• f~~ ~ ~ ~ iJ? -/" .... IYSH·1987 The Prime Minister of Sri Lanka, the Honourable R. Premadasa, initiated the movement at the UN General Assembly which led to 1987 being declared the International Year of Shelter for the Homeless. He agreed to be interviewed for World Health by Mr Manik de Silva, the Editor of the Colombo Daily News World Health : Mr Prime Minister, can you tell us briefly what inspired you to initiate the move to have 1987 declared the UN International Year of Shelter for the Homeless? Prime Minister: I have grown up among the urban poor of Colombo. I have worked with them through- out my youth and adulthood. I have been inspired by them-by their struggle, creativity and humanity. Through the successful housing programmes implemented in Sri Lanka from 1977, I have come to believe that housing is the finest form of investment in human be- ings. It is this conviction that made me appeal to the 35th General 2 Assembly of the United Nations in 1980 for an International Year to be devoted to Shelter for the Home- less. Let me quote a few lines from my address to the United Nations: "If we are able to give a solid house with a solid roof to each family, we will be providing them with not only a roof over their heads but also peace of mind, work, good health and more than anything else, a capacity to develop self-confidence. It is my belief that housing provides a key to the solution of several of these disabilities. The problem of housing ... is a global problem." WH: Can you also briefly explain for readers of World Health how Sri Lanka's "Million Houses Pro- gramme" was born and the pro- gress it has made? PM: Sri Lanka's Million Houses Programme was born out of two sources. The larger and more gen- eral source was what we call the "national mainstream," or the tra- ditional process of housing by indi- vidual families. The more immedi- ate source was the earlier Hundred Thousand Houses Programme from 1978-83, which was successfully implemented and from which we learnt a great deal. Therefore, what is very important about its birth is that it was internally generated by critically evaluating our own na- W oRLD HEALTH, July 1987 tional experience. It was, I may say, a triumph in learning. The Million Houses Programme is a national shelter programme of both the private and public sectors, spread over six years from 1984 to 1989. Progress-wise we are on target. In the two main sub-programmes focused on the rural and urban poor, which is the core, we have reached over 175,000 families dur- ing the last three years (1984-86). When you add the output of the other four sub-programmes, the to- tal works out to nearly 400,000 families getting one of their basic needs satisfied. WH: It is safe to say that all coun- tries face the problem of people lacking adequate shelter, but cir- cumstances vary widely from one nation to another. Do you feel that the Million Houses Programme is replicable in other countries? PM: The philosophy and methods of the Million Houses Programme are certainly replicable, though I prefer the word " learning" to "re- plicable" . That is, it provides a great opportunity for others to re- flect and learn. Let me illustrate this with an example. We have found it much more productive to support the housing initiatives of poor families and communities than for the government simply to build houses. This is called support-based Left: "We have found it more produc- tive to support the housing initiatives of poor families than for the govern- ment simply to build houses." Below: "Housing is more than mere shelter: it is central to all aspects of human development." Photos W HO/ILO/J. Maillard and W HO The Honourable R. Premadasa, Prime Minister of Sri Lanka. Photo WHO housing, and it is just like agricul- ture where farmers do the growing while governments create the necessary conditions. In this ap- proach, the family is in the centre of the development process. Family members make all the decisions, control the building and assume full responsibility for the product. Let us examine another popular myth- that housing is not economi- cally productive. On the contrary, we consider it highly productive, to the extent that it enhances human productivity, especially of the poor, and that it contributes to political stability. That myth, I think, has acted as a fetter in hindering more political commitment for housing. WH: Our particular interest is in the impact that the IYSH may have on public health, community health and individual health. Certainly there is a direct correlation between poorer housing and poorer health. Do you feel the Year can contribute directly towards improving health in the world? Cover: A hut in the jungle, a tent in the desert-what matters is to have a place to call one's home. Photos WHO/UNHCR IX ISSN 0043-8502 ' World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. The German edition is obtainable from : German Green Cross, Schuhmarkt 4, 3550 Marburg, FRG. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necess- arily reflect WHO's views. World Health, WHO, Av. Appia, 121 1 Geneva 27, Switzerland. Contents Investing in human beings The Prime Minister of Sri Lanka interviewed by Manik de Silva . . . 2 What is IYSH? . . . . . . . . . . . . . . . 5 Shelter and health by Robert E. Novick . . . . . . . . . . . 6 "His slum, not mine" by E. A. R. Ouano . . . . . . . . . . . . . 10 A roof for refugees by Annick Billard . . . . . . . . . . . . . . 12 Shelter for the homeless . . . 16-17 Health principles of housing Morris Schaefer. . . . . . . . . . . . 18 Where eight share one room by Kwasi Adarkwa . . . . . . . . . . . . 20 Learning how to control pests 22 Space around the houses matters too by Yuri Gubernski and Nikolai Litvinov. . . . . . . . . . . . . . . 23 WHO and IYSH : Implications for health. . . . . . . . 25 Governments come and go ... the community abides by Jorge E. Hardoy. . . . . . . . . . . . 26 Popular technology beats schisto by Paul Taylor . . . . . . . . . . . . . . . . 28 News Page . .. , . . . . • . . . . . 30-31 3 Investing in human beings PM: I feel the Year can contribute immensely towards improving the primary health, particularly of the world's poor. How? Take the way in which we have linked primary health to the Million Houses. The link is achieved through the 4,500 Village Level Development Coun- cils or Gramodaya Mandalayas. They constitute the lowest tier of local government. That is, they function at the base, which is closest to the point of action. Now the Village Level Gramodaya Health Centres, which are simple buildings for our -Family Health Workers to live and work from, are built by the Gramodaya Mandalayas using local materials and traditional technology. It is these same councils that select the poor families under the Million Houses Programme. The result is that we have mobilised thousands of small units to work from the bottom up on a preventive health programme, as opposed to the hierachy of hospitals which operate at the curative end. Do you not agree that a strategy based on such a largely spread network of units at the base, firmly committed to pre- ventive health, is capable of realis- ing significant trade-offs and di- vidends for primary health? WH: Of course. The slogan that WHO chose for World Health Day in 1973 was " Health begins at home " , and by "home" or " shelter" is meant much more than simply a roof over one's head. It refers also to water supply and sanitation, a safe environment, the food that is available to a family and the quality of life in general. Do you feel confi- dent that the Year can raise aware- ness throughout the world about all these aspects of modern living, in addition to the basic need to house the homeless? PM: Indeed, I feel very confident that housing is infinitely more than a roof: housing is a catalyst and a stimulus for all the basic needs of food, clothing, health, association, communication and so forth. The home-garden provides basic food needs . Rest and protection enable people to work better and also to engage in home-based pro- duction. With the incomes earned, they buy their basic consumer needs including clothing. All this directly contributes to improved health and the environment. Let's 4 Water-clean and plentiful-is essential for good family hygiene. Photo WHO not forget the benefits to the child and the mother. The house is also a place in which people meet and communicate. So, in a very pal- pable sense, housing is more than mere shelter: it supports the very act of living itself. In other words, housing is central to all aspects of human development. WH: The charge is sometimes made that "International Years" raise awareness about a problem for just one year but then all impetus is lost. Do you think there is a risk of this happening in the case of IYSH? PM: I would say that IYSH is, in that sense, different from all previ- ous International Years. We were very conscious of that pitfall and, from the very start, conceived of it as a continuing process rather than a single year. It is in that spirit that the UN resolution calling for the International Year talks of "solving the housing problem of some of the homeless by the year 1987, and of all the homeless by the year 2000 " . We always perceived the Year as a process, which would gather momentum from within. The momentum would come with the renewal and increasing of political commitment to housing. I stressed this same point in my last address to the UN Commission for Human Set- tlements (uNCHS) at Istanbul last year, when I appealed for the Year to be transformed into a Decade for the Homeless. WH: What particular actions are planned by the UN within the framework of the Year? PM: The UN has designated the UNCHS or HABITAT, based in Nairobi, to act as the executing agency for IYSH. UNCHS held its lOth Session in Nairobi in April. This year also happens to be the lOth Anniversary of UNCHS since it was first set up in Vancouver. That special session was open to all countries whether they are members or not, and the issue discussed was ''A new agenda for housing." We were all able to learn from the important experi- ences of the past, and to arrive at a clear as well as a new set of positive strategies. Crucial to this exercise will be the renewal of moral and political commitment for housing as a means of helping the poor to change their own conditions. The groundwork for this new search is being laid both by govern- W ORLD HEALTH , July 1987 ments and non-governmental or- ganizations, through a widespread debate on the critical issues in rela- tion to concrete programmes and experiences. In this context, the Sri Lanka Million Houses Programme is a key candidate. WH: All too rapid urbanisation has led to the cancerous growth of slum areas throughout the Third World, accompanied by a whole host of health problems. In your view, what can realistically be done about this disturbing situation? PM: A great deal can be done. I am very optimistic. Again, let me answer with reference to what we did and how we did it. What we did was to look for the answer within the problem itself. We realised that the poor them- selves are the greatest resource for their own change. How? Take the slums and shanties themselves. Don't they reflect great human de- termination, ingenuity and creativ- ity? Does not a shanty settlement contain, behind its surface appear- ance, a huge reservoir of latent initiative and hope? This approach has worked wonderfully in the Mil- lion Houses Programme. It has re- leased unimaginable creative ener- gies and talents of poor human beings. This is why I spoke earlier of investing in human beings. All this time, we have been looking for solutions from outside the prob- lem-and you know the dead-end we had reached. I would like to stress two other points. First, boldness. Second, the need to think big. Boldness derives from one's deep faith in the peo- ple-in their sincerity, humanity and reasonableness. Programmes need to be rooted in the people and their culture. When we changed the housing policy in 1983, from the conventional approach of govern- ment as doer to government as supporter, we were boldly changing paradigms. We learnt most from "user families" themselves. Then, when we articulated the new pro- gramme, we thought big, meaning on a truly national scale. In other words, we had taken a leap in thought from petty projects to countrywide programmes. Thus we went to scale, and it paid off. Any development effort, worthy of its name, has to have these attributes of commitment, boldness and vision. • W oRLD HEALTH, July 1987 What is IYSH? !though adequate shelter has been universally recognised as a basic right for more than a quarter of a century, the overall conditions of shelter and basic services for more than 1 ,000 mil- lion of the poor and disadvantaged in developing countries - and for a significant number in indus- trialised countries - is deteriorating alarmingly. Few governments to- day can claim to have national policies or programmes that effec- tively meet the basic shelter and related needs of their people, especially those of the poor and disadvantaged. Today, about one quarter of the world's population does not have adequate shelter; these people live in extremely unsanitary and unhealthy conditions . In the past 24'' hours, not less than 50,000 people have died from malnutri- tion and disease. much of it linked to inadequate shelter. water sup- ply and sanitation. Most of them were children. A Sri Lankan community takes in hand its own drainage. "Any development effort worthy of its name has to have these attributes of commitment. bold- ness and vision. " Photo W HO Some 1 00 million .people have no shelter whatsoever. They sleep in the streets, under bridges, in vacant lots and doorways. it is not uncommon for more than 1 ,000 men, women and children to de- pend on a single standpipe tap for their water supply. And as many as 85 per cent of residents in a squatter settlement may have no access at all to human waste dis- posal facilities. lt was to focus attention on this situation that the UN General As- sembly proclaimed 1987 as the International Year of Shelter for the Homeless. IYSH is not just a specific year but a programme of action before, during and after 1987. lt is based on an awareness that the poor and disadvantaged will build a greater part of the housing they need with their own hands. The philosophy behind the IYSH, therefore, is to secure renewed political commit- ment and effective action within and among nations to help the millions of poor, all over the world, to build or improve their shelter and neighbourhoods to such a degree that- by the year 2000- it will be possible to integrate them into the process of economic development. • 5 ·. ~~ .:~ ~·'"'.-/" -.,. ~;;....~ ' .· Grossly insufficient and degraded shelter has a severe and pervasive impact on health, particularly in developing countries. Mr Robert E. NOV/CK, Responsible Officer for WHO's new programme on environmental health in rural and urban development and housing (RUD), examines the factors that link shelter to health urrent and projected patterns of growth of urban popula- tions and the proliferation of urban slums and squatter settle- ments offer a challenge to public health. Urban populations of some developing countries are growing at an annual rate of five to seven per cent as a result of high birth rates and continuing migration to the cities from the countryside. By the year 2000 about half of the world's population will live in cities and towns. The poor comprise the ma- jority of urban populations in de- 6 veloping countries, and their needs for housing and community services often outstrip the resources of gov- ernments to provide them. In es- sence, more and more of these urban poor are slipping beyond the reach of governmental support and must provide their own housing and community arrangements. At the same time, housing, employment and community facilities in the countryside are such that they have not helped to counter the attrac- tions of the city's " bright lights". Grossly insufficient and degraded shelter is one result of these mas- sive demographic and economic trends; it has had a severe and pervasive impact on health, particu- larly in developing countries. The rapid and accelerating pro- cess of urbanisation is haphazard and chaotic. Standard residential areas impacted by burgeoning populations are quickly converted into slums, and homeless immig- rants who move to the towns tend to occupy land on the periphery and establish squatter settlements. In many developing country cities W oRLD HEALTH, July 1987 Left: Roughly one quarter of the world's population does not have ad- equate shelter, and lives in extremely unhealthy conditions. Right: Some 100 million people have no shelter at all ; they sleep in the streets, under bridges, in vacant Jots and doorways. Photos WHO/ILO and WHO/UN ICEF/J. Ling these low-income settlements ac- count for a majority of the popula- tion, for instance 90 per cent of Y ouande and Addis Ababa; around 60 per cent of Accra, Kinshasa, Bogota and Mexico City; about 50 per cent of Lusaka, Guayaquil and Dhaka; and more than 30 per cent of Nairobi, Istanbul, Delhi and Manila. Roughly one quarter of the world's population does not have adequate shelter and lives in ex- tremely unsanitary and unhealthy conditions, and some 100 million people have no shelter whatso- ever. They sleep in the streets, under bridges, in vacant lots and doorways. The health effects on more than 1,000 million people who today occupy inadequate and degraded shelter are severe and pervasive, and the implications for the future are even worse. Take the annual mortality of children in developing countries, estimated at about 15 million; 50 per cent of these deaths are of children aged under five. Most of these could be prevented if developing countries' standards of environmental hygiene could be brought up to those prevailing in the industrialised world. While many children die, many more somehow survive, although adverse conditions of habitat are likely to have permanently damaged their chances of normal growth and de- velopment. The small children of today represent the future of the greater part of the world. Most of the urban poor live in low quality, over-crowded, self- made shelter which is only mar- ginally served by public utilities and usually lacks an adequate water supply suitable for drinking and maitaining personal cleanliness. Re- sources will not be adequate for the removal or disposal of excreta and other wastes, so that it is common to see rotting garbage, human faeces and associated insect and rodent infestations. Residents have W ORLD HEALTH , July 1987 7 little or no access to health care, education, supervised food markets and other facilities which make for a reasonable quality of life and human development. These com- munities often suffer from greater exposure to dust, unpleasant smells, chemical and noise pollution, and the nature of the dwellings makes them less able to withstand such hazards. The residents themselves may unwittingly contribute to disease through traditional practices of food preparation, waste disposal and personal hygiene habits which were appropriate when they lived in the countryside but are no longer so in the city. Finally, it should be recognised that poor people are often less able to withstand these hazards because malnutrition and under-nourishment weaken the body's resistance to disease. The relationship of shelter to health is both intimate and com- plex, arising from a myriad of en- vironmental factors as well as from the nature and severity of the major 8 health problems. What should be the biggest considerations in plan- ning and developing the habitat from the standpoint of health? Historically, environmental man- ipulation has been one of the most effective tools of public health. Long experience has established that public health benefits are most freely and most rapidly achieved by applying design, engineering and construction practices which elimi- nate specific hazards. But govern- ments can seldom afford improved housing and community services. Provision of safe and convenient water supply is the most important single activity that can be underta- ken for the health of people, wher- ever they live. At the end of 1985, WHO estimated that 23 per cent of urban populations and 64 per cent of rural populations were without access to safe and adequate water supplies; and WHO forecast that 1,200 million people will still be without it in 1990. Human excreta-principal source of the pathogenic organisms of Shelter and health Left: Visible through the smog) the Acropolis of Ancient Greece looms over Athens. In any city, the poorest communities suffer from greater exposure to dust, unpleasant smells, and chemical and noise pollution. Right: Camera-shy) this Ethiopian woman at first ran away, but later posed with her baby before her mud-and-straw home. Quite apart from malnutrition, living conditions in low-income settlements often influence people's resistance to diseases. Photos W HOfT. Farkas and WHO/J. Bland many communicable diseases-is one of the most dangerous sub- stances with which people can come into contact. Infection may occur when faecal matter containing pathogenic organisms contaminates food, water or the fingers and is subsequently ingested. In some de- veloping countries, diarrhoea! dis- eases account for as much as one- third of all deaths in children under five years of age. WHO's 1985 esti- mate was that 40 per cent of city dwellers and 84 per cent of those living in the countryside lacked ac- cess to appropriate sanitation, and that anticipated progress up to 1990 would still leave 1,800 million people without. While pollution of the ambient atmosphere has long been recog- nised as unhealthy, recent studies are directing attention to the qual- ity of indoor air as a major causa- tive factor in acute respiratory infections. Smoke and soot from heating and cooking fires or from burning charcoal, crop residues or animal dung produce a complex of W ORLD HEALTH, July 1987 pollutants which affect hundreds of millions of people in developing countries. Food itself can transmit micro- biological agents and toxic chemi- cals unless it is safely prepared, stored and served. Makeshift shel- ters commonly lack facilities to pro- tect food from spoilage or from the ravages of insects and rodents. In some developing countries these losses can amount to as much as 30 to 40 per cent of the perishable foods. Quite apart from malnutrition, living conditions in low-income set- tlements often influence a person's resistance to diseases, affecting their mental health and psycho- social state of well-being. Health may be jeopardised by the un- certainty and stress associated with lack of employment, threats to family welfare, effects of poor environment such as noise and odours, the lack of efficient health care services, and generally de- ficient socio-economic circum- stances which hinder education, W OR LD HEALTH, July 1987 parent-child relations and "home- craft" or which encourage alcohol and tobacco abuse. Health promotion in terms of the habitat essentially means ensuring decent shelter, nutritious food, safe water, hygienic disposal of wastes and access to efficient health ser- vices. Since health is a beneficiary of economic and social develop- ment, health promotion will be most effective when it is included as an integral part of the planning and development of shelter and com- munities. Ideally, the governments might be expected to ensure safe shelter and basic community ser- vices for all citizens. In reality, most countries are far from possessing the resources to achieve this ideal in the foreseeable future. It fol- lows that efforts towards self-help and neighbourhood help repre- sent an important potential for improvement. There are several WHO pro- grammes whose activities directly or indirectly relate to habitat and health, ranging from community water supply and sanitation to vec- tor biology control and the organ- ization of health systems based on primary heaLth care. A great deal is known about the relationship be- tween housing and health. But it is evident that this information is gen- erally not being used. The challenge for the years ahead is to integrate health information with pro- grammes aimed at developing hous- ing and related community facilities and services. One step towards meeting this challenge was the set- ting up of WHO's new programme on Environmental Health in Rural and Urban Development and Housing, known for short as RUD. One of its functions is to serve as a channel for relevant health-promoting informa- tion, and to make that information readily useable by architects, hous- ing specialists and urban planners. The primary health care approach will help to ensure that individuals, families and community groups de- velop their full potential for self- reliant action in housing and health issues. • 9 "His slum not mine" ' 10 From first-hand experience of liv- ing in a· Philippines city slum, the writer comments: 11 Somehow, there is an intangible force which binds people to the slum area 11 by E. A. R. Ouano 0 c <0 ::> 0 u.i 0 I 5: 0 0 .c 0.. Q particular phenomenon in de-veloping countries since World War 11 has been the rapid population migration from the countryside to the cities, espe- cially to the capital. The waves of rural migration were spurred on by increasing population density, un- employment, unequal land distribu- tion and a lack of amenities in the countryside. Although a number of governments today have re- examined their developmental pro- grammes in favour of rural devel- opment, the general trend in newly independent countries was to de- velop the capital city as a show window and symbol of the new nation. Rural industries were often regarded as remnants of the colo- nial plantation periods or of primi- tive societies, even if this sector continued to support the national economy, and to boost the develop- ment of urban centres and the new heavy industries. Migrants from the countryside have diverse educational back- grounds and skills. Some are illiter- ate and unskilled, while some hold a university degree. Regardless of their individual backgrounds, their first stop is usually a relative's house close to the city centre. Most of the successful migrants rapidly move out of that area to suburban housing zones at the first opportun- ity, although a number may stay behind on account of the social and political ties they have established. The unlucky or unsuccessful mig- rants are often left behind. Through the years, the area tends to degen- erate into a slum settlement. A number of slum settlements in Manila were formerly middle-class neighbourhoods. When I first moved to "Metro Manila " , I stayed in a slum district of Leveriza, in Pasay City. The centre of the area was typical of any slum settlement, with its shanties, catwalks and di- lapidated houses, except that the periphery of the area was well de- veloped. Indeed, bordering the squatter colony there are a five-star hotel, a number of old mansions, several embassies, one of the best hospitals in town and first-class shopping centres. The whole area is criss-crossed by narrow streets, which are used by children and adults as playground, meeting place and garbage pile. When it rains, the streets are flooded, although the water readily W ORLD HEALTH, July 1987 drains an hour or so after the down- pour. Inside the settlement, the wa- ter may stay for weeks. The houses are connected to the street by cat- walks and narrow cemented path- ways. Maintaining law and order is a problem. On my second day in the area, I was accosted by a local gang and I was only saved by the timely intervention of a relative. Six months later, I moved to an upper-class neighbourhood 25 kilometres south of Metro Manila. Since leaving the original area eight years ago, I find myself a regular visitor to the place. My carpenter, furniture maker, tailor, barber, and some relatives are still residing there. Somehow, there is an intan- gible force which binds people to the slum area and which is absent in well-planned, upper-middle-class suburbs. In my present neighbourhood, the home-owners have an associ- ation. We elect officers, whose duties and functions are defined by our by-laws. In the slum areas, on the other hand, people behave ac- W ORLD HEALTH, July 1987 carding to undefined rules, working according to their abilities and capabilities. It is this same cohesive force which allows a slum dweller to build a house for only US $100, to survive on a salary of US $100 per month, and to go through all the emergencies and uncertainties of life. Yet an expatriate worker from overseas may find it difficult to live in Manila on US $3,000 per month. A Philippines citizen who builds a US $100 home in the slums will get two to three times as much in the form of free inputs from neighbours and relatives. In the same way, if he receives a monthly income of US $100 he will have rendered two to three times that value in free services to his community. Rural migrants settle down in the slum areas for security reasons, in spite of all the alarming statistics about law and order. During my six months in the slums, I used to leave my sports car 100 metres away from my house. I could do this with complete . peace of mind, but it might not be possible for a stranger. Local residents of a Manila suburb help the undermanned garbage collection unit to clean up the area. Photo WHO/E. Ouano In the slum areas of Manila, there are college students and profes- sionally qualified people mixed in with unskilled workers and the unemployed. The organization and social order prevailing in the slum area can be so complex and informal that it would be easy to conclude it does not exist at all. Recently I requested two of my former graduate students to take photographs of the sanita- tion and water facilities in the slum areas of their neighbourhood. One of them could not spare the time for this, so the other fellow had to do it by himself. The next day, he came to my office complaining of the neighbourhood tough guys he had encountered. I told him, "I thought · you used to brag to us that you could handle the tough guys in the area. " His reply was, "It is his slum; not mine." • 11 A roof for refugees ... \ Housing is one of the prime concerns of refugees who find themselves on foreign soil after fleeing their own home countries where their lives are at risk he general public remains largely unaware of the enorm- ous problems faced by refu- gees until massive flights occur which attract a geat deal of atten- tion in the media. Indeed, the ex- odus of hundreds of thousands of boat people from Viet Nam in 1979, of Afghans in 1980 and of Ethiopians in 1985 has captured the public mind to a far greater extent than the regular but less loudly trumpeted movements of families, tribes, whole villages or even entire ethnic groups from one country to another. Nevertheless, such movements are taking place all over the world 12 by Annick Billard and have increased to the point where, according to the Office of the UN High Commissioner for Refugees (HeR), there are no fewer than 12 million refugees around the globe. Moreover, to these must be added people who are seeking asy- lum and whose status has not been determined, as well as the Palesti- nians, who are dealt with by another UN Body, UNWRA (the United Nations Relief and Works Agency for Palestine Refugees in the Near East). The sheer numbers of these refu- gees demonstrate the size of one of the directly related problems, that of housing. Deciding where to accommodate the hundreds of thousands of people who arrive within the space of a few days in a place where no facilities exist for receiving them is one of the first items to be tackled in the face of such an insurge. The problem is aggravated by the fact that many 0f them arrive in very poor shape and have as great a need for health care and food as for shelter. Certainly, where there are refugees, housing looms large among their priority requirements. Wherever population move- ments occur, some form of shelter has to be improvised within a very short time. Such shelter may be W ORLD HEALTH, July 1987 very rudimentary, but it is essential at least to protect the people from the weather and afford them some degree of privacy when they are left with nothing at all. The deep shock suffered by those who have had to leave everything behind to save their lives must not be over- looked. Shelter has a very consider- able symbolic value to refugees, and means much more than just protection against rain, wind or heat. The fear which forced them to flee is succeeded by anxiety for the future. A roof over their heads, somewhere to live, helps them feel that they do exist and gives them fresh hope. Providing housing for refugees is therefore the first priority. An entire chapter is devoted to it in HCR's "Manual for Emergencies", which points out that "the provi- sion of shelter is a high priority, even when not essential to survival. Shelter must be available before other services can be developed properly." The manual also sets out the rules to be followed to preserve refugees' cultural identity while providing them with the best poss- ible type of accommodation com- patible with the emergency. "The location of the refugees may range from spontaneous settlement over a wide area, through organized rural settlement, to concentration in a very limited area. Circumstances can make this last possibility un- avoidable, but the establishment of refugee camps must be only a last resort. A solution that maintains and fosters the self-reliance of the refugees is always preferable." The particular emergency and the speed of events often, alas, leave no room for choice; refugee camps spring up or are dismantled, de- pending on the circumstances, in countless numbers. Nevertheless, when the emergency first occurs the refugee camp will be the most suit- Above left: Literally "boat-people," these refugees have built a temporary home in Thailand in the lee of an old fishing-boat. Right : Refugees in Sudan building their own homes. Shelter has a symbolic value for such people, and means much more than just protection from the elements. Photos WHO / UNHCR /J.·M. Micaud and WHO/ UNH CR/C. Penn able for the refugees' housing needs. There, they live in tents provided by the international com- munity or in makeshift dwellings built of branches, tarpaulins, rags, cardboard boxes suported by scrap metal or whatever comes to hand, like dismantled bicycles or old suitcases. Once it appears that the people are to be refugees for good, the camp undergoes a change and is given a new name. It may turn into a transit camp or centre, implying that it is a temporary arrangement pending the provision of more per- manent accommodation in another country. Or it may become a recep- tion centre like those often found in industrialised countries. These are places where new arrivals-even before their refugee status is recog- nised-usually spend only a few days or months and where they are offered care, language courses and so on. There are also, especially in Asia, refugee processing or holding centres where refugees from differ- W ORLD HEALTH, July 1987 13 A roof for refugees ... ent areas are brought together and where they prepare to leave again for another country. The more per- manent camps include those called closed centres. Some countries have adopted this method as an addit- ional discouragement from entering their territory since, while being given all kinds of assistance, the refugees cannot easily leave the areas allotted to them. Finally, there are settlements which are also for refugees who have come to stay, but which offer them far more opportunities. In such settlements, the refugees may resume an almost ordinary way of life. They live in traditional-type housing which they have generally built themselves, have a plot of land on which they can grow crops, and may even be able to ply some kind of trade. This system, which is becoming common throughout the world once the initial temporary tented accommodation stage is over, is one of the more satisfactory ones. If, for the sake of their own safety, the refugees cannot return to their home countries-and this, of course, is still the best sol- 14 ution-the HCR prefers integration in a country which has consented to accept them. The third possibility is resettlement in another country, which does help to relieve those countries to which the largest num- bers of people have fled. Clearly the greatest burden is felt by the poorest countries, whose own people face serious housing problems and are most vulnerable to natural disasters. They neverthe- less accept this burden, despite all their own difficulties, as a demon- stration of solidarity. At the 37th session of the HCR Executive Com- mittee last October, Mr Jean-Pierre Hocke, UN High Commissioner for Refugees, commented: "A huge majority (of the world's refugees) has found shelter in developing countries... Nevertheless, they have been received in an exem- plary manner by some of the world's least prosperous countries, which have offered them hospital- ity despite an empty table." Besides the far-reaching conse- quences for the economy caused by the settlement of large numbers of people in deprived areas, one of the Above : This frame of branches in Somalia will be covered with sacking or cardboard to create a home. Right: Stilts raise these huts above the high water mark in the Philippines. " In certain settlements, the refugees may resume an almost ordinary way of life." Photos WHO/U NHCR/L. Taylor and WHO/UN HCR/ P Herzig most alarming yet little appreciated results of housing huge groups of refugees in such countries has been the adverse effect on the envi- ronment. Take the arrival in Sudan, Somalia and Djibouti of hundreds of thousands of Ethiopians in 1985 and 1986. When the flood of people began, the HCR and other emergency organizations provided the newcomers with tents. As time passed and the refugees regained their strength, they began to build their traditional tukuls, huts made of branches which provide better protection against wind and heat than canvas. In drought-stricken countries where every year the de- W ORLD HEALTH, July 1987 sert nibbles away at the ever rarer areas of vegetation, wrenching up hundreds of thousands of bushes to build tukuls cannot but accelerate the encroachment of the desert -which itself has already caused massive population movements all over Africa. One African leader recently remarked : "We are caught up in a kind of tragic progress. One disaster begets another. How can we halt this evil juggernaut?" The same feelings have been ex- pressed in Pakistan, where what were once forests have become vir- tual deserts since the arrival of refugees from Afghanistan. Trees and bushes are used for everything : cooking, heating in winter, thatch for roofing, branches to lean against the windows of mud huts to provide shade and coolness. All the green- ery of the North-West Frontier Pro- vince, where no fewer than two- thirds of the Afghan refugees in Pakistan live, is being depleted in an apparently irreversible process. Nevertheless solutions exist. Be- sides avoiding wherever possible the setting up of highly concen- trated refugee camps, as the HCR W oRLD HEALTH, July 1987 recommends, and trying to supply materials from outside when natu- ral resources seem on the point of exhaustion, the provision of devel- opment aid to the host country as well as aid to the refugees would undoubtedly help to resuscitate foundering economies. Building an- cillary facilities for the benefit of local population and refugees alike, reviving agriculture, speeding up reafforestation, building access roads and so forth would all help to reduce the harmful effects suffered by countries which offer a welcome to huge new communities. These indeed were the pressing claims made by countries taking part in the second International Conference on Aid to Refugees in Africa, held in Geneva in July 1984. Sad to say, they remained largely fruitless owing to the famine which subsequently struck Africa. As Jean-Pierre Hocke insists : "The refugee problem has now assumed international proportions, and is of- ten inseparable from the problems of political, social, cultural and economic development in the Third World." • 1;r-he top' 20 ,, countries (as at 1 January'1986) Pakistan 2, 702,500 .Iran (lslamk Republic of) 2,300,000 Sudan 1, 164,000 United States of America 1,000,000 Somalia 700;000 Canada 353.0QO Zaire 283,000 China 279,800 Burundi 267.500 Tanzania (United Republic of) 212.900 Mexico ;France Algeria Uganda India United Kin~dom Germpny (Federal Republic of) Thailand :Zambia . Malaysia /'X 175,000 174,200 167,000 151,000 136,700 135,000 134,000 130,400 103,600 99,700 IYSf:l·1987 for the Millions living on the margins of our great cities have little protection from the elements- and none against disease (~~ Time and again, the bright lights of the ~ ~ city prove an irresistible attraction for ~/,if poverty-stricken families living in the JYsH 1987 surrounding countryside . They converge in ever-growing numbers on the already over-crowded capital cities, only to face drastic shortcomings in housing, water supply, sewage disposal. local transport and job opportunities . There is little hope that the rapid urbanisation and population growth of each great megapolis will slow down in the foreseeable future . Family planning does not stand much chance in the uneven David-and-Goliath contest to curb popu- lation growth . By the year 2025, according to UN data, the cities of the developing world will provide breathing space- and little more than that- for nearly 4,000 million people compared with over 1,000 million today. Humanity reached its first 1 ,000 mi llion in total population early in the nineteenth century and never looked back. Society has changed consider- ably since then, but living conditions have changed little for a disturbingly vast section of mankind . (The World Bank defines 800 million people as "the absolute poor" .) For most of them, "shel- ter" means minimal protection against the ele- ments, none of the amenities which the twentieth century takes for granted - and no defence against disease. These are the truly homeless. • Below : Playtime in the shadow of high-rise flats in Singapore. Photo W HO/ILO Below: House-building requires an effort ; men at work in Nepal. Left: Those who live in these shacks can only dream of moving one day to the modern apartments ; a scene in a French city . Photos WHO/ILO Below: Homeless and depressed in a European city . Photo L. Sirman © Above: Cairo slum children play in an abandoned car. Left: An Indian woman draws clean drinking water from the well. Photos WHO/UNICEF/ B. Wolf! and W HO/ILO Health principles of housing by Morris Schaefer helter, along with food and clothing, is a basic need for human survival- to provide protection against the elements and to serve as the focus of family life. Our dwellings should also provide protection against environmental hazards to health, both physical and social. At its best, shelter promotes emotional and social health by pro- viding psychological security, phys- ical ties with one's community and culture, and a means to express one's individuality. Too often, dwellings fail to pro- vide health protection, much less to promote health-obviously so for hundreds of millions of people who live in marginal housing or who are A slum clearance project in India en- sures that there are efficient drains to carry away surface waters-and help to reduce disease. Photo WHO/ILO altogether homeless. But any dwell- ing that fails to protect people against health hazards is likely to intensify the dangers of disease. Some of the relationships be- tween human health, human dwell- ings and human behaviour can be measured; for example, between indoor air pollution and acute and chronic respiratory illnesses, be- tween inadequate sanitation and communicable diseases. Our know- ledge of other relationships rests on less definite evidence, and some is based primarily on successful prac- tices-on "what works". Such knowledge may be stated in the form of "principles"-guiding rules of thought and action which, when adapted to specific situations, can provide leaders with the basis for health policies, programmes and activities. Two types of principle come into play: those that concern the in- teractions between housing condi- tions (and use) and human health, and those that indicate the lines of action to be taken to increase the health potential of housing. Principles of health needs 1. Communicable diseases can be reduced if housing provides for safe water supply, sanitary excreta and garbage disposal, adequate drain- age of surface waters, and neces- sary facilities for domestic hygiene and safe food storage and prepara- tion. In the absence of such provi- sions, exposure to disease patho- gens may be increased, whether through insect and rodent vectors, or directly through faecal-oral and contact infections. In the country- side, it is advisable to separate human living-space from animal quarters. 2. Housing should protect against avoidable injuries, poisonings, and exposures that contribute to chronic diseases and malignancies. But such hazards may actually be increased if houses are poorly sited, contain hazardous structural fea- tures and furnishings, generate in- door air-pollution from cooking or heating arrangements and are poor- ly ventilated, or if chemicals used in the home and home-based occu- pations are not handled properly. 3. Housing may promote mental well-being, since from prehistoric times the home has been a place of refuge from danger and stress. All too often, and especially when there is rapid urbanisation, stresses may arise from an unhealthy habitat. Overcrowding, squalor, un- certain tenure of the dwelling, ex- cessive noise, crime and threats to physical safety, isolation, and social alienation-all these can damage mental health. (Overcrowding is linked, as well, to increased com- municable disease.) 4. The neighbourhood and com- munity, as well as the dwelling itself affect health. The health ef- ' fects will be positive when the housing environment provides for physical security, enjoyable sur- roundings, constructive social in- volvement, and access to needed services (educational, health, social) and to commercial, cultural and recreational amenities. In disadvan- taged communities, the conditions and the effects will be just the reverse. W ORLD HEALTH, July 1987 5. Health depends also on how re- sidents use their housing. The best of structures will not protect or promote health if its occupants do not use the facilities safely and for healthful purposes-or if they do not maintain housing in such a way as to defend it against health hazards . 6. The dwelling conditions of cer- tain groups puts them at special health risk, leaving them especially vulnerable to multiple health hazards. Prominent among these groups are the residents of inner- city slums and of peri-urban shanty towns and squatter settlements, as well as displaced, mobile and refu- gee populations. Within these and all other groups, the health of chil- dren and women is of exceptional concern, because of their biological vulnerability and their greater ex- posure to hazards in the home. The aged, the chronically ill, and the disabled, in all countries, have spe- cial health needs with regard to their housing. Principles of health action Interventions to improve hous- ing-health interactions need to rec- ognise three social "facts of life" : - that poverty is the major barrier to improved housing, so that the future of housing-like that of health-is generally bound up with a country's social and economic development; - that housing decisions are highly decentralised-not only in the frag- mented responsibilities of many governmental agencies, but even more because most housing deci- sions are taken by builders and by families themselves; - that the health aspects of housing are poorly understood and weakly represented in governmental, com- munity and family decisions. These facts lead us to five princi- ples of health action. 1. Health advocacy in housing de- cisions should be strongly emphas- ised by health authorities, in al- liance with other concerned groups, at all levels of administration and through multiple channels and media. 2. In the governmental sphere, health advocacy should be directed at a broad range of policies. Issues relevant to health go well beyond those bearing on housing itself. W oRLD HEALTH, July 1987 They embrace priorities for social and economic development and the policies that provide for taxation and financing of ownership, land and housing tenure, local decision- making authority, management of urban migration, family planning, and the regulation of land use and building. In support of the Interna- tional Year of Shelter for the Homeless, WHO held a consul- tation in Geneva last month on "Housing-Implications for Health". This article, based on a working paper discussed during the consultation , sums up current information on health-housing relationships as well as approaches to solv- ing some of the problems. 3. To implement socially desirable policies, health advocacy should be intersectoral in its orientation; moreover, it should be integrated into technical and social processes that countries use to develop and maintain community resources. Along with economic values, health considerations should be rep- resented in the processes of devel- opment planning and management, IYSH Poster Game Devised for HABITAT (UNCHs) by the rjuman Settlements Programme, this dice-and-counters gall')e illustrates the prob- lems and frustrations faced by a poor family's search for area! home in a typical Latin American city. Of course it can be adapted ' to cities any- wher~ in the,world . . Play- ers start with their count- er on number 1' in the lower middle of the diag- ram. A throw of the dice shows how many spaces to move. The ,winner is the first player to reach numoer 60- but on the way, all players may en- counter setbacks. The IYSH Poster Game can be 0rdered from : UNCHS, P. 0. Bpx 30030, Nairobi, Kenya. urban and land use planning, and the setting of norms through legisla- tion, regulations and standards for housing design and construction. A key process is situation monitoring and surveillance, not only to imple- ment policies but also to provide information for planning future policies that will be relevant and responsive to human needs. 4. For policies and standards to be effective, extensive public and pro- fessional education is required to promote the provision and use of housing in ways that improve health status. Because so many indi- viduals are engaged in the construc- tion of housing-and virtually all people in its use and mainten- ance-educational efforts have to be extensive and pervasive. 5. Finally, and emphatically, com- munity involvement at all levels should support self-help, neigh- bour-help and communal coopera- tive action in dealing with the needs and problems of the human habitat. Although every dwelling belongs in some sense to its occupants, the community too has an interest in the condition and use of the hous- ing that shelters its members. The essential objective of community involvement is to help people im- prove their condition in tangible and direct ways, as well as in the intangibles of better health. • 19 Where eight share one room How do migrants from the countryside to the city cope with the problem of homelessness? The writer cites the case of two slum-dwellers in the Ghanaian city of Kumasi IJ or Ghana, the International Year of Shelter for the Home-less falls at a time when the number of homeless urban dwellers seems to have increased to an un- precedented level. In Kumasi, the country's second largest city, for example, the existing stock of rooms in 1980 was estimated at about 220,700 but-with an aver- age of three persons living in each room-it was estimated that as many as 20,000 additional rooms were needed. The situation has worsened since then. This shortfall compared to the need and demand is frightening, and as a result most migrants have adopted many in- novative responses to cope with the situation. The stories of two resi- dents of Kumasi demonstrate how some migrants manage to cope with their homelessness. Adongo was born in Zuarungu in the Upper East Region of Ghana. Fifteen years after his birth his father died and he was left in the care of his uncle. He reared his uncle's animals and worked on his farms in return for his daily bread. As he grew up he wanted to regain his independence and went to live in Kumasi some 18 years ago. He had hoped to get a job and earn enough money to buy cows for his marriage rites and accumulate some capital for a comfortable future. Adongo first settled with another uncle, who occupied a single room with his wife and five children in the suburb of Bomso. He had to content himself with a sleeping-mat on the floor, and this was how he lived for five years while doing odd jobs to make ends meet. His income was minimal and unreliable, as it depended on the availability of jobs, and he did not earn enough to rent a room. 20 by Kwasi Adarkwa When he got married, his wife came to join him in his uncle's room in Bomso, although there were al- ready eight people sharing it. Luck- ily for him, he found a semi-perma- nent job with the Bible College as a watchman. But he still earned only 2,000 cedis, and landlords at the time demanded an advance pay- ment of between 10,000 and 15,000 cedis. He put much faith in the weekly lottery, but the more he staked the more he lost, and any winnings were only just enough to cover his past debts. He became more and more frus- trated, and lost all hope of ever raising the deposit; finally, he moved into a wooden structure near the Bible College which had originally been built for storing ce- For Adongo, this hut for storing cement has been "home " for the past ten years. Photo WHO/J. Bonful ment. Adongo has now been living in this wooden structure for the past ten years. He has three children and his wife is unemployed, so he is the sole breadwinner of the family . There are no toilet facilities and no electricity in the structure; he uses the toilets and baths at the nearby preparatory school. Since he has not yet achieved the ambition for which he left Zuarungu, he does not intend to go home in the near future. Since the structure he lives in is temporary he does not plan to make any improvements to it. The vast majority of migrants like Adongo have similar stories to tell. They usually have no skills to en- able them to easily find employ- ment in the cities. Even when they do have a job, they are poorly paid; the high rents oblige them to find adequate and satisfactory accom- modation, and so they tend to cre- ate spontaneous settlements out- side of the existing institutional framework. W ORLD HEALTH, July 1987 A new migrant normally joins some close relatives who have al- ready settled in the city, and gets acquainted with city life as he roams round in search of a job. Close relatives continue to move in and share the accommodation-usu- ally a small room. As the room gets more and more crowded, family life disintegrates and privacy is lost. As many as seven or eight persons may share a single room ; the only top limit is the amount of available sleeping space. As new migrants arrive, earlier ones find substitute rooms, usually make-shift struc- tures built on unoccupied land from cardboard, packing cases and scrap metal. Ayambilla tells his story of home- lessness. " I have been living in Bantama in a structure made of cardboard and wood with my wife and five children. My income is only 5,000 cedis. Meanwhile to get a room to hire I need between 20,000 to 30,000 initial deposit which is well beyond my means. A year ago I was approached by a local gin retailer who wanted some- one to watch over her gin store at night. In order to supplement my income I opted to sleep in this kiosk at night while my family live in the other dwelling." Since he put up his structure without authority, he has been con- stantly harassed by building inspec- tors of the Kumasi City Council who have threatened to demolish it. He doesn't know how long he can continue to occupy this land. When last year Ayambilla won the weekly lottery worth about 120,000 cedis, he decided to put up a simple dwelling to live in but this has not been easy either. He was told that the land was not for sale-but it could be released to him upon the payment of "drinks money" for a period of 50 years ! After paying one fee for tempor- ary occupation of the land and another for help in obtaining regis- tration and a building permit, he realised that he could not even afford to start his house. So he is still living in the kiosk until he can raise enough money again. Complex planning and building regulations hinder people from starting their own homes. So the migrant simply builds for his own convenience, and does not go be- yond the minimum required to keep shelter over his family's head. W ORLD HEALTH, July 1987 A migrant community in West Africa. Housing built by migrants seldom goes beyond the minimum required to keep shelter over the family's head. Photo WHO/ILO Moonlight, when it comes, provides the only means of illumination, and a candle is seldom lit as he comes home tired and sleepy and only crawls onto the bamboo or straw mat which forms his bed. Yet migrants such as Adongo and Ayambilla are the envy of other less fortunate ones, many of whom have no permanent sleeping places but wander from place to place. Others sleep in kiosks, lorry parks, disused lorries and uncompleted or abandoned buildings. Migrants who work around the clock lose touch with their families. There is very little family guidance for their children and many of them become delinquents-a further con- sequence of homelessness. Since the migrants ' dwellings lack basic necessities like water, electricity, and toilet facilities, they may punc- ture pipelines to get water for domestic use and defaecate into nearby streams, rubbish dumps and gutters. The result is a steady in- crease in cases of such communi- cable diseases as cholera, gastro- enteritis and other water-related diseases among the migrants-the very people who have least access to primary health care. The implications for national planning in many developing coun- tries are obvious. More and more resources continue to go into cura- tive mesures of disease control, to the neglect of productive activities and other social services for the migrants. The increasing gap be- tween housing needs and housing supply is aggravated, to a large extent, by factors such as the high cost of land and building materials, and rigid building and planning regulations. Even where govern- ments have attempted to solve the housing problem by setting up housing institutions or production units, their functions are not always well-coordinated and such insti- tutions are not always responsive to the needs of low-income city- dwellers. In Ghana alone, it is estimated that an average of 1,000 to 1,200 houses must be constructed each year for the next 20 years if current housing needs are to be met. This is a huge task that can only be carried out by both private and public col- laboration. The present focus of the International Year of Shelter for the Homeless is to draw the attention of all governments to the housing needs of their people. Solving the housing problem must start with the homeless. Governments and con- cerned institutions have to take the first step by relaxing over-rigid building and planning regulations so as to cater for their needs. Only then might we begin to see a down- turn in the steadily rising total of city-dwellers without adequate roofs over their heads. • 21 LearBing how to control pests lmost all slum settlements are heavily infested with insect and rodent pests, and these contribute to high rates of vector- borne diseases such as filariasis, dengue, leptospirosis, Chagas' dis- ease and urban forms of malaria. Added to the threat of disease is the degraded quality of life as a result of the nuisance value of insects and rodents, the constant irritation of bites, and the depredation of food supplies. Recent studies show that people living in slum and squatter settlements spend a disproportion- ate amount of their meagre earn- ings on pesticides ; clearly they themselves give high priority to ridding themselves of the harmful effects of such pests. . The lack of community sanitation services invariably goes hand in hand with pest infestation. While the local government's role is essen- tial in proper waste management (e.g. trucks for garbage collection), many pest and vector problems are the result of careless behaviour on the part of residents. It is therefore essential that people be informed and involved if community waste management is to be effective in the control of pests. A current project run jointly by WHO and the UN Environment Pro- gramme (UNEP) seeks to train com- munity workers so that they can offer practical information to indi- viduals, families and community groups, who in turn can take action on their own behalf to improve their immediate environment and protect themselves and their chil- dren from insects and rodents in their homes and neighbourhoods. A kit which forms part of the project provides practical guidance on environmental control measures that can be taken, including instruc- tions for safe disposal of wastes, screening and rat-proofing of homes, and the use of covered wa- ter containers to prevent mosquitos breeding there. Much of the infor- mation is presented in graphic form so that it is easy to understand and translation can be kept to a minimum. Particular attention is being given to the design of ma- 22 terials which can be cheaply re- produced by local communities themselves. The kit is a gleaming silver box containing a series of cards giving basic facts about nine household pests and two rodents-how to identify them, how to keep them down, and how to destroy them when they have already taken over. Pests covered include Norway and roof rats which have travelled throughout the world with humans sharing their food and home. Two mosquitos are represented: Aedes aegypti famous in history as the yellow fever mosquito which also transmits dengue and Culex quin- quefasciatus · which transmits filariasis and encephalitis and is a pest mosquito . Both are highly domestic, breeding in habitats cre- ated largely by human ignorance and carelessness. The sandfly is there, the cockroach, the head and body louse, the housefly, bed bug and the bloodsucking bug that transmits Chagas' disease, a disease that improved housing and personal cleanliness could almost eliminate. Known as CIIRC, for "Commu- nity Intervention for Insect and Rodent Control," the kit was first Grain sacks damaged beyond redemp- tion by rats in a United Kingdom store. Photo WHO/FAO distributed to a large number of national health authorities, experts and institutions involved in various ways with pest control. Work is now beginning on a revised version, and the final result is expected to be available by the end of this year. Its greatest application will be in train- ing community workers of various kinds, particularly those engaged in primary health care or in housing improvement projects run by na- tional agencies and non-govern- mental organizations. A number of other guideline documents focused on environmen- tal health aspects of housing and urban planning are also being pre- pared by WHO and UNEP for this year or early 1988. They are as follows: - Upgrading environmental health conditions in low-income settle- ments: a community-based method for identifying needs and priorities; - Urbanisation and its implications for child bealth: potential for action; - Child survival in or near cities-interventions for a healthier environment ; - Indoor environment: a guide- book on the health aspects of air quality, thermal environment, light and noise; - Access to live-saving services in urban areas ; - Urban surface water drainage in developing countries. • W oRLD HEALTH, July 1987 Space around the houses matters too Two members of the Soviet Union's General and Municipal Hygiene Research Institute examine the medical criteria for the quality of city living, and suggest WHO might develop a special programme by Yuri Gubernski and Nikolai Litvinov lthough towns and cities cur- rently occupy only 0.3 per cent of the area of the globe, more than 40 per cent of the popu- lation of the planet is concentrated in them. In the United States 150 million people, or nearly two-thirds of the country's population, are town-dwellers, while the compar- able figure for the Soviet Union is around 70 per cent of the popula- tion. According to UN data, about half the population of the planet will live in towns by the year 2000. Projections for 2025 are truly stag- gering : Mexico City with over 30 million, and both Lagos and Dhaka with some 25 million. The concentration of the popula- tion in large towns, and especially in very large cities, has many nega- tive effects on health and hygiene, and on town planning. The pace of life is intense, people are divorced W oRLD HEALTH. July 1987 from the natural environment, the space for recreation is limited, and it is hard to ensure wholesome air and an agreeable " micro-climate " in the home. All these factors adversely affect health. The Soviet Union's policy is to restrict the growth of large towns and major cities. Our research shows that healthy living conditions are best found in small and medium-sized towns with no more than 300,000 residents . Town plan- ning measures with this aim in view are undoubtedly promising. But creating the best possible urban environment is not just a matter of limiting city growth. It also involves creating outer-urban and rural agglomerations that depend on the large towns and cities. Let us consider the medical criteria that can be applied to the quality of the urban and home envi- ronments and can form the basis of a hygienic approach to illness pre- vention. Town planning decisions should provide the most favourable conditions for the life, work and recreation of the residents. This can be done by setting aside areas for different purposes (industrial, resi- dential, municipal and recrea- tional), by siting these areas ration- ally in the town plan, and by mak- ing them as pleasant as possible. The lack of in-town building land for residential purposes has resulted in recent years in a tendency to step up the number of storeys in build- ings and to increase housing density. The green spaces are thus reduced Old housing comes down and new apartments rise in its place in a Soviet city. Photo W HO!T. Farkas 23 in size, and there are fewer play- grounds and recreation grounds for children and adolescents, and fewer sports grounds. As the average life span lengthens, the relative numbers of the elderly increase. But in the new towns, there is also an increase in the relative size of the juvenile and adolescent age groups. These are the very population groups who make most active use of "the space around the houses". Moreover, we know that increasing housing and population density leads to a higher sickness rate from communicable diseases among youngsters and adults. All these factors point to a need for stricter health-oriented regulations on the size of the areas around homes and on building density. Present and future town planning decisions have a key role to play in the formation of the urban environ- ment, so it is vital to determine a scientific basis for setting standards and recommending actions that will avert any possible adverse effects 24 of human activity on the environ- ment and on health. The medical aspects of town planning and of the formation of the urban environment are insepar- able from the health aspects of the home, or of the "dwel1ing environ- ment" as it has recently come to be known in the specialist literature. The concept of housing can no longer be restricted to the mere building of walls. As defined by WHO, it goes further than the dwell- ing and takes in not only the house yard but also the "micro-district," the residential area district and all the related services and facilities. The "dwelling environment" is necessarily artificial, since con- scious human activity has a decisive role in creating it, and today it has to satisfy an increased number of needs-activities in the home con- nected with work, participation in social life, study and self-education, cultural development, socialising, entertainment and recreation, in- cluding keep-fit activity and sports. A view of Baku, on the Caspian Sea, by night. Soviet planners recognise that the concentration of people in big towns has negative effects on health and hygiene. Right: Artificial sunlight helps to com- pensate these children for the Jack of sun during the long polar winter. Photos W HO!T. Farkas The constantly changing nature of the environment, its inner dyna- mism, poses special problems and may have positive or negative effects on the environment. Many of the health problems that arise can only be effectively solved, in our opinion, by adopting a com- mon approach in which health pro- fessionals, architects and town plan- ners work together to study how the environment of built-up areas is formed, and how humans interact with the home environment. It is difficult to make a total assessment of the quality of the W oRLD HEALTH, July 1987 home environment that is required to ensure a healthy lifestyle because only a proportion of the demands made on the environment arise from the physiological needs of the human organism. Those needs form the basis, for example, for framing regulations and health legislation on permissible levels of air pollution or noise, or on insu- lation and the micro-climate. How- ever, the sociological and health requirements that largely deter- mine the lifestyle of cities and that, in the final analysis, have a decisive effect on human health are of a completely different nature. So a comprehensive sociological and health-oriented assessment of the quality of the home environ- ment is vital if we wish to contrast different areas within one town, to study how best to take timely steps to satisfy the demands of various population groups (adults, children, pensioners) , to establish the sever- ity of actual adverse effects on human health, to determine the W ORLD HEALTH , July 1987 relationship between positive and negative factors in the home envi- ronment and to measure the effect of that balance on the population's health. The health and medical criteria of the quality of the city and the home environment are of particular im- portance because they are the basis for the hygienic approach to disease prevention- the approach that has particularly been chosen by the Soviet Union. On the basis of the experience already gained, we would suggest that the conditions are now ripe for WHO to develop an international medical and biological programme for the prevention of the adverse effects of the urbanisation process on human health. Such a pro- gramme would make a significant contribution to WHO's efforts -to solve the problems of the environ- ment and human health-and would be especially appropriate as we reach the end of the twentieth cen- tury and enter the twenty-first. • r WHO and IYSH: implications for health s a contribution to the In- ternational Year of Shelter for the Homeless, WHO last month convened an inter- regional consultation in Geneva on "Housing-the implications for health". Participants, who included goverment officials ex- perienced in health promotion, housing, town planning and sommunity participation, re- viewed the global situation of housing and health. They iden- tified a set of public health prin- ciples for housing, and drew up recommendations on the most promising lines of action to be taken by governments, com- munity groups and international agencies. wHo has also commissioned a series of case studies which examined national experiences in the fields of health and habitat. These studies have al- ready been completed on Brazil, Ethiopia, Ghana. India, Peru, Philippines and Sri Lanka. Another IYSH project calls for WHO to eo-produce with the UN Environment Programme (UNEP) a set of information and gu ideline documents. A panel of technical experts identified among the most crucial aspects of housing and urban planning : urbanisation and its implications for child health, child survival in or near cities, upgrading the environment in low-income set- tlements, community interven- tion for insect and rodent con- :trol, the indoor environment. access to life-saving services in the cities, and surface water drainage in big towns. • 25 Governments come and go ... the community abides Photo W HO/UNICEF/B. Wolff by Jorge E. Hardoy Wl ore than 15 years ago, two Latin American researchers related how 50 volunteer groups had offered their services and contributions to a squatter set- tlement outside Lima, Peru. Sud- denly, the importance of collective action was realised. Many such efforts deserve uncon- ditional praise and support. They have helped millions of people to learn to read, find skills, improve their homes and health, and de- 26 velop a higher capacity to run their organizations, with the result that pressure has been put on national and local governments to find ad- equate solutions to the more urgent problems. In many cases such efforts have provided openings to the world outside. I would like to believe that the number of viol- ent expulsions of squatters had decreased in recent years as a result of a public awareness created by the activities of community groups working with nongovernmental or- ganizations. Democratic govern- ments accept these activities and often support their actions. Moreover, I am sure that urban squatters are surprised by the num- bers of people from national and international charities, religious groups, political parties, university extension programmes, inter- national agencies and special public programmes that visit their settlements. W ORLD HEALTH, July 1987 ,- Nevertheless, hundreds of mil- lions of people remain in dire straits. It is easy to forget that the governments of at least half of the Third World nations do not always fully represent the interests and aims of their people and that social movements are frequently un- heeded. For various reasons, even elected governments hesitate when asked to decentralise decision-mak- ing and support local urban and rural community groups, whose vigour can broaden the base of participatory democracy. There is a direct link between poverty and cholera, viral hepatitis, typhoid fever, schistosomiasis, diar- rhoea! and parasitic diseases, tuber- culosis, anaemia and many other diseases that are carried by water or related to poor sanitation, over- crowding and poor diet. It follows that much can be done through a better coordination of the pro- grammes of agencies responsible for the improvement of health and the environment. Such levels of bureaucratic incompetence, dupli- cation, wastefulness and sectoral bias have been reached that it is easy to despair. "Poor housing is not given the attention it merits as a cause of disease. Low-cost rehabilitation, new building materials, the gradual removal of disease vectors, and better domestic hygiene- these all constitute a means to im- prove the community's envi- ronment and the community's health." Professor Abel Wolman, Emeritus Professor at the Johns Hopkins University, Baltimore, USA. writing in World Health Forum, Vol. 7, No. 2, 1986. With some exceptions, the United Nations system can hardly claim a better record. It has become too large, too complex, too slow, and too closely linked to govern- ments, forgetting that possibly half of the urban areas in the Third World have been built by the people themselves, independently of official plans, norms and standards. It is important to witness the pragmatism of communities. Much W ORLD HEALTH, July 1987 could be learnt from their actions. Governments come and go, rep- resentatives of international and public agencies explore the pos- sibilities of starting projects, and countless well-intentioned people approach communities to exchange views about improvement pro- grammes, but, at the end of the day, most programmes are selected and priorities adopted without consult- ing the people and their organiz- ations. People in communities have a very clear idea of the type of financial and technical assistance they need, but officials often see things differently, and aid may be almost impossible to obtain. Clearly, the worst environments cause immense suffering and may even make it impossible to earn an adequate income. Much could be done to improve them, but they will not disappear until extreme pov- erty is eradicated. This can no longer be seen as something to be achieved through international aid, nor even as the exclusive responsi- bility of Third World governments; rather it must be viewed as a task for the whole world. To emerge from the present situ- ation, it is essential to engage new people and bring about a radical change of attitudes. Attempts to improve environments of poverty have become bogged down because they are based on increasing the role of central governments, which too often are not inclined to work with the people. Central governments and international agencies have an important role to play, but do not have a monopoly of wisdom. We should be more ready to work with community organiz- ations and nongovernmental organ- izations. Loans of US $100,000 to a hundred community organizations will have a far greater impact on the living conditions of the poor than a $10 million loan to the government of the same country for conven- tional housing or a site and services project. And the chances of recov- ering the smaller loans will probably be higher. If nations and agencies take the view that this approach is out of the question, we may as well forget the envir- onments of poverty and all the rhetoric about the importance of community organizations and non-governmental organizations in improving health. • ·where' small is, not.beautilul ''C' ;~~o~: un~r,~~;on~~~in~~~vvf~ IJ houses or shacks constructed on illegally occupied or sub-divided land, buying water of dubious qual- ity from private vendors at 1 0 to 20 tinnes the pr'ice per litre paid by mi(jdle or upper income groups in reside[ltial areas served by piped water. Similarly, it is no\ uncom- mon to find a heavy concentration of publicly financed health care services and facilities in large cities and yet the low income population in that city having little or no ac- cess to them." In such circumstances, how can the .health of the poor and under- served millions flourish? These are among the findings of a collabora- tive research programme which looked into the present and poten- tial role or small and intermediate urban centres in the cjevelopment process. The findings are pre~ sented by Jorge E. Hardqy and David Satterthwaite in their book ";oSmall and Intermediate Urban Centres" published by Hodder and Stoughton, London, in association with the lnternational .lnstitute for Environment and D€welopment. from Whom it may be ordered (price £15 sterling). . The book includes five regional studies~two in India and one each in . Supan, Argentina . and Nigeria"'-qf the way in which social., economiC and political forces mould and shape urban systems over time, .. and thus contribute to, or constrain, the ;o develbprnent of such sma.ll and medium~sized cities. In commentaries on · these sttJ(jies, . the two ,editors ask w~eth~rthe existing concentration of-; urban-base? activities in the largest city or . cities (usually the capital) truly servesnational, social and economic dev~lopment goals. They quote other studies shovving .. that the quality of health and 'edu- cation provided in the larger cities was "far superior to :that in the smaller cities.::. And they. conclude that "only through the U[ban sys- tem and its links with smaller settlements can governments increase. the proportion of, the population with access t'O h~altb care, education, postage and telephones, and other public services" . • 27 Popular technology beats schisto 1J he traditional pit latrine smells, breeds flies and prob-ably is the source of more disease in the community than it controls. Most people dislike it and will only use it in an emergen- cy, or in areas of high population density where there is no natural vegetation for privacy. With de- forestation a common problem, the nearest bush for cover is often on the bank of a stream-but washing in the stream after excret- ing increases the risk of schis- tosomiasis. This disease can only be transmitted when first someone contaminates the water with ex- creta, and secondly other people come in contact with the same wa- ter. Over 60 per cent of school- children in some parts of Zim- babwe are infected, making schisto a very big health problem. Better health and better social status are inextricably linked. This is why Zimbabwe has given very high priority to improving water 28 by Paul Taylor supplies and sanitation, expected to have a wide-ranging impact on health and social development. The national policy for schistosomiasis control, as for many other diseases, envisages first improving water supply and sanitation in schis- tosomiasis-endemic areas. This ap- proach will reduce the risk of long- term dependence on the frequent use of drugs, undesirable both fi- nancially and because there could be a catastrophic reversal should the drugs become scarce. Long- term schistosomiasis control is therefore based primarily on im- provements in basic living con- ditions and changes in human behaviour. The Ministry of Health's Health for all action plan estimates that This bucket pump is one of several simple models designed for use and maintenance by the village. Photo WHO/L. Taylor only 15 per cent of the rural popu- lation today have adequate excreta disposal facilities and safe water. The estimated shortfall is some 750,000 latrines and 75,000 pro- tected water-points. An optimum programme calls for the construc- tion of 70,000 latrines and 7,000 water-points each year for 20 years. The Blair latrine, developed at the Blair Research Laboratory, Harare, has a vent pipe fitted with a fly-screen of fibreglass or stainless steel ; a variety of versions are now being built in Zimbabwe. The most important aspect of the sanitation and water programme has been sensitising the community and mod- ifying technology, particularly the latrine, to suit local · customs. Whenever the basic latrine is to be introduced into a new area or coun- try, it should be evaluated with that community, even if it takes several years. The advantage of community responsibility for the construction of the latrines is that people's pre- ferences became immediately appa- rent : they will not build what they do not want. In contrast to the traditional pit latrine, the Blair latrine generally does not smell (if correctly con- structed), actively assists in control- ling flies in the community, and is often used as a bathroom. These features explain the overwhelming support for it in Zimbabwe. A family building a latrine is given cement and a fly-screen to symbolise the importance the gov- ernment attaches to latrines in the family setting. In return, the family digs the pit, collects the sand and gravel, makes the bricks and builds the toilet. The family's con- tribution-whether in cash to pay a builder or in labour to do the job itself- is considered by far the big- gest, and it is the success of this community self-help which has W ORLD HEALTH, July 1987 made the sanitation and water pro- gramme so dynamic. Communal latrines are not recommended, ex- cept at schools, shopping centres or bus stops, for example, because they are too difficult to maintain. People prefer to have their own latrines near to home. The fact that very young children go with their mothers to water is the most likely reason for the high prevalence of schistosomiasis in children under six. It is important to provide not only good drinking wa- ter at a water-point, but facilities for all water-contact activities. In particular, this means washing- slabs, so that women can avoid the most common types of water-con- tact activity by themselves and their children. In one study in Zimbabwe, simple washing-slabs and washing-lines reduced the amount of water-contact at the nearby rivers by 80 per cent. The water programme is much more difficult than the sanitation programme because water-points are entirely communal and the technology is much more complex. Water technologies for use and maintenance in villages include the hand-operated drilling rig, a simple bucket pump, two types of simple hand pump and an improved type of deep well pump. As with the sanitation programme, the em- phasis is on community involve- ment and responsibility for mainte- nance. Every effort is made to see that the most reliable equipment is used, but it must be accepted that there will be breakdowns, so priori- ty technologies are those which can be maintained in the village. The water-point must be repairable with the minimum of delay. It is better therefore to have a pump which is made, and can be maintained, with parts from within the country. Although most large water sup- ply schemes, including deep bore- holes, tend to be set up with minimum community involvement, changes are coming rapidly. Now- adays, the community is often in- volved in digging pipelines and pro- tecting completed boreholes. This last is particularly important: the boreholes of the past had muddy and thoroughly unpleasant sur- rounds, whereas the newer ones have an apron and soakaway as well as a washing-slab built by the community. The community is also involved in the simple maintenance WORLD HEALTH , July 1987 Zimbabwe's favourite, the Blair latrine. It doesn't smell, keeps down flies and can even be used as a bathroom. Photo W HO/L. Taylor of the borehole and pump, such as greasing and tightening of bolts. The community's main contribu- tion has been installing and main- taining simple hand pumps. This became possible when a local com- pany developed the "Yonder Rig" -a robust yet simple-to-oper- ate drilling rig that can be used by local people with very little super- vision. Local people know the best sites for underground water and can be largely instrumental in deciding the location of their water-point. In contrast to human well-diggers, the rig's auger can get to below eight metres in less than a day, and may go down to over sixteen metres. If the drilling is unsuccessful, the rig can be moved to another site with only minor inconvenience. The disadvantage is that the auger can only cut through soil or decom- posed rock, not hard rock or stony substrates. The community gather, often in large numbers, to help in the drill- ing operation. The atmosphere is more that of a social occasion than of a labour gang-perhaps this is what a "working party" really means! Even if the auger is un- successful, progress can still be made by protecting existing wells, again best done with community assistance. The programme attracts enorm- ous community support and en- thusiasm largely due to the efforts of the village health workers and the community involvement and participation method. Water is a felt need, and the community have gained access to the technology that enables them to satisfy their own demands. Although the schistosome's life- cycle can be attacked at several points, with the arrival of new, safe drugs many national control pro- grammes have chosen to rely heav- ily on chemotherapy. This carries the risk of only short-term gains, as mentioned. If however, chemo- therapy is linked with improve- ments in water and sanitation, then the foundation exists not only for a permanent reduction in the schistosomiasis problem but also for a much better overall health and socioeconomic status within the community. • 29 Dutch Donate WHO X-Ray Machines To Third World SIMAVI, a small private foun- dation in Holland, has insta lled 10 wHo-BRS X-ray machines in hospitals in Africa and Asia from money donated by the Dutch population. The machines are now per- forming reliable X-ray diagnosis for patients in Benin, Came- roan, Ghana, Indonesia, Kenya, Tanzania, Uganda, Zambia and Zimbabwe. A Dutch manufac- turer of the wHo-BRS, Philips Medical Systems, sold the ma- chines to SIMAVI on specially favourable terms. Philips also gave an eleventh machine free of charge. This machine wi ll be used in an Amsterdam hospital for two years before going to a devel- oping country. All 11 machines are being evaluated by SIMAVI for technical performance, training results, quality, econo- my, and impact on patients and the standard of care. SIMAVI, which supports small medical projects in the Third World, ce lebrated its 60th anniversary in 1986, collecting money for its first five wHo-BRS machines as a specia l jubilee event. The other machines were funded from the founda- tion's annual budgets of about US $1.3 million, which are made up of a yearly public col- lection, gifts from individual do- nors, and donations from small groups such as schoolchildren. Eleven machines may seem only a drop in the bucket in comparison to world needs, say SIMAVI officia ls. But WHO considers that SIMAVI has made a highly significant contri- bution through its placement and eva luation of the machines. and its training activities for doctors and technicians. The WHO-BRS: A simple ma- chine that performs reliably. 30 ...... ....... ... ... ... ..... ...... ..... . .......... . ••••••• ••••••• ••• ••• ••• • ••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• • ••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• • • • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• • •••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• • ••••• • •••••••••••••••••••••••••• ... ... ....... ... ... ... ..... . ......................... . ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• VOLUNTARY COLLE OF ASHTRAYS COLLECTE VOLON. ~I DES CENORIER 11 Smash Hit for wHo" So proclaimed a two-column headline in the Times of London in describing the scene shown here that took place at WHO headquarters on 7 April, World Health Day. "As the world's conscience on health, we have decided to set a small example," Dr Halfdan Mahler, WHO's Director- General said just before smashing an ashtray. That symbolic ceremony signalled the start of a ban on smoking throughout WHO, including the cafeteria, and of WHO becoming - except for a staff room on the top floor - smoke-free. Earlier, a collection of ashtrays had been made and dumped into a wooden box for disposal. In outlawing smoking, WHO cited mounting evidence, including a report from its Internationa l Agency for Research on Cancer, in Lyon, that declared "passive smoking" - exposure to tobacco smoke - harmful to the health of non- smokers. A survey among WHO staff showed more than two- thirds do not smoke. Of six regional offices, five - Aiexandria, Brazzavi lle, Mani la, New Delhi and Washington- have pledged them- selves to smoke-free environments. SI MA VI has also made a spe- cia l point of trying to convince much larger Dutch reli ef organ- izations that the wHo-BRS shou ld be their first choice. In March 1987, the foundation invited government officials, radiologists, radiographers, Dutch NGOs and the press to see the BRS unit for them- selves, presented by the manu- facturer in a standard shipping container and fully operational on solar power. Dr Gerald Hanson, new chief of the Rad iation Medicine unit at WHO headquarters, also talked to the group. • Mortality from CVD in Elderly On the Decline While still accounting for about a half of all deaths in the majority of industrialised coun- tries, mortality from cardiovas- cu lar diseases has been on the decli ne over the past decade. And in many countries the decline has occurred in all age groups, including the "old elderly", that is, those of about the mid-seventies, according to a WHO study of 32 countries. This seems not to be the trend. however, for morbidity (the number of cases), the study also says. Presented at an Internationa l Symposium on Ageing in Mon- treux, Switzerland, the study shows that the decline in mor- tality has been greater among women than men. For all cardiovascular dis- eases, the median decrease, in age-adjusted death rates at age 60, was 19 per cent for females and 13 per cent for males. For ischaemic (coronary) heart diseases alone, the de- crease was 14 per cent and 7 per cent respectively, and for cerebro-vascular diseases (stroke) it was 27 per cent and 23 per cent respectively. The decline in al l cardiovas- cular diseases was "especial ly rapid in Japan, Austra lia, Malta, the United States and Canada," says Kazuo Uemura, Director of WHO's Division of Epidemiologi- ca l Survei llance and Hea lth Situation and Trend Assess- ment. The decline in deaths for all cardiovascular diseases in Japan was 33.1 per cent for males and 33.5 per cent for females from 197 4 to 1984; in Australia, 31 and 32.3 per cent from 1973 to 1983; in Malta, 25.8 and 34 per cent from 1974 to 1984; and in the United States, 25.5 and 27.1 per cent from 1972 to 1982, respect- ively. However, "most East Euro- pean countries have been showing high mortality, and the rate continues to increase," he adds. There is as yet an insufficien- cy of data to allow for a deter- mination of precise trends for morbidity, but what is avai lable, notably from Japan and the United States from surveys of sample households, indicate no decline has occurred which is commensurate with the mortality decline." As a result, according to esti- mates from Japan's Ministry of Health and Welfare, about 40 per cent of the total medical bill W ORLD HEALTH, July 1987 for the elderly goes towards cardiovascu lar diseases. They "continue to impose a great burden to society in gen- era l and to the elderly popula- tion in particular." he concluded "despite some improvements in survivorship." • AIDS: The Safety of Blood and Blood Products Transmission of the Human Immunodeficiency Virus (H IV) by blood transfusion or blood products has played a relatively minor role in the AIDS epide- mic. Nevertheless. for the few individuals who have actually caught AIDS in this way, as for the many more who depend on regular infusions of clotting fac- tors to control their haemophi- lia. the link between AIDS and blood has been devastating . AIDS places a new respons- ibility on health authorities. transfusion services. blood pro- duct manufacturers. laborato- ries and donors. How can blood and blood products be made really safe for the recipient? What is the best way to screen blood donors? If donated blood is shown to have HIV anti- bodies. what and how should the donor be told ? Should one country buy blood from another ? What manufacturing and screening techniques does WHO recommend, and are they followed? These and other technical and ethica l questions are an- swered in AIDS: The Safety of Blood and Blood Products *. newly published by John Wiley & Sons on behalf of WHO. The book contains scientific papers. and discussions that took place at a meeting of over 100 ex- perts, organized by WHO in Geneva in April 1986. "lt is unique in my experi- ence," says Dr John Petriccia- ni, Chief of the WHO Biologicals unit, "to have so many diffe- rent elements represented at one meeting . We had cooper- ation from commercial indus- try, government manufacturing institutions. voluntary organiz- ations. national control auth- orities, blood transfusion ser- vice representatives. and a broad spectrum of biomedical scientists." * Edited by J C. Petricciani. I. D. Gust. P.A. Hoppe and H. W. Kriinen. refer- ence ISB N 0 47 1 91338 3. In Engl ish only. Price US $50/£29.50. To order. write to: Department J K. John Wiley & Sons Limited. Baffi ns Lane, Chichester. West Sussex P019 1UD. Eng la nd. WORLD HEALTH, July 1987 News Briefs • A 'Progress' Report in Human Reproduction. This is the masthead of a quarterly news- letter just out, published by P-Pr--~a ~ WHO's Spec/3/ Programme of ~ ~-- Research, Development & Re- ~---~ .. ~---- search Training in Human Reproduction. In the first issue are reports on intrauterine devices, a vaginal ring developed by WHO. and trials of an anti-fertility vaccine. For a free subscription, clip this item and send to editor. Jitendra Khanna, at the WHO office listed above. • Finland: Twenty-five Years of Work. The Finnish Council for Health Education, which comprises 74 health organizations, this year celebrates its 25th anniversary with a new drive to help people to help themselves in promoting health and preventing disease. Says its Executive Director, Or T uulikki Juuse/a, of the Council: " it aims at furthering healthy habits and supporting people in their efforts to influence the decision-making process for the improve- ment of health. During the last decade, the emphasis has moved from sickness prevention to health promotion. " For further information, write · Finnish Council for Health Education, 150 Roobertinkatu 3 A 21 SF-00120, Helsinki. • Mental Health Succes. Created in Geneva, Switzerland, in 1983, the Association Succes has already proved a success in breaking away from antiquated systems of conveying information to the public about mental health problems. The association encourages exchange of information, fosters both public and private projects in the field of mental health, also covering alcoholism, drug dependence or depression, and supports all such efforts, professional or charitable. • On Wisconsin. In dedicating a day to the goal of "Freedom from Cancer Pain ", the State of Wisconsin has committed itself to a priority of WHO's cancer control programme- the relief of cancer pain. A proclamation issued 6 December 1986 by Governor Anthony S. Earl called upon his state's health organizations " to apply your knowledge, energy and creativity to improving cancer pain man- agement in Wisconsin. " In becoming the first US. state- and thus far the only one- to have taken this step, Wisconsin confirms its leadership role in the alleviation of cancer pain, WHO officials say. • People. Appointed as Director, WHO 's Division of Noncommunic- able Diseases, Or Evgueni Shigan (USSR), formerly head of public health management and health statistics, Central Institute for Advanced Medical Studies, Moscow. He is now responsible for these units: diabetes, rheumatic diseases, cancer, cardiovascular diseases, smoking and health, occupational health, and oral health. • The Top 5,000. The first edition of International Who's Who in Medicine, comprising some 5,000 men and women who have distinguished themselves in the medical sciences, has been published by the International Biographical Centre, Cambridge, UK. The 824-page reference work lists general practitioners, special- ists, dentists and nurses, as well as pharmacologists, adminis- trators, teaching staff, plus personalities in public health, and in research. To order write: Me/rose Press Limited, 3 Regal Lane, Soham, Ely CB7 5BA. UK, price £95, or US $7 50. In the next issue Ten years ago- on 26 October 1977- the world 's last endemic case of smallpox was located in Somalia . The patient, 23-year-old hospita l cook Ali Maow Maalin, made a complete recovery. The August-September issue of World Health marks this Tenth Anniversary w ith an overview of WHO's unique achievement in eradicating smallpox and rid- ding our planet of a mi llennia-long scourge . Authors of the Month The Honourable R. PREMADASA is Prime Minister of Sri Lanka, and Mr Manik de SILVA is Editor of the Colombo Daily News. Mr Robert E . NoviCK is Re- sponsible . Officer for WHO's programme on Environmental Health in Rural and Urban De- velopment and Housing. Mr E. A. R. 0UANO is a consult- ing engineer based in the Philip- pines. Miss Annick BILLARD is one' of the Editors-in-Chief of Refu- gees, the illustrated magazine of the Geneva-based UN High Commissioner for Refugees (UNHCR). Dr Morris SCHAEFER is Profes- sor Emeritus of Health Policy and Administration at the Uni- versity of North Carolina School of Public Health, USA. Dr Kwasi ADARKWA is with the Department of Planning at the University of Science and Tech- nology, Kumasi, Ghana. Professor Yuri GUBERNSKI and Dr Nikolai LITVINOV work at the Soviet Union's General and Municipal Hygiene Research In- stitute in Moscow. Professor 'Jorge E. HARt>o'Y is Director of the Human Settle- ments Programme of the Inter- national Institute for Environ- ment and Development in Buenos Aires, Argentina. Dr Paul TAYLOR is Director of the Blair Research Laboratory, Ministry of Health, Zimbabwe. WORLD HEALTH For readers everywhere 1987 Subscription Rates US$ Sw. fr. One year Two years Three years 14.~ 25.~ 24.75 45.- 33.~ 60.- ORDER FORM Please enter my subscription to "World Health" as follows: One year D Two years D Three years 0 I enclose cheque/international postal order ip the amount of: _ Name: ________________ _ Street : ---------------- City: ________ _ Country: ____ ___ _ World Health, WHO, Avenue Appia, 121 1 Geneva 27. Switzerland World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies. please contact your usual bookseller. 31 A refugee settlement in southern Mexico Jacks everything -including health care. Photo WHO/UNHCR/M . 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World Health: the magazine of the World Health Organization: July 1987 [full issue]: shelter for the homeless
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