WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTt
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Twenty-fourth session Wellington 28 August - 5 September 1973 Provisional agenda item 19
WPR/RC24/10 15 June 1973
ORIGINAL:
ENGLISH
SELECTION OF TOPIC FOR THE TECHNICAL DISCUSSIONS DURING THE TWENTY-FIFTH SESSION OF THE REGIONAL COMMI'ITEE The Executive Board at its eighth session adopted a resolution inviting the regional committees to consider the advisability of 1 holding technical discussions on matters of regional interest. This suggestion was supported by the Committee 2 and since 1952 technical discussions have taken place at each session. Attached is a list of the subJects.which have been selected during past years. As far as the topic for the technical discussions in 1974 is concerned •.the Committee may wish to consider the following suggestions:
1. 1.1
PROPOSALS MADE BY THE GOVERNMENT OF MAlAYSIA
The Planning and Organization of National Environmental Sanitation Programmes for the Control of Gastro-intestinal Infections
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The establishment of a clearly defined national policy on the control of gastro-intestinal diseases through the implementation of environmental sanitation programmes is an essential prerequisite the planning and development of such programmes. The benefits to the people and to the economy are well known and include the reduction of the demand for much more expensive and, in many ways, less satisfactory medical care.
lResolution EBB.R24, Handbook of Resolutions and DeCisions, Vol. I, 1948-1972, page 295. 2Resalution WPRVRC3.Rl4, Handbook of Resolutions and Decisions of the Regional Committee for the western Pacific, 1972, 7th ed., section 5.5.1, page 23.
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The technical and administrative methods needed to resolve these problems have been developed and applied sucoessfully in the developed and many developing countries. Generally, such programmes require centralized control over planning and funding in order to utilize efficiently the full range of the limited technically trained health manpower and facilities available, and to take advantage of international and bilateral sources of technical guidanoe, coordination and assistanoe, through such agencies as the World Health Organization, etc. On the basis of a defined national policy, basic goals and targets can be established, and work plans designed to meet these objectives can be developed and implemented. It is proposed that the disoussions be based on the development of a reoommended national polioy and on the establishment of basic goals and reasonable targets for aohievement of these goals. The central role of the Ministry of Health; its relationship to other agenoies, and the general pattern of development of the sanitation organization, and manpower needs wi thin the Ministry, should be considered in relation to the overall national development policy. 1.2 Progress and Problems in Tuberoulosis Control
In the developing countries where two-thirds of the world's population lives, tuberoulosis remains a major public health problem and its control in many of these oountries appears unsatisfaotory and has not had the desired impaot on the problem over the past deoade, despite the faot that there are available oontrol measures of proven effioaoy. The two main control measures, namely, protection of susoeptible persons with BeG vaccination and diminution of the transmission of infeotion by identification and treatment of the sources of infection, appear to have been applied inadequately or ineffectively. BeG has been applied widely for many years but such problems as unsatisfactory coverage and lack of potency of the vaccine administered still exist, for various reasons, although it can be said that, generally, significant progress has been made. The prinoipal difficulties experienced by developing countries lie in the identifioation of infectious tuberculosis oases and the treatment of these souroes of infeotion to render them non-infeotious. Present knowledge and experienoe gained from extensive olinioal trials and operations researoh, eto. indicate that it is possible to set up an effeotive national tuberoulosis programme in any developing oountry under varyitlg sooial and economio conditions. Yet, few suoh oountries have a really effeotive programme whioh has produced a signifioant impact on these two major problems.
WPRjRC24/10 p~e3
In many countries in the Western Pacific Region, tuberculosis control programmes have been in existence for a decade or more, and it would seem pertinent at this Juncture to have technical discussions on the progress made and the problems encountered, with a view to finding possible solutions to these problems. 1.3 Preventive Measures in Dentistry with Particular Emphasis on the use of Fluorides as a Public Health Measure developing countries, preventive measures in dentistry the attention they so rightly deserve and the dental the people in the Western Pacific Region is such that should now receive the attention of all the countries
In many have not had condition of this subject concerned.
Since dental caries is a rampant disease in this region and, indeed, allover the world, its prevention and control or the prevention of the progression of dental caries call for long-term planning and long-range implementation. In most developing countries, financial resources are limited and trained dental manpower, both professional and auxiliary, are in short supply. It is imperative, in view of this situation, that preventive measures in dentistry should receive priority and paramount attention as they are considered to be the answer to our dental problems. No country can ever hope to solve these problems if the traditional role of the dental services continues to be that of mainly rendering dental care for the people. Fluorides in various chemical forms, and reaching the teeth by varying methods of ingestion or application, have been found to have beneficial effects in preventing dental caries or preventing the progression of this disease, especially so in the case of fluoridation of the public water supplies, which is the most effective technique known today to prevent a high percentage of the incidence of carious dental lesions. The benefits of this public health practice will reach only about 35% - 40% of the population served by the reticulation system. Other ways and means to extend the beneficial effects of fluorides to others, especially to those in the rural areas not dependent on public water supplies, will have to be found. A technical discussion on the subject of preventive measures in dentistry, emphasizing the use of fluorides, will highlight the experience of other countries in this region and is especially appropriate at this stage as Malaysia is embarking on a national programme of fluoridation of the public water supplies throughout the country.
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1.4 The rmportance of Measles and its Control in the Western Pacific Region Measles is a world-wide disease showing definite periOdicity in many countries which have adequate reporting systems. In many of these countries the mortality and morbidity caused by measles has caused enough concern for these countries to embark on immunization programmes to control this disease. In the Western Pacific Region data on measles are generally limited because many of the countries in the Region do not as yet have reasonably functioning surveillance systems. Thus, information on the actual epidemiological picture of measles in the Region is not available. However, certain characteristics of the disease are well known. Susceptibility to measles is universal, and all those with no history of measles are susceptible. The complications of this disease are more pronounced in malnourished children and those with borderline malnutrition. These latter problems appear to be fairly widespread in the Region. Recent findings that measles also affects the I.Q. of all children infected is of some significance, because one of the main resources of many of the countries in the Region are human resources. Thus, this disease may, in fact, be causing untold longterm loss. The question thus arises as to what guideline policies should be employed in many of the countries of the Region to control this disease. Some of the factors, besides those of costs, cost-benefits and priorities, that require discussion are: (i) The types of vaccine to be used The use of live measles virus vaccines is now generally recommended. But the use of certain of these vaccines is associated with operational as well as economic difficulties. For instance, if the Edmonston B strain vaccine is used, it should generally be accompanied by MIG (Measles Immune Globulin). Thus, for the Region the choice of vaccine will generally have to be the cheaper further attenuated strains (Schwarz and Attenuvax). (ii) Age at Immunization Experience in some countries tends to indicate that the best sero-conversions of long-term efficacy are obtained by immunizing children 12 months and above in age. The earlier in life the immunization,
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the poorer the efficacy. This would entail operational difficulties because immunization programmes are now started early in life. Further, the attendanoes at clinics of children above one year of age are generally very much lower than in those below one year of age.
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A technical discussion on this subject would thus be of great value for those now considering, or likely to consider, this problem in the near future, because pressure is likely to be applied in the countries of the Region to embark on measles immunization beoause effective safe vaccines are now available. There is every likelihood that such pressures may come from doctors themselves.
1.5 The Need for "Generalists" rather
than "Specialists" in Medical
Care Systems in Developing Countries Many developing countries are facing the problem of extending more and more medical services, with limited financial, material and manpower resources, in order to meet the ever-increasing demands and needs of the population which, through various sooioeoonomic and eduoation programmes, is beooming more and more literate and more aware of the importance of such services. Furthermore, medical soienoe and knowledge have advanced to suoh a stage that the trend is now to develop specialists within a specialty. The high cost of training to become a doctor is a well-known fact. But the muoh higher cost of training a doctor to become a specialist or a specialist within a specialty is often wrongly, or rightly, justified by the need to provide the most up-to-date and the most sophisticated services to the population - more often than not, this is regarded as a status symbol. Yet, the services of these speCialists are usually confined to the larger hospitals in the cities and larger towns and seldom reach the people in the rural areas, who form the vast majority of the population in the developing oountries. The need to train doctors to become "generalists" or "all-rounders" who can provide the so-called "specialist services" in the district hospitals and clinics in the small towns and rural areas should be examined more critically. Some of the points to be looked into are: (i) the training of doctors, after their basic degree, in the major disciplines of medicine, e.g., obstetrics and gynaecology, surgery and general medioine, under speoialists for longer periods than usually required by "housemanship", so that they become more skilled and more confident to carry out basic and emergenoy operations in the small district hospitals on their own. It is essential that these young doctors be sent to the district hospitals after being trained under the various specialists;
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(ii)
the posting of speoialists to the district hospitals for a period of time in order to train and guide the young doctors working there; and when these young doctors are capable of providing "specialists servioes" on their own, the specialists should move on to other district hospitals and so on.
1.6
Postbasic Preparation of Trainers of Paramedical Health Workers
At present many of the trainers of public health inspectors, public health nurses and laboratory assistants, do not have any proper training programmes to prepare them to be trainers in their field. This has resulted in the gradual lowering of the quality of these training programmes. In addition. there is an increased demand for paramedical workers to man the various programmes, with the result that the training schools are called upon to step up these training programmes. The limiting factor here is the lack of suitably qualified tutors (public health inspectors, laboratory assistants, etc.) to conduct these courses. There is therefore a need to look into the whole subject of the postbasic preparation of these trainers.
2.
PROPOSALS MADE BY THE SECRETARIAT OF THE REGIONAL OFFICE
2.1
Public Health in Emergencies
The occurrence of certain natural or man-made catastrophies or disasters such as earthquakes, floods, volcanic eruptions, typhoons, war, riots, etc. may result in the large-scale evacuation of populations to areas where medical and health services and sanitation facilities either do not exist or are inadequate to meet the increased demands made on them. Such catastrophies usually result in an increased number of injuries or illnesses for which adequate medical care is necessary if mortality or disabilities are to be prevented. In addition, there is a need to provide preventive health services, safe and adequate water, food and shelter, and to maintain satisfactory sanitary conditions in the areas affected. A discussion on the planning, organization and implementation of emergency health programmes might be of interest to a number of governments.
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2.2
The Use of the Medical Assistant in Health Services
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The problem,of the delivery of health care, both to individuals and to the community as a whole, 1s one whioh faces all countries at all stages of development. People living in rural areas and in certain urban situations are not always adequately treated when sick, nor adequately covered by preventive health measures due to the difficulty of providing medical graduates for this purpose. The reasons for this situation are many and include the lack of trained doctors, migration of trained doctors, insufficient funds for the payment of doctors, and the unwillingness of doctors to work in what they consider to be disagreeable situations. The medical assistant is one possible solution to this problem and this is at the present moment being discussed by countries in all regions of the world and by countries at all stages of economic development. 2.3 Control of Vector Mosquitoes of Dengue Haemorrhagic Fever
In view of the increasing number of dengue outbreaks in the South Pacific and the recent discovery of dengue fever, probably with haemorrhagic manifestations in Khmer Republic, Niue and West Malaysia, control of the vector mosquito, Aedes aegypti, is of primary importance since there is no specific treatment or available vaccine for controlling an epidemic. It is well known that epidemics of dengue fever with haemorrhagic manifestations occur from time to time in Malaysia, the Philippines, Republic of Viet-Nam and Singapore. Several effective methods have been developed recently for controlling an epidemic of dengue haemorrhagic fever through vector control.
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Kuala Lumpur, Malaysia, where the Regional Committee will meet in 1974, would be an ideal site for technical discussions on the above topic becauseteahniaal personnel and facilities are available locally to support the discussions and field demonstrations can be easily arranged.
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TECHNICAL DISCUSSIONS TOPICS
1952 - 1973
Year and session
Subject COMMUNICABLE DISEASES
1957 (eighth session) 1958 (ninth session) 1959 (tenth session) 1963 (fourteenth session) 1969 (twentieth session)
Leprosy control Malaria control and eradication The control of tuberculosis The role of the local health services in leprosy control The planning and organization of a national epidemiological service DENTAL HEALTH
1961 (twelfth session)
Dental health
ENVIRONMENTAL HEALTH
1962 (thirteenth session) 1966 (seventeenth session)
The role of the health services in the improvement of community water supplies The role of the health department in environmental health services Environmental pollution problems and approach to their control in the Western Pacific Region FAMILY HEALTH
1972 (twenty-third session)
1955 (sixth session)
Domiciliary midwifery as an approach to the people in the development of rural health services
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WPR/RC24/l0 page 10 Year and session Subject FAMILY HEALTH (continued) 1956 (seventh session) 1967 (eighteenth session) Approach to and management of the pre-school child (from one to six) The integration of maternal and child health and family planning activities in the general health services HEALTH EDUCATION 1965 (sixteenth session) The use of health education services in national health programmes HEALTH MANPOWER DEVELOPMENT 1952 (third session) 1971 (twenty-second session) The education and training of medical and public health personnel Health manpower in developing countries: Problems and needs (deferred from twentyfirst session) STRENGTHENING OF HEALTH SERVICES 1953 (fourth session) 1954 (fifth session) Health planning Public health administration with particular reference to the organization of health departments The organization and administration of rural health services Health planning as an administrative tool The role of the hospital in the community and the financing of hospital-based medical care VITAL AND HEALTH STATISTICS 1964 (fifteenth session) The use of statistics in public health administration
1960 (eleventh session) 1968 (nineteenth session) 1973 (twenty-fourth slession)