(WPR/RC26/SR/3 )
SUMMARY RECORD OF THE TmRD MEETING
WHO Conference Hall, Manila Tuesday, 2 September 1975 at 9;00 a.m. CHAIRMAN: Dr T.M. McKendrick (Western Samoa)
CON'IEN'IS
1
Nomination of the Regional Director ••••••••••••••••••• Consideration of draft resolutions ••••••.••••••••••••• International programme for the improvement of water supply and sanitation in rural areas of developing countries ••••.•••••••••••••••••••• Current progress of programmes receiving WHO assistance in the Western Pacific Region Dengue haemorrhagic fever: Provision for assistance in emergencies ••.•.•....•............••.•.. Infant nutrition and breast-feeding ••..••.•••••••••••. Acknowledgement by the Chairman of brief reports received from Governments on the progress of their health activities (continued) AmlollIlcement •••••••••••••••••.•.•••.••••.•..•••• '•.••••
115 115
2
3
116 117 120
4
5 6
123
7
129 129
8
- 111 -
ll2
REGIONAL COMMI'l"1EE:
'l'tlENTY-SIXTH SESSION
Third Meeting Tuesday, 2 September 1975 at 9.00 a.m. PRESENT I. Representatives of Member states AUSTRALIA CHINA Dr C.P. Evans Mrs A.E. Broinowski Dr
Dr Chen Chih-ming Chen Wen Chieh Dr Wang Lien Sheng Mr Li Ching Hsiu Dr Yves Couturier Dr A. Tanaka Mr S. Kaneda Dr S. Osawa Dr PhouyPhoutthasak Dr Keo Phimphachanh Tan Sri Datuk (Dr) Abdul Majid
FlWl:E JAPAN
LAOS
MALAYSIA
bin Ismail Mr Onn bin Kayat Dr Lim Ewe Seng NEW ZEALAND
Dr R. Diclde Dr Dr Dr Dr Dr Dr Dr Dr Dr J. Sumpaico A.N. Acosta J. Dizon A. Galvez F. Aguilar R. Villasis E. Fernando T. E1icafio, Jr. I. Nebrida Mrs L.J. Zamora
PHILIPPINES
SUMMARY RECORD OF THE THIRD MEETING
113
REPUBLIC OF KOREA
Dr Kyong Shik Chang Mr Se Lin Huh Mr Sun Dong Yin Dr Tran Cuu Kien Dr Le Van Loc Dr Oon Beng Bee Dr S. Tapa Dr J.A.B. Nicholson J .C. King E. Nozigl1a Dr M. Kumangai
REPUBLIC OF SOUTH VIET-NAM
SINGAPORE TONGA
UNI'lED JaNGDOM UNI'lED STA'lES OF AMERICA
Dr
Mr
WES'IERN SAMOA
Dr T.M.
McKendrick
II.
Representative of Associate Member PAPUA NEW GUINEA Dr Ako Toua
III •
Observer DEMOCRATIC REPUBLIC OF VIET-NAM
Professeur Hoang Dinh Cau M. Nguyen Van Trong Dr Doan Xuan Muou
IV.
Representatives of the United Nations and Related Organizations 'UNI'lED NATIONS DEVELOPMENT Mr J.
Melford
PROGRAMME UNI'lED NATIONS CHIIDREN'S FUND
Mr Wah Wong
V.
Representatives of Other Intergovernmental Organizations IN'mRNATIONAL COMMIT'lEE OF MIUTARY MEDICINE AND PHARMACY
Captain J .E. Batoon, K:
114
REGIONAL COIIII!'D:
1WERT!'-SIX'!'H SESSION
VI.
Representati ves of Non-/5O!!rruaental Organizations IN'lERNATIONAL SOCIETY FCit REHAmUTATION OF THE DISABlED WORID :FEDERATION FOR MEDICAL EDUCATION CHRISTIAN MEDICAL COMMISSION MEDICAL W<JI!:N'S lJflEiUiA'l!I:ONAL ASSOCIATION IN'lERNATIONAL COMMI'l"IEE OF CATII>UC ~ WORID FEDERATION OF OCCUPATIONAL THERAPISTS
Professor C. Floro Dr J. C~gkeng
Dr G. Vi terbo Dr C. Asuncion Dr I. Y. Zalamea Mrs
...
M.R. Ordonez
Mrs C. Abaci
IN'.lmUiATIONAL PLANNED PARENTIDOD FEDERATION IN'llSRNATIONAL RADIATION PROTECTION ASSOCIATION IN'lERNATIONAL SOCIETY OF RADIOLOGY WORID FEDERATION OF UNI'lED NATIONS ASSOCIATIONS
Dr J. llano
Dr T. Elicaiio. Jr. Dr H. Zialcita Dr M.M. Al1!'JUI'UIlg
VII.
WHO Secretariat DIRECTOR-GENERAL SECRETARY
Dr H. Mahler Dr Francisco J. Dy
StJJl1ARY RF&QRD OF THE
THIRD MEE'l:[NG
llS
1
N<J4INATION <F THE REGIONAL DIRF&TOR:
Item 9 of
the
Agenda
(Document WPR/RC26/3) '!he CHAIRMAN stated that the Committee, in accordance with Rule 51 of the Rules of Procedure of the Regional Col1llli ttee for the Western Pacific, would consider this item in a private meeting. '!he meeting was held in private from 9.00 a.m. until 9.45 a.m. and resumed in public session at 10.00 a.m.
At the request of the CHAIRMAN, Dr PHOU'I'rHASAK (Laos), Rapporteur, read out the resolution that had Just been adopted by the Regional Committee in private session: '!he Regional Committee, ConSidering Article 52 of the Constitution; and In accordance with Rule 51 of its Rules of Procedure, 1. NOMINA'lES Dr Francisco J. Dy as Regional Director for the Western Pacific;
2. DECIDES that no names other than that of Dr Dy, the Regional Director in office, be submitted to the Executive Board; and
3.
REQUESTS the Director-General to propose to the Executive Board the appointment of Dr Francisco J. Dy for a further period of three years from 1 July 1976.
'!he REGIONAL DIRECTOR thanked the Committee for its expression of confidence in nominating him for a further mandate. He was gratified to have been able to serve the Organization for 25 years, in the capacity of Regional Director during nine of them. He was grateful to the Member Governments for their understanding and cooperation in promoting the ideals of WHO which was, above all, their Organization. His thanks were also due to the Director-General for his patience, understanding and support, and to the staff of the Western Pacific Region for their assistance in implementing the WHO programme. 2 CONSIDERATION OF DRAFT RESOWTIONS
'!he Committee 2.1
co~idered
the following resolutions:
Annual Report of the Regional Director (Document WPR,/RC26/WP/l) Decision: '!he draft resolution was adopted (see resolution
WPR/RC26.R2) •
116
REGIONAL COMMI'l"IEE: . 'DIEN'!'Y.,SIXTHSESSIOH
2.2
Resolutions of .regional 1nterestadopted by·the TWenty;e1ghth World Health Assembly and the Executive Board at 1tsfiftyfifth and fifty-sixth sessions {Document WPR/RC26/wp/2} Decision: '!he draft resolution was adopted (see resolution WPR/RC26. R3).
2.3 Speoialassistance to Cambodia, the Democratic Republic of Viet-Ham. Laos and the Rep'ubUc of South Viet-Nam (Document WPR/RC26/WP/3)
·nr KING (united states of Amerioa) stated that when resolution WHA28.79 was adopted by the World Health Assembly. although·a vote was not taken. his Delegation had indioated that it would oppose the resolution. He still oonsidered thatsuoh .resolutions would complicate the Director-General's attempts at orderly planning and management as the Director-General was responsible for determining the organization's funding requirements. taking into acoount the relative needs of Member states and the effeotiveness of measures proposed. Dr King welcomed the assuranoe given by the Director-General earlier in the session that the Organization would act as a multilateral technical cooperation partner in national health development. The Organization should not become "just another donor agency". Decision: The draft resolution was adopted . (see resolution WPR/RC26.R4) • 2.4 Promotion of.nat,1onalhealth;care services health care (DocumentWPRjRc26/wp 4) Deoision: The draft resolution was adopted (see resolution WPR/RC26.R5 ) 3 IN'mRNATI<liAL PROGRAMME FOR THE IMPROVEMENT OF WA'lER SUPPLY AND SANITATION IN RURAL AREAS OF DEVELOPING COUNTRIES: Supplementary Item 2 of the Agenda (Document WPR/Rc26/4)
The REGIONAL DIREX::TOR stated that the Director-'General attached considerable importanoeto the proposed international programme for the improvement of water supply and sanitation in rural areas of developing countries. He informed the Committee that document WPR/RC26/l4 described the action. planned or already taken. by a group of international organizations (the World Bank. IDRC, OECD. UNDP, UNEP. UNICEF .andWHO.) that had formed an Ad ~WorkingGroup on Rural Potable Water Supply and Sanitation. The participation in this Working GroupofrepresentatiVesf'J;>om two or three developing countries of the Western Pacific Region would be particularly beneficial.
SUMMARY RECORD OF THE THIRD MEETING
117
The Regional Direotor said that the Committee might wish to oomment on the proposals for an international programme and to suggest whioh oountries should be invited to send representatives to the next meeting of the Ad Hoo Working Group, to be held in Geneva in Novembe~ 1975,.' --,
,
'. Dr MAJID (Malaysia) said that the programme was worthy of bilaterai/international support. It was, however, important that expert assistanoe be implemented in the local context, as socioeconomic conditions and people's attitudes varied considerably. Malaysia was willing to state her experience in that matter.
The types of pumps and other equipment needed would also vary and they should, as far as possible, be available to the community, together with spares, at low cost. Staff familiar with locally available materials should be trained and assigned to the programme. Adequate salaries had to be paid to ensure stability in staffing. Firm support by the Government was needed for sucoessfUl implementation. Such programmes were of major public health importance and were vital to the sucoess of other preventive programmes. They should be integrated with applied nutrition and deworming activities. For maximum effectiveness, international agenoies should work in economically baokward countries, with their staff providing the necessary expertise and with the country making a firm oommitment to the programme, supplying adequate materials and making manpower available on a continuing basis. Inadequate provision of experts and materials had been shown to lead to failure. the
The CHAIRMAN thanked the Representative of Malaysia and asked suggestions as to whioh oountries might wish to partioipate in the Ad ~ Working Group to be held in November 1975. fo~
Dr TOUA (Papua New Guinea), Dr SUMPAICO (Philippines), and Dr CHANG (Republio of Korea) said that their oountries would be pleased to participate in the Working Group. There being no other comment, the CHAIRMAN referred the Rapporteurs to the draft resolution contained in document wpR/Rc26/14. (For consideration of the draft resolution, see the fifth meeting, section 1.1.) 4
CURRENT PROGRESS OF PROGRAMMES REX:EIVING WHO ASSISTAN::E IN THE WESTERN PACIFIC REGION: Item 12 of the Agenda (Document WPR/Rc26/6 and Corr.l) The REGIONAL DIRECTOR informed the Committee that doc.ument
WPR/RC26/6 oontained the third evaluation of the progress of programmes receiving WHO assistance in the Region and summarized the reports of
118
REGIONAL COETU:
'l'ilENTY-SIXT.H §f{j$ION
governments on the progress of long-term projects for the period July 1973 to June 1974. Tbe first evaluation, of projects receiving assistance between July 1969 and June 1970, had been submitted to the Committee at its twenty-first session and the second evaluation, for the period July 1970 to June 1971, to the Committee at its twenty-second session. The Committee, at its twenty-second session, had adopted a resolution requesting that such evaluations be prepared every two or three years. For the evaluation at present under review, a modified and refined questionnaire had been used in an attempt to obtain concise and pertinent information. The Reg10nal Director said that the comments of Representatives on the value to governments of the information thus obtained would be most welcome. After congratulating the Regional Director on the present report which was a most useful document and, belatedly, on his annual report, Dr EVANS (Australia) went on to seek clarification on the following points in document WPR/Rc26/6: (1) page 4, paragraph 4: it was stated that in 3?f1. of projects, governments could not meet their commitments; this seemed to be borne out in Table 2, page 24 by the figures given under "local resources fUlly and effectively utilized"; (2) paragraph (c), page 5: the figure of 60.6'.' for a positive relationship between projects and national socioeconomic development plans seemed to be low. Dr Evans said the question that could be asked was whether the original projects were the most suitable ones for the country and this was exemplified in the figures g1ven in Table 2, page 21, for the number of projects that had achieved their targets. Dr Evans ended by saying that the response rate to the questionnaire was very pleasing. Dr DICKIE" (New Zealand) sought clarification of the term, used once or twice in document WPR/RC26/6, "transferable teclmology". Dr ANGARA (Assistant Director of Health Services) replied that "transferable technology" meant techniques or procedures which were applied in the development of programmes. For example, in national health planning, certain techniques were developed involving (a) training, and (b) the application of methods, which were introduced during the course of projects or programmes, so that the country could familiarize itself with the procedures involved and so continue the work after international assistance had been'withdrawn.
SUMMARY RECORD OF THE THIRD MEETING
119
Dr KING (United states of America) congratulated the Regional Director on the report. The delegation of the United states of America was particularly impressed to see an evaluation of this nature being conducted on a regular basis. To the best of his knowledge the western Pacific Region was the only one where countries were involved in this type of evaluation. What steps did the Regional Director propose to take to rectify any difficulties revealed by the evaluations; evaluation was but a first step. It was noted with interest, from page 13, that 74% of the projects now had quantifiable results. Dr King went on to ask why the evaluation was primarily, or perhaps solely, applied to long-term projects? How was a long-term project defined? Results were often more easily quantifiable for short-term projects, say of one to three years, because the projects were aimed at a short-term goal. Perhaps evaluation of these projects miSht also be considered. Dr ANGARA (Assistant Director of Health Services) clarified the meaning of short- and long-term in the context of the evaluation. Projects involving visits by consultants, usually of less than 6 months' duration, had not been included. Projects of this kind were very limited in scope and did not involve the utilization of resources, which was the principle applied in the evaluation. Evaluation of projects involving only consultants was taken care of in a different way; the report of the consultant was assessed both by the government and in the Regional Office; its recommendations could ,either result in immediate action by the government or in a long-term project, requiring more than one year, in which case a plan of operation was prepared and the project was eventually included in an analysis of the type being reviewed at present. The present evaluation. was of projects lasting usually two years or more. It was preoccupied with the use of resources, on the part of governments and on the part of WHO, and the degree of cooperation existing between WHO and the national staff. Referring to Dr King's first question, the REGIONAL DIRECTOR said that i f the results were favourable WHO was of course happy. There were activities where the results were disappointing; when this happened the matter was taken up again with the government. Sometimes this involved the visit of a special mission, headed by the Regional Director or by other members of the Regional Office staff, accompanied by the WHO Representative, to enquire in detail into the factors causing the difficulties. Frank discussions were held with the government. Sometimes the priorities of governments changed and newer projects were justifiably given higher priority. There being no other comments the CHAIRMAN asked the Rapporteurs to prepare an appropriate resolution. (For consideration of the draft resolution, see the fourth meeting, section 3.1.)
120
REGIONAL CQl\It1IT'1EE:
'lWENTY-SIXTH SESSION
5
EMERGENCIES: the
DENGUE HAEMOllRHAGIC FEVER: PROVISION FOR ASSIST~E IN Item 13 of the Agenda (Document WPRj'Rc2617)
The REGIONAL DIRECTOR referred to document WPR/RC2617 which gave background to his request to the Committee to allow him to place US$lO 000 in the List of Additional Projects for 1976 and subsequent years, in order to be able to assist Governments, on an emergency basis, with supplies and equipment in the event of outbreaks of dengue/dengue haemorrhagic fever. Recent experience in the South Pacific area had shown that, quite often, neither ULV ground machines nor insecticides, without which control measures could not be put into effect, were immediately available in areas where outbreaks had occurred. The exact manner in which ~e equipment and insecticides would be made available to Governments upon request would vary in accordance with the situation prevailing in a country at the time an outbreak occurred. But it was envisaged that about six portable ULV application machines would be purchased and held in stock at the Regional Office for loan to Governments. Insecticides would not be held in stock, since they were liable to deteriorate if kept too long; the funds would be available to enable an immediate purchase to be made if it appeared to be necessary. Transport costs would be borne by the Government making the request. Dr DIZON (Philippines) stated that his delegation supported the proposal that the Regional Office should establish a stock of supplies and equipment to be made available to member countries in the event of an emergency. The intention' of the Regional Director to provide US$lO 000 for the immediate purchase of equipment and supplies was appreciated even though there was no provision in the budget for this. Vector control was the most effective method for controlling dengue haemorrhagic fever. He stated that while there had been sporadic outbreaks in the Philippines during the past 10 years there was a need to make preparations to control further- outbreaks. In line with the suggestion made during the twenty-fifth session of the Regional Committee, Member States should organize vector control units. In the Philippines, this was being done and arrangements were being made to procure equipment and supplies. Dr MAJID (Malaysia) commented that, based on Malaysia's experience in combating dengue haemorrhagic fever over the last few years, the proposal to have equipment and insecticides available in the Regional Office for any Member state in an emergency was supported by the Government of Malaysia. There were however limitations on the quantities which might be stocked. A city of 55 000 population would require nearly 950 litres of insecticide; a third of the emergency stock. A major outbreak in any Member State would ·soon deplete the stock. Thought should be given to the following problems:
\
"
SUMMARY RECORD OF THE TlITRD MEETING
121
(a) (b) (c)
the type of equipment to be stocked; the amount to be stocked; related to the amount to be stocked; the procedure to be used to replenish supplies.
In Malaysia, ULV ground application had been made with the LEGO H-D machine which had been found to be consistent in its aerosol dispersion, extremely reliable, easy to operate and durable. Its only disadvantage, besides its weight, was that it could not be used in areas that had buildings of more than two storeys. The machine had proved very useful in urban areas where most outbreaks had occurred. It would not be suitable for remote rural areas but no major epidemics had occurred there. Portable thermo-fogging machines had also been used in Malaysia. Two important considerations in relation to the type of machine kept in stock were: (a) (b) the fact that spares of the simpler expendable parts had to be stocked at all times; if a Member State had no personnel experience in the maintenance and operation of the machine, the Regional Office would not only have to send the machine but also a technician.
A manual of simple instructions for using the LEGO H-D machine, prepared in Malaysia, was available to interested countries. It was recommended that the LEGO H-D machine be obtained, despite its heavy weight, which should not exclude it for consideration when one machine could do the work of two or three one-ton machines. Since a few outbreaks would rapidly deplete the funds, he suggested that Member States pay for insecticides used so that revolving funds would always be available. If supplies could be obtained on say three months' credit this would help. The REGIONAL DIRECTOR thanked the Representative of Malaysia for his very useful comments. He hoped that governments would pay for the insecticides provided quickly. He realized that it was not always possible to get funds sanctioned immediately but an outbreak needed to be combated quickly. Dr COUTURIER (France) stressed the necessity for community action designed to eradicate breeding sites at all times not only during outbreaks. Such action could be entrusted to health workers at all levels - family, school, neighbourhood - and supported by radio broadcasts, advertisements and posters. The ecological, material and
122
REGIONAL COMMI'l"IEE:
'lWENTY-SIXTH SESSION
finanoial advantages of such a oourse, more oentred on oOllDllon sense than on teolmology, were obvious. In Frenoh Polynesia, the veotor man/hour index had fallen from 4 to less than one after only a sixweek effort of the sort described. It appeared that the threat of an outbreak was removed, without having to resort to ohemioals, when the index fell below one mosquito per man per hour. DICKIE (New Zealand) stated that his Government supported the proposal to plaoe the amount of US$lO 000 in the 1976 and future lists of additional projeots. Dr
Reoent outbreaks of dengue haemorrhagio fever showed the need for oontinuous vector oontrol. Knowledge that equipment was available might lull some authorities into complaoenoy. They were not absolved from the responsibility of themselves having to take measures to oontrol the veotors. Individual territories should have emergency plans for the deployment of adequate manpower, transport and plant in the event of an outbreak, even without WHO equipment and support. An outbreak oould be widespread and therefore the assistanoe provided would not be enough. It might be oonsidered neoessary to restriot the availability of equipment and supplies to the smaller islands where diffioul ties might be enoountered in purohasingand maintaining equipment. The Government of New Zealand was seeking ways of providing assistanoe in times of disaster of any kind, inoluding outbreaks of dengue fever. The CHAIRMAN stated that Western Samoa was in the middle of an outbreak at present, with over 300 oases having been reported by late August. The timely visit of the WHO regional adviser on vector oontrol had helped. He thought that an amount of US$lO 000 was insuffioient. In Western Samoa, which was a small island with a PQr'ulation of 160 000, the initial budget had been uS$2o 000.
Dr TOUA (Papua New Guinea) said that following the outbreak in Western Samoa, the Government of Papua New Guinea had taken steps to try and proteot itself by purchasing three ULV pumps and a few supplies oosting A$lO 000: the only staff available were for malaria oontrol. US$lO 000 would not be sufficient espeoially for larger countries. Governments needed to prepare for emergencies by ensuring that staff were available. The REGIONAL DIRECTOR amplified his initial statement by saying that WHO staff could be sent to train national staff in the use of the equipment. WHO had oonducted a number of oountry and interoountry oourses to train staff to deal with emergenoies and to maintain a continuous campaign to eliminate the vectors. If US$lO 000 was not sufficient, oonsideration could be given to inoreasing the amount.
SUMMARY RECORD OF THE THIRD MEETING
123
Professor CHOW (Regional Adviser on Vector Biology and Control) drew attention to document wp~/16, itA Critical Review of Certain Ground Equipment and Insecticides for Aedes Aegypti Control", mentioned by the Regional Director in presenting his Annual Report. This document provided the answers to questions raised by the Representatives of France and New Zealand. It was well known that basic sanitation and health education were fundamental measures in controlling the vector mosquitos. During epidemics it was obviously too late to carry out basic sanitation measures, which should have been undertaken at the very beginning. There was no specific treatment for dengue fever or dengue haemorrhagic fever; no vaooine had yet been developed. The only action to be taken was to kill the veotor mosquito and this was done with inseoticides. The proposal for emergency assistance was the outoome of experience gained during the outbreak in Fiji early in 1975, where an estimated 30 000 persons in Suva alone had contracted dengue fever. At that time, the Government had asked WHO to lend it the equipment and insectioides necessary for its oontrol campaign but the Organization did not have any readily available, nor did it have resouroes with whioh to take immediate action. Technical and advisory servioes had been provided instead; the South Paoifio Commission had given some equipment but no insecticides. Professor Chow agreed with Dr Majid that the IECO H-D equipment was useful but it was heavy and needed good roads to transport it. He also agreed that the sum proposed was small but it.was only to be used in oases of emergenoy. Replying to Dr Toua's oomments, Professor Chow said that a workshop on anti-mosquito measures had been held recently in Kuala Lumpur to train staff in new methods of controlling insect-borne diseases.
Dr EVANS (Australia) said that his delegation would support the Regional Director's proposal. It seemed to be an efficient, adequate way of making equipment freely available as an emergenoy measure. He agreed with the Representative of Malaysia that spare parts were essential for whatever maohine was purchased. There being no further comments, the Chairman requested the Rapporteurs to prepare an appropriate resolution. (For consideration of the draft resolution, see the fourth meeting, section 3.2.)
6
INFANT NU'mITION AND BREAST FEEDING: (Document wpR/RC26j8)
Item 14 of the Agenda item. He said that that it be included the subjeot. WHO and Member
Dr NICHOLSON (United Kingdom) introduced this the Government of the United Kingdom had suggested in the Agenda because of the extreme importanoe of Dooument wpR/Rc26,18, outlining the aotion taken by
'
....
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REGIONAL COMMI'lTEE:
'lWENTY-SIXTH SESSION
States in the Region and proposing future action, had been read with interest. It was gratif',y:l.ng to note that the circular letter sent to all Member States f'ollowing resolution WPR/RC25.RlO stressed that the resolution should not be considered in isolation but in association with the development of' programmes in other fields, such as social affairs, agriculture and community development including sanitation, communication and employment. Dr Nicholson congratulated WHO on the action taken so far. He emphasized the importance of' sustained health education, including education in the hygienic preparation and use of items needed for supplementary feeding, which merited continued consideration by health administrations as each generation of young women reached child-bearing age. With regard to the ethics of sales promotion methods used by artificial milk-food producers, it would be useful to mow the vielfS of health administrations in the Region on whether there had been violations of ethical codes in their countries. Dr MAJID (Malaysia) stated that the Government of Malaysia fully supported the concepts of infant nutrition and breast-feeding given in document WPR/RC26/8. In Malaysia, activities related to nutrition and breast-feeding were carried out in an integrated manner through the existing rural health infrastructure, as part of the family health programme. A national applied food and nutrition programme, coordinated by the Prime Minister's Department, in which the Ministries of Agriculture and Rural Development, ~alth, Education and Information were taking part, was in progress. Priority for the expansion of this programme had been based on infant mortality rates which were used as an index for malnutrition. Maternal and child health services, including nutrition services and nutrition education, were being strengthened in all areas covered by the applied food and nU\;1'1,tion programme and in areas where family planning services were integrated with the rural health services under the population project. This involved the coordinated and integrated efforts of the other Ministries - Education, Information, Agriculture and Rural Development - in supplementing the efforts of the Ministry of Health. Activities related to the promotion of infant feeding and breastfeeding were ~ntensified by all categories of maternal and child health personnel during the antenatal period and followed up during post-natal home nursing visits and sessions on child health. Cooking demonstrations during child health sessions stressed supplementary feeding using locally available foods. A campaign to promote breast-feeding and improved infant nutrition was planned as part of the applied food and nutrition programme. The feasibility of commencing a breast-feeding project was being studied by WHO, FAO and SIDA.
,
SUMMARY RECORD OF THE THIRD MEETING
125
A supplementary feeding programme for pregnant and lactating mothers, infants and children was being carried out through maternal and child health clinics. Skim milk was being used and the criteria for distributing it had been circulated to all health centres. It was hoped eventually to replace skim milk with locally produced foods. The maternal and child health unit worked closely with the Food Technology Institute in trying to develop and produce infant foods. With financial aid from the Government of Australia, the ABEAN countries were carrying out a joint project for the development of low-cost protein foods, based on soya bean, for infants and children. Training in nutrition of all categories of health staff was carried out parallel with the expansion of the applied food and nutrition programme. Nutrition was incorporated into the basic curriculum of the training programme for multipurpose workers and the training of auxiliary health workers in food and nutrition was under way. The following objectives, additional to those given in document wpR/Rc26j8, were proposed; (1) a code of ethics should be established and practiced giving priority to breast-feeding and preventing commercial firms from promoting artificial feeding; (2) there should be government control of advertisements relating to feeding of infants and young children; and (3) there should be proper labelling and control of formulae and modified milk for infant feeding. Dr laNG (United States of America) stated that his delegation was particularly pleased to see this item on the agenda and congratulated the Regional Director and his staff on the progress already made. It strongly endorsed the proposals for future action. It wished to suggest that the objectives be broadened to include not only the establishment of national food and nutritional policies but also the promotion of such policies as integral parts of national development plans. The delegation of the United States of America also placed emphasis on the importance of coordinating WHO's efforts with those of other international agencies, such as UNICEF, UNFPA and FAO, and recommended that studies, already proposed in section 2.2 of document WPR/RC26j8, be undertaken to provide information on the relationship between feeding practices and morbidity and mortality patterns.
Dr CHEN (China) welcomed the Representatives of the Republic of South Viet-Nam who had just arrived. The delegation of the People's Republic of China had found the document very interesting; in China breast-feeding and mixed feeding were the general practice. Chairman Mao Tse Tung, the Chinese COllllllUIlist Party and the Government had always been very concerned about the health and growth of children. The Constitution of the People's Republic of China explicitly
126
REGIONAL COMMITlEE:
'lWENTY-SIXTH SESSION
stipulated that mothers and ohildren should enjoy the proteotion of the State. '!he Party and the Government had taken various oonorete measures to faoilitate and support the praotioe of breast-feeding infants. Aooording to government regulations, working mothers were entitled to 56 days of maternity leave. If a woman gave birth with oomplioations or to twins, she was entitled to 70 days maternity leave and her wages oontinued to be paid. Provision was also made for mothers who were breast-feeding to have time off during working hours to feed their infants. Rooms for breast-feeding and infant day-oare oentres were widely established. In the rural areas, women oommune members were assigned to light work or worked olose to the oommune after materni ty_ leave. A great number of day-oare units and stations were set up during peak farming periods. To supplement mother's milk, low-prioed nutritious milk substitutes were produoed, wi th soybean protein as the main ingredient; fresh milk from oows and goats and other dairy produots were also used. '!here would be further researoh in China on milk substitutes and supplementary foods suitable for infants. Child-oare oentres would be established. Every effort was being made to improve the health of infants and ohildren. Dr DIZON (Philippines) said that his Government, fully aware of the gravity of the problem of malnutrition, not only in the Philippines but in other areas of the Region, had adopted, as one of the main objeotives of its health programme, the proteotion, preservation and promotion of the nutritional health and well-being of ,the population, particularly the vulnerable age groups, infants and pregnant and nursing mothers. Breast-feeding was reoognized as a major publio health measure whioh required the joint effort of the Government and private entities. '!he Department of Health had oonduoted a series of symposia on nutrition, maternal and ohild health and family planning for health professionals, inoluding one on breast-feeding. Emphasis had been placed on eduoating and training professional health workers with a view to eduoating mothers in breast-feeding and adequate supplementary and artifioial feeding. Motheroraft nutrition oentres served as child feeding demonstration centres for the rehabilitation of cases of malnutrition and provided an opportunity to educate mothers in nutrition. In "nutriwards" established in government hospitals for the rehabilitation of malnourished children the physical faoilities provided opportunities for the mother to play an active role. This arrangement also enabled the mother to learn about health in general and nutrition in particular. Dr OSAWA (Japan) described the national programme for breastfeeding advancement being developed at present by the Ministry of Health and Welfare. It oonsisted of: (1) a public information campaign; (2) the establishment of a study team on the effect of
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breast-feeding for the development of sound and healthy children; (3) training courses and public education activities; (4) requests to local governments and related voluntary organizations for cooperation in the promotion of a breast-feeding programme; (5) a study and a review of the guidance to be given with regard to advertisements for the sale of commercial products for babies particularly milk products. Mrs BROINOWSKI (Australia) stated that the Government of Australia had made every effort to enable a larger number of women to breast-feed; for example, women employees who would previously have had to artificially feed their babies to keep their Jobs. It had made it possible for women in government service to adjust the period of their maternity leave, from the pre-partum to the postpartum period, if they wished to continue with breast-feeding. It was hoped that private enterprise would follow the initiative of the Government. The Government's action had been in response to the concern, now being recognized, regarding the effect of artificial feeding on infants. It was suspected that artificial feeding was an important factor in development of coeliac disease, food allergies, cot-deaths and contributed to the effect of over-nutrition and the early failure of lactation. The Government was following the lead of the community in expreSSing its appreciation to the growing number of Australian women who were concerned with the promotion of breast-feeding. The Nursing Mothers' Association of Australia, a private organization, had expanded remarkably in recent years, particularly among the middleincome social group. It advocated that breast-feeding had many advantages worth defending, whatever impediments might be placed in the way. It was believed to be the Government's responsibility to make every effort to remove pressures against breast-feeding that might place difficulties in the way of women wishing to continue it. It was considered to be unfortunate that bodies such as WHO should speak of the need to improve the attitudes of mothers, which surely needed no improvement. What needed to be improved was the advice given, which varied according to the theories in vogue at the time. Twenty years ago, mothers had been told to improve their attitudes by purchasing formulae which would contain everything a baby needed, and not to continue with the so-called unhygienic, unpleasant and unscientific habit of breast-feeding. Later breast-feeding was advocated. It needed to be recognized that mothers had the wisdom to know what was good for their babies. Telling people what had been decided was best for them was a patronizing attitude that WHO could well dispense with. Dr DICKIE (New Zealand) thanked the Representative of the United Kingdom for having introduced the item.
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REGIONAL COMMI:TmE:
'IWENTY-SIXTH SESSION
Referring to the following statement in dooument WPR/RC26;8: "In sooieties where breast-feeding dominates as a tradition, supplementary feeding is usually introduoed too late and is unsatisfaotory", Dr Dickie said that there were areas in the Region where breast-feeding dOminated, but accompanied by supplementary feeding introduoed at an early stage; this proved to be very satisfactory. One important factor, which quite often resulted in malnutrition in infants in developing countries, was the arrival of another baby resulting in the previous baby being turned over to relatives and friends before it had been properly weaned. '!he abrupt oessation of the mother's milk, coupled with the inevitable trauma which resulted from the loss of her care and attention, were the chief faotors which resulted in malnutrition, rather than the unsatisfaotory nature of the supplementary food. Dr Dickie oonsidered the objeotives of the programme to be important in promoting an awareness in the population of the merits of breast-feeding; though ooncrete reasons needed to be given for why it was better, such as the faot that breast-fed babies reoeived antibodies from their mothers whioh they did not get from bottles. Dr Dickie upheld the importance attached by the Representative of the United Kingdom to the ethios of the question. Dr THAN CUU KIEN (Republio of South Viet-Nam) stated that breast-feeding was related to social problems. In areas of the Republio of South Viet-Nam that had been oontrolled for some time by the Provisional Revolutionary Government, nutrition was not a problem. This was beoause they were agricultural and oattle breeding areas and also beoause birth oontrol was enoouraged; thus there was food for all. In the area of Saigon however the majority of f..,dUes had at least six ohildren and often more than ten. Many mothers were among the two million without employment in the recently liberated areas. The feeding of children in the Republic oreated an acute problem. Aocording to evaluations made by international agenoies, there were between 800 000 and 1 500 000 orphans in an area that had only 37 orphanages with 2085 beds. While recognizing the superiority of breast-feeding, authorities in the Republic of South Viet-Nam were faced with a situation in which it was often impossible to advooate it. Dr Tran Cuu Kien asked for the Committee's assistance in solving this very serious problem. Dr TOUA (Papua New Guinea) said that he wished to support the statement made by the Representative of Australia regarding the eduoation of mothers. In some developing oountries the breast was the only way to feed the child. Only when a family moved from
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its own rural environment to an urban area, or when husbands went to seek employment in a different area did problems arise. When this happened parents neglected their children. In addition to educating mothers to breastfeed there was a need to educate fathers to provide the means to feed their children and their pregnant wives properly. In some areas breast-feeding was used as a way of spacing the children. The fact that mothers breastfed for a longer period resulted in unsatisfactory supplementary feeding. The CHAIRMAN said he supported the proposals for future aotion, In Western Samoa it had been recognized that it was necessary to develop some sort of weaning food. He was happy to say that a food oomposed entirely of ingredients available in the Western Pacific Islands was now almost ready for production. It had been tested and found to be quite palatable. The Government of Western Samoa would be happy to make its experienoes in developing this produot available to other countries. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate resolution. (For oonsideration of the draft resolution, see the fifth meeting, section 1.2.) 7
r
ACKNOWIEDGEMENT BY THE CHAIRMAN OF BRIEF REPOR'lS RECEIVED FROM GOVERNMENTS ON THE PROGRESS OF THEIR HEALTH ACTIVITIES: Item 8 of the Agenda (continued from the first meeting, .section 6)
The CHAIRMAN acknowledged a report on the progress of health activities received from the Trust Territory of the Pacific Islands.
B
ANNOUNCEMENT
Referring to the programme of work for 3 September 1975, the REGIONAL DIRECTOR suggested that, i f the Committee wished, the afternoon could be left free; business left unfinished after the morning session to be resoheduled for later in the week. It was so agreed.
The meeting rose at 12.00 noon.