•.
Over 600 projects applying modern scientific and control methods 'have b~e~ launched with WHO assistar..ce in remote outposts, as ~ell as .in
te·erriing ·metropolitan a::-eas of the Region; 102 are now in operation and
119 a :re at th~' -plart.i-1in:g s~age; embracing a wide range of activities..- 0£.Tom
the fight against communicable diseases at the outset to -studies -ofhea,lth
hazards stemming from indust:daEz~tion.
A great deal has been achie·.red through the 120 inter-country projects
sponsored by: WHO- in the past twenty years. · They have proved excellent
m 'edia "f&r ·co-ordination 6£ activities · and close co-operation between · ·
national health services in the Region , Similarly, the 220 inter-regional
EM/RC1·9./2 page 4
projects, mostly seminars and study courses, have paved the way for
a more enlightened and co-ordinated approach to our various health
problems.
Indeed, with the changing needs and priorities of countries undergoing
deep social and economic evolutions, the Organization has evolved and
oriented _its programme over the years in a number of directions.
When the Organization set out to assist its member countries twenty
years .ago, some were practically starting from scratch, barely coping
with their most pressing problems. Others had already a legacy of
public .health institutions, whose potential was however far from meeting
their needs. Most of them were confronted with a stubborn set of age-
old environmental problems which generally called for a grass roots
approach.
The technical means were meagre, the medical manpower scarce, and
knowledge of the local disease patterns was inadequate. Our early health
projects were mostly an exercise in the a rt of the possible. They saw
WHO advisers endeavouring to introduce practical know-how into a critical
situation and work out methods attuned to local needs I aims and resources.
Some of our pioneer projects, by setting the stage for concerted attack
against disease, have been paying off very handsomely indeed. But the
comp:i;-ehensive long-term projects, which now make up the core of our
work, were still in the planning stage, awaiting the required data about
their feasibility and training of more staff to run them properly.
_As._time went by - and as countries further built up their public health
infrastructure - an increasing knowledge and degree of sophistication about
EM/RC19/2 page S
public health methods led to a greater appreciation of the value of concomi
tantly planned activities, preferably on a long-range basis. The early,
piecemeal efforts to meet the most immediate health needs graclually g'avg
way to a co-ordinated public health approach, closely integrated in the
overall socio-economic development.
* Ano_ther significant trend is the increasing recognition among health
plann~rs .of _the need for investment in human resources.
Es.ti'mai:es · of manpower needs are mainly derived from economic and
social ta'rgets fixed by the planners and the productivity hypothes.is, u11der
lying the targets. Thus planners determine the projection of health ma,n
power need by sections, by occupational category and by educational. le.vel.
Manpower planning requires constant checking and adjustments in view
of a large number of assumptions which have to be made in order to arrive
at a realistic ·long, middle and short-term plan projections.
This adjustment will require a comprehensive understanding of the
projected quantity and quality of health services and the role of physicians
and of other professional personnel therein. In other words, the plans
for preparation of physicians and of other categories of personnel should
be designed to go along with goals and priorities established for the
solution of health problems in the context of the national plan for socio ..
econorriit: 'development. This trend .has gained steadily in th_e Region
and £i!teim countries have developed plans with comprehensive health
components. ·
EM/RC19/2 page 6
The past twenty years I record reflects the commendable efforts of
individual countries to make up their shortage of qualified _personnel.
Few had medical schools in the late _forties, most count:ries. having to
rely on faculties abroad for the trrining of their physicians~ And this
dependence on foreign teac hing institutions also applied to a . number of
other professional categories.
The situation, since then, has greatly improved in this Region.
Medical schools have increased in number from twelve to thirty-eight; . . .. . . .
pharmacy schools from sb/ to eighteen; dentistry sc.ho~ls from four to
eleven; nursing schools from ten to 144; sanitary' engineering schools
and departments from two to ·seven. Scores bf other training institutions
have been set up to produce auxilia,ry health woi-kers ranging from medical
_assistants to village midwives.-
This Region recorded an average; fourfold Increase ii{ iiiedicaf-itid ·
health manpower during the past·two-deta:des, ·and all its countries,· de- ··
spite a swift population growth, m·ana-ged to raise their ~octbri i>oJuiati'~n
ratios - the "regional r . .-10ds;" now b~ing_ one .p,h,y,s ici~p to. 4. ,5:<?P people,
compared with one tq 10 GOO tw~nty y~~-r~; ~go . .
Such p17ogres s, however., doe,s not 'afford any leas eriing of eff-6rts ~
Most Eastern Medit.errarrean countr0i e·s are still in dire need of m~;di<:al men - witness the wide range ·in the ; d6ctor/ population ·ratios: · 'f~om :400
inhabitants . per phys-ician in one country r tlei'ey cliinb ' critically fo 'w~il
above 10 000 people per doctor in c-ou:ntries coveTing twqJ:hirds ofithe
Region's population. Furthermore ; 'th~re is tfe.rious maldistributioil ci!'
general practitioners and specialists, with inequitable concentratlon in '·
urban areas.
EM/RC19/2 page 7
The shortage of qualified nurses is just as critical in most countries,
the ratios widely varyi ng from 1 000 to 20 OOG inhabitants per nurse; and
the dearth of auxiliary workers is no less serious in many categories of
health staff. Our educational endeavours, fruitful as they were, have but
partly filled this vacuum.
Meanwhile, the demand for medical care grows larger and louder
every day, often at the cost of disease prevention. It is stimulated in
some countries by poverty and m a lnutrition, in others by wealth and wel
fare. It is growing everywhe re as more rural population groups, long
left uncovered, are seeking medical assistance. And the demand, ac.cen-
tuated as it is by an onrushing population pressure, puts a tremendous
strain on health services, still mostly understaffed.
* ATJ. evaluation of the present health situation of the Eastern Mediterra
nean countries indicates that educational achievements of the past twenty
years, though commendable in scope, do not fully meet their actual need
for medical and public health workers.
Some 3 200 doctors are produc ed annually by their thirty-eight medical
· schools, but sixty more schools would be required to satisfy the present
need·s, according to the minimum g enerally acc e pted target of one school
for every two to three million population. And 160 more schools should
be added to the existing one s within the next thirty-odd years, if this
target should be met by the year 2 000, when our Region's population is
expected to number 500 m i llion people - just twice the present figure.
With a new sense of realism developing among health leaders, fresh
approaches to the shortag e of phys icians a re bei'ng worked out. Since in
most Eastern Mediterranean countrie s ther e is no possibility, for at least
EM/RC19/2 page 8
a generation, of producing enough physicians to carry out their traditional
£:unctions, these duties must be reallocated. Many activities, regarded '
as the s ·ole responsibility of the physicians, can well be performed by
auxilia.ry ,workers, if .they are suitably trained and adequately supervised.
Greater use is therefore being made, in many outlying areas, of sub
professional workers .
:)c
Looking back at our outstanding endeavours to produce suitably trained
"auxiliaries", one must acknowledge the considerable impact achieved by
pioneer projects such as the Health ::::entre and Training School in Sana'a
or the Health College and Training Centre in Gondar. Both projects were
set up with the aim of producing, in countries critically short of health
staff, a nucleus of well-trained sub-professional workers •
. . The Sana'a Centre, by providing Yemen with·its first batc:hes of as-sist
ant nurses, sanitarians and laboratory technicians, has already made
startling . changes in the life of the local population. Similarly, but on a
wider scale, the Gondar College has. had a considerable, impact upon
Ethiopian health services since its establishment, fifteen years ago. It . . . . .
has turned out over 500 health officers, community nurses, and _sanitarians,
now assigned to som e seventy health centreG covering the whole country •
. - These are .but two out of the many -i~ HC-supported endeavours to meet·
a widespread, .and often -overwhelming need for a suitable auxiliary mari
pow.~r,. . The.: a~ signment of medical assistants in the Ethiopian cotmtryi:H-de
and the -~ppearance of skilled nurses in Y emen 1s uplands are eve1itS' just 'as
significant as the mounting clamour for admission to medical facult~~s.jn ' ·''
Iran, Pakistan and the United Arab Repubhc. They _;reflect. th,e va4t_ .
EM/RCl ,/z page 'J ·
• conceptual and social changes which have gone hand in hand with the
Governments I efforts to build up their medical and health task force.
*
Particular attention is being given to the key-issue of medical training,
with the growing awareness among medical educators that the teaching
.programmes must be adapted to local conditions, and that medicine should
be taught with an eye towards the community students are to serve.
Where doctors should be educated to meet the present needs is a
question of burning concern to health policy-makers. ~ducation abroad
is increasingly regarded as a mixed blessing since many foreign-trained
doctors are virtually lost to their own countries. This outflow of medical
men is actually reaching critical proportions. It is bound to increase ina.
years ahead unless appropriate steps are taken by the countries concerned.
Their health leaders are therefore investigating ways and means to check
this "brain .drain". At lea.st part of the advance.cl medical training should
be provided doI'n:estically. nearer to the community to be served and it is
generally considered that the local provision of better research oppor~
tunitie.s and improved empl~yment conditions would alleviate this loss of
mecHcal manpower. Medic.al educators therefore strongly advocate the
local trai~iI).~ of doctors, and our Organization is promoting this . concept.
*
WH01s cont~ibution to thE: past twenty years I educational drive took
many forms: advisory se·rvices, assignment of teachers to educational
institutio·ns, training ·of teaching staff through the granting of fellowships,
sponsoring of study ~ourses and seminars. WH01 s interest in education
and training has led''.the Organization to extend more assistance in.this ·
EM/RC19/Z page ~·10
general area than in any other and is reflected in the numerous educational
projects it has sponsored in the past twenty years.
Every third project waa centered on training, a.nd a number of field
projects with other direct objectives have had a sizable educational
element. WHO' s continued policy along such lines is evidenced by its
current assignment list; out of the 275 field staff employed by the Organi
zation in this Region, no less than 110 hold teaching posts.
WHO is also actively contributing, through its fellowship programme,
to the advanced training abroad of the teaching staff of medical faculties,_
nursing schools and schools of public health: seventy-two professors and
teachers from twelve countries !;:,.st year improved their knowle_dge on
WHO grants for specialized study - yet another step ahead to staff ade
_qua_tely this Region's expanding schools of higher learning.
* Medical education was looked at afresh, in the light of the regional
health picture, at the 1962 conference conv.ened by WHO in Teheran - a
major milestone in the regional countries' painstaking efforts to put ·
medical training on the Tight track. The subsequent meetings convened
in Alexandria, Baghd2.d and .Khartoum, assessed the practical steps taken
by individll<'~l countrie s to turn out more, .::.nd better trained, physicians.
They also worked out realistic approaches to the quantitative-qualitative
dilemma confronting this !legion's hard-pressed medical schools.
These WHO-sponsored "brain trust" meetings also paved the· way for
the establishment of the Association of Medical Schools in the Middle Ea.st,
whose constitution was signed le.st year .in Khartoum by the -deans of thirty-
four medical faculties in the area. The Association is expected to con-
tribute much towards clos e r ::ollabor2. tion. ~nd exchange of views between
EM/RC19/2 page 11
medical schools of the <1.rea. With its broad membership, it is bound to
foster an extensive cross-fertilization of expert views on medical educa
tion patterns and priorities, promote the exchange of teaching personnel
and provide liaison with similar professional associations throughout the
world.
Another Association, proposed to be established later this year, is
that of schools of public health of this and neighbouring regions. Once
formed, this body should give a sizable impetus to the teaching and
practice of public health in its widest sense and to its adapt:,;ation to com
munity health .problems and needs.
* '
Contributing much to our educational drive was the WHO fellowship
programme, geared to the improvement of understaffed health services.
From thirty-two -in 1949, the annual number of grants rose to 495 last
year; 'bringing to 4 416 the total number of fellowships already awarded
by WHO to students from its regional member states.
In the past ten years, they have been awarded 3 227 fellowships - , . : : , : ·_
nearly three times as many as in the previous decade. Starting from a
modest $113 000 in 1949, the Organization expanded its annual subsidy
for fellowships to over $1. 5 million in 1968 - including the allocation from
UNDP funds.
As time went by, subjects eligible for WHO awards were also consider
ably diversified, · from a few basic fields to a wide array of over thirty
different disciplines ranging from anaesthesiology to zoonoses. This
pr~liferation of study subjects ·is symptomatic of the V.:idely-felt need for
expertise in expanding health and new medical fields.
EM/RCl9/i page 12
Another inter.:i s t ine trend, in ;'!, Region where the career drive is
catching up young we;men 2.s w e ll a s men, is the growing number of
female students an-wng ViHO idlons, the percentage rising from less
than five per cent in th~ e.:ir l y fifties to more than twenty per cent now.
This emergence c:f \".•o:.nen is r1lso ,.vitnessed in several medical faculties,
where they no'.v 2.ccour-t for up to fourteen per cent of student body.
The progress achieved in dealing with health problems in the Region
is naturally uneven, c:.nd gains achieved are clouded by new health hazards
concomitant with :?.·o.pid economic development and social evolution. But
the overall picture, a.s the Eastern lviediterranean co-operative effort
sponsored by WHO enter-s its t:~i:,:d decade, is one of sufficient progress
and preparedness to meet new health challenges.
In the field 0£ Mala ri.:: Er<l.dic,3.tion, advances are made, despite
technical obstacles and administrative difficulties. The phased eradica-
tion drive, backed b y;:;, task fo !'ce of 20 000 professionals and auxiliaries,
now protects an estimated 158 million people, as against sixty-seven
million barely fiv e y ea:rG :1.g o. T he once malaria-ridden Middle East is
virtually free from t h 2 disec:. s e in an area stretching from the Mediterra-
nean to the ,C<-~fpi:-- •.1. But t:.,e ":! radication campaign, as it approaches its
final stage.s, i G !10t 2.ll smooth sailing, and malaria could return if vigi►.
lance were slackened.
·skilled e·pidcmiol ogicc"..l sta£f are in short supply, measures to trac_e
residual toci o:.· irnported. cases are often inadequate, and eradication
work in some areas is slowed down by mosquito resistance to hydrocarbon
insecticides. The search for alternative approaches, including the use
EM/RC19/Z page 13
of organo-phosphoru::, i ::-,secticides , holds nevertheless great hopes of
overcoming the mosquito resistance in problem areas.
Smallpox is anoth~r disease accounting for increased co-ordinated
efforts towards its e radication. WHO assistance to this programme is
quite sizable, especially c:. s import2.nt endemic foci still persist in certain
areas of the Region, The sole use of fr eeze-dried vaccine is being re-
commended by WHO and l;:,.rge quantities have been supplied to several
countries as requir ed.
To facilitate laboratory diagnosis of smallpox, which is of the utmost
importance in non-endemic countries, the establishment of reference
laboratories is in the planning stage. After undergoing proper training,
laboratory technicians will he able to perform the most important tests
for laboratory diagnosis of suspected cases of smallpox, i.e. microscopic
smear examination, precipitation-in-gel test, and definite identification
of the disease through virus isolation on the chorio-allantoic membrane
of chiek embryo. Some laboratory technicians from countries in this
Region have alrea dy been trained in this respect, and more training
courses are being plc.nned,
*
The development of laboratory services in most countries of this
Region has been reb..tively slow and would need particular attention. The
tremendous advances of. modern medicine have resulted in an ever increas
ing demand for vital diagnostic tests and highly specialized methodology
in public health investigations. To-day the complexities of laboratory
science require trained staff with adequate knowledge and skill to carry
EM/RC19/2 page 14
out the intri cate a naly s es which ofte n spell life or d eath to the patients.
Consequently, t e -..:hnica l p e r sonnel r,atul"a lly r ema in the most important
single factor fo ;,._• t h e d ~v2l opmen t of labor.:i.tory s e rvices.
Another important fac t o ;:- i s t h e a vaila b i lity of the necessary equipment
and supplies. The n ew i nstrurnen t s now available allow for large degree
of automation, wh ich not only handle the work with a n accuracy and preci
sion equal or g r e a t e r tha 11 those ob taine d unde r the best hitherto prevail-
ing routine but sa-,es m a npowe r . Any laboratory that makes large
numbers of repetit ive tit r a t i o:is w ill find its work simplified, and its
staff fre e d for otb.ar w orks .
The importanc e of a nima1.s £or i :1°;~ ::-tig ations a nd research should be
stressed. Many s t udie s now r C'q_u ire g r eat numbers of a n imals, which in
some instances shou ld be of a s p e cia l s p ecie s , breed and ge:.1.otype.
Methodolog y and t e chnique s a r e also e s s ential for laboratory progress
and the most simple and reliable t ech n iques s hould be resorted to and
adopte d as standards . The n ew m e t h odolog y in compone nt with blood
banking reduc e s h azards a nd s aves blood f or further utilization, since
only one component of t h e "vhol e b l ood is u sed , w hile the others could be
kept for transius io r: t o c ase s whe r e this cmnpone nt is not deficient.
Rigid b i olog i c a l cont rol, especi 2.lly va ccine control should receive
special attention. A ny a ttemp t t o a s sure the competency of laboratory
work must include a syste m of p roficie ~cy testing with a l egal authority
_t:o. enforce t he co1· r ect ion of e r 1·ors .
It i s e x p e cted that our as sistanc e towards promotion of laboratory
services w ill expand in !'u.t ur e yea:..· s .
*
EM/~<:;19/2 page· 15 .
WHO, with its wide array of sc~_entific monitoring and assistance
devices, has been instrumental in much research work, ai~ing at
improved disease control. A variety of public health issues that need
an international approach have been investigated with the support of WHO,
which has already sponsor ed ove r fifty research activities in the Regiol\. . .
Applied research in the field of nutrition has been producing useful findings.
Mental disorders are being gauged in their local context.
childhood and youth are b e ing tackled with greater success.
Diseases of ... -. '
. The struggle
against degenerative diseases, diabet_es, cardio-vascular diseases an~ : . • . I . .
cancer is being stepped up. P.adiat ion medicine, with its considerable
potentialities, moves a:!lead. Compnter science, which should lead to a
more effective use of hea.lth, da~a , m ;:-.npower and !"esources, is being
explored.
The ''growing pains II of_ c_ountries caught up by a frantic urge to
modernize their social and economic structure are _also being _ increasingly
investigated along medico-social lines. The list includes pollution of air,
soil and ~ater; industrialization _.;ith its occupational hazards; urbaniza
tion with its possible squalor,· disease and social maladjustment; the
disruption of tr.ibal life and its impact on m e ntal health.
Industrialization is shifting hug<= rural populations into teem_ing cities. . .
The trallmatic_ en.counte.r 9£ rural youths with new urban struct_ure, or the
maladjustment of newly-settled nomads to c;:ity ways and indust_rial work, . .
are already}eatures of_ concern to h ealth planners. So swift is· the pace
of change that, in industria lizing areas, the ev eryday ,life.,<?.~ r??,an has
changed more in the past two decades than it did in the previous two
centuries. And the change on the medical-care horizon has been corres
pondingly great.
EM/RCl 9/2 page 16
As their problems pile up, the Eastern Mediterranean countries are
confronted by a demographic growth which, at its present explosive rate,
is expected to add within the next thirty years another 2SO million to their
multitudes. The task awaiting them, as they are passing the twenty-year
mark of ,their concerted he<1.lth drive, is obviously a demanding one. They
will have to continue to strengthen their medical task force to enable them
to cope with the tremendous quantitative and qualitative health needs in our
era of population explosion and quickened scientific progress.
WHO has therefore stepped, in recent years, into new areas of health
action or research for which it appeared, and proved to be, a suitable in-
centive. It moved into fields so far somewhat unexplored in this Region,
constantly reassessing its programme to assure that it is in line with
current needs, and that it retains enoug h flexibility to permit adjustments
to the changing scene. And it has steadily broadened over the years the
scope of its assistance, as new problems came to the fore.
Our 1969-1970 agenda of seminars and study courses in the Region
include such varied top ic c ::1. s air pollution, quality control nf pharma-_
ceutical preparations, cytopathology, human reproduction and health
aspects of family planning, virology, health and manpower planning,
· medical rehabilitation, medical, pharmaceutical and dental education,
coronary heart diseases, cancer control, place of psychiatry in medical
education, health problems of rapid urbanization. These indicate WHO I s
determination to meet the emerging health needs as its regional member
states are rapidly advancing in the mainstream of modern life.
*
EM/RC19/2 page 1 7
In the foregoing introductory remarks, I have attempted to review the
main health developments in the Region, with some emphasis on planning
and training of needed manpower. I have also briefly touched upon some
of the health problems to be faced in the future.
Time and space do not permit me to elaborate but this brief review,
coupled with the following main chapter of the report, is hoped to provide
background for examination by the Regional Committee and discussion by
the representatives of Member States. I look forward to their advice
and guidance which I am sure will prove most useful to our future work
in the Region.
After having finalized this Report, the Twenty-second World Health
Assembly approved, on Afghan Government 1s request, the transfer of
Afghanistan to the Eastern Mediterranean Region of WHO. I would like to
extend a hearty welcome to our new Member and I am confident that their
participation in our work will prove profitable to the health programme in
the Region.
- ILESTONES TO HEALTH A pictorial record of twenty years' wo rk in th e WHO Eastern Mediterranean Reg io n
Towa rds a prompt recovery lT uni si a) .
,,:~~
{ b
Invest igat ing health conditions at ah,; Qalyub pi lo t projec:r"';
-
DIAGNOSING BASIC HEAL TH NEEDS
These pictures taken in the early Fifties bri ng on memo ries of a young and just settli ng WHO, whc se first aim was to investigate the bas ic hea lth nee ds of its re gional par t ne rs. Pioneer activiti es co set the stage for a sound attack o n disease included fie ld studies of envi ronme ntal conditions and sample surveys of prevalent ailments. Such fac t-find i;,g projects, t h rough the valuable set of data yiel ded, paved the way to long- ra nge pro gramming.
Screeni ng tubercu los is suspects ( UAR).
Diagnosing eye d iseases (Sudan) .
Assessing malaria prevalence (Iran ).
J ( I ran )
(Tunisia) ( Suda1
I .,
I
-..JEW CONTINGENTS =oR MEDICAL CARE
From an anatomy course - ( left) to laboratory work • and beds ide traini ng
(below); from the chal lenges of th e operat ing room ( right) t o appren t iceship in obstetrics tomorrow 's doct o rs must be prepared to treat the"whole pat ient" and meet t he growing req uirements of medical t echnology in a changing Region.
Giving an injection against rab ies in a dressing station.
Medical care is skilfu i ly provided by health assist an ts in wide ou tlying areas of the Sudan.
MEDICAL PIONEERS AT W ORK
A milestone in th e past twen ty years' efforts to provide suitable med ,cal care was t he assignment, in many out lyi ng areas, of medica l assistants equipped with th e essential knowledge and know -how. Score s of rem ote he alth centres are now manned by a medical assistant, who has become a well-known, and well-liked, figure in such coun tries as Ethiopia and Su dan .
( Below) The leader of t he herm it colony of Ma ndaba. on the shores of Lake Tana (Ethi opia) , is proposed sulfone ta blets, while at El Obeid Hos pital (Sudan) ou tpatients are carefu lly regis:ered for exam i nation and treatment ( right).
""'·-·-· ...
WhethE·r weJring the traditional veil or the anti$ep tic mask . w ome n are making wide ly varied cont ributions to healt h progress from chil d care to labora tory work and surgery.
A test-tube introdu ction to the enemies w ithi n and the medica l weapons which combat them.
More candidates t o nurs ing and medical practice l Iran, U A R).
WOMEN JOIN THE RANKS
The caree r dr ive catching up young women is a posi t ive, an d w idely obse rved, develop ment of t he past twenty years in this Reg ion. The propor tion o f female students among WHO fell ows has sign ificantly increased from less than si ,, in the early Fifties to more than 20% now, and women account fo r up to 14 % of students in several medica l schools. A. picto ri al ev idence of the increasingly act ive pare they are t aki ng in publ ic hea lt h work is provided here.
I •·- . ...,,
.. .... ,! _
Practice of di ssect ion at the anatomy labo ratory of the Tehe ra n Medical Facul ty.
MORE PRACTICAL TOOLS TO WIPE OUT SMALLPOX
Prog ress in vacci nat ion - the long-used lancet is now incr<:. asingly rep laced by the bi furcated needle, which reduces vaccine re qu i rernents to one tenth, or the jet injec tor, which permits 500 - 1000 va:c:na• t ions an hour The long-used lancet.
The bifurcated needle. The jet in jector.
Vacc ine produc t ion: pocks sho w up on the egg membrane, 48 hours after ir,oculation , confirming the vaccine potency.
MORE POTENT
WEAPONS TO
CHECK TRACHOMA
From t he ea rly fi eld tr ia ls with aureomycine to t he: search for improved anti biotic o intm ents and a long-sought v.1cc in e - tracho ma con t rol stead ily moves ahead through refi ned techniques .
To count less cr.ildre n, antibiotic oin tm ents have become a healing salve.
A clos~ look at a trac hom;-i case: eye scrapings from conjunctiva ;i re flown ...
. . . to t he laboratory, where the virus strains i;olHed are cultivated to assess the efficiency of anubictics.
Looking for malaria par2sices in blood samples.
Keeping careful record of infected cases.
Sai li ng cowards the next operational area.
PRELUDE TO AN ALL - OUT DRIVE
A retrospec.tivc look at th e efforts of two countries - Iran and Pakistan - to put ma l aria e radication on the righ t t rack. From the painstaking search for malar ia paras ites co en tomological st udies and insecticide spray ings, t he dr ive has gained in effic i., ncy t hrough 1 m proved methodology.
Tak ing blc,od smears from Pakistan i ch ildre n.
iynote of success: systematic sprayi ng.
ecking the effectiveness of the insecticide.
Seasonal migration in Southern Iran.
THE NOMAD PROBLEM Si nee: the early days of WHO work, malario logists met with high technical and logist ic hurdles. Dealing with this Region·s countless nomads , who often elude malaria spray ing squads , calls for alter native cont rol methods, including t he mass dis tribution of malaria drugs o r med icated salt.
Distributing malaria d < ugs to Somali nomads.
Brains crust of medical research: The first meeting sponsored by WHO as pare of its priority programme to boost research work in the Rt:gion(Alexandr ia, 1966).
Introduction co research-laboratory work to foster the habits of inqu iry.
FOCUS ON MEDICAL RESEARCH
WHO's programme in chis Reg ion has been geared i;i creasingly co medica I research. Countless problems, from pa ras icic and bacterial diseases to vi ral infection~. hang on th e laboratory verdict. Some of the fifty-odd research act iviti es already sponsored by WHO are illustrated here .
A schistosomiasis control pilot area ( Iran).
Experimental advances against schistosomiasis. (Right) Studying its suspected link with cancer of th e bladdei' (UAR)-
Producing virus vaccines re quires a great deal of appli ed research ar,d investigation.
Unsaddling diseases , o ld and new, calls for easily-accessible drugs, whose quality muse be tho rough ly con trolled (Right) .
Under the cobalt bomb_
Patient undergoing co lposcopy at 1he Me dical Research Institu te in Alexandria.
STEPPING UP CANCER CONTROL
Built from the ground up , chis Reg ion's cancer institutes use an ar ray of lifesaving aids to perfo rm diagnosis and treatment of a d isease which is being given growing at tention , as more bas ic health problems move nearer to solution. Wicne~s these pictures from well equipped cancer units in Iran, Sudan and UAR.
Positioning a patient for radiot herapy a t the Radiation and Isotope Centre, Kharioum.
(Lef1) Telecobalto therapy of a ca ncer c·,se at the Tehera n Cancer I nsc icute. (Above/ the autotechnico n, an apparat us used fo r the preparation of tissue samples from patie nts for microscopic examination
THE REGIONAL COMMITTEE FOR THE EASTERN .MEDITERRANEAN
EIC-i:-ITEENTH SESSION
EM,IRC19/2 page 19
Sub-Committee A of the Regi onal Committee for the Eastern Mediterra
nean met in Nicosia (Cyprus ) from 20 to 23 August 1968. Sub-Committee B
did not take place , the Government of Israel having expressed its inten
tion not to participate in t he meeting and no other member state having
indicated a desire to att end - t here was, t herefore, no alternative but
to cancel the meet ing.
Sub-Committee A was attended by representatives of sixteen member
states and two .associate member s. The United Nations, t hP. United Nations
Development Programme , the United Nations Children's Fund, the United
Nations Relief and Works Agency f or Palestine Refugees were also repre
sented, as well as four i nternational non-governmental and inter
governmental organizations.
The proposed programme and budget estimates for 1970 were endorsed
for transmission to the Director-General. These provided for a working
budget of$ 6 900 000, to which should be added funds amounting to over
$ 2 500 000 from the United Nations Development Programme and several
governmental sources for FIT operations.
Points underlined during t he presentation of the Annual Report of the
Regional Direct or included t he i mport ance of long-term health plans and
the need for co-or di nation of health activities bet ween neighbouring coun
t ries and Regions ; the establishment of new medical schools in the Region;
the constitution of an Associat ion of Medical Schools in the Middle East
and of an Association of Schools of Public Health pertaining to four WHO
Regions (AFRO, EMRO, SEARO, WPRO); the eradication of malaria and of
smallpox; tuberculosis cont r ol and BCG vaccination; the role of labora
tory services; radiat ion protection ; nutrition problems; and community
EM;RC19/2 page 20
water supplies_. The other thn~e i terns on the agenda which aroused
considerable interest included the applications of e l ectronic data proces
sing in public hl.)2.l t h and medical ca.re services; health examinations and
screening procedures f or chronic non-communicable diseases; and the
nutrition of the 1•ie2.r.inQ; chi ld .
In collaborati on with UNRWA , vrrlO had been able to provide some
assistance, as requir ed , to the countries directly involved in the Middle
East crisis of 1967 so as to clleviate the health problems of the dis
placed persons .
The award of Dr Shousha l•'ounda-tion I s prize to Dr A.M. Kamal (UAR),
first recipient of the prize, was noted with satisfacti on.
11Health Hazards due to Cont:•.ml nz:.tion of Foodstuffs with Pesticides"
was the subject of the technical di scuss i o:'"s . It had been selected in
the course of the Seventee~th Sessi on, following the incidents which had
t aken place in Q,3.tar and Saudi Arabia in 1967, causing the death of
t wenty-six people . ttReview of the education and t raining of nurses to
meet the needs of t he Region11 was confirmed as theme for technical dis-
cussions in 1959. Sub-Comm:!.tt ae A further selected 11The problems of
main zoonotic di::;eases in the Eastern Mediterranean Region" and 110ccu
pational health services in neeting the health needs of the people in
developing countri es11 as s1-1bjects for discussi on i n 1970 and 1971,
respectively.
Sub-Committee A confirmed its previous decision to hold the
Nineteenth Session of t he Regioual Committee i n the Regional Office in
Alexandria, and fur ther accepted t he i nvitations of li=banon and Tunisia
to hold i ts 1970 and 1971 sessions, respectively, in those two countries.
PART I
GE N ERAL REVIEW
I ::\J)ITI SCRY AND TEC1-11'~CAL SE..BVICES
1. EDUCATION AND TRAINING
MEDICAL EDUCATI ON
EM,IRC19/2 page 23
Activities i n the devel opment and strengthening of medical educati on
continue to be an i mportar.t feature in t he overD.:i..l WHO Educa tion e.nd
Traini ng Programme . This is i n response t o a clear call by all countries
of this Region to adapt t o th(: mount ing challenge of present day r evolu
t i on in medical and alli ed sc i ences ~nd t o the imper ati ves of s ocial pro
gress in order to meet the health needs of the growing populat i on.
During the past few years, countries have shown growing interest in
the expans ion of medical education facilitie s or in establishing new
schools in r ecognition of the merits of t r aining doctors i n their own
environment , and nl so f or attaining an increasing growth of health man
power suitable for their needs and able to move wit h new knowl edge.
At present, ther e are thirty-ei ght medi cal faculties and schools f or
undergraduates, one of whi ch , the Aleppo Medical School, was inaugurated
and had its first enrolment of students in 1968.
are expected t o be established in Kuwait and Libya.
Two new medical schools
In all cases WHO assistance has been provided in one form or another
including consultants and teaching staff, f el lowships f or preparation of
national counterparts ar..d teaching sup:9J.ies and equipment .
During the period under r evi ew twenty short- tern1 consultants were
assigned in various countries to provide expert advice on vari ous disci-
plines, including the Special Group Meeting f or Medical Education. A WHO
Consultative Group on Medical Education vi s ited Libya during the first
quarter of 1968 f or the purpose of exploring t he possibility of establish-
ing a medical school i n the country . Similarly a WHO team of consultants
EM;RC19/2 page 24
visited Kuwait in the second half of t he year for the same purpose .
The recommendations emerging from both visi ts wer~ in favour of the
principle of establis:1r.:ent of me:dical s chools in tt.e t wo countries.
Teaching st::iff t o ,_,;~::.f,ti ng schools was provi ded to assist in
establishing relcv,".n:, ( i~p:w tments , i n or gani:;,; ing teaching and research
and in preparin~ ani orienti:ig nati onal counter parts . Eleven such pro-
fessors were in position curing the year i:1 s i x medical faculties or
schools including Ethiopia , Iran , Pakistan, Syrian Arab Republic, Sudan
and Tunisia.
Teaching supplies and equipment in the amount of$ 113 306 were
provided for medical schools in fifteen countries. In addition some
countries have made use of the r evolving f und f or obtaining teaching
supplies and equipment on a reimbursable basis in local currency amount
ing to$ 333 398.
The award of fellowships i ntended t o he l p i n the preparation of
t eaching personnel abroad for t he various schools continues to receive
high priority. During 1968 , seventy-two such fellowships were awarded
in various fields i nc1ud1.ng Bacteriology, Bi ochemistry , Paediatrics,
Pathology, Physiol oe,J , A·natomy, Eursing and other medical and allied
sciences. Of these one was in Et hiopia, twenty-one in Iran, eight in
Iraq, two in Israel, one in Lebru1on, eight in Pakistan, seven in Sudan,
seven in the Syrian Ar ~b P0,ublic , three i n Tunisia and f ourteen in t he
United Arab Republic .
During the second hal~ of the year, t~o events which constituted
important features of education and tr:1ining took place.
A symposium was he l d in the Medical Faculty of Teheran in which audio
visual material was displayed and advances in audio- visual technology and
teaching methodol ogy i n re l atior. to medical education were discussed by
EM;RC19/2 page 25
two experts from the National Audio-Visual Centre, Atlanta, USA, whose
services were secured by the Organization.
Region participated.
Several professors from the
A special Group Meeting on Medical Educa t ion took place from 9 to 13
December 1968 in Khartoum, Sudan. This meet i ng was a planned logical
follow..up of previous meetings or- medical education organized by the WHO
Regional Office for t he Eastern Mediterranean (in Teheran 1962, Alexandria
1963, Alexandria 1966 and Baghdad 1967), to review the development of
medical education in the Region with a view to its further progress and
promotion. Thirty-four schools of medicine participated in the meeting
and they represented ten countries including Iran, Iraq, Lebanon, Libya,
Pakistan, Sudan, Syrian Arab Republic , Tunisia, Turkey and the United Arab
Republic. A special group of temporary advisers (consultants) was en
gaged to assist the meeting and its discussions. The meeting offered an
opportunity for inter-count ry discussions and crystallization of thought
in relation to medical education in general and for the formation of an
Association of Medical Schools in the Middle East as a pr iority item in
particular. The Constitution of the Association was signed by all Deans
and Representatives of Medical Schools who participated in the meeting.
WHO will continue to stimulate the further development of the Association
which is expected to assist i n identifying the fields in which the Organi
zation can be helpful and i n which, with the limited budgetary resources
available, a maximum of impact can be exerted.
Exchange of professors in medical schools has also been a subject on
which attention was f ocussed during the year. A good deal of correspond
ence was exchanged in this respect with all medical faculties, medical . , : :1 , .
schools and schools of public health and also with Governments where these
schools exist for nomination of one professor from each s chool to partici-
pate in the activi t y on an exchange bas is at WHO expense . The response
EM;RC19/2 page 26
was indicative of the keen interest of the medical schools in the promotion
of such a scheme .
Training of auxtliary health personnel at all levels continues to
gain importance and to play o. constr;;_ctive role in many countries of the
Region. It serves as a means of provi ding categories of personnel rang-
ing from simple "skilled workers" who assist in acts which can form part
of a diagnostic , curat ive or preventive process to the highest grades of
auxiliary personnel ,·rhose training has in many cases the character of
simplified and abbreviated courses of par ~i cular professions. As a pa.rt
of organized health services they are invaluable as a source of health
manpower for expanding and strengthening the national health programmes
and for staffing services pa:'.'.'ticularly in the rural are3.s, The auxilia-
ries in Medicine are also valuable i n mul tipl ying the services which a
qualified doctor can give and i n r e leasing him f or more advanced work and
research.
This type of training has been r eceivi ng a t tention and assistance of
the Organization i n the form of l ong and short-ter m experts upon request
from Governments with a vi e-.: to rr.ecting tb_e ur gent needs existing in many
countries. In addition the fell Oi·rships programme is being increasingly
placed at the disposal of Governments for further trai :1.ing abroad for
prospective candi dates , especi ally national counterparts and teaching
s t aff in WHO-assi sted projects.
A snort-term consul t ant was assigned during 1968 especially to visit
and evaluate the \l~iO- a::;sisted projects in operati on in four countries,
namely Ethiopia , Libya, Saudi Arabia and Somalia. The consultant also
visited the People ' s Republic of Southern Yemen. He submitted useful
recommendations .
In project Somalia 0008 t he emphasis in training was shifted from
training auxiliaries in the fielcl of p~eventive medicine to training those
for curative medicine .
EM11Wl9/2 page 27
Arrangements wer e finalized for a new pr oject , EMRO 0141 , f or the
training of dent al hea l th personne l a t the auxi liary level in -Sudan. The
first course of two year s ' durati on commenced in April 1969. Besides the
Sudanese s tudents enroll ed i n the cour s~ , there were five WHO fellows at
tending, from Souther n Yer:ien ano. Yemen.
Post-graduate eciucat i on i n public :1ealth continues to r eceive the
assistance and e ncouragement of t he Organization with particular attent ion
to the development of Schnols of Pub lic Health. At present there are five
such schools i n Iran, Lebanon, Paki s tan and t he United Arab Republic.
There i s gr owing int eres t i n deve l oping the cent res and institut es
for post-graduate medical educo.tion f or specialization in the various
fields of clinical medicine with a ,, J e~-1 to trai ning sufficient numbers of
specialists r equired to man the medica l care programmes in t he se countries
as well as t o t raining teacher s and tutor s in various subjects.
Assistance to t hese s chool s , cent r e s or institutes was provided in
terms of . consultant t eaching staff and supplies and equipment.
FELLOWSHIPS PROGMJ'v'!!VE
It is har dl y necessary t o emphasize the importance of the role which
the Fellowships Pr ograr.ime conti nues t o play as a valid c omponent of the
Education and Training Progr amme i n the Regi on. To a large ext ent this
is attribut able t o the r i sir-g i nterest and appreciat ion of the Governments
of their progr amnes and t o t he conf idence borne of success achieved in
large groups of pr evious f e llowships which he lped in t he development and
s trengthening of. t he nati onal healt h s er vi ces of member stat es .
The demand for f ellowshi ps i n the Regi on continues to follow a pro
gressively increasing t rend and t he numbe r of awar ds issued during the
year was 493 in compari son wi th 457 in 1967 and the funds committed in
1968 were$ 1 566 901 against i l "3l iL ,S6~ ::omml t ted in 1967.
EM;RC19/2 page 28
This spectacular growth shows a growing r ealization by many countries
of the need for trained medical and auxiliary health personnel which will
help towards the solution of their problems of health manpower shortage.
The general picture and distribution of fellowships regarding the type,
the length and place of study was on the whole in the same pattern as in
the previous years, and the policy of making maximum use of the regional
training facilities was adhered to. Nearly 38 per cent of these fellow-
ships cover durations of one year and over in advanced training abroad.
The number of fellowships within the group "Health Organization and
Services" is foremost in the programme and it accounts for almost 44 per
cent of total awards given. The awards made in medical education and
clinical and basic medical sciences number ninety-seven; and thirty-nine
fellowships in undergraduate studies were awarded during the year.
The prospects of fellowships in the countries of this Region, in
general, hold promise of further progress. However, the maintenance of
this upward trend will be contingent on sustained efforts by all Govern
ments to follow the WHO policies and practices which will also result in
the improvement of the quality and efficiency of the studies. A project
for detailed evaluation of the fellowships programme is being planned.
It is important that all requests of fellowships should be associated
with projects or specific fields closely related as far as possible to the
priority health manpower requirement and the health needs of the country.
Sound selection of prospective candidates needs careful attention and
assessment by a special national selection committee. Unfortunately,
relatively few countries have established such committees. It is now
considered a matter of importance and of some urgency that all possible
steps be taken to secure the establishment of these committees in every
member country. A meeting of National Fellowships Officers is being
planned for 1970 and it is hoped t hat all problems and aspects of the WHO
fellowships programme in this Region will be discussed.
U) IL H :c (/) ;3: 0 ,-.l ,-.l t« ~
"' 0
c:i:: lal
~ ~
HGUP.E 1
NUMBER OF FELLOWSHIPS AWARDED BY WHO EMRO 19L9 - 196 8
(EXT:t:NS10N Nv r IllCLUDE.v)
COUNTR Y 1949-53 1954-56 AVERAGE li.V ll'Rar:F.
BAHRAIN a - - CYPRUS l - ETHI OPIA 8 5 I JIAJf 1J{. ;. ,'., 17 ?I..
IRAQ 8 10 ISRAEL 8 8 JORDAN 2 t;
lrTN a TT b - - LEBANON 7 12 LIBYJ. 2 6 PAKISTAN 10 8 f\.l, '!' 4R C - - s. ARA.IH A 2 3 S0M& T.TA - ~
s. YEMEN - - ~1mu1 3 12
SYRI A 7 12 TUNISIA ~ - 8 u. A. R. 13 2c;
YEMEN - ~- TO :'A L 90• 148 *
1JOO
a u'C I NED WHO I}; 1968 b JOI NED WHO I M 1960 c JOINED WHO IN 196~
1959 -63 1964 1965 1966 1967 1968 TOTAL AVEH aGE 1949-lQbE
- ~ - - - ?. 2
10 10 7 H .i2 26 , ?4 7 9 1 ,..,
· " q 2 '.) 18 16'i 26 ,>Q 3B 54 4-2 4-o 'i'i2
17 24 19 27 41 37 325 11 7 7 15 15 '.!.4 190 16 1 !j . 19 .. 35 }5 29 246
l 'j 2 7 c; 14 4v n 7 11 12 16 1'5 21R 7 6 10 8 22 15 ns
28 42 2() 3S 29 30 398
- 2 - 6 6 'i 10
)2 3 ~ 7 20 15 1~8 17 16 1 1 15 24 14 18'5
1 l 2 10 6 26 'iO 25 19 27 40 v; 11.t: 11 .:11.
Pi ) c; 18 '" -=. r, ,1, 297 1A 8 l fl lQ 2 c; 19 216 22 51 26 45 . .54 58 5'7 15 6 18 39 . ·· 2-2 •,. 36 212
259 • 275 274 '-+29 4·57·--· 1493 4-416
• SINCE FIGURES ARE RO!JNDED TO !JHITY, THE
TOTAL MAY NOT COIIBFSPOND TO THE SUM OP THE COt UMN,
d ASSIGNED TO EMRO I N 1956
··-- . J OI)
200
100
1949-195:5 • 1954-1')58 • 1959-1')6:5 • 1964-1968 * .
• FIVE-YE/,R ~VERAC ES
FIOORE 2
NUMBER OF FELLOWSHIPS AWARDED
FROM 1949 THROUGH 1968 BY SUBJECTS
0 50 100 150 200 250 300 350 4-00 450 500
I HEA LTH OROANIZATlON AND SERVIC ES
• • • • • • • • • • • • • • • • • ■ • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ■ • • • • • • • • • • • • • • • • • ■ • • • • • •
I ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ • ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ • • • • • • • • • • • • • • • • • • • • • • • ■ • • • • • • • • • • • Hurs1ng So.n1tat1on • - • ■ ••••••••••••••••••••••••• '
■ I • ■ ■ ■ ~ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
■~ ■■ a ■■■■■■■■■■■ • ■■■■■ •• ■ I - - - - - - - . - . . . . . . . . . . . . . . . . ~aterna l and ch1 ld hea lth Health sta tisti cs . . . . . . . . . - . . . . . - . . . . . . . . . . . . . . . . . . . . .
. - - - - - . - . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental health ' . . . . . . . . • ■ a ■ e ■ L ■ t Oc cupational h•~lth
M+YNMPQ Health educat1 nn . . . . . . . - t ■ -- ■ ■ ■ ■ • ■ I
Rehabilitation
itii$JUOQI Nut r it 1 on ......,.._¾¾\I Contro l of drugs
Dental health
II COMMlJ}( lC AB LH DISEASES SERVICES ... ·~• •·· ..................................... ' - - - ~- ••••• - - - - ••••••••••••• ■ ••••••••••••••••• Malaria
Laboratory •s-~•~~-·-·-·-·-·-·-·-·-• -•.•-·-·-·-·-·-·.·~·-·-·-·-·-·-·-·-·.·-·.·.·.·.·.·-• . -~:.;.,; . :.·.:■ - ■---.~- · · · - · - ·-·-· - ·-·-·-· - · - ·
Tubereul od &
SAAf W Venereal diaeaseg and treponeutoses
W$:M Sch111to60■1asis
MM ii M Trachosua 1:11 Veterinary public health B Chemotherapy, antibiotics
. ~. - . - . ~ •••••••••••••••••• ■• 1,j - - • ' - - - - - - • - - - - - - - .. • - • -
Other co-unicable diseases
III MEDICAL EDUCATION - CLINICAL AND BASIC MEDICAL SCIENCES
. . . . . ~ - - - .. - - - - Anaesthesiology Ra diology
Sur gery and medicine Medical educa t ion
· • •• ■ ••••••••••
- : ■:■ :-:•:•=· = · !Miii,J ........... . . . . . . . . -~- Basic medi cal sciences
Haem:~ to logy ~ a o • ■ • ■ • ■ ■ ■ ■ ■ ■ ■ ■ • • • • • • • • • • • ■ • • • - Other med lca l s peciali ties
IV UNDERGR .\,, tJATE STUnIES
..... ~ ................. ~ .. . ■ • ■ • • ■ ■ ■ ■ • ■ • • • ■ ■ • e • • ■ ■ • I
P'A*7...e' Nur~ t ng D!!D Pharm;i o.:.)'
I I
San1t a~y eng1nee r1ng Dent :l ;;~ r y
!li ed i c1ne
PH.a.
300 - ----- ·········· .. 250
- -..
200
[1] c,.. ... ;ji 31 0 ~ 150 ... le Ck, 0
I 100 a;
50
0
/,. , . .,,-
::;;--: , •••• 4 ••••• l-····
1949
FELLOWSHIPS BY TYPE OF STUDY
19,9 -1968
POSf-GftADUA'PB AlrD OTHBR COURSIS
STUDY VISITS
UlfDIRORADUATE S'l'UDl!S
/ ~
\ ~ I V
~
i ,✓; ~
) \ / ~ \ ,,,~ " \ I,
' ~ ---- \ \, ,~/
'I ' , "ii'
I ..... •• ..... ··••' .... •• •• • •••• •• • ►•··- ··••◄ •
-·-◄ ••••• 1954 1959
V ....._,_
' I ,
'
~ I
V I
/ _, /
_,-'
I I ~
I
/ ..... __ I
""/
J ••
'••·· ... • ••• • • • ••• ... 1964 1968
100
~ -_)
' 1 _· ~
.,
1 -1
. .t
,:Mr: o
PERCENTAGE DISTRIBUTION OF WHO EMRO FELLOWS
BY REGION OF STUDY
EURO
19-49 - 1968
(l-' JV2- E,.R AVi'.:il ,;GES)
1954 - 1956
, ■ I I ~ ••••••• - - e I
1959 - 191;3
THF..R 11EG10N!3
16
14
<n l "' H ;x:: r,J !II
l 0 ~ ..:I
~ t
a 6 ::, :a; .
4
FELLOWSHIPS FOR UNDERGRADUATE MEDICAL STUDIES
. - AW-ARDS ANO RESULTS PER VEAR
fCM FKLtoVSHIPS AWARDED
&r!:i¥~ l'E.LLOWSBIPS CORPLE'rBD
- PRLLOilSHIPS SUSPBllDED
1960-1964•
• .PIVK-Ylift AVBUOBS
1950 - 1968
1967 1968
l'4 I> H f-• <I( ►,i I:)
~ u
tr}
:lll 0
:l 1:4 LS&,
0
I • 0 ::r: :i.
II<. 0
gj ; µ,;
"' , .. ~ 0 H I!<,
;,~ l;O
220
200
180
160
14-0
120
100
So
60
40
20
0
FELLOWSHIPS AWARDED FOR UNDERGRADUATE MEDICAL STUDIES
STATUS OF FELLOWS AT ENO OF EACH YEAR 1956 - 1968
ooa $''1.'trDU;S CO!lll'Lii.-"J'~D
~ STILL S'l'UDUNG
- PllLLOk"SHU'S 3USPEMDll'.D
1957 1958 1959 1960 1961 1964 1966 1967 1968
l.&J a: :::::> I--0 z L&J 0.. X GI) UJ U)
en en -Q. I
:r U)
en an
3= a, -0
~ ..I l.&J I&.
0 :r 3=
-C/l
§ ll;i
..:i
...:i < --
0 0 \C ,-4
0 0 0 ....
0 0
CX)
SHV'1'10<J aNYSflOHJ.
0 0
'° 0 0 N
f!OIJRE 7
(X)
'° "' ....
:- '° °' ....
\C
'8, ....
..n
'8. ....
.:;t- \0 er- ,-4
IC"\ \,0
°' ....
(\I
'° °' ....
.... f 0
'8,, ....
er- II'\ 0-, ....
(X) II'\ c:r-....
('-
"' (1'\ ,-4
\4) it'\ 0-. ,-4
0
tr, ;;,. 0 ,_; ... ~ io1 I;;,
.... 0
,x:; ~
~ :;::, :i~
lll (l l 120
100
Bo
60
4.o
20
NUMBER OF WHO FELLOWS HAV1NG ATTENDED
WHO SPONSORED TRAINING COURSES
19L9 - 1968
1959-196:, • 1964
~ FI VE-YEllF. AV!~AOES
2. MALARIA ERADICATION
EM;1Wl9/2 page 29
STATUS OF MALARIA 2RADICATION ACTIVITIES AND GENERAL PROGRESS
The progress of the malaria eradication programmes in the Region
during 1968 has been marked by the entry into the consolidation phase of
large areas, particularly in Pakistan. At the end of 1968, out of a.n es-
timated total population in t he Region of 257 million of which 212 million
in potentially malarious areas , 7 .6 million v1ere recorded to be in the
maintenance phase, while 154. 8 million lived in areas in which a malaria
eradication programme was in operat ion. A total of 60. 4 million were in
areas protected by residual insecticide sprayi ng and 10.4 million were in
areas in which preparatory operations f or the initiation of the attack
phase were being implemented. A f urther 20 . 3 million live in areas in
which pre-eradication programmes are in operation, while 21.6 million live
in countries in which a malaria eradication programme is planned in the
near future. This leaves a population of 3.9 million only, in which no
plans have yet been made for the eradication of malaria .
only 1.5 per cent of the total population of the Region.
This constitutes
Even for this
small portion of the population of the Eastern Mediterranean Region which
remains under malaria risl( with no immediate plans for the eradication of
malaria or for the establishment of a pre- eradication programme, efforts
are being made t o encourage basic investigations and protective measures,
s o that in fut ure anti-malar ia operations can be initiated on a large
scal e. The figures given above obviously do not reflect the status of
malaria endemicity in the Re gion in so far as a population of 59.8 million
is still living in malarious areas, even though endemicity may greatly
vary within these areas and includes large area s i n which malaria is not
a serious public health problem as in the United Arab Republic (21.6
million). Due t o combined factors such as natural decline, control
EM;RC19/2 page 30
measures and large scale use of insecticides for other purposes, the inci
dence of malaria in this country has already been reduced to a very low
level.
The countries in which malaria eradication has advanced during 1968
are Jordan, Lebanon and Pakistan, where at present the population in the
consolidation and the maintenance phase amounts to a total of 46.8 million.
An.sacharovi has become resistant to DIYr in the Syrian Arab Republic.
This resistance, already suspected in 1967 in view of results of suscepti
bility tests carried out late in the year, was confirmed in 1968. This
problem has been investigated , and a chenge of insecticide decided.
Dieldrin has been used dur~ng 1969 in the Ghab focal area. Other areas
in the Syrian Arab Republic have also shown indications of DIYr resistance
of An.sacharovi and an entomological follow-up will be done in order to
allow the application of timely remedial measures as soon as required.
The problem of An.stephensi r esistance to DIYr and Dieldrin in the
South of Iran and Iraq has not yet been solved, although a change in
insecticide is f oreseen during 1969. A trial carried out in Southern
Iraq using OMS-33 has shown very encouraging entomological results. It
should be noted nevertheless that the high cost of this new carbamate
insecticide makes its use for l arge scale operations unlikely at present.
Malathion, which has been successful ly used in Southern Iran in connexion
with the resistance of An.stephensi to DIYr and Dieldrin will probably be
the insecticide of choice to cope with this problem. Particular emphasis
has been put on the use of larviciding as a supplementary attack measure
in Iran, Iraq, Jordan, Pakistan and Tunisia, particularly in dealing with
urban malaria or vector res istance to insecticides . In Jordan, the main
reason for the use of larviciding has been the exophilic behaviour of
An.sergenti. None of these countries has used insecticides as larviciding,
although trials with ABATE, with enccuraginr; results, have been carried out
EM;RC19/2 page 31
in Jordan and Pakistan . Other supplementary attack measures consisted of
large scale drug distri~ution, but the results so far achieved are to be
considered temporary. More encouraging results have been obtained in
Iran through t he use of mass radical treatment of nomadic population
groups.
One of the main problems facing malaria eradication in the Eastern
MediterTanean Region is the modest pace of development of the basic health
services. This problem assumes great importance in the areas which have
achieved the eradication of malaria. In particular Pakistan - where
approximately two million population live in areas in which epidemiologi
cal conditions for the maintenance phase have been reached ano 44 million
in areas in the consolidation phase - has felt the consequences of the
lack of a networl< of rural heal th services capable to undertake vigilance
operations. Studies have been carried out in these areas to explore the
feasibility of the integration of mass campaigns such as smallpox and
malaria eradication with the basic health service, so that the continuing
expenditure consequent to the continuation of the consolidation phase may be avoided. It is foreseen that by the end of 1969 the three zones which
have reached the maintenance phase in Pakistan, namely Djanpur, Sheikapur
and Sialkot will be integrated into the general health services, and the
responsibility for vigilance handed over to them. Such integration is
not void of risks, in view of the continuing influx of positive cases from
other areas in which transmission still occurs in Pakistan. The kind of
setbacks observed in other regions as a consequence of p~or vigilance
activities may well be observed in Pakistan if a detailed integrated plan
for the ·basi.c general health services is not implell')ented. All efforts of
the national malaria workers as well as of the WHO workers in the country
are being at present directed to the formulation of a workable plan to
ensure adequate vigilance operations.
EMft{Cl9/2 page 32
The status and development of malaria eradication programmes in the
Region, as at the end of 1968 , is shown on page 33.
TRAINING AND FELLOWSHIPS
Training of malaria workers is carried out in all countries of the
Region in which a malaria eradication programme is in operation. WHO
assistance in this field consist s of encouraging courses for training of
new recruits as well as refresher courses with the assistance of staff of
the Regional Office. I n addition, in the larger programmes such as
Ethiopia, Pakistan and Sudan, WHO has assisted malaria eradication train
ing centres to carry out routine training courses and refresher courses.
During 1969, two epidemiol ogy courses are planned for Pakistan, in
Lahore and Dacca respectively. In addition, an entomology course is also
being run in 1969 in Lahore. All these courses receive WHO assistance,
financial as well as technical by the provision of lecturers. Since this
activity has been initiated, four epidemiology courses and one entomology
course have been given in Pakis tan. The importance of training in epide-
miology has been f ully realized by the programme, as have the technical and
financial benefits that will be derived by an adequate epidemi ological
assessment carried out continuously in the programme .
The malaria eradication training cent res in Ethi·opia, Pakistan and
Sudan continued to receive WHO assist ance.
During 1968, eighteen fellowships abroad were awarded to malaria
workers, f or the most part in malaria t raining centres. Study tours were
also organized for medical officers. In total, eleven malariologists,
three instructors and four other categories of staff received training
abroad. More fellowships are being awarded during 1969.
STATUS OF MALARIA ERADICATION
D Hon ular1ous or aa1nte-nance phaee or eradlcatlon or aalarla olaiaed.
Attack or conaol1dat1on phase.
. . ' IN THE EASTERN
END 1968
MEDITERRANEAN REGION
Ir, the planning .st age or 1n prepa~a t ory phaee.
Malarlou9 w1th no malaria eradication progralllllte.
RELATIVE DISTRIBUTION OF THE TOTAL POPULATION OF THE REGION
ACCORDING . TO EXPOSURE TO MALARIA
1960 - 1968
100
90
80
70
60
~ 50 C, ...:
E u I.l o ea o..
}O
20
10
0
1960
~ J'()PULATIOH Ill MGK-MALAlllOUS AREAS .uro POPUL.&.TIOJI Ill COOll'l'RIU IIIHJftl ERADICATIOII CLAIMRD
0 ~~~ ... POPULATION Pk0H01'ED lJI MALARIOOS AHAS WHIH IRADICATIOII IOT YET CLUNBD
bl m ~ Cl
POPULATIOJI JIOT PROTEC1'ED IN MALARIOUS ARIWI ... it:.
Type of Pro- gramme
Malaria eradica..: ted or original - ly free
TOTAL
Eradi- cation
ToTAL
Pre- eradi- cation
TOTAL
Uncorn- mitted countries
TOTAL
G R A N D
EM,IRC19/2 page 33
STATUS A!ID DEVELOPMENT OF MALARIA PROGRAMMES IN THE EASTERN MEDITERRANEAN COON'l'RIES I END 1968
(POPULATION IN THOUSANDS)
Total i E r a d i c a t i No . Po;;ulation Populatioij o n
Countries of Um.fo r Mala- protected Year Year ending Populat:l.on r ia Risk b~• all s t art. consoli- Type
Methods attack dation
Cyprus 21 62c 620 620 F .T. I> .. I:- 81 81 81 Gaza ll87 487 487 Israel 2 803 2 803 2 803 Kuwait 581 - - Free from malaria
4 572 3 991 3 991
Ethiopia 24 094 12 Olf7 4 476 1966 1980 By stages Iran 27 369 23 116 23 11 6 1957 1976 " n
I
Iraq 8 759 5 486 5 4-86 1957 1976 Country-wide Jordan 2 279 1 186 1 186 1959 1973 II II
Lebanon 2 615 683 883 1957 1969 II II
Libya 1 835 87 87 1959 1973 II II
Pakistan 110 670 110 670 104- 303 1961 1976 By stages Syria 5 900 4- 313 4 313 1956 1974 Country-wide Tunisia 4- 719 3 925 3 925 1968 1975 II II
lJ.A.R. 3;, 076 21 651 10 237 In preparation
220 316 183 364- 158 012
Saudi Arabia 7 169 2 567 936 !/Populations in areas under Somalia 2 797 2 797 119 the preparatory phase of a Sudan l lf 964- 14 9 64- _37 malaria eradication pro-
gramme are not considered
24 930 20 328 1 242 as being protected.
Bahrain 205 205 205 2/ - F.T.A.I, = French Territory
Muscat & Oman 565 565 - of the Afars and the Issas,
Qatar Y 84 8l} - 3/ . . P.R.S.Y. 1 209 1 209 271 - P.R.S,Y ... People'·s Republic Truc1al Oman 147 147 - of Southern Yemen. Yemen 5 000 2 000 -
' . .
7 210 4 210 476
TO TA L 257 028 211 893 163 721
EM;RC19/2 page 34
STAFFING AND FINANCING
During the year under review, the staffing position has remained
satisfactory in most malaria programmes of the Region.
A substantial improvement in the service conditions of the malaria
staff has taken place in Iran. In 1968, about 4 000 employees who had
been with the malaria eradication organization from before 1966 on pro
visional cadres, were accepted by the Government of I ran as permanent
civil service personnel, thus giving them more security and assurance for
their continued future employment.
The daily paid employees in some programmes have again been reported
not to stay on their job for long durations, and consequently the turn
over has been frequent, resulting in difficulties in training as well as
in maintaining the operational standard up to the desired level.
The advisory assistance provided by the Organization to the malaria
prograrmnes in the Region during the period under review has remained at
about the same level as in the preceding year. At the end of 1968 , the
total number of established posts was fifty-seven, of which fifty were at
country level, two at inter-country level, and five at Regional Office
level. The provision of such assistance has been made to meet, as closely
as possible, the current needs of the programmes at their particular stages
of progress. The services of the Regional Advisers have been fully uti
lized to augment t hose of the field advisers in various activit ies related
to training, programme planning and assessment.
Governments of countries having malaria eradication or malaria pre
eradication programmes have continued to give full financial support to
their respective programmes. Budgetary provisions made by the Governments
for malaria eradication or pre-eradication purposes during 1968 are con
sidered adequate, and the allocation of funds generally timely.
EM;RC19/2 page 35
WHO has budgeted under Regular and UNDP/I'A a swn of$ 1 3Zf 377 for
malaria eradication and pre-eradication activities in 1969, representing
approximately 15.85 per cent of the tot~l regional budget for field activi-
ties. A further amount of$ 210 300 has also been budgeted under MESA,
largely for supplies. As MESA funds have been very limited in recent
years, the provision under Regular Budget for supplies and equipment has
been at an increased proportion, in order to help some of the programmes
out of difficulties in obtaining t he required imported commodities.
UNICEF is continuing its material assistance to the malaria eradication
programmes in Iran and Iraq, to an estimated value of$ 1 402 000 in 1969.
The assi:stance from UNICEF to the two programmes is appreciated, and it is
hoped that this will be continued. US-AID loan assistance to the eradica-
tion progrannnes in Ethiopia, Jordan and Pakistan, in the form of advisory
services, fellowships and supplies, is also being continued under bilateral
arrangements.
TECHNICAL PROBLEMS AND RESEARCH
Broadly speaking, the areas of the Eastern Mediterranean Region where
technical· problems exist are th:ose inhabited by the malaria anopheline
vectors An.stephcnsi/~orensis and An.sacharovi, the former bec~use of its
long standing phys"iological resistance to both the chlorinatedh;rdrocarbon
insecticides, and the latter due to its recently discovered resi'Stance to
DDT in the Syrian Arab Republic.
In the South of Iran, spraying with Malathion was applied at the end
of 1968 and the results appear to have been encouraging. Larvi.ciding has - - ..
also been applied, particularly in urban areas, supplemented by the wide-
spread use of G~busia affinis i n most of the provinces of the southern
part of the country.
nomadic groups.
Other measures included mass radical treatment of
EM;RC19/2 page 36
The results of these combined measures are not yet available, but
entomologically speaking, the application of Malathion has produced a
drastic reduction of density of An.stephensi. The claimed effectiveness
of DDT in partially controlling resistant An.stephensi has not been con
firmed by the happenings in pure An.stephensi areas of Southern Iran. In
fact, since July-August 1967 after the DDT spraying, the susceptibility of
An.stephensi decreased further, and transmission of malaria occurred.
When Malathion was applied in August 1968, the density of An.stephensi was
drastically reduced. In view of this, the programme has decided to use
only Malathion alone in 1969. Further evidence of the lack of efficacy
of DDT has been given by the sharp rise of transmission of P.falciparum
in this area, where in 1968 79 per cent of the cases were P.falciparum.
In the south of Iraq, tv"here a population of 1.9 million lives in
areas in which An.stephensi is resistant to DDT and Dieldrin, the epidemi
ological situation, when comparing 1967 happenings with 1968, has made no
progress towards eradication. In this area where DDT has been applied in
the two years under observation, the cases detected were as follows:
Liwas and Populat ion 1967 1968
Basra (687 095) 1 190 1 443
Amarah (353 596) 136 123
Nasiriyah (510 034) 50 46
T o t a 1 1 376 1 612
This shows that there is no tendency to reduce transmission in the areas,
despite the continued use of DDT.
EM;RCl9/2 page 37
In fact, outbrea.~s have been recorded, in particular in Hartha area.
During 1969, Malathion is being used instead of DDT in the south of Iraq.
A trial in a ver y limit ed area in southern Iraq was carried out using
0MS-33, a carbamate insecticid0 . Stringent precautionary measures were
taken, in view of the possi bi l i ty of toxic effects to the operators and to
the population. About 13 000 people live in the area protected with
0MS-33, and in view of these strict precautionary measures, toxic effects
on operators and population was negligible. Entomologically , spraying
of this insecticide produced a drama.tic disappearance of the vector, both
in the adult as well as i n the larval stage. Entomological investiga
tions consisted of hand catches, spray catches, human and animal bait
capture. It is therefore safe to conclude that An.stephensi could not
be detected in the 0MS-33 areas with the avai lable entomological tech-
niques. The number of malaria cases in the same area, expected · t_c, __ be
reduced when compared with the cases detected during the previous year,
remained quite hig.h, but an epidemiological investigation of a sample of
the positive cases detected revealed tha t the largest majority were re
lapsing cases from the previous year's transmission. However, a few of
these cases had to be classified as indigenous. A valid epidemiological ,
conclusion as to the efficacy of 0MS- 33 is therefore not yet possible.
The area will continue to be protected with 0MS-33 during 1969, when it is
expected that more r e li~ble epidemiological data will be obtained. As
mentioned earlier, the high cost of this insecticide prohibits its use for
large areas. If the ability of 0MS-33 to i nterrupt malaria transmission
is confirmed, it will still only be considered for use in very limited
areas, or as an emergency measure , but not for large scale use. Should
the price of 0MS-33 be later reduced, its use on large scale programmes
may then be considered. From t he experience gained in the south of Iraq,
even though special precautionary ~easures had to be taken, the toxic
effects of this insecticide appear to be modest and of a transient nature
and would not prevent its use .
EM/1'Cl9/2 page 38
The problem of An.sacharovi in the Syrian Arab Republic has assumed
importance in the Ghab area, where transmission of malaria with a high
reproduction rate has occurred after the application of DDT in the spring
of 1968. It has t herefore been decided that Dieldrin will be used in this
area during 1969. The same problem nevertheless also exists in Derik area
(Hasakeh Province) and in Raqqa area (Aleppo Province).
In these areas, susceptibility tests were carried out late in 1968
and their results could have been influenced by pre-hibernation changes
in the vector. Nevertheless, increased densit i e s and persistence of
transmission may well mean that resistance is developing in these areas
also. It has therefore been decided to replace the second round of DDT
with one round of Dieldrin in 1969.
CO-ORDINATION
The Eighth International Congresses on Tropical Medicine and Malaria
were held in Teheran, Iran, from 7 to 15 Septe,nber 1968.
Besides discussion in plenary sessions, open t o some 1 200 partici
pants from countries throughout the world, techni cal papers concerning a
wide variety of the aspects of malaria were presented and discussed in
detail by smaller working groups. For t his purpose malaria was divided
into the six general headings of parasitology and biology, entomology,
host/parasite relationship, chemotherapy, epidemiology and eradication and
control. Unfortunately, it was found that the presentation of papers
took so much time that there was lit tle time left for general discussion.
It nevert heless served to show the remarkable expansion of man's knowledge
of malaria which has taken place in a very short time relative to the age
of the disease.
Immediately following the Congresses on Tropical Medicine and Malaria,
a Scientific Group, convened by the invitat ion of the Director-General,
WHO, reviewed the Parasitology of Malaria.
Teheran from 16 to 23 September 1968.
EM;RC19/2 page Y.)
The meeting was held in
Previous Expert Committees on Malaria and Scientific Groups convened.
by WHO had reviewed a wide range of subjects including entomology, chemo
therapy and immunology, but this was the first time that such a group had
been convened to review the present state of knowledge of malaria parasi
tology and to suggest future priorities of work and research into this
important subject.
The EMR;EUR Inter-Regional Conference on Malaria was held in Beirut,
from 5 to 11 December 1968, with the participation of three WHO Regions.
The Eastern Mediterranean Region was represented by fourteen countries,
the European Region by three countries, and the South-East Asian Region
by one country.
pated.
Observers from UN, UNDP, UNICEF and US-AID also partici-
A wide range of working papers on subjects concerning malaria eradica
tion were discussed, in addition to Progress Reports submitted by each
country participating. These papers and reports reflected a general
advance towards eradication of malaria, despite the presence in some coun
tries of technical, o~eratione.l and administrative problems.
The Inter-Regional Conference recommended the formation of a Joint
Co-ordination Board. for Ethiopia, Somalia and Sudan.
A Joint Co-ordination Board Meeting was held in Beirut on 12 December
1968, immediately following the Inter-Regional Conference on Malaria.
Delegates from Iraq, Jordan, Lebanon, the Syrian Arab Republic and Turkey
were present ·. during the discussions.
The topics discussed were in relation to the problem areas where
malaria transmission was persisting, with particular reference to the
vectors An.stephensi and An.sacharovi, both resistant to DDT and the
EM~Cl9/2 page 40
former also resistant t o Dieldrin. There was general agreement tha t DDT
_should be replaced by Malathion in the An.stephensi areas of southern Iraq.
The appearance of DDI' r esistance in An.sacharovi in residual foci of
malaria in the Syrian Arab Republic was debated, but there were conflict
ing opinions as to whether Malathion or Di eldrin shoul d be used to replace
DDT. In the Syrian Arab Republic, although Malathion was first thought
to be the insecticide of choice in problem areas of DDI' resistant~
sacharovi persisting transmission, this decision was subsequently reversed
and Dieldrin will now be used.
Earlier in the year, 1,e. 18 to 20 June 1968, a s imilar Joint-Co-
ordination Board Meeting was held in Damascus. Iraq, for the first time ,
joined Jordan, Lebanon , the Syrian Arab Republic and Turkey in discussion
of common border problems. It was at this meeting that Turkey affirmed
her intention of replacing DDI' by Dieldrin in the Tigris Valley border area
with the Syrian Arab Republic where t ransmission of malaria was persisting.
The questionable susceptibility test results concerning An.sacharovi to DDI'
obtained in the Ghab area of the Syrian Arab Republic late in 1967 were
discussed, and a recommendation was made that the Malaria Eradication Eval~
a tion Team, EMRO 0058, should r epeat the i nvestigations . I t was also re
commended that the question of whether persistent transmission in the Derik
area of the Syrian Arab Republic was due to exophility of An,sacharovi or
to its physiological r esistance to DDI' should be investigated by EMtO 0058.
A recommendation was als~ ~~de t hat i nternational assistance to J ordan
should be continued in view of t he prevailing unset t led conditions .
The Eighth I r.ter-Count r y Border Meeting on Malaria Eradication was
held in Baghdad from 8 to 11 J anuary 1968 . Participants from Iran, Iraq,
Jordan , the Syrian Arab Republic and T~key were present . Progress r eports
from the particip~ti ng count ries covering the year 1967 were presented and
discussed.
EM/RC19/2 page 41 ··
Other i terns of the fa.genda covered. the problems con.vi.ccted with
An.stephensi in Iran and Iraq, and An.sacharovi in Iraq, the Syrian Arab
Republic and Turkey. The meeting recommended the early submission of
data concerning the epidemiologica l evaluation of Malathion as used by a
new attack measure in Iran, and also data accruing from operat ional r e
search being conducted on the carbamate OMS-33 (Baygon), larviciding and
other supplementary measures.
As regards the persistence of An.sacharovi transmission of malaria,
the Meeting recommended to 11 est.ablish as.early as possible the remedial
measure s necessary for the complete interruption of transmission in this
area".
Other reco!7lmendations concerned t he exchange of infor mation , t he dis
tribution of working papers for futur e meetings mid the s ize of adminis
trative units on border areas .
It was agreed ·to accept Iran's invitation to hold the Ninth Iran/Iraq
Inter-Country Border Meeting on Malaria Eradicat ion in Teheran during 1969.
FUTURE PROSPECTS
The future of malaria eradication in the East ern Mediterr~ean Region
is mainly concerned in the solution of three problems:
- Technical problems encountered in the South of Iran and Iraq and the Syrian Arab Republic, due to the resi stance of An.stephensi and An.sacharovi to DDT.
The organizational wea.~nesses , particularly i n s o far as super vision is concerned , of the programmes in operation.
- The continuation of the financial support of the national and · international agencies to the malaria eradication prograaunes.
To solve the technical problem rising fro,n t he resi stance of the
vectors to insecticides, t he policy of the & s t er n Medi terranean Region is
EM,fflC19/2 page 42
to encourage the use of effective insecti ci des ar.G the i mprove~cnt of
t echnical services in the pr ogrammes deali:-:ig with e !)i c-,cmiolosical and
entomological asse s sment . For t his purpose , Malat hi on has been recom-
r.iended in Iran and I raq ;·1her e ti1e local vector An . scephensi is resistant
t o both DDT and Di e l drin , and Dic l drin has beer. recommended i n the Syrian
Arab Republic t o cope with the problem of An . sacharovi t here . Further -
more , the use of supplementary me2.sure s , such ac larvici di ne; , has also
bee n encouraged , in part i cular to c.ope \·1i th the problem of An. stephensi
t ransmitted malaria in urban areas.
The second pr oblem ir, an internal one , for each programme i :i t he
Region . It implies the unC:erstanding of the concept of perfection of
the operat i ons to be carried out in a :na lar ia eradicat ion programme stated
i n the definiti on itsel f of a ·,:,alaria eradication. Problems of ar: or gan-
izational natur e exist in all malaria eradi ca t ion pro[;rammes in the Regi on.
The r oot of such probl e.i s varies from country to co'.mtry. In s ome coun-
tries of the Regi on it is the consequence of ~he lack of sufficiently
qualified staff , in others the consequence of complacency , i n others i t i s
determined by low salary scale s , or difficult wor},i ng conditions. These
organizational defects are mainly due to poor supervisi on , which in t urn
r esul ts i n incompl ete cov0rage , and ur1sat i sfactory s praying and case dctec-
tion operati ons . Such defec·e,s need. t o be CO::'rected at national leve l , a s
the WHO assistance i n correcting ~~ese defi ci enci es is necessarily limi ted
to t raining and rcfres~cr courses f or ~a ~i onal staff .
The third problem, whi ch i s mostly financ i a l in nature, has bee n and
remains the most serious i n some programmes , such as tnose of Tunisia. and
the Syrian Arab Republic . WHO hac di vcr t ee large amounts of i ts li,ni ted
financial r esources for the provision of supplies an(l equipment for t,hese
programmes . The short age of national funds for the r unning of the malaria
eradica t ion program~es has been a s er i ous probl em :Cor Ethiopia . Unfor-
tunately , s uch diffi cul tie::; cannot be sol ved by simpl y de layi ng t he phasec:
EM/RC19/2 page 43
plan for malaria eradication. In fact, delays in a phased programne
allow the exchange of positive cases from unprotected areas into malaria
free areas, thus prolonging the duration of protective measures, and
consequently extending in time the overall expenditure. Material assist-
ance from bilateral sources has been considerable, but regrettably there · ·
is a tendency for this assi stance to be phased out too quickly and this
is bound to create enormous difficult ies and problems for the recipient
countries and their Ma laria Eradication Campaign.
Although a continuing effort is necessary on the part of the Govern
ments in providing a good port ion of the health budget to malaria, at the
same time the basi c health services need to be developed and brought to a
level which can ensure total coverage in the country. This double burden
is heavily felt by the countries concerned in the present circumstances.
The policy of the Eastern Mediterranean Region in this connexion is
to encoura0e support to ant i-malaria operations as well as to the develop
ment of the basic he~lth services in view of the benefits that can be
derived in the future by such effort.
EM/RC19/2 page 44
SMALLPOX
3. COMMUNICABIE DI SEASES
VIRAL DI SEASES
It is grat i fyi ng t o report that the smallpox eradication programmes
conti nued their steady and progressive growth , i n spite of the many diffi
culties encountered, some due to political , administrative and budgetary
situations , and others to natural calamities .
This year's i ncidence of the disease remained unaltered f or the Regi on
a s compar ed to l ast year ' s figures. Ethiopia and Pakistan continue t o be
endemic f oci , and Sudan witnessed an impor tant outbreak of s mall pox, the
source of which was traced to uncontrol led movements of populat ion across
the borders .
The following table shows the reported nu.mber of cases of smallpox in
the Region for the past three years a
Country 1966 1967 1968
Pakii:;tan East, (3 207 ) (6 189) (9 252) Pakist an West (2 935 ) (4 849) (1 802)
Pakistan Total 6 142 11 038 11 054
Ethiopia 228 466 426
Sudan - 10 104
Trucial States - 10 2
Southern Yemen - - 1
Kuwait - 41 - F.T.A.I. 52 - - Somalia 2 - - Yemen 1 3 - Iraq 1 - - T o t a 1 6 426 11 568 11 587
SMALLPOX INCIDENCE tN THE EASTERN MEDITERRANEAN REGION
19 6 8
VA M~.E Tl!Mf 5/100 000
~ 0.5 - 5/100 000
~1 ms 'l'RAI o. 5/loo ooo
CASBS PD loo 000 POPULATION
~ H g
e .... ....
l'IOUU 12
SMALLPOX
MONTHLY ( FOUR-WEEKLY) REPORTED CASES
ETHIOPIA 1966 - 1967 - 1968
100 _____ ......;..._--.i---,---,--,----r-.---,--r--,
90 1----4----+--4----li----+---+--~it-t---+--+---t--t--.....
10 /
i"-..........i__~ __ .,....__,, __ ..J 0 _______ ..._____,_......., ____ ...__ ____ ......_ __ _
J P ll A !I J J .l S 0 I D
--- 1968 SomtCKz V'Dll! BPIDIXIOLOOICAL RECCIU> iro.8/1969.
- - - 1967 SOlJRCll Vau.D DAL'fB .ST.l'l'lSfiC! REP(ll'P Yot.21. •o.lJ, 1968.
--- 1966 SOOftCS1 KPIDDIIOLOOICAL AND TI'!A.L S'!'lTIS'l'ICS Ut>CliT VOL.20, 10.,, 19'7 •
:J ~ 0
Cit. 0
m ~ z:
2400
2100
1800
1500
1200
900
600
300
0
SMALLPOX
MONTHLY ( FOUR-WEEKLY) REPORTED CASES
EAST PAKISTAN 1966 - 1967 - 1968
J \ I \
' ' l
\! I
\ \
' • --- -,, I
\ I \ \ • \~ --
A \ ~ \ ..
Ii ' ' ', ~
1
l.---"'" I \ ', ~ ... I "-
£/ ,.J ' .\ .. ~, 1 I'\ '
~ .. , .,, ..... ... ·-· - ----....
,J F A M J ,J A s 0
---- 1968 SOURCE: il'UKLY EPIDEJ!'IOLOOI CAL RF.COAD N0.8/1969.
PIOOH l}
j
I I I I ... I I I ' ~~
~
N D
- - - 1967 SOURCE: WCIILD HEALTH ST.l.'rIS'.rICS REP~'!' VOL.21. N0.4, 1968.
1966 SOURCE: EPIDlmlOLOOICAL AJID VIUL STA'l'IS'l'ICS REPCltT VDL.20, N0,4, 196
ll'IOURB 14
1200
1100 .. ..
' 1000
900
800
700
600
500
•oo
,oo
SMALLPOX
MONTHLY REPORTED CA SES
WEST PAKISTAN 1966 - 1967 - 1968
" .. ~""
'I!
• ' ' ' • \
• ' \ - ' ,' ~, ,
I ·,. ·, ,· \ ~ ~~ ' .,--' ' .. .,
I I I I ,
J -~ ,-I ~ \ -, • i.-f
---
200
100
0 J p "
1968] 1967 SOURCE:
1966
......
' / ' I / t!o,,,. .i. ....
~ I' ~ ,r ........_,.
A M J J ,\ s 0 • D
HEALTH DEPARfflEll'l' • CIVIL SECTI<II, L.\H(llK
F'IOURE 15
SMALLPOX INCIDENCE JUNE 1968 - MARCH 1969
EAST PAKISTAN CASES PER l oo ,',()() POP!JLAT:::ON
~,'JRE THAN 5 / 100 C,•t)
0 . 5 - 5 / 100 000
LESS THAN 0 .5 / 100 000
N D .,. A
(ASSA~)
H
A
H
50 ::ail e -----
E'IG'JRE 16
SMALLPOX INCIDENCE 1968
WEST PAKISTA CASES PER • N . . , .:LA'l':t0H l00 00 0 p r, p r•
< ii::
H
~ MORE TJ' f..'i -~ 1 •• 5 / 100 000
~ '1. 5 - 5 / . 1 0 0 00 0 .
~ ~ LESS , 5 l•) O 000 '?'HAN O - /
ARABIAN SEA
.,..,
0 iiiiiiiiaiiiiiii15~oiiii~l~O~O;;;;;::~
150
AND
mile
EMjRC19/2 page 45
There is a pressing need for intensive development of surveillance
activities. "Fire-fighting11 t eams have bee n established to t his effect
i n the running projects o~ the Region. Their t asks :nainly consist of
coping with epidemics and case-detect ion. Several out breaks in Pakistan
were epidemiologically investigated, and this has thrown s ome light on the
epidemiological pattern of smallpox in Paldstan.
New projects were started under· WHO auspices in Saudi Arabia, Somalia,
Southern Yemen and the Yemen Arab Republic. Provision of supplies and
equipment was initiated and recruitment of personnel finalized.
Pakistan, with its total of 9 252 reported cases f or East and 1 802
for West, accouhts for 95 per cent of the t otal incidence of the disease in
the Eastern Mediterranean Region. Floods, sto~ms, political disturbances
as well as administrative and budgetary problems have hampered. a great deal
che field operations. However, a mass vaccination campaign has been car-
ried out in the pilot area of Dacca district and town. During· the attack
phase, five vacc'ination groups - about 150 vaccinators - using both the
bifurcated needle and the jet injector , working for forty-five days, have
performed as many as 823 325 vaccinations . Epidemiological investigation
of local outq_reaks is now currently in practice. A surveillance team has
been established and smallpox outbreaks have been contained in the area.
The project in the West wing seems to have taken a good start . · P.
mass vaccination campaign was planned t o be conducted in Karachi and Lahore
towns and districts. Ho'wever, s ome administrative anc. budgetary limi ta-
t.ions are· delaying the field operations to be initiated on a ·1arge scale .
Accordir,.g t o reports available, during 1968 over 34 million vaccinations
(primary a.nd '·:seconda.ry) in East Pakistan and nearly 14 million vacbinations
{primary and secon:lary) in West Pakistan have been perf:ormed · through r "autir..e
vaccinations.
EM;RC19/2 page 46
In the Sudan, the highest incidence of the c.isease since 1960 was
witnessed i'li th 104 cases reported for 1968. Surveillance activit ies and
containment measures were established efficiently. However, due to secu-
rity r:1easures in the Southern Provinces, total coverage of the affected
areas could not be achieved, and latent presence of the disease in the
South among the unprotected. population result ed in a fresh outbreak in t he
spring of 1969. Up to 10 April 1969 , already sevent y-five cases had been
reported . A WHO epidemioloe;ist was sent to assi s t the Government in epi-
demi ological .investigations and containr.ient mea~ures .
Little progress has been witnessed i n the implementation of anti
smallpox activities i n Ethiopia, which is t he seccnd important smallpox
focus and the only endemic count ry in the Region where no WHO-assisted
eradication programme i s currentl y being carried out . It is hoped that
negotiations at present underwa~r will eventually result in the implementa
tion of a smallpox eradication project in t he country to be carried out in
phases, and , if possible, combined with other mass vaccination campaigns
such as BCG.
Attention has been concentrated this year again on improving the
quality and increasing the quantity of locally produced freeze-dried small
pox vaccine, i n order to mee t the constant and increasing needs f or pot ent
vaccine. To this eff ect , requests for supplies and equi pment f or national
laboratories have been received and processed , fellowsni ps have been granted
to nationals .in charge of the production of freeze- dried. smallpox vaccine ,
consultantships were provided where necessary. The Pasteur· rnstitute ,
Teheran, has benefit ed this year f rom such consultantship servi ces , as well
as the I ns titute of Public Health, Dacca, where a serious problem was aris- ·
ing with the stoppering of vaccine vial s. It is planned to provide s i mi lar
assistance to the laboratories in Iraq, J ordan and t he Syrian Arab Republic
shortl y .
ships.
Iran, the Syri an Arab Republic and Tunisia benefited from fel low-
EM;RC19/2 page 47
Freeze-dried vaccine for use with bifurcated needle and Jet injector
was provided to several countries of the Region from WHO "donation basis"
stock. Nearly five million doses were provided for the year 1968 to
Lebanon, Pakistan, Somalia, Southern Yemen, Sudan and Yemen.
Special laboratory kits for the collection and shipment of smallpox
specimens for laboratory diagnosis of smallpox have been designed and will
be widely provided to Governments both in endemic and non-endemic countries
in the Region. This will greatly simplify shipment of biological material
for the confirmed diagnosis of suspected cases. A detailed Manual dealing
with laboratory procedures for the diagnosis of smallpox was prepared,
giving a step-by-step practice of three main laboratory tests: microscopic
smear examination, precipitation-in-gel test, and definite identification
of the disease through virus isolation on the chorio-allantoic membrane of
chick embryo.
An Inter-Country Training Course in Virology was convened in Cairo with
WHO assistance, in which the subject of laboratory diagnosis of smallpox was
covered.
Recruitment of suitable qualified national personnel for smallpox
eradication projects was a major activity for several of WHO-assisted
projects. Emphasis was placed on the organization of special training
courses for vaccinators, assessors and other supervisory staff engaged in
anti-smallpox activities.
WHO has committed itself further by considering additional per diem
to be paid to certain categories of national personnel while in the field
in countries where low salaries due t o local conditions result in the little
interest shown by field staff