World Health: the magazine of the World Health Organization: December 1986 [full issue]: water is development

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · DECEMBER 1986 water is development To meet human needs by Her Excellency Gro Harlem Brundtland, Prime Minister of Norway and Chairman of the World Commission on Environment and Development he International Drinking Water Supply and Sanitation Decade is of great social, developmental and environmental significance. Hu- man needs are largely identical with health needs, and meeting the human needs of their people is an important and an urgent development priority in all countries whether developed or developing. However, given the uneven in- creases in global incomes , the demand for resources and the increased popu- lations projected for the future, hu- man needs have not only to be met but ' they have to be met in a socially, economically and environmentally sustainable manner. The designation of the Decade has provided a suitable 2 occasion for governments to get in- volved in many-faceted human needs programmes , while simultaneously providing a format for a broader rela- tionship with the social, economic and environmental determinants of development. After five years , the achievements of the Decade-though modest-have been encouraging. Considerable ef- forts have been made in improving potable water supply and sanitation. More importantly, the Decade has contributed significantly towards rais- ing awareness, both at national and international level, of the importance of safe water and sanitation for health , well-being and socio-economic devel- opment. All this has been achieved against the background of unfavour- able international trends, which have affected the capacity of many govern- ments to invest more resources in public works and social programmes. The provision of good quality water in adequate amounts , when and where it is needed, is not just a question of disease prevention. Nor are · arrange- ments for waste and sewage disposal a separate question of sanitary signifi- cance only. The two are complemen- tary, and both are required to achieve the wider objectives of good health and general well-being. If the health benefits of water supply are to be maximised , the chain of disease trans- mission has to be broken and this calls for increased emphasis on sanitation. W ORLD HEALTH, December 1986 c 0 -~ LJ c ::J 0 lL LJ 0 lL 0 I s 0 0 £ ()_ Recognition of this complementarity is of fundamental importance to the planning of community water supply programmes. At the local level, community water supply needs to be integrated with other initiatives and investments in rural development. The early involve- ment of local people alongside health workers and technicians will ensure that the water supply has the max- imum impact on the general well- being of the population. Moreover, emphasis ·on other benefits of safe water and sanitation will promote local funding and better community participation , particularly for opera- tion and maintenance. Indirectly , such participation will help to reduce the current imbalances that favour water supply to the detriment of sanitation. The broader approach to health pol- icy through an emphasis on " primary health care" is the cornerstone of the WHO strategy of Health for All by the Year 2000. National health agencies should consider support for communi- ty water supply and sanitation as part of primary health care and therefore of the Health for All strategy. Health care workers in turn will need to strengthen community involvement and train community workers to stress the health and developmental signifi- cance of safe water and sanitation. During the remainder of the De- cade-given the constraints on finan- cial resources-greater emphasis will have to be placed on rehabilitating existing systems and making better use of them. This calls for appropriate training, and for technologies to be employed that are consistent with the resources available. Experience shows that, when maintenance is entrusted to women , the results are more satisfac- tory! In order to improve mainte- nance , the community and especially women must fully participate . It.is clear that the dimensions of safe water and sanitation are multisectoral. While adequate attention has to be paid to technical and health aspects, the underlying social forces have cre- ated a need for the social, economic, environmental and political variables to be considered in the design, con- struction, operation and maintenance of safe water and sanitation systems . Thus, as governments focus on safe W oRLD HEALTH, December 1986 water and sanitation, they will have to tackle a whole series of issues that are interrelated . And in planning and car- rying out community water pro- grammes, decisions about increasing the supply have to be tempered by considering just who makes what type of demand, where and when. In other words, "Water is not just pipes , it is people. " The priority for the next five years must be the achievement of the De- cade targets , in a context of overall social and development relevance. Safe water and sanitation must be seen as a health issue as well as a develop- ment issue; certainly it is no longer necessary to justify the expenditure Her Excellency Gro Harlem Brundtland, Prime Minister of Norway, and Chairman of the World Commission on Environment and Development (The "Brundtland Com- mission "). Photo S Farkas © involved. By the same token, the cost- effectiveness of the sector should not rely on health indicators alone. Com- munity water supply programmes have to be drawn up and put into effect as integral parts of the sectoral policies on agriculture, health, education, nut- ntwn, housing and environment. Bringing this about will be one of the greatest challenges of the future in the field of safe water and sanitation. • Cover: Safe water and sanitation: an essentia l precondition for social and economic development Photo WHO/T. Fa(kas IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor and this month's Theme Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English·. French. German, Portuguese. Russian and Spanish. and four times a year in Arabic and Farsi . Articles and photographs not copyrighted may be repro· duced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27. Switzerland. Contents To meet human needs by Mrs Gro Harlem Brundtland Millions in need . . . . . . . . . .. Health-giving rain by Branko Cvjetanovic ..... . . Quality of life for all by Dr Emil Salim ..... . . A plan to quench Haiti's thirst 2 4 5 7 by Serge Gaspard . . . . . . . . . . . . . . . . 10 Uphill work by Juliusz Kozinski ....... , . . . . . . . . 13 Water is development... . . . . . . . 16-17 Water development funding by Louis Laugeri . . . . . . . . . . . . . . . . . 18 Water for a million by Timo Vuori . . .... . . . 22 Quality groundwater for tomorrow by Janne Fors lund . . . . 25 The Decade at half-time by Gregor Watte rs. . . . . . . . . . . . . . . . 27 • Departments: Primary Health Care Common action by Pablo R. Imperio . . . . . . . . . . . ... . . . 9 Appropriate Technology Basic X-ray units in Kenya . . . . . . . . . . 20 X-ray Manual: Picture-Perfect Success.............. 21 News Page . . . . . . . . . . . . . . . . . . 30-31 3 4 Millions in need Drinking water and sanitation are health programmes, not disease programmes. They are the essential precondition for the promotion of health, where health is under threat from communicable diseases good drinking water supply is good for health. This simple fact was recognised more than a hundred years ago during one of the great cholera epidemics in London . John Snow stopped the pump on Broad Street that supplied parts of the city with water from the River Thames and, by doing so. not only demonstrated that the disease was caused by infected river water but also showed that diseases like chol- era cannot be permanently resisted unless people are provided with safe drinking water. Why then are researchers today spending time and money yet again to disprove what has already been proven? Because of a misconcep- tion. They start from the premise that drinking water and environmental sanitation are interventions designed to control the diarrhoea! diseases. This is wrong. Drinking water supply and sanitation are the only perma- nent solutions that can prevent infant deaths from diarrhoea (and re- member there are more than five million such deaths a year in the developing world) . But it is wrong to assume that they should be provided merely to fight the diarrhoea! dis- eases . Drinking water and sanitation are health programmes and not disease programmes; they are the essential precondition for the pro- motion of health, where health is threatened by a vast array of com- mun icable diseases. and often the only permanent solution. Moreover. drinking water and sani- tation are an essential precondition for community development. and ul- timately for social and economic de- velopment. Since we know this , we may ask why economists like the researchers referred to above con- tinue to ask questions about these Where health is threatened by a vast array of communicable diseases, safe water-and good sanitation - often con- tribute the only permanent solution. Photo WHO/UN/J. lssac essential services? Is it because they prefer to invest the money in pro- jects which seem to offer a higher financial rate of return? Is it because they shy away from putting money down for water supply and sanitation since- admittedly - to build and main- tain these services will call for more ingenuity and hard work than putting money into a bank where it will earn interest? When delegates to the 39th World Health Assembly last May reviewed the progress made so far in the International Drinking Water Supply and Sanitation Decade. they started by saying that the case for adequate water supply and sanitation did not need to be restated . However, they noted the disparities in progress made between urban and rural areas. and between water supply and sani- tation . They insisted that more should be done for water supply and sanitation in the future. and not less . Children and women are suffering most in the present situation and they felt it was important to promote local technologies for water supply and sanitation, and to develop hea lth education strategies aimed at in- creasing the awareness of com- munities of their role, especially in planning and maintaining their own water supply and sanitation facilities . The delegates also stressed that improving water supply and sanita- tion means meeting the basic needs of millions of people; it followed. therefore. that financial resources should be made available in the light of a new and more equitable interna- tional economic order and as a con-. tribution to the quest for peace . Everybody had to get involved, not only the health sector; the delegates concluded that intersecto ral coopera- tion would be of prime importance to the attainment of the objectives dur- ing the second half of the Decade. • W oRLD HEALTH, December 1986 Photo L. Si rman © From the sea to clouds, from rain to rivers, from rivers to the sea again: the magnificent natural cycle of water is matched in miniature by mankind's puny cycle of water supply and water use by Branko Cvjetanovic Water constitutes more than half of the human body , and our very existence forms part of the dynamic cycle of the water on our planet. Water is continuously evaporating, due to solar radiation, from vast surfaces of oceans and lakes. The winds then bring the clouds over the continents and rain-water is car- ried by rivers into the seas again. In this magnificent natural cycle, we hu- mans play a relatively tiny role with our own life-giving cycle of water usage , whether for drinking , cooking , washing, transport of wastes , agricul- ture , generating electric energy or other industrial purposes. However enormous the natural wa- ter resources may appear to us, our rapid population growth and industrial expansion should oblige us to consider them as limited and precious. Only wise and appropriate use can safe- W oRLD HEALTH, December 1986 guard this commodity which contri- butes so much to healthy living, well- being and a pleasant environment. There is a direct link and a dynamic process of interaction between the natural water cycle on this planet and the one developed for human uses. Professor Branko Cvjetanovic is Professor of Epidemiology at the Andrija Stampar School of Public Health, Zagreb, Yugoslavia . Mankind has from time immemorial been using water to improve its economy, health and well-being , and to this effect has been diverting ever- increasing amounts of water from the natural to the human water cycle. The supply of pure water eliminates diseases that are transmitted by un- protected and contaminated water sources, so safe water contributes di- rectly to health. Water in abundance faci litates gardening, agriculture, hus- bandry and food production for domestic use and marketing. So it has a bearing on better nutrition and pros- perity, which in turn boost further socio-economic development-one of the most vital factors required for achieving a higher level of health and well-being. It was in response to the demands and expectations of the world popula- tion , in particular of the developing countries struggling to meet basic health needs, that the UN General Assembly initiated the International Drinking Water Supply and Sanitation Decade starting in 1981 and ending in 1990. WHO and other UN agencies are deeply committed to the goals of the Decade and are trying to mobilise the 5 Health-giving rain necessary resources. Among the most valuable of these resources is the will and determination of people to ac- quire, and use properly, a safe and abundant water supply. The World Bank and other international and na- tional funding bodies are supporting national efforts by providing technolo- gy and "the hardware" (pipelines and pumps) . But "hardware" alone can- not generate better health unless the community takes an active part in the water supply programme and uses the water in an appropriate and effective way. So more attention is now being paid to the human factor and the "software" component of water sup- ply projects. The participation of the local community is of the utmost im- portance in the process of planning, construction, maintenance and proper use of the water supply. This proper use cannot be imposed upon the community by simply pre- scribing relevant rules. This is a com- plex social and educational process , since attitudes to water vary from one place to the next. Traditional practices or habits and deeply rooted beliefs have to be understood and taken into account in order to ensure that a community makes the best use of the water supply to improve its health. Washing of hands has been shown (for example, in a study carried out in Bangladesh) to decrease the incidence of dysentery by 80 per cent. But this simple hygiene cannot easily be turned into daily practice by a whole com- munity. The decisive force that will make this practice acceptable has to be identified , liberated and motivated. In traditional villages, water was always more than a simple commodity. Water wells were places for gather- ings, for religious and other rituals and festivities. The soothing sounds of wa- ter fountains were an expression of the harmony among humans and within nature. Water has affected the quality of life and played a part in our physical and mental health for millennia, as the aqueducts prove that were constructed in Roman times and are still in use in the Mediterranean basin. And water still has hidden powers in the hands of health-conscious and health-minded women and men who are motivated to use water to improve 6 health. Miracles can still happen .. Cholera could be eradicated, as it was in some villages in the Philippines when schoolteachers and their pupils took the trouble to improve the water supply and build toilets. Hand pumps installed in one Indian village to pro- vide safe water were shown to prevent the spread of diarrhoea! diseases. They also made available the man- power of" drawers of water" to stimu- late agriculture and for other gainful activities . As the community's health and economy improved more resources Roman aqueducts still in use in the Mediter- ranean basin, still adding quality to life over the millennia. Photo WHO/D. Keckemet became available. Electric pumps were introduced. Abundant water was now available for gardening and other purposes, and electric power helped to develop cottage industries. The village turned from a subsistence to a market economy. An irreversible process be- gan towards health, better life and prosperity. The nutritional and health status of the community improved; infant mortality decreased, enteric infections practically disappeared. Such cases have been substantiated by numerous field studies recently re- viewed by the WHO, and scientific scrutiny offers convincing evidence of the positive impact of water supply on health. On the other hand, the health- giving effects of different water sup- ply projects vary widely, because peo- ple use water in different ways. Again this points to the importance of the human factor. It will also depend on the prevalent mode of spread of wa- ter-borne and water-related diseases whether providing safe drinking water will have an immediate and direct effect on health, or a delayed one resulting from gradual improvement of social and economic conditions. Safe drinking water will eliminate those diseases which are exclusively water-borne, but some of them are also food-borne and can be spread also by dirty hands. To eliminate such diseases will call for hand-washing practices and food-safety measures to be adopted. Nor can a better water supply be expected to improve health at once in communities living at the level of ex- treme poverty, who may be unable to make the best use of water due to lack of resources, ignorance, overpopula- tion and ill-health. In such cases there will be a need for parallel projects aimed at boosting the economy to the point where the community can make proper use of its water. At the other end of the scale, in affluent communities already provided with abundant water, additional quan- tities may be irrelevant for further improvement of health. Such com- munities often waste water, and this underlines the social inequality preva- lent with respect to water supplies. Supported by UN agencies, the De- cade is contributing to the improve- ment of health status of the popula- tion, but it is community participation which will play a decisive role in determining the extent of the health benefits which will be derived from the water supplies. Better and more ex- tensive use of water for personal and domestic hygiene, safe food handling and environmental cleanliness will bestow greater health benefits. Every- thing depends on people themselves, on their health awareness, and on their degree of self-reliance and ability to care for their own health by usmg water wisely and well. • W oRLD HEALTH , December 1986 Quality of tife for all Or Emil Salim, Minister of State for Population and Environment of Indonesia, attended the technical discussions on intersectoral cooperation during the World Health Assembly in Geneva last May. He acted as moderator of the working group on "environ- ment, water and sanitation, habitat and industry." In a recorded interview, he discussed some of his views with World Health "~n most developing countries, disease is very much connected with poor environment. For in- stance, there is malaria where there is dirty standing water, and respiratory infections are also related to an in- salubrious environment. That is why I think there should be a common focus between those who work for health and those who work for the environ- ment. This is what we call intersectoral cooperation. " It means working together , having a common aim and dealing with prob- lems jointly. Up to now , health was c·onsidered a medical doctor's busi- ness, while on the other hand environ- ment had to do with nature , with water , sanitation, waste disposal. But these two groups of people were in fact tackling the same problem : how to improve the quality of life; how to give human beings an environment that is comfortable to live in and has no negative impact on their health. In Indonesia , an important proportion of diseases are directly related to poor conditions in the environment. Lack of clean water produces stomach con- ditions , closed and unhealthy air con- ditions in the houses cause or aggra- vate respiratory diseases. " Institutionally, the specialists are boxed in their ministries. Training too IS very specialised, so that firstly through education and secondly " There should be a common focus between those who work for health and those who work for the environment." Photo WHO/Zafar W oRLD HEALTH , December 1986 through the work process people are trapped into a certain vertical thinking process . Everyone is working in his or her own field and fails to see the interconnection with other fields. There is also a kind of rivalry between ministries. Everybody wants to be a big man, the boss in his own field , and to cut the ribbons on new projects, forgetting that different activities are interrelated and all focus on one and the same person-the consumer , whose well-being makes no distinction between different ministries , whether health or environment. Unfortunately, bureaucracy is growing in the same direction , and I feel the same criticism applies to the UN agencies. "In Indonesia, we are trying to develop what we call a 'quality of life index.' Rather than speaking about specific targets for health , such as the reduction of infant mortality rates or the increase of life expectancy, we now 7 Quality of life for all 8 try to work out other indicators, like accessibility to clean water, the space used per capita for housing, unem- ployment rates, illiteracy and so on. This index is then compared with the per capita income. "We have found out that provinces with a high per capita income do not necessarily have the best quality of life. In the region of Jogjakarta, for instance, one province in the island of Java was accorded number 22 out of the 27 provinces of Indonesia in in- come, but in the quality of life index it rated fourth. It has a low infant mor- tality rate, high life expectancy , high participation in education , a low il- literacy rate. This is because there are no big industries in this region, hence the low per capita income, but it is a centre of education, with many univer- sities and high schools, and a centre of culture . And that makes a significant contribution to the quality of life. This means merging two things: the quality of man, which is related to his brain, his mind, his education and spiritual life; and the quality of the environ- ment, which is the quality of the air, of the water, the sanitation. The combi- nation of these two creates the quality of life. "Health can also be improved if there is a concentrated effort directed to the lowest income groups, what in Indonesia we call the vulnerable groups. Some have the capital and the resources, and others don't. Then, if development means resource develop- ment, those who have capital, skills, resources and education also have the capacity to move faster upwards on the social ladder, leaving behind those who have nothing. And unless policies exist aimed at achieving equity in all sectors-equal access to clean water, for instance-health will never reach the vulnerable group, which is very large. Through a policy of equity you raise the vulnerable group and have their health taken care of and, by doing so, you raise the quality of life of the whole nation." • Safe water ensures for human beings an environment that is comfortable to live in and has no negative impact on health. Photo WHO/Zafar WoRLD HEALTH , December 1986 Primary Health Care Common action omposed of more than 7,000 small islands, the Philippines cover an area of some 300,000 km 2 • only 10 per cent of which is inhabited. Forty per cent of the country's 55 mil- lion people live in the towns; for the remaining 60 per cent who live in rural areas-as well as for those living in shantytowns- infectious diseases caused by poor sanitation are an ever-present problem. These include diarrhoea! dis- eases. infective hepatitis. malaria, and a number of parasitic diseases. In 1980, at the outset of the Inter- national Drinking Water Supply and Sani- tation Decade, 47 per cent of the popula- tion did not have a safe water supply, while 28 per cent of homes did not have adequate toilet facilities. and 25 per cent had none at all. By 1984, 80 per cent of the urban population and 55.5 per cent of rural dwellers were supplied with drinking water. Although the percentage of homes with adequate sanitation did not change significantly during the same period, by 1984 662,080 toilets had been con- structed out of a total of 2,123,200- the target figure for the end of the Decade. The growing demand for a safe water supply-brought about not only by the existing shortcomings. but also by the needs of an expanding population - called for a concerted effort on behalf of all the competent bodies. some of which were created to fulfil the aims of the Decade. lt was the need to coordinate their various activities that led to the introduction of a national integrated programme for water supply which operates through adminis- trative offices within the various minis- tries and governmental institutions con- cerned, and is based on a primary health care approach. ·A master plan has been introduced. with a twofold aim : improving the water supply and providing adequate sanitation . lt receives financial aid from international organizations such as the World Bank and the World Food Programme. as wel l as technical assistance from WHO. Detailed plans of work are drawn up at local level in the barangay- the smallest W oRLD HEALTH, December 1986 by Pablo R. Imperio Mr Pablo R. Imperio is Sanita- ry Engineer Adviser to the Fili- pino Rural Water Supply and Sanitation Programme of the Ministry of Health. Manila . administrative district in the Philippines. Everybody concerned takes part in an inspection of the available water supply, and in carrying out disinfection : the rural sanitary inspector. the barangay chief. the midwife. and the local health worker. If it is found necessary to install a water supply, the would-be consumers must present an application to the competent authorities. who will meet with the com- munity and with local officials to discuss the viability and the extent of the pro- posed project, as well as such details as when work will begin; the type of ser- vices required ; community participation in the project; and. of course. how much it is likely to cost. On the basis of these This barangay health worker has added to her duties the task of helping her com- munity to build two sanitary toilets each year. Photo WHO findings a plan is prepared and, if the project is accepted. an association is formed, whose members will in due course receive training in the working and maintenance of the water supply. When these preliminary stages are complete. construction work can begin. In rural areas 98 per cent of primary health care programmes were introduced through social and community-based ac- tivities . A safe water supply and adequate sanitation were quickly identified as prio- rity components of these programmes. and local health workers were given train- ing to enable them to respond to the need. Thus. it is the barangay health worker's task to encourage and help the community to build two toilets each year in the sector for which he or she is responsible. Favourable attitudes However. education for health and training are both crucial to the successful implementation of a water supply and sanitation project. because they promote. on the one hand, favourable attitudes towards, and community participation in. the project. and on the other hand provide the participants with a wide range of knowledge and skills contributing to a better standard of hygiene and health. The Decade programme in the Philip- pines is moving towards its objectives. and there are many factors which have contributed to its success so far. These include community participation. a pri- mary health care approach. and increased emphasis on education for health ; the financial help received on an international as well as a bilateral basis. and the technical support lent by WHO; the close cooperation between the various bodies concerned with carrying out the work. and with training administrators and primary-level workers. Finally, mention must be made of the importance of relying on appropriate technology and effective control measures carried out by the field staff in bringing the Programme's activities to a successful conclusion. • 9 A plan to quench Haiti's thirst The Caribbean republic of Haiti launched a community hygiene and drinking water supply project five years ago which has already reduced infant mortality from diarrhoea in one village by Serge Gaspard 11 he weathered bones of Haiti's limestone rocks poke through the parched soil almost every- where on the uplands which occupy three-quarters of the entire republic. Hardly surprising therefore that drink- ing water is a scarce commodity. It was estimated in October 1978 that 9.5 per cent of the population obtained drinking water from public supply sys- tems , and almost all of these were town dwellers , especially those in the capital , Port-au-Prince , and its adjoin- ing townships of Petion-Ville , Car- retour and Martissant. Of those living in the countryside , fewer than one per cent were served by public supply systems, most of which were in poor condition , unsatis- factory in operation and confined to a very small number of users. Although the situation remains pre- carious-only 32 per cent of the popu- lation had a drinking water supply in 1984 (54 per cent in the towns and 25 per cent in the countryside)- there are today at least 17 priority projects, valued at US $143 million, aimed at bringing water to the people. All of them were proposed during the last 10 eight years and in the context of the International Drinking Water Supply and Sanitation Decade . On 1 April 1981, the government inaugurated the Community Hygiene and Drinking Water Supply project known as POCHEP, with the coopera- tion of the Inter-American Develop- ment Bank, the European Economic Community and WHO. It will cost an Mr Serge Gaspard is an En- gineer and Executive Director of the POCHEP project in Haiti . estimated $6,850,000, and the project has received a loan of $4,100,000 from the IADB and a grant of $2,000,000 from the EEC. The govern- ment of Haiti has supplied the remain- ing $750,000. Aimed primarily at improving the supply of drinking water in the coun- tryside , it will start by installing 70 piped systems to serve about 100 localities with a population of 106,000. The second phase will install at least 150 more. The project will also protect water sources against pollution (partly by adequate replanting of trees , to pre- vent soil erosion), and will try to reduce the great distances that many people have to travel at present to get their water. It will support other rural development projects such as the building of health centres and country schools, and will encourage the use of taps in health centres and schools to promote personal hygiene and the storage of drinking water. Although it is aimed at the countryside , some towns with more than 2,000 inhabit- ants have been able to benefit from it with the permission of the National Drinking Water Service (sNEP). In short, it is a good example of the integrated approach which is charac- teristic of applied Primary Health Care. The 37 systems that have been in operation for several years provide 389 standpipes, 98 washing and bath- ing units , 804 domestic supply points and eight water troughs. Since they currently serve some 98,000 inhabit- ants, it is evident that by the end of the first phase the project will have W oRLD HEALTH . December 1986 reached a far wider population than was originally planned. A further 20 systems will be operational when pipes are delivered , and 13 systems are in the course of construction. Before beginning work on a system, POCHEP runs an intensive campaign of information, promotion and educa- tion, establishing a dialogue with the people and maintaining it as the sys- tem is installed . The objectives of the project are clearly explained, and the people are shown how it will enable them to avoid some diseases and what the savings will be. They are then asked to take part by providing unskil- led labour and materials available in the locality, and by collaborating with POCHEP officials and technicians. The outcome is the signature of a contract which spells out the obliga- tions of both parties and is signed for POCHEP by the Minister of Public Health and for the community by a six-member committee elected by the people . This committee deals directly with POCHEP and is a link between the community and the government. Things do not always run smoothly. A community may , for example, reject W oRLD HEALTH, December 1986 Left: A plan to quench Haiti's thirst Scarcely a quarter of Haiti's territory consists of fertile soil; and safe drinking- water is a scarce commodity too. Below: In some regions, fewer than one per cent of the population was served by public supply systems before the POCHEP project started. Photos L. Sirman © 11 Involving the community is as important as political will for the success of development activities such as water supply and soil con- servation. Photo WHO/FAO/F. Mattiol i the project because it has been urged to adopt a different solution. Access to the site of operations may be difficult , and this can slow down the work. During the rainy season , a river in spate may make a locality inaccessible for two or three weeks or even longer. The education campaign preceding the start of operations is intensive , but it never lasts long enough to be really fruitful and community participation is generally weak. At sowing and harvest time, the inhabitants tend to desert the site for the fields . Consequently, the project has found itself obliged to pay for unskilled labour that should have been free . The Haitian countryside is poor and often lacks resources, so some localities are unable to provide the local materials as specified by the contract. In order to ensure that the system operates properly , and to detect en- gineering problems and leakages , it is inspected from the catchment all the way to the supply points in the houses. 12 The funds collected are also checked and the expenditure assessed. Even so, there is sometimes a lack of maintenance of the facilities and the piping system at existing community water points. This is partly due to inadequate training of those who man- age the posts, and partly to lack of funds. Now the project has decided to assist with routine maintenance- cleaning the installations, repairing or replacing taps and valves, disinfecting the reservoir , and training a small team to carry out non-routine mainte- nance under a qualified plumber. Precise figures are not available so it is hard to make a proper assessment of the impact of the project, but the results are positive. At the hamlet of Camp-Mary , one mother told us that her children no longer suffered from the itch and other skin diseases since the system had been built. At another village , Totoye , infant mortality from diarrhoea has greatly decreased . Not only has the project distributed some $300,000 of income in the target community, but a dying area has been revived since the building of each system. What was a desert is becoming green. At Fonds-des-Negres, a local inhabitant who had been obliged to go and live elsewhere promised to return to his birthplace on the day the water supply system was inaugurated. The International Drinking Water Supply and Sanitation Decade is bear- ing fruit in Haiti . The POCHEP pro- ject is not the only initiative; there is also a master plan for the independent Metropolitan Water Works , a piped water supply project carried out in the south of the country by the Care Foundation, World Bank-assisted pro- jects for the most important secondary centres (with the participation of the Federal Republic of Germany), and other projects of UNICEF with a drink- ing water and sanitation component. Important contributions have come from non-governmental organizations. Water supply is a priority area which underlines the fact that Health for All must be the work of everyone. The next step would be for all these projects to be backed by a vast educa- tion campaign that would promote community participation, enable in- vestment to be reduced and contribute to the rational use and maintenance of the posts . Only in that way will exis- ting efforts be fruitful in the long term and put the people well on the road to Health for All. • W oRLD HEALTH , December 1986 Uphill Work Many small settlements in the Yemen Arab Republic are perched on the mountain tops. This makes it all the more difficult to supply safe water from underground sources in valleys far below 11 he Yemen Arab Republic is a mountainous country situated at the south-western corner of the Arabian Peninsula with an area of about 200,000 square kilometres . More than 87 per cent of the popula- tion live in rural areas , scattered among some 30,000 small settlements. More than 70 per cent of the area of the Republic lies above an altitude of 1,000 metres. The annual average rainfall is only 500 mm, and there is a lack of year-round watercourses , except on the Tihama coastal plain where several bilateral agencies are actively working on irrigation and agricultural projects. Mr Juliusz Kozinski is a WHO Sanitary Engineer working with the Water Supply Project in Yemen. The population relies on obtaining ground-water from dug wells, drilled wells and springs as sources of drink- ing water, and also on collecting rain water in open cisterns where other sources are not available. Sanitary conditions in the country- side are extremely poor, mainly be- cause at present only about 22 per cent of the rural population have easy access to safe drinking water supplies. This situation results in a high rate of The high incidence of water-borne diseases in Yemen makes it all the more essential to care for the water that is available. Photo WHO/M . Jacot W oRLD HEALTH, December 1986 by Juliusz Kozinski water-borne, vector-borne and faecal- related diseases; 30 to 40 per cent of deaths in the zero to five year age- groups are due to diarrhoea! diseases . Schistosomiasis has a prevalence of 97 per thousand of the population throughout the country. The development of rural water supplies is considered as one of the top priority programmes in the country. The government realises that without safe drinking water supplies in rural areas it would be next to impossible to improve the health and living stan- dards of the whole community. As a consequence of the tribal na- ture of the society, which has charac- terised the Republic until very recent- ly, most village settlements are located on the mountain tops for defence reasons. Except for rare mountain springs , safe underground water is found only in the valleys (wadis) which are usually several hundred metres below, making the construction cost , and therefore the per capita cost, of water supply systems so much higher when compared to other countries. Based on present patterns of service and technology, about 4,000 million US dollars would be required for com- plete coverage of water supply systems in rural areas. The impetus of the International Drinking Water Supply and Sanitation Decade in 1981 has been reflected by a very positive attitude on the part of the Government , which has made con- 14 siderable efforts to expand the water supply programme under the Second Five-Year National Development Plan. Future investment programmes have almost doubled in value com- pared to those of the First Five- Year Plan. In 1975, following a request by the Yemen Arab Republic Government, the United Nations Development Programme (UNDP) initiated a project to strengthen rural water supplies, undertaken by the Ministry of Public Works with WHO as an executive agency. The first phase of the project was completed in 1978 and the second phase in December 1981, with an extension until December 1982. The third phase , due to start in January 1983, did not materialise because UNDP ran into financial difficulties in trying to secure funds for an extension beyond June 1983. WHO then took over the financing because it was re- luctant to see a project with such potential for health improvement through primary health care aban- doned. As from January 1984 the project has been operating on a dim- Uphill Work Left: Many villages are located on the hilltops, and safe water is found only in the valleys. Getting water to the villagers presents a special challenge. Right: Operating and, maintaining water systems are essential aspects of water management, and health education of those who use the water is vital too. Photos WHO/M. Jacot inished scale, at about 50 per cent of its former capacity. But the technical assistance provided by the project has strengthened the Rural Water Supply Department in its difficult task of bringing safe water to the countryside. This sector has benefited in the past, and continues to benefit, from the substantial financial and technical sup- port of friendly governments and bila- teral/multilateral organizations. The rugged, mountainous terrain means that simple, cheap technology, such as the use of hand-driven pumps, cannot be used to supply the villages on the mountain tops with the under- ground water that is available in the valleys. Rocky ground makes digging the trenches for the pipes both difficult and costly , so galvanised steel pipes laid on the surface have to be used instead of cheaper PVC and asbestos- cement pipes. Local people prefer reinforced concrete storage tanks be- cause of their long-lasting, low main- tenance characteristics. Diesel engines are used to run the pumps since elec- tricity is scarce, and this equipment has to withstand local conditions where only basic maintenance is available. W oRLD HEALTH, December 1986 All the above-mentioned factors , together with difficult access to many sites, account for the comparatively high cost of construction. An analysis of sample projects completed by the Rural Water Supply Department in- dicates that systems based on dug wells-supplying water through public standposts-cost an average of US $55 per capita, while systems based on boreholes , with several stages of pumping, vary from US $100 to $200 per capita. Proper operation and maintenance are very important factors for any correctly working water supply sys- tem. However , the existing organiza- tional structure in the sector has many disadvantages in this respect. The Rural Water Supply Department which is responsible for planning, de- signing and building facilities has no formal responsibility , and therefore no financial resources, for operating, maintaining and training the personnel of already constructed systems. Upkeep and operation of the rural water supply systems are the primary responsibility of Local Development Associations. But these are not techni- W oRLD HEALTH. December 1986 cally trained to carry out this import- ant task. They lack trained operators and are not properly equipped with mechanical workshops , spare parts and tools. As a result the Rural Water Supply Department is continually be- ing approached for assistance to repair and maintain motors and pumps. A vast majority of complaints regis- tered by the department are due to improper operation and maintenance of the systems by unskilled operators, who unfortunately have no technical training or job experience . In view of all these difficulties, the WHOIUNDP project has initiated a training programme for rural water supply operators. To provide financial resources for training, programme funds under the fellowship component of the project have been diverted for local training. Training programmes, technical guidelines and a training centre have been started. Training began in 1980 and ended in 1983, when the available funds ran too low. But even on a limited scale the training programme has been a success and has gained great popularity among village repair and maintenance staff. The efforts of such UN agencies as WHO, UNDP, UNICEF and UNCDF (United Nations Capital Development Fund), working in the country to help bring about the Decade's objectives , are fully supported by the government, which has increased the budget alloca- tion considerably for water supply and sanitation under its Second Five Year Plan. The budget allocations for rural water supply projects have almost doubled, and the goal is to supply safe drinking water for an additional 1,350,000 people. This is good pro- gress for a country which started from scratch only a few years ago. However, even if the Plan is implemented 100 per cent, it will provide safe drinking water to less than 40 per cent of the rural population, and the time for attaining the Decade goals in the Yemen Arab Republic will have to be extended , perhaps as far as the year 2000. Nevertheless the Decade has al- ready made a considerable impact on both people and government, and has resulted in a determined mobilisation of resources and efforts to meet the challenge. • 15 Photo Zafar © ateris here is today just as much fresh water on the earth as there was millions of years ago: about 40,000 cubic kilometers. But whereas there were 1 ,000 million people on the planet in 1820, there are 4,000 million today and there will be 6,000 million of us by the year 2000. Obviously this means that there is less water to go round. In addition, since the advent of the industrial era, there has been a dramatic increase in demand for water, commensurate with population growth and impro- ved living standards. Each individual is using more fresh water every day for domestic, agricultural and industrial use, so it is all the more urgent to protect the water that is available, to make the most of it and share it equally. The International Drinking Water Supply and Sanitation Decade (1981- 1990). now half way through its course, is striving to bring safe water to everyone's doorstep. All too often, women and children spend hours in the drudgery of collecting water from remote and possibly polluted streams and wells. Having safe water means better health and nutrition, more time for education; it also means a better chance of a style of life that opens the way to social and economic growth. The technologies exist to bring water into every household. People must now work together to make this a reality and prove that "Happy are those who build their development on water". Health plays a crucial role in any effort for development, and good health is closely related to the status of water supply and sanitation. Our graph on the opposite page shows the direct and indirect effects of water supply and sanitation on health. lt indicates how water and health, in common with many other sectors, form a basis for development. • (.) ro <f) .:!!. ::2 z 0 .0 :c s development Photo WHO/C. Stauffer DIRECT AND INDIRECT EFFECTS OF WATER AND SANITATION ON HEALTH Economic development Production increase Marketing Improved nutrit ion Community and personal hygiene Interruption of water-related diseases Photos Water International © DJ In most developing countries, as here in Rwanda, women or children spend hours on the drudgery of collecting water from remote streams and wells that often are polluted. [I] When drought strikes in Mali, the wa ter has to be dug out from deeper and deeper into the ground. Prolonged drought is a disaster in both human and eco- nomic terms. [TIThe tap is the centre of attrac- tion in this Nepalese village, bring- ing progress and the hope of a better life to the inhabitants. @J & @J Hygienic disposal of hu- man excreta makes it possible to avoid contaminating the water used for human consumption. it guarantees protection against the infectious diseases that hamper development in so many rural and slum areas of the Third World. m To be able to wash is a luxury and a joy that should be available to everyone all over the world. Not only does it give a sense of comfort but, most importantly, it enables people to stay in good health. Photo WHO/C. Stauffer ••• Water development funding Water is a commodity of public interest, indispensable to health, and supplies should be extended to all. Can revolving funds-in spite of their drawbacks-help communities to reach this goal? evolving funds, which consist of fixed amounts initially invested , and then progressively increased by their periodic returns , can contri- bute efficiently to the expansion of domestic water supply and sanitation. This financing system is particularly well adapted to the characteristics of the water market , since the increase in funds keeps pace with the growth of demand , as is currently being demon- strated in Brazil and other countries. While the technical soundness of these accounting and planning methods is beyond question , their ability to facilitate expansion varies considerably from one country to another, and there may be specific constraints related to high service costs, slow demand growth, and inad- equacy of the institutional framework. Since the demand for water (and sanitation) is assumed to increase con- tinuously as a result of growth of population and the individual's pro- pensity to consume more, planners are faced with a commitment to fulfil a dual objective: water supply and sani- tation services should expand in order to achieve total coverage at a given point of time, and thereafter they should continue this expansion in or- der to maintain total coverage over an indefinite period. The difficulty of finding or generating the required in- vestment resources is compounded by the need to properly operate and maintain existing facilities. In poor areas of developing countries , whether in town or countryside, it is commonly recognised that internal fund genera- tion from water rates is, at best , barely 18 by Louis Laugeri sufficient to cover the recurrent costs of the service. In more privileged dis- tricts of the larger cities , tariffs can usually provide the resources required to cover the initial capital as well as operating and maintenance costs , and can sometimes generate a surplus for Can revolving funds contribute efficiently to the expansion of domestic water supply and sanitation ? Photo WHO/Zafar improving services or extending them to less favoured areas. As there will always be a need for constructing new works and re- habilitating and replacing existing ones, it is an admitted principle of sound financial management to pro- vide in advance for the corresponding expenditures. In strict accounting terms , this means recording allow- ances for depreciation of fixed assets, so that they can be renewed as needed , and for generating a surplus, which corresponds to the need to expand existing systems. Both entries should be calculated as percentages , not of historical values , which could be said to be meaningless , but rather of fixed- asset values adjusted for inflation, which should give an indication of current replacement costs. As stated above, a revolving fund consists of a fixed amount initially invested, plus the periodic return' on this investment (usually expressed as a percentage of fixed assets in opera- tion) . This concept has been found attractive by financial planners in the field of water supply, because revolv- ing funds are viewed as a permanent device allowing for investment finan- cing in phase with growing demand. In physical and financial terms , the fund and its proceeds are applied entirely to the construction of new assets for previously unserved populations, which in turn contribute a surplus to ensure continued expansion. As ser- vice is extended to less and less privileged social groups, tariff struc- tures should be designed to ensure that the more privileged will pay an increasing share of the total proceeds. This is required for the process to perpetuate itself and eventually pro- vide a permanent solution to the de- mand/supply equation of the water market. Water is a commodity of public interest , indispensable to health , and water supply services should be gradu- ally extended to all . The utility in W oRLD HEALTH, December 1986 charge of the supply is in most cases granted a monopoly, and the con- sumer usually does not have an option to abstain altogether from consuming , or to choose an alternative source of supply. The costing, pricing and mar- keting rules of the private sector gen- erally do not apply to the supply- demand situation which exists in water supply. As a result many governments have adopted the principle that water should be charged for, not according to its value based on what has been spent in the past for its production (a value which would be obtained from free competition on a private market) , but rather according to its future pro- duction cost. Where the revolving fund concept has been adopted , it is actually the difference between these two values which should represent the input to the fund and which should serve as the initiator of a dynamic process allowing extension of cover- age , thereby resulting in the continu- ous generation of additional proceeds. However, if due account is taken of inflation so as to reflect , in the cost price of water , realistic depreciation allowances and provisions for exten- sions through revolving fund arrange- ments, average tariffs may become so high as to defeat the purposes for which renewal and extension funds were created. They may exceed the thresholds of consumers' ability and willingness to pay for the service. Mr Louis Laugeri is a WHO staff member working for the Com- munity Water Supply Unit, Divi- sion of Environmental Health, Geneva . Also, the ratio of capital-related costs to average tariffs may become very high, leaving virtually no resource to cover recurrent operation and main- tenance expenditures. This constraint can be compounded by financial losses on debt service as a result of currency fluctuations. Besides, revolving funds can revolve only if growth occurs at every stage of the development process. The as- sumption that demand will either re- main stable or grow, irrespective of price changes, may apply within limits W oRLD HEALTH. December 1986 Sound financial management should ensure funds in advance for building new water facilities and repairing existing ones. Photo W HO/UNICEF to individual consumption; it does not apply, however, to the collective de- mand of most communities , which in many developing countries will consist of fast-growing , low-income consumer groups. Supply limitations (such as intermittent systems or high levels of leakage and wastage) may also severe- ly affect a revolving fund's potential for growth and service extension . Ef- forts to overcome these supply short- ages usually tend towards costly lump- sum capacity increases , as opposed to gradual rehabilitation of the facilities; as a result , the cost of water may again increase beyond affordable limits. Finally, the operation of a revolving fund requires a delivery system to transfer resources from big cities to medium-sized towns and eventually to rural areas. The institutions needed to channel such resources and to monitor their use are often absent or deficient at the levels where they are most needed , close to the communities. Centrally-managed public utilities are generally reluctant to extend their activities to small towns and villages since this will tend to lower their financial performance . This summary of constraints related to high cost, slow growth and inad- equate institutions suggests that re- volving funds may not always be the ultimate answer to extending water supply (and sanitation) services to all . Where they are feasible , however, they have the merit of forcing the sector into a disciplined and reliable organizational framework. While they do not generate resources, they can act as catalysts and long-term regulators. The entire water supply (and sanita- tion) sector can rely on their proceeds, industry can expand , labour can be hired , foreign currencies can be saved , and increasing health benefits can be expected. So it is always advisable to evaluate the intersectoral impact of revolving funds, and their benefits to the economy as a whole. It is also essential for governments to commit themselves to ensuring their continu- ous financial performance , and in par- ticular for all surplus income gener- ated in water supply to be earmarked so as to ensure that revolving funds do indeed revolve. • 19 Appropriate Technology Basic X-rav units in Kenya llwo of the Basic Radiological Sys-tem (BRS) units developed by W HO to enable small hospitals to make X-ray examinations without the need for highly qualified technicians in attendance have now been operating for 12 months in Kenya. For the last six months. the machines have been working without close supervision by radiologists or radiographers . The units are simple to use and repair. and can be worked from car batteries. The operators who use them need only short training. although it helps if they have some medical experi- ence so that they know how to look after patients and understand some- thing of anatomy. But to become a fully qualified professional radiographer re- quires two or even three years' full-time training. and this is not necessary for BRS operators . The units are therefore ideal for small hospitals which only need to X-ray three or four patients each day. After a 12-month period. the two units in Kenya were visited by WHO consultants Dr P.E.S. Palmer and Dr N.T. Racoveanu . They reported that the results were "entirely satisfactory." The doctors (and the patients) at both hospitals are very enthusiastic about the results and make good use of the equipment. Although most of the ex- aminations are for the chest and limbs. the equipment is used freely to ex- amine the spine. abdomen. skull. pelvis and for contrast examinations . Where necessary. good pictures have been obtained during the last weeks of pregnancy to show the exact position and health of the baby. After six months without real supervision, the X-ray operators were still maintaining high standards. Photo W HO/D. Gibson 20 WoRLD HEALTH, December 1986 At the end of 12 months, the con- sultants studied a random series of 200 examinations taken from the files of the two hospitals, all being work done dur- ing the last six months without direct supervision . Fewer than one per cent of the examinations did not provide the diagnostic information required . All the other radiographs (a total of 302 expo- sures in this random survey) provided , the diagnosis without difficulty. There were, inevitably, some minor errors; not all the radiographs were perfect. Most of the errors came from problems with processing the X-ray films, from scratches on the fi lms, or because some curious individual (not a member of the staff of the X-ray depart- ment) had gone into the darkroom and opened the box of film to see what was inside! This fogged some of the films and spoiled the results . Most of the small errors which occurred might be found in any X-ray department any- where. and all can be corrected as the operators become more experienced and have the help of trained radio- graphers on a regular basis . lt is very important to know that. after six months without real supervision. the operators, who are not qualified radio- graphers, still maintain the high stan- dards which they had learned and are still producing the answers which the doctors require . The two hospitals between them have examined over 2,700 patients during the year, all of whom would have had to be referred to other more distant hospitals or treated without benefit of X-ray exam- ination . lt is almost impossible to assess the saving in terms of travel , but it is easy to realise the benefits in terms of patient care (including saving patients from pain and discomfort when they are moved over rough roads), the advan- tage of being treated in a hospital near home rather than in some larger more distant hospital. and the better follow- up that can be provided . Equally difficult to estimate, but also of great import- ance, is the satisfaction felt by the doctors in their ability to provide really good patient care in their own hospital. and to see the benefits themselves without having to send patients some- where else. After this 12-month trial , the WHO consultants concluded, there can be no doubt of the suitability of the wHo-BRS units for the small hospitals for which they were designed . • X-ray Manual: Picture-Perfect Success WHO's new guide to X-ray images for G Ps (see World Health, November 1985) is catching on in a bigger way than expected. Apart from above- average sales (the first 10,000 copies sold out iri a matter of months), the book is attracting special mention in leading professional journals through- out the world. The surprise: for once, material developed to improve health care in the Third World is being hailed as a step forward for medicine in affluent societies as well. Which is not to say that the book has missed its market. One develop- ing country is now negotiating pur- chase of no less than 15,000 copies -a bold effort to get the manual into the hands of every doctor in the country. At the same time, the book is sufficiently complete and authori- tative ("superbly" so, to quote the British Journal of Radiology) to war- rant its use by doctors and students in any part of the world. The book, entitled Manual of Radiographic Interpretation for Gener- al Practitioners (price Sw.fr.23 or US $11.50, in English, French or Spanish), is part of the three-pronged wHo Basic W oRLD HEALTH, December 1986 Radiological System (BRS), made up of a specially designed X-ray machine, a set of three manuals, and a shor- tened training course for operators. Photo W HO The other two manuals (Manual of Radiographic Technique and Manual of Darkroom Technique) can be used to train operators to produce perfect radiographs in a matter of weeks. Both are also in great demand. Like the manuals, the wHo X-ray · machine seems destined for a good career in developed as well as de- veloping countries. Designed to be tough enough for the tropics, yet easy to use and repair, the machine also boasts the winning combination of high quality and low price. As the British Medical Journal noted, "the design is foolproof, simple to operate, and able to provide consistently high · quality radiographs." At the last count, the machine had been pur- chased by cost-conscious hospitals in Great Britain, the Scandinavian coun- tries, and Holland as well as in scores of developing countries. Such success is certainly a meas- ure of the extent to which the WHO BRS meets the need for prompt, economical, and accurate radiological services. lt's a universal need-and a universally acclaimed solution from WHO. • For further information on the manuals, write to : Distribution and Sales. WHO. 1211 Geneva 27, Switzerland. 21 Water for a million he challenge facing the Kenya- Finland Rural Water Develop- ment Project at the beginning of the Decade , in 1981, was great: to provide water to nearly a million peo- ple living in Kenya's Western Pro- vince, close to the border with Ugan- da , about an hour's drive from the northern shores of Lake Victoria. By Decade mid-point , however , more than one thousand water points were in operation, almost a quarter of a million people were reaping the bene- fits of an improved water supply, and the target seemed considerably nearer. The project, begun in 1981, is car- ried out by KEFINCO (formed by YIT General Engineering and Con- tracting Company Limited and Finn- consult , two Finnish organizations) , working under the supervision of the Ministry for Water Development of Kenya. The recipe for the success achieved so far? The determination of the Kenyan and Finnish Governments to cooperate in rural development; an annual investment of some US . $2.2 million; a team of 200 to 300 project workers composed of Kenyan nationals; emphasis on thorough pre- liminary investigation ; programmed development in prospecting for water; and the vital ingredient, a high level of community involvement. The project area Covering an area of 3,650 km2 (ap- proximately half the total surface of Western Province), and with a popula- tion density of 250/km2 , the project area is home to some 0.9 million people , although this figure is ex- pected to reach 1. 7 million by the year 2005. With an average per capita income of US $250, about 40 per cent of the national average, Western Pro- vmce ranks seventh among Kenya's eight provinces in economic terms . 22 by Timo Vuori The chief source of income is agricul- ture-maize , cotton, cassava , sugar and tea being the principal crops-and most farming plots are small, few cov- ering more than a hectare. The annual rainfall is 1,000-2,000 mm. with mean minimum temperatures of 14-16°C and maximum temperatures of 26- . 30°C. Although most of the area lies at an altitude of 1,200-1,300 m ., In this part of Kenya, springs represent the most reliable form of safe water supply. Photo WHO!T. Vuori the slopes of Mount Elgon reach 2,000 metres above sea level. The area benefits from 20 health centres, and 650 schools. Before the project began , 99 per cent of the population relied on rivers, springs , a few private wells and, of course, rainwater during the rainy sea- son for their water supply. This some- times involved carrying water for sev- eral kilometres during the dry season. For traditional reasons, the ground water resources were virtually unex- ploited, although an investigation car- ried out over a two-year period showed them to be plentiful. It was decided to construct three types of waterpoint: spring protection (about 200 a year); hand-dug handpump wells, typically shallower than 10 metres (150 a year); and drilled handpump wells , average depth 60 metres (a further 150 each year). Shallow wells are usually lined with concrete culverts , manufactured at a central location to facilitate quality control, and transported to the con- struction site by a vehicle of the Pro- ject fleet consisting of 20 Land Rov- ers, two pick-up trucks , five lorries, 20 motorcycles and 50 bicycles. For the centres within the Project area , com- pact piped schemes are constructed or rehabilitated and, whenever feasible , solar-power tested. Community participation A term widely used in development jargon, " community participation " is difficult to implement successfully, and nearly always more expensive and time-consuming than was hoped. Yet it is a vital factor in development, since it is the most cost-effective method of transferring technology to the target population . How is it being achieved in this region? The Project area comprises part of four Districts, 28 Locations, and 144 Sublocations. Well before construc- tion begins in a given area, the local administration is informed of the number of new water points allocated to that area for the coming year. Armed with this information , the local leaders decide , together with the peo- ple , on a priority list of water points . The number of meetings required be- fore all the problems can be ironed out is sometimes astonishing. In 1983- 1984, for example, the Community Participation Personnel , comprising about twenty people , arranged no fewer than 1,500 meetings at village level , with an average attendance of almost 100 persons. Tangible indi- WoRLD HEALTH, December 1986 cators of the success of community participation are in short supply, yet so far the results are encouraging. Al- most all of the 900 handpump wells so far constructed have a well committee , whose responsibility is to keep the well area clean and to pay the bills for its maintenance. The committee receives Mr Timo Vuori is Project Mana- ger of the KEFINCO project in Kaka- mega, Kenya. information concerning the recom- mended unit prices for spare parts , labour and transport, and at the end of 1985 80 per cent of all the mainte- nance bills had been settled by the consumers . Where a hand-dug well is to be constructed , the consumers are re- sponsible for digging down to ground- water level , under the supervision of the Project team , after which one of the 20 local contractors trained under the Project completes the well with materials transported to the site. If a spring protection is to be built , con- sumers must themselves collect stones and other building materials, and where a drilled well is to be introduced the necessary mud pit is dug by the local community. And in most cases it all works very well . W oRLD HEALTH. December 1986 Construction of a water point usually begins within six to eight weeks of the initial contact being made. As soon as the physical struc- tures are ready , education of the consumer begins . The Project has in- vested heavily in providing informa- tion : training materials on water pros- pecting, presence of water in nature , well construction , handpumps and their maintenance, health education etc. are being continuously developed. A great attraction has been the mobile film unit, which has drawn audiences of up to one thousand peo- ple. One film , " Water and Health ", has already been shown to no fewer than 60,000 people since August 1986. Manufacture and maintenance Local manufacture of handpumps began in 1983 when the first India Mk II was completed at the Western College for Arts and Applied Sci- ences, Kakamega. Currently, all the deep-well pumps required by the Project (150 per year) are produced locally. Obviously, local . manufacture offers big advantages over importa- tion: prompt modification, continuous development, flexible delivery, gener- ation of employment , and technology transfer . A hand-dug well under construction : the villagers will no longer need to walk miles for this water. Photo WHOfT. Vuori A mobile maintenance unit , em- ploying motor vehicles , is not only far too costly as a long-term solution to the problem of servicing ; it also leaves the initiative of the local people un- tapped . With this in mind , the Project has introduced a decentralised main- tenance team, composed for the most part of local bicycle mechanics , who are responsible for servicing some 200 handpump wells . The repairers travel by bicycle, servicing pumps and send- ing their bills directly to the local well committee. Of course , considerable training , development of tools and screening of candidates are all re- quired before the scheme can work smoothly, but the results are en- couraging. Experience has shown that even in this motorised age the decen- tralised team can match the perform- ance of their car-operated counter- parts. After all, the handpump re- pairer is as close as the nearest bicycle shop! Several factors have contributed to the high degree of success achieved so far by the Kenya-Finland Rural Water Development Project : • The two governments involved have been able to implement the terms of 23 Water for a million the agreement ever since the begin- ning in 1981. The financing of the Project has been based on realistic cost estimates . • The Investigation and Planning Phase (1981-1983) involved a suffi- cient amount of testing , both in drilling and construction (200 wells) , to enable quick launching of the implementation phase . The test programme represented a fair in- crease ( 40 ,000) in the population with access to a water supply. Peo- ple gained a clear picture of what they could expect. • Operation and maintenance were aspects of water supply which were accorded high priority from the outset. • Careful monitoring of other rural water projects, such as the UNDP South Coast Handpumps Testing Project , has yielded up-to-date in- formation on recent developments in pumps as well as maintenance equipment. • A flexible combination of both the old and the new in investigation and construction favours the quest for affordable, yet operational tech- nology. • No product, simple or sophisticated , can survive if the consumer is not interested. Where consumer de- mand for water supply was low , promotional measures were under- taken. • A safe water supply costs money. Consumers are induced to pay for the upkeep of their water supply , but will only do so when they are convinced they are obtaining value for money. • A lifespan of about twenty years was assumed for the project since it was considered that a generation is needed for the transfer of technol- ogy to be completed . The transition from centralised handpump maintenance to village- based responsibility for the repair and upkeep of installations is a slow and often costly procedure. Yet it must be remembered that money spent on promoting community involvement is , in the long run , money well spent-it is an investment in greater independence and jmproved health. • 24 Each well has its committee, whose members are trained to know that regular maintenance is essential for any water supply system. Photos WHOfT. Vuori W oRLD HEALTH, December 1986 Quality groundwater for tomorrow Water drawn from underground sources (groundwater) is widely used for domestic purposes. Urgent measures are needed to prevent the deterioration of its quality by Janne Forslund roundwater has long been consi- dered a source of safe drinking- water. In general , it is better protected and of higher chemical qual- ity than surface water. During recent decades, however, changing activities at the soil surface have influenced the quality of groundwater. Changes in quality are still at an early stage due to the length of time required for surface water to percolate down . However , widespread changes in groundwater quality can be expected in the future. Although "point sources " such as waste disposal sites, oil and chemical spills can be a serious threat to a local groundwater source, emphasis should be on pollution due to the agricultural use of the soil. Denmark has a large agricultural sector with statistics on land use , the use of fertilizers and pesticides, groundwater and rainwater quality covering many years. Analysing the situation in this country could point to the changes in groundwater quality affecting drinking-water supply that may possibly occur in the future . The pollution of groundwater in Denmark is due primarily to the in- crease in nitrate concentration. In some areas , increasing acidification has also been noticed . In addition, the growing use of pesticides in agriculture will increase the degree of pollution of ground water. The risk of groundwater deterioration is definitely escalating. Since 1960 the pollution of drink- ing-water by nitrate has been related to the occurrence of methaemoglo- binaemia in infants and present know- W oRLD HEALTH, December 1986 Mrs Janne Forslund is a chemi- cal engineer working with the Agency for Environmental Pro- tection, Ministry of Environment of Denmark. ledge about the in vivo transfor- mation of nitrate and the formation of N-nitrosocompounds justifies the as- sumption that nitrate is active in the aetiology of stomach cancer. On the other hand, existing epidemiological studies of the relationship between stomach cancer and nitrate intake, although incomplete , indicate that ni- trate is a factor of limited importance. The decrease in cancer incidence over a 30-year period would suggest that Groundwater has long been considered a source of safe drinking water. Like any other source, its quality has to be protected. Photo WHO/Manevy factors other than nitrate are related to the incidence of stomach cancer. The acidification of groundwaters will result primarily in increasing the metal content of drinking-water, and possibly also the deposits of heavy metals in the body. Metals, such as aluminium, lead, zinc and cadmium, are soluble depending on the minerals present in the underground. The metal content of groundwater can be re- duced to acceptable levels with ap- propriate water treatment. If ground- water remains untreated, which is usu- ally the case for private groundwater supplies in rural areas, the "natural", dissolved metals will be present in drinking-water together with the met- als dissolved from pipes and taps in contact with the acid water . At this level of concentration, intestinal prob- lems such as diarrhoea have been noted as well as hair discoloration. Increased application of all pesti- cides has been noted, but the highest increase has been in the use of herbi- cides, owing to the changes in both the choice of crops and the number of people employed in agriculture. For example, in 1940 about 25 per cent of the population was engaged in food production, compared to about 6 per cent today. But to date the observa- tion of negative effects on health due to pesticides in drinking-water has been limited. Important determinants of ground- water quality are the load of pollutants applied to the soil ; the degradation of the pollutants; the absorption pro- cesses ; and the amount of precipitation which will dissolve the pollutants and transport them to the groundwater. Since the Second World War the agricultural use of fertilisers has been on the increase and this trend con- tinues. Shortly after 1960, fertilisers made from ammonium salts and ammonia came into universal use. Together, ammonia and ammonium salts will oxidise within 2-3 weeks to ni- trate and acid. Thus , nitrate contami- nation of groundwater is likely unless the fertiliser is washed out during the first 2-3 weeks. Of the amount of nitro- gen fertilisers and manure applied to soil, half will be used by crops; of the rest , one quarter is transformed into nitrogen gas in the soil and the remain- der transported to the groundwater. 25 By and large , the threat to ground- water quality has not yet materialised. However , increases in nitrate and aluminium content as well as de- creases in pH have already been noted in sandy areas which are more vulner- able. Some changes in groundwater quality are already being observed in Denmark. A comprehensive study of nitrate concentrations in groundwater was carried out in 1983 by the Danish Agency for Environmental Protection with assistance from the regional authorities. The study is based on the analysis of samples of groundwater from some 10,000 wells and of sam- ples of drinking-water from 2,800 groundwater supply systems through- out the country. A time-series analysis showing trends of nitrate concen- trations in drinking-water from 184 waterworks has been completed. Groundwater samples are taken when water supply borings are made. Information from these analyses has been collected over the last 50 years and stored in a data base at the Geological Survey of Denmark which contains 17,000 such analyses, in- cluding 15,000 with data on nitrate concentration. The study of long-term trends in nitrate concentrations in groundwater has been carried out in about 11,000 analyses from borings deeper than 10 metres. During 1982, data on the nitrate content in drinking-water were col- lected from 2,800 waterworks which provide 99 per cent of the total quan- tity of water distributed by water- supply systems and some 88 per cent of the water intenped for human consumption. For the country as a whole , some 8 per cent of the waterworks investi- gated exceed the maximum admissible limit for nitrate in drinking-water either temporarily or permanently. In the eastern part of the country , i.e. the islands, lower nitrate concentrations are observed and only some 2-3 per cent of the waterworks exceed the maximum admissible value . Data were also collected on the nitrate content of private wells. Today results are available on 2,292 private wells in four counties: 45 per cent exceed the maximum acceptable con- 26 centration (MAC). However , these represent a very small proportion of the total number of private wells through- out the country , namely 160,000 . The quality of water in private wells is inferior to that of water-supply plants because the wells are not as deep and are usually closer to the sources of pollution. As a rule , groundwater sources are not monitored regularly for pesticide content. When a " chemical " taste is detected in drinking-water , samples are analysed in a laboratory equipped to detect very low pesticide concen- trations. During the last two years some waterworks situated far from pollution sources have started scan- ning for chlorophenols in drinking- water and found very low contents of different types. Changes in the farm use of the land may affect the quality of drinking-water. Photo WHO/E. Mandelman Generally , groundwaters m;ed for drinking-water supply at the above- mentioned waterworks are well pro- tected under clay cover and are as- sumed to be more than 30-50 years old. The groundwater currently being analysed should therefore originate from the period when pesticides were beginning to be used in significant quantities and when pentachloro- phenol was in general use. The quan- tity of pesticides detected to date could be viewed as the tip of the iceberg, as different types of pesticides and higher concentrations are likely to be in evidence in the future . The study has clearly shown that Danish groundwaters are polluted by nitrate and that the overall mean level of nitrate concentration has trebled within the last 20-30 years. The worst situation documented , however , is that of private wells with 45 per cent of those tested exceeding the maximum admissible level. There are great interregional differ- ences in nitrate concentrations and their trends, that can partly be ex- plained by differences in geological conditions. The aquifers in West Jut- land are susceptible to nitrate pollu- tion because very little clay is available for reduction of nitrate . On the other hand , in Zealand nearly all the aquif- ers are covered by boulder clay , result- ing in considerable reduction capacity. The general and overall rising trend evidenced by this investigation cannot be explained by the effect of "point sources" of pollution . A continuing study relating the use of fertilisers and manure to the increase in nitrate con- tent of the groundwater in the catch- ment area has shown a strong corre- lation between the application of nitrogen compounds and nitrate con- tent increase in groundwater. Although the quality of ground- water in Denmark today is acceptable, trends towards unacceptable concen- tration levels of pollutants are evident. In many places shallow groundwaters cannot be used for drinking, while deeper groundwaters are generally of very good quality . However , increased reliance on deeper groundwater may cause increased salinity in the water supply, giving rise to other problems. Measures to avert the threat of pollution through the ever-increasing use of fertilisers and pesticides must be implemented now , before it is too late. An action plan against the further pollution of groundwaters by nitrate and organic compounds was initiated by the Danish Government in 1985. It provides for restricting the application of manure and setting limits for dung- hills and silage stores in order to stop percolation. In addition , intensive re- search programmes , aimed at the re- duction of nitrate release , will be car- ried out for a period of three years. It is hoped that this research will soon lead to the introduction of measures to prevent further leaching of nitrate and organic compounds. Although this is an irreversible process , perhaps the reduction and absorption capacity of the soil will be sufficient to main- tain concentration levels below the MACvalue. • W oRLD HEALTH, December 1986 The Decade at half-time The winners will be those who, through the efforts and commitment generated by the International Drinking Water Supply and Sanitation Decade, will receive a supply when they previously had none at all 11 he end of the first half of the International Drinking Water Supply and Sanitation Decade (IDWSSD) on 31 December 1985 had many features in common with half- time at a football match. The players leave the field to contemplate what has happened during the previous 45 minutes, to identify their weaknesses and the opposition's strength, and to decide on their strategy for the second half. The analogy is particularly ap- propriate this year when a focus of world attention has been on Mexico and the World Cup. The similarity between the Decade and a football match goes even fur- ther. In taking on the individual chal- lenge, countries have established coor- dinating mechanisms and national committees (the teams), have de- veloped national plans (the strategy for the game), and have set their sights on goals. In the case of the _ID_WS_SD ,~ the spectators have been largely sup- porting the team trying to attain the national Decade goals, although there have also been a few supporters for the other side ; and goals were scored by the opposition. These take the form of additional constraints placed in the way of Decade progress and can range from the general~ the global economic situation~to the specific~ national disasters and civil strife. The World Health Assembly played its own role in the half-time assess- ment by a review, based on a mid- Decade report by the Director-Gener- al, at the 39th World Health Assembly in May this year. WoRLD HEALTH, December 1986 by Gregor Watters Dr Gregor Watters is a WHO staff member working for the Com- munity Water Supply Unit. Divi- sion of Environmental Health, Geneva. Post-mortem of play As with the half-time analysis of play, the mid-Decade review was in two parts: the post-mortem, and the strategy for the rest of the game. This post-mortem has its positive side which produced a certain cause The Decade-an opportunity to bring safe water supply and sanitation to those who have previously had none. Photo WHO/Zafar for optimism, but also some negative aspects which underline the task ahead and the pitfalls to be avoided. On the positive side, it was noted that WHO's member states had demonstrated a commitment to the Decade both in political and financial terms as far as economic constraints would permit. The increase required just to keep pace with the population growth and maintain the existing coverage at 72 per cent in towns and 32 per cent in rural areas for Water, and 54 per cent and 14 per cent respectively for sani- tation, would have meant a coverage of 123 million more people in towns and 38 million more in rural areas for water, a total of about 160 million. And it would mean covering 92 mil- lion more in towns and 17 million more in rural areas for sanitation, or a total of 110 million. These figures were largely outstripped as a result of five years of effort, as safe and ad- equate water supply was extended to some 270 million more people, cover- ing 77 per cent of the population in towns and 36 per cent in rural areas, while 180 million more people had access to sanitation, or 60 per cent in towns and 16 per cent in the country- side. These are notable achievements, especially because they have been made in the developing countries, in- cluding those classified as "least de- veloped," in the face of serious con- straints~in many cases a worsening economic situation, rapid population growth in the towns, pressing national needs such as increased food produc- tion, and an increase in external de- pendence for basic requirements. 27 The main cause for concern after five years of concerted effort on the part of governments, supported by the bilateral and international community, is that, despite an achievement which deserves loud applause and accla- mation from the supporters in the stands, the situation with regard to the number of people still unserved does not look encouraging. After five years of effort and a considerably increased investment in expanding service coverage, around 1,200 million were without water and 1,700 million with- out sanitation. Because of population growth, the absolute number without water supply has remained about the same while the number without sani- tation has increased by around 100 million. Certainly a cause for thought and concern. The fact that an estimated 88 per cent of the resources were directed towards the towns should also be a matter for concern, since such pro- gramme bias and imbalance can only perpetuate the plight of the rural poor. In addition, only 25 per cent of the resources expended in the countryside 28 were for sanitation-a clear bias in favour of water supply. It is clear that the opposition team will not change at half-time after their relative success during the first half, so the constraints faced from 1980 to 1985 will continue to have to be contended with. The strategy pro- posed has, therefore , been developed to take full advantages of the potential strengths of the team striving towards a Decade win. Strategy for the second half Firstly, although some increased funding to the sector from both inter- nal and external sources has been observed since the start of the Decade, despite the continuing global eco- nomic crisis, the solution to water supply and sanitation ills will obvious- ly not be found in large injections of additional funding. Even if these were to be made available, their impact is dependent on national absorptive capacity and this is often the real constraint. Five years of effort have brought about considerable progress in water supply cover- age, but a great deal remains to be done. Photo W HO/Zafar Methods of accelerating Decade · programmes must, therefore, be found elsewhere, and the required activities by member states, the external sup- port agencies and WHO itself were identified by the 39th World Health Assembly. At national level, the emphasis must be on reducing the programme imbal- ance between the town and country areas and between water supply and sanitation; strengthening collabora- tion between the different national and international agencies within each country; increasing involvement of the community ; identifying and mobilis- ing additional funds; finally, improv- ing operation and maintenance of sys- tems , and reducing costs through pro- grammes of rehabilitation and the upgrading of existing systems. At the level of external support, the agencies should continue giving high W oRLD HEALTH, December 1986 priority to water supply and sani- tation and increase the proportion of resources for the underserved population and poor areas. They should pay more attention to pro- grammes aimed at strengthening the national capability to operate the sec- tor more effectively, in parallel with the construction of new schemes and projects. They should also encourage the development of institutional and human resources, particularly health education and community partici- pation. Meanwhile better coordination amongst themselves at both country and international level would be most welcome. In support of these actions by coun- tries and by the external support com- munity, WHO will support and promote both water supply and sanitation pro- grammes, giving priority to the poor underserved segments of the develop- ing countries. It will encourage the integration of water supply and sanita- tion activities into national primary health care programmes, activities aimed at improving the operation and maintenance of systems, and the mobilisation of resources in cash or kind. The question arises : has the Decade been a success or is the match being lost? Possibly some who ask it may even be anticipating or hoping for a negative answer. At half-time, suffice it to say that the goals aimed for are those established by the individual governments, and the only winners will be those who, through the efforts and commitment generated by the Decade, receive a supply who were previously without. In the long term, there will be no "Health for All" without the total access of the world population to ad- equate and safe water supply and to appropriate sanitation. However, this must not be considered only in the narrow context of disease prevention, but rather in the light of the broad concept of WHO's definition of health. The increased availability of satis- factory water supply and sanitation services-the Decade's objective-will inevitably result in improved social well-being, which is fundamental to economic development, and to a broad improvement in the world's health. • WoRLD HEALTH, December 1986 Making available satisfactory water supplies and sanitation services will inevitably result in improved spcial well-being, better health and sounder economic development. Photos WHO/D. Taylor and WHO/M. Jacot 29 Female Lung Cancer Highest in English- Speaking Nations The rise in death rates from female lung cancer over the past two decades has been "particu- larly steep" in English-speaking countries, and also in Denmark. In addition, according to trends reported in WHO's Weekly Epide- miological Record (No 39), lung cancer is gradually replacing breast cancer as the No. 1 cause of cancer deaths among women in the industrialised world. Following a study of cancer mortality trends in developed na- tions carried out earlier, WHO sing- led out for analysis female lung cancer in 12 countries with the highest death rates . The analysis showed that from the mid-60s to the mid-80s death rates, adjusted for age, increased by 200 per cent in Australia, Ire- land, New Zealand, and the Uni- ted Kingdom. The rates rose by 300 per cent in Canada, Denmark, and the United States. "This may well reflect," WHO says, "an earlier breakdown of social taboos against female smoking in these populations," particularly in English-speaking countries. While the increase was less in five other countries, still mortality more than doubled in Norway, Sweden, Poland, and Japan. Hun- gary was the only country of those analysed where the in- crease was slightly less than 100 per cent. In a table giving death rates per 100,000 females, mortality for the United Kingdom is broken down for England and Wales, for North- ern Ireland, and for Scotland. The table shows Scotland's mortality from lung cancer as highest not only in the United Kingdom but as well among the gther countries Photo. WHO/Zafar An earlier breakdown of social taboos. 30 Saying 'Yes' to Life; 'No' to Drugs The rallying cries are differ- ent, but the intention is the same- to rouse public anger, and to instil in the public mind a sense of urgency to act, against the threat to societies everywhere posed by drugs. "Just say 'No,"' is the theme of a U .S. anti-drugs campaign and "Yes to life; no to drugs," that of the United Nations. The target: youth in particular. The U.S. goals are drug-free schools and workplaces plus To rouse public outcry against treatment for addicts, to be drug threat. achieved through strengthen- ing laws, creating greater public awareness. and increasing 1nternat1onal cooperation. In underscoring that commitment, President and Mrs Ronald Reagan appeared on nation-wide television together for the first time ever, the President to warn - "To those who are thinking of us1ng drugs, we say: 'Stop!' To those who are pushing drugs, we say: 'Beware I'" - and the First Lady to plead-" Help us create an outspoken intolerance for drug use." The U.N. General Assembly, in response to the growing alarm world-wide, earlier set 12 to 26 June next year for the International Conference on Drug Abuse and Illicit Trafficking to be held 1n V1enna. Drug trafficking is global in scope, according to Under-Secretary-General William Buffam, the conference's top U. N. officer, who said that international cooperation is the "only way to go." In preparation for the first conference of its kind, last August representatives from 82 countries drafted a convention on trafficking of narcotic and psychotropic drugs. While essential, law enforcement is not enough by itself, according to WHO . Needed as well are programmes in prevention and treatment, for the misuse and abuse of drugs is tantamount to "narco- terrorism" against a nation's health anywhere. • ::::::. ::::::: ::: ::: ::: .:::::: :::::: .. ::::: .. :::::. ::::::: ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ::: ::: ::::::: ::: ::: ::: •:::::: ::::::· :::.:::::::::: ::::::: ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• listed. For the mid-80s, the rate was 38 deaths per 100,000 women. The other rates : Denmark, 29.9 deaths per 100,000 for female lung cancer; England and Wales, 28.3; the United States, 26.8; Northern Ire- land, 24.6; Canada, 24.3; Ireland, 23.9; New Zealand, 20; Hungary, 16.6; Australia, 16.3; Sweden, 12; Japan, 11.8; Poland, 11 .6; and Norway, 11. In a section on the relationship between lung and breast cancer, the report says that during the 1960s "mortality from breast cancer was 3 to 7 times higher than from lung cancer." But, it adds, "in recent years this ratio has declined to around 1.5, and indeed in Scotland the death rate from lung cancer is now identical to that from breast cancer." That trend is already discern- ible, or is expected to be, in these seven countries: Canada, Den- mark, Ireland, Japan, New Zea- land, the United Kingdom and the United States. Although mortality varies from country to country, women between ages 55 and 75 are those most affected. • Do-lt-Yourself Home Building In the Slums A sizable though sorry part of some 70 cities in the Third World are their squatter settlements. In 16 cities, between 20 and 30 per cent of the population live in slums; in 12 others more than 60 per cent do so. According to a study by the International Labour Organisa- tion, slums throughout the Th ird World could be made over into decent neighbourhoods, and the urban poor provided with basic amenities, at an estimated cost of $116 billion -provided the slum dwellers are put to work in build- ing their own homes. "Tapping their labour would re- duce costs and at the same time could contribute to the easing of a major sociological problem in the urban centres of the Third World," the author of the study, S.V. Sethuraman, declares. On the basis that the do-it- yourself scheme proposed would require 120 million man-years of mostly low-skilled or unskilled labour, slum dwellers could earn from $35 to $60 billion between now and the year 2000. "Letting the slum dwellers build their own houses would not only generate employment for themselves, but would also con- tribute to the upgrading of what- ever skills they may possess," the study says. The question to be tackled is financing. Challenging planners to come up with a financial package comprising public funding and subsidy that would "guarantee" a return on investment, the study states: "lt is not beyond the capacity of the developing coun- tries, even with limited re- sources, to clean up these urban eyesores." The stakes are high - nothing less than the quality of life of urban populations in developing countries, at present close to 100 million strong, but whose num- bers are projected to increase to 2,115 million by the end of the century. • Being a Doctor No Longer Means Job Security A medical degree has always been a virtual guarantee of life- time service to humanity, and of life-long employment- at least up until recently. At first in the de- veloped world, but now also 1n the developing world, that is changing. There are, for instance, an esti- mated 4,000 doctors in Egypt, plus 6,000 in Pakistan, who can- not find jobs, and an estimated 14,000 are projected to be unem- ployable over the next decade in Mexico according to reports pre- sented recently at a conference in Acapulco, Mexico, which addres- sed the issue of "Health Man- power Out of Balance." These are representative of worldwide trends that show the supply of doctors is exceeding the demand for their services, WoRLD HEALTH, December 1986 paradoxically, even as there are far too few practising in rural areas. A similar trend is develop- ing for dentists and, in certain countries, even for nurses, par- ticipants said. An examination of MD-to- population ratios in 16 countries showed that only Sri Lanka consi- dered its number of physi- cians - 8.1 per 100,000 popu- lation - as being insufficient. While Brazil, Cuba, and the Re- public of Korea considered their ratios adequate to health needs, 12 other countries said they had too many doctors. To India, for instance, a ratio of 36.5 MDs per 100,000 constituted a surplus, and to the United States, 197.3 MDs. Among reasons cited for the excess of physicians are the fol- lowing: the world-wide econ- omic crisis that has forced cuts in health services; the training of physicians without taking into ac- count a country's needs; the mushrooming growth of new state and privately run medical Photo : WHO Too many students, too many doctors. schools; and, particularly affect- ing Third World countries. the measures taken by industrialised nations to stop the "brain drain" - the migration of doctors from poor to affluent countries. All of which "has led to incon- gruities, irrelevances. and imbal- ances in the planning, production and management of health man- power," says Dr Halfdan Mahler, WHO's Director-General. To re- dress the balance, countries need to train what a WHO study has termed a "sustainable level" of physicians. that is, only the number that can be put to work. The conference - the first of its kind - was sponsored by the Council for International Organi- zations of Medical Sciences (CIOMS) and WHO, in conjunction with the Secretariat of Health, Mexico. • WoRLD HEALTH, December 1986 Newsbriefs • Biology, Chemistry, Maths, Physics. Books on these subjects are wanted by an organization in Trieste, Italy, for science libraries in Third World countries. According to its secretary, Mohammed H. A Hassan, his organization is appealing to "libraries, publishing companies, laboratories and individuals . . . for books, journals, proceed- ings, and equipment they no longer need." Thus far, dona- tions have been sent to some 80 developing countries. (For details, write to: The Third World Academy of Sciences, P 0. Box 586, 34126 Trieste, Italy.) e Calendar. Of more than usual noteworthiness-a WHO symposium on improving safety of contraceptive steroids, from 7-4 February in New Delhi, organized at the request of India. The alms are, first, an exchange of views among scien- tists, clinicians, and the representatives of drug regulatory agencies, the pharmaceutical industry and consumer organi- zations; and second, to update standards for preclinical and clinical tests of fertility-regulating agents. e Name Change. The International Committee on Taxo- nomy of Viruses has recommended that the name of the virus causing AIDS should be shortened from LAV/HTL-111 to HIV- Human Immunodeficiency Virus . And WHO has recommended virus de l'immunodeficience humaine as the French, and Virus de la inmunodeficiencia humana as the Spanish translations. The abbreviation to be replaced, LA V/HTL -Ill, stands for a combination of lymphadenopathy-associated virus (LA V) and human T-celllymphotropic virus type Ill (HTL V-III) . • 'Why Not Freedom from Cancer Pain?'- That is the challenge central to this new, six-panel flyer on the relief of cancer pain, one of the priorities of WHO's cancer control programme. Among reasons cited why patients suffer needlessly: a fear by nurses and doctors of patients becoming addicted to pain-killing drugs; national legislation that limits the availability of drugs; the inade- quacy of medical education in cancer pain therapy; the lack of awareness that pain can be managed. Through a three-step ladder of ====== medication-the right drug, in the right dose, given at the right time- 80 to 90 per cent of pain can be relieved, WHO says. (The flyer is available free of charge. Clip out this Newsbrief and send it to WHO Cancer Control Programme, Geneva 1211.) In the next issue World Health Day 1987 -celebrated as usual on 7 April - will have as its theme" Immunization : a chance for every child." WHO's Expanded Programme on Immunization is trying to ensure that most of the world's children are protected against six killer dis- eases. Our January-February issue will focus on the progress of this programme. If you would like to obtain the catalogue of WHO publications, or re- ceive sample copies of other WHO periodicals which you want to evaluate before placing a subscription, please contact: World Health Organization, Distribu- tion and Sales, 1211 Geneva 27, Switzer- land. WORLD HEALTH For readers everywhere 1986 Subscription Rates One year Two years Three years US$ Sw. fr. 12.50 25.- 22.50 45.- 30.- 60.- ORDER FORM Please enter my subscription to "World Health" as follows: One year D Two years D Three years D I enclose cheque/international postal order in the amount of: _ ___ _ Name: _ ___ ___ __ ~_ Street: -------------~-­ City: --------------- - Country: ____________ __ _ World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national cur- rencies, please contact your usual bookseller. 31 Water-carriers in Peru. Safe water is a first step towards economic progress. Photo WHO/P. Almasy