World Health: the magazine of the World Health Organization: March 1986 [full issue]

Cover : The linked cham bers of the nautilus shell suggest a symbol for intersectoral action fo r hea lth . Design by Ted Gering IX ISSN 0043-8502 World Health is the off icia l illust rated magazine of the W orld Health Organizat ion. Editor: John Bland Deputy Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English. French. German. Portuguese. Russ ian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be repro- duced provided credit is given to the World Health Organization. Signed articles do not necessarily re flect WHO's views. World Health. WHO. Av. Appia. 1211 Geneva 27. Switzerland. Contents lntersectoral cooperation in primary health care by Aleya El Bindari Ham mad Health cannot do it alone! by Godfrey Gunatil leke 3 7 Rhetoric and reality by Mark L. Schneider . 10 Oncho : a concerted effort by Alasta ir Anderson The health sector cannot do it alone! 14 Design by Ted Gering 16-17 Health and the media by Jack Ling ... Think intersectoral! by M . A C. Dowling 18 and Roberta Ritson . ... . . .. . .... . . 22 IARC: 20 years old by Waiter Davis .... . . . . . . . 28 • Departments Education for health Literacy and well-being .. . . 6 Health for all by the year 2000 Fun and games . . . . . . . 20 Primary Health Care Only a volun teer by Glen Wi lliams 25 News Page . 30-31 2 W oRLD HEALTH, March 1986 Many hands make light work: the intersectoral principle in action. Photo WHO Famine strikes hardest at the young. The health sector alone cannot solve such problems. Photo WHO/UNICEFIW. Campbell - A Schoolteachers have a role to play in health, alongside the medical arid health professionals. Photo WHO/C. Stauffer lntersectoral cooperation in primary health care "The role of intersectoral cooperation in national strategies for Health for all." World Health this month examines the theme chosen for the Technical Discussions which will take place during the World Health Assembly, to be held in May in Geneva by Aleya El Bindari Hammad Improvements in the health status of a population cannot be achieved simply by ex- panding and developing the health services. The prevention and control of disease and the promotion of health require a concerted effort for the improvement of human well-being as a whole . In this task, what has been defined as "health care" has to be supported by improvements in the social and economic infrastructure , and contributions from various sectors other than health. Certainly there has been a broad understanding of the linkages between health development and development in other sectors. The health experience of the industrialised countries has con- tributed significantly to this under- standing. We know that the major causes of sickness and death arising out of a large cluster of diseases as- sociated with poor sanitation , illiteracy and low levels of income were effec- tively controlled in these countries well before the discovery of antibiotics and other spectacular curative "break- throughs " . The control of diarrhoea} diseases, tuberculosis and a wide range of communicable diseases was pri- marily achieved through far-reaching improvements in the urban infra- structure, housing and environmental sanitation, through the changes in health behaviour which accompanied higher levels of education and literacy , and through the improvement in nutri- W oRLD HEALTH , March 1986 tional status as incomes and living standards steadily rose . The positive outcome in health was therefore the result of an intersectoral effort. Higher levels of education result in improved levels of health. Photo W HO/Zafar The more recent experiences of a few developing countries illustrate even more dramatically the way in which health forms part of an inte- grated process of development. These countries have been able to achieve high levels of life expectancy and have shown remarkable progress in reduc- ing infant and maternal mortality at comparatively low levels of income. The state of Kerala, with per capita incomes well below the average for India as a whole , enjoys a health status- as measured by life expectan- cy, infant mortality and other health indicators-which is well above the rest of India. Similarly Sri Lanka , with a per capi- ta income in the region of US$ 300, has within a time span of 35 years raised life expectancy from 46 years to nearly 70 years and reduced mortality from 22 per thousand to six per thousand. Costa Rica, which is in the middle-income category of developing countries, has over a time span of 30 years achieved a spectacular reduc- tion in infant mortality and improve- ments in other health indicators. In all these cases, studies have shown that the efforts in the health field were simultaneously reinforced by developments in other sectors. In Sri Lanka , health was part of a welfare system which provided mass free edu- cation and guaranteed a subsidised ration of food to all households . This was combined with economic develop- ment policies which improved the pro- ductivity and income levels of the rural poor through a coordinated pro- gramme for food production in the peasant sector. The programme for the control of malaria in Sri Lanka during the 1940s 3 and 1950s is a striking example of intersectoral action. The control of malaria formed one component of a socio-economic programme aimed at resettling the malaria-stricken zone in the country, and at achieving self- sufficiency in rice, the staple food. Consequently, the health programme formed part of a larger economic and political commitment as a result of which malaria control received the highest priority. The socio-economic programme also meant developing the social and economic infrastructure of the areas where malaria was endemic. The rural peasantry engaged in rice cultivation, a severely disadvantaged segment, became the target of a varie- ty of government programmes which increased productivity and income, improved their nutritional status and raised the educational levels. The malaria programme was an integral part of these developments. In Kerala, India, long-standing pro- grammes directed at social welfare raised the educational levels of the population and developed a social in- frastructure, including a transport net- work which provided easy access to services. An effective programme of land reform had given poor people access to land resources for food pro- duction at the household level and this had far-reaching effects on the availability of food for the poor. In Costa Rica, social and economic reforms and educational improve- ments helped to change the health situation dramatically in three de- cades. During the 1970s particularly, a National Health Plan and a General Health Law took account of important intersectoral and national require- ments for achieving the planned ob- jectives. The health programme itself was part of a larger programme of social welfare which had the effect of redistributing income through ser- vices. Within the health programme itself an important place was given to rural and community programmes of primary health care. Community level institutions were promoted to involve the community more closely. The re- markable decline in infant mortality from 67 per 1,000 live births in 1970 to 21 in 1980 is attributed mainly to this community health programme. 4 An incubator ensures a better chance of life for a premature baby. But promoting and maintaining good health will require the combined efforts of many sectors other than health. Photo WHO/J . Mohr In all three territories, education (and female literacy in particular) has played a key role in improving the health situation. It enabled the health programmes to focus on the mother, on enhancing her knowledge of and capability for child care, on improving the immediate health environment of the infant and child, and on reducing the numbers of people at highest risk. The importance of intersectoral ac- tion in health development can also be very forcefully illustrated in a case where the lack of it had a negative outcome. The resident plantation workers in Sri Lanka, descended from Indian immigrant labour during the colonial period, had at the time of independence marginally higher health indicators, such as crude death rate and infant mortality, than the rest of the Sri Lankan population. During the 30 years that followed, the planta- tion workers were unable to partici- pate fully in the welfare system of the rest of the country. Educational levels and especially female literacy con- tinued to remain low. Housing condi- tions remained poor. Even though basic health services were provided, and the nutritional intake and income levels were marginally higher than those of the rural Sri Lank an peasant- ry in the surrounding area , health indicators for the population quickly fell below the national average and by the 1970s lagged far behind. Whereas, in the rest of the country, health development was an integral part of social development which raised edu- cational levels and improved the qual- ity of the habitat as a whole, the plantation workers were confined within an enclave which did not form part of this integrated process. Despite all that has happened in the past in the developed world, and de- spite the many experiences in develop- ing countries that prove the value of intersectoral action, few countries consciously incorporate such action in their national health strategies. This is partly because the health services al- ready face the daunting problem of extending their coverage to reach all the people. In addition, there is the technical complexity of the problems that require intersectoral action. The challenge is for all sectors to explore relationships about which useful data are scarce and for which most sectors are technically unprepared. Finally, what is needed is political leadership which is oriented towards social devel- opment, and not just to economic development. The Alma-Ata Declaration of 1978 and WHO's Strategy for Health for all, with their emphasis on prevention of disease and promotion of health, have W oRLD HEALTH, March 1986 identified intersectoral action as a key element in health policies and action programmes , and one of the most important guiding principles in for- mulating and implementing national health strategies. In the initiatives embodied in WHO's Health for all strategy , intersectoral · action has been emphasised and ar- ticulated as part of the entire health strategy, mainly because of the basic re-ordering of health priorities. Today the major emphasis is on the preven- tion and control of disease and the promotion of health through primary The community health worker can help to identify community problems and people at risk or in need ; he or she has a bridging function, putting the community in touch with health and other services. Photo WHO/J. Mohr W oRLD HEALTH, March 1986 Intersectoral cooperation in primary health care health care. This shift in priorities has immediately highlighted the inter- sectoral character of health care. Agri- culture and nutrition , housing , sanita- tion, water supply , literacy, health education and greater self-reliance in health care all are integrated in the current primary health care strategies. Achievement of the Health for all goals will depend vitally on sound intersectoral actio~ directed at specific health goals. On the one hand , eliminating the major causes of preva- lent sickness and preventing any specific cluster of diseases will require action in all those areas outside the health sector which currently contri- bute to the incidence of those diseases. And on the other , the broader aim of increasing well-being and resistance to disease as a whole while promoting and maintaining good health will re- quire the combined efforts of many sectors not immediately related to health. Neither the individual nor the household perceives well-being as fragmented into sectors-even if that well-being stems from a specific economic sector , or from education , or from health , or from employment. Well-being is a single unified condi- tion. The same is equally true of the well-being of a community. It is with this perception in mind that health planners and health workers need to act when drawing up strategies or putting primary health care into prac- tice. This will ensure that the health component is placed in the context of social development as a whole , and that other sectors are mobilised and motivated to lend their support to- wards achieving health goals . • 5 6 Education for Health Literacy and well-being The map of illiteracy coincides closely with the maps of poverty, malnutrition, ill-health. lt follows that literacy must form part of the strategy for achieving Health for all The basic statistics on illit- eracy are well known, and certainly provide abundant reason to reflect upon the inequalities of our world . By the most recent estimate there are 824 million illiterates of 15 years of age and above, over 800 million of whom live in the developing nations . While carefully compiled and calcu- lated, these estimates have to be taken with a . certain caution. First. while literacy is measured as a dichotomous variable, it is in fact a continuous one. lt may not be possi- ble to be a little bit pregnant. but it is certainly possible to be a little bit literate. Hence, the statistics de- pend upon where you draw the dividing line. UNESCO has its own definition : a person is literate "who can with understanding both read and write a short simple statement on his everyday life" . Definitions Recognising that this included some who were not sufficiently lit- erate to cope with the complexities of an industrial society, a committee of experts developed a second de- finition for functional literacy : to be functionally literate, an individual must be able to" engage in all those activities in which literacy is re- quired for effective functioning of his group and community . .. " and also be able " ... to continue to use reading, writing and calculation for his own and the country's develop- ment". As will be observed, the second definition is a relative mea- sure . The criterion is the capacity to Learn ing to read in India. The control of many diseases in many parts of the world has been facilitated by positive changes in health behaviour which accompanied higher levels of education and literacy. Photo WHO/F. Dupuy cope with the challenges and exi- gencies posed by the nature of the society in which one resides . So even the concepts of literacy are slippery. Only hard work will of course change the literacy situation , but the statistics are mere numbers on paper or in a computer. lt is noted that those who come to power 1n revolutions often count illiterates differently from their predecessors. But whether there are 824 million or 1000 million illiterates. there are clearly too many of them. What does illiteracy mean to the illiterate? Let us note here that the map of illiteracy closely coincides with the maps of poverty, malnutri- tion, ill-health, infant mortality, etc . Hence. in the typical case, the illiter- ate is not only unable to read and write but he - or more usually she - is poor, hungry, vulnerable to illness. and uncertain that even his or her present miserable circum- stances will not decline to the point where life itself becomes the issue. In these circumstances, does his or her literacy really matter? Would he or she even list illiteracy among life's major problems? While man does not live by bread alone, we can assume that the hunger of the body will normally take precedence over the hunger of the mind, particularly if the intellectual diet available to the new literate is as poor as is normally the case . lt follows that the best argument for doing something about illiteracy is not that it is part of the immense problem of inequality in our world, but that literacy can be part of the answer to remedying it. • From: Eleven issues in literacy fo r t he 1990s, by Arthur Gille tte and John Ryan Assignment Children (UNICEF), 63164, 7983. W oRLD HEALTH, March 1986 Case studies made by WHO in five countries examined how developments outside the health sector related to major changes in the health status of the population concerned It is now widely recognised that a sustained improvement in the health status of a popu- lation can only be achieved through the combined impact of a wide range of social and economic developments. In 1977, the World Health Assembly decided that the main social target of governments and WHO should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economi- cally productive life; for brevity, we call this Health for all. The Declaration of Alma-Ata, in 1978, defined primary health care as the key , in national health strategies, W oRLD HEALTH, March 1986 to the achievement of an acceptable level of Health for all, and it empha- sised that health is not the concern of the health sector alone but also re- quires the action of other social and economic sectors. In 1979, the World Health Assembly endorsed the Decla- ration of Alma-Ata and brought into sharper focus the need to coordinate a wide range of sectoral activities in order to achieve health goals. Health has therefore increasingly gained rec- ognition as a social goal which has to be integrated into a strategy of social development. As part of the response to these perceptions , a project on intersectoral action for health was initiated in 1981 which was envisaged as a series of studies, to be followed by a pro- gramme of research activities , in an effort to enhance understanding of the interrelationship of developments out- side the health sector and major changes in the health status of the population . Its main purpose was to examine how national health stra- tegies could affect interrelationships, making them more explicit and mobil- ising them for achieving health goals. Better health status for all people can only be achieved through the combined impact of a great many social and economic devel- opments. Photo W HO/Zafar 7 Health cannot do it alone I Five countries-India, Jamaica, Norway, Sri Lanka and Thailand- participated in the studies during the first phase of the project. In India , research activities were confined to Kerala State , because of the need to keep them within manageable propor- tions, comparable to the activities in the other countries , and because of the special socio-economic and demo- graphic characteristics of Kerala State . In the four other countries the studies were conducted on a national scale. The scale of the project in its first phase had to be relatively modest , since it was dictated by the resources available , and the countries taking part had to be selected from among those where the importance of inter- sectoral linkages in the field of health appeared to be recognised, thus offer- ing scope for meaningful analysis . Al- though the entire international range of health conditions and the socio- economic and cultural factors in- fluencing them were not represented, the nature of the project made it possible to gain initial insight into relevant problems by concentrating on a few case studies. The problems and issues revealed in the studies will be pursued through further research and related activities planned for the sub- sequent stages of the project. The conceptual approaches implicit in the work initiated under this project need to be seen in the wider context of the search in the 1970s for new and more meaningful concepts of develop- ment. In that search, the increasing emphasis given to human develop- ment was of special relevance for health goals . The central objective of development was redefined as " hu- man well-being" in its fullest sense . It is towards that goal that the various processes of change-economic, tech- nological , social and political-need to be purposefully directed. Such an approach to development implies that the processes of change in different parts of the economy and in society are interlinked ; they reinforce and nurture each other, and they need to move together for the full realisa- tion of development goals . This also means that the achievement of sector- a! goals whether in education, health , or economic productivity, requires 8 W oRLD HEALTH, March 1986 simultaneous action in several inter- connected parts of the socio-economic system and in relation to several inter- linked problems. For example , achieving the goal of Health for all by the year 2000 will require far more than an efficient and well-distributed national system for the delivery of health services. It will require, among other things, the simultaneous pursuit of techno- economic goals, to increase productive capacity and economic well-being ; so- cial goals, to ensure that the results of techno-economic achievement are dis- tributed equitably over the entire population; and political goals , to en- able the community to participate in the process of decision-making from the national to the local level. The capacity of a society to realise the goal of Health for all by the year 2000 will then depend on where it is located in the trajectory of development. Inter- sectoral action for health has to be placed in such a setting, in which the different sectoral development goals , and the processes and means for achieving them , are closely inter- woven . A busy fish market in the Western Pacific region. Fisheries, like agriculture, processing industries and other aspects of food produc- tion and distribution, all have a role to play in a nation's health. Photo WHO/P. Almasy The five case studies were of the health situations in countries with widely varying levels of per capita income and socio-economic develop- ment. The State of Kerala and Sri Lanka fall into the lowest-income category, with per capita incomes of approximately US$200 and $270 re- spectively. They have primarily rural economies, so that the modern manu- facturing sectors contribute less than 15 per cent to the gross domestic product. Jamaica and Thailand are at different levels in the middle income . group , with larger manufacturing sec- tors growing relatively faster. Norway enjoys a per capita income that is one of the highest in the world , and the majority of its population are in the industrialised urban sector. In the case studies, therefore, the changing patterns of human health covered a wide span of social and economic development , from condi- tions of poverty and insufficiency to those of affluence and excess. The original research plan was for the study to select several key non- health sectors with important health- related components. They included agriculture, industry , water supply and sanitation , and education. The idea was to identify any linkages between the selected sectors, as well as the contributions they might make to the achievement of health goals , and , in turn , the contribution the health sector could make to the programmes of the non-health sectors. In the course of the study , however, the interaction of the different sectors was found to be a complex process , occurring within larger and far-reaching societal changes that were having a major influence on the health situation . Changes in the health situation over time , leading to the current health status , had to be examined in the context of several other processes. First they had to be seen in the light of changes in the key sectors other than health that had contributed to the improvement of well-being. Next , the development policies and social pro- cesses that had affected the distribu- tion of resources and participation had to be taken into account. Then the impact of underlying cultural and religious values on community be- haviour and national decision-making, in matters concerning health and the realisation of health goals , had to be considered. The detailed findings of the studies in the five countries may be read in the WHO Offset Publication No. 83, " Intersectoral linkages and health development " (1984). Very broadly, they indicated that in implementing intersectoral programmes certain serious constraints need to be over- come , particularly political obstacles, institutional and bureaucratic impedi- ments , and deficiencies in regard to human, material and financial re- sources. The case studies in the five countries indicate that in implementing intersec- toral programmes serious constraints need to be overcome, such as political obstacles, institutional and bureaucra- tic impediments , and deficiencies in regard to human , material and finan- cial resources. An explicit political commitment is necessary which must be communi- cated to all the sectors involved . Thus , a national health council in Sri Lanka and a national rural development committee in Thailand have brought together the political decision-makers and enabled them to address them- selves to specific intersectoral policy objectives. The potential for overcom- ing political obstacles can be enhanced by .forming networks at local , regional W oRLD HEALTH , March 1986 An elaborate tea ceremony in an African household. Cultural values affect community behaviour and consequently national deci- sion-making in matters concerning health. Photo W HO/P. Almasy and national levels of the prime mov- ers within the various sectors. The non-governmental organizations , the mass media, and informal communica- tion networks should be used to gener- ate pressure in support of intersectoral action . Institutional or bureaucratic con- straints include the absence of govern- mental entities with formal responsi- bility for intersectoral action. Where such entities exist they often lack sub- stantive responsibility or specific goals. Mechanisms have to be worked out to overcome rivalries and the self-protec- tive behaviour of bureaucracies. The health sector needs to demonstrate that it is willing to contribute to the other sectors through the exchange of information , training activities , and similar types of support. As for deficiencies in huinan , ma- terial and financial resources , training staff together to work in teams and transferring staff from one sector to another may help to overcome such Health cannot do it alone! constraints. The pooling of expertise to contribute to the health-related ac- tivities of other sectors is another possibility. The orientation in regard to health of community workers in other sectors could also help to pro- duce more effective intersectoral ac- tion. All this has to be accompanied by an improvement in the allocation of health manpower and health expertise. With regard to material and finan- cial constraints , programme budgeting must improve in order to link financial allocations to intersectoral tasks and responsibilities. At the same time , ad- ditional resources need to be mobi- lised at community level , with the community assuming a considerable share of the responsibility for the way in which they are used. An important criterion by which to judge the degree of community participation is the mea- sure of financial independence the organizations that represent the peo- ple are able to acquire . Community participation and the enhancement of self-reliance call for action to improve and strengthen management skills within the community , so as to enable it to make the best possible use of the available resources. • ' A study made in the Region of the Americas by PAHO showed that the health sector was, all too often, not included in the national decision-making process by Mark L. Schneider The concept of intersectoral relations is alive and well in the Region of the Americas. However , the distance be- tween rhetoric and reality remains far too great. While there are certain natural linkages of health with other sectors occurring at the community level and through inter-ministerial coordination in specific programmes at the national stage, only limited consideration is given to the implica- tions for health goals and health con- ditions of macro-economic policies. The present economic crisis has underlined in stark terms the require- ment that adjustment policies be con- cerned with the health of the poor as well as with the balance of payments. Moreover, the crisis has made primary health care not merely the chosen strategy but the strategy most likely to provide an appropriate response to the current austerity environment which dominates decision-making in much of Latin America and the Caribbean. The 1978 Declaration of Alma-Ata set the global stage for changing the inward-looking attitude of health pro- fessionals to a broader , more corn- 10 prehensive vision of the important role that other sectors must play in achiev- ing Health for all goals. In the Americas, that awareness took a specific form . " Promotion and im- provement of intersectorallinkage and cooperation" was designated as a re- gional objective of the Health for all strategies, with an emphasis on the "linkages between health and national socio-economic policies and plan- ning " . Increasingly , intersectoral coordination was conceived as the primary engine to overcome inequities in health conditions. Mixed results As the decade of the 1980s began , Latin America and the Caribbean had already undergone a great many frag- mented and partially successful ex- periences with intersectoral action at the community , regional and national levels. Integrated community develop- ment projects in rural areas and re- gional development plans focused on raising both income and living stan- dards in previously neglected areas. National food and nutrition plans also demonstrated some limited success. In most instances , the absence of stable political commitment prevented suffi- cient resources from being dedicated to putting the various plans into effect over a sufficient time period to gener- ate a broad national impact. A 16-nation study by the Pan American Health Organization also cited institutional limitations and rivalries as being responsible for the absence of nationally successful in- tersectoral coordination. In most in- stances, the health sector was not included in the national decision- making process for priority economic development goals and policies or for the distribution of public resources. Even the wide prevalence of ministries of planning in the Region of the Americas, with two decades of experi- ence in national development plan- ning , had not remedied this problem. The national planning institutions were themselves divided into separate sectors, so that there was little cross- fertilisation of ideas on the potential health impact of macro-economic policies or investment projects. Nor could the potential be realised of other W oRLD HEALTH, M arch 1986 Research cannot take place in a vacuum. All health-related activities need to be integrated into national decision-making processes . Photo WHO/PAHO sectors collaborating in the ad- vancement of health goals , or of health contributing to the achievement of broader national economic objectives. The development style predominant in the Region, based on a growth model , tended toward "trickle-down" theories where social development was viewed as an automatic and even- tual consequence of economic growth. The dominant experience of inter- sectoral collaboration occurred at the inter-ministerial level, where a wide variety of quite specific linkages was forged between health and education ministries on the one hand, and health and agriculture on the other. When new emphasis fell on inter- sectoral action as part of the Health for all strategy, efforts were made to expand intersectoral action to attain broad national impact. Inter-minis- terial cooperative ventures have be- come even more frequent between W oRLD HEALTH , March 1986 health and agriculture (in the fields of nutrition and the use of pesticides) , between education and health , and between health and housing. A limited number of positive examples are now beginning to produce nationally im- pressive results. Colombia is one of those countries where the Rural Integrated Develop- ment project, begun in 1982 with both national and World Bank funding as well as support from PAHO/WHO, UNDP, UNFPA , UNICEF and the World Food Programme, was designed to be a major force in reducing inequities . Based on a national analysis of the geographic regions with greatest economic and social needs , the prior- ity municipalities in the five partici- pating departments were chosen. The indicators used included infant mortality , illiteracy , and health ser- VIce coverage. The project focuses on farmers with less than 20 hectares and seeks to expand their production capacity with new farming practices . At the same time, the economic objectives are link- ed to the extension of health services and water services along with the con- struction of latrines . Since 1982, the project has involved major increases in levels of immunizations, the con- struction and equipping of 75 new health posts , and improvements to another 43 facilities through a primary health care strategy that is reaching an estimated 80 per cent of the 2.1 mil- lion residents in those five rural departments. The critical national decisions that were taken were to integrate health and economic considerations into the initial selection of the rural areas to be served, and to ensure the intersectoral composition of the interventions which were designed to increase both family income and access to social services . Initial reports indicate a re- duction in infant mortality in the targeted areas. Another good example of effective socio-economic development at the national level is in Costa Rica which, despite its category as a middle- income country, succeeded during the 1970s in achieving levels of health equivalent to more developed coun- tries. One particularly impressive indi- cator was the reduction of infant mor- 11 Rhetoric and reality tality from 66.8 deaths per 1000 live births in 1970 to 20.8 deaths per 1000 live births in 1980. Equity-oriented social development policies had pre- vailed for several decades . Rising economic conditions and the conscious spread of the benefits of economic development reduced poverty to bare- ly one-quarter of the population by 1980. The democratic system permitted the popular desire for improving living standards to be reflected in a continu- ing priority on extending both educa- tion and health services. In the 1970s, public spending on education aver- aged more than 30 per cent of the federal budget , literacy reached beyond 90 per cent, and the percentage of women between 20 and 34 years of age who completed primary school rose from 42 per cent in 1970 to 65 per cent in 1980. As economic progress was occur- ring, national health policy sought to extend coverage to the high-risk rural population through a primary health care strategy. The Rural Health pro- gramme, begun in 1971, sent health workers out into previously unat- tended rural communities, built a host of small rural health posts, and set up community-based health committees. Intersectoral linkages with the nation- al institution dedicated to general socio-economic improvement in rural areas, the National Directorate of Communities, gave the health sec- tor an additional ally in public policy decision-making. The drop in infant mortality and the increase in life expectancy at birth in Costa Rica during the 1970s was di- rectly proportional to the coverage and number of years of the Rural Health Programme-a tribute to its success. The increase in life expec- tancy at birth in those rural areas served by the Programme was actually greater than in some urban areas where primary health care interven- tions were unavailable. Similarly, al- though there was little change in ac- cess to food in those areas, the reduc- tion in infectious diseases as a result of health interventions improved nutri- tion status and permitted the signifi- cant improvement in infant mortality and life expectancy. 12 Rhetoric or reality. For a little girl in a South American slum or for a family in a North American suburb, the effect of macro- economic policy-making on health has been almost uniformly negative. Photos W HO/H. Christoph Among all the aspects of inter- sectoral relations between health and the larger society, perhaps the most striking change from past decades has been the proliferation of attempts to examine the impact of industrial and commercial activity on the environ- ment and on human health. Far more attention is being paid to this problem by national governments today. Inter- national financial institutions are also responding to criticism that they had not hitherto adequately analysed the potentially adverse impact of the economic infrastructure on the envi- ronment and on health. The region as a whole still lacks a fully developed set of legal , institutional and technical instruments to ensure that possible harm to the environment is considered before major industrial developments take place. Among recent activities undertaken to boost national capabilities to con- duct environmental impact assess- ments , one example is the Caribbean initiative to control coastal water pol- lution among the countries of Antigua, Dominica, Grenada, Saint Christo- pher and Nevis, Saint Lucia, Saint Vincent and the Grenadines, through AMRO/PAHO , UNEP and the Caribbean Community (CARICOM). The countries were worried by the direct health implications of pollution as well as by the economic consequences for their important tourism industries. A second example is a project sup- ported by the Pan American Centre of Ecology and Human Health of AMRO/ PAHO , which involves research into the frequency and distribution of cancer pathology due to chemical contamina- tion of the environment. The first stage studied the epidemiological as- pects , and a second stage will survey Latin American industrial activities using substances which the Interna- tional Agency for Research on Cancer has concluded are carcinogenic. The School of Public Health of Chile is responsible for the first stage and the Environmental Sanitation Technology Company ( CETESB) of Sao Paulo, Brazil , for the second. These two ex- amples typify the increasing concern with the intersectoral aspect of indus- trial development and the realisation of regional health objectives. As a result of the economic crises, intersectorallinkages have become the focus of renewed attention not only by the health sector but by the most powerful national political leaders. The world recession of 1980-81 sharp- ly reversed almost two decades of positive growth (although growth was unevenly distributed and some 150 mil- lion people remained in poverty) in Latin America and the Caribbean. In the 1970s, regional economic growth W oRLD HEALTH , March 1986 grew at an average annual rate of more than 6 per cent. In 1981 , re- gional economic performance plum- meted. Real per capita income actu- ally declined 3.7 per cent in 1982, 5.7 per cent in 1983, and showed a bare rise of 0.2 per cent in 1984. In 12 countries, real capita income drop- ped again in 1984, and average gross domestic product (GDP) per capita in the Region was equal to the level of 1976. For nine countries , GDP per capita in 1984 was lower than it had been in 1970. Unemployment rose dramatically, and inflation in 1984 in Latin America and the Caribbean soared to an aver- age of 175.4 per cent. The available data show significant increases in the numbers of people living in poverty. The debt crisis was also a domi- nant feature of government concern, as debt payments consumed nearly 40 per cent of the region 's export earnings in 1983. Accumulated debt in 1984 reached US$360 billion, nearly US$24 billion more than the regional gross domestic product. The nations of Latin America and the Caribbean were faced with de- mands for adjustment policies which inevitably included austerity in public expenditures. The consequences were an increasingly consistent pattern of reduced public spending for health, although the levels and the timing of those reductions differed among the various countries. There was a decline in real spending per person of up to W oRLD HEALTH, March 1986 20 per cent in Colombia, Honduras , Jamaica and Uruguay, 25 per cent in Barbados, Chile , Ecuador and Ven- ezuela, and more than 40 per cent in Argentina , Costa Rica , Guyana, the Dominican Republic and Surinam, be- tween the peak period of spending in 1979, 1980 or 1981 and the lowest subsequent year. Disquieting trends The combined consequences of the economic crisis in reducing income and raising poverty levels and of aus- terity in public health spending are beginning to be seen . Increased mal- nutrition is occurring in Costa Rica and Bolivia. A halt to the decline in infant mortality in Costa Rica and a sharp rise in infant mortality in the state of Sao Paulo have been reported. Similarly there has been a dramatic increase in infant mortality in Bolivia related to malnutrition. UNICEF and P AHOI AMRO studies point toward rising malnutrition, increases in mor- bidity, and a slow down in the pre- vious trend towards reduced infant mortality. These factors have produced a new awareness of the direct consequence of macro-economic policy-making on health services and on health condi- tions generally. Even though studies of the health consequences of the recent adjustment policies are far from com- plete, the available information clearly demonstrates that the direction of Rhetoric and reality change is almost uniformly negative . In that situation , there is a clear need: - to monitor the implications for health and nutrition of macro- economic policies ; - to identify those complementary policies which can avoid the most serious health consequences, particu- larly to the most vulnerable popula- tion groups, without undermining the basic economic adjustment objectives; - to ensure that poor people have adequate access to food; - to maintain cost-effective interven- tions such as immunization pro- grammes and oral rehydration within the primary health care strategy; - to emphasise the importance of assuring safe drinking water; - to avoid cutbacks of tropical disease control measures. There are clear examples in Argen- tina, Brazil, Mexico and Peru of ef- forts to protect the poor. Recent re- ports from Sao Paulo for example , show targeted spending by both the State and municipal governments on vegetable gardens, on opening wholesale food distribution centres to the consuming public (with savings up to 40 per cent), on creating food cooperatives among the poor, and fi- nally on direct food distribution pro- grammes. In Argentina too, there is new emphasis on food distribution programmes for the poor , to prevent a drop in nutritional status. Intersectoral linkages which com- bine increased family income , educa- tion, and effective health services targeted to the most high-risk groups can yield positive improvements in health conditions . At the same time, there is a growing awareness that the failure to take account of the implica- tions of macro-economic policies and projects on the environment and on health can have serious negative consequences for national health goals. What Latin America and the Caribbean have learnt from the economic and adjustment crisis is that understanding the nature of inter- sectorallinkages and promoting mutu- ally productive intersectoral coopera- tion are not merely desirable; they are essential to the achievement of both Health for all and economic development objectives. • 13 Oncho: a concerted effort For the Onchocerciasis Control Programme, intersectoral action is not an abstract ideal but a practical working fact. Says OCP director Ebrahim M. Samba: "We are doing it!" by Alastair Anderson The Onchocerciasis Control Programme (OCP), which marked its tenth anniversary in December 1985 , is the inter- sectoral programme par excellence. It is a prime example of an activity which, in WHO's parlance , appears to be essentially a "vertical" programme but, by succeeding, has become thoroughly " horizontal". It is international, because it em- braces at present 11 countries of West Africa afflicted by the blackfly vec- tor of "river blindness", as well as 14 donor countries. It is inter-regional, because its suc- cesses are being watched by-and are being used by-other onchocerciasis- affected areas of the world, notably central and eastern Africa, Central America and the Southern Arabian peninsula. It is inter-agency, because it involves four sponsoring agencies of the UN system: the UN Development Pro- gramme (uNDP) , the Food and Agri- culture Organization (FAO)-both of these concerned with social and economic development-the World Bank as fiscal agency , and WHO as executing agency . It is inter-disciplinary. Besides the obvious physicians and entomologists, it involves chemists , biologists , hy- drologists , meteorologists, agro- economists, ecologists, zoologists, ich- thyologists , communications experts, sociologists, engineers, pilots and mechanics . (This is only a short list). It is inter-sectoral. OCP activities call for close collaboration, not only 14 with ministries of health of the coun- tries involved , but also with ministries of planning, finance , cooperation and development, interior , agriculture, civil aviation, very often the office of the President, and always the civil authorities at every level down to the village itself. For OCP, Intersectoral Cooperation is not an abstract ideal but a prac- tical , working fact. In the words of OCP Director Dr Ebrahim Samba: Even the art of casting a fishing net plays its part in the oncho programme. Photo WHO/J. Bland "We are not just discussing inter- sectoral cooperation-we are doing it. " At the macro level (the Presiden- cy) and at the micro level (the village -itself an integrated intersectoral body), OCP is intersectoral from top to bottom. It acts as a catalyst to set off a whole variety of activities in an almost unlimited number of inter- related fields. Some examples: Research: The two major fields of research in which OCP is engaged are insecticides/larvicides and chemo- therapy-drugs to beat the filariae in the human body. More than 50 chemical industries offer their col- laboration either directly to OCP, or through WHO's Vector Biology and Control Division, or through the Spe- cial Programme for Research and Training in Tropical Diseases. Re- search activities are being carried out in the Programme area, and this in turn is preparing nationals for research work in other diseases. But other parts of Africa are ben- efiting from this research , and send their nationals to be involved and to get training. In addition, OCP research reaches into the developed world. Many large pharmaceutical companies are col- laborating with OCP for developing and field testing drugs. The academic world in both de- veloping and developed countries is watching closely what emerges from the OCP's researches, for instance, the biology of the vector, and an increas- ing understanding of the parasite's life-cycle. Training: Training is not confined to operational staff of the Programme, although its officials are proud of their record for " Africanisation " of the staff; 96 per cent of the staff are Africans. But in addition, young scien- tists and technicians from all parts of the world are coming to the OCP to get African experience. A training in dealing with onchocerciasis is, by ex- tension, a training in other tropical W oRLD HEALTH , March 1986 diseases such as trypanosomiasis , schistosomiasis , and guinea-worm. Technology: Other than the actual spraying of rivers from helicopters and fixed-wing aircraft, the Programme is not on the face of it "high techno- logy". But there is increasing use of telecommunications-to determine prevailing wind directions (this has relevance to the problem of reinvasion by the blackfly), to gauge the precise flow of rivers (vital for determining the most cost-effective use of larv- icides) , and to obtain reliable meteorological forecasts. OCP is even making use of space technology. Fixed depth- and flow- gauges in eight rivers of the pro- gramme area are fitted with transmit- ters which beam the readings to the Argos satellite as its orbit carries it overhead. Argos beams back the read- ings to a central computer , where they can be read off and used to work out the optimum concentrations of chemi- cals for spraying operations. Some of these teletransmitters are installed and being used by the OCP countries for meteorological and hydro-agricultural purposes. Thus OCP and the govern- ments use these facilities each for its own ends. Bird's-eye view Meanwhile FAO is also undertaking a series of aerial photos of the area. By comparing "before" and "after" photographs , agronomists and other scientists can observe the effects of the ten-year-old programme on human demography , crops, farm animals and land-use in general. The Decade: Onchocerciasis is a water disease. The integration of the surveil- lance and control of this disease within a strengthened PHC system leads naturally to the control of other dis- eases such as schistosomiasis, guinea- worm and malaria. Where areas have been cleared of the blackfly and resettlement is occur- ring, people will need wells and ag- ricultural lands. The wells have to be made safe for human use . A further step will be to build latrines so that drinking water will not be polluted. Already , the action has moved from the diseases already mentioned to the diarrhoea} diseases. OCP has a special W oRLD HEALTH, March 1986 interest in the health risks of small- scale water developments, such as dams and irrigation channels. So the repercussions of OCP are immediate for the International Drinking Water Supply and Sanitation Decade. Examples such as these could be multiplied indefinitely. OCP has a bearing on food and nutrition , rural development in general,desertification and reafforestation , and of course on primary health care in all its aspects from health education to immuniza- tion and maternal and child care. When the Onchocerciasis Control Programme is concluded-in approxi- mately 12 years' time-the blackfly pest will not have been eradicated. OCP activities involve all levels of the West African community, from village chiefs to heads of state. Photo WHO/J. Turner That is not the purpose of the pro- gramme. But the parasite-host-vector cycle of the disease will have been broken. People will not enjoy being bitten by the fly but they will no longer be at risk of going blind. Better still, the skills and the tech- nology which have gone into the pro- gramme will be available to tackle other diseases, to solve development problems in other sectors. In the field of health , there is probably no other enterprise with a better claim to be " the intersectoral programme " . • 15 lntersectoral Acti_ More than ever before, the experts responsible for planning national economies are recognising that a country's health forms part of an integrated process of development. The experience of the world's industrialised countries showed that diseases associated with poor sanitation, illiteracy and poverty were eventually controlled, not by spectacular medical breakthroughs, but by improve- ments in urban services, housing and the environment, higher levels of education, and better diets. The moral for all the world today is that the health sector cannot do it alone! Many other ministries, services. institutions, official and unofficial bodies. and all levels of administration down to the community and the family must become involved in health. So the drive towards the goal of Health for all by the year 2000 can only be inspired and fuelled by concerted intersectoral action. Our graphic model suggests only the eight elements included in WHO's definition of Primary Health Care: education about health, proper nutrition, safe water and basic sanitation, maternal and child care including family planning, immunization. prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential drugs . But these symbolise a huge range of factors to which other sectors besides health must contribute if all people are indeed to attain a level of health that will permit them to lead a socially and economically productive life. Designed for World Health by Ted Gering Health and the media Without wholehearted backing from the media in convey- ing health messages to the greate'st number of people, we risk having only Health for Some instead of Health for All Within the broad spectrum of development, two sectors have stood out as among the fastest growing in the 1960s and 1970s. The media sector's growth has been phenomenal and is plain for all to see. Most countries have busily expanded and improved their physical infrastructure in the media sector, launching newspapers and magazines, establishing printing plants , setting up radio and television stations . In many least-developed countries-where lit- eracy is low and roads are few-radio is virtually the only nationwide system for delivering information. At the same time, the health sector has been expanding at a rapid pace . 18 by Jack Ling No government can ignore the health needs of its people , and most health ministries-though they may not rate high in the political hierarchy-have expanded their health and medical services in recent decades. Today the health sector recognises that there are limits to technological and medical interventions. Health is a social phenomenon , and better health for a nation can only come about with active support from many sectors. Health behaviour itself has many de- terminants, whether cultural, social, economic, environmental or " infor- mational ", in addition to biological and medical. Moreover, health must begin with the individual and the corn- m unity . So if health actions are to have a lasting impact , they must involve a public which has been adequately informed. The medical and health professions and the media do not make easy bedfellows. Doctors and scientists tend to regard journalists with deep suspicion, and the time-honoured tradition that "doctors don't adver- tise" may have influenced the attitude of many physicians in public health servtces. Media people in turn have little patience with highly technical medical material. The guarded formulae and technological jargon of medical publi- cations bore them ; they are inclined to want simple answers to straight ques- tions so that they can get a news-story to retail to the public. Today these two sides have reached a juncture where they must achieve mutual dependence. Without the in- volvement of the media , the health sector cannot hope to inform the general public on health issues or to stimulate a process of community involvement. Without the technical input of the health sector , the media cannot fulfil their obligation to serve the interests of the public-and these public interests certainly include health. Only in 1982, during the World Health Assembly held in Geneva, the Assembly President and Malaysia's Minister of Health, Dr Tan Sri Chong, Where literacy is low, radio may be the only nationwide system for delivering health information. Photo W HO/Za far W oRLD HEALTH, March 1986 A boy keeps abreast of the news in an Indonesian bird market. Newspapers too are a key source of positive health information. Photo WHO/C. Stauffer said: "Lifestyles are no longer con- ditioned by climate and culture. They are initiated as fast as communications speed information·from one country to another. " He was referring to those illnesses that have their principal roots in life patterns : cancer , heart diseases, alcohol and drug abuse, stress, and various environmentally caused and psycho-social illnesses. In effect , he had defined a new type of communicable disease: in addition to bacterial or viral or vector-borne dis- eases, we now have illnesses that are " communicated " by Images and information . So the power of the media includes the power to do harm to health. But when the media and health sectors work together, and work together in a systematic way, then that power can become a power for good. The media will need to become more aware of their own role in raising W oRLD HEALTH, March 1986 awareness , stimulating public discus- sion , articulating public needs in the fields of health and social develop- ment. And in turn, the health sector will need to recognise what media can do, not merely in serving as a platform for news-stories (since hard news ac- counts for only a small part of the media's content) but in employing en- tertainment as a means for conveying health messages and influencing social behaviour. Health messages can be very effective when they are presented as part of " life" in entertainment programmes. The health sector should focus on making technical subjects digestible and understandable to the layman. In particular the health professionals should identify existing, credible chan- nels of communication, including trad- itional ones , in order to reach the public. The media offer the public health community more than just ac- cess to air-time and newspaper space; they are also a source of that com- munications expertise that is needed to ensure the success of large-scale health promotion campaigns and to transmit technical information about health to a mass audience. What is more, useful follow-up to media-transmitted messages can be effected by village health workers. For instance, primary health care workers can be an effective mass channel of communication by delivering in per- son the same messages that have been delivered to a target audience in print or over the radio, thus increas- ing the overall impact of the educ- ational drive. To sum up, a dialogue has to be initiated between decision-makers in media and in public health. The object of that dialogue should be to heighten awareness among the media personnel about the important responsibility they hold for the health and well-being of their people, and equally to alert health professionals to their own re- sponsibility for ensuring that their health initiatives reach all people. Without this wholehearted backing from the media in conveying health messages to the greatest number of people , we risk having only Health for Some and not Health for All . • 19 Health for all by the year 2000 Fun and games In the early 1970s, family planning in Thailand was re- stricted to servicing through medical channels ; even men- tioning it tended to be a cause of social embarrassment. Today, public discussion of and advertisements for family planning methods have become commonplace . This change has largely resulted from the activities of a nongovernmental organization. the Population and Community Devel- opment Association (PDA) , which has shown impressive achievements in promoting social awareness of family planning and the widespread adoption of contraception . The founder and, until recently, Director of the PDA Mr Mechai Vira- vaidya, has been widely acclaimed for his energetic and imaginative efforts . His personality has become closely identified with the cause of family planning in Thailand. From the begin- ning, his approach has emphasised the need to introduce family planning in the context of people's attitudes and daily activities, and to demons- trate immediate practical benefits from lowered fertility. The programme's basic achieve- ments have been justifiably attributed to Mr Mechai's energy and charisma- tic personality. Its expansion and con- tinued effectiveness have, however, resulted from incorporation of all its initiatives within a total communica- tion strategy for family planning and social development. And a new understanding of social motivation - combined with a large measure of humour and audacity- has led to the development of a wide range of culturally adapted social mar- keting strategies which have been implemented through the PDA pro- grammes . Between 1974 and 1981, 20 one of these programmes, the Com- munity-Based Family Planning Ser- vices (CBFPS), grew from a pilot undertaking into a network of local self-help schemes reaching over 16,200 villages in 158 districts, with a population of 17 million. Its frank, consumer-oriented approach has Mechai Viravaidya publicises family plan- ning in Thailand by blowing up a condom. Photo M . O"Donnell© been adopted within the national family planning programme for ex- tending coverage and maintaining high user rates . Problems of lowered economic growth, individual income and food availability, associated with the rapid growth of population that occurred in Thailand from the 1950s, had by the 1960s been recognised by a wide segment of national leaders in gov- ernment. business and the univer- sities . The Thai government put a high priority on the control of population growth. The introduction of family planning was facilitated by socio-cul- tural features that made inhibitions in these areas easier to overcome than in many other countries . However, achieving widespread adoption of contraceptive practice required a re- versal of traditional attitudes, preva- lent in Thailand as elsewhere. The CBFPS Project was designed to use local resources-personnel, social and economic institutions- to promote and provide family planning services at the community level, as a means of extending and adding to the coverage achievable under the exis- ting health clinic network. The initial objectives of the project were: - to test the possibility of expanding access to, and information about. contraceptive methods; - to create new and increased de- mand for family planning at the village level and thus to increase the number of couples practising family planning and decrease the pregnancy rate; and - to become financially self-sufficient in four years . The medium and the message Since the programme started, the key message that has been conveyed links population growth to low stan- dards of living, on the one hand, and family planning to economic advan- tages, on the other. To convey the message through . the various com- munication channels, it was neces- sary to de-sensitise the taboos sur- rounding birth control techniques and the social embarrassment attached to discussing them openly. In Thai culture. humour and fun proved to be the best means. Birth control carnivals, games, condom- W oRLD HEALTH, March 1986 blowing balloon contests, raffles, village fairs, and weddings have served as occasions to promote fam- ily planning joyfully. One example : key-rings with plastic-encased con- doms attached are distributed with the message "In case of emergency, break glass. " Games devised on the "snakes and ladders" principle are printed on pa- kao-ma cloths traditionally worn by Thai men. Inches and centimetres are printed on birth control pill packets so that they can be re-used as rulers . Sheets, pillow-cases, piggy banks and business cards are all printed with family planning catchwords . The key message has been convey- ed by creative use of virtually all possible communication channels, resulting in a high level of public awareness of family planning and of the PDA programmes. Face-to-face education is undertaken by the village distributors, who are sent the information, motivational and publicity materials they need. In addition, television and radio broadcasts fiercely discuss family planning , and many programmes of general interest close with reminders about using contraceptives . In school, children learn about family planning; many of them have learnt a song describing the hardships resulting from having too many children . Troupes of traditional entertainers perform puppet plays containing fami- ly planning messages in villages all over the country, and T-shirts and other promotional materials with ap- propriate slogans have been distri- buted at formal state dinners and sent to foreign heads of state, emphasis- ing the legitimacy of the programme and the support of the government. Awareness of the benefits of family planning and knowledge of its avail- ability have not only been actively created but positively reinforced . The social communication strategy of the PDA has succeeded in breaking down cultural and psychological barriers to population control in all sectors of society. The stimulation of demand has been further increased by a com- prehensive reward structure, which has resulted in contraceptive user rates as high as 80 per cent in some areas . W oRLD HEALTH, March 1986 The Population and Community De- velopment Association , formed by Mr Mechai, is a non-profit and largely voluntary organization with over 300 staff members and 16,000 village vol- unteers working from five bureaus . This work has attracted intense pub- licity in the foreign press, and his is the only Thai voluntary relief agency working with refugees which pro- motes family planning in refugee camps and provides supplies through the office of the UN High Commission for Refugees. Community organizations also ad- dress problems of over-population, low productivity, malnutrition and in- adequate health care by linking family planning to environmental improve- ments, income-generating activities, technical advice on establishing home industries and increasing agricultural production, health care and nutrition education. The intersectoral activities of the PDA have confirmed that family plan- ning services can be successfully provided through ordinary lay people, given the necessary organizational support. at increased levels of use and without undue risk to acceptors . • Humour and fun have helped to de-sensit- ise the taboos surrounding birth control; today they can be openly discussed. Photo WHO/J. Mohr 21 One of ten natiqnal ~rojects .in Jhe wHcz!uNoe· Health;Lea~n­ mg . Materials progr~mme, the . c.~nt~(3 ''fqr Edu?ational De- velopment in Heallti inArusha, ~a~za.~i .. ?' is aprimee~a~pl~ (Jf a health project vyhich ~.ngage$ • man'Y.i[ Otper sectors It is usual to think of a health training institute as concerned only with health personnel and medical problems . In fact, in a developing country this is often far from the case. The reality of the daily routine for the director of a health training institute in a country like Tanzania means facing a host of differ- ent practical problems and conflicting priorities. To run a successful training school, you need to look beyond the health care field and "think inter- sectoral ". Dr Ezra Teri is Principal of the Centre for Educational Development in Health in Arusha (CEDHA) , Tan- zania. He first qualified as a doctor at the University of Makerere in Uganda, then studied public health in California, before going on to take his Master's degree in health personnel education at the University of New South Wales. His present job as Principal of the Centre in Arusha involves him in con- tacts with many sectors other than health. He has been obliged to de- velop new skills beyond those for which he was originally qualified. CEDHA is a national training institute of the Tanzanian Ministry of Health. 22 Its aim is to upgrade the health care system by improving the training of health service personnel. A primary activity, therefore , is the teacher training programme of the Centre. The teachers of the future must be good planners and managers, and not just experts in certain specific subjects. So CEDHA trains teachers of health personnel in pedagogic, man- agerial and research skills, as well as in primary health care. This entails close involvement with the Ministry of Edu- cation's institutions , whose teaching staff have the necessary knowledge of educational technology and can help to design and conduct courses for the health sector. These courses are very varied : some of the CEDHA students are just undergoing a complete voca- tional training, while many others are experienced health workers taking " refresher" courses of "in-service" training. Ezra Teri has close contacts with the Institutes of Development Manage- ment in Mzumbe, Morogoro and in Swansea, UK, which run PHC manage- ment courses at CEDHA for managers of district health teams. Dr Teri him- self attended a month's course in Oc- tober 1985 on managerial techniques in training teachers of health sciences, held partly in Moscow and partly in London. The Health Learning Materials pro- ject at CEDHA, Arusha, of which he is project manager, is one of a network of ten national projects in the WHO/ UNDP Interregional Health Learning Materials programme. The aim of this programme is to help developing countries to gain expertise in produc- ing their own teaching and learning materials for local health workers. This demands special skills in manage- ment from the national project leader, unlike most routine health posts. It also requires skills in communication, so that he can cooperate very closely with colleagues in many different sectors. Producing your own materials The production side of the learning materials project obliges the project manager to learn about the practical and technical side of printing, since he has to produce printed texts of manu- als, reference books and teacher guides, as well as other training mate- rials for health care workers. There is W oRLD HEALTH, March 1986 Dr Ezra Teri, manager of the Health Learn- ing Materials project in Arusha, Tanzania . Photo W HO also a heavy demand for health educa- tion materials,. which the health work- ers can use in their contacts with local communities. Since he took up his post as the first Principal of CEDHA in 1982, Dr Teri has recruited a medical illustrator and photographer for the project. He has also engaged an all-round technician to handle the offset printing machin- ery and all the other equipment needed in the illustration, printing and binding of texts . Students and staff at CEDHA carry out their own research into the kind of educational materials needed for the different cadres of health workers in Tanzania, and learn to write, illustrate and produce the finished materials on the spot. None of the medical staff at the Centre previously possessed real skills in writing or editing, let alone the production of materials. So specially- tailored training courses were de- signed for them. For this, the African Medical and Research Foundation W oRLD HEALTH, March 1986 (AMREF) in Nairobi, Kenya , was called in. AMREF is a non-governmental or- ganization which has many years of . experience in producing training materials for health personnel all over Eastern Africa. Dr Joe Popp, head of AMREF's training section, designed a special course at Arusha to provide CEDHA staff with the writing and editing skills they needed to develop their own teaching materials, and travelled to Arusha last March to hold the course. This was reinforced by an editors' course in July, conducted at AMREF in Nairobi, and attended by trainee editors from national projects m Ethiopia, Kenya and the Sudan, as well as from CEDHA . Training the key project staff at CEDHA is, of course, a priority for Ezra Teri. He is constantly on the look-out for appropriate training institutes and opportunities to get training for his staff. He sent Wilson Lendita, the librarian and audio-visual aids special- ist at CEDHA, to London in August 1985 to follow a specially-designed training course, organized by the Blat Centre, on audio-visual aids in the health library. Like AMREF in Nairobi, the Blat Centre (British Life Assurance Trust for Health Educa- tion) works closely with WHO in sup- porting the network of national health learning projects. As a result of this training, Wilson Lendita is now run- ning the library more efficiently and is in the process of developing it into an information resource centre for the health sector. Training and equipment , of course, need to be paid for , which means that another very time-consuming aspect of Ezra Teri's brief is fund-raising and public relations. It soon became obvi- ous that CEDHA needed its own public relations brochure, as well as more well-presented information materials if it could hope to attract funds from major donor agencies. Dr Teri has worked hard to develop public rela- tions skills and an extensive network of personal contacts in donor groups and non-governmental organizations. He has obtained support from a number of Dutch church organiza- tions, as well as the German Founda- tion for International Development based in Berlin. The German Founda- tion is now discussing a proposal with the Ministry of Health in Dar es- Salaam to part-fund a three-year pro- gramme of teacher training at CEDHA. 23 Institution building as one of the objectives of development aid has al- most become a cliche. In the case of the centre in Arusha, it has to be taken literally. Three years ago, CEDHA's premises in Arusha were a jumble of derelict buildings with broken windows, electrical fitments .torn out, and no equipment. Thanks to Dr Teri's fund-raising efforts, the Dutch church groups have now pro- vided the Centre with building mate- rials of all kinds, ranging from electri- cal equipment to cement, most of which are not easily or cheaply obtain- able in Tanzania. With no foreign currency available, the Centre could not have hoped to buy these abroad. Plans are now underway to build staff housing and enlarge the premises of the health learning materials pro- ject. More space has to be found to house the offset printing and binding equipment and printing supplies do- nated by WHO. A local publishing house, Tanzania Litho Arusha, has pledged to help Dr Teri to identify the kind of printing equipment he needs to produce his own health training mate- rials, as well as providing training for CEDHA print-shop staff. To get the Arusha Training Centre 24 operational, he has had to involve himself not only with builders and planners, management trainers and educational technologists, but also with illustrators and technicians re- sponsible for producing printed train- ing materials. He comments, "Inter- sectoral cooperation requires a great deal of public relations work and in- formation flow. It requires dynamism and personal commitment, teamwork and the pooling of human, material and financial resources for a com- mon goal..." As part of his drive to make the Centre better known to the public and the health sector, and in the hope of finding additional support, Dr Teri has built up a good relationship with the local Arusha office of the "Tanzania Daily News" and "Uhuru", a news- paper circulated in Swahili. Through personal contacts in the Shihata news agency, he gets newspaper coverage of the Centre's activities, and Radio Tan- zania has broadcast features on CEDHA's health programmes at least once a year. Dr Teri works in close contact with WHO, UNDP, UNICEF and other agen- cies, as well as with NGOs. WHO gives financial support to CEDHA in the form Both students and staff at the Arusha Centre learn to write, illustrate and produce finished materials on the spot. Photo WHO of equipment and supplies, by under- writing the study travel costs for key staff, and by providing a grant in local currency to cover the costs of work- shops and surveys. WHO also gives technical advice and helps to send suitable consultants to Tanzania with expertise in the areas most needed by CEDHA. The Centre is working very closely with a neighbouring village in training students on primary health care, so Dr Teri has to plan and provide infor- mation sessions for village leaders and their communities. This calls for close involvement with the villagers in order to achieve the objective of producing trained health personnel who will in future serve in the peripheral and rural settings. As Ezra Teri himself says: "All those involved must clearly define the goal of their cooperative venture and show commitment and involvement right from the planning stage through to its successful conclusion." • W oRLD HEALTH, March 1986 J ' ' Primary Health Care Only a volunteer A volunteer health worker in a small Indonesian village is paid only a tiny salary. But the community values her work. As one such woman expresses it: "That's enough reward, isn't it?" Mutiah w as the first woman in her Indonesian village to take the pill . "ltwas in 1971," she told me, "after having my fifth child . Later on I switched to an IUD." She lives in Kadiwulyo village in East Java Province. When I first met her in the kitchen of her bamboo- walled house, she was cooking rice and long beans for lunch . Barefoot. and dressed in a plain blue skirt and a simple blue blouse she looked no different from any other village woman as she squatted on the dirt floor, poking dried-out maize stalks into the clay stove. And yet. although she would be the first to deny it, Mutiah is a very special person . Ten years ago the village head chose her as the "family planning assistant", a job she still does today. lt has changed her whole life, and that of the community. At the start of the 1970s, family planning was virtually unknown in Kadiwulyo, and indeed in most villages throughout Indonesia. Yet to- day, 85 per cent of women of child- bearing age in Kadiwulyo use con- traception-and of them 56 per cent use the pill, 40 per cent an IUD, three per cent an injectable method and one per cent sterilisation . The others are either trying to have another child or are already pregnant. (Mutiah rat- tled off these figures without looking W oRLD HEALTH, March 1986 by Glen Williams up any records . Later I checked them at the local family planning office and found them to be correct.) lt is a remarkable achievement. I asked her why so many people had started planning in her village . "Parents feel the benefit." she re- plied. "Mothers know that too many " I feel that the community values my work. That's enough reward, isn 't it ?" Photo W HO/G. Will iams pregnancies are bad for their own health and the baby. And also a mother with small children can 't do other things . She can't go out so much and look for work or help her husband in the fields . So she's glad when her children are old enough to go to school." "But how," I asked, "did you per- suade people to actually start using contraception in the first place? Surely there was a lot of resistance at f irst?" "Most of the resistance," she said with a wry smile, "was amongst the husbands . " We introduced the idea of family planning through the women's organizations in each neigh- bourhood, and thei r: response was very positive . lt was the menfolk who weren't so keen ... " But Pak Lurah, the village head, had instructions from the government to "deliver" a target number of accep- tors per year. To achieve this he simply instructed his pamong desa- twelve men who serve as the village council - to go from door-to-door re- cruiting acceptors . "So there was a bit of pressure from Pak Lurah to recruit acceptors?" I asked . " Not really pressure," she replied, smiling again . "Nobody was forced to become an acceptor. lt was more a matter of giving information and, yes, trying to persuade people, especially the men .. . These days they all agree that family planning is a good thing ." I asked whether new acceptors received any financial incentives, and Mutiah said no, but there were certain economic advantages. When a woman starts family planning she joins an acceptors' club- there are 25 five in Kadiwulyo . The group meets every month, and acceptors using the pill can collect their supplies at that time. Furthermore, acceptors can also join a credit scheme using capital from a local bank. The only condition is that they use the money for produc- tive purposes-such as starting a small business or buying live- stock-and that they continue to prac- tise family planning . "What happens," I asked, "if a woman decides she wants another child? Does she just stop taking the pill or get the IUD taken out?" Mutiah explained that it was not that simple. First, the woman would report that she wanted another child to the head of her acceptors' club, who would inform Mutiah. If the woman had only one child, Mutiah would raise no objection . But if she already had two or more, Mutiah would point out the advantages of not having another. "And if she insists?" "Then someone else will speak with her -a community leader or the midwife from the health centre . " "And if she still insists?" "Well," she said with a laugh," she will probably have another baby .. . " There are over 180,000 family planning acceptors' clubs throughout Indonesia . Guided and supervised by 10,000 full-time family planning field- workers and backed by a huge mass communications campaign, the acceptors' clubs form the bedrock of a family planning programme which is remarkable by any standards. In 1970, when the National Family Planning Coordinating Board (BKKBN) was established, Indonesia had a population of 120 million and a crude birth rate of 46 per 1000. Modern means of contraception were avail- able to only a tiny section of the urban population. Today, the population has reached 165 million but the birth rate has fallen by one-third to 30 per 1000. Fertility is declining, partly because of the spread of education and the rising age of marriage, but largely because of the growing use of birth control methods. Nationally, 58 per cent of couples of child-bearing age are registered as "current users" of contraception. 26 And on the densely populated islands of Java and Bali-where two thirds of Indonesia's population live-the cur- rent user rate is now 66 per cent. Indonesia's family planning pro- gramme has sometimes been criticised for overstating its achieve- ments -and for using "authoritarian" methods- caveats which are not en- tirely without foundation. The current user figures, which are based on the numbers of contraceptives distributed (rather than actually used), may in fact "Being a kader is hard. You need a lot of time and patience to do it well. " Photos WHO/G. Wi lliams overstate usage by 10-15 per cent in certain areas. In addition, certain aspects of the programme-such as special drives to promote IUD usage-have sometimes involved cases of over-zealous village leaders and government officials us- ing promotional methods which tend to be more coercive than persuasive. These cases, however, are the excep- tion rather than the rule. The users of family planning in Indonesia generally regard it as a positive contribution to family health and welfare rather than as an imposition by the government. The official goal is now to reduce the national birth rate to 22 pe-r thousand by 1991-a decline (if achieved) of 50 per cent in only two decades. This is an ambitious objec- tive but not an unrealistic one. Its achievement will require much great- er community participation in organiz- ing and utilising family planning in provinces where current user rates are still low. And this in turn depends on the availability of volunteer communicators and organizers such as Mutiah. Mothers as weight-watchers But Mutiah's voluntary work does not stop with family planning . She is also the coordinator of 25 women volunteers, or kaders, who run a nutri- tion improvement programme started in the village three years ago. About 30 per cent of Indonesian children suffer some degree of protein-energy malnutrition, and around 100,000 suffer from vitamin A deficiency-a common cause of blindness. Poor nutrition is also an underlying factor in Indonesia's relatively high infant mortality rate of 90 per 1000 live births-compared with only 50 in the neighbouring Philippines. The main activity of the nutrition programme is child growth monitor- ing. This is done by weighing infants and under-five children every month, and recording the results in individual growth charts retained by the mothers. Since weight gain or loss is a very sensitive indicator of health status, growth monitoring enables the mother to monitor her child's health and to take timely action if the child's growth falters. Weighing is done by kaders at weighing posts set up in people's homes and also in the village hall. The monthly weighing post also serves as an educational centre where mothers learn how to treat common illnesses of childhood and how to promote healthy child development through appropriate hygiene and nutrition. Kadiwulyo village has five weighing posts-one for each neighbourhood -with about 65 under-fives registered at each. Average attendance at the monthly weighing sessions varies from 50 to 80 per cent, depending on the size of the group: the smaller the group the higher the average attendance. Over 100,000 weighing posts have now been established in about 60 per cent of Indonesia's 62,000 villages . W oRLD HEALTH, March 1986 More than half a million kaders, all women, have been trained, and around five million children are being weighed every month. In many vil- lages, women like Mutiah, already active as volunteer family planning workers, were automatically recruited to lead the nutrition programme. A year ago, Mutiah and the other 24 nutrition kaders in Kadiwulyo were retrained to undertake a dramatic expansion in the activities of the weighing post - now renamed the "integrated health post", or posyan- du. Grafted on to the weighing and nutrition education activities are a wide range of maternal and child health services: family planning, im- munization, pre- and post-natal care, simple curative care and control of diarrhoea (which accounts for 24 per cent of infant mortality). lt is now possible, for example, for a mother to take her child to the posyandu to be weighed, immunized and given a medical examination by a visiting nurse, while she herself has an IUD fitted, checked or removed. This new programme-called the Integrated Family Planning and Health Programme-is a major break-through in the organization of primary health care in Indonesia . lt has the effect of drawing health centre staff into the village to guide and assist a health programme run mainly by members of the community itself - the volunteer kaders. "But," said Mutiah, "being a kader is hard . You need a lot of time and patience to do it well. lt isn't just weighing the children every month that takes up time . There's also all the paper work - the report forms, the record books and so on. You also have to visit the mothers at home, espe- cially the ones who don't bring their children to be weighed. Sometimes a mother is ashamed to bring her child if she knows it's sick or malnourished. Others say they're too busy, or they forgot.. . " In the eyes of the medical profes- sion, Mutiah is "only" a volunteer health and family planning worker. Her technical knowledge and abilities, compared with those of the health professionals, are no doubt extremely limited . She does not even have a simple manual with basic information W oRLD HEALTH , March 1986 Besides being a volunteer health worker, Mutiah has to run her home and tend her market garden. about primary health care, let alone a medical kit to treat common illnesses. But as a communicator and organizer within the community, her role in primary health care is every bit as important as that -of a fully trained doctor, nurse or midwife. She might not have heard of the Hippocratic oath, but her sense of commitment to her work would put many health professionals to shame. I calculated that Mutiah spent at least ten days a month on family planning and health work in her vil- lage. For this, she receives the equi- valent of about US$ 15 a year from the government. "But how they cal- culate it I don't know," she admitted . And she is one of the lucky ones. Most volunteer health and family planning workers in Indonesia receive no payment at all from the govern- ment. lt is not as though Mutiah is a sort of wealthy lady who can afford to work endless hours doing good deeds for the community. She and her hus- band own some paddyfields and they are regarded as "having enough", as the Indonesians say. But they are by no means rich or even well-off. I asked her why she spent so much time and effort for so little reward. Her answer was very firm : "But there are rewards," she said, smiling broadly. "I feel I have learned a lot from doing this work. I understand more about health, and about the community. Above all, I feel that the community values my work. That's enough reward, isn't it?" • 27 IARC : 20 years old When the Eighteenth World Health Assembly , meeting in Geneva in May 1965 , decided to establish an International Agency for Research on Cancer, it brought into being the organization which fulfilled an appeal made by General Charles de Gaulle , the Presi- dent of France, two years earlier. The Agency began its work in July 1966. The governments of France , the Federal Republic of Germany , Italy, the United Kingdom and the United States agreed to become founding Par- ticipating States-each contributing US$ 150,000 a year towards the Agency. Very shortly afterwards, the Soviet Union joined, soon to be fol- lowed by Australia and the Nether- lands. Between 1970 and 1982, Belgium, Japan, Sweden and Canada added their support to the Agency. The budget in 1985 was close to US$ 9 million. During 1963-1965, whilst the Min- isters of Foreign Affairs and of Health discussed the proposal for an interna- tional cancer research body, other dis- cussions were taking place elsewhere. Mr Louis Pradel , the Mayor of Lyon, France , reacting quickly to the de Gaulle appeal, invited the future or- ganization to make its headquarters in Lyon. He offered the French Govern- ment a building site and undertook to share in the cost of putting up a suitable headquarters. In 1965, the International Agency for Research on Cancer was brought into being by the World Health As- sembly, with a unique statutory posi- tion. The Agency was clearly under the aegis of wHo, but it was stipulated that it should never be a charge on the budget of WHO . Participating States of the Agency were to form their own Govern- ing Council and pay separate annual contributions to the Agency. Whilst fulfilling the terms of its statutes , to promote international collaboration in 28 by Waiter Davis cancer research , the Agency has also developed its own cancer research pro- grammes. What its future activities might be were set out by the Advisory Scientific Committee, set up by Dr Marcolino Candau, then Director- General of WHO. This committee was the precursor of the Scientific Council established by the governing council to advise it , and the Agency's director , on its future research programmes. !ARC's headquarters in Lyon, France. The Agency began its work in July 1966. Photo WHO/J. Mohr In 1966, the Agency's first director , Dr John Higginson, was appointed and in May 1967, the staff nucleus moved from Geneva to Lyon. There for the next five years they developed their activities in the temporary ac- commodation put at their disposal by the municipal authorities, whilst the headquarters building was being con- structed. In June 1972, the 14-storey tower block was ready for inaugura- tion by French President Georges Pompidou, and soon after all the staff, by this time around 150, moved into their laboratories and offices. It was decided that the Agency's activities should be directed towards research into cancer causation, and the programme was developed with a two- pronged attack: epidemiological re- search on the one hand and experi- mental laboratory research on the other , but with the laboratory often providing essential support in the epidemiological field study. At the same time every effort would be made to coordinate the Agency's research with that going on in national laboratories, and to strengthen that coordination by collecting and dis- seminating information. Descriptive epidemiology of cancer at the international level had just been given a boost by the publication of " Cancer Incidence in Five Conti- nents", a technical report of the International Union Against Cancer (UICC), and the UICC asked the Agency to take over full responsibility for its future production. The Interna- tional Association of Cancer Regis- tries , for which the Agency provides a secretariat, has now in turn been in- volved in continuing the series. This compilation of reliable cancer registry data is proving of great value in the development of ad hoc studies in analytical epidemiology. The Agency assisted in developing the oncology section of the Interna- tional Classification of Diseases which helps cancer registries to standardise their classification and coding. While continuing to assist in the up- grading of cancer morbidity data, the Agency is expanding its collection of information from countries where population-based cancer registries have yet to be established , particularly from the developing countries. Such information is essential to local public health authorities in the forward plan- ning of their health services and may also indicate opportunities for inter- vention for cancer prevention. The Agency's scientific staff have been involved in analytical epi- demiological studies of several dif- ferent cancers and in many parts of the world. Examples are the association between primary liver cancer and W oRLD HEALTH , March 1986 aflatoxin contamination of food in Kenya; Burkitt's lymphoma and Epstein-Barr virus in Uganda; mesothelioma in Central Anatolia, Turkey; oesophageal cancer in France, Iran and China; and more recently the association between prim- ary liver cancer and hepatitus B virus infection in the Gambia. Co-ordinated studies of cancers of the pancreas, bile duct and gall bladder involve research groups in Australia, Brazil, Canada, the Netherlands and Poland. Glass fibre and rock-wool are in- creasingly used to replace the car- cinogenic asbestos, and in Europe, a large cohort of men exposed to these man-made mineral fibres has been studied for adverse health effects and especially lung cancer incidence. In Colombia where the incidence of cer- vical cancer is very high and in Spain where it is low, a collaborative case- control study is being mounted to determine to what extent the ten-fold difference in risk is related to either male or female sexual behaviour, and to human papilloma virus. Studies of the relation of dietary factors to cancer incidence are under way in Belgium, France, and Iceland, and are being planned in Sweden. And a large-scale international collabora- tive programme has been developed to evaluate the effect of mass screening programmes on cancer mortality, both for cancer of the cervix and of the breast. It is already clear that an efficiently run mass screening pro- gramme can drastically reduce mortal- ity in both diseases . The study has also indicated how best to organize a screening campaign to achieve a max- imum efficiency at minimum cost, a consideration of particular importance in developing countries. In 1968, Dr Lorenzo Tomatis, who in 1982 was to become Director of the Agency, was appointed to develop a programme in chemical car- cinogenesis. That programme took two major directions, which are still being followed. The first was the in- itiation of laboratory studies into the biology and mechanism of chemical carcinogenesis, and the second was the setting up of what has become one of the most important functions of the Agency-the evaluation of the car- cinogenic risk of chemicals to humans . W oRLD HEALTH , March 1986 !ARC's research workers are contributing to the control and, eventually, to the prevention of human cancer. Photo WHO/E. Schw ab Micro-analytical techniques have been developed in the Agency to de- termine the presence and concentra- tion of carcinogenic substances in en- vironmental samples, with particular attention to mycotoxins and nitro- samines. The development and stan- dardisation of such analytical methods is coordinated between the Agency's laboratories and a number of national institutes. The Agency has established an in- ternational network for the long-term carcinogenicity testing of chemicals, and has also developed methods for short-term mutagenicity tests, which are so necessary in screening the large number of chemicals that are being introduced into the environment. Biological research at first concen- trated on the role of viruses in human cancer, particularly in Burkitt's lym- phoma, shown to be associated with high levels of Epstein-Barr virus infec- tion, and in nasopharyngeal carcino- ma. More recently interest has centred on chromosomal translocations in the genesis of the disease. Among its many publications, the Agency has since 1971 issued a series of monographs on the evaluation of the carcinogenic risk of chemicals to humans. These monographs have now established a firm reputation both in scientific circles and in governmental regulatory agencies, and by 1985, thirty-seven volumes had dealt with the carcinogenic risks of more than 700 chemicals and industrial proces- ses. Of these, nine industrial processes and 30 chemicals or mixed exposures were identified as causally associated with cancer in humans, and a further 17 were considered to be probably carcinogenic. The educational activities of the Agency include a fellowships pro- gramme which gives priority to re- search training in cancer epidemiology and environmental carcinogenesis, and short specialist courses which are arranged in many different parts of the world. " The Agency's activities have de- veloped in many directions since 1966," says D,r Tomatis, Director of IARC, " and I would summarise them under four headings. "First, there is the collection, criti- cal analysis and dissemination of infor- mation. Secondly, analytical studies on etiology and prevention, including evaluation of mass screening pro- grammes, and the development of in- tervention studies as models for large scale public health initiatives. "Then, there are laboratory studies on the mechanisms of carcinogenesis and on the development of methods for detecting carcinogens, quantifying levels of exposure, and evaluating variability in the individual suscepti- bility to carcinogens. And finally, as an integral part of all these activities, the Agency continues its role in education and training. "Overall, the main thrust must re- main the search for etiological factors for human cancer, in order to contri- bute to the control and, eventually, the prevention of human cancer. " • 29 •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ............ , .......... ...... ... . ................ . Testing Physical Fitness in Children and Adolescents Somr~ 60,000 schoolchildren in the member states of the Council of Europe are acting as "guinea-pigs" for a "battery" of tests designed to measure their physical fitness. Under the title "Eurofit", the tests have been devised by the Council's Committee for the Develop- ment of Sport (CODS), which has been working on this prob- lem since 1978. Physical fitness depends on the integration of a number of physiological functions, each of which can be measured . How- ever, this normally requires sophisticated apparatus found only in specialised laboratories. The CODS has established a battery of carefully selected tests of physical performance, each depending on and limited by one prime physiological func- tion - for instance, the cardio- respiratory system, the muscles or neuro-muscular coordination. The results can be measured with simple apparatus, such as a stopwatch. a tape measure or an ergometric bicycle. The re- sults will be expressed as a time for a certain performance. a distance, a load overcome, a number of heartbeats. And they must be regarded both as qual- itative measures (an expression of the human function under test) and as quantitative mea- sures, related to the size and dimensions of the person being tested. The CODS has already ar- ranged four seminars on this theme. which have resulted in the compilation of an experi - mental "battery" and a provi- sional handbook (obtainable, in English or French from the Council of Europe, Postbox 431 R6, 67006 Strasbourg, France) In May, the CODS will hold a final seminar in cooperation with the Italian authorities and 30 Photo W HO/M . Jacot Standard tests for measuring the fitness of children. in particular the Italian National Olympic Committee, when a battery of tests and a definitive handbook will be agreed. Pro- fessor Erling Asmussen of the University of Copenhagen says in a foreword to the handbook: "A selected standardised bat- tery of tests for measuring the fitness of children and adoles- cents such as the one pre- sented in the Eurofit handbook is a .highly desirable and much- needed tool in physical educa- tion and sports." • Nairobi Meeting on Rational Use of Drugs "Cooperation rather than confrontation." This is how Dr Halfdan Mahler. Director- General of WHO, summed up the outcome of a five-day con- ference of experts on the ration- al use of drugs, held late last year in Nairobi. Kenya For the first time in a decade of polemic debate. experts from such dif- ferent fields as health policy and government drug regulation. health care provision, the phar- maceutical industry and con- sumer interests have agreed to work together, each in their own sphere of competence, to make the use of drugs more rational throughout the world. The conference spelled out the main responsibilities in this context of governments. the pharmaceutical industry, pre- scribers of drugs, universities and other professional bodies. the public and consumer groups. and the mass media. Under a proposed revised drug strategy now being drawn up, W HO'S own responsibilities will include: intensifying the promotion of national drug policies and the Action Pro- gramme on Essential Drugs. supporting the setting-up by governments of drug regulatory systems, enlarging the scope of WHO's Certification scheme on the Quality of Pharmaceutical Products Moving in Internation- al Commerce. improving the gathering and dissemination of information, training in rational drug use. promoting ethical criteria for drug advertising, and research. lt was unanimously agreed that there was no place for supranational drug regulation by WHO . However. WHO was asked to prepare guidelines on criteria for drug advertising by updating and expanding those which were originally laid down by the World Health Assembly in 1968. Governments would adapt these new guidelines to nation- al circumstances and make use of them in collaboration with the pharmaceutical industry. • UK Warning to the World : Smoking is 11 The Big Kill~~ In the United Kingdom alone, as many as one and a half million people will die prema- turely before the year 2000 un- less there are major reductions in cigarette smoking. This chil- ling warning was sounded in a publication entitled "The Big Kill" issued jointly by the British Medical Association and the Health Education Council. The booklet said that 55,000 men and 22,000 women in Eng- land and Wales die each year solely because they smoke. Some die from heart disease, others from lung cancer, bronchitis and emphysema. On average, 4,009 hospital beds are occupied each day by pa- tients suffering from these dis- eases, at a cost to the U K health service of £111 million every year. Sir Brian Bailey, Chairman of the Health Education Council. commented that the world was horrified when some 60 people Cigarette smoking-a habit that kills. Photo WHO/M. Puhl W oRLD HEALTH, March 1986 died in a recent aircraft hijacking episode, "but every day we butcher four times that number through smoking, but no one seems to bat an eyelid". • Family Planning Funds Are Cut The National Right of Life Committee praised the deci- sion. The Population Institute, another U.S. organization based in Washington, D.C., criticised it. In an editorial, the Washing- ton Post lamented it Rafael Salas, Executive Director of the United Nations Fund for Popula- tion Activities, whose agency is most affected, reacted with "deep distress" to it At issue is the decision by the U.S. Agency for International Development to withhold $10 million from its $46 million pledge to UNFPA this year. According to AI D Administrator Peter McPherson, the fund is involved in a "programme of coercive abortion and involun- tary sterilisation" in China, the support of which would violate legislation enacted earlier by the U.S. Congress. In a statement carried in the UN's monthly publication Devel- opment Forum, that claim is challenged . "We should like to state categorically that this con- clusion is in error", says Salas . "These charges have been re- futed by USAID itself, after careful reviews of UNFPA assistance to China in April 1984, and March 1985 ... UN FPA does not support abortion or coercion 1n any country. Its support of voluntary family planning is based on the premise that couples and indi- viduals have the basic right to choose freely and responsibly the number and spacing of their children". • In a related development, the International Planned Parent- hood Federation, London, an- nounced that its programme this year for 120 countries will be financed by a budget of near- ly $48 million-just $4 million less than last year following "vigorous fund-raising". The federation lost $17 million as a result of the AID cuts. • WoRLD HEALTH, March 1986 Newsbriefs • Launch of a newsletter. WHO 's Action Programme on Essential Drugs and Vaccines has started publishing a newsletter to keep interested readers informed about what the programme is doing, what other individuals and groups are doing in the essential drugs field, and how they can take advantage of experience gained in other countries. The Essential Drugs Monitor appears in Arabic, English, French and Spanish, and may be obtained free of charge from : OAP, wHo, 1211 Geneva 27, Switzerland. • Organic Puppet Theater. Using puppet shows to teach health awareness to children is not a new idea. But Illinois teacher Terry Schultz has carried the idea a step further with his "Organic Puppet Theater. " Children are encouraged to make inexpensive, jokey models of the stomach, lungs, teeth, skull, hand, the urinary system and the heart. A 90-page book written by Schultz and Linda M. Sorenson, with cartoon illustrations by Duane C. Barnhart, explains how these "puppets " - the skull might be made from a plastic milk container, for instance- are manipulated by children crouching behind an overturned table for the benefit of a youthful audience. The children have fun, but they also learn about bodily functions and what they can do to keep them in good shape. The book is published by Night Owl Press, 1537 West Iowa Avenue, Saint Paul, Minnesota 55108, USA, price $14. Learning about lungs. • Children's Ombudsman? One of the recommendations to emerge from a conference on battered children and child abuse held late last year in Berne, the Swiss capital, was for countries to appoint an Ombudsman charged with protecting children from abuse and defending their right to health development. The conference, held under the joint auspices of wHo and ctoMs (the Council for International Organizations of Medical Sciences) and hosted by the Berne University Children's Hospital, attracted more than 150 delegates from 30 countries. In the next issue Diarrhoea! diseases are a major scourge of mankind; in the Third World alone they kill millions of children every year. The April issue of World Health describes the efforts being made to treat, control and prevent this group of diseases, which include cholera, dysentery and typhoid fever. Authors of the Month Dr Aleya El Bindari HAMMAD is Chief of wHo's Intersectoral Action for Health unit in Geneva , and is Secretary of the Technical Discus- li!osions durin& ~he 1986 World Hef!Ith Assembly. •· · Dr Godfrey GuNATILLEKE is Direc- tor of the Marga Institute of Devel- opment .in Colombo, Sri Lanka. Mr Mark L. SCHNEIDER is a Techni- :Hto Cf!l Officer with ")'V~O 's RegionaLpf- fice for the Americas/Pan American Sanitary Bureau in Washington, D.C. , USA Mr Alastair ANDERSON is a journalist specialising in development affairs , tand is based in Geneva . ' M,r Jack LING is lthe Director of the Division of Public Information and Education for Health at WHO head- quarters in Gent<va. Dr M.A.C. DOWLING is Technical Adviser with .WHO's Division .. of H ealth Manpowe,r Development hnd Mrs Roberta Rl:TSON is Technical Officer with the same division. Mr Glen WILLIAMS is a development journalist based in London, UK. Dr Waiter DAVlS was in charge ofthe training programlne , and later ofthe scientific publications series , at the International Agency for Research on Cancer , in Lyon, France . He re- tired in 1982 and is now a consultant to IARC. . WORLD HEAL. TA For readers everywhere 1986 Subscription Rates US$ Sv.,:. fr. One year Two years Three years 12.50 25.L 22.50 45.- 30.- 60.- ORDER FORM Please enter my ~ubscription "World Health" as follows: o ·ne year D Two years D Three years D ! ,.enclose cheque/international postal order in the amouot of: · Name: ________________ ~~ Street: -----'----- - -- City: ---- ------ 9quntry: -------.!- ----"'-~ World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- script ion agencies. For payment in national cur- rencies. please contact your usual bookpeller. 31 Mass media and health; radio broadcasts reinforce more formal methods of health education. See page 18. Photo WHO