Mongola: striking progress [full issue]

x. s5' . 11. - _ VINNILD HEALTH THE MAGAZINE OF THE INCRLD HEALTH ORGANIZATION • APRIL 1976 • USA $1 MONGOL A: STRIKING PROGRESS 2 House-call by a Mongolian midwife at the yurt (tent) of a young mother and her baby. Cover photo by Didier Hen- rioud. Contents Worldwide patterns . 3 Senegal probe by P. Rossion ...... 4 Standing guard by J. Magee ..... 10 Mongolia: A leap across the centuries by L. Thapalyal .... 14 Kenya: One woman's liberation by R. Seitz .... 20 Philippines: Midwives among the Chocolate Hills by J Abcede 24 WHO News in Brief . . . . 28 Young World Health . . 30 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. worldwide patterns le he very word "epidemiology" is in-clined to put off the average reader, yet it lies at the heart of much of the work of the World Health Organ- ization. Since epidemic, as applied to disease, means "the number of cases within a given time limit exceeding what was expected", so epidemiology is the science or study of the relationships of the various factors deter- mining the frequency and distribution of diseases in a human community. In the modern world of rapid air travel and the mass movement of people, whether as tourists, as migrant workers, as long-dis- tance transport drivers or as people dis- placed by political or racial upheavals, it has become more important than ever before for the course of diseases to be kept under surveillance. Computer technology can help in this respect. Masses of information which pour into the data banks at wHo headquar- ters in Geneva can, at the press of a few keys, be correlated into a meaningful pat- tern which will show whether cholera is pos- ing a growing threat in some corner of the world, or whether a new strain of influenza virus may be on its way round the globe. Epidemiology relies heavily on data. Because of present population trends, devel- opments in medical care and changing pat- terns in morbidity, the demand is increasing for reliable health statistics information sys- tems. The collection, analysis and utilization of accurate and comparable data on vital and health statistics are a major priority in public health, and enable rapid assessments to be made of the epidemiological situation. Not only diseases are involved in this con- stant watch : emphasis is increasingly being placed on the development of epidemiologi- cal surveillance of the health effects of envi- <The task of epidemiology is to study the fac- tors determining the frequency and distribu- tion of diseases in a community. Here, while one member of the health team checks wheth- er this Ugandan woman's BCG vaccination against tuberculosis has "taken", another member makes a meticulous note of all the relevant details. Each item of information thus gathered will add another piece to the jigsaw pattern of disease and its control. (Photo WHO/J. Mohr) ronmental hazards, including air and water pollution. Research is continuing into ways of im- proving the collection of biomedical data to meet the needs of the epidemiologists and to develop early warning systems. Scientific in- stitutions collaborating with wHo have in- creased their technical involvement in the search for more efficient and more practical methods of epidemiological measurement and data analysis. Faster and cheaper com- puter techniques are being devised for ex- tracting relevant information from complex epidemiological records. Scientists are also intent on formulating a common scientific language so that the worldwide network of wHo Collaborating Centres can swing easily into action to identify the causative agent or the strain of virus involved in a specific epi- demic and pass on this information to the rest of the world. wHo makes every effort to encourage prompt and complete reporting from its Member States so that it can fulfil its obliga- tions to operate a warning system which will in turn enable national health services to be on guard, particularly against communi- cable diseases. Any delay in reporting infor- mation to the Organization, or the failure to do so, tends to limit the usefulness of the service. Even now, not all Member States are making full use of the daily automatic telex reply service which wHo has operated since 1973 to make available to everyone the urgent communicable disease information of which it has knowledge. One of the big success stories in recent years is the "fight to the finish" against smallpox. Once a mass killer which infected nearly every country in the world, this dis- ease is now reduced to a few pockets of resistance in Ethiopia. The dwindling scale of the smallpox threat is easy to trace in the unembellished pages of the Weekly Epide- miological Record. Prepared for the guid- ance of health administrations and health authorities, and containing data on all com- municable diseases of international impor- tance, the WER this year marks its first half-century of existence, and its 50-year his- tory is described in this issue of World Health. Another article explains the work of epidemiological surveillance by following one of the teams at work in Senegal. ■ 3 Senegal probe by Pierre Rossion L n April 1972 a team from the World Health Organization led by Dr Jean Ridet undertook a vast epidemiological survey at the request of the Govern- ment of Senegal; it was, you might say, the first check-up for the country. Today, after four years spent visiting 300 villages and covering thousands of miles on rough tracks, the end is approaching. No survey like that, carried out on a large scale and covering a very wide range of dis- eases, had ever been attempted before. Yet it was completed with limited means and staff—in itself quite an achievement. Although the final results of the work are not yet available, the preliminary findings already tell us things about the state of health of the Senegalese population. The first fact to strike us is that Senegal, like other countries of Africa, has not yet made good its late start in the health field; Africa has only 1.36 doctors to 10,000 in- habitants, as against 2.83 in Asia, and life expectancy remains the poorest in the world – 42 years, whereas it is 50 in Asia and 68 in Europe. The wHo team comprised, besides Dr Jean Ridet—the epidemiologist and team leader—Dr Louis Krikava, a nutri- tionist, Joey D'Costa, a serologist, Aristo Akribas, administrative officer, and a group of Senegalese male nurses to detect on- chocerciasis and dental caries. For ten days we shared the life of this team and its dis- comforts : to the stifling heat were added thirst, the continual onslaught of mosquitos and blackfly, and, worse of all, the journeys over rutted red tracks through thick clouds of dust that literally clung to the skin. Kedougou: it was there that our adven- ture began. This East Senegalese town, real- ly just a large African village, had been chosen as base camp, partly because of the airport linking it by twice-weekly flights with Dakar 400 miles away, partly because it boasted a few solid buildings necessary for harbouring the laboratory equipment (centri- fuge, microscope, and so on). The team also stayed in one of these buildings. At dawn, we were off to Missira Dantila, a village of 400 inhabitants in the heart of the bushland of East Senegal. Sixty miles of track like the big dipper, past baobab trees, silk-cotton trees (bombax), mango trees, wart-hogs, monkeys, hornbills, antelope and—hidden in the bamboo—panthers and lions. Then over the difficult ford on the River Gambia. Mandieme Diouf, who drove the landrover with great aplomb, got us through all right, and after three and a half hours on the road we arrived at Missira Dantila. Aristo Akribas jumped out of the car and crossed the boundary into the vil- lage, the population of which belong to the Diakande tribe. All at once an old sentry posted at the entry to the village yelled : "Who goes there?" "It's wHo!" The villagers, who for the most part have never seen a white man, were all agog, and the children ran for the huts. After a moment of confusion El Hadj Lassan Tan- dian, the village chief, arrived, followed by the religious leader. A few words were ex- changed on the village square, in the shade of a bombax tree. Akribas told them: "We are with you today to find out your state of health. With your permission we shall return tomorrow and carry out the necessary tests, using a sample of a hundred people drawn by lots. Afterwards a general medical exami- nation will be made and the sick will be treated." The marabout (muslim priest) leant towards El Hadj Lassan Tandian, who spoke in his turn. He did not know French, so the interpreter, in this case the male nurse Famara BA, translated : "We are very pleased that you came; there are many sick people among us and we lack medicine." He ended with the words : "Come by all means tomorrow." The equipment (tents, folding tables, microscopes, etc.) was then un- loaded. Missira Dantila was the 130th village to be visited by \vim since the beginning of the survey. Up to that point there had been only one refusal, by a marabout—for religious reasons. The next morning the whole team climbed aboard three landrovers, bound for Missira Dantila. The same route, again over the perilous ford, and one incident : the trans- mission shaft of one of the landrovers 4 Three vehicles of the WHO Epidemiological Survey in Senegal head into the interior of this West African republic on a mission to trace the patterns of such diseases as malaria, yaws, sleeping sickness, syphilis and on- chocerciasis (river blindness). ( Photos WHO/J. Marquis) broke, but it was soon put together again with whatever came to hand. At 10 a.m., to the beat of the tom-toms, we were welcomed by the whole population of Missira Dantila. The women had put on their most colourful head-dresses and really looked fine. The village chief, who had donned his ceremonial costume, insisted on a gesture of gratitude to the team, the sacri- fice of a goat, to be eaten at the midday meal. Using the census sheets distributed by the Prefet (head of the administrative department), he drew lots among the "clans"—the larger families. The check-up could then really begin for these hundred people. In the first tent: blood samples. Joey D'Costa, who comes from Madras, took blood in vacuum tubes, helped by two Sene- galese assistants, Mamadou and Baye. Thus began the most extraordinary adventure for blood collected in the heart of the African bush. After centrifuging and separation of the serum, it was split up into five samples, each to go to a different destination. The first was sent to the Pasteur Institute in Dakar where specific tests are carried out for a wide range of diseases : malaria, trypa- nosomiasis (sleeping sickness), arboviruses, filariases, viral hepatitis. The second sample was sent to the Wm laboratory in Dakar which is particularly concerned with the dis- covery of cases of the endemic treponema- toses : syphilis and yaws. The third would be analysed at the Faculty of Medicine of Dakar for possible brucelloses. The fourth went to Paris, to the Institut Alfred Four- nier, which is specially equipped to detect venereal diseases such as the gonococcal in- fections and syphilis, for forwarding to Rouen, where a directory of blood groups is kept. Finally, the last sample is kept to be checked later for liver cancer, for example, according to the alpha-feto-protein level. As for the clot, it would be kept for haemo- globinopathy studies. Nothing is wasted. Of course, all the laboratories' work is coordi- nated. Clearly, to complete the research it would have been possible to look also for diabetes, 'anaemias and parasitoses of the urinary and digestive systems, as it is planned to do in subsequent surveys. In the second tent: clinical examination by Dr Jean Ridet and investigation for nutritional disorders by Dr Louis Krikava, the Czech nutritionist. The population of Senegal as a whole suf- fers from nutritional deficiencies, which are particularly hard on children. The symp- toms of malnutrition obviously depend on which nutritive elements are lacking. It is not rare to find children with kwa- shiorkor, a disease caused by a protein defi- ciency and characterized by a swollen sto- mach in an otherwise emaciated body, and loss of pigmentation of the skin and hair. Lack of vitamin A—the vitamin normally found in fish oil, cheese and fresh vege- tables—is revealed by examination of the eyes, which develop corneal and conjunc- tival xeroses, and by skin tests showing dif- ferent kinds of dermatoses. Lack of vita- min B2, abundant in milk, is revealed by the existence of skin diseases. Finally, lack of vitamin C is signalled first and foremost by receding gums. All these nutritional defi- ciencies leave children susceptible to infec- tions; it is estimated that only 50 per cent of infants reach 15 years of age, after which adolescents and adults fall victim to the communicable diseases that abound on an endemic scale. The communicable diseases, including venereal diseases, are still the main chal- lenge confronting the public health authori- ties in Senegal; they are directly responsible for the high mortality in children and young persons, and hamper economic and social development. This is especially true of the sexually transmitted diseases. For while the pathogens that cause them are well known, the diagnosis fairly easy, the treatment effec- tive and well laid down, their incidence in Senegal, as in most countries of the world, is constantly increasing and often reaches epi- demic proportions. 5 Through observations in the field, and from the results communicated by the labo- ratories, Dr Jean Ridet has made a prelimi- nary assessment of the communicable dis- eases, covering the regions of the Senegal River and Basse Casamance. Treponematoses: these are diseases caused by a treponemal microbe, one of the spiro- chetes. One treponematosis which occurs throughout the world and is sexually trans- mitted is syphilis. We shall come back to it. The other group, the non-venereal trepone- matoses, are only found in the tropics. They are yaws, endemic syphilis or bejel, and pin- ta. All these diseases produce positive sero- logical reactions and can be effectively treat- ed with penicillin. The earliest findings of the epidemiologi- cal survey carried out in Senegal were of yaws in Basse Casamance and non-venereal syphilis in the Senegal River region. More than a hundred check points were covered by the survey, and a hundred people in each were examined, making 10,000 in all. Each subject was asked to reply freely to ques- tions on his or her health and family back- ground, and to have a clinical examination followed by blood sampling. The results showed that yaws, a disease similar to syphi- lis but not sexually transmitted nor congeni- tal, had been almost totally eradicated in Casamance, as the immunological sequelae (positive blood test) were only found in 4.5 per cent of the population and in none but adults—proof that transmission of the dis- ease has been interrupted. This result is attributable to the mass campaigns against the disease organized by wHo and UNICEF up to 1965. But in the Senegal River region, on the edge of the Sahelian zone and especially among the Peul nomads, the success of mass campaigns has been much less spectacular in the case of non-venereal syphilis, since transmission of the disease continues among children, for whom rates of 2.5 per cent for contagious cases and 21.1 per cent for those with a positive serological reaction were ob- served, while for adults these rates rise to 90 per cent. This is clear evidence that active transmission of the disease continues, neces- sitating close surveillance. Gonorrhoea is a gonococcal infection of the organism. The gonococci flourish in urethral exudations in man and in urethal and vaginal secretions in women; whereas venereal syphilis, an infectious communi- Top: The survey team's first task is to win the confidence and cooperation of the village elders. Centre: A lively dance performed by a local girl to the sound of drums draws a big crowd. Once the villagers have assembled, they will be told the purpose, of the WHO team's mis- sion. Bottom: Specialist members of the WHO team combine the two jobs of treating the sick and noting the distribution of disease among the village people. Top: The little boy is alarmed, but his mother does not seem to mind the needle going into her arm. Only a routine blood sample—but it will help to show up what diseases may be prevalent in the village. Centre : A small room serves as a temporary laboratory where the blood samples are care- fully arranged for subsequent analysis in Dakar and in France. Bottom: The thorough check-up made by the epidemiologists and health assistants includes a dental inspection, intended to show us any critical vitamin shortage in the diet. cable disease, is mainly spread through sex- ual contacts, can be passed on hereditarily, and is caused by a spirochete. For these two diseases the still incomplete results of the survey cover the Basse Casam- ance and Senegal River regions—and they are alarming: both infections, but especially gonorrhoea, are constantly on the increase, in rural and urban areas alike. We were well placed to see how they are spreading in east- ern Senegal; numerous cases were detected in the villages we visited, as well as in Kedougou, in the consulting-room at the maternal and child care centre. And they keep on spreading because of ignorance, the lack of information and health education, and the movements of population that occur in a country in the throes of economic change. Changing moral attitudes have not spared Senegal either. They have made their mark here, there and everywhere, weakening the family unit, lowering respect for religious beliefs and upsetting traditional practices. Out-of-work marabout healers are often to be seen in Dakar trying to find employment in psychiatric hospitals. Greater permissive- ness is especially to be seen in large towns like Dakar, Kaolack and Ziguinchor, where western-style urbanization has inevitably upset the traditional African village struc- ture. Finally, information about preventing venereal diseases is totally lacking. In Sene- gal—as in most countries of the world—the dissemination of simple, relevant facts is ab- solutely essential. Almost all the young peo- ple are ignorant about the use of contracep- tives for men and fail to see a doctor until a gonococcal infection has gone so far as to give them pain ; and the delay between the time they notice it and the consultation of- ten exceeds ten days. The authorities are aware of the problem and have already set up health education teams which are expected to do an excellent job. Meanwhile the radio programmes in Casamance are giving the matter their atten- tion and Mr K. Sane, who is in charge of regional broadcasting, says this has already had the effect of raising the number of requests for appointments at the Ziguinchor hospital. Brucellosis (or Malta or undulant fever): this disease, provoked by Brucella organ- isms, causes heart trouble and nervous dis- orders as well as enlargement (hypertrophy) of the liver and the spleen. The preliminary results of the epidemiological survey showed that these were common almost everywhere both in the Senegal River region and in Basse Casamance. Arboviruses: these diseases, communi- cated by arthropods, are caused by a group of viruses (arboviruses) of which several hundred strains have already been isolated. Some have been known for a very long time, for example, the yellow fever virus. Their natural mode of infection is through intro- duction of the virus to the susceptible host (man or animal) by the bite of a mosquito, tick or other arthropod harbouring such a virus in its saliva. From the investigations at the Pasteur In- stitute in Dakar it appeared that the arbovi- ruses were more active in the Senegal River region than in Casamance, and there seems to be some relation between the occurrence of certain viruses and the passage of birds on migration. It would be over-hasty to give the preliminary findings for viral hepatitis, trypanosomiasis and the haemoglobinopa- thies before the data have been fully ana- lysed. But the greatest worry for the medical au- thorities in the region of eastern Senegal is the spread of onchocerciasis, or river blind- ness, for it is common to find that 70 per cent of the inhabitants of a village have it. In the third tent: Arokouty Bessene, a Senegalese male nurse, is using special scis- sors to remove a fragment of skin from a patient's hip and is examining it under a microscope. The image reveals little worms (filariae), evidence of onchocerciasis. The insect vector carrying the disease is the blackfly, a little gnat-like creature called Simulium damnosum. Only the female can in- fect the parasite worm, Onchocerca volvulus, by biting man, owing to the peculiar config- uration of the parts of her jaws and mouth. The worm grows in the human body and, if female, reaches a length of 40 inches (70 centimetres) in three months. It may stay there for 15 years, giving off larvae or microfilariae which migrate under the skin. To begin with, there is no pain. People with onchocerciasis look healthy, but they all are sources of parasites which may be inoculated from them to others—the really healthy ones—with a transitional period for development of the parasite in the vector. Then the skin starts to itch and the sick per- son scratches till he or she bleeds. To pro- tect itself the body reacts against the para- site by forming resistant tissue to trap the worms. This extra tissue takes the form of large cysts (or nodules) covering the body; they may grow as big as a tennis ball. Final- ly, eye trouble develops, first in the form of impaired night vision, becoming worse until The team has found a boy obviously suffering N from kwashiorkor, the result of acute mal- nutrition. His eyes are also checked for signs of xerophthalmia, which might suggest a specific lack of vitamin A in the diet. 8 blindness is almost total. "After five o'clock in the evening all my village just feel their way around", one village chief told us. Unfortunately the few ways of treating onchocerciasis that do exist, whether with Suramine, which kills the adult filariae, or diethylcarbamazine (DEC), which kills the larvae, are impracticable because they require medical supervision, while the exci- sion of cysts has no lasting effect as deep cysts often pass unnoticed, and in any case there are free, un-nodulated worms. For want of an effective method of mass treatment, research workers thought that the disease might be prevented by an attack on the blackfly, but they soon found that it was a Herculean task; the range of the fly is about 100 miles. Fortunately experts ob- served that if the Simulium themselves could not be considered as a direct target, at least the attack could be levelled at the larvae— vulnerable as they are. And blackfly always lay their eggs in the eddying waters of fast- flowing rivers. At the start, the idea of pour- ing in DDT was mooted, but research work had to be focused on other insecticides in view of the stability of DDT and the fact that it accumulates in the food chain. Today, another preparation, Abate, is used which kills the blackfly larvae without caus- ing harmful effects to mammals or other aquatic fauna. It is added to river water in weekly doses of 0.05 to 0.1 mg per litre over a period of ten minutes. Onchocerciasis gives rise to serious eco- nomic problems. In 1955, wellmeaning mis- sionaries, noting that the land near rivers was more fertile, decided to take up agricul- tural science. "What if one were to grow rice?" said one, "You only have to irrigate and plant it", said another. "And then" said the third "we can feed the crop to the hun- gry population". But the thought that the rice-fields would become breeding-grounds for blackfly did not occur to them. Anyway, in order to irrigate fertile land, dams would have to be built on some of the rivers of Senegal, and where there are water- falls there are foci of Simulium. Thus in try- ing to do good, one could do harm. To counter this risk the Senegalese authorities have carried out epidemiological and ento- mological investigations in the regions which are to be exploited. At about midday, our epidemiological survey came to a close. But that does not mean that the work was all done. The sick villagers who had not been drawn by lot were invited to come and be treated. The medical examinations were over at 1.30 p.m. sharp, and we broke for a lunch of rice, meat, and goat's milk mixed with honey, all served in calabashes. Then at last the equip- ment was loaded ready to leave, and the fes- tivities began: the tom-toms beat out their rhythms and the women began to dance—a nice way of thanking Dr Ridet and his team. They convoy got under way, and in three and a half hours we were back in Kedou- gou. "I am thirsty", said Dr Krikava, and made for the fridge. Alas, the beer he needed so badly was not there; the lorry which usually brought it from Dakar had broken down. In the end Dr Krikava had to make do with palm wine. Then we all plunged into the Gambia River until dinner time. Lucien, an excellent cook from the Bassari tribe, had made chips. At dawn the next day the team split up. Dr Ridet, with Joe D'Costa, went to the Kedougou medical post to spend all morn- ing on gynaecological examinations. Afterwards the two of them went to the laboratory where the blood taken the day before was waiting in vacuum tubes. They centrifuged them and divided up the sep- arated serum into five samples for despatch by air to the Pasteur Institute in Dakar. Meanwhile, Aristo Akribas went with Man- diem& Diouf to Baitilaye to give the village chief notice of the vim visit the next day. During the Baitilaye survey, Mr Sid Fara Diaw, the Chief of the Saraya district (in eastern Senegal), insisted on accompanying Nutrition has a direct bearing on health. The WHO team notes the sort of diet the villagers prefer, and the ways in which the food is prepared. the wHo team. We took the opportunity to ask him about the medical situation in Sene- gal. "In some villages" he told us "we lack qualified health personnel. Senegalese doc- tors trained in Dakar or Paris will just have to set up their practices in the bush. At pre- sent, I am afraid, they too often remain in the large towns and it will take especially persuasive campaigns to give them the incentive to come. But surely, when one enjoys a job, one has to do it and give peo- ple the benefit of one's experience, wherever it is needed? Yes, we are for Senegalese medicine for Senegal, but it must come gradually; for the moment, we have to ad- mit, we badly need the cooperation of yam, which is helping us in many ways." In the meantime Senegal is trying very hard to improve the quality of life and the standard of living of its people. Experimen- tal collective farms in the villages are good proof of this; the crops from fields which are worked by villagers on a rota system are sold to finance a local project for the estab- lishment, say, of village pharmacies. A word must be added about the devo- tion of Senegalese nurses. After two, three or four years of training, depending on their specialty, they provide a very useful service, riding through the bush on their bicycles and vaccinating people or delivering medi- cine. Some even perform minor operations. "Thank you, I am grateful—very grate- ful", said the man suffering from onchocer- ciasis, as he got off the table on which he had just been operated for two large cysts under local anaesthetic. Famara BA, a nurse from the Major Endemic Disease Service at Kedougou, did the surgery with the instru- ments available, but strictly by the book. The patient went off on foot, with two rows of stitches in his back, to his village 50 miles away. Although in general Africans have good teeth, nevertheless, especially among the in- habitants of villages, numerous caries are found due to poor dental hygiene. As there are too few dentists for the country's needs, the Senegalese Government, with the assis- tance of wno, has opted for accelerated training of qualified staff at lower cost. These dental operators, as they are called, are first trained at the dental institute in Dakar and go on to a centre for practical demonstration and operational research in dentistry. One of their number, Louis Camara, had joined the wHo team. His part was to make an epidemiological survey on dental caries, to give dental first aid (extract- ing and scaling teeth), and to run health ed- ucation courses, especially for schools, as we were able to see for ourselves at Kedougou. Although toothbrush and toothpaste are the best way of ensuring good oral hygiene, they cost too much to be widely used in Senegal. Therefore the dental auxiliaries prefer to recommend the traditional tooth- stick, or sothiou, provided it is used proper- ly. The travelling dental operators also remove teeth for villagers. We should add that the survey team were also on the look-out for tuberculosis; when those examined showed signs of a bad cough, sputum samples were examined un- der the microscope. And to detect cancer of the uterus they made cervical smear tests on women with gynaecological disorders. The full results of the survey will be pub- lished when the computer has sorted it all out. Eventually the Senegalese Government is planning a vast mass prevention cam- paign, with WHO's support, against some of the diseases that were found which pose par- ticular public health problems. The findings of the epidemiological survey will clearly be of value to the authorities in their assess- ment of health priorities and will increase the effectiveness of any measures they may take. ■ 9 SECTION I•HVGIENE DU SECRETARIAT DE LA SOCIETE DES NATIONS HEALTH SECTION OF THE SECRETARIAT OF THE LEAGUE OF NATIONS RELEVE HEBDOMADAIRE N. I des rapports concernant la peace, le cholera. le hEvre Janne, le typhus exanthematique et la variOle recite par la Section d'hygiene pendant In semaine se terminant le 31 mars 1936 (non tarapris les donnas roues an Bureau de Singapour). WEEKLY RECORD No 1 of Reports regarding the Prevalence of Plague, Cholera, Yellow Fever, Typhus and Smallpox received by the Health Section during the Week ended March 31st, 1936 (mot including inlormalian received through 1St Singapore Bureau). AFIOQI flssd~ia Pe*. — Mag.. "• IILII 11 1 rn.c3.3 Oates AFRICA. ratia, ..,..,,,,,,. Madagascar 1 /X11411 All 11 277 10 DoElE, ns. Madagascar. ASIE IMIt'.111 III 104 ASIA. Ink ..”aanioryer . Pendoh I I - ''11 3.124 7. Bruvh .Mile: Provinces Init.. Bihar ei Orissa 1 'I 6-11 I ;I 6 II 1.113 212 Provinces Crel.. Presidea de Madras . il II 11 • 6 II . 162 RN 633 Central Provinces. Nladras Presidency. Ilyso„ Paidence de Bombay 31 1 • E II 31 I - 8 11 INI 2RI 113 -833":11a'y Presidency. Dirroaloe *Om easIndlens . ?Il /I - Ell 347 202 0'Z:iodise Stales. lode Melowrivil • va 37.1 -Mil 4,X11- 1 1 X11 — 3.2. 374 Den. Eon ladies: lava. ladarkm. franca)... . . 24 :I . / 1 11 - 30 .1 I I french Ixda-China. 1 .III-10 III ,at : Bagdad ?I 'l 3 11Tr ' II /mu Baghdad. 2 Siam. 3 11 -13 11 '/I1 -201 S1E ASIA. Inds lkilannique . . . . Provinces I. nies. . . . 31 I - 6111 3.013 8 1.770 Dried India: 3 United Novae. Bihar 0 Orissa . . Paidence du Deng!. 306 1.071 . 3E7 Bihar and Ora Bengal RenEDOCE Amoco ProvincesCentral. 26 241 ,, II Ma.. c,..,...3 ny.v,,...,... Residence de Madras 1.310.1 14 791 Made. Presidency. . Burma. (*sue lusserim . 1 111 11117111 308 47I Prem.* Inda-Cliaa. Anneal , . , , . , 113111.203111 1311 .2S/11 ■ 1/111:r3/111 471 110 NO 448 t:rnt:Le2, Corhinellins . . II/III-201111 1111 4811 36, o Cochin-Chinn. Laos 1111110/111 "IlrattIPI 20 71 3 leo.. diem 11 .1111-20 All 2411 del. to 07 1%11 :IVII 113 113 81 14,11 -20f11 137 ON Nev. lame -- Tallow Eger NLant. — NiL standing guard by James Magee te he Weekly Epidemiological Record is not given to sensational writing nor to heart-warming "human interest" stories. Usual- ly the greater part of its text consists of information relating to the occurrence of the major infectious diseases throughout the world. Yet it represents the proof, embodied week by week over the past 50 years, of the success of an idea. That idea is that nations can work together suc- cessfully to fight and to overcome some of the greatest enemies of human health. A slender document, generally of eight pages only, it appears with each column in English balanced by a column in French, but with frequent tables and maps. Nevertheless, behind the dry facts and figures lies a story of the develop- ment of a worldwide intelligence service, bringing the news from the battle fronts of cholera and smallpox, plague, yellow fever, typhus and relapsing fever. In ad- dition, it gives warning of other diseases such as influenza and rubella (German measles), and charts the massive world increase in gonorrhoea. In short, it reflects the shifting patterns of disease around our planet. How effective the ceaseless warfare waged by health teams on international fronts has become can be seen from the charts plotted by the World Health Or- ganization. But there are other indica- tions too. There was a time when out- breaks of smallpox produced thick wads of print-outs from the wilco computer data banks, where epidemiological infor- mation is stored and processed. Now those thick piles of paper have given way to a few sheets of data, as reports of cases of smallpox throughout the world have dwindled. The Americas, Europe, Asia and Australasia are already free of this killer disease, and Africa is almost clear. Only Ethiopia still has a few remaining pockets of infection to be cleared up. For 50 years, the WER has brought news from the world's battle fronts against disease. The front page of the first-ever issue, in April 1926, consisted of a bald list of cases of pla- gue and cholera. Right: The work of surveillance goes on, al- though today WER's reports often relate more closely to individual case histories. The front page of a recent issue deals with sal- monella, a type of food poisoning. ( Photo WHO/G. Causse) The WER also mirrors the evolution of ideas about health and disease. It came into existence in April 1926 as a publica- tion of the Health Organization of the League of Nations. Its main purpose at that time was to provide health officers in the world's ports with the most up-to- date information about epidemic dis- eases and quarantine measures. But its roots go even deeper into the past because, although the WER was published in Geneva, it derived a consid- erable part of its information about dis- eases from another centre of worldwide health work—the International Office of Public Hygiene in Paris. The Inter- national Office in turn dated from before the First World War, and exemplified the steady growth of the belief that nations must collaborate to combat epidemic diseases. The International Office was also a concrete symbol of the fact that the world had only quite recently emerged from a state of relative ignorance about how infection is transmitted. In the past, the only solution to an epidemic of cholera or plague was quarantine—the sealing off of a ship, a port or a country from potential infectious contacts. This idea, applied by sea-ports in different ways, caused so much disruption of travel and so often led to bribery and other abuses that governments were forced to come together to seek better answers to the problems involved. An important series of international conferences, which began in 1851, had not succeeded by the turn of the century in making decisive progress. This was largely because the laboratory findings about the causes of the major infectious 10 NW Wkly Epident. Re,. Releve hebd.: 1975, 50, 477-448 WORLD HEALTH ORGANIZATION GENEVA No. 52 ORGANISATION MONDIALE DE LA SANTE GENEVE WEEKLY EPIDEMIOLOGICAL RECORD RELEVE EPIDEMIOLOGIQUE HEBDOMADAIRE Epidemiological Surveillance of Communicable Diseases Telegraphic Address: EPIDNATIONS GENEVA Telex 27821 Service de la Surveillance tpiderniologique des Maladies transmissible, Adresse telegraphique: EPIDNATIONS GENEVE Telex 27821 Automatic Telex Reply Service Service automatique de reponse Telex 28150 Geneva with ZCZC and ENGL for a reply in English Telex 28150 Geneve suivi de ZCZC et FRAN pour une reponse en franca's Weekly epidemiological Record No. 52 is the last issue for 1975. The first issue of 1976, No. 1/2, is planned for 9 January. Le Releve ipidemiologique hebdomadaire N. 52 est le dernier numero publie en 1975. La parution du premier numero de 1976 (No 1/2) est prevue pour In 9 janvier. SALMONELLA SURVEILLANCE other than S. typhi and S. pararyphi 1973 Data for 28 Countries of Africa, The Americas, Asia, Europe and Oceania • 1 In 1973, under the WHO Salmonella Surveillance Programme, 31 national laboratories in 28 countries of Africa, the Americas, Asia, Europe and Oceania notified isolations of salmonella, together with the relevant epidemiological data. The present analysis covers the data from the United States of America in addition to those from the 27 countries already studied in 1972. The highest incidences usually correspond to the best-developed surveillance programmes. Moreover, comparative interpretation of the data received from certain countries is limited by the fact that the isolations notified to WHO reflect only the activity of their national salmonella reference centres, whereas in other countries, where a surveillance programme is in operation, the data are more representative of the country-wide situation. Even in such cases comparative interpretation is still limited by the differences in national systems of notification, in the selection of human specimens according to the severity of the disease, in the interest taken in case- finding, in methods of selection and collection of non-human specimens, in laboratory techniques and in the special interest taken by administrations in certain categories of persons, animals or commodities; such differing investigatory trends are particularly reflected in the frequency of the serotypes isolated from non-human material, for certain serotypes are to some extent associated with certain sources of isolation. Despite the present lack of a standardized methodology, the simultaneous study of isolations from man and non-human sources carried out by national laboratories has often led to the alarm being given and helped to guide the investigation when certain serotypes became more widespread. It was thus possible to determine the source of the infection and the way in which it spread (in particular, faulty hygiene in food production or food handling or poor hygiene resulting in contamination of a hospital environment), and the necessary measures could then be taken. Derailed information by country is available on request from Epidemiological Surveillance of Communicable Diseases Unit, WHO. Geneva. SURVEILLANCE DES SALMONELLA autres que S. typhi et S. paratyphl 1973 Donnees sur 28 pays d'Afrique, d'imnerique, d'Asie, d'Europe et d'Oceanie • 1 Dans le cadre du Programme OMS de Surveillance des Salmonella, 31 laboratoires nationaux de 28 pays d'Afrique, d'Amerique, d'Asie, d'Europe et d'Oceanie ont notifie en 1973 tears isolements de salmonella ainsi que certaincs donnees epidemiologiques les concer- nant. La presente analyse couvre les donnees des Etats-Unis en plus de celles des 27 pays deje etudies en 1972. On note habituellement une correspondance entre les incidences les plus elevees et les programmes de surveillance les plus developpes. On plus, l'interpretation comparative des donnees revues de certains pays est limitee par le fait que les isolements gulls notifient a l'OMS representent seulement l'activite de leur centre national de reference des salmonella, cependant que les donnees regues d'autres pays, oil fonctionne us programme de surveillance, refletent mieux la situation nationale. Meme dans ce cas, l'interpretation compara- tive reste limitee par les differences qui existent entre les systemes nationaux de notification, la selection des prelevements humain en fonction de la gravite de la maladie, l'interet pone au depistage des cas, les mdthodes de selection et de prelevement des echantillons non humains, les techniques de laboratoire et Einteret particulier pone par les administrations a certaines categories de personnes ou d'ani- maux, ou a certaines denties; cette orientation differente des investi- gations se reflete particulierement dam la frequence des serotypes Moles dans du materiel non humain, car certains serotypes soot plus ou moins associM avec certaines sources d'isolement. Malgre l'absence actuelle d'une methodologie normalisee, !'etude simultanee des isolements effectues chez l'homme et dans les sources non humaines par les laboratoires nationaux a souvent conduit a don- or l'alarme et permis d'orienter l'enquete tors de l'extension de cer- tains serotypes; i1 fut ainsi possible de mettre en evidence la source de l'infection et la maniere dont elle se propageait (en particulier, fautes d'hygiane dans la fabrication ou la manipulation des aliments, ou bien fautes d'hygiene causant la contamination d'un environnement hospitalier), et les mesures necessaires parent ainsi etre prism. Lea informations &willies per pays son, disponible, dernande adressn au Ser- vice de la Surveillance epidemiologique des Maladies transmissible, OMS. Epidemiological notes contained in this number: Communicable Diseases, Salmonella Surveillance, Salmonella wien Outbreaks, Smallpox. List of Newly Infected Areas, p. 445. informations epidentiologiques contenues dans cc numero: Maladies transmissibles, pousstm a Salmonella wien, surveil- lance des salmonella, variole. Liste des mum nouvellement infectees, p. 445. diseases were only gradually being dis- seminated and understood. At the 1851 conference, there was great insistence by some delegates that plague and typhus were one and the same disease, and were transmitted when there was contact with "infected air". The fact that plague is carried by fleas was not known until 1905, while only in 1909 was it dis- covered that the louse carries typhus fev- er. The British researcher John Snow showed in 1849 that cholera is transmit- ted by water polluted with human faeces, but his views were not accepted until the discovery of the vibrio, the organism that causes cholera, in 1884. These findings, and a spectacular list of successes in identifying the organisms that cause tuberculosis, diphtheria, typhoid fever, pneumonia, dysentery and syphilis—to name but a few—helped to create a modern scientific attitude to dis- ease and to make nations conscious of the need to be kept informed about their incidence and behaviour. One consequence was that the Interna- tional Office of Public Hygiene in Paris, set up in 1908, was required to keep its 12 Member States supplied with facts and documents about public health, and in particular to collect all available details in regard to cholera, plague and yellow fever. Typhus and smallpox were added later. In addition, the Interna- tional Office gave details of operations to destroy rats on ships and in ports and, in line with new advances in methods of travel, it formulated in 1933 an Interna- tional Sanitary Convention for Aerial Navigation. The flow of information was accelerat- ed by links between the International Airliners could all too easily transmit the car- riers of disease from one country to another. To test the effectiveness of insecticide sprays, used routinely by air stewardesses during take-off procedures, live mosquitos of the type known to carry malaria are released from laboratory test-tubes into cages, which are then placed in different parts of the pas- senger section. After landing at the next port of call, epidemiologists check whether the spraying killed all the mosquitos. These tests enable WHO to recommend the use of greatly improved insecticide sprays to airline mem- bers of the International Air Transport Asso- ciation. (Photos WHO/A. KocharIM. Jacot) Standing guard Office and the Far Eastern Bureau of the League of Nations in Singapore, the Pan American Sanitary Bureau in Washington, and the internationally ad- ministered Sanitary Office at Alexandria in Egypt. Most of the data supplied by governments through these channels was then re-transmitted from Paris to the Member States by telegram once a week, and this telegram was followed up by a weekly communique—the WER-sum- marizing the data and describing the progress of epidemics. The end of the Second World War also saw the demise of the International Office and of the Health Organization of the League of Nations in Geneva. Not until 1946, in the aftermath of the fight- ing, did the Interim Commission of the World Health Organization (which prec- eded the establishment of WHO as such) move into the Palais des Nations in Geneva, the old League headquarters. At the same time the Interim Commission took over the Weekly Epidemiological Record as well as the Library of the In- ternational Office of Public Health. All this may be quickly said. Yet it reflects the power of an idea to survive and develop in spite of the upheaval and collapse of old political systems. In fact, one of the provisions in the draft consti- tution of WHO was to draw up "sanitary and quarantine requirements and other procedures designed to prevent the inter- national spread of disease..." This led to steps to revise existing con- ventions and combine them into a single set known as the International Health Regulations, which deal in particular with the quarantinable diseases—plague, cholera, yellow fever and smallpox. The regulations require the health adminis- trations of WHO's 147 Member govern- ments to notify the Geneva headquarters of the appearance of such diseases on their territory, by airmail or if necessary by telegram, and to follow up this "early warning" by supplementary reports. WHO, in turn, has the responsibility of sending out the information to other Members, but it can only pass on the information it receives officially from Member States. Thus it can happen that an outbreak of cholera may reach the newspapers before WHO can make an official announcement. The delays and misunderstandings that may result from this kind of situation tend to work in favour of the disease, and to weaken the international defence arrangements that have so carefully been constructed. In pre-war days, the use of radio to transmit information about epidemics was not always welcomed by the more conservative public health administra- tions. Since the Second World War, swift radio news of the outbreak of disease in ports of call came to be recognized as essential, and so the WER developed an- other branch of activity. Each day, while the information coming in from many countries was being collated for the Record, one of the staff was also prepar- ing a radio bulletin. This was prepared in much the same way that news bulletins are prepared for radio broadcasting. The latest information was given first, but the previous data and any other useful infor- mation was summarized for the benefit of any listener who had missed previous newscasts. The bulletins were sent out every day, on eight wavelengths in English and four in French, and were re-transmitted by way of Singapore and Alexandria, as well as through a network of 12 stations throughout the Indian Ocean and the Western Pacific. But here too, each step in the technol- ogy of travel and communications makes an impact. The spread of telex connec- tions throughout the world has led to a further evolution at WHO. Today, epide- miological information is available to anyone who has a telex machine and who dials the appropriate number at the Geneva headquarters, while the radio bulletins have been superseded. At the same time, data about world disease out- breaks can be fed into the WHO comput- ers and stored there for general informa- tion but also for analysis by skilled epi- demiologists. The thinking behind the International Health Regulations is also changing in response to new developments in public health. Whereas the WER at its inception was used to disseminate information about the old pestilential diseases, it has gradually over the years become a vehi- cle for information about other com- municable diseases. Influenza is a good example. The virus, which alters so quickly that it is difficult to stock a vac- cine against it, is now being continuously surveyed by a network of WHO Influenza Centres in all parts of the world. As soon as a new variation is observed, the news is transmitted to laboratories so that the correct type of vaccine can be prepared as quickly as possible in time to cope with possible epidemics. In huge areas of the world, WHO is battling to control the scourge of malaria. Here too, continuous surveil- lance is essential, and is already bringing a warning that the disease is reappearing in areas where it had apparently been eliminated. Rabies is spreading among wild life in Western Europe, and has been put on the WHO surveillance list. Other diseases being watched closely in- clude dengue haemorrhagic fever in South-East Asia and the Western Pacific. Tuberculosis is dwindling in Europe, but is also being kept under surveillance by WHO. A recent addition to the list is salmonellosis, an infection usually result- ing from poisoning by contaminated food. But there is more to the processes of change than simply putting down more diseases for the watch-list. Even while vaio is getting steadily closer to the point where smallpox will disappear for ever from the quarantinable diseases list and while others are declining in significance, the work of epidemiological surveillance is also assuming new dimensions. Public health officials are beginning to realize that keeping track of the infectious agent of a disease is not enough. So they have begun to study all the other factors involved. One person may contract tuberculosis and another will not. What is the reason? The experts are probing into questions of the socio-economic en- vironment, into theories of social stress, asking more questions about the length and type of exposure to infection, ex- amining differences in food habits and nutrition. However, one fundamental need will remain—the systematic collection, evalu- ation and dissemination of the informa- tion that health authorities must have to be able to decide how to cope with infec- tious disease. It is in that area that the Weekly Epidemiological Record has and will continue to have a central role. ■ 13 Mongolia: a leap across the by Lalit Thapalyal • Photographs by Didier Henrioud ongolia, in the heart of the Cen- tral Asian land mass, is a country of infinite variety and climatic ex- tremes. Mountains and plateaus, lush meadows and arid deserts, alpine flow- er valleys and burning sand dunes are all part of its landscape. Barring a few river valleys, the country is a barren 1200-1500- metre high plateau ringed in the north-east by rugged hills of shale and the perpetual snows of the Altai mountain range, and ex- tending in the south-east to merge with the semi-desert of Gobi. In winter, which lasts half the year, mercury drops as low as -52° Centigrade and frosty north winds reach a velocity of 100 km. an hour. The short summer, punctuated by a rainy spell, can be intensely hot with temperatures shooting up to 40° C in the shade. Sudden rainstroms come pouring down in devastating floods. The burning heat of day alternates with the biting cold of night, and snow-storms on summer nights are not uncommon Under a thin layer of topsoil, the earth lies eternally frozen, allowing little to grow besides low brush and pasture grass. Drink- ing water is scarce and hard to come by. In winter, lakes and springs freeze and the only way to get water is by melting snow. Most of the year the air is crisp and dry and the sky cloudless. Like the smile of a capricious god, a bright blue sky looks over a million and a half square kilometres of picturesque desolation. A look at the map will show that the Mongolian plateau is in fact the eastern- most part of the vast wasteland spreading across the old world from the Sahara in Africa through Arabia, Iran, Transcaspia to Turkestan. One begins to wonder why the people who first chanced upon this forbid- ding land decided to strike roots there. Was it the irrepressible urge in man to attempt what seems impossible for no other reason than the challenge it offers? No one can say, but the fact remains that the inhospitable climate notwithstanding, human civilization 'flourished, and as Dou- glas Carruthers points out in his "Unknown Mongolia", the land became the home of some of the greatest Asiatic races, the Mon- gol and the Turk, and such widely separated people as the Finns of north Europe, the Magyars of Hungary, the Red Indians of America, the Samoyeds and the Eskimos. On these plateaus wandered the Huns who eventually overran Europe. On the basis of archaeological evidence, it is possible to speculate that the early set- tlers were perhaps favoured by a milder cli- mate in which crop farming was possible. For the evidence of the first people in Mon- golia has come down to us in the form of tools for hunting and primitive agriculture belonging to the paleolithic and neolithic periods. These artefacts are similar to those of the same period in northern China and southern Siberia, suggesting a continuous culture. As the bronze age arrived, the arte- facts—tools, weapons, domestic wares and decoration motifs—clearly suggest a domi- nant influence of animal husbandry on the life style. And ever since, for unknown thousands of years, man together with his domestic pets has faced the challenge of nature in Mongolia. Adapting life to the varying moods of nature, making the natural pas- tures their major resource, using all their ingenuity to feed and shelter man and ani- mal, countless generations of Mongols have given the answer to the land's barrenness by filling it with teeming life. In regions where the hardy mountain sheep, the wily wolf, the marmot in his burrow and the miraculously equipped two-humped camel alone seem fit to survive, the breeding of cattle has become the major industry. The story of man's triumph over nature in the Mongolian plateau is really the story of man and his animals. For it is certain that without his cattle man could not have sur- vived the lack of food and water and the rigours of climate. Throughout the centu- ries, the Mongol has eaten and drunk off his animals, dressed in their wool, lighted his home with animal fat, and cooked and kept warm with fire fed with the dung of his animals. His animal wealth gave him a unit of value which is unique. Besides the tugh- rik, the official currency, and its hundredth part, the mogo, values are expressed in terms 14 of bot or bodo — one bot being the equi- valent of one horse or one cow or seven sheep or ten goats. A camel is worth 1.5 bots. The Mongol has ridden the horse behind his flocks across the immense grass- lands and gone to war on horseback from the age of archery to that of gunpowder. His love for the horse has found expression in Mongolian mythology and folklore, in the national musical instrument, morin hur, shaped like the horse's head, and in the traditional festival of cross-country horse- racing. The country is sometimes called the land of five animals, and the five have been given a place of honour in the official em- blem of the country. It depicts the horse (with rider), the cow (which includes the yak), the sheep, the goat and the camel. A fitting tribute, considering cattle-raising was at one time the sole basis of the country's economy, and even today, 64 per cent of the people are herdsmen or engaged in trades associated with animal husbandry. Their principal occupation has imposed upon the rural people of Mongolia a nomadic pattern of life. With no agriculture to sustain a settled population, people took to a wandering life, moving with their flocks of sheep, goats, cows, yaks, horses and camels from pasture to pasture. They in- vented the remarkable yurt or tent house, a roomy structure made with latticed wood panels wrapped round with layers of felt, which can be set up in 20 minutes, taken down and packed in 40 minutes and carried by two camels. Once the grazing ground ran out of grass and water, the arat or herdsman, with his family on horseback, his yurt packed, would move on to another pasture. Owing to the climatic variety, pastures are ready for exploitation in different parts of the country in different seasons. There are autumn, summer and winter pastures where the herdsman must arrive with his flocks following the seasonal clock. How often a family moved in the course of a year would depend on feeding and water supply condi- tions in different regions, ranging from four removals in the northern areas to 20 in the more arid southern parts. This was the pattern of life of the Mongol people for centuries, unchanged by wars, subjugation, foreign migration or the in- fluence of the international caravan routes that crossed their soil. It remained un- changed even when the Mongols themselves threw up a leader of the stature of Jenghiz Khan, founder of a dynasty that established an empire extending from the Pacific to the Adriatic. The pattern is very much in evidence even today. Animal husbandry still accounts for 80 per cent of the entire agricultural production and 50 per cent of the gross national product. The country has 1.3 mil- lion people and a population of 24 million animals. Even today, huge flocks of cattle must be moved from one grazing ground to A land of infinite variety and climatic ex- tremes, Mongolia has since time immemorial been the home of skilled herdsmen and their sturdy livestock. As herdsmen, the rural popu- lation chose a nomadic pattern of life centred around the yurt, or tent house, which can be carried on the backs of two camels or erected in 20 minutes. the next. But there is a tremendous differ- ence : a modern state has put science and technology at the service of the arat and transformed his life and his ancient calling. Gone are the days when families of herds- men, holding tenuous grazing rights under an oppressive feudal system, fought lone battles against hunger and disease and weather. The business of animal husbandry today is run by state farms and cooperatives of herdsmen with the full backing of the state veterinary service and research devoted to preventing animal diseases, increasing milk yields, improving the quality of wool and breeding better animals. In many places, fanning has been entirely mecha- nized. Tractors are used to break the frozen soil and automobiles transport the produce. Electricity is used not only to dig wells but to shear sheep and milk cows and yaks. Planned exploitation of pastures, digging of wells for drinking water and cultivation and storage of fodder have been introduced to reduce as far as possible the seasonal migra- 15 tion of the people and their flocks. Tremen- dous efforts have been made to bring more land under the plough and encourage people to take to farming. Industrial developments of the past five decades—coal-mining, metal- lurgy, electric works, petroleum, timber, leather goods, wool washing, food products— have created new jobs, and new townships have come into being. Today 45.7 per cent of the people live in towns or urban type settlements. While seasonal migration conti- nues, distances have been reduced to ensure that long treks do not disrupt administra- tive, educational and welfare measures. These developments, which followed the creation of the Mongolian People's Repub- lic in 1921, have occurred alongside tremen- dous efforts to safeguard the health of the people. Today, even the people who must move from pasture to pasture with their flocks are within reach of the State health service. The human being is naturally regarded as a most valuable resource in a country where the density of population is less than one inhabitant per square kilome- tre. From the start the health services of Mongolia have given the highest priority to fighting diseases and conditions that cause high mortality among infants and children. The history of Mongolia's health services does not go too far back. The first step to create a state health service was taken only in 1925 when it was decided to create under the Ministry of the Interior a public health section with jurisdiction over a hospital with 15 beds and an outpatient department. It was nothing more than a symbolic gesture considering the enormous health problems inherited from pre-revolutionary Mongolia. While epidemic diseases ran rampant there was no scientific medicine in the country and no national medical establishment of any kind. Quack doctors and mountebanks exploited the people on the pretext of treat- ing them. There did not exist a single Mon- gol with a degree in modern medicine. In 1924, 13 per cent of women who bore a child died in giving birth. Infant mortality was so high that only half of the new-born lived to see their first birthday. It has been estimated that between 1862 and 1918, when the general world trend was for increasing populations, the population of Mongolia decreased by 4.5 per cent. In 1930, the Section of Public Health was made a full-fledged Ministry of Public Health. The health service began to grow, with expertise and other assistance from friendly countries, particularly the Soviet Union, and gradually overcame the difficul- ties posed by the lack of trained staff and training facilities, vast distances, widely scattered communities, nomadism, as well as the ignorance and superstitious beliefs of the people. Today Mongolia spends 10 per cent of its national budget on health and em- ploys thousands of doctors, feldshers (assis- tant doctors), nurses and technicians in a health service that covers virtually the entire country. Each citizen has the right not only to free medical treatment but to old-age pension, special grants in cases of prolonged illness and a life-long pension in the event of partial or total loss of working capacity. To understand the network of health ser- vices, reference must be made to the admi- nistrative set-up of the country. Mongolia is divided into 18 aimaks or provinces, which in turn are divided into about 20 somons or districts. The average population of an ai- mak is 50,000. Each aimak today has a 75- 150 bed hospital and polyclinic and a sani- tary-epidemiological centre. Each somon has its own medical centre and one or more feldsher centre, that is a unit placed under the charge of a feldsher. A somon hospital has 15 beds and controls one or two feldsher centres. A feldsher centre serves a radius of 15-100 kms with a population of 1,000 to 2,000. Up to 50 beds are provided in the inter-somon hospitals, which serve more than one somon. The medical centres and feldsher centres are equipped with ambu- lances for use in emergencies as well as pub- lic health laboratories for blood tests and other routine examinations. Medical and feldsher centres have been set up in all areas where people congregate, such as agricul- tural associations, state farms, machinery I II depots, railway stations, rest homes, indus- trial centres, and educational and adminis- trative establishments. Mother and child health care occupies a place of particular importance in the health service. A network of maternity homes and delivery centres has been set up and advice on mother and infant care, infant feeding, creches and nurseries is available all over the country. Expectant and nursing mothers receive medical care and advice not only in their own neighbourhood but at home through qualified visitors. Ninety-five per cent of the deliveries take place in maternity homes under the supervision of trained staff. A working mother is entitled to 45 days' leave with full pay before and 56 days after delivery. Mothers of large families receive special consideration. From the fourth child onward, a mother is entitled to receive, strictly for the needs of the child, a sum of 300-400 tughriks a year until the child reaches his or her eighth year. An amount of more than 20 million tughriks is distrib- uted annually under this head. (A tughrik is equivalent to about US$0.30.) The birth of twins is treated with special attention and in the event of triplets or other multiple deliv- eries, the State assumes full charge for the health and upbringing of the children until they reach the age of eight. If the birth has taken place in a remote rural region, the mother and babies are rushed to the central hospital in Ulan Bator, the capital city, by the fastest possible means. An innovation is the pension or rest home provided for expectant mothers in many state farms. Two weeks before the baby is due, the mother is brought to the pension to rest and relax and prepare for the coming of the baby. This is particularly important if it is a first delivery. The mother also receives from the nurse-midwife or feldsher instruc- tions in hygiene, infant feeding and the care of the baby and herself. She returns to the pension after delivery for another week of rest and practical demonstration in handling the baby. Eleven per cent of all babies born are raised in State-run creches with a total of 16,000 places. Intended for the children of working parents, these creches are medical establishments supervised by qualified pae- diatricians. Mongolia today has one paedia- trician for every 1,200 children (0-15 years). The policy of paying special attention to the health of mothers and children has paid rich dividends as the declining infant mor- tality rates in the following table will show: Deaths per 1,000 born 1923 1935 1940 1960 1965 1973 500 322 157 69.7 65.0 60.8 Life expectancy at birth doubled from 32 in 1930 to 64 in 1974. The deaths of mothers in childbirth were reduced a hundred times between 1924 and 1974: from 130 to 1.3 deaths per 1,000 births. The feldsher has played a leading role in taking health care to the people in the remote rural regions of Mongolia. The training of feldshers and nurses, begun in 1929, was one of the earliest undertakings of the young health service of the country. As the new cadres came out they were posted in rural areas to fight prejudice and supersti- tious beliefs about health matters and to enlist the support of the people for the newly introduced medical and sanitary mea- sures. Thanks to the intensive mass educa- tion drives of the early years, scientific medi- cine had been completely accepted by the people by 1940. Two years later was estab- lished the State University of Mongolia with its Medical Faculty, and the country began to train its own physicians. Towards the end of 1972—that is within a span of 30 years— Mongolia had a doctor-population ratio of 1:512 and 97 beds for every 10,000 inhabi- tants. However, the concept that health care delivery is a function of the health team rather than the physician alone was recog- nized from the start. The State pressed for- ward simultaneously with a programme to train several categories of auxiliary workers with emphasis on the feldsher. At the end of 1972, Mongolia had more than 11,600 medi- cal workers, 9,000 among them auxiliaries, Mongolia: A leap across the centuries A midwife from the Second Maternity Home in Ulan Bator, the Mongolian capital, calls at a yurt to check that mother and baby are doing well. Mothers and their babies usually stay for > eight days after the birth at the spick-and- span Maternity Home in Ulan Bator. Fifty years ago, only half of the new-born lived to see their first birthday. In 1973, the infant mortality rate was down to 60.8 per 1,000 births. r III which included feldshers, pharmacists, assis- tant pharmacists, nurses, midwives, nurse- midwives, laboratory technicians, X-ray technicians and dental technicians. The training of the auxiliaries, carried out in four schools, is based on a plan that takes into account specific needs of the communi- ty concerned, and all those successfully completing their courses find a place in the health service. In the Mongolian health system, the feld- sher—first used with great success by the Soviet Union—not only helps the physician but performs a number of independent func- tions such as introducing disease prevention and sanitary measures, making home visits, treating uncomplicated cases of sickness and assisting with the rehabilitation of disabled workers. He or she gathers health statistics, undertakes epidemiological investigations and works at sanitary-epidemic stations. The feldsher is encouraged to improve his or her professional qualifications and is entitled to be promoted to the cadre of graduate doctor. Between 1960 and 1972, the number of feld- shers increased more than 220 per cent. Economic development The progress in the health field has gone hand in hand with the socio-cultural and economic development achieved under a series of five-year plans launched by the Government. Railways and roads were built, telegraph and telephone lines laid, and an internal aerial transport network created to cope with the immense distances of the country. Radio played a major role in knit- ting the country together. In 1970, six radio transmitters were in service and 150,000 receivers-129 receivers per 1,000 popula- tion. There are 30 newspapers and 18 maga- zines, and television was introduced recent- ly. Illiteracy has been wiped out and there is virtually no unemployment. Cereals are not an important part of the Mongol diet but the little the country needs is no longer imported but grown locally. Agricultural and industrial output have been steadily rising. During the fourth five- year plan period (1966-70), for instance, the gross national product increased 1.6 times with an average growth rate of 9.9 per cent. Considerable increases were recorded in per capita output of such products as power (78 per cent), coal (77 per cent), and meat (56 per cent). Other examples of develop- A patient having an encephalogram reading at t> the First General Hospital in the Mongolian capital. Fifty years ago, there was only one 25-bed hospital to serve all Mongolia. Today there is a country-wide network capable of providing the most sophisticated services to meet the people's needs. 18 Mongolia: A leap across the centuries ment activities typical of Mongolia's special needs were : drilling of 5,900 wells to improve water supply over 18 million hectares of pasture, and building of 13,000 sheds to protect some 6 million head of livestock from winter frost and blizzards. Gains made in the health field over the past decade include a dramatic decline of death rates from such diseases as diphtheria, dysentery and virus hepatitis. A compulsory vaccination programme keeps in check poliomyelitis, diphtheria, whooping cough and tuberculosis. Smallpox, typhus and pla- gue have been eradicated. After a mass vac- cination drive, measles appears to have vir- tually disappeared. Institutions devoted to medical and veterinary sciences have been expanded and the pharmaceutical industry is being developed to meet the country's need for vaccines and other products. Mongolia's major concerns in health today are : further improvement in the mother and child health services, nutritional deficiency diseases, infectious diseases asso- ciated with lack of water and unhygienic conditions, and zoonoses, that is diseases transmitted between man and animals, mainly brucellosis and hydatid disease. The health authorities are taking a serious view of the fact that infant mortality rates, which showed a dramatic decline until the last decade, have remained more or less un- changed over the past few years. Part of the reason undoubtedly is improvement in the registration of death and disease, but dis- eases of infancy even though declining still take a heavy toll. A major problem recog- nized in 1972 was the high rate of deaths- 35 per cent— among child patients within 24 hours of admission to the Central Chil- dren's Clinic in Ulan Bator, the largest pae- diatric hospital and training centre in the country. A solution to the problem was sought by setting up an intensive care unit and strengthening the hospital's capacity to handle critically ill children. A group of six doctors was sent to take specialized training in the Soviet Union and joined the staff of the intensive care unit on its return. Infectious hepatitis and enteric infec- tions, both associated with lack of safe wa- ter and sewage disposal facilities, are still major causes of illness. Expansion of water supply and sewage disposal systems were therefore given top priority in the fifth five- year plan (1971-75). In 1972, only 50 per cent of the country's population was sup- plied with piped water, and only 2.6 per cent had a sewerage system. The problem of wa- ter shortage will be seen in its true dimen- sions when it is recalled that two-thirds of Mongolia's territory is without permanent rivers, brooks or lakes. The southern half is particularly arid with no fresh water sources on the surface—only a number of lakes con- taining salt water. Streams rising in the cen- tral mountain range of Hangai and flowing southwards disappear in the thirsty earth even before reaching the sands of Gobi. Large resources of underground water are, however, known to exist in the arid zones. With the major emphasis on safeguarding the health of the children, increasing atten- tion is being paid to their nutritional status. In a 1974 sample survey, a high percentage of infants in Ulan Bator and in a rural dis- trict were found underweight for their age and a small percentage were seen to suffer from severe malnutrition. A selective study of children from kindergartens showed vita- min C deficiency and iron deficiency anae- mias till the first year of life. Evidence of rickets was found in a high percentage of the children. The traditional Mongol diet consists of meat and milk: more meat in winter, more milk in summer. A popular drink is the fresh and cooling areg or kumiss, made from fermented mare's milk. From cow's milk are produced tos (butter), tareg (sour milk), orum (solid cream), besleg (cheese) and even a milk vodka known as arkhi. Bread was introduced in the Mongol diet comparative- ly recently. Strange as it may seem, the Mongols, although animal-breeders, never took to pig-rearing or poultry-keeping. The explanation, of course, is that pigs and fowl require for their growth a settled way of life and cannot withstand the strain of a nomad- ic life and climatic extremes. Eggs, chicken and ham are therefore foreign to the tradi- tional diet. So are fish, green vegetables and fruit. The people have plenty to eat and among adults calorie requirements appear to be ad- equately met, but deficiency conditions due to lack of vitamin C—found in green leafy vegetables and fruits—and D—of which milk and sunlight are important sources— are sometimes observed. There is also a ris- ing trend in dental caries which is possibly associated with over-consumption of soft foods. Fluorine deficiency may also be a factor. To add variety and the missing nutrients to the Mongol diet, the Government, through 33 State farms and 272 agricultural associations or cooperatives, has been pro- moting a programme to grow vegetables and develop piggeries and poultry farms. To meet the problem of milk shortage in winter months, plants have been set up to produce dry milk and milk foods for infants. Milk kitchens are being reorganized and expand- ed and centres being set up to produce and distribute vegetable-fruit and meat-vegetable purees for infants. Health education in nutrition is being treated as an important goal of the health services. The control of brucellosis, a disease which affects cattle, particularly sheep and goats, and can be transmitted to man, is still regarded as a top priority. Known by a vari- ety of names in Europe—undulant fever, Malta fever, Mediterranean fever, Cyprus fever, Gibraltar fever, Neapolitan fever, goat fever, etc.—the disease was first report- ed in Mongolia in 1932. Its symptoms in man are remittent fever, headache, constipa- tion, weakness and anaemia. The brucellosis problem is being tackled through mass vac- cination of animals with vaccine manufac- tured in Mongolia. With assistance from UNDP and wHo a brucella vaccine centre has been set up with a production capacity of more than 3.5 million doses a year. A labo- ratory has been established in the Institute of Hygiene, Epidemiology and Microbio- logy for the quality control and field testing of the vaccine produced. In summer months, a newly organized field service car- ries out mass vaccination of the livestock. The health service of Mongolia, based on the principles of State responsibility, free medical care, mass public support and dis- ease prevention, has made a tremendous im- pact on the life of the people. It recognizes no difference between service provided in the rural and urban areas, and the emphasis throughout has been on creating health units in the remote rural regions so that front-line workers should remain in con- stant touch with the population. Mobile health units providing laboratory, radiologi- cal and dental services have also played an important part in taking health care to the people. Simultaneously with preventive, educational and treatment programmes in communicable diseases, diagnostic and curative services have been developed to deal with cardiovascular diseases and cancer. Starting 50 years ago with no more than a 25-bed hospital, Mongolia's health services are today an all-embracing countrywide net- work, sensitive to the needs of the people and able to provide some of the most sophisticated services available anywhere. Indeed, the many-sided development of Mongolia within this brief span is a vivid example of the pace of life in the twentieth century. Between the early twenties and the seventies the country has telescoped centu- ries of progress. President Tsedenbal of Mongolia described this phenomenon in the following words: "Mongolia has passed directly from feudalism to socialism, without going through the phase of capital- ism. That's what is original and special about our development." ■ 19 one woman's liberation Invited to join a home economics club some years ago, Mrs Gichuki learnt how to improve not only her crops but the whole pattern of family life by Ruth Seitz it ladys Gichuki has never heard the hum of international women's lib. She doesn't lobby or litigate. As a small-scale farmer in the highlands of Kenya, she is too steeped in her work to analyse her status as a female. Her work is similar to that of her mother and grandmother. Cutting fire- wood. Bearing her husband sons, and daughters who will lighten her own load. Marketing to pay the school fees. Wom- en of the Kikuyu tribe have always plant- ed and harvested crops for the family food and, since her marriage over 30 years ago, she has filled this traditional role. But gradually, knowingly or not, over the past seven years Gladys has used that role for her own liberation. It is her approach to farming that has freed her and her family, economically and nutritionally. She used to plant only maize and beans, Kikuyu bases for irio and porridge. Now her five-acre shamba, the East African word for farm, is a rich source of tomatoes, onions, cabbages, potatoes, Swiss chard, and much more besides. Despite the high-potential soil at the base of the Aberdare Mountains, crop failure was a frequent occurrence. Fifty- year-old Gladys recalls the hardships of relying on two uncertain crops to feed her family of ten. "During one drought, my second son Elfred almost died while we were walking to a district 20 miles away for food." Such times were more dreadful because there was no seed maize for the next planting. The fear of being hungry no longer threatens the Gichuki household. There is plenty for three meals each day and snacks in between. Now a university graduate, Elfred is happy to return to "our good life". Gladys attributes this abundance to improved cultivation, the use of hybrid seeds and careful crop planning. Between the shelter of the house and the seven- foot-high maize stalks lie beds of carrot seedlings of different sizes and single- leafed pepper stems. Lettuce heads nestle in the shade of the grass thatch. Raising young plants is important because the timing is crucial for market- ing. To ensure a steady income, Gladys must have several vegetables to take to A woman's hand on the panga, the East Afri- can machete. There is nothing unusual about that in many parts of Kenya. But Mrs Gladys Gichuki has taken the trouble to learn how to farm efficiently. Right: Where once only maize and beans grew, her farm is now a rich source of toma- toes, onions, cabbages, potatoes and much more besides. ( Photos WHO' Blair Seitz) market each week. "The use of cash has changed everything. My grandmother never sold food from the land." The changes that made all this possible for Gladys began in the late 1960s when a Government field worker invited her to join a home economics club. Members planted a communal vegetable garden under the instruction of a Ministry of Agriculture employee. In these sessions, Gladys first learned about commercial fertilizers, transplanting, ridging and spraying. "I never knew that you had to do different things to each crop as it grows." Previously Gladys left her maize and beans to the whims of the sun, wind and rains. The Kenyan Government started a network of these clubs to upgrade the knowledge and skills of female agricultu- ralists. There was a growing demand for marketable produce in the densely popu- lated division where more than 100,000 people besides Gladys occupy 59,000 acres. According to a Ministry official, the clubs have been effective because women like to work in groups and the benefits of improved crop care are ob- vious within a short time. First-year members receive enough hybrid seeds, insecticide spray and ferti- lizer to plant a quarter acre of vegetables. Annie Wainaina, a consultant to the dis- trict, feels that these inputs help to en- courage a member to give extra care to her crops. "It is easier for a woman to improve an existing pattern than to do something entirely new", she explains. For these reasons, many Kikuyu wom- en farmers are amenable to the new ideas that reach them. Last year when Gladys was the chairman of her club, members discussed the possibility of tape-record- ing helpful observations about crop-rais- ing for other clubs. 20 ~~ 4 4044 IP a 4° Unfortunately, these clubs function in only a few districts in Kenya. Most agri- cultural extension services ignore the needs of women farmers. All the field workers are male, and women's leaders say their prejudices hinder females from seeking advice. Most agricultural education in the rural areas stems from the farmers' train- ing centre, an institution begun in colo- nial times. Gladys has received no train- ing in horticulture at the centre in her area, but she has attended several one- week courses on food preparation. "We talk about how to fix these new vege- tables and cook good meals. I try to give the family something from each of the four food groups every day." She makes a stew of fresh vegetables seasoned with chilis. She squeezes pas- sion fruits to make a nutritious juice and stores dried pumpkin and pea leaves in calabashes for the dry season. A few orange, papaya and banana trees flour- ish on the Gichuki plot. But her cakes are the children's favou- rites. Whether they are yam cakes or green maize cakes, she insists, eggs and milk are in all of them. With chickens scratching the red earth and two Grade cows producing milk, each family mem- ber gets his or her share of these protein foods. Gladys is adamant about the effect of an improved diet on her family. "My children who are now adults grew more slowly and didn't learn as fast in school. The younger ones are quicker mentally." Her ingenuity brought about a strange turn of events—for Kenya. Four years ago her husband quit his city job to make the shamba a family business. One can view Narickson's return home either as an attempt to keep an eye on the superior income Gladys was making or to lend a hand to increase production. The truth is probably somewhere in between. At least 60 per cent of the women in rural Kenya are heads of households because their husbands work in distant towns. These women depend on an occa- sional money order to buy store items and on an annual visit from their hus- bands. Gladys is relieved that her solven- cy has wiped out the wait for money from Narickson to buy essentials like cooking fat. However, the Gichukis still follow the traditional precedent for family finances. Kikuyu men have always handled cash and the possessions which symbolize it, such as land and stored grain. Cropping, including marketing fresh surplus, is the responsibility of women. But the men decide the future of dried grains. Gladys controls the shillings that come from sell- Mrs Gichuki's success encouraged her hus- band Narickson to quit his city job and help her make the . farm a family business—not just a smallholding relying on two uncertain crops to feed the family of ten. Today the Gichukis no longer fear hunger. Left: The fat maize cobs, ripened in the Kenyan sun, form the basis for good tradi- tional meals. But Mrs Gichuki makes sure that her maize dishes are also well fortified with such protein additives as eggs and milk to guarantee a rounded diet for her family. ing market produce. But her husband directs cash crop sales—the green pep- pers and coffee. The Gichukis are relying on their harvest of green peppers to pay next year's school fees. Their one acre of plants will bring in at least SH 4,000 per season, more than the minimum annual wage for a labourer. After paying for inputs, a farmer's net profit from the cannery is SH 2,000. They pay SH 1,485 (US$212.50) to send four children to school. Secondary school fees, which take most of the money, are scheduled to double next year. Dr Margaret Mead, the authoress and anthropologist, once said, "Every time we liberate a woman, we liberate a man". This seems to be true for the Gichukis. Narickson claims that he and Gladys plan together how to spend the returns from a cash crop. There is certainly evi- dence that they utilized the funds to ease work for both of them. Since they installed a storage tank that holds almost 9,000 gallons of drinking water, Gladys no longer has to walk 1,000 metres down a steep hill to the river. Rain caught in the spoutings runs into the cement tank, and Gladys fills her jugs at a tap five metres from her kitchen. Narickson points to his wife's clever- ness as a source of his own self-respect. "She made me want to improve my liv- ing condition; before, I didn't care where I slept." Now they entertain visitors who come for agricultural advice in a three- room wooden house with a cement floor and a metal roof. "Neighbours ask ques- tions about the timing of planting crops. They notice that my wife has not only learned modern agricultural methods but has also changed our way of living." Ten-year-old Eluid Gichuki is also aware of the change. After this young farmer had sold potatoes from the small plot he had cultivated, he was awarded the choice of two luxuries. He chose a pair of leather shoes and a warm jacket for the cold July weather at an altitude of 2,000 metres. (Many of his friends go barefoot.) Gladys likes hot chai on those chilly days. She doesn't fret about inflation when she opens up the knotted cloth at her waist to take out shillings for the tea and sugar. True, she spends more at the store each month for such items as soap than she did in a year during the sixties. But the rise in expenditure is tolerable because the other changes in her way of living are so good. ■ 23 E hocolate Hills and midwives seem unlikely ingredients for a story of rural uplift. But in the island of Bohol in the southern Philippines they appear to have mixed well. The mixture has in fact sparked a current that has put fresh life into this pastoral island. Life in its villages has visibly improved. Since tourism in the Philippines is now in top gear, visitors invariably hear about the Chocolate Hills of Bohol. These are more than 1,000 cone-shaped limestone mounds arranged—as if by design—over an area of several hundred square kilometers in the north-eastern part of Bohol. From a distance, they look like huge chocolate drops. Others say they resemble inverted kettle drums covered with grass. In fact they repre- sent a rare geological phenomenon, per- haps the only one of such extent in the world. Legends add colour to this natural wonder. Most local stories involve giants believed to have inhabited the isl- and in past ages. One such legend said that a young giant named Arogo fell in love with Aluya, the loveliest Bohol maiden. They lived happily together for some time and, when Aluya died, Arogo was deeply grieved. He wept prodigious- ly, and his giant-sized teardrops were scattered all over the place. The drops solidified to form these thousand small mountains. Geologists have their own theories. They suggest that the island lay under the sea many thousands of years ago. Volcanic eruptions created these irregu- larities which were polished off to per- fect cones by undersea currents. Eventu- Home visiting may mean a long walk for the newly-trained midwives based at Primary Care Centres in the Philippine island of Bohol. "But a merry heart goes all the day", and these young girls can be confident of find- ing a welcome wherever they go. (Photos WHO/J. Abcede) ally the land was pushed up by upheavals of the earth's crust to form the island. Whatever the origin, these hills are a charming sight. Bohol offers more: un- spoiled, pollution-free beaches, ancient churches, historical sites, mats, baskets, raffia and burl hats, bamboo crafts and pottery. Now Bohol has started to exploit these charms. Tourists travel to the Chocolate Hills in comfort along well- paved roads. Beach resorts and hotels midwives among the chocolate hills The Bohol Project in the Philippines uses only local resources trained midwives: yet its long-term implications are ambitious indeed by Jose Abcede 24 are already on the drawing boards. Local cooperatives have been set up to improve the quality and quantity of bas- kets, mats and other crafts. The same roads for air-conditioned tourist coaches serve farmers and crafts- men in the transport of their products. They are also vital arteries linking the people of the barrios (villages) to such amenities as the health services. This brings us now to Bohol's other "attraction". This is more mundane, involving or- dinary village folks, rather than the legendary giants. It is a human process, not a geological formation, and its ob- ject is to seek a better quality of life for the barrio people and the improvement of the health of mothers and children. Why is it special? Why is it an "attraction". The Bohol Province Family Planning Project is one of four such projects in the world assisted by the New York- based Population Council. The others are in Indonesia, Nigeria and Turkey. Family planning Like its counterparts, the Bohol pro- ject was started because there were still many unanswered questions about fami- ly planning. What is the best approach to reducing fertility? Does a maternal and child health (max) service provide the best framework for family planning? How can mai and family planning be integrated effectively? With what resources? How can community partici- pation be assured? International organizations interested in these questions teamed up with the Philippine Government and other bodies in Bohol to get some answers to these questions. They are the UN Fund for Population Activities (UNFPA), the Population Council and the World Health Organization (wHo). On the Philippine side are the Department of Health, the Population Commission, the UP Population Institute, the Bohol pro- vincial government and the Tagbilaran City health office. In July 1975, personnel trained in mcx and family planning set to work in the area and a number of project activi- ties were started. Thirteen primary care centres were opened. Project activities, in fact, revolve around these centres which are staffed by newly-trained mid- wives. These primary care centres (Pccs) are satellite clinics linked to rural health 25 Philippines : Midwives among the Chocolate Hills <Miss Nellie Sumatra making one of her home visits accompanied by a group of her collea- gues undergoing field training. The Primary Care Centre in La Victoria sees to the in- service training of midwives before they are posted to other centres. On four days of each week, Miss Sumatra r> checks on the mothers in all the barrios of Carmen Town under her control, to ensure that they and their babies are thriving. The midwife represents the starting point of pri- mary health care in any community. units and hospitals. They are located in barrios not regularly reached by rural health units. Eventually 60 PCCS are to be opened. The people had a voice in the selec- tion of the sites and in setting up the PCCS. Barrio funds were used to buy construction materials and the people themselves built some of the centres. One PCC was built from funds raised at a beauty contest among wives of the barrio captains. The barrio people also helped to provide housing for the mid- wives assigned to the centres. Miss Cornelia Sumatra is one of the young, newly-trained midwives posted to Primary Care Centres. On 4 August 1975, after her graduation from the Cebu School of Midwifery and follow- ing one month's training in the project headquarters, she took over the PCC in La Victoria, a barrio of Carmen Town in the Chocolate Hills region. Before the Pcc was set up, mothers and children in the barrios had to wait for the one-day-a-week visit of rural health units. Miss Sumatra—the local residents call her Nellie—now lives in La Victoria and provides basic health care every day of the week. Four days are devoted to seeing pregnant mothers or attending deliveries, checking on the new-born, giving immunization or talk- ing with the mothers on family plann- ing, nutrition and sanitation. Once a month, Miss Sumatra discusses family planning, nutrition and sanitation with barrio assembly members. Her area covers six barrios with a population of 4,411, and Miss Sumatra has to walk a great deal. Her main problem is the lack of transport during home visiting days. On Wednesdays and Thurdays, the young midwife stays at the centre for consultations, supervising the baby clin- ic, and attending to prenatal and sick calls. She carries out BCG and DPT (anti- tuberculosis and anti-diphtheria) im- munization of children. Since she is linked to a referral system, she sends patients she cannot cope with either to the municipal health officer or to the hospital in town. Dr A. Zahra, Director of the Division of Family Health at WHO headquarters in Geneva, was a recent visitor to Bohol. He summed up what he saw in these words: "The Bohol project is a good project because it is realistic. It is a good ap- proach for building up services where these did not exist or where they were not developed. It is good in the sense that the country—or any country for that matter—could afford that kind of service. "Training is done progressively. It is mostly based on in-service training and is related to the problems of the corn- 26 munity. The Bohol project is in the spi- rit of the WHO/UNICEF alternative ap- proaches for better health services." Dr Zahra added that "what needs to be done more is to exploit visits in the home to bring out more community in- volvement and participation". He sug- gested that this could lead to increased two-way traffic between homes and the barrio primary care centres. Dr Zahra was asked why the family planning project should be MCH-based. He replied: "If you analyse the most important leading causes of ill health, the diseases and complaints, you will find they are related to the mothers and children who form 70 per cent of the population." He said that if the problem is reduced to the most important group, it is found to concern the children of 0-4 years of age. This is the group that requires the greatest attention. Mortality rates of this group, and particularly mortality during the second year, are recognized indicators of socio-economic develop- ment. Attention to children of 0-4 years of age is an investment towards future national development. "When you analyse the conditions of the mothers, you find these are really always related to either diseases around pregnancies or conditions around preg- nancies", Dr Zahra explained, and he went on : "In all that, the midwife becomes the key person who has that contact with mothers and children of 0-4 years. This is the starting point of primary health care in any community, and it can be brought about by very modest means; the biggest value is really the motivation and the health education which will start from this point. "The midwife not only communicates with the mother but also with the corn- munity because she communicates with the hilot (traditional birth attendant). "The midwife is the person who has access to the homes : the secret is for her to be admitted into the homes and to be accepted." The Bohol project is realistic in the sense that local resources—the trained midwives—are being used to do the job. But it is ambitious too in its commit- ment to serve the whole target popula- tion of mothers and children through the deployment and support of the health workers in the villages. Young Boholana midwives like Nellie Sumatra who have returned to their native barrios have been accepted by the people. She is one of them. The people like her. They understand her. The Bohol project staff are confident that her message of family health will reach out to every home among the Chocolate Hills. ■ 27 WHO NEWS IN BRIEF rabies and the red fox The terrible disease of rabies has been all too well known for centuries, mostly result- ing from the bite of a "mad dog". It is a zoonosis—a disease transmitted from ani- mals to man—and in man it almost invaria- bly proves fatal. A rabies epidemic in Central Europe of the so-called "sylvatic" type, having its reservoir in wildlife, is now recognized as having started some 30 to 40 years ago in the eastern parts of the continent. Since then it has progressed westwards at a slow but steady pace estimated at between 25 and 50 km a year, spreading all over the German Democratic Republic and the Federal Republic of Germany, and reaching Den- mark in 1964. During the following years, it invaded Belgium, Luxembourg, Austria, Switzerland and France, and has recently made its appearance in the Netherlands. The "sylvatic" type of rabies is distin- guished from the "urban" type which pri- marily affects dogs and other domestic ani- mals. The two types differ markedly in their epidemiology and different preventive mea- sures are needed to combat them. All computer analyses of disease statistics, as well as elaborate field and laboratory studies under the WHO/FAO Collaborative Research Programme, have shown without any doubt that the red fox has been solely responsible for the spread of rabies in Cen- tral Europe. Cases of the disease in other wildlife are of much rarer occurrence. From extensive scientific investigations coordinat- ed by WHO it is now accepted that small wild animals, such as rodents and other creatures on which the foxes prey, do not play a role in the spread of the rabies virus. On the average, cases occurring in domes- tic animals amount to 20 per cent of all the cases diagnosed every year. Cattle, cats and dogs are the species most often attacked by rabies, and man is predominantly en- dangered by them. In the Federal Republic of Germany, for example, between 3,000 and 4,000 people a year receive post-expo- sure vaccination against rabies as a result of contact with infected or suspected animals. However, the vaccination procedure is not without risks of possible complications. In 1968, a programme of collaborative research on wildlife rabies and its control was initiated by WHO and FAO (the Food and Agriculture Organization), and this led to a better understanding of the epidemiology of the disease and to the development of new control strategies. Epidemiologists, ecolo- gists, virologists and economists from some 15 research teams in eight countries contrib- uted to this programme. The progress made was reviewed at WHO consultations in Frankfurt-on-Main in December last year in preparation for the Second European Con- ference on the Surveillance and Control of Rabies, expected to be held in Frankfurt in April 1977. What has become clear is that the final control of rabies in Central Europe can only be achieved when the disease in the red fox, the source of the epidemic, can be eliminat- ed. Good results have already been achieved by a temporary reduction in the fox popula- tion in Belgium, Denmark, the Federal Republic of Germany, France and Switzer- land. However, to obtain a lasting result it will be necessary to make a sustained effort over large areas, by control measures which take into account the changing epidemiolog- ical conditions. Now an international rabies surveillance system is being considered for the quick exchange of epidemiological infor- mation. At the same time, improved vac- cines and antibody preparations are being sought for treating exposed persons, and better methods are being devised for wildlife rabies control. WHO in the Maldives Although the 127,000 inhabitants of the Maldives are distributed over 19 atolls of the Indian Ocean, with 190 inhabited is- lands, the entire population had by mid- 1975 received malaria protection through DDT spraying and mass drug administration. Focal points of malaria were detected at the beginning of the year in the four northern atolls. In the first half of the year, a total of 24,789 blood smears were examined, of which 173 were found positive for malaria. During the second quarter of the year, 15,070 wells, cisterns and pits in Male, the capital, and in nearby Hulule were ex- amined, with some positive findings. Under the wHo-assisted malaria control project, entomologists carried out surveys in 21 is- lands of the four northern atolls. wHo staff participated in the training of the second and third groups of community health workers during the second quarter. Altogether during the past year a total of 13 community health worker trainers suc- cessfully completed their courses, so that they in turn can now train other health workers. A survey of leprosy and tuberculosis pa- tients in the Maldives is to be undertaken un- der a plan to promote the joint development of the islands' leprosy and tuberculosis control programmes. The plan will be financially assisted by the Danish "Scouts Help" Organization. A wHo consultant leprologist has been organizing and carrying out a case- finding survey of these two diseases, and arranging the treatment of detected cases according to methods recommended by yam. Meanwhile the wilco sanitary engineer assigned to the republic has continued to provide technical advice and guidance to the Maldives Water and Sanitation Authority (MWSA). 28 malnutrition A large percentage of the population of Asia, including both adults and children, suffers from chronic malnutrition, according to Dr Kalyan Bagchi, medical officer with wHo's Nutrition unit in Geneva. Specific nutritional deficiencies are especially concentrated in infants, young children, and pregnant and lactating mothers. In India, for example, blindness caused by vitamin A deficiency is tragically common, and in the seven states where most malnutri- tion cases are observed, some 13,000 young children are estimated to go blind from this cause every year. Reports from Bangladesh indicate that the number might be even greater there. In several countries in South-East Asia (and in some Latin Ameri- can countries), xerophthalmia or atrophy of the cornea due to vitamin A deficiency is an important cause of blindness among young children. In dealing with malnutrition or under- nutrition, says Dr Bagchi, the basic ap- proach should be to supply every individual with the amount of food which the body needs. Once this is achieved, certain mea- sures have to be taken to ensure that this is fully used by the body. Inadequate biologi- cal utilization of food is a common cause of malnutrition in many countries of Asia which have an unsatisfactory environment and a lack of clean drinking water. In sever- al parts of India, for instance, gastro-enteri- tis is the root cause of malnutrition in young children. The same is true of infestation. Round worm and hook worm are very common in India, Nepal, Indonesia and in many other Asian countries and these contribute very largely to malnutrition. Thus by providing clean water, improving environmental sanita- tion and imparting health education it is possible to dramatically improve the nutri- tion of vulnerable groups, even without any significant improvement in diet. Nutritional standards of people in Asia are also affected by cultural practices relat- ing to food. This is most marked in the case of young children and pregnant and lactat- ing mothers. Dr Bagchi, who was formerly Associate Professor of Nutrition at the All-India Insti- tute of Hygiene and Public Health, points out that in many parts of India there is a very deep-rooted belief in the minds of parents that the child should be kept on the mother's milk as long as possible—which is a very good practice—and that when the mother's milk is insufficient or not available the child should be given some other liquid as a milk substitute. Unfortunately this substitute is not the solid food which even the poorest family can afford. Instead the mother buys a very small quantity of sago or barley and puts it in an earthenware pot. She then adds a large quantity of water and boils it over a slow fire for an hour or more until the whole thing becomes a thick milky gruel. Now that is supposed to be a wonderful milk substitute, and children are kept on it for months, or even for years. All this time the poor child is really "eating its own flesh" because the milk substitute is nothing more than a small quantity of starch and possibly a little palm candy for sweetening. It is no wonder that thousands of young children suffer from severe marasmus- growth retardation and progressive wasting as a result of protein-calorie malnutrition. The simplest way to save the children is to give them properly cooked rice and daal (boiled peas). But such advice invariably gets a hostile response. Mothers feel very strongly that a child's stomach and intestine is very weak and no solid food should be given. It is a view that has been passed down from mother to daughter for many generations. Dr Bagchi adds: Of course there is more to malnutrition than cultural taboos. Poor nutrition is a result of socio-economic depri- vation, there is no doubt about that. But in certain phases of life, mostly in childhood, there are some feeding practices, supersti- tions and beliefs which help to create mal- nutrition. ■ 29 WORLD HEALTH WORLD HEALTH DAY POSTER World Health Day, April 7, is an annual event marking the anniversary of the coming into force of the Constitution of WHO, and the theme chosen this year—"Foresight Prevents Blindness"—has been graphically illustrated in a coloured poster (reproduced below) donated to WHO by the Inter- national Green Cross. As the February-March issue of World Health explained, two-thirds of the blindness in the world is unnecessary: at least six million sightless people need never have lost the use of their eyes. The World Health Day slogan spotlights the answer: prevention is better than cure. Foresight Prevents Blindness WORLD HEALTH DAY 1976 PUZZLE PICTURE What is it? A heat-ray gun for lighting paraffin lamps—or perhaps an extinguisher for snuff- ing them out? The round base might even be the turntable of a record-player: does the tube blow dust off the records to prevent them getting scratched? In fact a laboratory worker is lifting the screw-top off a calorie burner a device which substitutes for the human body when scientists want to measure the value of foodstuffs as fuel for the human machine. The food we eat is our fuel. Our stomach and intestines turn it into energy to maintain our blood- stream at the right temperature and to keep all our organs functioning correctly. Far too many people around the world get too little food to eat; some eat the wrong food; others may eat too much. Nutri- tional research—the study of what we eat—plays a vital role in assessing the food needs of the world's population. (Photo WHO/Spooner) 30 Dental auxiliaries at work in a rural health centre in Venezuela. (Photo WHO/P. Almasy ) Continuing our series on the different members of the health team, World Health this month introduces: THE DENTAL AUXILIARY Who is he or she? A public health worker qualified to perform, under super- vision, a number of tasks in dentistry. What are the duties? The dental auxiliary's duties include a combination of any of the following or similar tasks: carrying out certain procedures in the mouth, such as cleaning of teeth, filling cavities, simple extraction, charting the dental condition of patients, giving indi- vidual and group instruction in oral hygiene, preparing patients for surgical or other treatment, sterilization of instru- ments, assistance with X-ray work, care of patients after general anaesthesia, carrying out certain laboratory proce- dures, such as casting of moulds from impressions of the patient's mouth and construction of appliances for the mouth. What is the exact title? Two main categories are recognized : the opera- ting dental auxiliary and the non-ope- rating auxiliary. The titles in use for persons in the first category include School Dental Nurse, Dental Therapist and Dental Hygienist. For persons in the second category, the titles in common use are Dental Technician or Dental Assistant. What training is involved? The operating auxiliary must acquire a high standard of operating skill within a limited field based on an adequate knowledge of biological science. The training also qualifies him or her for dental health education and helps build a high sense of responsibility and social awareness. For the laboratory non- operating auxiliary, a formal course of training in laboratory techniques is a rigid requirement. The minimum educa- tional requirement for intending trainees is: not less than two years short of full secondary school education. Where is the training carried out? In a dental school associated with a dental hospital or the dental health programme of a public health service. What are the prospects of employ- ment and promotion? Dental auxil- iaries are usually employed for child dental services in dental hospitals and surgeries and, in some countries, in private dental clinics. With the growing trend to include dental health in primary health services, job prospects for auxil- iaries are widening in many countries. Some countries have opportunities for persons recruited as non-operating auxiliaries to become operating auxil- iaries after an adequate course of education. Who is the supervisor? The dental professional or the leader of the Dental Health team. What are the working hours? Nor- mally, about eight hours a day. Authors of the month PIERRE RossloN is a professional journalist working for the Paris magazine Science et Vie. JAMES MAGEE is a freelance journalist working in Geneva. LALIT THAPALYAL and DIDIER HENRIOUD work in the Division of Public Information at WHO head- quarters in Geneva. RUTH SEITZ is a freelance journalist based in Nairobi. Josh ARCEDE is the Public Informa- tion Officer at WHO's Western Pacific Regional Office. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$' Sw.fr.' One year 10.— 25.-- Two years 18.— 45.— Three years 24.— 60.— One year : Two years : Three years : enclose chedue/postal order in t he amount of Name: Street: City: Country: or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland ridcge life :n Senegal: see page 4. (Photo WHO/J. Marquis)