The work of WHO in the European Region 1986: annual report of the Regional Director

T l II · WORK OF WI 10 Tl II I llROPI Al\ RI (,ION 1981 THE WORK OF WHO IN THE EUROPEAN REGION 1981 Annual R eport of the Regional Director WORLD HEAL TH ORGANIZATION Regional Office for Europe COPENHAGEN 1982 ABBREVIATIONS The ab b reviations used in this report include the following: AMOL' Association of Medical Deans in L.urope AM EF Association for Medical ~ d uc-.i tion in l:urope ASPIIER Association of Schools of Public Health Cl: (EC CMEA of the European Region Council o f Europe Commission of the European Com- munities Council for Mutual l:conomic Assistance DANIDA Danish In ternational Development Agency i:ACMR 1:uropean Advisory Committee for Medi- cal Research I-Cl· Lconomic Commisston for Furopc 1:1-.C l·.uropcan Economic Community F-AO !FLA ILO OECD UICC UNDP Food and Agriculture Organization of the United Nations In ternational Federation of Library As- sociations and Institutions Inte rnational Labour Organisation (Of- fice) Organisation for Economic Co-operation and Development Inte rnational Union against Cancer United Nations Development Programme UNEP United Nations Envirnnmcnt Programme UNESCO - United Nations Educational, Scientific and Cultural Organization UNFPA - United Nations Fund for Populatio n Ac tivities UN ICEF - United Nations Children 's Fund ISBN 92 890 I 007 X © Wo rld llealth Organization 1982 Publications of the WHO Regio nal Office for Europe enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention . Fo r rights of reproductio n or translation, in part or in toro, of this publication application should be made to the WHO Regio nal Office for Europe, Scherfigsvej 8, DK -2 100 Copenhagen(/) , Denmark. TI1e Regio nal Office welcomes such applications. The designa tions employed and the presentation of the material in this publication do not imply the expression o f any opinion whatsoever on the part of the Secretariat of the World Health Organiz- ation concerning the legal status of any country, territory, city or area o r of its authorities, or con- cerning the delimitation of its frontiers o r boundaries. Where the designation "country or area" appear.; in the heading of tables, it covers countries, territo ries, cities or areas. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in pre ference to others of a simila r nature that are not mentioned. 1:-rrors and omissions excepted, the names of proprie tary products are distinguished by initial capital letters. PRIN fl() IN DLNMARK CONTENTS Page /11trod11ctio11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 1. Policy organs ..... . ................................ . ... . 2. General programme development, management and coordination ... General programme development .. . ... . ..... . Country health programming ......... .. .... . Information systems programme ... . ......... . Ex tcrnal coordination for health and socioeconomic development Collaboration with the United Nations system ........... . Nongovernmental and o ther organizations .............. . Emergency relief operations .................................. . Research promotion and development ................... . 3. Development of compre hensive health services ........ . General ..... . ... . .................. ...... ..... . 5 5 6 7 8 10 I I 12 13 17 17 Health services planning and management . . . . . . . . . . . . . . . . . . . . . . . 18 Primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Workers' health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Care of the aged, disability prevention and rehabilitation . . . . . . . . . . . . . 23 Appropriate technology for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Family health ..... . ............ . . . .. . Maternal and child health ................. .. . . ............ . Nutrition ............................... . ........... . HeaJ th education ....... . ...................... . Mental health ... . .... . ........... . ...... . ....... . Prophy lac tic, diagnostic and therapeutic substances ..... . .... . 31 3 1 35 35 37 40 4. Disease prevention and control . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Communicable disease prevention and control . . . . . . . . . . . . . . . . . . . . . . . 4 5 General ... . .. ... ......... . Epidemiological surveillance Malaria and other parasitic diseases .. Bacterial and virus diseases Preventio n of blindness .......................... . 4 5 45 46 48 49 V VI 4. Disease prevention and control (contd) 5. Noncommunicabll! disease prevention and control General Cancer . Cardiovascular diseases ........................ . Oral health ................................ . Other noncommunicable diseases ..... . Promotion of environmental health ... .. .......... . General ....... .. ........... . ........... . ............ . . . Environmental health planning and management .................... . Provision of basic sanitary measures ............................. . Recognition and control of environmental hazards . .................. . Water quality and pollution control .......................... . Air pollution control .................................... . Solid waste management ............. . Radiatio n protection ...... . . .. .................. . Food safety ........... . .... . .................... . Control of chemicals Country activities 50 50 51 52 56 57 6 1 6 1 63 64 65 65 66 66 67 67 69 71 6. Health manpower development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 General ........... . ......................... . Manpower planning and management .................. . Promo tion of training ............................ ... .... . l'duca tional d evelopment and support ........................ . Nursing .............................................. . . Country activities 75 77 78 8 1 8 1 83 7. llcalth information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Ccnt:ral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 llcalth statistics ............. ................. . WIIO publications and documents . ......... ....... . . llcalth legislation ............ ........... .... . ... . llealth literature services ................ . ......... . ll t:alth information of the public 85 86 87 90 90 8. General services and support programmes . . . . . . . . . . . . . . . . . . . . . 93 Programme planning and general support . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Staff development and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Conference, office and building services . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Budget and finance 94 94 95 Annex I. Annex 2. Annex 3. Annex 4 . Annex 5. Annex 6. Regular funds (biennial) .. . . 1:-x trabudgetary sources ......... ................. . Active and non-active Memher States of the World Health Orga111zat1on, 1:-uropcan Region, 31 December 1981 .... l'rofess1onal s taff 111 the l· uropea11 Region , 31 December 1981 .... Organizatio nal chart of the Regional Office, 3 I December 1981 ln tercountry meetings convened hy the Regional Office forl·uropein 1981 ..................... .... . 97 99 I OJ 103 WIIO~ponsore<l courses in the l' uropean Region , 198 1 . . . . • . . . . . . 111 l·stimated populallons in 1981 for the active Member States of the WIIO l· uropean Rcgion . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 17 vii The death on 13 July 1981 of Professor Samuel Halter, Secretary- General of the Belgian Ministry of Public Health and Family Welfare, is a sad loss for the World Health Organization at large and for the Regional Office for Europe in particular. During the past decade Professor Halter played an increasingly influential role in the Organi- zation as Belgium's representative at Regional Committee sessions and in the World Health Assembly of which he was President in 1975. He was a forceful promoter of WHO's leadership role, both inter- nationally and in direct cooperation with individual Member States, his own country included . In 1980 he received the Leon Bernard Prize in recognition of his contribution to public health. Over the years, Professor Halter took part in many activities sponsored by the Regional Office for Europe, often with voluntary contributions from his Government. INTRODUCTION In developing a truly European strategy for health for all by the year 2000. the maintenance of a correct balance between rhe responsibility of the individual for his own health and the responsibility of society or state is a vital factor. This was again stressed by the Regional Committee at its thirty- first session in I 981. Participants in the first Conference of European Ministers Responsible for Public Health. convened by the Council of Europe in Madrid in September, were also sensitive to this issue and welcomed the R egional Office's emphasis on healthy lifestyles, the need to minimize the detrimen ta/ effect on health of poverty and unemployment, the improvement of health care systems, and a more widespread use of preventil'e measures. For th e planning and development of national strategies for health for all. a varying degree of activity is to be expected in the Member States at this s tage, depending on their state of development. th eir health infrastructure and the health problems to be tackled. In the southern part of the Region. certain problems demand that immediate attention be paid to developing services based on primary health care. Thus, in coun tries such as Algeria, Morocco, Portugal and Turkey, activities and integrated programmes based on primary health care have been initiated as part of the reorientation of national health policy del'elopment. The highly industrialized countries of the Region have also arranged activities. such as the annual workshop on primary health care organized jointly by the R egional Office and the School of Pub- lic Health in Brussels. and a symposium on primary health care convened by the Fondation Roi Baudouin. also in Brussels ( to give two concrete examples from one country) together with rhe organization by many other countries of conferences and seminars devoted to primary health care and stressing the need for community participation. the involvement of social security organizations, and the need to rethink the infrastructure for primary care. The first WHO collaborating centre in primary health care, in Alma-A ta . which was designated in 19 79. began its work in 198 1. The theme of World Health Day in 198 1 ''Ilea/th for all by the year 2000" stimulated a series of rel'iews. meetings and seminars. all dealing with ix X health policies and services and their reorien tation towards the goal of health fo r all. Information received from Denmark. Finland, France. the Federal Republic of Germany, Hungary, the Netherlands. Norway, Sweden and the United Ki11gdom indicates that all these countries are mobilizing expertise and resources. A pilot study in Finla11d, 011 possible alternative strategies for national health del'elopment, will ser11e as a basis for similar studies which th e Office will i1111ite all countries in the R egion to undertake. The intensi- flcatio11 of involvement of collaborating centres thro11ghout the Region, as well as cooperation with regional bodies such as the Commission of the European Comm11nities. the Council of Europe, the Council for Mutual Economic As- sistance. and the Council for International Orga11izations of Medical Sciences, has been of infinite value in promoting the m0Peme11 t at national level. The multidisciplinary approach within the United Nations family itself has been furthered by the creation of posts of UNDP Resident Coordinator in some cou11tries, and work for the International Drinking-Water Supply and Sani- tation Decade proceeded well in the R egion, with full United Na tions support. This year. the Regional Committee for Europe met for the first time in the Cer111an Democratic Republic and was attended by delegates f rom all JJ active Member States. During the opening session 111any speakers paid homage to the late Professor Halter. His loss is, indeed. a cruel blow to all me111bers of the international community with responsibilities in the field of health. and partic11larly to this Office which has benefited i11 so many ways fro111 his experience and ability_ This report describes the Office's programme as imple111e11ted in 1981, supplemented by financial information showing disbursements for each pro- gramme in relation to the budget estimates for the biennium 1980/81. Once again. 1 should like to extend my sincere thanks to all those who have put their experience and expertise at the disposal of myself and my staff in fu rtherance of our common goal. k r.~ Leo A . Kaprio Regional Director Chapter 1 POLICY ORGANS At the thirty-first session of the Re- gional Committee the Director-General addressed the theme " Partnership for health for all", saying that the unanimous adoption by the Thirty-fourth World Health Assembly of a global strategy for health for all by the year 2000 was a major triumph for international co- operation in health. He related the new WHO policies to the problems of the European Region , and his statement was frequently referred to in discussions on the individual agenda ite ms and specific regional programmes. The Committee then decided on the nomination of the Regional Director in closed session and , in resolution EUR/ RC3 1 / RI , proposed that the Execu- tive Board ex tend the term of office of Dr Leo A. Kaprio for a period of three years from 1 February 1982. As a result o f reso lution WHA33. l 7 o n the study o f WHO's structures in the light o f its func tio ns, closer attention is being paid to coordinating the work of the Health Assembly, the Executive Board and the Regional Committees. In accordance with resolution WHA34 .29 on the duration and method of work of Health Assemblies, and to enable the Regional Committee to fulfil its role in monitoring and evaluating progress towards health for all by the year 2000 (HFA2000), it was decided to provide more time for discussion of the proposed programme budget by adding one more session to the length of the Committee in alternate years (resolution EUR/ RC3 l /R4) . The rela tio nship between peace and heal th having been emphasized in resolu- tion WHA34.38, o n the role of phys- ician s and o ther health workers in the preserva tion and promotion of peace as the most significant facto r for the attain- ment of health for all , and in resol- ution WHA34.39 (material war rem- nants), the Committee strongly recom- mended greater e fforts by the Organiza- tion and th e countries themselves in making a practical contribution to strengthening peace, if the goal of HFA2000 were to be achieved. The regional strategy for HF A2000 was a recurrent theme at the Regional Committee. The Director-General i.:om- me ndec.l the Region for its initiative in choosing the promotion of lifestyles conducive to health as an element of the regional strategy, but added that it would be advisable to ensure that there was no unnecessary interfe rence by governments or well-meaning plan- ners with people's way of life. The Regional Directo r stressed the im- po rtance of developing indicators and of clarify ing the relatio nship between the socia l, econo mic and biologi- cal factors influe ncing the etiology of disease. Resolutions WIIA 34 .36, o n the global strategy for HFA 2000, and WHA 34.3 7, on reso urces for strat- egies for I-lf-A 2000 , were carefully considered in the development of th e regio nal strategy, which encour- ages an integrated approach while keeping in mind the s pecific needs of diffe rent co untries. The regional strategy will also be updated and modified in the light of the possible negative effects on health of devel- opments such as poverty and unem- ployment. Data on recent tre nds in unemployment in some European countries arc shown in Fig. I . In March , the Regional Health De- ve lopmen t Advi ory Council (RHDAC) met to review the work done so far on the establish ment of targets for the regio nal strategy for HFA2000. Emphasis was to be placed on pre- ventive and promo tive measures, in- cluding relevant indicators for evalu- ative purposes. It was realized when co nsiJcring the targe ts set at the global leve l th at thei r adaptation to specific regional charac teristics would be necessary , and a steering com- mittee of the RI IDAC was set up to conduct the de tailed stud ies re- quired before realis tic targets could be fon11u lated. The stee ring committee met in March and Oc tobe r and will report on the progress made to the nex t meeting of the Council in 1983. In view of the co mplexity of the studies, it was agreed to present the regional t arge ts to the Regional Committee at its thirty-third session in 1983 , a year later than originally planned. Specific programme matters dealt with by the Regional Committee included drug policies and manage- ment, health education and li festyles, and the International Drinking-Water Supply and Sanitation Decade. The role of the Regional Office in drug evaluation and monitoring was dis- cussed. Keeping in mind the Organ- izatio n's ac tion programme on es- sential drugs, and following discussion at the Thirty-fourth Wo rld Health Assembly, th e Regio nal Office was expected to pursue th e feasibility of an international drug evaluation plan and report back to the next session of the Regional Committee . The recommendations contained in resolution WIIA34.30 were given close attention during the technical dis- cussions which dealt with " medical and social problems of disabled per- so ns". Stre ngthe ning of international cooperatio n in this fie ld was advo- ca ted and, for the European Region in particular, special attention should be paid to the proble ms of th e el- derly. In resolutio n EUR/ RC3 I / RI 3 the Committee recommended furth er collabora tion with Member States and o ther organizations to follow up the ac tivities. Spain United Kingdom Belgium Italy France Neth•rtands Finland Austria Sweden Norway Fig. 1. Unemployment in some European countries in 1979 and 1981 ( second quarter) as a percentage of the total workforce8 ~~--:. 7.5 7.3 l ) ti~ 1!1,.;•""';,.i'"'; ___ l"''"',•,"":""•-jn5l"'"_T'j 2.1 ..... --., 2.7 2.1 ..,. __ """" 2.2 ,----, 2.0 ~ .... eo--12.0 0 I 5 Percentage 85 8.4 8.5 11 .0 10.9 c:::J 1979 -1981 10 a Rates adjusted to conform with I LO defi nitions. Source: OECD main economic indicators, December 1981 . 13.6 15 3 POLICY ORGANS Proposed budget and actual expenditure for 1980/81 (US$} Proposed Expenditure budget 1980 1981 1980/81 Regular funds 171 000 115469 85 520 200989 Host government's contribution to the Regional Committee n .a. 43 474 46 948 90 422 UN funds Voluntary funds 171 000 I 58 943 132 468 291411 a a Being 0.83% of total expenditure. Publications issued in 1981 Les laureats europeens du Prix Leon Bernard, 1951-1980, by E. Aujaleu . 4 Participants in the thirty-first session of the Regional Committee gathered on the steps of the Palast Hotel in Berlin. Standing in the front row are (from left to right) Dr A. Grech, Malta (Vice-Chairman), Professor L. Meckl inger, German Democratic Republic (Chairman), Dr Leo A. Kaprio (Regional Director). Dr E.J.P. Duhr, Luxembourg (Vice-Chairman), Dr E. Aker, Turkey (Rapporteur) and Dr M. Violaki-Paraskeva, Greece (President of the Thirty-fourth World Health Assembly) Weltgesundheitsorganisatlon 31. Tagung des Regionalkomitees · fUr Europ~ Dr U. Frey, speaking on behalf of the outgoing Chairman, opening the thirty-f irst session of the Regional Committee The Director-General, Dr Halfdan Mahler, addressing the thirty-first session of the Regional Committee ·#91tgeeunclWJits- o,ganisation 3t~ cte. Regiol ....... ,itees uEuropa t the Lord Mayor's reception Professor Ludwig Mecklinger (centre), Minister of Health of the epublic, toasts Dr Emile Duhr, Vice-Chairman of the thirty-first session of the Regional Committee r Leo A. Kaprio being introduced to Dr Willi Stoph, Chairman of the Council of Ministers of the German Democratic epublic, during a visit paid by the Director-General, Dr Halfdan Mahler Chapter 2 GENER AL PROGRAM ME DEVELOPMENT, MANAGEMENT AND COORD INATION GENERAL PROGRAMME DEVELOPMENT On the basis of the regional st rat- egy for HF A2000, medium-term pro- grammes for the period covered by the Seventh General Programme of Work ( 1984-89) were drawn up . These were summarized and presented to the thirty- first session of the Regional Committee as the regional contribution to the Seven th General Programme of Work (document EUR/ RC3 I /7). In this new programming period increased e mphasis is being placed on lifesty les, on reducing risk factors through more active preven- tive programmes ( not only in health ser- vices but, even more so, in o ther sectors) and on more effective , e ffi cient a nd humane medical care. In more than one way the Seventh General Programme o f Work represents an important turning point: it carries a new health policy message through to a fairly detailed programming stage, and presents it in a new format which gives a better overview of the real o utput of the WHO programme, thus making it poss- ible for Member States to take advantage of it in national development. It is also shown how the 1984/85 programme fits i.n with subsequent activities for the re maining part of the Seventh General Programme of Work ( 1986-89). At the recomme ndation of the Con- sulta tive Group on Programme Develop- ment, a Seminar on Programme Consult- ation with Member States was convened in the Regio nal Office in November to (a) provide briefing for staff in national health ad ministrations responsible for coordin ating answers to the consultation lette r ; (b) consider the type of reply that would best provide guidance for futu re programme development; and (c) review national procedures used to sample opinion and formulate replies. In addi- tion , the new form of presentation of the proposed programme budget docume nt , as requested by the Regional Commit- tee a t its thirtie th session , was described. Following the adoption of new pro- cedures for more systematic planning of WHO's cooperation with individual Mem- ber States, the Director, Programme Man- agemen t , together with senior members of staff, visited Algeria, Mo rocco, Portu- gal , Turkey and the USSR for joint programme planning and evaluation exercises, and senior me mbers of staff fro m the ministries of health of those countries came to the Regional Office during the period under review. 5 The fifth meeting o f the Consultative Group o n Programme Development was convened in Copenhagen in April. Matters revie wed by the Group included issues to be submitted to the thirty-first session o f the Regional Committee: priori ties for the first bie nnium of the Seventh General Programme o f Wo rk ; the struc- ture, presentatio n and preparatio n o f the proposed p rogramme b udget fo r 1984 /85; the me thodology o f tech- nical discussions a t future sessions o f the Regio nal Committee; the recommenda- tio ns o f the subgroup o n the regio nal implications of the study o f WHO's structures in the light o r its functions ; and the recommendatio ns o f the main ad- visory bodies for the European Regio n . The G roup recomme nded inter alia tha t : (a) prio rities fo r the firs t b iennium of the Seventh General Progra mme o f Wo rk sho uld be discussed again afte r the thirty-firs t session of the Regio nal Co m- mittee had decided on the broad lines of the regional programme fo r the whole period ; (b ) the ne xt proposed programme budge t ( 1984/ 8 5) sho uld consist o f two parts the first containing an anno ta ted lis t of programmes and de tails o f a lloca- tio ns for each programme , supported by a s ta tement o f objectives, targets and ap- proaches, and the second giving de tails o f the projects envisaged during th at pe riod ; (c ) the secre taria t sho uld continue to organize technical discussio ns ann u- ally during sessio ns o f the Regio nal Committee; and (d ) the Regio nal O ffice sho uld consider the training of man- power for primary hea lth care. In lin e with the recommendatio ns of the study o f WHO's struc tu res in the light o f its fun ctions , and in o rder to ad apt the manage rial syste m and struc- tun: of the Regio nal Office to meet 6 present needs. a reorganiza tion o f so me units too k place and some d ecisio n- making responsibilities were dece ntral- ized as fro m I June. COUNTRY HEAL TH PROGRAMMING A Wo rking G roup o n Health Plan- ning and Management was convened in Ath ens in Octo ber to eval uate de- ve lopme nts in health management and p lanning in Member States since 1974, and to ensure that the manageria l pro- cess fo r na tio nal health development (MPNHD) is compatible with ex isting planning and ma nagement syste ms. The MPNHD guidelines, although indicative and ratio nal, seemed mo re suited to Me mber Sta tes with alread y established planning syste ms and/or a developing econo my. It was recomme nded that th e fo llo wing items be proposed for co nsidera tio n by the Regio nal Com- mi ttec, specifically during the technical discussio ns a t its thirty-second session in 1982, and a t the Euro pean confe re nce o n health p lanning and manage me nt to be held in 1984 : research , develo p- me nt and tra ining in the application o f MPNHD ; ne w me thodo logies applicable to MPNHD; the re sults of comparative studies o n th e use o f MPNHD ; the consolidatio n of natio nal and regional health development centres; and the revie w o f country-specific guid elines fo r MPNHD. A second WHO Internatio nal Wo rk- sho p o n Co untry Health Programming was o rganized in July in coopera tion with the Usher Institute, Edinburgh and the Nu ffie lcl Cen trc for Heal th Services Studies, University of Leeds. The main objectives of the Workshop were (a) to create an informed appreciation of MPNHD as a practical means of formu- lating and implementing health policies; (b) to share and learn from the direct managerial experience of individual par- ticipants; and (c) to explore together the issues that are emerging in the fields of MPNHD with regard both to developed and to developing and newly indus- trialized countries. Health planners and experts from the African , American and Eastern Mediterranean Regions at- tended , together with staff from the Regional Office and WHO headquarters. The Wo rkshop provided clear evidence of the high level of transfer of learning achieved, and of the value of having joint learning opportunities for national and international staff. Coun try activities Morocco. Following discussions with the Ministry of Public Health, it was agreed th at the Regional Office would provide technical support by drawing up a plan of operation for the project on the development of primary health care, and by recruiting a long-term con- sultant to assist in carrying out the project at the central level. Norway. The Regional Office was represented at a two-day meeting in Oslo to discuss a project on the evaluation of mental health. WHO evaluatio n tech- niques were presented and the Office expressed interest in testing them in the rationalization of mental health units. It was decided that a formal agree- ment should be establisht:d, prior to which a national group should indi- cate which evaluation aspects could be tested in each of three pi lot zones. Portugal. A consultant discussed with the national authorities indica- tors for evaluating the country health programming project in the north of Portugal, and assisted in organizing a small workshop for national and district planners. A second mission was carried out to assist in designing the evaluation indicators. The Regional Office has continued to give technical support to the project. INFORMATION SYSTEMS PROGRAMME The programme was actively in- volved in the preparation of the medium- term programmes and other planning documents in relation to the Seventh General Programme of Work. The preparation of the proposed programme budget for 1984/85 gave an opportunity to design systems for project submission and costing. Specifications for WHO programme management were developed in order to improve the first output of the joint WHO/Norway project on the use of minicomputers in health programme management. Consultant missions were undertaken in Algeria and Yugoslavia to develop national health information systems, in collaboration with the WHO collabor- ating centre for medical information and data processing in Uppsala. The Centre interuniversitaire de Traitcment de !'In- formation 2 des Universites de Paris (CIT! 2) was officially designated a WHO collaborating centre . 7 Professor Schneider and staff of the WHO collabo rating centre, Uppsala, gave Regio nal Office staff an introductory course o n computers in December . The implementation o f the com- puterized administratio n and finance system continued with the processing o f claims, and a budge t preparation system was established . The linkage between the computer and the text processing equip- ment became operational, and its first applicatio n was started . New applica- tions were developed o n the basis of the address register : a list of national coun- terparts, a directory o f offici al drug regulato ry agencies, and an experi- mental list o f resource persons covering th ree programmes (oral health , health ed ucation, and prophylactic, diagnostic and therapeutic substances). The establishment o f country infor- mation profiles was begun and a use- ful information base was set up using, among other sources, the data bases al- ready available on the computer and tex t processing facilities. The profiles are developed with a view to backing up the planning, programming and evalu- ation processes in the Office, and report- ing on the implementa tion o f national and regional strategies for H FA2000. The information systems programme continued to coope rate with other Un ited Nations agencies through the ECE Confe rence of European Statis- ticians. Work during the year with the Council of Europe and the Commis- sio n o f the European Communities covered , respectively, in forma tion sys- tems o n the impaired , disabled and hand icapped , and hospital statistics for po pulation-based health care and epi- demiology. Da ta protection in med ical 8 in form a tics is being stud ied together with the International Medical Infor- matics Association. EXTER NAL COORDINATION FOR HEALTH AND SOCIOECONOMIC DEV ELOPMENT The Declaration o f Alma-Ata and the develo pment of global and regional strategies for HF A2000 have consider- ably broadened the Regional Office's contacts with the outside world. While associatio ns for Jay care, self-help and mutual assistance have already been recognized as important sources of sup- portive health development, broade r socioeconomic development will call for new ty pes of contact. Consumer and special interest organizations, which are forming under the influence of economic change, may also be valuable partners in future developments, from sickness prevention to health promotion. A total o f 248 invitations to meet- ings were received - 94 from intergovern- mental organizations, 92 from organiza- tio ns within the United Nations system , and 62 from nongovernmental organ- izations in official relations with WHO - o f which 149 were accepted. Council of Europe (CE) The Regional Directo r delivered an address during the o pening ceremo ny of th e Conference o f European Ministers Responsible for Public Health , in Madrid in September. The Conference was or- ganized by CE to impleme nt the objec- tives of its second medium-term plan , which promo tes prevention and health education. In his speech the Regional Director highlighted the relatively new concern in Europe for a correct balance between the responsibility of the in- dividual for his own health and the responsibility of society o r state. He also pointed out that, whereas the youth of Europe is healthier and better educated than ever before , a large proportion of the present generation will be unemployed , a situation which itself creates new health hazards. The Regional Officer for Coordina- tion addressed the ninth meeting of the Eu ropean Public Health Committee on the Regional Office's new priorities for the Seventh General Programme of Work, stressing the importance of intercountry and interorganizational cooperation in the fields of environmental health and malaria control in particular. He also attended the tenth meeting of the Commi ttee. The Regional Office was represented for the first time at the Standing Confer- ence on University Problems , of which it will be a permanent observer. Rela- tions with the Committee of Experts on Legal Problems in the Medical Field and the Directorate of Education, Culture and Sport were also strengthened. A re presentative of the Health Division of CE visited the Office for briefing at the end of ovember. Council for Mutual Economic Assistance (CMEA) CMEA provided the Regional Office with infornrntion on its activities and on cooperation among the CMEA member countries in the field o f public hea lth , as well as material on environ- mental protection. Commission of the European Communi- ties (CEC) CEC contributed I million European Currency Units towards the construc- tion of one polyclinic and five health centres at El Asnam after the earth- quake in October 1980. It also collabor- ated in the preparation and implementa- tion of the Workshop for Preparedness in Facing Health Problems from Natural Emergency Disaster Situations, held in Rabat in November (seep. 12). The Director, Biology, Radiation Pro- tection and Medical Research, and the Chairman of the Committee on Medical and Public He alth Research visited the Office to forma lize collaboration. Mutual fields of interest are he alth education , health economics, accidents and disabil- ities, and epidemiological studies (particu- larly for the control of toxic chemicals). The Regional Office was represented at the seventee nth and e ighteenth meet- ings of Chief Medical Office rs of the Member States of the European Com- munities, a t which cooperation with WHO continued to be an agenda item. Organisation for /:,'conomic Co-operation and De11elopment (OECD) OECD was represe nted at Regional Office meetings on the control of toxic and o ther hazardous waste and on health economics, and the Regional Office at th e OECD Workshop on the Control of Ex isting Chemicals. A close working relationship was maintained in the road research pro- gramme. Contact was also maintained with OECD through the Centre for Edu- ca tio nal Research and Innovation. The 9 Regional Office participated in several activities organized by OECD to analyse the health manpowe r training and health service systems in some of its member countries in Europe. Nordic Council The Office was represented at the Sixth Congress on Social Medicine , held in o rway in June, and participated in the Fifth In ternational Symposium on Circumpolar Health in Copenhagen in August , o rganized by the Nordic Coun- cil for Arctic Med ical Research . Collaboration with the United Nations system The Regional Office works closely wi th ECE in environmental matters and, at any given time, is responsible for execu ting approximately 40 UNDP- finan ced projects. Collaboration with UNFPA is being ex tended from the less to the more developed countries of the Region ; the International Children's Centre gives st rong support in this field. Cooperation wi th U ICEF in pri- mary health care is being strengthened, and there is collaboration with FAO in food sa fety and zoo noses, and with I LO in occupatio nal heal th. The Regional Office has taken steps to foster much closer cooperation with United a tions organizations at the coun- try level. This has included more direct contacts with representatives of such organiza tions, as well as advocating a stronger role fo r UN DP residen t represen- tatives for United Nations activities at the country level, especially in the health fie ld. Six resident coordinators of the Uni ted Nations system's opera tional activities for development have been 10 appointed in the WHO European Re- gion - in Algeria , Greece, Morocco, Romania, Turkey and Yugoslavia. This shou ld greatly facilita te the international o rganizations' intersecto ral approach to HF A2000 at the country level. The Office was represented a t the eighth annual mee ting of the Board of Directors of the European Centre for Social Welfa re Training and Re- search, sponsored by the United Nations and held in Vienna in December. United Nations Economic Commission for Europe ( £CE) The Regional Office maintained its collaboration with ECE during 198 1, particularly in the fie lds of environ- mental health (water quality and trans- boundary air and water pollution) , road traffic accidents, and s ta tistics. United Nations Development Programme (UNDP) During the period under review th e Regional Office was the executing agency for 3 7 projects financed by UNDP, 27 of which concerned the environme nt ; three were intercoun- try projects. The Director, Programme Manage- ment. made a stateme nt at the inter- governmental consultation on the U DP Regional Programme for Europe in the third programming cycle, 1982 - 86, which was convened in Geneva by the Administrator of UNDP in 1.'.ollal>oration with the Executive Secretary of ECE. He explained the regional stra tegy for HFA2000, stressing the im portance of the environmental health progra mme and European ac tivities in connection with the International Drinking-Wate r Supply and Sanitation Decade, and the threat to con tinental Europe of the spread of malaria. The Regional Office was represen ted at a meeting in Belgrade in May of UNDP resident representatives in the European Region , when the principal subjects discussed were technical co- operation among developing countries (TCDC), government execution of proj- ects, and use of national experts. Innova- tive approaches to TCDC were discussed, by which European countries could co- operate with developing coun tries out- side the Region. The UNDP resident representative in Romania visited the Office in October. A UNDP-financed intercountry proj- ec t on European cooperation on environ- mental health aspects of the control of che micals is fully operational. The coun- tries involved include Bulgaria, Czecho- slovakia , Greece, Hungary, Malta, Po land , Portugal, Ro mania , Turkey and Yugo- slavia. UNEP and ILO have bee n in- volved in the compone nt of the Regional Office programme concerned with con- tinge ncy planning for , and response to, emergencies and accidents involving po tentially toxic chemicals. Food and Agriculture Organization of the United Na tions (FAO) A meeting was o rganized in Rome in O ctober to review current and proposed activities of mutual interest to the Re- gional Office amt FAO. The Office was represented at the fourtee nth session of the Codex Alime n- tarius Commission, in Geneva in Jul y. United Na tions Children's Fund (UNICEF) The UNICEF Director for Europe , while on a visit to Denmark , made a statement to the Regional Programme Committee in March on UN ICEF policy in Europe and cooperation with the Regional Office. The Coordinator of Programme Sup- port Services in the UNICEF Office for Europe attended the meeting of the Re- gional Programme Committee in October. The Deputy Executive Director of Operations, UNICEF Headquarters, New York , visited the Office in December , thus showing her inte rest in strengthen- ing ac tive cooperation between the two organiza tions. A representative of the Office at- tended a meeting of the UNICEF Wo rk- ing Group o n Exchange of Technical In- formation on Ch ild-related Issues, in Geneva in November. World Bank The Wo rld Bank was represented at th e Working Group on Basic Sanitation Operators , Professional Profiles and Training Requirements, convened in Delft a t the end o f March. Nongovernmental and other organizations Regular liaison was maintained with over 30 nongovernme ntal organizations through rep resentation at meetings on questions of commo n concern , per- sonal contacts to discuss programme matters, and exchanges of documenta- tion and publicatio ns. 11 The Regional Officer for Coordina- tion at tended the Third Regional Con- ference of ational European Societies of Red Cross and Red Crescen t , in Budapest in Ma y. The Regional Directo r spoke at the opening of the e ighth Inte rnational Congress o f the International Medical Association for the Study of Living Con- ditions and Health (AMI EV), held in Tampere, Finland in June. The working relationship with AMI I:, V wa main- tained by the Regional Officer for Pri- mary Health Care. The Regional Office participated in a meeting of the organizing commit- tee fo r the Fo rum of o ngovemmental Organiza tio ns, to be held in Vienna in March I 982. l MERGE CY RELIEr OPl· RATIO S The Regional Officer for Coordina- tion visited Algeria and Brussels to exped ite the use of the CEC gran t fo r the erect io n of p refabricated health centres and a polyclinic in the area of the l· l Asnam earthquake. Consu ltan ts visited Algiers to review the equipmen t required and to obtain final agree- ment on the type of s tructure and a contracting firm. l·ollowing a request from the Min- ist ry of Public llealth, the Office pro- vided vaccines and equipment, including two fully equipped ambulances lo ser- vice the prefabricated health cen tn:s and polyclinic in l:.1 Asnam. Further nego- tiations were conducted with U DP 12 and UN ICEF in Algiers, and UNFPA in Tunis, t o ob tain addi tional funds for providing med ical eq uipment , in- cluding radio-diagnostic appara tus and a dental unit . A Workshop for Preparedness in Facing Health Proble ms from Natural Disaster Emergency Situations, intended to enhance natio nal preparedness and self-re liance in disaster-prone countries and to coordinate international re- sources lo that effect, was hosted by the Moroccan Government in Rabat in November. It was at tended by 46 partici- pants from 12 Mediterranean coun- tries and 6 interna tio nal organizations, and by 7 temporary advisers. Financial support was provided by CEC and UNDRO. The participants, the ma- jority of whom had firs t-hand experi- ence of natural disaste r relief opera- tions, exchanged views through five working groups, a rranged by taking into accoun t ac tivities ranging from post-impact operati on to international a id coordination. The mee ting rccommendcd that the Regional Office prepare a "guidebook" for the use of cou nlrics at risk, and that a similar meeting be held in 1982. The Italian delegati o n ex pres ed its country 's wish to host the next meeting. The meeting was the first of its type organiLed by a Regional Office in re ponse to resolutio n WHA34.26. It was also the firs t to consider the ve terinary aspects of public health in re la tion to na tural disasters. The partici- pants linked preparedness and self- re liance to face the health aspects o f natural disa~ters to the primary hea lth aspects of areas al risk. The role of in- terna tional organiza tions, which is o f great value in the rehabilitation phase but irrelevant in the post-impact period, was well emphasized by the participants. RESEARCH PROMOTION AND DEVELOPM ENT The European Advisory Committee for Medical Research (EACMR) em- barked on its second phase, with rep- resentation from six new Member States. A total of 17 Me mber States is represented on the Committee. The seventh session of the EACMR was held in Co pe nhagen in June. It reviewed the activities of its subgroups in research priority areas, which included the Consultation on Standardization of Methods , Measurements and Ter- minology in Health Services Research (Copenhagen, April) , the Wo rkshop on the Control of Health Care Costs in Social Security Systems (Vienna, May) , the meeting of collaborators for the study on physicians' use of clinical sup- port services under non-life-threatening conditions (The Hague, June), and the Working Group on Guidelines for Clini- cal Trials of Minor Tranquillizers and Sedatives (Copenhagen , June) (for de- tails see under technical programmes) . It end orsed the recommendations of the Meeting on the Use of Residual Vision by Visually Disabled Persons ( Brussels, January ) , which was financed by the Belgian Government and which was the first WHO contribution to the Inter- national Year of Disabled Persons. The EACM R strongly endo rsed the suggestion of the Regional Committee that an inventory be drawn up of all research activities within European coun- tries, as without it there was a real risk of duplication. It also examined in detail the research aspects of the three ele- ments of the regional strategy for HF A2000: lifestyles, preventable con- ditions, and the provision of adequate health care for all. Where lifestyles were concerned, the EACM R considered educational and legislative measures unlikely to be of more than secondary importance; research should concentrate on means of improving the environment, which moulds the individual's way of life. It noted that it should be possible to construct models for preventable conditions to determine the environ- mental limits within which full adapta- tion was still possible and health could be maintained; a considerable number of specific suggestions were made. The Committee also considered that research directed towards providing adequate health care for all could be classified into various groups, and that studies to identify means o f improving health care delivery systems might well involve transnational comparisons. As a result of the review of ex- perience acquired during the first four- year period, the Committee iden tified the following problems relating to its own work. I . Current health research in the Region , includ ing the research com- ponents o f the Organization's own pro- grammes, is far too extensive to allow full revie w during the annual sessions without additional effort by the Co m- mittee members. 2. Communication on research pri- orities between the Regional Office on the one hand , and government agencies 13 in the Member States and research workers on the other, is difficult owing to the large number and variety of national research systems. 3. Certain types of research , such as health services research , are under- developed in the Region. Considering the lack of attention to systems research in some parts of Europe, i.e. studies devoted to the com- plex totality of health and disease, the EACMR recommended that a study group on the theory of research be established to examine this problem. A study group on health services research would continue the work of the former planning group on problems of health care delivery. A third group on com- munication and collaboration would assist the Regional Office with problems concerning relations with national and other research institutions and o rganiza- tions. Finally, to provide for more active participation by the EACMR in the work of the Organization, it was proposed that a small planning subcommittee be estab- lished , which could meet at more fre- quent intervals to assist the staff in regrouping and reclassifying the ele- ments of the research programmes; these could then be clearly reviewed and planned, thus strengthening also the personal links between the Com- mittee members and th ose responsible for the programmes. To implement the above recom- mendations, two meetings were con- vened: (a) a consultation of the p lanning subcommittee in Copenhagen in Octo- ber, which recommended an analysis of the research aspects of regional pro- grammes by the EACMR members ; and (b) a planning meeting for the pro- posed study group on theoretical models relevant to scientific analysis of health and health care issues (Berne , December) to discuss aims and objectives and a programme of work. GENERAL PROGRAMME DEVELOPMENT, MANAGEMENT AND COORDINATION Proposed budget and actual expenditure for 1980/ 81 (US$) Proposed Expenditure budget 1980 1981 1980/8 1 Regular funds 2 547 800 I 587 041 I 133 658 2 720699 UN funds 45000 I 128 2 574 3 702 Voluntary funds 202 200 86 157 125 486 2 11 643 2 795 000 I 674 326 I 26 1 7 18 2 936044° a Being 8 .40% of total expenditure. 14 Publications issued in 1981 Health services in Europe, 3rd edition. Health statistics: report on the Fourth European Conference . EURO Reports and Studies , No. 43. Health economics research into factors of health service growth: report on a WHO Workshop. EURO Reports and Studies, No. 52. 15 Q> ~ "' :J CT ~ "' cu 0 CX) . ' O'l Q> .c .., Cl C -~ 0 ~ "' ... cu Cl ~ E "' C V, <( w C -0 cu .., (.) e Q> V, e c Q> (.) .s::. ... ~ cu .c -0 ~ "' .g .D ~ e a. Q> .c .., 0 Q> C 0 "' C 0 ~ 4) 0.. "O 4) :0 "' "' 0 0 .... "' 4) >- "' C 0 ·;::; "' E ;!l C 4) -5 Cl C .... ::> "O "O ;!l .c Cl .c Cl .c a, C a. 0 u C "O 4) :0 "' "' '6 4) -5 0 , E 4) :0 0 a. 4) .c f- Chapter 3 DEVELOPMENT OF COMPREHENS IVE HEAL TH SERVICES GENERAL During the year programmes were reoriented to bring them into line with the aims o f the regional strategy for HFA2000. A core list of indicators, which should help in monitoring prog- ress, was initiated and several programmes completed their consultation procedures. Seve ral means of promoting primary health care (PHC) were proposed to the Member States and the Regional Office, and a study on management needs for PHC was launched. Collaboration with relevant collaborating centres in the Re- gion was intensified. Efforts towards the development of a medical technology assessment net- work were pursued , initially in six Mem- be r States, to be gradually ex tended to cover the en tire Region . Cost containme nt measures were studied , and it was stressed that these should be directed not only to the health care system but be ex tended by pro- viding adequate educa tion and informa- tion to all concerned. In relation to workers' health , in- creasing attention is being placed on vulnerable groups, including chronic exposure to hazardous materials over long periods and special occupational problems affecting women. Occupa- tional problems in hospitals were dis- cussed at a working group in the Nether- lands and a major programme is under way, in collaboration with !ARC, con- cerning the biological e ffects of man- made mineral fibres. Guidelines are being produced in relation to epi- demiological studies at the work- place and the need for comprehen- sive records in relation to occupa- tional risks sustained by workers is increasingly being emphasized. The regional programme on health care of the elderly was mainly con- cerned during the year with links be- tween disability and old age, with controlling disabilities at the primary, secondary and tertiary levels, with health manpower development, and with developing information centres and clearing-ho uses. The regio nal programme on acci- dent prevention focused on information syste ms, the preventive fun ctions of na- tional autho rities , and the promotion of measu res fo r minimizing injury and severity o f disability. 17 The main emphasis in the maternal and child health programme was on perinatal care, while in the family plan- ning secto r a series o f studies fo r the improvement o f na tional programmes, sex educatio n, legislation and evaluation were continued . Activities in the health education and lifestyles programme focused on three main subjects : health promotion, self care, and the third survey o n smok- ing and health. Mental health services in the Region received close attention . Improvements in info rmation and data collection pro- vided a sound basis fo r the assessment of programmes and policies. In the field o f drugs, the drafting of investigational guidelines was extended to sed ative drugs, n on-steroidal anti- infla mm atory agents, and slow-acting anti-rheuma tic drugs. The European studies of drug regula tion and the drug legislation studies were pursued . Health services planning and management Epidemiology In relation to the develo pment of the regional strategy for HFA 2000, activities were initiated to deve lop a core list of indicators to be used by countries for mo nitoring progress towards that goal. The first list , reviewed by the Workshop on the Use o f Health Indica tors in November 1980 , was superseded by an anno tated list prod uced a t a consultation in April. The list was sent to Me mber States for their comme nts o n the rel- evance and availability of the proposed indica tors, and fo r their advice on the need for furthe r research in fields 18 whe re no adequate indicators can be identified . Paralle l to that effort, and in view of the s trong emphasis placed in the strategy o n the stimu- latio n o f healthy behavio ur and re- du ction of self-imposed risks, joint activities were initiated with the Inter- natio nal Epide mio logical Association to develop positive indicators of health. An edito rial board was convened in Decem- be r to prepare the outline of a publi- catio n on that subject , which is expected to be issued in I 983 . The annual course (in French) on statistical, epidemiological and oper- ational me thods in medicine and pub- lic health took place at the School of Public Health , Free University of Brussels, fro m 2 February to 29 May. This was the only such course held during the year, and only one WHO fello w attended . This apparent lack of interest may be attributed to the intro- du ction of biennial budge ting in WHO, most o f the candidates having been designated for the first year of the biennium. This is confirmed by the large numbe r enro lled for 1982. For the same reason , there we re not enough candi- dates to organize the London and Bratislava courses in 1981 . The study on health care of the elderly in 16 centres in I I participating countries was comple ted. Data process- ing and tabulations were finalized and fo rward ed to the chief investigators. The edito rial bo ard me t in April and Nove mber to prepare the final report o f the study. A meeting o f the principal inves- tigato rs fo r the study on e pidemi- ological surveillance of e nvironmental hazards was convened in Reykjavik in May. It discussed and refined the de- tailed specific protocols, coordinated implementation of the pilot projects in the participating countries (some 14 European Member States have expressed interest), and made recommendations for further activities in the development and completion of the study. Health economics In line with the decision of WHO's Programme Development Working G roup that the Regional Office should be responsible for preparing guiding prin- ciples for programme budgeting, an interregional consultation was held in Copenhagen in February. Participants advised against the development by WHO of detailed guidelines for pro- gramme budgeting procedures, but rec- ommended that efforts be concen- trated on developing specifi c guiding principles on programme budgeting which would demonstrate how it sup- ports the overall managerial process for national health development. A Workshop on the Con trol of Health Care Costs in Social Security Systems, held in Vienna in May, stressed the importance of coordinating the primary care and hospital sectors, and emphasized that the search for cost containment must go beyond the health care system to encompass, for instance, environmental pollution and self-imposed risks. It was considered necessary not only that health personnel should have a grounding in health economics, but also that the general public should be made aware of the scope as well as the limitations of modem health care. Research should be carried out on technology assessment (using a broad systems approach), on methods of payment , and on health man- power distribution policies. Following a recommendation of the Workshop on Health Economics Research held in I 979, a meeting in The Hague in June determined that a new multinational study should be made of the use of technology by physicians, in terms of clinical support services for diagnostic and therapeutic purposes, in non-life-threatening situations. A second planning meeting for the study on the influence of economic development on health was hosted in Munich in September by the Institute for Medical In formatics and Health Services Research of the GSF Research Cen tre (MEDIS), on behalf of WHO. The meeting drew up detailed protocols for the study and reviewed recent research and experience in this field. It was recommended that MEDIS should act as a clearing-house for the exchange of information , research findings and meth- odologies and that anothe r meeting should be convened in 1982 or 1983 to review progress. An lnteragency Coordination Meet- ing on Health Economics, held at the Regional Office in November, recom- mended more frequen t technical col- laboration and communication among international organizations in the field of health economics. Those concerned at the present time are CEC, CE, the International Institute for Applied Sys- tems Analysis, ILO, the International Social Security Association , OECD and the Sandoz Institute, Geneva. "European health strategies in the absence of economic growth" was the topic of a lecture given by the 19 Regional Officer for Health Economics at the International Conference on National Health Care Systems in Non- Growth Economics, organized by the University of Linkoping in April. Work with the Council of Europe focused on the reduction of hospital costs. The Regional Office was rep- resented at the ILO Meeting of Experts on Social Security Financing, held in Geneva at the end of November. Primary health care The main activity in the primary health care (PHC) programme during the year was the Symposium on Pri- mary Health Care in Europe, held in Kuopio , Finland, in December. The Symposium suggested several concrete actions to be taken by Member States, the Regional Office and the scientific community to promote PHC. Reports reviewing the implementation of the rec- ommendations of the AJma-Ata Con- ference in eastern and western European countries were prepared for the Sym- posium. It is planned to update these reports fo r a conference on the organiz- ation of PHC in industrialized coun- tries, to be held in 1983. Several studies were either con- tinued or begun during the year. The first mee ting o f the principal inves- tigators for the study on management needs of primary health care, launched in 1979 with seven Member States participating, met in Tampere, Fin- land, in March. It reported on the results of the brainstorming phase and agreed on the main lines of the empi rical phase of the study, which was completed during the remain- der of the year. The research design 20 was prepared for a study on patterns of community participation in PHC, to begin early in 1982 with six Member States participating. The Regional Of- fice sponsored and supported the Euro- pean collaborative hospital study, orig- inally launched by the Association of Schools of Public Health of the Euro- pean Region. The Office also sponsored a study on the efficiency of PHC, which was conducted in three Member States and was originally suggested by the European Advisory Committee on Medi- cal Research as an example of health services research. The Regional Officer for PHC continued to be responsible for two other programmes: those in circumpolar health and in model health care pro- grammes and quality assurance. Contacts were established with national au th- orities and research institutions re- sponsible for, and active in , services and research both in Antarctica and in arctic and subarctic regions. Two consult an ts reviewed the reports on com- parative studies in circumpolar health and compiled an annotated bibliography for the Working Group on Comparative Studies in Circumpolar Health, in Copenhagen in August. The Working Group recommended ways of increasing the comparability of research results and methods of conducting truly com- parative studies be tween various areas and populations. The Office organized a special session on health care delivery in arctic regions in connection with the fifth International Symposium on Circumpolar Health, a t which the Regional Director was one of the open- ing speakers. It was decided to establish a new programme on hospitals and o ther health ca re institutions, and the Re- gional Officer for PHC was respon- sihle for preparing the first mediu111- ter111 programme. Country activities A /geria. Regional Office s taff par- tici rated in an Algerian PHC' workshop in June to continue work on the draft plan of operation fo r a PHC project. Spain. Advice was given on the development of pilot health centres in the region o f Catalonia. Turkey. Regional Office and WI IO headquarters staff participated in a workshop on PHC in re la tion to malaria control , in Ankara in February. A follow-up meeting with the national health authorities was organized in the Regional Office in March. Three para lle l PHC projects are developing models corresponding to the need s of dif- fe ren t areas: UNICEF is working o n one for rural eastern Tu rkey, and WI IO is developing the othe r two one for an agricu ltural area with en- demic malaria and the other for peri- urban slums. UNDP is supporting these projects, which will be run under the aegis of a national PHC commi ttee. USSR. The Regional Offi cer for PHC' visited the WHO collaborating centre in Alma-Ata and discussed the implementation of the plan of work. The Office provided the centre with audiovisual teaching aids and two grants: o ne o f US $50 000 to develop activities and another of US $ 15 000 to organize a training course in PHC' planning and management. Yugos/ul'ia. A drart plan of work was prepared with the Andrija Stam- par School o f Public.: Health in prep- aration for the projected designation of the School as a WHO collaborating centre in l'IIC. Workers' health In rec.:1.:11 t years many imlustria li,.t:d wun tries of the European Region have made progrt:~s in thl.! pn.:vt:ntion of aeuk and chronic occupa tio nal di seases. However, low lt:vels of exposu re to occupational hazards may induce pathological processes, the manifestation of wh ich can bl! delayed antl may even occur in su bs\!q uen t gen\!ra tions. Th us th er\! is a relationship betwel.!n th \! health status o f certa in populations and con- di tions of work. To e nsure e ffectivt: control of the working env ironmen t and workers' health, well qualified manpower must be available for the occupa tional health sc rvices, a point that rl'ceivcd consider- able attention in 198 1. The Consul- tation on Training of Occupational Health Personnel. he ld in Belgrade in June, examined training policies in the light of new technologies and new trends in occupatio nal hl!alth. It was emphasized that 11.:chnologic.:al develop- ments over the las t two decades have changed patterns of work. Atte ntion should be paid to the importance o f occupational stress, psychosocial factors, and the "humanization" of working conditions. Training or occupational health personne l shou ld he suitably adjusted to the changing demands of services. It was s trongly recommended th at the specialist nature of occupa tio nal medicine, occupational h ygiene, toxi- cology and occupational nursing sho uld 2 1 be recognized officially in Member States. These ideas were further de- veloped during the !LO/ WHO Inter- national Symposium on Education and Training Policies in Occupational Safety and Health and Ergonomics, which took place in Sandefjord , Norway, in August. Research provides new knowledge on the long-term effects of environ- mental hazards, and has changed the criteria of risk assessment. More at- tention is being paid to the remote specific effects of chemical, physi- cal and ergonomic factors , particu- larly the carcinogenic effects of in- dustrial chemicals. It was stressed at the International Symposium on Prevention of Occupational Cancer, in Helsinki in April , that the respon- sib le national agencies should take practical steps towards the prevention and control of industrial carcinogens. Attention was paid during the year to the working conditions of specific groups. The Working Group on Occupational Hazards in Hospi- tals, held in The Hague in October, identified the more important oc- cupational hazards and main occu- pational risk groups in hospitals. Particu- lar attention was paid to anaesthetic gases, cytotoxic agents, chemical ster- ilants and disinfectants, to which so me hospital personnel are exposed. It was also stressed that psychosocial factors are important in many areas of health care work. Women consti- tute a significant proportion of the hospital work force and many are of reproductive age; the Group the re- fore recommended that pregnancy out- come studies of hospital personnel be developed. 22 The unification of methods for moni- toring and evaluating airborne man- made mineral fibres was continued, and a central reference scheme was set up by a technical committee that met in Edinburgh in February. The first results of the scheme were discussed by the technical committee at a second meeting in Nancy in November, and will be reported at a conference on the bio- logical effects of man-made mineral fibres, to take place at the Regional Office in April I 982. Migrant workers form a large group of the working population in many European countries, and many of them arc employed in the building industry. A consultant stud ied working conditions in the construction indus- try and the report is to be published. Country activities National courses on different aspects of occupational health were organized in several countries of the Region . Bulgaria. Three WHO fellows from the European Region attended a work- shop on the organization of occupational health services, in Sofia in June. Finland. In temational courses sup- ported by WHO were convened on the following subjects: the psychosomatic approach to occupational stress; occu- pational hazards and reproduction ; epi- demiological methods; the ergonom- ics of confined and repetitive tasks, with special reference to neck and arm strain; vibration; and occupational accident research. A Symposium on Epidemiology in Occupational Health was convened in Helsinki in June, under the auspices of the Permanent Commission and International Association on Occupa- tional Health. Care of the aged, disability prevention and rehabilitation Health care of the elderly During the year the European Region experienced an upsurge of interest in the health problems of the elderly. This was due not only to the increasing numbers of elderly people in the Region, but also to the disabling con- ditions accompanying the aging process, particularly in the very old. Inadequate redistribution of resources in the health and social services creates problems, especially in long-term care, and con- tributes to disparities not only through- out the Region but in individual Member States. Fig. 2 and 3 show estimated trends in the elderly population in the European Region. The Regional Office followed up contacts with intergovernmental and non- governmental organizations concerned with care of the elderly, in preparation for the United Nations World Assembly on Aging to be held in 1982. A liaison meeting with intergovern- mental and nongovernmental organiza- tions was convened by the United Nations Centre for Social Development and Humanitarian Affairs (UNCSDHA) during its Technical Meeting on Aging, held in Frankfurt in June, at which the Regional Office was represented. The Of- fice was also represented at a meeting in Castelgandolfo in September, organized jointly by UNCSDHA and the Opera Pia International for Active Aging. The Regional Office has been ac- tively involved in the work of the International Association of Geron- tology and contributed in large measure to preparations for the twelfth Inter- national Congress of Gerontology, held in Hamburg in July. There was particu- larly close collaboration in areas of common interest, such as a glossary of terms in social gerontology, longitudinal studies on aging, men ta] health of the elderly, and long-term care. The Working Group to Define Means of Prevention of Disability in the Eld- erly, in Cologne in November, considered facts about the health and performance of the elderly in daily living, analysed and discussed the prevalence and inci- dence of disability in old age, and recommended action to be taken at the primary, secondary and tertiary levels. A follow-up meeting, on the organization of disability preventive services, is to be held in 1982. The Working Group on Behavioural Studies Related to Care of the Aged, held in Lubeck in July, came to the conclusion that more information was needed on (a) attitudes among the general public (including the elderly themselves) towards elderly persons; (b) attitudes of the various providers of care; (c) the behaviour of other groups towards elderly persons; and (d) different approaches and methods for changing attitudes of the general public and that of professionals caring for the elderly. Consultations on Teaching Geront- ology/Geriatric Medicine and Establish- ing a Clearing-House for Curricula were held in Copenhagen in March to consider the ability of physicians to manage the 23 1980 r f Fig. 2. Population trends in the European Region: estimated percentage of population aged 60 years and over 2000 ~ 10-14% .15-19% ■~20% Source: World population trends and prospects by country, 1950-2000: summary report of the 1978 assessment. New York, United Nations, 1979. 1980 r f rtrl < l% N Fig. 3. Population trends in the European Region: estimated percentage of population aged 80 years and over ~ 1-1.9% g 2-2.9% 2000 v, Source: World population trends and prNpeca by country, 1950-2000: &ummary report of the 1978 aues:&ment. New York, United Nations, 1979. health problems of the aged with regard to (a) the present situation in teaching gerontology and geriatric medicine in the European Region; (b) the fonnulation of recommendations for action in the con- tex t of the above point; and (c) the formulation of recommendations o n establishing a clearing-house for curricula and its function. Country activities Malta. A senior nursing officer from Malta made a six-week study visit to the United Kingdom to estab- lish criteria for nursing and rehabili- tating geriatric patients within the commuruty nursing services. Disability prevention and rehabilitation The technical discussions at the thirty-first session of the Regional Committee on "Medical and social problems of disabled persons" were the most important regional con tri- bution to the International Year of Disabled Persons (IYDP). Curren t prob- lems of disability were discussed in the light of the International classi- fication of impairments, disabilities and handicaps, published by WHO o n a trial basis in 1980. Basic con- cepts of disability prevention and the rehabilitation of disabled per- sons were clarified , with special ref- erence to disabilities prevalent in cer- tain age groups. The many problems faced by the disabled and their families could be reduced by education , and through simple rehabilitation techniques based on community support rather than on institutions; aids should be assessed accordingly. 26 In resolution EUR/ RC3 l / R 13 the Regional Committee recognized the im- portance of the WHO contribution to the IYDP; urged Member States to re- view the existing facilities for rehabili- ta tion, and to promote studies designed to facilitate participation of the disabled in daily life; and endorsed the proposal that a programme on disability prevention and rehabilitation be included in the Seventh General Programme of Work . A Meeting on the Use o f Residual Visio n by Visually Disabled Persons was convened in Brussels in January. Disability and handica p related to visual impairment hold an important place among disablements. Furthermore, in the aging population of European countries, the absolute number of those so disabled is likely to increase. A multidisciplinary approach to low-vision problems is needed , particularly in establishing institutes and centres with adequately trained personnel. More studies are needed on comparing legis- Ia tio n and regulations in different countries. Direc t attention should be paid to vision training as an import- ant component of rehabilitation pro- grammes, particularly in the area of mobility training. A Symposium on the Epidemiology of Accident Traumas and Resulting Dis- abilities was held in Strasbourg in March. The Symposium was organized in collaboration with the French Govern- ment, in connection with its activities for the IYDP. The participants studied the epidemiology of accident traumas, and activities relating to medical and social services to offset the severity of disabilities resulting from accidents. Dis- cussions were begun on the classification of disabilities resulting from accidents, and 0 11 evaluating the ir impac t o n h ealth sys te ms. It was recomme nd ed that a ny em t: rgency services th at were deve lo ped should include the pro vision of first aid fo r the injured as we ll as specia lized hospi ta l fac ilities. A study on the cost-effec tiveness of sophis- tica ted syste ms o f treatme nt was pro- posed . It was also suggested tha t at- tentio n be pa id to the organizat ion of can: fo r patients a t the primary and secondary levels a nd in the re- habilitation phase, and th at ed ucation of the public and trai ning o f educators, health personnel and policy -makers in accident prevention be unde rtaken . F ina lly, it was recommended that s tatis tics o n the injured and indices of severity, and the developmen t o f information systems re lating to acci- d ents, he give n prio rity. The health authorities of the United Kingd o m made a special e ffort to p ro mo te, throughou t the world , aware- ness o f the impo rtance of preven- tio n by convening an International Seminar on the Prevention o f Dis- able men t , a t Leeds Castle in Novem- ber. The conclusion o f the Semina r was that avoidable disablement - with all its consequences in wast ed resources a nd fru strated lives - need no lo nger be an inescapable part of the human pn:dicament. Its prevention , o n an unprecedented scale and at no great cost , is one o f the options now avail- able to the inte rnati onal community. Coun try activities Algeria. The ex is ting projec t o n training teache rs for d eaf children was ex tended to disability preven- tio n and rehabilita tion . A consultan t prepared a project proposa l for the education or profe:-.sional ~tall in various areas or disa bility. Prevention of road traffk accident!; For th e past live years th e regional programme on accident preven t ion has focu sed 0 11 consid ering and re viewing all public health issues of road accident prevention , emphasiz ing their impli- ca tio ns in te rms or the action they call for o n the part of public health au th- o rities, in the form of a la rge-scak multisecto ral approach. Some or the areas o n which the programme h.Js concentrated a re illustrated by the act ivi tit:s tha t took place during 198 1. Othe r aspects or the programrne will be develo ped in 1982 .Jnd 1983. The repo rt of the Technical (;roup on the Ro le of Health Se rvices in the Prevention o f Road Traffic Accide nts was issued and distributed to Me mbe r States during the year. The opportunit y was taken to use the re po rt as a basis for discussions in two countries in the Region as part o f programmes of col- labo ratio n be tween the Office and Mem ber States. In d eveloped countries the health of the driver is regarded as relatively insignifica nt as a cause of road acc.:i- dents resulting in injury. In less de- ve loped countries, however, the si tuatio n may be qui te diffe re nt, s in ce the re is not o nly a grea te r risk of a ccidents occurring, but a lso a g reater possi- bi lity of mo re severe conseq uences in te rms of death o r se rio us injury. A Wo rking Group o n the Ro le of Med ical Fac to rs in the Causation of Road Acci- de nts was he ld in Belgrade in May. Among the subjects d iscussed was th e controversia l issue of the med ical 27 examination of drivers, or of persons applying for driving licences. It was concluded that because the re was a lack of epidemiological data on the real contribution of medical factors to acci- dent risk, the formulation of efficien t guidelines for performing these exam- inations was difficult. It was felt that , to enable physicians to advise their patients on the risks they run while driving, studies needed to be undertaken on, for example, the relationship between the number and severity of heart attacks and the ability to drive. It was considered important to obtain more information about the risk of seizures among con- trolled epileptics while driving. The Group also felt that the e ffects of pharmaceutical drugs on a driver's per- formance should be studied. More informatio n is also needed on the consequences of diagnostic procedures and of the associated anaesthesia or sedation , bearing in mind the increase in the use of outpatient diagnostic proced ures and therapy. The last decade saw great advances in the developed countries with respect to the adoption of protective devices and restraint systems in vehicles. Most pass- ive devices are now incorporated into the basic design of vehicles. Because it is important for health authorities to have some knowledge o f restraint systems, a study was undertaken on bioengineer- ing a nd acciden to logy, reviewing the technical and legal aspects of the use of restraint systems. It is expected that the report on the study will form part of a publication on the wider aspects of road accidents in Europe. The development of and agreement on indicato rs of injury severity is funda- mental, not only for the planning of 28 services for the ameliora tion or im- mediate and long-tern, effeds of injury, but also to evaluate th e countermeasures that are introduced by the various agencies conce rned . The Symposium on the Epidemiology of Accident Traumas and Resulting Disabilities, held in Stras- bourg in March (see p. 26), began con- sideration of this and the wo rk will continue in 1982. The second mee ting of the Ad- visory Committee on Accident Preven- tion was convened in Dresden in Decem- ber. The Commillt:e reviewed the first five years of the regional programme and, while agreeing that the original objectives and targe ts of the programme had been met, felt that co nsideration should be give n to ways in which the information now available within th e Of- fice could be disseminated not only to health authorities, but also to transport ministries and other national institutions involved in the prevention of road traffic accidents. The Committee considered the ex tensio n of the programme to include o the r accidents, such as those in the home and those associated with sp orts and leisure activities. It also recommended that there should be dose cooperatio n betwee n the accident pre- ve ntio n programme and the workers' health programme in relation to acci- dents at work. TI1c Committee suggested some amendments to the proposed programme for 1982/83 and agreed, with some min or amendments, the proposed med ium-term programme on accident prcven tion for the Seven th General Programme of Wo rk . The Regional Officer for Accident Prevention attended the six th Inter- natio nal Conference of the International Research Commit tee on Biokinetics of Impact (I RCOBI) and presented a paper at the opening session o n "The role of WHO in road accident preven- tion". Discussions were also held on a programme of mutual cooperation be tween IRCOB I and WHO in the fie ld of bioengineering. Country activities Portugal. The Regional Officer for Accident Prevention visited Portugal to discuss the development of a com- prehensive programme for the pre- vention o f road accidents. As a re- sult , it was proposed tha t senior of- fo.:ials from the various ministries and other national bodies concerned should attend a seminar pla nned fo r Octo ber 1982. Turk ey. Two consultants carried out a de tailed analysis o f the traffic situation in the country and the e pi- demiology of traffic accidents, the organization of traffic sa fe ty, a nd the government departments and bodies involved. The report o f the visit which , among other things, made the rec- ommendation that a national coor- dinating body should be established for the prevention or accidents, re- sulted in a request being made to WHO for va rious educational and training mate rials in the fie ld of traffic safety. This in turn has stimula ted WHO to consider ways in which educatio nal m aterials could be made available to Member States. Appropriate technology for health During a la rge part of the year, activities centred on the new proj- ect on the development of a health technology assessme nt ne twork. A meet- ing was held in Copenhagen in June, at which representatives o f the six countries that had provisionally agreed to participate (France , Hungary, the Netherlands , Norway, Sweden and the United Kingdo m) discussed informa- tion exchange and organization o f the regional netwo rk . Specific tasks were assigned to members or the group and agreement was reached that a consultant be requested to pn:pare documentation 0 11 classification of technologies, guiudines for possible assessment procedures, and a plan or work ex te nding up to 1985. In the field o r poison con trol a work- ing group in Ro me in November studieu the pro blem of preventio n and , particu- larly a l the primary health can; level, rapid methods of informa tion exchange, the development or uata banks, lab- o ratory su ppo rt infrastructures, and education and training. The need for po ison contro l centres to have access to the complete formulas o f to xic and potentially toxic materials, as well as a positive relationship with the news meuia and the ge ne ral public , was stresseu . A joint Regio nal Office/European Association o r Poisons Control Centres mee ting, hclu in Copenhagen in May, discussed uata collection and e pidemi- o logica l aspects of po ison ing, as well as modern treatment o r intoxications with tri- an d te tracyclic antidepressant drugs, orga nophosphorus insecticides, bromide salts, pentachlorophenol and paracetamol. A Seminar on the Ro le or Cy- to logical and l.:ndocrino logical Services 29 in Primary Health Care and Family Planning was held in Malta in Dece m- be r. Apart from the teaching o f ap- propriate technology in cy tology and endocrinology, a great deal o f infor- mation was gathered through the inter- action of the knowledge accumulated in eight countries. Hospital-acquired in fections con- tinued to be a prio rity subject , and collaboration continued with the Euro- pean Working Party on Programmes for Recording of Hospital Infections. The preliminary results of s tudies that began in 1980 suggest that a com- mon approach is possible among the participating countries, of which there we re ten in 1981. The fourth meeting of the heads of European public heal th la bora- tories, held in Paris in June, dealt mainly with three the mes: atmos- pheric pollution monitoring, labora- tory support for the surveillance of communicable diseases, and quality assurance in various types and levels of laboratory service. These mee tings have proved to be ex tremely use fut as they provide an excellent forum for exchange of information , parti cu- larly on the development, assessment and utilization of various technologies. In the contex t of the European Committee on Clinical Laboratory Stan- dards, the Regional Officer for Ap- propriate Techno logy for Health par- ticipated in a seminar entitled " In- dustry and the clinical laboratory", which was convened in Cante rbury at the end o f March . Practically all the intergovernmental and nongovern- mental organizations interested in stan- dardization we re represented. 30 The Office collaborated with the International Federation of Clinical Chemistry (I FCC) at the eleventh International and fourth European Con- gresses of Clinical Chemistry, in Vienna in September. Coun try activities Algeria. In the contex t of the de- ve lopment of peripheral health centres , in formation on the basic radiologi- cal system (BRS) machine was sup- plied and , in collaboration with WHO headquarters, lis ts of laboratory tests and reagents to be used in health centres and provincial laboratories were drawn up. Hungary. As the next meeting of Member States participating in the health technology assessment net- work is to take place in Budapest in June 1982, collaboration in the field of techno logy assessment and utilization was initiated during a coun- try visit. Iceland. The Regional Officer for Appropriate Technology for Health visited Reykjavik and participated in four seminars on cost-consciousness in health care and technology assessment. Turkey. In fo rmation on the BRS machine was supplied ; the machine appears to be meeting the needs of the health centres and provincial hospitals. USSR . At the invitation of the Government , the Regional Officer for Appropria te Technology for Health participated in the international courses fo r public heal th administrators in Moscow in May, and lectured on health care support services, health care technology assessment and cost- consciousness. FAMILY HEALTH Maternal and child health The work focusing on the peri- natal period progressed very satis- factorily during 1981. The psychosocial subcommittee of the Perinatal Study Group met in Copenhagen in March. The objectives and role of this sub- group were clarified, and a decision was made to conduct a survey of existing literature on the psycho- social aspects of perinatal care. Fol- lowing this, a consultant was assigned to carry out the literature survey, to be submitted to and discussed by the full meeting of the Perinatal Study Group early in 1982. The perinatal surveillance subcom- mittee met in Prague in May. It was agreed that a standardization of defi- nitions and collection of statistics was needed. Furthermore , the possi- bility of a network of perinatal sur- veillance units in the Region was discussed. In the meantime, a sur- vey is being conducted of perinatal services in as many Member States as possible. The report will be pre- sented to the fulJ meeting of the Perinatal Study Group , and the Group will then determine its programme of research. Another study begun during 1981 was that on alternative perinatal services in the Region. It is clear that many im- portant services for pregnant women occur outside the official professional sector. This study is being conducted by a midwife and a medical sociol- ogist, the former with practical ex- perience in alternative perinatal ser- vices and the latter with theoreti- cal and methodological experience in this field. Difficulties were experienced in completing the study on the role of women and health in the Region; this will be con tinued in I 982. The Regional Officer for Maternal and Child Health is at present the focal point for the Expanded Programme on Immunization (EPI) in the European Region. Negotiations have been pur- sued for the establishment of two EPI collaborating centres in Europe - one at the International Children's Centre in Paris and another in the USSR. Progress has also been made on the development of information systems in the Regional Office with regard to EPJ services and diseases. A first planning meeting was held at WHO headquarters o n a programme concerned with the health care of chil- dren living in poverty in industrial- ized society. The Regional Office will maintain collaboration with WHO head- quarters on this subject because of the importance of poverty in the re- gional programmes. The Regional Officer for Maternal and Child Health contributed to the Union of National European Paediatric Societies and Associations Conference on the Chronically Sick Child , in Oxford in September. 31 Family planning Advice and assistance continued to be provided by the Regional Office in connection with the monitoring of and follow-up to family planning projects in Algeria, Bulgaria, Czechoslovakia, Hungary, Portugal and Turkey, as well as for the different intercountry activities. The country case study for improved family planning programmes and that on the definition of family planning were completed, and the reports prepared for review and distribution. The study on the evaluation of family planning pro- grammes is still under way. A study was conducted on family planning and sex education of young people, which aimed at assessing the status of sex education in different countries of the Region and giving examples of methodology, management and legal aspects of sex education in the family, the school and the community. Belgium, Italy, Morocco, the Nether- lands, Poland , Portugal and Yugoslavia participated. The various strategies iden- tified are to be discussed by a working group in 1982. A legal consultant was recruited to carry out a study on family planning legislation in Mediterranean countries (Greece, Italy, Morocco, Portugal, Spain , Tunisia and Turkey). Topics included voluntary sterilization, contraception and abortion. Recommendations will be made to national health planners on the type of legislation that would best help them implement their family planning programmes. As in previous years, and in view of the importance of education and training 32 in family planning, an international course on family health/ family plan- ning for instructors in nursing/ midwifery was held in Warsaw in September. Twenty-two fellows from 19 countries, mainly from the European Region but also from the African and Eastern Mediterranean Regions, participated. A Conference on Training in Family Planning fo r Health Personnel was organized in Paris in July, in collabor- ation with the International Children's Centre (ICC), to review training in family planning and to determine an appropriate basis for such training that will ensure that it meets the real needs of the population. The par- ticipants recognized that the teaching of family planning to physicians, nurses, midwives and other health personnel is at present far from satisfactory in most of the countries represented . In basic training programmes, it usually con- sists of brief theoretical lessons on the clinical aspects of contraception, sterility or abortion. It was noted that there are weaknesses both in practi- cal training and in teaching on aspects such as sexuality, psychology and soci- ology, and that there is no preparation for the relationship between health personnel and those who seek advice and care. However, a number of experi- ments in multidisciplinary refresher training were reported, which provide excellent preparation for teamwork and clarification of the roles of the different members of the health team. A draft educational handbook for teachers, prepared by the Regional Officer for Family Planning in col- laboration with ICC, the National School of Public Health , Rennes and the Free University of Brussels, was presented at the Conference. Country activities Algeria. The manager of the project on birth spacing and the development of a maternal and child health infrastruc- ture participated in the WHO/ ICC Confer- ence on Training in Family Planning for Health Personnel (see above). Two Algerian nationals cooperated in the country case study for the improve- ment of family planning programmes, and Algeria was involved in the study on the definition of family planning. Belgium. A workshop on basic health services was organized in Brussels in September in collaboration with the Regional Office . Bulgaria. At the request of the Bul- garian authorities, a specialist installed a spermokinesimeter at the Institute of Obstetrics and Gynaecology of the Medical Academy of Sofia, and provided training in its use. As a follow-up to two previous missions, a temporary adviser visited Bulgaria in June in connection with the project on screening of the new- born and at-risk families for birth- related diseases. The adviser assisted the authorities in their effort to continue the introduction of pre- natal diagnosis of inherited disorders, mass screening of the newborn (en- larging the scope of the latter to in- clude hypothyroidism), and the regis- tration of genetic disorders and con- genital malformations. A WHO fellow studied genetics for six months in the United Kingdom. Czechoslovakia. The Office helped organize an international seminar on primary health care for children, at the Postgraduate Medical and Pharma- ceutical Institute in Prague, for key personnel in child health care from English-speaking developing countries. The seminar was attended by 14 phys- icians from 12 developing countries in South America, Africa and Asia. Greece. The Regional Officer for Family Planning participated in a na- tional seminar organized by the Family Planning Association, in Athens in March, and addressed a multidisciplinary group of doctors , midwives, health visitors , social workers, nurses and pharmacists on subjects related to family planning. Hungary. An international post- graduate training course on methods of family planning was held in Debrecen in October. Thirteen people from I I countries participated; all were medi- cal doctors with ex isting or future in- volvement in national family planning activities, and a good knowledge of Eng- lish. The teaching staff consisted mainly of members of the Department of Obstetrics-Gynaecology and Urology of the Debrecen University Medical School. A member of staff from WHO head- quarters lectured on WHO's involvement- in family planning programmes. Malta. One fellowship was awarded, to study cy totechnology in the United Kingdom for one month. Morocco. The Centre national de Reproduction humaine et de Planning familial , Rabat, was designated as a WHO collaborating ct:ntre. A WHO temporary adviser visited Morocco in October to explore the 33 possibility of strengthening the health education aspect of family planning in professional training. A team including a paediatrician, an obstetrician and a midwife visited Morocco to carry out a preliminary evaluation of the current state of the maternal and child health services, as the first step in a programme of evalu- ation and innovation. Poland. The Regional Officer for Fanuly Planning prepared a chapter on the role of nurse/midwives in providing health care for the fanuly, for inclusion in a book to be published in Polish by the National Research Institu te for Mother and Child , Warsaw. Portugal. The Regional Officer for Family Planning visited Portugal to assist in the evaluation of the activities of a UNFPA project on fami ly planning in formation, education and communi- catio n in rural areas, and to conduct retraining sessions in family planning for health personnel. In the context of the project on assistance to the national fanu ly plan- ning programme, four fellowships were awarded fo r a to tal of 12 weeks to study family health and family planning in France and the United Kingdom. Two temporary advisers were re- cruited for the project on family planning training and services, to advise the proj- ect manager and other faculty members on the inclusion of contraception and fami ly planning in medical education a t the University of Lisbon. Two fellowships were awarded for a total of four weeks to study family planning in Belgium. 34 R omania. The Regional Office co m- mented on three Romanian projects proposed to UNFPA: (a) a seminar on the quantification of risk factors in the first year o f li fe; (b) population as related to legislation, economic development, health care, education, information, demographic documenta- tio n, statistics and fami ly planning; and (c) a study of law and popula- tion growth. Turkey. The Regional Officer for Family Planning participated in a sem- inar on primary health care, in Van in April. She also followed up on the activi- ties of the project on the development of integrated fami ly planning services and had various working sessions with the team of the General Directorate of Popula tion Planning on analysing and preparing informatio n on training in family planning. Advice and financial assistance was given to the Institute of Population Studies for the development of a research project o n the identification of risks to maternal and child health in adolescent mothers. Yugoslavia. Comments were made to UNFPA on three Yugoslavian proj- ect proposals: (a ) the basic determi- nants of reproductive behaviour in the econo mically underdeveloped rural regions o f the socialist republic of Macedonia, and a programme for its adaptation to fan1ily planning; (b) family planning as a h uman right in social work practice; and (c) psychosocial, pedagogical and medical aspects of contraception and abortion in ado- lescen ts in the socialist autonomous province of Vojvodina. Nutrition Activities during the year focused on the promotion of breastfeeding. Prior to the Thirty-fourth World Health Assembly, a number of country visits were made to discuss the draft Inter- national Code of Marketing of Breast- milk Substitutes. At the Health As- sembly in May, every Member State in the European Region voted in favour of resolution WHA34.22 , which adopted the International Code. The Regional Committee at its thirty-first session emphasized the importance of this resolution, and of resolution WHA33 .32 on the encouragement of breastfeeding, and urged Member States to implement the provisions of the International Code and to establish programmes in support of breastfeeding. Consultants in legal matters and nutrition made a number of country visits for further discussions at national level on the implementation of these two resolutions. Health education The new Regional Officer for Health Education was appointed in September; up to that time the programme had been run on a consultant basis. The new regional programme o n health education and lifestyles was introduced at the thirty-first session of the Regional Committee and was well received by the Member States. The Regional Committee also decided to choose "Ii festyles and health" as the subject of its technical discussions at its thirty-third session in 1983. A Working Group on the Concepts and Principles of Health Promotion was held in Copenhagen in November, at which the main background paper was a draft report providing an overview of health promotion concepts and prac- tices in the Region. The meeting recom- mended health promotion activities for 1982/83, commented on the medium- term programme fo r I 984-89, and dis- cussed the possibility of a European health tour. The overview, together with recommendations on the health pro- motion policy of the Regional Office, is to be published in 1982. A review was made of the third survey on smoking and health in the Region, covering the period I 97 5 - 77. The review concentrates on method- ological issues and makes proposals for further work on the subject during 1981 -83. A planning meeting on smoking control strategies in the European Re- gion is scheduled for January I 982. The sixth International Seminar on Health Education was held in Berg- neustadt , Federal Republic of Ger- many, in June and was organized by the Bundeszen trale fi.ir gesundheitliche Aufkliirung, Cologne, on behalf of the Regional Office. Some 60 partici- pants from 19 countries attended to discuss new approaches to planning for health education. Support was provided to two con- ferences focusing on women 's health issues: a conference on women and health in London in November, organ- ized by the Women and Work Hazards Group, and the Women and Health Meeting, organized in Geneva in June by ISIS, the women's international information and communication service. Contacts were established with the European Centre for Social Welfare 35 Training and Research to coordinate efforts for the International Year of Youth (1985), and in September the Regional Officer for Heal th Education attended its regional expert meeting on the conseq uences of the economic crisis for the present and future develop- ment of social welfare. Preliminary contacts were made with CEC and the International Union against Cancer to coordinate efforts in smoking control. Country activities Federal Republic of Germany. The Regional Officer for Health Education visited the Federal Centre for Health Education, Cologne, in July to discuss its further cooperation with the Regional Office. She also discussed collaboration with the European Bureau of the Inter- national Union of Health Education in Cologne in terms of joint meetings and publications. The Regional Office was represented at a seminar on lifestyles and natural resources, organized by the United Nations Association, in Bonn in Novem- ber; a German -American workshop, in Heidelberg in April, to discuss the relevance of self-help principles for the prevention of health problems; a conference on health education by physicians, in Breisach in June; and a meeting in Lich tenberg in November on an advanced training course in health education. Ireland. The Regional Officer for Health Education attended the inter- national conference on handicap and disability organized in Cong in Decem- ber by the Health Education Bureau 36 in Ireland and the International Union of Health Education (IUHE). Close collaboration was established between the IUHE working groups and the Regional Office programme. Italy. During a visit to the Medical Centre in Giugliano and affiliated insti- tutions for programme monitoring in community health , and to the disaster area around Naples after the recen t earthquake, the Regional Officer for Health Education discussed community research aspects of the management of earthquake disasters. This visit led to the participation of two members of the centre in the Workshop for Preparedness in Facing Health Problems from Natural Disaster Emergency Situations, held in Rabat in November. Netherlands. The Office was rep- resented at the seventh International Conference on Social Science and Medicine in Leeuwenhorst in June. Reference was made to the concept of HF A2000 , particularly in the section on ideologies, social policy, health and the structure of health care. United Kingdom. The Office was represented at the forty-first annual meeting of the Society for Applied Anthropology, in Edinburgh in April, at which the developing relationship between action on self-help and social science research was discussed. In connection with this trip, a visit was made to the Scottish Health Education Group to discuss collaboration in health education research and other activities of the Group of particular relevance to the health educat ion programme. The Regional Officer for Health Education lectured on "women and health" and Regional Office policies on HF A2000 at a seminar on Health for All - Policy, Planning and Politics, at Sussex University in December. MENTAL HEALTH The medium-term programme in mental health for the remainder of the Sixth General Programme of Work con- centrated on strengthening the mental health component of national health policies, promoting community mental health care, and developing aspects of the treatment and prevention of alcohol and drug dependence. I nfom,a tion and data collection studies have provided a basis for de- veloping the evaluation and assess- ment of mental health programmes and policies. An evaluation project on mental health services is being de- veloped in Norway. An analysis of mental health services for specific high-risk groups has led to the defi- nition of two areas of special con- cern to the programme: mental health of the aged , and child mental health and psychosocial development. Legislation on mental health and concern for the rights of the mentally ill have been put forward as areas for in- ternational collaboration. Considerable progress has been made in improving data collection on mental health services in Europe. Two short-term consultants assisted in the preparation of country mental health programme pro- files. In collaboration with national counterparts, programme profiles were completed for 25 Member States; these will be used as a basis for a project to assess the impact of the long-term men- tal health programme (1970-1980). An evaluation of mental health training courses was carried out, the main aim of which was to gather in- formation on the subsequent careers and activities of WHO fellows who had participated in earlier mental health training courses, to try to assess the usefulness of such courses, and to develop guidelines for their more sys- tematic evaluation. The seven mental health train- ing courses that took place between 1971 and 1978 were considered to have fulfilled a very useful function, both by the course directors who organ- ized them and by a high proportion of the fellows who participated. More formal attempts at evaluation had not been successful and, in view of the short duration of courses, the time that had since elapsed, and the im- possibility of studying systematically the influence of selection of participants , any further attempt at retrospective evaluation was considered of no poten- tial value. The main conclusions with regard to the organization of future courses were as follows. 1. Courses should maintain a balance be tween the scientific basis of planning on the one hand , and practical problems relating to men tat health resources and constrain ts on the othe r. 2 . Future courses should be organ- ized in the form of workshops, with small groups and active participation by fellows , rather than as formal train- ing courses. 37 3. Participants should be selected to include psychiatrists , public health physicians, administrators and statis- ticians, and also other health workers from the fields of nursing, social work and psychology. 4. Courses should be held in all four official languages of the Regional Office, with attention to the language proficiency of the fellows. 5. Assessment should be planned ahead , making use of a number of tech- niques, including systematic follow-up. It seems probable that the successful assessment and evaluation of future courses will depend (a) on the careful selection of fellows, and (b) on the ex- tent to which contact with individual fellows can be maintained in relation to further WHO projects and collabor- ative activities. The Eighth Meeting on Mental Health Services in Pilot Study Areas was held in Mannheim in August. The annual review of progress was carried out, and agreement reached on the procedures necessary to complete the analysis of data for 2 1 centres in 16 countries. This undertaking will be the joint responsibility of the centres in Geneva and Groningen. Eight established psychiatric case registers are represented in the study, and problems were identi- fied concerning the impact of data protection laws. A working group was convened in Athens in September to consider chang- ing patterns in suic ide behaviour in Europe. Major trends in the rates o f suicide and attempted suicide in many Member States were analysed and 38 summarized . Rising suicide rates were no ted in most countries; Greece and the United Kingdom, however, showed a reduction. Marked increases were observed among e lderly women and young adults. Attempted suicide rates in most countries were generally deemed to be underestimated by as much as a third to a half. The overall rate, how- ever, continues to increase steadily in nearly all European countries, with the greatest increase among teenagers and young adults (Fig. 4). Contrary to popular belief, the reduction in availability of coal gas seems to have no effect on the suicide rate; similarly, the massive increase in the prescribing of drugs seems not to explain the rise in the rate of attempted suicide by intentional self-poisoning. A considerable improvement in edu- catio n programmes on suicide and attempted suicide is required within existing health and social services to raise the quality of care, especially at the primary care level. During the year three WHO col- laborating centres for the mental health programme were designated in Europe: the Psychiatric Hospital, Risskov, Den- mark; the Department of Social Psy- chiatry, Academisch Ziekenhuis, Gron- ingen, Netherlands; and the Laboratoire d ' Etudes et de Reche rches scientifiques (Synthelabo), Paris. In collaboration with the Regional Office, the Nordic School of Public Health, Gothenburg, initiated a two- week training course in social psychiatry and mental health services develop- ment. The participants, from the Nordic - 30 I Fig. 4. Observed and predicted changes in suicide rates in 18 European countries, 1961 - 63to 1972- 748 Percentage change in suicide rate , 1961 -63 to 1972-74 - 20 - 10 0 10 20 I I I 1 -.. ~ England & Wales Greece 't: Scotland I Italy Austria Switzerland Germany, Fed. Rep. of Belgium Czechoslovakia Finland Sweden Norway Poland Netherlands Denmark I rel and Hungary t'I France [ t=J ~ I -- ~ I ~ .. ~,. ............. ~~,..,_ ·-~A.ti,...,.,._.~-........ ~ ~ I 30 40 I I Observed change Predicted change I ....... ~ I 50 J I I 8 Results of multiple regression analysis, using percentage changes in social variables. Variables included: percen tage of the population under 15 and over 65 years of age; room occupancy; women in tertiary education . Mult ip le A K 0.92. 39 countries, included senior professionals engaged in planning, administration, research and education for mental health services development. The Government of the Nether- lands hosted a joint Regional Office/ WHO headquarters working group on the psychosocial consequences of violence. The very diverse nature and form of violence , with its consequent wide range of victims and outcomes, requires continuing consideration and discussion at national, regional and global levels. Ways and means have to be found to raise the awareness of health personnel to early recognition or suspicion of victims of violence. Epidemiological studies in appropriate circumstances of national and international conflict or its aftermath will provide much needed information to aid in victim identifi- cation and therapeutic and preven- tive action, as well as to assist in ident- ifying the need for service provision and development. Activities concerned with the pre- vention of alcohol and drug depen- dence dealt primarily with the con- trol of alcohol consumption. The Re- gional Office participated in the work of the select committees of the Coun- cil of Europe on alcohol drinking in young people and on the prevention of drug dependence. In continuation of the Office's commitment to the international study of alcohol control experiences, a Work- ing Group on the Control of Alcohol Consumption was convened in Copen- hagen in March. The Group prepared an outline plan for a WHO symposium on the control of alcohol consumption , to be held in 1983, and completed work 40 on the final draft report of the inter- national study on alcohol control experiences in Canada, Finland, Ire- land , the Netherlands, Switzerland and the United States. The Regional Office collaborated with the European Science Foundation (on mental illness research), the World Federation for Mental Health (on suicide and on old age and mental health), the World Psychiatric Association, the Inter- national Association for Suicide Pre- vention, the International Federation for Telephonic Emergency Services, and the International Children's Centre (on mentally handicapped children). Country activities R omania. A fellowships training scheme on rehabilitation of the handi- capped was coordinated by a consultant in the United Kingdom, supported by temporary advisers in selected centres with experience of services appropriate to the requirements of seven fellowship holders from the different disciplines involved in the national pilot studies in Bucharest and Ia~i. PROPHYLACTIC, DIAGNOSTIC AND THERAPEUTIC SUBSTANCES In its third year of full operation the regional programme continued to concentrate on drug quality, safety and efficacy; drug policies and management (including drug regulation); drug util- ization; clinical pharmacology; and the action programme on essential drugs. A new and potentially very important departure was the initiation of a study on the potential role of the European Region in drug evaluation. The pro- gramme was presented and d iscussed at the thirty-first session of the Re- gional Committee. Following the favourable reception accorded to the investigational guide- lines on an tihypertensive drugs, work- ing parties were co nvened to draft similar guidelines on sedative and anti- rhe umatic drugs. Wo rk continued on the European studies of drug regulation, which are designed to examine the way in which drug regulatory systems operate and particularly the repercussions o f their work. Such work, it is believed, provides the only sound basis for adapt- ing drug regulatory systems to com- munity needs, and for creating new regulatory agencies that will perform a useful function without introducing unnecessary obstacles to the devel- opme nt and dissemination of new drugs. An unusual but fruitful approach adopted in this case has been to presen t the initial findings primarily in scientific journals and at professional meetings. This has resulted not only in useful discussion and constructive criticism, bu t also in the recruitme nt of scien tists able to perform similar studies in th eir own environment, in close collabor- ation with the project team using a standard ized methodology. Nine artic les have appeared in th e literature a nd more than 20 presentations have been made at scientific meetings. Currently the emphasis has shifted to the super- vision and completion of the many investigations now under way, so that a comprehensive Region al Office pub- lication covering the project as a whole can be compiled. The broad national studies of regu- latory systems, conducted in the Netherlan ds and Norway and published in 1980, have provided a sound model for similar analyses elsewhere. An independent study of the regulatory system in Great Britain was completed and published in I 98 1, and similar studies are well advanced in Hungary and Italy ; for the purposes of interregional comparison , the method is also being applied to an analysis of the situation in the Un ited States. More specific studies relate to particular drug groups. The model in this case is a study by the proj- ect team on the evaluation of non- steroidal anti-inflammatory agents which appeared early in 198 1 and has been widely quoted. With the number of such products curren tly marketed ranging from 7 in one Me mber Sta te to SO in another, the study succeeded in de- fining the basis for a regulatory policy which is likely to meet the needs of the pract1smg physician. A similar study on be ta-adrenergic blocking agents is now under way, and a similar analy sis of the situatio n as regards the so-called "geriatric drugs" has been completed for publication. Mu ch atten tion has also been at- tracted by a paper on " The effects of drug regulation on iatrogenic dis- ease" which was presented in April. Taking Australian regulatory practice as the principal model, because of the ready availability of information, the study succeeded in iden tifying a large number of instances in which a critical but balanced regulatory policy has succeeded in preventing outbreaks of drug-induced disease, a matter on which hard data have been virtually lack ing 41 up to now. Significa nt , too , was the finding that , whereas early clinical data prove highly reliable in identifying iatrogenic risks, ex tensive drug safety testing in animals commonly proves disappointing. A large volume of animal testing is currently demanded by many regulatory authorities, and there seems to be every reason to review the validity of such requirements. Highly encouraging is the active participation of three major research- based pharmaceutical companies and a large number of national regulatory agencies in a retrospective study of the manner in which a number of new drug applications have been handled. This ex tensive investigation , which is due for completion in 1982 , is throwing much light on aspects of regulatory practice which could be improved in the interests of all parties. The ten th in the series of annual symposia on clinical pharmacological evaluation in drug control was held in Schlangenbad , Federal Republic of Germany in October. Over the past ten years these meetings have come to perform a series of functions. They are virtually the only forum a t which represen tatives of drug regulatory agen- cies from all the Member States in the Region mee t to discuss their experiences and policies, an impo rtant fact in view of the process of controversy and change in which drug regulation is now involved. At the same time they have made influential recommendations on the development of clinical pharmacology as a science, one which is only slowly coming to fruition in some parts of the Region. Finally, they have brought together drug regulators , clinical phar- macologists and practitioners to define 42 policies on specific matters. The 1981 meeting was devoted to "drugs for in- fan ts and children" and highlighted some major problems both in the investigation and use of drugs in children, and in the way in which drug regulatory agencies deal or fail to deal with these issues in the course of their work. A meeting of the Drug Utilization Research Group (DURG) was held at Korcula, Yugoslavia in April, with wide international participation. A large number of independent studies that have been stimulated by this programme were presented, but much of the meeting was as usual devoted to the development and standardization of methodology, since drug utilization data can be of limited value and even misleading if methods fail in any respect. A meeting of the stee ring commit tee of DURG was devoted to priorities in future work. The overall methodology, including the anatomical therapeutic chemical classification (ATC) and the de fined daily dose (DOD) system, have now been widely accepted, but for specific purposes additional techniques are needed. In some respects, such as the desire to look for links between drug utilization and the state of health , the programme is c learly linked to that of the European studies of drug regu- lation. New in-depth studies are to be conducted on antihypertensive drugs, antid iabetic drugs and antimicrobials. With th e development of activities in the drug field it has become evident th at these cannot always be restric ted to questions of broad policy; to an in- creasing ex tent Member States have been seeking he lp from the Office in obtaining information on specific drugs which could help them in taking regulatory and other decisions. In view of this trend, and the repeated requests made by Member States at the World Health Assembly for assistance in matters relating to the efficacy and safe ty of drugs, a consultatio n was arranged to consider the possible role of the Office in drug evaluation . The consultation resulted in the formulation of a draft proposal for the establishment of a new Regional Office unit which would be capable of providing independent assess- ments of drugs with respect to their quality, safety and e fficacy. The reper- cussions of such a system would clearly be worldwide , and the draft was there- fore submitted to the Director-General, with whose approval it was subsequently distributed to and discussed with a num- ber of Member States in the European Region , as well as intergovernmental and nongovernmental organizations. In all these programme areas co- operation is maintained with CEC, CMEA, EFTA, the Wo rld Federation of Proprietary Med icine Manufacturers, the Interna tio nal Federation of Phar- maceutical Manufacturers Associations and the Nordic Council on Medicines. Country activities During visits to Portugal, Czecho- slovakia and Hungary in connection with the scientific evaluation of drugs, the o ppo rtunity was taken to study and discuss numerous aspects o f drug policy and management in these coun- tries. In Portugal particular attention was devoted to the establishmen t of a National Centre fo r Adverse Reaction Monitoring. In Hungary negotiations for the designation of a WHO collabor- ating cen tre continued. In Czecho- slova kia the structure and function of the drug regula tory agency in the Czech Socialist Republic was examined and technical input to the DURG programme discussed. DEVELOPMENT OF COMPREHENSIVE HEALTH SERVICES Proposed budget and actual expenditure for 1980/ 81 (US $) Proposed Expenditure budget 1980 198 1 1980/81 Regular funds 4 333 700 I 527737 3 359061 4 886 798 UN funds 2 290500 838 829 75 1934 I 590 763 Voluntary funds I 276 200 3 14735 397 330 712 065 7900400 2 68 1 301 4 508 325 7 189626° a Being 20.56% of total expenditure. 43 44 Publications issued in 1981 Planning and organization of emergency medical serJ1ices: report on a WHO Technical Group. EURO Reports and Studies, No. 35. External quality assessment of health laboratories: report on a WHO Working Group. EURO Reports and Studies , No. 36. Uses of the electrocardiogram: report on a WHO Study. EURO Reports and Studies, No . 37. Th e influence of alcohol and dmgs 011 driving: report on a WHO Ad hoc Technical Group. EURO Reports and Studies, No. 38. Health laboratory technology: report on a WHO Working Group. EURO Reports and Studies , No. 39 . Seat belts and o ther devices to reduce injuries from road accidents: report on a WHO Technical Group. EURO Reports and Studies, No . 40. Psychosocial factors related to accidents in childhood and adolescence: report on a WHO Technical Group. EURO Reports and Studies, No. 46. Meth ods of monitoring and evaluating airborne man-made mineral fibres: report on a WHO Consultation. EURO Reports and Studies, No. 48. The control of drugs for the elderly: report on the Ninth European Symposium on Clinical Pharmacological Evaluation in Drug Control. EU RO Reports and Studies, No. 50. Organization and methods for endocrinology laboratory services: report on a Working Group. EURO Reports and Studies, o. 5 1. Guidelines for health care practice in relation to cost-effectiveness: report on a WHO Workshop. EURO Reports and Studies , No. 53. Dr J.E. Asvall , Director, Programme M anagement (centre) pictured w ith Dr P.P. Petrov, Director of the WHO collaborating centre in primary heal th care, during a visit to Alma-A ta to review cooperation between the centre and the Regional Office Participants in the ten th European Symposium on Clinical Pharmacological Evaluat ion in Drug Control, Schlangenbad, Federal Republic of Ger- many, 27 -31 October 1981 Chapter 4 DISEASE PREVENTION AND CONTROL COMMUNICABLE DISEASE PREVENTION AND CONTROL General The Regional Office continued to assist Member States in providing in- formation on the prevalence and inci- dence of communicable diseases. The pattern of communicable diseases has changed greatly in recent years, partly due on the one hand to socioeconomic conditions or the direct result of im- munization, and on the other hand to an increase in the number o f new pathogens, greater resistance to anti- biotics, and the importation o f exotic diseases. Develop .n ents in special vac- cines, purified a ,tigens, antiviral drugs and interferon .1ave led governments to pay closer ,ttention to the prob- lems of infectio s in gene ral. Malaria is till a serious problem in Turkey. In a . attempt to provide a permanent so Jtion the Regional Office is supporting nalaria control programmes based on the Jrinciples of primary health care , with i ,dividual, fami ly and co m- munity par :icipation as the essential component!. Originally, it was expected that the n:,tional authorities would be able to contain the situation in 1981 , but this has not been the case and financial problems have resulted in staffing difficulties. The continual im- portation of malaria into Algeria and Morocco represents a potential threat, particularly in view of the increasing communication with countries south of the Sahara. Meetings, workshops and seminars on malaria problems in Mediterranean countries have contrib- uted to an improved exchange of inform- ation, mutual support, and coordination of malaria control activities. The situation regarding parasitic diseases, other than malaria, is not known in several countries of the Re- gion. Schistosomiasis is one disease whose control might prove to be im- portant in the near future. Epidemiological surveillance The Regional Office continued to as- sist Member States in the provision and exchange of in fo rmation and sur- veillance data on the prevalence and incidence of communicable diseases. Although Europe has fairly well devel- oped reporting systems, an analysis conduc ted by the Office showed con- siderable under-reporting, and wide 45 differences in reporting patterns and quantitative and qualitative indicators. The pattern of communicable dis- eases has changed greatly in most of the Region during the past decades. While some bacterial and virus diseases have become rare, bacterial pneumonia and the main virus diseases (e.g. influ- enza and all three types of viral hepa- titis) continue to be a major public health problem. The incidence of menin- gitis has not declined, and scarlet fever and rubella have increased in some countries. Vaccination policies and prob- le ms in respect of measles, mumps and rubella require thorough review in the Region. Some bacterial infections, such as those ca used by Gram-negative facultative pathogens, have become a most serious problem in hospitals and, together with increasing resistance to an tibiotics, need urgent attention. Foodbome enteric infections in- creased in a number of coun tries, and there were larger outbreaks of typhoid and dysentery. The importation of diseases due to the movement of millions of tourists has provided new problems of surveillance; cholera, for example, was imported to seven European coun tries. A number of new pathogens have become prominent, such as Yersinia e11tero- colitica, Campylobacter spp., rotaviruses, and ente rotoxige nic and enteropatho- genic Escherichia coli. legionella pneu- mophila infections occurred in eight countries of the Region . While the incidence of the classical venereal diseases has remained static, the second-generation sexually transmitted diseases, particularly ch lamydia! infec- tions, have shown a worrying increase. The same organisms are responsible 46 , for pneumonia in all age groups and now account for about 30% of all cases of pneumonia in ch ildren under six months of age. Specific zoonoses, such as brucel- losis and hydatidosis, have remained prevalent in a number of countries in the sou th of the Region, and animal rabies has continued to spread. Malaria and other parasitic diseases The inte rcountry project, financed by UNDP, on the control of malaria in so uth-east Europe ended in December. Its main achievements were th e tech- nical assistance given to Turkey and in keeping other participating countries fully informed. Three fellowships were awarded; two of these were awarded to entomologists from the Athens School of Hygiene fo r in tensive training at the Adana Malaria Institute. Responses were rel:eived from several Member States to the recommendations of the Conference on the Role and Participation of European Countries in the Fight against Malaria in the World , held in October 1980. Finland showed concern about the spread of malaria. G reece stated that the Athens School of Hygiene is interested in international col- laboration and that many refresher courses were organized in the School. The Bulgarian au thorities also expressed an interest in research and training. Bulgaria, Denmark , Finland, Spain and Switzerland have designated malaria diagnostic reference centres. A workshop on glucose 6-phosphate dehydrogenase (G6PD) deficiency was held in Adana, Turkey in October. The objective was to es tablish guidelines for the individual drug treatment of malaria and other diseases in persons with G6 PD deficiency, and for mass drug treatment in co untries where G6PD deficiency is a problem. One o f the many recommenda tions was that the (:ukurova Medical Faculty be established as a WHO collaborating centre for the testing of new drugs for safe use in G6PD-deficient individuals. Country activities Algeria. Two consultant m1ss10ns were organized at the req uest of the na tional authorities to help evaluate 198 1 activities, to participate in e pi- demiological surveys, and to give re- fresher training to local staff. The increased number of imported cases of malaria (61 from January to October 198 1: 56 P. vivax and 5 P. fal- ciparum) shows that a real danger of reintroductio n exists. The situation constitutes a threa t to the successes achieved by the Algerian malaria eradi- cation programme, and it will there- fo re be essential to maintain a good surveillance system. Morocco. In the first half of the year 2 1 cases of P. vivax infection were de tected ( 11 impo rted and IO autoch- thonous). The 1980 outbreak was com- pletely controlled and surveillance was intensified. A large-scale schistosomiasis control programme was initiated . Turkey, There was a serious deterio- ration in the epidemio logical situation in Turkey in 198 1, the number o f detected malaria cases being 54 411 , a 59% in- crease ove r the figure for 1980. The num- bers of cases detected each year for the period 197 5 -198 1 are shown in Fig. 5 . i ~ 0 I z Fig. 5. Numbers of cases of malaria detected in Turkey, 1975- 1981 100 !)44 11 50 31320 34 154 29324 1975 1976 1977 1978 1979 1980 1981 In an attempt to provide a perma- nent solution to the malaria problem the Regio nal Office, in collaboration with UNICEF, is supporting a ma- laria control programme based on the principles of primary health care. As a first step, a natio nal workshop was held in Ankara in February, follo wed by a consultation in Copenhagen in March , and resulted in collaboration and coor- dination among the different public ser- vices involved . The Government and the Regional Office are about to launch a large-scale pilot project for the most affected areas in the Adana region , and a vigorous campaign to control the many breeding sites caused by irrigatio n canals is taking place. However, as this is a long-te rm project , it will be necessary in the meantime to continue with the mo re traditional me thods. Six mon ths' consultant services were provided in 1981 to assist in the stud ies 47 being carried out in the Adana regio n by the Adana Malaria Institute. Many malaria training courses were given , with emphasis on integrated ac- tivities and the concepts o f health care. Bacterial and virus diseases The first Regio nal Scientific Wo rk- ing Group o n Diarrhoeal Diseases me t in Copenhagen in December. The G roup established prio rities in WHO-sponsored research and will appraise requests for re- search grants in this fie ld . The European system o f surveil- lance o f foodbome infections, based on the WHO collabora ting centre in Berlin (West), began operating in 198 1 with th e participation o f 13 countries. The control o f zoo noses, particu- larly echinococcosis, brucellosis and canine rabies, continued through the Mediterranean zoonoses control pro- gramme, which is part of a larger Medi- terranean programme in which seven European countries participate . An increasing interest in oral enteric vaccines a nd their use in public health practice, and the new gene tic e ngineer- ing techniques available in the develop- ment o f new vaccine strains, led to the conve ning o f a Wo rking Group on Oral Enteric Vaccines, in Frankfurt in May. The G roup considered that the Ty2 I a live o ral typho id vaccine de- veloped in Europe had proved safe a nd e ffective in its first controlled fi eld trial in Egypt , with an efficacy o f mo re th an 9 5% over three years. Ex te nsive field trials have also d emo nstrated the safety and effi cacy o f polyvalent SmD Shige/la 48 vaccines, as we ll as their limitatio ns in view of their t ype specificity and the need for multiple doses. These pio neer- ing experiences with SmD strains have stimulated e fforts to develop by genetic enginee ring new attenuated m uta nt- hybrid strains th at might be safe and effective fo llowing a single dose . With regard to Escherichia coli, the G roup considered tha t advances in enteric vaccine research, particularly on ente rotoxigenic E coli in veterinary medicine, had no t been sufficiently ex plo red with a view to developing human vaccines. It recommended that interdisciplinary cooperation among re- searche rs in the field o f ente ric vac- cines should be facilitated . New gene tic techniques also open up prospects o f producing new, attenuated cholera strains for o ral immunization against infectio n and clinical cholera. Candidate human rotavirus vaccine strains are be ing develo ped . The increasing importance o f human infections due to Yersinia, particularly in the no rthern hemisphere, mo tivated the Regio nal Office to organi ze a Work- ing Group o n Yersiniosis, in Paris in June. The disease now takes between second and third place among enteric bacte rial infectio ns diagnosed in Euro- pean laborato ries, compared with saJ- monellosis, campylobacteriosis, shigel- losis, and ente ritis caused by entero toxi- genic E. coli. The epidemiology o f yersiniosis is still insufficiently under- stood. In view of the economic costs, secondary complicatio ns (arthritis) and th e need fo r surgical interventio n in certain cases, yersiniosis presents a true public health problem similar to that o f salmo nellosis. Further stud ies were rec- ommended in the fields of e pidemio logy, su rveillance, pathophysiology, and stan- dardization of diagnostic antigens. The WHO collaborating centre at the Pas- te ur Institute in Paris provides help in this respect. A Working Group on the Economic Aspects of Communicable Diseases was held in Trie r, Federal Republic of Ger- many, in September. Communicable diseases continue to impose a substantial economic burden on society, which is probably underestimated by many health administrators. Direct costs have a more precise meaning than indirect costs, and their estimation provides valuable data, both on resources devoted to specific diseases and on the distribution of resource use between different cost complexes (preventive measures, hospital treatmen t, etc.). In evaluating alternative me thods of communicable disease interventio n , two aspects are involved: first, evalu- ation of individual control measures; and second, de termination of op ti- mal strategies in terms of the mix of individual interventions. More research is needed on both of these, based on cost-effectiveness methods of analysis. Evaluation should be undertaken on a multidisciplinary basis, with economists showing how to minimize the cost of intervention. Benefits should be measured on the basis of improved non-monetary or quantitative indicators of health outcome, specifically related to communicable diseases. The Regional Office organized a Wo rking Group on Legionnaires' Disease in Baden, Austria in Octobe r. The re- peated ou tbreaks of legionnaires' disease in European countries have focused attention on this new health risk , first reported in 1976, not only because of its as yet unclear epidemio logy, but also because of its importance to countries with a large tourist industry. There are no accurate data o n the incidence of l egionella infections, but pn:valence studies in several countries in Europe have indicated that l . pneumo- phila may be responsible for I -3% o f all pneumonias seen in hospital. There is a need for standardization and vali- dation of serological tests and also, in the European Regio n , for training, preferably sponsored by WHO, in the laboratory diagnosis of legionella infec tions. National surveillance pro- grammes shou ld be encouraged, and there is a need for a WHO collaborating centre in Europe. Country activities Morocco. A consultant studied the possibility of ueveloping a streptococcal disease surveillance project , to be fol- lowed in 1982 by the preparation of a plan of work . Prevention of blindness Disability and handicap related to visual impairmen t have a high prevalence in Europe, particularly among aging populations. The condition of being "blind" covers a large number of people who have residual vision ; however, current adoptive technologies are chiefly "broad spectrum" approaches and rela- tively little research is being done on technologies that would allow people with residual vision to use this to maintain their independence. The sol- ution to this problem was the subject of a Meeting on the Use o f Residual Vision by Visually Disabled Persons held in Brussels in January. The report 49 on the Meeting was received with much interest by many European research institutions and public health bodies. In co nnection with the Inter- national Year of Disabled Persons, a new symbol was introduced in the United Kingdom (Fig. 6). The symbol is in- tended to be used in a similar fashion to th e now internationall y known and recognized wheelchair sy mbol for physi- cal disability. The Meeting recomme nded that WHO encourage international ac- ceptance and promo tion of the symbol. Close contact and collaboration were maintained with WHO headquarters and bodies active in the field of public health ophthalmo logy. Coun try activities Morocco. Further consultant assist- an ce was provided to the Government for the development of public health ophtha lmology services. Romania. Fe ll owships were awarded to staff of the Bucharest Ophthalmology Fig. 6. Visual disability symbol 50 University Clinic under th e UNDP- financed project " Assistance to ophthal- mology and cornea grafts". NONCOMMUNICABLE DISEASE PREVENTION AND CONTROL General The continued developme nt of com- munity control programmes integrated into the general health services is one of the most important activities of the regional programme on disease preven- tio n and contro l. The primary health care approach and in tersectoral col- laboration have led to the e ncouraging results already achieved . In the area of ca rdiovascular diseases, the results obtained in the No rth Karelia project in Fin land clearly demonstrated th e feasibility and e fficacy of such com- prehensive community programmes. Malignant neoplasms continued to be the second most frequent cause of death in all developed countries, and the importance o f improving the train- ing o f oncologists a nd other health professionals is recognized by all gove rn- ments in the Region . The developme nt of additional cancer centres and com- munity cancer control programmes is enco uraged, in order to expand the promotion of public ed uca tion a nd to e nsure early diagnosis a nd a high standard of care. Activities in the field o f o ral health were expanded considerably during the pe riod under review. The discrepancy be tween , o n the one hand , countries with a decrease in the severity o f dental caries and surplus manpower and , o n the o ther, those with increasing severity o f dental caries and a sho rtage o f appro pri- a te manpower, is of particular interest and concern . T he observed decrease in the severity o f dental caries in so me countries in the Region has been shown to be the result of community-based or school- based preve ntion programmes in which the systemic or to pical use of nuoride h as been an important component. Appropriate technology for health, health ma npower develo pment , health in- formation and applied research continue to be important ele me nts in all pro- gramme areas. Cancer The main aims of the cancer pro- gramme in 198 1 were (a ) to assist coun- tries in developing appropriate national cancer contro l policies, including the establishment of comprehensive can cer centres and community-based control programmes; (b ) to set up model syste ms fo r specific cancer types to imp rove the management o f cancer patients; and (c ) to improve the relevance o f education and training programmes, including undergradua te and postgradu- ate medical training in oncology. A Wo rking Group o n the Develop- me nt of Cancer Centres and Community Cancer Co ntrol Programmes in Europe was held in Luxembourg in October. The aim of the meeting was to consider the responsibilities o f cancer centres and their relationship to general health services. It reviewed the present situation in the countries o f the European Region and made recommendations on (a) the need for cancer centres as an element of the natio nal cancer control pro- gramme; (b ) the main forms that cancer centres may take (comprehensive o r co- ordinating); and (c ) the main func- tio ns and ro les o f cancer centres and community-based programmes. A Preparato ry Consulta tion on Model Health Care Programmes in Colon Cancer was held in Leningrad in December as the first o f a series of consultations and working groups on the elabo ration of model health care programmes for defined types of cancer, chosen from among those considered most important in the European Region. Epidemiology and the possibilities of de tection , diag- nosis, combined treatment , follo w-up and rehabilitation we re reviewed . The re port o n this Co nsultation , along with those o n further consultations in other de fined types of cancer, should serve as background material for elaborating documented sets of recommendations on how to manage a patient with a specific type o f cancer in the best possible manner with th e availa ble resources. A joint UICC/WHO Meeting on Undergraduate Education in the Cancer Field was held in Geneva in April , in collaboration with the Swiss Govern- me nt , the Euro pean Organizatio n for Research and Treatment o f Cancer (EORTC) and the Ligue genevoise contre le Cancer. The Meeting reviewed the basic problems and ways o f improving under- graduate medical training in oncology and made a number of specific recom- mendations. The repo rt on this Meeting sho uld se rve as background material for further reappraisal and improveme nt of standards o f medical training in on- cology, a nd fo r the elabo ratio n of guidelines for undergraduate medical training in this field . 51 To avoid duplication , special atten- tion was paid to establishing effective mechanisms of coordination with WHO headquarters, IARC, CMEA, UICC, EORTC and other organizations in Europe with cancer control programmes. Cardiovascular diseases A follow-up Consultation on Health Care Related Hypertension Research was held in Munich in March, to review the administrative and budgetary situation of the programme. Two concrete fields for research coordination were proposed: salt problems and compliance with treatment. At a meeting dealing with the epidemiological and preven tive aspects of the salt-blood pressure problem, held in Lisbon in October, the dis- cussions centred on how collaboration between individual projects cou ld be established; the role of WHO in this area was defined. The final results of the study on the effects of rehabilitation and second- ary prevention in patients with cardio- vascular disease were reviewed by the editorial board at a meeting in Bonn in March. It was concluded that psycho- logical and social benefits of this active approach are definitely not accompanied by an increase in morbidity or mortality. The draft report was circulated for comments to participating centres , and is to be published in 1982. The recent decline in mortality from cardiovascular diseases (CVD), especially coronary heart disease , in the United States and also in some countries in Europe (see Tables 1-4) revitalized interest in the determinants of these diseases . Owing to a lack of appropri- ate data , no definite backing could be 52 given to any one of the three possible explanations for the decline: improved medical care, preventive measures, or changing disease patterns. To answer these questions a joint Regional Office/WHO headquarters study was launched, with an expected dura- tion of IO years, under the title "moni- toring of the incidence and determinants of cardiovascular diseases in popula- tions" (MONICA). At the first major meeting, held in Geneva in April , the draft protocol of the study was dis- cussed and amended. A meeting held in Geneva in October, at which the protocol was finalized , was attended by representatives of more than 20 centres from around the world. The study data on morbidity and mortality from CYD will be collected and analysed, together with indices of li festyle, be- haviour and environmen t in geographi- cally defined large populations. In June, the principal investigators of the European collaborative study on multifactorial prevention of ischaemic heart disease met in Londo n to review the first incidence results from three cen tres . Changes in risk factor levels were modest, but a reduction in inci- dence of about 15-20% is expected. The report is to be published in 1982. A joint Regional Office/WHO head- quarters meeting was held in Kaunas, USSR in November to finalize the con- cept of developing a more comprehen- sive approach to noncommunicable disease prevention and control, to dis- cuss ways of further developing and implementing that approach, and to design community-Oriented programmes to be tested on an experimental basis. Table 1. Trends in coronary heart disease mortality, 1968- 19778 Trend Oownwards No change Upwards European countries Belgium Finland Norway Austria Czechoslovakiab Germany, Federal Republic of Italy Netherlands Switzerland United Kingdomc Bulgaria Oenmark France Hungary Ireland Poland Romania Sweden Yugoslavia Non-European countries Australia Canada Israel Japan South Africa (white population) United States New Zealand 8 From a working paper by F . Epstein for the joint Regional Office/WHO head- quarters Meeting on Comprehensive Community Cardiovascular Control Programmes, Prague, 2-5 September 1980. b Pending confirmation by trend analysis. c Possibly a recent decline, except in Northern Ireland. 53 54 Table 2. European countries ranked in order of mortality from ischaemic heart disease in 1975 according to category A83 of ICD - 8 (deaths per 100 000; males of all ages) Highest six8 Lowest six 1. Sweden (456) 19. France ( 105) 2. Scotland 20. Poland 3. Den mark 21 . Portugal 4 . England & Wales 22. Romania 5 . Northern Ireland 23. Yugoslavia 6. I rel and (341 ) 24 . Spain (91) a Finland is not among the top six countries, although it leads in the age group 35-64 years (Table 3). This is explained by the much younger age composition of the Finnish population. Note also that Sweden is at the top of the list for al l ages, whereas it is not among the top six for age-specific mortality (Table 3) . Table 3. European countries ranked in order of mortality from ischaemic heart disease in 1975 according to category A83 of ICD -8 (deaths per 100000; males aged 35 - 64 years) Age group (years) Ranking 35-44 45-54 55-64 1. Northern I re land (81) Finland (420) Finland (1 007) 2. Finland Northern Ireland Scotland 3. Scotland Scotland Northern Ireland 4. Hungary Ireland I rel and 5. Ireland England & Wales England & Wales 6. England & Wales (59) Denmark (214) Denmark (630) Table 4. European countries ranked in order of percentage increase in mortality from ischaemic heart disease among males during the period 1968 - 1975 Age group (years) Ranking Al l ages 35-44 45-54 55-64 1. Poland (65) Poland (70) Poland (70) Po land (48) 2. Germany, Fed. Sweden Northern Sweden Rep . of Ireland 3. Sweden Hungary Hungary Hungary 4 . Switzerland Denmark Denmark Denmark 5. Czechoslovakia Ireland Ireland Czech osl ova k ia 6 . Denmark (30) Nonhern Ire- Czechoslovakia Ireland (6) land ( 11 ) The main purpose o f a meeting held in Budapest in November was to review recent progress in cardio logy diagnosis and th erapy, and to define priori ty fields. The aim is to produce at regu lar intervals , in close collabora tion with the working groups of the European Society of Cardiology, guidelines on modern diagnostic and therapeutic methods that can be recommended for wide-ranging application in primary and secondary health care. The rather encouraging results of the finaJ anaJysis of the North Karelia project (a comprehensive community programme for contro l of cardiovascu lar diseases) were published by the Regional Office on behalf of the National Public Health Labora tory of Finland. The reduction in risk factors, especially among men , was in general greater in North Karelia than (25) in the reference area. However, the changes in the mo rtality rates in North Kare lia did not differ significantly from those in the reference area, since CYD mortality was declining in the whole coun try during that period. There was a relative reduction in the number of disability pensions paid out in North Karelia during the programme, due mainly to a net reduc tion of 27% for me n and 12% for women in the number of C YD disability pensions in North Kare lia from 1971 to 1977. The ex- perience from the North Karelia project clearly shows the feasibility and ef- ficacy of this approach to the control of CYD, and allows its wider adoption to be recommended. On his retire ment from WHO, the fo rmer Regional Officer for Chronic Diseases, Dr G. Lamm, produced a 55 critical review o f the first 12 years of the cardiovascular disease programme in Euro pe .a Oral health Within the las t 4-5 years data have eme rged to show that there has been a significant reduc tion in dental caries in those countries whe re a concerted effort has been made to introduce comprehensive preventive programmes. In Norway, for in stance, the proportion of 5-year-o ld children who had never had any caries increased from I 0% in 19 65 to 41 % in 1980. For 12-year-old children the average number o f decayed , missing and fi.ll ed teeth decreased by 60% fro m 6.5 in 1970 to 2.5 in 1980 . Similar trends in the prevalence and severity of dental caries have been reported from Denmark, Finland , the German Demo- cratic Republic, Sweden , Switze rland and the United Kingdom. However , in contrast to these encouraging re- sults there are now clear signs o f an alarming increase in dental caries in those co untries in the Regio n which until recently have had a low to moderate level of d ental caries . Similar trends have been observed in the prevalence and severity o f gingivitis in children. The prevalence of periodontal dis- eases in adults is lo w to moderate, but still accounts for the majority o f toot h loss after the age o f 40 years. To tal loss of teeth fo r any reason is still high among the elderly in most European countries. a Lamm, G. Th e cardiovascular disease pro· gramme of WHO in J::urope. Copenhagen, WHO Regional Office for Europe, 198 1 (Public Health in Europe, No. I S). 56 While Europe as a whole has the largest number of qualified oral health sta ff in the world , the situation is far from satis factory. There are no w clear indications o f a n overproductio n of dentists in those countries of the Region where dental caries is o n the decrease, in contrast to a dramatic shortage in those where o ral d iseases (particularly dental caries) are on the increase. The major compo nents in the o ral health programme are therefore aimed at collaborating with Membe r States in implementing effective prevention pro- grammes, in deve loping appropriate o ral health manpower and in improving oral heal th services, particularly fo r underse rved popula tion groups. Close collaboration between WHO and the International Dental Federation (FDI ) resulted in the mutual adoption o f five global goals for achieving an acceptable level of o ral health for all by the year 2000. The mo nito ring o f these goals will be coordin ated through the global oral health epidemiological data bank at WHO headquarters. The Regio nal Officer for Oral Health assisted in the impleme ntati on of the WHO/ FDI Oral Health Manpower Deploy ment Project . He also presented two papers at the World Congress of FDI in Rio de Ja neiro in Septemb er, and was reno minated as consultant to the FDI Commission on Oral Health Research and Epidemi ology. Country actil'ities Denmark. The Regional Officer for Oral Health continued to fun ction as consultant to the pilo t drinking- wate r flu oridatio n project in Juliane- haab , Greenland. Iceland. The Regional Officer for Oral Health assisted the authorities in planning epidemiological surveys, oral disease prevention programmes and oral health manpower development, and in the preparation of a seminar on drinking-water fluoridation , to take place in Reykjavik in 1982. Morocco. An oral health situation analysis was carried out, the results of which will provide the basis for future collaboration in improving oral health services in Morocco. The situation analysis included the clinical exam- ination of more than 300 children aged 12 and I 5 years in four dif- ferent locaLities. Norway. The Regional Officer for Oral Health was invited to participate in the Seminar on Collaboration with Developing Countries in the Field of Oral Health, which took place in Oslo in February. He also visited Oslo for the initial preparations for a work- shop to review current recommen- dations on the organization and admin- istration of community oral health services in northern and western Europe, to take place in 1982. Portugal. The Office assisted in the planning of a national oral health survey and participated in initial discussions on the development of dental auxiliary training programmes. Romania. An oral physiology and occlusal rehabilitation centre was estab- lished in collaboration with UNDP. Sweden. The official report of the Committee on Fluoridation was sub- mitted to the Swed ish Parliament early in 198 1. The Regional Officer for Oral Health had participated in a clinical examination of enamel opacities, the results of which appear as an annex to that report. Other noncommunicable diseases Following the success of the WHO headquarters publication Cardiovascu- lar survey methods0 and its effec- tiveness in spreading interest among card iologists on population problems, two experts completed a manuscript for guidelines on simple methods for the epidemiological study of chronic lung disease, to be published by the Regional Office. The fourth meeting of principal investigators for the collaborative study on health promotion in youth was held in Helsinki in August. Progress achieved by the cen tres since the previous meeting was reviewed and the results were analysed. In particular, a favourable effect of intervention on smoking by schoolchildren was clearly shown. A meeting of investigators for the study on chronic lung diseases leading to pulmonary hypertension was held in Naples in October. Based on the experience of the first , re trospective part of the study, the prospective part was launched during the year. Measure- ments of pulmonary artery pressure (PAP) and a number of non-invasive techniques will be evaluated for at least five years in some 450 patients in four main lung disease categories. The aim is to develop a combination a Rose, G.A. & Blackburn, H . Cardiovascu· lar survey methods. Geneva, World Health Or- ganization, 1968 (Monograph Series, No. 56). 57 o f non-invasive metho ds best suited for predicting elevation o f PAP. These non- invasive measureme nts could then be used to select high-risk grou ps for intensive secondary prevention . Further e fforts were made to launch a joint programme on chronic rheuma tic diseases with the European League against Rheumatism (E ULAR). Represen tatives of this o rganization participated in the elaboration of the comprehensive chronic disease con- tro l programme. Country activities Malta. The Regional Office assisted WHO headquarters in develo ping a comprehensive diabetes control pro- gramme, which should serve as the first step towards a chronic disease control programme at the primary health care leve l. DISEASE PREVENTION AND CONTROL 58 Proposed budget and actual expenditure for 1980/ 81 (US$) Proposed Expenditure budget 1980 198 1 1980/8 1 Regular funds 2 133 100 869 387 1 074837 1944 224 UN funds 559 300 185 541 190 106 375 647 Voluntary funds 649300 374 254 834 186 1 208 440 3 341 700 1429 182 2 099 129 3 528 3 11 a a Being 10.09% of total expenditure . Publications issued in 1981 Community control of cardiovascular diseases - the N orth Karelia Project, published o n behalf o f the National Pu blic Health Laboratory of Finland . The cardiovascular disease programme of WHO in Europe, by G. Lamm. Public Health in Europe, No . 15. The use of residual vision by visually disabled persons: report on a WHO Meeting. EURO Reports and Studies, No. 41 . Surveillance and control of acute diarrhoeal diseases: report on a WHO Meeting. EURO Reports and Studies, No. 44. Surveillance of acute viral respiratory infections in Europe: report on a WHO Symposium. EURO Reports and Studies, No. 47. Undergraduate education in cancer in the European Region : report on a UICC/WHO Meeting. EURO Reports and Studies, No. 49. 59 Chapter 5 PROMOTION OF ENVIRONMENTAL HEALTH GENERAL The thirty-first session of the Re- gional Committee paid special attention to the implementation of the Inter- national Drinking-Water Supply and Sanitation Decade within the European Region , and adopted a resolution which laid down priorities for action . It was noteworthy that the objectives o f the Decade were no t only considered rel- evant to the needs of the less developed countries in the southern part of the Region, where there are still considerable deficiencies in population coverage in terms of safe water supply and adequate means of waste disposal. It was also considered important that the Decade should be regarded as a challenge to the Region as a whole , which contains many of the most highly industrialized coun- tries in the world , where new threats are being posed to drinking-water quality by the proliferation of chemicals in the environment. Considerably greater a tten- tion must be paid to the protection of sources, particularly when these are groundwater or lowland rivers. Priority was also given to the collection and dis- semination of systematic data relating to water supply and sanitatio n through- out the Region. During 198 1 work continued on the health aspects of water supplies in arid areas. Following a meeting in September on environmental health problems in arctic areas , the Office is developing in cooperation with several governments comprehensive guidelines fo r appropriate technology in relation to water supply and sa nitation in cold climates. The health problems of migrant and in- digenous workers in arctic areas are also under consideratio n. By the end of the year work was almost complete on the prod uction of guidelines for drinking-water quality, to be issued as a replacement for the ex isting WHO European and inter- natio nal drinking-water standards. These will place particular emphasis on new contaminan ts, especially minute quan- tities of certain o rganic chemicals which may have public health significance. It is expected that the guidelines will be published in 1982. With increasing energy costs, great emphasis is being placed on more ef- fective insulation of buildings. Reduced ventilation rates and the presence of harmful substances in construction mate rials, furniture and fittings has led to concern over the possible health 61 effects. Particular attention is at present being paid by the Office to the problems of formaldehyde and radon. Another im portant activity concerns the health effects of man-made mineral fibres , and a conferen ce on the subject is to be held at the Regional Office in April 1982. Considerable progress was achieved in the regional c hemical safety pro- gramme, which in a number of respects fo nns part of the International Pro- gramme on Chemical Safety, jointly sponsored by WHO, ILO and UNEP. An important component is a UNDP project which enables the less developed coun- tries of the Region to participate fully in pan-European cooperation . Much of the work during the year concentrated on manpower development in toxicology and related disciplines, and activities continued in collaboration with Member States on systematic con- tingency plans for , and response to, chemical emergencies. Ad hoc assistance following chemical accidents is increas- ingly being sought from the Regio nal Office. Seve ral consultant missions were ca rri ed out in relation to the consump- tion of contaminated cooking oil in Spain , which by the end of the year had resulted in the death of over 200 people. The Regional Office, a t the req uest of the Spanish Government , is now coordinating international e fforts in relatio n to the tox icology and epidemi- ology of this serious incident. Increasing fears are being expressed about the health e ffects of dumping hazardo us wastes. Guidelines on good management practice are being prepared by the Office in coUabora tion with U EP, for publication in 1982. 62 Following a process o f consultation with national institutes throughout the Region , a series of intercountry epi- demiological studies is now being de- veloped in relation to ten chemical hazards. There is growing recognition that, in spite of the cost and com- plexi ty of such studies, they will be- come essential if the potential health impact of such substances on vulnerable groups and on whole populations is to be ad eq ua tel y assessed. Legislative and administrative pro- cedures for safeguarding public health in relatio n to chemi cal hazards vary greatly in different countries, and the first results of a survey of practice th roughout the Region is now being circulated to governments for comments be fore publication . Following the com- ple tion of a survey on foo d safety ser- vices in Europe, similar works are in preparation covering natio nal services in water supply and sanitation , environ- mental health , and occupational health . A new unit dealing with environ- me ntal systems manageme nt was estab- lished and this is intended to stimulate the development of a huma n ecology approach to the physical, chemical , biological and behavioural aspects of environmental s tress. In relation to the target o f HFA2000, it is important that the impact of new technologies on human health should be assessed we ll be- fore their introduction. A study was begun during the year on the pred icted effects of b iotechnology, wh ich is li kely to become increasingly important in Europe during the next few years . The environmental health programme is being developed and implemented in close cooperation with a considerable number of international organizations, particularly ECE, UNDP, UNEP, F AO and ILO, and with intergovernmental organizations including CEC, CMEA and OECD. The Regional Office co-sponsored and participated in the International Conference on Heavy Metals in the Environment, held in Amsterdam in September. A paper was presented on WHO activities and publications related to this subject. ENVIRONMENTAL HEALTH PLANNING AND MANAGEMENT As in previous years, support through lectures and fellowships was granted to the international sanitary engineering courses in Delft, Lausanne and Rabat. A Working Group on Basic Sani- tation Operators, Professional Profiles and Training Requirements was con- vened in Delft at the end of March. The meeting was a contribution to the International Drinking-Water Supply and Sanitation Decade, whose train- ing component is directed towards basic sanitation operators and super- visors. The Group reviewed present practice m training water supply and sewerage personnel in France, the Federal Republic of Germany, Italy, the Netherlands and the United Kingdom. It also discussed plans for operator/supervisor training prepared by two countries on the southern coast of the Mediterranean Sea (Algeria and Egypt) . The participants designed separate professional profiles for operators and supervisors involved in the operation and maintenance of water supply networks, sewerage networks, drinking- water treatment plants, sewage treat- ment plants and pumping stations. They also specified training require- ments for each category. The organ- ization, methods and practices of training were discussed, together with the use of existing facilities and specially built education facilities for practical training purposes. A Workshop on Environmental Health Problems in Arctic and Sub- arctic Areas, held in Copenhagen in August, concentrated mainly on water supply, waste disposal and housing. It was attended by experts from 11 coun- tries in northern Europe, Asia, North America and the South Pacific. The expanding development of the arctic and subarctic, associated with the ex ploration and ex traction of minerals and oil, is creating additional environ- mental problems for the indigenous as well as the immigrant populations. The survey of environmental and water services in Europe and the in- ventory of sanitary engineering training institutions were continued. A Seminar on Appropriate Tech- nology for Drinking-Water Demineral- ization, held in Algiers in November, was attended by experts from eight European and North African countries to discuss reg uirements for drinking- water demineralization and progress in demineralization technology. The use of renewable energy in the field of water production and supply was also discussed. 63 PROVISION OF BASIC SANITARY MEASURES During the year the basic sanitary measures programme developed into the main Regional Office support to Member States in their efforts to attain the goals of the International Drinking-Water Supply and Sanitation Decade. This development culminated in the thirty- first session of the Regional Commit- tee adopting resolution EUR/RC3 l /R9, which recommended to Member States that they should place emphasis on: (a) the establishment of national drinking-water quality criteria; (b) the improvement of water source protection, including toxic chemicals control; (c) the improvement of rural water supply and sanitation, including adequate measures for quality control ; (d) the development and application of appropriate technology, including that for the re-use of water; (e) the improvement of structures for organization, management and the planning of water resources, both in relation to future demand and other land use; (j) the development of manpower, with emphasis on operational personnel; (g) the provision of the necessary resources to achieve the objectives of the Decade; and (h) support to research on the health effects of substances contained in water. The Regional Office participated in several important meetings related to the 64 Decade, organized by intergovernmental and nongovernmental organizations. One of these, the Inter-municipal Conference against Pollution of the Mediterranean Sea, convened by the Union of Mediter- ranean Municipalities in Barcelona, pro- vided an opportunity to relate the health risk and waste disposal aspects of the Decade with the main con- cern of the municipalities surrounding the Mediterranean coastal water quality. Another major concern in Europe, fluctuating populations related to tourism, was also discussed. The Office also participated in a meeting of the Inter-Agency Steering Committee for the Decade, in Geneva in September, and took part in the Interregional Meeting on the Water Decade, in Geneva in October, at which the draft WHO strategy for the Decade was prepared. This strategy was sub- sequently submitted to and approved by the Programme Development Work- ing Group. In December a Consultation on the International Drinking-Water Supply and Sanitation Decade in Europe was con- vened in Copenhagen, the purpose of which was to : (a) consider the objectives of the Decade in the contex t of the levels and quality of water supply and sewage disposal services in the Region; and (b) review the regional programme for the first half of the Decade on the basis of the expressed priorities of Member States, which place emphasis on manpower development, organization and management, appropriate tech- nology, source protection, safeguarding of rural supplies, water quality standards , and accelerated investment. Because of the particular need in the European Region to consider resource protection as a major aspect of attaining the Decade goals, and the importance of developing the necessary manpower, the basic sani- tary measures programme is sup- plemented by significant input from other programmes concerned with en- vironmental health. Also, in view of the importance of effective water manage- ment in the control of disease, the pro- gramme has been developed in consul- tation with those on communicable diseases and malaria. RECOGNITION AND CONTROL OF ENVIRONMENT AL HAZARDS The programme on recognition and control of environmental hazards col- laborated during the year with a number of United Nations and other organiz- ations, including CEC, ECE, IAEA, IARC, the International Commission on Radiological Protection, ISO, OECD, U EP, UNESCO and WMO. Water quality and pollution control The two-year programme to pro- duce new guidelines on drinking-water quality fulfilled the greater part of its commitment in Copenhagen in February when the important aesthetic aspects of water quality received con- sideration. The final phase of the pro- gramme is to terminate in March 1982 with a small consultation of experts to advise on permissible levels for both gross alpha and gross beta radio- activity in drinking-water. The final plenary meeting to approve all the recommendations and decide the form of presentation is also to be held in March 1982. The work received the financial support of DANIDA, with- out whose aid the project could no t have been accomplished in the period necessary to serve the needs of the International Drinking-Water Supply and Sanitation Decade. The second meeting of the con- tracting parties to the Convention for the protection of the Mediter- ranean Sea and its related protocols, held in Cannes in March, adopted a long-term programme on pollution monitoring and research (MED POL, phase II) within the overall frame- work of the Mediterranean Action Plan. This programme, designed to pro- vide continuous scientific and tech- nical input into the planning and decision-making process at both re- gional and national levels , is expected to cover the period 198 1 -1990. WHO is playing a significant role in this ., programme. In the monitoring component of MED POL, phase II , WHO's responsi- bilities include pollution sources and the health aspects of coastal waters. A detailed revision of project topics within the activity areas forming part of the research compone nt was also performed. Areas within the com- petence of WHO in this regard include the development of sampling and analytical techniques for pollution mo ni- toring and research , the developme nt of reporting formats for land-based pollution, the scientific rationale for environmen tal quality criteria, epi- demiological studies related to wate r quality, the development of guide- lines and criteria for application of 65 the protocol on protection of the Medite rranean Sea against pollution from land-based sources, and the sur- vival of pathogenic o rganisms in the marine environment. An evaluation was made o f the results o f the joint WHO/ UNEP co- ordinated pilot project on coastal water quality control in the Mediter- ranean, which formed WHO's main contribution to the pilot phase of MED POL and te rminated in Ma rch I 98 1. Wo rk started with UNEP o n the processing and analysis of the scien- tific results o btained by participating institutions during the course of the project (I 976- 198 1 ). Active participatio n was maintained in the other compo ne nts of the Mediter- ranean Action Plan, particularly the Blue Plan and the Priority Actions Pro- gra mme, to cove r the incorporation of the necessary health component in relevant interdisciplinary studies and pilo t projects. The final preparations for printing the three-volume handbook Examination of water for pollution control were completed , and it is expected to be pu blished by Pergamo n Press early in I 982. Routine contacts and evaluatio n o f activities of mutual concern were main- tained with the Water Research Centre in the United Kingdom on vario us aspects related to water quality a nd po llution control. The Regional Office continued to be represented at the ECE meetings dealing with water problems, and provided details on WHO activities. 66 Air pollution control The Regional Office was represented at two ECE meetings related to air pollution , nam ely the Working Party on Air Pollution Problems and the Interim Executive Body for the Convention on Long-Range Transboundary Air Pol- lution. A positio n paper on the e ffect on health o f sulfur ox ides and o the r air pollutants was presented at the latter meeting. Preparations began for the establish- ment o f two ne w WHO collaborating centres, one o n ambient air pollution and another o n indoor ai r quality. On the o ccasio n o f an inte rnational congress in the United States on indoor air quality, seven tempora ry advisers covered the different aspects of this impo rtant sub- ject. They also joined in discussions on ho w the Regio nal Office sho uld proceed with activities in this field . The fifth lntersecretariat Meeting on Air Pollutio n Problems in Europe was held in Geneva in September, with the participation o f 11 representat ives from United Na tio ns organizations and other intergovernmental and no ngovern men- tal organizations. Solid waste management A Working Group on Sewage Sludge to Lan d : Health Implications o f the Microbial Conten t was held in January in collaboration with the Govern- ment o f the United Kingdo m. It was recommended that measures be taken to reduce substantially the concen- trations o f pathogens in sewage sludge be fore it is a llo wed to come into co ntact with crops, such as fresh vegetables and fruit , that a re brought into the kitchen raw. Sludge contammg pathogens that may multiply in or contaminate meat, poultry and dairy products should not be spread on land where food animals are raised, unless an adequate interval of time has elapsed. The Group recommended various measures for disinfecting sewage sludge in or- der to permit its relatively unrestric- ted use. The problems arising from im- proper disposal of toxic wastes re- quire the development of guidelines for their effective management in Europe and elsewhere. In March a Working Group on Guidelines for the Control of Toxic and Other Hazardous Waste was held in Garmisch- Partenkirchen, Federal Republic of Germany. A code of practice for toxic waste management was drafted, which will form a background document for the continued activities of the Working Group. This activity was im- plemented jointly with the UNEP International Register of Potentially Toxic Chemicals. The Office was represented at the International Conference on Solid Wastes, Sludges and Residual Materials, in Rome in June, and a paper was sub- mitted on activities in this field. Radiation protection In a series of activities related to nuclear power production, a joint Re- gional Office/WHO headquarters Work- ing Group on the Basis for Public Health Action in Radiation Accidents took place in Brussels in November, in col- laboration with the Belgian Govern- ment. The participants analysed the various factors and agreed on the outline of a document which will include chapters on guiding principles, sources of exposure, evaluation of radiological hazards, countermeasures, final decision and balance of risk. FOOD SAFETY Between the beginning of May and the end of the year over I 2 000 new cases of toxic pneumonia and about 240 deaths associated with the con- sumption of adulterated cooking oil had been reported from Spain. The pattern of morbidity and mortality over the period is shown in Fig. 7. The majority of the 800 patients still in hospital in November were back for the second or third time. Exten- sive toxicological and epidemiological investigations are being carried out in Spain and other countries, with the assistance of WHO. The situation in Spain, which has adequate food legislation, illus- trates the need for an improved food control infrastructure and for en- forcement of food laws and regu- lations. Existing legislation in the European countries is sufficient to prevent criminal fraud and other forms of malpractice in the hand- ling of food, but only if properly ap- plied and if the necessary food con- trol is carried out by a sufficient number of responsible and well-trained food inspectors. Much of the work on food safety in the European Region is devoted 67 °' CXl "' GI "' "' 0 ~ GI z 1900 1800 1 700 1600 1 500 1400 1300 1200 1100 1000 900 800 700 600 500 400 300 200 100 Fig. 7. New cases admitted to hospital and deaths resulting from the consumption of contaminated cooking oil in Spain, May - December 1981 WEEK 7 14 21 28 4 11 18 25 2 9 16 23 30 6 13 20 27 3 10 17 24 1 8 15 22 29 5 12 19 26 3 10 17 24 31 MONTH May June July August September October November December j,~~ 15 j - ~ ~ - ~ ~ to assisting countries to improve their food control systems. A survey on food safety services in Europe was published in 198 1 (Public Health in Europe, No. 14) and was well received as a source of information , both within and outside the Region. The Codex Alimentarius Coordinating Committee for Europe has , as a follow-up , requested a study on cooperation and coordination between health, agriculture and other authorities in Member States. A Working Group on Health As- pects o f Residues of Anabo lics in Meat was held in the Netherlands in November. The mee ting agreed that the correct u se o f ce rtain hor- mones poses no known health prob- lems to the consume r, but that some substances should not be used be- cause they are persistent in food and may have carcinogenic activity. The first priority for the public health auth- orities must be to prevent the illegal use of banned products. This calls for a good food control system through the whole production chain , and adequate manpower to enforce the regulations. Work started on a survey of mass catering problems. Guidelines for ad- ministrative personnel at various levels are to be published , with emphasis on how to avoid health hazards in different forms of large-scale catering. Close collaboration was maintained with F AO, in particu lar the Food Standards and Food Science Service, with various othe r o rganizations ac- tive in aspects of food safe ty and, among nongovernmental organizations, with the European Food Law As- sociation, the Environme ntal Health Officers' Association, the Swedish As- sociation for Food Technology, and the British Institute of International and Comparative Law. CONTROL OF CHEMICALS In phase I of the manpower develop- ment programme, occupational profiles of personnel involved in the testing, evaluation and control of toxic chemi- ca ls were produced. In phase 2 , target training curric ula were developed for adaptation and use by training insti- tutions. In June, a Planning Group on Development of Curricula fo r Manpower Training for Occupations in Tox ic Chemicals Control met in Brussels, and discussed strategies for developing model curricula for postgraduate training in toxic che micals con t rol. The results of phases I and 2 are now available as a document.a As part of the strategy for post- graduate training, a seminar on the toxicology of pesticides was organized by the Institute of Hygiene and Occu- pational Heal th , Sofia, in September. The seminar encompassed a general revie w of methods used in pesticide application in agriculture and for public health, toxicology of selected groups of pesticides, and measures for preventing adverse effects o f pesticide use. a Manpower development for control uJ chemicals. Copenhagen, WHO Regional Office for Europe, 1981 (European Cooperation on Enviro nmental Health Aspects of the Con trol of Chemicals, Interim Document 2). 69 In the first stage o f the programme on contingency planning a conceptual model of countrywide emergency re- sponse systems for chemical acciden ts was developed , and a survey of ex isting system components in European coun- tries was conducted. Using these two background studies, a Working Group on Contingency Plan ning for , and Response to, Emergencies and Accidents involving Potentially Toxic Chemicals was held in Bilthoven in February. The main purpose of the meeting was to help develop a model of a comprehensive contingency plan , at various levels, for effective response to accidents involving the release of toxic chemi- cals. The model was subsequently included in a guideline document.a Rapid proliferation in the use of toxic chemicals necessitates a system- atic regulatory approach to their con- trol. This approach includes the elim- ination of overlap amo ng the various pieces of legislation and the admin- istrative responsibilities of different national agencies, while assuring compre- hensive coverage and e fficient implemen- tation. Towards this goal, a preliminary survey of legislative and ad ministrative procedures for tox ic chemicals control was implemented by the Institute of Hygiene and Occupational Health , Bul- garia, in cooperatio n with the UNEP International Registe r of Potentially Toxic Chemicals and the Mo nitoring a Planning emergency response systems for chemical accidents. Copenhagen, WIIO Regional Office for Europe, 1981 (European Cooperation on Environmental Health As- pects of the Control of Chemicals, Interim Document I). 70 and Assessment Research Centre, United Kingdom. The report of the survey served as a background paper for the Working Group on Regulatory Schemes for Chemicals in Consumer Products held in Varna, Bulgaria in September. The Group discussed regulations and control systems relating to toxic chemi- cals in consumer products and approved a model consumer protection act. Scientifically reliable, quantitative data in studies intended for use in legislation depend heavily on good management. This management requires proper organization of the test or measuring facility so that the quality of the data can be guaranteed. To ensure the validity and integrity of data used for assessing the risk of chemicals to human health and the environment , accepted and compar- able procedures are necessary. The importance of such quality control was underlined by a consultation on quality control in toxicological test laboratories held in 1980. The main working paper fo r that meeting, along with the principles of good labora- tory practice, as detailed by OECD and accepted by the consultation, were issued during the year. b The following studies were launched in I 98 1 and will help form the necessary background fo r meetings and other activities planned for 1982/83: b Quality control in the occupational toxicology laboratory. Copenhagen , WHO Re- gional Office for Europe, I 98 I (European Cooperation on Envi ronmental Health As- pects of the Control of Chemicals, In terim Document 4). - protection and rehabilitation of waters affected by the acci- den ta! re lease of potentially toxic chemicals; - a llergies and in tolerances caused by exposure to c he micals; - impact assessme nt of the petro- chemical industry ; reclamation and rehabilitation o f abandoned toxic chemical dumps; - draft guidelines on the safe pro- cessing and ultimate disposal of redundant products containing or emitting po tentially toxic chemi- cals; and - a review of the present and future environme ntal health impact of biotechnology. COUNTRY ACTIVITI ES At the country level, activities associ- ated with the International Drinking- Wate r Supply and Sanitation Decade concentrated on Algeria, Mo rocco and Tu rkey, which are the Member Sta tes with the highest popula tion growth rates and the greatest sho rtfalls in services. A full-time WHO sanitary e ngineer has been posted in each of these countries, and continuous cooperation has been possible with the gove rnme nts in de- veloping a strategy and planning for the Decade. Much of the work at the co untry level was undertaken through the UNDP country programmes , and additio nal activities to maintain the Decade mo- mentum were proposed for the third UN DP planning cycle ( 1982 - 1986). Algeria. The Regional Office con- tinued to assist in the training of en- vironmental health officers in three regio nal institution~, with emphasis on housing and vector con trol. Assistance with the sanitary e ngineering cou rse at the Algiers Po ly technic School con- tinued , and severa l training manuals were prepared in the fields of water technology, mi crobiology, air quality management , solid wastes manageme nt , and housing hygiene. The Office also as- sisted the Ministry of the Interio r in lau nching a large-scale project on the collection, manage me nt and disposal o f urban solid waste. The first phase of the rural sani- tat ion project in the Medea province was terminated, and the second phase initia ted. Preparations began with the Ministry of Wa ter Resources for a project to develop appropriate tech- nology for drinking-water supplies to smaller communities in the sou th of the country, and for a project on the transfer of techno logy for sewerage and/or industrial liquid waste treat- me nt and disposal. Greece. The UNDP-supported proj- ect " Assistance to the secretariat for physical planning and the environme nt" continued. The preliminary e nviron- mental impact assessmen t s tudy started in 1980 was successfully completed, and the report was submitted to the Government for further action. A co nsultan t and a temporary adviser visited G reece in August to advise the Governme nt on the structure, pro- gramme and fun ctions of the proposed Gree k National Environme ntal Institute . Two temporary advisers visited the country in December , one to advise on the establishment of a nationwide 71 environmental information system, and the other to plan a proposed seminar on assessing the environmen tal im- pact of the trans-European motorway, to be held in Greece in 1982. Malta. Within the framework of the UNDP country programme, the Regional Office continued to support the Govern- ment in its e fforts to upgrade the waste collection , treatment and disposal system, with emphasis on the re-use of treated sewage for agricultural purposes. Morocco. The planning report on the International Drinking-Water Supply and Sanitation Decade was finalized and ap- proved by the National Action Com- mittee; four priority projects were ident- ified. Cooperation with the National Water Supply Agency continued (a) to complete pre-investment studies on the extension of drinking-water production facilities and (b) to continue the study of the Bou Regreg Reservoir eutrophi- cation control project. Poland. The UNDP-supported proj- ect on environmental impact assess- ment continued, and a tripartite re- view meeting was held in Feburary. A workshop on environmental impact assessment was organized by a firm of specialist consultants under con- tract to the Office , and was attended by a large group of Polish scientists and engineers. Several Polish experts visited o ther countries under the fellow- ships programme. A proposed new UNDP project on the introduction of environmen tal and health impact assessment procedures into planning and decision-making pro- cesses was drawn up by the Government, but is not likely to commence until 1984 due to funding problems. 72 Portugal. Four projects were com- pleted during the year. That on water supply and waste disposal ended with the finalization of the planning docu- ment on the International Drinking- Water Supply and Sanitation Decade. Another , on dental caries' control through d rinking-water fluoridation , was evaluated at a seminar held in Lisbon in November. A third , concerning air quality management, resulted in the promulgation of new Portuguese legislation on air pollution control and in the creation of five regional agencies for air quality management. Finally, the project on public health aspects o f pollution control in the Tejo Estuary will be followed by a comprehensive project on the protection of surface water quality. Turkey. Cooperation with Iller Bank- asi (Bank of the Provinces) in its water supply and waste disposal programmes was successfully concluded at the end of 198 1. Support continued during the year to the training of sanitary engineers at Turkey's four main uni- versities, and a series of project pro- posals was submitted by the Govern- ment to UNDP to be considered for inclusion in its third planning cycle. The UNDP/WHO project on the strengthening of food control services under the Ministry of Heal th and Social Assistance came to an end. The project was successful as far as planned activi- ties were concerned, although some problems were caused by a lack of co- ordination at national level between the ministries responsible for health and agriculture. A Turkish coordinating com- mittee was set up, and discussions on a second phase began with F AO, UNDP and the national authorities. PROMOTION OF ENVIRONMENTAL HEALTH Proposed budget and actual expenditure for 1980/ 81 (US$) Proposed Expenditure budget 1980 198 1 1980/8 1 Regular funds 17541 00 736 198 I 203 I 78 I 939 376 UN funds 5 926900 2 339472 I 795 058 4 134 530 Voluntary funds 760 200 305 447 187 498 492 945 8 441 200 3 38 1 11 7 3 I 85 734 6 566 85 1 a a Being 18 .78% of total expenditure. Publications issued in 1981 Food safety services, edited by R. Johnson . Public Health in Europe, No. 14. Health aspects of treated sewage re-use: repo rt on a WHO Seminar. EURO Reports and Studies, No. 42. The risk to health of m icrobes in sewage sludge applied to land: report o n a WHO Working Group. EURO Reports and Studies, No. 54 . 73 Chapter 6 HEALTH MANPOWER DEVELOPMENT GENERAL The European compo ne nt of the global medium-term programme on health manpower deve lopme nt , as ap- proved by the Thirty-first World Health Assembly, fo cused during the year o n a few influe ntial areas such as (a) stre ng th- e ning health manpower planning in rela tion to health service needs; (b) sup- port fo r training in health manage- ment and administration ; (c) s timulating the development o f continuing edu- catio n , partic ularl y fo r primary health care personnel ; and (d) teache r tra in- ing activities. Em phasis was placed on developing closer collaboration with nongovern- mental o rganiza tions active in the fie ld o f medical and public health education , such as the Association for Medical Educatio n in Europe (AM EE); the Associa tion of Med ical Deans in Euro pe (AMO E) , which no w encompasses 125 me dical schools; the Associa tion o f Schools of Public Health o f the Euro- pean Region (ASPH ER) ; and the Nor- d ic Federation of Med ical Education . Similarly, collabora t ion was developed w ith national research and teaching cen t res such as the Central Institute for Advanced Medical Studies, Mos- cow; the BLAT ( British Life Assurance Trust ) Centre fo r He alth and Medical Education , Londo n ; th e Nuffield Centre for Health Services Studies, Leeds; and the Usher Institute, Edinburgh. Also, the idea of organizing educa tional work- shops, during which participants fro m Member Sta tes and from the WHO secre tariat work together to solve certain problems, was developed further. The theme o f the Annual Conference o f AM EE was the selection o f medical stude nts and curric ulum planning. The aim of the Confe rence was to bring toge ther teachers concerned with the selection o f medical students and c ur- riculum design , and to presen t ma te rial and repo rts on new approaches. By agreement with the Regio nal Office, AM EE made an initial review of the selection o f medical students in diffe rent European countries. The Third Advisory Co mmittee on the Health Manpowe r Developmen t Medium-Term Programme was convened in the Regio nal Office in Novembe r to assess progress since the previous meet- ing in 1978. It was attended by those respo nsib le fo r med ical e duca tio n a t the ministe rial and university levels, by 75 health service administrators, by medi- cal and other health personnel (teachers, nurses, environmentaJjsts, administrators and health managers) , and by represen- tatives of nongovernmental organizations collaborating with the Regional Office. In the field of communication and collaboration between and with- in the health and ed ucational sys- tems, studies had been undertaken dealing with both the mechanism and the quality of communication. The reports were available, and had served as background to meetings attended by participants from many of the Member States. However, it was pointed out that the results of these studies were not widely known at the country level. With a few ex- ceptions, improved communication still depe nded on personal contacts rather than official mechanisms. As a re- sult , in general the countries are not preparing as many doctors for pri- mary health care as are either needed or recommended. Continuing education of health personnel had been the subject of several working groups and the tech- nical discussions at the twenty-ninth session o f the Regional Committee, where it was seen as an important factor in raising the quality of health ca re rather than simply satisfying the professional inte rests of the various disciplines. Nevertheless, at national level, there was still a need to make continuing education relevant to the health services and available to all health professions. A first evaluation of re- sults, though not entirely satisfac- tory, showed that there were areas where con tinuing education was slowly becoming an agent of change. 76 T eacher training, which enjoyed the longest tradition and a ne twork of collab- orating centres, was regarded as a suc- cess and there was clear evidence of im- pact and response at country level. More- over, some 70 units for ed ucational re- search and development in different medi- cal schools cooperated with the Regional Office. The scale of activities developed by the Office was broad and responded to a wide range of perceived needs for skilled health management, as distinct from traditional public health and industrial hygiene. There was general agreement about the need to stress training for middle-level management. It was sti ll too early to judge the modem approach to training public health medical officers in health management and , by collaborating with ASPHER for example, new concepts were being applied and individual institutions in- fluenced with a view to developing a uniform framework for the programme of training and health management. The regional medium-term pro- gramme in nursing had as one objec- tive the improvement of nursjng edu- cation at all levels, and eight collab- orating centres in Belgium, Denmark , Finland , France , Poland , Switzerland and the United Kingdom had con- tributed greatly by implementing the med ium-term programme. In general, it was considered that this imagina tive programme was developing well. The Regional Office was rep- resented at an interna tional symposium en titled 'The education of the health professions - policies for the 1980s", organized by the Swedish National Board of Universities and Co lleges and co-sponsored by the OECD Centre for Educational Research and Innovation. MANPOWER PLANNING AND MANAGEMENT During the past few years the de- velopment and strengthening of health manpower planning has become an even more vital issue than before, owing to the emerging issues of over- production , oversupply and maldistri- bu tion of h ealth manpower. In the Me mber States there is a growing awareness that , without good health manpower planning integrated with health planning, the proble m can- no t be solved. Since manpower needs must be seen in relatio n to the concept and structure of health services, health manpower planning is one important key to achieving the necessary reorientation of health services towards community needs. The HFA2000 strategies require, as o ne prerequisite for their imple- mentation, an adequate number of well- trained personnel. It was for this reason that a study on health services/ manpower develop- ment was started, in collaboration with the Nuffield Centre for Health Services Studies of the University of Leeds. The aims of the stud y are to collect data for distribution to Me mber States, and to develop guidelines for health manpower planning. It is intended that the study will provide information on current and future intakes to medi- cal and o ther schools for health per- sonnel up to the year 2000 , and on the methods used in Member States in health manpower planning. A Wo rkshop on Health Manpower Planning took place in Copenhagen in October. It was a ttended by 12 national participants, and staff from the WHO Regional Offices for the Americas, Europe and the Western Pa- cific. The Wo rkshop concentrated on problems facing coun tries of the Eu ro- pean Region , such as the oversupply and overspecialization of physicians. The participants familiarized themselves with the organization a nd procedural aspects of health manpower planning, so that they might then undertake such activities in their own countries and formulate health manpower plans. Under a con tractual agreement with ASPHER a study o n the scope of train- ing in health management in schools of public health is to be carried ou t in the European Region . A pilot study covering five selected schools of public health in western Europe was under- taken during the autu mn of 198 1, and the o utcome was presented to a consultative meeting which took place in the Regio nal Office in December. The meeting evaluated the pilot study and outlined the design of the main stud y, whose aim will be to develop and im- plement a standard programme in management training. It is planned tha t fu rther devel- opment of the study will involve schools of public health o r institutions in eastern Europe. In this respect a small consu ltative meeting of public health administrators from Moscow, Sofia, Warsaw and Zagreb, together with a represen tative of ASPHER and Regional Office staff, met in ovem- ber to review in forma tion o n coop- eration with ASPHER, the health administra tion a nd management t rain- ing situation in the European Region , and prospective joint s tudies and ac- tivities. It was agreed th at the Regional Office should encourage Member States 77 to increase their representation and active participation in ASPHER. On the recommendation o f a consultation on continuing education he ld in 1980, a Seminar on the Con- tinuing Education of Health Workers in Primary Health Care was held in San Remo in October. It was attended by 23 participan ts from 15 countries, and by 4 WHO staff. It too k the form mainly of an exercise in which the participants took the regional strategy for HF A2000 and derived from it the main new forms that pri- mary health care must take, and the new skills that primary health care professionals will need to implement the strategy. Primary health care in- volves integrated teamwork , and the skills and attitudes that teams will need are mainly epidemiological, sociologi- cal, educational and communicational. They will be exercised in close touch with , a nd with the participation of, the local communities that the teams will serve. The Seminar indicated a number of activities that the Regional Office should undertake in cooperation with countries to develop furthe r the concept o f continuing ed ucation as a major suppo rt to primary health care and the goal of health for all. PROMOTION OF TRAINING Close collaboration continued with several teaching institutions, including the Cen tral Institute for Advanced Medi- cal Studies, Moscow, which runs annual internatio nal courses for public health administrators and for which WHO provides lecturers and fellows. During 78 the year several staff from the Regional Office lectured at the Moscow courses. Three WHO fellows from Mongolia attended the 1981 /82 course in the Russian language, and one WHO fellow from Afghanistan a ttended the English- language course. Two WHO fellows attended the In- ternational Summe r Course on the National Health Services of Norway, organized by the University of Oslo. The subjects studied by WHO fellows do not always re flect the health problems of the ir countries of origin nor the e mphasis placed by WHO pro- grammes on the solution of those problems. Table 5 shows the distri- bution of fellows by subject and Fig. 8 shows, for each Member State of the Region , the number of fellows that came to that country to study and the number from that country that studied e lse- where. As in previous years, the United Kingdom received the most fellows, fol- lowed by France, the Federal Republic of Germany, Switzerland . the Nether- lands and the USSR. As regards field of study, the highest number of awards ( 14.9%) was issued for studies in en- vironmental sanitation , followed by public health administration ( 11 .6%), othe r communicable diseases (8.8%) and laboratory services (7.9%). National fellowships officers from the Nethe rlands, Sweden and the United Kingdom visited the Regional Office in May to be briefed on the fellow- ships programme. The fellowships of- ficer from Poland also visited the Office in the autumn. National fellowships o fficers from Bangladesh , India, Sri Lanka and Thailand toured the main receiving countries in Europe and visi ted C°""'"''" ot or,..,. AltNn•• Alg,r,,, ..... ,11,,. S.lgium 9ulf6t•• CnchollO'O'~•• o. ........ '""'"" ··-CM,m~ O.m Rte, Gt~ Ftcl Rto ol G•Nt• "..,,..,.. ""'"" htl,nd 11.iv lu• -bO.l•t M.ii, .. _. M CHt'«O NttN•t~ __ ,, ,o1.nc1 ill'o,,11,,.i ·-· S.nM,,,no s..~ .., __ s,..,,,,.,1.nc1 Tu1._.._. USSR Un•te<:lKlnqdotft Yu,pltv-1 ..... "••0tn1'91' o l lot-1 Table 5. Fellowships awarded in 1981 by the Regional Office to fellows from the European Region, by subject $1.lb.-<1 ol Uu<I~ lm.t•n lt'OIJJJlol I s § • Q 11 0 l ' . i " 1 i ~ ' i l £ i ~ t i i § i l I J i ' ' t i g i i i t £ t; ! E . t I i . § J l § g i ! . I I ~ 9 ' ~ i i t 1 l ! ! ' i f • r j 1 J a • . ~ . l ' l • Ji ! • c • l AI ~ t p ! f ~ i ! I • l i i . I i i ii l « • $ cS ~ 6 J ~ ' , , J J ' . J I I , I ' I I I I I . I I I I I I I I ' I I I I I I I I . . ' I 2 I I I ' I I ' I I ' I I I I I I I 3 I I I I 3 I I I ' " , ' I I • I " I I I I I II ' I I I I ' I I I I ' I ' ' ' I I I I I J ' I I I I ,, ' I I " I 10 10 I ,. ' II I • J . • 2 ' ' ' " I I 3 , J ., .. 0 . 271 ,. 0 . 101 I 9 ., 0. " " I g JI 08 19 08 08 ., 0 • ,, 12 08 12 10 I I ~ ~ i . § i i c t t r i . . ! .a ! .f . I g I ,. . , I 0. I 0 . ' H ' I 0 I 0 . ' 01 I • " • I 9 ' " I " ., I ' " . II ' 01 I • " 0 00 I . " 0 00 II 43 J I 1 , 01 31 14 3 " 8 I " II 0 00 I J I , 08 I J " I " " I . " I . I g 2 " • 1 . I ,.. I g JI 79 Fig. 8. Distribution by country of fellows in the European Region in 1981 8 11 1 8 14 -J 16 1 5 111 6 3 103 172 5 46 1 14 9 23 25 43 Black figures indicate the number of fellows received in each country. 21 1 9 50 Brown figures indicate the number of fellows from each country studying elsewhere. 8 These figures refer only to those fellows who started their fellowships in 1981 . 80 the Office for brie fing. Because of the many jo int activities that take place with the Nuffield Centre for Health Se rvices Studies, Leeds, the admin- istrator o f the International Relations Departme nt visited Copenhagen to be- come acq uainted with the work of WHO, and fellowships in particular. C lose contact continued with the Coun cil o f Europe in the Medical Fel- lowships Selectio n and Assessme nt Co m- mittee, which is he ld annually. A me m- ber of staff also attended the fo urth meeting o f the Standing Conference on University Proble ms. EDUCATIONA L DEV ELOPMENT AND SUPPORT Ex perience has shown that there is a need to maintain e fforts to re- o rient medical educatio n, so that it is made mo re relevant to the needs o f the community and primary health care. Within the framework of the health manpower develo pment pro- gramme, a stud y on existing pat - terns in teaching primary health care was begun , the first phase o f which was to collect informatio n fro m the Netherlands and the United Kingdo m. The second s tage will be developed in close collaboration with the Associatio n for Medical Edu- ca tion in Euro pe (AM EE), which will make a situation a nalysis through its national associations, review the lite ra ture, and pre pare the study pro- tocol. It will also an al yse the e ffects of the Alma-Ata Declara tio n and WHO activities o n medical schools in the European Region. A Consulta tive Group o n the Organ- izatio n an d Scope of Research in Edu- ca tio n for the Heal t h Professions met in Prague in Se ptembe r to advise on what ac tio n sh ould be taken to promo te research o n the educa tion of health professionals, o r health manpower de- ve lopment , in the European Region . Furthermo re, the Group indicated what actio n should be take n by Member Sta tes and the Office to promo te such research in the contex t of the goal of HF A2000. T wo members o f sta ff o f the Cen- tral Institute for Advanced Medical Studies, Moscow, visited Belgium, Den- mark , the Federal Republic o f Germany, Sweden and the United Kingdom to become famili ar with the wo rk of diffe rent schoo ls o f public health . One o f them also participated in the first two weeks of the fi rst International Course on Educatio n fo r Health Services Admin- istratio n, in Lisbon in June, and the BLAT/WHO Course on Modem Me thod- ology for Teachers o f Health Sciences, in Lo ndon in June/July. NURSI NG The participation of Member Sta tes in the European medium-term pro- gramme in nursing/ midwi fery increased steadily and in te nsive work was ca rried out, supported by the programme manage rs o f the eight collaborating centres in Belgium, Denmark , F in- land , France, Po land , Switzerland and the United Kingd om. Followi ng a meeting o f the programme managers in May, proposals were fin alized for a study of needs, planning, implementation and 8 1 evaluation o f care provided by nurses, using two selected groups of people in the European Region. In add ition , 63 Type II participating centresa are actively involved in teach- ing the nursing process and in intro- ducing the method into nursing practice in both hospital and primary health care settings. Regular contact is kept with 119 Type III participating centres in preparation for their involvement in the medium-term programme at a later date. This collaborating and participating centre network developed throughout the year and the high level of enthusiasm among those involved in the study was largely sustained by the programme managers and contact persons. Visits were made to a number of Member States in the Region during the year to discuss national input to the nursing/ midwifery medium-term pro- gramme and/or to deliver addresses on the programme and o n primary health care. The Office provided input to the Select Committee of Experts on Post-basic Training of Nurses con- vened by the Council of Europe, and to a joint meeting of the Northern Nurses' Federation, the European Nurs- ing Group, the International Council of Nurses, and the Standing Committee of Nurses o f the European Communi- ties. The Nursing Officer attended an a For definitions of the three types of participating centre, and their relationship to the network of collaborating and participating centres, see the corresponding sections in the Annual Reports of the Regional Director for 1979 and 1980. 82 interregional meeting convened by WHO headquarters, at which the contribution of nursing to the implementation of the Alma-Ata Declaration and HFA2000 was ex tensively discussed. In April the Fourth Advisory Com- mittee on the Medium-term Programme in Nursing/Midwifery in Europe me t in San Marino. This was the first WHO meeting to be held there since the Re- public was admitted to the Organization in 1980. The Committee reviewed activities to date and discussed in depth proposals for the Seventh General Programme of Wo rk. The Regional Office contributed to the o rganization of a conference on primary health care in Europe, in the United Kingdom. Nurses from 16 Euro- pean countries attended. The most important topics discussed included teamwork , client participation in de- cisions related to health care, and the role o f nurse generalists in p rimary health ca re, with access to nurse specialists whenever necessary. A Working Group on Medicosocial Services in Hospitals, held in September in Helsinki, recommended that appropri- ate steps be taken to help medicosocial workers to identify the content o f this service. It was suggested that the Regional Office might set up a small task force to facilitate and expedite action and also to help identify ways in which medico- social workers might develop their own system of assessment , planning, implementation and evalua tion of care, using documentation similar to tha t cur- rently being developed in nursing. A Confe rence Med icosocial Work on Nursing and in the Care of the Elderly was held in Cohigne in November, a t the same time as a working group met to discuss means of prevent- ing disability in o ld age. Participants recognized that , in order to develop a shared approach and to deploy their combined skills to meet the diverse needs of the elderly and their families, me mbers of the interdisciplinary teams needed to know and understand each other's area of competence. This was considered to be of particular import- ance at the primary health care level in the prevention of premature aging, disease and disability. In developing any system of care, it is important to de fine the roles of the various pro- viders and to e nsure complemen tary development by each discipline involved. Students shou ld lea rn to participate in interdisciplinary work , in order to gain an appreciation of work in other disci- plines. This would help to achieve in tersectoral collaboration , which is considered essential to the attainme nt of the social goal of HFA2000. COUNTRY ACTIVITIES Belgium. In cooperation with the Regional Office, the Belgian authorities and the Free University of Brussels organized a multidisciplinary workshop in September on the organization , development and evaluation of primary care services, in the French language. Bulgaria. As a newly appoin ted me mber of the Joint Coordinating Committee for Cooperative Health Pro- grammes, the Director of Research, Planning and Human Resources visited Bulgaria in May to discuss the plan of action foreseen in the document of cooperation with Bulgaria; t o discuss the future development o f the Gabrovo health services model and cooperation with the Regional Office; to make plans for the sixth meeting of the Joint Coord inating Committee to take place in Copenhagen in February 1982; and to make preparations for future international courses. The course on planning, organization and manage- ment of health care delivery in sup- port of primary health care, planned to take place in October 1981, had to be cancelled owing to a lack of response from countries. In ovember a Regional Office team visited Bulgaria to advise on the evalu- ation of the Gabrovo health services model, with emphasis on the mass screening component, and with a view to issuing a revised edition of the Re- gional Office publication produced in 1980.0 The continuation of the project was also discussed. Federal Republic of Germany. The Academy of Public Health in Diisseldorf, with the support of the Regional Office and ASPHER, organized a workshop on the evaluatio n of educa tional programmes for public health personnel in Europe, in Ulm in November. The workshop is part of a series of WHO/ASPHER-supported activities leading to a network of col- laborating institu tions on training in modem aspects of public health. a Sokolov, D.K. et al. Th e Cabrovo health services model in the People's Republic of Bulgaria. Copenhagen , WHO Regional Of- fice for Europe, 1980 (EURO Reports and Studies, No. 27). 83 Italy. The Director, Disease Pre- vention and Control presented the medium-term programme on nursing at the Congress of the Italian Nurses' Association in Rome. Spain. The Regional Officer for Educational Development and Training gave two lectures related to the education of health and nursing personnel in pri- mary health care at the Congress of the Spanish Nurses' Association. Yugoslavia. At the request of the health authorities of Montenegro, a visit was made in January to discuss the organization of health services and health manpower education. HEALTH MANPOWER DEVELOPMENT 84 Proposed budget and actual expenditure for 1980/81 (US$) Proposed Expenditure budget 1980 1981 l 980/8 I Regular funds 3 293 900 I 610928 I 871 7 14 3 482 642 UN funds 151 800 38474 2 1 301 59775 Voluntary funds 264400 I SI 071 46536 197 607 3710100 1800473 I 939 55 I 3 740024° a Being I 0. 70% of total expenditure. Publications issued in 1981 Legislation concerning nursing/midwifery services and education: report on a WHO Working Group. EU RO Reports and Studies, No. 45. Chapter 7 HEAL TH INFORMATION G ENERAL The Health Informa tio n Service is p rogressively adapting its programmes to the requirements of the regio nal strategy for HFA2000, and broad ening its cooperation with Me mber States. In the develo pment o f health statistical and other informa tion suppo rt services, greater emphasis is being placed o n the fo rmulatio n of national stra tegies, on monito ring progress t owards health goals, and on the internatio nal ex - change o f in fo rmation. With a view to mo nito ring progress, the Member States were consulted on the use and value of a wide range of health indicators. They were aJso asked to jo in in developing health projectio ns up to the year 2000 as a long-te nn p ro- gramme. This may eventually require a longitudinal fo llow-up o f the health of communities in several Member States, as well as the use o f health ser- vices by those communities. Cooperat ion with the mass media to bridge the gap between the comm unity and the health authorities is being actively pursued, and the med ia are progressively being directly involved in the p rogrammes o f the Regional Office. Input by the Health Legislation unit to o ther regional programmes continued to expand : 16 programmes now have a legal component. A review of policies and legisla tio n fo r the dis- abled was made during the year. A manageme nt study o n the pub- lications programme was carried o ut during the year. Imple mentation of the recommenda ti o ns of the study, togethe r with the installatio n o f new tex t pro- cessing and photo-typese tting equipme nt sh ould result in greater efficiency and fewer delays in pu blication . The Regional Offi ce's health litera- ture services are expanding their refer- ence and bibli ographic services in new social, economic and behavio ural topics of importance fo r the success of the strategy fo r HF A2000. HEALTH STATISTICS A new project concerned with esti- mating the future health situation 85 in Europe was initiated, with the aim of assessing the current situation, fore- casting trends in health care resources, service utilization and risk factors, and developing a suitable methodology for projections. The outcome of the project is expected to help Member States to formulate and choose between alternative strategies for improving the health of their populations , and to increase the efficiency of their health services by the year 2000. Thirteen countries have indicated an interest in participating in the project and ten have designated collaborating per- sons or institutions. A study on trends in the demo- graphic structure of the European Region, with a view to identifying the health and social implications, was initiated in collaboration with 15 Member States. Country reports on the subject were received, and are to be used as the basis for a tech- nical meeting in 1982. The steering group met in 1981 to discuss the contri- butions received. The WHO collaborating centre for classification of diseases, London , organ- ized a first evaluation of the content of, and users' opinions on, the Ninth Revision of the International Classi- fication of Diseases. The results were discussed at a workshop in Canterbury in September. Similar exercises will be organized with the collaborating centres in Moscow and Paris. Plans for research into the standard- ization of methods, measurements and terminology in health services research were proposed at a consultation held in Copenhagen in April. The outcome of the study will be a publication which 86 will include standard definitions and examples of applications in different national settings. WHO PUBLICATIONS AND DOCUMENTS A management team from WHO headquarters visited the Regional Office during the year and made a study of all aspects of the publi cations process. The study dealt mainly with publications and translation , but also looked into text processing, printing and distri- bution , and considered the budgetary implications. The management report supported the general trends along which the publications programme was being developed. Its recommendations were directed mainly towards a more ra tional allocation of work and towards improving the planning and scheduling of publications and documents. French editions of two issues in the WHO Regional Publications, European Series appeared during 1981: No. 5, Oral health services in Europe; and No. 8, Studies in drug utilization. French editions of two issues in the series Public Health in Europe were a lso pro- duced : No. I 0 , Psycl1ogeriatric care in the community and No. 12, National drug policies. Two new issues in the series Public Health in Europe appeared during the year: No. 14, Food safety services and No. 15, The cardiovascular disease programme of WHO in Europe. The former publication is the outcome of a survey on national food safety services in the Region ; through this book the services may be be tter understood and communication with and amo ng them may be facilitated. The latter summarizes and assesses the achieve- ments and weaknesses of the regional programme over the past 12 years, the reports on which contain a wealth of data, accounts of methods and general guidelines. The third edition of the important reference work Health services in Europe was published. This book sets out the current situation and can be used as a basis for assessing the changes that will inevitably occur in the future . Volume l provides an overview of trends in public health administration. The first part of volume 2 reviews the health situation in each Member State of the Region ; the second part comprises tables summarizing the main fea tures of the health situation in the vario us countries, together with some vital statistics and economic and social data. Other non-serial publications pro- duced included Les laureats europeens du Prix Leon Bernard and Community con- trol of cardiovascular diseases: the North Karelia project. The former gives a portrait of each Leon Bernard prize win- ner from the European Region during the period 1951-1980, together with an outline of his work and contribution to medicine and public health . The latter , published on behalf of the National Pub- lic Health Laboratory of Finland, describes the first five-year period of a comprehensive community programme for the control of cardiovascular diseases in a Finnish county. Co-publications issued during the year include: Prospective longitudinal research, Aging: a challenge to science and society and The rise and fall of malaria in Europe, all published on behalf of the Regional Office by Oxford University Press. A special effort was made to reduce delays between the closure of meetings and the publication of reports. This resulted in the publication of 20 new issues in the series EURO Reports and Studies. The number of publications and documents requested from the Regional Office in 198 1, by language , and the distribution of requests by region are shown in Fig. 9 and 10, respectively. The sales value of Regional Office publications sold through WHO head- quarters was some Sw.fr. 85 000. HEALTH LEGISLATION The health legislation programme developed substantially during the year. New types of activity were included at the request of Member States, more countries became involved in existing activities, and the legal compo- nents of other regional programmes were developed. The Advisory Committee on Health Legislation, the fi rst to be established by a Regional Office , held its first meeting in Dresden in June, and brought together public health administrators and legal experts. In its general considerations the Committee recognized that health legis- lation is a very important tool for putting in to effect health policies and an im portant contribution to the regional strategy for HF A2000, particularly in 87 88 Fig. 9. Copies of publications and documents requested from the Regional Office in 1981, by language 67 (0.4%) 2356 (14.7%) 55 (0.3%) 13534 (84.5%) ■ Engl ish Ill French rm Lill German D Russian Fig. 10. Requests for publications and documents received by the Regional Office in 1981, by region, expressed as percentages 100 90 80 74.2% 70 ~ 60 !9 C: 50 B ... 4> 40 Q. 30 20 10 0 EUR AMR OTHER Region the areas of health promotion , life- styles, primary health care, and equality of access to health services. The Committee gave absolute pri- ority to the study on trends in health legislation with the aim of assessing progress towards HFA2000. It also recommended that the Regional Office invite Member States to take steps to incorporate heal th legislation in to the curricula of schools of public health . An international health legislation course for senior public health officials was also suggested. It was recommended that effect should be given as soon as possible to the proposal to draw up a list of ex perts in medical and health law, and hospital , environme ntal , phar- maceutical and food hygiene legislation . The final report of the Advisory Com- mittee was sent to the five other WHO Regional Offices, for use in their own health legislation activities. In December a plann ing meeting for the study on trends in health legislation was held in Copenhagen. An intensive two-day brainstorming session led to the elaboration of the protocol of the study including its scope and limitations, its overall design , the me thodology, and a schedule of activities. The pilot notificatio n system in- itiated in 1980 was expanded during the year, a nd was me t with interest by natio nal ad ministrations as well as some nongovernmen ta! and in te rgovern- mental organization s. The information collected will be passed o n to WHO head- quarters for publicatio n in the Inter- national digest of health legislation. As a contribution to the Inter- natio nal Year of Disabled Persons, a study was made of policy and legis- lation for the disabled . This review and analysis of trends in Europe was made possible by contributions re- ceived from national ministries of health and social services, as well as a number of intergovernmental and nongovernmental organizations active in th is field. Input to other Regional Office programmes for the d evelopment of the legal aspect of their activities in 1981 was mainly concerned with those on maternal and child health, family planning, health care of the elderly, disability prevention and rehabilitation , me ntal health , and environmental health. This aspect of the work increased considerably, with 16 regional pro- grammes having activities concerned with legal aspects. The Regional Office was rep- resented on two committees of ex- perts on legal problems in the medical field organized by the Directorate of Legal Affairs of the Council of Europe. The committees completed th e drafting of a recomme ndation for the protection of rights of persons suffering from me ntal disorders. Country activities Algeria. The Directorate of Legal Affairs o f the Ministry of Pu blic Health consulted the Regional Office for in- formation o n health codes and laws concerned with the organization of health services in countries both within and outside Europe. Belgium. The Regional Officer for Heal th Legislation was invited by the Belgian Government to lecture at 89 the Faculty of Medicine of the Ca tholic University, Leuven. On the occasion of this visit contacts were also strengthened with the Ministry of Public Health and Family Affairs. Greece. The Ministry of Social Ser- vices plans to proceed with the simpli- fication and updating of health legis- lation , and has sough t collaboration with the Regional Office. Morocco. At the request o f the Ministry of Public Health , the Re- gional Officer for Health Legislation lectured at the National School of Public Ad ministratio n , Rabat , on com- parative and international aspects of heal th legisla tio n. HEALTH LITERATURE SERVICES The Librarian o f the Ministry of Public Health , Morocco spent two weeks in the Regional Office library to become acquainted with the hand- ling of documentation and biblio- graphical research and to align the methods or systems used in Morocco with those in the Office. Within the framework of collab- oration with libraries and in forma tion centres in the biomedical and related fields in Member States, a visit was made to the lnstitut fi.ir Wissenschafts- in formation in der Med izin and the library of the Akademie fi.ir arztliche Fortbildung, in the German Democratic Republic. Arrangements were made with the Institut to supply the Office, on request , with microfiches of indexed 90 literature and , with the Akademie, for the exchange of photocopies. Further- more, cooperation with the Deutsch es lnstitut fi.ir medizinische Dokumentation und In formatio n , in Cologne, was de- veloped and its courses on bibliographical data retrieval were attended by a mem- ber of the Office staff. The Regio nal Office library participated actively in the work of the International Federation of Library Associations and Institutions (I FLA) and is assisting in the compi- lation of a world directory of biological and medical sciences libraries. A management study was con- ducted in December to review the library services in the light of the new require- ments of Member States and the Re- gional Office. HEALTH INFORMATION OF THE PUBLIC Involvement of the mass media in the Organization's efforts to pro- mote HF A2000 was the prime objective of the Public Information Office in 1981. Only by creating public aware- ness of this goal can the task under- taken by Member States be assured of even tual success. In practical terms this has mean t that the role of journalists should be upgraded from the status o f observer to that of active participant in the health dialogue whenever possible. The basis fo r this new policy had been laid in 1980, and in February 1981 the first informal agreement was reached in Paris with the Association nationale des Joumalistes d'Information medicale (ANJIM), who agreed to collect news of interest to their members - and there- fore to the public at large. Later in the year ANJIM nominated two of its members to attend the session of the Regional Committee in Berlin and the Working Group to Define Means of Prevention of Disability in the Elderly, in Cologne. It is now hoped that similar arrangements can be concluded with other respo nsible professional bodies among the European mass med ia . Closer links were also establ ished with the German Green Cross, a non- governmental organization established in Marburg, Federal Republic of Ger- many, which has been most active in the public information field , notably in countering smoking advertising. HEALTH INFORMATION Proposed budget and actual expenditure for 1980/ 81 (US$) Proposed Expenditure budget 1980 1981 1980/8 1 Regular funds 3 679 700 I 528 244 I 925 346 3 453 590 UN funds Voluntary funds 38 700 26957 26957 3 718400 I 528 244 I 952 303 3 480 547° 0 Being 9 .96% of total expenditure. 91 Chapter 8 GENERAL SERVICES AND SUPPORT PROGRAMMES PROGRAMME PLANNING AND GENERAL SUPPORT The d ecision taken in resolution EUR/ RC'30/ R7 to convene the Re- gional Committee a t the Regio nal Office every two years, beginning in I 982, was recognized as a wel- come opportunity for government rep- resentatives to meet staff and visit facilities in the Office. It will a lso have the advantage o f providing a full range o f services and facilities in support of the Regional Committee. The Thirty-fourth World Health Assembly approved the constructio n of an elevator and to ile t facilities for the handicapped in the confer- ence a rea, a nd work was completed towards the end o f the year. An architectural s tudy fo r a new build- ing was also carried o ut in the same period. Initial steps were taken to extend the computerization of budget and finance fun ctions to the Regional Offices. The European Office served as a pilot area, and towards the end of the year the budget and finance functio ns were fully co mp uterized and work ing reasonably, providing the in- form ation needed for Organization- wide reporting in a computer-readable fo rm. The Office was also host to staff from the Regio nal Office for Africa, for briefing o n computerization of budget and finance operatio ns. The tex t processing unit , enlarged to include reports and secre tarial services, was t ransferred from the support programme to the health in- formation programme. The support programme collaborated close ly with the health information programme in arrangements to decentralize text pro- cessing in the Office, including con- t racts with suppliers. The financial situation, which was critical during the first half of the bi- ennium, eased somewhat during 198 1. STAFF DEVELOPMENT AND TRAINING Throughout I 98 1 the programme on staff development and train ing 93 (SOT) continued to build on its five basic elements: briefing, languages, man- agement, continuing educa tion , and counselling. Conso lidation and prog- ress were shown by the broader range of activities offered in the year's cal- endar of training events. Attention has la tely focused on the ro le of SDT in furthering the mana- gerial process for WHO's programme develo pment (M PWPO). In so far as MPWPD is a domestic reflection of a worldwide strategy, the managerial process for national health develop- ment, the role of SOT can be seen in a much wider contex t than the traditional one of skills training and career development. Hence the recent request by the WHO governing bodies for a general review o f past SDT pro- grammes, with a view to defining inter- regional SOT policies and strategies and the formulation of global trajning objectives for the Seventh General Programm e of Work. PERSONNEL During the period under review, three professional posts were estab- lished in the Regional Office (one fund ed by UNFPA) , and one in the field (financed by UNDP). T wo professional posts were abolished in the Regio nal Office, a nd two in the fie ld (o ne finan ced by UNOP). Of the 76 professional posts in the Regional Office , 16 (2 1 %) were held by women. 94 CO FERENCE, OFFICE AND BUILDI NG SERVICES Insulation in some of the buildings was improved , resulting in considerable savings in heating costs. There we re 4 7 WHO meetings and 16 non-WHO meetings held a t the Regional Office, with 9 14 and 794 participants respectively. A to taJ of 1898 participants a t- te nded the 74 WHO meetings held away from the Regional Office during the period under review. BUDGET AND FINANCE Regular funds (biennial) With the introduction of full biennial budgeting and accounting for th e period 1980/8 1, regular funds we re allo tted for two years and are reported only at the end o f the bienn ium. A total of US $24 85 1 69 1 was expended under regular funds during th e biennium, representing I 00% o f the regular budget allocat ion . At the e nd of each chapter of this report are to be fo und com- parative figures showing actual ex- penditure incurred during 1980/ 8 1, as compared to the proposed budget contained in docume nts EUR/ RC28/ 3 (regu lar funds) and EUR/ RC30/ 6 (extra- budgetary funds). Ex trabudgetary sources United Nations funds (annual) Under United Nations sources, namely UNDP , UNEP and UNFPA, a total of US $3 403 444 was ex- pended in 1980 and US $2 760 973 in 198 1. This covered the implemen- tation of some 55 projects in coun- tries of the Region and several inter- coun try projects. Other funds (biennial} Under other funds , which in- clude the Voluntary Fund for Health Promotion , Funds-in-Trust , the Spe- cial Account for Servicing Costs, and the Real Estate Fund , a to- tal of US $3 858 700 was expended in 1980/8 1. Member States provided consider- able assistance by cove ring the local costs of WHO meetings and of at- tendance by national experts at meet- ings abroad. The collaboration of in- stitutes in Member States in the re- search programme o f the Regional Office is another form of assistance which is not easily expressed in mon- e tary terms. A breakdown by source of vol- untary con tribu lions received during 198 1 is shown in Table 6. In ad- dition, US $46 948 was contributed by the Government of the German Democratic Republic towards the cost of the thirty-first session of the Re- gional Committee. Table 6. Voluntary contributions, including Funds-in-Trust, received during 1981 (US$) Austria 125 688 Belgium 76350 Denmark 185000 Finland 71 254 Germany, Federal Re- public of 206432 Netherlands 15153 Norway 18075 Switzerland 29 707 Commission of the European Communities 10950 Danish Nurses' Organization 21 111 Japan Shipbuilding Industry Foundation 58812 Joint European Medical Research Board 17 000 National Institute on Aging, USA 20000 Order of St John of Jerusalem (Denmark) 25000 Salvat Editores, Barcelona 31 753 912 285 95 GENERAL SERVICES AND SUPPORT PROGRAMMES Proposed budget and actual expenditure for 1980/81 (US$) Proposed Expenditure budget 1980 198 1 1980/81 Regular funds 5 913 700 2 857 406 3 365 967 6 223 373 UN funds Voluntary funds Real Estate Fund n.a. 6850 65449 72 299 Special Account for Servicing Costs n.a. 559 357 377 387 936 744 5 913 700 3423 613 3 808803 7232416° 0 Being 20.68% of total expenditure. 96 Annex 1 ACTIVE AND NON-ACTIVE MEMBER STATES OF THE WORLD HEALTH ORGANIZATION, EUROPEAN REGION 31 December 1981 At 31 December I 981 the European Region of the World Health Organization had 33 active Member States and 2 non-active Member States. They are listed below with their date of entry to the Organization. Albania 26 May 1947 Italy 11 April 1947 Algeria 8 November 1962 Luxembourg 3 June 1949 Austria 30 June 1947 Malta I February 1965 Belgium 25 June 1948 Monaco 8 July 1948 Bulgaria 9 June 1948 Morocco 14 May 1956 Byelorussian SSR0 7 April 1948 Netherlands 25 April 194 7 Czechoslovakia I March 1948 Norway 18 August 1947 Poland 6 May 1948 Denmark 19 April I 948 Portugal 13 February 1948 Finland ? October 1947 Romania 8 June 1948 F rance 16June 1948 San Marino 12 May 1980 German Democratic Spain 28 May 195 1 Republic 8 May 1973 Sweden 28 August 1947 Germany, Federal Switzerland 26 March 194 7 Republic of 29 May 195 1 Turkey 2 January 1948 Greece I 2 March 1948 Ukrainian SSR0 3 April 1948 Hungary 17 June 1948 USSR 24 March 1948 Iceland 17 June 1948 United l(jngdom 22 July 1946 Ireland 20 October 194 7 Yugoslavia 19 November 194 7 0 No n-active Member State. 97 Annex 2 PROFESSIONAL STAFF IN THE EUROPEAN REGION 3 1 December 1981 REGIONAL OFFICE Executive Management Regional Diiector Dr Leo A . Kaprio Diiector, Programme Management Dr J.E. Asva/1 Programme Monitoring Programme Policy Ms V.S. Pedersen Ms C. Celinder Development of Comprehensive Health Services Director Appropriate Technology for Health Family Health Family Planning Dr W.A. Wahba Vacant Dr M.G. Wagner Ms W. Haddada Vacant Global Programme for Care b of the Aged Dr DM. Macfadyen Health Ca re of the Elderly (Regional Programme) Health Education Nursing Primary Health Care Prophylactic, Diagnostic and Vacante Ms I . Kiekbusch Vacante MsE.Stum· Dr H. V. Vuori The rapeutic Substances Mr A. Grimsson Disease Prevention and Contro l Director Global Programme for Accident Prevention a Paid by UNFPA. b Paid by WHO headquarters. Vacan t Dr C.J. Romerb c Duties performed by a consultant. Disease Prevention and Control (contd) Accident Prevention (Regional Programme) Cancer Chronic Diseases Communicable Diseases Malaria Mental Health Oral Health Dr J. T. Jones Vacant Dr V. Zaitsev Dr B. Ve/imirovic Dr K. Lassen a Dr J .H. Henderson Mr J.U. Hannibal Dr /.J. M,pller Pro motion of Environmental Heal th Dire<:tor Mr J./. Waddington Basic Sanitary Measures Environmental llealth Planning and Management Dr G. Watters Mr E. Giroult Environmental Systems Management Toxicology Food Safety Recognition and Control of Environmental Hazards Workers' Health Dr A. Gilad Vacanrb Ms B. Blomberg Dr M.J. Suess Dr M. Mikhee11 Reseuch, Planning and Hu man Resources Director Country Health Program ming Educational Develo pment Dr A .M . Wojtczak Dr I.S. l.uculescu and Training Dr R . Manrique de l.ara f'cllowships Administratio n Mr E.C. Fricke Dr V. Vodoratsky Mr Y. Timmermans a Duly station in Turkey, paid by UNDP. b Duties performed by consultants. 99 Research, Planning and Human Resources (contd) Health Economics Health Legislation Health Manpower Planning and Management Research Promotion and Development Heallh Information Director Coordination with other Organizations Epidemiology and Health Statistics Health Information of Dr H. Zollner Ms G. Pinet Vacant Dr 8. Niietic Vacant Dr A. Weber Dr W. Fritsche Ms N. Humbert Dr A. Romensky the Public Mr J.M. van Gindertael Health Literature Services Info rmation Systems Ms A. Mercier Programme Publications Dr J.P. Jardel Mr/. Vin ther.Jl,rgensen Ms M. Abou Shabanah MrM.Jones Mr F.E. Theakston Vacant Heallh Information (contd) Reports and Secretarial Services Ms C.F. Murphy Translation and Editorial (Chief) Mr J.-M. Deramat (English) Mr P.J. Boyle (French) Vacant Ms M. Lindemann Ms N. Donald Mr R . Compton-Smith (German) Vacant (Russian) Support Programme Director Administrative Services Budget and Finance Conference Services Personnel Staff Development and Training Mr U. Senn Vacant Mr V. Khortsev Ms E. Safonova Mr G. Y. Sokolo v MrJ. Donald Mr C.G. Chatelier Mr P. laaninen Mr J.P. T. Mulvaney Mr R . Eggleston Mr 1. Tolstoy FIELD STAFF Algeria ALG/BSM 002 (UNDPJ - Promotion of Environ- mental Health Senior Technical Adviser Vacan t ALG/EHP 001 (UNDPJ - Training of Sanitary Engineers, Algiers Sanitary Engineer-Tutor Morocco Dr J. Schulman MOR /ESD 001 - Surveillance and Control of Communicable Diseases, Rabat Biologist Dr F.A . Gatti /CP/PTR 005 - Sanitary Engineering Centre, Rabat Sanitary Engineer Dr N.O. Akmanoglu Turkey TUR/BSM 004 - Appropriate Technology In En- vironmental Health Sanitary Tutor (part-time) Mr P. W. Jolly 100 Turkey (contd) TUR/EHP 001 (UNDPJ - Urban Water Supply and Sewerage, Ankara Senior Technical Adviser Vacanta TUR /FSP 001 - Food Safety Programme Senior Technical Adviser (part-time) Mr P. W. Jolly lCP/MPD 005 - lntercountry Malaria Team, Ankara Field Operations Manager Mr J.O. Espinoza Cajina Sanitarian (part-time) Mr P. W. Jolly /CP/MPD 00 7 (UNDPJ - lntercountry Project for Control of Malaria in South-East Europe Malariologist Scientist Dr K. Lassen Mr J.l. Qarke a Duties partly performed b} a consu ltant. 0 Annex 3 ORGANlZATIONAL CHART OF THE REGIONAL OFFICE, 31 DECEMBER 198 1 OEVELOPMENl OF COMPREHE~VE HEAL TH SERVICES Appropu11e ll!Chnology to, Health Family HH1th1 Health Care of tht Elderly Health Education Nursmg Prc>phylacoc, 01agnost1c and Therapeutic Substances DISEASE PRE\/ENTION ANO CONTROL Mental HUl(h PROMOTION or ENVIRONYENTAl HEAL TH e nvironmentiil Heiiillh Pt..,,n,ng Ind MaNJl)ltf"MfH Envuoomenul Sys1ems M~agtmtnl Food Safety Rec:~11,on and Control o t Env,ronmenQI Hazards EXECUTIVE MANAGEMENT' RES[ARCH PLA.NNll"'IG ANO HUMAN RESOURCES Coonlry Health Programming Educational Development and Tra,n11,9 Fel~•P\ Adm1mstr111on Health Economics Health leg1sla11on He.alth Manpowet Ptann,ng Ind Managemtnt Rese,rc:h Promolion ar.a Oevelooment ' Comor1NS offtc:• ot tnt Ati91C>f"l• j O,.-.c10, 1na ot ff'• Ou'9ctor P,o,r9mme M W19m ent If weu •• tnei, 101nt 1.cre1ar111 1 Comon,e, M.a(tf"n .. and 01110 H • nr, , no Nuv1110,, J C ompr1.- 1110 Othttf Paras1hC 0,Jt...,. HEAL TH INFORMATION Coordinat10n Wllh othe, Organ,,a11ons E ptdem iology and Health S1a1,s11a Health lnformatl(>f"\ of the Public Health Luer-an.are Services lnformat,on Systems l>rogramme Pubhc,11001 Reports and Secreur\11 Services Translation and Ed110f11I SUPPORT PROGRAMME Conferef"ltt Ser.-,~ Personnel Staff Developmen1 and Training ICP/ RCE 401(5) ICP/ DPM 003 ICP/SPM 049 ICP/ RCE 209 ICP/ RCE 903(7) ICP/WKH 014 ICP/ PHC 0 19(2) ICP/ MNH 027 ICP/ MCH 022 ICP/ RCE 402( I) Annex 4 INTERCOUNTRY 0 MEETINGS CONVENED BY THE REGIONAL OFFICE FOR EUROPE IN 1981 Working Group o n Sewage Sludge to Land : Health Implicatio ns of the Microbial Content , Steve nage, 6- 9 January (English) Consultation on the Role of the Regio nal O ffi ce in Internatio nal Drug Evaluation and Registratio n, Copenhagen , 7 - 8 January (English) Meeting on the Use of Residual Vision by Visually Impaired Dis- abled Persons, Brussels, 28 - 30 January (English) WHO Guidelines for Drinking-Water Quality - Consultation on Organ oleptic Aspects, Copenhagen , 2 - 5 February (English) Working Group on Contingency Planning for, and Response to, Emergencies and Accidents Involving Po te ntially To xic Chemi- cals, Bilthoven , 9 -1 3 February (English) Technical Committee on Monito ring and Evaluat ing Airborne Man-Made Mine ral Fibres, Edinburgh , 26-27 February (English) Study o n Manageme nt Needs of Primary Health Care - First Meeting o f the Principal Investigato rs, T ampe re, 2 -4 March (English) Wo rking Group on Control of Alcohol Consumption , Copen- hagen , 2 - 6 March (English) Perinatal Study Grou p Su bcommittee on Psychosocial Factors , Copenhagen , 16- 17 March (English) Wo rking G roup o n Guidelines for the Control of Toxic and Other Hazardous Waste, Garmisch-Partenkirchen , 17-20 March (English) a Several o ther mee tings held during the year were financed through country project funds. Some o f these, tho ugh no t listed here, were of considerable interest to mo re than one count ry. 103 ICP/ADR 045 Consultations on Teaching Gerontology/Geriatric Medicine and Establishing a Clearing-House for Curricula, Copenhagen, 19-20 March (English) ICP/ADR 051( I) Symposium on Epidemiology of Accident Traumas and Resulting Disabilities, Strasbourg, 19-21 March (English, French) ICP/CVD 022(1) Consultation on Health Care Related Hype rtension Research , Munich, 20-21 March (English) ICP/CVD 005( 18) Study on Effects of Rehabilitation and Secondary Prevention in Patie nts with Cardiovascular Diseases - Meeting of the Editorial Board , Bonn, 30-31 March (English) ICP/ EHP 005 Working Group on Basic Sanitation Operators, Professional Pro- mes and Training Requ irements, Delft, 30 March - 3 April (English) ICP/GPD 003(2) Regional Health Development Advisory Council, Copenhagen, 3 1 March - 2 April (English, French, German, Russian) ICP/GPD 001(5) Consultative Group on Programme Development, Copenhagen, 2-3 April (English, French, German, Russian) ICP/ PPM 002(4) Fourth Advisory Committee on the Medium-Term Programme in Nursing/ Midwifery in Europe, San Marino , 2-4 April (English) ICP/CAN O 13 UICC/ WHO Meeting on Undergraduate Education in the Cancer Field, Geneva, 6 - 8 April (English, French , German, Russian) ICP/SPM 043(1) Consultation on Indicators for HFA2000, Copenhagen, 6- 9 April (English) ICP/RPD 004(4) Consultation on Standardization of Methods, Measurements and Terminology in Health Services Research , Copenhagen, 27- 30 April (English) ICP/DPM 002 Meeting of the WHO Drug Utilization Research Group, Korc ula (Yugoslavia), 28-30 April (English) ICP/ MCH 022 Perina tal Study Group Surveillance Subcommittee, Prague, 4-6 May (English) ICP/MPM 026(2) Meeting of Programme Managers from Collaborating Centres Associated with the Medium-Term Programme in Nursing/Mid- wifery in Europe, Copen hagen, 4-9 May (English) 104 ICP/ RCE 903(9) Planning Meeting on Monitoring and Epidemiological Studies for Toxic Chemicals Control, Copenhagen, 5-8 May (English) ICP/ BVM 008 Working Group on Oral Enteric Vaccines, Frankfurt, 11-12 May (English) ICP/ ADR 044 Working Group on the Role of Medical Factors in the Causation of Road Accidents, Belgrade, 12 - 14 May (English) ICP/ RPD 803( I ) Workshop on the Control of Health Care Costs in Social Security Systems, Vienna , 25-28 May (English) ICP/SPM 008(2) Meeting o f Principal Investigators for the Study on Epidemio- logical Surveillance of Environmental Hazards, Reykjavik , 25-28 May (English) ICP/CVD 002(20) Wo rking Group on the Prevention of lschaemic Heart Disease , London , 1-2 June (English) ICP/ RPD 006(4) Working Group on Guidelines for Clinical Trials of Minor Tran- quillizers and Sedatives, Copenhagen , I -2 June (English) ICP/ BVM 005 Working Group on Yersiniosis, Paris, 1-3 June (French) JCP/ RPD 001(7) Seventh Session of the European Advisory Committee for Medi- cal Research , Copenhagen, I 5 -1 7 June (English , French, Ger- man, Russian) ICP/ RCE 903(10) Planning Group on Development of Curricula for Manpower Training for Occupations in Toxic Chemicals Control , Brussels, 15- 19 June (English) ICP/ATH 010 Meeting on Health Technology Assessme nt Network , Copen- hagen, 17-1 8 June (English) ICP/ HLE 002 Advisory Committee on Health Legislation , Dresden, 24-26 June (English, French, German, Russian) ICP/WKH 010 Consultation on Training of Occupational Health Personnel, Belgrade, 24- 26 June (English) ICP/ RPD 80 I( I) Meeting of Study Collaborators (Physicians' Use of Clinical Sup- port Services under Non-Life-Threatening Conditions), The Hague, 29-30 June (English) 105 ICP/MCH 025 Joint ICC/WHO International Conference on Training in Family Planning for Health Personnel, Paris, 6-11 July (English, French) ICP/ADR 054 Working Group on Behavioural Studies Re lated to Care of the Aged , Lubeck, I 0-12 July (English, German) ICP/BSM 003(6) Workshop on Environmental Health Problems in Arctic and Sub- arctic Areas, Copenhagen, 3-7 August (English, Russian) ICP/PHC O 17 Working Group on Comparative Studies in Circumpolar Health, Copenhagen , 8-9 August (English) IC P/OND 011(2) Meeting of Principal Investigators for the Collaborative Study on Health Promotion in Youth, Helsinki , 17-19 August (English) IC P/ MNH 007(8) Eighth Mee ting on Men tal Health Services in Pilot Study Areas, Mannheim, 25 -28 August (English, French , German) ICP/SPM 031 Working Group on Medicosocial Services in Hospitals, Helsinki , 1-4 September (English , French) ICP/ HST 005 Workshop on the Evaluation of ICD-9, Canterbury, 1-5 Septem- ber (English) ICP/ RPD 804(2) Progress Meeting for the Study on the Infl uence of Economic Development on Health , Munich, 9-11 September (English) ICP/ESD 003(1) Working Group on the Economic Aspects of Communicable Diseases, Trier (Federal Republic of Germany), 2 1-23 Septem- ber (English, German) ICP/ RCE 903( 12) Working Group on Regulatory Schemes for Chemicals in Con- sumer Products, Varna (Bulgaria), 21 -25 September (English) ICP/ PPM 004 Consultative Group on the Organization and Scope o f Research in Educa tion for the Health Professions, Prague , 28 September I October (English) ICP/MNH 036(1) Working Group on Changing Patterns in Suicide Behaviour, Athens, 29 September - 2 October (English) ICP/CVD 022(2) Consultation on Health Care Related Hypertension Research , Lisbon , 6-7 October (English) ICP/RPD 00 I Meeting of EACMR Planning Subcommittee, Copenhagen, 6 - 7 October (English) 106 ICP/CVD 023 Joint HQ/ EURO Meeting of Investigators on New Monitoring Systems for the Incidence of CVD in Populations, Geneva, 12-15 Octobe r (English) ICP/CVD 002(21) Meeting on Primary Prevention of lschaemic Heart Disease (Atromid Trial), London , 19 - 20 October (English) ICP/ BVM O I 5 Wo rking Group on Legionnaires' Disease, Baden (Austria), 19- 2 1 October (English) ICP/MPM 019 Seminar on the Continuing Education of Health Wo rkers in Primary Health Care, San Remo, 19-2 1 October (English, French) ICP/CAN 007 Wo rking Group on the Development of Cancer Centres and Community Cancer Control Programmes in Europe, Luxem- bourg, 20-22 October (English, French) ICP/MPD O 12 Workshop o n Glucose 6-Phosphate Dehydrogenase Deficiency, Adana (Turkey), 20-22 October (English) ICP/WKH 007 Working Group on Occupational Hazards in Hospitals, The Hague, 20-22 October (English) ICP/OND O 13( I) Study on Chronic Lung Diseases Leading to Pulmonary Hyper- tension - Mee ting of Investigators, Naples, 26-27 October (English) ICP/SPM 028 Wo rking Group on Health Planning and Management, Athens, 26-28 October (English) ICP/ MPM 0 28 Workshop on Health Manpower Planning, Copenhagen, 26- 30 October (English) ICP/PHB 009 Tenth European Symposium o n Clinical Pharmacological Evalua- tion in Drug Control: Drugs for In fants and Children , Schlangen- bad (Federal Republic of Germany), 27-30 October (English , French , German, Russian) ICP/GPD 003(4) Mee ting of the Steering Group fo r the Further Development of the Regional Strategy fo r HFA2000, Athens, 29 -30 October (English) ICP / RCE 903(13) European Cooperation on Environmen ta) Health Aspects of the Control of Chemicals - Second Meeting o f the Steering Commit- tee, Athens, 2-5 November (English) 107 JCP/ PPM 003(2) ICP/ PHC 0 13( I ) ICP/CVD 02 1( 1) ICP/SPM 004(9) ICP/SPM 022(3) ICP/ATH 0 14 ICP/FSP 002 ICP/MCH 025(3) ICP/ EHP 003(7) ICP/ADR 024 ICP/SPM 032 ICP/CVD 020 ICP/GPD 0 10 108 Third Adviso ry Committee on the Health Manpower Develop- ment Medium-Term Programme, Copenhagen, 3-5 November (Engl ish) Study on Efficiency of Primary Hea lth Care - Study Group Meeting, Copenhagen , 6 - 7 Novem ber (English) Meet ing on the Evaluatio n of Diagnostic and Therapeutic Ad- vances in Cardio logy, Budapest, 9- 11 November (English) Third Mee ting of the Editors for the Report on the Study on Heal th Care o f the Elderly, Copenhagen, 9 -11 November (English) Interagency Coordination Meeting on Health Economics, Copen- hagen, 10 -11 November (English) Working Group on Poison Prevention and Role of Poison Control Centres in Health Care Systems, Rome, I 0- 13 November (E ng- lish, French) Working Group on Hea lth Aspec ts of Residues of Anabolics in Meat, Bilthoven, 10 -1 3 ovember (E nglish) Meeting of the Steering Group on the Study on Trends in the Demographic Structure in the European Region: Health and Social Implications, Copenhagen, 12- 14 November (English) Seminar on Appropria te Technology for Drinking-Water De- minerali zation , Algiers - El Djezair, 14-1 9 November(French) Working Group to Defi ne Means of Prevention of Disability in the Elderly, Cologne, 16- 19 November (English, Ge rman) Conference on ursing and Medicosocial Wo rk in the Care o r the Elderly, Cologne , 16- 19 Nove mber (English, French , German, Russian) Joint EURO/ HQ Mee ting on an Integrated No ncommunicable Disease Prevent ion and Control Programme, Kaunas (USS R), 16 - 20 November (English) Seminar on Programme Consu ltation with Member States, Copen- hagen, 19-20 ovember (English , French, German, Russian) ICP/ ERO 001 ICP/WKH 0 14 ICP/ HED 019 ICP/PHC 0 14 ICP/ ADR 005 ICP/ BVM 005 ICP/SPM 043(3) ICP/ HLE 004 ICP/CAN 01 9 ICP/ RPD 006(5) ICP/ BSM 003( I ) ICP/ATH 01 5 Wo rkshop for Preparedness in Facing Health Problems from Natural Disaster Emergency Situatio ns, Rabat, 22 -25 Novem- ber (French) T echnical Committee on Monito ring and Evaluating Airbo rne Man-M ade Mine ral Fibres, Nancy, 24 Novembe r (English) Wo rking Group o n the Concepts and Principles o f Health Pro- mo tio n , Copenhagen , 26- 28 November (English) Sy mposium o n Primary Health Care in Europe - From Theory to Action , Kuopio ( Finland) , 30 November - 3 December (English) Advisory Committee on Accident Preve ntion , Dresden , 1- 2 December (Engl ish) F irst Regional Scientific Working Group on Diarrhoeal Diseases, Copenh agen , 1-2 December ( English , French) Meeting of Ed ito rial Board fo r the Publicat ion on Positive Measurements of Health , Copenhagen , 1-3 December (English ) Planning Mee ting on Study on Trends in Health Legislation , Copenhagen , 3-4 December (English) Preparatory Consultatio n on Model Hea lth Care Programme in Colo n Cancer , Leningrad , 7- 8 December (English , Russian) Wo rking Group o n Guidelines for the Evaluation of Non-Steroid Anti-Inflamma tory Drugs and Slow-Acting Anti-Rheumatic Drugs, Copenhagen , 7-8 December (English ) Consultatio n on International Drinking-Wate r Supply and Sanita- tion Decade in Europe, Copenhagen , 7 -11 December (English , French ) Seminar o n the Role o f Cy tological and Endocrino logical Ser- vices in Primary Health Care and Family Planning, Malta, I 0- 12 December (F rench ) 109 Annex S WHO-SPONSORED COURSES IN THE EUROPEAN REGION, 1981 In ternational Sanitary Engineering Course, Lisbon , February 1980 - Ju ne 1981 (POR/ EHP 001) In ternational Sanitary Engineering Course (English language) , Ankara, February 1980 - July 1981 (TUR/EHP 003) Environmental Engineering Course (English language), Istanbul , Febru- ary I 980 - July 1981 (TUR/ EHP 003) Sanitary Engineering Course, Istanbul, February 1980 - July 1981 (TUR/EHP 003) Sa nitary Engineering Course , Izmir, February 1980 - July 198 1 (TUR/ EHP 003) Sanitary Engineering Course, Algiers, February 1980 June 198 1 (ALG/EHP 001) Sanitarian Training Course, Ankara , September 1980 July 198 1 (TUR/ BSM 004) Sanitarian Training Course, Algie rs, Sep tember 1980 - June I 98 1 (ALG/ EHP 002) Course on Medical Physics in Radiothera py, Geneva, September 1980 - March 198 1 Sanitary Engineering Course, Rabat , October 1980 July 198 1 (ICP/ PTR 005) Course in Sanitary Engineering, Delft , Octo ber 1980 September 198 1 Course on Environmental Scie nces and Technology, De lft , Oc to- ber 1980 - September 1981 Course for Public Health Adminis trators (Russian language) , Moscow, October 1980 - July 198 1 (ICP/MPM 006) I I I 11 2 Course for Public Health Administrators (English language), Moscow, Oc tober 1980 - July 198 1 (ICP/MPM 007) International Sanitary Engineering Course, Lausanne , January - Dece mber 1981 (ICP/ EHP 001) International Sanitary Engineering Course (Russian language), Warsaw, January - December 1981 (ICP/ EHP 001) Special Course in Sanitary Engineering, Algiers, February 1981 - July 1982 (ALG/ EHP 00 1) International Sanitary Engineering Course, Lisbon, February 1981 - June 1982 (POR/ EHP 001) International Sanitary Engineering Course (English language) , Ankara, Fe bruary 1981 - July 1982 (TUR/ EHP 003) Environmental Engineering Course (English language), Istanbul, Febru- ary 1981 - July 1982 (TUR/ EHP 003) Sanitary Engineering Course, Is tanbul , February 1981 - July 1982 (TUR/EHP 003) Sanitary Engineering Course, Izmir, February 1981 - July 1982 (TUR/EHP 003) Course on Productio n of Lyophilized BCG Vaccine , Copenhagen , February - April 1981 Workshop on Malaria and Primary Health Care in Turkey, Ankara, February 198 1 (TUR/ MPD 003) Wo rkshop on Environmen tal Impact Assessment, Jablonna, Febru- ary 198 1 (POL/ RCE 003) Interregional Training Course in the Epidemiology and Control of Communicable Diseases (French language) , France/Upper Volta/ Ivory Coast, February - June 198 1 Training Course on Appropriate Technology for Liquid Wastes Treat- ment (French language), Algie rs, March 198 1 (ALG/ EHP 001) Seminar on Drinking-Water Demineralization (French language), Algiers, February 1981 (ALG/EHP00I) Interregional Training Course in the Epidemiology and Control of Communicable Diseases (English language), Geneva/Czechoslovakia/ USSR/Cameroons, February - July 1981 Interregional Course on EPI Planning and Management (French language), Rabat, March 1981 Seminar on Psychopharmacology for French-speaking Countries, Louvain , March - April 1981 Course in Immunology, Lausanne, April - July 198 1 Course on Production of Lyophilized BCG Vaccine, Copenhagen, May - July 1981 Interregional Cou rse on Health Aspects of Environmental Po llution, Sofia, May 198 I Seminar on Primary Health Care for Children , Prague, May - June 198 1 (CZE/ MCH 002) Fourth Internatio nal Training Course in Occupational and Environ- mental Toxicology, Belgrade , May - June 198 1 Workshop on Organization of Occupational Health Services, Sofia, June 1981 Eighth Vaccine Course , Bilthoven , June 1981 WHO/ UNFDAC Seminar on Public Health Problems and Psychotropic Substances - Development of a Manual , Finland, June 1981 First International Course on Education for Health Services Adminis- tration , Lisbon , June - July 1981 Workshop on Primary Health Care, Medea, June 1981 Medical Care and Public Health Services, International Summer School , University of Oslo, June - July 1981 Fourth BLAT/WHO Course on Modem Methodology for Teachers of Health Sciences, London , June - July I 98 1 WHO International Wo rkshop o n Country Health Programming and Related Managerial Processes for National Health Development , Leeds/ Edinburgh , July 198 1 (ICP/CHP002) 113 I I 4 Co urse for Public Health Administrators (Russian language), Moscow, October 198 1 - July 1982 (ICP/ MPM 006) Course for Public Health Administrators (English language), Moscow, October 198 I - July 1982 (ICP/MPM 007) Course on Production of Lyophilized BCG Vaccine, Copenhagen , August - October 198 1 International Symposium o n Education and Training Policies in Occu- pational Safety and Health and Ergonomics, Sande fjord, August 198 I Course on the Application of Biochemical Micro methods for the In- vestigation of T ropical Disease Pathogens, Novosibirsk , August - September 198 1 Internatio nal Course on Toxicology of Pesticides, Sofia, August - September I 98 I (ICP/ RCE 903/ 11) Sanitary Technology Course, Algiers, September 198 1 - July 1982 (ALG/EHP 002) Sanitarian T raining Course , Ankara, September 198 1 - July 1982 (TUR/BSM 004) WHO/ NRIMC Interna tional Course on Fami ly Health/ Fanu ly Plan- ning for Instructors in Nursing/ Midwifery, Warsaw/ Rabka, Septem- ber 198 1 ( ICP/ MCH 025( 1)/8 1) Workshop on the Organization , Developmen t and Evaluation of Basic Health Services, Brussels, September 198 I (ICP/ PHC 023) Seminar on th e Planning and Organization of MCH Services (French language), Sofia, September - October 198 1 Seminar o n Water Hygiene and Drinking-Wate r Quality Surveillance, Moscow/E revan, September - October 198 1 Course on Environmental Impact Assessment , Aberdeen , September - October 198 1 Course on the Health Services of the Ge rman Democratic Republic, Berlin , September - October 198 1 International Sanitary Engineering Course, Delft , October 198 1 - September 1982 ( ICP/EHP 001) International Environmental Specialist Course, Delft , October 1981 September I 982 ( ICP/ EHP 001) Interregional Training Course and Study Tour on the Application of Isotope and Radiation Techniques in Medicine , Moscow, October - November 198 1 UNEP/WHO Interregional Workshop on Air Pollution from Motor Vehicles, Moscow, October 198 1 Third Travelling Seminar in the USSR on the Safe Use of Psychotropic and Narcotic Substances, USSR, October 1981 International Postgraduate Course on Methods o f Family Planning, Debrecen , October 198 1 (H UN/MCH 00 I) Course on the Quality Control of Drugs, Paris, October 1981 (ICP/ PHB 002) IAEA/WHO Training Course on Calibration o f Dosimeters Used in Radiotherapy and Radiation Protection, Neuherberg, October November 198 1 Seminar on Integrated Control of Mosquito Vectors, Adana, Novem- ber I 98 1 Training Course on Sexually Transmitted Diseases, Morocco, Decem- ber 198 1 I I 5

Annex 6 ESTIMATED POPULATIONS IN 198 1 FOR THE ACTIVE MEMBER STATES OF THE WHO EUROPEAN REGION (in th ousands)a Albania 2 792 Luxembourg Algeria 19 589 Malta Austria 7 475 Monaco Belgium 9840 Morocco Bulgaria 9052 Netherlands Czechoslovakia 15 41 6 Norway Denmark 5 130 Poland Portugal Finland 4 883 Romania France 53 663 San Marino German Democratic Republicb 16 859 Spain Germany, Federal Republic ofb 60765 Sweden Greece 9384 Switzerland Hungary l0779 Turkey Iceland 233 USSR Ireland 3 345 United Kingdom Italy 57 111 Yugoslavia 358 346 26 20954 14142 4092 36148 9907 22 442 2 1 37696 8 273 647 1 46354 267989 55 836 22498 a Based on World population prospects as assessed in 1980. New York , United Nations, 1981 . b The figures for the German Democratic Republic and the Federal Republic of Germany include the relevant data for Berlin. This is without prejudice to any question of status that may be involved. 11 7

THE WORK OF WHO IN THE EUROPEAN REGION 1986 THE WORK OF WHO IN THE EUROPEAN REGION 1986 Annual Report o f the Regional Director WORLD HEALTH ORGANIZATION Regional Office for Europe COPENHAGEN 1987 Feature Environmental health in the Mediterranean: WHO and the Mediterranean Action Plan (between pages 74 and 75) Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0 , Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. P R IN T E D IN D EN M A R K EUR/RC37/2 ISSN 1014-4323 (print) CONTENTS Page F o r e w o r d ........................................................................................................................................... ix 1. R e g io n a l p o lic y d e v e lo p m e n t, e v a lu a tio n a n d p ro g ra m m e m an a g e m e n t .................................................................................. 1 General programme management and development ...................................................... 1 Country programme coordination ....................................................................................... 3 Health information of the public .......................................................................................... 4 Support programmes ............................................................................................................... 4 Personnel............................................................................................................................. 4 General administration and services ............................................................................ 5 Budget and finance .......................................................................................................... 5 Staff development and training ............................................................................................ 6 Publications............................................................................................................................... 7 Epidemiology and statistics ................................................................................................... 8 2. H ea lth fo r a ll in E u ro p e by the y e ar 2 0 0 0 ......................................................... 11 Target 1. Equity in health ................................................................................................... 11 Target 2. Adding life to years ............................................................................................ 13 The elderly ........................................................................................................................ 13 Target 3. Better opportunities for the disabled ............................................................. 13 Health legislation ............................................................................................................. 13 Community-based rehabilitation ................................................................................... 14 Target 4. Reducing disease and disability ....................................................................... 15 Disability prevention ........................................................................................................ 15 Genetic services ................................................................................................................. 15 Rheumatism ...................................................................................................................... 16 Mental health .................................................................................................................... 16 Communicable diseases ................................................................................................... 17 Diarrhoeal diseases .......................................................................................................... 19 Oral health ........................................................................................................................ 20 v Target 5. Eliminating seven specific diseases .................................................................. ...... 22 Diseases preventable by immunization ............................................................................. 22 Malaria ............................................................................................................................... ...... 25 Schistosomiasis ................................................................................................................. ...... 25 Target 6. Life expectancy at birth ........................................................................................... 25 Target 7. Reducing infant mortality rates .............................................................................26 Target 8. Reducing rates of maternal mortality ............................................................. ......28 Target 9. Combating diseases of the circulatory system ............................................... ......30 Target 10. Combating cancer .............................................................................................. ......31 Target 11. Reducing accidents .............................................................................................. ......32 Accident prevention ..............................................................................................................32 Disaster preparedness ..................................................................................................... ......34 Target 12. Stopping the increase in su ic id es.............................................................................35 Evaluation. The oral health programme during the period 1984-1985 ..............................36 3. Lifestyles conducive to health .................................................................................. ......39 Target 13. Healthy public policy ................................................................................................39 Health promotion ............................................................................................................ ......39 National drug policies ..................................................................................................... ......41 Target 14. Social support systems ....................................................................................... ......41 Target 15. Knowledge and motivation for healthy behaviour ............................................42 Health education and health promotion .................................................................... ......42 Sexuality and family planning ....................................................................................... ......43 Target 16. Promoting positive health behaviour ............................................................. ......46 Sexuality and family planning ....................................................................................... ......46 Nutrition ...................................................................................................................................48 Smoking and h ea lth .......................................................................................................... ..... 50 Stress ......................................................................................................................................... 50 Target 17. Decreasing health-damaging behaviour .............................................................. 52 Research ............................................................................................................................. ..... 52 Drug abuse ........................................................................................................................ ..... 53 Alcohol abuse ......................................................................................................................... 53 Child abuse ........................................................................................................................ ..... 54 Evaluation. The health education programme during the period 1984-1985 .............. ..... 54 v i 4. H e a lth y en v iro n m en t ..................................................................................................... ...... 57 Target 18. Policies for a healthy environment .................................................................. ...... 57 Target 19. Monitoring, assessment and control of risks in the environment .................. 58 Chemical hazards ............................................................................................................ ...... 58 New technologies..................................................................................................................... 60 Nonionizing radiation ..................................................................................................... ...... 60 Ionizing radiation ............................................................................................................ ...... 60 Target 20. Water pollution ................................................................................................... ...... 62 Mediterranean Action Plan .................................................................................................. 67 Target 21. Protection against air pollution ............................................................................. 68 Target 22. Food safety .......................................................................................................... ...... 68 Target 23. Protection from hazardous wastes .................................................................. ...... 69 Target 24. Healthy homes ..................................................................................................... ...... 69 Target 25. Healthy working conditions .................................................................................... 70 Evaluation. The environmental health programme during the period 1984-1985 . . . 71 5. A p p ro p r ia te ca re ..................................................................................................................... 75 Target 26. A health care system based on primary health care .......................................... 75 Nursing/midwifery .......................................................................................................... ...... 76 Hospitals ............................................................................................................................. ...... 76 Target 27. Rational and preferential distribution o f resources according to need . . 77 Health service delivery ..................................................................................................... ...... 77 Health care providers ..................................................................................................... ...... 78 Health in stitutions............................................................................................................ ...... 79 Target 28. Content of primary health c a r e ......................................................................... ...... 80 Target 29. Providers of primary health care .................................................................... ...... 81 Target 30. Coordination of community resources for primary health c a r e ....................... 81 Target 31. Ensuring the quality of services ............................................................................. 81 6. R e se a rc h a n d h ealth d e v e lo p m e n t su p p o r t ...................................................... ...... 85 Target 32. Research and health for all ................................................................................ ...... 85 Target 33. Policies for health for all .................................................................................. ...... 86 Collaboration with other organizations ............................................................................. 87 Target 34. Management of planning and resource a llocation ........................................ ...... 89 Target 35. Health information systems .................................................................................... 90 Target 36. Planning, education and use of health personnel for health for all .......... 92 Fellowships ........................................................................................................................ 94 Target 37. Education of personnel in other sectors to support health for all ............ 97 Target 38. Health technology assessment ......................................................................... 97 Pharmaceuticals ............................................................................................................... 99 Eva luation . The health economics programme during the period 1984-1985 ............ 101 7. G lo b a l p ro g ra m m e s ........................................................................................................ 103 Global programme for accident prevention ....................................................................... 103 Advocacy for safety .......................................................................................................... 103 Health and safety promotion .......................................................................................... 104 Collaboration with nongovernmental organizations ............................................... 104 Global programme for appropriate health care technology .......................................... 105 Global programme for health of the elderly .................................................................... 106 8. E v a lu a t io n o f the re g io n a l p ro g ra m m e ................................................................ 109 Introduction ............................................................................................................................. 109 Evaluation of the 1984-1985 program m e........................................................................... 110 Evaluation findings ................................................................................................................. I l l Annex 1. Active and non-active Member States of the World Health Organization, European Region, 31 December 1986 ....................................................................... 1 13 Annex 2. Estimated populations in 1986 for the active Member States of the WHO European Region .............................................................................................. 114 Annex 3. Professional staff in the European Region, 31 December 1986 .......................... 115 Annex 4. Organizational chart of the Regional Office, 31 December 1986 ..................... 117 Annex 5. Intercountry meetings convened by the Regional Office for Europe, 1 January — 31 December 1986 ................................................................................ 118 Annex 6. WHO-sponsored courses in the European Region, or courses relevant to EURO programmes, 1986 .................................................. 125 Annex 7. List of WHO collaborating centres with which the Regional Office concluded plans of action covering the year 1986 .................................................. 128 Annex 8. Major activities in 1986 in countries with medium-term programmes, by regional target .......................................................................................................... 136 In d ex .................................................................................................................................................. 139 V ll l Foreword The year 1986 was an eventful one in Europe and a hectic period of work for the Regional Office. The publication in 1985 of the regional health for all (HFA) target documenta accelerated the pace of discussion of this new policy throughout Europe. The translation or adaptation of the book into 13 European languages and the distribution of some 25 ООО copies by the end o f1986 helped to spread the debate widely, both in the health sector and beyond. However, it is clear that we have only just begun to scratch the surface of this work. An important marker of progress was the steady growth in the number of Member States that have initiated large-scale planning exercises to review the 38 regional targets in the light o f their own epidemiological situations and current strategies, and to work out appropriate new health policies. By the end of the year, five Member States hadfinished this process, some ten countries were in the middle of it and a number of others were planning joint national conferences with the Regional Office to raise this issue officially during 1987. In addition, the administrations at province, city and district level in several countries have started to take a keen interest in the policy and its application at local level. Another important aspect was that nongovernmental organizations have also begun to take a serious look at this policy. Several of them instituted cooperative programmes with the Regional Office in order to adapt the European HFA policy to their own work. Most significantly, the Association o f Schools o f Public Health in the European Region decided to establish a task force to work out how the principles f this policy could be worked into the teaching and research programmes of all European jchools of public health. The first meeting between representatives o f the Member States’ medical associations and the Regional Office, in October 1986, proved to be a great success and revealed broad support for the regional HFA policy from the large majority of medical associations in Europe. The meeting ended with a pledge by all the associations present to cooperate closely with the Regional Office, and it was agreed that the Office would act as a clearing-house for the exchange of information between all Europe’s medical associations. The debate on lifestyles and health intensified in many forums throughout the Region, and it became clear that the Regional Office is increasingly recognized as having a leadership role in this field. This was underlined by the fact that the Director-General a Targets for health fo r all. Copenhagen, WHO Regional Office for Europe, 1985. i x of WHO decided to make the Regional Office responsible for planning the first ever International Conference on Health Promotion, held in Ottawa in November 1986. Bringing together scientists, politicians, health care administrators and representatives of non­ governmental and intergovernmental organizations, the Conference ended with the adoption of a charter which clarifies the conceptual issues related to health promotion and helps define the framework for practical action in countries. In 1986 a new project — "Healthy Cities” — was launched by the Regional Office, with the aim of applying the regional HFA policy at city level, with particular emphasis on health promotion and environmental health issues. Originally planned as a small pilot project, it quickly attracted such a large number of interested European cities that it became a major project, requiring considerable replanning by the Regional Office. Compared to other regions of the world, Europe is often regarded as a rather quiet area where health problems tend to be of a chronic, long-term nature and do not receive much attention from the mass media. This was not the case, however, in 1986. The accident at the Chernobyl nuclear power plant at the end of April jolted the public and experts alike out of their long-standing complacency about the potential danger to health that such power plants represent. Within a few days a large number of European countries had been exposed to radioactive fallout. The subsequent need to immediately assess the significance of this fallout and to decide whether special public health measures would be required presented many of those countries with a difficult problem. The accident revealed that almost all countries were caught unawares, without a functioning monitoring system and with in­ sufficient planning on how to deal with decision-making, how to assess the level of risk and how to inform the general public. The quick reaction by the Regional Office in extracting valid information from an extremely confused picture and organizing an expert group to give measured advice on the situation was widely recognized as a very efficient approach which offered helpful support to the Member States. The Regional Committee in September discussed the shortcomings of the response in Europe and requested the Regional Office, in cooperation with other international organizations, to take a number of steps to improve Europe’s preparedness in this field. These measures are now being implemented. Another environmental disaster occurred later in the year when a chemical plant caught fire and large quantitites of toxic material were washed into the Rhine, spreading ecological destruction as it flowed through several countries on its way to the North Sea. These two events were forceful reminders that Europe now has a large number of industrial complexes which represent great potential threats to the environment if accidents occur, threats that can quickly involve many countries beyond the original site o f the disaster. This dramatically underscores the need for much closer international cooperation in this field. The year 1986 was also when Europe realized in earnest that it had been struck by another disaster in the health field — the acquired immunodeficiency syndrome (AIDS). Although the first cases had been imported into Europe at the beginning of the 1980s, the numbers were quite small. As the epidemic rapidly spread, however, all European countries realized by 1986 that they could not escape the disease and that they urgently had to prepare themselves for the consequences. This was also the year when public reaction to AIDS cases started to become problematical in several countries, and the broad range of ethical, legal, social and other problems that follow in the wake o f this disease became apparent. For the Regional Office, too, 1986 was a particularly difficult year. True, the very success o f the HFA development was a great stimulus to the staff: one encouraging result of their work was that they were increasingly invited to become directly involved in health development in more and more Member States. However, 1986 was also the year when sudden and unexpectedfinancial difficulties hit WHO, with great uncertainty about the payment of contributions by some Member States. As a consequence, the Office had to cut its expendi­ ture for the 1986-1987 biennium by US $2 million. This necessitated freezing a number of vacancies and undertaking a considerable amount of replanning, both of which substantially increased the sta ffs workload. The economic instability led to uncertainty about the situation that the Office would have to face in the future, and this naturally affected the morale of staff, who could see no logical link between that unfortunate development and their own performance. Nevertheless, the Office managed to achieve an impressive output during the year, including handling the emergency situations mentioned above. The adoption of the 38 regional HFA targets in 1984 started a chain reaction, not only on health policy development at country level but also on the work of the Regional Office. In 1986 regional programme planning (i.e. for the 1988-1989 programme budget period) was reoriented to bring it into line with the regional targets. At its thirty-sixth session, the Regional Committee asked for the Regional Director’s annual report to be similarly restructured, and this report is the first to follow the new structure. The Regional Com­ mittee also requested that more evaluative material should be included in the report in alternate years, as well as a chapter summarizing the activities related to the global programmes for which the Regional Office is responsible. That has now been done in this report. It should be noted, however, that this report, as already mentioned, is structured on the regional targets, while the 1984-1985 activities that were evaluated in 1986 were from a programme budget based on a WHO programme classification structure. This has made it somewhat more difficult to present a description of the evaluations; the procedure will be optimized only in 1988-1989. As usual, the report also includes a special feature article, this year describing the action plan to combat pollution in the Mediterranean. This issue was selected because the plan is an extremely interesting example of successful cooperation between United Nations agencies and Member States, uniting as it does 17 countries, the United Nations Environ­ ment Programme and WHO in joint long-term action to combat pollution in this large and very important sea. WHO, working through this Office and an operational unit in Athens, is responsible for the health-related aspects o f the plan. It should be noted, however, that this is not the only WHO health project in the Mediterranean area. The Regional Office is deeply involved in a host o f other activities that address themselves specifically to the Mediter­ ranean countries, since they share geographical, climatic, cultural and developmental characteristics that make close cooperation in health matters important. The Office there­ fore plays a major role in stimulating such cooperation on environmental health issues, health promotion, zoonoses, primary health care development, health manpower develop­ ment and other aspects that are reported on in the main body of this report. XI The Regional Committee has repeatedly called for greater efforts to make WHO's work better known throughout the Region. It is hoped that this annual report on the Regional Office’s activities can contribute to those efforts and that countries will help disseminate this report more widely to different target groups, so that it can become the primary source of information on WHO’s work in Europe that it is intended to be. J.E. Asvall Regional Director P a r t i c i p a n t s in t he t h i r t y - s i x t h s e s s i o n o f t h e R e g io n a l C o m m i t t e e g a t h e r e d in f r o n t o f t h e R e g io n a l O f f i c e in C o p e n h a g e n . Dr J van L o n d e n , o u t g o i n g C h a i r m a n , o p e n i n g th e t h i r t y - s i x t h s e s s i o n o f t he R e g io n a l C o m m i t t e e in t he m a i n a u d i t o r i u m of C o p e n h a g e n Un iv e r s i t y . A t t e n d i n g t he i n a u g u r a l c e r e m o n y of t he t h i r t y - s i x t h s e s s i o n o f t h e R e g io n a l C o m m i t t e e a r e . f r o m l e f t t o r i g h t , M r E . W e i d e k a m p , Lo rd M a y o r o f C o p e n h a g e n , P r o f e s so r 0 . Na th an , Re c to r of C o p e n h a g e n Un iv e r s i t y , M r K. E n g g a a r d , D a n i s h M i n i s t e r of t h e I n t e r i o r , D r J . E . A s v a l l . R e g io n a l D i r e c t o r a n d M r s Asva l l , a n d D r J . - P . J a r d e l . D i r e c t o r , P r o g r a m m e M a n a g e m e n t an d M r s Ja rd e l . T h e o f f i c e r s at t h e t h i r t y - s i x t h s e s s i o n o f t h e R e g i o n a l C o m m i t t e e . F r o m le f t t o r igh t , P r o f e s s o r B a r b r o W e s t e r h o l m ( R a p p o r t e u r ) , P r o f e s s o r A. M a l e e v a n d Dr P. de S c h o u w e r ( V i c e - C h a i r m e n ) , S i r D o n a l d A c h e s o n ( C h a i r m a n ) , D r J.E, Asva l l , R e g io n a l D i r e c t o r , and Dr J. -P. J a r d e l , D i r e c t o r , P r o g r a m m e M a n a g e m e n t , T h e C h a i r m a n o f t h e t h i r t y - s i x t h s e s s i o n o f t h e R e g i o n a l C o m m i t t e e , S i r D o n a l d A c h e s o n ( lef t ) a n d t he R e g io n a l D i r e c t o r , D r J.E. Asva l l . T he D i r e c t o r , P r o g r a m m e M a n a g e m e n t , D r J. -P. J a r d e l ( lef t ) a n d t he D i r e c t o r , S u p p o r t P r o g r a m m e s , M r E. W e s t e n b e r g e r a t t e n d i n g t h e i r last s e s s i o n o f t h e R e g io n a l C o m m i t t e e b e f o r e t a k in g u p n e w a p p o i n t m e n t s e l s e w h e r e w i t h i n t h e O r g a n i z a t i o n . P i c t u r e d at t h e t h i r t y - s i x t h s e s s i o n o f t h e R e g io n a l C o m m i t t e e are m e m b e r s o f t he d e l e g a t i o n f r o m B e l g i u m , t h e h o s t c o u n t r y f o r t h e t h i r t y - s e v e n t h s e s s i o n in 1 9 8 7 . 1Regional policy development, evaluation and programme management General programme management and development 1.1 Upon the adoption of resolution WHA39.1 by the Thirty-ninth World Health Assembly in May, Morocco officially became part of the Eastern Mediterranean Region. It was agreed that in the initial stages of the transfer Morocco would continue to collaborate with the European Region. 1.2 At its fifth meeting in Copenhagen in April, the Regional Health Development Advisory Council reviewed proposals for research for health for all (HFA). The Council recommended that if WHO were to assist Member States in developing national health policies, both research policy and a research action plan should be considered. It welcomed the presentation of indicators in quantitative form whenever possible, ac­ cepted the idea of “ supplementary” rather than “ optional” indicators, and stressed the importance of population-based surveys and the need to add a few indicators on environ­ mental health and lifestyles. It noted that the proposed revisions to the HFA plan of action were in line with the outcome of the last HFA evaluation exercise, while pleading for a better balance between action to be taken by Member States and by the Regional Office, and recommended the inclusion of major regional conferences in the plan. Finally, it proposed “ tobacco” as a first theme for the HFA promotional campaign. 1.3 The Regional Committee endorsed the Council’s recommendations at its thirty- sixth session. It also accepted the programme budget proposals for the biennium 1988- 1989, and welcomed the new structure of the programme budget which corresponds to the regional HFA targets. 1.4 It is encouraging to see that since the 38 regional HFA targets were adopted in 1984, there have been dynamic developments in several European countries as regards the formulation and/or reorientation of national health policies in the framework of the European policy. The Regional Director visited 15 countries to discuss the changes. By the end of the year 13 countries had made a firm commitment to reassess their health 1 policy and bring it into line with regional HFA target 1, and five of them had actually completed the process. Seven other countries had begun examining the question. In September, representatives of United Nations bodies and other intergovernmental and nongovernmental organizations met in Copenhagen to discuss HFA principles and national health development. All expressed keen interest in expanding their collabor­ ation and involvement in health-related activities. Three organizations will take steps to place the regional HFA policy before their governing bodies. 1.5 A first meeting between WHO and national medical associations on health for all in Europe (Vienna, October) brought together representatives of the associations and Re­ gional Office staff to discuss regional HFA issues; this resulted in an agreement to enter into collaboration, which will include active support to the regional anti-tobacco campaign. I 6 The Consultative Groups on Programme Development and on Budgetary Ques­ tions met in Copenhagen in April to review the proposed programme budget for 1988-1989 and preliminary outputs for 1990-1993, and to discuss the financial situation in 1986-1987 and steps for protection of the programme budget in the future. A contingency plan was drafted for the attention of the Regional Committee. The Con­ sultative Group on Programme Development reviewed the draft regional contribution to the Eighth General Programme of Work, and heard a statement by a representative of the Regional Office's staff association. It also made a proposal that the Regional Director’s annual report should be structured according to the regional HFA targets, and this was endorsed by the Regional Committee. 1.7 The delivery of country and intercountry programmes was evaluated in the usual way. Following testing in 1984 and comments by the external auditors, the evaluation guidelines were amended to ensure standardization of the procedure and to provide clearer recommendations. The evaluation focused on the way the different programmes were helping Member States to progress towards the goal of HFA by the year 2000, using as indicators the four main roles assigned to the Regional Office in the Seventh General Programme of Work, namely: to help make existing knowledge better known by ident­ ifying innovative and improved health care approaches in Member States; to promote priority health research; to act as a catalyst in promoting national health policy de­ velopment in line with HFA principles; and to improve cooperation and coordination between international organizations active in the health field. The evaluation was carried out in three steps covering programmes, services and the Office as a whole. In each case four issues were analysed: programme achievement, adherence to the Regional Of­ fice’s four main roles, resource utilization and geographical distribution. More details of the outcome of the evaluation exercise are given in Chapter 8 of this report. I.к Development of the Office’s computer-assisted programme management system continued throughout the year. For the first time, it will be used to produce background material for the next planning phase, providing all programme managers with the material they had produced for the previous planning cycle, together with the comments and priorities given by Member States. 1.9 To strengthen planning, monitoring and evaluation within the Regional Office, the Programme Planning, Programme Monitoring and Country Programme Coordination 2 units were regrouped into one unit that will carry out these functions for both country and intercountry programmes. Country programme coordination m o The Regional Director visited Austria, Czechoslovakia, the Federal Republic of Germany, Iceland, Ireland, Israel, Italy, Portugal, Spain, Turkey and Yugoslavia to discuss HFA strategies and the development of national health policies with the auth­ orities. In turn, delegations from the Federal Republic of Germany, Iceland, Ireland, Israel, Italy, Malta, the Netherlands, Norway, Romania, Spain, Sweden, Turkey and Yugoslavia visited the Regional Office and a briefing programme on the Office’s work was arranged for each. Discussions were held with a Moroccan delegation when Morocco joined the Eastern Mediterranean Region. i n As part of the joint programme planning and evaluation arrangements de­ veloped with European Member States, senior officials from the ministries of health of the German Democratic Republic, Greece, Hungary, Israel, Portugal and Spain visited the Regional Office to review the implementation of their medium-term programmes and agree on future joint activities. м 2 The Pro-President, Pontifical Commission for the Apostolate of Health Care Workers, Holy See visited the Office in May to discuss cooperation between WHO and the Commission on the humanization of medicine. из By resolution EUR/RC34/R5, the Regional Committee at its thirty-fourth session requested the Regional Director to ensure that the programme of work and budget allocations of the Regional Office gave priority to activities that would provide Member States with adequate support in working out national strategies for HFA, and to those developments in the Region that would facilitate the attainment of the regional HFA targets. In response, the structure of the intercountry programme budget for 1988-1989, presented to the Regional Committee in 1986, was changed to follow the pattern of the target document. At the same time, all the medium-term programmes with individual Member States were changed, to address the regional targets more directly. 1.14 The structure of the medium-term programmes is now as follows. They begin with an introduction describing the health situation, the health system and the national health policy in the country. This is followed by the operative part consisting of five main chapters on: I. Health development support (targets 32-38); II. Disease prevention and control (targets 2-12); III. Lifestyles conducive to health (targets 13-17); IV. Healthy environment (targets 18-25); and V. Appropriate health care system (targets 1 and 26-31). Each chapter is subdivided into objectives, outputs and activities, specifying where necessary the input foreseen, the timing, the budget requirements, the responsible national institution and the responsible unit at the Regional Office, and giving an identification number. Each programme clearly indicates how and by whom it will be monitored, sets criteria for evaluation, describes the evaluation process and gives guide­ lines for reporting. 3 1.15 Medium-term programmes with Bulgaria, German Democratic Republic, Greece, Hungary, Israel, Malta, Portugal, San Marino and Spain were signed during 1986 while others with Finland, Italy, Poland, Romania, Turkey and Yugoslavia are in preparation. 1.16 The Director, National Health Policies and Systems led the WHO delegation at a third meeting of the joint coordination committee for the Yugoslavia/WHO cooperative health programme (Belgrade, January), organized by the Federal Committee for Labour, Health and Social Welfare. Health information o f the public 1.17 Work started in 1986 on the three components of the HFA promotional campaign: the campaign network, materials production and concerted European action on tobacco. A working group on the campaign met in Reykjavik in March, making recommendations on documentation and briefing for various target groups, a clearing-house for infor­ mation, and use of the campaign logo, and proposing tobacco, immunization and cardiovascular diseases as campaign themes. The campaign logo, selected by compe­ tition, was used by the Regional Office and Member States on a number of publications. 1.18 The Regional Committee adopted tobacco as the first theme for concerted European action in the HFA promotional campaign (see target 16). The Regional Office will collect and disseminate data on successful national information materials and projects and propose specific measures to be taken by each participating country. Regional Committee resolution EUR/RC36/R3 also urges Member States to agree to the principle of a “ European nonsmoking day” . 1.19 The Regional Office brought out a new brochure on its policy and programmes and a simplified version of the HFA target book. HFA was also promoted at meetings in Member States, during country representatives’ visits to the Regional Office, on World Health Day, and at meetings with the press. Support programmes Personnel 1.20 The Director, Programme Management left the Regional Office in December to become Assistant Director-General at WHO headquarters. 1.21 Recruitment for most vacant professional posts at the Regional Office was frozen in 1986 due to a shortfall of funds resulting from delays in payment of regular contri­ butions to WHO. During the second half of the year, recruitment was gradually started again, so that in December only four vacant professional posts remained frozen. 1.22 The post of Special Representative of the Regional Director in Turkey was established by simultaneously abolishing the post of Field Operations Manager, Ankara. Two time-limited field posts were abolished, and one field post in Morocco was trans­ ferred to the Regional Office for the Eastern Mediterranean. An associate professional post, paid for by voluntary contributions, was abolished. One professional post previously 4 funded by the Director-General’s Development Fund was re-established under the regular budget by simultaneous abolition of a general service post. An epidemiologist post was created by transfer of the post of Regional Officer for Health Documentation Services. In addition, two professional posts (in Translation and Editorial and the Reports Office) were abolished, to be replaced by posts of Country Programme Coordi­ nator and Administrative Officer, Publications and Documentation. One editor post was split into two part-time posts. General administration and services 1.23 Many economy measures were introduced, including a reduction in servicing contracts and the use of reduced air fares whenever possible. Improved banking con­ ditions were successfully negotiated. 1 .24 The Regional Office’s translation and publication services were restructured following a survey by the Administrative Management unit from WHO headquarters. The changes are expected to result in tighter production control, increased cost- effectiveness, and a reduction in lead times. Budget and finance 1.25 In 1986, two matters of importance affected the overall financial situation relating to the regular budget. Firstly, the Director-General, for considerations of prudent financial management, was obliged to withdraw from the working allocation for this Region a proportionate share of the total expected shortfall in income due to the non-receipt of assessed contributions for 1986-1987. The amount withdrawn was US $2 079 000. Action taken by the Office to offset this deficit has, in the first instance, concentrated on reducing structural costs, basically by freezing or delaying recruitment and lowering travel costs. The situation is, however, under constant review and measures are being adapted to meet the constraints of the contingency planning at present under formulation in connection with the 1988-1989 programme. Secondly, resolution WH A39.4, adopted by the World Health Assembly in May, allows the Director-General to extend to the regional offices an arrangement for the use of casual income to reduce the adverse effects of currency fluctuations. While this facility has provided protection against currency fluctuations in 1986, the continuing downward trend of the US dollar could, however, adversely affect the delivery of the regional programme in 1987. Regular budget (biennial) 1.26 Out of a total of US $30978 100 allocated for the biennium, US $13 304 224 had been spent by 31 December, representing 42.95% of the regular budget for 1986-1987. Extrabudgetary sources United Nations funds (annual) 1.27 The Regional Office was the executing agency for various UNDP, UNEP and UNFPA projects. A total of US $1 383 742 was expended in 1986, covering 28 country and intercountry projects in the Region. 5 Other funds (biennial) 1.28 These funds include the Voluntary Fund for Health Promotion, Funds-in- Trust, the Special Account for Servicing Costs and the Real Estate Fund. A total of US$1205401 was expended under these headings in 1986. Many Member States also provided considerable assist­ ance by covering the local costs of WHO meetings and the costs of attendance by national experts at meetings abroad. Col­ laboration by institutes in Member States in the Regional Office’s research pro­ gramme is another form of assistance not easily expressed in monetary terms. A breakdown by source of voluntary con­ tributions received in 1986 is shown in Table 1. Tab le 1. V o lu n t a r y co n t r ib u t io n s , i n c lu d i n g Funds- in -Trus t . received d u r i n g 1 9 8 6 (US $) Aust r ia 1 6 6 3 6 3 Belg ium 2 6 104 F1 n 1 a n d 3 2 0 0 0 France 2 b 9 7 0 Germany. Federal Repub l i c of 2 0 3 3 0 9 Italy 34 0 0 0 Nether lands 2 2 6 0 0 0 Norway 3 6 3 6 3 Sweden 1 1 5 1 1 Wor l d Federat i on of Propr ietary Med i c i ne M a nu f ac tu r e r s 2 0 0 0 0 Others 7 1 1 782 331 Staff development and training 1.29 Seven new Regional Office staff members attended briefing sessions at WHO headquarters in 1986. About 100 people took in-house language tuition; 16 sat for UN language proficiency examinations and 11 were successful. 1.30 The group training programme included management courses for almost all staff. There were five sessions of talks called “ Communicate with the communicators” , organized jointly by the units of Staff Development and Training and of Health Infor­ mation of the Public to support the HFA promotional campaign. Topics included communication with the media and the public, a successful national antismoking cam­ paign, and the need for members of the public to be told even the “ best known” medical facts so that they can take important decisions. 1.31 WHO collaborating centres in France and the United Kingdom organized three courses for national officials and WHO staff on aspects of modern methodology for teachers of the health sciences, including management of health audiovisuals, and teach­ ing technology in the health sciences. Staff also had the opportunity to participate in an international course on health economics organized at the Regional Office in August by the University of Aberdeen. l 32 Computer technology continues to be a subject of great interest to staff. There are regular briefing sessions on facilities available at the Office and courses on the use of professional computers. A new course entitled “ Computer awareness” familiarizes staff with the query language of various office information systems, such as the health legislation data base. 6 Publications 1.33 Fifty-three publications were issued or went to press in 1986: 17 original titles in English totalling 2266 printed pages, 11 translations into French of 728 printed pages, 9 translations into German of 740 printed pages, and 16 translations into Russian of 1239 printed pages. Production in original English during the year almost reached the target set for the entire biennium, and several other large books were due for publication in early 1987. A certain amount of editing, typesetting and printing was done outside, but much less external contracting will be possible in future owing to the financial situation. 1.34 The following titles were published in English in 1986. European Series No. 19 and 20; Public Health in Europe No. 27; EURO Reports and Studies No. 100-104; and the non-serial publications Care o f children in hospital, Guidelines on AIDS (First revised edition), Health projections in Europe, Investigating practices in health manpower plan­ ning, Migration and health, Scientific approaches to health and health care and Standard model designs for rural water supplies. The regional volume of the Seventh report on the world health situation went to press at the end of the year. 1.35 The 1986 edition of Vaccination certificate requirements for international travel came out in German. Thirty-seven translations of serial publications were published or went to press: in French, European Series No. 15 and 16, Public Health in Europe No. 19, and EURO Reports and Studies No. 80, 92, 94, 95, 97, 99, 100 and 102; in German, European Series No. 14, 15,16and 18, Public Health in Europe No. 25, and EURO Reports and Studies No. 78, 80,92 and 95; and in Russian, European Series No. 13, 14 and 16, and EURO Reports and Studies No. 54, 58, 64, 65, 67, 75, 76, 79, 80, 86, 88, 89 and 92. 1.36 Four co-publications appeared in 1986, as follows: Health hazards and biological effects o f welding fumes and gases, published by Elsevier (Netherlands) on behalf of the Regional Office, IARC, CEC and the Danish Welding Institute; Trends in health legis­ lation, published by Masson (France); Perinatal health services in Europe, published by Croom Helm (United Kingdom); and Quality assurance in long-term care: policy, re­ search and measurement, published by the International Centre of Social Gerontology (France) in English and French. 1.37 Because of financial constraints and rising printing and distribution costs, a review was made of the computerized mailing list in the second half of the year, and the number of free copies distributed cut down. To compensate for this to some extent, arrangements were made for routine announcement of new titles to certain addresses. The value of publications sold through WHO headquarters and its global network of sales agents in 1986 was Sw.fr.370 548. This represents a 39% increase over 1985. More than 2200 requests for documents and free copies of publications were received. 1.38 During 1986, a Publications Promotion unit was set up to plan and coordinate the production, co-production and dissemination of promotional materials for the regional HFA campaign and for national advocacy programmes. The unit will develop a network of national publishers and other collaborating institutions that can selectively translate and publish Regional Office material. It will also promote and market regional publications and coordinate publishing with bodies outside the Regional Office. 7 1.39 One indication of increased interest in the Office’s work has been a substantial rise in the number of requests for translation rights and of translations actually produced in different countries. Fifty translation contracts were issued during the year, and 43 translations of Regional Office publications or documents into non-working languages were produced. The system of granting translation rights ensures selectivity, taking the country’s needs into account as far as possible. Country visits are used to help develop this joint publishing work as part of the overall policy of information support to national strategies for HFA. Epidemiology and statistics 1.40 The regional evaluation of progress towards HFA and country reviews were published as Vol. 5 of the Seventh report on the world health situation. The evaluation showed areas where the tools for assessment are themselves deficient, e.g. disability, lifestyles, environmental health and the equitable distribution of resources. It also highlighted areas of little or no progress, either in the Region as a whole or in individual Member States. These include equity (little progress in most cases, with large or growing variations between and within countries and between socioeconomic and geographical groups); lifestyles (inadequate progress on reducing alcohol and tobacco consumption, and scarce information on other subjects); and environmental risk factors (lack of quantifiable information). The country reviews have by and large provided a realistic picture of progress at the country level, pinpointing specific deficiencies in several cases. 1.41 Several Member States provided statements of policy along lines inspired by their participation in the HFA evaluation. In the long run, a corollary of this development should be the adaptation of national health information systems to provide more appropriate answers to the questions raised by HFA. 1.42 The set of indicators developed for the HFA evaluation needs finer tuning. Adjustments continued throughout 1986 and were presented to the Regional Health Development Advisory Council and to the Regional Committee. Contributions and suggestions were received from Member States, individuals, institutions and Regional Office units for a revised list of indicators to be submitted to the thirty-seventh session of the Regional Committee and, subject to approval, to be used by Member States for the regional and country monitoring exercise in 1987-1988. The development of an appro­ priate data base to support HFA information has turned out to be more complex than expected, but it should ultimately permit a better and more detailed analysis of HFA progress. Once tested, it is expected to become available progressively throughout the Region, providing Member States with sets of data on both historical and current trends in the attainment of the HFA targets. 1.43 Information received in the course of evaluation and monitoring has been closely integrated with other information tools such as country and target profiles, and with operational tools such as the medium-term programmes developed jointly with Member States. 8 R E G IO N A L P O LIC Y D E V E L O P M E N T , E V A L U A T IO N A N D P R O G R A M M E M A N A G E M E N T Publications issued in 1986 Health projections in Europe: methods and applications. Non-serial pub­ lication. Evaluation of the strategy for health for all by the year 2000: seventh report on the world health situation. Volume 5: European Region. Non-serial publication. Documents issued in 1986 Health for all by the year 2000: report on a European seminar (docu­ ment ICP/EXM 015). 2Health for all in Europe by the year 2000 Target 1 BD 2.1 The Regional Office carried out a study of the systems used by 22 Member States to collect data and assess inequities due to geographical, educational, occupational, socioeconomic and cultural factors. Certain countries included this activity in their medium-term programmes. The study was based on recommendations made at a 1984 meeting on the health burden of social inequities, one of the main proposals being that each country should collect an agreed set of data on core variables and a second set reflecting its own needs and problems. Indicators of changes regarding the most typical health inequities in each country, such as the reallocation of health resources and activities in favour of socially disadvantaged groups, were considered to be of particular interest. The results of the study will be analysed and discussed at a meeting of principal investigators in Lisbon in September 1987. 2.2 The Regional Office assisted the Portuguese authorities with a national meeting on inequities in health, held in Lisbon in December. A second such meeting is planned to coincide with the intercountry meeting of principal investigators in Lisbon in 1987. 2.3 Attention was given to organized violence in such forms as armed conflict, captivity in concentration camps, torture, rape and the taking of hostages, which constitute a violation of basic human rights and an important health hazard all over the world. A meeting was held on this problem in The Hague in April, in collaboration with the Government of the Netherlands. It recommended promoting research to identify, describe and assess the range of organized violence and its impact on health, with the support of research workers and institutions at the national, regional and global levels and the involvement of national or international nongovernmental organizations. Since organized violence, in addition to being a health hazard, also helps create refugees, it was By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level o f health of disadvantaged nations and groups. 11 recommended that research, intervention and assessment should cover not only recipient countries but also home countries and refugee camps. It was also agreed that networks should be built up to facilitate cooperation between the organizations responsible for providing services and aid to refugees. The Regional Office staff member responsible for health research was appointed focal point for follow-up action, and a standing com­ mittee was set up in collaboration with the Danish Red Cross and the Government of the Netherlands. 2 .4 As a direct consequence of a 1985 meeting on vulnerability among long-term unemployed, held in Ljubljana, Yugoslavia, the Regional Office began a multicountry study with the collaborating centre for research on social equity and health in Dublin. The aim is to collect information on factors that contribute to individuals becoming socioeconomically disadvantaged, with special focus on the long-term unemployed. The results will be discussed at a consultation to be held in collaboration with the European Centre for Social Welfare Training and Research, Vienna, in 1987. 2.5 To stimulate the development of national multisectoral policies and strategies adapted to the special health needs and situation of particularly disadvantaged groups, bibliographic studies were made in France and the Federal Republic of Germany on the mental health problems of migrants and the health-related and psychosocial effects of migration. The results of these studies will be widely distributed in order to promote research leading to preventive action. 2.6 Migration and health — towards an understanding of the health care needs of ethnic minorities was published in late 1986. It stresses that research is a vital component of any system aimed at improving not just access to health services for ethnic minorities in Europe but also the quality of these services, and that it is time to look at the needs from the minorities’ as opposed to the care-givers’ point of view. 2.7 As a direct outcome of the technical discussions at the World Health Assembly in May 1986, to which the Regional Office made a major contribution, a meeting on intersectoral action to combat inequities in health was held in Gothenburg in De­ cember, in collaboration with WHO headquarters and the Nordic School of Public Health. It brought together high-level representatives from different sectors who discussed ways of promoting effective intersectoral action and reducing inequities as a key politico-managerial task for both national and local administrations. The report of the meeting, to be issued jointly by the Nordic School of Public Health and WHO, will offer guidelines for action that can be used by all sectors within and outside Europe. 2.8 The Regional Office’s participation in the Xlth World Congress of Sociology (New Delhi, August) led to collaboration with the International Sociological Associ­ ation and will boost activities by a wide network of experts. The Regional Office also worked closely with the European Society of Medical Sociologists and the Nordic College of Caring Science, and with the WHO collaborating centre for psychosocial factors and health and the International Network on Unemployment and Social Work in Stockholm. 12 Target 2 SO The elderly 2.9 The main emphasis in activities concerned with the health of the elderly was on fostering social policies that support the development and maintenance of health po­ tential, building up a data base on disabling conditions, disseminating information on humane and cost-effective programmes for long-term care, and providing appropriate training. 2.10 Participants in a consultation on the measurement of independence in activities of daily living (Amsterdam, July) designed a simple tool for screening the elderly from the médicosocial point of view. The approach taken is to translate the needs of the elderly into information that can be used by primary staff working with individuals, and to plan for their care in the community. 2.11 A working group on continuity of care of the elderly met at Piestany, Czecho­ slovakia, in October. It recommended that national policies should ensure continuity of care through the health and social services structure; that assessments of the need for and type of support should be made at times of critical life events (discharge from hospital, rehousing, bereavement); that misplacement of the elderly should be avoided; and that teams working with the elderly, including informal carers, should be better trained. 2.12 The units of Environmental Health Planning and Management and of the Elderly, Disability and Rehabilitation drew up a plan to study the environmental aspects of the health of the elderly. 2.13 The Regional Office supported a two-week course in social gerontology, held at the Inter-University Centre of Postgraduate Studies, Dubrovnik, in May/June. Target 3 SO Health legislation 2.14 As a contribution to the United Nations Decade of Disabled Persons ( 1983— 1992), the Health Legislation unit launched a study of health and social legislation entitled “ Health and equity for the disabled — legislation for action” . Its aim is to By the year 2000, disabled persons should have the physical, social and economic opportunities that allow at least for a socially and economically fulfilling and mentally creative life. By the year 2000, people should have the basic oppor­ tunity to develop and use their health potential to live socially and economically fulfilling lives. 13 evaluate progress in legislation in the Region since the International Year of Disabled Persons (1981), and to advise on further legislative strategy in the spirit of the United Nations World Programme of Action concerning Disabled Persons. 2.15 Twenty-five Member States reviewed their legislation relating to disabled people in 1985 and 1986. This common review centres on five main points: first, recognition of the rights of the disabled in various national policy instruments, constitutions and plans of action; second, national involvement in international action for the disabled; third, the legislative strategy for equality; fourth, the role of legislation in eliminating discrimi­ nation or social prejudice, in providing for social reintegration and full participation of the disabled, in preventing disability and in guaranteeing a system of income support; and fifth, progress accomplished since 1981 in terms of comparing successes and failures, the impact of measures already taken, and the work ahead. 2.16 The review will support international action taken by agencies of the United Nations system and other bodies. It takes into account statements on policy or proposed legislation received from six intergovernmental organizations — CEC, CE, ILO, ECE, UNESCO and UNICEF — and from eight nongovernmental organizations active in the field of rehabilitation and disability prevention. 2.17 A comparative analysis of the national review data was carried out. It reveals that health and political action taken with regard to disabled people has been unduly narrow, promoting the attitude that people with disabilities are automatically sick, unable to work, and so on; yet HFA can only mean that a positive, healthy life is within the reach of the disabled, to the same extent as for everyone else. The conclusion is that a new legislative strategy is needed to promote the full participation and equality of disabled people, and many countries are in fact developing such a strategy. In general, although the total picture remains complex, the European review has thrown light on some common trends. 2.18 An international meeting of experts on legislation on the equalization of oppor­ tunities for the disabled was organized in Vienna in June by Rehabilitation International, with the support of the United Nations and the Regional Office. The three main themes discussed were legislative and social policy provisions for the equalization of oppor­ tunities, the role of nongovernmental organizations in the legislative process, and the implementation of legislation. 2.19 The Regional Officer for the Elderly, Disability and Rehabilitation attended a joint meeting of the International Epidemiological Association/Association of French- language Epidemiologists, held in Paris in November, and described the Regional Office’s work in this field. Community-based rehabilitation 2.20 The Regional Office organized a joint consultation with the University of Edin­ burgh in June on innovative approaches to community-based care of the disabled. The participants noted that the objective of ensuring that no disabled person remains unnecessarily in an institution requires a proper balance between institutional and 14 community-based services, and emphasized that the Regional Office should work with research centres to develop guidelines for reliably measuring not only needs but also the outcome and effectiveness of services; that relatives, friends and other informal carers make an enormous contribution in this area and deserve much greater recognition and support, both in practical ways and through research; and that brain damage is a concern of increasing importance for community-based rehabilitation. 2.21 In September, a consultation on community-based rehabilitation was held in Turku, Finland, to review the WHO activities to date. 2 .22 The Regional Office collaborated with the Medical Commission of Rehabilitation International on matters relating to implementation of the International Classification of Impairments, Disabilities and Handicaps, community-based care of the disabled, and specific support to Turkey; and the Regional Officer for the Elderly, Disability and Rehabilitation attended the Commission’s annual meeting in Prague in September. Target 4 SO Disability prevention 2.23 The Regional Office co-sponsored a study by the Postgraduate Medical and Pharmaceutical Institute, Prague, on disability prevention at the primary and secondary levels. All children in the study will be examined on entry into paediatric care and at specified ages up to five years to detect those with developmental impairments, diseases, and biological or social risk factors. The pilot phase has been completed and will be evaluated at a consultation in January 1987. 2.24 A consultation on the economic aspects of the prevention of disease and dis­ ability was held at the Regional Office in July, bringing together economists and epidemiologists from eight countries to review methodology and help establish prin­ ciples for studies in this field. While prevention may, indeed, save money spent on health services, the participants stressed that it is essential to analyse such factors as cost- benefit, cost-effectiveness and equity. An attempt will now be made to introduce the relevant study methods into the programme on countrywide integrated noncommuni- cable disease intervention (CINDI). It was recommended that WHO should continue to promote the training of non-economists, including epidemiologists, preventive health workers and indeed WHO staff, and to invite economists to assess the economic aspects of the targets for HFA. Genetic services 2.25 A survey of genetic services in the Region is being conducted with the assistance of two temporary advisers. By the year 2000, the average number of years that people live free from major disease and disability should be increased by at least 10%. 15 2.26 The Regional Officer for Maternal and Child Health attended a meeting of European geneticists (Brussels, March) to establish contacts, explain the European programme and explore the needs as seen by this group, and also a meeting on appro­ priate technology for artificial reproduction and genetics (Mallorca, October) where particular attention was paid to the ethical and social ramifications of the two subjects. Rheumatism 2.27 In October, an informal meeting was held in Rome with the European League Against Rheumatism (EULAR) to discuss collaboration on rheumatic degenerative diseases for the next biennium. Possible areas for collaboration include improved teaching of rheumatology and primary prevention within the programme for prevention and control of chronic noncommunicable diseases. Mental health 2.28 A report on the prevention and reduction of mental health problems in the elderly was distributed to health professionals in many countries; it underlines the importance of planning flexible yet comprehensive services, with effective coordination among the many disciplines and sectors involved. Another report, dealing with priorities for research and collaboration in research training in child mental health in Europe, was distributed to the principal research and training centres for child psychiatry; it stresses the need for common approaches to assessment, classification and diagnosis. 2.29 Current patterns of training in child mental health and psychosocial develop­ ment for European primary health care workers were reviewed and analysed in a study which showed that European countries vary enormously in the level of training and service provided and in the degree of professional interest and concern, and outlined special educational and training requirements. 2.30 A working group on mental health services in southern countries of the Euro­ pean Region was organized by the Spanish authorities at the Ministry of Health and Consumer Affairs in Madrid in May, with support by the collaborating centre for research and training in mental health in Paris. Participants from 11 Member States, CEC, the World Psychiatric Association and the collaborating centre for health, psycho­ social and psychobiological factors in Brussels/Louvain exchanged information on their mental health policy planning, implementation and evaluation. The mental health problems of migrants to and from the southern countries of Europe figured prominently in the discussions. 2.31 The Regional Office cooperated with WHO headquarters and the collaborating centre for research and training in mental health in Groningen on the publication of Psychiatric case registers in public health, which lists almost all existing psychiatric case registers in the world, illustrates the main uses of registers for epidemiological, admin­ istrative and operational research, gives the criteria for establishing registers and de­ scribes types of data collection and retrieval. 16 Communicable diseases 2.32 WHO’s global mortality estimates of August 1986 show that, out of approxi­ mately 51 million deaths in 1980, nearly 10 million (20%) occurred in developed coun­ tries and over 5 million (10%) in Europe, where communicable diseases were the third leading cause of death (8%) after cardiovascular diseases (54%) and neoplasms (19%). 2.33 Information on the incidence of communicable diseases exists in all European countries, but underreporting does occur and needs correction. The estimated annual incidence of major infectious diseases in Europe, based on special surveys and sentinel surveillance, is as follows. 2.34 Despite some progress in prevention, representatives of Member States at the thirty-sixth session of the Regional Committee noted the continuing and ever-changing threat of infections in Europe, and emphasized the need for more effective and better integrated surveillance and control systems than in the past. 2.35 WHO collaborating centres make an indispensable contribution to surveillance and research on communicable diseases in Europe. The collaborating centre for AIDS in Paris collects, analyses and collates information and publishes a quarterly report on the epidemiological situation of AIDS in the Region. The collaborating centre for research and training in food hygiene and zoonoses in Berlin (West) organized an international congress on foodborne infections and intoxications in May and has published the proceedings. The collaborating centre for reference and research on viral hepatitis in Munich issued several reports on the latest achievements in research and control of hepatitis A, B, D and non-A non-B. The collaborating centre for legionellosis in Stockholm organized a European meeting on legionellosis surveillance and control in April. The collaborating centre for health and disease surveillance in Rome continued, with support from the Regional Office, to collect, analyse and collate data and publish reports on infectious diseases in the Region, serving as a data base for regional control programmes. Finally, the collaborating centre for zoonoses in Moscow made a review of campylobacteriosis in Europe. 2.36 The technical discussions at the thirty-sixth session of the Regional Committee dealt, among other things, with evaluation of the control of viral infections, viral hepatitis and zoonoses in the Region. Acute respiratory infections 2.37 Over 90% of acute respiratory infections in Europe are caused by viruses, and from 10% to 35% of all pneumonias are due to pneumococci, the incidence being D isease Acute respiratory infections Pneumonia Enteric and foodborne infections Infectious diseases commonly acquired in childhood Other infectious and parasitic diseases C ases (m illions) s 600 12.4 S245 ë 12 ê 10 17 from 2 to 5 cases per 1000 population per year or up to 4.3 million episodes. However, while these infections are a main cause of morbidity and mortality, it was necessary for financial and practical reasons to limit activities to improving surveillance systems and developing projects for secondary prevention. Acquired Immunodeficiency Syndrome (AIDS) 2.38 Because of the AIDS pandemic, with an estimated one million Europeans already infected by the end of 1986 ( 10 000 of whom had developed the disease), most of the Communicable Diseases unit’s efforts and resources had to be concentrated on policy formulation, definition of regional strategies and other activities connected with the control of human immunodeficiency viruses (HIV). 2.39 At a meeting on AIDS containment, organized by the Regional Office with support from the Austrian Government in Graz in April, representatives of all the European Member States reviewed the epidemic, considered the social, legal and ethical aspects of the problem, and drew conclusions regarding surveillance, health education, information, legislation and the safety of blood and blood products. A member of the Health Education unit attending the meeting stressed that, in the absence of a treatment or vaccine, health education is essential and that it is important to adopt a scientific, nonjudgemental approach. WHO was asked to give priority to surveillance. 2.40 The Regional Officer for Communicable Diseases attended a WHO headquarters meeting on the safety of blood and blood products (Geneva, April) and gave a short review of the situation in the Region, showing that the seropositivity rate among blood donors in Europe is very close to the rate in the United States. 2.41 The Regional Officer also addressed an international meeting on AIDS organ­ ized by the Nordic School of Public Health, Gothenburg, in May. He estimated that the number of AIDS cases in Europe is doubling every 8-14 months and could reach almost 4 million within 10 years unless the epidemic is taken very seriously by all Member States. 2.42 At a second international conference on AIDS (Paris, June) the WHO collab­ orating centre for AIDS presented a prognosis based on a mathematical model, esti­ mating that the number of AIDS cases in Europe will reach about 30 000 by 1991 and that the number of infected people will be between 1.5 and 3.0 million. 2.43 The Regional Committee, at its thirty-sixth session, endorsed proposals for regional AIDS containment activities and urged Member States to develop national control programmes and to join the European regional programme as soon as possible if they had not already done so. In particular, many speakers expressed serious concern about AIDS among intravenous drug abusers, who form a risk group of growing importance, especially in certain southern European countries where they account for more than half of all AIDS cases identified. 2.44 Participants in a consultation on AIDS among drug abusers, held in Stockholm in October with support from the Swedish Government, concluded that measures such as the provision of sterile needles might have some impact on the spread of the virus but that other factors are probably more relevant. They reiterated that treatment for drug abusers 18 must be made widely available, since treatment agencies and peer group organizations are essential for making contact with drug abusers and persuading them to adopt “ safe-needle” and “ safe-sex” practices. They also recommended national training of trainers in the necessary additional skills as a possible way of preventing AIDS being spread among and by drug abusers. 2.45 By November, 28 European countries had reported about 3800 AIDS cases to WHO, and only four countries (Albania, Bulgaria, Monaco and San Marino) did not report cases. The regional network of collaborating centres for AIDS virology and serology is growing fast, with more than 16 institutions in 11 Member States. Case reporting and prevalence surveys on HIV infections indicate relatively high rates of infected people in a number of countries. The epidemic is apparently spreading from western Europe southwards and eastwards. A new HIV-II virus was introduced to France, the Federal Republic of Germany, Greece, Portugal and Sweden from West Africa. 2.46 Although the risk groups for AIDS in Europe are similar to those in the United States, with homosexuals (67%) and intravenous drug abusers (11%) predominating, more and more evidence of heterosexual transmission was seen in several Member States. 2.47 The Regional Office set up close cooperation on control with 90% of the Member States and with the WHO global control programme, EEC, the Council of Europe and the Nordic School of Public Health, Gothenburg. In addition, the WHO collaborating centre for AIDS in Paris, with the assistance of the Regional Office, has developed an efficient information system on AIDS cases in 28 European countries. It publishes reports on AIDS in Europe every three months and distributes them widely. With support from the Regional Office, it has also produced and distributed to interested Member States a video for medical professionals on protective measures against virus transmission in hospitals. Finally, training for national and international medical and laboratory personnel was arranged at the WHO collaborating centre for AIDS in Berlin (West) through WHO or bilateral arrangements. Diarrhoeal diseases 2.48 The control of diarrhoeal diseases continued to progress in the Region. Turkey has undertaken an accelerated programme with the support of UNICEF and WHO; a programme has been drawn up for two areas with high infant mortality in Yugoslavia in accordance with the regional target, while Albania, where infant mortality is also high, has not yet developed a national programme but has begun operational research to evaluate the effectiveness of oral rehydration therapy and community health education. 2.49 Representatives of Turkey and Yugoslavia attended an interregional course on the planning and management of the national communicable disease programme, held in New Delhi in March. 2.50 A seventh meeting of the technical advisory group on control of diarrhoeal diseases was held in Alexandria in March. A consultant represented the Regional Office and presented major developments in the Region. A consultant, as well as representa­ tives of Greece and Yugoslavia, also attended a meeting of programme managers of 19 the Expanded Programme on Immunization (EPI) and communicable disease control in Cyprus in July to review national programmes and discuss plans for future activities. 2.51 A consultant visited Greece in July to explore the possibility of WHO collab­ oration with the Ministry of Health in areas where diarrhoeal diseases are an important public health problem, and to help revise a research proposal submitted by a Greek researcher. Oral health 2.52 The oral health programme concentrates on the coordinated planning of oral health services, with emphasis on prevention, manpower production or reorientation, and appropriate technology. Coordination and monitoring call for continuous updating and expansion of the oral health information system. 2.53 “ Financing of dental care in Europe, Part I” , also produced during the year, describes the different financing arrangements in Europe and analyses their effects on the inputs and outputs of dental care delivery systems, with particular regard to efficiency and equity. 2.54 Meetings were held on such topics as the planning, implementation and evalu­ ation of the oral health components of noncommunicable disease projects (Kaunas, Lithuanian SSR, September) and the formulation of national goals for oral health for all by the year 2000 (Turku, Finland, October). 2.55 The Regional Officer for Oral Health presented papers at a summer school on “ Nordic visions — alternative future” (Elsinore, Denmark, July) and at the yearly meeting of the European regional organization of the International Dental Federation (Munich, May). He also joined 100 participants from the Nordic countries at a Nordic conference on epidemiology in oral health (Gothenburg, March), convened with the main objective of reaching a consensus on indicators and health parameters to be used for recording, reporting, monitoring and evaluation. 2.56 At a seminar on financing systems for dental health in EEC countries (Barcelona, June), frequent reference was made to the national oral health pathfinder survey for Spain and the study on financing of dental care in Europe, both initiated by the Regional Office. 2.57 The Regional Officer attended the executive committee meeting of the Asso­ ciation for Dental Education in Europe (London, January) and a course in public oral health planning (Malmö, Sweden, June). 2.58 “ Country profiles on oral health in Europe, 1986” was issued, providing infor­ mation on epidemiology, manpower development, service structure and preventive programmes. For certain countries, the document also gives national goals for oral health and can therefore be used for monitoring these goals. 2.59 The WHO collaborating centre for oral disease prevention in Erfurt published in English and German Prevention of oral diseases, a collection of papers presented at the 2 0 inauguration of the centre in 1983. Staff of the centre again helped field test the new community periodontal index of treatment needs for measurement of periodontal disease. 2 .60 The WHO collaborating centre for child dental health in Iassy/Bucharest carried out two studies dealing, respectively, with simple methods of persuading children to adopt appropriate oral hygiene measures, and with assessing the oral health status of handicapped children. 2.61 The Regional Officer visited the USSR in August and September to discuss future collaboration, to conduct a WHO working group in Kaunas on the planning, implementation and evaluation of oral health components of noncommunicable disease projects, and to investigate the possibility of setting up a subcentre of the WHO collaborating centre for dental education (Moscow) at the Stomatological Institute in Erevan. That centre is currently drafting curricula for the training of operating dental auxiliaries, especially for developing countries, while the collaborating centre for research in dental epidemiology in Moscow has collected extensive oral epidemiological data from a number of the autonomous Soviet republics. 2 .62 The French Ministry of Social Affairs and Employment organized a technical seminar on fluoride and oral disease prevention (Paris, September), at which the partici­ pants stressed the need to establish a national oral health epidemiological baseline to monitor the effect of fluoridated salt, introduced on to the French market in October. 2.63 The national oral health pathfinder survey in Hungary went according to plan. In November, the Regional Officer visited Budapest to help interpret the results, which were later presented and discussed at a meeting of district chief dental officers from all over the country. 2.64 The national oral health pathfinder surveys were completed in Malta and Morocco and the data are being analysed; they will be used as the baseline for future monitoring of the countries’ oral health care delivery systems and, in the case of Morocco, for assessment of future oral health manpower needs in terms of numbers, types and distribution. 2.65 On completion of the first part of the medium-term programme with Portugal, a meeting of government officials and members of the dental profession was held in Lisbon in February; the Regional Officer participated and presented a paper based on the results of the national oral health pathfinder survey carried out in 1985. 2.66 At the interregional level, the Regional Officer collaborated with the staff of the WHO Intercountry Centre for Oral Health, Chiang Mai, and the Dental Faculty, Chulalongkorn University, Bangkok, in developing an appropriate technology de­ fluoridation device (the ICOH-defluoridator); presented a paper on the prevention of dental fluorosis at the First Africa Health International Conference, held in Nairobi in November; and directed the twelfth WHO/DANIDA course in dental public health, which also took place in Nairobi in November/December with participants from ten countries in the African Region. 21 Target 5 SO Diseases preventable by immunization 2.67 Diseases of importance in the Region that can be controlled by immunization programmes include those covered by the EPI, namely diphtheria, pertussis, tetanus, measles, poliomyelitis and tuberculosis, as well as mumps, rubella, viral hepatitis, hepatitis B, meningococcal and Haemophilus influenzae infections, pneumococcal in­ fection and herpesviral infection. The incidence rates for some of these diseases have fallen dramatically in the last two decades (see Fig. 1). 2.68 Sentinel surveillance introduced in Belgium, France and the United Kingdom has demonstrated that the true incidence of measles, rubella, mumps and other EPI infections is unknown owing to underreporting by the existing national notification systems. Hungary, Italy, Poland, Portugal, Spain and Switzerland were encouraged to set up similar surveillance, and the number of countries participating in the regional EPI information system has almost doubled (from 16 to 28) over the last two years. Infor­ mation on immunization coverage rates has also improved. Member States have found it necessary to revise their reporting systems extensively and have begun to provide more reliable information to WHO. 2.69 A few countries have already established elimination targets for rubella and mumps (Finland, Iceland, Norway and Sweden) or plan to introduce large-scale routine immunization against these diseases in 1987 (Albania, Denmark, Netherlands and Switzerland). It is too early to evaluate the impact of such immunization as only a few countries are involved, the programmes are quite recent, and reporting and surveillance are poor all over Europe. However, 21 countries provide routine immunization against rubella and five against mumps. 2.70 Currently, all 32 countries are immunizing against diphtheria, poliomyelitis and tetanus, and 30 against pertussis and measles. As a result, diphtheria and poliomyelitis are disappearing in more than 60% of Member States. Tetanus immunization started routinely between 1951 and 1960; together with improvements in maternal and child care, it has helped eliminate tetanus neonatorum in a large proportion of the European population, although the disease is still a problem in older, unvaccinated people. While pertussis is not listed among the target diseases, countries with conventional pertussis vaccine in their immunization schemes were able to demonstrate the effectiveness of their programmes (Bulgaria, German Democratic Republic, Hungary, Israel, Poland, Romania and San Marino). Sharp increases in morbidity have, however, recently been observed in Italy, the Netherlands, the Scandinavian countries and the United Kingdom, which do not carry out routine immunization for this disease. Measles immunization By the year 2000, there should be no indigenous measles, poliomyelitis, neonatal tetanus, congenital rubella, diphtheria, congenital syphilis or indigenous malaria in the Region. 22 N o. o f ca se s (in m ill io ns ) N o. o f ca se s (in th ou sa nd s) Fig. 1. Cases o f se lec ted i n fe c t i o u s d iseases in the Region, 1961 and 1 9 8 3 60 _ 50 _ 40 30 20 10 1961 1983 Diphtheria Tetanus Poliomyelitis Pertussis Measles Mumps Rubella Tuberculosis 23 proved successful in Albania, where no cases have been observed for some years, and in Bulgaria, Czechoslovakia, Finland, Hungary, Romania and Sweden, where monitoring of the programme is of high quality. For other countries, the position is less satisfactory, the average incidence still being quite high at over 100 per 100000 population. 2.71 Although 27 countries provide routine immunization against tuberculosis, the disease is far more difficult to control by this means than the other infections mentioned because it is typically conditioned by socioeconomic factors. Between 1972 and 1986, tuberculosis morbidity and mortality rates fell by about half for the Region as a whole. In Romania, for example, after the nationwide BCG immunization campaign in 1973 and the introduction of rifampicin and ethambutol for the treatment of patients, a sharp, 6.5-fold drop was observed in the morbidity rate, particularly among children aged under 14 years. In Hungary, BCG vaccination increased the protection of children 2.8-fold. Further progress will depend to a large extent on socioeconomic and living conditions and on systems of surveillance, early diagnosis, immunization and secondary prevention. 2.72 The EPI campaign in Turkey, organized with the help of WHO and UNICEF, helped improve immunization coverage in the country in 1985. Babies born during the last five months of 1986 were vaccinated at least once. 2.73 All these developments give reason to hope that regional target 5 will be achieved on time. However, there have been problems concerning the availability of effective vaccines and the operation of the EPI. 2.74 Effective vaccines that could substantially reduce the excess of morbidity and mortality, and disability and economic loss, i.e. vaccines against measles, mumps and rubella, pertussis, Haemophilus influenzae infection, meningococcal and pneumococcal infections, and hepatitis B, are not yet included in many national immunization pro­ grammes. Many European countries could not afford these antigens because of prohibi­ tive cost or because the technology of production and quality control are not always in the hands of the health authorities. Moreover, as noted, even available antigens proved to be effective and safe are excluded from the immunization calendar in some countries without any scientific justification. 2.75 The European Advisory Group on the EPI, meeting in Copenhagen in September, summed up the results obtained in 1984-1985 and found that only some of the rec­ ommendations of the Second Conference on Immunization Policies in Europe (Karlovy Vary, 1984) had been implemented successfully. The achievements and failures were also reviewed by the EPI Global Advisory Group in Delhi, India, in October. 2.76 Visits by WHO consultants to about half the Member States were also arranged in 1985 and 1986 to evaluate the national EPI activities and step up progress. By 1986, nine Member States — Bulgaria, Czechoslovakia, Greece, German Democratic Repub­ lic, Malta, Romania, Spain, USSR and Yugoslavia — had presented a formal declaration on their support for regional target 5 and on their national EPI targets as recommended at the Karlovy Vary conference. 2.77 The quality of national EPI management has gradually improved with the establishment of continuous mechanisms for reviewing the progress of work at the 24 national, regional and global levels. Experience gained with EPI advisory groups in some countries, e.g. Spain, and in the Region has also been very useful for promoting new approaches and technology available from the global EPI. 2.78 In general, however, it seems that better management is still needed for the full implementation of the EPI, and experience gained by the global EPI has not been used, for no good reason. EPI training opportunities have consisted only of visits by medical professionals to developing countries. Health education at the regional level plays practically no role in promotion of the regional EPI. At the same time, evaluation of the EPI is difficult in several countries because there is no reliable information system due to decentralization of the public health services and poor cooperation with the private medical care sector. 2.79 Finally, there is no valid reason for the enormous variety of immunization schemes used in Europe, where almost every country has its own calendar. Moreover, the programme suffers from lack of funds, imprecise case definition, inadequate cold chain monitors, long lists of contraindications, poor information on adverse reactions to various antigens, and so on. These are only a few of the immediate problems which need solving if the regional HFA goals are to be attained. Malaria 2.80 A working group on the malaria risk for travellers, meeting in Budapest in October, called for a uniform, systematic approach to the problem, including the management of imported malaria cases, further studies on the malaria risk for different groups of travellers, a careful balance between safety and efficacy in chemoprophylaxis, and the use of other preventive measures. 2.81 While the Black Sea coast of Turkey has until recently been unaffected by events over the last few years in the southern parts of the country, increasing numbers of malaria cases have begun to be reported in Samsum province. Schistosomiasis 2.82 Schistosomiasis could become a problem in south-east Anatolia, Turkey, where a large-scale water resource development scheme is being set up. The Regional Office and WHO headquarters are planning a mission to assess the situation on the spot. Target 6 SO 2.83 Long-term cohort studies for risk-factor assessment continued in 1986 with the development and testing of questionnaires. This included the drafting, at a meeting in Oslo in August, of guidelines and questionnaires for the pilot study to be undertaken By the year 2000, life expectancy at birth in the Region should be at least 75 years. 25 in 1987-1988. The aim of the studies is to throw more light on the factors influencing health status in infancy and childhood. National centres in the USSR and the United Kingdom are coordinating the work, with active support from other countries. Factors contributing to long life were described in three papers received by the Regional Office in 1986. 2.84 Since 1983, the Hungarian Central Statistical Office, in collaboration with the Ministry of Health, has been carrying out a comprehensive research programme to attempt to identify the nature and causes of trends and differentials in mortality. The parts of the programme relating to socioeconomic and regional differentials in mortality have been completed, while a longitudinal study of the impact of social mobility and of the effectiveness of preventive health care continued. Target 7 SO 2X5 Activities in the field of health promotion and birth included a joint interregional conference on the use of appropriate technology following birth (Trieste, October) which brought together participants from both Europe and North and South America. Be­ lieving that all parents and infants have the right to be in close contact from the time of birth, they recommended that closeness between mother and infant should be promoted in all circumstances. They also strongly recommended early discharge from the hospital following birth and the use of a home-based record for both the infant and the mother. A further recommendation was that parents should be given the right to active early involvement in the care of an unhealthy infant by encouraging visits to the special infant care unit, feeding and skin-to-skin contact whether or not the infant is connected to monitoring systems, and participation in decisions regarding diagnosis and treatment, and by providing facilities where parents can live while their infant is in special care. The complete recommendations were distributed to Member States and a number of them were also published in The Lancet. 2.86 Increased attention was paid to midwifery. The Regional Officer for Maternal and Child Health visited the United Kingdom to explore the possibility of establishing an international information system for midwives. He was also invited to describe the European experience to a special committee of the state legislature in California, United States, in connection with a move in that state to broaden the legal basis of the practice of midwifery. In Canada, he attended a regional conference of midwives, held in Vancouver in May, and made a presentation on Having a baby in Europe. On this occasion, he had discussions with the health authorities and professional organizations, and with task forces on midwifery appointed by the Ministries of Health of Ontario and Quebec to make recommendations on the possibility of legalizing midwifery in these provinces. 2.87 One of the striking findings of the work of the European perinatal study group, reported in Having a baby in Europe, was the considerable (as much as four-fold) variation in obstetrical intervention rates, as shown in Table 2. There is, moreover, no By the year 2000, infant mortality in the Region should be less than 20 per 1000 live births. 26 Table 2. Procedures fo r operative birth in 1 7 European countr ies supp ly ing data, as a percentage of all b irths C oun try / reg ion Procedure3 Total interventions [a + b + c) Forceps (a) Vacuum (b) Caesarian section (c) Operative vaginal 1a + b ) National data 1 NR NR 7.2 NR a + b + 7.2 2 1.3 1.0 4.0 2 3 6.3 3 0.7 8.6 10.3 9 3 19.6 4 0.3 3.4 1 1.9 3.7 15.6 5 8.0 4.0 8.0 1 2.0 20.0 6 0.4 2.0 8.0 2 4 10.4 7 1.7 3.6 3.6 5.3 8.9 8 3.2 3.4 8.0 6.6 14.6 9 0.8 0.4 5.0 1.2 6.2 10 NR NR 4.6 NR a + b + 4.6 1 1 0 3 6.8 1 1.7 7.1 18 8 12 13.3 NR 7.3 13.3 + b 20.6 + 6 13 13.0 NR 10.7 1 3.0 + b 23.7 + b Regional data 14 1.8 11.1 1 2.7 12 9 25 6 1 5 4.7 0.3 4.5 5 0 9.5 16 0.6 1.0 0.9 1.6 2.5 1 7 0 6 2.0 5 9 2 6 7 5 a NR = not re p o r te d significant statistical relationship between these intervention rates and perinatal mor­ tality rates. If the figures for North America were added to the table, a five- or six-fold variation would result; the caesarean section rate in Canada and the United States is about 20% of all births, and the forceps or vacuum rate is a further 10-20%. These striking variations in obstetrical practice and the lack of significant correlation with the outcome have prompted the Regional Office to mount a study of the determinants of ob­ stetrical intervention in selected Member States. Countries representing various levels of intervention from the lowest to the highest will participate. It is hoped that the findings will lead to rational programmes that will modify the rates. 2.88 Information concerning health promotion and birth was disseminated at the national level in various ways. In particular, the recommendations of a joint inter­ regional conference on appropriate technology for birth (Fortaleza, Brazil, 1985) and Having a baby in Europe led to considerable discussion about national policies on perinatal care. In Austria, the Regional Officer discussed the implications of these recommendations with officials from the Ministry of Health and Environmental Pro­ tection and suggested further meetings to evaluate existing practices. Similarly, a birth 27 conference, organized in June by the Spanish Ministry of Health and Consumer Affairs, together with other governmental and nongovernmental organizations, brought to­ gether more than 100 participants from all over Spain who discussed their perinatal services and the possibilities for innovation. A Greek perinatal survey, supported in part by the Regional Office, formed the basis for an important birth conference in October, sponsored by the Ministry of Health, Welfare and Social Security and directed by the Institute of Child Health, Athens. It was attended by several hundred participants from all over the country, including midwives, nurses, obstetricians, neonatologists, rep­ resentatives of women’s organizations, sociologists, psychologists, health administrators and journalists. Having a baby in Europe and the WHO recommendations on appropriate technology for birth were presented at a birth conference in Switzerland in November, organized by a nongovernmental organization and attended by about 400 participants. Several other national birth conferences are planned for the near future. 2.89 As far as preventive child health services are concerned, the recommendations of the working group on new perspectives in prevention in childhood (Kiev, October 1985) were followed up by an analysis of services in Czechoslovakia and the Netherlands. The recommendations were presented at a meeting of the British Paediatric Association, and it is hoped that other paediatric nongovernmental organizations in Member States will also become interested in reassessing such services. Target 8 SO 2.90 Maternal mortality is on the decrease in all but one country in the Region, and several countries have already reached the regional target. The one exception is due to an increase in mortality from abortion. However, while maternal mortality is not a major concern in the great majority of Member States, maternal morbidity and the need to strengthen the health-promotive approach to women remains a high priority everywhere. 2.91 The role of the individual pregnant woman in determining the care she receives is a widely discussed subject, and the collective role of users in planning and evaluating perinatal services was covered at length at the birth conferences held in Greece, Spain and Switzerland (see target 7). Tables 3 and 4, taken from Having a baby in Europe, illustrate the limits of the woman’s choice, and the man’s, in perinatal services in Europe. 2.92 The Regional Office is gathering information on models and examples of con­ sumer participation in care during pregnancy, birth and the first year of life. As part of this activity, it hosted two meetings on the subject of sudden infant death, both organized by consumer groups in Denmark in collaboration with professional nongovernmental organizations, and these discussions were reported in the Danish media. 2.93 The Regional Office supported a meeting in the United States on health pro­ motion and birth, organized by the Boston Women’s Health Collective and the Esalen By the year 2000, maternal mortality in the Region should be less than 15 per 100000 live births. 28 Table 3. W om en 's cho ice in selected rou tine procedures in uncom p lica ted births in 23 coun tr ies Procedure No. of countr ies offering: choice no choice Shaving 5 18 Birth method 0 23 Birth posit ion 3 20 Anaesthesia /analgesia 10 13 People present 10 13 Choice of doctor 8 15 Holding dead newborn 1 1 12 Electronic fetal monitor ing 5 18 Episiotomy 1 22 Institute of California. The participants concluded that birth provides a perfect oppor­ tunity for translating the concepts and principles of health promotion into practice. At a European meeting covering the same field, organized in Berlin (West) in August by the units of Maternal and Child Health and of Health Promotion, the recommendations of the first meeting were adapted to the European situation. A set of draft proposals were then presented at a WHO conference on health promotion in industrialized countries, held in Ottawa in November (see target 13). 2.94 The Danish Institute of Clinical Epidemiology was contracted to make a study of postpartum depression and unhappiness among women in Denmark, and the results Table 4. The poss ib i l i ty of the fa ther being present dur ing birth in 23 countr ies No. of countr ies: Father s presence during: permit t ing not permit t ing father's father's presence presence labour 13 10 non-operative bir th 12 11 operative bir th 5 a 18 a On r eques t , o r by sp e c ia l a r ra n g e m e n t . 29 were presented at the Regional Office/PAHO Symposium on Appropriate Technology following Birth, held in Trieste in October (see target 7). The study revealed that the factor most commonly associated with unhappiness or depression in the postpartum period is separation of the woman from her infant at or soon after birth. This finding should now be taken into consideration by perinatal care systems to prevent deleterious effects on the baby, the woman and the family. Target 9 20 2.95 The psychosocial substudy of the project on monitoring trends in cardiovascular diseases (MONICA) was expanded in 1986, and 35 of the 41 MONICA collaborating centres are now studying the link between psychosocial variables and cardiovascular diseases. The coordinators of the substudy attended two consultations, the first in Munich in March and the second in Berlin in September. Documents for the manage­ ment and organization of the substudy were prepared, as were a protocol and a data book. The Regional Officer for Chronic Diseases attended MONICA steering committee meetings on study management, aspects of data analysis, quality control and content of the first publications. 2.96 Thirty-two representatives of 20 centres met in Heidelberg, Federal Republic of Germany in October to discuss the project on European risk factors and incidence — a collaborative analysis (ERICA). They assessed progress, reviewed the first analysis of prediction of coronary heart disease on the basis of risk factor level (hypercholes- terolaemia, hypertension, smoking, obesity) and decided to publish a “ risk map” show­ ing the risk factors in coronary heart disease in Europe. 2.97 A meeting on the collaborative trial of multifactorial prevention of coronary heart disease (Rome, November) brought together participants from Belgium, Italy, Poland, Spain and the United Kingdom, who summarized the 10-year follow-up data and discussed the content of the final publication. 2.98 At a meeting of principal investigators of the WHO European hypertension research action programme (HYRAP) in Geneva in November, progress reports were given from the centres in Bucharest, Budapest, Ljubljana, Munich and others. The investigators also updated the protocol of the hypertension audit project and discussed an expansion of the project. 2.99 Participants in a working group on the non-invasive diagnosis of pulmonary hypertension in chronic respiratory disease (Warsaw, October) reviewed progress and agreed on the content of a prospective study report. 2.100 Special emphasis was placed on community-based prevention of chronic dis­ eases. A report on the comprehensive community cardiovascular control programmes (CCCCP), coordinated by WHO in Europe, was prepared for publication. The CCCCP By the year 2000, mortality in the Region from dis­ eases of the circulatory system in people under 65 should be reduced by at least 15%. 30 served as a basis for the development of the programme on countrywide integrated noncommunicable disease intervention (CINDI); nine countries have formally joined this programme and others have expressed interest in it. The principal investigators of CINDI met in Reykjavik in June to discuss a paper on intervention modules, the CINDI protocol and guidelines for monitoring and evaluation (which were approved) and to review the progress of country activities. Most of the participating countries have already completed the baseline population survey and have begun intervention. The investi­ gators discussed the links between MONICA and CINDI and made proposals for practical cooperation between the CINDI data management centre in Heidelberg and the international MONICA data centre in Helsinki. 2.101 A group of investigators from Denmark, Finland, Sweden, USSR and Yugo­ slavia began to follow up cohorts of stroke survivors, using data from the community- based stroke register study carried out by WHO in 1971-1974. About 10% of identified stroke patients had survived. Information was collected on their degree of disability, state of health, living conditions and need for support, and a preliminary analysis started. 2.102 Participants in a consultation on social marketing for effective strategies in the field of noncommunicable disease prevention (Bregenz, Austria in March) discussed the nature of social marketing, its role in noncommunicable disease prevention, experience in the practical application of this approach, and resource needs. 2 . юз Regional Office staff visited Israel and Morocco to study possible collaboration in the field of noncommunicable diseases. Target 10 B0 2.104 The Regional Office continued to assist Member States either to develop national cancer control policies and programmes or to reorganize and take full advan­ tage of those already in existence. A national course on cancer control programming, held jointly with the Yugoslav authorities at Opatija in February, was the starting-point for pilot field testing of the Regional Office’s guidelines on this subject. 2.105 To ensure optimum services for the community, consultations were held on organizing multidisciplinary cancer care at different levels of the health system, and guidelines for this purpose were completed. Cooperative efforts continued in setting up model care programmes for the specific problems of cancer at selected sites, e.g. for breast, cervical and colorectal cancer. The focus was on introducing early detection measures wherever they are scientifically justified. 2.106 Assessment of the appropriateness of health technology used in cancer control is a basic requirement in ensuring efficient and ethical delivery of cancer care. For this purpose, a multidisciplinary working group met in Athens in May to give guidance on technology assessment in the context of cancer care programmes. The group rec­ ommended the preparation of courses to communicate the concept and methodology of By the year 2000, mortality in the Region from cancer in people under 65 should be reduced by at least 15%. 31 such assessment to people who influence cancer care in Member States. New projects in this field, started in 1986 and carried out in collaboration with expert groups, involve a wide range of technologies, e.g. breast self-examination, the occult blood test for colorectal cancer, diagnostic procedures for early breast cancer, computer-assisted radiotherapy, the biohazard protection facility in cancer centres, and education of the public on cancer. 2.107 Following a consultation on the implementation of occupational cancer pre­ vention, held jointly with the Occupational Health unit in Prague in December, an opinion survey was conducted among national experts in both occupational health and cancer control, and programmes were designed for use by individual Member States. 2.108 Cooperation with IARC, CEC, CE, the Nordic Council and the Organization of European Cancer Institutes on various aspects of the regional cancer programme has increased. A course on cancer epidemiology was organized jointly with IARC in Holzhau, German Democratic Republic in April/May, and an international seminar on primary prevention of cancer took place in Antwerp in March, under the co-sponsorship of WHO and a number of other organizations. 2.109 Collaborating centres in the German Democratic Republic, Hungary and the United Kingdom helped conduct technical projects on the establishment of a data bank to assess technologies used in cancer control, on manpower development for cancer control, and on a comparison of the outcome of cancer treatment with and without the care programme approach. 2 .110 One consultant helped develop a systematic approach to the Albanian national cancer control programme, while another helped evaluate the cervical cancer screening programme and the continuing study of breast self-examination in the German Demo­ cratic Republic. The Regional Office also helped establish a computerized call-and-recall system in Hungary to support the countrywide screening programme and, in collab­ oration with UNDP, continued to support the implementation of the national cancer programme in Poland. Target 11 SO Accident prevention 2.111 The third activity in the collaborative programme with Morocco was a national workshop on statistics for accidents, held in January. The participants recommended the introduction of a basic data set to be used by all the sectors concerned. 2.112 The second collaborative programme activity in Iceland — a workshop on education for accident prevention — took place in February, with participants from all By the year 2000, deaths from accidents in the Region should be reduced by at least 25% through an intensi­ fied effort to reduce traffic, home and occupational accidents. 32 sectors, including schoolteachers and members of parliament. They agreed on the adoption of a coordinated approach and the development of education-for-safety pro­ grammes, especially in schools and health centres. 2.113 The first step in the development of a national policy for Hungary, a national workshop held in November, involved all the relevant sectors. The participants rec­ ommended a review of the statistical base for accident recording and the establishment of a steering group to develop an overall policy, with emphasis on home accidents. 2. l и In November, a meeting on alcohol, drugs and driving formed the third activity in Spain’s medium-term programme. Participants recommended the establishment of a multisectoral group to prepare a data base on the use of alcohol and drugs and their role in accidents, and to discuss an agreed terminology, a common approach to the treatment of offenders, and countermeasures. The media showed interest in the outcome of the workshop and interviewed the participants. 2.115 The Regional Officer for Prevention of Accidents visited Yugoslavia to help prepare a first national workshop, held in March. He also had preliminary discussions in Italy in November and visited Greece in December. 2.116 The Regional Officer represented WHO at a congress of the International Federation of National Societies of Automotive Engineers in Belgrade in June. He presented a paper on programmes for accident prevention and took part in a round­ table. The congress recognized the need for closer contacts between industry and the health sector, particularly on vehicle design, and welcomed future collaboration with WHO. 2.117 A working group organized jointly by the Regional Office, the International Programme on Chemical Safety, the World Federation of Associations of Clinical Toxicology Centers and Poison Control Centers, the European Association of Poison Control Centres and CEC met in Münster, Federal Republic of Germany in December to help identify high-risk circumstances for acute poisonings, practicable options for pre­ vention, and the roles of various bodies. The group recognized that in most countries drugs, household products and pesticides are the most frequent causes of acute poison­ ings, though not necessarily in that order (see Fig. 2). Pesticides may be the main cause in agricultural countries. The age distributions in acute poisonings are rather uniform, children under five years of age being at greatest risk. 2.118 Preventive programmes call for the identification and prediction of circum­ stances under which acute poisonings may occur, the establishment of preventive options and the assessment of their practicability. No single body has a unique role in identifying high-risk circumstances and carrying out preventive measures. Information from poison centres plays a major part, but it should be used by the authorities together with information from other recognized sources. Once introduced, poison prevention pro­ grammes should be monitored and evaluated. 2.119 Activities in the field of information exchange included the meeting of a steering committee on statistical indicators for accidents (Berlin, October) which agreed on the 33 Fig. 2. Causes of ac u te p o i s o n i n g in Be lg ium, Po r tuga l and Turkey В Ш Belgium В 8 8 Э Portugal B l Turkey establishment of a data base for accidents. A first forum for the exchange of experience on national accident control policies was held in Budapest in November. The partici­ pants recommended more community involvement in prevention programmes and the encouragement of “ social awareness” of the magnitude of the accident problem. They agreed to work with Johns Hopkins University to develop a procedure for showing progress made by Member States towards attainment of target 11. Work continued with OECD on the in-depth analysis of accidents, including on-site investigations. Joint studies of home accidents with CEC also continued. 2.120 The unitsof Environmental Health Planningand Management and of Accident Prevention distributed a report on the architectural aspects of domestic accident pre­ vention, based on a collaborative study in the Netherlands of building design criteria for reducing the risks of domestic accidents in Europe. Disaster preparedness 2.12! Two members of the Regional Office’s panel of assessors on disaster prepared­ ness worked on guidelines on needs assessment relating to the environment and on hazard mapping, for use by local communities. Three of the assessors led workshops in Addis Ababa and Brazzaville and will be visiting Member States in the European Region as part of collaborative programme development in disaster preparedness. 34 2 .122 The Regional Office’s “ Guidelines on disaster preparedness” were sent out in response to the many requests for advice from Member States following the accident at the nuclear power plant at Chernobyl, USSR (see target 19). The immediate convening of the “ in-house” task force enabled the Office to react promptly, and the ready response by Member States to requests for information made the task much easier. 2.123 A second course on health aspects of disaster preparedness, held in Marrakesh, Morocco in July, was attended by participants from Europe and Africa. They drew up plans of action for use at the local community level and made proposals for a workshop to be organized at this level, with a strong emphasis on hazard mapping. Pilot appli­ cations of these plans will be made in Africa in 1987 and in Europe in 1988. The International Water Decade unit also participated in the course, helping to draw up guidelines on adequate water supply and sanitation services in emergencies. 2.124 Disaster preparedness activities were undertaken jointly with UNDRO and the League of Red Cross and Red Crescent Societies. Some work was also done jointly with WHO headquarters and the regional offices for Africa and the Eastern Mediterranean. At the Regional Office for Europe, the Regional Officers for Nursing and for the International Water Decade and Chief, Coordination with other Organizations are also actively involved. 2.125 The Regional Office was represented at the two European workshops on edu­ cational aspects of health in disasters (San Marino, February and November) and at a first meeting on comparative study of the organization and functioning of emergency medical assistance services (Strasbourg, February). Target 12 SO 2 .126 A working group on preventive practices in suicide and attempted suicide was held in York, United Kingdom in September to consider official suicide data from European countries and proposals for collecting internationally comparable data on trends in attempted suicide, and to devise preventive strategies appropriate to the achievement of target 12. In general, the group endorsed the view that official suicide statistics from European countries are sufficiently reliable to be used to establish trends over time in particular countries. The group did not favour the monitoring of police and hospital records for attempted suicide incidence, and instead proposed a multinational research project involving local area data collection for more effective and reliable study of the incidence and analysis of the causative factors. The Inter­ national Association for Suicide Prevention, the International Federation of Telephonic Emergency Services, the Canadian Suicide Information Education Centre, the United Kingdom Samaritans, the World Psychiatric Association and the World Federation By the year 2000, the current rising trends in suicides and attempted suicides in the Region should be reversed. 35 for Mental Health were represented at the meeting, as were the WHO collaborating centres for research and training in mental health in Umeâ and Aarhus. Evaluation: The oral health programme during the period 1984-1985 2.127 The performance of the oral health programme during 1984-1985 was assessed by the European Advisory Committee on Health Research0 in February. The Committee was informed that the research component in the programme was mostly epidemi­ ological, and it found that there was close cooperation between the Regional Office and WHO headquarters on this aspect. The programme structure, with its emphasis on oral hygiene, was regarded as satisfactory. 2.128 The programme was then reviewed at service level in August. Of the 38 inter­ country programme activities, 30 had been completed, 4 had been merged to avoid duplication, 2 had been postponed owing to unforeseen constraints and 2 had been deleted at the previous programme review meeting in February 1985. More than 80% of intercountry activities, in addition to all the 41 country activities, had been delivered on time, an achievement that was also recognized in the Regional Programme Committee’s report on evaluation of the Regional Office’s programme for the 1984-1985 biennium. 2.129 At a peer review in November the oral health programme was judged to be one of the best programmes with regard to planning, implementation, use of resources, reporting, geographical coverage and overall outcome. 2.130 More generally, the success of the programme is already evident in the improved oral health that has been observed in many Member States, and in the increasing emphasis placed on preventive measures against oral disease. The programme has also resulted in changes and improvements in dental educational systems and dental care delivery systems in many countries. The impact has been most marked in those countries for which medium-term programmes have been established. a T h e title o f the E u r o p e a n A d v i s o ry C o m m it t e e o n M e d ic a l R e se a rc h w as c h a n g e d to E u r o p e a n A d v iso ry C o m m it t e e on H ealth R e search at the Thir ty-ninth W o rld H ea l th A s se m b ly in M ay . HEALTH FOR ALL IN EUROPE BY THE YEAR 2000 Publications issued in 1986 Tick-borne encephalitis and haemorrhagic fever with renal sydrome in Europe: report on a WHO meeting. EURO Reports and Studies, No. 104. Guidelines on AIDS in Europe. First revised edition. Non-serial publication. Colledge, M. et al., ed. Migration and health: towards an understanding of the health care needs of ethnic minorities. Non-serial publication. Documents issued in 1986 Development of care programmes for cancer: guideline document 2 (docu­ ment ICP/CAN 119). Development o f health economics training: report on a WHO study group (document ICP/MPN 503/m01). The health hazards o f organized violence: report on a WHO meeting (docu­ ment ICP/HSR 811). Social justice and equity in health: report on a WHO meeting (docu­ ment ICP/HSR 804/m02). Systems for providing aids for disabled people: report on a WHO meeting (document ICP/RHB 005A01). Vulnerability among long-term unemployed: longitudinal approaches: report on a WHO meeting (document ICP/HSR 801/m02). Co-publications and journal articles issued in 1986 Phaff, ed. Perinatal health services in Europe: searching for better childbirth. Beckenham, Croom Helm. Leenen, H .J.J. et al. Trends in health legislation in Europe. Paris, Masson. A better life for the elderly: report of a joint meeting. Paris, International Epidemiological Association/Association of French-language Epidemi­ ologists. Prevention of oral diseases: report on a WHO workshop on community oral health services. Erfurt, Medical Academy of Erfurt. ten Horn, G. et al., ed. Psychiatric case registers in public health. A world­ wide inventory 1960-1985. Amsterdam, Elsevier. AIDS in Europe: report on a WHO meeting (Graz, 7-9 April 1986). AIDS-Forschung (AIFO), 1(7): 361-399 and 1(9): 488-519 (1986). Medical sociology and the WHO’s programme for Europe. Social science and medicine, 22(2): 113-284 (1986). 38 3 Lifestyles conducive to health Target 13 30 Health promotion 3.1 In January, the units of Health Promotion and of Environmental Health Planning and Management launched the Healthy Cities project. Its aim is to help European cities improve the health of their citizens by explaining the determinants of health in cities and reviewing possible indicators; by carrying out a wide range of health promotion activities and communicating models of good practice to othercities; and by developing measure­ ments and methods for monitoring city progress towards HFA. 3.2 The first Healthy Cities symposium was hosted in Lisbon in April by the three founding partners of the “ Health for Lisbon” project: the Municipality of Lisbon, the Re­ gional Health Administration and Santa Casa da Misericordia. Representatives of 33 cities in 19 countries attended and later were advised on developing their own activities. They concluded that priority should be given to developing strategies and mechanisms, and devising objective and subjective measurements of a community’s health. 3.3 At a workshop on strategies for the Healthy Cities project, held at the Nordic School of Public Health, Gothenburg in October, special attention was paid to en­ vironmental health issues. The participating cities’ progress reports emphasized the necessity for local political commitment to the project, its usefulness in promoting intersectoral cooperation, and the need to involve the community. Frameworks for action on environmental health and health promotion were distributed. National networks for healthy cities have now been started in Finland, the Netherlands and Spain. By 1990, national policies in all Member States should ensure that legislative, administrative and economic mechanisms provide broad intersectoral support and resources for the promotion of healthy lifestyles and ensure effective participation of the people at all levels of such policy-making. 39 3.4 The journal Health promotion appeared for the first time in 1986. It is designed to serve as a focal point for disseminating ideas, research, policy and practices that promote health, and it covers such topics as housing, employment, the environment, agriculture, education, the humanities, the arts, economics and clinical health research. This ap­ proach reflects a growing awareness among health planners that the determinants of health are intersectoral and that future advances will depend on contributions from all social sectors. 3.5 The first issue of the journal came out in May. Copies were made available at the World Health Assembly, but the actual launch took place in London in June. The second issue was distributed during the Regional Committee session in September. It included a provisional health promotion glossary based on material produced by the Regional Office. 3.6 In an effort to identify health promotion projects and programmes in industrial­ ized countries the Regional Office, in collaboration with the Institute for Health Pro­ motion of the University of Wales, Cardiff, started a regular newsletter. Positive health. It provides a lively and up-to-the-minute forum for news, information and practical ideas. Issues are distributed both separately and together with the journal. 3.7 The third annual summer seminar on health promotion took place in Porvoo, Finland in August, in a series designed to develop innovative national approaches. The discussions focused on the move from policy to implementation. The 13 participants from 10 countries included administrators, planners, academics and health decision­ makers. 3.8 A “ Dialogue on health policy and health promotion” was held in Vienna in September, the first of three meetings sponsored by the Regional Office and the Austrian Federal Ministry of Health and Environmental Protection. The 20 participants from 11 European countries were invited to explore the problems and prospects of incorpor­ ating health promotion strategies into social policy as part of a broader challenge of identifying, involving and supporting a wide variety of people engaged in health pro­ motion activities and making them advocates for healthy public policies. 3.9 The Regional Office cooperated with WHO headquarters in organizing an interregional conference on health promotion strategies in industrialized countries. As part of the preparations the Health Promotion Steering Group met in Copenhagen in February to draft the final programme, and in May a policy consultation was held to finalize a framework for health promotion policy and to advise on three country case studies currently in preparation (German Democratic Republic, Japan and Sweden). The conference itself took place in Ottawa in November. This joint effort by WHO, the Canadian Department of National Health and Welfare and the Canadian Public Health Association attracted 200 participants from many countries. Its main purpose was to stimulate debate on a new perception of public health based on advocacy and strategies. It culminated in the issue of a “ Charter on health promotion” . 3.10 The Health Promotion unit commissioned a study on creating a momentum for healthier public policies, which describes network-building for this purpose and dis­ cusses opportunities and obstacles in health policy planning. The study was one of the 40 workshop topics at the interregional conference and is now used for health policy planning by the Regional Office. National drug policies .V11 The drug abuse problem, being relatively new to many Member States and in any case subject to very rapid change, calls for well defined national policies. Essential questions concerning, for example, the responsibilities of local authorities and the integration of services remain largely unanswered in many countries. A study on this subject, focusing on national policies in selected countries, was completed for use at national workshops to be held in 1987. Target 14 SO 3.12 A workshop on support for self-help, held jointly with the International Infor­ mation Centre on Self-Help and Health in Leuven, Belgium in January, brought together participants from several Member States in the Region and also from the United States. They reviewed the present situation and prepared an operational model of support systems for self-help. The Centre continues to collect information and disseminates it through a regular newsletter. 3 .1 3 The family environment is extremely important in the etiology of drug abuse, as in many other psychosocial disorders. A study was started of factors that determine the part played by the family in prevention and treatment of drug abuse, which can vary in the Member States from no role to deep involvement. 3 .1 4 The draft report of a consultation on artificial reproduction, organized in response to increasing concern about the ethical issues involved in technical advances, was circulated for comments to members of the newly formed standing committee for the study of ethical aspects of human reproduction of the International Federation of Gynaecology and Obstetrics, and to the European Society of Human Reproduction and Embryology. The comments and additional information are reflected in the final report, which was distributed in September. 3 .1 5 Under a contractual services agreement, staff at the European Centre for Social Welfare Training and Research, Vienna and a co-researcher from the Pro-Familia association in the Federal Republic of Germany began an assessment of changes in sex roles and their implications for family planning and sexual counselling services. This study involves a literature survey and a direct compilation of existing research on sex roles in five European countries: Austria, the Federal Republic of Germany, Spain, Sweden and the United Kingdom. The researchers will analyse developments at various By 1990, all Member States should have specific programmes which enhance the major roles of the family and other social groups in developing and sup­ porting healthy lifestyles. 41 levels of society in the period from 1970 to 1985. They assume that changes in the roles of men and women (e.g. in work patterns, social life, family formation patterns, family types, family responsibilities and family size) and also growing unemployment, which is affecting men and women in different ways, exert a considerable influence on sexuality, partnership and contraceptive practices. These changes need to be documented in order to improve and, if necessary, reorganize family planning services. Target 15 SO Health education and health promotion 3 . 1 6 On behalf of WHO, the International Union for Health Education organized a meeting at the Regional Office in September on the role of nongovernmental organiz­ ations in the promotion of HFA, specifically with regard to healthy lifestyles. This was a major contribution to developing and strengthening collaboration with relevant non­ governmental organizations in the European Region. 3.17 During 1986, the Region’s collaborating centres for health education underwent a major joint review to ensure that their work was contributing both to their own objectives and to the common goal of health for all. For maximum economy and effectiveness, each centre will in future take the lead role in a specific area. 3 .18 A member of the Health Education unit and senior members of the Health Education Bureau, Dublin visited Malta and drew up a draft protocol for “ twinning” between Ireland and Malta. 3.19 An international symposium on the health-promoting school was held in Peebles in May, in collaboration with the Scottish Health Education Group. The participants stressed the importance of intersectoral collaboration and the need to see the school as part of a total health-promoting environment. 3.20 The steering group for a cross-national survey of health behaviour in school­ children met in Edinburgh in May. This joint project, covering the lifestyles of schoolchildren aged 9-15 years in 11 countries, has attracted considerable interest in Member States. 3.21 A major new project on health promotion for young people in the 12 member states of the European Community is being developed by CEC in collaboration with the Regional Office and CE. It focuses on school health education and the dissemination of experience to neighbouring countries. A project proposal has been prepared. 3.22 A seminar on health education in the pre-service training of teachers, covering such aspects as health education/health promotion in the initial training of teachers and strategies and teaching methods, was organized by EEC in collaboration with the Regional Office. By 1990, educational programmes in all Member States should enhance the knowledge, motivation and skills of people to acquire and maintain health. 42 3.23 The generally accepted techniques of health education now need to be revised. Accordingly, a series of annual seminars was planned with the collaborating centre for health education in Dresden. The first of these seminars, on exhibitions, health museums and posters, took place in Dresden in June. It was pointed out that health museums give people an opportunity for recreation combined with education and motivation. To a great extent, they also overcome problems of language and illiteracy and are thus relevant to both developed and developing countries. In October, the Regional Office and the Mersey Regional Health Authority of the United Kingdom collaborated in a workshop on the same theme in Liverpool, where plans for a health museum are well advanced. Sexuality and family planning 3.24 The Sexuality and Family Planning unit continued to produce teaching modules for training in family planning and sexual health. Besoins spécifiques des migrants en matière de planification familiale (in French only) was published by the British Life Assurance Trust, London, and the teaching module “ Guidelines on psychosocial prob­ lems of family planning clients” was translated into Portuguese by the Directorate- General of Primary Health Care of Portugal. The latter also organized a workshop in April to adapt a Portuguese version of the module “ Sexology for health professionals” to conditions in Portugal. A temporary adviser from the National School of Public Health, Rennes helped the local team develop a practical strategy. 3.25 An intercountry teacher training workshop on natural methods of family plan­ ning in a non-religious context was held in conjunction with the collaborating centre for the promotion of family health/family planning (Warsaw) at Jablonna, Poland in August. The 18 participants from 14 countries discussed the different methods available and agreed that their full potential can only be realized if natural family planning services are provided in a non-religious, non-judgemental way, especially at a time when men and women are taking greater interest in their physical, psychological and social wellbeing. The workshop was seen as a positive step in the integration of natural family planning into general health and family planning services. It has aroused considerable interest in some Members States as well as in the Holy See and among international organizations. 3.26 In the framework of assistance to family health activities in Albania, four Albanian doctors went on a four-week study tour to paediatric institutes in Denmark, France and the Federal Republic of Germany in order to see maternal and child health services at community and health facility level, including services pertaining to child- spacing. Two WHO temporary advisers later visited Albania to help choose equipment for the Institute of Paediatric Studies, Tirana, and to finalize a project request for UNFPA assistance with equipment and fellowships for the Institute. 3.27 A WHO temporary adviser visited the Research Institute of Obstetrics and Gynaecology, Sofia to help set up an artificial insemination by donor service. He also addressed postgraduate students and senior clinicians on infertility and on projections for infertility services and artificial insemination by donor services for the next 10 years. 43 3.28 A Bulgarian fellow studied cytological methods in prenatal diagnosis at Erasmus University, Rotterdam from March to June, while in October a WHO temporary adviser visited Bulgaria’s family planning counselling project for families at risk to evaluate progress since 1983. An additional budget allocation was received from UNFPA for the purchase of computer equipment for the project. 3.29 The collaborating centre for teaching and research in human reproduction and family planning in Rabat contributed to the continuing education of national and international personnel, including physicians, midwives and nurses, in family planning and contraceptive techniques, and of physicians in surgical contraception (lapar­ oscopy); to information support, by updating and improving service records used for family planning and contraception; and to research, by conducting further operational studies on the reproductive health of adolescents and clinical investigations of new contraceptive products. The centre and its staff have made a considerable impact on national family planning policy and programmes, especially with regard to replicability in obstetrics/gynaecology services provided by former trainees. A family planning unit is being set up in the centre, and new record forms and technology are being used by former trainees. 3.30 The collaborating centre for the promotion of family health/family planning in Warsaw was again very active in promoting family planning and training medical teachers. It organized two postgraduate courses in family health education and family planning for primary health care workers (obstetricians, paediatricians, nurses and midwives); the first was held in Warsaw in March, with 18 participants, and the second in Bialystok in April, with 16 participants. An evaluation of the two courses was presented at a meeting of the Association of Paediatric Education in Europe, held at the National School of Public Health, Rennes. The Alma-Ata Declaration was translated into Polish and distributed to the participants in the two courses and to other health workers. The centre promoted a school for prospective parents, with the active participation of fathers, and continued regular teaching on family life, including sexuality and family planning. Finally, it is working out an evaluation procedure for parent education. 3.31 Two new WHO teaching modules were tested: guidelines on problems of sexually transmitted diseases and guidelines on certain aspects of homosexuality. 3.32 Extracts from the WHO information bulletin Entre nous were translated into Polish for the benefit of Polish journals on obstetrics/gynaecology, paediatrics and family health. 3.33 The Regional Officer for Sexuality and Family Planning visited France in June to follow up a study on the role of men in birth and contraception at the National School of Public Health, Rennes. At the International Children’s Centre, Paris she discussed the report of a working group on the improvement of family planning services for migrant populations, a teaching module on psychosocial aspects of family planning and areas of future cooperation. She also visited the Council for Sex Information, Family Planning and Family Education, for discussions with the secretary-general and other officers. 3.34 At the request of the Government of Hungary, a Hungarian social worker was invited to make a two-week study visit to the Belgian Family Planning Federation in 44 Brussels in February. Equipment was ordered for the departments of obstetrics and gynaecology at the medical schools in Debrecen and Budapest. Two Hungarian pro­ fessors of medicine visited Ecuador, Jamaica, Mexico and Peru in April and May to make an on-the-spot evaluation of the progress of former participants in their family planning courses. .1.35 The Regional Officer visited Morocco in June to follow up the project on professional training in maternal and child health/family planning, for which two consultants were recruited in November/December, one for evaluation and the other for health manpower. A study tour to Canada was again organized for eight Moroccans in November/December. 3.36 During a visit to Lisbon in February the Regional Officer reviewed, together with the project team, the integrated project for basic education in literacy, health and family planning for the Cape Verdean community in the Lisbon area, and had discussions with a WHO consultant engaged to carry out an intermediate evaluation and support a training workshop held in Lisbon in February/March. On a second visit in October, the Regional Officer, the Chief, Europe Branch, UNFPA/New York, and the Senior Liaison Officer, UNFPA/Geneva, worked with the Cape Verdean Association and other institutions in coordinating activities, exchanging experience and widening the scope of the work in order to facilitate the Cape Verdean community’s interaction with the Portuguese commmunity, and improve its intervention and decision-making capacity. UNFPA was asked to extend its support to 1987-1989. 3.37 Activities under the Portuguese Ministry of Social Affairs included work by the Regional Officer and the Chief, Europe Branch, UNFPA/New York with the national counterpart for maternal health and family planning in the Directorate-General of Primary Health Care, which has made great efforts to train health professionals in family planning and to increase the coverage and effectiveness of family planning activities, with emphasis on rural areas and high-risk groups. The Regional Officer also visited Faro and Albufeira, where she saw excellent work in maternal health and family planning and addressed health professionals on the subject of sex education of the young. On this occasion she also had discussions with the Portuguese Family Planning Association and the Commission on the Status of Women on current and projected activities in family planning and in sex education of the young. Finally, the first of six courses in family plan­ ning and sterilization techniques took place in Porto in November. 3.38 In Turkey, two temporary advisers were recruited for the UNFPA-funded proj­ ect on strengthening integrated family planning/maternal and child health services in 17 provinces of Turkey, executed partly by the Sexuality and Family Planning unit. In October, they helped organize a supervisory workshop aimed at enabling physicians from these provinces to plan and implement “ calendars” for supervision and evaluation at local health facilities. At the same time, the Directorate-General of Maternal and Child Health and Family Planning was contracted to organize a tour by 34 provincial health directors (and/or their deputies) and physicians to selected provinces to study the implementation of family planning/maternal and child health services, the training of health professionals in intrauterine device insertion, the organization of refresher courses and the use of records. The Regional Officer visited Turkey in April to follow up 45 project activities with the Directorate-General and field health personnel, and again in November to conduct a mid-term review of the activities, together with a staff member from WHO headquarters. On this occasion, she attended a conference of the Ankara Gynaecological Society, where she gave an address on family planning and the sexuality of young people. Target 16 SO Sexuality and family planning 3.39 The report of a consultation and research findings on sexuality and family planning, written from a broadly north-west European viewpoint, was circulated to key people in southern and eastern European countries with a request for further infor­ mation on prevailing views, current issues and new or anticipated trends, before being adjusted, published and distributed. This survey of general problems relevant to the sexuality and sexual health of Europeans focuses on policies, programmes and services that can help people lead healthy and emotionally satisfying sexual lives. Special atten­ tion is paid to social attitudes that condemn or deny the sexuality of certain groups, such as homosexuals, people with mental or physical handicaps, the elderly and people living in institutions. The importance of sex education and of expanded services for family planning programmes is also emphasized. 3.40 The Regional Officer for Sexuality and Family Planning attended the Inter­ national Symposium on the Health-Promoting School in Peebles, Scotland in May (see target 15) to give an address on adolescent sexuality and sex education. 3.41 The Family Planning Association of the United Kingdom was contracted to conduct a study on sexuality and physical disability. It was based on the first-hand experiences, conclusions and recommendations of people with physical disabilities who had attended three workshops run for the purpose by the Association. The unusual feature of this study was that the workshops were attended only by physically disabled people and offered them an opportunity, in a small group, to explore their own experi­ ences and consider what they themselves might do to improve their sexual lives and relationships. They could then move from the private and personal to the general and political to make their recommendations. In other words, they analysed the barriers to the development of sexuality and relationships, and recommended resources, infor­ mation, services or support that could be used. 3.42 The National School of Public Health, Rennes completed a study begun in 1984 on the role of men in birth and contraception. The main findings were as follows. In general, men are willing to share the responsibility for contraception. Vasectomized men By 1995, in all Member States, there should be sig­ nificant increases in positive health behaviour, such as balanced nutrition, nonsmoking, appropriate physical activity and good stress management. 46 are very happy with their contraceptive choice. Men want to he able to “ accompany” their wives psychologically in pregnancy and play a bigger part in childbirth. Artificial reproduction evokes many ethical problems for men, who are, for example, very con­ cerned about the children conceived from their sperm. Men regard child-rearing as a shared responsibility and believe that the parental roles are interchangeable. The re­ searchers recommended that further research be done on men’s attitudes to birth, contraception and parenthood. 1.43 Entre nous, the twice-yearlv information bulletin in English and French, con­ tinued to play an important part in information exchange on sexuality and family planning. The seventh and eighth issues were sent to the 2000 readers in January and July, and the ninth came out in December. Spanish translations of No. 6 and 7 were received from the Instituto de la Mujer, Madrid. Nine hundred copies were sent to the Regional Office for the Americas for distribution in Latin America, and others went to the Regional Office for Africa for distribution in Equatorial Guinea. One hundred copies of the Spanish editions of No. 5, 6 and 7 were sent to the UNFPA Conference on Women, Population and Development in Latin America, held in Montevideo in November. Beginning with No. 6, Entre nous was translated into Portuguese by the Directorate- General of Primary Health Care of the Ministry of Health of Portugal, which will print and distribute 1000 copies of each issue. A further 1200 copies in Portuguese will be printed at the Regional Office and sent to the regional offices for Africa, the Americas and the Western Pacific for distribution to other Portuguese-speaking countries. A leaflet on the sexuality and family planning programme was distributed early in 1986. and was then reprinted to meet a considerable increase in requests. Finally, the report of a multinational pilot study on the evaluation of family planning programmes was published and distributed early in 1986. It is hoped that its findings will contribute to improved management of family planning, and ensure that programmes meet real needs, including those of populations at risk. 3.44 Members of the executive committee of the International Planned Parenthood Federation, Europe Region, visited the Sexuality and Family Planning unit in March for discussions on policy and activities in areas of mutual interest, mainly with regard to youth, male responsibility in family planning, and infertility. They were given an up-to- date list of the Regional Officer’s counterparts in the Region. 3.45 The Regional Officer took part in a consultation on information exchange and collaboration in health-related activities in Europe (Copenhagen, September). The representative of the European Youth Centre, Strasbourg was especially interested in the Regional Office’s work on child rearing, sexual counselling and equal opportunity for teenagers. The Regional Officer also acted as a resource person at a European parlia­ mentarians’ forum on child survival, women and population (The Hague, February) organized under the auspices of the Ministry for Development Cooperation of the Netherlands, in cooperation with WHO, UNICEF and UNFPA. About 150 parliamen­ tarians, journalists and United Nations staff attended. The forum challenged parlia­ mentarians on their responsibility for the less developed countries, and gave them an opportunity to discuss their role in generating support and guidance for the social and economic programmes of the United Nations. 47 Nutrition 3.46 An advisory group on the nutrition programme, meeting in Oslo in January, endorsed the main direction of the programme and stressed that Member States should be encouraged to adopt nutrition policies. It also drafted a brief for studies of nutrition strategies in certain Member States and drew up a list of research priorities in public health nutrition. These and other programme activities can now be communicated to the professional community by means of a computerized list of over 700 persons, institutions and associations working in nutrition in the Region, which is maintained by the Nu­ trition unit. 3.47 Participants in a multidisciplinary meeting, held in Floriana, Malta in August, produced a report that could serve as a model for setting nutrition policy objectives in other countries. A group of experts from Italy, Poland, Sweden and the United Kingdom produced a draft for a publication entitled Healthy nutrition: preventing nutrition-related diseases in Europe, which describes the frequently undesirable changes that have taken place in diets over the last few decades (see Table 5), the changes in diet-related diseases, and the nutrient goals currently recommended by national groups in various European countries. Another expert group, meeting in Copenhagen in November, discussed topics relating to nutritional surveillance, including a possible book for nutrition policy-makers on where to find dietary data in Europe and how to use them. Preparations were also made for a publication on ways to improve nutrition through mass catering, using the results of a comparative study on this subject carried out in Denmark and Hungary. 3.48 Three meetings were organized jointly with the Pharmaceuticals unit to prepare a study on the use and regulation of vitamin and mineral supplements in Ireland, Italy, the Netherlands, Poland and Sweden. It appears that these products, which fall variously under food or drugs legislation, sometimes escape any form of control and are often used unnecessarily, resulting in waste and possibly adverse reactions. 3.49 Close collaboration continued with the CINDI programme (see target 9) in view of the importance of nutrition as a risk factor in chronic diseases. Other collaborative activities included contacts and work with the European Cancer Programme, the EELC forecasting and assessment of science and technology (FAST) programme, the Federation of European Nutrition Societies and the International Union of Nutritional Sciences. 3.50 Activities with specific reference to infant feeding included the drafting of a report on infant nutrition in the European Region, based on information received from 16 Member States in 1985. It showed that the prevalence of breastfeeding seems to be slowly increasing again in the European Region after falling to an all-time low in the 1970s. In some Nordic countries about 70% of mothers are still breastfeeding when their babies are three months old. A survey of maternity-ward feeding routines in Europe revealed that the extent to which modern infant feeding practices are adopted varies considerably in the Member States. A further study, dealing with written advice on infant weaning and based on material collected in three Member States in 1984, again demon­ strated quite disparate practices, even within a particular country. Concerted guidelines on infant feeding may therefore be needed. 48 Table 5. P e rc en tag e o f total d ie ta ry intake p rov id ed by fats, in 3 0 c o u n t r ie s of the Eu rop ean R e g i o n 3 C o u n t r y H 1 s t o r i c a l v a l u e ( 1 9 7 0 ) C u r r e n t v a l u e (1 9 8 3 ) A n n u a l p e r c e n t a g e c h a n g e ( l i n e a r ) A l b a n i a 1 7 . 1 1 1 8 8 0 0 . 7 6 A u s t r i a 3 5 6 3 4 0 1 7 0 9 8 B e l g i u m 4 1 3 7 4 4 1 5 0 5 2 B u l g a r i a 2 1 . 8 7 2 8 . 4 7 2 . 3 2 C z e c h o s l o v a k i a 2 8 9 3 3 1 . 5 6 0 7 0 D e n m a r k 4 1 . 3 3 4 4 8 6 0 6 6 F i n l a n d 3 6 2 4 3 9 6 5 0 7 2 F r a n c e 3 7 2 5 4 0 8 3 0 7 4 G e r m a n D e m o c r a t i c R e p u b l i c 3 5 . 1 3 3 5 4 2 0 0 6 G e r m a n y . F e d e r a l R e p u b l i c o f 3 8 . 0 2 3 8 . 6 8 0 1 3 G r e e c e 3 0 7 9 3 7 81 1 7 5 H u n g a r y 3 0 6 5 3 5 4 7 1 21 I c e l a n d 3 5 31 3 6 8 3 0 . 3 3 I r e l a n d 3 4 9 3 3 3 7 5 - 0 2 6 I t a l y 3 0 . 1 7 3 2 7 9 0 6 7 L u x e m b o u r g 4 1 . 3 7 4 4 . 1 5 0 . 5 2 M a l t a 2 9 51 2 8 6 7 - 0 2 2 M o r o c c o 6 1 5 7 6 1 8 1 2 1 . 1 5 N e t h e r l a n d s 4 4 . 7 5 4 5 5 6 0 1 4 N o r w a y 3 9 81 3 8 . 1 3 - 0 3 2 P o l a n d 2 7 2 3 2 8 . 0 6 0 . 2 3 P o r t u g a l 2 6 8 8 3 0 2 9 0 9 8 R o m a n i a 2 1 3 9 2 5 7 9 1 5 8 S p a m 3 0 . 8 2 3 5 7 8 1 2 4 S w e d e n 4 0 . 3 5 3 7 . 9 1 - 0 . 4 6 S w i t z e r l a n d 3 8 5 6 4 2 7 3 0 8 3 T u r k e y 1 9 . 7 1 2 1 8 1 0 8 2 U S S R 2 3 1 3 2 5 1 5 0 6 7 U n i t e d K i n g d o m 3 9 2 8 3 9 5 9 0 0 6 Y u g o s l a v i a 2 2 6 0 2 6 9 4 1 . 4 8 E u r o p e a n R e g i o n 2 9 1 0 3 1 0 6 3 Representing 99 49% of the regional population ^ Although Morocco is now a member of the Eastern Mediterranean Region, it was a member of the European Region during the period covered by the table. 49 3.51 In October, representatives of health workers’ organizations met in Copenhagen to discuss how they could contribute to the implementation of the International Code of Marketing of Breast-milk Substitutes. They agreed to continue working towards a European breastfeeding promotion strategy. To strengthen information exchange in this field, a statement produced for a European Parliament subcommittee on “ The WHO code versus the IDACE voluntary agreement” was circulated to all paediatric societies in the Region. A set of recommendations for research on the effects of different methods of infant feeding on morbidity is also available for those intending to study the question of breastfeeding versus artificial feeding. Smoking and health 3.52 At the thirty-sixth session of the Regional Committee, all Member States agreed to take concerted action on tobacco throughout the Region, and to work for the adoption of a European declaration on tobacco and health. The European action plan on smoking and health was discussed at a consultation in Copenhagen in May, and in December a member of the Health Education unit attended a national workshop on smoking control policy in Warsaw, sponsored by the Ministry of Health and Social Welfare and the Polish Anti-Smoking Society. 3.53 The problem of smoking among health professionals was examined at an international symposium organized in Venice in May by the Italian League Against Cancer, in collaboration with the Regional Office and WHO headquarters. The results of the southern European survey on smoking among health professionals, carried out in France, Italy, Portugal and Spain under the direction of the Southern European Committee on Health Promotion and Smoking Control, were presented. It appears that the level of smoking among health professionals in many southern European countries is very high, although increasing efforts are being made to reduce it. Partici­ pants stressed the importance of exemplars in society, especially with regard to smoking. 3.54 As shown in Fig. 3, the general trend of smoking in the Region is downwards, the reduction from initially high rates being somewhat more marked in the case of males. At the same time, there is considerable variation from country to country in the contri­ bution of smoking to overall mortality, as can be seen from Fig. 4. Stress 3.55 Activities in this field included a consultation, held at the collaborating centre for research and training in mental health in Sofia, on psychosocial interventions to prevent disability and improve the quality of life. The participants concentrated on the two major research topics of interventions for common mental health and psychosocial problems, and prevention of disability in people with serious mental disorders, and agreed on protocols for intercountry collaborative research. 50 Pe rc en ta ge Pe rc en ta ge Fig. 3. P erc en tages o f sm o ke r s in the p o p u l a t i o n aged 1 5 years and over, fo r 1 4 c o u n t r ie s of the W H O Eu ro pea n Reg ion , 1 9 7 6 and 1 9 8 0 90 80 70 60 50 40 30 20 10 0 1 I ? AU T CZE □ 1976 I 1 .a. Males ? .a. г i 1 IRE FIN UNK ÉZ22 1980 NOR FRA SWI SWE NET DEU BEL DEN POL I I 1976 ES3 1980 51 Fig. 4. S m o k i n g - r e l a t e d d e a t h s 3 e s t i m a t e d as a p e r c e n t a g e o f al l dea t hs , f o r 2 8 c o u n t r i e s or a reas o f t h e W H O E u r o p e a n R e g io n , a r o u n d 1 9 8 4 POR FRA GRE ISR MAT BUL SWI LUX DEU HUN ICE IRE FIN E *W Ö YUG SPA POL DDR ROM AUT ITA BEL NOR CZE SWE NET SCO0 DEN a Based on the assumption that 90% of deaths from lung cancer. 25% of deaths from ischaemic heart disease and 75% of deaths from bronchitis, emphysema and asthma may be attributed to smoking SCO Scotland. fc&W England & Wales Target 17 SO By 1995, in all Member States, there should be sig­ nificant decreases in health-damaging behaviour, such as overuse of alcohol and pharmaceutical pro­ ducts; use of illicit drugs and dangerous chemical substances; and dangerous driving and violent social behaviour. Research 3.56 At a symposium on health behaviour research and its application in health promotion (Pitlochry, Scotland in February), researchers from 13 countries, including Canada and the United States, expressed the need for research to move in new directions, especially with regard to indicators for both health and health promotion. 52 3.57 In June, the Institute of Social and Preventive Medicine, Berne organized a workshop on new health promotion indicators for measuring health behaviour and health, in cooperation with the Department of Health of the Canton of Berne, the Swiss Federal Office of Public Health, the National Institute on Aging of the National Institutes of Health/US Department of Health and Human Services, and the Regional Office. The participants evaluated major developments and drew up guidelines for the definition and selection of relevant health measurements. The workshop also helped establish a network that should facilitate coordination and continuity of work in health research and health indicator development. Drug abuse 3.58 The staff member dealing with the abuse of psychoactive drugs attended a conference of ministers of health on narcotic and psychotropic drug misuse (London, March), a thirteenth “ International institute on drug dependence” of the International Council on Alcohol and Addictions (Noorderwijkerhout, April) and national drug abuse conferences in Spain and the United Kingdom. 3.59 In most Member States, little information is available on the priorities applied in granting funds for the vast amount of research that is being done. Coordination of research activities is rare, and there are no clear linkages between research results and policy decisions. A drug abuse research coordination system has therefore been set up and will be linked to the work of the European Advisory Committee on Health Research. The Regional Office also started to develop methods that can be applied on a large scale to evaluate different treatments for drug abuse. 3.60 The Regional Office has continued its contribution to a multiorganization proj­ ect on health education against drug abuse, carried out in cooperation with CE and CEC. The project is interesting in that it covers not only school health education but also promotion of the health of the socially deprived. Alcohol abuse 3.61 The Edinburgh-based study on epidemiological approaches to identify groups at a high risk of developing problems associated with alcohol consumption, carried out with the participation of Finland, France, the Federal Republic of Germany, the Nether­ lands, Spain and the USSR, was completed. It was found that epidemiological studies in this field have expanded greatly in recent years, although few of them deal with the social, psychological and economic aspects of alcohol use and misuse. 3.62 A consultation on the influence of economic and other interests in alcohol consumption and related problems was held in Dublin in November. Among the background documentation were the reports of other activities in 1985/1986 carried out for the alcohol programme in relation to the subject. These included two studies by an Irish consultant on public revenue from and direct expenditure on alcohol consump­ tion, as well as a review of alcohol and the mass media and a paper on the impact of 53 international trade agreements on the availability of alcohol (with a chapter on tourist and tax-free alcohol), both by researchers at the Finnish Foundation for Alcohol Studies. 3.63 The WHO collaborative study on community response to alcohol-related prob­ lems continued, and consultant missions were arranged to advise on the French and Portuguese components. 3.64 The staff member dealing with the prevention and control of alcohol abuse at­ tended a thirty-second “ International institute on the prevention and treatment of alcohol­ ism” , organized in Budapest by the International Council on Alcohol and Addictions in collaboration with the Hungarian State Committee against Alcoholism. At the same time, he was able to visit the national principal investigator of the community response study. He also took part in an international symposium on alcoholism and heredity, held in Leningrad in June, and had preliminary discussions with representatives of the All-Union Centre for Medico-Biological Problems of Alcohol Abuse and Alcoholism Prevention in the USSR. Child abuse 3.65 The report of a consultation on sexual abuse of children was issued in May. It makes recommendations for professional training, intersectoral cooperation and co­ ordination, public information, sex education, crisis services and essential research, and establishes the principle that, in all decisions in child abuse cases, the child’s interest should take the highest priority. It also emphasizes that support for all involved is more important than punishment. Evaluation: The health education programme during the period 1984-1985 3.66 At their meeting in February, members of the European Advisory Committee on Health Research commented on the importance of a strong horizontal health education programme and congratulated the Regional Office on the excellent work done in this field over the past five years. They showed particular interest in the linkages between health promotion and education for health, and agreed to the “ settings” approach (i.e. work in schools, workplaces, families, cities, etc.) adopted by the Office. While approving the high priority given to young people, children and families, and to health promotion activities related to the school and the workplace, they called for greater emphasis to be given to work with the elderly. 3.67 The Committee welcomed the regular research overviews carried out by the Health Promotion unit and the special studies it had coordinated on the links between lifestyles and health. In particular, members of the Committee appreciated the work that had been done on positive health and on health indicators. However, they pointed out 54 that a balanced geographical distribution of studies must be achieved, in order to avoid bias, and advocated giving support to countries which need to develop their lifestyle research activities still further. 3.68 Overall, the work of the health education programme was found to be based on sound scientific evidence concerning the relationship between health behaviour and health outcome. L I F E S T Y L E S C O N D U C I V E T O H E A L T H Publications issued in 1986 Langfeldt, T. & Porter, M. Sexuality and family planning: report of a consultation and research findings. Non-serial publication. Documents issued in 1986 Artificial reproduction: report on a consultation and research findings (document ICP/MCH 504/m02). Child sexual abuse: report on a consultation (document ICP/MCH 504/m03). Sexuality and family planning programme (document ICP/MCH 500). 55 A n I n t e r n a t i o n a l C o n f e r e n c e o n H e a l t h P r o m o t i o n , j o i n t l y o r g a n i z e d by W H O , H e a l t h and W e l f a r e C a n a d a , a n d t h e C a n a d i a n P u b l i c H e a l t h A s s o c i a t i o n , w a s he ld in O t t a w a in N o v e m b e r A b o v e , t he o p e n i n g p l e n a r y s e s s i o n o f t h e C o n f e r e n c e . B e lo w , t h e D i r e c t o r - G e n e ra l o f W H O , Dr H a l f d a n M a h l e r , a n d t h e E x e c u t i v e D i r e c t o r o f t h e C a n a d i a n P u b l i c He a l t h A s s o c i a t i o n , M r G e r a l d Da fo e , e n j o y i n g o n e o f seve ra l " e x e r c i s e b r e a k s " he ld d u r i n g t he C o n f e r e n c e . T w o d e v a s t a t i n g i n d u s t r i a l a c c i d e n t s w i t h f a r - r e a c h i n g e n v i r o n m e n t a l c o n s e q u e n c e s o c c u r r e d in t he E u r o p e a n R e g io n d u r i n g 1 9 8 6 : t he e x p l o s i o n at t h e n u c l e a r r e a c t o r at C h e r n o b y l , US S R in A p r i l and t h e f i r e at a c h e m i c a l s w a r e h o u s e at Bas le, S w i t z e r l a n d in N o v e m b e r . Right: d e a d eels, n o r m a l l y a m o n g the h a r d i e s t o f f i sh, b e i n g r e m o v e d f r o m the R iver R h in e f o l l o w i n g p o l l u t i o n by m a n y t o n s o f c h e m i c a l s as a r e s u l t o f t h e Bas ie w a r e h o u s e f i re. Below: No. 4 r e a c t o r at C h e r n o b y l f o l l o w i n g t h e e x p lo s io n . 4 Healthy environment Target 18 BO 4.1 Preparations for the forthcoming European conference on health and the en­ vironment began with a planning meeting in Copenhagen in October, attended by four government advisers in environmental health. 4.2 A French-language course on the environmental and health impact assessment of water resource development projects was held in Liège, Belgium in February, with 23 participants. It was very positively evaluated in Geneva in September by the joint W H O /U N EP /FA O Panel of Experts on Environmental Management for Vector Con­ trol, who recommended continuing it and organizing a similar course in Portuguese. A seventh international course on environmental impact assessment was held at the Uni­ versity of Aberdeen in July. 4.3 A working group on strengthening health and safety considerations in environ­ mental impact assessment met in Copenhagen in February. It reviewed the report of a collaborative study in this field carried out by WHO, the Centre for Environmental Management and Planning (CEMP) in Aberdeen and the collaborating centre for health and disease surveillance in Rome, and recommended greater involvement of public health authorities and experts in the assessment as well as increased intersectoral collab­ oration between environmentalists and health professionals. 4.4 The Regional Office was represented at a European symposium on the scientific basis for soil protection in the European Community (Berlin (West), January) and a meeting of EC government advisers on environmental impact assessment (Geneva, January); and a representative of CEC visited the Office in connection with the European Year of the Environment 1987. 4.5 Other activities included the completion of the country project to establish an en­ vironmental and health impact assessment system for development projects in Poland. It By 1990, Member States should have multisectoral policies that effectively protect the environment from health hazards, ensure community awareness and in­ volvement, and support international efforts to curb such hazards affecting more than one country. 57 will now be used as a model, especially for other countries with centrally planned economies; and the report has been released for wider distribution. The Regional Office also helped with a course on environmental and health impact assessment at the collab­ orating centre for health and disease surveillance (Rome, November) and with a meeting on environmental and health impact assessment in Mediterranean coastal areas (Split, Yugoslavia in July). Finally, a plan to develop community awareness and involvement in environmental health issues was drawn up with CEMP with a view to establishing a WHO collaborating centre in Aberdeen, which would execute the plan together with the collaborating centre in Rome. Target 19 BO 4.6 The British Institution of Environmental Health Officers and the Regional Office organized an international conference on environmental health education in Wolver­ hampton, United Kingdom in July. Later in the year, the newly appointed collaborating centre in the Department of Environmental and Public Health Studies, University of Umeâ, Sweden helped the Navarra Public Health Institute in Spain to strengthen its environmental health courses, including an M.Sc. programme. 4.7 Technical assistance was again given, with UNDP support, to the national centre for sanitary and environmental engineering at the Mohammedia School of Engineering, Rabat. Now that Morocco has joined the WHO Eastern Mediterranean Region, this centre may also be able to serve other Arab countries in the area. Chemical hazards 4.8 Control of chemical hazards in the human environment depends on the availability of accurate, specific and uniform methods of exposure assessment which, when applied to multinational epidemiological studies, give comparable results that can be used for health risk assessment. As part of the regional chemical safety programme, a method of assessing exposure to acrylonitrile, a carcinogenic chemical, was developed following studies in Czechoslovakia and Poland. This method, which is based on the monitoring of cyanoethylmercapturic acid in urine, allows exposure assessment of individuals and will facilitate epidemiological study of the health impact of exposure to acrylonitrile. 4 9 The study on lead neurotoxicity in children, conducted by the collaborating centre for health effects of exposure to lead in Düsseldorf, reached its final stage and investi­ gators from nine participating countries discussed and adopted a uniform approach to By 1990, all Member States should have adequate machinery for the monitoring, assessment and control of environmental hazards which pose a threat to human health, including potentially toxic chemicals, radiation, harmful consumer goods and biological agents. 58 statistical evaluation of the results obtained. At a joint consultation organized by the above collaborating centre, the Regional Office and I ARC in Lyon in November, a plan was drawn up for an epidemiological investigation of morbidity and mortality in stainless-steel workers exposed to welding fumes and gases containing chromium and nickel. The studies on mortality will be coordinated by IARC and those on morbidity by the Regional Office. Several European countries and the United States will take part. 4 . 1 0 Studies on the health effects of long-term exposure to organophosphorus pesti­ cides were initiated and the development of a pilot phase was reviewed at a meeting in Budapest in September; the quality control programme of the studies was then estab­ lished. Two new activities were added to the programme of the network of institutions collaborating on acute poisonings and the health aspects of exposure to pesticides, developed as part of an ongoing project on the control of chemicals supported by UNDP. At a meeting held in Bucharest in November, five countries agreed to collaborate on a methodology for the control of chemicals in drinking-water, concentrating on such substances as mercury, selenium and the trihalomethanes. The National Institute of Hygiene in Bucharest will coordinate this work, while the collaborating centre for occupational health in Budapest is to coordinate studies on the biological monitoring of exposure to lead and tetrachloroethylene, as agreed at a meeting of representatives of six countries, held in Budapest in November. 4 . 1 1 Efforts in the prevention of acute poisonings should concentrate on the high-risk circumstances at which most accidental poisonings occur. A working group on this subject was held in Münster in December, with the support of the Federal Republic of Germany and involvement of the International Programme on Chemical Safety, CEC, and the World Federation of Associations of Clinical Toxicology Centers and Poison Control Centers. It identified as high-risk circumstances in this context certain groups of household and industrial chemicals; the population groups of the elderly and small children; and certain workplace and home situations. Health and education authorities and organizations, industry and the mass media, among others, were recognized as in­ dispensable partners in the prevention of acute poisonings. 4.12 The health risks of many chemicals and groups of chemicals in the environment are not yet known because they have never been thoroughly investigated toxicologically. Polychlorinated dibenzodioxins (PCDDs), polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) belong to these groups. The public is concerned about them because of their relatively high toxicity in animals and their persistence in the environment and in human tissues. 4.13 Activities in this field, including health risk assessment and prevention of health hazards, continued with a consultation in Lilleström, Norway in October. After this consultation, an investigation by Scandinavian countries into the content of PCDDs and PCD Fs in breast-milk was expanded to form a larger multinational collaborative study based on a uniform protocol, with five countries in Europe and in North America participating. Quality control was introduced to ensure comparability of analysis and results. Existing data on human exposure to PCDDs and PCDFs, their content in breast-milk and their toxicity were evaluated and collated to support health risk assess­ ment in breastfed infants. A working group held in Naples, Italy in March, with the 59 support of the Regional Government of Lombardy, confirmed that PCDDs and PCDFs are contained in emissions from the incineration of municipal sewage sludge. However, the group also noted that modern incineration technologies are available, and that they significantly reduce the emission levels and thus the health hazard. Finally, a group of experts, meeting with the support of the Government of Finland in Helsinki in January and Copenhagen in February, drew up guidelines for prevention of the health hazards of PCBs, PCDDs and PCDFs at the workplace and in the general environment. 4.14 The Regional Office was represented at a workshop to evaluate the pilot phase of an epidemiological study on the health effects of pesticides (Budapest, September) and at the fifth steering committee meeting of the UNDP-supported project for European cooperation on the environmental health aspects of the control of hazards (Lodz, Poland in October). New technologies 4.15 Papers describing the Regional Office’s work on visual display terminals were presented at an international scientific conference on work with display units, held in Stockholm in May. Nonionizing radiation 4.16 The WHO collaborating centres for nonionizing radiation (NIR) in Ottawa and Rockville, MD, completed work on the second edition of Nonionizing radiation pro­ tection (European Series, No. 10). A Chinese version was published in Beijing. A complementary directory on NIR was also issued, giving a global review of NIR legis­ lation and listing major national institutions and almost 400 individual experts working in this field. Ionizing radiation 4.17 After the nuclear reactor accident at Chernobyl, the Regional Office set up a small team to respond to the emergency in the Region. The team prepared guidelines, gave advice in response to queries, and collected, analysed and disseminated data. On 6 May, 10 experts attended a consultation at the Regional Office to begin evaluating the public health aspects of the accident; their report was issued four days later. Documents containing the latest radiation data and health measurements provided by national authorities were widely distributed on a bi-weekly and then weekly basis until mid-June. Peak values in the external exposure rate reported after the accident are shown in Fig. 5. 4 18 A working group on the assessment of radiation dose commitments in Europe due to the Chernobyl accident was organized in Bilthoven, Netherlands in June by the Regional Office and the collaborating centres in Bilthoven and Neuherberg. The meeting was attended by 23 experts from 16 countries as well as seven representatives of FAO, 60 Fig. 5. Geographica l d is t r ibu t ion of reported peak values in the external exposure rate (pR/h) Note. The two domina t ing p lume s ituations are indicated schematically , the exact borderlines of the initial p lumes being diffuse and affected by factors such as rainfal l and variable winds. The local deposit ions, causing peak exposure rates from the ground, are highly dependent on rainfall. 61 IAEA, UNSCEAR, WMO and CEC. With fresh measurements and new information at their disposal, the participants reviewed the concentrations and depositions of radio­ nuclides and prevailing meteorological conditions, using predictive models. They attempted to estimate the degree of contamination of foodstuffs and to make a tentative prediction of the population dose from external exposure, inhalation and ingestion. More information is expected to become available in due course following a more comprehensive evaluation. 4.19 The Regional Office was represented at a meeting on post-accident review of the Chernobyl nuclear accident (Vienna, August) and a meeting of the OECD Committee on Radiation Protection and Public Health (Paris, September). 4.20 The collaborating centre for radiopathology in Fontenay-aux-Roses and the National Radiological Protection Board of the United Kingdom in Chilton provided two rapporteurs to complete the report Nuclear power: accidental releases — practical guidance fo r public health action, to be published in the European Series in 1987. Target 20 SO 4.21 Efforts continued to promote national commitment to the objectives of the International Drinking Water Supply and Sanitation Decade and to monitor the results. A third consultation on the Decade in Europe was held in Izmir, Turkey in April, in accordance with resolution EUR/RC35/R6, which urged Member States to improve Decade evaluation procedures in order to assess the water and sanitation services provided for the European population. It was attended by 19 participants from 15 coun­ tries, in addition to 50 experts from Turkish institutions. Key recommendations were that studies should be carried out on the quality of the equipment and material used in water systems in order to avoid the release of substances with detrimental health effects; that losses in water and sanitation networks should be reduced by the systematic introduction of leak detectors and by the rehabilitation of old pipeline networks; and that international development agencies should be made aware of the financial diffi­ culties some countries of the Region are experiencing in achieving Decade goals. 4.22 Two seminars dealing with water and sanitation problems on large and small Mediterranean islands and their tourist resorts were organized jointly with the UNEP Regional Activity Centre for the Priority Action Plan, Split. The first, held in Mallorca in September, noted that fresh water continues to be a major factor limiting development on small Mediterranean islands and in isolated coastal areas and that the protection of water resources from pollution is an equally important concern, and recommended exploring and developing rational and safe methods for reuse of wastewater to solve the water shortage problem. The second, held in Malta in December, focused on problems of coastal water quality resulting from the presence of large, fluctuating populations By 1990, all people of the Region should have adequate supplies of safe drinking-water, and by the year 1995 pollution of rivers, lakes and seas should no longer pose a threat to human health. 62 during the tourist seasons. Activities also continued in collecting data from the European countries participating in the UNEP/WHO Global Environmental Monitoring System (GEMS) water component. 4.23 Proposals for the implementation of five UNDP-supported intercountry projects were presented and approved. They included activities for water quality protection of the River Danube; environmental and health impact assessment; land-use practices and the protection of surface water and groundwater; prevention and control of environmental pollution from toxic chemicals and hazardous wastes; and the development of effective systems for public health aspects of food safety. 4.24 WHO/UNDP assistance continued in the highly successful Moroccan pro­ gramme for the Decade, to be completed in 1987. It includes a project for technology transfer to the central laboratory services aimed at improving drinking-water quality throughout the country and ensuring application of the WHO guidelines, and pre­ investment studies for water supplies in smaller communities, which will be followed by a new US $44 million loan from the World Bank. WHO also helped the authorities prepare a new Decade programme, to be financed by UNDP during the 1987-1991 cycle. This programme will include a large-scale project on maintenance of water supply facilities and drinking-water conservation, a project on master planning for sewerage and sani­ tation, another on master planning for rural water supply, and a joint WHO/ FAO/UNDP project on treated sewage reuse for agricultural irrigation. UNDP has allocated US $4 million to Decade projects in Morocco for the period 1987-1991, includ­ ing US $2.8 million to projects to be assisted by WHO. However, as that country has now joined the Eastern Mediterranean Region, the new programme will be carried out by the Regional Office in Alexandria. 4.25 The UNDP regional project on water resources development, in which the Regional Office acted on behalf of the regional offices for Africa and the Eastern Mediterranean, was successfully concluded. Activities included the holding of a French- language seminar on the health aspects of treated sewage reuse in Tunis, with the contribution of a WHO epidemiologist, and the completion of the sub-project relating to the control of reservoir eutrophication in warm climates, with the help of the Swedish Environmental Research Group, Stockholm. A report on this activity was issued in French, and will appear in English in 1987. 4.26 Participants from Mediterranean countries attended a workshop on ap­ propriate technologies for water supply and sanitation in arid areas at the National Centre for Sanitary and Environmental Engineering, Mohammedia School of En­ gineering, Rabat in November. They reviewed technological progress in the fields of reuse of treated sewage, demineralization of brackish water, conservation of drinking- water, piped network leakage detection, and treatment of sludge and slurry on drying beds. 4.27 Activities by the WHO collaborating centres included a workshop on the con­ tinuing training of operators of small-scale sewer networks and sewage treatment plants, organized at the collaborating centre for wastes disposal in Nancy, in April, in order to review bilingual guidelines prepared by the centre and to promote use of the WHO 63 guidelines for water supply and sanitation. Nineteen countries were represented. After­ wards, Morocco and Turkey requested UNDP and WHO support to strengthen their national centres for water supply and sanitation operators, while the UNEP Regional Activity Centre for the Priority Actions Programme, Split helped to upgrade the training of sewage treatment plant operators in the Mediterranean countries, with WHO assist­ ance. The collaborating centre for water resources protection in Budapest organized a consultation in September to review water denitrification technologies. Staff of the centre also represented the Regional Office at several international Decade meetings. The collaborating centre for drinking-water and water pollution control in Medmenham and the International Reference Centre for Community Water Supply and Sanitation in Rijswijk helped the Regional Office to publish guidelines on slow sand filtration. The collaborating centre for wastes disposal in Nancy took part in Decade meetings and in October organized with the Regional Office a consultation on a manual for rural water supplies disinfection. In October, the collaborating centre for rural sanitation and waste disposal in Lyon (CEMAGREF) organized with the Regional Office a meeting on waste stabilization pond techniques. Staff of the centre also took part in Decade meetings and provided facilities for the training of engineers from other countries of the Region. Finally, the collaborating centre for primary health care in Alma-Ata helped to draft guidelines on an intersectoral approach to the organization and management of water supply and waste disposal systems, to be published in 1987. 4.28 In Belgium, the University of Liège organized a course on environmental health impact analysis in February. The Government also supported the Decade programme by sending participants to the Izmir and Lyon meetings at its own expense. 4.29 Czechoslovakia has a total of 3695 public water supplies extracting water from surface water and groundwater sources (50% each) and serving two thirds (4730 com­ munities) of the approximately 15 million population of the country. The high concen­ tration of nitrates in drinking-water is a problem, particularly for the two million people living in rural areas and supplied by private wells. The Water Resources Authority has been actively involved in monitoring water quality and controlling industrial pollution. 4.30 The Technical University of Denmark and other collaborating institutions as­ sisted in the preparation of a manual on waste stabilization ponds. The Greenland Technical Organization also helped revise the two sets of guidelines on water supply and sanitation and on solid waste management under cold climate conditions. 4.31 Finland supported Decade programme monitoring in 1986, sent participants to Decade meetings at its own expense, and participated in activities related to environ­ mental health in cold regions. Seventy-five per cent of the Finnish population are now served by public water supplies under regular control of the health authorities. Water pollution is still a problem, but the National Board of Health is taking preventive measures. The main concern at the moment is the removal of nitrates from private rural household systems (covering about 20% of the total rural population); present tech­ niques are too complex for private domestic installations. 4.32 Decade activities in France were aimed not only at solving quantitative problems but also at improving quality control of water sources. Special attention is given to 64 protecting coastal tourist areas and inland recreational waters. Wastewater treatment and reutilization methods are also special features of the programme. National insti­ tutions cooperated with the Regional Office on research into the denitrification of water. A computerized water quality monitoring system was successfully developed. 4.33 The German Democratic Republic participated in WHO meetings related to new technological developments. In Bad Elster, the health risks of a method of removing nitrates from drinking-water by ion resin exchange was investigated. It was found that the removal of ions other than nitrates, such as iodine, may be a disadvantage. 4.34 The Federal Republic of Germany helped monitor Decade activities and took part in research and meetings connected with advanced water and sanitation technology. 4.35 Greece, Italy and Malta participated in studies of water and sanitation problems on Mediterranean islands. In addition, Italy is actively engaged in protecting ground­ water sources, monitoring the presence of pesticides, herbicides and fertilizers, and assessing related health effects; while Malta, whose nitrate levels are rising due to the indiscriminate use of nitrogenous fertilizers in agriculture and soil permeability, is attempting to introduce modern methods of water denitrification. 4.36 Hungary stepped up its efforts to attain Decade goals, substantially increasing the coverage of water and sanitation services for the population, in addition to activities related to protection of River Danube water sources. 4.37 In Ireland, nearly all houses in urban and rural areas now have a water supply. All houses in urban areas, and almost all in rural areas, also have a water-closet. In the past few years, the public has become aware of the need to protect the environment, so that the collection and disposal of liquid and solid wastes have reached satisfactory standards. 4.38 Safe drinking-water and adequate sanitary facilities are apparently available to the whole population of Israel, and about one third of all inhabitants are supplied with fluoridated water. The main Decade problems still to be solved are occasional network breakdowns in both water and sewage systems, the completion of wastewater treatment plants for large municipalities, and the scarcity of water resources in general. Monitoring of water quality and sewage systems is the responsibility of the Public Health Division of the Ministry of Health. Other ministries are also involved in monitoring the general quality of the environment. Israel is expected to make important technical contributions in dealing with water and sanitation problems of other Member States with limited water resources, to which the recycling and reuse of wastewater for industrial and agricultural purposes appear to be the solution. 4.39 The Netherlands supported water quality control, Decade monitoring and the dissemination of technical documents through the International Reference Centre for Community Water Supply and Sanitation, Rijswijk, and sent participants to meetings at its own expense. A new water management policy has been introduced to provide a network of water systems that will ensure a balance between human needs and ecology. 4.40 Norway supported activities related to water and sanitation problems in cold regions, and monitored Decade results. The water authorities are laying great stress on 65 the routine monitoring of water quality parameters for both rivers and lakes. Special methods for computing the average quality of watercourses have been developed (e.g. stratification of the Telemark River basin) on the basis o f random sampling, and are now a common feature of the national water quality control programme. 4.41 The main problem for the Decade programme in Poland is the pollution of groundwater and surface water sources due to the discharge of untreated wastewater and to agricultural practices that contaminate wells. 4.42 Decade activities continued in Portugal, including the training of environmental health personnel at the New University of Lisbon and the National School of Public Health, and a project for pollution control in the Tejo River. The national water supply and sanitation services have been reorganized and are giving full support to Decade activities. 4.43 Romania is the operational base of an intercountry UNDP-supported project of which the monitoring of chemicals in drinking-water is an important component. 4.44 Spain was active in Decade monitoring activities, particularly in relation to water supply and sanitation on Mediterranean islands, as was Sweden, which trained environ­ mental health inspectors at the collaborating centre for the training and utilization of environmental health officers in Umeâ, and participated in matters related to sanitation in cold climates. 4.45 Switzerland sent participants to meetings at its own expense, and offered facilities for the training of middle-level staff in water and sanitation operational plants. One of the country’s main concerns is the disposal of residual products of wastewater treatment plants. 4.46 In addition to developing the water and sanitation component of diarrhoeal disease control activities, the authorities in Turkey studied the possibilities for im­ plementation of several WHO/UNDP-supported projects to strengthen the national services dealing with environmental problems. Particular attention was paid to the training of personnel in charge o f drinking-water and wastewater treatment plants. 4.47 As in other European countries, nitrate concentrations in United Kingdom water supplies are rising, largely as a result of agricultural practices. Research on nitrate control was carried out by the water authorities and by the collaborating centre for drinking-water and water pollution control in Medmenham. Ion exchange and bio­ logical plants are the most common denitrification methods. The disposal of liquid and solid wastes is also being monitored and investigated, as are all factors related to marine pollution. 4.48 WHO assistance to the Spreca River pollution control project in Bosnia, Yugo­ slavia and to the underground water pollution control project in Macedonia continued. A new project on food and water quality control was started with the Public Health Institute, Novi Sad. 6 6 Mediterranean Action Plan 4.49 A full description of WHO’s involvement in the Mediterranean Action Plan is given in the Special Feature at the end of this chapter. 4.50 In 1986, more emphasis was placed on the prevention and control of pollution from land-based sources in the health-related activities of the Plan, and in general, good progress continued to be made on all aspects of the Plan for which WHO is responsible, although the major constraints, including financial pressure and procedural difficulties at overall programme level and with regard to national counterparts, remained and led to unavoidable delays. 4.51 Monitoring activities included the provision, again in 1986, of technical assist­ ance, equipment and fellowships to national institutions to monitor marine pollution sources and coastal water quality as part of the long-term programme constituting M ED POL Phase II. The series of microbiological and related reference methods for use by laboratories in the programme was expanded, and existing methods updated and/or revised, with emphasis on new, non-intestinal pathogens. The series of intercalibration exercises on microbiological methods for coastal water quality monitoring, conducted from 1982 to 1985, were comprehensively reviewed. It was found that comparability of the different methods for determination of the main bacterial indicator organisms is satisfactory, but that laboratory personnel need further training, especially in interpret­ ation and evaluation of data and in quality control. By the end of 1986, all 17 countries participating in the Plan had national marine pollution monitoring programmes that were either operational or at an advanced stage of development. 4.52 Nine research projects were completed in 1986, 16 were extended, and 17 were started. Subjects covered by new projects include the development of models for pol­ lution load assessment, the estimation of the receiving capacity of marine areas, the efficiency of submarine outfall structures, the scientific rationale for emission standards, and environmental quality criteria for recreational waters and shellfish. 4.53 Principal investigators from research projects in Israel, Italy and Yugoslavia and a representative of IARC attended a small consultation on carcinogenicity and muta­ genicity of marine pollutants (Athens, June). The aim was to improve collaboration between participating institutions and ensure coordination with work going on else­ where. At another consultation, dealing with the health effects of methylmercury in the Mediterranean area (Athens, September) participants from Egypt, France, Greece, Italy, Morocco, Poland, Spain and Yugoslavia and representatives of FAO, IAEA and the International Oceanographic Foundation agreed on modifications to the pilot phase and reviewed a comprehensive protocol for clinical and epidemiological studies, to be used at the next stage. National coordinators also attended a fourth UNEP-sponsored working group on scientific and technical cooperation (Athens, June) and agreed on provisional reporting formats for authorizations issued for the discharge of liquid wastes into the Mediterranean. 4.54 In the Priority Actions Programme, the Regional Office stepped up its work on water resource management, liquid and solid waste management and environmental 67 impact assessment in collaboration with the UNEP Regional Activity Centre for the Programme in Split. Guidelines on monitoring the efficiency of submarine outfall structures were also produced for use in pilot studies in selected areas, which began in mid-1986. Target 21 SO 4.55 Representatives of nine intergovernmental and nongovernmental organizations took part in a ninth intersecretariat meeting on air pollution problems in Europe, convened by the Regional Office in Geneva in November, while 35 experts attended a final meeting on air quality guidelines for the European Region, held in Copenhagen in the same month. 4.56 The Regional Office submitted to ECE material dealing with the health effects of nitrogen oxides (NOx) and photooxidants as part of activities under the Convention on Long-range Transboundary Air Pollution, and was represented at the fourth session of the Convention’s executive body (Geneva, November). 4.57 Five consultants assisted the Government of Greece with the UNDP-supported project on abatement o f air pollution from industrial sources in the Greater Athens area. At the request o f the Government, they also gave advice on aquatic plants as indicators of chemical pollutants in water bodies, wastewater treatment, water pollution control, design of a system for biogas recovery from a large landfill site, and follow-up of risk assessment. Target 22 SO 4.58 Thirty-four experts and observers took part in a working group on the health impact and methods of control of irradiated foods, held at Neuherberg, Federal Republic of Germany in November, with the aim of re-examining previous conclusions and reviewing the identification and dosimetry methods currently applied to irradiated foods. 4.59 Staff of the Regional Office attended a meeting of the Regional Coordinating Committees of the Codex Alimentarius Commission for Asia and Europe (Rome, February) and the fifteenth session of the Codex Alimentarius Coordinating Committee for Europe of the Joint FAO /W H O Food Standards Programme (Thun, Switzerland in June). The role and function of the coordinating committees is being redefined to give By 1990, all Member States should have significantly reduced health risks from food contamination and implemented measures to protect consumers from harmful additives. By 1990, all people of the Region should be effectively protected against recognized health risks from air pollution. 6 8 much greater emphasis to the problems of food safety in the various regions. A staff member also attended the Second World Congress on Foodborne Infections and Intoxi­ cations, held in Berlin (West) in May. Target 23 SO 4.60 At the request of the authorities in southern Italy, a working group was convened in Naples in March to study the risks to health of dioxins from incineration of sewage sludge and municipal waste, as part of the overall regional programme on the health effects of dioxins and similar substances. A detailed analysis of emission data has shown that old and badly operated incinerators will emit up to many thousand ng/m1 of PCDDs and PCDFs, although most modern, highly controlled and carefully operated plants emit them at a very low level. At modern incineration plants, the contribution of municipal incinerator emissions to the overall environmental load and to human ex­ posure is in the range of about a tenth to a few per cent of the total dioxin background daily body-burden. Nevertheless, efforts should be made to reduce these levels still further. A study on the identification of priority chemicals in hazardous waste in relation to their possible health aspects was completed under a contractual services agreement with a United Kingdom firm. It included the establishment of a numerical ranking scheme to develop a list of priority chemicals in waste potentially disposed of by landfill in Europe. Target 24 SO 4.61 Existing research on the health impact of housing was consolidated in the form of updated health criteria for housing, produced in collaboration with the housing committee of the American Public Health Association. Housing hygiene was also the topic of a French-language course conducted by the Human Ecology Centre of the Uni­ versity of Geneva in April, in collaboration with the School of Public Health of the Free University of Brussels and WHO, and of a conference on unhealthy housing, organized at the University of Warwick in December, in collaboration with the British Institution of Environmental Health Officers. 4.62 A consultant report on the environmental factors of psychosocial stress in urban areas was used as a background document for a global WHO meeting on human ecology and health (Delphi, Greece in September/October) at which two consultants from the European Centre of Human Ecology represented the Regional Office. By the year 2000, all people o f the Region should have a better opportunity of living in houses and settle­ ments which provide a healthy and safe environment. By 1995, all Member States should have eliminated major known health risks associated with the disposal of hazardous wastes. i 4.63 Technical assistance to Portugal and Turkey on housing hygiene continued. Proposals were drawn up in both countries to obtain UNDP support for WHO-assisted projects on housing hygiene and environmental health improvements in urban fringes, in the framework of primary health care development. The “ Healthy Cities” meeting in Lisbon in April (see target 13) gave the participants an opportunity to see project achievements in Lisbon suburbs. WHO also assisted in a large-scale UNDP-supported project on environmental and health protection against the impact of industrial, mining and urban development in Kosovo, Yugoslavia. Target 25 BO 4.64 On behalf of WHO, the Institute of Occupational Medicine, Milan organized a training course in February on neurobehavioural assessment, theory and practice, as part of international research on the neurotoxic effects of long-term, low-level exposure to organophosphorus pesticides. 4.65 An international symposium on man-made mineral fibres (MMMF) in the workplace, organized with IARC and the Joint European Medical Research Board, was held at the Regional Office in October with the aim of reviewing the most recent research on exposure to MMMF and its biological effects. Extensive epidemiological studies from Canada, Europe and the United States were updated. On the basis of observations of nearly 50 000 production and maintenance workers, many of whom were followed for at least 30 years, and many laboratory experiments, the participants concluded that there has been an increased risk of lung cancer for people employed in the early days of both the rockwool and glasswool sectors of the industry, amounting to some 50% above normal 30 years after first employment. Although proportionally the added risk is relatively small, numerically it is substantial because lung cancer is so common. At the same time, the increased risk may not necessarily be attributed to the fibres alone, in that a variety of carcinogens occurring in the factory environment could have contributed to the hazard. 4.66 The Regional Office’s technical committee on monitoring and evaluating air­ borne MMMF met in Copenhagen in October. According to information provided at the international symposium, it appears that the regional reference scheme for the measure­ ment of fibres has been successfully established in the national laboratories of six European countries, with a resulting reduction in inter-laboratory variation in quality assurance schemes. Although this reference scheme was established primarily to increase the comparability of data obtained from epidemiological studies, it is now clear that it will be even more useful for the development of a standardized control system through­ out Europe. The next steps will be to include other national laboratories in the reference scheme and to develop an acceptable method of distinguishing between MMMF and other fibres present at a low level. By 1995, people of the Region should be effectively protected against work-related health risks. j 4.67 A WHO/ILO-sponsored international conference on musculoskeletal injuries in the workplace was organized in Copenhagen in May by the World Rehabilitation Fund and the Hospital for Joint Diseases, New York. Evaluation: The environmental health programme during the period 1984-1985 4 .68 Several evaluations have recently been made of the Regional Office’s environ­ mental health programme. A systematic assessment of the whole programme during the latter part of 1986 highlighted the special characteristics of the situation concerning potential hazards to human health resulting from environmental factors in Europe. To deal with this situation, a wide-ranging medium-term programme is being implemented, based on a careful appraisal of priorities, but a flexible approach has also been adopted, to take account of new problems and to cope with emergencies. The pace of change in this field calls for rapid dissemination of information, and the Environmental Health Series of reports was regarded as being a useful mechanism for this purpose. Each report is widely distributed to government agencies, professional institutions and individual scientists and researchers throughout the Region and in other parts of the world. 4.69 As many of the issues involved in environmental health are multisectoral in nature, the evaluation stressed the extent to which the Regional Office inevitably had to continue to work in close collaboration with other international organizations. The extent of dependence on extrabudgetary funds was also emphasized (some two thirds of the total funds used for programme implementation in 1984-1985 came from this source). 4.70 The European Advisory Committee on Health Research evaluated the Regional Office’s work on housing and settlements at its meeting in February. It laid particular emphasis on indoor climates and environmental factors associated with psychosocial stress, including noise. 4.71 From its evaluation of the major intercountry project implemented by the Regional Office on health aspects of the control of chemicals, UNDP concluded that the project was making a substantial impact on the degree of cooperation among partici­ pating Member States, and recommended that more attention should be paid to the intersectoral and transfrontier dimensions of the project. H E A L T H Y E N V I R O N M E N T Publications issued in 1986 Health impact o f different energy sources: a challenge fo r the end o f the century. WHO Regional Publications, European Series, No. 19. I Karvonen, M. & Mikheev, M.I., ed. Epidemiology o f occupational health. WHO Regional Publications, European Series, No. 20. Health and the environment: report on a WHO meeting. EURO Reports and Studies, No. 100. Indoor air quality research: report on a WHO meeting. EURO Reports and Studies, No. 103. Standard model designs fo r rural water supplies. Non-serial publication. Documents issued in 1986 Air quality guidelines fo r major urban air pollutants: report on a WHO working group (document ICP/CEH 002/m69). Chernobyl reactor accident: report of a consultation (document 1СР/ CEH 129). Consultation on linkage o f occupational exposure information with morbidity data: summary report and working papers (document ICP/OCH 002). Fifth report on microbiological methods fo r coastal water quality monitoring: report on a joint WHO/UNEP meeting (document ICP/CEH 001/m07). Health hazards and biological effects o f welding fumes and gases: report on an international conference (document ICP/CEH 502/m01). Suess, M .J. & Benwell, D.A., ed. Institutions and legislation concerned with nonionizing radiation — a directory. Institutional catering and food inspection: reports on two meetings (En­ vironmental Health Series, No. 7). Treatment and discharge o f industrial wastewater in the Mediterranean area: report on a WHO workshop (Environmental Health Series, No. 8). Lang, J . Assessment o f noise impact on the urban environment: a study on noise prediction models (Environmental Health Series, No. 9). Environmental toxicology and ecotoxicology: proceedings of the third inter­ national course (Environmental Health Series, No. 10). Public health response to acute poisonings — poison control programmes: report on a joint working group (Environmental Health Series, No. 11). Occupational health as a component o f primary health care: report on a WHO meeting (Environmental Health Series, No. 12). Indoor air quality: radon and formaldehyde: report on a WHO meeting (Environmental Health Series, No. 13). Environmental aspects o f the control o f legionellosis: report on a WHO meeting (Environmental Health Series, No. 14). I Co-publications and journal articles issued in 1986 Stern, R.M. et al., ed. Health hazards and biological effects o f weldingfumes and gases. Amsterdam, Elsevier. Pescod, M.B. et al. Slow sand filtration. Marlow, Water Research Centre. Health aspects of work with visual display terminals. AmericaI journal o f occupational medicine, 28(9): 833-848 (1986). Health impact of acidic deposition: report of a WHO working group. Science o f the total environment, 52: 157-187 (1986). Risk management in chemical safety. Ulm, Federal Republic of Germany, 8-10 November 1984. Science o f the total environment, 51: 1-263 (1986). I 73 'S Environmental health in the Mediterranean WHO and the Mediterranean Action Plan ч__________________________________________________________________________ / 'S WHO and the countries of southern Europe are working for health through a host of environmental health activities. In the Mediterranean Action Plan, countries all around the Mediterranean Sea have joined forces to preserve the environment and the health of their people. By taking part in the Plan, the Regional Office is contributing substantially to a project conceived and implemented in the best spirit of the regional strategy for health for all. The Mediterranean Sea has incalculable cultural, social and economic value to the 350 million people who live in the countries around its shores and to the 100 million tourists who visit it each year. Ironically, socioeconomic development in the region has both resulted from the Mediterranean’s richness and threatened to destroy it through pollution. Recognizing this threat and wanting to preserve their heritage, 17 countries of the region and the European Community adopted the Mediterranean Action Plan and bound themselves in 1976 to abide by its legal framework, the Barcelona Convention. Action in the first decade of the Plan was based on many of the ideas at the heart of the health for all strategy. When 17 countries came together to fight a shared problem — pollution in the Mediterranean Sea and its effects on people and the environment — they acknowledged the close links between socioeconomic development, the environment and health. To improve all three, the signatories of the Barcelona Convention and its four protocols have created an international programme attacking all aspects of the problem with the aid of all levels of government and sectors of society and of international and nongovernmental organizations. United Nations agencies have been actively involved from the beginning. The United Nations Environment Programme is the coordinating agency for the Plan. WHO participates through the Regional Office for Europe and with the collaboration of the Regional Offices for the Eastern Mediterranean and Africa. Working mainly from its project office in the coordinating unit in Athens, WHO helps Mediterranean countries to safeguard the health of their people from the effects of pollution. 4. J N Photo: UNEP The Genoa Declaration The Mediterranean Action Plan clearly embodies many of the ideas underlying health for all. The Genoa Declaration for the Second Mediterranean Decade, which was made in 1985 and set the direction and goals for the next phase of action, showed even closer links with health for all. The Mediterranean countries not only continued to stress prevention and international and multisectoral work but also adopted 10 targets as their priorities for action. Like target 20 of the European regional targets for health for all, these targets are intended to safeguard people from health hazards related to water pollution by 1995. WHO has focused on two parts of the Mediterranean Action Plan: the Priority Actions Programme and the Long-term Programme of Pollution Monitoring and Research in the Mediterranean Sea (MED POL Phases I and II). Priority Actions Programme The Regional Office for Europe (most often through its International Water Dec­ ade unit and its Environmental Health Planning and Management unit) and the Regional Activity Centre for the Priority Actions Programme, in Split, Yugoslavia, have increased their joint efforts to im­ prove the management of water resources, the disposal of solid and liquid waste and the use of environmental impact assess­ ment in plans for development. In addi­ tion, guidelines for monitoring the effi­ ciency of submarine outfall structures have been produced for pilot studies in selected areas. The Genoa Declaration stresses the importance of all of these. MED POL Perhaps the most important priorities for the Second Mediterranean Decade, however, are the targets for “ concrete measures to achieve substantial reduction in industrial pollution and disposal of solid waste” and for the establishment of “ sewage treatment plants in all cities around the Mediterranean with more than 100 000 inhabitants and appropriate outfalls and/or appropriate treatment plants for all towns with more than 10 000 inhabitants” . WHO contributes to these goals through its continuing work in MED POL. About 85% of the pollution of the Mediterranean Sea originates from land- based sources that discharge municipal sewage, factory waste and agricultural chemicals into the sea either directly from the coastline or through rivers. The third protocol of the Barcelona Convention is the means to fight this problem. By sign­ ing the protocol, 16 countries have bound themselves to accept and enforce its region-wide measures to control pollu­ tion, which will take into account the capabilities and the existing legislation of the countries of the region. MED POL is the scientific base for the implementation of the protocol and the largest part of the Mediterranean Action Plan. This pro­ gramme monitors the amount of pol­ lution in the sea and supplies the data used to create control measures. WHO assisted in the preparation of the protocol itself and collected needed information in the first phase of MED POL by coordinating a comprehensive survey of land-based pollutants and com­ piling an inventory of relevant national legislation in 1976/1977. The survey and the inventory will be repeated in 1987 to provide a comparative estimate of current conditions as part of MED POL Phase II, which extends from 1981 to 1990. P h o t o : U N E P , T F a r k a s J AP h o t o U N E P F B o t t s ( F A O ) MED POL in action The monitoring and research arms of the second phase of MED POL produce the information needed for preparing the wide range of guidelines, standards and criteria necessary to implement the protocol against pollution from land-based sources. Work has begun on guidelines for effluents requiring separate treatment, and draft guidelines for authorizations to discharge liquid waste are almost complete. Draft guidelines for computations for submarine outfall structures are also approaching completion. These structures are extensions of pipelines under the sea, so that effluents are not discharged right at the coastline where they would remain and cause severe pollution but at one or more points far enough out to sea to allow them to disperse. MED POL also produces material that governments will use in developing their national strategies and mechanisms for pollution control. WHO performs a considerable part of this work. As well as assisting in the drafting of regional control measures WHO, with other United Nations agencies, helps to develop monitoring programmes and organizes research projects. Laboratories and research institutions in Mediterranean countries carry out these projects, and the countries will use their results to help preserve the marine environment and the health of the people who depend on it. 'S Monitoring the quality of coastal water and seafood Regular monitoring of the more im­ portant chemical pollutants and patho­ genic microorganisms, particularly in coastal areas, is vital to assuring the safety of the Mediterranean Sea. As part of MUD POL Phase I, the WHO project on quality control for coastal water deter­ mined concentrations of polluting bac­ teria in several coastal areas used for rec­ reation and shellfish cultivation. Apart from providing valuable data, the project furnished a framework for firm, compre­ hensive monitoring programmes. In the monitoring component of MLD POL Phase II, WHO helps Mediter­ ranean countries to develop and improve health-related programmes for monitor­ ing marine pollution by: • assessing overall microbial pollution through evaluating the data collected in national monitoring programmes; • upgrading national capabilities by giv­ ing expert advice, purchasing equip­ ment and training personnel: • harmonizing monitoring activities among institutions and countries by preparing standard methods of sam­ pling and analysis and bv organizing laboratory intercalibration exercises to standardize laboratory practices; and • ensuring greater overall efficiency and cost-effectiveness through liaison with related work in WHO country activities. P h o t o I n s t i t u t P . i s t - ' u r I u n s J MED POL Phase II r e s e a r c h p r o je c t s 120 - - 100 - - 80 60 - - 40 - - 20 - - 1983 1984 1985 1986 Number o f participating institutions jjijjjl Number o f research projects | ^ J Assistance from WHO in thousands o f US$ Research to control marine pollution In the research component of MED POL Phase II, WHO organizes health- related studies that take account of Medi­ terranean conditions and requirements. WHO acts as a catalyst by providing uni­ versities and other research institutions with the grants or equipment needed to perform these studies, as well as the necessary coordination and administra­ tive support. By assisting research proj­ ects, WHO is helping Mediterranean countries to create their own solutions of their common problem. In 1986, 9 projects were completed, 16 extended and 17 begun. These activ­ ities include: • developing and updating microbiologi­ cal methods of sampling and analysis; • investigating the relationship between pathogens and indicator organisms in seawater, the survival of pathogens in the marine environment and the carcinogenicity and mutagenicity of marine pollutants; and • conducting epidemiological studies of the correlation between health and the quality of seawater and seafood. P h o t o : U N E P , T F a r k a s Improving the quality of bathing waters The Mediterranean Sea is a major recreational amenity for both tourists and people who live in the region. The discharge of untreated sewage (which can contain pathogens causing such dis­ eases as viral hepatitis, dysentery, po­ liomyelitis and cholera) from major cities and tourist complexes near bathing beaches is a significant problem. Al­ though a number of Mediterranean coun­ tries enforce microbiological quality cri­ teria for bathing waters, these are not always specifically designed for Mediter­ ranean conditions. WHO is trying to find the answer to these problems with the help of institutions in various countries, to ensure the safety of Mediterranean beaches for both the local people and the more susceptible tourists. Criteria to safeguard bathing waters have been discussed at several WHO consultation meetings. In 1985, Mediter­ ranean states provisionally accepted in­ terim criteria based on available know­ ledge. WHO also initiated epidemiological studies in selected areas to discover the relationship between the microbiological quality of the seawater and people’s health and eventually to recommend firm criteria based on the findings. Definite links have already been es­ tablished between the degree of sewage pollution and the incidence of gastroin­ testinal diseases among bathers. More work is required, not only to confirm available data but also to discover the exact source of a number of other health problems that occur regularly. Some of them — such as infections of the ear, eye and skin — are apparently unrelated to sewage pollution. Seafood and methylmereury: protecting people at risk Mediterranean seafood contains rela­ tively high levels of methylmereury — enough to risk harming the health of con­ sumers. Methylmereury in seafood does not appear to threaten the general popu­ lation in the region, but some groups of people, who consume more seafood than most, seem to be at risk. In 1982, WHO started a project on methylmereury in Mediterranean populations and the re­ lated health hazards, to identify high-risk groups by applying existing global experi­ ence to case studies on selected Mediter­ ranean populations. The objectives are to ascertain the scale of the problem and eventually to provide recommendations to governments for appropriate action. Pilot studies began in Yugoslavia in 1984 and in Greece and Italy in 1985. They included determinations of the levels of methylmereury in seafood, dietary sur­ veys of the people studied and analyses of samples of their hair for methylmereury. This pilot phase is expected to end in 1987. Experts from Mediterranean coun­ tries and other regions attended three consultations, held in Athens in 1982 and 1986 and in Zagreb in 1984. Organized as part of MED POL Phase II and with the active support of the chemical safety pro­ gramme of the Regional Office for Europe, their work had three results. First, preg­ nant women and adult fishermen were identified as high-risk groups. A fetus can suffer irreversible damage to the central nervous system from amounts of methyl- mercury innocuous to an adult, and fisher­ men (and possibly their families) can be harmed by excessive amounts of methyl- mercury ingested because they live on their catch. Second, a protocol for clinical studies of people showing high levels of mercury in their hair has been prepared and will soon be available. Finally, the work revealed that con­ trol measures must extend beyond the set­ ting of emission standards for mercury discharges (because most of the mercury in the Mediterranean comes from natural sources) and upper limits for mercury in saleable fish (because people who eat a great deal of legally saleable seafood could still ingest unacceptable amounts of mercury). Therefore recommendations on amounts of seafood that can safely be consumed must be the backbone of future control measures. J rFor the future Progress towards a safe and healthy Mediterranean continues. By the end of 1986, all the countries participating in the Mediterranean Action Plan were either running national programmes to monitor marine pollution or completing their construction. In addition, bathing beaches are becoming safer to use and governments have adopted a wide variety of new and more comprehensive legislation against pollution. Work towards the goal continues as well. Because marine pollution can harm people’s health in many ways, the role of Wl Ю in the Action Plan remains vital. By acting on the ideas and strategies shared by the Genoa Declaration and the European regional strategy for health for all, and bv contributing to this international, intersectoral and interregional programme, WHO is working for the health ol all the people of the Mediterranean. P h o t o U N E P . A D c m c t r o p o u l o u s 5 Appropriate care Target 26 DO 5.1 In April, a consultation took place at the Regional Office to prepare a protocol for the information collection component of a study on the development of primary health care (PHC) in the European Region. The study focuses on selected aspects of community participation, multisectorality, integration of health services and the reorientation of personnel for PHC. The nine participating European countries are Finland, Greece, Italy, the Netherlands, Poland, Portugal, Spain, Sweden and Yugoslavia, chosen to reflect different types of health care system. 5.2 This year, the annual forum on PHC development in southern Europe was held in Verona, Italy in November, and dealt with management issues in PHC. Participants from Malta and Yugoslavia attended for the first time. 5.3 The Primary Health Care unit produced three issues, in English, French and German, of the newsletter “ 2000” , which disseminates new ideas and news of WHO publications to over 1000 readers at various levels of health care around Europe. The collaborating centre for primary health care in Alma-Ata published five study reports on aspects of PHC, such as intersectoral collaboration, ambulatory care and the role of the midwife, and an information leaflet about the centre. All these documents are available from the Primary Health Care unit on request. 5.4 The seventh international postgraduate course on planning and management of PHC in developing countries was held in English in June/July at the collaborating centre for primary health care in Zagreb, and attended by 24 participants from Europe, southern America, India, Africa and the Western Pacific. It was considered instrumental in promoting strategies for the implementation of HFA policies and strengthening PHC generally. By 1990, all Member States, through effective com­ munity representation, should have developed health care systems that are based on primary health care and supported by secondary and tertiary care as out­ lined at the Alma-Ata Conference. 75 5.5 The sixth international course on the organization and evaluation of PHC for developing countries was held in French in September at the School of Public Health of the Free University of Brussels, and attended by 32 participants, mainly from French- speaking Africa and other developing countries. It was aimed at improving the efficiency of PHC services by making optimum use of existing resources and adapting them to the médicosocial context. Nursing/midwifery 5.6 The newsletter Nursing/midwifery in Europe appeared twice in 1986, in English, French, German, Russian, Hungarian, Finnish, Serbo-Croatian and Portuguese. The Danish Nurses’ Organization funds the services of an editor, while collaborating centres and volunteer nurses do the translations. 5.7 A joint meeting of the Advisory Committee/Collaborating Centres/Associ­ ations Liaison Group on the Nursing/Midwifery Programme in the European Region (Ljubljana, Yugoslavia in October) was attended by representatives of 13 countries and three nongovernmental organizations. It reviewed all nursing outputs in the proposed programme budget for 1988-1989 and made recommendations on nursing management training, a communication/information structure, regular meetings of government chief nurses and nursing collaborating centre managers, more creative use of WHO fellow­ ships, the forthcoming European conference on nursing, nursing curricula, compre­ hensive national manpower information systems, and model guidelines on nursing practice standards. 5.8 The nursing/midwifery programme was presented to 1700 delegates from 40 coun­ tries at the four-yearly congress of the International Committee of Catholic Nurses (Lisbon, October), after which several non-European countries asked for assistance from the Regional Office. A presentation on future perspectives and orientations in nursing practice was also made for the 700 participants in the annual educational congress of the Centre chrétien des professions de santé (Paris, November). Hospitals 5.9 An analysis of support by first-referral hospitals to PHC services, including hospital activities in disease prevention and health promotion, began in 1986. Its aims are to describe the types of support that hospitals are currently giving to PHC services in Europe; to determine the potential for increasing the scope, scale, appropriateness and effectiveness of that support; and to make recommendations on policies. Ten countries have been invited to participate — Austria, Bulgaria, Greece, Ireland, Norway, Portugal, Romania, USSR, the United Kingdom and Yugoslavia. 5.10 Eight hospital institutes were approached with a view to forming a collaborative network aimed at facilitating support by hospitals to PHC services and reorienting hospitals to PHC. All the institutes approached have experience of hospital functioning at the first referral level and their integration into a district health system or local 76 equivalent. They also run training courses in areas of identified needs and generally advise hospitals and government bodies. 5.11 Health-system-related research activities, focusing on district-level collaboration between hospitals and PHC services, continued in nine countries with the help of the European Collaborative Health Services Studies Group. 5.12 Close collaboration continued with the International Hospital Federation (IHF). The responsible officer for the hospitals programme attended the tenth health care planning workshop of the Cities Consortium within the IHF, held in Stockholm in June. The main topics were health policy from planning to implementation in new situations, reorientation of the health care system to PHC, and the strategic direction of health services. 5.13 As part of the hospitals programme, a study on the response of hospitals to the changing needs of the population was launched with the participation of Finland, France, the Federal Republic of Germany, Israel, Italy, the Netherlands, Sweden, USSR and the United Kingdom. The aim is to evaluate different hospital activities with a view to increasing the effectiveness of services while ensuring quality of care and meeting the health needs of the population. New forms of organization, new activities and new management methods will be evaluated and the relative cost-effectiveness of hospital and ambulatory care compared. Consideration will be given both to efficiency and to satisfaction of the population’s needs. Target 27 BO Health service delivery 5.14 A study on institutional long-term care, particularly for the elderly who are now the overwhelming majority among those in need of such care, was launched with the participation of Czechoslovakia, Finland, France, the Netherlands, Spain and Yugo­ slavia. The aim is to collect and analyse information about the overall social and economic infrastructure of the countries; their care systems for the elderly; the structure and functioning of their long-term care institutions; collaboration between these insti­ tutions and other health facilities involved in long-term care; and national developments influencing care for the elderly. 5.15 The responsible officer for the hospitals programme attended a national work­ shop on health, welfare and local government organized by the Central Union of Municipalities and Communities of Greece (Athens, May) which covered such topics as health services at the local level, health services in a decentralized system, and the role of By 1990, in all Member States, the infrastructures of the delivery systems should be organized so that re­ sources are distributed according to need, and that services ensure physical and economic accessibility and cultural acceptability to the population. 77 local authorities in providing comprehensive care for both inpatients and outpatients. He presented a paper on the role of local governments in health care in Europe, and this was followed by a discussion of present problems in Greece. 5.16 A working group on information for PHC was organized in Kuopio, Finland in December by the Universities of Tampere and Kuopio, which together form a collab­ orating centre. The meeting was attended by participants from Belgium, Denmark, Finland, France, the German Democratic Republic, Hungary, Israel, the Netherlands, Poland, Spain, Sweden, the United Kingdom and Yugoslavia, who assessed selected indicators for monitoring PHC development and prepared a framework for the col­ lection of information needed at the local level of PHC. Their recommendations will be tested in pilot areas. Health care providers 5.17 Analysis of legislation governing the practice of nursing/midwifery continued, and included a review of Hungarian legal texts with special attention to midwifery. 5.18 The Portuguese Association of General Practitioners, which publishes a PHC journal and runs national courses on PHC, held a second international teacher training course on PHC in Lisbon in September. The international courses held in 1985 and 1986 have started a trend towards sub-regional training activities for countries at the same level of PHC development. Participants have been mainly from southern Europe, with some teachers from France and the United Kingdom. 5.19 In June, a first workshop on advanced nursing management in Europe was held in Charlottenlund, Denmark, in collaboration with the Danish Nurses’ Organization and the European Association of Programmes in Health Services Studies, with partici­ pants from 18 countries. The objective was to enhance the leadership and management skills of a group of potential nurse-managers through a carefully designed programme combining theory and practice, with emphasis on the use of research findings and selected technology for nursing care management and planning. 5.20 Staff of the Nursing unit took part in a European meeting of French-speaking postbasic schools of nursing, held in Marseilles in April. The group decided to carry out an evaluation of their programmes in the light of the 38 regional targets and WHO’s global expectations for nurses, as defined at a meeting on nursing leadership for HFA, organized in Tokyo in April by WHO headquarters. Staff of the unit also attended a meeting of German-speaking postbasic schools of nursing in Göttingen, Federal Republic of Germany in September, and were invited to exchange ideas on the changing role of nursing in the attainment of HFA through the targets. 5.21 In September, a WHO consultant helped the University of Turku to introduce a curriculum based on the 38 regional targets. Further recommendations included the appointment of qualified nursing staff able to undertake not only teaching but also research and other academic activities. Collaboration between the universities of Turku and Toronto and WHO continued. 78 5.22 National workshops included three on PHC nursing in Turkey, organized by the Nursing unit, the Turkish Ministry of Health and Social Assistance and the Turkish Nurses Association and attended by representatives of all the nursing schools in the country, and one in Ljubljana, Yugoslavia on the reorientation of curricula to the 38 regional targets. 5.23 National meetings took place throughout the Region in preparation for the European conference on nursing, to be held in Vienna in 1988. A discussion paper on the reorientation of nursing to serve the 38 targets was approved by the Liaison Group meeting in Ljubljana in October (see target 26). This paper and the shortened version of the document “ Targets for health for all: implications for nursing/midwifery” now exist in the four official languages. Nursing groups throughout the Region are deeply com­ mitted to the conference and are working closely with the International Council of Nurses, the European Nursing Group, the Northern Nurses’ Federation and the Inter­ national Committee of Catholic Nurses. Health institutions 5.24 A paper was produced on methods and levels of planning for the hospital sector, describing the situation in the Federal Republic of Germany, Israel, the Netherlands, Sweden and the United Kingdom and summarizing overall trends in the Region. 5.25 The hospitals programme launched its most extensive study to date on meth­ odologies to determine the bed/population ratio and its use. Three coordinating centres are evaluating what is usually understood by the term “ hospital bed” in the European countries; investigating the methods used to establish the ratio and its current use for both the hospital sector and different specialties and degrees of specialization; and making proposals for more appropriate use of the ratio in the different health care systems. The centres will also assess other data that can be used for planning in the hospital sector and will study the utilization of hospital beds. 5.26 Belgium, France, Luxembourg, Portugal, Spain, Switzerland and the United Kingdom are developing nursing/patient classification systems, while ways of pro­ moting more rapid exchange of information between interested countries were discussed at a meeting of European nurses from ministries of health of the EEC countries and Switzerland (Paris, April). 5.27 Austria, Belgium, Czechoslovakia, Denmark, France, the German Democratic Republic, Hungary, the Netherlands, Portugal, Spain, Sweden, Switzerland, USSR, the United Kingdom and Yugoslavia are collaborating in a study on cost-containment strategies in the hospital sector, which is being coordinated by the collaborating centre for the hospital programme in Düsseldorf. 5.28 The hospitals programme, in collaboration with the Nursing unit, initiated a study of models related to medical and nursing clinical decision-making in hospitals, to which Belgium, France, the Federal Republic of Germany, Greece, Hungary, the United Kingdom and Yugoslavia are contributing; it focuses on similarities, differences and problems in the overall development of health services in the various countries. 79 5.29 A study on linkages between internal departments of hospitals at different levels in Hungary, forming part of a wider investigation being made by the Semmelweis Medical School, Budapest, was completed. 5.30 The hospitals programme’s expanding network of focal points in various countries of the Region played an important part in preparing several of the above studies and will also help to complete them. 5.31 The responsible officer for the hospitals programme took part in a twelfth international hospital symposium in Berlin (West), which covered such topics as out­ patient organization, information, cost-containment, effectiveness of hospital work, and problems related to functioning. Economic aspects of services were also discussed at a planning meeting for studies of the shift of health expenditures in favour of PHC, held in Kiel, Federal Republic of Germany in November. Target 28 BO 5.32 A team from the demonstration project in Graz, Austria, on the delivery of nursing care for the elderly in their own homes, prepared an educational programme in German for community nurses working in this field, as part of its study instruments. 5.33 The units of Nursing and of the Elderly, Disability and Rehabilitation began a joint project on comprehensive home care of the adult population with disabilities in northern Moravia, Czechoslovakia, aimed at identifying measures to be taken in the household that will help old people readapt and maintain the best possible health on discharge from hospital. 5.34 A working group on the respective roles of PHC and specialized services in the design and implementation of programmes for problem drinkers met in Oslo in August, with support from the Norwegian Government. In particular, the group was asked to identify regional PHC structures and specialized services for drinkers, and to propose appropriate intervention/treatment models and programmes. Its recommendations covered health promotion by PHC teams; education about alcohol in the training of health personnel; better cooperation between PHC, specialist services, other social services and voluntary agencies; systematic case-finding and early detection; and the economic and service implications of improved performance by PHC teams in this field. 5.35 A study revealed that, in many Member States, the proportion of drug abusers in the prison population is rising — a finding that has implications for the prevention and treatment of drug abuse in the community. The feasibility of joint action with CE in this domain is being explored. By 1990, the primary health care system of all Mem­ ber States should provide a wide range of health- promotive, curative, rehabilitative and supportive ser­ vices to meet the basic health needs of the population and give special attention to high-risk, vulnerable and underserved individuals and groups. 80 Target 29 SO 5.36 Preparatory work was completed for a survey of current midwifery practice. National data for a pilot study were collected in Hungary and their analysis begun. Target 30 SO 5.37 Preparatory work began for a consultation on mechanisms for the integration of social and related services at the local level. Target 31 DO 5.38 Although interest in model health care was limited, the subject of quality assur­ ance attracted increasing attention in Member States in 1986. Activities included the organization of training courses in Finland, Italy and Spain under Regional Office sponsorship; the holding of meetings in Ireland, Italy, Spain and Sweden; the initial development of national quality assurance systems in Portugal and the United Kingdom; the founding of national associations in France, Italy and Spain; and the publication of a journal in Spain. Regional Office staff took part in many of these activities and Regional Office documents were widely used as background or teaching material. The circulation of the “ European newsletter on quality assurance” , sponsored by the Regional Office and published by the Netherlands National Institute for Quality Assurance in Hospitals, increased rapidly. 5.39 A third English-language training course in quality assurance was held in Arandjelovac, Yugoslavia in August and a first French-language course in Brussels in November. Both courses were fully attended by participants from many disciplines. 5.40 In Finland, the Regional Officer for Research Promotion and Development ran a three-day postgraduate course in quality assurance at the University of Helsinki. In Spain, he presented a paper on the regional programme at a fourth national symposium By 1990, all Member States should have built ef­ fective mechanisms for ensuring quality of patient care within their health care systems. By 1990, all Member States should have mechanisms by which the services provided by all sectors relating to health are coordinated at the community level in a primary health care system. By 1990, in all Member States, primary health care systems should be based on cooperation and teamwork between health care personnel, individuals, families and community groups. 81 on quality assurance (Oviedo, May) and participated as a faculty member in a workshop for directors of social security hospitals (Madrid, November). 5.41 Quality assurance in relation to the use of technology in health care is dealt with under target 38. 5.42 Advanced technology and its high cost have revived interest in medical ethics in most Member States. The Regional Officer for Health Technology Assessment attended a meeting in Maastricht, Netherlands in September, at which ethical issues were dis­ cussed, and presented a position paper on medical ethics and economics in medical education. 5.43 Work on standards of nursing practice continued with the holding of a consul­ tative meeting in Brussels in June, at which core group members from Belgium, Finland, the Netherlands, Norway and the United Kingdom were joined by a member from Portugal, an editor of a nursing journal, a journalist and a Canadian nurse expert. The group reviewed and amended a slide/tape presentation on standards, agreed to set up demonstration projects in each of the core countries, and improved their own knowledge of standard-setting so as to be able to lead national groups. 5.44 The Regional Office’s policies and activities relating to model health care pro­ grammes were described at a first international conference on philosophy, methodology, ethics and economics in clinical cancer research, organized in Kos in May by the Hellenic Cancer Society. 5.45 Bulgaria, Greece, Hungary, Israel, Malta, Portugal, San Marino and Spain now have national medium-term programmes in nursing. 5.46 The programme manager of the new collaborating centre for PHC nursing in Maribor, Yugoslavia represented the European Region at the meeting on nursing leader­ ship for HFA, held in Tokyo in April (see target 27), while the collaborating centre for the medium-term programme in nursing/midwifery in Europe in Helsinki continued to serve as a model for PHC development in Europe, providing consultative services to countries within and outside the Region and receiving nurses from Europe for study tours. A P P R O P R IA T E C A R E Publications issued in 1986 Children and family breakdown: report on a WHO meeting. EURO Reports and Studies, No. 101. Nizetic, B.Z. et al., ed. Scientific approaches to health and health care: proceedings of a WHO meeting. Non-serial publication. Stenbak, E. Care of children in hospital: report on a study. Non-serial publication. Documents issued in 1986 Nursing and the 39 European regional targets for health for all: a discussion paper (document NURS/EURO 86.3). Stussi, E. A simplified guide to nursing in WHO (document NURS/ EURO 86.2). Targets for health fo r all: implications for nursing/midwifery (document NURS/EURO 86.1). Vuori, H. & Levine, S. Proceedings o f the conference on primary health care in the industrialized countries. Co-publications issued in 1986 Chambers, L.W. Quality assurance in long-term care: policy, research and measurement. Paris, International Center of Social Gerontology. 83 6Research and health development support Target 32 BO 6.1 At its twelfth session in February, the European Advisory Committee on Health Research (EACHR) reviewed the document “ Research for health for all” , comprising two volumes on research policy and research action respectively, before its submission to the thirty-sixth session of the Regional Committee in September. Member States and the European research community were later asked to comment on the relevance and priority of the proposed activities, and to make additional suggestions for high-priority research. A final draft incorporating their responses will be submitted to the thirty- seventh session of the Regional Committee in 1987. The EACHR also reviewed the research components of the regional programmes on accident prevention, the elderly, disability and rehabilitation, housing and settlements, and oral health, and of the global programmes on accident prevention and health of the elderly. It recommended that the purpose of research-related courses organized or sponsored by the Regional Office and the qualifications of participants should be more clearly specified, to ensure closer linkage of the courses to the regional HFA targets and research policy. 6.2 Finland and San Marino have already drawn up policies on research for health for all, while Portugal held its first national meeting on health research promotion and development in April. 6.3 Collaboration on research projects continued with the European Medical Re­ search Councils and the health services research concerted action committee of CEC. The Regional Officer for Research Promotion and Development participated in a European symposium on the use of results of public research and development, organ­ ized by CEC in Luxembourg in September. The Regional Office also collaborated extensively with the European Association of Programmes in Health Services Studies. Before 1990, all Member States should have formu­ lated research strategies to stimulate investigations which improve the application and expansion of knowledge needed to support their health for all developments. 85 6.4 A task force met in Groningen, Netherlands in May and in Ulm, Federal Republic of Germany in August to look into the feasibility of setting up a network of universities with experience in interfaculty and multidisciplinary health-related programmes and research activities, while a workshop on health services research methodology was organized in Barcelona in September to discuss the evaluation of specific national and regional health programmes. Three of the participants in the latter meeting were from the South-East Asia Region. Target 33 BO 6.5 The Regional Office assisted Ireland, Israel, Malta, the Netherlands, Norway and Switzerland in the development of national HFA policies. 6.6 Representatives of seven southern European Member States met in Alicante in July at the invitation of the Government of Spain to study health policy trends and identify factors that could contribute to HFA. A similar consultation, organized in Vienna in June with support from the Government of Austria, brought together rep­ resentatives of health ministries, hospital, medical and nurses’ associations, health insurance schemes and trade unions from six countries belonging to the group of European federalistic and/or market economy systems. A debate on HFA was also organized with the Government of the United Kingdom in Leeds in March and dealt, among other topics, with the role of subnational health authorities in HFA action and the need for comprehensive health policy guidance. 6.7 An international symposium on legislative strategies for dental caries prevention in European countries, sponsored by CEC and EC, was held in Paris in June at the invitation of the French Dental Association. For this symposium, the Regional Officer for Health Legislation made a comparative study of European strategies, examining both the drafting and the enactment of dental health legislation, and the success or otherwise of its implementation. In general, it was found that the existing legislation relates either to the use of fluorides or to other means of prevention such as oral hygiene and dietary change. The study also considered the availability and accessibility of preventive services, the training of health manpower and the status of health insurance and social security. 6.8 The Health Legislation unit has been making a study of legislative strategies to enhance the health and wellbeing of the elderly. These strategies address the following points in particular: the social environment of the elderly and the neighbourhood groupings they could benefit from; preventive health programmes; health care services, town planning and housing for the elderly; the need to ensure income support for the elderly; the importance of regarding the elderly as active participants in social life; health Before 1990, all Member States should ensure that their health policies and strategies are in line with health for all principles and that their legislation and regulations make their implementation effective in all sectors of society. 8 6 insurance schemes; and research and training programmes in gerontology. The outcome of the study is a set of proposals for reforms of legislative action at both international and national levels, giving examples of various effective strategies and methods. 6.9 In collaboration with the Communicable Diseases unit, the Health Legislation unit maintained a register of new laws relating to AIDS, showing that national legislators are faced with such questions as how to reconcile social control and individual freedom, what type of legislative controls are acceptable and effective, and what legislative measures are effective in motivating individuals to change their behaviour. 6.10 The computerized health legislation data base continued to provide up-to-date information to both Member States and the Regional Office. Twenty-five Member States contributed 310 new texts introduced in 1985, bringing the total number of texts to 1310. The annual report and compilation of the data, which is available to Member States, presents the texts by technical field, by country and by HFA target. With the help of the collaborating centre for medical information and data processing in Uppsala, country profiles on health legislation in Europe have also been computerized so that they can be kept up to date by linkage with the ad hoc annual notification systems of countries. 6.11 The Regional Officer for Health Legislation helped Member States to prepare national debates on subjects involving ethical issues, such as legislation on in vitro fertilization, euthanasia and sterilization. She also took part in a first national workshop on health legislation in Hangzhou, China in April and collaborated with the Boston University School of Law in the preparation of a special issue of the American journal of law and medicine. Collaboration with other organizations 6.12 A consultation on information exchange and collaboration in health-related activities in Europe was held in Copenhagen in September, bringing together represen­ tatives of other international organizations and United Nations agencies such as ECE, UNDRO, UNFPA, IARC, CE and its European Youth Centre, CEC, OECD, the Nordic Council, the World Tourism Organization, the League of Red Cross and Red Crescent Societies, the Danish Red Cross, and the Turkish and International Children’s Centres. 6.13 Compilation of data on health activities by various intergovernmental and nongovernmental organizations was resumed in 1986. The updating and retrieval of these data, which are available to all the organizations concerned, will help to promote further cooperation and prevent duplication. 6.14 A number of activities were undertaken to strengthen the Regional Office’s cooperation and coordination with the United Nations system. Chief, Coordination with other Organizations, visited the UN Division of Narcotic Drugs in Vienna to discuss programme matters in March. Links were strengthened with UNICEF/UNIPAC in Copenhagen, particularly by means of continuous information exchange, and staff of the Regional Office attended UNICEF’s fortieth anniversary celebrations at UNIPAC on 11 December. The Regional Director headed a WHO delegation to a UNDP/ECE intergovernmental consultation on the UNDP regional programme for Europe in the 87 fourth indicative planning figure cycle (Geneva, April) and the Regional Office is the proposed executing agency for important intercountry and country projects included in the fourth UNDP programming cycle 1987-1991 in the priority environmental areas of control of hazardous chemicals, land-use practices and protection of surface water and groundwater, River Danube water quality protection, and effective food safety systems. A UNDP staff member visited the Regional Office in November to discuss these projects. At the same time, the Regional Office continued its activities as executing agency for 17 UNDP-financed projects in nine European countries, connected mainly with en­ vironmental protection and the International Drinking Water Supply and Sanitation Decade. Cooperation with UNEP flourished as WHO continued its programme of activities under the WHO/UNEP joint project on health-related aspects of the Mediter­ ranean Action Plan, MED POL Phase II (see target 20). The Regional Office was represented at the UNESCO Second Round Table on a New World Information and Communication Order, held in Copenhagen in April. Finally, the Director, Environ­ mental Health, attended the meeting of the IAEA Board of Governors, held in Vienna in September/October. 6.15 The Regional Office cooperated with CE and CEC in running pilot health education projects aimed at preventing dependence and addiction in various European cities. The Regional Office also collaborated with CE on such questions as the impact of new technologies on health services, AIDS, multidisciplinary care of cancer patients and the elderly, blood transfusion and immunohaematology, drug trafficking, food hygiene, pharmaceuticals, pesticides and rehabilitation of disabled people. Chief, Coordination with other Organizations, attended the 19th and 20th sessions of the European Health Committee, held in Strasbourg in June and November. On the latter occasion, he also visited the European Youth Centre, which has connections with 600 national organiz­ ations in 24 countries and acts as the secretariat of the Conference of European Ministers of Youth, and had discussions on possible future collaboration on sexuality, the anti­ smoking campaign, the environment and the promotion of peace. 6.16 The Regional Office was represented at a European symposium on the scientific basis for soil protection in the European Community, held in Berlin (West) in January. Chief, Coordination with other Organizations, also visited the CEC’s Director of Health and Safety in Luxembourg in February and, together with the Regional Director, took part in a meeting of chief medical officers of the European Community in London in October. The discussions covered tobacco and health, the anti-tobacco campaign, the lessons to be learnt from Chernobyl, communicable diseases including AIDS, and other current problems. 6.17 Cooperation with other intergovernmental organizations included information exchange with the Council for Mutual Economic Assistance and cooperation with OECD in the preparation of guidelines for improving the safety of elderly road users, which were subsequently published by OECD. The OECD’s Directorate for Social Affairs, Man­ power and Education is also collaborating with WHO on the second of these subjects. 6.18 Cooperation with the Nordic School of Public Health, Gothenburg continued, and the Nordic Council has endorsed a proposal by the Nordic Council of Ministers to expand this institution in 1987-1991. 8 8 6.19 Danish nongovernmental organizations were invited to the Regional Office on World Health Day, 7 April. The Regional Director introduced the theme “ Healthy living — everyone a winner” and made a presentation on the HFA strategy and the activities of the Regional Office. The United Nations Information Centre for the Nordic Countries in Copenhagen was also involved in all major events at the Regional Office. 6.20 The Regional Office was represented at the CEC-sponsored twelfth general assembly of European nongovernmental organizations (Brussels, April), the twelfth annual meeting of the board of directors of the European Centre for Social Welfare Training and Research (Vienna, April) and the fifth world congress of the International Society for Prosthetics and Orthotics (Copenhagen, June/July). 6.21 A study was started on the health effects of the threat of war. A letter was sent to 35 organizations dealing with peace promotion and the prevention of war, asking for details of their health and health-related activities. The United Nations and related agencies staff movement for disarmament and peace at the Regional Office produced a bibliography on the health effects of war and promotion of peace. In resolution EUR/RC36/R5, the Regional Committee expressed its appreciation of the Regional Office’s activities in connection with the International Year of Peace 1986, and asked for them to continue. Target 34 BO 6.22 Work continued in reviewing methodologies to support Member States in long- range planning for health. Activities in this field included an international workshop organized jointly with the Government of the Netherlands (Noordwijk, October) at which it was recommended that other countries should test scenario techniques in their own planning systems, as part of the effort to encourage long-term planning with a strategic and outcome orientation and to help Member States cope with the uncertainties stemming from the present economic crisis. 6.23 Country activities included the drafting of a five-year plan for health services development in Malta, along the lines of the regional HFA policy, with Regional Office collaboration. The PHC development project in Morocco was evaluated prior to that country’s transfer to the Eastern Mediterranean Region. In Portugal, a team from WHO headquarters and the Regional Office joined a national task force in evaluating WHO’s collaborative activities, and a national workshop on evaluation with emphasis on quality control was held in Evora, attracting the attention of local and central health authorities. Finally, a consultant visited Turkey in October to help set up national working groups on health care financing and economics. Before 1990, Member States should have managerial processes for health development geared to the at­ tainment of health for all, actively involving com­ munities and all sectors relevant to health and, accord- ingly, ensuring preferential allocation of resources to health development priorities. 89 6.24 The report of a comparative study on health financing, budgeting and payment systems, involving 14 countries, was issued as background for a workshop on primary medical care financing systems, organized jointly with the Government of the Federal Republic of Germany and the collaborating centre for public health research in Kiel in November. The meeting was attended by experts from 10 countries and two international organizations, who called for more experimental and demonstration projects on the impact of financing, physician payment and budgeting systems on the structure, process and outcomes of primary medical care; greater emphasis on evaluating both existing and proposed medical procedures, programmes and health policies, with additional invest­ ment; and collaboration in this field among clinicians, epidemiologists, statisticians, economists and members of other disciplines. 6.25 Activities in planning and management training included four more reviews of the relevance of training programmes to actual public health needs in Europe, carried out in collaboration with the European Association of Programmes in Health Services Studies. At the same time, international courses held in previous years sparked off new developments in several countries, and the network of collaborating centres is actively promoting planning-related courses in the four official languages. 6.26 A workshop on health economics for German-speaking teachers was organized jointly with the collaborating centre for health planning and economics in Munich. The participants reviewed English draft modules included in a study on the development of health economics training, and suggested supplementing them with additional teaching units on health service organization and financing in the countries represented. 6.27 In August/September, a second WHO international seminar on health legis­ lation was held in France, thanks to a voluntary donation by the town of Montpellier and to active collaboration by the commune of Montpellier and the faculties of law and economics and of medicine at the University. In addition to providing a forum for the exchange of knowledge and experience, the seminar was designed to promote an under­ standing of the ways in which legislation can be used as a tool for developing and implementing health policy and for attaining health for all. Twenty-four health admin­ istrators, lawyers, physicians and economists discussed the right to health as recognized at national and international levels; the rights of patients; legislative strategies to promote healthy lifestyles and support preventive action for health; legislative action to protect the environment; legislation in support of PHC; legislation governing health care providers; legislation influencing the health and wellbeing of the elderly; and legislation to support social networks and promote equity in care. It is hoped that this seminar will lead to the organization of similar training sessions at national and international levels. Target 35 SO 6.28 A consultant revised the list of HFA indicators, and it was circulated to insti­ tutions and experts in Member States for analysis. Staff of the Epidemiology and Before 1990, Member States should have health in­ formation systems capable of supporting their national strategies for health for all. 90 Information Support unit took part in meetings to strengthen the development of indi­ cators for environmental health, nutrition, mental health and health promotion, such as a workshop on measuring health behaviour and health (Berne, June), a working group on preventive practices in suicide and attempted suicide (York, United Kingdom in Sep­ tember) and a working group on information for PHC (Kuopio, Finland in December). 6.29 A collaborating centre for health situation analysis related to the mortality indicators in Europe was established in the Department of Epidemiology and Health Programming of the National Research Institute for Mother and Child, Warsaw. 6.30 Health projections in Europe: methods and applications was issued in 1986 to help Member States study future trends in health status, and was discussed at an international workshop held in Noordwijk, Netherlands in October (see target 34). Health and bio­ medical information in Europe was also issued, outlining current needs in the Region and describing the services and networks available to health personnel. 6.31 A consultation on measuring the adequacy of health care and consumer satis­ faction took place in Ioannina, Greece in September/October, at which guidelines for field studies by national centres were proposed. 6.32 An international course in English for teachers on statistical, epidemiological and operational methods in public health was held in Moscow in July, with participants from Czechoslovakia, Finland, the German Democratic Republic, Hungary, Indonesia, Norway, Sweden and the USSR, and lecturers from Finland, Switzerland, the USSR and the United Kingdom. The annual course in English and French on statistical, epidemi­ ological and operational methods in medicine and public health was given in Brussels, with participants from Morocco, Norway, Portugal and the USSR and from Africa, the Americas and South-East Asia. The intended joint course in medical statistics and community medicine held in London in fact covered only statistics, as there were no candidates for the community medicine part. Finally, an international course on the application of statistical, epidemiological and managerial methods to medicine and public health was held for the first time in German (Berlin, October) with participants from Czechoslovakia, the Federal Republic of Germany, Sweden and Switzerland. 6.33 The Regional Office continued to help with the UNDP-supported project on a computer-supported health information system in Yugoslavia. 6.34 A first European conference of medical librarians took place in Brussels in October under CEC and WHO sponsorship, with the participation of staff of the collaborating centre for health and biomedical information in Berlin and over 300 health librarians from 26 countries in the Region. It covered new developments in health documentation and the role of health librarians in supporting management for HFA, and recommended the establishment of an association of European health librarians for countries of the Region. 6.35 Work continued on a bibliographical data base (EURODOC) which will include Regional Office documents, duty travel and consultant reports, resolutions and rec­ ommendations of the WHO governing bodies, Regional Office publications, infor­ mation from Member States concerning HFA targets and library acquisitions, and 91 non-WHO health documents. The data are indexed according to HFA target, WHO programme and other organizations involved, and by technical subject in conformity with the Medical Subject Headings classification. A new reference system was also introduced to serve the needs of individual Regional Office units. The Regional Office also continued to make extensive and effective use of the data bases of the German Institute for Medical Documentation and Information, Cologne and other European “ hosts” on a fee-for-service basis. Target 36 SO 6.36 Collaboration continued with Member States and international, governmental and nongovernmental organizations, with the aim of fostering dialogue and promoting health manpower development policies and strategies in accordance with the European regional targets for health for all. Particular attention was paid to questions of policy, planning, training and the use of manpower. The Regional Office also became in­ creasingly involved in the collection and dissemination of information on health per­ sonnel among the countries of the Region. 6.37 A data base for monitoring trends in the demand and supply of health manpower was set up in association with the collaborating centre for health manpower information statistics (CSDM) in Paris. As the usefulness of such a data base depends entirely on the completeness and validity of the information provided by Member States, a survey was undertaken to identify the relevant sources of information and the appropriate channels of communication, and advice was given on the computer equipment required. The first issue of an annual publication suggesting ways of analysing health manpower infor­ mation was distributed. 6.38 The Regional Director’s addresses at the annual conferences of the Association of Medical Deans in Europe (AMDE) and the Association for Medical Education in Europe (AMEE), both held in Lisbon in September, emphasized the role of medical schools in educating future health professionals for HFA. A joint project was also begun with these associations to identify the educational consequences of the HFA targets for physicians. Another joint project, with the Association of Schools of Public Health in the European Region (ASPHER), was designed to encourage schools of public health to incorporate the spirit and content of the targets in their teaching programmes. These and other networks of participating and collaborating institutions in health manpower development are being expanded constantly, as they provide an effective means of reaching different professional groups. 6.39 The pressing need to review manpower policies was highlighted in a number of studies undertaken in preparation for a conference on “ Health manpower out of Before 1990, in all Member States, the planning, training and use of health personnel should be in accordance with health for all policies, with emphasis on the primary health care approach. 92 balance” , organized by the Council for International Organizations of Medical Sciences (Acapulco, Mexico in September). Both the studies and the conference itself focused on the actual and projected discrepancies between the numbers, types, functions, distri­ bution and quality of health workers on the one hand, and the countries’ needs for and use of health services on the other. 6.40 Investigating practices in health manpower planning was published as part of a study carried out with the collaborating centre for the managerial process fo national health development in Leeds (Nuffield Centre). It identifies correct health manpower practices, examines their compatibility with and support for the HFA strategy, and describes three different success stories. A detailed description of the study will be issued in book form through a commercial publisher. A later study tested the feasibility of scenario techniques for identifying health and non-health manpower implications of the HFA strategy. 6.41 Work was begun or intensified on programmes and guidelines for training in health manpower planning and management. The Regional Office and ASPHER sponsored a second international workshop on health management training in Düsseldorf, Federal Republic of Germany in November, using the revised version of a workbook designed for organizers of courses in health management and a training module on motivation. 6.42 In Portugal, the Regional Office helped organize a fourth national workshop on health manpower in April, followed by an evaluation of the impact of all four workshops on the participants’ subsequent activities. A national seminar on health manpower prac­ tices was held in July, using the results of the Nuffield Centre study mentioned above. 6.43 The first part of a study on systems and organization of continuing education was completed. Information on the current situation and trends was collected in eight countries (France, Hungary, Italy, Spain, Sweden, USSR, United Kingdom and Yugo­ slavia), with particular reference to PHC. A consultation of country investigators was convened in Copenhagen in April to plan the second part of the study, consisting of specific case studies. A comparative study involving nine countries was also undertaken in collaboration with the Department of Health and Social Security of the United Kingdom and examined the roles, functions and training of medical officers working in public health and community medicine. 6.44 The seventh scientific session of the USSR/WHO international courses for public health administrators, held in Varna, Bulgaria in April, was devoted to health manpower development in relation to health priorities and targets. Cooperation con­ tinued with the collaborating centre for health management and human resources in Moscow, where the 1985/1986 courses for public health administrators in English and Russian finished in June and the 1986/1987 courses started in September. 6.45 A meeting took place in Copenhagen in March to analyse trends in the field of multiprofessional education in the Region and to outline strategies for the team training of health workers. Participants from Belgium, Finland, France, Greece, Portugal, Sweden, USSR, the United Kingdom and Yugoslavia recommended developing col­ laborative mechanisms between the institutions involved and WHO, and made plans for a network for multiprofessional education in the health sciences. 93 6.46 A three-week intercountry travelling seminar conducted in Bratislava, Budapest, Prague and Warsaw in June/July dealt with various aspects of research methodology in education for the health professions, including policy formulation, identification of needs, planning, implementation and evaluation. 6.47 A second international workshop on educational theory was held at the medical faculty of the University of Paris XIII (Bobigny) in May. Close cooperation continued with the BLAT collaborating centre for health manpower development in London, where a ninth course on modern methodology for teachers of health sciences and a course on the management of a collection of health audiovisuals were held in July and August respectively. 6.48 The Regional Officer for Health Manpower Development (Management) visited Israel in November to help with activities related to the planning, education and use of health personnel. 6.49 Cooperation continued with the Region of Veneto in Italy on the basis of the plan for 1985-1987, and the Regional Officer gave an address on PHC and the medical profession at a national meeting of community physicians in Rome. Fellowships 6.50 In 1986, greater efforts were made to direct the fellowships programme according to the provisions of resolution EB71.R6 which, among other things, calls on regional directors to respond favourably to requests for fellowships only if they are in strict conformity with the Organization’s policy on fellowships, relevant to the health man­ power needs of the country, and so designed as to have a positive impact on the achievement of health for all by the year 2000. 6.51 The number of fellowships awarded worldwide continued to increase, rising by 15% in 1986. Fig. 6 shows the number of fellows from each country studying elsewhere in the European Region in 1986, and the distribution by receiving country of fellows from various parts of the world studying in Europe; Fig. 7 shows the subjects of study of European fellows in 1986; and Fig. 8 shows the regions of origin of the fellows received in Europe. 6.52 The general trend in the European Member States was to make increasing use of fellowships to promote the regional and national HFA policies, and to select candidates accordingly. The emphasis of the Fellowships unit’s work therefore shifted from an administrative to a more technical approach, so as to guarantee the best and most cost-effective training for each candidate. This is seen as the start of a process necessarily leading to evaluation to ensure that only the best training institutions are retained for future use. This process must, moreover, be continuous and thus requires uninterrupted feedback from countries. It is therefore hoped that all Member States will give full attention to the fellowships reporting system. 6.53 The Fellowships unit regularly distributes a list of WHO-sponsored courses and training activities, and data on a large number of individual training possibilities are 94 Fig. 6. D is tr ibu t ion by coun try of fe l lows in the European Region in 1 9 8 6 a Black figures indicate the number of fellows from each country studying elsewhere in the Region. Coloured figures indicate the number of fellows received in each country. a These figures refer only to those fe llow s w ho started the ir fe llow sh ips in 1 986. 95 Fig. 7. Percentage d is t r ibu t ion of European fe l lows in 1 986 by sub ject of study Fig. 8. D is tr ibu t ion of fe l lows in the European Region in 1 986 by region of orig in 96 being collected and computerized to enable the Member States to plan their fellowships well in advance, according to national and WHO plans. Target 37 BO 6.54 Most technical units at the Regional Office have now adopted a multisectoral approach to their programmes, good examples being activities in the Healthy Cities project (see target 13), the HFA promotional campaign, environmental health (see target 18), the Mediterranean Action Plan (see target 20) and chemical safety (see tar­ get 19). The multisectoral approach and the HFA targets were also the main topics of discussion during a visit by Chief, Coordination with other Organizations to the National Council of Voluntary Organizations in London in October. 6.55 The Regional Director addressed the Vlth Inter-Parliamentary Conference on European Cooperation and Security, held in Bonn in May. He explained the relevance of HFA in Europe and described the regional HFA strategy and its three major focuses for change: lifestyles, environment and the health services themselves. He highlighted cer­ tain of the targets and spoke of the encouraging results already obtained, but stressed that they were only the start of a long, complex process of change. He then invited his audience of politicians to support the European strategy by introducing new policies in all sectors and by promoting crucial public understanding and motivation. Target 38 BO 6.56 Advanced medical technology offers great promise for the future care of the sick, but at the same time puts a severe strain on the economy and threatens people’s values; the lack of resources to pay for the full use of modern knowledge challenges ideas of distributive justice, and the absence of a philosophical-ethical frame of reference to help in choosing among technological options places great burdens on policy-makers and clinical decision-makers alike. 6.57 Society’s reaction has been to introduce broad, multidisciplinary assessment of technologies, and of the social, ethical and economic consequences of their use. Many Before 1990, all Member States should have estab­ lished a formal mechanism for the systematic assess­ ment of the appropriate use of health technologies and of their effectiveness, efficiency, safety and accept­ ability, as well as reflecting national health policies and economic restraints. Before 1990, in all Member States, education should provide personnel in sectors related to health with adequate information on the country’s health for all policies and programmes and their practical appli­ cation to their own sectors. 97 M ember States are setting up institutes, offices, academ ic departm ents and com m ittees to carry out the assessm ent in a more form al way and to decide how the technologies should be distributed and used. This development may have im proved the quality o f decisions, but it has not sim plified them, nor m ade them less time-consuming. Instead, it has highlighted the difficulties caused by the fact that rapid technological development outpaces the policy-m aking process so rapidly that decisions are already obsolescent by the time they are made. 6.58 The aim o f the health technology assessm ent program m e is thus to help those responsible to make wise policy decisions and to use health care technologies more parsim oniously. The situation can be im proved by developing new approaches to policy-m aking in relation to medical devices, including inform ation systems on safety, efficacy and usefulness, legal classification system s, and regulations on the transfer o f technologies within and am ong countries; sharing inform ation globally on assessm ents o f technologies, on experience o f their use and on the principles that guide their use; developing assessm ent m ethods, with em phasis on quality o f life m easurements; intro­ ducing early warning system s based on prior analysis o f new technologies; educating health personnel at all levels in technology assessm ent, quality assurance, ethics and econom ics; and clarifying the ethical issues involved (see target 31). 6.59 Program m e activities relating to medical devices focused on inform ation de­ velopment, hazard reports, and the classification o f devices for the purposes o f safety, legislation and transfer am ong countries. 6.60 Two meetings were organized with the International W orking G roup for M edi­ cal Device Testing, one in Copenhagen and one arranged by the collaborating centre for health and disease surveillance in Rom e; such topics as the com parative testing o f health devices, especially im plantable cardiovascu lar devices, and legal aspects were discussed and a joint project was agreed on. 6 .61 The concept o f a centre for inform ation on technology for health, to provide a data base for medical devices, was developed in collaboration with the O rganization for Applied Scientific Research (TN O ) in the Netherlands and the Emergency Care Research Institute (E C R I) in the United States. 6.62 The Regional Office, in collaboration with W HO headquarters and the U S Food and D rug A dm inistration (F D A ), organized a conference o f medical device regulatory authorities in W ashington, D C in June. 6.63 A meeting on innovation and international regulation in biotechnology, drugs and devices, arranged by the Regulatory A ffairs Professionals Society (R A P S) in Munich in M ay, examined legal and classification issues related to medical devices. 6.64 In M ay, a joint meeting with the Center for M edical Technology Assessm ent, Linköping, Sweden discussed lithotriptor treatment o f kidney stones and technologies for tooth im plantation. The Center’s lithotriptor study is the first in Europe to try to gain an overall view o f the dem and for such treatment in relation to epidem iology and to the 98 econom ic, social and clinical consequences o f its use. Im plantation o f teeth is a new and advanced method o f restoring the bite function, but is as expensive as a hip replacement, and a rapidly increasing dem and for this service could consum e an unacceptably large proportion o f health resources. The establishm ent o f indications for different methods in this field is therefore essential. 6.65 In collaboration with the Governm ent o f the Netherlands, studies are in progress to identify future technologies which may have a considerable im pact on the future delivery o f health care and should therefore be taken into account in policy decisions as from now. Out o f a large num ber o f technologies considered, four were chosen and assessed with respect to their future health and policy im plications, in the areas o f regeneration, repair and reorganization o f nervous tissue; health care applications o f lasers; genetic screening with social im plications; and new biotechnology for vaccines and m onoclonal antibodies. 6.66 A ssistance was given in a course on health technology assessm ent and the appropriate use o f technology with reference to decision-m aking at the policy and clinical levels, held in the autonom ous region o f the A zores, Portugal for 25 participants from various levels o f the Azorean health care services; and the Regional Officer for Health Technology Assessm ent lectured on this subject in Finland, France, Italy, the Netherlands, Sweden, the United Kingdom and the United States. 6.67 M ost health technology assessm ent activities were carried out in collaboration with other organizations, including F D A , E C R I, the European M edical Research Coun­ cils, the U S N ational Institutes o f Health, R A P S and T N O , and the Regional Office also cooperated in this field with E C E , C E C , and the N ordic Board for the Evaluation o f Medical Technology. Pharmaceuticals 6.68 A s the proper therapeutic and prophylactic use o f pharm aceuticals is relevant to the attainm ent o f many H F A targets, a balanced pharm aceuticals program m e provides essential support to many other regional activities. The A dvisory Com m ittee on the Pharm aceuticals Program m e endorsed this program m e approach at a meeting in Copenhagen in April and m ade detailed recom m endations for the continuation and developm ent o f projects. A project to investigate special registration conditions for particular drugs in various countries and the effect o f conditional registration on some model substances was initiated under a contractual services agreem ent, as part o f the European studies o f drug regulation. In collaboration with the Nutrition unit, a project was also started to examine the best policy approach to vitamin preparations. 6 69 The fourth International Conference o f D rug Regulatory A uthorities, held this year in Tokyo, enabled authorities from all over the world to discuss com m on problem s. The European Region was represented by both M ember States and W HO staff. 6.70 The second and third issues o f the “ D rug regulatory index” , com piled by the collaborating centre for drug inform ation and quality assurance in Budapest, were 99 distributed during the year. The second issue covered documents issued by public and private international organizations, while the third listed documents issued by national agencies. The annual “ Directory of drug regulatory agencies in the European Region” was also published. 6.71 Close collaboration continued with the Action Programme on Essential Drugs and the Pharmaceuticals unit at WHO headquarters and with other regional offices. In particular, discussions were held on the implications of resolution WHA39.27 on the rational use of drugs and the European pharmaceuticals programme’s role in its implementation. 6.72 The “ Drug bulletins review” , revised in format and content, now contains a survey of articles printed in many different national drug bulletins in Europe and is expected to further strengthen collaboration between such bulletins. The Pharma­ ceuticals unit helped both Malta and Turkey to establish national drug bulletins; in such cases the responsibility is transferred progressively from the Regional Office to the Member State. 6.73 A project looking into the role and function of the pharmacist in health care systems in Europe was initiated jointly with the professional organizations concerned. 6.74 For the first time, the proceedings of the WHO Drug Utilization Research Group were issued in full in order to promote wider knowledge of the Group’s work and the methods it has developed. An advisory committee met in Barcelona in December to plan the next meeting of the Group and to advise on the updated and expanded edition of the book Studies in drug utilization (European Series, No. 8), which has proved to be very influential. 6.75 The collaborating centre for drug statistics methodology in Oslo continued to help Member States classify drugs according to the Anatomical/Therapeutic/Chemical classification system and the Defined Daily Dose system. The collaborating centre also took over compilation of the “ Drug utilization bibliography” , which lists publications and articles dating from 1981 to 1986, most of them produced with Regional Office collaboration. The bibliography is updated and issued annually. 6.76 Various aspects of drug utilization in pregnancy, which continues to pose serious problems, are under study. One question being examined in depth relates to late compli­ cations of the use of diethylstilbestrol (DES). In some parts of the Region, DES must be regarded as having caused a major disaster in the second generation as a result of its now discredited use for the treatment of threatened and habitual abortion; it seems clear that only a small fraction of the injuries produced have as yet been detected. 6.77 ’’Drugs and money” , now a widely used review of drug costs and pricing in Member States, which also contains proposals for further research, went into its fifth draft edition in June. It was presented and discussed at various meetings organized by the pharmaceutical industry and health authorities in the Netherlands and Switzerland. 6.78 A course in drug regulation for drug regulatory assessors was held in Norway, with participants from both the European and the African Regions. 6.79 The number o f “ Guidelines for clinical investigations” either available or in preparation has risen to 26, so that the series will soon cover m ost o f the m ajor therapeutic groups, and it will be possible to move on to updating the guidelines. An im portant recent addition was the final guideline for the assessm ent o f drugs for use in self-m edication, which reflects the increasing trend o f m aking certain com pounds avail­ able without prescription. Two new revised drafts were related to the assessm ent o f behavioural teratogenicity and to bioavailability studies. The series as a whole is very much in dem and. 6.80 This year’s annual sym posium on clinical pharm acological evaluation in drug control, held in Schlangenbad in October, dealt with drugs and the immune system. 6 .81 The Regional Officer for Pharm aceuticals took part in the third in the series o f world conferences on clinical pharm acology and therapeutics, organized by the Inter­ national Union o f Pharm acology in Stockholm in Ju ly /A u gu st. He also visited Czecho­ slovakia, Greece, Israel, M alta, the N etherlands, Norw ay, Turkey and the United Kingdom for discussions. Evaluation* The health economics programme during the period 1984-1985 6.82 The health econom ics program m e was developed to stim ulate routine economic evaluation o f health strategies, to m obilize econom ic resources and realign budgeting and financing system s in support o f health for all, and to prom ote education and training in health econom ics. The program m e has given considerable support to a number o f other regional program m es, and there have therefore been som e delays in carrying out program m e activities. M ost o f the work done has been o f direct assistance in attain ing health for all; it is generally recognized that the econom ic aspects o f health have gained in im portance as a result o f the efforts that are being m ade to achieve this goal. 6.83 In their evaluation o f this program m e, mem bers o f the European Advisory Com m ittee on Health Research singled out the coverage o f training requirements by an active international network as a particularly successful undertaking. The Com m ittee found the program m e to be technically and scientifically sound, and m ade a number o f recom m endations for its future developm ent. These included strengthening health econ­ om ic inform ation at national and international levels, and carrying out research on H FA activities in other sectors o f national econom ies. The economic im plications o f work tow ards health for all would also require further study. Recognizing that the program m e had only limited m anpow er with which to reach its objectives, the Com m ittee rec­ om m ended that it should be given appropriate support. 101 RESEARCH AND HEALTH DEVELOPMENT SUPPORT Publications issued in 1986 Weiss, P. Health and biomedical information in Europe. Public Health in Europe, No. 27. Planning and management for health: report on a European conference. EURO Reports and Studies, No. 102. Investigating practices in health manpower planning: report on a country case study. Non-serial publication. Documents issued in 1986 Drugs in hospitals: report on the fourteenth European symposium on clinical pharmacological evaluation in drug control (document 1СР/ DSE 105/m02). Fifth WHO meeting o f European national fellowship officers (document ICP/HMD 105/m01). Health and equity for the disabled — legislation for action (document ICP/HLE 113). Health legislation in Europe — what is new in 1985? Our computer tells you . . . (document ICP/HLE 115). Co-publications issued in 1986 Skeet, M., ed. The age o f aging: implications for nursing. International Council of Nurses/WHO co-publication. 102 7Global programmes Global programme for accident prevention 7.1 Accidents cause nearly 3 million deaths each year, almost 2 million of them in developing countries. They account for 5% of the general mortality, but a much higher percentage of general morbidity. For instance, in the United States there are 45 000 deaths each year from motor vehicle accidents, against 3.5 million disabling injuries, and 13 000 deaths from falls, against 11 million injuries. 7.2 Accidental injuries are one of the most expensive health problems in developed countries. In the United States motor vehicle injuries alone cost US $100000 million per year, and in the European Community about US $50000 million per year. The striking universal feature is that accidents are the leading cause of death in industrialized countries for people aged between 1 and 40 years and are now also tending to become the leading cause in many developing countries. Advocacy for safety 7.3 Advocacy for safety and the promotion of national policies through technology assessment and information exchange are a key component of the programme. Although the importance of safety measures is today better recognized, they still tend to be thought of, if at all, as a by-product. This is particularly true in developing countries, even though the consequences of accidents can be very serious in places where there is no infra­ structure to manage injury cases. Activities in this field focused on road safety and domestic safety. 7.4 In OECD countries, the road safety policies established by the 1960s have brought definite results, mainly due to political will and increased public acceptability of counter­ measures. This successful experience provides a platform for promoting such policies elsewhere in the world where safety is a far greater problem and no policy exists. WHO, the only agency with a global perspective and mandate in road safety, is playing an important advocacy and coordinating role in this respect. 7.5 At the technical level, a policy analysis is being conducted in selected groups of countries. So far, it has covered the European Community countries, Brazil, Canada, India and the United States. A second phase will cover countries that have initiated policies and control activities, such as Brazil, the Caribbean countries, Côte d’Ivoire, 103 Cuba, Indonesia, Kenya, Malaysia, the Philippines and Thailand. Extensive collab­ orative work on this subject will be carried out in 1987. Guidelines for the establishment of road safety programmes in the Caribbean countries were also drawn up at a workshop in Barbados, to which European experts contributed. These guidelines were adopted by the eighth Conference of Caribbean Ministers of Health, and their field testing is being coordinated by the WHO/PAHO Caribbean Epidemiology Centre, with USAID fund­ ing and WHO technical support. 7.6 At the policy level, WHO was also involved in a recent CEC-sponsored European forum on new policies for road safety (Aix-en-Provence, October) organized by the Government of France in the framework of the European Road Safety Year, which strengthened the Organization’s collaboration with the transport sector. The transport ministers of several European countries discussed the need to give a greater role to local authorities in this area and to promote a more community-oriented approach. 7.7 Domestic safety, which includes prevention of falls, burns, poisoning and drown­ ing, is far less well documented than road safety, especially in developing countries where deaths and disability due to injuries are fatalistically accepted as a part of daily life. A comprehensive review of domestic safety programmes, legislation and activities was begun, covering particularly Australia, Europe and North America. It includes a sys­ tematic analysis of successful interventions or programmes. Examples are the reduction of burn injuries from clothing ignition in children in the United States, improved domestic products in Denmark, the prevention of falls among the elderly in Sweden, a reduction in the incidence of drowning in Australia, and the prevention of child poison­ ing by the use of child-proof containers. Health and safety promotion 7.8 Activities relating to this programme component included pilot programmes on community safety promotion undertaken in southern India and Nepal, with the aim of mobilizing public and private local organizations and industry to promote safety at home and on the road. The emphasis in 1986 was on burn prevention. Collaboration with nongovernmental organizations 7.9 A second global liaison meeting with nongovernmental organizations on accident prevention took place in May in Geneva, and set a target for action on domestic burn prevention. Collaborative research on child safety was organized through the Inter­ national Paediatric Association (IPA) and through the Latin American Paediatric Association in Brazil, Chile, Cuba and Venezuela. In Cuba, the project started in two districts but was later extended to the whole country, and a national committee on accident prevention was set up. 7 io The IPA standing committee endorsed a WHO recommendation on accidental injury prevention in childhood and adolescence during the IPA congress in Honolulu in July. The recommendation places increased emphasis on safety promotion in PHC and on participation by various elements of the community, especially nongovernmental organizations, consumer organizations, families, children and adolescents themselves. 104 7.11 WHO cooperated with the International Center of Social Gerontology, Paris in coordinating research on domestic accidents among the elderly in Australia, Belgium, Canada, France, Sweden, Switzerland and the United States, and with the Indian Burns Association and the International Society for Burn Injuries (European branch) in research on burn epidemiology, with the involvement of burn centres in Denmark, India and Turkey. Global programme for appropriate health care technology 7.12 Appropriate health care technology covers the appropriate use of drugs, devices, equipment, procedures and organization of methods in health care systems, with empha­ sis on policy, research, cost-effectiveness, quality assurance and the communication of information. The aims of the programme are to identify technologies in need of assess­ ment; to develop assessment methods by studies and literature review; to convene consensus groups; to publish global reports; to prepare and distribute study protocols on cost comparison; to develop national models; to advise on standards for health workers, policy-makers and the public; and to promote contacts with the mass media, specialized journals, consumer groups and industry. 7.13 Activities during the year focused on a series of key issues identified as having high priority through consultation with all parties. 7.14 A questionnaire was sent out in an effort to identify priority issues relating to communication technology and information exchange in all WHO regions, and some 550 replies were analysed. The respondents gave top priority to the methodology of assessment, with communication technology in health care in second place. Health policy-makers and professionals, third-party payers, administrators, industry represen­ tatives, researchers and representatives of the media also attended a number of WHO/ European Health Policy Forum meetings in Brussels, producing extensive material which was widely disseminated and resulted in several publications. A number of national meetings on these lines took place at the country level, in the official and various other languages. Finally, information exchange was pursued with industry, insurance companies and developers and manufacturers of equipment, devices and reagents, and the newsletters of professional societies were used to disseminate information. 7.15 The main activities in relation to variations in health care practice and cost- effectiveness included a meeting on health care indicators (Berne, June), the issue of a newsletter and the preparation of an extensive bibliography. The collaborating centre for the study of regional variations in health care in Copenhagen made arrangements for international studies and a series of meetings and courses, including an international congress held in November. 7.16 A position paper on the economic aspects of the global programme was issued, and a clearing-house was set up to disseminate such information. 7.17 An international workshop on the methodology of technology assessment in PHC was held in Copenhagen in February. 105 7.18 The usefulness of cost-effective laboratory tests was discussed at various meet­ ings, but implementation was slow. The assistance of nongovernmental organizations in this field was sought. National studies on appropriate laboratory test use and cost- effectiveness were promoted. 7.19 The WHO Basic Radiological System (BRS) was presented at meetings, and radiologists and administrators from Member States visited functioning BRS units. More efforts are required to overcome the resistance of some professionals, who still prefer to use very sophisticated, less cost-effective imaging technologies. Evaluations of BRS performance were collected from all regions where it is in use. 7.20 Activities concerned with safety in health care included collaboration with an EEC project and with the European working party of leading microbiologists in hospital infection control. The need for cost-effectiveness studies of the preventive measures taken by various countries and infection control committees was emphasized. Protocols for evaluation were developed in association with the collaborating centre for health and disease surveillance in Rome. The report of a meeting on the rational use of biosafety measures in health laboratories in 17 different countries in two continents (Madrid, 1985) is now available. 7.21 Several activities were undertaken on the subject of drug utilization. A study on the use of aminoglycosides and the occurrence of bacterial resistance was completed and the results are being analysed. More Member States have expressed the wish to use the common protocol and to participate in the study. A strong correlation has been estab­ lished between the widespread use of aminoglycosides outside hospitals and the occur­ rence of multi-resistant bacteria. Optimum iron supplementation was discussed at an international workshop (Pilisszentkereszt, Hungary in November) which recommended further studies, as little is known about this subject. Finally, data were collected on the cost-effectiveness of various therapeutic regimes for respiratory infections, and a study protocol was circulated for comments. Global programme for health o f the elderly 7.22 The World Health Assembly’s policies on aging, and related resolutions of the regional committees for the Americas and the Western Pacific, are reflected in regional and country programmes that now exist in all six regions. In the current biennium, regional and country programmes have more than doubled, that in the Americas being the largest. Indeed, the UN Secretary-General’s report to the forty-first session of the General Assembly states that WHO’s activities account for half of the United Nations system’s budget for aging. 7.23 Voluntary, non-profit nongovernmental organizations are WHO’s philanthropic partners in promoting the wellbeing of the world’s elderly people, the yearly global coordination meetings with these organizations being reported in English, French and Spanish. A first regional nongovernmental organization/WHO collaborative group on aging met in Washington, DC with the aim of establishing cooperative projects in the Americas. 106 7.24 The health of the elderly and health trend assessment programmes developed a new system of presenting information by means of “ visual epidemiology” . This consists of data atlases that display demographic, health and social profiles of the elderly in an organized and intelligible way. The presentation has evolved continuously in response to users’ needs, e.g. in Cuba and Iceland. The ease of producing computer-generated maps from data sets makes them a particularly apt tool for the district health policy enunciated by the Director-General at the Thirty-ninth World Health Assembly. Within-country comparisons were made for WHO-supported planning for health of the elderly, as in Cuba where comparisons extend beyond provinces into municipalities and even cities. 7.25 Pioneering efforts are being made to introduce teaching on aging into schools of public health, and to use the tools of epidemiology in the field of aging. The WHO annual international course at the London School of Hygiene and Tropical Medicine attracted some 50 participants from five regions, all of whom work with their own data and commit themselves to continue working on an epidemiological project. WHO support also extended during the current year to national courses in the regions of the Americas and Western Pacific, which provided training in rational approaches to the planning of health services for the elderly. 7.26 The WHO programme supported a first Latin American conference on aging in Bogota, Colombia; a first congress on gerontology of the Indian Ocean in Mauritius and La Réunion; an intercountry workshop on planning for the needs of the elderly in Harare, Zimbabwe; interregional workshops on aging in Hyderabad, India; and a technical meeting on falls among the elderly at WHO headquarters. Missions for national plan­ ning and programme development visited Jordan and Tunisia. A WHO international meeting on health promotion in the elderly took place in Hamilton, Canada. 7.27 The major new development during the year was a recommendation made by the subcommittee on aging of the Global Advisory Committee on Health Research, and endorsed by the Director-General, to establish a WHO international research pro­ gramme on aging that will be executed through a network of regional centres. The aim is to strengthen research in the new “ aging” countries, and to develop preventive medicine for old age through cooperation between researchers in the fields of epidemiology, nutrition, immune function and dementia. G L O B A L P R O G R A M M E S Documents issued in 1986 Coordinated action on aging: report of the fifth meeting of the NGO/WHO collaborative group on aging (document IRP/HEE 115.2.2). 107 8Evaluation of the regional programme 8.1 As requested by the Regional Committee in resolution EUR/RC36/R1, more evaluative material is included in this annual report. Summaries of evaluations of specific programmes made by the European Advisory Committee on Health Research (EACHR) have been included at the end of certain chapters, while this chapter describes the evaluation process and presents some general conclusions. The issue of evaluation will be further developed in future reports of the Regional Director. Introduction 8.2 The use of all resources has to be accounted for, and WHO’s resources for health are no exception. One aspect of evaluation is to ensure that WHO’s inputs have been efficiently delivered and effectively used to help attain the targets and objectives of national programmes. In addition, however, one should be able to show that they have had an impact on people’s health. It is often difficult to make this type of evaluation, not only because of a lack of data at country or regional level on the final outcome of the Office’s activities, but also because of the time lag between implementation of a WHO programme and its effect at country level. Lastly, it is not easy to determine how much of the impact is due to Regional Office initiatives and how much is the result of national health programmes, socioeconomic development or programmes from other inter­ governmental organizations. 8.3 Evaluation of the work of the Regional Office, both by external groups and through internal mechanisms, has been in operation for many years. Systematic in-house evaluation of all programmes dates back as far as 1963. Other mechanisms have gradually been added. The EACHR now analyses the research elements of three to four pro­ grammes at each of its annual meetings. Advisory groups of external experts make in-depth reviews of technical programmes at regular intervals, and especially of those that have been recently developed. The Consultative Group on Programme Development (CGPD) has on several occasions considered the evaluation mechanisms used by the Regional Office. Surveys are regularly carried out by management consultants to ensure that the Office adapts to changing needs in Europe; and internal and external auditors scrutinize the management of the Office’s resources. The medium-term programmes 109 drawn up in cooperation with individual Member States are subject to annual reviews and evaluation, and more recently also to financial audit. Lastly, regional evaluations of the effectiveness of the strategy for health for all are now carried out jointly by the Regional Office and the Member States at regular intervals, as part of a global process and in response to resolution WHA34.36. The most recent exercise took place in 1985, and a full account was published in 1986.a Evaluation o f the 1984-1985 programme 8.4 During 1986 the Regional Office evaluated the country and intercountry pro­ grammes implemented during the 1984-1985 biennium. These programmes had been planned before the 38 regional HFA targets were endorsed, but two other major policy documents had influenced their preparation: the regional HFA strategy (document EUR/RC30/8) and the regional contribution to the Seventh General Programme of Work (document EUR/RC31/7). 8.5 The strategy had identified the following issues as being of vital importance for the European Region: the promotion of more healthy lifestyles; the intensification of efforts to reduce preventable conditions through intersectoral action on risk factors; the pro­ vision of adequate health care accessible to all through more effective, efficient and acceptable systems based on primary health care; and the strengthening of political, managerial, technical, manpower and other types of support. In order to promote these issues in the Member States, the regional contribution to the Seventh General Pro­ gramme of Work specified the following four main roles which the Regional Office would have to play: • to help make existing knowledge better known, by identifying innovative and im­ proved health care approaches in Member States; • to promote priority health research; • to act as a catalyst in promoting national health policy development in line with the principles of health for all; and • to improve cooperation and coordination between international organizations active in the health field. 8.6 These four main roles were used as indicators to measure how the different pro­ grammes had assisted Member States in progressing towards the goal of health for all. 8.7 The 1986 internal evaluation exercise concentrated on assessing the extent to which each programme had been delivered as planned, on schedule and within the limits 0 Evaluation o f the strategy fo r health fo r a ll by the year 2000: seventh report on the world health situation. Vol. 5. Copenhagen. WHO Regional Office for Europe, 1986. 110 of the resources allocated; analysing whether the changes introduced during the im­ plementation phase had reinforced or distorted the thrusts of the programmes in accord­ ance with the Office’s four main roles mentioned above; scrutinizing the ways in which resources had been utilized and external resources attracted; and finally, looking at the geographical distribution of the expertise used during programme implementation. Evaluation findings 8.8 For the programmes as a whole, some 90% of activities were implemented on schedule, but many of these were replacements for ones originally planned. This “ sub­ stitution phenomenon” is the result of a variety of factors, such as the reorientation of activities to bring them into line with the HFA targets; changes in the overall political and economic climate in Europe; the need to react to developments in the outside world in a fast-moving environment; and responses to ad hoc requests from Member States. By definition such requests cannot be foreseen at the planning stage. The overplanning which became apparent during the evaluation will always be necessary to some extent, in order to ensure the flexibility to respond to sudden needs or to make the best use of any additional resources which may become available. 8.9 The evaluation provided important pointers as to the ways in which the Re­ gional Office can work most effectively. One crucial aspect is the support which the Regional Office gives to developing, implementing and maximizing the impact of HFA policies. As many countries are taking steps to rationalize health spending and financing, economic and related ethical issues will increasingly serve as entry points for promoting HFA. Lastly, priority must clearly be given to continued work on HFA indicators. 8.10 Given the variations in progress within and between Member States, more emphasis will have to be placed on country programmes which are supported by an intercountry component, to allow for further research and exchanges of experience. The main focus in programmes should also gradually shift, to give more prominence to the Office’s advocacy role. Many of the new programmes, such as that on health promotion, have achieved a high degree of visibility in the European Region and have demonstrated a capability for effective action, especially as regards this role. In view of the existing knowledge base and new programme approaches, however, it is recognized that this shift of emphasis will vary from programme to programme. Nonetheless, it is already evident in the increasing number of country medium-term programmes, which reached a total of 24 in October 1986. Their very rapid development has represented an additional and unplanned burden on the Regional Office. 8.11 Another aspect of the Regional Office’s work which was critically reassessed during the year was the distribution and sale of the many publications and documents produced by the Office. While some of these are of most value to a relatively small number of policy-makers in the Member States, others can be of use to a wide range of potential readers both within and outside the health professions. A special unit for publications promotion was created in 1986, and a particular effort is now being made to complement WHO’s own publishing activities by more extensive со-publishing with other parties. Investigations have also showed that there is considerable interest in 111 translations into national languages; Italian, Spanish and Danish are some of the languages in which the Office’s work is now becoming available, generally in close collaboration with the Member States concerned and without calling on the Office’s own limited resources. Evaluation of the resulting impact continues. 8. 1 2 An impressive number of publications and documents have been produced under the intercountry programmes, and many consultant reports released by the larger country programmes supported by UNDP. A number of reports issued in 1984-1985 were much in demand, with 620 individual requests, in addition to the circulation list of 2000 names, received for Chronic effects of organic solvents on the central nervous system and diagnostic criteria (Environmental Health Series No.5). In view of the Office’s low overall capacity for producing such reports, new ways and means will be found of speeding up production. This is of paramount importance, especially in fast-moving subjects such as those related to the environment. Other methods of publicizing the results of the Office’s activities, such as articles in professional journals, newsletters, etc., will also be explored. 8.13 Multisectorality is an issue that will need more attention in the years to come. It is hoped that instruments such as the Healthy Cities project, the countrywide integrated noncommunicable disease intervention programme (CINDI) and the tobacco campaign will help develop intersectoral collaboration. Many problems will have to be tackled at an international level: in particular, those that extend beyond national boundaries (e.g. the pollution of major rivers) call for a joint approach by all the countries concerned. In the 1984-1985 programme, the promotion of international collaboration (the Regional Office’s fourth role) was mostly implicit and not expressed in specific projects; a pro­ gressive change towards more explicit collaborative efforts is now under way. 8.14 Finally, a number of activities are planned on the assumption that voluntary donations will be received. When these do not materialize, as has been the case in recent years, programme delivery is affected and changes in planned activities have to be made. 112 Annex 1 ACTIVE AND NON-ACTIVE MEMBER STATES OF THE WORLD HEALTH ORGANIZATION, EUROPEAN REGION 31 December 1986 At 31 December 1986 the European Region of the World Health Organization had 32 active Member States and 2 non-active Member States. They are listed below with the date on which each became a party to the Constitution of WHO. A lb a n ia 26 M a y 1947 A u s t r ia 30 J u n e 1947 B e lg iu m 25 J u n e 1948 B u lg a r ia 9 J u n e 1948 B y e lo ru ss ia n S S R a 7 A p r i l 1948 C z e c h o s lo v a k ia 1 M a r c h 1948 D e n m a r k 19 A p r i l 1948 F in la n d 7 O c to b e r 1947 F r a n c e 16 J u n e 1948 G e r m a n D e m o c r a t ic R e p u b l ic 8 M a y 1973 G e r m a n y , F e d e r a l R e p u b l ic o f 29 M a y 1951 G re e c e 12 M a r c h 1948 H u n g a r y 17 J u n e 1948 Iceland 17 J u n e 1948 Ireland 20 O c to b e r 1947 Israel 21 J u n e 1949 Italy 11 A pri l 1947 L u x e m b o u r g 3 J u n e 1949 M a l t a 1 F e b ru a r y 1965 M o n a c o 8 J u l y 1948 N eth er lan d s 25 A pr i l 1947 N o rw a y 18 A u g u s t 1947 P o la n d 6 M a y 1948 P o rtu ga l 13 F e b ru a r y 1948 R o m a n ia 8 J u n e 1948 S a n M a r in o 12 M a y 1980 S p a in 28 M a y 1951 Sw e de n 28 A u g u s t 1947 Sw itze r lan d 26 M a r c h 1947 T u rk e y 2 J a n u a r y 1948 U k ra in ia n S S R a 3 A pri l 1948 U S S R 24 M a r c h 1948 U n ited K in g d o m 22 J u l y 1946 Y u g o s la v ia 19 N o v e m b e r 1947 a N o n -a c t iv e M e m b e r Sta te . 113 Annex 2 ESTIMATED POPULATIONS IN 1986 FOR THE ACTIVE MEMBER STATES OF THE WHO EUROPEAN REGION (in thousands)0 Albania 3 115 Luxembourg 362 Austria 7 486 Malta 384 Belgium 9 882 Monaco 27 Bulgaria 9 257 Netherlands 14 554 Czechoslovakia 15710 Norway 4158 Denmark 5 146 Poland 37 871 Finland 4 889 Portugal 10 142 France 54 765 Romania 23 231 German Democratic Republic* 16628 San Marino 22 Germany, Federal Republic of* 61008 Spain 39 324 Greece 9 986 Sweden 8 270 Hungary 10 805 Switzerland 6 268 Iceland 244 Turkey 51 149 Ireland 3 635 USSR 280994 Israel 4 377 United Kingdom 55 659 Italy 57 007 Yugoslavia 23 350 Total estimated population in the Region: 829 705000 a B a s e d o n W o rld p o p u la tio n p ro sp e c ts , e s t im a te s a n d p r o je c tio n s a s a ss e s se d in 1982. N e w Y o r k , U n ite d N a t io n s , 1985. * T h e f ig u re s fo r the G e r m a n D e m o c r a t i c R e p u b l ic a n d the F e d e r a l R e p u b l ic o f G e r m a n y inc lude the re levant d a t a f o r Berlin . T h i s is w ith ou t p re ju d ice to an y q u e s t io n o f s t a t u s that m a y be involved. 114 PROFESSIONAL STAFF IN THE EUROPEAN REGION 31 December 1986 Annex 3 R E G I O N A L O F F I C E Executive M anagem ent R egional Policy and Program m e (contd) R egio n al D irector P rogram m e Policy D irector, P rogram m e M an agem en t A d m in istrative O fficer N ational H ealth Policies and S ystem s D irector H ealth E con om ics H ealth Legisla tion H ealth M an pow er D evelopm ent M an pow er P lan n ing and M an agem en t E d u catio n a l D evelopm ent Fellow sh ips D rJ .E . Asvall M s C. Celinder D rJ .-P . Jardel Ms C. Skaanild Vacant Dr H. F. K . Zöllner M s G. Pinet Dr J.-P . Menu Dr V. Vodoratski Vacant Dr V.M. Telish Ms E. Pelle H ealth Policies and P lan n ing N u rsin g Prim ary H ealth C are H o sp ita ls S ta f f D evelopm ent an d T ra in in g R egional Policy and Program m e D irector E p id em io logy and S ta tistic s Dr I. S. Luculescu D r J .R . Bengoa Renteria Dr M. Farrell Ms E. Stussi Vacant D r W. Hubrich Vacant Vacant Vacant D r R . Prokhorskas Dr M. C. Thuriaux M s M. Abou Shabanah H ealth fo r A ll P rom otion C o o rd in a tio n with other O rgan ization s H ealth In form ation o f the Public P ub lication s P rom otion In form atics Su p p ort Plan n ing, M on itorin g and E valu ation P rogram m e Planning P rogram m e M on itoring and E valuation C oun try P rogram m e C o o rd in a tio n R esearch P rom otion and D evelopm ent H ealth R esearch D isease Prevention and Control D irector A ccident Prevention (G lo b a l P rogram m e) A ccident Prevention (R eg ion al P rogram m e) A p p ro p ria te T ech n ology fo r H ealth (G lo b a l P rogram m e) H ealth T ech n ology A ssessm en t (R eg io n al P rogram m e) C an cer C h ron ic D iseases C o m m u n icab le D iseases Dr A. Piga Rivero M s N. Humbert Dr M .A . Danzon Vacant M r I. Vinther-Jergensen M r A. Malagodi Vacant M s V.S. Pedersen Vacant D rH .V . Vuori Dr P.-G. Svensson D r E . Leparski D r C .J. Römer“ D r J. T. Jones Dr K . S tahr Johansena D rJ .O . Vang D r L . Döbrössy D r A. Shatchkute D r B. Bytchenko Paid by W H O headquarters . 115 Disease Prevention and Control (contd) Environmental Health (contd) M alaria O ral H ealth P h arm aceu tica ls H ealth Prom otion D irector H ealth E d u cation H ealth P rom otion S m ok in g H ealth o f the E lderly (G lo b a l P rogram m e) E lderly , D isab ility and R eh ab ilitation (R eg io n al P rogram m e) M atern al and C h ild H ealth M ental H ealth P sy ch osocial F ac to rs and M ental H ealth A b use o f P sych oactive D ru gs Prevention o f A lcoh o l A buse N utrition Sexuality and F am ily P lan n ing Environm ental H ealth D irector A ir Q uality G u id elin es C o n tro l o f E n v iron m en tal H ealth H a za rd s Vacant Dr l .J . M eller D r M. N. G. Dukes Dr P. O. Petersson D r I. Kickbusch Dr D. O'Byrne D r D .M . Macfadyen“ Dr H. M. Hermanova Dr M. G. Wagner Vacant M r C. Goos M r J . U. Hannibal M s E. Helsing Ms W. Haddad1’ M r J . I . Wadding ton Dr R. Turckd Dr M .J . Suess E nviron m en tal H ealth P lanning and M an agem en t Internation al W ater D ecad e M r E. Giroult O ccu patio n a l H ealth T ox ico logy Support P rogram m es D irector A d m in istrative Services Budget and F in an ce C on feren ce Serv ices Personnel M r J . O. Espinoza Cajina Vacant D r S. Tarkowski Dr F. La Ferla M r E . Westenberger M r C. G. Chatelier M r K . Thoby M r J . M iller M r O.H. J 0rgensen Vacant M s R.C.E. Néagoé Vacant T ran sla tio n , P ub lication s and Text P rocessin g P u blication s P roduction T ran sla tio n an d E d itoria l M s C.F. Murphy M r F .E . Theakston Ms P .M . Charlton M r J.-M . Deramal M r J.-P . Bercot M r P. Boyle M r A. David M r M. Khoussainov M r R. Kranich Ms M. Lindemann Ms C. Madanoglu M r V.G. Paveliev M r G. Pignasty Vacant F I E L D S T A F F Greece ICP/RCE 211 (UNEP) - Mediterranean Action Plan Sen ior Scien tist Dr L .J . Saliba Turkey TUR/PHC 001 - Primary Health Care Specia l R epresen tative o f the R egio n al D irector Dr U. Broccolo-Tommasi Paid by W H O headquarters . Paid by U N F P A . Pro tempore a lso responsib le for F ood Safety. Paid by vo lun tary funds. 116 117 Annex 4 ORGANIZATIONAL CHART OF THE REGIONAL OFFFICE 31 December 1986 NATIONAL HEALTH POLICIES AND SYSTEMS Health Economics Health Legislation - Health Manpower Development Manpower Planning and Management Development Fellowships Health Po lices Nursing Prim ary Health Care Hospitals Staff Development and Training Epidemiology and Statistics Coordination with other Organizations Health Informatio of the Public Publications Promotion Informatics Support Planning, Monitoring jn o Evaluation Programme Planning Country Programme Coordination Research Promotion and Development Health Research A ir Quality Guidelines Control of Environmental Health Hazards Environmental Health Planning and Management International Water Decade Occupational Health Su p p o r t p r o g r a m m e s Adm inistra Services Budget and Finance Conference Services Publications and Text Processing Pubhcatic Productio Text Processing Systems and Training ie offices of the Regional 0 ,re Annex 5 INTERCOUNTRY“ MEETINGS CONVENED BY THE REGIONAL OFFICE FOR EUROPE 1 January — 31 December 1986 ICP/CEH 538/A ICP/PHC 114 ICP/CEH 547 1C P/NUT 199 ICP/HSR 602/g01 ICP/HSR 632 ICP/MAL Oil ICP/HSR 648 ICP/HSR 327 IPC/RUD 004/m01 ICP/RPD 101/m05 Second Consultation on the Epidemiological Study on Health Effects of Exposure to Cadmium in the General Population, Amsterdam, 14-15 January (English) Workshop on Supporting Self-help, Leuven, 22-24 January (English) Consultation on Guidelines to Control and Prevent Exposure to PCBs, Dioxins and Related Compounds, Helsinki, 27-29 January (English) Programme Advisory Group on Nutrition, Oslo, 27-29 January (English) Second Meeting of the Health Promotion Steering Group, Copenhagen, 3-5 February (English) Symposium on “ Research on Health Behaviour: its Application in Health Promotion", Pitlochry (United Kingdom), 8-11 February (English) Meeting on Coordination of Malaria Control, Hatay (Turkey), 10- 14 February (English) Consultation on Health Promotion Indicators, Edinburgh, 12-14 Feb­ ruary (English) Fifth Steering Committee and Third Avisory Committee for the Dem­ onstration Project on the Delivery of Nursing Care for the Elderly in their own Homes, Graz, 17-21 February (German) Working Group on the Health and Safety Component of Environ­ mental Impact Assessment, Copenhagen, 24-28 February (English) Twelfth Session of the European Advisory Committee for Medical Research (EACMR), Copenhagen, 25-28 February (English, French, German, Russian) a S e v e r a l o t h e r m e e t in g s h e ld d u r in g th e y e a r w e re f in a n c e d t h r o u g h c o u n t r y p r o je c t fu n d s . S o m e o f th e se , th o u g h n o t l is te d h e re , w ere o f c o n s id e r a b le in te r e s t to m o re th a n o n e c o u n tr y . 118 ICP/CEH 037 ICP/NCD 029 ICP/IEH 010 ICP/DSE 128 ICP/HSR 625 ICP/DSE 199/mOl ICP/CDS 013 ICP/CWS 014 ICP/EXM 001/m08 ICP/GPD 102/m04 ICP/GPD 102/m08 ICP/CWS 035 ICP/HSR 811 ICP/COR 129 ICP/HSR 639 ICP/CAN 118 Working Group on Risks to Health of Dioxins from Incineration of Sewage Sludge and Municipal Waste, Naples, 17-21 March (English) Consultation on Social Marketing for Effective Strategies in the Field of Prevention of Noncommunicable Diseases, Schwarzenberg (Austria), 18-20 March (English) Working Group on the HFA Promotional Campaign, Reykjavik, 19- 21 March (English, French) Consultation on Guidelines for the Medical Assessment of Drugs for Use in Self-medication, Copenhagen, 3-4 April (English) Symposium on Healthy Cities — Action Strategies for Health Pro­ motion, Lisbon, 6-10 April (English) Advisory Committee on the Pharmaceuticals and Drug Utilization Programme, Copenhagen, 7-8 April (English) Meeting on AIDS Containment, Graz, 7-9 April (English) Third Consultation on the International Drinking Water Supply and Sanitation Decade in Europe, Izmir (Turkey), 7-10 April (English) Regional Health Development Advisory Council (RHDAC), Copen­ hagen, 14-15 April (English, French, German, Russian) Consultative Group on Programme Development (CGPD), Copen­ hagen, 16-17 April (English, French, German, Russian) Consultative Group on Budgetary Questions (CGBQ), Copenhagen, 17 April (English, French, German, Russian) Workshop on Continuing Training of Operators and Supervisors of Small-scale Sewage Treatment Plants, Nancy, 22-25 April (English, French) Working Group on Health Hazards of Organized Violence, The Hague, 22-25 April (English) Consultation on the Nuclear Reactor Accident at Chernobyl, USSR, Copenhagen, 6 May (English) European Symposium on the Health-promoting School, Peebles (United Kingdom), 12-16 May (English, French) Working Group on Criteria for Evaluation of Care Programmes in Cancer: Interaction with Technology Assessment, Athens, 21-23 May (English) 119 ICP/ADA 519 IRP/APR 216/m33I ICP/RPD 124 ICP/NCD 516 ICP/MPN 022 ICP/HSR 323 ICP/HSR 648 ICP/NCD 025 ICP/COR 129 ICP/CWS 038 ICP/RHB 021 ICP/MPN 501/m01 ICP/HSR 620 ICP/MCH 124 ICP/ADA 010 ICP/PSF 011 120 Working Group on Mental Health Services in Southern Countries of the European Region, Madrid, 25-29 May (English) Consultation on Problems related to Alcohol and Psychoactive Drugs, Edinburgh, 27-30 May (English) Consultation on the Prevention of Occupational Accidents, Copen­ hagen, 29-30 May (English) European University Network for Health for All — Task Force Meet­ ing, Groningen, 29-31 May (English) International Symposium on Tobacco Smoking among Health Pro­ fessionals, Venice, 30-31 May (English) Consultation on Health for All Management in Countries with Plural­ istic Systems, Vienna, 10-11 June (English, French, German) Second Consultative Meeting on the Development of Standards of Nursing Practice, Brussels, 10-13 June (English) Meeting on Health Promotion Indicators, Berne, 16-19 June (English) Meeting of Principal Investigators of the CINDI Programme, Reykjavik, 16-21 June (English) Working Group on Assessment of Radiation Dose Commitments in Europe due to the Chernobyl Accident, Bilthoven (Netherlands), 25- 27 June (English) Consultation Meeting on Mutagenicity and Carcinogenicity of Marine Pollutants, Athens, 25-27 June (English) Consultation on Continuing Care of Disabled People in the Com­ munity, Edinburgh, 25-28 June (English) Consultation on Economic Aspects of the Prevention of Disease and Disability, Copenhagen, 2-4 July (English) Summer Seminar on Health Promotion: Implementation of Health Promotion Policies, Porvoo (Finland), 11-15 August (English) Consultative Meeting on Health Promotion and Birth, Berlin (West), 19-21 August (English) Working Group on the Respective Roles of Primary Health Care and Specialized Services in the Development and Implementation of Pro­ grammes for Problem Drinkers, Oslo, 26-29 August (English) ICP/CWS 056 ICP/DSE 134 ICP/HSR 623 ICP/EXM 026 HUN/HST001 ICP/ORH 111 ICP/EPI 012 ICP/CEH 054 ICP/COR 112 ICP/PSF 017 ICP/CWS 021 ICP/CEH 537/B ICP/IEH 111 ICP/HST 125 I C P /E X M 015 Fourth European Seminar for Leading Public Health Administrators on Health for All by the Year 2000, Newmarket-on-Fergus (Ireland), 26-29 August (English) Working Group on Removal of Nitrates from Drinking-water, Buda­ pest, 2-5 September (English) Consultation on Behavioural Teratogenicity, Copenhagen, 5-6 Sep­ tember (English) Vienna Dialogue on “ Health Policy and Health Promotion — Towards a New Conception of Public Health” , Baden (Austria), 6-11 September (English) Consultation on National Health Policy Development, Copenhagen, 8-9 September (English) International Seminar on the Socioeconomic Aspects of Differential Mortality, Zamardi (Hungary), 9-12 September (English) Working Group on Planning, Implementation and Evaluation of Oral Health Components of Noncommunicable Disease Projects, Kaunas, 9-13 September (English) European Advisory Group on the Expanded Programme on Immuniz­ ation, Copenhagen, 10-12 September (English) Consultation Meeting on Health Effects of Methylmercury in the Med­ iterranean Area, Athens, 15-19 September (English) Consultation on Information Exchange and Collaboration in Health- related Activities in Europe, Copenhagen, 22-24 September (English) Working Group on Preventive Practices in Suicide and Attempted Suicide — Monitoring and Influencing Trends in Suicidal Behaviour, York, 22-26 September (English) Seminar on Water and Sanitation on Small Mediterranean Islands, Palma de Mallorca (Spain), 24-26 September (English, French) Workshop on Evaluation of the Pilot Phase of the Epidemiological Study on the Health Effects of Pesticides, Budapest, 24-26 September (English) Meeting on the Role of Nongovernmental Organizations in the Pro­ motion of Health for All, Copenhagen, 25-26 September (English) Consultation on the Adequacy of Health Care and Consumer Satis­ faction, Ioannina (Greece), 29 September - 3 October (English) 121 ICP/PSF 019 ICP/CEH 599/A ICP/CLR 017 ICP/ADA 535 ICP/ORH 118 ICP/MCH 116 ICP/CVD 111 ICP/EXM 016 ICP/HSR 624 ICP/MAL 012 ICP/HEE 217 ICP/MPN 017 ICP/APR 113 ICP/NCD 030 ICP/HSR 311 122 Consultation on Psychosocial Interventions to Prevent Disability, Sofia, 6-9 October (English) Fifth Steering Committee Meeting on the UNDP-supported Project “ European Cooperation on Environmental Health Aspects of the Con­ trol of Chemicals” , Lodz (Poland), 6-9 October (English) Joint European Medical Research Councils/US National Institutes of Health/WHO Meeting on Transfer of Information, Copenhagen, 7- 8 October (English) Consultation on AIDS among Drug Abusers, Stockholm, 7-9 October (English) Workshop on Formulation of National Goals for Oral Health, Turku, 7-10 October (English) EURO/PAHO Symposium on Appropriate Technology following Birth, Trieste, 7-11 October (English) Working Group on the Non-invasive Diagnosis of Pulmonary Hyper­ tension, Warsaw, 8-11 October (English) Joint Meeting between WHO and National Medical Associations on Health for All in Europe, Vienna, 9-10 October (English, French, German, Russian) Healthy Cities Project: Workshop on Strategies, Gothenburg, 13- 17 October (English) Working Group on Malaria Risk for Travellers, Budapest, 13- 15 October (English) Working Group on the Continuity of Care of the Elderly, Piestany (Czechoslovakia), 13-16 October (English) International Workshop on Scenarios and Methods to Support Long­ term Health Planning, Noordwijk (Netherlands), 14-16 October (English) Steering Committee on Statistical Indicators for Accidents, Berlin, 14-16 October (English) Meeting of Principal Investigators of the ERICA Study, Heidelberg, 16-17 October (English) Joint Meeting of the Liaison Group on the Nursing/Midwifery Pro­ gramme in the European Region, Ljubljana, 20-22 October (English) ICP/OCH 125 ICP/NUT 112 ICP/NCD 032 ICP/NCD 020 ICP/APR 111 ICP/NUT 118 ICP/CEH 028 ICP/CEH 540 ICP/HSR 649 ICP/CEH 038 ICP/ADA 022 ICP/MPN 519 ICP/PHC 314 ICP/CEH 535/A ICP/DSE 112 Fifteenth European Symposium on Clinical Pharmacological Evalu­ ation in Drug Control: Drugs and the Immune System, Schlangenbad (Federal Republic of Germany), 21-24 October (English, German) International Symposium on Man-made Mineral Fibres in the Working Environment, Copenhagen, 28-29 October (English, French, German) Meeting with Health Workers’ Organizations on the WHO Inter­ national Code of Marketing of Breast-milk Substitutes, Copenhagen, 31 October (English) Meeting of the Principal Investigators of the WHO Collaborative Trial on Coronary Heart Diseases, Rome, 6-7 November (English) Meeting of Principal Investigators of the European Hypertension Research Action Programme, Geneva, 10-11 November (English) Meeting of the Forum for the Exchange of Experience on National Accident Control Policies, Budapest, 10-12 November (English) Consultation on Nutrition Surveillance, Copenhagen, 10-12 November (English) Final Meeting on Air Quality Guidelines, Copenhagen, 11-14 Novem­ ber (English) Meeting on Health Effects of Occupational Exposure of Welders to Chromium and Nickel, Lyon, 17-18 November (English) International Conference on Health Promotion — the Move towards a New Public Health, Ottawa (Canada), 17-21 November (English, French) Working Group on the Health Impact and Methods of Control of Irradiated Foods, Neuherberg (Federal Republic of Germany), 17- 21 November (English, German) Consultation on the Influence of Economic and Other Interests in Alcohol Consumption and Related Problems, Dublin, 18-21 November (English) Workshop on Primary Medical Care Financing Systems, Kiel, 24- 28 November (English, German) First Annual Forum on Primary Health Care Development in Southern Europe, Verona (Italy), 25-27 November (English) Consultation on Progress in the WHO Collaborative Study on Lead Neurotoxicity in Children, Düsseldorf, 2-5 December (English) 123 ICP/DSE 127 ICP/IEH 012 ICP/HSR 816 ICP/CEH 555 ICP/CWS 028 ICP/PHC 333 ICP/NUT 122 Meeting of the Advisory Committee of the Drug Utilization Research Group, Barcelona, 8-9 December (English) Consultation on Fund-raising for the European Concerted Action on Tobacco, Copenhagen, 8-9 December (English) Meeting on Intersectoral Action for Health and the Reduction of Health Inequities, Gothenburg, 8-10 December (Nordic languages) Working Group on the Prevention of Acute Chemical Poisonings, Miinster (Federal Republic of Germany), 8-12 December (English) Seminar on Water and Sanitation Problems on Large Mediterranean Islands and in Tourist Coastal Areas, Valetta (Malta), 9-12 December (English) Working Group on Information for Primary Health Care, Kuopio (Finland), 9-12 December (English) Consultation on the Study of Policy with Respect to Use and Regulation of Vitamin and Mineral Supplements in Europe, Oslo, 16-18 December (English) 124 Annex 6 WHO-SPONSORED COURSES IN THE EUROPEAN REGION, OR COURSES RELEVANT TO EURO PROGRAMMES, 1986 International Sanitary Engineering Course (French), Rabat, 15 February 1985 - 30 June 1986 (MOR/RUD 001) International Training Course for Public Health Administrators (Russian), Mos­ cow, 24 September 1985 - 20 June 1986 (ICP/HMD 101/c05) International Training Course for Public Health Administrators (English), Mos­ cow, 24 September 1985 - 20 June 1986 (ICP/HMD lOl/сОб) International Postgraduate Course in Hydraulic Engineering (English), Delft, 23 October 1985 - 12 September 1986 (ICP/RUD 002) Second International CIDESSCO/WHO Course in Malariology (French), Bobo- Dioulasso/Bondy/Paris/Grenoble/Marseille/Bordeaux, 25 November 1985 - 11 April 1986 (ICP/MAL 199/g20) National Course on the Implementation of Cancer Control Programming (Eng­ lish), Opatija (Yugoslavia), 3-8 February 1986 (ICP/CAN 101/c01) International Course on Statistical, Epidemiological and Operational Methods Applied in Medicine and Public Health (English, French), Brussels, 3 February - 30 May 1986 (ICP/HST 131) International Course on the Impact of Water Management Installations on Environmental Health (French), Liège,9-22 February 1986(ICP/RUD001/c02) Ninth Postgraduate Course on Food Microbiology and Hygiene (English), Zeist (Netherlands), 7-26 April 1986 (ICP/FSP 025) European Housing Hygiene Course (English), Geneva, 10-18 April 1986 (ICP/RUD 138) Course on Drug Evaluation (English), Oslo, 21-25 April 1986 (ICP/DSE 124) International Workshop on Occupational Health in Agriculture (English), Sofia, 25 May - 6 June 1986 (ICP/OCH 199/g20) Second International Workshop on Educational Theory in the Health Sciences (French), Bobigny (France), 26-29 May 1986 (ICP/HMD 145) 125 Internat ional C ou r se on Social Ge ro n to lo gy (Engl i sh) , Dubr ovn ik , 26 May - 6 J u n e 1986 ( I C P / H E F ; 199 /g20) Workshop on Diabetes Care as a Model for Primary Health Care (English), Stockholm, 9-11 June 1986 (ICP/NCD 199/g20) Workshop on Advanced Nursing Management for European Nurses (English), Copenhagen, 16-27 June 1986 (ICP/HSR 313) Joint Course in Medical Statistics and Community Medicine (English), London, 16 June - 25 July 1986 (ICP/HST 129) Workshop on Health Exhibitions, Museums and Posters (English, German, Russian), Dresden, 22-27 June 1986 (ICP/IEH 122) WHO Intercountry Travelling Seminar on Research Methodology in Education for the Health Professions (English), Warsaw/Prague/Bratislava/Budapest, 23 June - 12 July 1986 (ICP/HMD 138) Workshop on Health Economics Training (German), Munich, 26-28 June 1986 (ICP/MPN 503/CÛ3) Training Course on HTLV-III Serodiagnosis and Confirmation Tests (English), Berlin (West), 28-30 June 1986 (ICP/CDS 025) BLAT/WHO Ninth Course on Modern Methodology for Teachers of Health Sciences (English), London, 1-18 July 1986 (ICP/HMD 140) Course on Environmental Health Impact Assessment (English), Aberdeen, 6- 19 July 1986 (ICP/RUD 117) Course on Health Aspects of Disaster Preparedness (French), Rabat, 14-18 July 1986 (ICP/COR 003/c02) International Course for Teachers on Statistical, Epidemiological and Op­ erational Methods in Public Health (English), Moscow, 14-26 July 1986 (ICP/HST 132) BLAT/WHO Course on the Management of a Collection of Health Audiovisuals (English), London, 5-21 August 1986 (ICP/HMD 141) Third European Training Course in Quality Assurance (English), Belgrade, 25- 30 August 1986 (ICP/HSR 027) International Seminar on Health Legislation (French), Montpellier, 25 August - 5 September 1986 (ICP/HLE 105/c03) Intercountry Teacher Training Workshop on Natural Methods of Family Plan­ ning in a Non-religious Context (English), Jablonna (Poland), 26-29 August 1986 (ICP/MCH 518) 126 International Environmental Engineering Course (French), Lausanne, Sep­ tember 1986 - June 1987 (ICP/CWS 004) Training Course in Tuberculosis Control Methods (French), Paris/Algiers, 3 September - 16 October 1986 (ICP/CDS 199/g20) Sixth International Course on the Organization and Evaluation of Primary Health Care for Developing Countries (French), Brussels, 9-26 September 1986 (ICP/PHC 324) Second Teacher Training Course in Primary Health Care (French), Lisbon, 15-26 September 1986 (ICP/PHC 324) International Workshop on Health Services Research Methodology (English), Barcelona, 15-27 September 1986 (ICP/RPD 122) International Training Courses for Public Health Administrators (English, Russian), Moscow, 23 September 1986 - 19 June 1987 (ICP/HMD 129 and ICP/HMD 130) International Environmental Engineering Course (English), Ankara, Septem­ ber 1986 - June 1988 (TUR/CWS 002) International Postgraduate Course in Sanitary Engineering (Portuguese), Lisbon, October 1986 - June 1987 (POR/RUD 001) International Sanitary Engineering Course (English), Delft, 1 October 1986 - 30 September 1987 (ICP/CWS 004) International Environmental Engineering Course (French), Rabat, 1 October 1986 - 30 June 1988 (MOR/RUD 001) International Workshop on the Managerial Process for National Health De­ velopment (English), Moscow, 7-18 October 1986 (ICP/MPN 024) National Workshop on Nursing Curriculum Development (English, Slovene), Ljubljana, 13-17 October 1986 (ICP/HSR 330) International Course on the Application of Statistical, Epidemiological and Managerial Methods to Medicine and Public Health (German), Berlin, 13- 23 October 1986 (ICP/HST 135) Training Course on Diagnosis and Treatment of Acute Poisonings (English), Lodz (Poland), 13-24 October 1986 (ICP/CEH 503) International Course on Quality Assurance in Health Care (French), Brussels, 17-21 November 1986 (ICP/HSR ООЗ/сОЗ) Second Workshop on Health Management Training (English), Düsseldorf, 23- 28 November 1986 (ICP/HMD 125) 127 Annex 7 LIST OF WHO COLLABORATING CENTRES WITH WHICH THE REGIONAL OFFICE CONCLUDED PLANS OF ACTION COVERING THE YEAR 1986 Target 1 WHO Collaborating Centre for Research on Social Equity and Health Eastern Health Board, Research Department, Dublin, Ireland Target 4 WHO Collaborating Centre for AIDS Institut de médecine et d’épidémiologie africaine et tropicale, Hôpital Claude Bernard, Paris, France WHO Collaborating Centre for Aging Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA WHO Collaborating Centre for Bacterial Meningitis National Reference Laboratory for Bacterial Meningitis, National Institute of Public Health, Amsterdam, Netherlands WHO Collaborating Centre for Child Dental Health University Hospital, Children’s Clinical Department of Dentistry, Iassy, Romania WHO Collaborating Centre for the Coordination and Standardization of Clinical Immuno­ logical Research Faculty of Immunology, Pirogov Second Moscow State Medical Institute, Moscow, USSR WHO Collaborating Centre for Dental Education Department of Community Dental Health, Preventive Dentistry and General Practice, University of Dublin, Ireland WHO Collaborating Centre for Epidemiological Surveillance of the Trans-Saharan High­ way with regard to Vectors Institut français de recherche scientifique pour le développement en coopération (ORSTOM), Paris, France 128 WHO Collaborating Centre for Health Care of the Elderly National Research Institute for Gerontology and Geriatric Medicine, University of Mel­ bourne, Australia WHO Collaborating Centre for Health and Disease Surveillance Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanità, Rome, Italy WHO Collaborating Centre for Health of the Elderly Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan WHO Collaborating Centre for Joint Cooperation on Research on Care of the Aged National Institute on Aging, National Institutes of Health, Bethesda, MD, USA WHO Collaborating Centre for Legionellosis Laboratoire national de la santé, Lyon, France WHO Collaborating Centre for Legionellosis National Bacteriological Laboratory, Stockholm, Sweden WHO Collaborating Centre for Oral Disease Prevention Sektion Stomatologie, Medizinische Akademie, Erfurt, German Democratic Republic WHO Collaborating Centre for Reference and Research on Rapid Diagnosis of Viral Infections and Acute Respiratory Infections Ministry of Health and Consumer Affairs, Madrid, Spain WHO Collaborating Centre for Reference and Research on Viral Hepatitis Max-von-Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Fed­ eral Republic of Germany WHO Collaborating Centre for Research on Aging Institute of Gerontology of the Academy of Medical Sciences of the USSR, Kiev, USSR WHO Collaborating Centre for Research on Care of the Aged Brookdale Institute of Gerontology and Adult Human Development, Jerusalem, Israel WHO Collaborating Centre for Zoonoses Central Research Institute of Epidemiology of the USSR Ministry of Health, Moscow, USSR Target 7 WHO Collaborating Centre for Perinatal Studies in Europe Institute of Child Health, Aghia Sophia Children’s Hospital, Athens, Greece 129 Target 9 WHO Collaborating Centre for Development of Appropriate Technology in the Control of Diabetes Mellitus Institute for Diabetes, Endocrinology and Metabolic Diseases “ Vuk Vrhovac” , Medical Faculty, University of Zagreb, Yugoslavia WHO Collaborating Centre for Research and Training in Cardiovascular Diseases Laboratoire de recherches cardiologiques. Faculté de médecine et de pharmacie, Université libre de Bruxelles, Belgium WHO Collaborating Centre for Research and Training in Cardiovascular Diseases Institute of Cardiovascular Diseases of the Medical Academy, Sofia, Bulgaria WHO Collaborating Centre for Research and Training in Cardiovascular Diseases Central Institute for Cardiovascular Research of the Academy of Sciences of the German Democratic Republic, Berlin, German Democratic Republic WHO Collaborating Centre for Research and Training in Cardiovascular Diseases Abteilung Klinische Sozialmedizin, Klinikum der Universität Heidelberg, Federal Republic of Germany Target 10 WHO Collaborating Centre for Detection Methodology and Training in Cancer Control National Institute of Oncology, Budapest, Hungary WHO Collaborating Centre for Technology Assessment in Cancer Control Zentralinstitut für Krebsforschung, Robert-Rössle-Institut, Berlin-Buch, German Demo­ cratic Republic Target 11 WHO Collaborating Centre for the Prevention of Road Traffic Accidents Transport and Road Research Laboratory, Department of the Environment and Depart­ ment of Transport, Crowthorne, United Kingdom Target 13 WHO Collaborating Centre for Health Education Bundeszentrale für Gesundheitliche Aufklärung, Cologne, Federal Republic of Germany WHO Collaborating Centre for Health Education and Health Promotion Research Scottish Health Education Group, Edinburgh, United Kingdom 130 Target 15 WHO Collaborating Centre for Health Education Deutsches Hygienemuseum, Dresden, German Democratic Republic WHO Collaborating Centre for the Promotion of Family Health/Family Planning National Research Institute for Mother and Child, Warsaw, Poland WHO Collaborating Centre for Teaching and Research in Human Reproduction and Family Planning Centre national de reproduction humaine et de planning familiale, Rabat, Morocco Target 18 WHO Collaborating Centre for Health and Disease Surveillance Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanità, Rome, Italy WHO Collaborating Centre for Risk Management in Chemical Safety International Institute for Scientific Cooperation (IISC), University of Ulm, Schloß Reisens- burg, Federal Republic of Germany WHO Collaborating Centre for Rural Sanitation and Waste Disposal Centre national du machinisme agricole, du génie rural, des eaux et des forêts (CEM AGREF), Paris, France Target 19 WHO Collaborating Centre for Health Effects of Exposure to Lead Medizinisches Institut für Umwelthygiene (MIU) an der Universität Düsseldorf, Federal Republic of Germany WHO Collaborating Centre for the Training and Utilization of Environmental Health Officers Department of Public Health and Environmental Studies, Umeâ University, Sweden Target 20 WHO Collaborating Centre for Drinking-water and Water Pollution Control Water Research Centre, Medmenham, United Kingdom 131 WHO Collaborating Centre for Primary Health Care Department of Public Health Administration and Social Hygiene, Institute for Research on Regional Pathology, Ministry of Health of the Kazakh SSR, Alma-Ata, USSR WHO Collaborating Centre for Water Resources Protection Research Centre for Water Resources Development, Budapest, Hungary Target 21 WHO Collaborating Centre for Air Quality Management and Air Pollution Control Institute for Water, Soil and Air Hygiene, Langen Centre, Langen, Federal Republic of Germany Target 26 WHO Collaborating Centre for Primary Health Care Andrija Stampar School of Public Health, Zagreb, Yugoslavia Target 27 WHO Collaborating Centre for Health Economics SAGO Research Institute for Health Service Organization, Milan and Florence, Italy WHO Collaborating Centre for Hospitals German Hospital Institute, Düsseldorf, Federal Republic of Germany WHO Collaborating Centre for Primary Health Care Universities of Tampere and Kuopio, Finland Target 29 WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Hôpital Saint-Raphael, Université catholique de Louvain, Belgium WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Danish Institute for Health and Nursing Research, Copenhagen, Denmark WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Nursing Research Institute, Helsinki, Finland 132 WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Hospices civils de Lyon, France WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Faculty of Nursing, Medical Academy, Lublin, Poland WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Department of Nursing Studies, University of Edinburgh, United Kingdom WHO Collaborating Centre for the Medium-term Programme in Nursing/Midwifery in Europe Department of Nursing, University of Manchester, United Kingdom WHO Collaborating Centre for Primary Health Care National School of Public Health, Lisbon, Portugal Target 31 WHO Collaborating Centre for Primary Health Care Nursing Public Health Nursing Service, Maribor, Yugoslavia Target 32 WHO Collaborating Centre for Community Medicine Centre coopératif d’études et de recherches “ De la santé de la famille à la santé communau­ taire” , Nancy, France WHO Collaborating Centre for Public Health Research Institut für Gesundheits-System-Forschung, Kiel, Federal Republic of Germany Target 33 WHO Collaborating Centre for Health Development and Technical Cooperation among Developing Countries Centre for Health Cooperation with Non-Aligned and Developing Countries, Zagreb, Yugoslavia Target 34 WHO Collaborating Centre for Health Planning and Economics Institut für Medizinische Informatik und Systemforschung (MEDIS), Munich, Federal Republic of Germany WHO Collaborating Centre for the Managerial Process for National Health Development Department of Community Medicine, Usher Institute, Edinburgh, United Kingdom WHO Collaborating Centre for the Managerial Process for National Health Development Nuffield Centre for Health Services Studies, School of Medicine, University of Leeds, United Kingdom Target 35 WHO Collaborating Centre for Health and Biomedical Documentation Institut für Wissenschaftsinformation in der Medizin, Berlin, German Democratic Republic WHO Collaborating Centre for Health Information Computer Centre of the Ministry of Health of the Latvian SSR, Riga, USSR WHO Collaborating Centre for Health Situation Analysis Department of Epidemiology and Health Programming, National Research Institute of Mother and Child, Warsaw, Poland WHO Collaborating Centre for Medical Information Centre interuniversitaire de traitement de l’information 2 des universités de Paris (CITI 2), France WHO Collaborating Centre for Medical Information and Data Processing Data Processing Centre (UDAC), University of Uppsala, Sweden Target 36 WHO Collaborating Centre for Health Management and Human Resources Central Institute for Advanced Medical Studies (CIAMS), Moscow, USSR WHO Collaborating Centre for Health Manpower Development British Life Assurance Trust (BLAT) Centre for Health and Medical Education, London, United Kingdom WHO Collaborating Centre for Health Manpower Information Statistics Centre de sociologie et de démographie médicales (CSDM), Paris, France 134 Target 38 WHO Collaborating Centre for the Development of Research for Blood Transfusion Services Haematology and Blood Transfusion Centre, Bucharest, Romania WHO Collaborating Centre for Drug Assessment Pharmacological Committee of the All-Union Ministry of Health of the USSR, Moscow, USSR WHO Collaborating Centre for Drug Information and Quality Assurance National Institute of Pharmacy, Budapest, Hungary WHO Collaborating Centre for Drug Statistics Methodology Norwegian Medicinal Depot, Oslo, Norway WHO Collaborating Centre for Fundamental and Applied Immunology Institute of Immunology, Academy of Medical Sciences of the USSR, Moscow, USSR 135 1 2 3 4 5 6 7 8 9 10 1 1 1 2 1 3 1 4 1 5 16 1 7 18 1 9 20 Annex 8 ACTIVITIES" IN 1986 IN COUNTRIES WITH MEDIUM-TERM PROGRAMMES BY REGIONAL TARGET C o u n t ry B U L D D R G R E H U N IS R M A T P O R R O M S P A S S R 21 X X 2 22 0 23 0 24 X 1 25 X X X 3 26 X X X X 4 27 X X X X X X X 7 28 X X 2 29 X 1 30 0 31 X X 2 32 X X X 3 33 X X X X 4 34 X X X X X X 6 35 X X X X X X 6 36 X X X X X X X 7 37 0 38 X X X X X X X 7 No. of targets covered (out of 38) 10 16 10 19 9 9 18 7 1 7 12 a It should be noted that a considerable amount of work towards the HFA targets was also done in countr ies that do not have formal medium-term programmes of cooperation with the Regional Office INDEX Main references by subject are in bold type. Abortion, 2.90 Accident prevention, 2.111-2.120, 6.1, 6.17 global programme, 7.1-7.11 Acquired immunodeficiency syndrome (AIDS), 2.35, 2.38-2.47, 6.9, 6.15, 6.16 Acute respiratory infections, 2.33, 2.37 Adolescents and young people, 3.21, 3.29, 3.40 Aging, see Elderly, health of AIDS, see Acquired immunodeficiency syndrome Air pollution, 4.55-4.57 Albania, cancer, 2.110 diarrhoeal diseases, 2.48 immunization, 2.69. 2.70 maternal and child health, 3.26 Alcohol abuse, 2.114, 3.61-3.64, 5.34 Appropriate technology for health, cancer, 2.106 global programme, 7.12-7.21 maternal and child health, 2.85, 2.88, 2.91, 2.94 oral health, 2.66 quality assurance, 5.41 see a lso Health technology assessment Association for Dental Education in Europe, 2.57 Association of Medical Deans in Europe, 6.38 Association for Medical Education in Europe, 6.38 Association of Paediatric Education in Europe, 3.30 Association of Schools of Public Health in the European Region, 6.38, 6.41 Australia, 7.7, 7.11 Austria, AIDS, 2.39 country programme coordination, 1.10 health promotion, 3.8 hospitals, 5.27 maternal and child health, 2.88 noncommunicable diseases, 2.102 nursing, 5.32 primary health care, 5.9 sexuality and family planning, 3.15 Basic Radiological System (BRS), 7.19 Belgium, accident prevention, 7.11 coronary heart disease, 2.97 environmental health, 4.2, 4.28 family planning, 3.34 health manpower, 6.45 hospitals, 5.27 housing, 4.61 infectious diseases, 2.68 mental health, 2.30 nursing, 5.26, 5.28, 5.43 primary health care, 5.5, 5.16 quality assurance, 5.39 self-help, 3.12 Beso in s spécifiques des m igrants en m atière de p lan ifica tion fa m ilia le , 3.24 Blood donors, 2.40 Brazil, 7.5, 7.9 Breastfeeding. 3.50 139 Breast-milk, 3.51, 4.13 Budget and finance, 1.25-1.28 Bulgaria, country programme coordination, 1.15 human reproduction, 3.27, 3.28 immunization, 2.70, 2.76 mental health, 3.55 nursing, 5.45 primary health care, 5.9 Burn injuries, 7.7, 7.8, 7.11 Campylobacteriosis, 2.35 Canada, accident prevention, 7.5, 7.11 health behaviour research, 3.56 health promotion, 3.9, 7.26 man-made mineral fibres, 4.65 maternal and child health, 2.86, 2.87 nonionizing radiation, 4.16 nursing, 5.21, 5.43 suicide, 2.126 Cancer, 2.104-2.110, 5.44, 6.15 Cardiovascular diseases, 1.17, 2.32, 2.95-2.103 C are o f ch ildren in hospital. 1.34 CCCCP, see Comprehensive Community Cardiovascular Control Programmes CE, see Council of Europe CEC, see Commission of the European Communities Chemical hazards, 4.8-4.14, 4.57, 4.60, 4.71, 6.14, 6.54, 8.13 see a lso Water supply and sanitation Child abuse, 3.65 Children’s health, accident prevention, 7.7, 7.10 disability, 2.23 health education, 3.19-3.21, 3.60 immunization, 2.72 infant feeding, 3.50, 3.51 life expectancy at birth, 2.83 mental health, 2.28 oral health, 2.60 poisoning, 2.117, 4.11 sexual abuse, 3.65 toxic substances, 4.9 see a lso Maternal and child health Chile, 7.9 China, 4.16,6.11 Chronic diseases, 2.95, 3.49 CINDI, See Countrywide !!.: noncommunicable disease ink p cntion programme C M E A , see Council for Mutual Economic Assistance Collaborating centres, 1.31,2.35, 2.45,2.95, 2.109, 3.17,4.27,5.7,6.25 Collaboration with other organizations, 2.124, 6.12-6.21, 6.54, 8.5 see a lso under names of individual organizations Colombia, 7.26 Commission of the European Communities, 6.12, 6.16, 6.20 accident prevention, 2.117, 2.119, 7.6 cancer, 2.108 environmental health, 4.4, 4.18 health education, 3.21, 3.60, 6.15 health legislation, 2.16, 6.7 health technology, 6.67 medical librarians, 6.34 mental health, 2.30 research, 6.3 Communicable diseases, 2.32-2.47, 2.49, 6.9 see also Immunization 0 Community Periodontal Index of Treatment Needs, 2.59 Comprehensive Community Cardiovascular Control Programmes, 2.100 Congo, 2.121 Consultative Group on Budgetary Questions, 1.6 Consultative Group on Programme Development, 1.6 Contingency plan, 1.6, 1.25 Convention on Long-range Transboundary Air Pollution, 4.56 Coronary heart disease, see Cardiovascular diseases Côte d’Ivoire, 7.5 Council of Europe, 2.16, 2.47, 2.108, 3.21, 3.60, 5.35,6.12, 6.15 Council for Mutual Economic Assistance, 6.17 Country programme coordination, 1.9, 1.10-1.16, 1.22, 6.5, 8.3, 8.6, 8.10 Countrywide integrated noncommunicable disease intervention (CINDI) programme, 2.24, 2.100, 3.49 Cuba, 7.5, 7.9, 7.24 Cyprus, communicable disease control, 2.50 140 Czechoslovakia, child health, 2.89 country programme coordination, 1.10 disability, 2.23, 5.33 environmental health, 4.8 epidemiology and statistics, 6.32 health manpower, 6.46 hospitals, 5.14, 5.27 immunization, 2.70, 2.76 water supply and sanitation, 4.29 Data bases, 6.35, 6.37, 6.61 see a lso Information systems Data processing, 6.10 Denmark, accident prevention, 7.7, 7.11 Danish Red Cross, 2.3, 6.12 hospitals, 5.27 immunization, 2.69 maternal and child health, 2.92, 2.94, 3.26 nursing and midwifery, 5.6, 5.19 nutrition, 3.47 oral health, 2.55, 2.66 primary health care, 5.16 publications, 8.11 stroke, 2.101 suicide, 2.126 water supply and sanitation, 4.30 welding fumes, 1.36 Diarrhoeal diseases, 2.48-2.51, 4.46 Diphtheria, 2.67, 2.70 Disability, 1.40, 2.12, 2.14, 2.15, 2.23, 3.41, 3.55, 5.33, 6.1, 6.15 see a lso Rehabilitation, community-based Disaster preparedness, 2.121-2.125 Disease prevention and control, 1.14, 2.24 Drug abuse, 2.44, 2.46, 2.114, 3.11, 3.13, 3.58-3.60, 5.35, 6.15 Drugs, regulatory agencies, 6.69, 6.70, 6.78 utilization, 6.74, 6.75, 6.76, 7.21 EC, see European Communities ECE, see United Nations Economic Commission for Europe Ecuador, 3.34 EEC, see European Economic Community Egypt, 4.53 Elderly, accident prevention, 4.11, 6.17, 7.7 global programme, 7.22-7.27 health of, 2.9-2.13, 5.14, 6.1, 6.15 health legislation, 6.8 Elderly (contd) health promotion, 3.66 mental health, 2.28 nursing, 5.32, 5.33 Emergency services, 2.123, 2.125, 2.126 E n tre nous, 3.32, 3.43 Environmental health, 1.2, 1.14, 1.40, 4.1-4.71, 6.14, 6.28, 6.54, 6.55 planning and management, 2.12, 3.1, 3.3 programme evaluation, 4.68-4.71 Epidemiology and statistics, 1.40-1.43, 6.28-6.32, 6.75 accident prevention, 2.111, 2.113, 2.119 alcohol abuse, 3.61 cancer, 2.108 chemical hazards, 4.8 elderly, 7.24, 7.25, 7.27 mortality trends, 2.84 oral health, 2.55, 2.61 suicide, 2.126 Equatorial Guinea, 3.43 Equity, 1.40, 2.14 ERICA, see European risk factors and incidence — a collaborative analysis Ethiopia, 2.121 Ethnic minorities, 2.6 European Advisory Committee on Health Research, 2.127, 3.59, 3.66, 4.70, 6.1, 6.83, 8.1, 8.3 European Association of Poison Control Centres, 2.117 European Association of Programmes in Health Services Studies, 5.19, 6.3, 6.25 European Centre for Social Welfare Training and Research, 2.4, 3.15, 6.20 European Collaborative Health Services Studies Group, 5.11 European Communities, 4.4, 6.7, 7.5 European Economic Community, 2.47, 2.56, 3.22, 3.49, 5.26 European League Against Rheumatism (EULAR), 2.27 European Medical Research Councils, 6.3, 6.67 European nonsmoking day, 1.18 European Parliament, 3.51 European risk factors and incidence — a collaborative analysis, 2.96 141 European Society of Human Reproduction and Embryology, 3.14 European Society of Medical Sociologists, 2.8 Euthanasia, 6.11 Expanded Programme on Immunization (EPI), 2.50, 2.67-2.79 Family planning, see Sexuality and family planning FAO, see Food and Agriculture Organization of the United Nations Federation of European Nutrition Societies, 3.49 Fellowships, 3.28, 4.51, 5.7, 6.50-6.53 Finland, alcohol abuse, 3.61, 3.62 cardiovascular diseases, 2.100, 2.101 chemical hazards, 4.13 country programme coordination, 1.15 epidemiology and statistics, 6.32 health manpower, 6.45 health promotion, 3.3, 3.7 health service delivery, 5.14 health technology, 6.66 immunization, 2.69, 2.70 nursing, 5.21, 5.43, 5.46 primary health care, 5.1, 5.13, 5.16 quality assurance, 5.38, 5.40 rehabilitation, community-based, 2.21 research, 6.2 water supply and sanitation, 4.31 Food and Agriculture Organization of the United Nations, 4.2, 4.18, 4.24, 4.53, 4.59 Foodborne infections, 2.33, 2.35, 4.59 Food safety, 2.35, 4.58-4.59, 6.14, 6.15 France, accident prevention, 7.6, 7.11 AIDS, 2.35, 2.42, 2.47 alcohol abuse, 3.61, 3.63 health legislation, 6.27 health manpower, 6.37, 6.43, 6.45, 6.47 health technology, 6.66 hospitals, 5.14, 5.27 infectious diseases, 2.68 ionizing radiation, 4.20 maternal and child health, 3.26 mental health, 2.30 migrants, 2.5 nursing/midwifery, 5.8, 5.26, 5.28 oral health, 2.62, 6.7 primary health care, 5.1, 5.13, 5.16 publications, 1.36 France (contd) quality assurance, 1.36,5.39 sexuality and family planning, 3.24, 3.30, 3.33, 3.42 smoking, 3.53 water supply and sanitation, 4.27, 4.32, 4.53 Funds-in-Trust, 1.28 Genetic services, 2.25-2.26 German Democratic Republic, biomedical information, 6.34 cancer control, 2.108, 2.109, 2.110 country programme coordination, 1.11, 1.15 drinking-water, 4.33 epidemiology and statistics, 6.32 health education, 3.23 health promotion, 3.9 hospitals, 5.27 immunization, 2.70, 2.76 oral health, 2.59 primary health care, 5.16 Germany, Federal Republic of, AIDS, 2.47 alcohol abuse, 3.61 cardiovascular diseases, 2.96, 2.100 country programme coordination, 1.10 data bases, 6.35 environmental health, 4.9, 4.11 epidemiology and statistics, 6.32 food safety, 2.35, 4.58 health manpower, 6.41 hepatitis, 2.35 hospitals, 5.13, 5.24, 5.27, 5.31 maternal and child health, 3.26 migrants, 2.5 nursing, 5.20, 5.28 poisoning, 2.117 research, 6.4, 6.24 sexuality and family planning, 3.15 water supply and sanitation, 4.34 Gerontology, see Elderly, health of Global Advisory Committee on Health Research, 7.27 Global Environmental Monitoring System (GEMS), 4.22 Greece, accident prevention, 2.115 air pollution, 4.57 country programme coordination, 1.11, 1.15 diarrhoeal diseases, 2.51 health manpower, 6.45 health service delivery, 5.15, 5.28, 5.44 immunization, 2.50, 2.76 142 Greece (contd) maternal and child health, 2.88, 2.91 nursing, 5.45 primary health care, 5.1, 5.9 water supply and sanitation, 4.35, 4.53 G uidelines on A ID S , 1.34 H aem ophilus in fluenzae infection, 2.67, 2.74 H aving a baby in Eu rope , 2.86, 2.87, 2.88, 2.91 H ea lth and b iom edica l in fo rm ation in Eu rope , 6.30 Health care, planning, 5.12 systems and services, 1.14, 2.130, 5.1, 5.10, 6.8, 6.31,6.73,7.12 workers, 2.29, 5.17-5.22 Health development support, 1.14 Health economics, 1.31, 2.24, 5.31, 5.42, 5.44, 6.23, 6.24, 6.26 programme evaluation, 6.82-6.83 Health education, 3.16-3.23 accident prevention, 2.112 AIDS, 2.39 diarrhoeal diseases, 2.48 drug abuse, 3.60, 6.15 family health, 3.30 immunization, 2.78 oral health, 2.130 programme evaluation, 3.66-3.68 schoolchildren, 3.21, 3.60 smoking, 3.52 Health for all by the year 2000, passim data base, 1.42 disability, 2.17 evaluation of progress, 1.2, 1.7, 1.40, 1.43, 6.28, 8.3, 8.8, 8.9 fellowships, 6.52 health legislation, 6.27 immunization, 2.79 nursing, 5.20-5.23, 5.46 oral health, 2.54 policies and strategies, 1.3, 1.7, 1.10, 1.13, 1.39, 1.41,5.4, 6.5, 6.6, 6.23,6.36, 8.4 promotional campaign, 1.2, 1.17, 1.18, 1.30, 1.38, 6.54 research action plan, 1.2, 6.1 H ealth hazards and b io log ica l e ffe c ts o f welding fu m es and gases, 1.36 Health information of the public, 1.17-1.19, 1.30 Health laboratories, 7.18, 7.20 Health legislation, 2.14-2.19, 6.11, 6.27 AIDS, 6.9 elderly, 6.8 Health legislation (contd) information system, 1.32, 6.10 oral health, 6.7 Health manpower, 1.31, 5.7, 6.36-6.49 AIDS, 2.44, 2.47 cancer, 2.109 family planning, 3.25, 3.29, 3.30,3.35,3.37,3.38 health planning and management, 6.25 health promotion, 5.34 medical education, 5.42 mental health, 2.29 oral health, 2.61, 2.64, 6.7 primary health care, 5.4, 5.5, 5.18 quality assurance, 5.39 research, 6.1 smoking, 3.53 Health planning and management, 2.12, 3.1, 3.3, 6.22, 6.23, 6.25, 6.41 Health policy, 1.7, 1.10, 3.8, 3.10, 3.11, 3.47, 6.5,6.6,7.14,8.5 H ea lth p ro jections in Eu ro pe : m ethods and applications, 1.34, 6.30 Health promotion, 3.1-3.10, 3.16-3.23, 3.66, 6.28, 8.10 alcohol abuse, 5.34 elderly, 7.26 maternal and child health, 2.85, 2.88, 2.93 research, 3.56, 3.57 smoking, 3.53 training, 3.22, 3.66 H ea lth p rom otion , 3.4 Health services, delivery, 2.6, 5.14-5.16, 6.15 development, 6.23, 6.55 research, 6.3, 6.4 see a lso Hospitals and Nursing/midwifery Health technology assessment, 6.56-6.67 see a lso Appropriate technology for health “Healthy Cities”, 3.1-3.3, 4.63, 6.5, 8.13 Hepatitis, 2.35, 2.36, 2.67, 2.74 Herpes, 2.67 Holy See, 1.12 Hospitals, infection control, 7.20 infrastructure, 5.14, 5.24-5.31 role in PHC, 5.9-5.13, 5.15 Housing, 4.61-4.64, 6.1, 6.8 Human ecology, 4.61, 4.62 Human reproduction, 2.26, 3.14, 3.27, 3.28, 3.29, 3.42, 6.11 Human rights, 2.3 143 Hungary, accident prevention, 2.113 alcohol abuse, 3.64 cancer conrol, 2.109, 2.110 chemical hazards, 4.10 country programme coordination, 1.11, 1.15 epidemiology and statistics, 6.32 family planning, 3.34 health manpower, 6.43, 6.46 hospitals, 5.27, 5.28, 5.29 hypertension research, 2.98 infectious diseases, 2.68, 2.70, 2.71 malaria, 2.80 mortality trends, 2.84 nursing, 5.45 nutrition, 3.47 oral health, 2.62 primary health care, 5.16 water supply and sanitation, 4.27, 4.36 Hypercholesterolaemia, 2.96 Hypertension, see Cardiovascular diseases IAEA, see International Atomic Energy Agency IARC, see International Agency for Research on Cancer Iceland, accident prevention, 2.112 cardiovascular diseases, 2.100 country programme coordination, 1.10 elderly, 7.24 health policy, 1.10 immunization, 2.69 ILO, see International Labour Organisation Immunization, 1.17, 2.50, 2.67-2.82 India, 7.5, 7.8, 7.11, 7.26 Indonesia, 6.32, 7.5 Inequities, see Social equity and health Infectious diseases, see Communicable diseases Infertility, see Human reproduction Information systems, 1.41, 6.33-6.35, 6.58 AIDS, 2.47 health legislation, 1.32, 6.10 immunization, 2.68, 2.78 nursing/midwifery, 2.86, 5.7 oral health, 2.52 Intergovernmental organizations, 1.4, 2.16, 4.55, 6.13,6.17 International Agency for Research on Cancer, 4.9, 4.53,4.65,6.12 International Association for Suicide Prevention, 2.126 International Atomic Energy Agency, 4.18, 4.19, 4.53, 6.14 International Center of Social Gerontology, 7.11 International Children’s Centre, 3.33, 6.12 International Classification of Impairments, Disabilities and Handicaps, 2.22 International Code of Marketing of Breast-milk Substitutes, 3.51 International Committee of Catholic Nurses, 5.8, 5.23 International Council on Alcohol and Addictions, 3.58, 3.64 International Council of Nurses, 5.23 International Dental Federation, 2.55 International Drinking Water Supply and Sanitation Decade, 2.123, 2.124, 4.21, 6.14 see a lso Water supply and sanitation International Epidemiological Association, 2.19 International Federation of Gynaecology and Obstetrics, 3.14 International Federation of National Societies of Automotive Engineers, 2.116 International Federation of Telephonic Emergency Services, 2.126 International Hospital Federation, 5.12 International Labour Organisation, 2.16, 4.67 International Oceanographic Foundation, 4.53 International Paediatric Association, 7.9 International Planned Parenthood Federation, 3.44 International Programme on Chemical Safety, 2.117, 4.11 International Society for Burn Injuries, 7.11 International Society for Prosthetics and Orthodontics, 6.20 International Sociological Association, 2.8 International Union for Health Education, 3.16 International Union of Nutritional Sciences, 3.49 International Union of Pharmacology, 6.81 International Working Group on Medical Device Testing, 6.60 International Year for Peace, 6.21 In vestiga tin g p ra c tice s in health m anpower planning, 1.34, 6.40 IPPF, see International Planned Parenthood Federation Ireland, alcohol abuse, 3.62 health education, 3.18 144 Ireland (contd) health policy, 1.10, 6.5 nutrition, 3.48 primary health care, 5.9 quality assurance, 5.38 social equity and health, 2.4 water supply and sanitation, 4.37 Israel, country programme coordination, 1.11, 1.15 health manpower, 6.48 health policy development, 1.10, 6.5 hospitals, 5.24 immunization, 2.70 noncommunicable diseases, 2.103 nursing, 5.45 primary health care, 5.13, 5.16 water supply and sanitation, 4.38, 4.53 Italy, accident prevention, 2.115 coronary heart disease, 2.97 country programme coordination, 1.15 environmental health, 4.3, 4.5, 4.13, 4.35, 4.53, 4.58 health manpower, 6.43, 6.49 health policy, 1.10 health technology, 6.66, 7.20 infectious diseases, 2.35, 2.68, 2.70 nutrition, 3.48 occupational health, 4.64 primary health care, 5.1, 5.2, 5.13 publications, 8.11 quality assurance, 5.38 smoking, 3.53 Jamaica, 3.34 Japan, 3.9 Joint European Medical Research Board, 4.65 Jordan, 7.26 Kenya, 7.5 La Réunion, 7.26 League of Red Cross and Red Crescent Societies, 2.124, 6.12 Legionellosis, 2.35 Life expectancy, 2.83-2.84 Lifestyles, 1.2, 1.14, 1.40,3.16,3.20,3.67, 6.55, 8.5 Luxembourg, nursing, 5.26 Malaria, 2.80-2.81 Malaysia, 7.5 Malta, country programme coordination, 1.15 health education, 3.18 health policy, 1.10, 6.5 health services, 6.23 immunization, 2.76 nursing, 5.45 nutrition,3.47 oral health, 2.64 pharmaceuticals, 6.72 primary health care, 5.2 water supply and sanitation, 4.22, 4.35 Man-made mineral fibres, 4.65, 4.66 Maternal and child health, 2.26, 2.85-2.94, 3.26, 3.45, 3.50, 6.76 see a lso Children’s health and Sexuality and family planning Mauritius, 7.26 Measles, 2.67, 2.68, 2.70, 2.74 Medical associations, 1.5 Medical technology, see Health Technology assessment Mediterranean Action Plan, 4.49-4.54, 6.14, 6.54 feature on, between pages 74 and 75 Mental health, 2.5, 2.28-2.31, 3.55, 6.28, 7.27 Mexico, 3.34 Midwives, see Nursing/midwifery Migrants, 2.5, 2.30, 3.33 M ig ra tion and health — tow ards an understanding o f the health care needs o f ethn ic m inorities, 1.34, 2.6 Model health care and quality assurance, 1.36, 5.38-5.44, 6.58 Monitoring trends in cardiovascular diseases (MONICA), 2.95 Morocco, accident prevention, 2.111 disaster preparedness, 2.122 environmental health, 4.7, 4.53 epidemiology and statistics, 6.32 family planning, 3.35 noncommunicable diseases, 2.103 oral health, 2.64 primary health care, 6.23 transfer to the Eastern Mediterranean Region, 1.1, 1.10, 1.22 water supply and sanitation, 4.24, 4.26, 4.27 Mortality, chemical hazards, 4.9 global estimates, 2.32 145 Mortality (contd) infant and maternal, 2.48, 2.87, 2.90 smoking, 3.54 trends, 2.84, 6.29 Mumps, 2.67, 2.68, 2.69, 2.74 Neoplasms, 2.32 Nepal, 7.8 Netherlands, alcohol abuse, 3.61 cancer, 2.108 child health, 2.89, 3.45 domestic accidents, 2.120 fellowships, 3.28 health planning, 6.22 health policy development, 1.10, 6.5 health promotion, 3.3 health service delivery, 5.14 health technology, 6.61, 6.65, 6.66 hospitals, 5.24, 5.27 immunization, 2.69, 2.70 ionizing radiation, 4.18 mental health, 2.31 nutrition, 3.48 organized violence, 2.3 pharmaceuticals, 6.77 primary health care, 5.1, 5.13, 5.16 publications, 1.36, 6.30 quality assurance, 5.38, 5.42, 5.43 research, 6.4 water supply and sanitation, 4.27, 4.39 Noncommunicable diseases, 2.24, 2.27, 2.54, 2.61, 2.102, 2.103 Nongovernmental organizations, 1.4, 2.16, 2.18, 2.88, 2.89, 2.92, 3.16, 4.55, 5.7, 6.13, 6.19, 6.20, 6.36, 7.9-7.11, 7.18, 7.28 Nordic College of Caring Science, 2.8 Nordic Council, 2.108, 6.12, 6.18 Nordic School of Public Health, 2.7, 2.41, 2.47, 3.3 Norway, chemical hazards, 4.13 epidemiology and statistics, 6.32 health policy development, 1.10, 6.5 immunization, 2.69 nursing, 5.43 pharmaceuticals, 6.78 primary health care, 5.9 water supply and sanitation, 4.40 Nuclear energy, see Radiation N uclear pow er: a cc iden ta l re leases — p ra c tica l guidance f o r p u b lic health action , 4.20 Nursing/midwifery, 5.3, S.6-5.8, 5.17, 5.19, 5.26, 5.28, 5.36, 5.43, 5.45 elderly, 5.32, 5.33 information system, 2.86 targets for HFA, 5.20-5.23, 5.46 Nutrition, 3.46-3.51, 6.28, 6.68, 7.27 Obesity, 2.96 Occupational health, 2.107, 4.10, 4.13, 4.64-4.67 OECD, see Organisation for Economic Co-operation and Development Oral health, 2.52-2.66 legislation, 6.7 programme evaluation, 2.127-2.130 research, 6.1 tooth implantation, 6.64 training, 6.7 Oral rehydration therapy, 2.48 Organisation for Economic Co-operation and Development, 2.119, 4.19, 6.12, 6.17, 7.4 Organization of European Cancer Institutes, 2.108 Peace, 6.15, 6.21 P erin a ta l health serv ices in Europe , 1.36 Personnel, 1.20-1.22 Pertussis, 2.67, 2.70, 2.74 Peru, 3.34 Pesticides, 2.117, 4.10, 4.14, 4.64, 6.15 Pharmaceuticals, 3.48, 6.15, 6.63, 6.68-6.81, 7.21 Philippines, 7.5 Pneumonia and pneumococcal infection, 2.33, 2.37, 2.67 Poisoning, 2.117-2.118, 4.10, 4.11, 7.7 Poland, cancer, 2.110 coronary heart disease, 2.97 country programme coordination, 1.15 environmental health, 4.5, 4.8 epidemiology and statistics, 6.29 health manpower, 6.46 infectious diseases, 2.68, 2.70 nutrition, 3.48 primary health care, 5.1, 5.16 sexuality and family planning, 3.25, 3.30, 3.32 smoking, 3.52 water supply and sanitation, 4.41, 4.53 Poliomyelitis, 2.67, 2.70 Portugal, alcohol abuse, 3.63 country programme coordination, 1.11, 1.15 146 Portugal (contd) epidemiology and statistics, 6.32 health manpower, 6.42, 6.45 health policy, 1.10 health promotion, 3.2 health technology, 6.66 hospitals, 5.27 housing, 4.63 inequities in health, 2.2 infectious diseases, 2.68 nursing, 5.26, 5.43, 5.45 oral health, 2.65 primary health care, 5.1, 5.9, 5.18, 6.23 quality assurance, 5.38 research, 6.2 sexuality and family planning, 3.24, 3.36, 3.37, 3.43 smoking, 3.53 water supply and sanitation, 4.42 P ositive health, 3.6 Primary health care, 3.30, 3.37, 4.27, 5.1-5.46, 6.26, 6.28, 6.43, 6.49, 7.10, 7.17, 8.5 Programme budget, 1.3, 1.6, 1.13,5.7 Programme management and development, 1.1-1.9 Programme planning and evaluation, 1.11, 1.14, 8.1-8.14 environmental health, 4.68-4.71 health economics, 6.82-6.83 health education, 3.66-3.68 oral health, 2.127-2.130 Programme of Work, Eighth General, 1.6 Seventh General, 1.7, 8.5 P sych ia tr ic case reg isters in pub lic health, 2.31 Publications, 1.22, 1.24, 1.33-1.39, 1.40.6.30, 8 .11, 8 . 1 2 Quality assurance, see Model health care and quality assurance Q uality assurance in long-term ca re : po licy , research and m easurem ent. 1.36 Radiation, ionizing, 4.17-4.20 nonionizing, 4.16 Refugees, 2.3 Regional Committee for Europe, 1.3, 1.6, 1.13, 1.17, 1.42, 2.36, 2.44, 3.5, 3.52, 6.1, 6.21, 8.1 Regional Health Development Advisory Council, 1.2, 1.42 Regional Office for Africa, 2.124, 3.43, 4.25, 6.32. 6.78 Regional Office for the Americas, 3.43, 6.32, 7.5, 7.22, 7.25 Regional Office for the Eastern Mediterranean, 1.1, 1.10, 1.22,2.124, 4.24, 4.25, 6.23 Regional Office for South-East Asia, 6.4, 6.32 Regional Office for the Western Pacific, 3.43, 7.22, 7.25 Regional Programme Committee, 2.128 Regular budget, 1.26 Rehabilitation, community-based, 2.20-2.22 see a lso Disability Rehabilitation International, 2.18, 2.22 Research, 1.2, 1.7, 1.28, 2.3, 6.1-6.4, 8.5 drugs, 3.59 health behaviour, 3.56, 3.57 health economics, 6.24, 6.83 health education, 3.67 health manpower, 6.46 hypertension, 2.98 mental health, 2.28, 3.55 nutrition, 3.46 oral health, 2.61 sexuality and family planning, 3.39 social equity and health, 2.4 suicide, 2.126 water supply and sanitation, 4.32, 4.52 Rheumatism, 2.27 Romania, country programme coordination, 1.15 health policy, 1.10 hypertension research, 2.98 immunization, 2.70, 2.71, 2.76 oral health, 2.60 primary health care, 5.9 water supply and sanitation, 4.10, 4.43 Rubella, 2.67, 2.68, 2.69, 2.74 San Marino, country programme coordination, 1.15 disaster preparedness, 2.125 immunization, 2.70 nursing, 5.45 research, 6.2 Schistosomiasis, 2.82 S c ie n t if ic approaches to health and health care, 1.34 Self-help, 3.12 Self-medication, 6.79 Seventh repo rt on the w orld health situation . Vol. 5, European Region, 1.34, 1.40, 8.3 147 Sexua li ty a n d fam ily p lan n in g , 3 .14, .4.15, 3.24-3.45, 6.15 Sexua lly tr a n sm it te d d i se a s e s , 3.31 see o /voA cq u ircd im m u n o d e f ic ie n c y sy n d ro m e S m o k in g , see T o b a c c o Soc ia l equity an d health . 2.1, 2.2, 2.4, 2.7 S o c io lo g y . X l t h W orld C o n g re s s , 2.8 Sp a in , acc iden t preven tion , 2 .114 a lco ho l a b u s e , 3.61 c o ro n a ry heart d i sea se , 2.97 co un try p r o g r a m m e c o o rd in a t io n , 1.15 d ru g a b u se . 3.58 Entre nous. 3.43 en v iron m e n ta l health , 4 .6 health m a n p o w e r , 6.43 health pol icy , 1.10, 6 .6 health p r o m o t io n . 3.3 h o sp i ta l s , 5 .14. 5.27 im m u n iz a t io n . 2 .68 . 2 .76. 2.77 m aterna l an d child health , 2.88, 2.91 m ental health . 2.30 nursing , 5 .26 , 5 .45 ora l health , 2 .56 pr im ary health c are , 5 .1 , 5 .16 p u b l ic a t io n s , 8 . 11 qual i ty a s s u r a n c e , 5 .38 . 5.40 research , 6.4 sexua li ty an d fam ily p lan n in g , 3.15 sm o k in g , 3.53 w ater su p p ly a n d sa n i t a t io n , 4 .44 , 4 .53 S t a f f a s s o c ia t io n , 1.6 S t a f f d e v e lo p m e n t a n d tra in ing , 1.29-1.32 Stan dard model designs fo r rural water supplies, 1.34 Stress , 3 .55 . 4 .62 , 4 .70 S t ro k e , 2.101 Studies in drug utilization, 6.74 S u ic ide , 2.126. 6.28 S u p p o r t p r o g r a m m e s , 1.20-1.43 Su rv ey s , p o p u la t io n - b a s e d , 1.2 Sw e de n , acc iden t preven tion , 7.7, 7.11 A I D S , 2 .44 e n v iro n m e n ta l health , 4 .6 e p id e m io lo g y a n d sta t is t ic s , 6.32 health m a n p o w e r , 6 .43 , 6 .45 health policy d e v e lo p m e n t , 1.10 health p r o m o t io n , 3.9 health te c h n o lo g y , 6 .64 , 6 .66 h o sp i ta l s , 5 .24, 5.27 Sw e de n (co n td ) im m u n iz a t io n , 2 .69, 2.70 leg ionel lo s is , 2.35 m enta l hea lth , 2 .126 nutrit ion , 3.48 pr im ary health care , 5.1 , 5.13, 5.16 qua l i ty a s s u r a n c e , 5.38 sexua l i ty a n d fam ily p lan n in g , 3.15 s t ro k e , 2.101 u n e m p lo y m e n t a n d soc ia l w ork , 2.8 w ater su p p ly a n d sa n i ta t io n , 4 .25 , 4 .44 S w itze r lan d , acc iden t p reven tion . 7 . 1 1 e p id e m io lo g y a n d stat ist ics , 6.32 health policy , 6.5 health p r o m o t io n , 3.57 h o sp i ta l s , 5 .27 h o u s in g , 4.61 in fect ious d i se a s e s . 2 .68 , 2 .69 m atern a l a n d child health . 2 .88 , 2.91 nurs ing , 5.26 p h a r m a c e u t ic a l s , 6.77 w ater su pp ly a n d sa n i t a t io n , 4.45 T e ta n u s , 2 .67 , 2 .70 T h a i la n d . 2 .66 . 7.5 T o b a c c o , 1.2. 1.5, 1.17. 1.18, 2 .96. 3.52-3.54, 6.15. 6.16, 8.13 T o x ic su b s ta n c e s , see C h e m ic a l h a z a rd s Trends in health legislation, 1.36 T u b e r c u lo s i s , 2 .67 . 2.71 T u n is ia , 4 .25 T u rk e y , acc iden t preven tion , 7.11 c o m m u n ic a b le d i sea se s , 2.48, 2 .49, 2 .72 co u n try p r o g r a m m e c o o rd in a t io n , 1.10, 1.15 health e c o n o m ic s , 6.23 h o u s in g , 4 .63 m a la r ia , 2.81 nursing , 5 .22 p h a r m a c e u t ic a l s , 6 .72 s c h is to s o m ia s i s , 2 .82 sexua li ty a n d fam ily p lan n in g , 3.38 w ater su p p ly a n d sa n i t a t io n . 4 .21 , 4 .27 , 4 .46 W H O sta f f , 1.22 U N , see United N a t io n s U N D P , see U n ited N a t io n s D e v e lo p m en t P ro g r a m m e U N D R O , i w United N a t io n s D i s a s te r Re lie f O ffice U n e m p lo y m e n t an d soc ia l w ork . 2.4 . 2.8. 3.15 1 4 8 UNEP, see United Nations Environment Programme UNESCO, see United Nations Educational, Scientific and Cultural Organization UNFPA, see United Nations Fund for Population Activities UNICEF, see United Nations Children’s Fund Union of Soviet Socialist Republics, alcohol abuse, 3.61, 3.64 child health, 2.83 disaster preparedness, 2.122 epidemiology and statistics, 6.32 health manpower, 6.43-6.45 hospitals, 5.27 immunization, 2.76 oral health, 2.61 primary health care, 5.3, 5.9, 5.13 stroke, 2.101 zoonoses, 2.35 United Kindgom, cancer control, 2.109 coronary heart disease, 2.97 disability, 2.20 drug abuse, 3.58 elderly, 7.25 environmental health, 4.2, 4.3, 4.5, 4.6, 4.20, 4.47 epidemiology and statistics, 6.32 health economics, 1.31 health education, 3.19, 3.23 health manpower, 6.40, 6.43, 6.45, 6.47 health policy, 6.6 health promotion, 3.6, 3.56 health technology, 6.66 hospitals, 5.24, 5.27 housing, 4.61 infectious diseases, 2.68, 2.70 maternal and child health, 2.83, 2.89 nursing, 5.26, 5.43 primary health care, 5.9, 5.13, 5.16 publications, 1.36 quality assurance, 5.38 sexuality and family planning, 3.15, 3.25, 3.40, 3.41 suicide, 2.126 United Nations, 1.4, 1.27, 1.29, 2.16, 2.18, 3.45, 6.12, 6.14, 6.19,6.21,7.22 United Nations Children’s Fund, 2.16, 2.48, 2.72, 3.45,6.14 United Nations Decade of Disabled Persons, 2.14 United Nations Development Programme, 1.27, 2.110, 4.10, 4.14, 4.23, 4.24, 4.25, 4.27, 4.43, 4.46, 4.57, 4.63,4.71,6.14, 6.33 United Nations Disaster Relief Office, 2.124, 6.12 United Nations Economic Commission for Europe, 2.16, 4.56, 6.12, 6.14, 6.67 United Nations Educational, Scientific and Cultural Organization, 2.16, 6.14 United Nations Environment Programme, 1.27, 4.2, 4.22, 4.27, 4.53, 4.54, 6.14 United Nations Fund for Population Activities, 1.27, 3.26, 3.28, 3.36, 3.37, 3.38,3.45,6.12 United Nations Scientific Committee on the Effects of Atomic Radiation, 4.18 United States of America, accident prevention, 2.119, 7.5, 7.11 AIDS, 2.40 health promotion, 2.93, 3.56, 3.57 health technology, 6.61, 6.62, 6.66, 6.67 housing, 4.61 legislation, 6.11 midwifery, 2.86 nonionizing radiation, 4.16 occupational health, 4.67 self-help, 3.12 welding fumes, 4.9 UNSCEAR, see United Nations Scientific Committee on the Effects of Atomic Radiation Vaccination certificate requirements for international travel, 1.35 Venezuela, 7.9 Violence, 2.3 Visual display terminals, 4.15 Voluntary contributions, 1.28, 8.14 Voluntary Fund for Health Promotion, 1.28 Wastes disposal, 4.27, 4.60 Water supply and sanitation, 2.123, 4.2, 4.10, 4.21-4.4S, 4.53 see also International Drinking Water Supply and Sanitation Decade Welding fumes, 1.36, 4.9 WHO-sponsored courses, see Fellowships WHO headquarters, 1.24, 1.29 AIDS, 2.40 disaster preparedness, 2.124 elderly, 7.26 149 WHO headquarters (contd) environmental health, 4.2 family planning, 3.38 health planning and management, 6.23 health promotion, 3.9 health technology, 6.62 mental health, 2.31 nursing, S.20 oral health, 2.127 pharmaceuticals, 6.71 schistosomiasis, 2.82 smoking, 3.53 social equity and health, 2.7 World Bank, 4.24 World Federation of Associations of Clinical Toxicology Centers and Poison Control Centers, 2.117,4.11 World Federation for Mental Health, 2.126 World Health Assembly, 1.1, 1.25, 2.7, 3.5, 6.72, 7.22, 7.24, 8.3 World Health Day, 1.19 World Psychiatric Association, 2.30, 2.126 World Rehabilitation Fund, 4.67 World Tourism Organization, 6.12 Yugoslavia, accident prevention, 2.115 cancer, 2.104 communicable diseases, 2.49, 2.50, 2.76 country programme coordination, 1.10, 1.15, 1.16 elderly, 2.13 environmental health, 4.5,4.48, 4.53, 4.54, 4.63 health manpower, 6.43, 6.45 health service delivery, 5.14 hospitals, 5.27 hypertension research, 2.98 infant mortality, 2.48 information systems, 6.33 nursing, 5.22, 5.46 primary health care, 5.1, 5.2, 5.4, 5.9, 5.16 quality assurance, 5.38 stroke, 2.101 Zimbabwe, 7.26 Zoonoses, 2.35, 2.36 150