Health in the Americas [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEAL-H ORGANIZATION • AUGUST-SEPTEMBER 1977 • USA $ 1.60 health in the americas 30 Guaquitepec against the measles by F. Vargas-Tentori . Cover: A happy mother, a well-fed child, photographed at a Peruvian health centre by Y. Pouliquen. Contents Community Participation in Health by H.R. Acuria . 3 Fellowship of ideals by R. Valladares .. 8 My land, my people, my mission by F. Huenuman 14 Elected by the community by P. Harrison 18 Health: a right and a duty for all by E. Aguilar Paz 26 Young World Health 36 News Page 38 World Health appears in Arabic, English, French, German, Persian, Por- .tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. WORLD HEALTH health in the americas community participation in health AS THE PAN AVERICAN HEALTH ORGANIZATION VARKS ITS 75TH BIRTHDAY, WE REALIZE THAT DEVELOPVENT IS POSSIBLE ONLY THROUGH A RESPO\SIBLE, ACTIVE AND INFORVED COMVUNITY by Dr Hector R. Acuria When an international health organization for the Western Hemisphere was proposed 75 years ago by delegates from the nations of the Americas meeting in Mexico City, the world was very different from today. True, the problems of poverty and lack of coverage by the health services are still with us; but at that time many of the great strides that have since been taken against some of the most devastating diseases were yet to come. Moreover, while the nations of the Americas were already intent on economic advance- ment, there was not yet a concerted, coordinated campaign to raise living standards for the population as a whole. As a result, the aims of the Interna- tional Sanitary Bureau, the predecessor of today's Pan American Health Organ- ization, were different from those of today. Its small staff, housed in a corner of the Pan American Union Building in Washington, D.C. faced a relatively clear-cut task : to straighten out the maze of quarantine regulations which were then hampering commerce between the countries of the hemisphere. It was the first time in history that an organization had been founded to coordinate health matters among nations. Although its aim by today's standards was modest, its work was very significant, and the fledg- ling organization succeded in this, its first task. Then, as now, its strongest asset was the spirit of cooperation among the Above : Dr Hector R. Acwia, Regional Director for the Region of the Americas of WHO since February 1975. (Photo WHO) Opposite page: This barefoot waif will grow up in the fast-changing world of the Americas. For 75 years PAHO has battled to ensure that children like her will have their rightful share of health and health care. (Photo WHO/ Y. Pouliquen) nations of the Americas to confront and solve common problems. This year, as PAHO celebrates its 75th birthday, cooperation is still the driving force behind the organization, but now we can count on additional impetus from the cooperation of individual people liv- ing in the hundreds of thousands of cities, towns and villages throughout the Americas. Only by enlisting the support of the people at the grass-roots level can today's great goals of both PAHO and WHO — basic health services for all — become a reality. For this reason, PAHO'S Member Governments selected «Community Par- ticipation in Health» as the theme for the Pan American Health Organization's 75th anniversary. This new goal and this new theme have brought to the fore new concepts which must guide our work for the future. The articles in this special issue of World Health illustrate how these principles, recognized in all the Regions of WHO, are being put to work in the Americas. The first of these concerns is the role of the community. Until quite recently, ex- perts working in international develop- ment in the Americas and throughout the world tended to overlook the com- munity as an important agent for its own change. Those same experts believed that rapid economic growth alone would generate the momentum to carry society forward as a whole. Although pro- grammes were not to be specifically tail- 3 ored to aid disadvantaged groups, it was expected that their lot would improve along with that of society in general. Unfortunately this did not happen. As a result, we were forced to the conclusion that all elements of society do not move together on their own accord. If they are to function together, then that must be made a specific objective. If whole institutions and social systems must change — and they must — then many individuals must be motivated to assume new responsibilities which will help themselves and their communities. The health and development pro- grammes of the future must take cog- nizance of the fact that change cannot be imposed from outside or from above: it must be generated from within. Our future approach must depart from previous experience. We can cite exam- pies of past development programmes which have used communities to achieve objectives that were pre-established by technical personnel, where the needs and expectations of the communities were disregarded, and where the attitudes and behaviour of their members were ignored. The result invariably was an atmosphere of distrust and frustration, which the development experts inter- preted — incorrectly — as either apathy or indifference. In part, the problem has been that developing countries adopted models and methods from the developed coun- tries, even though the cultural, political and socio-economic conditions of the former often had very little in common with those of the latter. Moreover, development experts ex- pected that those foreign models would Above: This child living on the high plateau of Peru bears the marks of exposure to extreme frost and heat on his face. ( Photo WHO/P. Harrison) Right: A snowy peak makes a chilling back- drop to an already bleak human settlement in the Andes. (Photo WHO/Y. Pouliquen) be put into effect by the communities. In other words, the communities were not considered as partners in the develop- mental process, but simply as the instru- ments to operate health services or to confirm the effectiveness and efficiency of specific techniques which may or may not have been relevant to those com- munities. We realize now that our goal is to educate people at the community level to 4 ...-774•••.•••• ,st • '' .1"11j0.' 4411rAMIS ft*, *-ismisc , 411,r. a. 11* ".. :I* I"- .4•-- r.r• ,..4404.001045000001._ , #11`. • • or rrh ik4r° "Or • - 3 ■•• _ -• 4.1.• ■••• 7 • ) 407 • • :"". : ••• *" -• .4":C. , • 4,4": ...!* • ' " , trr• r 174 # • - • ilts „‘d• ‘" • •••• Sirr ,00•8•••.. _ • -.a- Ape ovir ro. w p • • ....--‘7"r"-•• • v . • . -- - .4);■14,,,, 44€01.101g...0,................ , .. • -air 0 4 .,... eiofte r '4"4•• - .vee't /:.4■06.44:01f -s-; .. ,. -IPPee .. 41, v ...t . .144 ..• • " ' , .;.•,...' A., 7t* - ; . ' "'''''', . .4; ..' . j.,..• , ..L. .. '••• - , I:1k ...Ail,' .0, •••••‘•:. . • ,....... - • •0 • • . ir • . . •.; . ''. • 0. „.. • 40. ._ jr, •" .' '..•“- ... •• . V. 3-. • ..4 , ... 04r7 . • . fej, -: ' - • - •• - - 4„ , , • ••• •••• • ...•••• • .• • • . • c r.",` • 1.4.!•■ • _ • • community participation in health Left: These cheerful citizens of tomorroiv are condemned to grow up in a sprawling urban slum. Thefirst priority for the work of PAHO is a concerted compaign to satisfy the basic needs of the poor. Right: Already important advances in the sphere of public health and hygiene have been made in many countries of the Americas, as this gleaming water purification plant in Brazil shows. Over vast areas of the continent, it is only by enlisting the support of the people at the grass-roots level that today's great goals of PAHO and WHO—basic health services for all—can become a reality. ( Photos WHO/ P. Almasy) identify and solve their own problems, to rely on their own efforts. PAHO, WHO, the World Bank and other international or- ganizations as well as many governments have now recognized that development is possible only through a responsible, ac- tive and informed community. Closely allied to the concept of com- munity participation is the fact that these programmes cannot be planned and im- plemented by the health sector alone. Only a multisectoral approach can set in motion the processes that lead to self- sustaining development. The benefits of visiting a health centre will be short-lived indeed if the person returns to the same environment that caused his ill health in the first place. All conditions must im- prove educational, economic, social, and of course health — if there is to be any real, lasting improvement. Within this strategy, the first priority must be a concerted campaign to satisfy the basic needs of the poor. Rather than merely redistributing human and material resources, we must develop and expand their availability. Health aux- iliaries must be recruited from the com- munities which they will serve, streng- thening what is now the weakest level in the system of health services. From the most fundamental to the most sophisti- cated, each element in the system must be integrated so that health care will not only be available to all but will be of the highest quality as well. Yet another area in which change must take place is in our use of techno- logy. We have become accustomed to regarding technology as an end rather than a means. The more sophisticated, the more complicated, the better. It is now time to rediscover that technology does not exist for its own fulfilment but for the benefit of the people it serves. In the past, when developing countries have been supplied with machinery, in- struments, equipment and engineering services, these items were regarded as valuable assistance because they aided the process of modernization. They did not, however, confront the central prob- lem which is not modernization but im- proving the quality of life for the people. In the health sector, as in the other sectors, technology must be developed and applied. It must be appropriate tech- nology, and on this basis alone it should be judged. Does it solve human prob- lems? That is the relevant question, not whether or not it is sophisticated or advanced. Once this is accepted, it no longer becomes axiomatic that technolo- gy must flow from developed to develop- ing countries. One of the more encourag- ing recent shifts of attitude has been the interest of developing countries in the interchange of just this kind of appro- priate technology. In many cases the developing countries must invent this technology, and an important role of PAHO/WHO will be to work in close col- laboration with them in evolving new ideas, methods, and skills. Thus developing countries will become self-reliant and confident in their own ability to solve their problems. Since its earliest years, our Organization has found that serious and complex problems can be solved through cooperation among sovereign states. The more ambitious our goals and the more we demand from our nations and our people, the more es- sential this cooperation becomes. ■ 7 fellowship of ideals by Rogelio Valladares When confronted by the problems of sickness and health, nations can no longer afford to remain iso- lated one from another. As the world has advanced and as the in- terests of trade—the prime mover of in- ternational relations in the modern era— have intensified, so the need has grown for countries to unite for their mutual protection against the inroads of disease. The second half of the 19th century saw no fewer than eight International Sanitary Conferences taking place in Eu- rope—in Paris, Constantinople, Vienna, and Dresden—and one in the Ameri- cas—in Washington (1881). However, none of these conferences resulted in the establishment of a permanent body dedi- cated to international cooperation in health. When, in January 1902, the Second International Conference of American States, meeting in Mexico City, ap- proved the report of its Tenth Commit- tee on "International Sanitary Policy", it was agreed that a first International San- itary Convention should be held. Its ob- jectives would be to organize the interna- tional reporting of quarantinable dis- eases and of activities in the health field, to convene further meetings from time to time, and to establish an International Sanitary Bureau, whose costs would be covered by contributions from the Mem- ber States. In fulfilment of this resolution, the First International Sanitary Convention took place in Washington D.C. between 2 and 4 December 1902. The participat- ing governments pledged themselves "to transmit information promptly and regu- larly on the sanitary situation in their countries and to cooperate in investigat- ing outbreaks of disease; to reduce the periods of quarantine to the shortest pos- sible time... to take steps to keep their ports healthy; to use the prophylactic measures against yellow fever that had been so successful in Havana; to study the geographic distribution of the mos- quito of the genus stegomyia, the carrier of yellow fever (now known as Aedes aegypti), so that this knowledge might be put to practical use in the future; to adopt suitable measures for the sanitary disposal of garbage and wastes in order to prevent the spread of bubonic plague and other diseases" ... The duties of the International Sani- tary Bureau were to include : "offering the best possible aid and experience so as to obtain the greatest possible protection of the health of Member States, bring about the elimination of diseases and facilitate trade between the nations", and "obtaining all possible assistance in car- rying out complete scientific studies of outbreaks of contagious diseases which may occur in these countries". And so, 75 years ago, was born what was later to be called the Pan American Sanitary Bureau, with a programme which we would today call "epidemiolog- ical surveillance" of the quarantinable diseases, and pledged to give its assis- tance and experience to Member States in order to wipe out disease and ease commercial relations between countries. And in order to carry out this work, the governments concerned had to raise the princely sum of—just US $5,000. It is fitting to record here the names of the first President and the group of "not less than five" who constituted the em- bryo of what, many years later, was to become the Executive Committee. President: Dr Walter Wyman (United States) Committee members : Dr Juan Guiteras (Cuba), Dr Eduardo Moore (Chile), Dr H. A. Doty and Dr Rhett Goode (United States), and Dr Eduardo Liceaga (Mexico) Secretary : Dr Juan J. Ulloa (Costa Rica) At the Second and Third Conventions, it was formally spelled out that "the quarantine periods and campaigns against epidemic diseases should remain under the control of the national health authorities", thus establishing from the start that the execution of these pro- grammes should remain the responsibili- ty of each Member State, and that the International Sanitary Bureau should constitute a mechanism for coordination and assistance. The problem of maintaining continu- ity of leadership was resolved by having some members of the governing body remain in office, thus in effect instituting the principle of partial renewal of the Council. The International Informative Com- mission was set up in the Member States, responsible first of all for the interna- tional notification of diseases and, secondly, serving as a link between governments and the Bureau. The Founding Fathers of PAHO. Photo-C. graphed in 1902, the first executive board of the International Sanitary Bureau—precursor of the Pan American Sanitary Bureau—com- prised (top to bottom and left to right): Dr H.A. Doty (USA), Dr Juan Guiteras (Cuba), Dr Juan J. Ulloa (Costa Rica), Dr Walter Wyman (USA), Dr Eduardo Lic- eaga (Mexico), Dr Eduardo Moore (Chile) and Dr Rhett Goode (USA). (Photo WHO) 8

A subsidiary Bureau was founded in Montevideo "to serve as a centre for the Commissions of the Republics of Argen- tina, Bolivia, Brazil, Chile, Uruguay and Paraguay". This set in train a process of sub-regionalization which has changed with the passage of time and with the development of more elaborate systems of communication, but which remains a fundamental principle in the health field and has grown even stronger in the sphere of economic cooperation. The Conventions took on the new name of International Sanitary Confer- ences after the fourth meeting, which took place in San Jose, Costa Rica, in January 1910. By this time the related activities were no longer confined merely to quarantinable diseases. A growing concern was already apparent over inter- national cooperation in smallpox vacci- nation, campaigns against malaria and tuberculosis, the study of national health legislation, and the need for research into tropical diseases in order to give the pro- grammes a scientific basis. At the Fifth Conference, in Santiago, Chile, in November 1911, it was pro- posed that delegates "should whenever possible be trained hygienists" ... and that "at least one delegate should be a senior health official or a person who had taken part in a previous Confer- ence". Resolutions such as these reflect- ed the clear determination of Member States to maintain a high technical stan- dard of discussion at the Conferences, the need for national authorities at the decision-taking level to participate, and the hope of combining both principles in each national delegation. It seems likely that this Fifth Confer- ence was the first occasion that an inter- national body should recommend governments to organize "formal and practical courses in hygiene and sanita- tion, with special disciplines if required, at a sufficiently high professional stan- dard to undertake health activities in the future". On 21 November 1911, the first Presi- dent, Dr Wyman, died. The Conference of 1913 could not take place, and pre- sently World War I occupied the full at- tention of the world. In May 1920 Dr Hugh S. Cumming, Surgeon General of the US Service of Public Health, convened the Sixth Pan American Sanitary Conference, which was held in Montevideo in December of that year. Now a new stage in the Organization's history was reached with the restructur- ing of the Bureau, and with the publica- tion of the Pan American Bulletin of Health (1922) and of the Monthly News- letter of Pan American Health. The Bureau now had a Director, a Secretary and four more members, appointed by the Conference. The budget was set at US $20,000, contributed by the govern- ments according to a similar scale of pay- ments as that employed by the Pan American Union. Dr Cumming himself was designated as Director, a post which he held until January 1947. In order to devote himself entirely to the work of the Bureau, he retired in February 1936 from the post of US Surgeon General. In later years his deputy directors, Dr Bolivar Lloyd and Dr Edward C. Ernst, were also given ex- ecutive powers. The number of senior officials at no time exceeded half a dozen. Of particular value was the work of many hygienists seconded to the Bureau from the US Public Health Ser- vice and from some other countries; their efforts put the hallmark on a whole era of intense studies, field investigations and work programmes throughout the American continent. The Seventh Pan American Sanitary Conference, held in Havana in 1924, ap- proved the Pan American Sanitary Code, and this was ratified within a few years' 10 fellowship of ideals Left: Delegates pose for a souvenir photo- graph at the Fourth International Sanitary Conference, held in San Jose, Costa Rica, in 1910. Already there was growing concern with international cooperation in smallpox vaccina- tion, malaria and tuberculosis control, national health legislation and tropical disease research. Right: In 1949, a formal agreement was signed in New York between the Pan Ameri- can Sanitary Organization and the fledgling World Health Organization. PASO was henceforth to be known as the Pan American Health Organization PAHO and the Pan American Sanitary' Bureau was constituted a Regional Office of WHO. ( Photos WHO) time by all the governments of the Americas. Starting in 1926, the Conferences of Health Directors were convened every four or five years until eventually they turned into Meetings of Health Minis- ters. We can thus see taking place, as time unfolds, the evolution of that tech- nical and political duality within the in- ternational health agencies which en- sures that, when solutions are found, they are at the same time technically valid and will also have all the necessary political backing at the decision-making level. From May 1929 there were eight an- nual meetings of the Council of Direc- tors, which were presently replaced by Meetings of the Directing Council under the terms of a new statutory modification approved during the Tenth Pan Ameri- can Sanitary Conference at Bogota in 1938. The first Permanent Committees, com- posed of leading experts in each field, were also created around this time : that of foodstuffs (1937), which changed its name the following year to nutrition; that of the Sanitary Code (1941); that of typhus and other flea-borne diseases (1943); and that of sanitary engineering (also 1943). These were the first examples of expert committees in the field of health, thanks to whose work so much of the progress in international health up to the present day has been possible. An important role was played during those years by the extrabudgetary contri- butions made by governmental and non- governmental institutions, such as the US Public Health Service already men- tioned, the Bureau of International Af- fairs, the Commonwealth Foundation and the Rockefeller Foundation. These contributions covered the costs of scho- larships and working grants which con- stituted the training programme for health personnel, as well as the costs of various publications and certain special field programmes—for constructing latrines and rural aqueducts, for in- stance. Among the non-governmental bodies, the Rockefeller Foundation had a considerable influence in the develop- ment of public health in the Americas. The Twelfth Pan American Sanitary Conference, held at Caracas in January 1947, marked the beginning of a third new stage. Delegates to this meeting resolved that henceforth the Pan Ameri- can Sanitary Organization should consist of: the Pan American Sanitary Conference, supreme body of the Organization, meet- ing every four years when it would elect the Director; the Directing Council, formed by one delegate from each of the Member States, meeting in the years when there was no Conference; the Executive Committee, formed by seven members (this number has recently been increased to nine), elected by the Council for overlapping periods of three years; and the Pan American Sanitary Bureau, the permanent executive body. At this same 1947 Conference, dele- gates discussed and approved the basic principles of an agreement with the World Health Organization, then in the process of being formed. The subjects considered on that occasion give some idea of the ways in which the planning and activities of the Pan American Sani- tary Organization have evolved : the or- ganization of national health services, relationships between social security and health, animal diseases that may be transmissible to man, food and drug reg- ulations, health problems of the post-war world (such as displaced persons), Chagas' disease (the American form of trypanosomiasis), rheumatic diseases, and cooperative programmes of basic health care. 11

fellowship of ideals Dr Fred L. Soper, who was elected Director of the Bureau, came from the ranks of the Rockefeller Foundation and had been engaged in the battle to eradi- cate the urban vector of yellow fever in Brazil. The team of officials increased in num- ber; the Organization occupied its first home in Washington, with the help of interest-free loans from the Kellogg and Rockefeller Foundations; its activities multiplied—and the annual budget in- creased in proportion. Its usefulness was amply acknowledged by all the govern- ments of the Americas. Dr Soper was re- elected Director at the Thirteenth Pan American Sanitary Conference (Santo Domingo, 1950) and again at the Four- teenth (Santiago, Chile, 1954). In 1958 the Fifteenth Conference (San Juan, Puerto Rico), elected Dr Abraham Horwitz of Chile as Director. He won re- election three times and thus completed a period of 16 years in office during which—as Norman Howard-Jones wrote in the December 1972 issue of World Health—"by a skilful blend of determi- nation and diplomacy he built a solid edifice on the foundations already laid". It was also an edifice whose technical, scientific and ethical bases gained physi- cal expression with the inauguration—in 1965—of the Organization's handsome new seat in Washington. In due course the Nineteenth Confer- ence, held three years ago in Washing- ton, elected the present Director, Dr Hector Acufla of Mexico, who took office in February 1975. Today, in the 75th year of its existence, the Pan American Sanitary Bureau com- mands a budget of US $60,959,851, which includes the quotas of 31 Member Governments, the regional contribution from WHO, funds from other UN agen- cies, and subsidies and grants from the Kellogg Foundation, the Canadian In- ternational Development Agency (cIDA), the US Department of Health, Educa- tion and Welfare, and other sources. A total of 1,593 officials of all grades lend their services to the nations of the Americas—whose populations total 551 millions—with the object of develop- 4 Peruvian villagers listening attentively to a talk by a voluntary health auxiliary. PAHO has helped to integrate national policies and programmes that bring health within reach of all. (Photo WHO /Y. Pouliquen) ing : prevention and control of diseases through services to individuals, family health, infrastructure of the health ser- vices, manpower training, environmental health and biomedical research. Agreement with WHO With effect from the Third Interna- tional Sanitary Conference in 1907, the Bureau was authorized to establish rela- tions with the Office international d'Hygiene Publique in Paris—relations which were further strengthened by the participation of delegates from the Americas as members of that Office as well as of the Health Section of the Lea- gue of Nations (1938-1939). However, as yet no concrete plan existed for establish- ing international coordination in health programmes. In June 1946, convened by the Secre- tary-General of the United Nations, the International Health Conference met, bringing together representatives of vir- tually all the Member Governments of the UN, and of certain other countries such as Sweden and Switzerland who incorporated themselves into the world health movement. It was this Conference that laid the foundations of the World Health Organization, and at the same time discussed the future of the Pan American health institutions which had by then already been in existence for more than 40 years. The governments of the Americas decided to retain their own health insti- tutions. But at the same time they sup- ported the creation of WHO and, apart from one single exception, all the coun- tries of the Region became members. For the people of the Americas this decision entailed a double contribution to inter- national health : the quota of the Pan American Sanitary Organization, which had a budget for 1947 of US $1,285,000, and the quota of WHO. This has made it possible to maintain the traditions, the functions and the effectiveness of the Pan American bodies; to offer the backing of the Americas' regional contribution to the activities, programmes and financial resources of WHO; and in turn to receive from WHO the orientation, support and fresh experience which its worldwide scope confers on it. It was possibly out of a wish to avoid the uncoordinated proliferation of inter- national health organisms that the First Constitution of wHo had written into it Article 54, Chapter XI, which incorpo- rated within the new world organization all health agencies already in existence. On the other hand it is quite possible that the regional experiences of the Americas dictated the contents of Article 50, au- thorizing the Regional Committees of WHO to recommend the adoption of regional budgets, made up of supplemen- tary contributions from the govern- ments, so as to cover the special needs of each region. Dr Brock Chisholm, the first Director- General of WHO, and Dr Soper, the Director of PASO, together hit on the right formula enabling the Pan American agency to unite with the world agency while maintaining its financial autonomy and the same organizational structure which it had evolved over the years. On 1 July 1949, the agreement between the two organizations was signed in New York. The Pan American Sanitary Con- ference and the Directing Council were kept intact, to act as a Regional Commit- tee of WHO for the countries of the Americas. The Pan American Sanitary Bureau did not change either, but was constituted a Regional Office of WHO. The Executive Committee continues to function, with responsibilities similar to those of WHO's Executive Board. The Pan American Sanitary Organization was henceforth to be known as the Pan American Health Organization—PAHO. Thus over the course of the years, and with all the trials and errors that are common to human activities, we have arrived at a fellowship of ideals and an integration of policies and programmes that aim to bring health within the reach of all the populations of the world. On looking back into the past and looking forward into the future, it is alarming to see how close we are to the year 2000 and how opportune it is to recall the forecast of a Latin-American health expert, Dr Daniel Orellana. Writ- ing in the Bulletin of the Pan American Sanitary Bureau in May 1972, he predict- ed : "The year 2000 will confront the in- ternational health organizations with serious problems of coordination at the institutional level and of simplification at the administrative level; yet even these will not be as serious as the ancient dilemma of whether to give preference to the requests of Member States rather than to the organizations' own initia- tives. The situation will continue to be dominated by the conflict between what is asked for, what can be offered, and what really can and ought to be done." ■ 13 ERVICIO NACIONAL OE .5ALY: my land, my people, my mission A HEALTH WORKER IN A REMOTE AREA OF CHILE DESCRIBES HOW TRADITIONAL HEALING CEREMONIES BY WITCH-DOCTORS CALLED MACHIS HAVE GIVEN WAY TO VODERN MEDICAL CARE by Florencio Huenurnan Casa de Piedra, where I work as an auxiliary health worker, is in a beautiful mountainous region in Chile through whose virgin hills and valleys the mountain lion still roams as a king. The beautiful flower Copihue grows profusely, and from its fruit we make teas called guauhue and yepu. There are no rivers here, only crystal- line streams and pools. Their water, fil- tered in the sand and rocky beds of swift mountain brooks, is delicious to drink. Where the brooks cascade into the sea, the pounding surf at high tide makes it impossible to use fishing boats. But at low tide, the people gather shellfish, some for their own use and some to sell in the upland town. The trip to town is long and arduous, taking sometimes as long as three or four days on horseback or in carts. The pea- sants make the trip not knowing to whom they can sell their catch, when they will return, or what might happen to them or to the animals they depend on for their living. The long-suffering campesinos in the coastal communities of Cautin Province have lived and worked in this way for many years. When it is properly fertilized, the land here produces everything we need. We grow potatoes and wheat. Sometimes the potato harvest is so large there is no mar- ket for it, and we have to feed the pota- toes to the livestock. The head of each family owns about 10 animals and 12 chickens. The food supply is irregular, and the people often eat the same food, over and over. Their dietary habits are improving only slowly. In former times, all the local commu- nities had machis, or witch-doctors. Of- ten they were women. They prayed for what the people wanted, and healed the Above: The simple plaque of a rural medi- cal post in Chile. Opposite page: Persuading the reluctant soil to produce rich crops is hard work, for man and beast. Yet when properly ferti- lized, the land can produce everything the local people need. ( Photos WHO/ P. Almasy) sick with special ceremonies. The com- munity would get together and decide what it would ask from God ; if it was a dry year the people prayed for water, and if there was too much rain, they prayed for sunshine. If there was an epidemic of disease, they prayed for the sickness to end. The machis would speak with God, and then would tell the community what had to be done. In order to pray for rain, for example, they would have a guillattin or rain ceremony. They placed black flags on a cinnamon tree, and asked the people for black horses and two or three head of black cattle. Then they went to a high waterfall and shouted and splashed water on one another, and danced, pray- ing for rain. This ceremony lasted two or three days. It was very costly for a campesino to have a guillatim performed. He had to kill one or two sheep and provide food for his friends who were going to take part. When someone was sick, an article of his clothing was taken to the machi, who slept with it to find out what was wrong with the sick person. The machi usually said that the illness was the work of powerful sorcerers, and he or she had to go to the sick person's house to cast out the demons. The sick person might be placed be- tween two cinnamon bushes, and his family would call in ten or more neigh- bours, each carrying a stem of a leafy 14 f -.t . A.,...„, A ,s, / ,. „,,,,,,,'". . ,,,i, 7 . —,:.'"4 ' , ' . 111 i t .,, .', . i ',, ..t. (6“ J._,, .. ,., c . (i f • r -,..----4 ' .'... \ ..., ‘. .. .. , .. t ;, ,, .,4 . i to *'' ''.t.,.., 1 7i • # / 1 • , : .,, '.1 ; , -,/... • ,s ir, j.., f. .4. /./. . ,,, 4 ,N,—,...i=to .„. , 4. , ...,-..r ., . ,t....,.. . .*S • ',.. L4t4in;ft • ' 7•-• x..- *%$'114 " lfq iP41 „la:Age. 0 At' ; 411/t Olt _riklallt. 1,0 ate, mi's=vt, Aotte?` my land, my people, my mission Left: A mirror rej7ects patients waiting not without some anxiety—to describe their ail- ments to the health worker at a rural medical centre. Right: Ensuring supplies of safe water for rural communities is a perennial problem. An integral part of the auxiliary health worker's job is to instruct the local populace about the importance of personal hygiene, the clean preparation of food, and the need for proper waste disposal. (Photos WHO/P. Almasy) creeper called colihue. The machi was the leader and doctor, while two captains were appointed as assistants. The sick person's family prepared meat or other food, wine for the machi and a drink called chicha for the assistants. Now the ceremony began. The machi called to the spirits, played an instrument called a cultrun, and sang. Some distance away, the others would shout an accom- paniment. The machi divined what illness the sick person had, who had made him ill, whether he could be cured, and whether the sickness was going away. The machi usually said that the sick per- son had been poisoned because someone had given him bad food. In this case, the sick person would be operated on. Some- times, the machi said the spirit of the sick person had gone from his body, and would call to the spirit until it returned, or would "send some stones to the sky". The stones would find out what remedy the sick person needed. The young people of today no longer believe in these things. But because of such beliefs and this way of life that I have described, the people of our com- munities led lives of poverty and back- wardness. While my father took part in these things, and while the machis came to our house to perform the ceremonies, there was poverty and misery. When I was 16 years old, I told my father what I thought of this, and from then on he no longer took part in the ceremonies. His economic position at once began to im- prove because the sheep that previously had been killed for the guillatan now reproduced and the herd grew. Today the guillattin is only a charming fiesta, or a show of belief in our God. Casa de Piedra had a severe epidemic of measles in 1970, and 37 children died in 40 days. Families lost one, two and even three children. At that time, chil- dren received no vaccination from birth up to the time they started school and there was no medical care available. In 1974, a miracle happened. The National Health Service came to Casa de Piedra and began to solve our health problems. I was chosen to be trained as a health auxiliary, and began an eight- month course in the city of Puerto Saave- dra. Then complete health supplies were flown in by helicopter. The community provided a house that the campesinos themselves had built as a first-aid station. There I began my duties as health aux- iliary for this sector. I always have plenty to do. The station in Casa de Piedra serves some 1,800 peo- 16 ple from nine communities. These people have access to the Carahue hospital when I refer them there. My job is to give the people instruc- tion in health problems, cess-poll sanita- tion, prevention of disease, and diet. The people must be made aware that proper food prevents disease, and that a good diet means eating a variety of foods dur- ing the week rather than large quantities, since our bodies need all kinds of nutrients. I also visit the school to check on the children's personal hygiene. If this had been done 20 or 30 years ago in the iso- lated areas of Chile, the people would be more intelligent and vigorous. If we look back only 10 years we real- ize that a great change has taken place in Casa de Piedra. Then, machis performed their ceremonies for a child who was showing symptoms of worms. Now the child is taken to see the auxiliary health worker at the health centre. The health worker examines him, talks with the mother, gives a remedy, and the disease is cured. Today, of every 100 children born, only two or three, or even fewer, die. In the old days, 10 per cent of them died. In 1974, only four children died in the nine communities, and in three of these cases, the health worker was not in the area. The fourth fatality occurred because the mother did not follow instructions : the auxiliary insisted that the child should be taken to the hospital, but the mother refused. This kind of problem has now been largely solved, and when the health worker refers patients to the hospital, the campesinos comply, and as a result fatalities do not occur. In 1975, only two children died, both from dystrophy. There were also only two deaths in 1976: one 11-month child, from broncho-pneumonia, and another child, aged five years and seven months, who was diagnosed as tubercular. Despite all that has been accom- plished, much remains to be done. The health workers are doing a fine job, but could be given more help in running the rural centres. The National Health Ser- vice might send people to the rural areas to watch the health workers in action and see for themselves the needs that still exist. The rural health plan is a very good one. It is the only way the National Health Service can reach isolated areas. Our hope is that, God willing, Chile will be able before too many years have gone by to eliminate its health problems. ■ 17 elected by the community THE HEALTH AUXILIARY IN PERU VUST SERVE ALL WHO NEED HIS HELP-"EVEN IF THEY ARE NOT HIS FRIENDS"-AND VUST RESPECT THEIR CONFIDENCES AS A PRIEST WOULD A CONFESSION by Paul Harrison r p' G• r%'p High in the Peruvian alti- 4.111• • piano of Puno, days can be n scorchingly hot under the n • • . 11 • tropical sun. But in the cold nights, frosts, icy winds and driving rain kill off one in three of the young llamas and alpacas—animals bred for the low temperatures. How much harsher, then, is this treeless, infertile habitat for human beings. The hardy Aymara and Quechua Indians, who scrape a precarious living here, have no time for self-pity. Women and children go out before dawn, in all weathers and often barefoot, to pasture the family herds—more concerned about the ani- mals' health than about their own. In contrast to most tropical areas which are low lying, here respiratory ill- nesses such as pneumonia, whooping cough, and tuberculosis cause four times more deaths than gastro-intestinal com- plaints. Infant mortality rises and falls with the harshness of the weather; local health officials believe that the rate in rural areas is as high as 500 per 1,000. Often you see children with their angelic round faces scarred by rows of chil- blains. Many factors about the Puno region point to the need for a community-based health delivery system to cope with these health problems. Away from the over- crowded shores of Lake Titicaca, the population is sparse and the few urban centres with health facilities are far away down dirt roads with only rare lorries for transport. Cultural and economic obsta- cles are equally powerful barriers against the penetration of formal health services. With an average income of only US $44 per head, Puno is one of the poorest regions in Peru and local people cannot readily afford fares or doctors' fees. Nearly two-thirds of them speak no Spanish—the language of doctors and hospitals. They patronize, instead, traditional healers who use incantations, occasional sacrifices, coca to deaden pain, and her- bal remedies—some effective, some use- less or even harmful. Superstition pre- vails in local views on the origin and treatment of disease : they see illness as caused by evil humours, diarrhoea as due to catching cold. Traditional midwives seem more concerned with such rituals as burning rubbish on the threshold or put- ting crosses of straw on the mother's sto- mach than with cleanliness. More than a third of them use broken glass, stones or knives to cut the placenta, contributing (along with poor health) to the maternal death rate of 8.7 per 1,000 live births. More than half the population of the region have no access to the formal health services. The provision of medical personnel is extremely low even by Third World standards—one doctor per 22,000 population—while rural areas are almost entirely deprived. Three-quarters of Puno's 42 doctors, along with 43 of the 44 nurses and all the 8 dentists are concentrated in just three towns. Few qualified personnel are willing to live and work in the villages where the need is highest, but where the facilities their westernized education has led them to expect in life are entirely lacking. As one of the poorest regions in the country, Puno was chosen as the location for an integrated development approach in Peru's national development plan for 1975-78. If the economic and human resources were to be fully developed, then clearly health would have a major role to play in eliminating the debilita- tion due to illness and malnutrition. So the Peruvian Government drew up, in conjunction with wxo and UNICEF, a tri- partite plan to improve the region's health services. UNICEF was to provide most of the outside finance, $1.5 million going towards equipment, transport and training. The plan set itself certain objectives. Overall, the aim was to increase the coverage of medical services by 25 per cent in five years, and to push up the pro- portion of the population covered by simplified medicine from 22 per cent to 40 per cent. Other specific targets were laid down, including an increase of 40 per cent in pre-natal attention, of 60 per cent for children under one; the halving of mortality from tuberculosis; vaccination of all nursing mothers and one in five pre-school children. There were some novel features too. Drinking water, currently available to fewer than one in 50 of the rural population, was to be supplied to one in eight. In many set- tlements, this would be achi6ed by way of a highly "ecological" water unit—a wind-pump to raise the water, and an array of solar panels to heat it. Most alti- plano peasants don't like to wash too often because the water is so cold. Nutrition was an important aspect of Near the shores of Lake Titicaca, in the Peru- vian altiplano, a skilled weaver works at her brightly coloured cloth. (Photo WHO/ P. Harrison) 18

the plan. In the rural areas, between 75 and 90 per cent of all pre-school age chil- dren show some degree of malnutri- tion—with all that entails in lowered resistance to disease and retarded mental development. The local diet is based heavily on potatoes, with very little meat or vegetables : insufficient in protein, vitamins and even calories. The nutrition programme will seek to provide an extra 450 calories a day and 30 grammes of protein for two-thirds of the school- children. These are the quantities by which their normal diets fall short of recommended levels. But it is not enough to supply food, like charity, to passive recipients. The programme involves a strong element of community participation. Local nutri- tion committees are being formed in each area, while schools and families will be helped and encouraged to start up vege- table gardens and rabbit or chicken farms, so people can improve their diets by their own actions. A key element in increasing the cover- age of the health services is the primary health worker : the voluntary health aux- iliary. Trained to overcome the multiple obstacles to the penetration of health services which were mentioned earlier, these auxiliaries are local men or women, speaking the local language (though they must be able to read and write Spanish): people already known and trusted, and easily accessible for consultation. I saw how health auxiliaries were working in Pilcuyo district, a densely settled area of smallholdings by the reedy shores of Lake Titicaca. Strong elements of community participation are built into their methods of work. Victor Charca, a 24-year-old farmer, was elected (as all auxiliaries have to be) at a village meet- ing of the 92 families of Machajmarca, thus ensuring that he was not imposed on the local inhabitants from above. Charca spends about two hours a day on health work, but receives no Govern- ment salary: instead, his services are paid for by his patients. The community itself has to meet to decide on an appropriate scale of fees and charges for drugs: in Charca's case a consultation or cure costs 5 soles (about 7 cents), a night visit 10 soles. Penicillin tablets come some- what expensive at 8 soles each—almost equal to the daily average income, which may prove a deterrent to using them even when they are needed. The third—and perhaps most telling— element of participation in Charca's work is the fact that the community built with its own hands the smart, mauve- painted, tin-roofed building that serves as his community health post. Each fam- ily—some of them very poor—contrib- uted between 150 and 500 soles ($2.20 to $7.35) towards the 15,000 soles cost. In- side the long one-roomed building, woo- den benches line the walls for patients to wait on. At one end, overlooking Char- ca's table, the words "Welcome to Machajmarca" are written alongside pic- tures of the heroes of the Peruvian revo- lution—General Velasco and Tupac Amaru II. Charca has made a handwritten poster for his patients' guidance, listing the ser- vices offered by the health auxiliary : "Sanitary education, home visits, first aid, tuberculosis examinations, vaccina- tions, attendance at births, supply of medicines, personal medical attention, coordinates with local authorities and institutions, daily and monthly reports A children's cemetery lying among the barren hills of Peru testifies to the heavy toll of infant mortality. (Photo WHO/P. Harrison) on activities." Next to this poster he has pasted 10 handmade drawings (done on his training course) showing, month by month, what foods mothers should feed to their babies. In fact, Charca's functions are broader than this brief catalogue suggests. He provides attention to mother and child, with pre- and post-natal care and advice, as well as acting as midwife at the birth. He can give vaccinations against tuber- culosis, measles, polio, smallpox, yellow fever, rabies (when needed) and a triple dose against whooping cough, tetanus and diphtheria. It is his responsibility, too, to organize vaccination campaigns to inform and convince people of the need for immunization. He promotes sanitary improvements—latrines, or fil- tration of water—and tries to teach his community, by way of meetings and talks, to prevent disease by good hygien- ic practices : urging them to wash their body every day, wash hands before eat- ing, wash plates, wash and change clothes regularly, clean the house fre- quently, keep animals in their corrals, throw rubbish in covered containers, protect food against flies, and so on. As he goes along, he keeps a continu- ing census of births, illnesses and causes of death. And he is, of course, trained and equipped to deal with the most com- mon and straightforward ailments, such as diarrhoea, pneumonia, aches and sprains, wounds, eye infections, stomach pain, anaemia and skin complaints. Where a case is outside his competence, he must refer it to the nearest health centre. Charca's diary—beautifully written in flowing longhand—records some of his Above: A village midwife uses a simple but effective hearing aid to listen to the baby's heart-beat. ( Photo WHO/ Y. Pouliquen) Right: Children being taught the habit of washing their hands regularly before eating— another task for the voluntary health aux- iliary. ( Photo WHO/P. Harrison) activities: 7/11/76—cure a burn, injec- tion; 10/11/76—vaccination campaign, 30 children, polio, BCG, triple; 2/12/76—talk on menstruation. While I was at Machajmarca an old man, wear- ing a thick brown poncho, stocking cap and hat, walked slowly and deliberately up to the community health post and waited patiently until Charca had finished chatting to me. He had come for a consultation, complaining of pains all 22

elected by the community over his body, and inability to eat or swallow. Charca was sensible enough to admit to doubts about the diagnosis, and decided to refer the case to the health centre about three miles away in Pilcuyo. Charca's transport is represented by a bicycle (paid for by UNICEF). His basic equipment allows him to deal with the most common eventualities: the aux- iliary's kit consists of basic drugs like analgesics (in pill, syrup and injectable form), a few antibiotics and sulpha drugs, alcohol, antiseptic, cough mix- ture, eye ointment, chest rubs, as well as cotton, gauze, hypodermic syringes and needles, scissors, thermometers, steriliz- ing dish and two planks of wood to make a stretcher. It is his responsibility to keep the kit fully stocked, and he can of course add extra medicines if he finds them useful. One of the most important items of his equipment is his "Health Auxiliary's Manual". Its 110 cyclostyled pages be- tween a green cardboard cover contain, in simple everyday language and illus- trated with graphic cartoons, a complete guide to all the subjects Charca covered on his initial training course : basic anat- omy, prevention and sanitation, first aid, hints on diagnosis, and how to treat the most common diseases. For every medi- cament in the auxiliary's kit, correct indi- cations and dosages are given. It is an object lesson to contrast this with the huge textbooks of conventional medi- cine, and shows how relatively little spe- cialized knowledge is needed to cope with 90 per cent of health problems. The text also gives more general ethical guid-, ance : the auxiliary, for example, is ex- pected to attend to all those who need his help, "even if they are not his friends". He will not talk about his patients' ill- nesses to other people and must keep their confidences with the same trust as a priest would a confession. He must warn patients about the dangers of overdos- ing, in case they think, as many do, that two tablets must be better than one. He must avoid deceiving them by leading them to expect a cure too early. The manual does not entirely dismiss the work of traditional healers—with whom the auxiliary will have to find a modus vivendi if he is to avoid damaging conflicts. It explains that healers work. partly by suggestion, partly by the effec- tiveness of some of the herbs they use. Auxiliaries are encouraged to keep on good terms with them, but also to try to persuade them to send over the patients 24 whom they cannot cure. This coopera- tion will be an important factor, for if the health auxiliary came into open conflict with the healer in the early stages, the sympathy of most local people would probably lie with the healer. But Charca seemed to be making headway at Machajmarca, establishing himself in people's minds as a genuine source of help and advice, slowly begin- ning to suggest the changes in lifestyle that could prevent so much disease. The element of community participation, plus his own roots in the local communi- ty, made that task much easier. It will be his job to persuade villagers to undertake the collective improvements—sewage, piped water and so on—that will im- prove health. There is a health commit- tee in the village to back him up. Like most Peruvian Indians, Victor Charca was a quiet, reticent young man with strangers : but when questioned on basic health matters, he seemed to know his stuff. In case some auxiliaries do not, the programme has a built-in element of supervision. Each auxiliary is supervised continually from the beginning of his training and, every month or two, must attend refresher courses, sit exams to test his knowledge and keep it active. He (or she) has to keep a diary of patients seen, reported symptoms and action taken. He must show this regularly to his supervi- sor, who can then judge if he is on the right lines, or correct him if he is going wrong. The auxiliary has no automatic job security. On the contrary, his official card will only be renewed each year if he does his work to the satisfaction of his supervisors, and of the community (who have to re-elect him). This element of supervision is a key one if the pro- gramme is to succeed. It would be easy for an auxiliary in a far-flung rural area to make errors, even grave ones, which could destroy the basis of trust on which he or his successors must build. In order to create confidence among people wh o have never known modern medicine, it is essential that the voluntary health aux- iliary's work should be effective and competent. ■ ...An old man walked with difficulty to the> health post, complaining of pains all over his body, and inability to eat or swallow. The health auxiliary sensibly decided to refer the case to the nearest health centre... (Photo WHO/P. Harrison)

health: a right and a duty for all COMMUNITY PARTICIPATION IN HONDURAS IS AN INEXPENSIVE SYSTEM WHICH FOSTERS IN THE COMMUNITY ITSELF A SPECIAL SENSE OF HEL- PING TO IMPROVE ITS OWN PEOPLE'S WELFARE by Enrique Aguilar Paz Seventy-five years ago the oldest regional health or- ganization was founded. Its splendid objective was to watch over the health of all the peoples of the Americas. The initial activities of the Pan Ameri- can Sanitary Bureau were beset with problems and difficulties because of the technological shortcomings at the begin- ning of this century, the isolation of vast regions of the Americas that had not yet developed an infrastructure, and the low cultural level of many communities, still barren of any educational system. But the indomitable spirit of men of vision prevailed over all these handicaps. These individuals took advantage of the scien- tific advances being made at a variety of research institutions in the health field, and began to discover formulas for solv- ing the many different and complex problems. Over three-quarters of a cen- tury, the achievements of PAHO have been undoubtedly positive. In order to score so many successes, action has had to be undertaken within the framework of an organization which is continually undergoing change and improvement, implementing its activities at the regional level and deploying the most modern methods and systems. At the same time, a great army of highly competent officials and experts in public health matters has been recruited and trained. The method of operation has involved coordinating activities between the health officials of each member country, so as to bring about considerable techni- cal assistance in the context of the re- spective social development plans freely created by each country on the basis of its own needs. By means of this well-coordinated sys- tem, PAHO has been able to increase its complement of officials who are needed in large numbers in order to implement the many health programmes established in the American continent. Yet if we delve more deeply into the fine task performed by PAHO, we note that a new and highly efficient official has quietly and almost simultaneously in the dif- ferent countries been incorporated into this huge undertaking. This new "offi- cial" is the community itself. The formal title of this valuable entity is "Community Participation". This in- novation overthrows the traditional concept of the community as a passive recipient and offers instead a new notion—that the community itself can contribute to its own welfare. This idea also radically changes the guidelines laid down in most manpower development programmes. By proposing to recruit and train members of the community at the appropriate level to carry out func- tions in the sphere of health, we are starting a movement to transform all the peoples of the Americas into co-partici- pants in health activities. At first glance In a small Honduran village, a young mother> comes to the Health Guardian for advice. Elected by his own community, the Health Guardian has a key role to play in it. ( Photo WHO) 26

such a situation may seem utopian, but nevertheless it is not impossible. In Honduras, a small country of Cen- tral America, the government has placed special emphasis on the health sector within its social programmes. The government has set aside a relatively high proportion of its budget to create the physical structure of a formal health service system, paying special attention to coverage of the rural areas. As a result of our experiences, we have discovered the great importance of incorporating a new type of worker into our health teams, namely those members of the community who offer their cooperation voluntarily and without charge, in accor- dance with the standards established by the Ministry of Public Health. There are now three kinds of people cooperating with us in this way : (a) the community representative, (b) the "Health Guar- dian" and (c) the lay midwife. The first two are selected by the community itself, which also reserves the right to replace them if necessary. The community representative is a born leader of the community. His main duty is to participate actively in health promotion. He also provides valuable logistic support, arranging transport and board and lodgings for visiting teams of health officials in remote towns and vil- lages which have not yet established their own services. This is invariably done in a routine and businesslike manner for the visitors. The community representative makes an invaluable contribution towards building the most basic health care units in our organizational struc- ture— the Rural Health Centres. He also cooperates in other basic health activi- ties, including even improving roads and building bridges, and has become an important factor in such environmental health programmes as latrine-building, disposal of solid wastes, and providing water supplies. The Health Guardian is also selected by the community, and plays a leading role in it. He is required to know how to read and write so that he can undertake the necessary training and can form a link in the information network which is a vital part of epidemiological surveillance. Usually the person chosen is keen on first aid, and in some cases has already practised traditional healing in districts < Another job for the Health Guardian. This community health worker decided that the swollen finger was not within his capacity to handle, so he referred the case to the nearest health centre. ( Photo WHO! R. Hamilton) not yet reached by permanent staff sent from the Health Ministry. The Health Guardian receives first aid training, and is taught some basic guidelines for treat- ing the main diseases which are endemic to his region. He learns to collaborate closely with the auxiliary nurse attached to the Rural Health Centre (CESAR, as it is called in Honduras). Guidance is given on the referral system for cases which are beyond his capacity to handle, and a handbook lays down the precise limits of the health services he is able to provide, while his instructions include an account of the data which he must pass on to the auxiliary nurse, so as to expand the range of the epidemiological surveillance sys- tem. He is provided with certain first aid materials and basic drugs enabling him to offer medical treatment to patients showing early symptoms of such com- municable diseases as can be controlled at this level, when treated in time. The Health Guardian also plays a part in health promotion and health education programmes by fostering better hygiene habits among the inhabitants in his area. The third type of community health worker is the lay midwife. In Honduras, a chiefly agricultural country where 70 per cent of the population live in rural areas, assistance for mothers-to-be has since pre-Colombian times been the re- sponsibility of local midwives who have learned their skills according to tradi- tions passed down from family to family. In the not too distant past, with the advent of specialist doctors, a campaign began to prevent lay midwives from practising. However, the same specialists are to be found only in the country's main cities and as a result the lay mid- wives have continued to operate in rural populations without any kind of control. We adopted a policy aimed at changing this attitude towards these health work- ers whose services are so vitally needed today. Lay midwives are given training courses in their field which emphasize the importance of avoiding infection and instruct them when they should refer complicated cases to a higher level of medical care. They are also provided with a complete, up-to-date kit for at- tending births. All the community volunteers remain under constant multi-disciplinary super- vision. They offer their services com- pletely free of charge, and this they feel gives them special prestige in the eyes of the community. The fact that no salaries are paid makes community participation in Hon- duras an inexpensive system that could easily be applied in developing countries which face severe financial limitations in expanding their health service coverage. On the other land, the system fosters in the community itself a special sense of contributing towards improving its peo- ple's welfare. Nearly five years ago when I assumed responsibility for the health situation in Honduras, it quickly became clear that no substantial improvement in the health of the Honduran people could be expect- ed if we could only count on the scant human resources of our traditional team of health personnel. We were struck by the efficient way in which local commun- ities, through a system of volunteers, had collaborated in the campaign against malaria, and felt that these communities could also provide us with "volunteers" for promoting and strengthening other programmes, including individual health care services. This creative approach es- tablished a philosophical principle which was later to guide our work methods. If our communities have the right to receive health care from the government, they also have the responsibility to par- ticipate in these same health activities. A new motto was coined in the Ministry : "Health: the right and the duty of all". Soon this theoretical concept was ap- plied in practice and, as the latest evalua- tion has shown, the results have been very satisfactory. At the same time, we have been eradi- cating the deep-rooted "paternalism" which tends to stifle community initia- tive. Through participation, the mem- bers of the community see health activi- ties as the result of their own labour and therefore they support these activities, keep an eye on the way they develop and take a personal interest in them. We in the Public Health Ministry of Honduras have come to rely on the valuable cooperation of PAHO—now a veteran in the field of health care. PAHO'S representatives, technicians and consul- tants have dedicated themselves whole- heartedly to solving our country's vital health problems, and their collaboration and cooperation with Honduran officials have always been harmonious. Out of these coordinated activities has emerged a solid phalanx of fighters in the cause of health. In this remarkable army, the front line is manned by the local people of the community. So we have witnessed an extraordinary phenomenon in the shape of greatly in- creased human resources for health. On the occasion of PAHO'S diamond anniversary, a new and proficient mem- ber of the health team has made its presence felt in the Organization—the community itself. ■ 29 Guaquitepec against the measles TO SAVE THE CHILDRE\, A CO V VU \ITY IN SOUTHER \ VEXICO FOR THE FIRST TI V E SET ASIDE ITS SUSPICIO \ S AND WORKED FOR THE COV MON GOOD ON A PROJECT STARTED BY AN OUTSIDER by Fortunato Vargas-Tentori Around midnight, the peace and quiet of Guaquitepec were shattered by the cla- morous barking of the vil- lage dogs. Two strangers were approaching the town at the end of a four-hour ride on mule-back. The arrival of Dr Maximino Leon with his guide on 7 February, 1976, was to change the life of the town. Dr Leon, who at 26 years of age had recently graduated in medicine, had come to practice in Guaquitepec. Mexican law requires physicians to serve a year in a rural area before they can be profession- ally registered. Dr Leon was to provide medical care for the 3,200 people living in 476 scat- tered houses over an area of nine square miles. He would also be responsible for the 29,000 inhabitants of Chilon Munici- pality in the State of Chiapas in southern Mexico, close to the Guatemalan border. The young doctor fell asleep that night firmly convinced that the world was round. He awoke in the midst of people who still thought that the world was "flat and sustained by four gods". According to local belief, "to combat a plague of locusts, the important thing is to set off firecrackers and to pray". Just as in bygone centuries, natives of the area continue to believe that dreams are omens, that dancing can bring rain, and that blowing and touching are excellent ways of treating disease. The Tzeltal people who inhabit this area are descendants of the ancient Mayan civilization which flourished be- tween 1300 BC and the 16th century. They comprise 95 per cent of the popula- tion of Guaquitepec. The remaining 5 per cent is made up of "ladinos"— people of mixed blood who yet have adopted most of the customs and the traditions of the Tzeltal people. The Mayan civilization, swept away forever with the coming of the Spaniards in the 16th century, was the most highly developed of the New World cultures. The Mayans were deeply religious and had a great love for beauty and order. Their discipline and strength of character enabled them to conquer the jungle and to develop their extraordinary culture. Dr Le6n was familiar with this back- ground when he arrived in Guaquitepec. He was to find that these Mayan descen- dants still preserve many of the ancient customs. Grouped together in small close-knit communities, the Tzeltal peo- ple follow the traditional Mayan belief that the individual is an integral part of the whole people. They live close to nature and view present, past, and future time as a single fused entity. All share in the work and take part in the social life. Soon after his arrival, the doctor made contact with the Council of Elders whose function is to guide the people, make inportant decisions, maintain civil order and serve as a repository for the old traditions. He also met with the village leaders who carry out administrative functions, and with the capitanes, who are in charge of religious celebrations. In addition, he contacted the "vigilance committees" which cooperate with the government authorities in applying the law, as well as other officials in charge of health, roads, schools and parishes. Through his contact with the people, he learned that there were two ele- mentary schools in the area with 318 students. Despite an adult education programme, the illiteracy rate among adults was still high. In accordance with ancient traditions, informal education takes precedence over formal schooling since the Tzeltal gains all his practical knowledge from nature. From his dealings with the peasants, ... Of the 40 recorded cases of measles in the I> village, 33 were treated at the convent and recovered. Of the seven whose families refused help, two died ... ( Photo WHO/UNICEF/J. Weisblat) 30

Guaquitepec against the measles Left: ... Another dream of the people in this little community in southern Mexico, practi- cally cut off from the outside world, was to bring water from a spring 300 yards away to a central location where it would be available to all ... Right: ... There were two elementary schools in the area with 318 students. But despite an adult education programme, the illiteracy rate among adults was still high ... ( Photos WHO/UNICEF/D. Mangurian) Dr Leon could see that they conti- nued to follow traditional methods of cultivation. The Tzeltal people believe that the soil should rest for a year follow- ing two consecutive harvests. As soon as the boys of the community are old enough to work in the fields, they join the ranks of the young men who work shoulder to shoulder with their fathers. Most of the production is con- sumed by the community itself, and the land is held in common ownership. Com- merce is entirely in the hands of ladinos though a local cooperative and a govern- ment-subsidized store sell produce at reduced prices. The average daily income of the Tzeltal is 15 pesos (US$1.75), as compared with 30 pesos for the ladinos. Practically cut off from the outside world at the time of Dr Leon's arrival, Guaquitepec had very little in the way of communications. Mail arrived twice a week, and only two or three people had battery-operated radios. The town itself was very primitive. Most of the houses were made from plaited twigs, though some were made of brick, wood, or adobe. Very few had separate kitchens, and only half had windows. Overcrowd- ing was considerable. Meat was scarce, and the basic diet consisted of corn, beans, coffee with brown sugar, seasonal fruits, a few cooked vegetables, and an occasional egg. Dr Leon found little to distinguish the health conditions in Guaquitepec from those in other rural areas of Latin America. Statistics on morbidity and mortality were non-existent, but in deal- ing with the people, he was soon able to identify the most common health prob- lems among children under the age of five as gastroenteritis, diarrhoea, para- sites, common contagious diseases, skin diseases, accidents, complications from childbirth, and secondary malnutrition. He discovered that the population had its own firmly established treatments for specific diseases. The most frequent ills— diarrhoea, dysentery, coughs, scabies, stomach-aches, rheumatism, wounds, and fractures—were treated with a wide range of roots, leaves, flowers, and bark. Healers and "witch-doctors" made the diagnosis and gave treatment according to age-old customs. A health centre, built by the community, was not well attend- ed, mainly because the physicians came and went within the space of a year, failing to win the confidence of the peo- ple that was needed in order to introduce new medicines and new habits. For Dr Leon, things went differently. It all began one night shortly after his arrival when someone knocked urgently at his door. Though he hadn't yet mas- tered the language, Dr Le6n realized from the man's gestures that something serious had happened. In torrential rain, he followed the man for an hour until they reached a house. Opening the door, he saw a 30-year-old woman lying on the floor covered with blood. A deep wound in her leg left bone, tendons and muscles exposed. Dr Le6n administered first aid treatment, then asked the family to help him carry the woman to the health centre. To his sur- prise, he found the family united in their opposition. Finally, after much insistence, he managed to convince them that it was a question of life or death. They impro- vised a stretcher and slowly carried the woman back to the town. The doctor hurriedly started up the electric genera- tor so that he could begin to reduce the fracture, tie up the blood vessels and suture the muscles and skin. With diffi- culty he persuaded one of those present to wash his hands, disinfect them with alcohol and assist him. Forty-five minutes later came another delay... The gasoline had run out in the generator, plunging them into total dark- ness. Under the flickering light of a burning log, the doctor quickly covered the wound, shed his surgeon's gloves, and dashed out in search of fuel. He managed to get half a gallon from the local store. Close to four in the morning, the operation was over. Not long after- wards, the patient recovered. From then on, Dr Leon's reputation began to grow. Everyone talked about him, and a few of the local healers even began to send him their more difficult cases. In a short time, the doctor had learned enough Tzeltal to enable him to talk with the people and learn about their basic needs. The people confided that one of their great dreams was to finish the 17 miles of road they were building so as to link up with the highway leading to San Cristobal de las Casas, the district capital. Another dream was to bring water from a spring, 300 yards away, to a central location where it would be avail- able to all. People began to ask Dr Leon for advice on how to improve their corn crops or to prune their fruit trees. One day in May, some women came to the health centre with two children who appeared to be suffering from measles. 33 s ,•46 * OS,' • r4r 444 ••• 4444.• e , • r'• +46,4 .Alit '0; „• ■‘.4.• 1** " t 4 • #. 4,0 vor . - • 31111 • • 4/1 tia 4 ,E • e • t " • *44. ."`",, t`*-- ' -44 4 .4 44. • ti. • Guaquitepec against the measles After a few days, there were ten con- firmed cases, and within a week twelve more fell sick. Many children were seriously ill and the inhabitants began to be alarmed. In an unusual gesture, the village lead- ers went to the doctor to ask for his help. Aided by a young Tzeltal nurse, and by what he had learned of the language, the doctor was able to discuss the situation with the authorities. He explained that it was impossible for him to take good care of 25 sick children while going from house to house since their homes were widely separated. He insisted that it was important for all the children to be con- stantly supervised so as to treat the seriously ill while preventing others from developing complications. What he then proposed was the improvisation of a modest hospital where the entire com- munity could assist in providing care. The idea of using the school was rejected since this would involve suspending classes. Other buildings, such as the health centre or the place where the village leaders met, were all too small. Finally, they settled on the convent— in other words the church. This would be the first time that it had been used for anything other than religious purposes. Following their custom, they put their dilemma before the council of elders. Once the elders had given their approval, the priest and the church authorities also consented. With great ceremony, they then called for the keeper of the keys to open the convent door so the patients could be moved in. For the first time, the entire community had set aside its suspi- cions, and worked for the common good on a project started by an outsider. However, the problems were only just beginning. Medicines, personnel and funds were all in short supply. Besides treating the sick, the confidence that had already been won had to be maintained. Skilfully, Dr Leon organized what he called "Guaquitepec against the ... Once the measles outbreak was over, the people showed that they were interested in continuing to work together. Thanks to one of these cooperative projects, water was finally brought to the village centre ... (Photo WHO/E. Schwab) Measles". Doctor and villagers joined forces to carry out the campaign which they divided up into different tasks : while some cleaned out the convent, mes- sengers travelled throughout the area explaining to everyone the decisions and actions taken jointly by the doctor and the authorities. The town hummed with activity. Mothers hugged their sick children in their arms while others came and went with cleaning utensils. Some took charge of bringing water from the well or with supplying beans, tortillas, coffee, fruits and vegetables. Others boiled water and prepared the food. One group was to accompany Dr Leon on his trip to San Cristobal de las Casas to request help from the health unit and other assistance organizations. There they were given medicines, serums, gaso- line for the electric generator and other vitally needed supplies. Three of the people who volunteered to help care of the sick children were practitioners of traditional medicine. Each was assigned a specific function or responsibility, such as supervising the giving of medicine to the 33 children. The hospital treatment was consolidated by traditional practices. Every after- noon, people would come to pray togeth- er with the Yax cha'abtay, or reciter of prayers, who called on the saints to intercede "before the Supreme Being for the souls of the stricken children". During several days of intensive work, traditional and modern medicine joined forces. Thermometers, stethoscopes, capsules, serums, and injections were complemented by the cleansing of the sick with the branches of medicinal trees, and with blowing and special prayers. Together the two kinds of medicine not only cured the measles, but they also brought peace and hope. The people and the doctor were united by a common objective: to save the children. The experiences of that period—from 11 May to 4 June when the last patient was released—were memorable both for the doctor and for the community. Of the 40 recorded cases of measles, 33 were treated at the convent and all recovered. Of the seven whose families refused help, two died. Day after day, as Dr Leon was able to release some of the children, a tender scene was repeated with mothers bring- ing baskets filled with fruits or chickens, the ultimate proof of friendship and ap- preciation for having saved their chil- dren. Once the outbreak was over, the peo- ple showed that they were interested in continuing to work together. Not only had the doctor gained the people's trust, but by identifying with and becoming one of them, he had also become a strong pillar of the community. Spurred on by their first experience of solidarity, they began a series of meetings to organize future cooperative projects. At the request of the traditional heal- ers, a short training course was orga- nized for nine health agents, just like those being offered in San Cristobal de las Casas; four healers attended them. In a short time, two health centres had been built in neighbouring areas. A date was set aside to commemorate Health Day, and water was finally brought to the village centre. One sunny morning, on 3 February 1977, the village dogs set up their cla- mour again. Everyone in Guaquitepec turned out, not to watch for a stranger, but to observe the welcome arrival of a four-wheel-drive jeep. The vehicle had been provided by PRODESCH (the Socio- Economic Development Programme of Chiapas) and carried equipment for the health centre, seeds for more fruit trees and better stocked vegetable gardens, materials for the school, and a more powerful electric generator. What is the end of this story? It is still unknown. Soon after, perhaps for ever, Dr Leon returned home. Who will come to replace him? Who knows... The important thing is that Guaquite- pec remains. Its people await another opportunity to demonstrate what a rural community can achieve when it actively and conscientiously participates in its own development. Guaquitepec repre- sents millions of communities through- out the world, anxiously awaiting partnership with national and interna- tional institutions in order to solve its problems and improve its individual and collective wellbeing. ■ 35 WORLD HEALTH PUZZLE PICTURE It looks a bit like a toy covered-wagon from the Wild West, awaiting a toy horse to be hitched to the shaft. Or it might be an instrument to measure the amount of pollution emitted by a pipeful of tobacco. Well, it's neither of these. But what is it? It is in fact a sort of toy, but with a serious purpose. The three little balls seen in the foreground are rolled down the metal groove and—depending on their size and speed—arrive in one of the numbered boxes marked with easily recognized symbols. This is one of many devices assembled by the Geneva Institute for the Sciences of Education to test the psychological development of children and compare how their concepts of velocity and distance evolve as they grow older. A child being tested has to guess which box the ball is likely to reach; the older the child, the easier he or she will find it to pick the correct box. (Photo WHOIE Schwab) Country Population 1 Per capita income 2 ARGENTINA 25,383,000 1,922 BAHAMAS 204,000 BARBADOS 245,000 617 BOLIVIA 5,634,000 299 BRAZIL 107,145,000 723 CANADA 22,831,000 5,672 CHILE 10,253,000 647 COLOMBIA 29,717,000 478 COSTA RICA 1,968,000 799 CUBA 9,330,000 DOMINICAN REPUBLIC 4,697,000 480 ECUADOR 6,733,000 474 EL SALVADOR 4,007,000 373 GUATEMALA 6,080,000 470 GUYANA 791,000 360 HAITI 4,584,000 158 HONDURAS 3,037,000 306 JAMAICA 2,029,000 1,066 MEXICO 60,145,000 632 NICARAGUA 2,155,000 650 PANAMA 1,668,000 935 PARAGUAY 2,647,000 457 PERU 15,839,000 444 SURINAM 422,000 970 TRINIDAD AND TOBAGO 1,080,000 927 UNITED STATES 213,611,000 5,949 URUGUAY 3,064,000 717 VENEZUELA 11,993,000 2,052 Source: 1 UN Demographic Yearbook 1975. 2 In US $: UN Yearbook of National Accounts Statistics 1975. Rates per 1,000 live births: World Health Statistics Annual, Vol. 1, 1973-76. World Health Statistics Annual Vol. III, 1973-76. MEMBER STATES OF PAHO 30 CTS CORREO A.E;FD CANADA 12 COSMOS .14Item, AVON ethapeas I (15o MEXICO N REPUBLIC OUATEMILA~JAMAICA HONDURAS NICARAGUA .-BARBADOS 0-TRINIDAD & TOBAGO VENEZUELA,( GUYANA `— S AM COLOMBIA, ECUAD BRAZIL CORREIO 5ct.. GUAY VP EL SALVADOR ( COSTA RICA R,,NAMA UNITED STATES OF AM ERICA Infant mortality' Population physician 58.9 450 32.6 1,430 33,1 1,530 77.3 2,120 1,660 15.5 600 78.0 2,420 62.8 2,180 44.8 1,580 27.5 1,150 38.6 1,870 75.8 2,840 59.1 4,070 79.1 4,430 42.3 3,270 25.8 1 3,050 39.3 3,360 26.2 3,510 51.9 1,440 46.0 1,720 33.3 1,240 30.0 2,220 65.1 1,800 30.4 2,030 24.4 2,380 17.6 610 48.6 910 46.6 870 (FRANCE, NETHER- LANDS and UNITED KINGDOM are par- ticipating governments in PAHO, representing dependent territories in the Americas) •• •••• ••••••• ••• •• • ••• • ••••• •• •••• •••• • •• •• • •• • •••• • •••••• ••••••• ••• • •• ••• ••••••• ••••••• ••••••• ••••••• ••••••• ••••••• ••••••• ••• ••• ••• ••••••• • •• •••• •••• ••• •• •• •• • • • ••••• ••• ••• • •• ••• ••• •• • • • • ••• ••• ••• ••• ••• ••• ••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• ••• •••• ••• ••• ••••••• ••• ••• ••• ••••••• ••••••• ••• ••• ••••••• ••••••• ••• • •• ••••• • • • •• ••• ••• •••••• •••••• ••••••• ••••••• ••••••• ••• ••• ••• ••• ••• ••• ••• • •• ••••••• ••• ••• ••• ••• ••• ••••••• ••••••••••• ••••••• ••• •• •• •• • •• •• •• • •• •• •• • ••• ••• • • •• • •• • •••••• •• • • • • ••••• ••• ••• ••• ••••••• ••••••• •• • • •• •••• • •• • •••••• • •• • • •••• ••• • •• •• • • •• •• •• • •• • • Monkeypox infections under vigilance With the smallpox virus on the verge of extinction, a close watch is being maintained on monkey- pox, a smallpox-like illness, to determine whether there is a possibility of the smallpox virus subsisting in an animal reservoir so far unknown. All evidence available until now indicates that no such reservoir exists. Monkeypox, first recognized in 1958 in a captive monkey colony, can be transmitted to man, though very infrequently. Its virus is easily distinguishable from variola virus in the labora- tory, but the monkeypox patient presents a clinical picture very similar to that of smallpox. Since 1970—when the first case of monkeypox in man was observ- ed—a total of 28 cases have been diagnosed in west and central Africa. The reservoir of monkeypox virus is still un- known. During 1977, five cases of human infection due to monkeypox virus were detected in Zaire in February and March as the result of a special monkeypox survey conducted by the national health authorities in collaboration with WHO between September 1976 and March 1977. Teams went looking for possible additional cases to 13 villages which had reported 15 cases of human monkeypox between 1970 and 1976, and the surrounding 630 villages. Over 120,000 persons were examined for pockmarks and vaccination scars and many reports of rash with fever were investigated. Similar surveys were carried out by national/ WHO teams in Liberia, Nigeria, Sierra Leone and Ivory Coast during 1975. No new cases came to light. Indonesia set to expand immunization effort Indonesia has prepared a plan to immunize in several stages Months-old babies are vaccina- tion drive targets. (Photo WHO/J. Mohr) selected population groups against diphtheria, pertussis (whooping cough), tetanus and tuberculosis. When the country became free of smallpox in 1972, the large number of vaccinators trained in the course of the eradication programme were switched to the BCG campaign. Thus BCG vacci- nation was added to the small- pox vaccination programme. Shortly after, epidemiological surveillance brought to light tetanus of the newborn as a serious public health problem, closely followed by pertussis and diphtheria. It was decided to introduce control of tetanus of the newborn by immunizing pre- gnant women, and several field trials were carried out. Results of these trials as well as the experience gained in the smallpox and , BCG campaigns form the basis of the new programme which aims at reach- ing the following targets in a planned, gradual process: — Vaccination against diphthe- ria, pertussis, tetanus and tuber- culosis of 80 per cent of children in the 3-14 month age group living in accessible com - munities (located at a distance of not more than an hour's foot journey from the nearest health facility); BCG, diphtheria and tetanus boosters for 80 per cent of the children in the first grade of primary school; Anti-tetanus vaccination for 80 per cent of all pregnant women. With this coverage, Indonesia hopes to bring down the inci- dence and mortality rates of these diseases as follows: 80 per cent reduction in illness and deaths caused by diphtheria and tetanus. 50 per cent reduction in per- tussis incidence and 80 per cent reduction in mortality. 30 per cent reduction in tuberculosis incidence. The geographical area under the programme will expand gradually until nation-wide coverage is achieved before the end of the third five-year plan period (1979- 84). The programme will be fully operational during the plan period. Two staff categories in the health service will be in direct charge of vaccinating the people : the former smallpox vaccinators, now called immunizers, with at least one in each sub-district; and the nurses and midwives in the health centres and sub- centres. Both categories will work under the sole leadership of the head of the health centre. It is expected that by 1979, 3,400 health centres will have been set up as compared to 2,343 at the end of 1976. The average cost of full im- munization for a child against tuberculosis and two DPT (Diphtheria, Pertussis, Tetanus) injections is at present estimated at $2.00 per head, and is arrived at as follows: price of vaccine $0.60; staff salaries $1.25; other expenditure $0.15. The cost is likely to be reduced as the pro- gramme coverage improves. Declining trend in cholera A total of 66,804 cases of cholera reported in 1976 was the lowest number recorded in five Cholera vigil costs millions to national health budgets. (Photo WHO) years, according to a recent ana- lysis of data received by WHO under the international health regulations. The number of countries-26—reporting the cases was the lowest in seven years. In 1971, cholera reached a peak with a total of 155,555 cases reported by 36 countries. The declining trend noticed since 1975 appeared to continue in the first part of the current year. As of 10 May 1977, seven countries in Africa and eight in Asia had notified a total of 9,332 cases of cholera. How to prevent food-borne disease in aviation All catering establishments pre- paring, storing or transporting meals, snacks or drinks for airline passengers should be under the control of responsible health authorities, according to the recommendations of an ex- pert group convened by the WHO Regional Office for Europe. The group of international ex- perts from various disciplines was brought together late last year following a number of outbreaks of food-borne diseases among airline passengers and crews. The revised "WHO Guide to Hygiene and Sanitation in Avia- tion" to be published this year served as a basis for discussion. The group endorsed the prin- 38 ciples and practices set out in the Guide and recommended its wide distribution to organiza- tions concerned directly or in- directly with aviation catering. In its recommendations publish- ed recently, the group stresses that catering establishments should take great care to pre- vent cross-contamination bet- ween raw food and processed food. Whenever possible food should be handled by mecha- nical means. All food handlers, including cabin crew, should be encouraged to maintain high standards of personal hygiene and, in particular, to keep their hands scrupulously clean. The group recommended that medical advisers of airlines should carefully consider the composition of menus for each type of operation—short, medium or long flight—giving Inspector at work to prevent food-borne disease. (Photo WHO/E. Schwab) special attention to the potential hazards of high risk foods such as shellfish, raw meat, raw sea food, egg products, and bakery products containing cream. Cooling after preparation of food, it was stated, requires close attention. All cooked food should be cooled rapidly to a tempe- rature of 4°C (±2°) and remain stored at this temperature. Fro- zen food should be kept at a temperature not higher than —18°C. Hot food prepared for distribution in the aircraft should be kept at a temperature of not less than 65°C until served. Q fever: Story of a transmission What appears to be the first documentation of transmission by blood transfusion of a rickett- sia) disease has been reported from the United States. A 48-year-old man underwent surgery in a hospital in San Francisco and was discharged after a successful operation without any complications. Three days after he had left hospital he came down with sudden chills, fever, sweats, headache, and a general feeling of dis- comfort. Re-admitted to hospital, he was treated for hepatitis of undeter- mined etiology and went home, fully recovered, after 17 days. But a sample of blood taken during his convalescence revealed that his disease had been Q fever, an acute febrile disease caused by Coxiella burnetii, a micro- organism in the rickettsiae group. Now a hunt started for the usual sources that could have exposed him to the organism. He was asked if he had work- ed in a slaughter house, had any contact with sheep, goats, cattle or their ticks, if he had handled natural fertilizers, wool or goat hair, drunk raw milk or travelled in rural areas or as- sociated with anyone with symp- toms similar to those of his illness. The answer to all the questions was in the negative. Then a review of hospital pro- cedures and medication during his first hospitalization revealed the source of his illness: a single unit of whole blood that he had received during surgery. It turned out that the unit of blood had been obtained from a 20-year-old volunteer donor, who three days after giving blood, had an attack of fever, chills, sweats, headache and other typical symptoms of Q fever. He attributed his symptoms to flu, however, and sought no medical advice. A serum test four months later confirmed his illness to have been Q fever. The donor's own exposure to the disease was traced to his assistance, 20 days before donat- ing his blood, in the delivery of three kids from a goat. Serum Sheep and goats are among natural reservoirs of O fever. (Photo WHO) samples from the goat and two of the kids were found to be positive for Q fever. Q fever was first recognized in Australia by Derick in 1937. It was he who provisionally called it Q fever—Q for query—to emphasize the uncertain nature of the disease at that time. The name has continued in standard usage. World Health binder For the convenience of our readers, we are now able to offer a hard-cover binder, design- ed to hold a full year's com- plement of ten issues of World Health. The red cover bears the symbol of the World Health Organization, and a series of simple spring-clips make it easy to slip each succeeding issue into place. The binders are available, in a limited quantity only, at a price of 16.00 Swiss francs each, from Distribution and Sales, WH0,1211 Geneva 27, Switzerland. Authors of the month Dr H.R. Acui:1A is Director of the wHo Regional Office for the Ame- ricas in Washington, USA. Dr R. VALLADARES G. is Chief of the Office of International Public Health with the Venezuelan Minis- try of Health and Social Assistance in Caracas. Mr F. HUENUMAN is an auxiliary health worker in a remote area of Chile. Mr P. HARRISON is a British free-lance journalist and photo- grapher specializing in develop- ment topics. Dr E. AGUILAR PAZ is Minister of Public Health of Honduras. Dr F. VARGAS-TENTORI is Regional Adviser in Health Services Ad- ministration with the Pan Ame- rican Health Organization in Washington. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: One year Two years Three years US$* 10.— 18.— 24.— Sw fr.* 25.— 45.— 60.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City • Country: * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Water-carrying is a heavy chore for these Colombian children. ( Photo WHO/P. Harrison)