World rheumatism year [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JUNE 1977 • USA $ 1 Contents Cover designed by Peter Davies. World Rheumatism Year by M.A. Akhmeteli ... 3 The common factor is pain by R.G. Robinson .. 4 Taking the offensive Interview with V. Nasonova 10 A long road ahead by F. Delbarre 14 A ray of hope by J C George 18 Solving the riddles by J.L. Decker ... 22 The role of WHO by P.H.N. Wood . ..... 26 News Page 30 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. Water treatment eases a rheumatic sufferer'spain. World Rheumatism Year 1977 spotlights international endeavours to prevent, control and resist rheumatic diseases. ( Photo WHO/T. Farkas) WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JUNE 1977 • USA f 1 WORLD RHEUMATISM YEAR

the common factor is pain THE IMMENSITY OF THE PROBLEM OF RHEUMATIC DISEASES AND THE NEED FOR FURTHER STUDIES DESERVE EMPHASIS: COMMUNITY SUPPORT FOR ALL MOVES TO IMPROVE THE SITUATION IS VITAL by R.G. Robinson In common parlance the terms "arthritis" and "rheumatism" are adequate for communica- tion—arthritis implying dis- ease or inflammation of a joint while rheumatism denotes pains in various parts of the body, usually referring to the soft tissues, such as the ligaments, ten- dons and muscles. Science must be more specific. The disease has to be identified with precision and accuracy, according to the history, the disease pattern, the clinical findings and the laboratory and radiological changes. So while arthritis and rheuma- tism satisfy the needs of everyday con- versation, science defines some hundreds of forms of rheumatic disease. These range from minor, painful problems of tissue strain, through tissue wearing processes, to emotional, infective and inflammatory troubles. What is not com- monly understood is that many general diseases may be accompanied by rheu- matic symptoms (coronary occlusion, for example, may be followed by gout) and that many rheumatic diseases may affect vital organs (as seen in the involvement of the lungs or nerves by rheumatoid arthritis). The importance of realizing the ubiqu- itous nature of these diseases is that early treatment can be effective, whereas if left untreated, or treated imperfectly or im- properly, irreparable damage may result. Rheumatoid arthritis can cause deformi- ty and destruction, infective arthritis may totally destroy a joint and put life at risk, gout may produce prolonged pain- ful disability, giant cell arteritis can result in blindness and lupus erythemato- sus may be lethal. As examples of the rheumatic diseases, all these have a cure rate and all can be controlled if diagnosed early and accurately, allowing specific treatment to be applied. So diagnosis and assessment have to be made very carefully and exactly if the many effec- tive remedies and treatments are to be applied appropriately at a time when they will yield their maximum benefit. The chief complaint of most patients is pain. There may be stiffness, restricted movement and constitutional features of illness like fever, fatigue and weakness. The doctor has to decide whether the disease is a rheumatic or a non-rheumat- ic one and whether it affects primarily the joints or primarily the tissues. Whichever decision is made, a definitive diagnosis must follow before a complete long-term suitable course of therapy can be mapped out. There are very many known causes of arthritis (inflammation of joints). In ad- dition to inflammatory arthritis like rheumatoid arthritis, joints may be af- fected by strain, by wear, by ageing, by other diseases of the body, by infection with bacteria, viruses and other agents, by injury, by nerve and spinal disease, by chemical abnormalities like gout, by hor- mone alterations as in thyroid disease, by congenital and genetic abnormalities and even by growths and cancers. Rheumatic diseases occurring in chil- dren before the age of 16 fall into the category of juvenile chronic polyarthri- tis. Juvenile rheumatoid arthritis can oc- cur at any age, even as early as six weeks, but is most commonly seen between two and five and between nine and twelve. These children may show a high fever and profound illness before the polyarth- ritis is recognized. It may occur in one, a few, or many joints or it may have the symmetrical form of the adult disease. There may be enlargement of the liver, the spleen and the lymph glands and a characteristic salmon-coloured measles- like rash. Although on the whole the outlook for this disease is good, many children have involvement of the neck with stiffness, or of the jaw with tightness and underdevel- opment, and some may have general or local abnormalities of growth. One of the more serious systemic manifestations of juvenile rheumatoid arthritis is inflam- mation of the eyes, which may result in blindness. Juvenile ankylosing spondylitis is a disease affecting the spine and the joints at the bottom of the spine, the sacro-iliac joints; this can lead to considerable stif- fening of the spine. Both this and juve- nile rheumatoid arthritis often appear early on as puzzling general diseases, and because they are often thought to follow an injury or a sickness, diagnosis may be Unless checked in time, rheumatoid arthritis >. can be slowly, progressively damaging, des- troying joints and causing gross deformity. (Photo WHO/T. Farkas) 4 <et delayed. They may be confused with rheumatic fever and other generalized diseases if the available diagnostic clues are not given sufficient consideration. Rheumatic fever follows an infection with a streptococcus (Group A). It owes its importance to the involvement of the heart, whose valves may suffer chronic scarring and deformity leading to poten- tially lethal heart failure or to valve in- fection later on. The classical attack of rheumatic fever appears as an acute migratory polyarthritis accompanied by signs and symptoms of an acute febrile illness. The large joints of the extremities tend to be involved most, and there is usually severe pain. The heart involve- ment is first recognized by the appear- ance of murmurs in the heart valves. Chorea or St. Vitus Dance—so called because of the involuntary jerky move- ments of the patient—is not now as com- mon a complication as it was. The characteristic but infrequent rash is pain- less, not itchy, disappears quickly and may be overlooked. There is a tendency for overdiagnosis of rheumatic fever, and many such cases are only correctly labelled at a later stage as the disease shows a definitive appearance. 6 A number of other less common dis- eases have to be considered when chil- dren suffer from rheumatic complaints. Arthritis is sometimes related to psoria- sis (scaly lesions of the skin), to bowel disease, to urinary tract disease, to blood disorders and to auto-immune inflam- mation (a situation somewhat akin to the rejection phenomenon seen in kidney transplants). Rheumatoid arthritis is a chronic dis- ease in which inflammation of joints is frequently combined with a variety of extra-articular signs. The disease begins with an inflammation of joint linings, causing swelling of the joint due to fluid accumulation and due to thickening of the joint lining. If uncontrolled it pro- gresses on to destruction of the joint and finally loss of function, deformity and even fusion by fibrous tissue or by bone. There may be weakening of tendons, ligaments and supporting structures, sometimes leading to gross instability and partial dislocation. The disease may be benign and self-limiting, it may be episodically progressive or it may be slowly, progressively damaging. Systemic manifestations include high fever, stiffness (particularly iii the morn- ing), muscle tenderness and soreness, pleurisy, inflammation in the heart, in- flammation of the eyes and—most un- pleasant of all—inflammation of ar- teries, leading to damage to vital organs. When the spleen is involved, affecting white cell production and being associat- ed with recurring infection and ulcers on the legs, the condition is known as Felty's Syndrome. Sjogren's Syndrome is a chronic inflammatory disorder charac- terized by diminished secretion from the glands in the body which provide mois- ture to the eyes, nose, mouth, gastro- intestinal tract, vagina and skin, so that all these tissues become dry and painful. The lungs and the kidneys are not un- commonly involved, and at least 50 per cent of the patients have rheumatoid arthritis or one of the other more severe rheumatic types of complaint. These diseases have to be dealt with under a total plan of treatment utilizing all the available experience of a team of trained workers. Rest, nursing, physical therapy, occupational therapy, drugs, surgery and rehabilitation all have a place, according to the needs of the patient and the status of the disease. the common factor is pain Left: The non-rheumatic bowler in action. Regular sports activities probably help to keep rheumatism at bay; but excessive activities May impose unwanted stress on certain critical joints. ( Photo WHO/Ciba-Geigy) Right: Trace-elements being injected into a patient to help detect the precise sites of rheumatic lesions. Only a small percentage of sufferers are at present cured; further research into preventive and therapeutic measures is essential. ( Photo WHO/T. Farkas) . Only a small percentage of sufferers are at present cured, and it is clear that further study of preventive and therapeutic measures is essential. More facilities are needed for those whose dis- ease can be controlled in various degrees, and continued rehabilitation is mand- atory for those whose disease resists treatment and results in disability. For many years it has been possible to separate rheumatoid arthritis, which gives a positive test for what is called a rheumatoid factor in the blood, from a group of diseases which look something like rheumatoid arthritis, but which do not give a positive test for the rheuma- toid factor. More recently, a tissue mark- er (called the histocompatability antigen HLA-B27) has been shown to have a high incidence in the rheumatoid factor- negative arthropathies. It is now possible to define a group of arthropathies in which there is a polyarthritis resembling rheumatoid arthritis but with a different pattern of joint involvement, pursuing a different clinical course, often associated with characteristic extra-articular invol- vement, and in which repeated tests for a rheumatoid factor are consistently found to be negative. The common diseases in this group are ankylosing spondylitis, psoriatic arthritis, Reiter's Disease, and colitic arthritis. These diseases often cause inflammation of the sacro-iliac joints and may be associated with or complicated by manifestations of disease involving the eyes, the skin, the heart, the bowel, the lungs and the renal system. The most common of this group is ankylosing spondylitis, an erosive arthri- tis with a marked tendency to cause bony fusion and with a strong predilec- tion for sacro-iliac joints and the spine. The disease characteristically develops in men in the third decade or life, although women too may be affected. In three-quarters of the cases the in- itial symptom is low back pain which radiates outwards to the buttocks and thighs. Sleep is interrupted and morning stiffness is prominent. The cardinal changes in the sacro-iliac joints may be difficult to define in younger patients, may be slow to develop in older ones, and—just to confuse the issue—about 10 per cent have their onset in the periph- eral joints of the limbs. Inflammation of the eyes is common, while the aortic valve, the heart, the bowel, the lungs and the kidneys may be affected. A form of arthritis which is associated with psoriasis characteristically involves the end joints of the fingers, the joints of the toes and the sacro-iliac joints. It may be somewhat localized or may be wide- spread, looking like rheumatoid arthritis, but lacking its symmetry. Reiter's Dis- ease is notable for acute attacks of polyarthritis with a preference for the lower limbs, the sacro-iliac joints and the spine, and is associated with inflamm- atory disease of the renal tract and the bowel. Inflammation of the eyes and lesions of the mucous membranes and the skin are common. Colitic arthritis occurs in about 10 per cent of patients with ulcerative colitis and Crohn's Dis- ease. It may affect one or two of the larger joints for a short period of time or may develop the picture of ankylosing spondylitis. There are some interesting interrela- tions within this group. Sacro-iliitis is common and the histocompatability antigen HLA-B27 correlates well. Eye inflammation is seen to have a high incidence, skin lesions of each of these conditions may be indistinguishable, and family interrelationships also occur. These common features suggest the pos- 7 the common factor is pain sibility that these disorders represent no more than different reaction patterns modified by variations in the stimulus and variations in the genetic makeup which determine the host response. Just as all tissues and organs go through stages of wearing with age, stress and disease, so the joints and the soft tissues undergo a process of ageing. This is almost a physiological process but it is varied by many factors during the life of the individual. Osteoarthrosis, or degenerative joint disease, is the con- dition which arises when the symptoms and signs are disproportionate to the chronological age of the patient. When the tolerance of the joint to the stresses applied to it is overcome, an inflammato- ry component is added resulting in pain, tenderness, heat and excess formation of fluid, a condition often called osteoarth- ritis. These conditions affect all the joints of the body and have their background in genetic, metabolic, glandular, inflam- matory, anatomical, neurological and traumatic factors. Clinically, osteoarthrosis usually in- volves a single joint or only a small num- ber of joints. The symptoms often bear little relationship to the radiological ap- pearance and of course the most stressed joints, such as the hip, the knee and the bunion joint, tend to be most affected. It is not widely recognized that the joints of the spine and the intervertebral discs suffer similarly. The manifestation of the mechanical disorders which result unfortunately are often imperfectly un- derstood and are dismissed with such "diagnoses" as slipped disc, lumbago, sciatica and fibrositis. The opportunity to effect early helpful measures is then lost. A variety of conditions, some of which are relatively trivial and others which may be important, do not fall into any ready-made category and may have a number of different causes. These in- clude shoulder disorders, painful elbow conditions, entrapment of nerves in cer- tain sites, inflamed tendons and tendon sheaths, and various disabilities resulting from painful tissues—muscles, tendons, ligaments, nerves and blood vessels. The commonest of the metabolic dis- eases of bone is osteoporosis, a disease in which the lattice work of bone is thinner than normal allowing small fractures to occur under stress. It is most commonly seen in elderly women and may be a complication of cortisone therapy and of some diseases. Most commonly it is 8 Treatment of rheumatic diseases must utilize all the available experience of a team of trained workers. Rest, nursing, occupational therapy, physical therapy, drugs, surgery and rehabilitation all have a place. (Photos WHO/E. Mandelmannl T. Farkas) demonstrated in the spine where the ver- tebral bodies collapse under the weight of the body or as a result of injury. Gout—traditionally associated with over-indulgence in alcohol—is actually caused by an excess of uric acid in the body which ultimately leaves deposits of crystals in the tissues and joints. Large collections of urate material may occur in the cartilage of the joints, tendon sheaths, and bursae (fluid sacs which lub- ricate the joints). Stones of urate may occur in the kidneys and deposits may damage the kidneys and impair their function. Deposits of the urate crystals in the joints result in acute inflammatory arthritis, which is well-known to affect the great toe. Blood pressure, diabetes and heart dis- ease have an increased incidence in peo- ple with gout, and unfortunately some of the drugs used for these conditions can increase the basic problem of excessive uric acid in the body. The "rheumatic" involvement of ar- teries is called arteritis, or when it in- volves all types of blood vessels, vasculi- tis. Because the blood supply is critical to tissues, any tissue, part or organ may suffer. The variety of clinical symptoms produced will depend on the variation and size of blood vessels involved, the severity of the inflammation and the importance of the tissues affected. Vasculitis may be induced by sensitivi- ty to drugs and other agents, it may complicate the rheumatoid arthritis picture or it may be associated with the group of diseases known as the auto-immune diseases. Generally the appearance of vasculitis is a bad feature which demands urgent investigation and aggressive therapy. The personality of the patient, the background and social factors which det- ermine patient response to pain, disease and disability all require careful evalua- tion. With this information the physician can prescribe for the patient as well as with regard to the disease. Various syndromes are associated with differing occupations, and the effect of heavy work on the incidence of spinal troubles is well known. Preparation or training in some tasks does help to pre- vent troubles resulting from repetitive strain, while careful selection of the worker for the task, and modification of the task wherever possible, will help to reduce this problem. The effect of a certain occupation on an undisclosed rheumatic disease or on an established one may present a diagnostic challenge which in terms of therapeutic results is very important. There are many other rheumatic dis- eases besides these common conditions, but the point to be emphasized is the immensity of the problem of rheumatic diseases and the need for study and information. The community must be encouraged to support all programmes aimed at improving the situation for those who are affected. This can only occur when everybody understands that the rheumatic diseases can be effectively attacked and that a gradual and progres- sive increase in cure and control rate can be attained. ■ 9 taking the offensive ON BEHALF OF WORLD HEALTH, NOVOSTI CORRESPONDENT DMITRI TULAEV INTERVIEWED PROFESSOR VALENTINA NASO- NOVA, DIRECTOR OF THE I\STITUTE OF RHEUVATISV AT THE SOVIET ACADEVY OF MEDICAL SCIENCES I\ VOSCOW WORLD HEALTH : How is medi- cal care delivered in the field of rheumatic diseases within the overall public health system of the Soviet Union? Prof. NASONOVA: Until the 1930s, rheumatism was one of the most wide- spread complaints in our country. The year 1928 saw the establishment of the All-Union League against Rheumatism, one of whose main tasks was to work out a system of medical care in the domain of rheumatology. Thirty years later the Institute of Rheumatism was founded, giving fresh impetus to the work of per- fecting and putting on a proper scien- tific footing the system for controlling rheumatic diseases. Consulting units for rheumatic heart disease were established in children's and adults' polyclinics. Today the Institute is the largest scien- tific body in the Soviet Union investigat- ing the prevention and treatment of rheumatic diseases, and works in close liaison with the public health services, preparing documentation on methodolo- gy and helping to establish the most rational system for control. Within the overall public health sys- tem, there is close cooperation between the rheumatologist and the internist. Un- til recently, it was actually the internist who provided curative and preventive care, while as a rule the rheumatologist gave consultative assistance. Nowadays it is the rheumatologist who provides a regular follow-up service for the patient although, of course, he keeps in touch with the internist. Orthopaedic surgeons also play a role in the treatment of patients both in the polyclinics and in specialized research institutions, and in hospitals where there are wards for surgical treatment of patients with rheumatoid arthritis and other chronic joint diseases. Patients with rheumatic diseases, particularly an- kylosing spondylitis, have to be seen by a neuropathologist, and physiotherapists are actively involved in treating patients with arthritis. Thus rheumatology, within the general public health system, is one of the specia- lized services, extensively developed and well equipped. As for how effective this service is, I need only mention the fact that practically no new cases of acute rheumatic fever are seen today in the Soviet Union. So you see, rheumatic fever as a mass disease in our country can be termed a thing of the past... This is a matter of very great impor- tance. The public health service has suc- ceeded in a remarkably short time in practically wiping out what was formerly a very widespread disease and reducing the problem to minor proportions. Nevertheless, rheumatic defects of the heart valves still remain fairly common, though their frequency too is declining steadily, while mortality from these con- ditions has markedly decreased. Our rheumatologists have mounted an offensive against other rheumatic dis- eases, systematically following up not only patients with rheumatic heart dis- ease, including those who have under- gone heart valve surgery or prosthetic operations, but also patients with rheu- matoid arthritis, ankylosing spondylitis, and connective tissue diseases (systemic lupus erythematosus and other systemic disorders). The doctors examine the other members of families in which cases of rheumatic disease have occurred. This work is done according to a uniform methodology worked out by the Institute of Rheumatism jointly with other medi- cal and research institutes. The basic principle in caring for rheumatic patients is phased treatment : inpatient treatment, ambulatory treatment, and finally a third phase of health resort therapy. WH : How is the health resort service in the USSR organized and financed? Prof. NASONOVA: The health resort ser- vice in our country is run and financed by the trade unions. We try to arrange for every patient being treated to receive attention every year for three years. Ex- perience shows that such regular health resort treatment consolidates the results of hospital and outpatient care to a sig- nificant degree. Patients are given trade-union passes to health resorts free of charge or for 15- 30 per cent of the cost. In addition, for treatment at specialized health resorts, patients are often issued with sick notes, which means that they receive sick bene- fit at their places of work without losing the right to their regular holidays. Over almost the entire country there is an extensive network of health resorts for rheumatic patients, and of specialized units at other types of health resort. Thus for patients with rheumatoid arthritis, we have Evpatorija in the Crimea, Pjati- gorsk in the Northern Caucasus, and the Caucasian Black Sea Coast, including a number of sanatoria at Sochi. Pjatigorsk Rheumatic patients in the Soviet Union can stay without charge or at special low rates in one of the country's many health resorts. Here sufferers are "taking the waters" under medi- cal supervision at a spa on the Kamchatka Peninsula in the Soviet Far East. (Photo WHO/Novosti) 10 .1 • ..`.0. 4tt...7•....,',"':. 4';:■;•,1 .'. Jr..) .' ji, . • ,',0 1 :f. ,- 4;7. .! ?...z.• • , II ..~7' ' ;' =':„,., ▪ ..: -til.?■4%. ,i..i. J.- ...1%;• -. - c. 1 : ,.4.,":„..' e".-4-' ! _41- ...... ..,... , ...... .”."... .1 f si .,.• ..... .,... . .7i4:0_,' " 0..: - ...-1. ' • 'SY, ' - s'''' ".%.:',i1r: fl 4/ e* . 'A...." . • . ../A*14; ' ....Z3.7.;- 'tf •• . 4. P;' ,i' ' 7 • • • - . .._..„."3", , . . 1‘ - ' - -7•V "4-4.,- ('';'r -..:),..7 -Z.' -.AK. ,',.*.i...-•• ir ::-; '-'' '', ' i ‘t-:•! .`.•i•. , ..• I • v -.. A ,-. — . , ,•s -•. .., • • ',J.* i• • ' "e ■ . • -• •••••■•,...11111,1111111114.111111.100....ftVP • 411, _ - - ••• ;- — *41** . - - 4110•■• ....-- . — taking the offensive Left: Professor Valentina Nasonova, 1975 winner of the N.D. Strazesko Prize awarded by the Soviet Academy of Medical Sciences, is the Director of the Academy's Institute of Rheumatism. Right: A patient taking part in a study of radio- isotope diagnosis of rheumatic diseases at Moscow's Institute of Rheumatism, the largest scientific institution in the Soviet Union inves- tigating the prevention and treatment of these ailments. (Photos WHO/Novosti) is developing more and more as a health resort for rheumatoid arthritis and anky- losing spondylitis cases as well as for sufferers from disorders of the gastro- intestinal tract. I.might add that, on our initiative and with the help of the trade unions, specia- lized laboratories have been set up at these resorts. At Sochi-Matsesta, labo- ratories have been established for clinical immunology and radioisotopic diagno- sis. Kislovodsk, with its network of treat- ment resorts for patients with rheumatic heart disease, has become the centre for an interesting functional diagnostic ser- vice which uses computer techniques. On leaving each resort the patient is again placed under the supervision of a physi- cian at his polyclinic. WH: How is the training of specialists in rheumatology carried out ? Prof. NASONOVA : At medical schools, starting in the third year, students are taught various branches of rheumatolo- gy as part of internal medicine. In their fourth and fifth years, the students learn about various diseases and their diagnos- tic and clinical aspects. A physician can become a rheumatologist when he or she has had not less than three years of practical experience in internal medicine. Primary specialized training of rheuma- tologists takes place at the Institute of Rheumatism, during a two-year course at institutes of advanced medical studies and in various departments of medical insti- tutes (about 100 chairs of internal medi- cine at medical colleges are occupied by rheumatologists). Under the Institute of Rheumatism's system, doctors become thoroughly versed in all branches of rheumatology and become specialists, as a rule, in charge of the second echelon of the anti- rheumatism service—the rheumatologi- cal centres, of which there are over a hundred in the country. In addition, to speed up the training of doctors, espe- cially for the polyclinics, where the spe- cialists have to deal with patients whose diagnoses have already been established, they are given instruction while continu- ing their normal work. Internists or pae- diatricians are able to take a two- or three-month course at the Institute of Rheumatism or in the relevant depart- ments of medical schools and institutes for advanced medical studies. Every rheumatologist is sent once every three to five years on a refresher course to keep him or her abreast of new advances in scientific knowledge. Our Institute con- ducts annual seminars in different local- ities for internists and paediatricians. The great majority of health resort doctors and orthopaedists are trained at the Institute of Rheumatism. Thanks to this system, these specialists have thorough knowledge not only in the field of specialized physiotherapeutic and spa treatment, but also in general rheumatol- ogy. In the light of the new tasks assigned by WHO, extensive training programmes for rheumatologists are being drawn up. These pay special attention to the demands made on general rheumatolo- gists who have thorough knowledge of rheumatic diseases in the strict sense and also of rheumatic syndromes which oc- cur in other diseases. WH: Could you tell us something about the coordination of scientific research in rheumatology, and about the investiga- tions at present going on at the Institute of Rheumatism? Prof. NASONOVA : The Institute of Rheumatism exercises central responsi- bility for coordination and methodology. One of its major tasks is to work out the scientific principles for further improving the anti-rheumatism service. Our recom- mendations on methodology, once they have been endorsed by the Ministry of Health, provide guidance for ministries and public health departments through- out the country. The immediate in- struments of all the innovative develop- ments at the Institute of Rheumatism are the rheumatological centres I mentioned earlier. It is through them that the coor- dination and practical organization of rheumatological care in the network of polyclinics and the specialized inpatient departments of hospitals is carried on. 12 For such a large country as ours, agreement on the interpretation of the different courses the disease can take is particularly important. First of all, working classifications of the nomencla- ture of rheumatism were produced, and then similar classifications were worked out for rheumatoid arthritis, systemic lupus erythematosus, and systemic scleroderma. Work is now proceeding on classifications of ankylosing spondylitis and osteoarthritis. Equipped with such a classification, any rheumatologist can not only establish a diagnosis, but also describe in precise terms the course of the disease and the degree of activity of the morbid process at the actual moment when the patient is examined. We have established a special commit- tee on rheumatology, whose membership includes senior staff members of the Institute and leading Soviet rheumat- ologists. Within the organizational frame- work of the Academy of Medical Sciences, this committee works in close contact with special committees on other problems. At present we are preparing a national programme to investigate the distribu- tion of such major rheumatic diseases as rheumatoid arthritis, ankylosing spondy- litis, the main forms of osteoarthritis, and some systemic diseases of the con- nective tissue. In the field of research, between 600 and 800 separate studies are planned every year. Ensuring coordination be- tween these investigations is also the responsibility of our Institute, where we are looking, for example, into the etiolo- gy of various rheumatic diseases, notably the mechanisms of the injurious action of the streptococcus, both under ex- perimental conditions and in patients. We are interested in the mode of devel- opment of valvulitis—of primary or so- called "latent" rheumatism leading to the formation of valvular defects without any history of acute rheumatic fever. The Institute is conducting fundamental research on the physiology, pathology and immunology of the connective tissue in rheumatoid arthritis and systemic lupus erythematosus, and making an in- tensive study of immunity and genetic predisposition within families to various rheumatic diseases. WH : Finally, could you tell us about your research into systemic lupus erythemato- sus? Prof. NASONOVA : I have been studying systemic lupus erythematosus since 1958, looking into the prevalence and distribu- tion of early signs, the etiology of the disease, and viral factors that may be responsible for its development. We have studied failures of immunity and predis- position to this disease, and conducted special investigations into the systemic and genetic aspects. Particular attention has naturally been accorded to problems of treatment. I should emphasize that the entire staff of the Institute of Rheuma- tism has worked on these problems. We have been able to develop and introduce throughout the country's cardio-rheumatological establishments procedures for study and diagnosis of the disease as well as systems for long-term follow-up and treatment. Thanks to these procedures and their introduction into standard practice, only about ten per cent of patients suffering from systemic lupus erythematosus die from kidney failure, whereas previously this was an invariably fatal disease. It is particularly gratifying to us that our patients, after a suitable course of treatment, can resume their full status as valuable members of society and can continue in productive employment. Many of the women sufferers have been able to have children and experience the joy of motherhood. So now we doctors are, as it were, the grandmothers of an already large group of children born to patients who only a few years ago would have been written off as hopeless cases. A wide circle of scientists, not only in the Soviet Union, are now involved in active research on this problem. We col- laborate closely with a number of coun- tries and are conducting a joint investiga- tion into methods for treating patients who do not benefit sufficiently from cur- rent methods. ■ 13 a long road ahead THERE ARE OVER 100 TYPES OF RHEUMATIC DISEASES, WHICH HAVE GROWN MORE COV VON AS OTHER VALADIES HAVE VANISHED AND THE LIFE-SPA\ HAS LENGTHE\ED by F. Delbarre The treatment of rheumatic disease has made enormous progress in the past 20 years. Before the Second World War, we had only aspirin, a useful pallia- tive against pain but now overtaken by better medicaments. The discovery of the spectacular anti-inflammatory action of cortisone derivatives marked a decisive step forward in 1950, but the frequency and severity of the side-effects soon became a matter for regret. Around 1955 came the discovery and introduction of several non-steroid anti- inflammatory drugs, then the appear- ance of various derivatives, but these were still only palliatives; the point at which they act lies somewhere between the still unknown causes of inflammato- ry rheumatism (whether a genetic predis- position against which nothing can be done, or some hypothetical virus, or an immunological imbalance whose nature and causes remain a mystery) and the consequences of the inflammation, namely pain, osteo-articular destruction, subsequent deformities and, eventually, disablement. Over the past decade, research has been going on, notably at the Rheuma- tology Institute of the Cochin Hospital in Paris, into the preventive measures that may be deployed against rheumatic disease, that is, into the means to pre- vent physical damage, deformity and dis- ablement. New techniques have been brought into play. At this point it needs to be emphasized that the problem of rheumatic disease is of particular medico-social importance. Of course attention has to be focussed on promoting research into cancer, leukae- mia and heart diseases, but it is too easily overlooked that the rheumatic diseases represent another scourge. Except for rheumatic fever (which has shown a spectacular decline in most of the devel- oped countries), they cause few deaths. On the other hand they take many forms and occur very frequently. In France alone, they attack nearly ten per cent of the population. Half a million people, mostly of an advanced age, suffer from sporadic attacks of rheumatoid arthritis, to the detriment of both the individual and society; against the pain, inflamma- tion and destruction of joints which it causes we are only just beginning to find weapons. Methods of treatment are still largely empirical. For instance chrysotherapy- treatment with gold—was introduced nearly 50 years ago by Coke and Fores- tier and remains, despite years of scepti- cism in the English-speaking world, one of the best answers to rheumatoid arthri- tis, especially in the early stages when, of course, the osteo-articular lesions are not too far advanced. Regular treatments with weak doses, rather than periodic heavy dosages, ap- pear to be easily tolerated, provided the precaution is taken of watching for any counter-indications and the first signs of intolerance, and provided they are used only in cases of true rheumatoid arthri- tis. Progress still remains to be made. It seems to matter little whether the treat- ment is continuous or at spaced out intervals. Everything depends on the concentration of the heavy metal at the afflicted area and consequently on the amount of gold used. It is also high time that we understood the mechanism of the action of the gold. Does it combine with and inactivate certain enzymes respon- sible for the inflammation, which are set free in the course of a pathological immu- nological reaction? Or does it correct certain immunological imbalances which play a large role in rheumatoid arthritis? These questions remain unanswered. In treating rheumatoid arthritis there are also a large number of drugs which are specific to the inflammation itself but not to its cause. The value, tolerance, efficacity and mechanics of action of these products vary widely and, whatever may be their powers and their practical Millions of people, mostly of an advanced age, suffer from sporadic attacks of rheumatoid arthritis, to the detriment of both the individ- ual and society. (Photo WHO/T. Farkas) 14 .••••0,*4 a long road ahead interest, an uncertainty remains. This is particularly the case with corticoids and non-steroid anti-inflammatory drugs. In practical terms, the action of such drugs is highly complex. Some of them can check a disease in a spectacular manner and may also be useful in small doses as preventives. Some are more effective in the first stages of the inflammation cycle while others have a gentler action but work over a longer period of time. The lack of understanding of just where they operate, their varied effectiveness and the need to switch drugs during courses of treatment in order to avoid long-term side-effects—all these highlight the long road that still lies ahead before we reach a better understanding of the mechan- isms of actions taking place on a molecu- lar scale. Anti - inflammation agents Since the work of Vane and de Shen, in particular, attention has been drawn to drugs which specifically inhibit the enzymes involved in the inflammation cycle. Thus certain inhibitors of the hor- monal mechanisms, such as prostaglan- din synthetase, can be regarded as anti- inflammation agents. It is in this direc- tion that the latest research is moving. However interesting the vistas that are opening up, this type of drug still only acts in a late stage of the process which provokes rheumatism. In rheumatoid arthritis, inflammation is already a con- sequence of complex immunological dis- orders. It was tempting to attack this cause of inflammation, and immuno- suppressors have been used for several years with a certain degree of success. And on the other hand the immuno- effectors can be very useful even though we scarcely understand how they act. Some may even function simply by a direct inflammatory action of their own. But this type of treatment ought to be reserved for serious cases which do not respond to chrysotherapy, non-steroid anti-inflammatories or ordinary reme- dies, since certain hazards such as serious hematological disorders have been reported. Treatment of infection of the vertebrae in the lumbar region—ankylosing spon- dylitis—has today been well codified, and basic drugs are available which reduce attacks and control the inflamma- tion, but these may also produce gastric complications. In any event, drugs are only a part of the treatment, and health counselling (for instance, moderate phys- ical exercise, a degree of rest, possibly a change of job, or sleeping on a hard bed) is very important. Eventually, if the hip is so damaged that the patient is dis- abled, artificial walking aids are very useful. The metabolic form of rheumatic dis- ease is gout, which is on the increase and particularly attacks men aged over 40 whose diet is over-rich. It is caused by an accumulation of uric acid in the or- ganic liquids and tissues. The classical treatment calls for a strict diet and chemotherapy against attacks. Some progress has been made with daily pro- phylactic treatment and, during the past ten years, with inhibitors which reduce the synthesis of uric acid. Victory is far from complete. Once the painful attacks subside, the patients tend to resume their bad eating habits and, since 30 per cent of the gout-ridden also have difficulty with the metabolism of fats, there is a risk of them suffering from other ailments, including such serious ones as atherosclerosis. In the field of arthritis much remains to be done. It could be said, with wry humour, that the only progress made in recent years has been the discovery that the classical treatments, especially those based on sulphur, iodine and extract of cartilage, are useless. Two important advances have been made, however. Particularly since Pau- wels' work, it has been known that cer- tain arthroses such as arthritis of the hip can be prevented by correcting an ana- tomical anomaly, whether congenital or acquired, which was causing a mechani- cal imbalance and, in the medium or long term, arthritis of neighbouring joints. And artificial aids, especially the artificial hip or to a lesser degree the artificial knee joint, have proved highly effective and have restored the disabled to active life. So we are not lacking in weapons to treat the rheumatic diseases, whose prev- alence will rise proportionately as many age-old scourges disappear and as the life-span has progressively lengthened. The scale of the problem is well defined today. There are more than 100 types of rheumatic disease, whether inflammato- ry, degenerative or metabolic, each with its own clinical symptoms, its own degree of severity and its own poten- tial development, and each requires dif- ferent treatment. We have more and more drugs that have replaced often worthless classical remedies. Some are very specific and their increasing potency necessitates ever greater care in their selection, careful surveillance and research into the requi- site doses, the counter-indications and side-effects. The treatment of rheumatic disease is generally a long process, so that complications resulting from the use of drugs are more common than is the case with other maladies. All future progress will henceforth depend on the progress of research into treatments concentrating particularly on lesions detected at the cellular or even the molecular level. Time for reflection Finally, let us hope that World Rheumatism Year will offer time for reflection on the problems of prevention. Countless rheumatic patients become in- valids because of the irreversible articu- lar lesions and deformities, because an exact diagnosis was not made early on and because the right treatment and the vital health instructions were not pre- scribed in good time. Education of both the public and the medical profession is therefore indispensable, and so is research into ways of ensuring accurate diagnosis. The example of rheumatic fever shows the value of correct preventive measures. Attacking streptococcal infection with antibiotics and, when rheumatism strikes, treating it systematically with corticoids have spectacularly curbed the most serious rheumatoid heart diseases in all countries with advanced levels of health care. Now these same measures have to Eventually, if a joint is so damaged that the D patient is disabled, artificial walking aids may be needed. Important advances have been made in developing such aids to restore the disabled to active life. (Photo WHO/T. Farkas) 16 be extended to countries which do not enjoy that advantage. We have also realized what the avoid- ance of harmful postures can do for a young person afflicted with ankylosing spondylitis, and what the correction of mechanical, congenital or acquired dis- orders can do for the prevention, for example, of osteo-arthritis of the hip joint. Meanwhile the correction, through en- zyme inhibitors, of the biochemical im- balance responsible for gout means that we shall presently see the last of these attacks and of the deposits in the joints so often described in classical imagery. Recently there has been similar prog- ress in the prevention of rheumatoid arthritis, not so much by attacking the cause itself—which is impossible in the present state of our knowledge—but by forestalling lesions, deformity and dis- ablement. The surgeons showed rather more than ten years ago that this disease can be prevented by surgical removal of the synovial membrane and of the syn- ovial pannus, a "benign tumour" formed between two joints which erodes and destroys first the cartilage and then the bone through the enzymes which it secretes. In about 50 per cent of cases, the synovial membrane grows again in a normal form. Unfortunately there have been many setbacks. There may be lasting stiffness; removal of the synovial membrane is difficult in certain cases, and impossible in the hip—if total, there is a risk of necrosis of the head of the femur; if partial, the pannus may re-develop; and inevitably the surgical scars are unsight- ly. As a result we give preference to what we call synoviorthosis, that is to say, to non-surgical means of destroying the synovial pannus by intra-articular injec- tions of metals. This treatment carries no risks, even over many years and even if the injections are repeated in cases of relapse. It is seen at its best in the case of rheumatoid arthritis of the knee, where the "cure" may exceed five years and elimination of the pannus ensures the prevention of erosion and disablement. It is this particular problem of the prevention of articular lesions which ought to inspire all those who treat the rheumatic diseases today. ■ 17 a ray of hope A STUDY, BACKED BY WHO, HAS STARTED IN INDIA TO VERIFY SCIENTIFICALLY WHETHER TRADITIONAL AYURVEDIC VEDICINE CAN OFFER A SATISFACTORY CURE FOR RHEUVATOID ARTHRITIS by Joseph C. George "Since June 1973 I have been able to resume prolonged reconstructive surgery in the field of my interest, that is, cancer of the head and neck, thanks to Ayurvedic treatment", said Dr K. Ramankutty, Professor of Surgery at the Coimbatore Medical College and Hospital. To quote his own words : "The first time I noticed pain in my left hand was in September 1972. It came intermittently and used to pass off in a couple of days, but by November, the pain was persis- tent. I diagnosed the malady as rheuma- toid arthritis. I had to stop operating at this stage. On December 19, I started getting Ayurvedic treatment." Asked why he thought of Ayurvedic treatment when he himself was a leading practitioner of modern medicine, Dr Ramankutty replied : "We know by tradition and conviction in this part of the world that Ayurveda has much to offer for auto-immune musculo-skeletal disorders and diseases of the joints." He went on : "After various combina- tions of decoctions and external applica- tions of medicated oils and pastes, the disease aggravated a little, as had been envisaged at the beginning of the treat- ment by the Ayurvedic physician. This was in January 1973. I continued inten- sive Ayurvedic treatment and the pre- scribed dietary regimen as an out-patient at the Arya Vaidya Pharmacy at Coim- batore. By the end of February, I was able to go back to the operating theatre and perform controlled surgery. By June, I had noticed a considerable improve- ment." Shantha Kumari, the mother of four children, lives in Singanallur, a suburb of Coimbatore, and is a farmer's wife. About two years ago, she felt pain in the joints of fingers of both her hands, ac- companied by morning stiffness; then elbows, shoulders, and knee joints were affected. Severe pain started in the whole body and Shantha Kumari became bedridden. Allopathic treatment from the Coimbatore Medical College Hospi- tal gave her temporary relief. After about two months, she went to a local Ayurvedic physician, who later referred her to the Arya Vaidya Pharma- cy where she was hospitalized. After a month's treatment, she felt some relief. In addition to herbal medicines, she was medicated with oil and paste applica- tions all over her body. Her condition improved. She was discharged from the hospital after two months but nonetheless continued taking treatment for six months to avoid a possible relapse. AYURVEDA Ayurveda, meaning the science of life, is one of the three main branches of traditional Indian medicine; the others are Siddha, the southern Indian Tamil system, and Unani-Tibbi, which is of Greek origin. Ayurveda is based on the holy Vedas (Hindu scriptures), which are among the earliest classics of the world. This is perhaps the earliest medical science that lays stress on positive health a blend of physical, mental, social, moral and spiritual welfare. Ayurvedic medicine may be taken as an example of the efficacy of a fairly well-organized indigenous sys- tem of medicine and health care. Indian in origin, it has been practis- ed there and in neighbouring coun- tries for more than 3,000 years. It is estimated that about 80 per cent of the population living in these coun- tries still use the Ayurvedic and other forms of traditional medicine today. Now Shantha Kumari is back home and able to do all the usual work of a housewife and mother, even milking her cows. Luckily for her, the disease left no deformity, as it had been diagnosed and treated in the early stages. A special study was launched this year to evaluate the therapeutic efficacy of Ayurveda in rheumatoid arthritis. Al- though reliable figures of the number of people in South-East Asia suffering from rheumatic disorders are not available, it is believed that cases of rheumatoid arth- ritis, systemic disorders of connective tissues and inflammatory arthritis are fairly common in this Region. These disorders cause not only untold human suffering but also morbidity resulting in considerable economic loss. For centuries, Ayurvedic treatment has been known to be effective in chronic metabolic diseases. WHO, as part of its programme to stimulate and encourage research in traditional medicine, has initiated research in collaboration with the Indian Council of Medical Research to substantiate scientifically whether Ayurveda has a satisfactory cure for rheumatoid arthritis. The objective of this four-year study, which started in April 1977, is to evaluate alternative Ayurvedic therapy for cases of rheuma- toid arthritis; it is being conducted at the Ayurvedic Trust and Research Institute at Coimbatore, under the joint sponsor- ship of WHO and ICMR, with the latter as the executing agency. Members of the ICMR'S Advisory Com- mittee visit the research centre at Coim- ...Now Shantha Kumari is back home and f> able to do all the usual work of a housewife and mother, even milking her cows .. . (Photo WHO/A. Kochar) 18

batore every two months to observe and guide the research programme, carefully scrutinizing the progress of the research, monitoring and evaluating the pro- gramme continuously. This will continue until the end of the study period. The efficacy of the Ayurvedic drugs will also be tested pharmacologically on animals, and the drugs will later be subjected to chemical analysis. Teams of Ayurvedic and allopathic physicians will work in close collabora- tion with each other. The Ayurvedic physicians make the preliminary diagno- sis of patients selected for the study. If their allopathic counterparts confirm the diagnosis, these cases are referred to the nearby Kuppuswami Naidu Memo- rial Hospital for thorough investigations. If the re-investigations confirm the diag- nosis, the cases are referred to the Ayurvedic Trust Hospital where, out of the available 50 beds, 25 have been exclu- sively reserved for patients admitted un- der this research programme. All the data collected will be standard and in accordance with the criteria laid down by the American Rheumatism Association. The Ayurvedic medicines used for treating patients in this study are also, as far as possible, of standard quality, and the Ayurvedic Trust already has a phar- maceutical plant, some 25 kilometres from Coimbatore, for processing the herbs and other ingredients. The pic- turesque Western Ghat mountains which provide a backdrop abound in plants and herbs of medicinal value. Men, women and children of the local hill tribes diligently collect them to sell them at a number of centres set up by the Trust. The pharmaceutical unit uses modern technology to prepare potions and pills, and has plans to standardize its products. Rheumatoid arthritis, according to the Ayurvedic system of medicine, is caused by a disturbance of metabolism in the human body. Some of the factors that may be responsible for this condition are : over-indulgence in grief, alcohol or sexual activity; heavy and strenuous physical exercise or hard manual labour; and consumption of food incompatible with the body's requirements. These ac- tivities or actions tend to vitiate the motive force which controls all move- ments of the body in persons of delicate as well as corpulent constitutions. Men of mild and delicate constitution, as well as those who are obese or sedentary in their habits or are addicted to unwhole- some foods, are generally prone to this metabolic disorder. Vatha, as defined in Ayurveda, is the motive force which controls all move- ments of the body. When disturbed, it enters the blood vessels and obstructs the normal flow of the blood stream. This gives rise to rheumatoid arthritis, known in Ayurveda as Vatha-Raktha. Raktha in Sanskrit means blood. The charac- teristic pain, which at first confines itself to the extremities, gradually extends over the whole body. The symptoms de- scribed in the Ayurvedic shastras (man- uals) are almost the same as those de- scribed by the allopathic system for rheumatoid arthritis. In Vatha-Raktha the common symp- toms are : severe pain, sometimes prick- ing pain, throbbing of vessels, and con- striction of the main arteries in all joints especially of the fingers; stiffness of the whole body; shivering and numbness in the affected parts. In the early stages the legs perspire and become cold and flab- by. The disease progresses slowly, either from the lower extremities or from the smaller joints of the upper extremities, and may gradually involve other joints in the body. Discolouration and numbness may also be noticed in the affected parts. According to Ayurveda, Vatha-Rak- tha has two main stages : Uthana and Gambheera. In the Uthana stage, which is easily curable, the disease affects the skin and muscles. At this stage the skin colour turns coppery red or dark. It will 20 a ray of hope <1...Soon Indrani found it difficult to stretch or bend her joints and she noticed swelling, espe- cially of her knees and fingers ... ...The Ayurvedic Trust accepted her as an in-1> patient, and treated her with oral herbal medi- cines and external applications of medicated oil and paste. She should be fully restored to health after a further six months treatment ... (Photos WHO/ A. Kochar) be dry and give rise to an itching sensa- tion. There is also stiffness, a burning sensation, throbbing and constriction. If the symptoms are neglected and proper treatment is not taken, exacerba- tion of the disease occurs and this stage is termed Gambheera. Eventually this con- dition becomes irreversible, with general emaciation, wasting of muscles around the affected joints, deformity of the joints and severe weakness. This stage is reached when Vatha completely invades the blood in the body. The principles of Ayurvedic treatment of rheumatoid arthritis revolve around the correction or setting right of the disturbed elements of the body rather than treating the symptoms such as pain or swelling. The basic concept of Ayurveda is to treat the patient as a whole rather than his disease. Thus rheu- matoid arthritis is treated by various cleansing procedures and specific drug therapy, aimed at neutralizing the dis- turbed metabolic activity by giving ap- propriate drugs, diet and physiotherapy. A large number of herbal and biological preparations are used singly or in combi- nation, depending on their pharmaco- dynamic properties. Before the research programme start- ed officially, the procedure as laid down was used in the case of Indrani, a round- faced and bright-eyed girl who, at 16, is under-sized for her age. She lost her father when she was seven years old and her mother brought up Indrani and her three brothers and sisters by working as a house-maid. Some three years ago, Indrani complained of a shooting pain in her knee joints. For a week she went through intermittent pain but was not taken to a doctor because her mother could not afford the treatment. Soon Indrani found it difficult to stretch or bend her joints and noticed swelling, especially of the knees and fingers. Unable to bear the child's suffering, Indrani's mother pawned her only pos- session, her mangla sutra (sacred wed- ding necklace) and took Indrani to the Medical College hospital in Coimbatore. The girl was prescribed some "injections and medicines" which relieved her of pain for a while but it reappeared and has persisted until recently. On the insistence of her mother's employer, Indrani was brought to one of the four out-patient clinics run by the Ayurvedic Trust where the Chief Ayurvedic Physician examined her. He diagnosed the ailment as rheumatoid arthritis. To confirm the diagnosis, he referred the patient to his allopathic counterpart, a leading medical practi- tioner. The latter's examination provi- sionally endorsed the Ayurvedic physi- cian's diagnosis, and he described the condition as the second stage of rheuma- toid arthritis, bordering on the third. Indrani was refered to the Kuppuswami Naidu Memorial Hospital for various laboratory tests and radiological exami- nation. Pending the results of these tests, the Ayurvedic Trust accepted her as an in- patient, and treated her with oral herbal medicines and external applications of medicated oil and paste. Within a few days she appeared to be responding, and the prognosis of the Ayurvedic physician is that she should be fully restored to health after a further six months treat- ment. Rheumatoid arthritis is an insidious disease which surfaces at one time and lies dormant at another. The treatment therefore has to be prolonged and con- tinuous. This crippling disease spares neither young nor old, rich nor poor, man nor woman, and it takes a heavy toll in terms of human suffering and eco- nomic loss. But sufferers need not de- spair. They have a ray of hope. This meeting of modern and ancient medicine in a far-away town in the South of India could offer one answer that may bring relief at last to millions of sufferers the world over. ■ 21 PERIOSTEUM SUBCHONDRAL JOINT BONE PLATE CAPSULE ARTICULAR CARTILAGE solving the riddles THE CAUSATIVE FACTOR I\ RHEUMATOID ARTHRITIS IS STILL U\KNOWN BUT, IN VIEW OF THE LONG-TERM NATURE OF THE PROCESS, IT IS PROBABLY SELF-REPRODUCI\G AND THUS LIVING-PERHAPS A VIRUS by John L. Decker Arthritis (joint-arthron ; in- flammation-itis) is the most prominent manifestation of a large number of diseases and at least a small part of more than 100 dif- ferent processes. The research scientist usually directs his efforts towards a par- ticular disease rather than to the•arthritis per se and, thus, to appreciate World Rheumatism Year research, we must think about particular disease entities. Their diversity, and with it, the enor- mous scope of investigational fields now active, is astounding. The two most common rheumatic dis- eases, degenerative joint disease and rheumatoid arthritis, illustrate the situa- tion. Degenerative joint disease is also called osteoarthritis (bone-osteo ; joint- arthron ; inflammation-itis) or osteoarth- rosis (bone-osteo ; joint-arthron ; a con- dition of-osis). It is increasingly common with advancing years so that, by the age of 70 or 80 years, virtually everyone shows typical X-ray changes although the majority have not had and will not have pain or stiffness in the affected joints. The process is one of gradual breakdown of the cartilage which caps the ends of each bone where it articulates with, or meets, another. As the condition of the cartilage worsens, apparently of- ten accelerated by abnormal mechanical stresses, the underlying bone is consid- ered to "react" by showing extra growth and hardening of the bone tissue where cartilage is worn away. Current research is centered upon un- derstanding the "life-style" or metabol- ism of cartilage and bone. Efforts are being made to identify the enzymes (or digestive juices) which are responsible for destroying this tough tissue. From where do they come, and, more particu- larly, why are they increasingly active with advancing years? Scientists are able to grow human cartilage in tissue culture and then analyze its build-up—called anabolism—and its destruction—called catabolism. Extraordinarily delicate techniques for measuring chemical activ- ity within a tiny fragment of cartilage are being used to compare specimens of healthy cartilage with adjacent specimens showing degeneration. The possibility of developing inhibitors of enzymatic cata- bolism is a real one; such inhibitors might be able to prevent the cartilage destruction. Rheumatoid arthritis is a chronic, in- The critical tissue in rheumatoid arthritis is not the cartilage, although it mar he damaged, but the synovium—a soft hag enclosing hone, cartilage and the joint space. (Photo WHO/J. L. Decker) flammatory disease of joints which has its own timetable—sometimes fast, sometimes slow; sometimes intermittent- ly active, and, in other cases, very persis- tently active. It can begin in childhood, in adult life, or in advanced years and is said to affect as many as one in every 100 persons. In some, but by no means all cases, it causes severe damage to joint structures. The joints may lose the ability to move and, in the fingers especially, they may become twisted into abnormal positions. The critical tissue in rheumatoid arth- ritis is not the cartilage, although it may be damaged, but the synovium. This is a fine, velvety tissue which invests the ends of both bones, forming a joint; it is really a sort of soft bag which encloses bone, cartilage and the joint space. That "space" is not empty in life and only becomes apparent when, in the course of inflammation, it becomes filled with fluid and enlarges. The primary event in rheu- matoid arthritis seems to occur in the synovium which, microscopically, is crowded with immunologically active cells. Some are producing antibodies just as are the immunologically active cells in a person who has received a "foreign" injection like typhoid vaccine. Some are lymphocytes capable of reacting just as they do in a person who has a positive skin test and local inflammation upon a "foreign" injection like tuberculin. The ultimate initiator or "foreign" factor in rheumatoid arthritis is still unknown but, in view of the chronicity of the process, it is probably self-reproducing and thus living, perhaps a virus. The immune reaction appears to incite a "proliferative" change in the syno- vium; that is, where once there were ten Opposite page: Abnormal mechanical stresses often appear to accelerate the breakdown of cartilage tissues associated with degenerative joint disease osteoarth- ritis. (Photo WHO/ILO) 22

Above: Osteoarthritis is increasingly , common with advancing years; so that by the age of 70 or 80 years virtually everyone shows typical X- ray changes at one or more of the joints most at risk. Left: A scientist engaged in rheumatic research at the National Institutes of Health in Bethesda, Maryland, USA, adjusts apparatus used to separate proteins such as antibodies from each other, (Photo WHO/J.L. Decker) cells, 1,000 similar cells grow—thicken- ing the synovium and causing it to in- vade and destroy cartilage and bone, again by enzymatic action. Research in rheumatoid arthritis has focussed in recent years on the immunological events, the cells and their products which are involved, as well as on the stimulus which initiates the reaction. Thus within only two of the rheumatic diseases, work is proceeding in a variety of scientific disciplines—biochemistry of cartilage, biomechanics of joint motion, immunology, inflammation, and micro- biology. These are fundamental disci- plines, really part of the science of life- biology—and, in many respects, the fruits of these studies may also be impor- tant in understanding cancer or disease of the blood vessels, for example. Their broad applicability does not, however, remove them from our point of in- terest—arthritis research. Clinical research is often a bit closer to the patient and deals with such factors as the fullest possible understanding of his disease, how it affects him, and what can be done to alleviate, modify or cure it today. The fundamental sciences are more likely to lead us eventually to an understanding of the ultimate causes of disease (and thus potentially to a cure), whereas the clinical sciences are of the utmost importance for today's patient. The two levels of work must, and do, go hand-in-hand with new revelations at either level illuminating and advancing our understanding of the other. The "levels" are illustrated in the world's best rheumatic disease research groups. These units commonly enlist the minds and efforts of basic scientists who are uncom- fortable at the bedside and clinical scien- tists quite incapable, for example, of dissecting the binding sites of collage- nase, an enzyme involved in joint des- truction. The research unit allows each to contribute his or her expertise to the common problem and not only is the best milieu for the growth of new ideas and fresh approaches but is also the best training ground for incoming scientific workers in the rheumatic diseases. No one region of the world has a monopoly on high quality arthritis research. All investigators—wherever they are—remain in close contact with each other through the medium of the scientific literature which, incidentally, includes a rapidly expanding number of journals devoted to the rheumatic dis- eases. New findings, new ideas, new treatment modes are published, debated, discussed, and tested throughout the world. Some innovations stand up to these critical studies and analyses but many do not—such is the nature of the scientific process. From the viewpoint of the patient, who is the ultimate consum- er, the system, chaotic as it may appear, will rapidly spread worthy advances to every area. The type of communication involved will be much in evidence at the XIVth International Congress of Rheu- matology in San Francisco this month. Recent advances which have, in fact, involved both clinical and more fun- damental concepts include the identifica- tion of several new diseases, for example, a form of gout which is not gout at all. The acute attack of gout seems to be related to the appearance of crystals of uric acid salt within the involved joint. A body waste produce, uric acid, which should remain dissolved and invisible in the body waters, precipitates into solid crystals which can be seen in the micro- scope and which induce acute inflamma- tion and the agony of an acute attack. Scientists studying such attacks noted, in certain patients, crystals with optical properties which did not match those of sodium urate. Further analysis by X-ray crystallography showed the crystals to be a form of calcium phosphate and a re- investigation of groups of patients with such crystals in their joint fluid showed them to have a separable group of find- ings clinically and by X-ray; a "new" 24 solving the riddles disease, chondrocalcinosis or pseudo- gout, was born. Another finding involved the identifi- cation by immunologists of a distinctive antibody protein in the blood. It was capable of reacting with cellular material present in all mammals. Re-examination of a series of patients who manifested the unusual antibody revealed a special group of patients who had a disease process intermediate between a number of previously recognized illnesses— another "new" disease was born. The identification in this way of "new" diseases is of importance for two rea- sons. First, proper treatment can be ex- pected to differ from that applied to the general pool of patients from which they come. This clarifies treatment both for the new entity and for the general pool which becomes more homogeneous by the separation of the new entity. Second- ly, as we look for fundamental causative factors it is important to work with groups of patients who have the same disease with the most homogeneous pos- sible pattern. A similar recognition of new processes within an overall pattern is now going on in rheumatic disease research units with reference to the in- flammatory joint diseases which affect children. This latter process has recently been accelerated by work in genetics and trans- plantation immunology. In an effort to reduce the body's tendency to reject for- eign tissue grafted or implanted in it, tissue typing methods have been devel- oped so that tissues manifesting, for ex- ample, Protein X, were transplanted only into persons whose own tissues included Protein X. A substantial number of pro- tein antigens, inherited by the individual from his father or mother or both, have been identified. Two laboratories, sep- arated by thousands of miles, discovered simultaneously that one of these antigens was present in more than 95 per cent of persons with a rheumatic disease called ankylosing spondylitis, but in only 6 or 10 per cent of persons in the same com- munity without the disease. The illness is difficult to recognize in children but today tissue typing, easily performed on a blood sample, helps to identify children susceptible to ankylosing spondylitis and raises what physicians refer to as "diag- nostic suspicion". The current capability virtually to eliminate gouty arthritis is a result of research into the chemical mechanisms involved in the production and excretion of uric acid. The medications of today permit the physician both to increase the excretion of the chemical and to suppress its manufacture in the patient's body. In earlier years stringent diets eliminating chemicals which were digested to uric acid were used; today, when research has demonstrated that the greater part of this chemical is produced by the body from ubiquitous food stuffs and that the possi- bility exists of controlling that produc- tion, difficult and burdensome diets are no longer needed. Clinical research on rheumatoid arth- ritis has not yet succeeded in controlling it to the degree achieved with gout, but enormous strides have been made since the awarding of the 1950 Nobel Prize in medicine to Dr Philip S. Hench of the USA for his part in demonstrating the action of cortisone in the disease. Today researchers and rheumatologists are at work on two broad classes of medica- tions. One group has an effect over hours or days and acts, for the most part, to relieve pain and suppress the joint in- flammation. Many of them suppress the production of a series of inflammatory chemicals, the prostaglandins which have been the subject of great interest over the past five years. Drugs in this class are now the subject of intensive clinical research. The studies are often conducted by inviting patients with ac- tive rheumatoid arthritis to volunteer to take for a short period a study drug (for example, X) or an inactive drug (for example, Y) which look just alike. With the patient's agreement, he or she is "randomized" to receive one or the other; this is done by drawing the next envelope in a previously prepared and ordered sequence of envelopes which con- tain orders to the controlling pharmacy to give X or Y to that individual. As the patient takes the medication over the next few weeks, intensive observations of his pain, joint swelling, and status are recorded. When all persons have finished the trial, it may be possible to say that X produced better results than Y in some proportion of the patients. If that pro- portion is large enough and adverse ef- fects are not observed, it becomes pos- sible to say that X is a potentially sui- table drug for patients with rheumatoid arthritis. This fairly elaborate scheme is necessary because of the remarkable nature of the disease which can improve without any treatment, in other words, spontaneously. As many as 30 to 40 per cent of patients given drug Y, in the above cited study, might be expected to be better at the end of a month of obser- vation. These spontaneous improve- ments, incidentally, are often responsible for the claims of efficacy presented by all manner of charlatans—persons who prey on the gullibility of the chronically ill. Similar modes of research have been brought to bear on slow-acting agents which are considered to do more than suppress inflammation and are some- times capable of substantially altering the long-range outcome of rheumatoid arthritis. How exactly most of these act is still unknown. In one class, however, drugs capable of suppressing immuno- logical responses in animals are capable of partially suppressing the immunologi- cal response which was mentioned earlier as the primary event in the disease. These drugs work essentially by stopping cellu- lar division and have been used for that purpose in cancer. Unfortunately they affect many cells of the body in addition to the offending immunologically com- petent cells, and thus are too dangerous for general use. Nevertheless they have advanced our understanding of the process. Clinical studies, of course, go far beyond work on potential drugs. Per- haps the outstanding achievement of the last ten years has been the development of the surgical technique of joint replace- ment. It has become possible to replace excruciatingly painful, functionally im- mobile hip joints with plastic and metal- lic inserts, themselves connected to living bone by quick-setting methacrylate polymers. The resulting pain-free motion in a once invalid patient is a joy to behold. This type of arthroplasty may not give perfect results over an entire life span. Since it is so new, there are no extended observations but the immediate benefits tend to reduce the significance of the unknown remote risks. Other studies now in progress bear on physical modalities such as heat, exer- cise, splints and braces; psychiatric and emotional factors which seem to impinge on the disease; and aspects of the cost, availability and use of health care. All of these—and more—are a part of the war against rheumatic disease. World Rheumatism Year-1977—finds arthri- tis research flourishing and each passing year brings advances—slowly, it seems, but quite swiftly in the aggregate—which tend to reduce the dreadful cost, both human and financial, of rheumatic dis- ease. ■ 25 the role of WHO THE CONTRIBUTION OF PRI VARY CARE TO THE CONTROL OF RHEUVATISV HAS BEEN WIDELY UNDERESTI VATED, YET THIS IS HOW IMPROVED CARE WILL REACH MOST PEOPLE: V/HO IS ANXIOUS TO PROVOTE THIS MESSAGE by Philip H.N. Wood In pursuing the goal of com- plete physical, mental, and social well-being, WHO is in- volved in what are known as control activities, measures directed at containing and reducing' the suffering and incapacity resulting from various states of ill health. With certain matters of health concern WHO is able to play a very direct role. This is exemplified by surveillance, monitoring, and other ac- tivities concerned with the control of communicable diseases. With rheumatic disorders, however, as with so many health problems, WHO's main objective is to function as a catalyst and an enabler, interacting with the governments of Member States on the one hand, and with non-governmental professional bodies like the International League Against Rheumatism (ILAR) on the other. Successful control of any disease is based on scientific understanding and the resultant development of appropriate technologies. The potential these create can then be applied, in response to the will of the community to overcome the problem. But the community's purpose also influences earlier stages in this process. Although dedicated individuals and organizations may make some prog- ress in furthering understanding, they are dependent on resources to enable this progress to take place and these resources have to be made available by the community. Thus there is an intimate interrelationship between demand and resources, and between both of these and the level of knowledge and technology. If WHO is to influence situations like this, it has to involve itself with three levels of concern : appreciation of the problem in order to encourage allocation of resources to its solution; formulation of agreed standards and provision of expert advice on how to implement them; identification of obstacles to effective control and of the policies that might overcome them. Perhaps the most fundamental diffi- culty in regard to rheumatic diseases today is that the problem is insufficiently appreciated; there is an information defi- cit. Data which would illustrate the mag- nitude of the problem may all too often not be available, or, if available, may originate from multiple sources and therefore cannot be assimilated. Further- more the nature of rheumatic suffering and its impact on the life style of individ- uals affected by these diseases, as well as on the communities in which they live, is also very often not comprehended. At present we can map the outlines of this problem only very crudely, and to do even this we have to rely largely on intui- tion. Rheumatic disorders embrace four main types of health problems : Rheumatic fever and its complications, chronic rheumatic heart disease. Al- though these conditions may appear to be less important then other health prob- lems, the toll of mortality and morbidity they cause in developing countries is very considerable. Their occurrence is much influenced by social conditions. In some technologically advanced countries these diseases are still an important cause of death in young adolescents, and they are also responsible for a considerable amount of disability and invalidity. Articular disorders, or "arthritis", consti- tute an important and universal cause of crippling and invalidity. The term arthri- tis is often equated with rheumatoid arthritis, a serious condition with a fre- quently catastrophic impact on the indi- vidual. However, a walk through streets in any part of the world soon reveals the frequency of various disorders of joints, and of the consequent impaired ability to use the limbs normally; even in hospital joint deformities are too often ignored. The nature of the underlying condition differs of course from one country to another, in some being related to trauma or antecedent infection and in others to degenerative changes or specific forms of arthritis. Back troubles. These are often dismissed as an inevitable accompaniment of mid- dle age, particularly in women who have borne children. However, they give rise to serious incapacity which interferes with the smooth functioning of industrial and other processes— the awareness of which may too often be restricted to factory doctors. This is true in Africa, in the Americas, in Europe, in fact any- where that industrialization has oc- curred. Soft-tissue (non-articular) rheumatism. Although usually shorter in duration than the previous three categories, the cumulative morbidity burden from these ill-understood symptomatic conditions is nevertheless a heavy one. WHO has always been aware of rheu- matic disorders as a serious public health problem throughout the world—indeed A walk through streets in any part of the world I> soon reveals the frequency of various disorders of joints, and of the consequent impaired ability to use the limbs normally. ( Photo WHO/E. Mandelmann) 26 - a 6.••••11. •.. `‘.).,,,. 11a15 . .lit . brf% • ••• ?S. • I.: .4 u."4° • ,V. . 'V • • • ...■ 04 iP ' • - .1. a .. . . • %. . ' l • ''',......,:.', 4,, s' 'Psi . *1p. . • 1 ..‘ ,.., . 44 1'4' ' l• ;% ., 61", • AO • • . . , ... I .. i•ox . 7 4 . • .1,1: 4 ' , f'i I . • ly ' 1/4 ' *is • 1 • 0. i , • 1 , ,. . , , s , di, :'' 4 .4.16: I .. . et ' .44., • f . • ..„,N Ws , , .4 # 4 A 4 " .4.. A • • , ,,,,, 4 these conditions were accorded number six priority in a resolution passed at the First World Health Assembly in 1948. However, confronted as they are with other more dramatic health challenges, Member States have not found it easy to perceive that in the background rheuma- tism was quietly causing considerable disability and invalidity. The means were therefore needed to display the problem more graphically. In preparing the Ninth Revision of The International Classification of Dis- eases (IcD), WHO has worked closely with representatives of ILAR and its consti- tuent regional leagues in Europe, the 28 Americas, and the South-East Asia and Pacific Areas. The chapter concerned with diseases of the musculo-skeletal sys- tem and connective tissue has been ex- tensively revised, and should now relate more closely both to current clinical concepts and to the nature of generally available health data. When the Ninth Revision comes into use in 1979 it should shed increasing light on the magnitude of the problem. The limitations of morbidi- ty data have been exacerbated by termi- nological confusion, and so the work of ILAR in developing a rheumatological nomenclature is being integrated with the efforts of the Council for Interna- tional Organizations of Medical Sciences (cloMs) to overcome these difficulties. Also important has been the prelimi- nary exploration of methods of studying the consequences of chronic diseases, including arthritis. This has been carried out by WHO's ICD Unit and Division of Strengthening of Health Services, in con- junction with a representative of ILAR'S Standing Committee on Epidemiology. A classification of impairment, dis- ability, and handicap has been adopted for trial use, and has been supported by Rehabilitation International. All these developments should help Member States to draw up more realistic policies the role of WHO This elaborate system of weights and pulleys helps to rehabilitate the patient's rheumatism- damaged fingers. Part of WHO's work in the field of rheumatic diseases involves stimulating exchanges of experience in prevention, treat- ment and rehabilitation. (Photo WHO/T. Farkas) and priorities, since they can relate deci- sions to more meaningful and represen- tative information. However, it will be some time before the fruits of this work can be savoured, and in the meantime WHO has to carry out shorter-term activi- ties aimed at promoting control. Acceptable standards can be encou- raged on two planes, one influencing the pattern of work of individual health care professionals and the other guiding the organization of health care delivery sys- tems. WHO has been active in both direc- tions and, in a rheumatological context, this is best indicated by work related to the control of rheumatic fever. In 1953 the Organization convened an Expert Committee to consider chronic rheumatic diseases of articular and non- articular types. Although by no means confining its deliberations to these condi- tions, the Committee stressed that rheu- matic fever could be controlled and per- haps prevented by chemoprophylaxis, and that this offered an opportunity for preventive action on a worldwide scale which could not fail to be a major concern for WHO. Two further Expert Committees have been convened since then, to guide future work and to take stock of the progress made by control activities. The range of work that WHO endea- vours to coordinate is considerable. The scope of individual activity is reflected by clinical studies of diagnostic criteria and by efforts to standardize laboratory methods, as well as by meetings con- vened with the object of reaching agree- ment on such matters. Evaluation is en- couraged by operational studies on pri- mary prophylaxis and the prevention of relapses. Pioneer work on the organiza- tion of health care has been carried out by strategic campaigns to promote com- munity control programmes for rheu- matic fever. This is undertaken in con- junction with epidemiological research into its incidence and prevalence and into rheumatic heart disease. More fun- damental research will be considered shortly. Once standards have been formulated on the basis of international agreement, Member States will often request expert assistance on their implementation. Again the two planes of activity can be distinguished. As regards individual ac- tivity there are two main options; for a consultant expert to visit the country and advise, or for training facilities to be made available at a given centre under the WHO Fellowship Programme. The Organization has been more directly in- volved in developing community control programmes, where WHO staff members often play a key role in the field. Although work on rheumatoid arthri- tis has been more limited, it has followed similar lines. Since it poses a special problem for societies with longer life expectancies, it is natural that WHO's Regional Office for Europe has taken the lead. The EURO office has convened a number of technical conferences or working groups, which have considered both the standardization of diagnostic and investigative procedures and the basic requirements for public health pro- grammes. WHO's Headquarters has also expanded its commitment, and is stimu- lating community-oriented programmes for the prevention and treatment of rheu- matic diseases. It does this by coordinat- ing epidemiological studies, supporting pathomorphological and clinical studies in different population groups, dissemi- nating recent findings and stimulating -exchanges of experience in prevention, treatment, and rehabilitation, and cooperating with the appropriate national institutions or international and non-governmental organizations. These approaches have provided Member States with the means of mak- ing the most of current knowledge. Given an improvement in information input, the adoption of minimum stan- dards for health-related activities, and the will to overcome the problem of rheumatism, further progress is limited only by shortcomings in understanding and technological potential. WHO pursues limited research pro- grammes of its own directed at some of the outstanding problems; this is partic- ularly true in the field of immunology. But the Organization augments this work by coordinating research policies pursued by national institutions. Since the expansion of research activities depends on creating the right climate of opinion, WHO supported ILAR in its designation of 1977 as World Rheuma- tism Year. The overriding goal is the acquisition of knowledge that will enable primary prevention to be undertaken for all rheumatic disorders. Until this happy day, much can be done to improve secondary and tertiary intervention. As with most health problems, the contribu- tion of primary care to the control of rheumatism has generally been under- estimated. Yet it is by this means alone that improved care and control will be made available to the bulk of mankind, and the Organization is anxious to pro- mote understanding of this fact. ■ 29 000 000 000 000 000 000 000 000 000 000 000000 000 000 041004110 41 41, *mon: 000 see... 000 0.• 000 000 000 000 000 000 000 000 010 000 6• 000 0.• 000 000 000 4100 000 000000 000 000 000 0041 1100 000 000 1100 00004110 0410 000 000 000 00• 000 ••• *** Source of poison in edible fish identified The primary source of poison in edible fish caught in coral reefs around many islands in the south and west Pacific regions has now been identi- fied. Some 1,500 people suf- fer from fish poisoning in these areas annually. A fine food may at times become poison. (Photo WHO) The poison is produced by a dinoflagellate, a microscopic plant (60 to 100 microns in size) which attaches to an alga, according to Dr Takeshi Yasumoto, WHO consultant on the surveillance of biotox- ins in marine food fish in the Western Pacific Region. Dr Yasumoto, who worked on the project in close collab- oration with scientists of the South Pacific Commission, of the Institut de Recherches medicales of French Polyne- sia, and of the Hawaii University, said the dino- flagellate was identified at the Mie University in Japan on the basis of specimens sent by him. It is a new spe- cies, and this is the first time that it has been identified. It has been tentatively named Diptopsails sp. nob. How the episodes of fish poisoning occur is explained thus. Dinoflagellates, nor- mally present in coral reefs, seem to be provoked to mul- tiply when there is a distur- bance in their environment, and contaminate on a large scale the abundant algae in the reefs. Small fish feed on the algae ingesting the poi- son, and are, in turn, eaten by bigger fish. The poison passing through the food chain accumulates in the bodies of the bigger fish. The bigger the fish, the greater the potential toxicity. The poison gets into the flesh of the fish and cannot be removed by washing or cooking. When man eats a poisoned fish, it is his turn to sicken or even die, for the human be- ing is highly susceptible to the toxin. According to Dr Yasumoto, 0.76 of a milli- gram of this toxin, when ingested, can cause the death of a person weighing 100 kilograms. What causes the explosive growth of dinoflagellates is not known precisely but Dr Yasumoto suggests that in many cases man himself may be responsible for the disturbance that triggers the mechanism, as when reefs are blasted off or cut in building a runway, wharf or a pier. Natural causes such as a heavy rainfall may also cause a heavy growth of the toxin. The surgeon fish, found throughout the Indo-Pacific area, excluding Hawaii and the Red Sea, is known to ac- cumulate the toxin more than any other species. Nearly 60 per cent of reported poison- ings in Tahiti and other South Pacific islands are attributed to the consump- tion of this fish. The surgeon is a favourite food of the Moray eel, known as Otsubo in Japan and reef eel in Aus- tralia, and by 10 different names in the Philippines and by eight in Sri Lanka. The Moray eel can become high- ly poisonous to man. With the identification of the source of the toxin, the search is now on for the sub- stance that would inhibit or reduce the growth of the highly poisonous dinoflagel- lates. One man's illness An African youth travelling from Somalia to visit his mother in neighbouring Kenya in December last developed a rash on his body. Almost immediately he became the subject of an in- tensive man-hunt—wanted as a suspected case of small- pox by the health authorities of the two countries. Even though he could never be found, his rash had proved to be the dread symptom of smallpox since his sister came down with the disease shortly after he left. He had imported small- pox into Kenya, which had been free from the disease since 1974. The incident vividly demon- strates how smallpox is still being tracked down as the eradication programme draws to a successful con- clusion. It occurred in Ledhi, a small nomadic settlement in the Mandera district of Kenya, a desert area inhab- ited mainly by nomadic peo- ple, but under a close vigil because of its location near Kenya's border with Ethiopia, the last country to have en- demic smallpox, and Somalia where an outbreak imported from Ethiopia had occurred. The man developed a rash on 26 December. Within three days, the suspicious symp- tom was reported to the Kenyan surveillance health team. On 29 December the team arrived only to learn that the man had left. The team returned on 13 January on being informed that the visitor's sister had developed a rash—on 9 January—and collected a specimen. Smallpox was confirmed by a WHO Reference Laborato- ry, and the surveillance team hurried back to Ledhi. Mean- while, the eleven-member nomad family had moved on. They were located on 26 January camping in Karo, 27 km and one day's march from Ledhi. Four persons— the sister and her three chil- dren—were now suffering from smallpox. The other seven members of the family were vaccinated and kept under observation. Water, food and other neces- sities were provided to pre- vent the family from moving on too soon. Vaccination of people in settlements around Karo was simultaneously launched. Engaged in the operation at one stage were 30 trained Kenyan staff, in- cluding seven supervisors and provincial and district officers, and two WHO epi- demiologists. The outbreak was contained and no further cases occurred. Surveillance activities have been intensified in selected districts of Ethiopia, Somalia and Kenya, where the last known cases of smallpox occured, respectively, in August 1976, February and May 1977. Mothers learn to treat acute diarrhoea A simple and inexpensive but very effective method of treating acute diarrhoea in children, with mothers play- ing a key role, has been tried successfully in the suburbs of Bacolod City, Philippines. The standard treatment for acute diarrhoea is the in- travenous drip given in a clinic or hospital to replace the fluids and salts that the patient begins to lose rapidly with the onset of the disease. When the loss reaches 10 per cent of body weight, dehy- dration becomes severe and is often fatal. The intravenous drip, while effective and essential for severely dehydrated cases, is an expensive process and must be given by a skilled person. Moreover, it is not available to rural communi- ties far from clinics or hospi- tals. The new treatment con- sists of replacing the body's fluid loss orally. The diarr- hoea sufferer drinks a fluid containing some easily avail- able salts and glucose. 30 A palatable drink to tight diall- hoea. (Photo WHO/B. Cvjetanovic) During the first phase of the Philippines trial, mothers coming to the health centres with their sick children learnt from auxiliary nurses how to prepare the fluid and how much to give. They were also taught what food to give the sick children and were stron- gly advised against starving the diarrhoea patient, an un- fortunate but common prac- tice. The mothers themselves gave the treatment at home. The trial was a complete suc- cess and proved very suitable in treating children under five years of age. They recovered and gained weight much fas- ter, and the fact that treat- ment was done at home was welcomed by the mothers as a great convenience. In the second phase of the trial, now under way, an ef- fort is being made to deter- mine whether the same care can be provided by enlisting the services of community leaders in areas where health centres or even auxiliary nurses may not be available. The salts and glucose used in the Philippines trial were available prepackaged in alu- minium foil marked ORESOL (oral electrolyte solution). All the mothers had to do was to mix the contents of a packet with a litre of water. The simple mixture consists of sodium chloride (table salt) 3.5 grams; sodium bicarbo- nate (baking soda) 2.5 grams; potassium chloride 1.5 grams and glucose 20.0 grams, dis- solved in one litre of potable water. A packet costs 70 Philippine centavos (p 0.70) or less than ten US cents. The Bacolod trial, which may provide the basis for a nation-wide programme, is an undertaking of the Philippine Department of Health in which WHO is cooperating. Will road link favour spread of foot-and-mouth disease? Delegates to a recent meet- ing in Washington of high level veterinary public health officials expressed concern that the imminent comple- tion of the last link of the Pan American Highway may aid the northward spread of foot-and-mouth disease, confined until now to the southern states of the hemi- sphere. Looking for symptoms of foot- and-mouth disease. (Photo WHO) In the Pan American road system, stretching from Pata- gonia in the southern tip of Argentina to the Alaskan Arctic, there is only one break: a 400 kilometer stretch of forest, swamp, and rivers along the border of Panama and Colombia called the "Darien Gap". Construction work in the Darien Gap has been held up for a number of reasons, but the delay in bridging it has its positive side. Health officials have repeatedly warned that the highway's completion would remove a major obsta- cle to the spread of foot- and-mouth disease. A highly contagious viral infection that can decimate whole herds of cattle, the disease costs cattle ranchers and the economies of developing nations in the Americas Region millions of dollars annually. It also means the wastage of much-needed animal protein. The presence of the disease in South America was an ever present threat to live- stock everywhere, a delegate told the Inter-American Meeting on Foot-and-Mouth Disease and Zoonoses Con- trol. In the past the danger of infection for livestock was associated with sea and air traffic. Now, "the Pan Ameri- can Highway will provide the third dimension of traffic by land". The spokesman for the Pan American Highway Con- gress, however, did not agree. Construction work in the Darien Gap would have no untoward effect on the con- trol of the disease, he said, "since its spread would be interrupted by the wide and impassable barrier consti- tuted by the Atrato Marshes, across which for the time be- ing there is no possibility of traffic toward the Panama- nian frontier." The completion of the high- way, he added "will enable us to exploit our riches more fully, which will in turn give us the means to be freer and more sovereign, for it is ob- vious that no country can make progress unless it makes use of the resources offered by its territory". Colombia, the northernmost infected country, reported how it was strengthening its efforts to control foot-and- mouth disease "within the limits of its economic resources". The delegates stressed the need for action to reduce prevalence of the disease in the endemic areas, and close international coop- eration under PAHO's guid- ance to prevent its spread. Educational Handbook Copies of the 1976 edition of WHO's Educational Handbook, referred to on page 31 of the April issue of World Health, are avail- able on request from any of the six Regional Offices of WHO. Authors of the month Dr M. A. AKHMETELI, until recently Director of wHo's Division of Non- Communicable Diseases, has now returned to the Soviet Union to take up a post at the Gamaleja Institute of Epidemiology and Microbiology, the Soviet Academy of Medical Sciences. Dr R. G. ROBINSON is the President- elect of the International League against Rheumatism, and a member of the executive committee of SEAPAL, the South-East Asia and Pacific region of the League. Professor V. NASONOVA is Director of the Institute of Rheumatism, the Soviet Academy of Medical Sciences, Moscow. Professor F. DELBARRE heads the Clinic of Medical and Social Rheu- matology at the Institute of Rheuma- tology, the Cochin Hospital, Paris. Mr J.C. GEORGE is the Acting Public Information Officer at WHO'S Regional Office for South-East Asia, in New Delhi. Dr J. L. DECKER is the Clinical Director of the National Institute of Arthritis, Metabolism and Digestive Diseases at the National Institutes of Health in Bethesda, Maryland, USA. Dr P.H.N. Wool) directs the Epide- miology Research Unit of the Arthri- tis and Rheumatism Council for Research at the University of Man- chester, UK. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* One year 10.- 25 Two years 18. 45 — Three years 24.— 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 Rheumarc diseases do lot onby attack the elderly. Many children tgc have to undergo the long, stew course of treatrnenn that these diseases us:bady entail. (.q!o!`o Len Simian ) •0 FORWARD TOGETHER Appropriate Technology for Health FORWARD TOGETHER Appropriate Technology for Health The health bill of the industrialized nations, with less than 30 per cent of the world's population, is already over 300 thousand million dollars each year. All countries have a right to expect at least the same level of health, but many of them can hardly shoulder such an immense financial burden. Moreover, there is no direct relationship between the amount of money spent on conventional medi- cal care and the overall health of the people. A totally new approach is therefore needed. One of the most fundamental of WHO's activities in partnership with the developing countries is its pro- gramme on primary health care and rural development. Yet attempts to bring health care and protection against disease to the remoter and least well served areas of the Third World are constantly handicapped by the absence of simplified, low-cost materials, methods and techniques designed for or adapted to local conditions. In the past it was too easily as- sumed that technology imported from the industrialized countries would automatically solve the deve- loping nations' problems, including those of health. This led to the wholesale adoption of costly and inappropriate methods and techni- ques which benefit only a few peo- ple and contribute little to the widely dispersed communities of rural farm- ing societies. Money that might have been better spent has been squan- dered on such efforts and, in the process, the developing health ser- vices have become unduly depen- dent on the advanced industry of the developed world. Indeed many in- dustrialized countries are now begin- ning to reassess the appropriateness of their own technologies. The right tools for the job A resolution adopted by WHO's Member States at the World Health Assembly in May 1976 stressed that primary health care and health tech- nology must go hand in hand. As a direct result, WHO has now em- barked on a new programme entitled "Appropriate Technology for Health." Its objective is to help national governments solve the problems encountered in primary health care programmes (particularly those problems aggravated by the lack of an appropriate technology), at the same time both reducing the current dependence on imported technology and increasing the effec- tiveness of national health services. Why "appropriate" technology? Because the kind of technology the programme is searching for must be right not only for the particular prob- lem but also for each individual country's situation. It must be scien- tifically sound and operationally ef- fective — in some cases advanced scientific skills will be necessary for its initial development. But it must also be acceptable both to the deci- sion-makers and to the communities it serves; it must be tailored to the existing local financial, technical and manpower resources; and it must recognise local cultural constraints. The targets Drawing on skills, knowledge and creativity from many disciplines, the programme will concentrate on health care problems which a sui- table technology might help to solve. Sometimes an effective solution al- ready exists, but is either little known or unacceptable; or it has been found, but needs to be improved. When there is no known solution, a new technique has to be sought out and tested. The search will focus both on methods and materials — equip- ment, tools, devices, chemicals, drugs, biological substances — and on how to use them to best effect. But this is only part of the story. The technical difficulties confronting a health project are often aggravated by operational, financial or cultural constraints. So the WHO programme will also deal with ways of encou- raging people to accept new tech- nologies, training staff for their use and maintenance, and the proper production, distribution and applica- tion of instruments and materials in the countries where they are needed. The simple medical kit provides all the basic needs of this rural midwife. (Photo WHO/P. Almasy) The year 1977 has been ear- marked for planning and preparation. A major activity will be the develop- ment of a plan of action for the first six years (1978-1983), in which ap- propriate technology groups in dif- ferent countries, national institutions and other UN agencies will be close- ly involved. A newly created appro- priate health resources and technolo- gies action group in the U.K. headed by D r Katherine Elliott, affiliated with the Intermediate Technology Devel- opment Group in London, is already working closely with WHO. What we mean by "technologies" Some examples of what is needed: Household treatment of diarrhoea by oral rehydration. Ways of ensuring safe cold storage of vaccine. Simple, reliable field methods of sterilizing medical equipment. Simple and reliable diagnosis of anaemia at village level. A cheap effective two-way communication system. Further steps will be: in collabora- tion with the countries concerned to build up a list of health care prob- lems; to make a census of appro- priate technology already in use that could be applied in other countries; and to draw up an inventory of insti- tutions, groups and individuals throughout the world with a special interest in appropriate technology for the health sector. An essential ele- ment will be a system for collecting information on existing and new technologies and making it available to those whose needs are greatest: namely those who face the actual problems in the field. Designed in Thailand and being sed in Kenya, this cement water pot is an exam pie of simplified, imported tech n - y. (P,to W NICEF) Once a list of priority needs has been worked out, research and development contracts will be nego- tiated with appropriate technology groups in various parts of the world. The intention is to begin work as soon as possible on some of the technological problems already iden- tified and to start field trials in one or two countries. In all these activities, WHO is assuming a coordinating role. Challenge for the future A great deal is already happening all over the world today in the field of appropriate technology. Those activ- ities which are potentially of value to the health sector need to be identi- fied and coordinated. The success of the new programme will depend on the readiness of countries to commit themselves to its aims and chal- lenges. Many still have to be con- vinced that locally produced, low- cost, simple technologies are not automatically second-rate. In fact to develop appropriate technologies in the developing world calls for much more ingenuity than is generally believed. Health professionals in all countries must be prepared to modify present conventional attitudes and accept alternative ways as well as some traditional practices of proven value. Because the new programme reaches beyond the usual bound- aries of the health sector, it has been planned from the start as a collaborative effort with all those agencies, institutions and individuals concerned in the development of national resources. It provides an unprecedented op- portunity for the developed and developing world to work in partner- ship for the benefit of all. Primitive — but it works. Weighing scales like this, made from a stick, a little string, some leaves and balls of clay, can help mothers to ensure a "balanced" diet for their families. A two-man pedal-driven pump, con- structed from locally available materials, raises water from below the surface to where it can be diverted into irrigation channels. (Photos WHO/UNICEF) The medicinal value of local herbs is being scientifically evaluated in many countries today. (Photo WHO/Novosti) A migraine sufferer having treatment by acupuncture — a technology requiring great skill but a minimum of materials. (Photo WHO/Interfoto) What can you do ? We need your ideas Essential to WHO's new programme "Appropriate Technology for Health" will be a free flow of information and "feedback" about innovations and traditional methods that have already worked, about practical experiences in all parts of the world, and about potential needs that have to be met. Our own sources may not be enough and we welcome any information from our readers, especially if it appears to have a direct appli- cation to health problems. We need your help... ... to put these ideas into practice. In many countries, official agencies, institutions and individuals are already facing the problems of developing locally applicable technologies, and it will be WHO's task to help them in their work. But we need to know much more about people and institutions anywhere in the world who have the interest and capacity to help in this coordinated programme. We need funds Developing and applying simplified tech- nology where it is urgently required will cost money. Donations and gifts in kind can be put to immediate use and may be sent to: Volun- tary Fund for Health Promotion (Appropriate Technology for Health), the World Health Organization, 1211 Geneva 27, Switzerland. WORLD HEALTH ORGANIZATION Appropriate Technology for Health Programme Avenue Appia 1211 Geneva 27 SWITZERLAND Printed in Switzerland - '73 •0 FORWARD TOGETHER Appropriate Technology for Health