• WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
vlPRO 0153
15 February 1968 15 f'evrier 1968 ENGLISH: FRENCH
ANGLAIS: FRANCAIS SUMMARY REPORT ON A HEALTH SURVEY OF THE LOWER MEKONG :BASm
(Cambodia, Laos, Thailand, and Viet-Nam) Corrigendum CAMBODIA P~
61, paragraph 3.l.4(b), second last line:
Delete "of' leprosy patients, especiall;r children, at Troeung leprosarium" and replace by "of leprosy contacts, especially Children, living in Troeung leprosarium"
RAPPORT SOMMAIRE D I ONE ENQUE:l'E SANITAIRE SUR I.E l3ASSm INFERIEUR DU MEKONG
(Cambodge, Laos, Thailande, Viet-Nam) Erratum CAMBODGE Page 63, :pe.ra.grapbe 3.1.4, alinea b, derniere ligne SU;p;primer "des lepreux et specialement des enfants a. la leproserie de Troeung" et reselacer par "des contacts, et specialement des enfants, qui vivent a. la leproserie de Troeung:"
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WPRO 0153
SUMMARY REPORt' ON A HFAIll'H SURVEY OF THE LCWER MEKONG BASIN
(CAMBODIA. lACE. THAIIAND AND vmI'-NAM)
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Dr. J. Bierdrager WHO Publio HeaJ.th Consultant and
Mr. Z.J. Buzo WHO Sanitary Engineering Consultant
REGIOOAL OFFICE FOR THE WESTERN PACIFIC OF THE WORID HEAIlrH ORGANIZATION MANIIA
WPR./414/67
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NCrE
The views expressed in this report do not neoessarily re:t'lect the official policy of the World Health Organization. The report has been prepared by the Western Pacific Regional Office of the World Health Organization for submission to the ECAFE COIIIIIlttee for the Co-ordination of Investigations of the Lower Mekong Basin.
Nor FOR SAIE
PRIN1'ED AND DlSl'RlBOI'ElJ by the REGIONAL OFFICE FOR THE WESI'ERN PACIFIC of the World Health Organization Manila
TAmE OF CON'tEN'l'S '
PART I
1. 2.
mmOllJCTION
••••••••••••••••••••••••••••••••••••••••••••
1 2
.......................•.....•........ COumRI REPOR'l'S •••••••••••••••••••••••••••••••••••••••••
2
Tha1land ••••••••••••••••••••••••••••••••••••••••••• 2 Laos •••••••••••••••••••••••••••••••••••••••••••••••• V1et-NarD ••••••••••••••••••••••••••••••••••••••••••• 3
Cembod1a
••••••••••••••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••••••••••
, , 4
4. ACKNOWU:IGEMI!:N
PART
n .
GENmAL BECOMMENDA.TI0N3
1.
..
•••••••••••••••••••••••••••••••••••••••••••••
5 5
S~IAT
••••••••••••••••••••••••••••••••••••••••••••••
3. ANTI-MAIARIA CO-oRDmATION BOARD ••••••••••••••••••••••••• 4. <EGANIZATION OF A BEAIlrH INrELLIGENCE SERVICE •••••••••••• llNOLVEMEm! OF THE MINlS'mIES OF BEAurH IN PIANNmG THE ENV:mClNMElfrAL S:AN:I!rATION ASPECTS OF THE IEVEIDl'!J.IE:NIr 1?R.OJECllB ...................................... SURVE! OF llIDIVm1AL COUl'flmREFCm'S THAIIAND
6
6
5.
7
X!l f eo 1,7S Ii frT /11 If f! t} ( 10
1. •
ClRGANIZATION eF NATIONAL BEAIlrlI SERVICES •••••••••••••••• MEDICAL EDtXlATION ••••••••••••••••••••••••••••••••••••••
2.
11 11
3. THE NORTH-EASTERN HEnION
4.
CHlENGRAI PROVINCE
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•••••••••••••••••••••••••••••••
18
19 21
6. RECOl+fImDATIOE
••••••••••••••••••••••••••••••••••••••••
l..
IACS
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ORGANIZATION OF THE HFAmH SERVICES EDUCATION AND 'l!RAINING
................... '3 35
2.
••••••••••••••••••••••••••••••••
3. HEA.IJrH ASPECTS OF THE COtJNIlRY
••••••••••••••••••••••••• ••••••••••••
4. HEA.IJrH lMPLICATIONS OF THE 5. RECOMMENDATIONS
MEIro~ PROJECTS
............•..............•........... VI&r-NAM
37
1.
ORGANIZl"d'ION OF THE BEAIlrH SERVICES EDUCATION, 'l!RAINING AND REEEARCH
•••••••••••••••••••
2.
••••••••••••••••••••••
43
3.
HEALTH ASPECTS OF THE COt.JN.rRY
•••••••••••••••••••••••••
45 48
4. HEA.IJrH IMPLICATIONS OF MEKONG PROJECTS 5. RECOMMEND!\TlOE
••••••••••••••••
•••••••••••••••••••••••••••••••••••••••
50
CAMBODIA 1. ORGANIZATION OF THE BEAIlrH SERVICl!S
................... .................
57
2.
MEDICAL EDUCATION AND 'l!RAINmG
••••••••••••••••••••••••
BEAIlrH ASPECTS OF THE COt.JN.rRY ••••••••••••••••••••••••••
59
4.
BEAIlI.'H lMPLICATIONS OF MEKONG PROJECTS
5. RECOMMENDATIONS •••••••••••••••••••••••••••••••••••••••• .ANNEXE5 - ORGANIZATION OF A BEAIlI.'H INTELLIGENCE SERVICE MAP OF THE !£MER MEKOlfl BASIN
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PART I. 1.
GENERAL
IIfl'ROrocTION
The IQwer Mekong BaSin Development Programme is a multi-purpose water resources development scheme, involving the lower part of the M:!kong river and its tributaries. The objective of the scheme is the developmeo.t of the agricultural. and industrial poteo.tial of the area through the construction of dams and locks, which would lead to the irrigation of farmlands, flood control, the generation of hydro-electric power and navigation improvement on the main river. The couo.tries having most or a part of their territory within the Basin are cambodia, Laos I '!'hailand and Viet-Nam. A proposal that a 'WHO team should study the health implications of the Lower M:!koap; Bado. Development Plan was formulated and forwarded to the ECAFE Committee for Co-ord1nation of Investigations of the Lower l-1ekong Basin in Naveuiber 1965. This proposal was accepted • Between January and October 1967 a vffiO team, consisting of a public: health adviser and a sanitary engioeer, reviev1ed the health services io. the ripar1ao. countries at various levels of organization. The possib1l1ty of schistosomiasis being introduced into the development area was also studi.ed. The team made recommendatiOns covering p:lssible improvements and expaasions of the health services to meet the basic health needs of the population as part of an overall socio-economic development programme. It was recognized that this study was not meant to be an end 1n itself I but would be the basis of proposals to improve health conditions which, it was hoped, would be included in the ten-year development plao. for the ~er Mekong Basin. Detailed reports have been presented 00. E.sch couo.try visited. The parts dealing with the medical and public health aspects contain a great deal of detailed information and statistics that are considered useful in the assessment of health problems. These have been taken f'rom numerous reports, some of thich are o.ot readily available, or collected from io.terviews in the course of the team's surveys. This su.nmary report has been prepared for the purpose of presenting the findings of the team in a convenient form. It also deals with subjects 'Which are considered of direct interest to the Mekong Development CoUJDittee in regard to programme planning. Certain health measures will have to be taken into consideration in order to ensure that 111health does DOt interfere with the smooth progress of undertakings. These mostly concern the protection of workers and families from diseases which are prevalent in the area or might be introduced in an environment where sanitary requirements have not been gi~n sufficient attention.
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The part of the main reports dealing with environmeatal sanitation conditions appears already in a somewhat condensed form due to the fact that existing facilities are limited and inadeauate. It was considered that detailed descriptions were not only unne<seeuar,y bIlt also likely to be misleading. For this reasoll most of the material appearing in the main reports has been reproduced in this SUIIIIIaI"Y report. The team came to the general conclusion that the beneficial effects of the Mekong projects on public health are expected to outweigh possible harmful effects.
(1)
To assess the health conditions and the needs of the population in the development area of the Lower Mekong Basin. To establish epidemiological baselines from which future changes in the health situation can be judged. To study the prevailing environmental f'actors relevant to health, iDCluding the health aspects of' the population movements into the development area. To make recOIIIJIIendations on measures to prevent, as far as possible, the spread of major diseases to the development area and on the provision of basic health services to the population.
(2) (:~)
" T
(4)
3. 3.1 Thailand
COUN'l'RY REPORTS
The health survey in the Thailand portion of' the Mekong drainage area started early in January 1967 and lasted until the middle of' April. Because of the extensive and rather complicated organizational structure of' the health services in Thailand, a period of several weeks was needed to become acquainted with the numerous departments and divisions of the various ministries and agencies concerned with health in the areas under study. Three field viSits were made, two to ~~e north..eastern region and one to Chieograi provi.nce in the northern part of the country. Thanks to the excellent assistance given by the Government, which made available expert staff to accompBOY the team in the f'ield, sufficient information on health and sanitary conditions could be collected to serve as a basis for recommendations for the development of' measures to control diseases w.n1ch might be caused by the Committee's activities.
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In laos, the health survey ,.. carried oul; between 16 April and ~ May 1967. Due to 1Dsecur1ty on a number of roads, most travel had to be done by offic1al and nco-ac:heduJ.ed tl1ghts and SaDe places of 1nterest to the Mekoag Develo:r;ment Progr8lllll8 could UDfortuaatel¥ not be ns1ted. B'owver, the pr1nc1pal area, calsist1ng ot the V1entiane Plain and the 1fam,..Hgum dam s1te, 1188 stud1ed in scme detall. As the mal.ar1a inc1dence 1s disturb~ high in the mounta1nous area ~ Laos special attent10n 1188 g1ven to the protection ot labourers, once the coastruct1on 'WOrks on the Ham-Bgqn dam start. ,., V1et-Ham
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laos
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The V1et-Ham portion ot the Lower Jlekong Basin cons1sts ot three proriacesin the H1gbJ e nds, namel¥, Kant,., Ple1k.u, Darlac, and nine prov1nces in the Delta. Both areas, lIb1ch are entirel¥ different in most aspects I 1Ie1'8 ns1ted during the survey in V1et-Nam lIb1ch lasted fran 29 May to 21 July' 1967 •
Despite the ditt1cult1as resulting :fran the 1I8l', there are extensive act1tities in var10us fields of publ1c health and medical education. Most health progr8lllll8s are be1ng carried out with the financ1al ass1stant of the UiU.ted States Agenq tor InterDational Develo:r;ment (Am) and of other countr1es, which together etfectivel¥ canpensate tor the Goveroment' s 1'inancial and manpower shortage. The team stua1e4 the lons-term publ1c health and sanitation Deeds of the Mekong dra1nage area to determine tbat act10n 1iOUld be required ,men the s1tuation returned to normal and V1et-Nam voWd be largel¥ an 1ts own again. Part1cular attention 'WaS devoted to the highland provinces.
,.Ji.
Cambodia
The team ,.. in Cambodia fran 21 July' to 9 September 1967 1hen 1t returned to Bengkok to t1nal1ze 1ts report. As a result of the excellent co-operation received fran the Guve:tlJlilEl11t, it _s possible to visit the pros:pect1ve dam sites and to have discussions with 8~ r1ties in the various fields of eCC4""Q1 c, social and health develo:r;ment.
It -.s noted with interest that the Guvermnent, su;pported by private init1ative, had greatl¥ expanded 1ts nat10nal baalth 1ntrastructure and strengthened 1ts general health services in the past five years. In the health section, the country has been CQ181dered as a 1ihole, tor practical reasons, as ~ tw small port1Q18 are not included in the Lower MekoDg Basin.
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4.
ACKNCMIEInEMENl'S
The team wishes to record its appreciation of the impressive efforts made by all authorities concerned with the health survey. The platmiog of field trips, the prompt and timely notification of the local authorities and the arrangements with regard to transportation and accommodation have earned its gratitude and admiration.
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1.
INCLWION OF A BEAIlrH COMPONENT IN Ca3'l' ESTIMATES OF }ROJECTS
Although the benef'icial implications of' the Mekong projects on public health are numerous and are expected to outweigh any possible harm1'ul. effects, adverse iaf'luences, which might lIIBke their appearance, should be studied well in advance and in detail when planning development projects. The prevention and control of' specif'ic diseases attributable to the construction of' projects should be considered as a part of' the responsibIl1ties of' the constructing authorities. The improvement of' economic conditions in the development areas after completion of constructions will result in an increased demand f'or health and sanitation services. The enviroomental conditions in the development areas will have to be improved to a desirable level along the lines given in tb1s ~. Dnprovement of' health should be considered in direct relation to the project and as an integral part of' economic progress • Educatiooal. f'acilities will have to be promoted to meet the need f'or adequate staffing of the newly created health and sanitary services. The costs of such commitments will have to be calculated for each project' separately, as local coDditions in the Lower Mekong Basin, as well as the magnitude of' the projects and of the development areas involved, differ. XI; is reCOlllllended that constructing authorities lIIBke early estimates of' the cost of health protection and promotion in the development areas and include these in the overall cost estimates of each particular project. '
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2.
A PUBLIC HEAIlrH msK IN THE
MEK01'lG CCHQ!L"l'EE SECRE1.l!.ARIAT On the basis of the itrf'ormation provided in this sUlllllfU"y' report, the WHO team reCOlllDends that a public health administrator and a sanitary engineer should be attached to the Office of' the Executive Agent on a permanent basis. It became abundantly clear during the survey that the majority of health problems in the area are related to unsatisf'actory environmental conditions. Within the context of the Committee's projects, sanitary requirements can best be translated into integrated COIIIIlUnity planning with the assistance of' a sanitary engineer. The public health administrator would maintain
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11aison with the national health serv1.ces· of' the riparian countries and exercise epidemiological intelligence. 3. ANTI-MALARIA CO-ClRDllVI!rION BOARD
From 1958 to 1962 there existed an anti-malaria co-ordination board, which was established at an inter-country malaria conference convened by WHO in 1956. The participating courrtries were Burma, cambodia, Laos, MalaYSia, Thailand and Viet-Name At that time eradication programmes were being undertaken in Burma and Thailand and preeradication programmes were underway in Cambodia and Viet-Name In Malaysia there was a malaria eradication pilot project and Laos had all action interrupted. During the above period the annual meetil'l8s 01' the Board were firmly established on a rotation basis. ;. there were great d1fterenees in the eot1.'IIbr1es ()()JlIJE!tued W'11lh regII:L'd to the developmerrt 01' country programmes, of general health services and the socio-economic Situation, the general objective of co-ordination of' anti-malaria campaigns in the border areas remained in a very preliminary phase of' accomplishment. M:Llaria 1s still a major public health problem, largely hamperil'l8 economic development. It is believed that eradication can only be achieved on a regional basis. It is recOlllllended, therefore, that the Anti-Malaria Co-ordination Board should be reestablished. WHO might provide a malariologist who would serve as secretary to the Board, if this were considered necessary. 4.
ORGANIZATION OF A HEALTH INTELLm~ SERVICE
It is clear that the health situation in the Lower Mekong Basin is not generally prosperous. The people I s health is threatened by communicable diseases, nutritional deficiencies and poor sanitation, although the Governments concerned are 1l8king considerable efforts to neutralize and master these adverse 1nfluences. In the context of the Committee's activities it would seem of' importance to f'ollow this process closely and eventually assist the Governments in an advisory capacity by organizing a basin-wide health intelligence service. Although a world-wide service exists for the quarantinable diseases, the countries in the Mekong Basin would prof'it from an intelligence service to assist them to solve their collective health problems. This service could be organized by the public health administrator assigned to the Of'f'ice of' the Executive Agent of the Committee. (A detailed plan is given in Annex 1).
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5. INVOLVEm1'f.I! OF T1
MlmSTRlES OF BEAI.IrR m PLANNING T.8E ENVIEtI AI. SJ\Nr!1lrICfi ASPEC'l'S OF TB! IEVELOPl<Elfr PROJECTS
J:OiE'.Ji;al san1ta111oD
The involvement of th ministries of bealth in the enviaspects of the ~ project, ehoul4 include 'j;he follmpg p+;l.nc1 1 activities:
5.1 'lbro~ its ~tent sem.~esl the .n1stry should participate in the planning process I mal! available field and advisory staff I and exercise superv1s~~n, an( control over field activities. 5.2 Resettlement schemes uld lead to the estabUshment of model v1llages I for Which su1tabl' enviromoentat health standar.ds should be set for lAnd uSe I hausiQ , water suPPlY I sewerage and drainage, refuse disposal'l etc" . , • 5. , The design of Canals waterways, equalizipg reservoirs, overflows, etc., should be subje'cted t a cr1t1cal pubUc health engineeripg review in ~rder to m1n1m1ze the dapger of disease transmission. 5.4 Consideration MOulCl be given to the establishment of a surveillance system qn vectors of sease and to the possibU1ty that control measures m1ght ha~ to be set up in the future. Training of staf'f' il the environmental health field should be cooducted 'in conjunctIon W: the activities resulting from the Ministry's involvement in tb varlous development proJects. F1na~ I the team w es to express the opinion that environmental sa.nitation serv:tces and f8.c1l1tleff 'are the very foundation of public health a.nd d1sease trtrol. Early planning and 1mplemetrtat1on of such services and .tacU ties are necessary i f the benefits expected of the proposed projects a to be %'e8llzed.
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THAILAND VlBLE OF COltrmtL'S
1.
OmANlZATION OF NATmNAL lD!'.A.LTH SERVICES
•••••••••••••••••
:"'0
2. MEDICAL PIlUCATmN
•••••••••••••••••••••••••••••••••••••••• •••••••••••••••••••••••••••••••••
11 11 11
Health services Medical services Diseases of public health importance
.•..•.........•...................... •.....•...........•.......•......... ••••••••••••••••
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,.,.1 ,.,.2
13 13 14 14 15 16 17
'.,., ,.,.4 '.'.5
Water-.related diseases ••••••••••••••••••••••• Diseases due to poor sanitation •••••••••••••• Insect-borne diseases •••••••••••••••••••••••• other infectious diseases •••••••••••••••••••• Nutritional diseases •••••••••••••••••••••••••
... T
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'.5 4.1 4.2
Inter-.min1sterial and inter-.de:partmental eo-operation in the field of rural heal.th developoent • • • • • • • • • • • • Inter-m1nisterial agencies collaborating in eD¥1ronmental sanitation •••••••••••••••••••••••••••• •••••••••••••••••••••••••••••••••••••••
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4. CHlENGRAI PROVINCE
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Health services ••••••••••••••••••••••••••••••••••••• Diseases of public health tmpartance •••••••••••••••• • •••••••••••
19 19 19 21
5.
6.
.....•.•..•...................•....•.....• 6.2.1 6.2.2 6.2., 6.2.46.2.5 6.2.6 6.2.7 Overall plann1ng S~
6.1 Health needs •••••••••••••••••••••••••••••••••••••••• 21 6.2 EDviraamental sanitation •••••••••••••••••••••••••••• 22 ••••••••••••••••••••••••••••• •••••••••••••••••••• ••••••••••••••••••••••••••••••
Community ~anning end housing ••••••••••••••• PUblic ~ter supplies •••••••••••••••••••••••• aDd waste disposal Ref\Jse diSpOsal
22 22
, •
23 23 24 24
Food preparation end handling •••••••••••••••• Provision of sanitary facilities end 1nstltuticm.s •.•••••••••••••••••••.••••••••••. 6.2.8 Stream and. air pollution •••••••••••.•••••••••
25 25
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6.,
Measures for disease centrol
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25
6.'.1 Water
6.,.4 Chemical trea1;ment of 'Water bodies 6.'.5 n enn1 ng aDd 111t1Dg of call1llUll1ties 6.,.6 ChemolU"oWlelds 1n the cartrol of .paras!tic d1a.aases
6.,.,
6.,.2 Water ccmtrol in irrigaticm schemes ••••••••• Drainage awl j~lling of marshes
control1n general
••••••••••••••••••••
••••••••••••• •••••••••• ••••••••••
•••••••••••••••••.••• •.•••• ••••••••••••••••••••••••••••
Health
educa~Lan
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THAILAND
l... CBlANlZATlON OF NATIONAL BEAI:rH SERVlCES The major responsibility for the heal.th of the population rests with the Ministry of Public HeaJ.th. However, when it was recognized that the impl1cations of heal.th management affect many aspects of life, national. committees were created to def1ne pol.1c1es and guidelines al.ong wh1ch public heaJ.th principles coul.d be put 10:1;0 practice. The M1n1stry of Public HeaJ.th has reached a high degree of organ1zation as all aspects of public heal.th are represented. Wbil.e some techn1cal departments are placed directly under the Under-8ecretary of state for Publ.1c HeaJ.th, he 1s assisted by three directors-general. who act as department chiefs for public health, med1cal. services and medical. sciences. In the Department of Heal.th, which has sixteen d1visions, there 1s a wide d1versification of responsib1lities. Such an organ1zational. structure requires a high degree of co-ord1nation and co-operat1on, but it is al.so an incentive to an industrious work programne. S1nce compl.etion of the First Five-Year Plan for ecoDOlllic and social. devel.opment I new targets have been set to meet the growing demands of a rapidly increasing popul.ation. These targets rel.ate to the number of medical and para-medical. personnel. and heal.th facilities, incl.11d1ng hospital. b.ds ll requ1..~d.. An outl.ay of 2.5 billion balrts has been envisaged to impl.ement these targets. Emphasis has been l.aid on improvement of the heal.th conditions in the rural. areas, particul.arly in the north-eastern region, which appears retarded in devel.opment in comparison with other parts of the country, due mainly to poor soil. fertil.ity and l.1mited water resources. Since the med1cal faculties have been pl.aced under the Office of tiJ.e Prime Min1ster,tbe ac-G:'vities of the Department of Med1cal. Sciences have been rel.atively limited. However, importao:l; progress has been achieved in the public heal.th laboratories' programme. The Department of Medical Services supervises the operation of eighty-four government hospitals and their supply. There is at l.east one hospital. in each province and additional. ones are situated in some heavily populated districts. T
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m$l.OO .. baht 20.65
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.... Since 1960 the University at Medical. sciences and all the other uDi.vers1ties bave been UDl3er the National Council ot Education, of which the Prime Minister is the Chairman. The University bas its own Council and Bector, who exerciSes detaUed contrOl within the I1m1ts· of policy laid down by the BatioDBl. CoUncU. 'fhe rectors at .the medical. faculties are at thesalile time directors of the teaeh1ng ·hospitals. Thereare two medical facu1t1es 1n :Bangkok and one 1n Ch1engmal. !bout 250 students graduate annu a 1]Yi 2';If, are women. 'l!la:Ue.nd bas about 4500 qual.Uied physicians, equivaleat: to one per 8000 people, but about two-thirds reside in the metropolitan area. The P'acul.-q of Ptlbl1e Hee1th and the Faculty at Tropical Medic1ae. provide facilit1es for post-graduate studies. The Faculty of Public BeeJ.th offers a degree ot: MUter at Public Health, the Diploma of Publie Health Bursiug, the Diploma of SaDi.tary- Science and the degree of Bachelor ot Science in Sanitary Science. The Faculty of Tl"Opicai Med1cineprov1des a s:1x-month post-graduate course leading to· the Diploma at Tropical Medicine and Hygiene (D.T .M.&H. ) • The School of Public Beal.th aims at prepar1Qgheal.th -officers and parallledical staff' far administrative, preventive and C01IIIIU1'l1ty health fUnctions. The Faculty ot Tropical Medicine trains technical research workers Who are able to deal with epidemiological. problems ot lo~ prevaleat: . diseases. Of'ten the solution ot these problems 1s ot· iDIIIediate i S 1 n t e s t ead related to economic developmeat: proJects vh1ch are be1ngpl.armed or undertaken.
w
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o
,.l
Bea.lth services
, -
Basic health services tor the rural population are provided by the provinCial haalth otticestbroUgh a; network atper1theral health units, located in distrlct townS .andv1llages. The provincial health atticer, who is d1reCt~ reeponsible to the D1rector-General. ot Public Health in the M1D1st17, is the key figure in the implementation ot all provincial public healtA actiVities in his province. To assist him in his heavy workload: thediirisions of the ])epat tment ot PublicBealth have established their own sub-beadquartera in the region and mobile tealils ce.rry out special health progl'&lIIIIes. '!'he per1pbe:ral. heal.th uDi.ts 1n a province consist of first-class and seCOnd-class health centres and m1dwUery centres. While the tirst-class centres pJrOrtde all the baSic health serv1.ees, the activities of the second-class ceatres&re mo8f;q l1m1ted to maternal. aDd ch1ldcare, enviroDdut:al. aan1tat1on and simple medical. care.
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A beeJ.th unit,. COtlBist1ns of one first..elase centre, tour eecond..elus centres and ten midw11'ery centres, normally serveS 50 000 people, which is approximately consistent with a district. A problem is how to provide the staff for the network of health centres.
3.2
Medical services
The provincial hospitals are under the Medical Services Depart_ ment of the Ministry. In the uorth-eastern region, there are fifteen hospitals in the provincial capitals and two in the districts. ~st of them have been built in recent times. They are all equipped for surgery, gynaecology, obstetriqs and roentgenology. Ambulance services are also provided. With a few exceptions, dental clinics are attached to the hospitals. Only the larger hospitals have special wards for children. In the past the hospital admission rate has been very low, around 0.6 per hundred population per year, although it is reported to be increasing. A study of effective bed use has revealed that with the exception of one or two hospitals there is sufficient bed space. The available number of beds in the region is 2873, which is equivalent to almost one bed per 3000 population, against a rate of one per 250 population in :Bangkok-Ihonburi. As distances are IlOl'JDBlly a limiting factor for hospital attendance it would appear desirable DOt to expand exuting hospitals - with a few exceptions - but to establish hundredbed hospitals at strategic locations. To bring the bed/population rate to one per two thousand population in the nat"th-eastern region, twenty-two such hospitals would be required.
:It is estimated that the construction cost of a hundred-bed hospital amounts to 1.5 million babts aDd the cost of installation and eqUipment to aaothSE' !Dinion. '.ebe provision of tweuty..two ~ would, therefore, come to 55 mUl10n bahts. The operational cost is estimated at 15 000 bahts per bed per annum. The total operational cost of the expanded progr8IIIIIe WOUld, therefore, amount to 33 million 'hahts per year. There are 174 hospital physicians in the north-eastern region and Chiengraij this is eqUivalent to one physician per sixteen beds. Although it would appear that hospital physicians have a full da1J.;y task Without being o'gerloaded, there is a serious shortage of nursing staff. Only 663 nurses are available for clinical nurSing 10 the region, the equivalent of one nurse for 4.3 beds. A ratio of 1:2.5 would be more suitable. some hospitals in the region are of special significance. The Korat Hospital in Nakornrasj:lma derives major importance through its School of NurSing, M1dw11'ery and Public Health, for which it serves as a training area. Attached to the Ubolrajthani Hospital is a practical nursing training school offering a one-year course. AD important feature of the hospital at Rbonkaen is that it is the training area for a school of midwives. The Ui!ornthani Hospital has for •
- 1,SOllll8 years hosted the 1Mted States ot America canPonent ot the SEATO Mea1ca:L Beeearch Labal'ataries, 118'"1 Y tor ~aaitoJ.og:Lce.1 studies. .
,.,.1 fran
D:l.8eases ot public hee.1th importance Water-related diseases (a) Schistosaniasis
An autochthonous case of schistosaJd.asis in a Laotian subject reparled in 1957. This fj Ming gave rise to a nunber ot investigations by :parasitologists in order to confirm the existence ot scb1stosaniasis in the area and to study the eventual danger of propagation by means of irrigation. Attar sane investigations in 1960 and 1961,. 'Which gave Deptive results, I1jima and Garcia (1967) studied the Khong tslmid area and tound cases ot schistosaDa. '!'hese have been described in the Laos portion of the report. (See page 33).
Pakse ws
As far as Thailand is concerned, there has been in the north-eastern region only one accidental post-mortem finaing ot ~. ja;ponicum eggs in intestinal mucosa, ol'1.ginating fran Ubol. :. The possible health implications of the construction of dams and irrigation projects in relation to the endEmicity of schistosomiasis have been fully realized fran experiences in Egypt. However, the ecologl.cal circ\DStances in the Lower Mekong ksin are entirely
different.
Wb.e:reas in Egypt irrigation schemes conducted wter to
hitl:lUto dry areas, 1dl1ch are, therefore, unsu1table for the tran8J.lIission of b1lharziasis, the cond1tions in the Mekong ksin for the spread of the disease have al1lays been favourable. There is little doubt that this would have occurred it the parasites and hosts were present. Tha annual inundations of vide areas on both sides of the river 'WOuld represent a far better means of dissemination of infected
SBails than tmyirr1gatian SchElll88 could do. There 18 evidence that 8tre.1ns of scb1stosaIIIl may difter in pathogenicity. It is s1gn11'1cant that rio infection on Khong Island could be disclosed in dQll8stic animala ~ that IlQ Oncauela.n1a snails could be found in theendElll1c tocus, 1Ih1le there bave been n9 positive fjnd 1 ngs in Wattebledia snails. 'rhereis, hCwever, a need tor the above findings to be further veritied in view of the fact that the survey conduW...ed by I1j1ma and Garcia _e rather l1m1ted in t1m8 and space. (b) . Op;l.stborcb1asis (liver fluke) L1~ fluke is w:l.despread, but particularly high in the provinces of Udorntbani, Sako1nakorn, Kalasin and Mahasarakam, 1Ihere the infection rate in scme villages is over 9C1f,. . It is estimated tbat 1i1 the n0rth.eastern region al.one three million people are infected, vith possibly s~al millions in other areas of the Lower Mekong ksin. The trtmSmisslon of this parasite depends on two intermediate hosts, i.e., Bi'l:bl>n:lB snails and Cmin01d fish, 'Which are often eaten raw or
I I
II
- 14 _ 1DfJu:fficieat:q «lOlled. f.nteetatioo ot 1l'Ye:' f'l.uke undoub~ Q&I.HIes disease but the actual morbidity is di:f1'icult to determine because it is not known how much 11ver damage should be accredited to other inf'ections and malnutrition. However J hospital statistics provide sufficient evidence that opisthorchiasis ranks hi.gh 8.II1OtIg the causes of death in adults and to a considerable extent contributes to hospi talization.
(c)
Cholera
Cholera remains sporadic. In the first ten months of sixty-folIt" cases and tlIO deaths were reported in ICorat. ~.~.2
1966,
Diseases due to
poor
sanitation
Camnon intestinal helminths are udesPt'ead. Bacillary dysentery in endemic form in various parts of the region but sanet1mes gives rise to explosive outbreaks. Leptosp:l.rosis is widely distributed over Thailand end also occurs in the north-eastern region, sanetmes 'With high seasonal endemicity. OCCIIt"S
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Insect-borne diseases (a) Malaria
The entire north-eastern region is included in the country's malaria eradication programme and is presently in the lhase of lIho1esale attack. A considerable lieerease in transmission bas been ac:bieved in various zones. In others, particularly 1ihere there are foothills and often more than one vector I malaria is still a serious problem. The hi.g1lest incidence is found in Nongkai province. During the past few years particular attention has been paid to the resistance of Plasmodium falci~ to chloroquine. Resistant strains have been imported to the north-eastern region from the Central Plateau. Notwithstanding considerable achievements and its rather mild Cl:I8racter in cam.:perison with other regions in the Basin, malaria must still be considered as a major disease in the region, were it ranks hi.gh as a cause of mortallty in hosp! tal statistics. (b) Haemorrhagic fever
Although this dengue-related disease has been mostly limited to the BaDgkok.-Ibonburi metropolitan area, in more recent years there has been a steady geogra}ilical spread and larger ep:l.demics have been established. These epidemics have all occurred in the rainy season and appear to have been due to transmission by Aedes aegypti. A f'omdamental method of reducing the vector remains the provision of adequate pi:ped 'Water supplies, reducing dependence on storage containers.
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(c)
Scrub tYllhus
, ~te..borne typhus ls due to 1ntectlon 'With A small outbreak' of scrub ty:phus in Ubol prov1nce in the attent10n of the heal.th authori tles to this disease. '!'he' fstal1 ty. rate UDder different cond1tlons varles locally but may be as h1gh as
fnI,.
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other 1ntect1ous diseases
Ca) f'uberculosls This contlnues to occupy lta place as one of the foremost health probl.ems ln '1'halland. COtXtrol measures have been carried out with internatLonal asslstance and techn1cal advice fran WHO. Clinically, lt ls mainly a disease of adults. b trea~t ls almost entirely' ambulatory and in th1s the first-class health centres play a ma,1or role. There 1s a regia:l8l centre for tuberculosls control in J<bonlcaen. BCG vaccination i8 actively practised and ls done 'Without pr10r tuberculi.n testLng in ch1]dren up to elght years of age.
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(b)
Le1ll'OSY
Leprosy 18 partlQularly prevalent. Whereas the average prevalence in the country 1s five per thoUS8D4 population, 1n the nortb.oeastern region it ls about thirteen per thousand. Most of the provinces in the nortb.-east are UDder observat1cm and at least partlally und8l' treatment. The corrtrol of leprosy ls partially integrated in the provincial health services. Moblle teams give the necessary support to this progl'8IIIIIe. (c) the reg1on.
Venereal dlseases and yaw!
have been 'WeJ.l.-clet1m d areas of h1gh y&'W8 endemicity in At present .. the prevalence i8 at a very low level and active cases are wll belov:the margin, me&Ding that lt bas lost ltapl1c health1mportaQce. The ya'W8 campaign has given impetus to the establ1sbmentof serolog1cal lab~atories which. are ~sently used 88~sease laboratories. The regLOIl has taken its full share in the general. rise of venereal disease all over the world.. posllibly as a result of accelerated socio-eccman1c develo:pnent and defense activities. The extent of sYlh1l1s and gonorrhoea can only be detem1ned inccmpletely, but sero-positlvity has been fom!.d in aroUDd lEfI, of' lIl"egDant wanen in the nortb-eastern provinces. Eight cl1n1cs rmd!Jix laboratories are exercising extensive control measures.
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For a, l.alg time there has been evidence that trachaDa is a fairly QCJIIDlOll eye 41sease. A natica.-'Wide survey revealed that the h1ghest prevalence rates were in the nortl:l.-eastern region (Korat
_ 16. -~ J.
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province 4~.~). The onset of the disease was in the 0-5 years ~~ group aDd the regressive stage was most frequent~ seen among young adults. The general. pattern was usua~ m1ld in the COuntl'Y as a whole l but in the north-east a relative~ higher rate of severe optical symp. toms was noted. In 1961 a trachoma control project was set up in Karat. This was later exteDded to other north-eastern provinces.
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3.3.5 NUtritional diseases Although there may be no reason for concern about the quantitative nutritional requ1rements l in a qualitative sense mal.nutrition is a perSistent menane to the population, particul.ar~ in the rural ~as. . The major symptoms of malnutrition ~ those due to protein deficiency and avitaminoses. The cause iSlin many cases,not even the absence or shortage of desirable protective foodstu1'1's, but the lack of knowledge &bout them and prejudices aDd taboos againsttheb use. them. In some respects the diet of the. people in the north-eastern region differs from that 1n other regions in Thailand. The most important one is the preference for glutinous rice. Another is the consumption of raw fish and uncooked snails, both of which may be disease carriers. In comparison with other areas, the region has a scarcity of natural resources, ~ 1JPM"1l1 PI'O&" aZlU _ jrJ.JII1~ve means of communication. Still 1 the people do not su1'1'er and their basic subsistence is reasonably well assured. The problem is that too many calories in the diet are derived from one source only, which is rice, and this may lead· to protein deficiency 1 particular~ in the vulnerable groups such as ch:[1dren in the pre-school age aDd pregnant and lactating women. (a) Beri-beri Beri-beri appears to be a s1gu1:f'icant cause of 11l-health 1 especially in expectaat and nursing mothers. Dramatic deaths from acute beri-beri ~ almost exclusively seen in in:f'aats. Three factors seem to be important in in:f'luencing beri-ber! !n this ~a. These are rice m1lls 1 methods of coOldng aDd the diet pattern. Xeroptha1m1a, which is a major cause of infantile bliDdness in some Asian couatr1es outside the Basin, requires further investigation.
t
(b)
Goitre
Although the highest prevalence rate of goitre in Thailand has been found in the northern region, it constitutes also a problem in the north-eastern region. The NUtrition Survey (1962) carried out by the Interdepartmental Colllll1ttee on NUtrition for National Defense 1 United States of America l 1'ouDd 14.2% of enlarged thyroids in population groups in Udorn and 23.2% in Ubol, mostly in children.
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A II&tioaal progt8liiiUe for goitre coutrol has been worked out for the north-east provinces. IJ.'be method of control will be through the d1str1but1on of :1odated salt, of which 4000 tons have already been coamel'c1al1zed. tJDfOl'tuDately, the Gove:t t:CDeat does ,not have the monopoly of salt production as this 'WOuld have made compulsory lod1zation so 1II1ch easier. (c) Bladderstone diSease
\f" /r .U"-t c..
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'fhe problem of veeical calcuJ.us is particularly maD1fest. The majority of cases OCCUl' in ch1ldl'en under ten years of age and the peak incidence is reached at the age of about five years. Vitam1n A deficiency bas long been suspected to play a role in the aetiology'. The h1gb.est ~valence rates have been observed in RhoDkaen and Ubol provinces, 18.6 and 1.2.0 per thousawi, respectively. A study of ioi'antfeed1Dg' practices bas revealed a str1k1ng correlation with earl¥ rice feeding. Further metabolic studies will be required before definite conclusions can be arawn.
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Cd)
Parasitic diSeases and nutrition
A major pib11e health problem in the field of lIIltritlon is l"EllAted to the local custom of consuming raw fish of' a species which is of major 1mportance in the transmission .of Opisthorchis viverrin1. In areas bordering the DBin stream the incidence appears to' be lower, a8 fish from the Mekong do not seem to be highly IDf'ected. :rt is a
tragic COincidence that the h1ghJy needed source of protein functious tis a carrier of a disease which poses an 1lDportaut public health problem. !!!he P8rasltic D1sease tJUit in l'lakDrDJ:8D011l has 'WOrked out a health education prograume a:lmed at the adoption of a food' preparation method which wouJ.d prevent the propaption of Uver fluke disease. UDf'ortunately, acceptance of DXIern nutritional. ideas by the vUJ..agers is generaJ.l.y a slow process.
3.4 " hnter-m:1.u1sterial and _eM Of rti@O health
aeve_
inte~ntal co-operatlon in the
A ~. of ~ ~ omcBleDl!'d 14th ~·'~,beaWt· ~ JiII!Icv'e beeG eagelIto cadlb4Ge tliIe1Ir eft'lA tlB ~ ;reapone1.b1Utiea aaI to caut1It~ 111
to
4e1;em 1ae tb3:I.r
'Clbdzo ~ular field.
(a)
The Thal..sEATO Regioaal Developnent Technical Assistance
centre in tib01
t
The Centre was established near the capital of Ubol province aDd functious as the headquarters for the community developnent prograume in fifteen nortb.-eastern pro'dnces. The actiVities cover a wide field of technical SerVices, including health and sanitation. The implementation of community proJects is based on the active participation of the people to improve their living conditions and on the provision of technical assistance through which self-help can
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be more effectively put to use. An important feature of the Ubol Centre is 1ts training school for community development workers. )
(b)
National Security Council Mobile Teams
The headquarters are in Ban Phan Huan, near Ubol. The aim is to balance undesirable political influences. In its methods there is similarity with the project sponsored by the National community Develop_ ment COmmittee, but the impact is more direct and there is no delimitation of areas ~ ..".,ni l&1Iea~ liclluleaa.. (c) Mobile Medical Teams
The Medical Services Department of the Ministry of Health bas established IOObile teams to provide curative services in remote areas. Teams normal.ly. stay for three months after which they are replaced. The aim is to accelerate the provision of medical services in places where provincial medical care is scarce. A team may consist of two to four physicians and four nurses, who are recruited from major hospitals in the country. other mobile medical teams are established by the National Security Council. These are working in the border areas and the team leaders are army medical officers.
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3.5
Inter-m1nister1al agencies collaborating in environmental saIl1tatlon
A number of agencies from various ministries collaborate in the f'ield of' water supply, sanitation and the establishment of new settlements. Thus, the Department of Mineral Resources, Ministry of National Development, bas been involved in the construction of wells in various parts of the north-eastern region. Another agency collaborating with the Health Ministry in the field of water supply is the Department of' Public and Municipal Works, Ministry of Interior. The Department of Local Administration, of the same ministry, makes a contribution in the field of water supply and sanitation at the village community level. ~e Department of' Accelerated Rural Development, which 1s under the Office of' the Prime Minister, works in close collaboration with the health authorities in the broad field of rural sanitation. The Department of Irrigation co-operates in connection with water supplies for domestic use and the National POwer COIIIII1ssiou in cases of resettlement as a result of the construction of water power projects.
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4. cm::EmRAI PROVINCE Chiengrai is the most northern province of Thailand aDd is included in the Lower Mekong Basin. The population is around one
m1ll1on.
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4.1
Health services
i!le .health personnel o~the province C01l81stS o~ ~our physiciaas and additional. personnel. ihe service operates ~our first-claSs and fourteen second-claSs centres and twenty-three m1dw1:tery centres. Activities coasist of v1llage health and san1.tat1on developnent, schoo1health services and the prevention and control of COIIIIIun1cable diseases. ihe existing health services are reinforced by the presence o~ a mobile team of the Medical Faculty of Chiengmai Un1versity.
4.2
Diseases of publlc health importance
The principal causes ~ illness are: (a) gastro-intestinal infectious and infestatioas, (b) nutritional deficiencies, (c) upper respiratory infectioas, (d) pulmonary tuberculosis and (e) goitre. Tuberculosis. ihe sub-headquarters for tuberculosis control in the northern region is located in Chiengmai. Out ~ the sixteen provinces in this area the prograua:oe is only operative in Chiengmai and Lampong. It is hoped that 1n 1968 a few districts of Chiengrai will also be included. For the time being this area will continue to be served by periodic visits of a mobile team, until meallS have become available for further expaasion o~ the programme. Endemic gOitre. :In some districts otChiengrai province the prevalence Of goitre is exceptionally high. It appears that most grade I goitres be10ng to the school-age group. Grade II gOitres are equally spread between adolescents and. adults, while Grade III gOitres are only found in the adult age group~ Cret1as and deaf mutes appear to be . rare. !lie _ _ ill . . . .CUt . . . . . . . . . . . .' _ :w. :Ierds ~ imtne. M!llaria is still highly prevalent in Chiengkong district, where cerebral SymptOlllll are not intrequentq· seen. It is feared that traasmission at least partq or1gi.nates :from lAOs where no &nti-ualar!a measures are in operation.
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5.
PUBLIC BEAIIrH IMPLICATlOE
(jg MEKOlli
PROJECTS
The estabUshment ~ water utll.1zation schemes is attended by maoy and varied human activities having direct and indirect health lmpllcatioas. These lmpllcatioas are in1'l.uenced by the extent of pbysica1, ecological and demogroaphic changes that result from such devel.opDents. Thus, in arid or low rainfall areas, profound changes are brought about by the introduction ~ irrigation, and conditiollS for the introduction and spread of parasitic and other diseases rray be created. It water-related diseases gain a foothold in such areas then serious health problems·voaJd ttol.low. On the other hand, in wellwatered areas like the Mekong Basin, ecological changes brought about by the introduction ~ suppl.ellentary irrigation are somewhat llmited.
_ 20_
Conditions are already favourable for the transmission of parasitic and other diseases but the likelihood of the introduction of 8IIW diseases seems very remote. The health impl:l.cations theref'ore are more in the nature of an intensification of transmission d1rect:Qr attributable to the increased sources of water and indirectly attributable to the effect of changes on the pattern of human population distribution and dyaam1cs, and activities. Likewise, changes in the demographic pattern of the region There will not be large tracts of new land opened up for settlement and farming. MOst of the irr1gation water will be used on existing farms. There will, of course, be increased commercial.and industrial activities and accelerated growth of population in urban centres. These may easi:Qr lead to overcrowding and insanitary conditions which will necessitate preventive measures. In 1ira mIral. II:¥MI'MI!!ti;t;iaa Eiim:l.lm" ~ a 5sea UtPAP'i«ttal UIIl iacreased contact with water sources that may become contaminated with parasite eggs and pathogenic organisms will tend to increase the chances of disease transmission.
...
are not likely to be great.
Observations have shown that under present conditions snails that serve as hosts for the transndssion of l:I.ver fluke diseases multiply during the rainy season, and decl:l.ne during the dry winter and summer months as numerous habitats dry out. Likewise, the colllllOn carp which acts as a secoed intermediate host in the transndssion of opisthorchiasis, when present in the same water bodies as Bithyn!a snails, perishes. With the increase in water sources during thedry season resu1ting from the establishment of irrigation works, such habitats may not dry out and, i f close to sources of' contamination with l:I.ver fluke eggs, will act as transmiSSion sites and preventive measures will be needed. In order to effect disease control and health promotion, the following measures should be considered as part of the collll11taent of the constructing authorities:
t
(a) (b) (c)
control of specific diseases attributable to the construction of the project; prOvision of health services to deal with tile ailitl:"c-,' 1(1. . . . . .ae by the project; improvement of health services and environmental conditions to a deSirable level as a del:l.berate investment in human resources needed for the fu1l real:l.zation of the benefits of the enterprise.
These three objectives should be considered at an early stage in the investigations and cost estimates of the proposed development, and their implementation should become an integral part of the development plan.
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fac111ta~ the extens10n ofhea1th and medical services. Publ1c_tar s~ .~ ·11111 becaue available to relieve the acute shortage that affl1cts large areas of the Dortbo-eastern reg:l.CXl durinStl:i8 . dry season. '!'be 1D!.provement of uav1gatiCXl in the Mekong a1vv will also prove ofpubl1c health bene:f'1t since 1t w111 fac111tate the movement of health 'W01'ker$ and of people seek1 ng medical. care.
health .~ n1.lD81'OUS aDd far outw1eb any poss1ble he.rmf'ul effects •.. !I.'h~, suppl.aDentary 1rrigation v.lll result in increased crop prodUltiCXl, higher incaues, and better l1UtrltlCXl. Flood protect1on and drainsge 'W01'ks 'V111 check the spread of 'Water and soiJ..transm1tted paras1t1c and other.. diseases. '!'be 'WOrks 'V111 improve road camnm1 cations eild
'!'be benefic1al 1mpl1cat1ons of the Mekong projects CXl publ1c
6.1
Health needs
!
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'!he needs of ilhe people in regard to the provisien of health services ca:mat be expressed in absolute terms, but there 1s no doubt tbatthe ilemaM far health serv1ces is increasing. Expenditures en health tend to rise in proportion to the gross uatl. anal product 8Z¥l greater concentratien of population is associated w.1:th greater. l!! cai!te expenditures far publ1c health services. For this reason, it is the 1nterest of the people of the nor:th-eastern region, now. resia1ng in a great nauber of small villages, to praDOte agg'auerat1en. C(JJID1m1 cat1CX1Sare. of major 1mportan.ce i f effect1ve use 1s to be made of health fac111t1es. If theee are poor, no attendance can ~ be expected trem far-off locat100s, the dro;p be:lng propcrt1caate to the square of the distance.
Hospital. services are nat equally spread ewer the province in the nortb.-eastern regien. '!'be expansiCXl of fac111ties should not in the :1'1rst place be sougb.t by enlarging ex1stinghospitals, but their n\lliber should be iDlreased in. accara8nce v.lth the pattern of populat1en spreading. lfevhospitals. should 1lOl'!II8l.ly not exceed a ' 2O()..bed capacity.
In ardel' to. fl.mct1CXl effecti-vely 1t is recanmen13ed that the prorinc1al hospitals are provided with adequate~ equipped and staffed cl1nical labarator:l.es. .It YCW.d. appear d$s1rable to intens1ty the training of labaratory techn.1c1ans and to arrange for a qual1:f'1ed labaratory ];byslclan or sc:l.ent18t to inepect hosp1tal laboratories in the n.ortb.ooeastern region at regular 1nterVal.8. Hospital. aam n1 st,..at1oas should DOt on.ly' tr~t their hospital. aata to the Hospital Statistics Sect10a in Bangkok, but they sboul4 analyse the1l' aata on. a <lClIlt1nuous basis. tb.emsel;ves I and inteJ!pr;tet them mean1ngtUlJ.y, iaOl"der to 1mprove andfac1l:1tatA cent1'a1' planning; taking· into account ·lDCal· eirCUlistances. '. .
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... Regionalization should be further encouraged. It was observed that regionaUzation of some divisions of the h~th department l which· have· already established regional sub-headquarters, has had an important impact on the general health services in the provinces. As the north~tern region accommodates one-third of Tha1land' s population I it would seem that there 1s a need for more train1ng facU1ties for pa.ra-medical personnel. At the moment there 1s one school tor graduate nurses I ocefor midwives and one for health workers. The establ1shment of a medical faculty at the University of Rbonkaen would also be an important contribution to the strengthening of the health services of the region and raise the cultural prestige of the l.aaet developed part of the country.
6.2 6.2.1
Environmental sanitation Overall planning
EnVironmental sanitation servioes and facilities are closely linked with the location and physical layout of communities. Surveys of urban conmunities should be initiated as soon as possible so that outline planning schemes may be produced, i f possible, by 19rO. For this work, the Town and County Planning Division will require extra staff. At present, the Division is engaged in the planning of several towns in the north-eastern region. At present the urban population of the north-eastern region has been estimated at one million but this is expeoted to double by 1980. Early physical planning of the sites needed to accommodate the additional communities should be effeoted in order to prevent the oreation of conditions detr1mental to publio health.
.. •
6.2.2 Community plann:l.ng and hOUSing Accelerated developments in lII&D;y directions are to be expected as a result of the realization of planned Mekong projects and these will attract more people into the area. Rural comnunities should be planned well in advance so that they can be properly located with respect to one another and the urban centres. This kind of planning calls for the services of a specialist in rural planning. The introduction of irrigation and the resettlement of communities offer good oPP9rtun1t1es for rural planning. Rousing requirements will have to be assessed, typ1cal designs adapted to local conditions and materials will need to be prepared. With a basic pattern I the provision of sanitation services and facilities can be effected with ecooomy 80nd efficiency. At present"the Welfare Department and the Town and County Pla~ng Div1sio:n are eoge.ged in cOlllDUnity planning and could expand their activities for the pUrpose of p}ann1ag in the north.-ee.stern region 8lld Chiengrsj. prav1n.ce.
,
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6.2.:S Public vater supplies . Total requirements for vater supplies 1n both rural. and urban communities have been estimated. Thene should be reduced by the quantit1es of exist1ng supplies and further reduced as new schemes are completed. The present programme ot rural water supply installations is very well-planned and 1s being implemented expedit10usly. Greater progress could be made in the construction ot surface vater treatment plants by prefabricat10n of some components ,such as concrete towers. Consideration should also be given to the subst1tution ot hea-vy gauge galvanized COl'l'Ugated steel tanks by concrete tacks. The training and supervision ot operators are essential tor the proper functiOning ot the treatmeut plants. There are examples where the need tor th1s is very evident. Where groundvaters are encountered with high total dissolved solids or high iron content, consideration should be given to their use tor other than drinking purposes. waters containing iron up to one ppm should not be abandoned for that reason and iron contents of say 0.6 and 0.7 ppm can be used without treatment under special circumstances. The collection ot rain vater should be encOUl'88ed. A number of urban Communities, however, have inadequate vater supplies and there is a pressing need tor a special progrume to install new schemes and to extend existing ones. The tormulation ot such a prograume would require the services ot a water supply engineer tor a period ot one to two years. 6.2.4 Sewage and waste disposal
ihe problem ot sewage and waste vater disposal is tar more acute in urban than in rural cOlllllll.n1ties. In rural COUIIIIlnities the programme of vater-seal. latrines construction is well under way and is being accelerated. In urban COIIIIII1nities, on the other hand, the problem has hardly ~en toUched, and this bile to 'bIt.aood SOQIeI! fRl _ _ • AI) .(tQr~ sWt shcaW 1* 21114e. to Ul4.t1e"te 8\11 vep, 8114 tf1lll 'lat_ .cwrhd $81 go. .
_i..
In view of the high cost of coaventional sewerage and treatment works, consideration should be given to the adoption ot simpler schemes for urban collmnn1 ties. A mod1:f'1ed system adopted in some parts ot Africa consists of vater-seal latrines discharging their efi'luent into a sewer which conveys it to stabilization ponds in the outskirts of the township. savings are also effected by constructing the latrines back-to-back on the bouDda:ry t:Jt two house lots and USing one pit for both. The effluent 1s then. conducted to the street sewer through a tom-inch pipe. Where gravity :flow is not possible all the W8.'¥'. simple. pumping stations may be used. For new settlements, consideration should be given to draiaage requirements both for storm water
.. 24 _
and sewerage in planning and zoning the area. With proper planning and implementation by stages, such schemes should not prova a burden to the community. A substantial share will have to be borne by public institutions and through some time_payment schemes the facilities can be extended to low income groups without undue stress. The preparation of a prograume for the gradual proviSion of urban sewerage would re. quire the services of a consultant for one or two years.
6.2.5 -".Refuse disposal _. The role of refuse collection and disposal in the p!:evention of filtb.-bOl.'Ile diseases is not usually appreciated and saae authorities are more concerned 'With the· nuisance and unslgbtllness resulting fran lack of an adequate service. Yet there can be no doubt that exposed refuse provides favourable breeding condi tiona for 1'l1es, rodents and other disease vectors. A refuse co1.lectiGll and disposal service does not need to be an 1ml'easooable financial burden GIl the camnun1 ty. Collection involves covered containers for each household, ID81'ket place 1 food establisbment and 1nst1tution, and collection by covered trucks at regular intervals. Disposal methods, on tLe other hand, involve a little mo:i.'e care, experience and knowledge about local conditions. usually there is room for more than one method of disposal. For example, incineration can be used for wastes containing a good portion of combustible matter, such as wastes from hospitals, schools, business premises. In any case, individual incinerators should be used b¥ such institutions • Waste from market places, household, etc., can best be disposed of by burying it in trenches with at l.east one foot of clean soil on top. In large communities trenches may be excavated by small buJ.ldozers. In some areas there may be low-lying areas that can be filled in this way, but in all cases systematic covering of refuse must be insisted upon. There seems ample justification for assigning an engineer to advise local authorities on this method of disposal.
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6.2.6 Food preparation and Ilandling Dish-washing facilities should be completely separated from food preparation and cooking. Facilities should include adequate hot water, soap, scrubbing and air-drying in a screened rack. Restaurants should be adequately screened to exclude flies. The DDst 1mportant step in achieving some sort of protection of food against contamination is the total enclosure of toilets and washing facilities with tight-fitting and self-closing doors and adequately screened windows. Soap dispensers and paper towels should be provided. There should also be facilities for flushing toilets and there should be a supply of sanitary paper. There should be regular inspection of eating establishments by a qualified sanitary inspector. He should have power to order certain necessary measures to be taken and to close places that do
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not comply with orders and regulations. An effective way of ensuring co-operaUon from restaurant owners is to adopt a grading system. of their establishments. There should also be regular medical exami1J8tion of t'ood-bandlers.
6.2.1 Provision of saQitar;r facUit1es aDd institutions In plaDD1ng and implementing a programme f'or the provision of' sanitary f'acUities aDd .services in a cODlllUD1ty, consideration should be given first to public institutions. Their needs are of'ten more pressiog than those of' private dwellings, and funds and co-operation ~ more readily available. Health centres. The needs of health centres f'or environmental sanitation facilities aDd services can be satisfied with modest fUnds. !!hey should all have the benefits of' running water and sanitary sewage disposal. This can generally be provided f'or less than f1ve hundred dollars. HOS~tals. The need for basic sanitary facilities aDd services is most ob OUB 1n the hospitals. '!bese comprise: ruDD1ng water, sewerage, refUse acd waste disposal, laundry, food preparation and serving, d1sh-wash1ng facilities. The cost of providing such facilities may not amount to more than a hundred dollars per hospital bed. Advantage can be taken of' the assistance provided by an international agency such as UNICEF.
Markeiu;laces. Some of' the more pressing needs invelva drainage, re collection and disposal, water supply, toilet tacilities and tbeprotectionof food from flies and dust.
e
6.2.8
stream and air pollution
With the development of agricultural aDd extraction industries this will become a public health problem. :rt is suggested that the Division of' sanitary EDg1neer1ng watches for any dsns thnt point to the creation of health problems as a resul.t of the pollut:1.on of streams and of air. Measures for d1S.~e
control
6.3.1 Water control ill general The importance of' water control 10 the prevention of the transmission of many diseases may be appreciated by cons:1.deriog the role of water as a carrier. Dl the case of intestinal parasitic diseases, vater creates the habitat for the breeding of snails, fish and crab
-26.
bosts. water is also one 00£ the important med:la o£or the spread 00£ bacterial enteric diseases. A basic condition o£or a bealtby environment is thereo£ore the control 00£ water in such a way as to prevent suro£ace accumulations, water logging 00£ soils and pollution 00£ streams. Tbe measures o£or tbe realization 00£ this condition call o£or adequate drainage of surface water ~ o£illing 00£ low-lying areas ~ the protection 00£ water sources '£rom pollution and the sao£e disposal 00£ waste water.
6.3.2 Water control- in irrigation schemes Tbe introduction 00£ irrigation in the north-eastern region is likely to create o£avourable conditions for the transmission of water. related diseases during the dry season, unless adequate provision is made in the construction and operation of the schemes to ensure effective water control. Aspects 00£ irrigation practice '£rom the point of view of public bealth are covered in the WHO Monograph No. 42: Snail Control in the Prevention 00£ Bilharziasis.
6.3.3 Drainage and filling 00£ marsbes Low-lying areas that get water-logged are potential disease. transmitting sites. Such areas~ when near settlements, should be drained or filled and graded. The cost 00£ such works is usually re· covered within ten years '£rom the resulting benefits.
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6.,.4 Chemical treatment of 'W8ter bodies After all measures to reduce 'Water bodies have been applied, consideration can be g:lven to the use of chemicals for killing snails and fish 'Which are agents in the transmission ~ :parasitic disease such as opisthorchiasis. Situations 'Where control ~ transmissicm by the applicaticm of components toxic to snails and fish might be applied 'Where observed alang the settled edges of the Nam Pa:Ig reservoir, lIhere within a short space of time the parasitic cycle is completed. The kind of chemical, the concentration e.Dd the timing and '£requency of applicaticm 'Will have to be determined.
6.3.5
!?ann1ng and siting of communities
Wherever possible, new camll1.mities sbould be planned and sited a'Way '£rClll potential sources O'f infection. The establishment of irrigation schemes and the resettlement 00£ cc:mlllmities offer opportu.nities for the selection of sites that tend to reduce h\lD8Jl contact with potential sources of infection.
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6.,.6 Chemoprophylaxis in the •
contro~
of parasitic diseases
The ro~e of chelllOpl ophylactic measures 1n the coatro~ of parasitic diseases is Umited. certain drugs contribute to the reduction of infection in intermediate hosts by suppressing the passage of eggs from infected persons for a l1m1ted period. Heto~ is being tried for the treatmeat of opisthorchiasis with some success. Drugs are useful. in reducing the worm burden of heavily infected people, but it ehould be real.1zed that in the absence of satisfactory sanitary fac1l.1ties reinfection will almost certainly occur. For this reason drug treatment is not a satisfactory 8O~ution to the problem.
6.'.7
Health education
The longest I but surely the most effective way to combat endemic diseases which are due to faulty habits is by way of health education. Such 1s the case with the" parasitic diseases which are prevalent in the DOrth-eastern region. Probably the best way to influence hygienic consumption of animal protein is through the health and maternal and ch1l.d heuth prograrmues and" through an organized prograume of heuth education in the schools • •
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LAOS TABLE OF COl'llERl'S
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OlDANIZATION OF THE HEALTH SERVICE5
.............................. .
1.1 Ministry of Public Health •••••••••••••••••••••••••• 1.2 The Malaria Control. Service. .............. e' ........................... .. 1.3 Materrlal a.nd Ch1l.d Bee.lth Seilw;lces ' ••••••••••••••••• ~.4 D1vision of laboratories end Prevent!va .Serv:i.ces ~.6 a-a ... ' •••.•• • . •.• ' ••.•.•.•.• ..........................................
1.5 Hosp1 tal services 2.
Erovincial and rural health services
2.2 Nursing education
2.1 Medical education
•.......•...... .................•...............• .•...•............................ ••••••••••••••••••••••••••••••••••
••••••••••••••••••••••••••••••••••
HEALTH ASPJOOTS OF THE cotntrRY
........................... ••••••••••••••
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Diseases of public health importance
,.1.1 General 3.1.2 Water-related diseases 3.1·3 Diseases due to poor sanitation ••••••••••••• ,.1.4 Insect-borne diseases ,.1.5 Other infectious diseases ••••••••••••••••••• 3.1.6 Nutritional diseases
...•....•............................
......................................
•.......•.............. ........•.....•...•.....
Internati0llB1 and bilateral assistance in the field of health •••••••••••••••••••••••••••••••••••• 34Agencies collaborating in environmental sanitation •• 35
4.
4-.1 General 4-.2 Effects of irrigation
. ........•..... ........•.............................•.....
4.3 Effects of storase reservoirs
.............................. ...................... •••••••••••••••••••••••••••
...•..........................•...•.....• Health services •.•...•.•..•...........•.•....•..... Environmental sanitation
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GeDeral
)pe nn1 ng
••••••••••••••••••••••••••••
Refuse disposal
•••••••••••••••••••••••••••••
/
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Camnm1ty 'Water supplies
5.3
.....................•............ Measures far disease control •..•.................. ............••...................... 5.3.~ Malaria 5.3.2 Leprosy .........................••......••• Vientiane
'Water drainage ••••••••••••••••••••••• Drainage I fl.ood protection and sewrage in
Storm
...........•....... 39 39
5.3.3 5.3.4
Nutrition •••••••••••••••••••••••••••••••••• Hauth education •••••••••••••••••••••••••••
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LAOO 1. CBGANlZATION (JE
THE HEAIlrH SERVICES
1.1
Ministry of PUblic Health
'!'he Minister of Public Health, assisted by an adviser, has under him a Director-General who is responsible for the technical aspects of the health services. The Director-General, in turn, has a deputy who assists him in the administration of hospitals and medical supplies. He also has three aSSistants, service chiefs, who are responsible for ~H, pharmacy, laboratory and preventive services. He personally heads the malaria control programme. Thus, the responsibility for health services at ministerial level rests with five officials. 1.2 The Malaria Control Service has its headquarters in Vientiane and two regional offices, one in Vientiane and one in Luang Prabang, each under a regiooal chief. There are nine provincial laboratories, each with a team leader and about five assistants. Visits are made to about 60 000 homes each IIIOnth to collect blood samples.
-1.3
Maternal and Child Health Services
The K:H activities include ante-natal and post-natal clinics in the main population centres and the provincial capitals. The MTII teams are usually accolllllOdated in hospitals j some operate as mobile teams. Training facilities are availab!.e for doctors, auxiliary nursing and midwifery personnel. Up to 1965 some 48 nurses and 57 students had completed their training in ~.
1.4
Division of Laboratories and Preventive Services
The Division of Laboratories and Preventive Services provides limited clinical and diagnostic facilities and, to a very limited extent, public health facilities such as the examination of drinking water, be- verages and food, and venereal-disease serology. The laboratory occupies a very old building, and lacks adequate supplies, equipment and staff. To date, only five technicians have been trained. !
Other activities of the Ministry include vaccination, venerealdisease control, and school hygiene. 1.5 Hospital services
Hospital services are provided by the Mahosot Hospital in Vientiane, the provincial hospitals, mobile CliniCS, in1'1rmar1es"
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dispensaries, first-aid posts, and leprosaria. There are, in addition, a number of hospitals operated by Operation Brotherhood. In Vientiane, the MUlosot Hospital with 200 beds and the Operation Brotherhood Hospital with 100 beds serve a population of some 150 000. There are also five provincial hospitals. In general, conditions in'the hospitals and the services provided are below 00l'!IlIll standards.
1.6 Provincial and rural health services are provided by hospitals, health centres, and dispensarIes. 2. 2.1 Medical education
ElXX:ATION AND 'mAINlm
The Medical School, which was established in 1958 as a faculty of the Sisavong Vong University in Vientiane, offers at present only four-year courses for medical assistants. The minimum entrance requirements are ten years of education. There are no full-time professors and there is a serious shortage of lecturers in the pre-clinical sciences. The lectures a:"El 6i van by F'retlch e.od laotian physicians. Each year a1:x\ut ten students graduate after four years of studies. A number of foreign countries have provided fellowships to enable students to complete their stUdies abroad. 2.2 NurSing education
Students who have completed their primary education can be admitted to the School of Nursing. Nursing training has met with considerable difficulties. The premises and the school-building are not suitable and the practical training area provides no opportunity for the students to observe good quality nursing care. Recently, more courses have been created in the provincial hospitals but a difficulty is the absence of qualified nurses able to act as tutors. About two hundred Laotians have been trained as auxiliary nurses. The duration of the new training programme is two years. Training for MJH nursing is given to nurses in an additional course. Recently, M::H teams have been established by training students without previous nursing training. This has proved rather successful. The political situation prevents services being extended to all the rural areas and therefore a great number of rural midwifery stations cannot be visited for supervision. There are four schools for rural midwives located in Vientiane, Luang Prabang, Pakse and Thakhek. These provide one-year courses.
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·There are o~ six qual1fied midwives (three-year course) and 144 rural midwives in the country •
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There are no training facilities for other categories of paramedical personnel. 3. HEALTH ASPECTS OF THE COUNTRY
3.1
Diseases of public health importance
3.1.1 General In Laos there are few diseases of which the extent or importance as a public .health problem is known. This being the case, the results of medical investigations in neighbouring couatr1es become particularly
important.
3.1.2 Water-related diseases Evidence about the endemicity of schistosomiasis in Bhong Islaoo, the largest island in the Mekong River, in the province of Sithandone, has recently been confirmed. stools examined by the direct smear method were found to be positive for ova of §. •. japonicum in 8.59% of 547 itJbabitants tested. No ova of §.. japonicum were found 10 buffaloes, in the stools of other domestic animals. or in mice, which are usually infected in s. i~nicum areas. No Oncomelania snails were found although the-Wa ledii crosseana species was common. No snails harbouring S. japonicum cercariae were discovered. Although it is assumed that endiin1c fOci. of ~. japonicum may· be present· in other· places along the Mekong l'1ver, the 1IIIDediate host could not be established. There is, therefore, a nee4 for further surveys to be conducted so that the snail vec;tor can be 1dentU1ed. .. ,< . ,.,.- .
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Enteric parasites are omnipresent and ,.are found in a large percentage in all villages. Typhoid is believed to be common. All hospital reports mention a multitude of cases every year, particularly after the onset of'the rainy season. Information about the evidence of amoebiasis is conflicting. ~ ~
3.1.4
Insect-borne diseases
Malaria is the most serious public health problem. It occurs in every province of the country. In 1956, a residual spraying programne USing llDl was undertaken with the assistance of the United states OVerseas Mission. The houses of nearly one million people were covered and spraying was done annually aDd bi-annually. mostly at the end of the dry season.. ADop::eles mio1mua 1 the prtnci.pal vector I '!f8B found 111 almost half of theviuages. A. balabacensis was also found. infected (Colbourne, Chow & Echavez-; 1960). nthough there was a
reduction of mal.ar1ometic indices in areas sprayed twice, interruption could not be achieved. These operations were discontinued after three years. In the Vientiane Plain the malaria situation is marked~ more favourable than elsewhere. Along the ~kong, malaria endemicity is general~ low. 3.1.5 other infectious diseases No cases of cholera or plague have been reported recent~. The last cases of smallpox were reported in 1953. Whether the venereal diseases are a :fC<)blem or DOt is not known although they deHDltelY exist. Yaws used to be common; an eradication programme in the southern prov1nceB"iieveral years ago great~ reduced the incidence. Tuberculosis appears to be widespread. In Thakhek its importance A WHO ~l i;uberculoeis advisory team started iavestigations in 1967 to determine the extent of the problem and the practicabillty of organizing an economical and effective coatrol programme on a long-term basis. is onl.y superceded by that of malaria. ~&rosy.
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tered.
Approx1mate~ 1300 leprosy patients have been regisses are spread all over the country.
A high incidence of trachoma among schoolchildren has been reported. Umbilical tetanus in newborns remains alarmingly high. 3.1.6 Nutritional diseases Protein malnutrition is rel.ative~ frequent~ observed in the paediatric clinic of the Mahosot hospital. Beri-beri was reported by Dooley (1958) in tribal areas around Ham Tba in northern LaOs. Little is known about other nutritional deficiencies and diseases. 3.2 International and bilateral assistance in the. field of health
The health services are greatly dependent on foreign aid, financially as well as technica~. The proviSion of medical aid to Laos has taken on a rather permanent character as no projects have yet been taken over by the Ministry of Health. One reason is that genera~ the counterpart personnel have a limited basic and technical background which prevents them from profiting fully from the experts' knowledge and experience. If foreign assistance were to be withdrawn, the health services would suffer considerab~.
wa
has provided technical assistance in various fields, including
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malaria eradication, laboratory Services, rural health development, nursing education, maternal and child health and publlc health advisory services. A multi-ageucy integrated rural development project has been operating since 1961. The United Nations agencies participating in
-,,this project are the :Bureau of Technical Assistance Operation, UNESCO, FNJ, lID, WHO and UNICEF.
Among the bilateral a1d programmes, that of Operation :Brotherhood, Inc. has had the greatest impact on the provincial health services. This is by far the most important health agency in Laos. It operates seven medical units in various provinces and in Vientiane.· The need for 1ntegration of its activit1es into the general health services has been recognized, but the process has been slow. Operation :Brotherhood also provides training courses for nurses. The undertaldng 1s ~ financed by the United states AgerJ£Y'fO'l: International. Development (AI1». . The French Mission, the :British Colombo Plan and the Public Health Division of Am also provide assistance to the Government in the field of health, part1cular attention being given to the needs of ref'ugees and displaced persons. ,., Agencies collaborating in environmental sanitation
The most important international agency collaboraticg with the Government in the f1eld of environmental sanitat10n is Am. The programme is carried out as a special activity of the Department of Rural A:f'1'airs and covers the whole field of environmental health from rural COIJIIlI1n1ty development programmes to the provision of water supplies in urban areas. In the field of water supplies AID technical assistance has been particularly impressive. The accomplishments of the United Nations integrated rural development project in the field of sanitation cover village water supplies and latrine construction, drainage, waste disposal and vermin control. Some work in environmental sanitation was done earlier by Operation :Brotherhood, Inc. but these activities were curtailed because of more urgent calls on their services for medical care.
4.1
General
~
The establ1shment of water utilization schemes brings about various human act1vit1es that have direct or indirect health implications depend1ng on the oature of the development and the extent of physical, ecological and demograph1c changes. For example, in arid or low rainfall areas the introduction of irrigation causes profound physical changes which may create conditions favourable for the transmission of parasitic diseases. on the other hand, in well-watered areas like Laos, such changes would be limited. The comprehensive development of the Mekocg :Bas:l.n provides for eight tributary projects entirely in Laos, two tributary projects to be shared with Thailand. and cambodia;
-36three mainstream projects ent:lrely in laos, and five mainstream projects to be shared with Thailand; a rail and road bridge across the Mekong from Nong Rbai to Vientiane.
These projects will provide water for irrigation, hydro-electric power and cOlllDUnity water supplies. The dams and reservoirs will also be used to regulate the riverflow for flood control and the improvement of navigation. These developments are bound to affect public health and some aspects are considered in the following sections. 4.2 Effects of irrigation
The proposed irrigation schemes cover a total area of approximately 350 000 hectares located in six provinces and involving about 100 000 people. Population changes are bound to occur both within the existing communities and in areas to be resettled. Irrigation will be practised mainly during the dry season and will result in the creation or augmentation of water sources which, in turn, may support biological activities detrimental to health. Conditions, however, are already favourable for the transmission of parasitic diseases and the likelihood of the introduction of new diseases as a result of supplemental irrigation is rather remote. The public health implicatiOns, therefore, are more in the nature of an intensification of disease transmission directly attributable to increased water sources and indirectly attributable to the effect of changes on the pattern of human population distribution, movement and activities. With proper engineering care in the design and construction of irrigation schemes and adequate management and water control the risk of the spread or intensification of diseases can be considerably reduced. Canals are especially important as they can become carriers of pathogenic organisms if they are not adequately protected from pollution. Irrigation should be planned in such a way that the propagation and dissemination of disease are avoided. 4.3 Effects of storage reservoirs
The creation of water storage reservoirs affects public health in various ways. It may involve the transfer of communities from the' areas to be inundated to areas above or below the dam; the establishment of new communities along the shores of the reservoir; aquatic animals that serve as hosts or vectors in the transmission of diseases may invade the reservoir; the water provides the medium in which parasite eggs, miracidiae, cercariae and pathogenic organisms can move about to maintain disease transmission. Thus a reservoir can set the stage for an adverse effect on public health. The transmission of Qpisthorchiasis illustrates best the conditions provided in storage reservoirs for the spread of diseases. Its tracsnUtulion depends entirely on the presence of infected people, bithynia snails and carp fish. Eggs of infected people can reach the snails in the water and the cercariae from snails can reach the fish.
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The eating of uncooked fish completes the cycle as the encysted metacercariae in the fish enter the human body and develop into egg-laying
worms. However I with appropriate planning of human settlements I the provision of sanitary fac1lities and the protection 01: the reservoir from pollution, the potential threat of a reservoir can be checked and it can be beneficially used for such purposes as community water supplies.
,.1
Health services
'!he health services have been recently reviewed by a WHO consultant on health planning and recomnendations made as to how they might. be strengthened. l These recommendations cover the various levels of health administration and are generally supported in this report. !
At the national level the Ministry of Public Health should be responsible for the co-ordination of foreign assistance in the field 01: health and for ensuring that this aid fits into an overall health prograume.
,.1.1
'.1.2 The Office 01: the Director-General of Health should be expanded to include new divisions for health stat.istics, health education and personnel training. control of communicable diseases and environmental sanit.ation.
5.1.3 The training of medical and pe.ramed1cal personnel should have a high priority. The present training facilities for nurses are un.. ooord1nated. Supervision of student pract1ce is insuff1cient. Nursing tutors should receive special training for this job. There is also· a need for the training of other categories of para-medical. personnel.. The absence of sanitation personnel is a particularly serious handicap to the development of rural and urban health services. In the absence of a well-developed secondary educational syetemand unt1l such t~ as the Qove1"Qlllent is able to train itsell' the medical and para. medical personnel required to serve the national health service, consideration might be given to the possibility of tapping the abundant educational resources of ~l1and within the context of the Mekong Devel.opment Programme. Although encouragement should be given to the creation of an institute of public health training, it will be necessary to include in the curricula of all aux1l1ary train1.ng courses some form of
lAss1gnment report of Dr Marcel Bonnaud, 25 November 1966 15 January 1967 (WPRO 0079). .
• pre...pl'Of'essional tra.1n1~ in genEn"8l.. educatic:.m.. nm~nt of the hospital and public health services depends entirely on the availability of qualif:f.ed personnel. 5.1.4 Nam-Ngum dam construction The construction of the Nam-Ngum dam will require special provisions to safeguard the health of the labourers and their families. It is estimated that a fifty-bed hospital, outpatient and domiciliary services will be required for the five thousand persons involved. Cost estimates of construction, equipment and operation will need special study. 5.2 Environmental sanitation
5.2.1 General planning The first step in the realization of substantial improvements in sanitary conditions throughout the country would seem to be the establishment of an environmental sanitation bureau in the Ministry of Health. Technical assistance could be procured from WHO by implementing the environmental sanitation project (Laos 0011) which presently appears under Category II. For planning and implementing environmental sanitation the country could be organized into two main regiOns, each under a sanitary engineer, and each consisting of five units supervised by the same number of sanitarians. A sanitary engineer should head the environmental sanitation bureau of the Ministry of Health to ensure the co-ordination of work in the two regions and be responsible for overall national planning in this field. 5.2.2 Refuse diSposal Refuse collection and disposal are important public health measures and well within the modest resources of most communities. In hospitals and other institutions incineration in simple brick or mud chambers reduces the bulk to be carried away. The first step in effecting an efficient collection is the provision of suitable bins, made of galvanized iron, provided with lids and handles. Forty-gallon oil drums can also be used. Disposal of refuse can usually be best effected by burial in prepared trenches. The importance of providing a sufficient budget for refuse collection and disposal cannot be over-emphasized. 5.2.; Community water supplies
•
•
The investigation and designing of water supplies for each provincial capital, with the exception of Vientiane, can be done efficiently and expeditiously either by a team of water supply engineers or a consultant assisted by engj.neers and technicians of the Public Works Department. In all, fifteen water supplies would be required for the present population of approximately 150 000. The necessary data for a cost estimate can be collected in a period of six to twelve
months. Another prograume could be planned to provide water supplies in the rural areas J particularly for health centres, schools, public buildings and market places.
,.2.4 storm water drainage The need for street drainage is very obvious in Vientiane and the other towns in !aos. The grading of streets and roads is essential to the prOvision of drainage. Drainage is also needed in the rural collll1Wl1ties.
,.2.5 Drainage, flood protection and sewerage in Vientiane ])le to its location, topography and high rainfall, Vientiane is subjected to frequent flooding, water-logging and serious pollution. These conditions will be getting worse at a time when the City is expected to play a very important role in the development of the country. This factor makes the provision of drainage, flood protection and sewerage a matter of urgency. The authorities are aware of this problem and have already prepared a town planning scheme and engineering designs. Although. the design is comprehensive and provides for future extension, it still lends itself to implementation in two or more stages. This would greatly assist the authorities in spreading the financial obligations over a longer period of years. The central part of the City is in the greatest need of drainage and sewerage. Cost estimates of this work made in 1966 amounted to W$l 170 000. The sewerage will be discharged into the Mekong River, below the City, without treatment, except f'or screening. The minimum flow in the river is adequate to effect satisfactory dilution. The second stage of the scheme compl:'ises the remaining area and is estimated to cost about the same amount.
5.3
~asures
f'or disease control
There is no doubt that malaria is the most important hazard to the health of the !aotian people. The results of insecticide spraying in the years 1956-1959 must have been offset after many years of' relative idleness. It does not appear justifiable to leave malaria as a major public health problem greatly untouched. Although a country-wide eradication programme would be unrealistic in the present situation of partial insecurity 1 there are areas where anti-malaria measures could be effectively applied as is presently being done in Viet-Name The area ot activity "Should be delimited by the Government on the basis of security. VlHO should assist the Government to revive its malaria programne.
5.3.2 Leprosy The general attitude of' the health off'icials with regard to leprosy control 111 in favour of segregation and modern concepts of
.40-
leprosy control are not general.4r accepted. As there is 00 organized early case-detection system, leprosy as a public health problem bas not yet been seriously approached. It is recommended that WHO assistance be requested to study the possibilities of a campaign being undertaken against this disease.
5.3.3 Nutrition Nutrition education is needed as an integral part of the maternal and child health activities and of the teacher-training prograume. Nutrition is insufficiently represented in the curriculum of the School of Medicine and could have more accent in the nursing training prograume. Dietary services in the hospitals require to be improved. }.breover~ too little is known about the extent of nutritional deficiencies 1D the population.
5.3.4 Health education Initiative in this field should be encouraged as it is the least expensive way of promoting the health of the people.
VIlrl!-NAM .'l!ABIE .OF C01'i'J!El'lL'S
1. CBGANlZNrIIR OF !BE l~l
~
SERVICES •••••••••••••••••••••
Ministry of Health •••••••••••••••••••• ~ ••••• ~~~~ •••
1.2 Rural health programme ••••••••••••••••••••••••••••• 2. EDUCATION1 'l'RAINml AND RESEARCH ••••••••••••••••••••••••
2.1 Medical education ••••••••••••••••••••••••••••••••••• 2.2 Paramediea~ training ••••••••••••••••••••••••••••••• 2~2~1
43 ~
Nursing training ••• , •••••••••••••••••••••••• M1d:w1fery training ••••••••••••••••••••••••••
2~2~2
2.2.3 Other training institutions ••••••••••••••••• 2., Research ••.•••••••••••.•••••••.••••••.•...••••...•• The Pasteur Institutes •••••••••••••••••••••• The Walter Reed- A1'tny Medical:Resetl.t'eh- .
44 44 44 44
44
Institutes' •• ~ •••••••••••••••••••••••••• ~ •• Other units ••••••••••••••••••••••••••••••••• ,. HEADf.R ASPECTS OF THE co~
•.••••••.•••••.•.•••.••..••
45 45
3.1 Diseases of public health importance ••••••••••••••• 3~1.1 General ••••••••••••••••••••••••• ;. .... ' .......... . 3.1.2 Water-related diseases •••••••••••••••••••••• 3~1.3 Diseases due to poor sanitation- •••••••••••••
3~1.4
Insect-borne diseases •••• ~~ ••••••••••••••• ~.
3.1.5 other infectious diseases ••••••••••••••••••• 3.1.6 NUtritional diseases •••••••••••••••••••••••• 3.2 International and bilateral assistance in the" field of health ••••••••••••••••••••••••••••••••••
3.3 Agencies collaborating in eaviroomental sanitation •
48 48
4. •
REAlI1'H IMI?Ln::ATIQlIIS OF MEKONJ PROJECTS
..................
4.1 Proposed projects •••••••••••••••••••••••••••••••••• 4.2 The efiects of such extensive ana: rapid" development on public health ••••••••••••••••••••• 5• RECO~TIO!I3
•••••••••••••••••••••••• • • • • • • • • • • • • • • • • •
50
5.1 Hea1th services •••••••••••••••••• ~.................
50
- 42 -
f!2 5.1.1 5.1.2 5.1.3 5.1.4 5.2 Manpower •••••••••••••••••••••••••••••••••••••
•
Medical education •••••••••••••••••••••••••••• Pasteur Institute' •••••••••••••••••••••••••••• Hospitals •••••••••••••••••••••••••••••••••••• sanitation •••••••••••••••••••••••••••• .~
!O
51 51 51
~ironmental 5~2.1 5.2~2
51 51 52. 52 52. 52 52
Environmental sanitation services
••••••••••
5.2.!j. Storm water and sanitary'sewerage •••••••••••• 5.2~5
Conmunity planning· ~ .............. ~ ~ • ~ •••• :. .... . 5.2.3 Refuse disposal •••••••••••••••••••••••••••••• lPoOd hJgiena" •• ~~~~~~~ •••••••••• ~ •••••••••••••
5.2.6 Water supplies ••••••••••••••••••••••••••••••• 5.2.7 Sewage disposal ••••••••••••••••••••••••••••••
53 53
5.'
Measures for disease control ••••••••••••••••••••••••
•
-" VIET-NAM
1. 1.1
ORGAl.'lIZ.ltrION OF TEE HEAIlrH SERVICES
Ministry of Health
In recent years the Ministry of Health has been subjected to some radical changes. In 1964, a semi-autonomous rural health development prOgraIlmle, strongly supported by AID, was created. This included provincial hospital development, malaria eradication, communicable disease control, training, health education and logistics. The programme was called Administration-General of Health Development (AGHD). This programme, which was ambitious in its concept and 1'iD8.ocially powerful, was not able to meet expectatiOns for administrative reasons, and was reintegrated in the Ministry of J':[ealth in 1966. The creation of a Directorate of Public Health, under a DirectorGeneral. of Health, followed. This is now an important feature of the technical sector of the Ministry. It consists of three departments (a) environmental health, (b) preventive medicine, and (c) health education, each under a director, whose activities are supervised and guided by a Director-General. of Health. In l.966, the budget of the Ministry of Health amounted to 1 465 000 000 piastres, equivalent to less than "' of the total government budget. 1.2 Rural health pro§ramme The rural health prograIlmle dates from 1956.
In the following Its highest degree of development was reached in 196~, when seven thousand strategic hamlets had been established inVolving a population of 5 500 000; 95'1> of these bsmlets bad a rural. beslth post. 'W1th~Dl8llY :parts af'-tbecOllll'tz'y becan1 n g inaccess1ble .1'or .heal.th wor.k., actiVities han to be cOllfined to more restricted areas, -which could be&erVed by an iJ:J:teI:lsi.1" 8Di 1Jztegre.ted public beal.th service. years it has been subjected to various reorganizations.
2. 2.1 •
ElXJCATION I 'l.'RAINJ1tl .AND RESEARCH
Medical education
Rue.
There are two medical faculties, one in Saigon, the other in The Faculty in Saigon, which was 1'ormer.~~ttered over a great number of bu11dings, has occupied sinc~a new compl.ex of buildings, which is called the USaigon Medical Education Centre". It is located in Chelon and can accommodate two hundred medical and fifty dental students per class. The Medical Faculty of HUe University was established in 1960. The first graduation took place in
•
1967, when twenty-six students qualified. OVer two hundred Vietnamese medical students reside in France and post-graduate fellowships to the United states of' America e,re- granted every year in gre;;:G numbers. 2.2 paramedical training
2.2.1 NUrsing training The training of nurses has been subject to a considerable number of modifications in past years. Because of the serious shortage of physicians a school was set-up in 1956 to train technicians who would occupy a position intermediate between physicians and nurses and would in fact become "rural doctors". Shortly after the establishment of this training school, the concept of "rural doctors" was no longer found acceptable. Although the title of "technician" was retained, training was· oriented in two directions: hospital technicians and health technicians. While the training of health technicians was discontinued in 1960, that of hospital technicians has continued. They are in fact nurse-technicians. About two hundred health technicians were trained in the period 1956 to 1960.
2.2.2 Midwifery training The standard of the midwives is high. There are two midwifery schools, one at the TU Du Maternity Hospital in Saigon and the second in Hue. Special COlll'ses are organized at the Bing Duong Rural Midwifery School for instructors and supervisors. The training of rural midwives for work in districts and villages has been decentralized and takes place in the provincial hospitals under the guidance of midwifeinstructors.
2.2.3 Other traini~ institutions for paramedical persaaae~ are the National SChool of' 13olOgy whiCh is, in tne first instance, a school for medical laboratory technicians i the School for Sanitary Agents, which co-operates with the rural health development programme; the Gia Dinh Training Centre for public health personnel; the Caritas Nutrition Centre and the School of Hospital Economists.
2. 3
Research
2.3.1 The Pasteur Institutes have built up a reputation for medical and veterinary researCh in many tropical countries. Of tile tbree in Viet..I1em, the p:inciIl81 one in Saigoo is msin.ly cancerIled with medical research.. In the past three years it has l'ece1.ved cOllt!idereble assistance fran the Wal.ter Reed Army Medical. Research :mstitute~ Y4lich has financed the conatructiao...and inst.a.lla.tion of new- laboratoriee for the study of plague, cho.le1"a, entero-bac1ierial diseases and zoonoses.
2.,.2 The Walter Reed Army Medical Research Institute The main fields of interest of this institute are infectious diseases generally, but particularly in so far as they affect or might affect the military forces.
other units engae;ed in medical research are the t1n1ted states Ninth Medical Laboratory, the Epidemiologicai Survey Team of the Special Forces and the Twentieth Preventive Medical Unit. ,. HEAlIl'H MPECTS OF THE COUNl'RY
2.,., ,.1
Diseases of public health importance
,.1.1 General In Viet-Ham, the principal diseases Which constitute a public health problem are well defined, but knowledge about their magnitude is often not readily available. In many illStances information on the disease pattern in the various parts of the country can ·only be derived from hospital records which have serious l1m1tatiollS. Special surveys USing random sampling methods will be needed to obtain accurate information on the extent of IIIOSt of the important diseases. The nomadic population constitutes a permanent epidemiological danger to the rest of' the people. If they are not medically supervised by the health services and receive no immunizations, they may play an important role in the spread of' plague, cholera and" potentially, smallpox.
3.1.2 water-related diseases (a) Cholera
The explosive. spreading of cholera El Tor has greatly affected Viet-Name Cases are still reported from all four regions in Which the country has been administratively divided but unexpected f'J.are-ups are no exception. The f'atality rate has been drastically reduced since the re-hydration technique has been perfected. In 1966, a total of 2.8 million vaccinations were given. .
(b) !Y@0id • This has been frequently reported in the highlands. An increasing resistance ct Salmonella straillS to chloramphenicol is reported. (c) Leptospirosis has been reported since 1931. Four strains, i.e., L.australis, L. batav1ae, L. ictero-haemorrhagica and L. canicu1us govern itS epldeiil1oiOgy in-Viet-Nam. - -
-!,.6-
• 3.1.3 Diseases due to poor sanitation (a) Diarrhoeal diseases constitute one of' the major disease problems. The establishment of an enteric bacteriology laboratory in the precincts of' the Pasteur Institute in Saigon 1s expected to provide val.uable knowledge about the occurrence of' bacterial enteropathogens and their control. (b) Amoebiasis 1s reported more of'ten than bacillary dysentery. This is contrary to f'indings in other countries and theref'ore needs further investigation. (c) Parasitoses
The prevalence of' the various paraSites inf'esting the human enteric tract is not exactly known. Zeville (1960) reviewed the f'indings of' twenty-eight hospital laboratories in relation to the incidence of' enteric paraSites; stool examinations of' 37 917 cases (71 144 examinations) resulted in a positive rate of' 53.39~. '..-r
3.1.4
Insect-borne diseases (a) Milaria
Malaria has always been considered one of' the most important f'actors inf'luencing morbidity and mortality in Viet-Name Between 1955 and 1958 spraying operations were conducted with assistance from mOM. A well-organized malaria service has been built up, but due to the deterioration in the security situation by the end of' 1960, it has not been possible to guarantee spraying operations on a continuous basis and limitation of' the programme has appeared inevitable. In 1966, despite the lowering of' the target, the programme was only able to cover a population of' 1.44 million. (b) Haemorrhagic f'ever
In 1964 there were 1043 cases and 177 deaths. The Government has started surveillance measures with assistance from the Walter Reed group. (c) Plague
The disease has been endemic in Viet-Nam since 1906. A:f't;er 1915 there was a gradual decline until only sporadic cases were observed. Since 1964, however, the number of' cases has increased and plague has become an important health problem. The Delta area had been relatively f'ree untU AprU 1967 when nineteen cases of' pneumonic plague were reported in Roch Gia, just outside the ~kong drainage area, The Highland provinces, and Darlac in particular, have regularly reported cases of' plague in the last f'ew years.
The principal reasons for plague dissemination have been found to be: (a) insecurity problems which den;y access to man;y areas for the necessary control work; (b) failure to take 1lImediate action when foci are still small; (c) lack of eqUl~nt, insecticide and personnel to deal with massive outbreaks, and (d) uncontrolled shipments of foodstuffs from endemic foci to non-infected areas. An important step in the study and control of plague has been the estab] 1 shment of a plague research laboratory in the precincts of the Pasteur Institute in Saigon.
3.1.5 other infectious diseases (a) Tuberculosis
Data on the extent of tuberculosis are stUl incomplete. The proportion of reactors to tuberculin under five years of age has been reported as ll~ in Saigon •. For all age groups, it was over 5B;.. The headquarters of the National Tuberculosis Prograume is located in the Hong Bang Hospital in Saigon, where three sub-centres are also being constructed. There are also centres in HUe, QUang Ngai and can Tho. Only the latter is located in the Mekong Basin. As a national progr&lllll8, tuberculosis control is still in the initial stages of developnent and outside the capital city its impact is hard~ t~. (b) LeF?sy
Leprosy is more frequent in the m ghl ands than in other parts of the country and some areas show figures which are among the highest in the world. The Government still considers leprosy control within the context of isolation in leprosaria and actually little is done in the way of systematic control. Existing regulations should be reviewed in favour of lOOre flexible legislation putting an· end to ~ory isolation.
(c)
Trachoma
Trachoma ranks high in the l1st of notifiable C01IIIIUnicable diseases. During the last few years the Government has organized mass campaigns in various parts of the country. Trachoma control should . receive the attention of the NatiotIBl School Heal.th Service.
(d) •
Sm&lle
Viet-Nan bas been :tree i'ran 8Il8llpax since
1960.
(e>
Pol1mc;rel1tis
Since 1962 there has been a progressive increase in the incidence of pol1omyel1tis. This' is typical of a country where socioeconomic conditions are improving. Epidemics can be expected in the group ased two to four-an4-e..h e J.,. years.
- ll.8 • (b) Venereal. disease
As in most other countries venereal disease is on the increase. There is no compulsory reporting and no law which would permit punishing a person transmitting venereal disease consCiously. Contact tracing and follow-up are difficult to carry out because of the shortage of social workers.
3.1.6 Nutritional diseases A nutrition survey in 1960 indicated low intake of thiamine, riboflavin and vitamin A. Beri-beri occurs among infants in Saigon. Anaemias are common and attributable to iron deficiency. Prateincaloric deficiency (marasmus and kwashioskor) and xeroptha1m1a are comnon1y seen in saigon hospitals. Goitre is endemic in some rural areas. ;.2 International and bilateral assistance in the field of health
As a result of the present political Situation, Viet-Bam is very dependent on foreign assistance. M!lssive aid is granted by individual countries. Contributions have ranged from unlimited aid by the United states of America to less conspicious offers by other countries. WHO baa provided assistance to the following programmes: maternal /:ind child health, malaria, tuberculosis, leprosy and venereal disease control, national health planning, health laboratory Services, quarantine services, health statistics, environmental sanitation and rodent control. UNICEF' has also contributed to a number of these projects.
3.3
Agencies collaborating in environmental sanitation
By far the greatest contribution in the field of environmental sanitation is being made by AID. The accomplishments cover all aspects of environmental health, including municipal and rural water supplies, housing, schools, roads and hospitals. Australia, the Philippines and the Republic of Korea are also assisting in this field. The Australian Government is in the process of constructing a water supply scheme in Can Tho, in the heart of the Delta. 4. ImJIIIl'H IMPLICATIONS OF . MEKONG PROJECTS
4.1
Proposed projects
Preliminary plans for the development of the Lower Mekong Basin include an area of about 30 000 square kilometres in the Central Highlands drained mainly by the Se San and Srepok rivers. The proposals provide for the construction of a number of small dams for power generation and for some limited irrigation. The feasibility studies for Se San
- 119 have shown that there is a potential of up to 800 000 kilowatt capacity and up to 7000 hectares of irrigable land. Reconnaissance studies for Srepok have shown a potential· irrigable area of about l2 000 hectares. uydro-electric power generation possibilities are promising but no estimates have yet been made. In the Mekong Delta, proposals for projects comprise river dredging, drainage, flood control, pumped irrigation, and a bridge at My Thuan.
to. addition to the above specific projects, the Mekong Committee has considered a large number of other projects under the following categories: (a) Public Works and Services: highways, vaterways, ports, airports, thermal and hydro-power, vater-supplies, schools, health centres, welfare Services. An idea of the magnitude of these proposals may be gained by noting that the estimated cost amounts to nearly 00$500 000 000. Community DevelOpment and Housing:
(b) (c)
estimated costs
00,110 000 000. AgricuJ.tural Development: irrigation, animal husbandry, industrial crops, fisheries, forests. Estimated costs:
tB$225 350 000. (d) Industrial Developuent: cement, fertilizers, p a p e r ) m11ls, rayon plant, sericulture, etc. Estimated costs: (,:.:
tB$l27 500 000. Thus, estimates amount to tB$940 200 000, and the proposals .•. are intended to be implemented in the next twenty-two years • Proposals for implementation over the next few }1ears provide for an expenditure of nearly US$200 000 000.
.----i
)
4.2
The effects of such extensive and rapid development on public hea1th
•
Such extensive and rapid development is bound to affect public health profoundly in many vays. Some of the effects will prove beneficial to public health but others may prove detrimental unl.ess adequate precautions are taken. The first concern of the public health authorities is the fear of the introduction of new diseases or the intensification of existing ones. Such fears are usually well-founded when the developments lead to the establishment of cond1tionsfavourable for the transmission of disease. This is usually the case in arid countries. In Viet-Nam, however, changes in ecological conditions are not likely to be profound, particuJ.arly 1n the Delta reg1aa..
- 50 • The second concern is the effect of the changes on the demographic patterns as these my lead to the creation of new communities, to rapid urbanization, and the setting-up of industries ilhat are either abnoxious or a danger to public health. This second concern implles that extensive community planning and housing projects must precede the proposed developments and particularly the establishment of industries and the large-scale irrigation schemes. The proper siting of communit1es and the provision of essential. services, such as drainage. sewerage and water supplies, are the best means of protecting publlc health and the most economical in the long run. In addition to the provision of basic environmental services and facil1ties, comprehensive health services and hospital.s shoul.d be planned and provided ahead or parallel with the developmeat projects.
Some concern has been shown by the public health authorities about the l1keUhood of schistosomiasis gaining a foothold in the Delta or el.sewhere where irrigation schemes are projects. There is no evidence to support this fear. Concern has also been expressed with regard to the possible introduction of plague in the Delta area as a result of flood and water control, which woul.d tend. to reduce the chances of rats and neas drowning as at present ~ .Again it may be said that there is no evidence to support such a fear. Observations have shown that where water development schemes are properly planned, constructed and maintained, the chances of creating health hazards are negligible and even in areas where water-related diseases are'endemc, their control does not present any insurmountable problems. water devel.opment schemes can offer opportunities for more efficient disease control. and for the promotion of the general wel.l-being of the popul.ations concerned. Planning for the needs of the communities and the implementation of health proposal.s usually take longer to achieve than in the case of agricultural or industrial enterprises. There are financial demands and personnel. requirements to be met and. these take time to satisfy. In this report information has been presented on the existing facilities, services and personnel. concerned with publ.ic health and recommendations have been made to satisfy preseat demands and as a basis for planning future requirements in accordance with population growth. These requiremeats are of necessity of a general nature and can be spelt out in detail only after field surveys have been conducted and prevalent costs assessed.
•
• 5.1 Health services 5.1.l. Manpower Massive recruitment for service in the Armed Forces has drained the Ministry of Heal.th of professional. and auxiliary staff. It is
- 51 -
~
d1:tticult to compensate for this situation by itItensifled training programnes alone. However, under any circumstances the country needs to expand its facilities for medical education and the training of ~a1 .. penmnel.. 'W1U1 tbe sapp:rt of WOO, the GCMrl'IIIIII8Dt is favourably considering the establishment of an institute of public health for the purpose of co-ordinating and developing the training of public health personnel at the middle level. 5.1~2
Medical education
In. view of the high prevalence of diseases directly related to poor sanitary COnditiOns, it would seem that medical education should be more oriented towards the preventive aspects of conmunicable disease cotItrol. Although it is most desirable for preventive medicine to be integrated in all branches of clinical medicine, the creation of a department of preventive and social. medicine wou1d be an answer to a number of weaknesses in the present curriculum, and in the teaching of' paediatrics in particular.
5.l.., Pasteur Institute The assistance given by the Institute in upgrading the hospital laboratory services 1 al.though clearly the responsibility of' the Ministry of' Health, shou1d be continued until more appropriate arrangements can be made. Unsatisfactory laboratory facilities in the provincial hospitals lessen the value of' the health statist1cal data and the epidemiological. information collected, both of which are urgently needed as a basis for heal.th programme planning. I f a certain resistance to itItegration in the national health services can be overcome, it wou1d appear relatively easy to convert the Institute in Saigon into a Faculty of Tropical. Medicine.
5.1.4 Hospitals
:rt is d1:tticul.t to make a prediction on the hospitalization facilities required once the situation returns to normal. There is no doubt that under present conditions there is an alarming shortage of' beds, but it would seem that much of the sickness and subsequent hospital care are in direct relation to the consequences of' war. It is recommended that an overall study of the hospital situation in the Mekong Basin provinces be made at a convenietIt time. Special attention shou1d be given to the needs of hospitalizatioil at the district level where facilities appear to require improvement. • Environmental sanitation 5.2.1 Environmental sanitation services A modest start has been made to set up an environmental sanitation service in the health departmetIt staffed by public health engineers. More needs to be done to ensure the success of the proposed Mekong
- 52 projects, particular~ in the l)elta region. :rt would seem that present requ1rements call for at least two civil engineers with public health training to serve the rural provinces in the Delta and one engineer in the Highlands. In addition, each province should have at least one ~ trained and experienced sanitarian.
5.2.2 COIIIIIIUnity planning :rt is recommended that the Government plan the location of new settlements and co1lllllUnities, both rural and urban, -well in advance of the need for actual occupation. The next concern should be to control and guide the gro-wth of existing c01lllllUnities and introduce improvements in environmental conditions in an efficient manner. The influx of large numbers of people in the last few years has great~ increased the population of towns like Pleiku, Ban Me Thuot, My Tho and can '!bo, thus straining sanitary services.
5.2.3 Refuse diSposal The problem is acute in the provincial towns. There is not always sufficient appreciation of the role that refuse plays in disease transmission.
5.2.4 storm 'Water and sanitary sewerage The accumulation of rain and 'Waste water in street ditches and open spaces is a sight common both in the Delta and the Central Highland provinces. The problem is essentially one for the Department of Public Works and local authorities to solve. Effluents from septic tanks, especially those serving hospitals and other institutiOns, should pass through absorption fields before discharging into drains.
5.2.5 Food hygiene Conditions under -which food is prepared and served are generally t':Jsatisfactory from the point of view of public health. There is little doubt that contaminated food is an important factor in disease transmission.
5.2.6 water SUpplies Although precise data are not available, it may be said that the majority of the people living in the Mekong Basin area in Viet-Nam do not have access to adequate and safe water supplies for domestic purposes. Existing waterworks have often been allowed to deteriorate. In planninG a water supply proG,ramme, proposals should be formulated to rehabilitate the existing systems. At present there are two provincial capitals -without water supplies, Kontum and Phu Vinh. New water supply schemes are required for a population of 100 000 at an estimated cost of US $15 per head. The planning and implementation of a community water supply proeramme CaD best be done by a small group of water supply engineers
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and managers assigned to the Directorate of Water Supply in the Department of PUblic Works. After the needs of the provincial capitals have been met, consideration should be given to extending the programme to other urban ceatres and large villages. In the meantime, it should be possible for the environmental sanitation service of the Ministry of Health to initiate a rural water supply programme.
5.2.7 Sewage diSposal None of the provincial capitals has a sewerage system. :rt is recommended that a sewerage section be established in the Ministry of Public 'Works. This would be responsible for surveys, designs and supervision of sewerage schemes, mainly for the urban population. _ The responsibilities for sewage disposal in rural. conmunities shoul.d rest with the environmental sanitation service of the Ministry of Health. In this respect rel.1ance w1l.l have to be pl.aced on simple processes such as oxidation ponds.
5.3
Measures for disease control
The control of communicable diseases, particularly of malaria, tuberculosis, leprosy and enteric diseases on a long-term baSiS, and of plague and cholera as 1umediate objectives, will be the major task of the periPheral. health services. Experience has shown that these services need strong administrative and technical support from the central health organization if they are to operate effectively. To this end, the establishment of a division of communicable disease control. with appropriate sub-divisions might be considered.
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CAMBODIA TABLE OJ' coml1MS
1.
....................... . 1.l. General. •••••••••••••••••••••••••••••••••••••••••••••••
57 57 57
1.2 Hosp:!.tala .•..•.•.........••.........•..•...•.•.•...•.. 1.~ The rural health services
............................. • ••••••••••••••••••••••••••••
58
2.
2.1 Schools of Medicine 2.2 Earamedica1 tra1n1ng ••••••••••••••••••••••••••••••••••
................................... 58 59 59
2.2.1 NuraiDg tra1Dtng ••••••••••••••••••••••••••••••• 2.2.2 M1d'W1fery training ••••••••••••••••••••.•••••••• 2.2.~ Training of sanitary agents •••••••••••••••••••• 2.2.4 Tra1n1ng of clinical laboratory technicians •••• ~~
59 59
ASPECTS OF !BB COUkt.RY ••••••••••••••••••••••••••••••
~.l
Diseases of pUblic health importance ••••••••••••••••••
59 59 60 60
,.1., ~.1.4
~.l.l
Water-related diseases
,.1.2 Diseases due to poor sanitation ••••••••••••••••
.........................
Insect-borne diseases .....•......••............ other infectious diseases .................•.... ,.1.5 Nutritional diseases ••••••••••••••••••••••••••• International and bilateral assistance in the field
61 62
,.2 4.
of health •••••••••••••••••••••••••••••••••••••••••••
62 62
.................... . ..................................•........ Health services The Ministry of Public Health ............•........... Medical services ....•.•.........•..•...•.•........... Rural health services ................................ Hospitalizatioo .......•.............•.....•....•..... Nursing services ••.••................................ Medical education •••••••••••••••••••••••••••••••••••• Env1roamental sanitation .•..•...•...•.•........•.....
64 64 64 65 65 66 66
......................................
.
67 68
.. 56!!2 68 68 68
• •
5.8.1 5.8.2 ,.8.3 5.8.4 5.8.5 5.8.6
General Canmuni ty planning and housing
.............................................................
................
Surface drainage and sanitary sewerage Refuse disposal. Ccmnuni ty water suppl.y Technical personnel
.......................................................... ............................................ ....................................................
........
69 69 70
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CAMBODiA
•
1. 1.1 General
CRlANlZATION OF THE BEAIII'H SERVICES
In the past few years the health services have been considerably strengthened. The effort to improve and extend medical education has resu1ted in an increase in the number of physicians who are gradually taking over the posts formerly occupied by health of'f'1cers (of'f'iciers de sante). An important feature in recent years has been the establishment of the first provincial public health service in the province of Kompong Cham.
At the M1nistry of Public Health, the Bureau of Statistics and Ep1.dem1ology has been re in1'orced and a WHO adviser has been appo1.nted to assist in setting up modern methods of statistical registration. The Department of Malaria Eradication and Communicable Disease has been placed under competent leadership • •
In 1966, an applied nutrition programme was initiated with WHO and FAD asilistance and. an Inter-Ministerial Committee for Nutr1.tion and. Alimentation was established. There are six departments, each headed by a director, under the authority of the Director-Qeneral of Public Health. 1.2 . Hospitals
In recent years, considerable efforts have been made to improve and. extend the hospitals in the prov1nc1alcap1tals. TO a great extent financing has come from voluntary contributions. However, the laboratory services are still weak as a competent cadre of laboratory technicians is lacking. Another dra'wback of the provincial hospitals is the absence of paediatric departments. Hospitals of direct interest in connection with the Makong Development Scheme are situated in K. Chhnang, Pureat, Battambang, K:rat1e, stung Tretg and Kompong Speu. The bed capacity in Cambodia is: Hosp1.tals 1.n the capital Hosp1.tals in the provinces Health centres Leprosaria
20" 82
1 500 900
Psychiatric hospitals Plantat1011 hospitals
1 174 537 6230
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This 1s roughly equival.ent to one bed per l.()O() population. In the provinces, however 1 the proportion is one bed per 4200 1nbab1tants. A comparison between 1963 and 1966 shows that there has been an increase in hospital admissions from 0.6 to 0.8%. 1.3 The rural health services
An official plan for the deve10pment of rural health services has not yet been formulated, but the aim is to establish one health centre in each district, of which there are 102. - These health centres will gradually be placed under a medical officer. Nine rural health centres have already been established; seven of these are in the Mekong Basin. The location of the health centres is to a great extent left to the decision of the rural communities, which provide for their financing and construction. As a result, they are not evenly spread throughout the country as most of them are located in the prosperous regions. In addition to the health centres, there were, in January 1967, over 400 infirmaries, 644 midwifery stations and some 50 medlca1-aid posts. 2. MEDICAL EDtX:ATION AND 'mAINlID
2.1
School of Medicine
In 1962, the School of Medicine became by law the Royal Faculty of Medicine, Pharmacy and Paramedical Sciences. 'n1e fCll.'lDelE' four.year training course for health officers was discontinued in 1964. The Faculty consists of fifty-seven professors and six technicians. The majority, however, have additional responsibilities in hospitals, laboratories and elsewhere. The improvement of medical education is greatly dependent on a stable cadre of Cambodian professors, the creation-of services for basic and clinical sciences, and organizational planning. 2.2
Paramedical. train1llg
2.2.1 Nursing training Nursing education in Cambodia dates from 1951 when WHO nurses arrived in the country. Physical facilities improved considerably after a permanent building, constructed with aid from tEOM, we p,lt into use.
-59In 1961, a new ordinance establishing the Royal School 01' Nursing and M1dwUery was promu.lgated. ![his is now the basis 1'or the operation 01' the school. In the same year, a three-year course 1'or state registered nurses and midwives began and a one-year course was set up to prepare auxiliary working personnel. As 01' 1966, ninetytwo state mn-ses had been registered.
•
2.2.2 M:l.dwif'ery training In 1961, the training 01' midwives was reviewed and extended, with more emphasis given to paediatrics, prenatal and post-natal care and home visiting services. The midwives trained along these lines are recognized as state registered midwives. Between 1961 and 1965, sixty-one state midwives were registered. Rural midwives have been trained since 1949 and by 1966 a total 01' 622 had been trained. The long-term objective 01' this programme has been to replace gradually the traditional midwives. 2 .• 2.' Training 01' sanitary agents In 196" a training course 1'or sanitary agents was set up with the primary objective 01' assisting the malaria pre-eradication project. The Government requested assistance 1'rom WHO in order to bring this course more in line with environmental sanitation requirements. An experienced sanitary technician was provided by the Organization in 1965. Sanitary agents are being used as multi-purpose workers in various programmes. 2.2.4 Training 01' clinical laboratory technicians A training course 01' three years' duration 1'or laboratory technicians was started in 1966 in the Institute 01' Biology. Twenty students will be admitted each year. The establishment 01' this course is expected to improve clinical laboratory services in hospitals all over the country.
,.1
Diseases 01' publiC health importance
,.1.1 Water-related diseases (a) Cholera
El .Tor cholera was introduced in 196,. About 350 cases were registered and bacteriologically confirmed in 196, and 1964. A second outbreak occurred in Phnom-Penh in April 1966. cases were most~
-60-
~
sporadic and inorlaUty was low. In 1967, there was a abort, llm:I.ted in Battanbang province. (b) Typhoid
•
Typhoid exists in endemic form. The number of cases reported is on the increase, but the fatality rate has dropped to between 4% and fiI,. Most cases occur in the lower age-group. There are generally more cases during the wet season. (c) Schistosaniasis has never been reported.
(d) Paragoni mi as1s occurs in a circumscribed area of Mondul K1ri, a focus which probably extends into Viet-Name 3.1. 2 Diseases due to
poor
sanitattoo.
Physicians in Cambodia are impressed by the importance of diarrhoeal diseases as a cause of deaths in infants. Diarrhoeal disease is the most frequently encountered ailment in the Kantha Bopha Paediatric Centre in Phnom-Penh. Entero-parasitic infestations are reported to be widespread. 3.1.3 Insect-borne diseases (a) Malaria
With the exception of a relatively small region in the Central Plain, Cambodia is by nature a highly malarious country. The· malarious area occupies roughly three-quarters of the country and a population of about 2.7 million is under malaria risk of varying intensity. In 1954 and 1955, good results were obtained in controlling this infection by means of DDl' spraying of houses in areas of relatively low endemicity where A. minimus was the vector. In 1957, a new vector, A. balabacensis, was found infected in the rural areas. Delimitation the 'bal8Obacens1s area has shown that this vector is widespread in areas where there is considerable malaria transmission. The problem is aggravated by its extensive distribution in areas difficult of access and by its generally exophagic and exophilic habits. FUrther studies on the bionomics of this vector are required. Another technical problem is the presence of chlat'oquiue resistant strains of P. falcif81l."Ull. Th1s was first reported in 1962 from Pailin but later was alSo encountered in the rural areas. The improvement of the malaria situation is of the greatest importance for the success of the Mekong development projects. Newly irrigated areas where farm crops will be produced to increase the gross national product and potential settlements of industries must be 1:ohabitable and not subject to continuous or periodic malaria transmission.
of
- 61_
(b)
Dengue and Ch1kuogun;ya
•
1be Pasteur Institute 1n Phnom-Penh has carried out serologIcal studies on dengue sInce 1"961 and has isolated the Dl type virus from naturally infected Aedes aeFI. Chastell isolated Ch1kungunya virus from a Chinese chIld in 196~Aedes &egypti is very widespread in the capItal. 3.1.4 Other infectious diseases (a) Tuberculosis
The extent of the tuberculosis problem in Cambodia is not exactly known, but Indications are that the situation is serious. A BOO campaign in the former decennium, covering over one million persons, reported an overall tuberculosis index of 54~ in the age-group 4-14years. A National Tuberculosis Control Service was established in 1965. Although it was understood that BOG vaccination should have prIority, it ws recognized that a treatment progranme had also to be included. BOO vaccination in the capital has been decentralized by using the exIsting district dispensarIes for this purpose. In 1966, a vaccination prograume was introduced: in a number of provinces using mobile teams. This was followed by ambulatory treatment in the provincial out.patient cUnics under the supervision of the National Tuberculosis Centre. By Mliy 1967, 250 000 persons had been tested and 1525 were under treatment. (b)
•
Leprosy
There is one central leprosarium and two treatment centres in In 1966, 6802 patients were registered. :rt is obvious that a cotlBiderable number of leprosy patients escape registration and treatment. Systematic detection aDd control measures should be initiated, . starting in the capital where the endemicity is probably highest. The estabJ1sbment of preventive measures against the infection of leprosy patients, esPecially children, at Troeung Leprosarium is recommended. Phnom-Penh.
(c) Yaws A yaws coatro1 programne was successful.ly conducted in the northern province from 1959 to 1964, covering a population of 800 000. Since then, a smaller-scale p:rograDme has been operating in other parts Of the. country. Yaws still prevails in patches in many pr0vinces, but the impression is that the disease is gradually disappearing.
-
•
_ 62 -
(d)
Trachoma
Endemio trachoma is the main feature of the pathology in Cambodia (IA§pine). Poor sanitation favours the spread of conjunctivitis and eye 1Pf'eations. (e) Infantile paralysis
PoliO!IWel1tis with paralytic symptoms 18 seldom observed. but the infection 1s widespread and capable of immunizing the population at a very young age. The results of over one hundred neutralizing reaotions have shown that at the age of five years all children have acquired antibodies against all three types of virus. This circumstance 18 attributable to the standard of sanitation in the country, which favours enteric infection by the ingestion of contaminated matter.
(f)
Rabies
In 1965, the Rabies Treatment Centre at the Institute of Biology reported that it had vaccinated 2059 persons against possible rabies. In the same year, 8000 persons were reported to have been exposed to this d1sease.
3.1.5 NUtritional diseases Until now there have been no real opportunities for assessing the nutritional status of the population, but protein-calorie deficiency, vitamin A deficiency and nutritional anaemias are known to be prevalent among young children.
3.2
International and bUateral assistance in the field of health
Cambodia receives assistance from a number of foreign countries. WHO is giving assistance to the following proJeots: malaria preeradication, tuberculos1s control, nursing admin1stration, stat18tics and epidemiology, training of sanitarians and nutrition. UNICEF has also contributed to a number of these projects.
4.
HEALTH IMPLICATIONS OF MEKONG PROJECTS
Due to its location and topography, Cambodia has considerable potentialities for the development of water utUization projects both on the Mekong River and its tributaties. On the main stream, the preliminary proposals provide for a storage dam at Stung Treng and a run-at-river dam at Bambor. The Toole Sap regulation barrage intended to control the Grand Lake 18 of special signifioanoe as a flood oontrol project. Tributary proposals comprise the follOWing:
•
•
Se Kong, Se San Srepok, shared with Laos and Viet-Nam, and t1t'teen other possible proJeots located wholly in Cambod1a •
The tirst two tributar.v proJeots ll8ted tor implementation in the next tive years are: Prek Thnot and Battambang, estimated to oost $32.75 million and $20.4 mUlion, respectively. Both are power and lrrip.tion projects. Prek Tlmot will be a roolc-and-earth till dam, 10 kilometres long, impound1ng ll20 million oubio metres ot water trom a oatchment area ot 3600 square kilometres and tOrming a reservoir w1 th an aI'ea ot 195 square ldlometres. It wUl be located some 70 kilometres from Phnom-Penh. A divereion w111 be oonstruoted some 12 kilometres downstream to teed irrigation canals on both sides ot the river tor an aI'8a ot 70 000 hectares. The power station w111 have a oapaoity ot 18 000 kilowatts. The Battambang project has a catchment aI'ea ot 1800 square kilometres, a st\)rB.ge ot 1000 milllon oubic metres, a powercapaoity ot '5 000 kilowatts and an 1rr1gat10n oapacity ot 60 ::>00 heotares.
Both projects involve laI'ge populations who w111 require improved health and sanitation services. The first concern ot the Government would seem to be the planning of rural cOll'lllUIlitles in areas where large-soale irrigation 18· to be establl8hed. EaI'ly planning would ensure the provision .f suitable environmental health conditions. Key urban centres would also need to be planned and provlded with health services and facilities to serve increasing populations and activities. These imply the provision of suitable hOusing, water supply, drainage, sewerage,ref'uae disposal. Key towns,l1ke Stung Trang, Kratie, Kompong Chlmang. and others, need to be prepared for the important roles they will have to pl.ay. More specifio implioations of the oonstruction projects involve provision for oonstruotion oamp sanitation, measures for the proteotion of the people from conmmioable diseases and, more particularly, from malaria. AdeqUate housing and the prevention of overcrowding would be important measures in the control of respiratory diseases. There 18 no evidence to suggest that the proposed schemes will introduoe . new diseases in the area. The prevalenoe ot existing waterrelated diseases need not be intensified i t water control 18 effeot1ve and adequate drainage is provided •
•
In general, the adoption of the l'8OOIIIII8ndations regarding disease oontrol and improvement of environmental oonditions will ensure that the Mekong projects are benef10Ial to publio health.
_64_
5.1
Health servioes
On the attainment of independenoe the Kingdom of Cambodia was left with very limited health servioes, whioh vere almost exclusively oriented toward curative medioine. Medioal and paramedioal eduoational facilities were only available outside the oountry. The systematio manner in whioh the health servioes have been developed bears witness to the Government1s strong determination to improve the health of the people 88 an integral part of seaio-eoonomio progress.
The organization of Cambodia1s health services has been markedly influenced by the French ooncept of "hygiene publique". This has been taken into account when formulating reoommendations. 5.2 The M1nistrz of PUblio Health
Well-organized health services, extending their influence to the periphery of the country, are dependent on strong central health services in any centrally administered country. As long as the various aspeots of public health are not properly represented at miniSterial level, development in the peripheral areas will be weak and un-ooordinated. As a result of the shortage of qualified personnel, the DirectorateGeneral has for many years not been in a pOSition to staff its technical departments properly. This situation has improved recently as a result of the graduation of more physicians from the Royal Faculty of Medicine, Pharmacy SI¥l Paramedical Sciences. Still, in a qualitative sense there remains a general need for more public health orientation among the younger group of graduates. As the majority of diseases in Cambodia are probably induced by poor sanitation, an environmental sanitation department should be established as a separate department within the Directorate-General under the charge of 8 sanitary engineer. In the present concept of "hygiene publique", which is already represented in the Ministry as a department dealing with disease prevention, too IIIlCh emphasis is being put on Vaccination as the primary means of disease control. It should be recognized that - notwithstanding the value of vaccinations - only improvements in sanitary conditions oan lead to a reduction in the enteric diseases, which oontinue to take the lives of many ohildren. An environmental sanitation department could oonveniently replace the Department of "Hygiene Publique" whose funotions are intimately related with the Department of Communicable Disease Control (See also section 5.8.1 page 68).
•
The :!apartment of Health Ee.ucation has already I to a lIIOderate extent, taken responsibil1ty in the field of environmental san1.tation. For some years san1.tary agents have been trained as san1.tarians and are now being employed as multi-purpose workers in a number of different services. There can be no objection to this in principle. The danger lies in the fact that as sanitation workers they are left without techn1.cal guidance, so that their work in this field is bound to deteriorate in the long run. In view of the great willingness of the people "to help themselves" and to contribute to the health construction programme by building a network of health centres and infirmaries, the Department of Health Education might draw their attention to their sanitary needs, thus aroUSing their interest in san1.tary construction works. With the expansion at rural health activities, which is a combined effort at various services (to which tuberculosis control has recently been added), there appears a rea1 need for the establishment of a dep.rtment at rural health which would exercise appropriate co-ordination aad promote actiV1tes. This department is considered to be of major importance i t a smooth and balanced development at the rural health services is to be achieved. At this t1me there is no appropriate central body tor plann1.ng and co-ordination. Departments ~ relatively tree to launch their own prograumes 1 irrespective of . priority needs and the potentiality of the provincial health services. A rural health department would SOOn take a predominant place in the overall health administration.
•
5.3
Medical services
The Iilysical improvement and expansion at provinCial' hospitals as a continuous process and the strengthen1.ng ot the medical staff are 1mpcrtatxt achievemetxts of the last few years. In the field of nursing, despite considerable qualitative improvement, the need for more cl1n1.cal nurses bas remained unchanged. Another weakness is the inadequacy of the laboratory facilities. ibis condemns qualified physicians to work below their staiid8i::a of academic education. The art of basing diagnosis on symptomatology,. which was highly developed in former centuries J has been replaced by technology, micrObiology and biochemistry, which now have their legitimate place in IIIOdern cl1n1.cal medicine. This was undoubtedly realized by the Ministry of Publ1c Health when it decided to establish a course tor professional laboratory technicians.
5.4
Rural health services
•
, !lhe presetxt rural health infrastructure is the result of the initiative of the people. It follows" therefore, that health centres have been built in areas where the population is most dense. This is understandable and very reasonable from the. poitxt of view of curative medicine. The promotion of a more homogeneous spreading of health facilities should be considered by the Government, within the limitation
- 66 -
of its financial possibil1ties, as a part of its responsibUlty for the control 01' communicable diseases • The maJ.aria eradication programme, for example, which has been constituted by law, cannot be ei'i'ectively carried out without the support of an eve~ spread network of basic health services. 5.5 Hospitalization
The urban population in Phnom-Penh is in a better situation than the people in the proVinces as four hospital beds per thousand populat:ton are available. In the proVinces the rate is o~ 0.24. As a first step the Government should aim at the establishment of a rate of 0.5 bed per thousand rural. population. This could possibly be achieved in the next five years. The increase in hospital admissions is an indication of growing interest in medical facUlties. Most of the hospitals are still in a posit1.on to absorb a larger number of patients. For this reason, prior:1ty should be given to the establishment of more health centres at district level. These should be proVided with 18-20 beds for general medicine and maternity cases. O~ the provincial hosp:i.tals with an effective bed occupancy of over 85'1> would require expansion. At a rate of 0.5 per thousand population, 2900 beds 'WOuld be required. This implies an increase of 1600 beds in the coming years. It is estimated that:J.. the cost of this project would probably come to 250 million riels or 400 000 riels per health centre. The Government I s plan to have a health centre in each district would thus be achieved. It is obvious that the expansion programme must take into considerat:ton available manpower and for this reason the shortage of personnel in the proVincial hospitals should be dealt with in the first instance.
•
5.6
Nursing servi~
The rapid extension of peripheral health facilities has I in some instances, given rise to problems for which the central health adm:1n1stration cannot always find easy solutions. One of these is the staffing of the oewly constructed establishments I which sometimes had to be effected to the detriment of the sta1'1'ing 01' the provincial hospitals. Although there is undoubtedly a shortage in most categories 01' nursing personnel, it cannot be denied that they have not always been used effectively. Understaffing of the provincial hosp:1tals is partly influenced by the relative overstaffing of the municipal hospitals. Diploma nurses are taldng places in which their
l.
tB$l= 35 riels
II
- 67-
• training and experience cannot be put to effective use. The utilization of nurses for hospital administration, radiology, etc., is a1s0 evidence of an under-est1mation of the requirements for such posts. Wh11e on the one hand nurses have been put to use outside their profession, they have a1s0 suffered from insuffiCient recogn1tion in their specific field of professional. nursing. The role of mr.'ses as members of the health team with a physician as leader is receiving increasing recognition. As pointed out by the D1rectorGeneral of WHO on the occasion of World Hea1th Day in 1967, a te81ll consists of "partners in health". Partnerships implies that the various skills of the participants are recognized as different entities and that they are given ample opportunity to contribute fully to the performance of the team. Nursing arts have developed along their own lines and yet :t'ull. recognition is withheld from state-registered nurses and midwives, who are the highest quallfied professional. nurses in the country. In the hospita1s they have l1m1ted responsib1l1ty and little authority. They are subordinated to less qualified staff with more years of serv1.ce which are not always justifiab~ translated into experience.
On the credit side, the establishment of a llUreau of Nursing Administration has been a significant achievement in the development of nursing services in Cambodia. Nurses and midw1ves are by far the most t:WDerOUS group of personnel in the M1n1stry of Public Hea1th. Moreover, they are scattered all over the various hea1th services and medical institutions, each of which imposes its own' working conditions and demands ada:tJt;ation to its awn speo1flc D6ed.S". llext to advising and assisting the M1n1stry in eva1uating the nursing requirements in present and future hea1th programmes and in establishing progressive education and tra1ning prograumes for the preparation IJf nursing personnel, an :important activity of the llUreau w1li be to review existing legislation and to make reccmmendatioris Which will give the nursing profession due recognition within the context of the country's health admin1st~t~on.
5.7
Medical education
In many countries in accelerated development the diseases which are responsible for the bulk of morbidity and mortality are often l1m1ted in number. In Cambodia they are mainly confined to ma.lar1a, tuberculosis, bronche-pneumonia, parasitosis and enteric infections 1 trachoma, malnutrition and complications of childbirth. Medical education in any country should be focused on its major ep1dem1ological problems. However, medical education is usually in the hands of h~ learned specialists in various fields of medicine 1 who are not no~ intimately associated with the disease pattern of the country. This state of &ffairs can only be remedied by the establishment of a~ment Ofe!i1dem10logy and preventive medicine within the context<rthi Mea! FaCUlty.
- 68 -
It has been noted with interest that an important number of theses, written by graduates of the Medical Faculty, have been devoted to the epidemiological problems of the country. This shows that the need for epidemiological information is generally recognized by the medical students.
5.8
Environmental sanitation
5.8.1 General The first step toward the planning and implementation of a national programme for environmental sanitation is too creation of a service in the health ministry staffed by sanitary engineers and the provision of funds for the proper functioning of the service and for the construction of faci:!1ties. The establishment in 1968 of a sanitary engineering advisory project with WHO assistance will provide opportunities for collaboration with public works engineers in the field of community water supplies. Furthermore, the agreen;ent of His Excellency_ the Head of State. to send one or two fellows on WHO fellowships each year to prepare sanitary engineers for the country is distinctly a step forward.
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5.8.2 Community planning and housing The implementation of the various Mekong projects will create the need for the establishment of new cOmmdnities and the expansion of existing ones. Advantage should be taken of these opportunities to select suitabl.e sites ~ to provide housing, drainage ~ sewerage, water suppl.y, and heal.th services. As these new demands are met 1 attention can be transferred to the improvement of existing communities. It is strongly recommended that rural planners be employed by the Government under the appropriate ministry for the purpose of planning new communities. This activit7 should be carried out in co-ordination and co-operation with the heal.th auth~ritles.
5.8.} Surface drainage and sanitary sewerage This is a country-wide problem which calls. for collaboration between the Ministries of Public Health and Public Works. Consideration shoul.d be given to requesting the services of an international adviser for a period of several years for the purpose of preparing a programme of work and demonstrating its implementation. All the provincial capitals are in need of surface drainage and sanitary sewerage. For the City of Phnom-Penh the task of preparing a master plan, as recommended by Professor Fontaine of the B.lreau Central d 'Etudes pour les Equipements d' outre-Mer (~OM), should be assigned to a firm of consulting engineers. The Government may wish to consider approaching the United Nations Development Programme/SpeCial Fund for technical assistance in this connection. WHO would be glad to provide all the' necessary information and guidance in the formulation of the request and the subsequent implementation of the project.
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Phnom-Penh is one of the cl.eanest cities in South-East Asia. The refUse collection system is prompt and efficient, particul.arl.y in the main cOll%ercial. and better-cl.ass residential. streets. However, the disposal. of refuse in Phnom-Penh is fast: becoming a serious probl.em and in view of the rapid growth of the City and its increasing importance, steps shoul.d be taken now to deal. with this situation. Possibl.y the best approach woul.d be to engage a consul.tant for a period of three months to work out a scheme for the disposal. of refUse in col.l.aboration with the municipal. engineers. Meantime, attempts can be made to introduce incineration in certain estab' 1 shments such as hospital.s, business houses and government offices.
5.8.5 Community water suppl.y The present rate of construction of community water suppl.y is too l.ow to meet the pressing demands of the popul.ation and the gap between suppl.y and demand il!. increasing. For instance, at the present annual. rate of popul.ation growth, an increase of", new water suppl.y shoul.d be provided for l.80 000 people per year. At the average cost of $10 per head of population, this woul.d amount to $l. 800 000 per year. The total. Jl2"Oduction of water from the provincial. waterworks is now 12 734 m3/day, which, at the rate of only 50 litres per head per day, is sufficient for about l./4 m1l.l.ion peopl.e. The total. yiel.d of well suppl.y is about 36 000 m"5/day, which is sufficient for 700 000 peopl.e. This leaves about 4 mil.l.1on peopl.e in provincial. communities without piped water supplies. There are, of course, other sources of water among which are wel.l.s fitted with a hand pump which may be free from pollution, but the main picture remains unal.tered. The preparation of a community water suppl.y programme is, therefore, of primary importance. Considerabl.e international. technical. and financial. aid is needed for such a programme. The ex1et1Dg water suppl.y section in the Ministry of PUblic Works needs to be expanded to shoul.der some of the responsibillty for new construction and to give adequate supervision to the existing waterworks, most of which are in need of' maintenance, repairs, extensions and improvements. :rt is recommended, therefore, that the Ministry of PUbl.ic Works expl.ore the possibilities of' hunching a country-wide community water suppl.y programme. Preference woul.d need to be given to towns which are affected by the construction works of the Mekong Project, such as Kompong Chhnang, Pursat, :Bat'hambang, Siem Reap, Kbmpong Thom, Kratie and stung Treng.
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5.8.6 Technical. personnel. Al.though good progress is being made in the training of engineers and intermediate technical. personnel., more effort is needed to increase the output of civil engineers and public works technicians for publ.ic heal.th works. The engineers should be given additional training over a period of nine to twel.ve months. Due to the special. demand for such services in connection with the Mekong projects., consideration should be given to making the conditions of employment and salaries attractive.
-71ANNEX 1
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• Information on diseases, their increase and decline is valuable for the evaluation and assessment of health prograumes. Medical records provide a basis for continuous improve_ ment in health and medical care. In fact, the health statistics of entire countries must take these records into consideration as they .erve as background information in health planning. This source of medical intelligence has been large~ neglected but could with advantage be used by agencies interested in the follow-up of health programmes. In order to derive full advantage from medical records, new filing systems may have to be introduced. In South-East Asia, Thailand is leading with respect to statistical report1ng and the processing of health data and medical record-keepiog has reached a comparable standard. extreme~
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Hosp1tal medical. re'COl"ds are a good source of morbidity data. Final diagnosis established in in-patient departments are cons1dered to be the most accurate. It 1s true that they do not provide a representative sample of the sick population, but they do pro~de valuable information on illnesses which require treatment in hospitals and thus are the best source of 1nformation on the hospital facilities required. OUt-patient records, although not always as accurate as those for in-patients, provide broader information on the incidence and prevalence of the pathology of the population. It is important, therefore, to tabulate and ana4rze data f'rom all hospital medical records. Bas1c tabulat10ns should includesll incidence diagnoses grouped in the 150 causes of the Intermediate List (List A), d1stributed by age, Selt and departments. other tabulations could include concomitant diagnoses, surgical operations with some information on conditions under which these operations were performed, type of aD8estbeeta, and whether or not post-operation infect10ns were observed; length of stay of in-patients and number of repeated visits of out-patients for the same episode of illness. After acceptable standards have been achieved in basic tabulations, other cl.assifications, such as occupation of patients, place of residence, socioeconomic s1tuation and others may be introduced. Statistics on in..patients should be based on data upon discharge o~ and consolidated for specific periods (mon~ or weekly, dependiog on their f'requency). out..patient tabulations should be based on the daily out-patient register of each OPD consultation room. Because of the relative~ large numbers of OPD visits, tabulations of the approved distribut10ns should be made every day at the end of the 41n1c session. The data thus collected should be transferred On to special work-sheets, so that the information. can be consolidated by specific per10ds (weeks, months, etc.). The out-pat1ent record should provide for a clear recordiog of first visits (new cases) and revisits (old cases) in addition to all the relevant information such as age, sex, reSidence, occupat10n, type and duration of the treatment and so on. By this procedure the problem of tabulating a voluminous amount of out-patient data is aVOided.
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Basis of reporting Episodes of illness will provide information on disease incidence in different pertinent distributions such as age, sex, place of residence, occupation and others, and also, i f tee observa_ tion of all cases is organized, response to treatment incl.uding lethality and duration of the disease. The number of out-patient visits, including first vis:f.ts and revisits 1 will provide information on workload. This and tabulations of type of treatment and person giving the attention (attendant) will provide for programme planning and evaluation of medical care. Episode of illness Episode of illness can be considered the period during which a morbid condition causes a deviation from the patient's normal state of health, and which terminates by recovery to that normal state of health, or recovery to a different but relatively constant state of hea1th, or by death. A person suffering from an episode of acute tonsilitis . . can recover to a steady-state of chronic tonsilit1s. The _()~~~iv~if1 recovery to a steady state of health. From the standpoint of' OPD the beginning and ending of the episode are not seen. The patient usually appears at the OPD with a well-developed condition and seldom returns when recovery is under way. The difficulty 1a determining what constitutes an episode comes primarily with the situation where the patient returns at widely separate intervals with the same or related diagnosis of' some acute disease. This problem could be solved by having the phySician enquiring i f there was recovery in between, but this may unfortunately be impractical and theref'ore, some more or less arbitrary criteria should be established. Criteria: 1. CODa1der an episode: a visit or sequence of visits in which the diagnosis remains constant or only trivial changes are made and which is followed either by a long period of' time with no return visit for the same diagnosis or by a visit resulting in a new and unrelated diagnosis. The period of time that must elapse before the same diagnosis can be considered as a separate episode varies with the diagnosis. For instance, for the nose-throat infections which are the ones that cause most trouble, the period should not be less than ten days. 2. Consider an episode: a series of visits in which the diagnosis changes in a constant manner during the course of the morbid condition and the sequence CODstiimtesa 2'eOO@ll:lzable eJlUty. ~ of this episode may be: coryza pharyngitis bronchitiS
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3. Consider an emode: a series of visits in which the morbid condition changes radlca and the final diagnosis can be established only after sufficient observation. Example of this episode may be:
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• coryza pbaryng1tis measles
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The final diagnosis, measles, is not reaJ.:Q' a change of diagnosis to the two morbid conditions previously detected, but is only the diagnosis established at the final stage of the episode.
4. Consider an episode: a series of visits in which the diagnosis changes markedly, but one illness is the consequence of the other. Examples: measles infected umbilica _ pneumonia - septicemia
This episode has to be treated separately for morbidity and mortal1ty. For morbidity, the two diagnoses should be tabulated. For mortality, only the underlying cause should be taken for tabulation, the terminal cause being mentioned in the first line of the certificate of cause of death. Note: :rt is estimated that twenty provincial hospitals I proportionately spread over the riparian countries could effectively provide the data needed for a health intelligence service. These data should be collected on a daily basis and consolidated at specific periods such as the week, the month and/or the quarter. Minimal information required is: name of hospital name of patient age of patient sex of patient date of onset diagnosis
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