WHO's six regions [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • OCTOBER 1976 • USA $1 WHO'S SIX REGIONS 1.4 141:4;_t EASTERN MEDITERRANEAN REGION AFRICAN REGION 1! - ; • ,- . '`.1:- • -. • 3. -y., - • ' ' - ' ' '. .,1 , jj 7' '' • . ' Y ..-..-. • --, . - . ...t ., - - ....,...- - -R;;,...;„:?4.16*•= - ' ---.:.4; . A.-=-1.-T.i- - :-. .. - - ; .1;:.1_4: '21a..'4 ,- .f. '. ... 17.....:7,..--:;-,,,t-n-ic , tt:. .^....- -,;•-- - a„,, ..., ":4-4---..a.,,, ' t s., ' - - ...41` •I'--•• * c.-11F...7:1*---*--4.7Att. , ,i .,, I," *;5.1,/ • SOUTH-EAST ASIA REGION REGION OF THE AMERICAS EUROPEAN REGION ''t , ... ..-• - " - • 6 = - - _ .-,,,, .. • , ' - " , . :•••• vv. 400.4m., r v . • ,..1/ .4' et • • tf IOU ,Etlir • • ffa•., . - • ,s;*4 9-"• r••• - .11?"" WESTERN PACIFIC REGION (Photos WHO) 7. -J... - ct -• -41 1 * 117.t. 4.= uch of the effectiveness of the World Health Organization has often been attributed to its decentralized structure, which enables it to come to grips as directly as possible with local and regional realities. WHO's Constitution itself foresha- dowed this decentralization, which took the form of the creation of six geo- graphic regions, each dependent on a Regional Office. These six regions are : Africa, the Americas, the Eastern Medi- terranean, Europe, South-East Asia and the Western Pacific. The advantage of such a structure is plain to see. First and foremost, the countries served by each Regional Office have many factors in common. Second- ly, it is much easier to deal with local problems at close range. The Regional Office for Africa, for instance, from the vantage-point of Brazzaville, Congo, can much more easily tackle a problem which may arise in Tanzania or in Guinea than would be the case from WHO's headquarters in Geneva, Switzer- land. These advantages are so self-evident that the present trend is to continue the decentralization process still further by allowing the maximum of autonomy to each Regional Office. The most recent step in this direction was the creation last year of advisory committees on medical research in each of the six regions. Hitherto, only the Regional Of- fice for the Americas and the Geneva head office had committees expressly concerned with medical research. This issue of World Health includes six articles, each emanating from one of WHO's regions. It goes without saying that each region faces a multitude of tasks and that the selection of public health problems cited here, whatever their intrinsic importance, are far from being the only ones. The article from Africa underlines the advantages which could accrue to the public health authorities from greater collaboration between traditional medi- cine and modern medicine, while at the same time it highlights the chronic shortage of health manpower from which this Region suffers. The story from the Americas describes a problem of veterinary medicine with an impor- tant bearing on the huge numbers of cattle reared in many countries of Latin America. Malnutrition is still a global problem, and its effects are no less disastrous for the health of the nomad populations than for more settled populations; our story from the Eastern Mediterranean Region focusses on this aspect of mal- nutrition and its consequences. Cardio- vascular diseases are another world- wide scourge, but one which strikes par- ticularly hard in some industrialized countries, as the story from the Euro- pean Region explains. Everyone has the right to expect the provision of a basic health care service; unfortunately large numbers of people still have no access to any health service, even of the most rudimentary kind. Consequently many countries today are taking steps to organize such services, with the active collaboration of the local communities who will benefit from them; an experiment of this type is de- scribed in the article from South-East Asia. Finally, in some parts of the Western Pacific Region, tuberculosis still takes a heavy toll; the battle against this dreaded disease is the subject of our story from that Region. It is an undeniable fact that tubercu- losis is on the increase everywhere in the world, that malnutrition and cardiovas- cular diseases cause suffering in every latitude, that many countries face a shortage of qualified health personnel. Moreover every region is confronted by a great number of complex health prob- lems. This issue of World Health can do no more than touch on a few of the fun- damental questions which have to be tackled in different regions of the world. WHO'S SIX REGIONS Cover design by Peter Davies. Contents WESTERN PACIFIC REGION TB in New Guinea by J. Abcede 4 AFRICAN REGION A traditional doctor speaks by J. 0. Mume 8 EUROPEAN REGION High-risk hearts by P. Puska 12 SOUTH-EAST ASIAN REGION Medicine man by J. Loftus 16 EASTERN MEDITERRANEAN REGION Nomads into fishermen by J. Simon ........ 20 REGION OF THE AMERICAS Pampas plague by N A. Haverstock 24 WHO News in Brief . 28 Young World Health . 31 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. WHO'S SIX REGIONS Solving local problems at close range WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANISATION- OCTOBER 1976 - USA $1 ata Iru and her children came into the treatment room. From a table with medicine tray, she picked a bottle labelled INAH and took a tablet. She crunched it up and stirred the powder in a tiny glass of water. Her three-year-old son, Wil- son Varo, readily gulped down the con- tents. She repeated this for her one-year- old daughter, Bellian Varo, who also seemed used to the powdery drink. Mata Iru then swallowed three tablets herself. Nearby, Sister Hilda Boga looked on. When the medicine had been taken, she prepared the syringe. Without any prompting, Wilson Varo spread himself face downwards on the bed for his streptomycin injection. Little Bellian followed suit, but protested a bit as her mother held her tight and the needle pierced her buttock. Later it was Mata Iru's turn for the injection. It was all over in a few minutes. The family was out in the street and headed back for home. The scene was the Badili health centre in Port Moresby, capital city of Papua New Guinea. Mata Iru, 22-year-old mother, and her two children all have extra-pulmonary tuberculosis. But when their treatment has been completed in November, this family will be free of the disease. Mata Iru and her children are among the 387 sufferers from tuberculosis who regularly visit Port Moresby's 21 health centres for INAH tablets and streptomycin injections. More than 3,000 tuberculous patients are registered for ambulatory treatment throughout the whole country. Mata Iru and her family came from the village of Wairori in the Central Province; they moved to the city after Mata Iru's husband found work in a hotel. Brought to the Port Moresby General Hospital one day, Wilson and Bellian attracted attention because they did not have BCG scars. Like their mother, they were found to be suffering from tuberculosis and were subsequently put on a course of supervised drug treatment. Standardized ambulatory drug treat- ment is part of an integrated tuberculo- sis control service being worked out in Port Moresby and Rigo sub-provinces for eventual application throughout Papua New Guinea. Started in 1974, this new community approach includes such "innovations" as: use of general health service person- nel; detection through sputum examina- tion; diagnosis based on bacteriological confirmation; a defaulter tracing system; BCG vaccination of all newborn babies and school entrants; emphasis on health education during the whole period of the treatment. Until 1971, tuberculosis control in Papua New Guinea was more clinically- oriented and hospital based. Dr Kila Wari, Assistant Secretary of Health (Tuberculosis) said that the diagnosis of tuberculosis was, at that time, based merely on X-ray examinations. Treat- TB in New Guinea Youngsters returning to the highlands from New Guinea's coastal areas encourage the spread of tuberculosis. A new TB control pro- gramme stresses protection and prevention BY JOSE ABCEDE 4 ment using a three-drug regimen lasted as long as 24 months, and a review of hospitalized tuberculous patients was made by specialists only once every six months. Dr Kila Wari recalled that in 1968 anyone found with tuberculosis in the Highlands was brought down to the capital town for treatment, and anyone going to the Highlands was given an X- ray chest examination. The object was "to keep the infection out" of the High- lands. Several factors brought about the breakaway from tuberculosis institu- tional care. The disease was relatively new in the country and today's modern drugs are very effective. The closure of the tuberculosis and leprosy hospital on Gemo island off the coast of Port Moresby was carried out gradually; some of the staff of this hospital were integrated in the new programme. Dr Kila Wari added that the Papua New Guineans in any case do not like hospitals and are not anxious to stay in A Two nurses from a rural health centre in New Guinea visit a stilt village in search of a form- er tuberculosis patient who is not keeping up his regular visits to the centre. Ambulatory (out-patient) drug treatment is part of an in- tegrated tuberculosis control service which will eventually have nation-wide application. A young patient receives a powdered tablet> dissolved in water, part of his supervised drug treatment for tuberculosis, at the Badili health centre, near Port Moresby. (Photos WHO/J. Abcede) them because this disrupts their family life. The beginning of a community-orient- ed tuberculosis programme can be traced back to 1971. Dr Kila Wari had been granted a WHO fellowship in 1968, and in 1971 he joined a WHO regional seminar on tuberculosis control in Seoul at which emphasis was placed on the fact that only bacteriological examina- tion can provide a conclusive diagnosis of tuberculosis, and that case finding is profitably carried out amongst sympto- matic patients by means of direct exami- nation of sputum smears with the help of the microscope. Major policy changes began in 1973, after visits by WHO advis- ers, consultants and the WHO Regional Tuberculosis Advisory Team (RTBAT). In March 1974, Dr Kila Wari moved his office from the hospital to the tuber- culosis headquarters in the Department of Public Health so as to provide managerial direction for the new pro- gramme. The pilot scheme in Port Moresby and Rigo was launched early in 1975. In his monograph "Tuberculosis and New Guinea 1871 to 1971", Dr S.C. Wigley said that tuberculosis in New Guinea "is largely a coastal prob- lem and very much one of the towns, where the infection is fairly diffusely spread throughout the community. The farther one gets away from the coast, the lower the prevalence of infection and the more likely it is that the infec- tion will be found amongst the adult members of the community, particularly the adult males." Details of this unique disease pattern were reported in the 1975 report of the WHO Regional Tuberculosis Advisory Team as follows: A virgin area, virtually free of tuber- culosis, existed in the remote parts of the Western and Eastern Highlands, and in the Enga and Chimbu districts. Pre- valence of infection rate was below one per cent, indicating virtual absence of the tuberculosis bacilli among the inhabitants. The people in these isolated areas have had very minimal outside contacts. The second group of communities showed intermediate infection level. Representative areas have been delineat- ed in the Kainantu sub-district and the Eastern Highlands which were opened to outsiders only recently following con- struction of a highway. Infection started in the age group from 10 to 14 years. Of those from 25 years and above, only an estimated 30 to 40 per cent were found to have been infected. Above: Health workers at all levels are en- gaged in the search for sufferers who may spread the disease. A laboratory worker ex- amines sputum slides for traces of the bacilli. Left: Patients reporting for treatment at the Kwikila health centre. The accent is no longer on hospital care for tuberculosis sufferers now that easily-administered modern drugs have proved effective in controlling the disease. (Photos WHO/J. Abcede) The third infection pattern emerged clearly in the coastal areas and outlying islands. An average of 40 per cent of the population had been infected. In some coastal towns, this had gone up to about 70 per cent. Indeed, as Dr Wigley had observed, tuberculosis infection among the Papua New Guinea peoples "is directly related to the degree and duration of contact they have had with European communi- ties, and to the degree of urbanization or culture change they have under- gone". Of the coastal areas, Port Moresby shoulders the heaviest burden of tuber- culosis. Historically, this city had been most subjected to outside influences. Recently, the accelerated urban drift has aggravated the tuberculosis problem there. Dr Wigley also drew attention to the disturbing spread of tuberculosis in the centre of tertiary education in Port Moresby. In the three colleges and one university in the capital, tuberculosis was found to be from five to six times higher than in the most severely affected rural areas. "Since the group involves those from whom the future leaders and teachers of the community will emerge, it presents a disturbing problem in the light of the rapid social and economic development of the country." Dr Wigley noted that "previously closed" areas have been opening gradu- ally. Tuberculosis is being introduced even in very remote areas of the High- lands by returning indentured labourers. The WHO Tuberculosis Advisory Team also commented that more and more uninfected people, mostly young- sters, have been coming down from the Highlands, attracted by city life. They are the most likely to be affected. Some of them will develop the disease and become sources of infection. On return to their Highland villages, they will in- evitably raise the level of infection. A further inescapable trend will be the progressive levelling or merging of these three groups of people with different in- fection patterns. Dr J. C. Tao, WHO tuberculosis advis- er for the Western Pacific, summed up the situation. "The whole picture is a repeat history of tuberculosis", he said. "This disease was introduced to Papua New Guinea by people with a longer history of fighting the disease. These people (who introduced tuberculosis) have a moral obligation to help in this country's fight against tuberculosis." The new tuberculosis control pro- gramme being tried out in Port Moresby Papua New Guinea: land and people of infi-rite variety Papua New Guinea occupies the eastern half of the island of New Guinea, off the northern tip of Australia. It has a land area of nearly 462,000 sq.km . (184,000 sq.m.) and lies fully within the humid tropics. The topography is equally varied, with extensive swamplands, tropi- cal rain forests, volcanic mountain ranges, glacial landscapes, water- ways, cascading waterfalls and meandering rivers. More than 30 species of fabulously colourful birds of paradise thrive in the jun- gles of this country. A land of infinite variety, Papua New Guinea is home to nearly three million people with a kalei- doscope of culture, speaking over 700 different languages. Many tribes have existed for hundreds of years in isolation, each with their own unique traditions, customs and beliefs. Brief history The south-east portion of the is- land of New Guinea was declared a British protectorate in 1884 and was annexed as a British Crown Colony in 1888. It was transferred to the Commonwealth of Australia in 1905 under the name of Papua. A German protectorate was pro- claimed over the north-east por- tion of the island in 1884 and this territory was formally annexed by Germany in the following year. It was occupied by Australia during the First World War, and in 1921 became the Australian Mandated Territory of New Guinea. The mandate was transformed into a Trust Territory in 1946. The Terri- tory of Papua and the Trust Terri- tory of New Guinea were merged in 1949 to form the Territory of Papua and New Guinea, jointly administered by the Government of Australia. Papua New Guinea attained its in- dependence on 16 September 1975. The country became a member of the United Nations on 10 October 1975 and joined WHO as the 150th Member State on 29 April 1976. Health situation The health situation is what must be expected in a country at a very early stage of social and economic development: it is characterized by a very wide spectrum of dis- ease and diverse epidemiological patterns. Practically the whole gamut of tropical diseases is found, including some uncommon disor- ders of special research interest. Malaria is of immense health and economic importance. But the greatest single cause of death and sickness is respiratory disease. and Rigo sub-district stemmed from a policy of protection and prevention adopted by Papua New Guinea's Department of Health. Basic to the pro- tection concept is BCG vaccination of all newborn babies and school entrants throughout the country. To obtain the highest possible coverage, this is being integrated with existing maternal and child health services for newborn babies and the multiple immunization services for school entrants and leavers. BCG vaccination has been carried out for many years in the country. Surveys in several provinces showed a very high coverage, ranging from 60 to 80 per cent. In some areas, nearly 100 per cent coverage of the population had been reported. However, the effectiveness of this ser- vice has been questioned. Studies have shown that BCG vaccination should be able to prevent all forms of tuberculosis. But Papua New Guinea has an unusual- ly high incidence of extra-pulmonary tuberculosis among children and young adults. And a good proportion of these sufferers have one or more BCG immun- ization scars! In this context, Dr H.T. Lin, WHO medical officer in the Papua New Guinea tuberculosis control project, raised some vital questions about the potency of vaccine at the time it is used, inadequate vaccination techni- ques, and a deficient immunological re- sponse among the people. These short- comings are being looked into in order to ensure BCG's rightful contribution to tuberculosis control. On the prevention aspect, the objec- tive is to discover as many of the infec- tious tuberculous cases as possible and to render them non-infectious. This should prevent the spread of the infec- tion with tuberculosis. In technical terms, this process is called case-finding and treatment management. As with BCG vaccination, the search for those who spread tuberculosis bacilli through their sputum, the diagnosis and the supervision of their ambulatory drug treatment will have to be done by work- ers in all health posts, sub-centres, main health centres and outpatient clinics. Some time late in 1976, the five-man WHO Regional Tuberculosis Advisory Team will return to Papua New Guinea to assess the performance of the pilot project in Port Moresby and Rigo. The Government has already committed it- self to a nation-wide extension of this community-oriented programme. It is therefore important to evaluate the ef- fectiveness of these new methods before they are applied to the whole country. ■ 7 a traditional doctor speaks BY J. O. MUVE y interest in traditional medi- cine has lasted virtually all my life, since I began several years of apprenticeship under a mas- ter of the art back in 1939, when I was ten years of age and just starting pri- mary school. In those days, that was the only system of education available for anyone wishing to qualify as a tradi- tional doctor, or what is today known as a tradomedical doctor. In the past, the health of an African nation was in the hands of the tra- domedical physicians who used African medicinal plants to treat disease. But the coming of the Europeans spelt catastro- phe for the traditional medical services. The introduction of foreign medicine was a humiliating experience; a whole cultural heritage was violated without any consideration for the feelings of local people who had experienced the benefits of herbal medicine. The value of herbs in the successful treatment of disease has a very long his- tory. Ancient clay tablets show us that the Sumerians used herbs for medicinal purposes, and the Assyrians knew the virtues of about 250 plants. A follower and pupil of Aristotle wrote ten books on the history of plants, and Alexander the Great made a number of expeditions into Africa, Persia and India, and brought back herbs in use in those regions. Dr J. 0. Odumosu was the first Nigerian to publish a book on herbal practice, in 1906. An Indian education- alist, S.C. Singha, who taught science in a number of Nigerian colleges, wrote a book entitled "Medicinal Plants of Nigeria", in which he listed the names of about 100 medicinal plants then in use. My own involvement with tradi- tional medicine and its practitioners has enabled me to recognize about 900 me- dicinal plants and trees, 300 of which have so far been identified with their traditional names. The very first medicines ever used were those derived from the vegetable kingdom. Any vegetable which ap- peared on the table was considered as a food, while any bitter tasting vegetable was regarded as a medicine. Today it is almost forgotten that "bitters" were common to the table. They were made from herbs that were rich in minerals and were very good tonics. Herbs may act as alkalinizers, acidi- fiers, tonics, diuretics, diaphoretics, lax- For some years, the World Health Organization has been encourag- ing the use of "traditional healers" and "traditional midwives" as local health workers in countries where health manpower is scarce. Given a short period of training in "orthodox" methods and in such matters as simple hygiene, these traditional local practitioners can make a positive contribution towards meeting health needs, particularly in remote rural areas. Already in several countries of Africa traditional herbalists and healers are being invited to send their special potions for laboratory analysis to determine which of them contain genuine healing properties. Today, World Health gives a plat- form to Dr J.O. Mume, a "tradi- tional doctor" with his own nature cure centre in Nigeria. Much of what he says is entirely in accord with modern "orthodox" medi- cine. Some of his beliefs may be greeted with scepticism by "or- thodox" physicians. But above all, Dr Mume makes a plea for "tradi- tional" and "orthodox" medicine to come together and find com- mon ground in the interests of health. With that conclusion, World Health is fully in agreement. atives and so on. There is a class of herbs known as nervines, which are nerve foods. Tradomedical physicians believe that these herbs are mineral foods, furnishing potash, magnesium and phosphorus. The vegetation which we see around us has been growing on earth since before the creation of man. We could say that these plants and trees in the garden were made for him, and have been used as diet and as medicine to cure his ailments and to restore him to good health. Although science has revealed the curative properties of insignificant-look- ing plants, we do not know why they have powerful therapeutic effects on the human body. We only know that dif- ferent plants act directly not only on the various organs—heart, lungs, eyes, brain, liver, skin, blood and nerves—but can even be accurately directed to spe- cific parts of an organ. The recent dis- coveries of vitamins as being absolutely essential to life remind us again of our dependence upon the vegetable king- dom, where these are contained in their fullest measure. Today, more and more scientists and medical experts around the world are emphasizing the value of herbal reme- dies for health. In Nigeria, universities have established departments where researches into herbal medicine are be- ing conducted, and the results coming out have been encouraging. At the turn of the century, it was common for scientists to belittle the workings of nature on the grounds that anything nature could do could be dup- licated in the laboratory. Today we find allopathic medicine engaged in a vicious effort to discredit traditional medicine. The old insult used to be to refer to tra- domedical physicians as native doctors or juju worshippers. Now these names have been replaced by disparaging 8 The patient believes that his ailment eras caused by witchcraft. The healer, treating him in lit, "consulting room", regards him more or less as a mental patiev and seeks to relieve his con- dition by invoking a particular traditional "charm - . ( Photo WHOIJ.0. Mume) remarks about the educational back- ground of such practitioners. The fact is that herbalists have been so singularly successful with their plants and other tradomedical methods that the curiosity of serious researchers has been aroused. Certainly at this critical moment in the history of the medical system, there is a need for medical reform, a protest against medical orthodoxy and medical monopoly. The present medical system in Africa is a colonial legacy which is both unre- lated to and unsuitable for our health needs. Many laudable proposals for a review of the system and the incorpora- tion of traditional medicine with mod- ern medicine have been made by indi- viduals and by organizations including the World Health Organization. But so far very little has been done in practice. It is reasonable to wonder why this is so. In the same countries of Africa and during the same period, so much has been reformed and revised in education, commerce and industry, and so many attempts have been made to revive the African cultural heritage. But tradi- tional medicine has been virtually aban- doned. Nevertheless, traditional medicine has effected wonderful cures with herbs and without the use of well-advertised mira- cle drugs, surgery or radiation. We who carry out this kind of work know that the practice of traditional medicine is not child's play. We have hundreds of herbal preparations and hundreds of patients, as the years go by. Those who request our aid are in a spe- cial class; for them, traditional medicine has a meaning, even if they do not un- derstand the principles. They do not put themselves in our care just because we are doctors. Perhaps friends have encou- raged them, or they may have learnt of some difficult case where the other kind of doctors failed and we have been suc- cessful. As a single example, take the case of a patient who consulted me. He had been involved in a serious motor accident and had been told by a medical doctor working in a general hospital that one of his legs must be amputated. The patient refused and he was asked to sign a paper conceding the responsibility if the wound resulted in his death. He signed it and determined to consult a tradomedical bone-setter. I treated the leg with traditional herbal medicines af- ter setting the bones in their proper position. In three weeks the patient started to walk again. Such diseases as gonorrhoea, diabetes and epilepsy have been treated success- fully by the use of African medicinal plants. During my long years of research in tradomedical knowledge, I have met many great healers who use only herbal preparations, yet in my view ought to qualify for Nobel Prizes for their role in solving the health problems of the nation. Some of them specialize in herbal medicine and surgery within the tradomedical school. One such remarkable surgeon I met told me that he was the senior tra- domedical military surgeon attached to a village "army" during the intervillage battles of that time. Today his aged hands trembled, but he said he had per- formed many intricate operations to remove bullets and poisonous arrows from wounded tribal soldiers; he had methodically stitched up the wounds while applying herbal medicines. Some traditional surgeons were eye specialists and could remove cataracts by operating. Again, they applied herbal medicines. It is a matter for regret that most of the great tradomedical herbal doctors have died. The few remaining ones have grown old, and even if they venture to practise their gifted science some section of a law will be cited to prevent them. What now impedes traditional medi- cal reforms is to be found in the nature of government medical services and the old colonial system of education which laid more emphasis on foreign culture. Traditional medicine has for too long been ridiculed by medical men and per sons in positions of power. In fact, government departments often use their powers and influence to aid the medical profession to retain a monopoly in heal- ing. It is difficult to understand how a government interested in the welfare of its people can take sides with allopa- thy—treatments producing a condi- tion antagonistic to the condition to be cured or alleviated, by contrast with homeopathy, the use of treatments pro- ducing symptoms like those of the dis- ease to be treated—and can favour its growth to the detriment of the cultural heritage of traditional medicine. Wherever modern research is con- ducted today on medicinal plants, the emphasis is always on finding out the principal elements and isolating them for therapeutic purposes. Tradomedical doctors fail to share this view. We believe that treatment with herbal reme- dies is a natural process : herbal medi- cines enter the body in food form in their crude natural state to stimulate a healing reaction that can produce a curative effect. Scientists can only probe the chemical constituents of medicinal plants. They cannot probe the unique complex of natural substances. Herbal remedies are living things. Ev- ery living thing releases invisible vibra- tions and a concentrated form of energy stored in them. This vibrative energy produces the "life-force" which we believe is inherent in all living things. A scientist can analyse the green chloro- phyll of plants and know the chemical constituents, but he cannot detect the cosmic composition of a life-force. That is why scientists have not been able to make a living thing. Traditional doctors using herbs do not limit their practices to any one treat- ment. They make use of the various Two women who are recognized in their Nigerian community as traditional healers. The woman on the right specializes in problems related to childbirth. (Photo WHOIJ.0. Mume) Opposite: A rural village in Nigeria. When disease strikes, the inhabitants may turn first to the traditional healer or herbalist, as their forebears have always done. In any case, there may be little or no access yet to modern "orthodox" medicine. ( Photo WHO) methods which are embodied in the tra- ditional system of cure. In doing so, they take many things into considera- tion. The patient's state of mind, for in- stance : does he attribute the cause of his ailment to witchcraft, dead ancestors, sins he has committed? What about his environment, his diet and so forth? Once he knows these things, the tradi- tional doctor proceeds to apply his skill in prescribing herbal remedies and directing any method that will aid in the 10 restoration of health as quickly as pos- sible. What is the cause of disease according to the traditional concept? We believe that disease is due to transgression of natural laws which God has set to govern our movements. These laws we constantly violate out of ignorance; sometimes we even deliberately indulge ourselves in affairs we clearly know are ruinous to our health—such indulgences as wrong feeding, improper care of the body, living habits tending to set up ner- vous exhaustion and worry, excesses of all kinds, sexual abuse, the constant drugging of the body with so-called an- tibiotic preparations and so on. With these factors in mind, tradi- tional therapy maintains that if the bio- logical requirements are intelligently employed, the result will be normal body function. When any of the biologi- cal requirements are not used properly, there will be a manifestation of what we call disease. A trained traditional therapist is interested in keeping his patients well by educating them in the proper use of air, water, sunshine, balanced natural food, activity, rest, emotion and environment. On the other hand, when you are ill, the traditional practitioner is primarily interested in finding out the definite cause or causes of the disease and he proceeds to remove the cause or causes of the ailment. What is clear today is that traditional medicine has begun to attract so much international attention that the time is ripe for a scientific enquiry into its effi- cacy. For a long time, it was seen as yet another element of the African which, together with his mode of dressing, or worshipping and so forth, constituted his basic "heathenism". The African also began to doubt the potentialities handed down by his forefathers. Yet "orthodox" modern medicine has often sought the collaboration of traditional medicine to achieve better results. In my candid opinion, what ought to exist between the two forms of medicine is not hostility but communication and mutual cooperation in order to find an- swers to diverse human ailments. There is a great need for forums to be spon- sored where enlightened herbalists and traditional doctors can exchange views and ideas with "orthodox" physicians, so that each may learn to respect the other's point of view. Provided the necessary encouragement is given in the appropriate quarters, including individ- ual governments and the World Health Organization, traditional medicine may yet attain new heights and greater recog- nition. ■ high-risk hearts Death risks from heart attacks in one part of Finland rate among the world's highest. A plan to control cardiovascular disease has won the community's full response BY PEKKA PUSKA te he population of North Karelia, in Eastern Finland, suffers from a heavy burden of cardiovascu-lar disease and especially coro- nary heart disease. The cardiovascular diseases have increasingly become a major health problem in the developed countries, where they are usually re- sponsible for about half of the mortality and shorten life expectancy by nearly ten years. Usually the coronary problem is associated with industrialization, stress and the low physical activity or excessive weight of the population. This, however, is not the case in North Kare- lia: coronary disease is most common among the male North Karelian popula- tion living in the countryside, who un- dertake hard physical jobs and are usually very little overweight. Statistics and surveys confirm the pathological situation in North Karelia. The highest mortality rates in the world from coronary heart disease among males appear to be in Finland. And within Finland it is the county of North Karelia that has the highest figures. Covering about 18,000 square kilome- tres, it consists mainly of beautiful rural countryside with lakes, hills and vast forests. Nearly 70 per cent of the 180,000 inhabitants live in rural areas and the main sources of livelihood are farming and forestry. The capital is the town of Joensuu, with 40,000 inhabi- tants. The high occurrence of coronary heart disease among males has also been shown by an epidemiological study made in seven countries, published in Finland in 1966, and by the myocardial infarction register using WHO methodol- ogy. The register indicated that in 1972 there were about 1,000 attacks of acute myocardial infarction among the popu- lation, and half of these attacks oc- curred among males below 65 years. The high morbidity is indicated by the fact that in 1972 nearly a third of the men aged 45 to 59 residing outside the capital who had suffered heart attacks were pensioned off because of their con- dition. Newspaper articles about the health statistics and the results of surveys helped to concentrate public interest on the problem, and in January 1971 a peti- tion was drawn up by the local popula- tion. Signed by all the county's par- liamentary representatives, and the top officials of various public and voluntary organizations, it asked for national as- sistance in this major health problem. It conceded that the county administration was unable to handle the problem, and asked for urgent action to "reduce the coronary mortality that is possibly the highest in the world". National experts worked together with local representatives in reviewing the situation. Presently WHO was in- volved, and offered existing knowledge and planning assistance. WHO represen- tatives recognized the unique possibility of taking a major step forward in the 12 Factory workers listening to a health educa- tion lecture on smoking risks. The percentage of middle-aged men who smoke has already dropped significantly since North Karelia's programme for curbing heart attacks and strokes began. The programme was originally asked for by the community's representatives, and involves local participation at all levels. ( Photo WHO/D. Henrioud) field of cardiovascular disease control at the community level. The planning stage took into account all existing knowledge about the back- ground situation as well as data on the epidemiology of cardiovascular diseases in North Karelia and elsewhere. The combined level of the three "hard" risk factors—smoking, high cholesterol and hypertension—was quite high among the male population, and seemed to ex- plain a greater part of the high inci- dence. Information was collated about the population and the area, about the attitudes and opinions of the local pop- ulation, decision-makers and health per- sonnel, and about the structure of pub- lic services. The aim was to make a kind of diagnosis of the situation prevailing in the community. The North Karelia project was launched at the beginning of 1972. The plan was to carry out a systematic and comprehensive programme of cardio- vascular disease control throughout the whole area, and to call on scientific research to evaluate the results. In response to the original petition, the main aim of the programme was to bring about a decrease in mortality and morbidity from cardiovascular diseases among the whole population of North Karelia, with special emphasis on the middle-aged male population. As a comprehensive programme it consists of primary prevention and secondary pre- vention, but the main emphasis is on primary prevention of the numerous at- tacks of myocardial infarction in the community. A few intermediate objectives consid- ered of strategical importance in pre- venting disease have been defined. A decrease in smoking, the change of diet to lower the high cholesterol level, and the reduction of high blood pressure are among the most important tasks. Activi- ties are directed towards the whole pop- ulation, with special efforts for people at very high risk. Because the disease is common and the risk factors involve practically the whole population, the strategy relies on mass action in the community. It was only sensible to integrate the pro- gramme's services with the existing health and social services of the county, so these local services are directed and developed to meet the needs of the pro- gramme, that is, to control this modern epidemic. Because the problem is essentially one of people's behaviour and the task is that of changing it, a high degree of community involvement is essential. 13 A public health nurse, making her rounds, calls at an isolated farm in North Karelia. < Locally produced sausages are a popular dish in the region. The management of this saus- age factory was reported to be "very recep- tive" to the idea of producing low-fat-content sausages. The public health nurse checks the blood pres- p sure of an elderly patient. Such routine checks will help to reduce the threat of heart attacks and strokes in this high-risk area of Finland. (Photos WHO/D. Henrioud) This was of course facilitated by the great public concern which initially trig- gered the project. The health education aspect has called for community action on a broad front, to bring about envir- onmental changes in such matters as food production and marketing. It in- volves a great number of official and voluntary organizations, in particular a very strong housewives' group. It also entails the training of health educators and an element of public information. The project group has taken great pains to make the programme relate as closely as possible to the community. Sub-programmes have spelled out in fine detail the practical tasks which have to be carried out in the various parts of the community, including organizing ser- vices, training personnel and stepping up health information. The anti-smoking sub-programme, for instance, entails continuous health infor- mation being given through the radio, newspapers, leaflets and posters. Regu- lar advice is given during child and maternity counselling, by the school and military health services, by the occupa- tional health services, in connection with screening activities, and for the benefit of various high risk groups such as hypertensives or heart patients. Spe- cial anti-smoking groups are organized in the local villages. Training and advice on anti-smoking health education are regularly given to various community groups. Finally smoking restrictions in most public places have been intro- duced. Under the hypertension sub-pro- gramme, which forms part of a WHO collaborative study, people with per- manently elevated blood pressure are detected by blood pressure measure- ments and screening carried out by the health services. Those at risk are regis- tered and systematic follow-up examina- tions are carried out mainly by specially trained public health nurses. A doctor reviews the situation of each patient an- nually and up-dates the follow-up record form for the register. Nurses un- dertake health education about hyper- tension and other risk factors, and they also check on persons who fail to turn up at the annual follow-up. The North Karelia project is an offi- cial development project of the Finnish health authorities, so the implementa- tion and administration of the pro- gramme is integrated with the normal health services of the area. The county's department of health and social affairs is responsible for implementing the pro- gramme on the advice of the special staff of the project. Scientific research to evaluate the results is an essential part of the project, the aim being to evaluate over a five- year-period (1972-1977) the feasibility, effect and costs of the programme and to get a comprehensive picture about its effects on the community. This research is done at the project's Co-ordinating Centre, which is attached to the Univer- sity of Kuopio. Feasibility evaluation is concerned with showing to what extent it was pos- sible to carry out the planned activities. The effect of the programme entails pos- sible changes both in the mortality and incidence, and in the risk factors. Mor- tality statistics, myocardial infarction and stroke registers, and random sample surveys are used to measure these changes, and since changes can also result from other factors, another coun- ty with similar features has been chosen for comparison purposes. With the help of economists, the costs involved in the 14 programme are assessed and related to the possible effects. The multidiscipli- nary research team aims at studying as carefully as possible the various changes that have taken place in the community prior to, parallel to or because of the programme. It is important to get a pic- ture of what unintended effects the pro- gramme may have caused in terms of side-effects, changes in income, stress and so forth. Continuous planning of the pro- gramme relates closely to the national applications of the project, which become more and more positive as the data accumulates. The object is to use the results and experience from this pilot area of North Karelia for a national programme in Finland for the control of cardiovascular diseases. The results of the final evaluation will fur- ther guide national activities in this field. In spite of a shortage of medical resources, the programme's proposed activities have proved to be feasible, and have been well accepted by the popula- tion and the health workers. Response rates in the surveys and screening usual- ly averages 90 per cent, and the health workers, especially the public health nurses, have worked enthusiastically for the project. The first follow-up surveys show that information about the two-and-a-half- years old project and its aims has al- ready reached most of the population. The percentage of middle-aged males (25-59 years) who smoke has decreased from 54 to 42. Since a major proportion of the total fat consumed in the area comes from dairy products, bringing about a change in such consumption has been one of the key aims. The percent- age of middle-aged males who consume low-fat milk increased during the same period from 17 to 41, while that of males using butter on their bread decreased from 86 to 72. Nearly every adult's blood pressure was measured during this period in the area, and the percentage of middle- aged males in the whole population us- ing antihypertensive drugs was found to have increased from 3 to 9. From the follow-up record forms, a reduction in blood pressure can be seen among those registered, now totalling some 16,000 persons. Local groups for the rehabilita- tion and prevention of a reinfarction have been formed all over the county for the great number of myocardial in- farction patients. It is too early, of course, to detect any definite changes in mortality and mor- bidity. The registers seem to show, however, that the number of heart att- acks has levelled off and that, from the third year onwards, strokes may even be decreasing in the area. This is, of course, based on very preliminary information and without comparison with the refer- ence area. The experience gained so far in the North Karelia project indicates that control of cardiovascular diseases in a community through an integrated ser- vice-oriented programme is feasible. Since the area must be considered as having rather limited medical resources compared with most developed coun- tries, control should be feasible in most of those countries. The positive results so far could be attributed to the deep involvement of the community and to the systematic integrated service activi- ties. It remains for future detailed evalu- ation to indicate what has been the final impact and effectiveness of the pro- gramme. ■ 15 ice` .:P„ medicine man Under Thailand's scheme for bringing primary health care to the rural population, volunteer workers are meeting local needs while fostering new attitudes to community development BY JOHN LOFTUS L iam Gansa-noi treats his fellow villagers for minor diseases and injuries; he also teaches them how to maintain health and pre- vent sickness. Occasionally he even drives out "ghosts". A farmer for almost 50 years, Liam has long been respected as a medicine man by his neighbours in the village of Ban Ka Choraj in northeastern Thai- land. It was only natural that his fellow villagers earlier this year chose him to be a "local health communicator" in the Ministry of Public Health's programme to bring primary health care to the for- merly neglected rural population. While it is too early to judge accurate- ly the results of the pilot project in Liam's village, the first achievements look promising. The villagers have re- sponded enthusiastically to the health project, and Liam himself is asking for more training so that he can broaden the scope of his voluntary medical work. Because of his background and training, he also serves as a "village health volun- teer". Communicators, the basic agents in the programme's structure, work mainly in health promotion and disease prevention; volunteers have more train- < Liam Gansa-noi, a "village health volunteer" under Thailand's programme for bringing pri- mary health care to its rural population, pre- pares a cough syrup using juices prepared from the bark of a tree. Such traditional rem- edies, often based on age-old recognition of the healing properties of herbs and plants, are readily accepted by his patients. ( Photo WHO/J. Loftus) ing and may perform limited medical tasks. Although his tree-shaded village looks like many other which dot the endless paddy fields of rice-rich Thailand, Liam has seen dramatic changes in attitudes towards health during the 58 years he has lived there. To prove his point he gives an example. "In the old days, folks used to apply a poultice to the navel of newborn babies. The paste was made from powdered yellow 'cumin' root and mud from hornets' nests." Today trained midwives employ modern pre- and post-natal techniques taught them a few years ago by a team of students on a field trip from Mahidol Faculty of Pub- lic Health in Bangkok. "We don't stick to old customs if the modern ways are better", adds Liam, whose chest and arms are neatly decorated with tattoos— an indelible memento of a custom performed on children; it too is losing its grip in Thai villages. Liam does not limit his treatment of disease and injury only to what he has been taught by Public Health authorities during the annual training course held in the provincial capital of Nakhon Rat- chasima. (The progressively complex course embraces first aid, midwifery, nutrition, sanitation and disease control as well as family planning.) He also draws on his knowledge of traditional herbal medicines, which he prepares himself from a pharmacopoeia written generations ago in an ancient script by his ancestors. This imaginative village health volun- teer often mixes tea and sympathy to effect cures as well; it is important that he maintain the villagers' trust in his position as former medicine man and confidant while gradually learning more about modern medicine. "Recently I had to deal with a woman who thought she was possessed by a ghost. I recited a few meaningless occult words over the twitching, frightened woman; she imme- diately calmed down. Then I was able to examine her. She was merely suffering from a lack of attention and a common bladder complaint, for which I gave her a herbal potion", he explains. Not all cases are so simply dealt with and Liam knows it. If the sickness or injury is beyond the scope of his knowl- edge, he refers the case to the next health centre. In this way lies the secret of the programme's success. At first glance it may seem foolish to think that a man with only a third grade education could possibly improve the village's level of health care. Yet trial and error in earlier experimental health programmes have demonstrated to the Thai authorities that "imported metho- dology" will not work. The pilot project in Ban Ka Choraj works because it is really an improvement of an existing system rather than something entirely new. Liam is not an outsider appointed to the remote post or enticed there by extra pay; his position as health volun- teer and communicator is a natural ex- tension of his role as medicine man. Only a native villager such as Liam could have known what treatment the "possessed" woman really needed. Only such a man can handle the majority of 17 medicine man his village's uncomplicated health requirements. He is health communica- tor/volunteer because he responds to a village need, not because someone told him to perform the task. And now his value is enhanced as he becomes part of a chain that will link villages throughout the country to the public health system. Despite his seemingly unsophisticated ways, Liam figures prominently in the success of introducing to his village oth- er progressive attitudes related to com- munity development. At the time when he completed his first public health course and helped his neighbours in building a little clinic near his house, there were only four privies in the 36 households that make up Ban Ka Choraj. Three months later 28 houses boasted privies. Liam had convinced his neighbours that they themselves held the key to breaking the cycle of parasitic infection (intestinal worms). No-one came from Bangkok to lecture the villagers on the disposal of their wastes. Instead, Liam himself was the first to build a privy; he dug the cesspool with his own hands, thus demonstrating by example how easily and cheaply such things can be done. His conviction that a privy marked a contribution to increased good health was obvious to his neigh- bours, who soon followed suit. The people of Ban Ka Choraj trust Liam. He knows their family, their background, their needs, and their fears. He speaks their language and under- stands their customs. He too is a poor farmer, but is an instrument of change now that the central government recog- nizes the healing and leadership skills that the villagers long knew he pos- sessed. Those skills will be augmented each year with continuing advanced public health training. Quiet Ban Ka Choraj now has a voice that can be heard in distant Nakhon Ratchasima or Bangkok, and the village enjoys a link with modern medicine through Liam. As a neighbour and friend, he can command attention for village needs because he holds an offi- cial, though non-paying and non-govern- mental—position in the public health structure. The Thai Government intends to put great emphasis on villagers like Liam over the next few years in order to broaden that structure. A new Public Health programme, which focuses on delivery of primary health care through village communicators/volunteers, is be- ing incorporated in the fourth Five-Year Development Plan. Drawn up by the Ministry of Health with WHO technical cooperation under the sponsorship of the National Economic and Social Development Board, the plan will be in force before the end of this year. While its exact contents are still confidential, public health officials say that the national plan calls for the training of 24,000 village health volunteers and 200,000 local health communicators, who by 1981 will be administering pri- mary health care to 50 per cent of the country's rural communities. The plan is not simply wishful think- ing on the Ministry's part. The entire Government is very serious about pri- mary health care, which will be coordi- nated with other ministries' programmes during the next five years. And this commitment is backed up with money. Of the Ministry of Public Health's pro- jected five-year budget of 23,000 million baht (US$ 1,150 million), the bulk will be spent in funding rural health pro- jects. WHO and other UN and bilateral agencies are, or will be, involved in developing the primary health care scheme through relevant support pro- jects. In the past Bangkok has consis- tently devoured most of the money spent on health services even though it contains only 10 per cent of Thailand's 43 million citizens. More than half of Thailand's approx- imately 7,500 graduate physicians live and practice in Bangkok. The majority of the others live in provincial capitals and large towns. In 1972 the ratio of doctors to population was 1:1,412 for Bangkok and 1:22,070 for the pro- vinces. Some estimates put the ratio as high as 1:84,000 in the provinces because the doctors tend to practice in the provincial capitals rather than the countryside. Four medical schools at present pro- duce no more than 400 doctors a year; even when two more recently-opened provincial medical schools and a mili- tary medical school start graduating their students in a few years' time, the total number of new physicians will not exceed 550 annually. A significant num- ber of doctors have also left Thailand after seizing opportunities for further training abroad. An estimated 1,500 Thai doctors are reported to be working or studying in the United States; as a result there are more Thai doctors in that country than there are in all Thai- land's provincial health centres com- bined. With the population growing by more than a million people each year, there is clearly no hope of trying to tap existing medical facilities to produce the doctors necessary to treat the rural pop- ulation. This is why there is a need for men like Liam under the new Public Health programme to be established in other villages throughout Thailand. Although the pilot project in which he is involved reflects the programme's basic structure in Nakhon Ratchasima Province, variety best describes the approaches to Thai- land's new Public Health offensive. In the village next to that of Liam, the health volunteer has had no medical background except the first aid training he received during his time in military service. However, he puts emphasis on teaching the prevention of disease, and also stimulates the villagers to find out more about maintaining their health through proper nutrition. This volunteer has a secondary school diploma and more than two years of engineering school behind him; he can speak knowl- edgeably about the benefits of an inte- grated approach to health education. Although he has a well stocked medi- cine chest in his health post, he knows that indiscriminate use of drugs is dangerous. Prominently displayed on the post's bulletin board is a list of patent medicines that have been declared dangerous by the government. "Because most farmers dread visiting a doctor or hospital in the provincial capi- tals, they buy drugs to treat themselves— and a lot of them are unsafe", he warns. Some pilot projects have hitched their schemes to on-going community devel- opment programmes. The big village of Promaraj has such a united and progres- sive community spirit that it actually has a surplus of health communicators. With 149 households grouped in 12 clusters, most of the village's 17 commu- nicators find time to involve themselves in other activities that contribute to the well-being of the prosperous communi- ty. The guiding light in this community of 901 people is a Buddhist monk, Phra Kru Tawatchaimoonee. Besides being the popular abbot of the local temple, he is the organizer and coordinator for a variety of improvement programmes that include agricultural extension ser- vices, water storage and purification, 18 " 1` - - - 4 ...a.. 3,- lf: Peasants in north-eastern Thailand harvesting cassava, a root crop which forms one of the local staples of diet. Improved methods of farming will have a direct impact on the nutri- tion of the local population. (Photo WHO/J. Loftus) primary health care, day care and chil- dren's nutrition improvement. The ab- bot has even shown the villagers how to build a bio-gas generator which supplies fuel to the monastery's kitchen. Although Phra Kru Tawatchai- moonee has worn the bright saffron- coloured robes of a Buddhist monk for 23 years, he has only been involved in his people's temporal affairs for half that time. "Other religious groups have a high degree of social involvement that often produces a lot of benefits for their people; I didn't think we should be any different." He has learned a few things about working with people during those years. "The needs of the people—not of community development officers—must be met and their solutions to their own problems encouraged." And encourage his people he does. Eighty-five per cent of Promaraj's households now have privies installed; 100 per cent of the residents have been vaccinated against smallpox and 85 per cent of children aged up to five years against tuberculosis. A wide variety of educational literature fills the library built by the people themselves. No one needs to tell the people in Promaraj about the advantages of good health. Yet the health posts seem to blend into the background because med- ical care is integrated into many activi- ties that are generally taken for granted in the cheerful village. What has been done to encourage self-help in Promaraj is also done in other villages throughout the sprawling district. Phra Kru Tawat- chaimoonee spends two to three months of each year on the road as do several groups of monks from the monastery in Promaraj. They go from village to vil- lage teaching the people the same lesson as they taught in Promaraj: "You can help yourselves to a better life." Primary health care is one way to a better life. Public health and community devel- opment programmes were not always so obviously successful. Prior to 1969, health services in Nakhon Ratchasima Province consisted of many specialized projects both at the central and provin- cial level. Because the programmes were non-integrated, health post volunteers often lacked training and a precise idea of what their position was supposed to mean to the community. Some of them compared their incentives to the salaries and benefits of government workers and the resulting jealousies crippled several projects. A few other volunteers devel- oped ego problems; they became too important to demean themselves by treating the sick. Some would think of themselves as assistants to the govern- ment rather than aides to their neigh- bours. Still a few others tried to use their position for personal gain. Because outside government health workers were directing such projects instead of help- ing and advising the villagers in finding solutions to their problems, both com- municators and volunteers were reluc- tant to disagree with their "bosses" even if they knew better. It was only when a more democratic approach—based on systems already existing in villages such as Liam's Ban Ka Choraj—was adopted that the projects became viable. Although Thailand still has a long way to go before health care reaches all its citizens, the adoption of primary health care programmes will do much to alleviate the feeling of hopelessness that many villagers had thought was their inevitable fate. ■ 19 nomads into fishermen For Somalia's nomads to dream of returning to their drought-stricken pastures was just wishful thinking: thousands have now been taught new skills as fishermen BY JAN SIMON de he African drought that blighted the land from coast to coast south of the Sahara over the past few years has brought the para- dox of imminent economic disaster and potential social progress to Somalia—a harsh, arid country lying along the horn of the continent, between the Gulf of Aden and the Indian Ocean. The view of international agencies in- volved in relief operations is that Soma- lia has been comparatively successful in handling a drought that has afflicted its traditional nomadic way of life for more than five years, affecting nearly a mil- lion people out of a population of three million. Soon after the drought began in the northern, and worst hit, half of the country, the Government moved fast to set up relief camps. It shelved a major rural development programme and started an all-out effort to settle about 250,000 people, mostly nomads, as farmers and fishermen. Somalia's economy has always leaned heavily on its nomadic population whose herds of camels, cattle, sheep and goats used to account for 70 per cent of its foreign exchange earnings. In recent years, however, much of the overgrazed rangeland, which had long supported the nomads and their herds, turned bar- ren in what UN experts called a truly Malthusian disaster. The age-old nomadic way of life began to crumble through the understandable failure of the Somali clans to outdistance the drought, leaving over a third of the country's 15 million head of livestock dead or debilitated—and countless nomads hard-pressed for a living. "I lost my whole herd in a matter of months," an old camel trader from the northern rangeland told a social worker when he joined a relief camp in late 1974. "This is just another dry year," he said in his typical matter-of-fact way. "Yes, it's a dry year, and for many, that simply spells disaster. There was plenty of rain in the late sixties, and fine grass too. When your grazing area turned barren, you just moved to another. Then the rains began to fail. The 1972 rainfall was scanty. There was even less rain in 1973. In bone-dry 1974, the rangeland yielded only dust. Most of the people around here just folded up and left." By February 1975, over 200,000 nomads had taken refuge in the 18 relief camps set up in the North. Many of them had spent months wandering across the northern range in search of grass and water, only to collapse upon arrival. Medical teams who were rushed to the camps did their utmost to meet immediate needs as more nomads liter- ally staggered out of the drought areas with emaciated children and the remains of bareboned herds. The camps, each containing up to 25,000 persons, were staffed entirely by Somalis, in accordance with the Government's policy of self-reliance. Hundreds of first aid workers were mobilized, given relief-oriented training and assigned to emergency care, includ- ing mass vaccination. Technical cooperation from overseas was nevertheless gratefully received. Some $140 million worth of assistance in cash and kind, including food, medi- cal supplies and equipment, has been provided or pledged by the world com- munity to support Somalia's relief and resettlement operations since the Gov- ernment sounded its alarm in late 1974. Sizeable support came too from UN agencies, including the World Food Programme. WHO provided on-the-spot medical expertise on specific emergency and longer-term relief operations, meet- ing the most immediate needs through air-lifted consignments of life-saving drugs and other supplies. Special feeding programmes for the severely malnourished were instituted by the UN Children's Fund, whose emergency supplies included a high-pro- tein food mixture with oil, "K-Mix-II", which was to make the rescue operation far more effective. "Thousands of chil- dren have been pulled back from the brink of death with carefully measured supplements of this nutrient," said one relief worker from UNICEF. "The children were pretty dehydrat- ed when they got to the camps," he went on. "A great many of them had Successive years of drought have left thou- i> sands of nomadic people in Somalia suffering from severe malnutrition, like this woman's two children. (Photo WHO) 20 ft; nomads into fishermen < Special relief camps have saved the lives of thousands of nomads whose traditional grat- ing lands have reverted to barren desert. Now the Somali Government has seized the oppor- tunity to persuade the nomads to try alterna- tive ways of life, as farmers or as fishermen. Women work side by side with the men as they use unfamiliar tools to turn sandy soil into arable land. A good catch. Until recently, these men were content to live in tented encampments, follow- ing their herds wherever there was pasturage. Now they have been encouraged to learn the basic skills which will ensure them a more stable existence in a fishing village. ( Photos WHO/UNICEF/Campbell) developed gastro-enteritis, losing what remained of their body fluids. In most cases, however, dehydration was promptly forestalled by giving fluid in- travenously to children who vomited or choked on liquids taken by mouth." Disease was rife and the death toll high among the children in the early days of emergency. More than 17,000 nomads, most of them children under 10, died in the relief camps. At the Beer Camp, 600 miles north of Mogadishu, where 27,000 nomads had sought relief, deaths at first amounted to around 50 every day. Clinically acute forms of gas- tro-enteritis, pneumonia and measles took by far the highest toll, according to mortality records. Reacting promptly, the Somali Government managed to step up its life- saving effort in the relief camps, recruit- ing more doctors and auxiliary health workers to care for drought refugees flowing in at the rate of up to 3,000 a day. The camps, with their neatly aligned huts made of wooden frames covered by grass mats, were gradually equipped with water supplies and latrines. Thornbush shelters were con- verted into simple but well-tended health centres where row upon row of patients received medical attention. Within months, the daily death toll was down to an average of four to five per camp. And as health conditions im- proved, many of the refugees left the camps—up to 150,000 of them returning within a space of a few months to nomadic life. For many others, however, the dream of returning to their pastures was mere wishful thinking. UN experts returning from the drought-stricken rangeland warned that it could not support the return of all its nomads. "In much of the area," said a report by the United Nations Development Programme (UNDP), "the impact of the drought was heightened by a gradual, decade-long, deterioration of the grazing lands through over-stocking, and the drought in turn accelerated this form of environ- mental degradation." Clearly, there was only one alterna- tive. Looking upon the river deltas and the southern coast as areas where the drought-hit nomads could start a new life, the Somali Government decided to move them nearly 2,000 miles to resettle them as farmers and fishermen. Within weeks, more than 120,000 were taken by Soviet transport planes to three poten- tially-fertile areas along the Wadi- Shebele and Juba Rivers, and to coastal villages beside the Indian Ocean. Aware that no nomad would turn to farming or take to the sea for any rea- son other than dire necessity, relief offi- cials took every step to make the transi- tion easier. The nomad families were kept together and allowed to bring along their mat huts, camel skins and other belongings. The women could carry on their daily chores just as when they were on the range, and tribal habits remained largely unchanged. But the resettlement operation was a time of change and adjustment for the men, whose new activities made them feel a world away from the days when they roamed the northern range at a leisurely pace. Taking to the sea was a bitter ex- perience for many of the 15,000 nomads flown to the coastline, but their com- plete lack of fishing knowledge was soon overcome through intensive training in swimming, boat handling, seamanship and other basic skills. In Brava, a tiny coastal village turned into the largest fishing community, about 1,000 of the 6,000 settlers have already registered in offshore fishing and allied trades, ad- justing to the new skills in a way that surprised the experts of the Food and Agriculture Organization (Pao). All three new fishing settlements, in- cluding Brava, have now their own cold storage units where daily catches of tuna, shark and other assorted fish are being processed for both local consump- tion and export. As more of the 240 boats ordered by the Government become available, the new settlers are well on the way to self-sufficiency. 22 Meanwhile, in the three inter-riverine agricultural settlements, fields are being levelled and irrigation canals dug as thousands of nomads learn to grow crops that most of them had never heard of. Experimental farms have been started to demonstrate what can be achieved in produce from a fixed water point or how to grow fodder reserves which will enable the main body of the tribe, left behind on the rangeland, to survive the next drought. If things work out as the Somalis hope, the three pro- jects will bring another 160,000 acres under irrigation, and will help to make up a sizeable share of Somalia's cereal deficit. Providing medical care to the new- comers is another huge task currently being carried out with the financial sup- port of the African Development Agen- cy. Emphasis is on spreading a network of dispensaries, health centres and hos- pitals over the resettlement areas, which are not spared such health hazards as malaria and schistosomiasis, both highly endemic. With the almost overnight in- flow of thousands of settlers, these problems are being given renewed atten- tion by WHO epidemiologists, and con- tingents of locally-trained control work- ers have been enlisted under a far-reach- ing health indoctrination drive. To put it crudely, the Somali Govern- ment has a captive audience for this kind of education. Every advantage is being taken of the social windfall from the dry winds that have scorched grass and bush in much of the country's pas- ture-land. "Within months, the drought has achieved what otherwise would have been a long drawn-out persuasion process," said a Government official. He added : "However a forced change in the nomadic lifestyle had never been contemplated." Soon after it took power in late 1969, the Government had already planned to ease the nomads and their valuable livestock away from the arid scrublands into more productive areas where agri- cultural development would provide year-round grazing for the herds and, it was hoped, would encourage many of the wandering herdsmen to set up fixed farming communities. The need for such action was dramat- ically highlighted by nature during the past dry years. UN experts assigned to the hard-hit areas came up with disturb- ing findings about the deterioration of the rangeland. "The last drought," said a UNDP report, "was not something from which recovery will take place with the first rain, but a situation which requires long and careful planning and implementation if the rangeland is ever to be returned to production." "Without a radical change in land use practices," warned Mr Curry-Lindahl, an expert from the UN Environment Programme (uNEP), "within a few decades Somalia will be desert-like ex- cept for some perennial river valleys and the moist southern region." Steps are now being taken with the assistance of the World Bank, UNDP and other agencies to rehabilitate the grazing lands through development of water catchments, water spreading schemes, erosion control and afforestation. A rangeland conservation school has been started in Northern Somalia, and 17 famine range reserves with a total of 500,000 acres are being planned to serve as drought relief areas in lean years. Meanwhile, the Government is press- ing for a diversification of Somalia's economy to offset its heavy reliance on livestock. A phased development pro- gramme with emphasis on technical ed- ucation, road building, port extension and the establishment of agro-industries is under way, spurred on by assistance from the World Bank and Arab oil states. In these and other ways, Somali activ- ists expect to correct mismanagement of the precious national resources repre- sented by their grass lands, and to set up social defences which they hope will soften the blow of the next period of drought. ■ 23 pampas plague BY NATHAN A. HAVERSTOCK s it celebrates its 25th anniver- sary, the Pan American Foot- and-Mouth Disease Centre in Rio de Janeiro can take comfort from the fact that the incidence of this disease is declining. But Aftosa, as this disease is called in Spanish, still exacts a heavy toll among cattle in Latin Ameri- ca, resulting in the loss of protein needed to build healthy children and in lost earnings from reduced meat ex- ports. Dr Mario Fernandes was recently as- signed to the Pan American Health Or- ganization headquarters in Washington, DC, after 11 years at the Aftosa centre in Rio—seven of them as director. "While it is impossible to quantify the loss in protein from milk and meat ow- ing to Aftosa", Dr Fernandes said, "we know the loss is tremendous, and we know that we must do everything we can to get rid of the disease because South American youngsters, particularly those less than six years old, need ani- mal protein." It is precisely because of Aftosa's im- pact on people that PAHO, which deals with human health problems, is in- volved in the fight to control it. A trim and intense 47-year-old, Dr Fernandes is Portuguese and grew up in Angola. He said that there is substantial progress to report in the fight to eliminate Aftosa in Latin America—a fight in which he has played an important role. "Within this hemisphere, the disease seems to have been confined to South America. Panama, Central and North America and the Caribbean are free of the dis- ease. Outbreaks of the disease anywhere in the hemisphere have become extreme- ly infrequent." Dr Fernandes divides the history of the Rio centre into three periods. The first, lasting some five to seven years, saw a small institute helping PAHO mem- ber countries to perform diagnostic work, and to train qualified diagnosti- cians. During the next decade, the coun- tries themselves started to realize the im- portance of controlling the disease and Although the incidence of foot- a nd-mouth disease in Latin America is declining, it still exacts a heavy toll in lost protein and unrealized foreign trade earnings 24 welcomed the technical assistance of the Aftosa centre. And finally, the past ten years have seen these countries, support- ed by international lending agencies, in- vesting heavily in the prevention and control of Aftosa. Foot-and-mouth disease is caused by a particularly tiny virus, and one which has proved extremely difficult to elimi- nate. Thanks originally to research car- ried out at the Plum Island Animal Dis- ease Centre, off Long Island, New York, operated by the US Department of Agriculture, new vaccines have been developed that are now being tested in South America. The new oil-adjuvant vaccines, resulting from laboratory work, will provide animals with longer periods of immunity against the disease than those currently in use. As Dr Fer- nandes explained, "At the moment, each of some 230 million head of cattle in South America must be vaccinated three times a year to prevent Aftosa. But with the new vaccines, it will be necessary to inject adult animals only once a year and younger animals only twice a year." He stressed that before the new vac- cines come into widespread use, they must be thoroughly field-tested. In Bra- zil, under the supervision of the Rio Af- tosa Centre, field testing is at present going ahead on some 50,000 animals. The new vaccines will be economical, Dr Fernandes said, a one-time immun- ization for the average adult animal costing less than 25 US cents. "But the important thing in mounting a pro- gramme like this is installing all the necessary infrastructure. Compared with that, the cost of the vaccine itself is small." Before Aftosa can be eliminated, pub- lic awareness of the high cost of the dis- ease must be forged. It is not difficult to convince farmers and ranchers of the need for big investments in controlling the disease. (A popular motion picture called "Hud", starring Paul Newman and Melvyn Douglas, turned on a ran- cher's love for the cattle he must kill On the rich cattle producing plains of Argen- tina, a horseman uses his lasso to catch a calf for vaccination. At present, each of about 230 million head of cattle in South America have to be vaccinated three times a year to prevent foot-and-mouth disease. (Photo WHO/P. Larsen) and bury in a mass grave because of foot-and-mouth disease.) But it has proved more difficult to convince some governments, especially those attempting to juggle conflicting demands for scarce development funds. Slow to come at first, that awareness has taken hold in the last 15 years or so, Dr Fernandes believes. He calculates that South America is still losing any- where from US$400 million to $600 mil- lion a year in meat products because of Aftosa, not to mention tremendous potential export earnings from countries where the disease is still known to exist. In recent years, development-oriented governments have come to realize fully 25 the impact of the disease, as indeed have the international financing agencies. Like all of those involved in the Aftosa campaign, they realize that investments in fighting the disease—in quarantine facilities, vaccine programmes, the train- ing of veterinary personnel, and so on— can be employed in the eradication of other animal and human diseases such as tuberculosis and rabies. The Inter-American Development Bank has already invested some $65 mil- lion in loans for programmes whose purposes include the elimination of Af- tosa. At least two governments have provided extraordinary support for the work of the Aftosa Centre, according to Dr Fernandes. Brazil's support for the centre, which is working on its own home ground on a disease of significant economic importance, has been all-out. Venezuela has been providing extra con- tributions to the centre, over and above its regularly allocated contributions. But Aftosa remains a stubborn foe. Originally described and added to the world's list of ills in the 16th century, its first known appearance in the New World received a mention in the records of the Sociedad Rural Argentina in 1870—an outcropping of the disease in the province of Buenos Aires. It is spec- ulated that the disease either found its way to Argentina on the shoes of some immigrant European farm workers of the period, or in the blood of some ani- mal imported from Europe as part of a breeding programme. Whatever the truth of the matter, the stories underscore the most troublesome aspect of foot-and-mouth disease—the ease with which it is communicated by a tiny virus. A highly contagious malady, Above left: Heavy saliva and lesions around the cow's mouth—dreaded symptoms for the rancher. (Photo WHO/P. Larsen) Above: The tiny viruses that cause foot-and- mouth disease as seen through an electron microscope, magnified to one and a half mil- lion times their actual size. (Photo WHO) Right: Artificial lighting helps the vet as he inspects healthy cattle to ensure they remain free from infection. (Photo WHO/P. Larsen) it attacks practically all cloven-hoofed domestic animals, including cattle, pigs, sheep and goats. In rare cases, it even attacks humans too. Within the brief span of two to four days, the disease produces lesions on the tongues and feet of animals, or around their mouths, and on the udders of milk cows. Though usually not fatal, the dis- ease acts immediately to inhibit the amount of meat or milk produced by affected animals. Within South America, only a few countries and areas are entirely free of this disease, including Guyana, Suri- nam, French Guiana, and more recent- ly, Chile. The Patagonia area of Argen- tina is also free of Aftosa. The disease is endemic in much of the rest of the con- tinent, though outbreaks of the disease are very low in Uruguay, Paraguay and Peru at the moment. Travellers to and from South Ameri- ca, said Dr Fernandes, "should be mindful that the virus can be carried on their shoes. Above all, they should not carry uncooked meat products from any of the affected countries." Once en- trenched, Aftosa is easily spread and hard to stop. ■ 26 ::a ~ : A cholera victim receiving emergency rehydration treatment at a dispensary near Calcutta. (Photo WHO/D. Henrioud) While the number of cases of smallpox in the world is shrinking away to vanishing point, two other age-old scourges of humanity continue to strike— cholera and plague. Largely as a result of the increasing national capacity to control and treat cholera in many countries—since cholera is spread by the drinking of wa- ter contaminated with human faeces— the number of cases of this disease and deaths caused by it have in fact signifi- cantly declined during the past 12 months. In the first eight months of 1975, 12 countries of Africa, 14 countries of Asia and two European countries had provi- sionally reported a total of 34,479 cases and 2,554 deaths. However, during the same period in 1976, there were reports from only seven African countries, and nine in Asia; altogether there were 28,653 cases and 1,834 deaths. Cholera is an acute intestinal disease characterized usually by its sudden on- set. The sufferer may have severe diarr- hoea and vomiting, accompanied by rapid dehydration, and death may occur within a few hours of the onset unless there is prompt treatment. Fatality rates in untreated severe cases can be as high as 50 per cent. Many who acquire the infection without diarrhoea or only as a mild disease may play an important role in its spread. During the last century, pandemic cholera repeatedly spread from its tradi- tional home in the Indian sub-continent to most parts of the world leaving suf- fering and death in its wake. During the first half of the present century, it was largely confined to the Indian sub-con- tinent, although a severe epidemic oc- curred in Egypt in 1947. Since 1961, cholera has spread extensively from a focus in Indonesia throughout most of Asia and the Middle East into Eastern Europe and Africa, and later into the Iberian peninsula and, in 1973, into Italy. Cases among air travellers have occurred in many parts of the world otherwise not affected, resulting in more than 40 cases and at least one death. Plague is the dreaded disease which in past centuries was called "the pest" or "Black Death". The most common form, bubonic plague, is characterized by acutely inflamed and painful swell- ings of lymph nodes draining the site of the original infection. The patient may develop toxaemia, pneumonia, high fev- er, shock, delirium and coma. Yet even this form is not as deadly as primary pneumonic plague, the most serious and highly infectious form of the disease. Untreated bubonic plague has a case fatality rate commonly reported to be 50 per cent; untreated cases of primary pneumonic plague are usually fatal. Today, urban plague has been con- trolled in most parts of the world. Rural bubonic plague of rat origin was until recently a serious health problem in In- dia and Burma, but is now relatively rare. But in many parts of the world, plague continues to be potentially dangerous because there are still vast areas of wild rodent infection and con- tacts between wild rodents and "domes- tic" rats. The wild rodents are the natural reservoirs of the plague, and the infectious agent is the plague bacterium, Yersinia pestis. Bubonic plague is trans- mitted by the bite of an infective flea or by handling infected tissues or having contact with pus from an infected ani- mal. Pneumonic plague may be spread by the airborne route, by inhalation of exhaled droplets from patients already suffering from the disease. Again there appears to have been a decline in the spread of this disease be- tween 1974 and 1975. In 1974, four Afri- can, four American and two Asian countries were affected, with a total of 2,737 cases and 164 deaths. In 1975, there were a total of 1,478 cases, of which 99 were fatal, in five African, four American and two Asian countries. However, there can never be room for complacency about "the pest", and only a study of reliable statistics over a period of two to three decades can en- able safe judgments to be made about whether its incidence is on the increase or on the decrease. cholera and plague continue to strike 28 GREETINGS CARDS immunotherapy in cancer vn The world's last case of smallpox may already have been found in Ethiopia, the last country to record transmission of this disease which once scourged most of the The now well-established finding that immunotherapy can be effective in the treatment of a number of experimental- ly induced animal tumours formed the background of a meeting on the possi- bilities of specific active immunotherapy in human cancer convened recently by WHO in Baden, Austria. Seventeen scien- tists from 11 countries attended the meeting to discuss these experimental findings. It was emphasized that the suc- cess of this form of therapy required a considerable amount of knowledge of the various immune parameters in- volved. It was also recognized that the treatment was not universally successful, and that there were animal tumours against which it was not possible to in- stitute specific active immunotherapy. The possibility of applying this treat- ment in human disease is supported by numerous studies in recent years show- ing that immune response to tumour- associated antigens can be demonstrated in cancer patients. While in many human cases the presence of tumour- associated antigens has not been fully substantiated, there is strong enough evidence to suggest that this type of therapy may also be applied in the human disease. Evaluation essential The meeting discussed the guidelines for conducting immunotherapy clinical trials. It was made clear that the treat- ment of human disease by specific and non-specific immunotherapy was only possible in the hands of experienced in- vestigators. Of prime importance here is the development of reliable methods of evaluating the response to treatment, as well as a sound understanding of the principles involved in well-controlled clinical trials. It was underlined that this approach is not appropriate unless the treatment modalities are properly defined and are based upon well-established animal sys- tems. Vaccines used in non-specific im- munotherapy have to be prepared ac- cording to well-defined procedures, and careful standardization is particularly important. Therefore, while immuno- therapy has clear potential, it should not be considered as a method which may be generally applied, and much more research into each form of cancer will be required. ■ r7. 1? planet. Although two further years must elapse before an international commission confirms that Ethiopia is clear of smallpox, a Greetings Card for the New Year festivities has been prepared to mark the end of the ten-yearlong intensified eradication campaign. The card features a full-colour reproduction of a traditional Ethiopian painting depicting the work of the Smallpox Eradication Programme in that country. The cover is in gold, with the global symbol of WHO, and the card carries greetings in seven languages. Greetings Cards may be ordered now from: The WHO Staff Association, WHO, 1211 Geneva 27, Switzerland, or from any of the six Regional Offices of WHO in Alexandria, Brazzaville, Copenhagen, Manila, New Delhi and Washington. The price is US$3.00 or 8.00 Swiss francs per packet of ten. Proceeds from the sale of cards will go to WHO's Voluntary Fund for Health Promotion. A special documentary film about simplified methods of tuberculosis control and treatment at the vil- lage level in Africa has been made by the Joint Dutch Anti-Tubercu- losis Foundation in cooperation with WHO. A 16 mm film running for 15 minutes, it is entitled "Did you take your tablets?". Copies of the film, price US$300 each, may be obtained directly from the pro- ducing company at the following address: Pando Film, Dorpstraat K 202, Twisk, Netherlands. TB DOCUMENTARY This picture is one of a set of 35 black and white slides prepared by the World Health Organization to illustrate the theme of Primary Health Care. The slides show various aspects of village health activities in the African Region. The sets of slides are available, together with synchronized cas- sette commentary and written text in English or French, from the Division of Public Information, WHO, 1 211 Geneva 27, Switzer- land. Please send a cheque or money order for 25 Swiss francs or 10 US dollars together with your order. No invoice or pro for- ma will be sent. SLIDE SERIES Dr Comlan A. A. Quenum Dr A. H. Taba Dr Hector R. Acuna Dr Leo A. Kaprio Dr V. T. Herat Gunaratne Dr F. J. Dy (Photos WHO) WHO's MEMBER STATES Up to May this year, there were 151 full Member States belonging to the World Health Organization. However, the merging of the two halves of divided Viet-Nam into one nation brought the membership back to a round figure of 150. With just a few exceptions, they are grouped according to their geographic location under the appropriate Regional Office. Here is a full list of the 150 Member States, the six Regional Offices and the Regional Directors. African Region (Regional Office—Brazza- ville, Congo) Director: Dr Comlan A.A. Quenum Angola, Benin, Botswana, Burundi, Cape Verde, Central African Republic, Chad, Comoros, Congo, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, South Africa, Swazi- land, Togo, Uganda, United Republic of Cameroun, United Republic of Tanzania, Upper Volta, Zaire, Zambia. Region of the Americas (Regional Office—Washington, USA) Director: Dr Hector R. Acuna Argentina, Bahamas, Barbados, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Sal- vador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Surinam, Trinidad and Tobago, United States of America, Uruguay, Venezuela. Eastern Mediterranean Region (Regional Office—Alexandria, Egypt) Director: Dr A.H. Taba Afghanistan, Bahrain, Cyprus, Democratic Yemen, Egypt, Ethiopia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libyan Arab Republic, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen. European Region (Regional Office—Copenhagen, Denmark) Director: Dr Leo A. Kaprio Albania, Algeria, Austria, Belgium, Bulgaria, Byelorussian SSR, Czechoslovakia, Den- mark, Finland, France, German Democratic Republic, Federal Republic of Germany, Greece, Hungary, Iceland, Ireland, Italy, Lux- embourg, Malta, Monaco, Morocco, Nether- lands, Norway, Poland, Portugal, Romania, Spain, Sweden, Switzerland, Turkey, Ukrai- nian SSR, Union of Soviet Socialist Repub- lics, United Kingdom of Great Britain and Northern Ireland, Yugoslavia. South-East Asian Region (Regional Of- fice—New Delhi, India) Director: Dr V.T. Herat Gunaratne Bangladesh, Burma, Democratic People's Republic of Korea, India, Indonesia, Mal- dives, Mongolia, Nepal, Sri Lanka, Thailand. Western Pacific Region (Regional Office Manila, Philippines) Director: Dr F.J. Dy Australia, China, Democratic Kampuchea, Fiji, Japan, Lao People's Democratic Repub- lic, Malaysia, New Zealand, Papua New Guinea, Philippines, Republic of Korea, Sing- apore, Socialist Republic of Viet-Nam, Tonga, Western Samoa. WORLD HEALTH ...Virus... .. Bacterium... ...Parasite... WHAT CAUSES WHICH? Among the micro-organisms that can attack our bodies and cause sickness are viruses, bacteria and parasites. The way in which viruses survive by living in the human cells was described in the August-September issue of World Health. Bacteria, on the other hand, include a wide variety of single-celled organisms, capable of self-reproduc- tion; by no means all of them are harmful to us. Parasites range from tiny organisms living in the bloodstream or internal organs up to such insects as ticks and lice or plants like mistletoe or bindweed; what they have in common is that they live on or within another living organism, and derive some advantage from it. Do you know which of the following diseases are caused by viruses, bacteria or parasites? The answers are given at the bottom of the page. Smallpox 6. Cholera Tuberculosis 7. Trypanosomiasis (sleeping sickness) 3. Syphilis 8. Influenza 4. Measles 9. Schistosomiasis (bilharziasis) 5. Malaria 10. Gonorrhoea - sal!seied Aq pasneo we 6 pue 'L '9 : e!Jaloeg Aq pasneo we 0 L pue '9 'E 'z :sasru!A Aq pasneo ate 8 pue 't ' L :sJamsuv Authors of the month Jost ABCEDE is the Public Information Officer at WHO's Western Pacific Regional Office. Dr J.O. MUME is a "traditional doctor" with his own nature cure centre in Nigeria. Dr PEKKA PUSKA is the Principal Investi- gator of the North Karelia project on cardiovascular disease, Finland. Mr JOHN P. LOFTUS is a journalist work- ing in Bangkok, Thailand. JAN SIMON is the Public Information Of- ficer at WHO's Eastern Mediterranean Regional Office. Dr NATHAN A. HAVERSTOCK iS a consul- tant and writer on Latin American af- fairs. based in Washington, D.C., USA. WORLD HEALTH for readers everywhere OR DER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr. • One year 10.— 25.— Two years 18.— 45.— Three years 24.— 60.— One year : Two years : Three years : I enclose cheque/postal order in the amount of Name: Street : City : Country : *or equivalent in local currency. 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