International cooperation: the key to cancer control [full issue]

INTERNATIONAL COOPERATION: THE KEY TO CANCER CONTROL WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION NOVEMBER 1975 • USA $1 2 Contents Cover: In search of a cure ... a cancer immunology expert at the Jefferson Medical College, Philadelphia, USA. (Photo American Cancer Society) International cooperation by A.S. Pavlov 3 Unmasking the agents by W. Davis 4 A common language by A. M. Garin & L. Sobin . 10 How education helps by G. Gastrin 14 Breast self-examination . 18 One woman's experience by M. Bayh 20 Shifting patterns by N.T. Racoveanu 22 African success story . 25 Progress and research by R. L. Clark 26 WHO News in Brief & Letters 32 Young World Health . 34 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. international cooperation is the key BY ALEXANDER PAVLOV f recent years there has been a markedly increased interest in many countries in the problem of cancer. The problem is being discussed today not only in scientific conferences and congresses but also in national parliaments and in meetings at the highest level. It even came up for mention at the Conference on European Security and Cooperation, at which cancer research was sin- gled out as one of the most promising spheres for scientific cooperation. There are substantial grounds for this interest in cancer. In many countries of the world it is already, or is becoming, one of the most common causes of death. According to conservative estimates by the World Health Organization in 1974 and 1975, there was an annual average of over six mil- lion new cases of cancer, and about five million deaths from cancer were recorded in the world as a whole. Statistics also show that in recent years the increase in the mean expectation of life has slowed down in many devel- oped countries. This phenomenon is partly due to a number of diseases, including cancer, for which it is still often diffi- cult to effect a radical cure. Of key importance in the investigation of malignant neo- plasms is basic research designed to throw light on the bio- logical nature of malignant growth. It has been established that the normal cell is transformed into a malignant cell under the influence of chemical compounds (carcinogens), oncogenic (cancer-inducing) viruses, or ionizing radiation, and the number and amount of these carcinogenic sub- stances or factors in nature are constantly increasing. It is therefore extremely important to establish a system of con- trol with a view to protecting our planet from pollution with various chemicals, including carcinogens, formed as waste products in industry, transport and other sectors. Important branches of basic research are the study of the features of the genetic apparatus of the tumour cell, the study of the processes of metabolism and synthesis that occur in the interval between the division of the cells, elucidation of the mechanisms that trigger off cell division, determination of the function of the cell membranes, and the detection of specific antigens and many others. This multitude of subjects for research in cancer studies makes it necessary to enlist the services of specialists in allied branches of science such as cytology, genetics, biochemistry, biophysics, immunology and so forth. It seems reasonable to suppose that only by such an integration of knowledge can we come nearer to solving the riddles of cancer. It must be remembered, however, that cancer has in fact already yielded up some of its secrets. Within the last centu- ry great successes have been achieved in the study of the problem throughout the world, and the knowledge that has been accumulated has enabled basic measures to be devel- oped for the prevention, diagnosis, and treatment of cancer. .1 Treatment of a skin tumour by laser beam at the Ukrainian Acade- my of Sciences in Kiev, USSR. (Photo Novosti) The most effective method of disease control is preven- tion. This applies equally to cancer. Protecting people against chemical carcinogens, safeguarding the environment, encouraging people to give up smoking and other harmful habits, fostering better personal hygiene, and treating pre- cancerous conditions in good time, will, in a number of cases, prevent the development of cancer. Methods of treating cancer are also being constantly im- proved. Today, in addition to surgical operations, use is being made of radiotherapy, chemotherapy, and immuno- therapy as well as other methods. Radioisotopes, powerful gammatherapy installations, betatrons, linear accelerators and other radiation sources are being used to irradiate tumours. The rapid development of chemotherapy has attained a qualitatively new level in that there is promising evidence of its ability to achieve radical cure for some cases. The results of cancer treatment are improving. According to data from a number of large cancer establishments, mod- ern methods of treatment now make it possible to cure three or four out of every 10 cancer patients. Treatment is highly effective in the case of cancer of the skin, lip, larynx and uterine cervix. Successes have also been achieved in recent years in the treatment of Hodgkin's disease, chorioepithelio- ma, and other tumours. In the relatively early stages of cancer of the uterine cervix, treatment is effective in 60 to 80% of cases. Statistics from the Ministry of Health of the USSR indicate that about 1,500,000 people in the Soviet Union are alive today who were cured of different forms of cancer five or more years ago. To carry out on a national scale the complex set of cura- tive and preventive measures needed requires the establish- ment of a special cancer service, such as was established in the USSR in the 1930's. A number of other countries now have such services. In 1973 the Twenty-sixth World Health Assembly, in view of the importance of the problem, adopted a resolution call- ing for the development of a long-term programme of inter- national cooperation in cancer research. The overall aims of the programme and the forms it will take have now been established, priorities have been laid down for the various types of research, a standard cancer terminology and code are being developed for computer use, and a mathematical model of the programme is being constructed. Given the present level of the medical and biological sciences, it is not unreasonable to assume that the cancer problem will be solved within a few decades. But to achieve this aim will require the mobilization of international and national scientific and financial resources to the greatest pos- sible extent. WHO is well aware that the successful implemen- tation of the programme called for by the World Health Assembly will be possible only if the activities of national institutes and international organizations alike are permeat- ed through and through by the spirit of cooperation. ■ 3 unmasking the agents More than four-fifths of human cancers seem to be caused by toxic substances in man's environment: identifying them would help to minimize the risks BY WALTER DAVIS edical services in all parts of the world are making major efforts to achieve earlier diagnosis of cases of cancer and better treatment for the patients once they have been diagnosed. With the modern techniques available, clini- cians are able to improve the chances of long-term survival for some cancer patients. For many patients, unfortunately, the most modern and highly sophisticated methods of treatment are not available, and not all medical services can assure the much- desired early diagnosis that can be so impor- tant. For breast cancer, for example, mortality has remained at the same level for 50 years. In the face of statistics like these, it is not surprising to find that increasing resources are being devoted to primary cancer control, i.e. to the prevention of cancer. At the present time we know little about the actual cause of most human cancers, but statistical analyses of data collected from many different parts of the world indicate that it is highly likely that more than four- fifths of all human cancers are caused direct- ly or indirectly by toxic substances in man's environment. If some of these substances that are capable of causing cancer in man (carcinogens) can be identified, it may then prove possible to remove or to minimize the risk of human exposure. The mission en- trusted to the International Agency for Research on Cancer by WHO is precisely to identify some of these environmental carci- nogens. The starting point for the hunt for carci- nogens is the strangely irregular pattern of cancer statistics. Whilst cancer occurs in all human populations, some cancers prove to be much more common in some parts of the world than in others. For example, lung cancer is 7 times more common in Britain than in India, and oesophageal cancer is 60 times more common in the north of France than it is in Hungary. We could quote con- trasts of similar magnitude for cancers of most sites, and we have good reasons for believing that what lies behind such varia- tions are differences in exposure to some cancer-producing (carcinogenic) substance or substances, present in the environment. Perhaps the most telling evidence has been that obtained from studies of migrant population groups. Stomach cancer in Japan presents a very serious problem, with an average of 98 cases per 100,000 of the population; in the United States this cancer is much rarer, with about 15 cases per 100,000. The Japanese families who emigrat- ed to the West Coast of the United States during the last few decades were very care- fully studied by Dr Bill Haenszel and Dr Minoru Kurihara. They found that Ameri- can-born children of these migrants had a lower risk of stomach cancer than if they had been born in Japan, although the risk was still higher than that for other USA- born children. These findings strongly sup- port the role of environmental factors in the causation of cancer and, in this particular instance, suggest that a carcinogen capable of producing stomach cancer was present in the environment in greater quantities in Japan than on the West Coast of the USA. The Agency, under the direction of Dr John Higginson, has set about the task of finding population groups that appear to be at a higher than "world average" risk for a given cancer and then, by focussing down on to individuals in that population group, trying to identify the possible carcinogens to which they were exposed. A seven-year study of liver cancer has recently been rounded off at the Agency's research centre in Nairobi. The study covered areas in Kenya and other parts of Africa, where this cancer is many times more common than in most European coun- tries. By carefully analysing the food eaten in three areas of low, medium and high inci- dence of liver cancer, it was shown that there was a strong correlation between the amount of aflatoxin in the food and the in- cidence of liver cancer. Aflatoxin is a chemi- cal substance formed in foodstuffs that have been infected with a mould and stored in hot, moist conditions. The problem of how to reduce the level of aflatoxin contamination under the economic and climatic conditions that prevail in the A laminar flow hood ensures sterile conditions i> as tissue cultures are being prepared at the International Agency for Research on Cancer (IARC) at Lyon, France. IARC carries out research in carcinogenesis for WHO. (Photo WHO/J. Mohr) 4

NA* . • :It. ► ; area still remains, but at least the essential first step, the identifying of a probable causal factor, has been taken. In the Geneva cancer registry, a study of liver cancer cases there has shown a quite different causal agent — excessive consump- tion of alcoholic beverages. Another cancer that has occupied the at- tention of the Agency's research teams is oe- sophageal cancer, which occurs with dra- matically high frequency in a belt extending from the north-east corner of Iran, across the central Asian republics of the USSR, through Mongolia to the north of China, but also in a relatively small area in the north of France. In Asia, the study area is confined to Gonbad, in the north-east of Iran on the southern shores of the Caspian Sea where Agency scientists have worked in collabora- tion with Iranian research workers coming mainly from the Institute of Public Health Research and the Tadj Pahlavi Cancer Insti- tute in Teheran. The teams have gone from family to fami- ly in the villages in the regions both of high and of low incidence of oesophageal cancer, making a detailed study especially of nutri- tional habits. Results to date, which are cur- rently being re-checked by field studies, show that in the high-incidence areas people eat bread and, in the low incidence areas, rice. Moreover, there was a close association between the frequency of oesophageal cancer and the consumption of sheep's milk and of yoghourt made from the milk. Many food samples have been analysed chemically in the laboratories of the Agency and of its collaborators, so far without any evidence that they contained significant amounts of any known carcinogen. One important piece of information was that almost no alcoholic beverages are drunk by the people in the high incidence area, who are Turkoman by origin and Moslem by religion. The Agency's study in the north of France in collaboration with research work- ers from the National School of Public Health at Rennes, France, has narrowed down the search by showing that it is among the heavy drinkers in Brittany that the majority of the cases of oesophageal cancer are found. It seems highly likely that the cause will be found in the spirits made from apple cider that are drunk locally. This will be investigated by epidemiologi- cal methods, comparing statistically the drinking habits of oesophageal-cancer patients with those of the general popula- tion, and also by chemical analysis of sam- ples of drinks to determine whether they • 6 unmasking the agents <Ketva has a high incidence of liver cancer and systematic analysis of some foodstuffs has suggested that certain moulds may have carcinogenic effects. Here samples are being taken by Workers at the Cancer Research Laboratory in Nairobi, which was set up by the IARC. (Photo WHO/P. Almasy) Unloading sugar cane at a Jamaican distil-> lery. Scientists are trying to determine wheth- er the drinking of locally producedalcohol in certain parts of the world may explain an increased incidence of throat cancer. (Photo WHO/P. Almasy) contain any carcinogen and if so, how much. These analyses are being done in the Agency's laboratories at Lyon. The task is far from easy, for even though these labora- tories are equipped with highly sophisticated apparatus, the amounts of carcinogenic subs- tances that the scientists are attempting to measure may be only of the order of one part per million—one milligram in a kilogram of the drink sample, or less. They are using gas chromatographs and mass spectrometers, apparatuses that can virtually detect ions— charged atoms or molecules. But before they start their analyses, the chemists need to have some idea of what substances are likely to be present in the sample, and among those present, which are likely to be carcinogens. The answers to these questions should come from the laboratories all over the world, where chemicals are being tested by administering them to experimental ani- mals—usually rats or mice—to see whether they produce cancer. This type of testing is a slow and costly business, since large num- bers of animals are necessary, particularly if weak carcinogens are to be identified, and they must be followed for the whole 2-3 years of their life span. Even if all the labo- ratories available were doing this work, pro- bably no more than 400 substances could be tested in this way in any one year. There- fore, efforts are now being made at the Agency to develop a rapid and standardized screening test, which will deal with more substances more quickly. The basis of this rapid test, which was first developed by Dr Bruce Ames of the University of Califor- nia, is that nearly every substance known to produce cancers in animals can also cause mutations in bacterial colonies, that is, change their genetic behaviour. This is only one type of rapid test; others are based on the ability of chemicals to change the growth pattern of mammalian cells raised artificially in culture, or to produce abnor- malities in the chromosomes of dividing cells, or to inhibit the biochemical mechan- isms by which cells can repair themselves after their nucleic acid has been damaged. The Agency, in collaboration with labo- ratories in several countries, is trying to es- tablish to what extent these more rapid tests can be relied upon to indicate whether a given chemical is or is not going to be a carcinogen for man. This is of course a cru- cial question. Some 40,000 new chemical substances are being produced yearly. Of these, several hundred may be used in large scale production and distributed widely among the population. There are also very many substances already in use that may 7 unmasking the agents never have been properly tested for carcino- gens. It is impossible, therefore, to exagger- ate the importance of rapidly building up an efficient and fast system for carcinogenicity testing. In the last year, the Agency has been much concerned with problems posed in the plastics industry by the discovery that vinyl chloride monomer, the primary material used to make the plastic PVC, is a human carcinogen. PVC—polyvinyl chloride—is be- ing manufactured in vast quantities through the world. It is estimated that in 1975 more than 9 million tons will be produced for a vast variety of uses including electrical insu- lation, all sorts of packaging, water- and drain-pipe systems and even for surgical tubing. There is absolutely no indication that PVC itself presents any carcinogenic risk, but since it may contain a few parts per million of vinyl chloride, scientists and pub- lic health authorities are keeping a close watch, especially where the plastic is used in food containers. The real danger is in the factories where the plastic is made : some of the factories are more than 30 years old, and until two or three years ago nobody ap- parently considered that vinyl chloride was particularly toxic. Some men in the industry were exposed to considerable concentrations of vinyl chloride vapour, especially in the early days, and there are now more than 40 recorded cases of people dying from a rare cancer of the liver—haemangiosarcoma- caused by vinyl chloride. There has been an immediate reaction in all the countries where PVC is made. Control measures have been introduced to reduce exposure to vinyl chloride to the absolute minimum—though that minimum figure varies from one coun- try to another from between 1 and 50 parts per million. Medical control of workers who might have been exposed has become man- datory, but this offers little protection against the cancer risk. In certain cases, where factories were not using the more modern processes, plants have been shut down and will have to be re-designed. Overall, a great deal is being done to cut down the risk of cancer among plastics workers, but no one has seriously suggested that the PVC industry should close its doors. Just as "society" continues to accept that coal miners risk their lives and health to provide us with coal, so "society" accepts a level of carcinogenic risk for those in the industry that provides us with our very use- ful PVC. This situation may not seem so acceptable to the people actually exposed to the risk, but, in any case, it is absolutely vital that they should be very accurately in- formed about it. Any change in that situa- tion will need political and economic deci- sions of great impact and beyond the reach of the scientists. What the Agency is doing is to compile all the available data, not only on vinyl chloride, but on hundreds of other chemical substances, in order to make as objective and authoritative an evaluation as possible of the level of carcinogenic risk for each chemical or group of chemical substances reviewed. The team of scientists and biblio- graphic researchers doing this work has the assistance of experts from many different countries for consultation before preparing monographs in which data are set out and an evaluation made. These monographs provide government officials and those in industry with the scientific facts on which decisions for control can be taken. Thus, in the field of cancers caused by industrial or occupational exposure, there does seem to be the possibility of applying the dictum "prevention is better than cure". One very big question today is "do viruses cause cancer in man?" Viruses, much smaller than bacteria and visible only with the aid of an electron microscope, cause a variety of diseases—smallpox, measles, mumps, chicken-pox, infantile paralysis and influenza are all examples of virus diseases, each caused by a different known virus. The challenge of determining the role of viruses in human cancer has been taken up in the Agency. Two forms of cancer are be- ing studied, nasopharyngeal carcinoma and Burkitt's lymphoma. The former is a cancer that affects the 'space at the back of the throat and is exceedingly common amongst the southern Chinese in Canton and in Sin- gapore and Hong Kong; it is rather rare among all other people. The latter is a gen- eralized disease that often produces large tumours in the jaw; it occurs in equatorial regions around the world, but is mainly be- ing studied in Uganda, where it attacks chil- dren between 6 and 8 years of age. There is a virus, named after its discover- ers, Epstein and Barr, that has been found in cells grown in culture from both these cancers. Moreover, immunological tests made in the blood of patients with these two cancers show evidence of infection by the Epstein-Barr virus. But this is not yet evi- dence that the virus has caused the cancers, especially since amongst the southern Chinese and the children in Uganda Ep- stein-Barr virus infection is very much more frequent than are cases of cancer. On the other hand, scientists in the United States have infected monkeys with the Epstein- Barr virus and produced a disease similar in some ways to Burkitt's lymphoma. Much more research is under way on both cancers. In Singapore, at the wHo Collaborating Centre for Research and Training in Immu- nology, a study has been made of the genet- ic make-up of the Chinese population, who are much more susceptible to nasopharyn- geal carcinoma than, for example, their neighbours who are of Indian or Pakistani origin. Using sophisticated immunological techniques, the scientists there have detected minute genetic differences between patients with nasopharyngeal carcinoma and healthy Chinese people. That would seem to be that, although not all southern Chinese have the genetic make-up that goes with susceptibili- ty to nasopharyngeal carcinoma, and it is only among the southern Chinese that the susceptible people are found. This does not tell us anything about what may be causing the disease, but it implies that if two people, one with the "susceptibility gene" and one without, are exposed to the same carcino- genic hazard, be it virus or chemical, the former is much more likely to develop naso- pharyngeal carcinoma than the latter. The Burkitt's lymphoma study is continu- ing in the West Nile district of Uganda, fol- lowing up a hypothesis that there is a rela- tionship between Burkitt's lymphoma and malaria infection. One of the Agency's col- laborators in Uganda has shown that malaria is twice as common in the lowlands of the Mara region in Uganda as it is on the neighbouring high plateau, and Burkitt's lymphoma occurs only in the lowlands and never among the children who live on the plateau. Eptstein-Barr virus infection and malaria seem to be co-factors, together play- ing a part in the causation of Burkitt's lym- phoma. It is planned to try to reduce the level of malaria, by giving children sufficient supplies of chloroquine tablets, in the hope of reducing the incidence of Burkitt's lym- phoma. Our present-day knowledge indicates a great complexity in the environmental fac- tors that combine to cause some of the cancers in man, but we can be confident that with the techniques at our disposal it will be possible to unmask more and more causal agents. The subsequent task of trying to remove them from the human environment may not prove very easy either, but we are sure that the possibility of primary cancer prevention is an attainable goal. ■ A type of cancer affecting the upper part of l the throat (nasopharynx) is extremely com- mon here in Hong Kong, as well as in Singa- pore and Canton, but is rather rare elsewhere in the world. Scientists are trying to find out why. (Photo WHO) 8

a common language Nearly 300 leading pathologists from 50 countries collaborate actively with WHO to determine standard names and diagnostic criteria for over 100 tumours BY A.M. GARIN & L. SOBIN t ancer affects people in all countries and on all continents. The term is a collective one and covers over 100 varieties of the disease, each with different clinical manifestations, symptoms, course and prognosis. It is well-known that the prevalence of various forms of cancer differs from one country to another and from one area of a country to another. However, should a tumour of the same ori- gin and the same structure develop in an Australian and a European, the clinical fea- tures of the disease, its diagnosis and the sensitivity of the tumour to radiation or chemotherapy will be the same or very simi- lar in both these people, though they are from widely separated parts of the globe. But although the governing principles are the same, they are variously perceived, inter- preted and described by physicians in dif- ferent countries and of different schools. Something must be done to ensure that the successes and failures encountered in cancer control in one country are made known to the rest of the world, for everyone can learn from failure and, of course, from success too. The World Health Organization considers one of its most important and key tasks to be the development of a "common lan- guage" for medical staff and research work- ers in the cancer field. The International Classification of Dis- eases, now in its ninth revision, is one of the Organization's major achievements. wHo experts review and supplement this list of human diseases every 10 years. In it, tumours are classified by site (lung, stomach or other organs) and by biological beha- viour (malignant or benign). The numbering system ensures the universal applicability of these characteristics and a special coding system to be introduced shortly will also make it possible to record the histological (tissue) type of the tumour. As we have already mentioned, there are over 100 clinical varieties of tumours, and the number of histological variants, visible under the microscope, is far greater. For ex- ample, over 30 types of bone tumours have been described, and the same number of ovarian tumours. The variety of names given to a single histological form of cancer is a serious hindrance to recording and com- paring data from different countries. The same type of kidney tumour may be referred to by different pathologists as hypernephro- ma, clear-cell carcinoma or Grawitz tumour. In the salivary glands a tumour known as adenolymphoma has also been called papillary cystadenoma or Warthin's tumour. Sometimes the same name is used to describe different types of tumour—for instance, the term clear-cell carcinoma may be used to describe unrelated tumours found in the kidney, ovary or lung. A \vim programme for a unified and stan- dardized histological classification of tumours was lauched in 1958. It had not only to determine standard names for all varieties of tumours but also to draw up criteria (morphological characteristics) for the establishment of a given histological diagnosis. A WHO Collaborating Centre was selected for each tumour site (lung, bone, skin, etc.). These centres worked with a number of other laboratories designated by wHo in different countries. A total of nearly 300 leading pathologists from 50 countries are taking part in this \\rim programme. The members of each group exchange histological preparations, describe their characteristics, establish diag- noses and eventually draw up, at joint meet- ings, an international standardized classifi- cation of the tumours. \vim has so far pub- lished a series of books containing informa- tion on the classification of tumours of the lung, breast, soft tissue, mouth and oro- pharynx, bone, skin, salivary glands, ovary and thyroid gland. Classifications of tumours at remaining sites are being pre- pared for publication. These books contain colour photomicrographs of all types of tumours and are also accompanied by colour transparencies. They have been wide- ly distributed by wHo; in particular, all fac- ulties of pathology at medical schools have been sent them free of charge. In this way, future physicians in all countries are being given an opportunity of studying an up-to- date histological classification of tumours prepared collectively by leading patholo- gists. Tumours may be preceded by morpholog- ical changes called precancerous lesions. Re- cognition of precancerous lesions and their elimination is one way of preventing cancer, Use of a uniform terminology helps to make r> the study of data on cancer at hospitals and cancer registries more efficient and therefore more effective. (Photo WHO/T. Farkas) 10 ; and systematization of what is known about precancerous processes would lead to a bet- ter understanding of the pathogenesis of the disease. Following the same lines as in its work on the classification of tumours, who has enlisted the services of a number of col- laborating centres in the morphological typ- ing and evaluation of precancerous lesions at several, sites. Cytological diagnostic methods (establish- ing a diagnosis on the basis of description of the structure of tumour cells obtained by tumour puncture or from swabs, microscopy of urinary sediment, mucus, etc.) have been extensively developed and applied by the oncological services of many countries. Cytological diagnosis (in the case, for exam- ple, of tumours of the breast or uterine cer- vix or of lymph nodes) frequently provides a basis for a whole range of subsequent therapeutic measures, including surgery, radiotherapy, hormone therapy or chemo- therapy. Unification of the body of knowl- edge on the cytological forms of various tumours will be helped by the standardiza- tion of nomenclature being carried out un- der WHO auspices by cytologists from 14 countries. One handbook has already been published and a second is in press. Colour transparencies and photomicrographs illus- trate what is meant in practice by the termi- nology which has been developed on a col- lective basis. One long-term project on which WHO has embarked is the standardization of hospital- based cancer registers. Many cancer hospi- tals and institutes have collected much valu- able information on the natural course of the disease, the characteristics of metastatic spread of tumours and the results of surgery, radiotherapy, chemotherapy' and combined therapy. This information has not been unified, however, and is not compar- able because of differences in terminology, classification, quality and completeness. The work on standardized data-recording has been carried out in several stages. Twenty- six registers from European countries and the Eastern Mediterranean region were first compared and analysed. Then a punched card was devised in the form of a question- naire covering the essential basic data and additional desirable information. In design- ing the card, the aim was to make it easy to complete even in different countries. The next step was to submit the card for trials in 19 institutes throughout the world, which even- tually analysed 10,000 completed cards. A meeting of experts was then convened to One of a series of books produced by WHO to promote the use of uniform criteria and terminology in cancer diagnosis. An illustra- tion from the book showing cancerous tissue forms the background. draw up a final version of the hospital-based registration card. This provides, inter alia, information identifying the register and the patient, data on the bases for diagnosis, data on the distribution of the disease and data on the type of treatment and its imme- diate and long-term effects. In all, 52 types of information are provided. The card, which has still to be introduced on a wide scale, will promote improved follow-up of patients after treatment and provide insti- tutes with data on the results of treating various types of cancer. A register based on it can provide information on changing trends in prevailing methods of treatment, show the relative prevalence of localized and disseminated forms of the disease, and so on. Countries which have not established hospital-based cancer registers can use this model, while countries that already have registers can easily adapt to it. In preparing a standardized hospital- based cancer register, wHo had in mind two basic functions that would be required of such a system : the internal function of col- lecting and evaluating data on the treatment and management of cancer patients within a given country, which is important for public health administration, teaching purposes, etc.; and the external function of comparing international trends in cancer therapy. Many countries are carrying out a search on a wide front for anti-tumour agents among synthetic chemicals and plant and animal products. Since much of the mechan- ism of carcinogenesis remains obscure, em- pirical methods prevail in experimental chemotherapy. Substances are studied on experimental models of tumour growth (in the mouse, rat or hamster). These models are not equivalent to human tumours, but they do serve to indicate the anti-tumour potential of the substance concerned. Some scores of active agents against human tumours have been found in this way in France, Hungary, Italy, Japan, the Soviet Union, the United Kingdom, the United States of America and other countries. A special conference convened by wHo decided that strict standardization in this field was unadvisable as it would narrow the field of investigation and lead to the selec- tion of closely related preparations. The conference did however recommend that those concerned with the initial testing of anti-tumour agents should use a single stan- dard of comparison, the mouse leukaemia 1210 model. Since information would then be available on the sensitivity of a single type of tumour to all substances investigat- ed, comparative studies would have much greater significance. Another decision taken A wide variety of chemotherapeutic agents— one of them is being used here to cure a mal- ignant tumour in a rat—have to be meticu- lously tested for possible future use in humans. ( Photo Len Sirman © ) at that time, to publish data on the sensitivi- ty of the models used in various countries for selecting new anti-tumour agents with a view to their use as anti-tumour drugs, is now established oncological practice (and has been followed in the case of such sub- stances as cyclophosphamide, methotrexate, fluorouracil, bleomycin, vinblastine and others). yam devotes a large amount of time to standardizing reagents, drugs, diagnostic methods, markers, methods for evaluating the immediate and delayed effects of onco- logical treatment, and other matters. The unification and standardization of knowledge about cancer is serving to con- solidate what has already been achieved, to raise the level of the separate efforts made nationally, to lay down a quantitative and qualitative foundation for generalizations and theoretical assumptions, and to help to develop a common language for the use of all those involved in the protection of human health. ■ 13 how education helps Few anti-cancer activities could save as many lives or avoid as much human suffering as education aimed at prevention, early detection and support for patients BY GISELA GASTRIN ardly any disease is subject to so much misunderstanding and misin- terpretation, nor connected in peo- ple's minds with so much fear, as cancer. On the other hand little can com- pare with the joy and hope that transfigure a patient cured of this disease. Here is a field ideal for the application of health education and health screening, not only to reduce cancer's medical and economic ill-effects, but also to improve health and the quality of people's lives generally. People can be motivated to adjust their outlook towards health and disease, but before this can happen their negative atti- tudes have to be countered with factual in- formation. Where cancer is concerned, the main reason for the pessimism that prevails among the general public is that the word cancer is commonly used to cover several tens of diseases that in fact are of different origin, develop differently, and are treated differently, with varying rates of success. Since certain of the diseases in this group do respond very poorly to treatment, this creates an impression of general incurability for all cancer diseases. Fear is the result, and fear makes people passive instead of ac- tive. There are instances where the develop- ment of cancer could be prevented, where curable pre-cancerous changes could be detected, and even where actual cancer could be diagnosed in time, but all over the world fear and ignorance cause delay in seeking aid. There is in fact cause for optimism in that it is possible for people on their own initia- tive, provided they are well informed, to prevent some cancers and to detect others in time (treatment at an early stage always gives the best results). The role of health education on cancer therefore is to inform each person about factors that are impor- tant both for him or her as an individual and for society at large. Education needs to be part of a comprehensive programme in which responsibilities involving the health authorities and others are clearly delineated and resources allocated. What sort of people can benefit from health education on cancer? Here are a few examples : Children and young people. Natural his- tory lessons should include the natural history of cancer, so that the new genera- tion is alerted to the problem. A healthy person exposed to cancer-pro- ducing agents. There are two types of situ- ation here : (a) Cancer-producing agents are prevalent in certain occupational envi- ronments. In this case research centres should provide information to occupa- tional-safety authorities about possible ways of reducing the risk. At the same time, workers should be motivated to fol- low instructions designed for their protec- tion. (b) People inhale cancer-producing substances smoking tobacco. Encouraging them either to stop smoking or not to start can cut down the development of cancer. An apparently healthy person with "pre- cancerous" changes. These changes can be detected if people are motivated to enrol for mass screening procedures, e.g. cervi- cal screening. In this way really curable cases can be caught and treated. An apparently healthy person who has cancer. He or she should know about the symptoms of cancer and the possibility of detecting them oneself, so that treatment can be undertaken as soon as possible. For example, cancer of the breast can be detected by regular self-examination, and there are other known symptoms of cancer in other organs which should im- mediately be brought to the attention of a physician—certain skin changes, bleeding from the intestinal or urinary tracts, per- sistent cough or hoarseness, abnormal bleeding from the genital organs, and so forth. A person in whom cancer has been diag- nosed. He or she should receive informa- tion about the nature of the disease, the treatment, the possibility of cure, and rehabilitation (adequate follow-up, appli- ances if needed, recovery of speech after laryngectomy, etc.). A cancer patient with social or financial problems. Some agency should exist to ad- vise on support available to the patient and his or her family. Distribution of the various cancerous dis- eases varies in different parts of the world. Some are related to age, others to living conditions or other factors. This means that the risk of getting cancer is different for dif- ferent people, so that the educational mes- sage should be specially adapted for the dif- ferent target groups within the population. To be effective, the message should also be varied from time to time. Communications The educational methods used in a coun- try or community should be regularly eva- luated and revised in line with social devel- opment. In many countries the introductory phase has consisted of private initiatives in- cluding person-to-person information through lectures, contact with physicians, and so on. Mass-communication (radio, TV, press, exhibitions, pamphlets, etc.) can also been used, and can improve the knowledge of a large part of the population—particu- larly if it is continuous—and help to correct common misconceptions. Person-to-person communication is, however, a more effective Encouraging young people either to stop> smoking or not to start at all reduces the risk of cancer developing. (Photo American Cancer Society) 14 • tool for influencing people's behaviour—for example encouragement given for stopping smoking, or for examining the breasts regu- larly, or for attending screenings has a posi- tive effect. It depends on the health authorities in each country how and when health educa- tion on cancer is to be carried out, and funds must be allocated according to priori- ties. The International Union Against Cancer, its member organizations and local cancer associations will all give continuous support. At the moment cancer organiza- tions are operating in about 100 countries. They set up various programmes and collect money from the public for, among other purposes, education. Their activities are always planned in co-operation with the health authorities; and both cancer organ- izations and health authorities can in turn expect substantial support from other bodies in return for resources and co-opera- tion. National cancer organizations can use the mass-media for education, enlisting the help of experts to popularize, for example, news of recent medical progress and its conse- quences. Other experts can plan person-to- person education, deciding on methods and training key-persons for health centres, schools, and so on. The key-persons—sup- ported, like the voluntary workers, by the cancer societies can organize educational work at the local level, developing person- to-person communication adapted to their audience. They should be given not only the relevant training but also continuous assis- tance in their work in the form of educa- tional material and other services. Opinion-formers Many of these key-persons can function as important opinion-formers. The most ex- perienced among them can also give guid- ance to others about how to set up individ- ual educational programmes, how to co-op- erate with the local press and other mass media, and how to influence political deci- sion-makers. How far education on cancer really becomes available to the public at large—independent of socio-economic con- ditions or location—depends mainly on what local resources in the form of both finance and physical aid can be used to pro- vide support material for the key-persons. The recipients of education on cancer, i.e. the target-groups, can be, for example, young people at school or in youth organ- izations, young men and women in the armed forces, people attending health cen- tres or health services at workplaces, groups at special risk for certain types of cancer, patients attending hospitals or physicians' offices, chronic patients in care institutions or at home, members of certain organiza- tions, and so on. The message should take into account not only the target-group but also the channel being used to reach it (see Tables on this page). Educational efforts against cancer can be divided roughly under three categories—ac- tivities aimed at prevention, activities aimed at early detection, and activities which give support to cancer patients. Smoking control is the best illustration of how education can be used to prevent cancer. In 1971, the World Health Assembly stressed that primary responsibility for smoking control at the national level should rest on specialized bodies, and this was again strongly recommended by the wHo Expert Committee on Smoking and its Ef- fects on Health in 1975. In Sweden, for ex- ample, the Swedish National Smoking and Health Association has worked out a 25- year smoking control programme, which could be used as a basis also for general cancer education programmes. In the United States, Sweden, Norway and Fin- land, special programmes have been set up in which physicians and other medical ex- perts, and volunteers too, are used as key- persons in person-to-person communication aimed at encouraging cessation of smoking. Material has also been specially designed, as in Finland and Sweden, to be used by specialists and volunteers in their work with the large number of smokers who already have the motivation to stop smoking and do not need complicated or expensive cessation methods. This material analyses individual problems connected with cessation and gives smokers practical advice for the cessation period. Finnish campaign An example of education used for early detection of cancer is the initiative taken in 1972 by two Finnish women's organizations, Marttaliitto and Finlands svenska Mar- thaforbund, to promote a campaign for the early detection of breast cancer through self- examination of the breasts. I was chosen to design and lead the campaign, and in 1973 a pilot study began among 10,000 volunteers drawn from these organizations' member- ship. First, I spoke personally to 2,000 members at their local branches, telling them why, how and when to examine the breasts, and answering their questions. Then each branch appointed a key-person, and these key-persons passed on the information to the other 8,000 volunteers. Each partici- pant was given a calendar to note down the date of each of 12 self-examinations during the year and the findings. Planning for the study included organiz- ing the facilities for those who reported sus- pect findings to be examined by a physician (myself). Each participant was informed who would examine her and where (at the out-patient clinic of the cancer society in her area). During one year, 230 participants found symptoms, and 15 of them were found to have breast cancer. EXAMPLES OF EDUCATIONAL ACTIVITIES USING MASS-MEDIA TO REACH A BROAD UNSPECIFIC AUDIENCE News about recent findings of scientific research. Information regarding governmental action, present and planned. Documentary programmes on cancer on TV and radio. Distribution of journals, printed educational material, etc. EXAMPLES OF EDUCATIONAL ACTIVITIES COMMUNICATING DIRECTLY WITH SPECIFIC GROUPS Environments Examples of relevant matters School health services The natural history of cancer, curability,, the smoking problem, sexual hygiene. Screenings for cervical cancer Maternal health centres Sexual hygiene, self-examination of the breasts, smoking cessation. Health services of the armed forces Smoking cessation. Health services at places of work Smoking cessation, cancer of the gastro-intestinal tract. Women: cervical cancer, breast cancer. Men : prostate, larynx and rectal cancer. Patients at hospitals and in or- ganized groups Information on supplementary care, rehabilitation, follow-up, social support. Different organizations (youth, women's, men's, etc.) Specific educational campaigns. Voluntary work Establishment of cancer patients' associations for support and information in all relevant areas. 16 In 1974, a further 30,000 members of the women's organizations enrolled voluntarily in the campaign through their local bran- ches throughout the country, and by 1975 the total number of participants was 56,000. Serving the overall campaign as educators are one physician (myself), two specially trained nurses, and almost 1,000 key-per- sons at the local branches. Information is passed down to the local branches by the central offices of the women's organizations, and TV, radio and local press are involved. A three-minute film about self-examination has now been shown on television 40 times. Twenty physician volunteers co-operate with me and take care of those women who have symptoms. So far the findings of the overall campaign correlate with those of the pilot study—a definitive evaluation will be made in 1976. The work as a whole has been paid for by the members of the organizations themselves, who when they enrol pay one finnmark each (about 27 US cents), and by a few donations. This campaign is a good example of how the initiative can be taken by non-profes- sionals and how they can work together with experts. The experience gained has been used to organize similar activities at workplaces, with the health service staff act- ing as key-persons and using material designed by myself. This material is avail- able from the women's organizations and paid for by the employers. Support for patients Education designed to give support to patients who have cancer can be provided in two ways. Firstly, there are central or local cancer patients' associations, established usually on the initiative of the patients themselves. These associations pass on to their members information of all kinds, but especially on problems connected with med- ical and psychological rehabilitation and with the psychological, financial and social condition of the patient's family. Secondly, informative brochures can be given to patients as they leave hospital. In Finland brochures have been prepared on my initia- tive for the various categories of patients, including important facts about care at home, follow-ups, and so on. The informa- tion in the brochures is collected by the Fin- nish Cancer Society using authors who are experts in the various specialities, and the money to pay for them is collected by a men's organization in collaboration with the Learning to speak again is a special problem for those who have lost their larynx to cancer. An instructor is challenging her class to ex- periment with new sounds. (Photo American Cancer Society) Society. The aim is to improve the cancer patient's quality of life through better knowledge. How effective can health education on cancer be expected to be? Dr Lars M. Ram- stroem of the Swedish National Smoking and Health Association has estimated that in Sweden the lung cancer death rate among men would decline from 33 per 100,000 peo- ple in 1970 to 22 per 100,000 in 1990 if the number of smokers could be cut by half in each of the two decades. Also, the cases of breast cancer detected in the Finnish self- examination campaign can be regarded as a direct result of educational efforts. These ex- amples and other considerations suggest that no other weapon against cancer could save as many lives or avoid as much human suffering from cancer as educational mea- sures aimed at prevention and early detec- tion of the disease, and at support for those who have already become cancer patients. ■ 17 breast self-examination I he breast is a common site of cancer in women. Like all cancers, the earlier it is detected and treated the better the chance of cure. Many cancers give signs of their presence, as does breast cancer, which is one of the easiest to find. Every woman concerned can do something about it by examining her breasts herself, regularly. Breast self-examination takes only a few minutes once a month, preferably the day after the end of the menstrual period. After the menopause a definite monthly date can be set for the examination. Remember that (1) an unusual lump or thickening in the breast, (2) an alteration in the shape of the breast, or (3) a blood-stained discharge from the nipple can have a variety of causes, cancer being only one, but upon noting such a change it is most important to see a doctor straight away. When the cause is not cancer, treatment may also be necessary and helpful, and the mind is set at rest. The following guidance has been prepared with the help of the International Union against Cancer. Stand in front of a mirror with your arms hanging loosely at your sides. Look for any puckering or dimpling of the skin, any changes in outline. You may notice that one breast lies a little lower on the chest than the other; this is quite normal. Raise your arms above your head and go on looking at your breasts, turning a little from side to side so as to see the breasts from all angles. Look for any changes since last month. 18 Lying down on your bed, place a small pillow or fold- ed towel under your left shoulder. This helps to spread the breast tissue evenly and makes examination easier. Place your left hand under your head and use your right hand to examine the left breast. Feel for any lump or thickening with your fingers together, flat but not stiff. Think of the breast area as being four quarters of a circle; begin with the upper, inner quarter. Start examining well out from the breast, from the ribs above the breast and from the breast-bone in the centre of the chest. Press gently, moving towards the nipple; examine the area around the nipple too. In the same way examine the lower, inner quarter, again starting from the breast- bone and from the ribs below the breast. Bring your left arm down to your side and, again start- ing well out from the ribs below and at the side of the breast, examine the lower, outer quarter of the breast. With your left arm still at your side, move your fingers as shown in the sketch along the upper, outer quarter. Finish by continuing to feel from the upper, outer quarter, right into the armpit. To examine your right breast, place the pillow or folded towel under your right shoul- der and put your right hand under your head. Using your left hand follow the same procedure as before. Re- member to bring your right arm down to your side when you examine the outer half of the breast. SEVEN WARNING SIGNALS Change in regular bowel or bladder habits A sore that does not heal Unusual bleeding or dis- charioe Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness If you have a warning signal, see your doctor 19 one woman's experience Doctors today have the knowledge to cure 12 out of 15 women who develop cancer of the breast, provided it is discovered in time—and properly treated in time BY MARVELLA BAYH nthethenum United I j one a States cause breast of d ao caenact h o er i sf women between ages 40 and 45. It is the major cause of cancer death for women of any age; it will strike one in every 15 women in the United States. It is of course also a worldwide prob- lem. I was one of those cold statistics in 1971. It seemed impossible that it could happen to me—I was only 38 years old and was feeling great physically. In February of 1971 I just became aware of my right breast. I know it sounds strange because there was no pain or aching, but I was constantly aware of it. I've always believed that our body has little ways of giving us signals that something may be wrong, so I went immediately to my gynaecologist for a check-up. There was an examination, and he felt nothing but sent me immediately for a mammogram. He called the next day— "Good news! Mammograms are nor- mal." Great! "Don't worry—it's just a little glandular activity and it will pro- bably go away." It did : what a relief! I had a busy summer. In September my husband, Senator Birch Bayh, repre- sented our country at the Interpar- liamentary Union Conference meeting in Paris, and I went along. A few days after we returned from the trip, the awareness of my right breast returned, only this time about four times a day I would get a short, zippy little pain. There is usually no pain with a breast malignancy. Again, immediately I made an appointment to see my doctor. Again there was the examination, again the mammograms, and again the report showed them to be clear and per- fectly normal. I sat by the doctor's desk feeling very relieved when he said to me, "Mrs Bayh, I want to do a biopsy." I was surprised and I asked, "But Dr Hawkin, is a mammogram ever wrong?" He hesitated a moment and said, "Sometimes we rely on them too much. There's only a ten per cent danger something is wrong, but I can't take that gamble with your life." I wanted to go into the hospital im- mediately to get it over with. He called the hospital as I sat anxiously by his desk. They could not take me for six days. The days passed slowly and the upcoming biopsy was on my mind con- stantly. Finally it was time to enter the hospital. My diary notation for October 6 says, "Scared. Pray, pray breast condi- tion not cancer." There is no gentle, easy way to tell someone they are a cancer victim. "Cancer" is one of the most dreaded words in the world. Birch was by my side. I remember shaking all over and crying, "But I'm only 38 years old and I have the most wonderful son." I was thinking about Evan, our 15 year old, and about Birch, who was only 12 when his mother was taken from him by cancer of the uterus. He said to me over and over until it was burned into my mind, "We're going to lick this thing!" I wanted to live. The most important thought in my mind was, "How early have we discovered it? Will I survive?" Only later did I think about losing a part of my body. I remember saying to Birch, "Just think, I'll have to go through the rest of my life with only one breast." He smiled at me across the room and said, "I'm five years older than you, and I've had to go through my life without any. Do you think I married you because of your breasts? I married you for YOU." The surgery the next day went smoothly. They performed a modified radical mastectomy, which means the breast was removed and also the lymph glands under the arm, but most of the chest muscle was left. The doctors felt they had surrounded the cancer, but decided as a precaution to give me two months of daily radiation treatments and weekly chemotherapy injections for 18 months. At the time I wished my surgery had not had so much publicity, but because my husband is a Senator, I had no choice. However, soon I was grateful. I became the beneficiary of the great love and caring in the hearts of people. We read and hear so much about man's in- humanity to man that we sometimes forget about the goodness that exists in the world. The cards, letters, flowers and prayers were so heartwarming and appreciated. I received letters from hus- bands and wives who had been through this before. After all, breast cancer strikes about 90,000 women a year in the United States. Most women who have had a mastectomy tell me the ex- perience has made their marriage better. Any time you walk through the Valley 20 I cu r IUN SAVES LIVES... ... IT MAY SAVE YOURS .► mpo tam: of Death with a loved one, it brings you closer together. I had almost no pain in the chest area, which was a pleasant surprise. The loss of the lymph glands under the arm was the biggest problem. It was difficult for me to raise my arm to do simple tasks like put a clip in my hair. I won- dered how I would cope with this arm and get the use of it back. I had not yet looked at my breast area either directly or in the mirror. I dreaded what I would see. This would be the body I would have to live with for the rest of my life. Finally on the fifth day I made myself do it. It wasn't so bad, and I decided it was a good trade to save my life. I still felt like the same me. The next day Dr Hawkin told me he had asked a lady from the American Cancer Society's "Reach to Recovery" programme to visit me. That afternoon an attractive woman with a very good figure walked into my room. She looked terrific. She had a kit with literature tell- ing about clothes adjustments, a small ball and some rope to use in doing the arm exercises she demonstrated, and a temporary breast prosthesis. As she talked, she mentioned that she and ev- ery other volunteer in the "Reach to Recovery" programme had also had a mastectomy just as I had. I couldn't believe it. I quickly sat up in bed and looked at her more closely. What news! If she could look like that, so could I. I was so excited. She left her telephone number in case I had any further questions and she was gone. But what a difference she had made in my out- look. Shortly afterwards I was told that I would be taken for a couple of hours to another hospital for some special tests. I decided that I would not go in a robe but would wear my dress. My stitches had not yet been removed but Dr Haw- kin gave his consent. The nurse and I got out my bra and pinned in the tem- porary prosthesis.. I've never been overly endowed in the bustline and we got the giggles as we kept taking out more and more stuffing to make the prosthesis small enough. My dress was sleeveless and I could wear it. What a thrill! I finished my treatments just before Christmas. But midway through the weeks of radiation treatments I started the weekly visits to the doctor for chemotherapy injections. These were to last for a year-and-a-half, which seemed like forever. The doctor explained that the chemical they were putting into my vein would seek out rapidly dividing cells and kill them. This was a precau- The wife of a US Senator, Mrs Bayh under- went surgery for breast cancer and is now an active campaigner for the early detection that saved her life ... and may save yours! (Photo Bayh ) tion just in case any cancer cells had escaped into my bloodstream at the time of surgery. Sometimes I felt as if they were taking too many precautions and wondered if these boring trips were real- ly necessary. With the exception of the weekly chemotherapy injections, life returned to normal for me. Six months to the day after my surgery I was in Africa with Birch attending the Spring meeting of the Interparliamentary Union Confer- ence in the Cameroons. In 1973, Birch and I accepted the Co- Chairmanship of the Cancer Crusade in Indiana and in 1974 I served as Co- Chairman of the National American Cancer Society Crusade. More breakthroughs are being made every year in the fight against this mon- ster. It has been such a privilege to have the opportunity to tell my story, and I hope that others have benefited from it. Doctors today have the knowledge to cure 12 out of every 15 women who develop cancer of the breast if it is dis- covered and properly treated early. However, in almost half of the cases the patient has waited too long to see her doctor, many times because of fear. It's so important for everyone to have an annual physical check-up. In addi- tion, every woman should examine her breasts once a month. If she discovers a lump, the chances are it is benign. Only about 25 per cent of the biopsies show malignancy, but only a doctor can tell for sure. There are tens of thousands of us who have had this experience and are today living full happy lives because we were alert to the early warning signals. The many months since that black day in the hospital when I was told I had cancer are now just a memory, but one that has left a lasting impression on my life. How have I changed? It's hard to put into words, but it's the little things that make the difference. When I'm out for a walk I don't rush so fast; I take time to stop and watch the squir- rels play. I see the beauty of the clouds and the colours of the sunset more clearly. I believe I've been able to put into proper perspective material achievements that used to seem so im- portant. During this struggle I've been blessed in a thousand ways, but most impor- tantly by the caring and love from other human beings: those who for years have devoted their time and talent to making progress toward conquering this dis- ease—unknown friends who remem- bered me in thought and prayer— cherished personal friends who stood by when the going was rough—trusted sympathetic doctors who gave me the best of care—my son who showed in lit- tle ways that he understood—and my husband, who gave me the courage to fight, and the will to see it through. ■ 21 shifting patterns Eastern Mediterranean countries which have succeeded in controlling communicable diseases are now having to deal with cancer as their third major cause of death BY N.T. RACOVEANU IF or Eastern long etdiimteerracnoeuanntreieosnsoidferthede communicable diseases as their major health problem, together with maternal and child care and nutri- tion. With recent successes in control- ling most communicable diseases through the reorganization of national health services, and as a result of im- provements in the economic and social status of the population, a mutation in health priorities is emerging. The fact, recently stressed in a WHO publication, that cancer constitutes the third cause of death in countries of the Eastern Medi- terranean considered as a whole, con- firms this change. Cancer control in the Middle East became a very real problem for the health authorities because of specific as- pects which cancer epidemiology revealed in this area. A panel of Eastern Mediterranean cancer specialists met this year at the WHO Regional Office for the Eastern Mediterranean in Alexan- dria and defined some of the patterns of cancer epidemiology in the region, based on the experience of local oncolo- gists. These could be summarized as fol- lows : 1. Due to the lack of awareness of the population, and of some general practi- tioners, a high percentage of cancer cases are seen by cancer specialists in such advanced stages that a cure or long-term survival are possible for ex- tremely few of them. In comparison with Europe or the United States, where 30 to 40 per cent of detected cancer cases are achieving more than five years' survival, only a small percentage is in the same favourable situation in most of the Eastern Mediterranean countries. The age distribution of cancer patients in the Eastern Mediterranean follows that of the population in these countries and is therefore some eight to ten years lower than for European coun- tries or the USA. Due to some geo-climatic, beha- vioural, social, economic and religious factors, cancer epidemiology in the Mid- dle East shows certain peculiarities of distribution as regards various cancer types and sites. Statistical information is incomplete, but existing data show that skin cancer is relatively common in areas where sun exposure—very intense in all Middle Eastern countries—has a higher intensity, such as in the Atlas Mountains or on the coast. Oral cancer is common in areas where tobacco, betel or khat chewing, snuffing and other sim- ilar habits are common. Nasopharyn- geal cancer appears with a quite high frequency in some populations on the north and north-west African coast. (Esophageal cancer has a very high inci- dence in some areas in Northern Iran, but a much higher percentage than usual is also observed in Afghanistan, Saudi Arabia, Democratic Yemen, Ye- men Arab Republic, etc. Cancer of the urinary bladder is very common in areas where schistosomiasis (bilharziasis) infes- tation is widespread—the Nile, Tigris and Euphrates valleys—and constitutes one of the most common cancers in Egypt. Lymphomas seem to represent about 10 to 15 per cent of all cancers in many Middle Eastern countries and a particular type of gastrointestinal lym- phoma called "Mediterranean lympho- ma", first described here, was later recognized also in other areas (Greece, Italy, Spain, South America, and South East Asia). A particular type of inflam- matory breast cancer is observed in a quite high percentage of breast cancer detected in some Middle Eastern coun- tries and in others a higher percentage than usual of male breast cancer has been recognized. An unusually high percentage of bone sarcomas is observed in some areas in Pakistan. Some of the cancers common to European and North American populations, such as lung, colon, gastric and uterine cervix cancers, are quite rare in the Middle Eastern countries, but there appears to be an increase in the number of lung cancer cases due to the habit of smok- ing. The trends of modern life which will change the Middle Eastern coun- tries, such as industrialization, higher urbanization, and changing social beha- viour, are expected to modify the natural patterns of cancer described above. While some of the present cancer types related to environmental factors are expected to decrease as a result of a proper control of etiological agents, oth- er types will increase. For example, the change from traditional clothing—the galabeya (long robe) and the kuffia (head gear) which protected large sur- faces of the skin from solar exposure— to modern European dress exposing much larger areas is expected to increase Cancer clinics and cancer institutes have been D set up throughout the Eastern Mediterranean Region. This woman is having a mammogra- phy test—which uses X-rays to check for pos- sible breast cancer—at the Salah Azalz Cancer Institute in Tunis. (Photo Ministry of Health, Tunisia) 22

the frequency of skin cancer. The con- tinuous increase in the habit of smoking among younger generations will increase the amount of lung cancer and, if prop- er countermeasures do not protect the general as well as the working environ- ment in petrochemical and other indus- trial activities which are developing in Middle Eastern countries, exposure to various carcinogens is bound to add new types of cancer to those quoted above. All these data justify the preoccupa- tion with cancer control which is now apparent in some Middle Eastern coun- tries. As is usual in all medical speciali- ties, the main activity in the field of cancer control is being developed at the level of cancer treatment. Cancer clinics or even cancer institutes have been developed in Cyprus, Egypt, Iran, Iraq, Israel, Kuwait, Lebanon, Libya, Pakis- tan, Sudan, Syria and Tunisia. Cancer surgery is available on an even wider basis, although the surgeons treating cancer patients are not always specia- lized in this particular field. In view of the distribution of cancer units, specialists and equipment needed Sudanese washing their feet in canal water. A correlation has been detected between the incidence of urinary bladder cancers and schistosomiasis (bilharziasis) infestation— caused by a water-borne parasite—in some river valley areas. (Photo WHO/E. Schwab) for this activity, large areas and many millions of inhabitants still do not have easy access to cancer diagnosis and treatment. This is one of the reasons for the late discovery of a high percentage of cancer cases, permitting only pallia- tive treatment without hope for long survival or cure. Cancer associations, through which medical specialists and lay people work together, are beginning to be organized in Middle Eastern countries. These asso- ciations are devoting their activities to education of the public concerning early detection and prevention of cancer, and to increasing the number of patients and output of cancer treatment units by of- fering help to patients attending cancer units, providing means of transporta- tion, hostels for patients' accommoda- tion, day care clinics, home care and social help to those in need. Also, at the urging of some cancer associations, cancer detection clinics or follow-up clinics in remote areas have been orga- nized. The present situation was comprehen- sively examined by the Regional Office of the World Health Organization at two special meetings held in 1971 in Baghdad and in 1974 in Alexandria. Recommendations made by the first meeting regarding ways to improve cancer control were re-emphasized dur- ing the second meeting which also suc- ceeded in preparing a regional cancer programme. The aim of this regional programme is to facilitate the develop- ment of national cancer programmes in individual countries. A national pro- gramme should develop the existing cancer organization within the country, and establish prevention as a basis for cancer activity. Work should proceed on the assumption that the public itself and the basic medical network constitute the first and largest base for cancer detec- tion and prevention. The programme should gradually increase the involve- ment of a medical network specialized in cancer diagnosis and of special cancer units for the adequate treatment and follow-up of patients. Cancer prevention including all as- pects of primary prevention (decrease of exposure to environmental carcinogens) and secondary prevention (early detec- tion, diagnosis and treatment) was em- phasized as one of the most important activities to be developed throughout the Eastern Mediterranean Region of vim. Cancer registration, which offers the best way to obtain realistic data about cancer distribution, is also recom- mended as one of the basic activities to be implemented. It is thought that co-ordination at the national level of all efforts being made today in respect of cancer control will enable cancer programmes to start in most Eastern Mediterranean countries, improving the existing infrastructure and making better use of the financial and human involvement in cancer activ- ities in this region. By using the expertise of existing Cancer Institutes and starting new wHo Regional Reference Centres for different types of cancer (urinary/bladder, oeso- phagus, lymphoma, breast, etc.) it is believed that adequate orientation of cancer control activities to the particular conditions of the Eastern Mediterranean will be achieved and that real progress can be expected. ■ 24 Before — 18 January 1968 After -- 16 August 1968 African success story rom two widely distant areas of Africa come two similar accounts of success in the perennial battle against cancer. Both cases concerned Burkitt's lymphoma, a malignant jaw tumour which may occur any- where in the world but is found with unusual frequency in African children. A detailed account of this condition is given in the WHO Memorandum Histopathological Definition of Burkitt's Tumour (1969). A young boy named Kaketo was admitted to the Uganda Cancer Institute in January 1968 with a swollen jaw and loose teeth on the left side. He had lost two molar teeth and was found to have a tumour involving both mandible and maxilla (top left). He also had abdominal masses and absent reflexes in his lower limbs. After two courses of cyclophosphamide, the tumour regressed. Six courses of oral metho- trexate followed and, within two months of therapy beginning, all symptoms of the disease had abated. Only slight swelling was still to be observed by August 1968 (top right). Kaketo has had no further trouble in the past seven years. In Nigeria, a seven-year-old boy with Burkitt's lymphoma of the man- dible was admitted in 1969 to the Department of Surgery and the Oncology Clinic of the University College Hospital at Ibadan (lower left). He too was treated by chemotherapy, made a speedy recovery and has had no recurrence of trouble since then. These are only two among many similar cases occurring at cancer institutions throughout Africa. They offer heartening evidence that cancer need not be a fatal disease. (Photos Uganda Cancer Institute and University College Hospital, lbadan.) 25 progress and research When cancer is no longer a major scourge for mankind, no one individual or single group will be responsible: credit for the victory will be shared by the whole world BY R. LEE CLARK he best of all possible "cures" for any disease is prevention of that disease. Physicians and scientists have exerted their utmost efforts through the cen- turies to cure cancer—an uncontrolled growth of cells which have reverted to a "younger" stage of growth (or differentia- tion) in an organ or tissues. Physicians have used whatever tools were available during a particular time span. In ancient times, caut- ery and caustics were applied to external growths with little curative effect except for certain skin cancers. The 19th century saw the advent of surgical cures resulting from Pasteur's "germ theory" of disease, which led to Lister's revelation in 1865 of infection introduced by the septic surgical environ- ment. As aseptic and antiseptic techniques became widely accepted by surgeons, and anaesthesia, first used by Long in 1842 dur- ing the removal of a vascular tumour, gave surgeons more time to investigate and learn during the surgical procedure, the first cures of internal cancers were achieved. When the cancer is localized, surgery remains the best and most frequently used means of cure. Additional means for controlling or cur- ing local and regional cancer were made available with Roentgen's definition and use of "X-rays" in 1895 and the discovery of radium in 1898 by the Curies. Surgery and radiation therapy, used either singly or together depending on the type and stage of development of the cancer, are now capable of curing or controlling cancer in one out of three patients. Future progress will depend on the development of treatment techniques that can attack the cancer cells which have spread to other organs or structures through- out the body. Two such methods, the results of exten- sive research during the past quarter of a century, are chemotherapy amd immuno- therapy. Chemotherapy is the administra- tion of chemical agents, either orally or in- travascularly, to obtain a systemic destruc- tion or reduction of foci of cancer cells. There are now approximately 40 antitumour chemical agents of proven effectiveness. These agents are administered in very elabo- rate and complex regimens by trained oncol- ogists (cancer specialists). Some of these drugs, used singly or in combinations, have actually resulted in long-term relief and even some cures in a few generalized types of cancers. Immunotherapy, or the activation of the immunological defence of the patient, is in the early stages of development and, while it shows much promise, awaits further devel- opments from research to develop fully its usefulness. Parallel to these efforts to cure have been searches for the factors and circumstances that change a normal cell into a cancer cell, which rapidly creates more identical cells and begins an inexorable attempt to destroy all normal cells by crowding, spreading to other parts of the body (metastasis) and depriving these cells of nourishment. Many factors are being discovered which are believed to precede and ,contribute to the formation of cancer cells. Numerous things that human beings can do to protect them- selves from cancer are being found, al- though much still remains to be learned. If cancer is to be conquered as a major cause of human death, each person must learn what she or he can do to help, since physi- cians and scientists alone, without the help of the individual, cannot prevent cancer. As is true with the control of any other disease, a person's style of daily living and understanding of the basic principles of hygiene and health can in great measure det- ermine whether cancer has a good chance or a poor chance of developing. Most people in the developed countries of the world know, for instance, that subjecting their lungs daily for years to tobacco smoke (and other air- borne particles such as asbestos and some types of industrial chemicals) will gradually change the normal lung cells and increase greatly the chances for the development of lung cancer cells. Foods contaminated with certain moulds (fungi) or that contain other toxic substances contribute to cancerous changes in normal liver or stomach cells. Persons throughout the world who work or play long hours in the sunshine and who do not protect their skins from ultraviolet rays while exposed often develop cancerous changes of their skin cells. In addition, radiant energy from X-rays equipment or radioactive isotopes is one of the most potent of cancer-causing agents if used im- properly. The list is much longer, but the general principle is that long-term abuse of any body tissue may cause irreversible changes in that tissue, often leading to cancer. In addition, there are some hereditary conditions that can lead to cancer in family This physician at the Centre for Adult Dis- eases in Osaka, Japan, is using advanced diagnostic techniques involving X-rays, televi- sion and fluoroscopy for the detection of lung cancer. ( Photo WHO/E. Schwab) 26

rr members. If these families work with a physician to correct the condition before the cancerous changes occur or have examina- tions at regular intervals to detect early development of cancer, they need not fear cancer any more than other diseases. Some families have a hereditary type of thyroid cancer (medullary or solid carcinoma), which can be detected before any symptoms occur by measuring the level of a hormone (calci- tonin) in samples of blood. Members of cer- tain families tend to develop malignant melanoma when changes occur in moles on their skin. The moles can be removed by a knowledgeable physician before they cause serious problems. The female members of some families have a high incidence of breast cancer. The younger women can pro- tect themselves if they have regular breast examinations with the diagnostic tools avail- able for detecting early development of breast cancer. Generally, attention to good health habits and early attention to any changes in nor- mal body appearance or function will great- ly reduce a person's chances of developing cancer. This personal attention and respon- sibility constitute the best cancer control that can be devised. But, what about treatment after a person has a diagnosis of cancer? Many new dis- coveries, coupled with early medical atten- tion to body changes, are responsible for more cancer cures. One cause of greater suc- cess is the increasingly accepted philosophy that many cancers shed cancer cells which metastasize to other parts of the body much earlier than was previously suspected. It is estimated that between 65-70 per cent of cancer patients (excluding those with skin cancer) have at least microscopic metastases at the time that cancer is first diagnosed. Cancer physicians are beginning to remove with surgery or destroy with radiation the visible early cancers, then use antitumour drugs to seek out any escaped cancer cells and destroy them wherever they may be in the body. Some of the areas of progress which are contributing to better cancer control and cure are: Diagnosis and thermography monitoring – Mammography, thermography and xerog- raphy More than 90 per cent of breast lesions are first discovered by women, who then fre- quently (but unfortunately not frequently <A patient receiving radiation treatment, from a cobalt apparatus provided by WHO, at the Tirana Cancer Institute in Albania. (Photo WHO/D. Henrioud) enough) visit a physician to determine if the "lump" is a cyst, a benign or a malignant tumour. As previously mentioned, by the time of diagnosis a large percentage of these tumours have already metastasized. Breast cancer is the leading cause of cancer death in women throughout the world, so it is imperative that methods for screening and earlier diagnosis be used widely. A combina- tion of mammography and xeroradiography (X-ray examinations), thermography (a heat- sensitive detection device that does not use radiation), and physical examination by a physician is being used in 27 breast cancer screening projects in the United States for screening 270,000 women over 35 years of age during a two-year period. Evidence is accumulating that a combination of these detection methods, all painless and of rela- tively short duration, is detecting breast lesions of much smaller size than has pre- viously been possible. Perhaps these techni- ques, if adopted throughout the world, will significantly reduce the mortality rate from breast cancer by making therapy prior to metastasis possible. ExfoliatiVe cytology The second greatest cause of cancer death among women throughout the world is cancer of the uterine cervix. A method for early diagnosis (the Papanicolaou or "Pap" smear) has been available since the early 1940s. It is still not widely used, although it has been used sufficiently in certain coun- tries to demonstrate a reduction in deaths due to this form of cancer. The technique is a simple, painless sampling of loose (exfo- liated) cells on the surface of the cervix, spread on a glass slide, stained with dyes, and examined by a pathologist or cytologist. The cells reveal the presence of abnormal conditions of the cervix and can alert the physician to the need for treatment. Varia- tions of this technique can be used for the detection of cancers of the respiratory tract, the digestive tract, and the reproductive and urinary systems of both sexes. Biological markers Radioimmuno-assays have been devel- oped to aid in the detection of substances in the blood which indicate the presence of some types of cancer. Consequently, these measurements, used in conjunction with other diagnostic procedures, are helpful in detecting cancer when it is suspected, for obtaining information about a patient's re- sponse to therapy, in indicating whether the therapy has been successful in eradicating all tumour cells, and in determining whether a cancer has recurred. Serological and immunological screens also help to determine the presence of cancer and its possible responsiveness to therapy. Searches are continuous to discover more tumour-specific markers and design tests of sufficient sensitivity and reliability to use for early detection. Radiopharmaceutical scanning Although most of the radiopharmaceuti- cal agents used are not specific for cancer but also delineate non-malignant conditions, the information obtained can be utilized with other diagnostic clues to help pinpoint the location and even the type of cancer. Scanning of organs or the whole body is done with a scintillation or gamma camera or with a rectilinear photo scanner. Computerized tomography uses X-rays to diagnose cancer of the brain and orbits and a different type of unit reveals information regarding other internal body structures and their comparative tissue densities and con- formation. It provides approximately 100 times the degree of tissue differentiation achieved with standard X-ray film. Electron- ic photomultiplier tubes instead of film receive the X-rays, measure the beam differ- ences after they leave the body, transmit the information to a computer, and register the images in a sectional or "slicing" display. The information can be visualized on a digi- tal printout and/or on a cathode ray tube which can be photographed. Ultrasound has as its chief diagnostic ad- vantage that ionizing radiation is not used. Longitudinal sound waves (acoustic fre- quencies) travel through matter with dif- ferent velocities depending on the density of the matter. Pulse-echo ultrasound is most frequently used for medical diagnosis. Two- dimensional and three-dimensional informa- tion can be obtained. A technique for diag- nosis of breast lesions is still in the develop- mental phase. The breasts are immersed in water, which conducts the sound waves. Computerized equipment produces images which can be analysed for the presence of lesions. Fibre-optic scopes of various sizes and types, using flexible lucite fibres that con- duct light and can "see around corners", al- low diagnosticians to visualize lesions in previously inaccessible areas of the body and to biopsy (remove tissue for microscop- ic examination) with special instruments in- troduced through a tube of the scope. Sociological and economic difficulties are encountered in attempting to screen popula- tions for asymptomatic cancers. It has been suggested that selected groups who are the most likely to have early cancers of certain sites should be screened : lung—male cigarette smokers over 45 years of age; female cigarette smokers over 55 years of age; bladder—smokers and others over 55 years of age; uterine cervix—females over 20 29 years of age; breast—females over 40 years of age; bowel—all persons over 50 years of age; and all who know of a history of cancer in several members of their family. Epidemiologists are attempting to identify other high risk groups as a means of pre- venting cancer or at least of preventing death from cancer through early diagnosis. Workers in certain industries should be pro- tected from long-term exposure to harmful substances, since in many cases cancer does not develop until a person has been exposed for 10-20 years. Therapeutic advances – Immunotherapy—although the importance of the immunological system in combatting disease has been known for decades, it was not until wide acceptance of the results of animal experiments in the 1940s occurred that attention refocussed on the ability of an intact immune system to reject tumour for- mation. It is now known that cancer cells produce antigens against which components of the immune system react. If, however, something has caused the immune system to function improperly or become ineffective, in some patients the immune system can be reactivated or stimulated in several ways. One method which shows promise is the in- troduction into the cancer patient of bac- terial extracts such as the BCG vaccine for tuberculosis (bacillus Calmette Guerin). Im- munotherapy alone is effective only when the total number of cancer cells is relatively small, but when used in conjunction with chemotherapy, surgery and/or radiation therapy, good therapeutic responses are be- ing achieved in some patients with acute leu- kaemia, melanoma, skin cancer, and osteo- genic sarcoma. – Chemotherapy—as mentioned earlier, drugs are being used successfully in earlier stages of disease to prevent the establish- ment of metastatic foci. Much experimental work to determine when cancer cells are most vulnerable to drug action, and more sophisticated pharmacological investiga- tions, have led to the design of multiple drug protocols which are often more effec- tive than single drug treatments and are fre- quently used before or following surgery or radiation therapy. Chemotherapy is also achieving cures for types of cancer for which surgery and radiotherapy can do very little, as the cancer is widespread at the time of diagnosis; e.g. acute and chronic leukae- mias, Hodgkin's disease and other lympho- mas, multiple myeloma, choriocarcinoma (a cancer of the placenta) and some central nervous system cancers. As one can see, the most successful cancer therapy is frequently administered by a team of oncologists who carefully plan each cancer patient's treatment so that the max- imum benefit will result from the total clini- cal knowledge. Cancer is a complex disease which often involves other body systems and functions to such an extent that several medical problems must be treated concur- rently with the cancer. Except for early cancer, which is often difficult to define because micrometastases cannot be identi- fied, it has become inappropriate for a single physician to attempt cure. A good physician realizes his inability to be well informed about each new advance in cancer care for every type of cancer (over 100 types), and he consults regularly with oncologists at cancer centres who work full time with basic scien- tists to solve the myriad problems. – Surgery—the philosophy of surgical therapy has been changing with the increas- ing successes of chemotherapy and immuno- therapy, which are most effective when cancer cells are few in number. Traditional- ly, the surgeon attempted to remove every 30 progress and research < Workers exposed to certain forms of indus- trial dust have been shown to run an increased risk of lung cancer. Here a technician looks at tiny asbestos fibres visible through the cali- brating grid of an electron microscope. 11 vestige of cancer. Frequently, the surgical procedure, although heroic and sometimes curative, was extensively mutilative and caused psychological, sociological and eco- nomic problems for the patient. In other cases, the tumour was so extensive that there was no chance for total removal, so nothing more than palliation to keep the patient comfortable was attempted. Cur- rently, the team approach to therapy makes possible the surgical removal of a major portion of the cancer, thus reducing the total number of cancer cells, and allowing one or several of the other therapeutic modalities to destroy them. Surgery for problem cases has been made safer with supportive services such as newly developed antibiotics, blood components such as platelets to prevent haemorrhage and white blood cells to assist the patient's suppressed immune system to combat infec- tion and reduce the possibility of spread of cancer cells. Intravenous hyperalimentation, the infusion of nutritionally rich and balanced fluids, assists in preparing patients to withstand surgery and to heal more rapidly following surgery, particularly when the surgery involves the alimentary tract or oral structures which would prevent normal food intake. - Radiation therapy—as with chemotherapy and immunotherapy, the greatest success in tumour destruction with radiation therapy occurs when the total accumulation of cancer cells is relatively small and well oxyg- enated. Large tumour masses contain poorly oxygenated cells in the centre, which are very resistant to the lethal effects of radia- tion. Consequently, in many patients, suc- cessful treatment includes radiation therapy combined with surgery and/or chemothera- py, and occasionally with immunotherapy. Radiation therapy is very successful for palliation of advanced cancer, as it gives relief of pain, intractable cough, intestinal obstruction secondary to tumour, oedema, haemorrhage, inability to swallow, patho- logical fractures, and varying degrees of paralysis secondary to brain metastases. Cyclotrons which produce fast neutrons (high LET or linear energy transfer radia- tion) are showing promise for the treatment of some types of inoperable cancer which are bulky and poorly oxygenated and, there- fore, are resistant to other forms of radia- tion therapy. These fast neutrons can pene- trate to deeply seated internal tumours while sparing the intervening normal tissue, in- cluding the skin. Laboratories and cancer hospitals around the world are using all available funds and trained personnel to ferret out the molecular secrets that create and sustain cancer cells. Worldwide cooperation among cancer insti- tutes and researchers is being fostered by the establishment of international communica- tion systems for rapid exchange of informa- tion, international exchange of clinical and research personnel, and attempts to standar- dize cancer terminology and ways of report- ing results so that cancer statistics and labo- ratory results will be uniformly understand- able. Epidemiologists and demographers are cooperating on studies of selected popula- tions to characterize environmental factors which may contribute to the development of cancer. No longer need a person or group work in isolation for years or have significant con- tributions to the total cancer knowledge overlooked because of publication, distribu- tion, and language barriers. When the final knowledge regarding the control of cancer is recorded, and the disease is no longer a major human scourge, there is no doubt that no one individual or one group will be responsible for the final solution. The con- quest of cancer will be accomplished by citizens of the world. ■ Thermography—shown here being carried out D at the Guttman Institute in New York-L-mea- sures heat patterns of the breast and pictures this thermal image on variations in skin temperature may be an important indicator in early breast cancer. (Photos American Cancer Society) 31 Dr F. J. Dy, Regional Director of WHO's Western Pacific Region, (right) receiving a cheque from Mr Ryoichi Sasakawa, President of the Japan Shipbuilding Industry Foundation (left). Japanese Health and Public Welfare Minister Masami Tanaka looks on (centre). (Photo WHO) WHO NEWS IN BRIEF Japanese Help The Japan Shipbuilding Industry Foundation has made a voluntary con- tribution of 300 million yen (US $1,016,949) to the work of WHO. The largest voluntary contribution from a non-governmental source ever received by the Organization, it was donated in support of wHo's programmes for the global eradication of smallpox and for leprosy control. Dr Francisco J. Dy, WHO Regional Director for the Western Pacific, received the cheque from Mr Ryoichi Sasakawa, President of the Japan Ship- building Industry Foundation, and of the Sasakawa Memorial Health Foun- dation. The ceremony took place at the Japanese Ministry for Health and Public Welfare in Tokyo, in the presence of the Minister, Mr Masami Tanaka. Mr Sasakawa commented : "Because of my belief in the brotherhood and sis- terhood of mankind, I and my Founda- tion wish to do everything possible to combat two of the most dreaded dis- eases—smallpox and leprosy." Conference centre in Europe WHO's Regional Office for Europe in Copenhagen is increasingly being used as a conference centre by non-govern- mental organizations active in the field of health. The main conference hall alone has space for 520 participants, although most meetings only run to about 200 delegates. There are special booths for screening audio-visual presentations and for interpreters. In August alone there were two im- portant gatherings which attracted med- ical experts to the Danish capital. The first was a Symposium on the Role of the Individual in Primary Health Care, sponsored by the Joint Centre for Studies of Health Programmes of the University of Copenhagen and the University of California (Los Angeles), and the Sandoz Institute for Health and Socio-Economic Studies in Geneva. Thirty leading physicians, health plan- ners, administrators and social scientists from various European countries, Israel and the United States took part in the symposium. The second meeting in August was a Regional Workshop of the International Epidemiological Association. Arranged by the Danish Medical Association, the workshop considered the evaluation of screening programmes, the use of hospi- tal data, research priorities, and the role in primary health care of epidemio- logy—which is the study of the various factors determining the frequency and distribution of diseases. WHO's Regional Office for Europe in Copen- hagen. (Photo WHO) 32 APARTHEID LETTERS TO THE EDITOR e have received several letters concerning Thomas J. Gray's article on Apartheid which appeared in our July issue, includ- ing a protest from Mr F.H. Stroebel, Acting Permanent Representative of the Republic of South Africa in Geneva. Despite its length, we print his letter here for our readers to judge. On one score, certainly, Mr Stroebel is right. In all good faith we reproduced a picture which was sent to us by a photographic agency as being in South Africa when in fact it was taken in the United States. We also agree that in relation to tuberculosis the word should have been "suffered" not died. But the wide discrepancy between the figures for blacks and whites remains, and racial segregation is not likely to reduce the gap. For these slips, we apologize to our readers, but they in no way alter the substance of Mr Gray's article. Mr Stroebel does not dispute that racial segrega- tion exists in South Africa, nor that differences exist between the health care available for different racial groups. These shameful differentials are un- deniably harmful to the health of the least privil- eged South Africans—the black majority. Mr Stroebel also describes South Africa as a deve- loping country, whereas it is included among the world's developed economies in such publications as the recently issued United Nations World Eco- nomic Survey for 1974. All its citizens, therefore, should expect to enjoy a high standard of medical care—if the gross national product and the high medical standards available in the country were fairly and equitably shared. The Editor. Dear Sir, The article "Apartheid—disease of human rela- tions", which appeared in the July 1975 edition of World Health, recently came to my notice. Its author—Thomas J. Gray—seems to have in- tended to mount a political attack against the South African Government rather than to give an objective and dispassionate account of the prob- lems of health care in South Africa, a developing country in which certain areas and population groups are less developed than others. Mr Gray's approach is, inter alia, clearly ex- posed by the emotionally-loaded content of his as- sertions (an example—"racial discrimination—the South African way of life"), and by the skilful way in which he selectively and distortedly quotes those statistics which seem to substantiate his thesis, while carefully suppressing those which sup- port contrary interpretations. Thus he maintains that 55,000 blacks died in South Africa in 1970 from tuberculosis, compared to 824 whites. In reality, however, these figures relate to reported cases, not to deaths. Statistics also reveal that the number of new cases of all forms of tuberculosis reported during 1973 shows in the case of blacks a decrease of 34 per cent, in the case of Asians a decrease of 8 per cent, in the case of coloureds a decrease of 31 per cent and in the case of whites a decrease of 40 per cent, com- pared with cases reported in 1964. Mr Gray refers disapprovingly to the varying rates of incidence of leprosy and typhoid—two of the 28 disease entities reported on routinely by the Department of Health—which testify to a high in- cidence among blacks and a relatively low inci- dence among other groups. But he does not men- tion those communicable diseases which, as it were, show whites up poorly by comparison with other groups—for example, encephalitis and infec- tious hepatitis. The conclusion is irresistible that Mr Gray intended his readers to be left with the impression that blacks are worst off in regard to the incidence of communicable diseases. As regards hospital beds, the figures of 10 and 5.57 beds per 1,000 for 1972, for whites and non- whites respectively over the Republic as a whole, are correctly quoted. But the reference to 3.48 beds per 1,000 Africans in the homeland areas is incor- rect—either that, or else an astonishing improve- ment was registered in a remarkably short time, since the relevant figure for 1973 was 5.03! What is not mentioned is that in terms of world health standards a ratio of 5 beds per 1,000 population is reasonable, even by western standards. Nor is it mentioned that the provision of beds for non- white South Africans is vastly superior to the situ- ation in any other African country. Mr Gray suggests that segregated health services lead to "drastically disparate rates of disease inci- dence and life expectancy between black and white groups". His own figures, however, make it ob- vious that factors other than the Government's policy of separate development play a major role since all groups are equally affected by the policy, yet rates of disease incidence and mortality vary widely. Socio-economic factors are obviously in- volved, but knowledge of elementary principles of hygiene is thought to be even more important, which serves to explain the comparatively low inci- dence of diseases among South African citizens of Asian extraction. He states that the incidence of sexually transmit- ted diseases in Cape Town in 1972 was 22.4 per 1,000 among non-whites and only 1.6 per 1,000 among whites. This overlooks the tendency among non-whites to report for treatment to public health clinics, which maintain records of venereal cases, whereas whites tend to approach private medical practitioners. Inasmuch as venereal diseases are not reportable, none of the latter category is reflected in the records. Mr Gray alleges that "access to qualified medi- cal attention is a function of race and not of the availability of the best resources" in South Africa. If this is intended to suggest that only whites have reasonable access to medical attention, it is not only incorrect but veritably malicious. Mr Gray himself admits that in practice many black patients in urban areas visit white doctors. In fact, 80 to 90 per cent of the medical attention received by non- white patients in South Africa is given by white doctors. Thus the doctor/population group ratios may be of interest from the statistical point of view, but they bear no relevance to the actual degree of access of members of different popula- tion groups to medical attention. Before concluding, Mr Gray avails himself of a parting shot at blood donations in South Africa, saying that "the labelling of blood donations by race strikingly illustrates the unscientific attitude underlying South African apartheid". It is not known exactly what point he is making, but if he is alleging that blood donated by one population group may only be used by members of the same group, this is nonsense. For example, 97.4 percent of the blood obtained by the South African Blood Transfusion Service is donated by whites, while non-white patients comprise some 60 per cent of the recipients of this blood. That Mr Gray's article is exclusively political in character is dramatically highlighted by the photo- graph of the adjacent water-coolers appearing across pages 4 and 5—the one, under the "white" sign, obviously superior to the other, under the "colored" sign, from which a black gentleman is refreshing himself. Your readers will be forgiven if they should display a subjective preference for the considerably more hygienic-looking and efficient "white" facility. But this was no doubt one of the motives for illustrating the text, which purports to relate only to the situation in South Africa, with this particular photograph. The photograph is, however, of a social situation which prevailed in the Southern United States some years ago. A political attack of the nature exposed above is regrettable, but hardly surprising since the World Health Organization itself has fallen victim to political influences which should have no place in a technical organization ostensibly dedicated to up- lifting world health standards. Admittedly South Africa has problems in sup- plying adequate health care to its developing pop- ulation groups. But what is denied most categori- cally is the meanness of spirit attributed by impli- cation to the South African Government which would have it deliberately subject the less privil- eged members of society to inferior and inade- quate health care. South Africa, in truth, not only provides a health service to all of its inhabitants, irrespective of population group, which is unrivalled in Africa, but it also provides assistance to its neighbours— Lesotho, Swaziland and Malawi. Teams of special- ists, nurses and medical students regularly visit these countries which have, to a large extent, come to rely on South Africa for certain specialist ser- vices: Yours sincerely, F. H. Stroebel, Acting Permanent Representative South African Permanent Mission, Geneva Dear Sir, I was very impressed with your article on Apar- theid. The appalling consequences of this policy supported by the formidable array of supporting facts and figures bring home the inhumanity of the South African policy. The painstaking research by the writer deserves praise. This article has discou- raged my family and myself from a considered em- igration. Yours faithfully, Mrs Rita Reynolds Bath, England Dear Sir, Your recent article on South Africa and the sys- tem of apartheid brought back to me memories of my stay in Johannesburg. Not all these memories are, unfortunately, beau- tiful: the long queues of despondent African moth- ers waiting outside "non-white" hospitals; ragged African ten year olds eating half loaves of white bread at midnight in the suburbs, with nowhere to sleep at night. No wonder that this otherwise love- ly land has these health problems. You do all those in the rest of the world a ser- vice by bringing these facts home. Yours sincerely, Mrs B. E. Pude, London 33 34 QUIZ What is the best way to protect yourself against cancer? A. Have annual check-ups; B. Eat natural foods; C. Exercise daily. How many chemical agents of proved effectiveness against cancer are at present in use? A. 40; B. 20; C. 10. How many years longer can a man of 25, who has never smoked, expect to live than a man of 25 who smokes 20 to 30 cigarettes a day? A. 1 year; B. 3 years; C. 61/2 years. Normally, if you stop cigarette smoking, actual benefits to the body will begin: A. Within six months; B. Almost immediately; C. After one year. Fewer women die of cancer of the cervix today because of what simple, quick test? A. Blood test; B. "Pap" test; C. X-ray. What is your best every-day protection against cancer? A. Knowing the 7 warning signals; B. A daily walk; C. Taking multi-vitamins. •V . 9 '9 . 9 'El ..t7 '3 'CV . Z 'V • L :svemsuv WORLD HEALTH Puzzle Picture What is it? An improvement on the traditional Scottish bagpipes? A vacuum-cleaner that sweeps the ceiling at the same time as the floor? A nuclear-powered coffee percolator? No, in fact it is an experimental artificial heart, made of plastic and intended to undertake temporarily the pumping action of the real heart. (Photo USIS NIH/WHO) Heart beats From the mechanical viewpoint, the heart is one of the most efficient pumps ever known. Though you may live a hundred years, your heart must never stop doing its job of moving life-giving blood around your body. Yet few of us know a great deal about this vital organ. Here are some statements aimed at increased understanding of the heart. Try not to miss a beat as you identify them. True or False: The heart is the largest organ in the human body. False. Several other organs are larger; for instance, the liver. The bigger your heart, the better. False. There is no relationship neces- sarily between the size of your heart and the state of your health. Certain diseases may either lessen or enlarge it. Generally speaking, heart size should correspond with body build. The pulsebeat felt in the wrist cor- responds with the heartbeat heard in the chest. True. Both beats are a measure of cardiac activity. However, with certain disturb- ances of the heart rhythm, some beats may not be felt in the wrist pulsations. There is no difference between the hearts of men or women. True. Examination of the heart gives no clue as to whether it is a male's or a female's. Blood can be safely transfused from one person to another so long as they belong to the same ethnic group. False. Both persons must have the same type of blood, and these biological variations do not correspond to ethnic groupings. The heart circulates both fresh and "used" blood. True. It sends fresh blood through the arteries to feed the body with nutrients. It also sends "used" blood to the lungs to get rid of waste products and receive a fresh supply of oxygen. The heart is always on the left-hand side. False. Rare cases of dextrocardia- where the heart is positioned on the right-hand side—do occur. Heart disease was originated by the modern style of life. False. While such things as stress, fatty diet and inadequate exercise may ag- gravate the situation, heart disease has plagued man for many centuries. Its effects have been seen even in ancient Egyptian mummies. Sleeping on the left side is bad for the heart. False. Although this organ lies toward your left side, it is not affected by sleeping position. The heart never rests. True. Even between contractions, it is actively regenerating itself during the few tenths of a second between beats. The heart begins to beat when the newborn baby takes its first breath. False. The heart starts work fully seven months before birth when it begins moving blood through the vessels of the develop- ing embryo. 10 . 18 — 24 25. 45.— 60. 0 Authors of the month Dr ALEXANDER S. PAVLOV is Assistant Director-General of the World Health Organization. A radiotherapist, he is a Member of the Soviet Academy of Medical Science and was formerly Director of the Herzen Cancer Insti- tute in Moscow. Dr WALTER DAVIS is Chief of the Research, Training and Liaison Unit at the International Agency for Re- search on Cancer at Lyon, France. Dr A. M. GARIN is Chief of the Cancer Unit at WHO heardquarters, and Dr L. SOBIN is a pathologist in the same unit. Dr GISELA GASTRIN is a Finnish phy- sician who has undertaken a major study in early detection of breast cancer. Mrs MARVELLA BAYH is the wife of a US Senator. Dr N.T. RACOVEANU is Regional Ad- viser on Radiation Health and Cancer at the wito Office for the Eastern Mediterranean in Alexandria. Dr R. LEE CLARK is President of the University of Texas System Cancer Center, and President of the M.D. Anderson Hospital and Tumor Insti- tute in Houston, USA. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$' Sw fr * One year Two years Three years One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City : Country : or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland ie s R eu n ie s S. A. L au sa n ne 'ti nt ed in S w itz er la nd Specid'ists at a cancer clinic in Kemerovo, Wester? Siberia, ready'ng a gamma-radiation machax for use. (Phot Novosti)