Health for all by the year 2000: the count-down has begun [full issue]

WORLD H THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • FEBRUA 1983 EALTH FOR ALL BY THE YEAR 2000: the count-down has begun Cover : World Health Day poster contributed , by the International Green Cross. • IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, German, Portuguese, Rus- sian and Spanish, and four times a year in Arabic. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Health for all by the year 2000: the count-down has begun by Halfdan Mahler 3 Latrines on show by Jitendra Tuli 5 Television can save lives! by Pekka Puska 8 There's no substitute for mother's milk by Andy Chetley 12 The children of today: the adults of the year 2000 Design by Jean-Francois Chretien 16-17 Use and misuse of the media by Sumanta Banerjee 18 New WHO guidelines for drinking water quality by Igor Fiozov 21 Getting the message across by Maggie Jones 22 Smoking and health by Kurt Baumgartner 25 Self-help : one way to health Interview with Lowell Levin 26 News Page 30 There are many ways of conveying the messages of health—as these examples from the South-East Asia, African and Eastern Mediterranean Regions of WHO suggest. Effective education for health should heighten individual and community aspirations towards better health. Photos WHO/UNICEF/J. Danois, WHO/T. Ade Laoye and WHO/D. Henrioud WORLD HEALTH DAY 7 APRIL 1983 the count-down has begun by Dr Halfdan Mahler Director-General of the World Health Organization Only 17 years are left until the target date of health for all by the year 2000. The Member States of WHO have pledged themselves to work together so that, by then, all people everywhere will have at least such a level of health that they will be capable of working pro- ductively and taking an active part in the social life of the community in which they live. But Member States are not made up of governments alone. To be sure, governments have a responsibility for the health of the people, but people, too, have the right and the duty to take an active part in maintaining their own health and, when they are ill, in looking after themselves. They have the same duty with respect to their families, their workmates, their neighbours. To what kind of people am I refer- ring? I am referring to people in all walks of life. All of them can be agents of change for health— ordinary citizens going about their daily business in villages and towns, grouping together in families and communities, and as- sociating with one another in all forms of social and political groups, educa- tional and research institutions, non- governmental organizations, and pro- fessional associations. Health workers, too, are part of the people ; so are others who have community responsi- bility, such as civic and religious lead- ers, teachers, magistrates, community workers and social workers. Without the dedicated involvement of people, health for all will be a constantly receding horizon. But to act wisely, people must understand what health is all about. And it is the duty of those who possess health knowledge to share it with others. The days are over when action for health was the prerogative of all-knowing individuals holding their professional secrets to them- selves and handing out doses of it to ignorant, passive, patients lining up for charity. To bring about widespread understanding about health was the reason for giving pride of place among the essential elements of primary health care to education concerning prevailing health problems and methods of preventing and controlling them. What can people do about their health? To give a few examples, they can take individual and community action to ensure that they have suffi- cient food of the right kind They can get together to make the most of whatever safe water is available, or can be made available, making sure that it is protected from pollution. They can insist on acceptable stan- dards of hygiene in and around their homes, in market places and shops, in schools, in factories, in canteens and restaurants. They can learn how to space the children they desire in such a way as to give each and everyone of them a good chance of survival, a reasonable education, and a decent quality of life. Women can help one another to remain healthy during pregnancy and breastfeeding, seeking the advice of health workers as necessary. Parents can learn how to rear their infants in a healthy manner, to look after them if they get diarrhoea or respiratory in- fections, and to ensure that their chil- dren are immunized against the pre- vailing infectious diseases, for which the country and community can afford to provide immunizations. They can be taught to recognise those serious conditions that require attention from more knowledgeable health workers. Communities, with the help and guidance of community health work- ers, can undertake to fight against such 3 This year is World Communications Year—a timely reminder of the role that telecommuni- cations can play in saving lives, as here in a speeding ambulance in Thailand. Photo WHO/International Telecommunication Union diseases as malaria and other parasitic diseases, for example, by organizing insecticide spraying and the control of insects and other carriers of disease such as rats and snails. Mothers and fathers can make sure that their chil- dren get the drugs they need to pre- vent and treat malaria and ensure that their elderly parents or the disabled receive the care they need but are unable to provide by themselves. Communities can see to it that school children receive training in first aid and in the elementary care of simple illnesses. Communities can also take action, in accordance with the coun- try's political, social and administra- tive procedures, to ensure that those drugs that are essential become avail- able to them at a cost they can afford. Please do not think that all this relates to people in developing coun- tries alone. On the contrary, people in more affluent countries, most of whom have had the privilege of a formal education, must rise to their health responsibilities, eating wisely, drinking moderately, smoking not at all, driving carefully, taking enough exercise, learning to live under the stress of city life, and helping one another to do so. Education for health requires both motivation and communication. For communication can and should not only provide insight into what is needed to remain healthy and what should be done when health begins to fail ; it also can and should heighten individual and community aspirations towards better health. Effective com- munication will give rise to greater motivation and this in turn to im- proved communication. A steady flow of information is required, not only by the written word, whether once a year on World Health Day or through local, national and international newspapers and jour- nals, but also through talks, group discussions, radio, television, comic strips, plays, films, vocal music and the like. And this communication should take place in families, schools, fac- tories, offices, universities, social and religious groups, trade unions, politi- cal parties, and wherever people meet. This is the urgent message I should like to get across on this World Health Day : " All people have the power to act for health ; the time to act is now. " The count-down for health for all by the year 2000 has begun. ■ 4 Latrines on Show In the Indian town renowned for its connection with the social reformer Mahatma Gandhi, a remarkable institute is helping people towards a healthier lifestyle. Its front yard boasts—instead of flower-beds or a lawn—a display of various water-flushed latrines by Jitendra Tuli TAhmedabad, in north-west In-dia, is known for its textiles, and as the place where Mahat- ma Gandhi (1869-1948) lived for many years in the Sabarmati Ashram. It was from this Ashram, now a nat- ional memorial, that the Mahatma launched some of the social reform movements which later changed the course of history. Close to the quiet and peaceful Ashram, where visitors feel impelled to lower their voices to a whisper, is an institution that is truly unique. Known as the Safai Vidyalaya (sanitation in- stitute), it was established in 1964, primarily to work on the conversion of bucket latrines as the means to achieve the emancipation of scavengers. As those people say who have watched the work of the institute closely, the movement it has launched may well bring about a social revolution. "If we are able to achieve even a fraction in terms of bringing about a change in people's attitudes towards this work, we shall have achieved a lot ", says Mr Ishwarbhai Patel, the Principal of the Vidyalaya. Having already spent over 30 years in this work, Mr Patel speaks with a great deal of conviction and authority when he says that sanitation is not merely a question of excreta or waste disposal. "It is a way of life. It should also mean better ventilation, proper light, cleaner surroundings—in gen- eral, a healthier lifestyle. " Over the Public conveniences in the Indian city of Patna meet a public need—thanks to public health messages about good sanitation. Photo WHO/A. S. Kochar years, through various training courses and the organization of rural sanita- tion camps, he has spread the message and importance of sanitation through- out the State of Gujarat. What these activities have also helped to highlight is the fact that the primary health care approach is cer- tainly workable, and that the goal of health for all can be achieved, not by the health sector alone, but through the concerted efforts of all. Written material has been specially prepared by the institute to popularise different types of water-flushed la- trines. The front yard of the Vidyalaya has, instead of flower beds or a lawn, an area where prototypes of latrines are on display which have been spe- cially developed to use the minimum amount of water. These are used as practical training aids by the scores of students—village leaders, National Service Scheme volunteers, overseers, municipal sanitary engineers, social workers and others—who attend the regular courses at the Vidyalaya. What Mr Patel stresses repeatedly is that, in order for the new water-seal latrines to be used, it is essential to keep in mind the various cultural and behavioural factors of the users. " One cannot just blindly adopt any system and hope that it will work. It needs careful study, even to the extent of measuring the gap between the foot- rest, the amount of water that is 5

This small factory produces more than 300 water-seal latrines every day. Upper left: Instead of flower beds, a "sani- tation garden" in the front yard of the special institute in Ahmedabad. Left: Concrete slabs cover the input channel to a biogas plant, where human waste is converted into useful energy. Photos WHO/A. S. Kochar needed, and what people generally put into latrines. " Having studied these and other aspects, the institute has designed a series of latrines using appropriate local technology, and has also educated thousands in their proper use and maintenance. Through various schemes launched by the State Government, house- holders below a certain income level are given financial assistance to en- able them to convert their dry latrines into water-seal ones. Since 1964, more than 150,000 dry latrines, over 85 per cent of the total, have been converted. The conversion is usually initiated at rural sanitation camps organized by the Vidyalaya. Mr Patel says that these are very effective and cites the exam- ple of how, at a recent camp, they converted 110 latrines in 10 days. In all these activities the most vital component is the community's partici- pation. To ensure this, the institute has 18 field workers who involve the local student and village leaders, women's organizations, youth clubs and the vil- lage panchayats (councils). Here, the message is not only sanitation but smokeless ovens, soakage pits and proper ventilation. Through various assistance schemes, the villagers are helped to improve their living condi- tions. And it always works. "All it needs is a little understanding, a little patience and the ability to take people along with you—with work, and not words, " says Mr Patel. The success of this approach is obvi- ous as one walks through one particu- lar residential locality with narrow streets and lanes where, in the past couple of years, more than 650 dry la- trines have been converted until today there is not a single dry one left. As for those who used to service—that is, to shovel out—the dry latrines, they have all been absorbed in alternative jobs. The story is repeated in several other localities, where householders proudly take you indoors and show you privies in the smallest of places or tucked away in the most unimaginable corners. "The best part of it is that there is no smell and no question of any pollution, " com- mented one householder. According to Mr Patel, the best part is that the scheme is fulfilling a long- felt social need. In the process, it is also helping to give new life to the vision of Mahatma Gandhi. ■ 7 Television can save lives! Finland is still assessing the long-term impact of a series of nationwide television broadcasts aimed at curbing smoking and promoting better life-styles. What is certain is that about 700 fewer people aged under 65 are now dying each year from heart disease in Finland than was the case ten years ago by Pekka Puska n many countries today, every second citizen dies prematurely as a result of a heart condition. Heart disease rates have increased particu- larly among the middle-aged popula- tion, and throughout most of the in- dustrialised world since the Second World War, cardiovascular dis- eases—and especially coronary heart disease—have become the foremost public health problem. So the success of any major public health effort to prevent premature mortality and disablement must start by trying to control this modern epidemic of heart disease and the chronic health problems related to it. Not all industrialised countries are equally affected. In the 1960s mortal- ity statistics showed that the highest rates of death from heart disease were found in Finland, especially among the male population. In the early 1970s, a wHo-coordinated register study con- firmed these differences between countries. Later findings showed that there were regional differences within Finland itself, and that the highest rates were in Eastern Finland, and particularly in the county of North Karelia. Armed with this alarming informa- tion, a national project began in Fin- land to develop and test methods of controlling this epidemic on a com- munity scale. A petition submitted by representatives of the local residents to the Finnish government, asking them to do something to reduce the high heart disease rates, resulted in the launch of the North Karelia project in 1972, with close cooperation between Finnish experts and wHo. The project's aim was to carry out a comprehensive community-based pro- gramme and to evaluate the results for possible nationwide and international use. In North Karelia itself, the objec- tive was to bring about a decrease in the mortality and morbidity rates from cardiovascular diseases among the whole population, but with special reference to middle-aged men (that is, those under 65). The main emphasis has been on primary prevention of heart attacks through a reduction of such well-established hazards to health as smoking, high serum choles- terol levels and high blood pressure. These factors were found to be preva- lent in the area at the outset. People have been encouraged to stop smoking, to change their diets and to have their blood pressure checked. Based on local community action and local service structures, a comprehensive educational pro- gramme has sought to bring about the kind of lifestyles that reduce the risk factors and promote health. Evaluation of the results has relied on repeated health check-ups and sur- veys of representative population sam- ples, on special country-wide disease registers and on mortality statistics. The coordinating centre of the project is at the National Public Health Insti- tute in Helsinki, and the University of Kuopio is an important research centre for the project. The findings during the first five- Forestry provides most of the jobs in North Karelia, a region with the highest death rates from heart disease in Finland. Photo WHO/N. Willard 8

year period of the project, from 1972 to 1977, showed that : the feasibility of the programme was good ; the programme had clearly reduced the risk factor levels ; the cardiovascular rate had started to decrease in the area ; the costs were modest and the ob- served savings (through reduced disability payments) were consider- ably higher than these costs ; the local population participated ac- tively in the programme, was very satisfied with it, and appeared to suffer no major adverse emotional consequences. In the spring of 1982, a large ten- year follow-up survey was carried out in North Karelia and in two other areas to assess the latest develop- ments. At the same time, the most recently available mortality data were collected and analysed to observe the trends of heart disease rates in North Karelia and elsewhere in Finland. These results too showed that the risk factors in North Karelia had con- tinued to decline during the second five-year period, from 1977 to 1982. Smoking and serum cholesterol levels in particular had decreased. In 1972, more than 50 per cent of adult men in the area smoked ; now only 30 per cent of them smoked, and for the first time, North Karelian men actually smoke less than men elsewhere in Finland. On the other hand, no further improvement in the blood pressure was in evidence. The latest available mortality fig- ures, for the period 1969 to 1979, show that deaths from heart disease among middle-aged men in North Karelia fell by 27 per cent. Most of this reduction-19 per cent—took place during the last five years of the period, when the decline in the risk factors was most in evidence. Fewer women too died from heart disease ; the mortality rate fell by 42 per cent among middle-aged women. At the start of the project, there had been Television can save lives ! Left : Aimed at bringing down mortal- ity and morbidity rates from cardio- vascular diseases, North Karelia's community-based programme in- cluded regular checks for high blood pressure. On a national scale, television programmes proved successful in im- proving lifestyles—and almost certainly have saved hundreds of lives. Right : Woodcutters cooperate in a sample survey undertaken by an offi- cial from the North Karelia pro- gramme. Between 1969 and 1979, deaths from heart-disease among middle-aged men in this region fell by 27 per cent. Photos WHO/D. Henrioud about 250 fatal heart attacks every year among both men and women ; today that number has been reduced by about 100 each year. Television broadcasts One of the first nationwide manifes- tations of the project was an anti- smoking programme put out on Finn- ish television in the spring of 1978. It consisted of seven sessions broadcast over a four-week period, and involved a voluntary group of ten smokers in the studio. The programme also con- veyed general health information to the viewing public. In North Karelia itself, lay people were recruited to help form some 100 local self-help groups. Later evaluation showed that between ten and 20 per cent of smo- kers in the country followed the pro- gramme and, of these, around ten per cent (10,000 persons) stopped smok- ing permanently. In North Karelia, this proportion doubled compared to smokers who watched the programme 10 in a non-organized setting. The results were at least as good when the anti- smoking sessions were screened again a year later. In the spring of 1980, Finnish televi- sion started a national programme aimed at reducing all the heart disease risk factors. This time the emphasis was on stopping smoking, on increas- ing physical activity during leisure time, and on a wiser diet—less fat, salt and sugar and more vegetables. The programme consisted of ten half-hour sessions every second week over a four-month period, and involved eight volunteers in the studio. About 20 to 30 per cent of the adult population watched the sessions, and altogether 0.5 per cent of all smokers (5,000 persons) stopped smoking perma- nently. More than one per cent of the total who watched (60,000 persons) reported losing weight as a result. The organizers concluded that the effects of such television programmes are limited at the individual level, but that, in view of the large numbers of viewers involved, the absolute effects are substantial and make such efforts cost-effective. In the spring of 1982, a third comprehensive programme to promote health and reduce the risk factors was screened nationally, and although its effect has not yet been finally evaluated, its success has been evident. The North Karelia project has been associated with national developments in the public health field and has actively contributed to these develop- ments, as the results of the television campaigns show. National figures indi- cate that, during the last ten years, mortality from heart disease has started to decline throughout Finland. The reduction among middle-aged men has reached 17 per cent. Even though the 27 per cent reduction re- corded in North Karelia is significantly higher, this favourable result on a national scale means that about 700 fewer middle-aged people die from heart disease each year than was the case ten years ago. The programme is still going on, and is considered important for training purposes and for national and inter- national demonstrations of the value of health education. Further monitor- ing of the risk factor and disease trends will be important in order to assess the long-term impact of these activities. At the same time the scope of the programme is being enlarged so as to take into account related major non- communicable diseases in an inte- grated way, and also to emphasise the promotion of positive attitudes to health. The programme is actively continuing to extend the application of its experiences on a national scale, through the national health services, through several mass-media activities, and through the preparation of health education and other materials. Finally, the worldwide implications of this first major project of its kind are being made known through active collabora- tion with wHo and other international channels. ■ 11 There's no substitute for mother's milk by Andy Chetley "Simply promoting breastfeeding is not enough ... We need to go public. Why not use the media to promote what is good, healthy and nutritious ?" Health workers in Bangladesh are striving to make sure that this wholesome practice is accepted and protected N7 ima and Hasan were both born 1 in Dhaka, Bangladesh, during April 1982. In September, Mima's mother took her for a regular check-up at the Community Health Re- search Association (cHRA) clinic. Mima was healthy and thriving, and her mother left the clinic with a happy smile. Not far away, at the Children's Nutri- tion Unit (cNu) hospital, Hasan lay in a cot suffering from marasmic kwashiorkor. He weighed only 2.6 kilos (5 pounds 12 ounces)—less than his birth weight. His mother hovered by his cot, distress and worry showing plainly in her face. The difference in the health of these two infants could be traced to the way they were being fed Mima's mother had attended an anti-natal clinic run by the CHRA. There she learned the importance of breastfeeding and how to prepare for it. Hasan's mother received no advice about infant feeding. After only five weeks of breastfeeding, she switched to using the " modern " feeding bottle and the "scientifically formulated" infant formula. At first, the formula seemed fine. But it was so expensive. Hasan's mother had only 2 Taka (one US cent) per day to spend on food for each member of the family. To give Hasan the right amount of formula would cost about 7 Taka per day. She began to " stretch " the milk powder—over-diluting it. Because she was unable to read, she could not follow the instructions on the tin about boiling the water and sterilising the bottle. Hasan began the downward cycle of infection and under-nutrition that eventually brought him to the CNU. According to Dr M. A. Muttalib, President of the CHRA, Hasan's case history is far more common than Mima's. "We have a situation in the urban areas of Bangladesh where eight A mother is assured that no antibiotic is needed to treat her baby's diarrhoea. Some inexpensive oral rehydration salts and con- tinued breastfeeding will do the trick. Photo WHO/UNICEF/J. Myers out of ten babies are malnourished from the misuse of milk powder. That's why we stress the message : ' There's no sub- stitute for mother's milk' " He points to surveys which show that a very large proportion of mothers in the urban educated community bottle-feed their babies by the time they are three months old. While some of those who market infant foods have argued that it is acceptable for mothers in this sector to bottle-feed, Dr Muttalib disagrees vehemently. "From whatever socio-economic strata, if a baby is bottle-fed, the baby suffers. The baby, even in a relatively wealthy family, often suffers from diar- rhoea. Even in a city like Dhaka, no mother should use the bottle because the water is so polluted, " he says. The situation in the rural areas is assumed to be much better. Recent statistics suggest that 90 per cent of rural mothers breastfeed. However, early results from a survey being conducted by the CHRA in more than 60 villages throughout Bangladesh are causing con- cern. "We're finding a large number of mothers introducing the bottle at an early age, " says Dr Muttalib. Certainly the infant formula is avail- able in the rural areas. A UNICEF rep- resentative in Bangladesh commented that this was evident even at small roadside stalls. "The thing is, no one could afford to buy it, " she said. " One of the large-size tins costs about 150 Taka. No family could afford that. My worry is that, like many products in Bangladesh, the stall owner will open the tin and sell small amounts. The mother would buy a few Taka's worth at a time. " Any hope of safe preparation and uncontaminated feeds would vanish under such a system. While milk powder is expensive, feed- ing bottles come cheap. The CNU hospi- tal has a prize collection of feeding bottles that were used by some of the babies treated there. They include old medicine bottles, cooking oil bottles— almost any type of glass or plastic bottle with a teat stuck on top. Most are impossible to wash clean. The 40 staff at the 60-bed CNU hospital have their hands full. They admit only third degree malnourished babies—about three or four new cases every day. The three doctors on duty were unanimous about why the infants were so malnourished : "Bad feeding practices—either bottle-feeding, or the failure to introduce solid foods at the right time. " The CNU encourages mothers to stay with their babies while they are in the hospital and has provided a housing shelter in an adjoining building. The mothers are given a week-long training course in basic nutrition with practical demonstrations of how to prepare inex- pensive and nutritious local foods. " We encourage breastfeeding and tell the mothers not to bottle-feed," said one of the doctors. "We show them how to use a cup and spoon. The importance of the programme is that the mothers see that it is food, not some medicine or drug that we give their babies to help them recover. They then see the import- ance of the right kind of food—and food that they can afford. " The programme works. None of the children treated there return in a mal- nourished state. Similarly, other children from the same family are spared the 13 debilitating affects of severe malnutri- tion. And the mothers act as a referral service. " Once their child has been here, they are able to recognise malnu- trition. They know what it is and they tell other mothers to come to the hospital. " Dr Muttalib's clinic operates with a similar objective, although he hopes to catch mothers before their babies be- come malnourished. "We see ourselves as a guiding centre more than a treat- ment centre, " says Dr Muttalib. " Our objective is to create a cadre of mothers who will motivate themselves in the community. We have many vocal mothers now, and they have made a change in maternity and paediatric prac- tices. They challenge the doctors :` Why do you tell me to bottle-feed? Why can't I have my baby with me right after delivery ? ' In this way, they are indi- rectly training the doctors themselves in better child-care practices. " Dr Muttalib sees some members of the health profession as part of the problem of poor infant-feeding prac- tices. Often, he says, they give the wrong advice to mothers. " Until 40 or 50 years ago, bottle-feeding was unknown to Bangladeshi women. Mothers learned bottle-feeding from these health wor- kers who wanted to demonstrate that they had something new, modern and scientific to show to mothers. " Advertising and promotion of pow- dered milk and feeding bottles have reinforced the attitude that bottle-feed- ing is the " modern " way. In recognition of the undue influence that the commer- cial promotion of these products can have on feeding patterns and infant health, the 34th World Health Assem- bly (which took place in Geneva in 1981) overwhelmingly approved an International Code to deal with these marketing practices. . Dr Muttalib was a member of a small committee which studied the useful- ness of the Code in Bangladesh. The committee has recently recommended to the government that the Code should be applied in its entirety. But, along with the Code, Dr Muttalib wants to see a solid programme of health education to change the motivation of people to- wards breastfeeding. Says Dr Muttalib, " We can reduce the amount of bottle- feeding if we fight and work hard to There's no substitute for mother's milk Left : In Zaire, this little sufferer from kwashiorkor needed three months of treatment before he could be restored to his family. Wiser feeding habits could have prevented the child's mal- nutrition. Right : A nutrition class in Thailand. Mothers who have already learnt the value of breastfeeding are more ready to appreciate the importance of the right kind of food as their children grow bigger. Photos WHO/P. Almasy and WHO/A. S. Kochar remove the current attitudes in favour of it. " Progress in translating the aims of the International Code into action appears slow in some other parts of Asia. Mr David Haxton, UNICEF's Regional Director for South Central Asia, notes that the pace of implementing the code is " not fast enough. " " Whether or not there is an International Code, everyone would be in favour of improving infant- feeding practices. But there has not been much progress, " he says. WHO's Regional Director for South- East Asia, Dr U Ko Ko, concurs and notes that one of the factors holding up progress has been the "expected resist- ance by some vested interests. " Despite this, Dr Ko Ko hopes that countries will be able to implement strategies to put the code into effect quickly. Mr Haxton sees part of the problem as a lack of innovativeness. "This prob- lem needs to be attacked on a wide front. Simply promoting breastfeeding is not enough. We need to get to the health services, to teachers' training courses, even to include human nutri- tion in agricultural training. We need 14 to go public. Why not use the media to promote what is good, healthy and nutritious ? " Working in conjunction with a con- sumers' organization in India, UNICEF tried this approach last year. A specially designed leaflet answering some of the basic questions about infant feeding was inserted into the Indian edition of the Reader's Digest. The response was phenomenal, says Mr Haxton. "We could barely deal with the response from people writing in for more information. " Long-term effects? Back in Dhaka, several babies were in the playroom of the CNU hospital, nearly at the end of their three-week stay. The treatment they received had taken away the worst signs of the devastation their malnutrition had caused, and they were beginning to reach for toys, to smile and to respond to the things and people around them. The long-term effects of severe malnutrition at such an early age, however, could only be guessed at. In the CHRA clinic, Dr Muttalib finished an examination of a six-month- old baby whose mother was still breast- feeding. She had introduced some solid foods about six weeks earlier and the baby was doing well. Dr Muttalib's next visitor was a salesman from a drug company, offering three new antibiotic treatments for diarrhoea in infants. He listened politely to the sales talk, ques- tioned some of the research findings justifying the medicines and sent the representative on his way without a sale. As he put away the free prescription pads advertising the products which the representative had been trying to sell, Dr Muttalib said, " What we need in this country are simple treatments and basic health education. Our doctors should be able to deal with this. It is a tragedy that we can easily prevent many of the prob- lems of infant health and we don't do so. If breastfeeding is there, no antibiotic is needed for the treatment of diarrhoea. If diarrhoea does occur, some inexpen- sive oral rehydration salts and continued breastfeeding will be enough. " His ambition is to make sure breast- feeding is accepted and protected in Bangladesh. For ten years he has kept up his struggle to improve infant-feed- ing practices. "I'll continue this until we've won. It's a long and continuous process and, slowly, we're seeing the necessary changes. " The telephone rang. It was a mother who had given birth the day before. She called to say that she was fine, the baby was fine and that she was breastfeeding and enjoying it. She thanked him for all the help that he and the other staff at the clinic had given in preparing her for breastfeeding. Dr Muttalib put down the phone and smiled. Another child was started successfully on the road to health. ■ Breastfeeding . . . the modern way. This is the title of the WHO/UNICEF joint calendar for 1983, and it underlines the message that today's mothers are learn- ing, or re-learning, all over the world. Breast milk is the perfect food at the perfect temperature; it is also the only milk that protects a baby against infec- tion; and it is the convenient milk— always readily available. That is why modern mothers feed their babies the modern way—at their breasts. 15 The children of today: the The healthy growth and develop- ment of the children of today are the foundations of health for all in the year 2000. In many developing countries, the healthy growth and development of children is endangered by three main factors : MALNUTRITION, which is widespread in many developing countries and all too often goes undetected because mothers do not recognise the symptoms ; INFECTIONS, particularly diarrhoeal diseases : a malnourished child is more vulnerable to infectious diseases ; and CLOSELY SPACED PREGNANCIES, which endanger the health not only of the children but also of the mother and thus of the whole family. The means to combat these threats are simple and should be available to everyone. Growth can be monitored with the Growth Chart, prepared by WHO, which enables parents, health personnel and other development workers to compare each child's progress with that of healthy children. The line should rise steadily. If the child fails to grn\N, or hArgins to lose weight, something is wrong and corrective action must be taken. The foundations of health are already laid before the child emerges from the woriib. A I leal 11 iy I r lull iei vvill have babies with an adequate weight at birth. From that point onwards, mother's milk provides all the nutrition the baby needs for the first four to six months of its life. Breast-milk is a food precisely adapted to a baby's needs ; it also offers natural protection against infections. Breastfeeding enhances the natural bonding of child and mother. Moreover, breastfeeding contributes to birth-spacing since a woman who is fully breastfeeding is less likely to conceive. After four to six months—the critical point in a child's growth—the child begins to need other food in addition to its mother's milk. Usually the ordinary family fare, finely mashed, is all that is needed, and the baby will learn to fond from a spoon At fist., llie food earl include cereals and vegetables ; later it can include other food. 10001/6 ell 4 1001 ■1 I NJOIMIY VA/11 1101y1Cili 16 RS V I VI °Nig tOlMOKI moluo., IPI vADIOIDI 151111111.1TP _ _ Kg 13 ivio ►voivio ...441111 111 11P211111P110.11-7 — - . .1—... gill in 12 II I III ,IrArdi KIP 11 11111111griglIN:i1111 11Prigillill CAPPArgillinii iiiilli ilror.-7,N111 - - 1111111 - -- I II ) 9 7 81111 — II — - — — - - - p, .... , .. • ._,...,711 ,e... .. "__ ,.. i I . ; MI i . ._ ......\ lowatcm . .„ liciaNCTIGNI 1111111011E1ERIEMMT adults of the year 2000 Better nutrition not only ensures normal healthy growth for the child; it also strengthens its resistance to infection. But in addition, suitable immunizations as advocated by WHO's Expanded Programme on Immunization can combat six killer diseases of childhood. Two of these diseases, measles and whooping cough, frequently combine with malnutrition to check the child's growth. The other four diseases for which protection is readily available are tuberculosis, diphtheria, tetanus and poliomyelitis. s. 1 vas 293031S2553435 Where there is good family hygiene, there is much less diarrhoea. Nevertheless, no fewer than four or even five million children die from diarrhoeal diseases each year. A child suffering from diarrhoea loses vital liquids and salts and these have to be restored. The child must be given a mixture of certain salts and sugar, Oral Rehydration Salts, dissolved in water; nursing babies should continue to be breastfed as well as having the salts. UNICEF produces large quantities of these salts, ready to mix, or they can be made up at home. Use and misuse of the media The coming years will probably see increased activities by a variety of voluntary organizations, through the media, aimed at protecting consumers from the adverse effects of unscrupulous advertising of medicinal drugs and sub-standard food products by Sumanta Banerjee eporting in 1956 on the excessive n amount of space taken up by advertisements in Indian news- papers, the Indian Press Commission commented : " The largest field of ... objectionable advertising which we feel should be put down by law is of drugs and proprietary medicines ... The volume of advertising of such commodities ranks next only to the volume of advertising of cosmetics. Quite a number of the drugs and medicines advertised are harmless if not always effective. A number of these preparations are, however, offered to persons suffering from diseases for which drugs of proved therapeutic value have not so far been developed. The harm that arises from such advertising is that the pa- tients might be deluded into dosing themselves with these medicines and delay medical examination or advice till the disease reaches an incurable stage. " Since then there has been a prolifer- ation of both drugs and advertising (which today has an annual turnover of about US $400 million). The in- creasing numbers of newspapers and magazines during the last two decades have enlarged the scope for advertis- ing these drugs and medicines. Radio and television have become even more effective vehicles for such advertise- ments, since they reach a wider audi- ence in the rural areas. Songs, jingles, skits and short films are commissioned by drug manufacturers to sell their products through television and radio, and a variety of health foods, tonics, glucose, vitamins and minerals are being aggressively marketed. By contrast, the opportunities for nutritional education through news- paper columns or by radio and televi- sion are limited. The ill-effects of excessive intake of vitamins or glu- cose, pointed out occasionally by doc- tors in press articles, remain unknown to the general public who seem almost hypnotised by the advertisements. This tendency to advertise drugs for diseases for which a cure has not yet been discovered is not confined to any particular country. Two years ago, an English-language daily newspaper in South-East Asia trumpeted the intro- duction of some brand-name capsules which it described as a "life-saving anti-cancer agent. " This inaccurate characterisation would not have been permitted in the United States. The "Physicians' Desk Reference ", an au- thoritative directory of vital informa- tion on drugs sold in the US, described the drug as of extremely limited effec- tiveness and added that it could gener- ate deadly adverse reactions. Sections of the Region's press also exploit the credulity of the general public by offering magical cures for sexual deficiencies. A typical example reads : "Your dreams may come true. For health, vigour and vitality—An- cient Ayurvedic and Unani formulas consisting of rare ... herbo-mineral combinations which were once used by RAJAS AND NAWABS. Now you can also avail of these restorative for- mulas and can enjoy the real charm of happy married life ... ". To counter such advertisements, the Ganoshasthya Kendra (People's Health Centre) of Bangladesh carried out an investigation and exploded some of the myths. The Centre's rep- resentatives visited various sex drug shops in Dhaka and other places, and later narrated their experiences in the centre's journal, exposing the false claims. Besides drugs and medicines, the other important items that are widely advertised in the newspapers and media, are baby foods and their ac- cessories. After the passing, in 1981, of the WHO code regulating advertise- ments of infant formula, some manu- facturers have resorted to various alternative techniques of promotion. Thus, one popular magazine carried a full-page advertisement promoting the use of feeding bottles and nipples made by a manufacturing company which produces baby food. It has been reported that, instead of directly ad- vertising baby foods, these companies 18 One Asian consumer organization uses newspaper cartoon techniques to put across the message that "junk foods" are bad for children's health. Photo R Seitz © send their sales representatives to pediatricians, hospitals and nursing homes to sell their baby food, or leave free supplies there as incentives for nursing mothers. Although the campaign against baby food promotion in the media has not yet caught on in India, in a few other Asian countries the media are playing an important role in promot- ing breast feeding and weaning women away from infant formula. The Singa- pore Breastfeeding Mothers' Group, for instance, has produced a film called "The Second Link ", proposing breastfeeding as a baby's second link to the outside world, the first link being the mother's womb. The topics covered include the history of breast- feeding, breastfeeding in hospital, at home and in public, hygiene, proper diet, weaning and so on. In Indonesia, wide publicity has been given to an investigation which revealed that more than half of bottled milk given to infants was contaminated. The Consumers' Association of Penang, Malaysia, described cases of babies and small children affected by food poisoning suspected to have been caused by powdered milk and liquid milk sold in packets, often manu- factured by well-known companies. The promotion of smoking through cigarette advertisements still continues in the pages of the Region's dailies and magazines, and on television and cinema screens. One English-language newspaper last September carried a string of advertisements introducing a new cigarette on five of its pages. By contrast, the consumer and health movement in Malaysia scored a victory in March 1982 by bringing about an official ban on all cigarette advertisements on radio and televi- sion. Since the ban has not been ex- tended to the print media, it seems likely that cigarette companies will switch their massive advertising ex- penditure on radio and TV (currently running at $6.4 million a year) to newspapers and magazines. At least 19 100 groups—consumers and voluntary organizations — are running publicity campaigns to stop the smoking habit in Malaysia, and about 20,000 people signed a petition sponsored by the Consumers' Association of Penang, calling on the Malaysian Health Minis- try and the cigarette companies to stop promoting cigarettes. Consumers' protection groups are springing up in several countries of Asia, and are trying to make use of the media to warn the public against spuri- ous drugs, baby foods and other potentially dangerous products. The Karnataka Consumer Service Society in south India has produced a film entitled " Consumer Awareness ", and proposes to print posters and handbills from time to time to explain the ill- effects of certain types of medicines and foodstuffs, and urge their replace- ment with natural nutritious food items. In Indonesia, a group of pharmacists have set up the Indonesian Informa- tion Centre on Medicines to inform and protect consumers from harmful drugs. There are about 7,200 kinds of medicines circulating in Indonesia, produced by 250 pharmaceutical com- panies. Of these about 40 per cent are advertised for self-medication. The In- formation Centre, through publicity in the press, seeks to warn consumers away from harmful drugs advertised by manufacturers. In Sri Lanka, the Bureau of Ceylon Standards annouced through the press in February 1980 the names of 27 manufacturers of sub-standard food and drink and other consumer goods. These firms marketed certain brands of carbonated beverages, beef and pork sausages, butter, pasteur- ised and sterilised milk, vinegar, safety matches, toothpaste and electric bulbs. A one-year broadcasting project for consumer education was started in January 1979 by the International Or- ganization of Consumers' Unions and the Asia-Pacific Institute for Broad- casting Development, with the spon- soring of the Government of New Zealand. The project led to the involvement of media practitioners in the Asia-Pacific region and the broadcasting of regular education programmes for consumers. The coming years will probably see increased activities by such voluntary organizations, through the media, to protect consumers from the adverse effects of unscrupulous advertisements of medicines and sub-standard food products. In India in March 1982, a National Alliance for the Nutrition of Infants came into existence with rep- resentatives from the Consumer Gui- dance Society of India, the Indian Federation of Consumer Organiza- tions and the Voluntary Health As- sociation of India. A comprehensive programme of action through publicity in the media is being planned to coun- teract promotion by the infant formula companies. India's big national news- papers occasionally carry special sup- plements devoted to problems like malnutrition, breastfeeding, medicines and drugs, and it is to be hoped that they will also give adequate publicity to the information being collected by various consumers' organizations about the ill-effects of spurious drugs, infant formulae and smoking. ■ Use and misuse of the media Newspaper advertisements contrive to suggest that smoking a certain brand of cigarettes will be the passport to success and "the good life." The statutory warning that "Cigarette smoking is injurious to health" is too readily over- looked. 20 Primary Health Care New WHO guidelines for drinking water quality by Igor Rozov 1 legitimate question to ask about A the International Drinking Water Supply and Sanitation Decade (ipwssD) is whether it is only concerned with supplying water in quantity, or whether it will also ensure the quality of that water. The Decade addresses itself to both aspects : quantity—by bringing drinking water to millions of people in the world, and quality—for there can be no mean- ingful and lasting improvements in the health of those people unless the water to be provided is safe. Since the early 1950s, WHO has been actively working on the problems of water quality, and issuing international standards for drinking water quality. The recommendations made by WHO have been adopted in their entirety in a number of countries, while in others they have been used as the basis for setting up national standards. The documents have now been re- viewed, revised and combined, and the resulting three volumes will be pub- lished this year as WHO Guidelines for Drinking Water Quality. Starting in 1978, with the financial support of the Danish International De- velopment Agency (DANIDA), the prepara- tion of the new Guidelines involved the participation of hundreds of scientists from nearly 30 Member States. The "standards" of the former WHO publications have now become "guidelines" of a universal advisory nature, as they are meant to provide a common basis on which countries will be able to build their national standards. The need for a thorough consideration of the standard-setting process, includ- ing follow-up activities, is very much emphasised. Another feature of the guidelines is that they cover more substances— primarily chemicals—than the old stan- dards did, and there have been a few changes in the recommended concent- ration levels of toxic elements by com- parison with previous editions. The new guidelines will be issued in three volumes. Volumes I and II are expected to be published early this year. Volume I will present the prop- Drinking water being checked for purity in a Nigerian community. WHO recom- mends specific criteria for water quality. Photo WHO/D. Henrioud osed values per se, together with es- sential information required to under- stand the basis for these values as well as information on the monitoring re- quirements and, where possible, sug- gestions regarding remedial measures. The guidelines include such advice as the following : "Treated water entering the distribution system should yield water free from coliform organisms, however polluted the original raw water may have been. In practice, this means that it should not be possible to demon- strate the presence of any coliform organisms in any sample of 100 ml. A sample of the water entering distribu- tion which shows any deviation from this value would call for an immediate investigation into both the efficacy of the treatment process and the method of sampling." The second volume is essentially an environmental health criteria document, reviewing those substances/contamin- ants which were examined in recom- mending guideline values. Volume III contains recommenda- tions and information about what needs to be done in small communities and in rural areas with respect to safeguarding local water supplies. This volume will be printed in much greater quantities and in more languages than Volumes I and II, in the hope that it will reach and be used by local authorities in as many countries as possible (particularly in the developing countries). It is still under preparation and is expected to be avail- able by the end of the year. WHO hopes that the new guidelines will prove useful to governments, at all levels, to help them set national drink- ing water quality standards where they do not exist or to update and expand existing ones. Standards embodied in the laws and regulations of a national or provincial authority do not automatically translate into improved water supply services and better protection of the population. Vigorous assessment, monitoring and enforcement are the complementary actions which the WHO guidelines are now suggesting. ■ 21 Gelling the message across Convincing people about the advantages of family planning can be difficult ; it might take years to register the beneficial effects. A Japanese specialist has found a way of getting communities interested, first of all, in parasite control. Since the benefits are immediate, the adults in the community are much more ready to respond to and rely on a subsequent family planning message by Maggie Jones G ommunicating the benefits of modern health care to poor, rural people poses a major prob- lem for government health pro- grammes—and nowhere is this more true than with family planning A drug which cures a fever or an injection which prevents a baby dying have concrete benefits ; but the advantages of family planning are long-term ones, which can only be seen at a later date when both mothers and children are stronger and healthier. Mr Chojiro Kunii, a remarkable pioneer of parasite control pro- grammes in struggling post-war Japan, seems to have found an answer to this problem. "People are very realistic," runs his argument. "They understand only what they can touch and what they can see." He thinks that family planning is too often presented to people as part of a "population con- trol" programme, a concept which either has no meaning for them or else creates hostility. In Japan, Mr Kunii says, " We had to develop strategies based on the people's own perceptions and not on the government's desire to bring down population growth. How was this done ? By combining parasite control and family planning pro- grammes, the Japanese were able to pfoduce an immediate health im- provement which gained the trust and support of the people and made them more accepting of family planning." Through JOICFP, the Japanese Or- ganization for International Coopera- tion in Family Planning, of which he is the Executive Director, Mr Kunii is promoting this idea elsewhere in Asia and more recently in Latin America. Projects are now under way in such countries as the Republic of Bangladesh, Indonesia, Korea, Malay- sia, Nepal, the Philippines, Sri Lanka, Thailand, Brazil, Colombia and Mexico. Parasite control remains the most useful adjunct for this kind of work, Mr Chojiro Kunii, executive director of the Japanese Organization for International Cooperation in Family Planning. Photo WHO/IPPF/J. Hamand since many health programmes have tended to ignore it, on the grounds that drug costs are too high and the likelihood of reinfection is too great to make it worthwhile ; so they have been inclined to concentrate on the deadlier and more spectacular diseases. How are Mr Kunii's ideas translated into practice in the village com- munities selected for the projects? In Iguacitos, a rural area of Colombia lying to the southwest of the capital, Bogota, and largely isolated from the outside world, the answer is : through the children in the schools. The pro- moters made their first contact with the schoolteachers and then with the children who were introduced to the subject of parasite control through talks and film shows. The children learnt how parasites entered their bodies, the harm they can do and how they can be eliminated. The younger children learned only the basic facts, while older ones were taught to distin- guish the different kinds of parasites and how they affect the health and nutritional status of the family. Once the children had been pre- pared, they were given anti-parasite drugs in the form of a tablet. They were then encouraged to pass on the information to their families ; adults were able to buy the drugs at less then cost price from the schools, or from the existing family planning promoters in the area. The grown-ups were also given talks about the benefits of family planning, to encourage those who were not using contraception to do so and to support those who already were using them. A further benefit of this approach is to motivate older children towards becoming rural health promoters themselves, so that they can pass on what they know about parasite con- 22 trol, nutrition, and primary health care to their parents and other adults in the community. Most of the households in Iguacitos have received treatment, and the level of parasite infestation has dropped considerably. However, the project still has a long way to go. The Colom- bian government has started a pro- gramme to provide proper latrines at the cost of about one US dollar each, to help prevent reinfection, but the supply has not been able to keep up with the demand started by the project. In Thailand, imaginative use has been made of a local drug, Ma-Klua, prepared by extracting the juices from the berries of an indigenous plant, which has proved highly effective in combating parasites. The people have more trust in its efficacy than they have in pills—the drug's bitter taste and black appear- ance convince them that it must do them good ! In one village reached by the project, programme staff, local government officials and volunteers spent several hours transforming the Ma-Klua fruit into a thick black fluid, sufficient for 2,000 doses. The follow- ing day the team set up a " dispen- sary" in the grounds of a temple to give out this drink to large numbers of villagers for a small fee. The Thai government is now promoting the growth of Ma-Klua trees and inves- tigating how the drug works. As in the Iguacitos project, children are much involved. Other projects have been run in schools showing films, slides and exhibits to motivate the children, and specimens have been collected in the course of screening for parasite infection. These lectures have proved to be an excellent way for the health workers to gain the interest and involvement of all sections of the com- munity in the project : they are able to put across the family planning message and find a ready audience of adults who will respond to it with equal trust and acceptance. Perhaps the most successful of these projects has been the one in Indo- nesia, in the depressed coal mining area of Sawahlunto lying at the heart A glass jar containing worms taken from an Indonesian miner becomes a powerful argu- ment for taking part in an anti parasite campaign. One health message absorbed means that it is easier to deliver the next. Photo WHO/IPPF/J. Rowley 23 A schoolboy in Iguacitos, Colombia, demon- strates his knowledge of parasites on the blackboard. Photo WHO/IPPF/M. MacDonald of West Sumatra. Hygienic conditions in the area were abysmally poor, and 88 per cent of all dwellings had no latrine. There was a very high rate of parasitic infection ; eight out of ten miners suffered from hookworm, and many also had ascaris and trichuris worm infection. The incidence of mal- nutrition and anaemia was very high. One miner was found to have no fewer than 180 worms in his body. Displayed in a glass jar, these became a powerful argument for taking part in the programme which JOICFP launched with the collaboration of the Sawahlunto coal company, the gov- ernment health services and the In- donesian Planned Parenthood Associ- ation. The government simultaneously agreed to provide clean water and latrines in the area, thus making a major contribution to the project's success. Another key factor was the involvement of local communities ; the women's groups particularly met regu- larly for baby weighing, nutrition edu- cation and family planning, and have become involved in a whole range of activities such as tree planting, build- ing health centres and latrines, and even creating fish ponds. Recent surveys in the area have shown that more than 30 per cent of eligible couples are now using family planning methods, that the incidence of hookworm among miners is down to 20 per cent, and that the number of children seriously malnourished is down to about ten per cent. Not all these improvements can be credited to the project, since the region is now more prosperous and less isolated that it was seven years ago when the pro- ject started. Nonetheless, its impact has been considerable, both in helping to change the attitudes of the villagers and in persuading the government to take action. The final proof of its success came this year when the local government took over responsi- bility for funding the continuing programme. Of course, the programme has had its problems. Its critics argue that without constant re-dosing to prevent reinfection, and without substantial changes in sanitation and lifestyles, the parasite control programme cannot be effective. Even Mr Kunii agrees that it is not likely to work among the poor- est communities, where there is no money to build latrines or to buy shoes. Yet he feels that in the mean- time the human suffering caused by parasitic infestation cannot be ig- nored, and that the principle is sound. Mr Kunii explains that two doses of drugs will keep a man free of parasites for one year. During that year, there is time to educate villagers about health, sanitation, and nutrition, to build latrines and to change attitudes. Peo- ple who are riddled with parasites are too tired and ill to take any action to change their lives. The dramatic change in a community's health de- monstrates to its members that things can be done to improve their lot, and this consequently affects their attitudes to family planning. In Mr Kunii's words : "The concept of family planning derives from the process by which man is awakened to rationalism, and wishes to protect his life and bring happiness to his family. It was not created only to solve the population problem or only as a means of social and economic development. Family planning campaigns must put more emphasis on the human ele- ments. " True words, which can equal- ly be applied to any preventive health measure. ■ 24 LIFESTYLES Smoking and health by Kurt Baumgartner moking is on the wane—and has been so among men in much of the industrialised world for the last 15 to 20 years. The tobacco industry had perceived this trend long before anybody else and has hence directed its advertising strategies at the only sources of new consumers in the developed countries : women and children. In Canada, for instance, we have witnessed a steep rise in the smoking rate among women and a significantly earlier onset of smoking in adolescents. But today's women have started to react to this exploitation. And female nurses know that they are particularly significant in this fight—because as health care workers they are exemplars, and as professionals they are looked up to by many adolescent girls. As smoking is becoming increas- ingly a minority habit in the Western World, the multinational tobacco com- panies have begun to look for new markets. And they have found them —in the developing countries. Many Third World nations have welcomed the new "prosperity" that tobacco agriculture has brought ; indeed they have provided economic initiatives to attract these companies. The industry has thus enjoyed special privileges and freedom in many parts of Africa and the Far East. By contrast with North America and Europe, in many developing nations the tobacco manufacturers are free to advertise cigarettes with no legal restrictions, "voluntary" promotion codes and other government measures. So while there has been a steady decline in "tar" and nicotine levels in the Western World, the Third World has become a dumping ground for cigarettes with high tar and nicotine contents not permissible elsewhere. But more and more countries are starting to fight back, realising that unless they act now, they will have a smoking epidemic on their hands with- in a generation. The leadership for this new attitude is coming from the Member States of WHO, through the World Health Assembly. Already, among a number of sweeping recom- mendations, a WHO Expert Committee has called for the development of non- An international conference in Winnipeg this July will tackle the smoking epidemic now sweeping the Third World. Photo WHO/T. Farkas smoking as the social norm ; the total prohibition of all forms of tobacco promotion ; the establishment of upper limits for tar, nicotine, and carbon monoxide and the progressive lower- ing of these limits ; and a listing of tar, nicotine and carbon monoxide levels on all cigarette packages. Many countries are heeding WHO's warning. The Fifth World Conference on Smoking and Health, to be held in Winnipeg, Canada, this July, is thus particularly important for its emphasis on women and smoking, and on the increasing smoking problems in developing countries. The priorities that have been iden- tified will be addressed through the following five subject areas : Harmful health consequences of smoking Smoking cessation and mainte- nance of cessation Public information and education programmes The socio-economic implications of tobacco Government action to control smoking. Further information may be obtained by writing to : Mr Kurt Baumgartner, Secretary-General, Fifth World Con- ference on Smoking and Health, P.O. Box 8159, Terminal P.O., Ottawa, Canada KlA 0C1. In the tradition of previous world conferences on smoking and health, Canada is pleased to gather together prominent researchers, health educators, and health professionals, to review and discuss smoking and health. But this conference will intro- duce several important innovations. Baseline data will have been gathered from around the world on smoking patterns of women, plans will be made for lowering smoking statistics on a world scale by 1987, and special workshops will provide opportunities to discuss and plan strategies for dealing with the mounting smoking problems in developing countries. ■ 25 Self-help : one way to health Dr Lowell Levin, Professor of Public Health at the Yale School of Medicine, was interviewed for World Health by Mr Nedd Willard Nedd Willard: As we come up to World Health Day 1983, what can you advise people to do about helping themselves in matters of health? Lowell Levin: Perhaps it is neces- sary to separate the problems that exist in developing countries from those in the developed—or over- developed—countries. One thing that amazes me is how rapidly the develop- ing countries are, in fact, developing ; and unfortunately they are catching many of the problems we in the developed world have long suffered from. As they become urbanised, they are going to begin to share some of our morbidity patterns much more quickly than was perhaps anticipated. That's why it's so important not to export outdated and obsolete technology to the countries of the Third World. NW: What do you mean by obso- lete technology ? LL: Obsolete technology would in- clude a mass of commitments to hospi- tal construction. Building hospitals in an attempt to solve all health problems is inappropriate and indeed represents political misjudgement, as far as I am concerned, as to what is in the public interest. We should concentrate in- stead on developing primary health care research ; that seems to me the most resourceful of any of the options we have and the one that offers most potential. It involves giving ordinary people ordinary skills to protect, pro- mote and develop health, to treat minor illness and injuries, and to be able to manage chronic disease. I am speaking of lay people, by-passing professionals altogether. But to answer your question about self-help in health, let me start with a developed country. In the United States we now have blood pressure " cuffs " available to ordinary people who, given a few moments' instruc- tion, can measure their own blood pressure. Hypertension is a very im- portant problem in the U.S. You can't expect people to show up every day at clinics or doctors' offices to have their blood pressure read. We have do-it- yourself Pap smear tests (to protect women against the risk of cervical cancer), we have do-it-yourself preg- nancy tests, we have a whole range of In all parts of the world, jogging has become a fashionable way of keeping fit. Photo L. Sirman @ what we call available or appropriate technology that ordinary people can learn to use effectively. There is also a whole new range of self-monitoring technology available to ordinary people at a very low cost. NW: Isn't there a danger that you may be increasing hypochondria ? LL: Of course, but danger is a relative thing. Someone once said "A little knowledge is a dangerous thing," and my retort is : " Well, is no know- ledge less dangerous ? " I think we physicians have to be more sensible about what ordinary people are cap- able of doing. We have always tended to depreciate the role of lay people, and considered everyone but ourselves to be rather stupid. NW: What about some examples from developing countries. LL: The developing countries have always had a tradition of community feeling, a notion of togetherness, a sense of tribal responsibility—of indi- viduals to each other and of the tribe to the individual. And this cohesive- ness, this social strategy of interdepen- dency is probably the most profoundly beneficial health strategy, and I under- score health strategy, of any we can produce. NW: I can see what you mean by social cohesiveness, but some of the problems may arise out of people's dislocation from rural areas. In large cities in Asia and Africa there are major problems of sanitation, for example, a simple lack of soap and water. Are you saying that maybe the community itself should be the one to tackle such problems ? LL: I think the only social organ- ization that really feels the problem, knows the problem and knows the benefits that will result from solving it are the people who have that problem. And we in the world of public health have for many years recognised the importance of community invol- vement in decision-making. But we haven't always followed through because our value system has not been attuned correctly. NW: Let me go back to our city in a 26 developing country. How are the peo- ple living there going to establish the priorities—what they want to do first? How can they make the connection, let's say, between disease and an unsafe water supply? LL: That's a question that I'm not wise enough to answer, except I do know that where we have helped peo- ple understand that they have the capability, the responsibility, the right and the privilege of posing the prob- lem as well as solving the problem, we have set out on the road towards some kind of success. Unless we can ensure that people have the information they need, so they can appreciate and solve their problems, then we're in trouble. Experts often say "Look, that com- munity is naive ; we will go in there and tell them what the problem is and then involve them in the problem- solving process. " I think that attitude is changing now, indeed I know it's changing now. NW: But in many countries the leadership tends to find it threatening when people at the bottom of the pyramid start to pose problems. LL: When you start to pose the problems, you may discover that the problem isn't quite what it seemed. It's never too early to start health education. But the message will be lost if the " package" is moralistic, negative, paternalistic, conde- scending. Photo WHO/D. Henrioud Too often a small group was intent on telling you what the problem was—the health professionals, the government, a bureaucracy, vested interests of all sorts. NW: Take something as simple as food habits. Everybody has been say- ing for years we can't get people to have better food habits, but people selling soft drinks and many other 27 products have had tremendous success in changing habits—not always for the better. LL: Yes, changes are always taking place in a very small way but we don't often see them. People are hungry for association, for growth, for identity, for a satisfying life, for a future. In the pasts we have "packaged" some very heavy medicine in the guise of public health ; very moralistic, very negative, very paternalistic, very condescending. No-one likes to swallow that kind of message or medicine. And so it's no wonder that often our technology has been rejected. And maybe that is a sign of good health—the degree to which a community can reject some of the kind of paternalistic material we have tried to get them to adopt. NW: In the U.S., a great many people are jogging for health. Is this a form of self-help or self-care where people feel that they are making them- selves healthy ? LL: It has been estimated that in America there are 32 million joggers —and 31,999,000 seem to pass my home at 6 o'clock in the morning. You know that in America some people say we've become neurotic about health, that we have made enormous invest- ments in personal health and personal health-behaviour chains. There is some truth in that. The health business has become industrialised, like the medical business, and is now a multi- billion dollar industry. We have new health specialties. There is even a new specialty in medicine called " sports gynaecology !". If you choose to seek it, you can have a pre-joggers' examination for US $200. In other words we are begin- ning to see the market-value of health and health promotion, and the com- mercial interests are jumping on to this very quickly. NW: People are certainly con- cerned about their health, but perhaps they are not doing the right thing about it ? An anxious search for jobs at the labour ex- change. Studies suggest that the unemployed fall sick more often, and may even die younger than people who are happily employed. Photo WHO/ILO/J. Maillart LL: Wherever there are people in the world, they are concerned about health, preserving and maintaining it, and perhaps even improving it. The problem comes when people perceive the solution as largely, if not wholly, a question of individual behaviour rather than as something that has positive social implications. NW: Would you say buying and taking vitamins is an example of positive health behaviour? LL: Contrast buying a suitcase full of vitamins against being a friend with somebody. In many cases, the nut- rients of friendship will probably have more to do with health and the preser- vation of health than all the vitamins on sale. 28 Books and publications Community-based training for the disabled A steady demand continues for the WHO Manual "Training the Disabled in the Community," due to be repub- lished in 1983 in a third edition incor- porating the comments and experi- ence of users in ten countries. Na- tional groups have already adapted and translated the Manual into Som- ali, Burmese, Malayalam, Sinhalese, Urdu and Setswana. A Portuguese version is in preparation. Originally published early in 1981 —the International Year of Disabled Persons—the Manual is illustrated with simple line drawings, and in- cludes separate sections suggesting how planners, community leaders and teachers can help people who suffer under various kinds of disabili- ty: those who have difficulty in hear- ing, speaking, seeing or learning ; those who can only move with diffi- culty; those who have fits or who behave strangely. Information on any of these adap- tations, or on the English and French editions of the Manual, can be obtained from : Rehabilitation Unit, WHO, 1211 Geneva 27, Switzerland. For information on the Spanish edition, write to : Advisor on Rehabili- tation, World Health Organization, Regional Office for the Americas, Pan American Sanitary Bureau, 525, 23rd Street, N.W., Washington, D.C. 20037, USA. A talking Manual Visually handicapped people, either potential trainers or those needing training, will be interested to know that the Swedish Federation of the Visually Handicapped has re- corded part of the Manual on tape in English. The set of seven cassettes, with braille labels, reproduces the "Training Package for those who have Difficulties with Seeing." For more details, write to : Syns- kadades RiksfOrbund (Swedish Fed- eration of the Visually Handicapped), 122 88 Enskede, Sweden. ■ Community training enabled this lit- The training manual will help the woman to tie disabled boy to bathe, wash and cope better with her disabled relative. dress himself. Photo WHO/G. Nelson Drawing by Jacqueline Bradshaw-Price NW: Are you referring just to men- tal health, or can it be physical? LL: I mean physical health. There is now substantial evidence suggesting that friendships and social relations are very important in maintaining health and reducing the risk for both morbidity and mortality. I guess one could say that the most important thing in life is happiness. Health plays a role in that happiness sometimes —though not always. NW: A study carried out recently in the United Kingdom shows that people who are unemployed fall sick far more often, and even die much younger than others. LL: One has to say that these are political, or economic, or social causes of morbidity, sickness and death. We, in the health field, have tended to think by and large in biological terms, rather than in social, economic and political terms. And now we are begin- ning to realise that people really do need each other. They really do have to have meaningful work, not just full employment, but meaningful work. They really do have to have a sense of worth in themselves. These things are, in fact, as important as the kinds of things that we have always offered advice about : eat green, leafy vegetables, sleep eight hours a day, have a good breakfast, brush your teeth and comb your hair, and so forth. Not that those things are unim- portant, but we have to put them in perspective. NW: To conclude, what should we be proposing for the future ? LL: In my view, we have to re-think who the experts are in this world, and to understand that all of us, from the mother raising a child to the physician or scientist, all have some expertise. All are valuable. We have to develop systems of health care which include ordinary people as well as the health professionals. And we have to stop encouraging a kind of warfare, psychological or technical or logistical, between these two components. We must honour and increase the poten- tial of lay-people to identify their problems and to begin to participate in their solution. Once that time comes, once this mutual respect occurs, then we shall begin to make some headway. ■ 29 ORE THAN 70,00 EOPLE LIVING ALON HE VOLTA RIVER BASIN RE BLIND HELP ERADICATE IVER BURNES It B.t. H-14, a 'Biological Pesticide,' Goes Into Action Against the Blackfly A 'Social-Profit' Motive Advocated Just as the pharmaceutic a l industry is often criticised for acting from "hard-nosed, business-profit motives," so WHO is frequently faulted for its "starry-eyed, social motives," Dr Halfdan Mahler, WHO's Director-General admits. What is needed is for the two to join forces to generate a "social- profit motive," he suggests. "By that I mean profiting both the health and social development of the underprivileged countries . . and the enlightened self-interest of the pharmaceutical industry." In a keynote address to the recent 11th Assembly of the International Federation of Pharmaceutical Manufacturers' Associa- tion in Washington D.C., he said " I hope we see each other as friends and not as opponents. I think we need friendship more than controversies and confrontations." Although they comprise 75 per cent of the total world population, the people of the Third World consume only about 15 per cent of all drugs produced globally. However, some 40 pharmaceutical com- panies recently agreed to supply 200 drugs listed as essential to these countries under "favourable conditions." That development, Dr Mahler said, ushers in a "new era of cooperation between WHO and IFPMA. " ■ 0•• 000 000 0410 000 000 00• 000 000 000 000000 000 0410 00000 0• 00 000 00 0 000 .0000• 000 0• 000 0041 000 000 000 000 000 000 000 000 ••••00 00 0• 000 00 000000 000 000 000 000 000 000 0• • 000 000 00000• 000 000 0• 000 0• 000 000 000 000 000 000 To Dr Joel Margalit of Israel's Ben Gurion University, and Dr Leonard Goldberg of the University of California, standing by a dry river bed in the Negev desert south-west of Beersheba, it was a fascinating find. What the two scientists came across in a stagnant pool of water, which is normally the breeding place of mosquitos, were mosquito larvae not alive—for reasons not understood then—but dead. Working in their laboratory, with growing excitement, to isolate the lethal agent in the larvae, the scien- tists discovered it was a bacterium. Once that was determined, they put it to test, introducing it to live mosquito larvae—with deadly results. The bacterium—later designated Bacillus thuringiensis israelensis, or B.t., serotype H-14—produces a toxic crystalline substance that kills larvae, a few hours after it is ingested. In essence what the two scien- tists found was a "biological pesti- cide," a bacteria with the killing properties of an insecticide, but, as far as is now known, without the propensity to produce resistance, which is a grave and growing prob- lem with chemicals. WHO Photo/D. Deriaz A health education poster, Ghana Among the best known exam- ples of resistance is that of certain malaria-carrying Anopheles mos- quitos to DDT and dieldrin, but resistance has also developed in a species of the Simulium blackfly, prevalent in West Africa, to temephos and chlorphoxim. The blackfly is the transmitter of on- chocerciasis, a debilitating parasitic disease that afflicts some 30 million people. Not only is B.t. H-14 highly effec- tive against mosquitos and black- flies, says Dr Norman Gratz, Direc- tor of WHO's Division of Vector Bio- logy and Control, but it is also specific, attacking the larvae only. As a WHO report explains : "This microbial insecticide is comparable to a stomach poison. It is effective only when eaten by the insect, and has no contact action." That makes it safe environmentally. "No harm- ful effects have been recorded in safety tests with bees, vertebrates, mammals and man, " the report says. " Insects themselves are un- harmed, even at enormous doses." Thus far, B.t. H-14 has been used in small-scale tests in rivers, rice fields, sewage lagoons, mountain streams, roadside ditches, salt marshes, and storm drains of Africa, Asia, and the United States. "Products containing B. thuring- iensis are remarkably safe," the report says. "To date, at a very conservative estimate, over 5,000 tons have been used without harm." It is available in different formula- tions, in a water concentrate or as a water dispersible powder, for in- stance, and is now produced com- mercially by three companies, two in North America, and one in Europe. " Experimental powders and derived formulations have also been prepared in China, France, and the Soviet Union," the report adds. China, for example, uses a semi-solid medium : a mix of either wheat bran and corn meal, or soya bean and cotton seed cake. The development of the biologi- cal pesticide comes at the right time for use in the Volta River Basin programme against onchocerciasis, or as it is commonly called, river blindness. Launched in 1974, the pro- gramme covers an area 765,000 square kilometers in size in seven countries—Benin, Ghana, Ivory Coast, Mali, Niger, Togo, and Upper Volta—where a million people are estimated to be afflicted with the disease, and at least 70,000 are blind from it. In some villages, over 50 per cent of the men have lost their sight, and have to go about their daily business led on a stick, generally with the help of a child, as this poster from Ghana shows. The programme is supported by the governments concerned, as well as by WHO, the UN Food and Agricultural Organization, the UN Development Programme and the World Bank. As a result of spraying the black- fly's breeding places with chemical larvicides, transmission of the dis- ease has stopped in 75 per cent of the area, thus re-opening to far- mers the land they had hitherto abandoned. However, resistance to temephos has developed in close to 20 per cent of the area. And so, beginning from last year, B.t. H-14 is being applied against the insecticide-resistant blackfly on a large scale—four years after that autumn day in 1977 when the two scientists speculated upon the significance of the dead mosquito larvae. ■ Human Plague in '81 Was 'Lowest Ever Formally Notified' Eleven countries reported a total of 191 cases of human plague in 1981, including 24 deaths, accord- ing to WHO's Weekly Epidemiologi- cal Record, the " lowest ever for- mally notified." The figures for 1980 from 10 countries were 505 and 56 respectively. This sharp decline is attributable to some extent to "fluctuations which occur in natural foci," ac- cording to WHO, while adding : "There is unfortunately still a ten- dency for some health administra- tions to impose restrictive mea- sures against countries reporting plague, which have no epidemi- ological justification." The breakdown by region is as follows : —Asia. The decrease was most marked in this region, with the numbers declining from 283 cases, including 29 deaths, in 1980, to just 13 cases and no deaths in 1981. Of the three countries reporting, Vietnam registered the greatest drop—from 180 cases, including 5 deaths, in 1980 to 11 cases only in 1981. Burma and China reported one case each in 1981, which repre- sents for the former country a de- crease from 73 cases, including 4 deaths, the previous year, and for the latter, a decrease from 30 and 20 respectively. —Africa. A fall from 80 cases, including 20 deaths, reported by four countries in 1980 to 50 and 12 respectively by three countries in 1981. Angola reported 6 cases and no deaths in 1981, a drop from 21 cases, including 4 deaths, in 1980; and Tanzania just 3 cases, a consid- erable drop from 44 and 9 respec- tively over the two years. Only in Madagascar did the figures increase, rising from 10 cases, including 5 deaths, in 1980 to 41 and 12 respectively in 1981 ; these were the highest numbers since 1976. An outbreak in the capital, Antananarive, accounted for most of the country's total, 7 deaths out of 20 cases. —Americas. A decline from 142 cases, including 7 deaths, to 128 and 12 respectively over the two years. Brazil topped the region in 1981, with 59 cases, but the figure was still lower than the 98 for 1980. Four other countries also reported. Bolivia reported 21 cases, includ- ing 1 death, in 1981, a decline from 26 and 2 respectively during the year before. The United States reported 13 cases and 4 deaths, a drop from 18 and 5 respectively. Of these cases, 4 occurred in Arizona ; 1 in Califor- nia; 1 in Colorado ; 1, a fatality, in Oregon ; and 6, including 3 deaths in New Mexico. "Humans were infected with plague through the bites of fleas, while skinning a sick bobcat and rabbits, and through the bite of a sick domestic cat," WHO says. These cases resulted from "hunting and foraging," the report adds, and have "no epidemiological significance... to the spread of the disease internationally." Ecuador and Peru also reported human plague in 1981, 8 cases for the former ; and 27, including 7 deaths, for the latter. Ecuador last reported in 1977 and Peru in 1978.• 30 Authors of the Month Dr Halfdan MAHLER is the Director-General of WHO Mr Jitendra Tuu is the Public Information Officer at WHO's South-East Asia Regional Office, New Delhi. Professor Pekka PUSKA is Direc- tor of the Department of Epidemiology at the National Public Health Institute, Helsinki, Finland. Mr Andy CHETLEY works with the UK-based development agency War on Want, on international health issues, and is the author of "The Baby Killer Scandal." Miss Sumanta BANERJEE is a journalist in New Delhi, and a regular contributor to New Inter- nationalist. Mr Igor Rozov is a Public Infor- mation Officer at wHo headquar- ters in Geneva. Miss Maggie JONES was formerly a staff writer for People, the magazine of the International Planned Parenthood Federation, and is still a regular contributor to that journal. Mr Kurt BAUMGARTNER iS the Secretary-General of the Fifth World Conference on Smoking and Health, to be held from 10 to 15 July in Winnipeg, Canada. Dr Lowell LEVIN is Professor of Public Health at the Yale School of Medicine, New Haven, Con- necticut, USA. WORLD HEALTH For readers everywhere 1983 Subscription Rates One year Two years Three years US$ 15. 27.— 36. Sw. fr. 25.— 45.— 60. ORDER FORM Please enter my subscription to "World Health" as follows: One year Two years Three years I enclose cheque/international postal order in the amount of • Name • Street • City • Country • World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national currencies, please contact your usual book- seller. A WHO Answering Service Gives News About Diseases WHO Epidemiological Bulletin. Summary for period 6 to 10 De- cember 1982, influenza surveil- lance... Localized influenza out- breaks in Lower Saxony, Federal Republic of Germany, in Northern Scotland and in British Columbia, Canada. Influenza A H3N2 con- firmed in Canada and Federal Re- public of Germany. Sporadic cases A H3N2 reported in United States of America. EPIDNATIONS The above message was sent out over WHO's Automatic Telex Reply Service in response to queries about diseases of inter- national importance throughout the world on 10 December last year. On that day, the tenth anniver- sary of the service's establishment, WHO advised on the status of in- fluenza. A decade ago, it reported on cholera and on smallpox, a disease that has since been eradicated. ATRS was set up in 1972 to meet the provisions of WHO's Constitu- tion and of the International Health Regulations which give WHO the responsibility for disseminating information about communicable diseases deemed important to international travel. The service is part clearing house for reports from national health authorities, and part answering service. Information is received, punched on tape and fed into a machine and then transmitted auto- matically to callers. It operates 24 hours each day. arnammompumesimpriree WHO Photo Ten years of health up-dates Callers dial 28150 Geneva, the symbol ZCZC and then the letters ENGL for an epidemiological up- date in English, or FRAN, for French. The response to queries is immediate. A message saying "No new in- formation" means that WHO has received no reports that are of significance to the traveller. ATRS also provides a weekly sum- mary of health developments from Thursday 1900 hours to Monday 0900 hours, Geneva time, which is Greenwich mean time plus one hour. During 1981, an average of 450 calls were handled each month by the answering service. ■ Newsbriefs Kits About Women. Now published, a second printing of "Women, Health and Development," an information and education kit produced by several UN agencies, including UNICEF and WHO, and non-governmental organizations. "The aim is to raise consciousness to the essentialness of the women's role in development– often ignored by those, mostly men, who forge the destinies of others," according to the introduction. The kit is available in English, French, and Spanish for Swiss francs 10.- (approx. US$ 5.–), or its equivalent from Development Education Centre, UNICEF, Palais des Nations, Geneva, Switzerland. Also in the series is "Women and Disability". Measles in the Americas. Bahamas, Barbados, Canada, Cuba, and the United States have met the goal set a decade ago by countries of the Western Hemisphere for measles. The five countries all reported a mortality rate of less than one death per 100,000 population during the seventies. Thanks to a new immunization drive launched in 1977, indigenous measles in the United States is on the brink of eradication, US officials believe, although cases are still expected to be imported into the country. 'Only Child Glory Certificate'. A range of incentives and disincentives are being offered in China by provincial authorities, beginning in 1978, to encourage couples to limit their family to just one child, according to the International Planned Parenthood Federation. The couples are urged to apply for a one-child certificate–in some provinces called the "Only Child Glory Certificate "–entitling them to a host of benefits. Although varying from urban to rural areas, among the incentives are a bonus paid each year until the child reaches 14, or in the case of a rural family, extra work points; preferential treatment for housing and for medical care; and priority later in life for admission of the child to schools, and for consideration of employment. In urban areas, the bonus may range from 5 to 8 per cent of monthly pay. Moreover mothers may be allowed two extra weeks on paid maternity leave. Among the disincentives to having a second child : the loss of bonus, and of course of the certificate, and, in certain cases, even a cash fine. By the end of 1979, the first year of the one-child programme, more than five million certificates were issued. By mid-1981 the numbers had reached 11 million or "a one-child certificate rate of 57 per cent of eligible couples," IPPF reports. China's aim is to reach zero population growth by the Year 2000. ORS in Jordan. After they were treated with oral rehydration salts in a general hospital in Amman, 1,720 out of 1,732 patients suffering from diarrhoea recovered, for a success rate of 99.3 per cent. Estimates put the annual incidence of diarrhoeal diseases in Jordan at 1,600 cases per 1,000 children under five. As a counter-measure, Jordan began the large-scale use of ORS in September 1980, WHO's regional office for the Eastern Mediterranean reports, and has distributed approximately 1.8 million sachets of the live-saving rehydration salts since then. Sight in Pakistan. A recent survey in the Rawalpindi-Islamabad area of Pakistan showed that 15 per cent of the 2,000 children examined experienced difficulties in following lessons on the blackboard. Findings such as these led to a programme, supported by teachers and opticians, to provide low-cost spectacles–for about US$ 2 a pair–to the children. In addition, acting on a WHO recommendation, Pakistan designed a course aimed at helping primary school teachers to recognise problems of sight in the classroom at an early stage. Singapore's High-Risk Group. Citizens of Indian and Pakistani origin are more predisposed to ischaemic heart disease than those of Chinese or Malay ancestry, Dr Shanta C. Emmanuel of Singapore's health ministry told a recent meeting, in Geneva, on cardiovascular diseases in the developing countries. Variola Virus Stocks. British health authorities have advised that stocks of smallpox virus held at the Centre for Applied Microbiology and Research at Porton Down have been transferred to the US Center for Disease Control, in Atlanta, Ga.–one of the three laboratories still holding stocks. The other two labs are the National Institute of Virology at Sandringham, South Africa, and the Research Institute for Virus Preparation in Moscow. In the next issue The theme of the Technical Discussions to be held concurrently with the 36th World Health Assembly in Geneva, in May, will be : New policies for health education in primary health care. The April issue of World Health looks at some of these new policies and surveys future developments generally in health education. 31 La basura es nuestro problema Attractive posters from Mexico's Ministry of Health and Welfare drive home the messages of health.- that nutrition is life; that trees are wholesome and unauthorised rubbish-tips are not; that the health services are there to be used. Photos WHO ,Dr in te d in S w itz er la n d — D to - S ad ag G en ev e NUTRICIN 4===." ES VIDA LA BUENA ALIMENTACION NO ES COSA DE SUERTE CO ALIMENTOS RICOS EN PROTEINAS PESCADO. NUEVO. CARNE. FRIJOL, LECHE. COMA DOS RACIONES AL DIA DE ORIGEN ANIMAL Y DOS DE ORIGEN VEGETAL C) FRUTAS Y VERDURAS COMA TRES RACIONES DIARIAS. SON RICAS EN VITAMINAS 0 LOS CEREALES COMA CUATRO RACIONES 0 MAS CADA DIA. SON RICOS EN ENERGIA, VITAMINAS Y MINERALES Colaboremos en el control de los desechos NECESITA USTED CUALQUIERA DE ESTOS SERVICIOS ? ACUDA AL CENTRO DE SALUD MAS CERCANO A SU DOMICILIO Coordlnacion pars la Ateneion Integral de la Salud del Nino