Summary reports on meetings 1978

SUMMARY REPORTS ON MEETINGS 1978 t?; i I : I ..., WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE COPENHAGEN D ' ,.,., . -, i:,; l J /f I , -,_/ f I ,.j/ SUMMARY REPORTS ON MEETINGS 1978 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE COPENHAGEN 1979 ISBN 92 9020 I 94 0 © World Health Organization 1979 Publications of the World Health Organization enjoy copyright pro­tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen (/), Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men­tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in these reports do not necessarily reflect the deci­sions or the stated policy of the World Health Organization. PRINTED IN DENMARK Reissued under ISBN: 9789289024976 (print) in 2025. Originally published under ISBN-10: 9290201940. This collection of summary reports on meetings organized by the Regional Office for Europe reflects the main activities carried out in different fields of health in 1978. From 1973 to 1977 the collection appeared in a single volume, in English, French and Russian. Since the introduction of German as the fourth working language of the Regional Office, summary reports have also been issued in this language and it was therefore considered preferable, for reasons of convenience and economy, to publish the collection in separate volumes, in the four languages. The Regional Office will be pleased to supply further information on any of the activities described in the reports. Leo A. Kaprio, M.D. Regional Director CONTENTS Alcohol and Drug Dependence Cancer Cardiovascular Diseases Chronic Lung Diseases Clinical Pharmacology Environmental Health Basic Sanitation Control of Environmental Hazards Drinking Water Control Health Aspects of Tourism Toxicology Family Health Health Care of the Elderly Health Education Health Laboratory Services Health Management Health Manpower Development Malaria Mental Health Nursing and Midwifery Ophthalmology Prevention of Road Traffic Accidents Primary Health Care page 1 7 11 15 19 25 27 29 34 38 41 45 55 61 69 75 81 89 93 99 107 111 119 - 1 - ALCOHOL AND DRUG DEPENDENCE Conference on Public Health Aspects of Alcohol and Drug Dependence Dubrovnik, 21-25 August 1978 Introduction - 3 - SUMHARY REPORT ICP/MNH 048 IV(S) 19 September 1978 The Conference, convened in collaboration with the Government of Yugoslavia, was attended by psychiatrists, sociologists, psychologists and public health administrators from 26 Member States of the WHO European Region as well as representatives of governmental and nongovernmental international agencies active in the prevention of alcohol and drug abuse. The countries have been concerned about alcohol and drug abuse for over a century, yet it is still a major public health preoccupation in the Region. In particular there is concern over the rise in overall consumption of alcohol, exacerbating the alcohol-related problems now faced. To support Member States in this field, the WHO Regional Office has established a long-term mental health programme with provision for action each year from 1970 to 1980. Epidemiology is of major interest in the programme because of its importance for etiology and prevention; but treatment and rehabili­ tation have also received much attention. The Conference reviewed the public health measures taken in different parts of the Region and the prospects for improved coordination of the efforts made by community, social, educational and health serivces. Emphasis was given to consideration of the epidemiological and preventive aspects of health education and control, and to development of warning indicators of high-risk situations requiring concerted action by different agencies. Topics Since 1950 there has been a startling growth in consumption of alcohol in the countries of the Region - in some cases of over 300 per cent and it is clear from evidence presented to the Conference that there has been an accompanying increase in the range of medical and social problems due to alco­ hol. There has also been a rise in drug-related problems. These facts are causing considerable anxiety among public health administrators and to all other staff of the medical and social services. 7hus the participants were unanimous in advocating that all known measures for limiting the consump­ tion of alcohol and illicit drugs should be applied, having regard to their feasibility in political and social terms in each country. One such measure that was discussed is control of the availability of alcohol, e.g., by specification of the hours and places of legally permitted consumption, adjust­ ment of price and tax levels to ensure that alcohol does not continue to grow cheaper in real terms, and control of advertising. The participants emphasized the urgent need to explore effective measures for prevention and control of the consumption of alcohol in view of the magnitude of the problems it causes and the lack of controls as compared with the legal restrictions on illicit drug use which al­ ready exist in all countries. The need was stressed for education on alcohol and drug problems in all sections of the commu­ nity. Such education should start early in life, be continuous throughout the school programme and involve the famliy and the whole community so as to foster a favourable attitude to the introduction of control measures. It was agreed that the treatment of alcohol and drug abuse should be multidisciplinary involving personnel in every facet of the medical and social services as well as the voluntary and self-help organizations, to provide a comprehensive range of services. Finally, attention was drawn to the necessity of initiating research on the efficiency of control policies and the evaluation of health education and early detection and treatment policies. - 4 - Conclusions 1. The evidence indicates increasing consumption of alcohol and of licit and illicit dependence­ producing drugs in most countries of the Region. There is a clear trend towards similarity of types of alcoholic beverages consumed. Most of the increases in alcohol consumption seem to have occurred between 1950 and 1970, al­ though varying in time and scale. The relationship between increased consumption and national economic circumstances merits further investigation. 2. The view is generally accepted that there is an association between increase in per capita con­ sumption of alcohol and growth in related problems. 3. There is a need to involve many different types of health and social professionals as well as voluntary organizations and self-help groups within the community in the prevention, early diagnosis, treatment and support of cases of persons harmed by alcohol and drugs. A comprehensive range of services, with emphasis on community facilities, should be available. 4. The need for improved education, not only of the public and patients but also of all persons involved in the health and social serivces, to ensure greater awareness of the importance of earlier detection of the problem and utilization of early intervention techniques. 5. It should be recognized that the purpose of control measures in relation to alcohol and drugs is the promotion of health by restricting consumption to the extent feasible in the country. Such measures should not be changed or relaxed without consideration of the possible public health con­ sequences. 6. Control measures are not a substitute for other action in limiting the problems; they are ad­ junctive and complementary and form only part of the national strategy from the public health stand­ point. 7. Public support is necessary for the successful application of control policies. Thus the public as well as governments must be made aware of the size and nature of the economic and social costs of alcohol- and drug-related problems. Key persons in the community have a particular duty to exhibit responsible attitudes and behaviour in relation to alcohol and drugs. 8. A need is recognized for multidisciplinary health and social education programmes for children and adolescents. These should be developed in the community with participation of the school, the health service and especially the family. Health and social education is now seen as a part of the socialization process stressing the importance of individual responsibility in behaviour relevant to health. 9. Research is urgently required on the economic and social consequences of alcohol- and drug­ related problems. The effectiveness of control policies in restricting consumption should be care­ fully examined, and health education programmes should be critically evaluated in relation to method­ ology, content and results. Recommendations 1. Governments are urged to monitor the level of consumption of alcoholic beverages and to develop national strategies that will prevent further increases in consumption or effect a decrease. Steps should be taken to moderate the extensive promotion of alcoholic beverages, by restricting or banning advertising. The possibility of international cooperation in control measures should be explored. 2. Emphasis is placed on the value of national coordinating mechanisms for investigating and monitor­ ing alcohol and drug problems and for developing policies and programmes to deal with them. Govern­ ments not having such mechanisms are urged to consider their establishment. 3. Graduate and postgraduate education and training of all health workers in the field of alcohol­ and drug-related problems should be established. International exchange of experiences in education and training should be encouraged. - 5 - 4. Agencies, whether national or regional, dealing with the problems caused by alcohol and drugs have a responsibility to inform governments and the public about the extent of the problems and the need for remedial action, At the same time governments should ensure that there are adequate pro­ grammes of education on alcohol and drug use available for children and adolescents. 5. Research is research include policies and the required on many aspects of alcohol and drug problems. Areas urgently in need of the epidemiology of alcohol- and drug-related problems, the effectiveness of control evaluation of educational programmes and treatment measures. - 7 - CANCER - 9 - Training in Clinical Oncology 5 February 1979 The Hague, 6-8 December 1978 SUMMARY REPORT Introduction The Group included 15 temporary advisers and 1 member of the Regional Office secretariat. The purpose of the meeting was to analyse models for postgraduate training in clinical oncology and to evaluate their suitability in relation to the different types of cancer control services in countries. Discussion The Group began by reviewing statistical and other information about the widely varying arrange­ ments made in the countries of the Region for the postgraduate training of physicians involved at different levels in aspects of cancer control, including prevention, diagnosis, treatment, follow-up and rehabilitation. Recognizing the growing challenge of cancer for the health care services, for example as analysed in the report of the Conference on Comprehensive Cancer Control held in Copenhagen in July 1977, the Group was concerned by the shortcomings revealed in its review, in particular the frequently inadequate scale of postgraduate training arrangements and the lack of coordination of programmes. The participants recognized the close relationship between postgraduate training arrangements and the structure of cancer control services in different countries, and although they approached their task by considering desirable patterns of postgraduate training in oncology, they had con­ stantly in mind the need to tailor the training arrangements to existing health care structures. They began by examining the postgraduate training needs of the three types of physician concerned with the diagnosis and treatment of cancer: the general physician (general practitioner), the non­ oncological specialist and the full clinical oncologist, whether a radiotherapist, a medical oncolo­ gist or a surgical oncologist wholly committed to this specialty. They were clear from the outset, however, that there could be no rigid separation between specialties, and that at all stages of can­ cer control there must be a multidisciplinary approach involving specialists in various fields, at certain stages general physicians, and also nursing and other health professionals. Thus all post­ graduate training must, it was felt, include training in interdisciplinary cooperation and teamwork. The Group considered that the main role of the general physician lay in the fields of primary prevention and education of the public, early diagnosis, follow-up and rehabilitation, and that his role in treatment was secondary, though with the trend towards outpatient treatment of cancer and (in some countries) towards larger and more remote cancer cantres there was increasing scope for him to play a part in the total treatment process (e.g. by carrying out blood counts or administering chemotherapy). His postgraduate training should therefore cover primary prevention and education of the public, early diagnosis, modern treatment methods and existing facilities, follow-up and rehabilitation. It was noted that with the development of cancer therapy there would probably be an increasing role for the non-oncological specialist in the management of cancer patients, and that although such a specialist might not have to be trained to carry out all the most advanced oncological techniques, he should be aware of these procedures and the facilities for performing them, and should also know what could be achieved in other disciplines. The Group agreed, therefore, that formal specialist preparation of the non-oncological specialist should cover epidemiology and biostatistics; biology and pathology related to cancer; prevention, diagnosis and treatment; follow-up and rehabilitation. - 10 - For training of the full clinical oncologist, the Group considered two models: (a) full spe­ cialization, through basic training and preparation in clinical oncology; and (b) special training in surgery, radiotherapy or chemotherapy within other Specialties (e.g. surgery, medicine, radiology, gynaecology). The majority of the Group favoured the first model, which seemed appropriate to a control service based on large cancer centres, though it appeared that in some countries the second model was preferable. The Group saw the training of a medical or surgical oncologist according to the first model as requiring a minimum of two years' preparation in oncology, in addition to basic training in medicine or surgery. Recommendations The Group made detailed recommendations about patterns of training as well as more general recommendations about the need for close relationships between institutions for cancer treatment and for teaching, the importance of ensuring that training in oncology was on practical lines and that treatment centres were also ''teaching-oriented'', the necessity of providing continuing post­ graduate education at all levels of specialization, and the scope for development of international collaboration in oncology training. See also: - 11 - CARDIOVASCULAR DISEASES - Health Education: Working Group on Health Education of the Public in Cardiovascular Diseases, ICP/CVD 008(2)(S), page 66 Meeting to Evaluate the Study on Rehabilitation and Secondary Prevention - 13 - in Patients with Acute Myocardial Infarction Berlin, 24-27 October 1978 SUMMARY REPORT Introduction ICP/CVD 005(14)(5) 10 January 1979 Plans for the study on the effects of rehabilitation and secondary prevention in patients with cardiovascular diseases originated at working groups held in Prague and Moscow in 1970 and 1971. These groups drew up the necessary protocols while 21 regional centres and 1 in Israel volunteered to participate. The main purpose of the study was to determine whether systematic rehabilitation and comprehensive secondary preventive measures could prolong life and reduce recurrences in patients who had suffered from acute myocardial infarction. Over 3100 patients were enrolled in the study and a three-year observation period, due to expire in November 1978, was set. At the last meeting of the investigators, held in Valencia in 1977, it was agreed that the results of this important study should be published in the form of a monograph. This would sum­ marize the present knowledge on aspects of rehabilitation following acute myocardial infarction and give the results of the study with an analysis. A draft table of contents was drawn up, and groups and individuals were designated to draft the different chapters. The present Meeting, convened by the WHO Regional Office in collaboration with the Government of the German Democratic Republic, brought together 30 cardiologists from centres participating in the study in order to discuss the final results of the study and to finalize the draft of the mono­ graph. As this was the last general meeting of the principal investigators, problems relating to the presentation, analysis and interpretation of the final results were also dealt with. The discussions centred on the following topics: (a) presentation of statistical tables; (b) main and additional results of the study and their interpretation, including a possible multiple logistic analysis; (c) the draft of the monograph; (d) plans for finalization of the monograph; (e) areas for future research. Conclusions The following conclusions were reached: 1. The overall study should be regarded as a series of comprehensive intervention studies at national level adapted to local conditions. Attempts at international pooling of data and evalua­ tion of the trends, as outlined at the inception of the study, should be continued. 2. The study is of importance in promoting cardiac rehabilitation in the Region and in strengthening local centres for the purpose. 3. Random allocation of patients to the rehabilitation or to the control groups should continue throughout the study. All patients accepted for the study should be traced irrespective of attend­ ance and the appropriate record forms should be sent to WHO headquarters in Geneva. 4. A five-year breakdown (40-44, 45-49, etc.) is considered suitable in respect of the age-groups for final evaluation and analysis. - 14 - 5. Lists of important variables, drawn up by the Meeting, are proposed for use by the participating centres. 6. WHO will make a separate analysis of the data for each centre where they are needed for evalua­ tion of the study as a whole. Individual centres should, however, analyse their own data in the framework of local or national studies. 7. Copies of documents accepted for publication on national studies conducted as part of the over­ all study should be sent to the Regional Office for preparation of the monograph. 8. According to a timetable for completion of the study and of the monograph, approved by the Meeting, the revised chapters of the monograph should reach WHO in Copenhagen by 1 April 1979 and the analysis of data should be finalized by 15 December 1979. The principal investigators are com­ mitted to strict compliance with this timetable. 9. Thanks are due to the Institute for Information and Statistics, German Cancer Research Centre, Heidelberg, Federal Republic of Germany, for its help in the preliminary evaluation of the study. 10. Suggested areas for further research include: (a) rehabilitation as a part of comprehensive cardiac care; (b) early mobilization and evaluation after acute myocardial infarction (methodology and significance); (c) evaluation of professional activities in relation to physical working capacity; (d) prognostic indices (also in relation to physical working capacity) at different stages of rehabilitation; (e) evaluation of physical exercise tests - hypokinetic reactions; (f) normal reference values for physical exercise testing; (g) new methods for physical training of cardiac patients (e.g. arm work, static exercise). Alongside specific controlled trials, research on national application of experience gained from studies in cardiac rehabilitation should be promoted. - 15 - CHRONIC LUNG DISEASES Working Group on Early Detection of Chronic Lung Diseases Vienna, 31 May - 2 June 1978 Introduction - 17 - SUMMARY REPORT ICP/OND 002(S) 18 July 1978 The Working Group met at the United Nations Industrial Development Organization in Vienna and was arranged in collaboration with the Austrian Government. It included 14 temporary advisers and 4 WHO staff ,,,embers from headquarters and the Regional Office for Europe. The purpose of the meeting was: (1) to advise on the identification of groups and individuals, who may be most at risk of de­ veloping chronic lung diseases; (2) to review and evaluate methods that may be used for the prevention and control of these diseases; (3) to suggest which of these could be the basis for community action against these diseases; (4) to identify areas needing further investigation and development. Discussion Chronic non-specific lung disease (CNSLD) at present causes a large number of deaths in the European Region (in a number of countries from 5% to 8% of all deaths in males, although generally less in females). It is likewise responsible for high morbidity and much of existing disability. The disease patterns with regard to age, sex and socioeconomic and other factors seem to differ from country to country, as do approaches to prevention, diagnosis, care and rehabilitation. The meeting opened with a description of current activities in the field of chronic lung disease carried out by or in collaboration with the WHO Regional Office for Europe. This was followed by a review of routinely collected data available in the European Region on mortality from CNSLD, dis­ ability, use of hospital services, morbidity in general practice and sickness absence. It was noted that some of these data were not available for certain countries. In discussing epidemiological studies on CNSLD carried out in the European Region, it was observed that in only a few of these could population estimates be obtained for the national prevalence of this condition. As regards available mortality data on CNSLD for countries outside Europe a general lack of information from many countries in the world was noted. The meeting then turned to a discussion of the natural history of CNSLD and of factors influencing its onset and progression and on this subject some dif­ ference of opinion was encountered. There was general agreement that smoking was the major known factor in the etiology of CNSLD, and that occupational and environmental exposure to air pollutants could also contribute. There was no general agreement about the underlying pathophysiology of CNSLD. There was, however, general agreement that the disease could take various courses; in some persons, for example, it developed from minor symptoms and signs leading to severe disability and fatal outcome, while in others the disease might not proceed beyond minor phlegm production and mild airways obstruction. However, sufficient gaps in knowledge of the natural history of this condition were identified to indicate the need for further research. Methods for the early detection of CNSLD were then discussed. Among these were the use of questionnaires, tests of ventilatory function, clinical examination and chest X-rays. Doubts were - 18 - expressed about the adequacy of these methods in the early detection of CNSLD. The efficiency of available methods for control of the development of CNSLD, when diagnosed at an early stage, was found to be doubtful, so that further studies would be needed. There was general agreement that a number of the necessary prerequisites for introducing screening programmes for the early detection of CNSLD in the general population were not present. The possibilities for primary prevention of CNSLD were outlined. ological factor, much of the discussion centred on ways to control it. and industrial exposure was also discussed. As smoking is the major eti­ Limitation of environmental Secondary prevention, which referred to the management of persons in the early stages of CNSLD was discussed in relation to giving up smoking, limitation of environmental exposure and clinical management. There was general agreement that giving up smoking at this stage would be of benefit. However, there was no general agreement that current clinical management so far available has con­ vincingly shown how to change the course of this disease, which fact indicated the need for further controlled studies of clinical therapy. Recommendations The Working Group made a number of recommendations, some of which concerned the various ways of controlling smoking by means of education, legislative measures, etc. The Working Group also re­ commended that further studies on the natural history of CNSLD be carried out. As regards the diagnosis of patients with CNSLD the Working Group recommended the development of techniques for early detection of the disease. The value of present therapeutic methods should also be evaluated by randomized control trials. The Working Group finally recommended that general population screening for the early detection of CNSLD should not be undertaken until its potential benefit is demonstrated by special studies. - 19 - CLINICAL PHARMACOLOGY Seventh European Symposium on Clinical Pharmacological Evaluation in Drug Control Deidesheim, 14-17 November 1978 Introduction - 21 - SUMMARY REPORT ICP/PHB 003(S) (ICP/PHA 006) 6 December 1978 The Seventh European Symposium on Clinical Pharmacological Evaluation in Drug Control was held at Deidesheim, Federal Republic of Germany, from 14 to 17 November 1978. Since 1972 this series of meetings, originally held at Heidelberg and later at Deidesheim, has formed a basis for scientific discussion of the clinical problems and procedures associated with drug control in the broadest sense. Such meetings have proved to be a useful complement to the regional and national structures already existing in certain areas of Europe for the harmonization of drug control legislation and procedures. All the meetings have formulated recommendations on both general and specific problems, and later meetings have also developed and updated the findings of earlier symposia. An innovation at this Symposium was the discussion of draft guidelines for clinical trials of antihypertensive drugs, prepared in advance by a specially convened Working Group. The Symposium was attended by some 40 participants from many countries of the European Region, together with representatives of other organizations, temporary advisers and WHO staff members. Recommendations Four principal topics were discussed and the main recorrnnendations may be summarized as follows. Clinical trials of drugs 1. Since the shortage of trained clinical pharmacologists and the lack of facilities for their work remains the greatest obstacle to the performance of efficient and safe clinical investigations of drugs, governments should give high priority to the development of training and career openings in this field. 2. Drug regulatory agencies should be given the authority and staff necessary to assess the suit­ ability of new chemical entities with regard to clinical investigation in man. The procedures adopted should be flexible, so that undue delays are avoided and requirements for preclinical work can be adapted individually to the drug in question. Since the creation of such a regulatory struc­ ture is hardly feasible in some countries at the present time, the possibility of establishing an advisory corrnnittee under WHO auspices to advise countries on individual applications for investi­ gational drug licences should be examined. As a transitional measure, governments should at least ensure that drug regulatory agencies are fully informed of studies currently in progress. 3. Procedures analogous to those outlined under 2. should be established for licensing new clinical studies of drugs already marketed. 4. The information supplied to physicians conducting clinical investigations should be more com­ plete than is often the case, as regards both preclinical and clinical studies of the drug in ques­ tion, its pharmaceutical formulation (and any change introduced therein), and the need to adhere strictly to the protocol. 5. Ethical committees should be established, preferably on a local or regional basis, to examine proposed clinical trials with a view to assessing their ethical, legal and scientific merits. 6. The design of clinical experiments should be further developed to reduce risks to the trial subject, e.g. by utilizing experimental designs which make it possible to limit the scope and dura­ tion of studies. - 22 - 7. Legal or other binding provisions should be introduced to ensure that clinical studies are conducted only for sufficient reason, that the risks are acceptable, that informed consent is ob­ tained, and that the principles outlined above and those inherent in the Declaration of Helsinki (as modified at Tokyo) are respected. 8. Governments, the medical profession and clinical pharmacologists should work together to ensure that the public is given adequate and balanced information on the need for clinical investigations and the steps which have been taken to exclude improper and disproportionate risks. 9. Measures taken to protect patients acting as trial subjects should also be applicable to healthy volunteers, if the latter are to be involved. 10. Facilities for the comprehensive insurance of subjects involved in clinical trials are essen­ tial and should, if necessary, be guaranteed by the state. Post-marketing evaluation of drugs 11. Improved integration of all the types of information that become available on a drug subsequent to marketing (e.g. as a result of planned studies, spontaneous reporting in the literature, and data from various sources on adverse reactions) is essential if the use of a drug is to remain optimally attuned to the current state of knowledge. 12. Long-term studies must be regarded as a necessity for those drugs which are likely to be ad­ ministered over a period of many years, with a view to obtaining data on changes in efficacy, on effects on the quality of life, and on long-term adverse reactions and interactions. 13. The planning of long-term post-marketing studies of efficacy is often less than ideal, and investigational techniques for this purpose need to be further developed; both open and blind trials in this phase can provide better data than are usually obtained, e.g. trials of antihypertensive and antirheumatic drugs or hormonal contraceptives. Checks on patient compliance should be included. 14. Multiple drug comparisons over a long period should be conducted (e.g. under the sponsorship of scientific associations) to complement the drug studies sponsored by industry and to provide data on the relative place of each drug in therapy. 15. With regard to drugs used for long periods, international multicentre studies are needed in order to determine the extent to which the effects of such drugs are ultimately influenced by national and regional factors. Monitoring of adverse drug reactions 16. As with efficacy data, information on adverse reactions to drugs on the market should be better integrated than is currently the case, so as to mobilize all the sources of information available and enable conclusions to be drawn more rapidly. 17. Means to render the spontaneous reporting of adverse reactions more attractive to the physician and more effective to the community should be studied. 18. The experience already gained in a limited number of countries concerning medical record link­ age should be analysed to determine to what extent corresponding techniques can be employed elsewhere as a means of identifying those serious adverse reactions to drugs which are relatively rare and occur only after prolonged administration. 19. The role of the medical literature in adverse reaction reporting deserves careful study, since much valuable information is currently obscured by the presence of invalid and repetitive data. 20. The current redevelopment of the WHO Adverse Reaction Monitoring Programme at Uppsala, Sweden, should be regarded as an opportunity to broaden the basis of work in this field so as to mobilize sources of information other than that provided by national centres, e.g. information available to industry. - 23 - Guidelines for clinical evaluation of drugs 21. Guidelines for the clinical investigation of specific groups of drugs, such as those already drafted by a WHO Working Group,1 should continue to be developed and issued in the form of recom­ mendations to medical investigators in Member States. 22. National and regional agencies developing guidelines for the clinical sections of new drug applications should be encouraged to take into account the existence of the relevant WHO recommenda­ tions and of guidelines issued by other agencies, in order to avoid unnecessary discrepancies. 1 Working Group on the Harmonization of Guidelines for Clinical Trials of Drugs - Antihypertensive Drugs, Uppsala, 24-25 April 1978. - 25 - ENVIRONMENTAL HEALTH BASIC SANITATION page 27 CONTROL OF ENVIRONMENTAL HAZARDS " 29 DRINKING WATER CONTROL " 34 HEALTH ASPECTS OF TOURISM " 38 TOXICOLOGY " 41 Working Group on Basic Sanitation Technologies suitable for Smaller European Communities Rennes, 6-10 November 1978 - 27 - SUMMARY REPORT Introduction ICP/BSM 003(5) 27 December 1978 The meeting, held on the premises of the National School of Public Health, Rennes, was attended by 27 sanitary engineers and public health physicians from 11 countries. Its purpose was to compare the experience of various European countries in sanitation for smaller communities and, on that basis, to draw conclusions concerning technologies applicable to the special conditions in the Region. Background Problems of community water supply and sanitation in the Region were discussed at an earlier meeting held in Copenhagen in December 1976. Participants in this meeting noted that the major difficulties faced in the Region were the removal and treatment of liquid and solid wastes in smaller communities. Indeed a "rapid assessment" of the situation of water supply and sanitation in Europe, conducted by the Regional Office in pursuance of World Health Assembly resolution WHA30.33, showed that while 90% of people in the Region had a satisfactory water supply, only half this population could claim to have adequate waste disposal facilities. In both cases, those without proper facili­ ties live in rural areas and in communities of less than 5000 people. Discussion The Group considered the following problems: quality control of water supplies in rural areas and smaller communities; hygiene specifications for individual sanitary facilities including septic tanks; collection, treatment and disposal of household refuse; treatment and disposal of waste-water; cle.aning of streets and public places. The Group also studied the possibilities for regional grouping of smaller communities into units sufficiently large for basic sanitary services to be profitable and technically efficient. Conclusions The following conclusions were reached: 1. Unless population density is low, as in subarctic, arid and mountainous regions or small islands, smaller European communities should be grouped for the provision of water supply and sanitary services. However, for technical reasons the grouping should be made on a different basis for the three public services responsible for water supply, treatment and disposal of waste-water, and collection and treatment of household refuse. 2. Regular quality control of water supplies in smaller communities, and especially water in the individual or shared wells still found in rural areas, must be ensured. 3. Household refuse should be collected at least once a week, or even twice a week, during the summer in the southern countries. 4. The Group considers that composting, despite operational difficulties, remains the most suitable method for treatment of household refuse in smaller communities. 5. Sanitary landfilling of crushed refuse also seems a suitable technique for smaller communities; however, small-scale incinerators are not recommended. - 28 - 6. Individual sanitary facilities should be used only for isolated dwellings or those in sparsely populated areas. Such facilities comprise rural latrines in poor areas with inadequate water resources and septic tanks in most cases. 7. Even privately owned septic tanks should be inspected annually by the sanitary service. They may prove difficult to operate either if the sludge is emptied too infrequently or, in most cases, if the soil draining the clarified effluent is insufficiently permeable. 8. Sewer networks seem advisable once there is sufficient density of population; the choice between shared and individual sewerage depends on the local topography, geography and climatology. 9. Low energy aeration techniques including oxidation ponds are the most suitable for waste­ water treatment in smaller communities in the Region, but this certainly does not mean that intensive techniques with prolonged aeration should be ruled out in all cases. 10. Land disposal of sewage should not be used unless the effluent has undergone preliminary clarification. 11. The technique for waste-water treatment in a smaller community should be selected in the light of a comprehensive feasibility study taking into account both sanitary and technical factors and financial factors such as operating costs. 12. Except in special cases, disinfection of treated waste-water before discharge into the natural environment is neither necessary nor advisable. Recommendations 1. The Member States in the Region should continue their efforts to increase the proportion of the population having proper sanitary facilities. 2. The governments should maintain their policy on grouping of smaller communities to improve the effectiveness of the basic sanitary services, i.e. those responsible for water supply, and the treatment and disposal of liquid and solid wastes. 3. Each Member State in the Region should establish a national sanitary engineering reference centre. 4. The governments should step up the training of technical staff of sanitary services in smaller communities. 5. The Member States should include health education in the general curricula of government schools. 6. Sanitary engineering research institutes in the Region should continue their studies to develop low energy aeration techniques including oxidation ponds for wastes treatment, as well as their research on combined composting of household refuse and sludge produced by treatment of waste-water or drainage materials. 7. Managers of sanitary services should maintain satisfactory health and safety conditions for employees in liquid or solid wastes treatment plants. 8. The Regional Office should continue its activities relating to basic sanitation in rural areas and convene a meeting on hygiene specifications for septic tanks, a matter that was last discussed at the Third European Seminar for Sanitary Engineers in 1952. 9. The Regional Office should undertake activities relating to low energy aeration techniques including oxidation ponds for sanitation in smaller communities and prepare a European manual on the subject. 10. The Regional Office should ensure wide distribution of its reports on the problems of water supply and sanitation in smaller communities of the Region. Seminar on Environmental Health Impact Assessment - 29 - Argostoli, Kefalonia, Greece, 2-6 October 1978 SUMMARY REPORT Introduction GRE/RCE 001/80/2(S) 1 November 1978 The Seminar, organized in conjunction with the Government/UNDP/WHO project for environmental pollution control in the metropolitan area of Athens, was attended by over 60 persons in fields such as public health, engineering, the environment and planning. The main purpose of the Seminar was to discuss the impact and assessment of environmental haz­ ards as well as the functions of health services, staff training and the role of WHO in this respect. The participants were also asked to review the experience of different countries in environmental health assessment, on the basis of case studies of major projects in various countries and reference materials made available, and to propose a code of practice for the health component of such assess­ ment. Speakers at the opening of the Seminar mentioned the need to include consideration of environ­ mental and health factors in development planning; the self-defeating nature of single-minded pur­ suit of economic development, in destroying the quality of life; the positive rather than negative role of preventive health measures in economic development, in that they offset the damage caused by the latter; and the requirements for improved international collaboration. Discussion There is a clear correlation between economic development and environmental impact, in degree but also in form. Now, for instance, communicable diseases are less frequent and more manageable while the problem of toxic and carcinogenic and mutagenic materials in the environment is growing. Environmental assessment is becoming a powerful tool in development planning, but in many cases inadequate attention has been paid to health aspects. For this purpose more health specialists will have to be trained at undergraduate and postgraduate levels, while the public health departments where they work must be broader based. It is essential to assess possible negative health effects of a proposed course of action before­ hand so they may be avoided or minimized by appropriate technology or consideration of alternative courses. Assessment is required not only of individual substances but also of specific technologies and industries, such as that of synthetic organic chemicals. Impact on nonhuman targets, i.e., plants, animals and materials, must also be assessed. Recommendations Underlying all the recommendations concerning environmental impact assessment was the partici­ pants' conviction that the objectives of achieving acceptable levels of health and high standards of environmental quality are closely linked. Their recommendations were as follows. 1. There is a need for assessment in the planning of projects and the formulation of strategies and policies for development; it should take account of physical, technical, economic, social and en­ vironmental health factors. 2. Assessment should include an evaluation of alternative courses at all, as well as the determination of necessary precautionary and should be paid to the possibility of improving existing conditions. construction stages should be considered. of action, including no action control measures. Attention Both the construction and post- - 30 - 3. Human health requires more emphasis in any assessment, which should be an integrated and co­ ordinated process. Health professionals must be included in multidisciplinary teams for the pur­ pose. 4. A prerequisite in the execution of projects is the establishment of an adequate data base, in­ cluding health indices, against which changes can be measured. 5. Assessment should be based on total exposure of an individual to hazards from various sources, with account taken of all possible cumulative and synergistic effects, 6. Impact and risks should be identified as precisely as possible and preferably, be quantified. They must be ranked in order of importance, for weighing against other factors. 7. Community involvement should be facilitated, using all appropriate means including the develop­ ment of monitoring and feedback systems. 8. Consideration should be given to land use and planning at all levels as well as any implications for other countries. 9. To facilitate the necessary multidisciplinary and interdepartmental contributions, a single agency should assume the coordinating role and have responsibility for the monitoring and feedback. 10. Overall responsibility for assessment will depend on national regulations but, whatever the machinery, account should be taken of the views of the appropriate health agencies. 11. In view of the finite assimilative capacity of the environment, the likely impact of associated developments should also be assessed. 12. WHO's activities for evaluation of toxic hazards and health criteria could be strengthened and accelerated with a view to producing and publishing, as soon as possible, the factual data needed for decision-making. 13. A model code of practice for environmental health impact assessment could usefully be produced under WHO auspices, to assist governments. 14. An international effort should be made to support governments in providing personnel with the necessary training and multidisciplinary orientation. Programmes could be developed to enable phy­ sicians and other health professionals to play an active part in the process, with particular ref­ erence to health. 15. An international or regional reference centre on environmental impact assessment should be es­ tablished with the function, in conjunction with WHO, of disseminating information, stimulating re­ search, developing methodology and supporting educational efforts. 16. Multilateral or bilateral financing bodies should require the inclusion of an assessment com­ ponent in the projects they sponsor. Symposium on Environmental Protection Programmes in Industrial Areas Katowice, Poland, 23-28 October 1978 1. Introduction - 31 - SUMMARY REPORT POL/RCE 001/80/4(5) 17 November 1978 This Symposium, sponsored jointly by the WHO Regional Office for Europe and UNDP in cooperation with the Polish Ministry of Administration, Land Resources Management and Environmental Protection and the Environmental Pollution Abatement Centre, Katowice, was attended by 92 participants from 13 countries and 2 staff members from the WHO Regional Office for Europe. 2. Background During the six years 1973-78 a UNDP/WHO project in environmental pollution control has been carried out in a selected area of the Upper Silesian Industrial Region. The scientific work was entrusted to the Environmental Pollution Abatement Centre, Katowice and was assisted by numerous research institutions in Poland. The model area selected for study has a great concentration of heavy industry, particularly mining and metallurgical industries, and environmental pollution in the area is severe. The aim of the project was to identify problems in the sectors of air, water and land pollution and to devise optimal solutions for the abatement of environmental pollution in the model area. The purpose of the Symposium was to draw upon the experience of a number of countries in the planning, evaluation and implementation of environmental health protection programmes in industrial areas and to discuss the methodologies used in the preparation of such programmes in the UNDP/WHO­ assisted project in the Upper Silesian Industrial Region. 3. Discussion Twenty-one papers were presented, covering the subjects of legislation and economics in relation to environmental pollution control; environmental pollution control and regional planning, and pol­ lution control programmes and methods. 3.1 Legislation and economics Forms of legislation reflect differences in the social and economic structure of societies. Specific laws can work against effective pollution control because they tend to be either too strin­ gent (with adverse effects on economic development) or not stringent enough. 3.2 Regional planning Environmental pollution has no artificial boundaries, but for practical and administrative reasons boundaries have to be defined for particular studies or projects. "Imported" pollution has to be taken into account in regional planning and there are difficulties in quantifying this and in taking protective measures. Programmes for land exploitation and subsequent land use should be correlated. zones should be provided between industrial areas and areas of habitation. Protective Regional environmental control plans should relate to the wider social and economic plans for a region or country. The relationship between regional planners and environmental specialists is important and planners should know the projected environmental and economic consequences of special­ ists' proposals. - 32 - It was generally agreed that the main problem in all industrialized countries, whatever their political complexion, is how to strike the correct balance between maintaining or improving material living standards and preserving the environmental quality of life. 3.3 Pollution control progr.:immes and methods The institutional and technical problems involved in planning environmental pollution control programmes and the methodologies to be employed were discussed. While there was agreement that the solution to environmental pollution control programmes required an integrated approach, there were differences of opinion as to the methodology to be used. Some participants held the view that sys­ tems analysis and the use of mathematical models were essential tools for the preparation of pollution control programmes. A differing view was that the effort and resources involved in producing soph­ isticated mathematical models required for optimization studies did not justify the results obtained, and that a more pragmatic or "incremental" approach to decision-making would be more cost/effective and produce quicker results. Mathematical modelling and optimization were valuable in finding "least-cost" solutions to some sectorial environmental problems, as long as they were not regarded as decision-making processes in themselves. There was a consensus that a wholly scientific approach to environmental pollution control was not yet feasible because the science of measuring environmental and health damage resulting from various sources of pollution was not yet fully developed. 3.4 Health hazards The most serious hazards to health from environmental pollution in industrial areas were con­ sidered to arise from air pollution, the principal elements being dust, S02 and nitrogen oxides. In the Upper Silesian Industrial Region, research has shown a close correlation between air pollution levels and the death rate. Lead, zinc and cadmium are more likely to reach the human organism by becoming concentrated in the food chain, while air and water are less important sources of intake. 3.5 Environmental quality standards The fixing of standards for air, water, soil or food quality in different countries is a complex problem because of the difficulty of assessing the long-term effects of pollutants and the synergistic effect of various toxic compounds. Approaches to the matter of standards in various countries were discussed. The "polluter must pay" principle was regarded as a basic tenet of environmental pollution con­ trol, whatever mechanism was devised, but there were differences of opinion as to the value of stan- dard international pollution indices. No revolutionary new treatment methods were foreseen. In future, there is likely to be a much more careful evaluation of technical alternatives and their relative cost/effectiveness. Treatment plants of the future will probably have to receive more complicated mixtures of industrial and do­ mestic wastes and computer systems will play an important role in day-to-day operation and monitoring. 3. 7 Solid wastes The impact of solid wastes is difficult to quantify, but the visual and immediate effects of poor waste management and disposal practices on the environment are more evident than the effects of air and water pollution. In highly industrialized regions there is an urgent need to develop new methods for the utilization of residues from industrial processes, particularly where huge volumes of waste materials arise, e.g., in mining and power production industries. 4. Conclusions 1. Environmental pollution control requires an integrated approach and must take account of economic and social factors. 2. The to allow valuable ability to model interrelated environmental and economic factors is not sufficiently developed a wholly scientific approach to environmental pollution control, but optimization models are in finding "least-cost" solutions to sectorial environmental problems. 3. There is no unanimity on the method of devising standard pollution indices, or on the practical value of international standards. - 33 - 4. Methods of measuring the effects of pollution on health require much more development; national or regional environmental quality standards provide the best practical basis for developing environ­ mental pollution control strategies. 5. Effective monitoring and enforcement procedures are essential for environmental pollution con­ trol. 6. The long-term aim must be to reduce pollution at source by modifying industrial processes to reduce residues or effluents. This will include the use of alternative materials and the maximum practicable "in-house" recycling of waste materials. - 34 - Working Group on Health Significance of Chemicals Occurring Naturally in Drinking-Water Brussels, 20-23 March 1978 SUMMARY REPORT Introduction ICP/RCE 101(7)(S) 2 May 1978 In collaboration with the Government of Belgium the WHO Regional Office for Europe convened a working group to discuss the health significance of substances occurring naturally in drinking-water, with special attention to the implications to health from the use of desalinated and demineralized water. Topics discussed The Working Group considered the long-term health effects of substances normally or occasionally present in drinking-water. Special attention was given to certain substances occurring in small quantities in water either naturally or through treatment processes such as desalination, demineral­ ization or water softening. It was recognized that desalinated water is usually corrosive to plumb­ ing and, unless it has been adjusted by the addition or replacement of some of the constituents natur­ ally present in drinking-water supplies, health considerations may make it unsuitable for drinking even though the raw water it is prepared from may be acceptable. One of the substances of greatest interest is magnesium. Magnesium ions are one of the two main components of what has commonly been called "hardness"1 in water. They have recently been recognized as being probably the most important factor in the inverse relationship between death from heart disease and the concentration of calcium and magnesium ions in drinking-water supplies. Calcium is usually adequately supplied by food in contrast to magnesium. Calcium, however, has an important technical function in drinking-water supply systems. Water that is undersaturated with calcium carbonate is considered to be aggressive and can leach metals such as lead, cadmium, copper and zinc from pipes and plumbing. Water saturated with calcium carbonate is stabilized and has a greatly reduced potential for corrosion. Many natural waters contain calcium and magnesium in a ratio of about three to one. Stabilized water, containing calcium and magnesium ions at about this ratio appears to be satisfactory from both health and technical aspects. The Working Group reviewed other elements found in drinking-water. In every case it was con­ cluded that there was at present insufficient justification for recommending the addition of any other element to water that is deficient in minerals. In most of the cases, the daily intake of minerals from food greatly exceeds the quantities contained in drinking-water. Sometimes, to pro­ vide magnesium and calcium ions, it will be useful to add all the ions present in a naturally miner­ alized water, when such water is blended with product water of low mineral content. In such cases, of course, the resultant blend should be stabilized and should meet the appropriate drinking-water standards. However, in some special cases such as zinc, if & deficiency is observed, it would be better for the supplement to be given through food. Sodium ions are present in some drinking-water at least for certain segments of the population. this matter to a subsequent WHO Working Group at at levels which are considered to be excessive, The Working Group deferred any recommendations on The Hague (1-5 May 1978) which was to discuss sodium and chlorides in drinking-water. 1 "Hardness" is an imprecise term and should be avoided. It refers to the number of polyvalent ions in water, quantitatively, the two chief ones being calcium and magnesium. - 35 - Recommendations The Working Group recommended that special attention should be given to further studies of the effects of magnesium in drinking-water on human health, including the sudden infant death syndrome. Moreover, further studies are needed on the absorption and bioavailability of minerals in food and water, since it is now apparent that water can provide a significant fraction of some of the mineral requirements of the human body. Changes in the content and availability of minerals produced by modern methods of food preparation, including cooking, should be evaluated. The mineral content of a local diet should be considered when changes in the mineral content of the drinking-water are contemplated. Working Group on Examination of Drinking-water for Radioactive Substances Brussels, 7-10 November 1978 - 36'- SUMMARY REPORT Introduction ICP/RCE 101(8)(S) 6 December 1978 In collaboration with the Government of Belgium, the WHO Regional Office for Europe convened a Working Group to discuss the examination of drinking-water for radioactive substances, special atten­ tion being given to revising the 1968 WHO European Standards for Drinking-water. Topics discussed The Working Group considered the revised recommendations of the International Commission on Radiological Protection (ICRP) and their implications with regard to permissible concentrations of specific radioactive isotopes in drinking-water. The contribution of radioactivity from all sources, natural or man-made, was considered when setting levels below which no action would normally be taken by the water supplier. These levels were also considered in the light of the ICRP recommenda­ tion that the goal should be the lowest practical or achievable levels of exposure. Specific items of discussion included levels of radon and radium in natural waters, the importance of source control of radiation resulting from human activities (mining and well-drilling; nuclear power and military activities), occupational vs. individual and population exposures, specific problems encountered in various geographical areas and radioactivity in bottled waters for table use. The Working Group identified the primary radionuclides, both natural and those resulting from human activities, found in drinking-water, which should be considered when examining the radioactivity level of drinking-water. Naturally occurring radionuclides listed included carbon-14, radium-226 and 228, lead-210, polonium-210, radon-220 and 222, uranium, thorium, and potassium-40. In the category of radionuclides found in drinking-water as a result of human activities, the following were listed: tritium, cobalt-58 and 60, strontium-89 and 90, caesium-134 and 137, iodine-129 and 131, plutonium-239, and americium-241. In both categories of radionuclides the need to measure gross alpha and gross beta-gamma activity was also recognized. Subsequent discussion defined the significance of each of these radionuclides in drinking-water, as well as the use of gross alpha and gross beta-gamma levels for characterizing radioactivity in drinking-water. The Working Group defined the fraction of the annual dose equivalent to be assigned to drinking­ water, since the latter would contribute only a small percentage of the total radioactivity to which populations are exposed. The Working Group agreed that the annual dose equivalent due to naturally occurring radioactivity should be added to that contributed by radionuclides resulting from human activities. The Working Group considered the potential exposure resulting from drinking-water containing radon and concluded that the greater degree of exposure resulting from radon was related to inhala­ tion of the radon released from water rather than to the water itself. In addition, the actual amount of radon drawn from the drinking-water tap and present in drinking-water was difficult to measure in terms of radon actually ingested. The Working Group identified an appropriate method­ ology for the determination of radon in drinking-water. These procedures will be added to the chapter "Radiological examination" prepared by N.T. Mitchell, as a part of the Manual on analysis for water pollution control, WHO Regional Office for Europe, Copenhagen (in press). The Working Group agreed that the new drinking-water standards should use the new SI units (1 pCi/1 = 0.37 Bq/1). - 37 - Additional subjects discussed by the Working Group included the potential for exposure of waterworks personnel involved in the treatment of water for the removal of radon by aeration and in the handling of waste sludges and/or concentrates from water treatment processes such as sedimenta­ tion, ion exchange, reverse osmosis, distillation, etc. Conclusions The Working Group concluded that the level for gross alpha in drinking-water should remain at 0.1 Bq/1 (~3 pCi/1), which is based upon exposure to radium-226, and that the current level for gross beta activity be reduced from 1.2 Bq/1 (~30 pCi/1) to 0.8 Bq/1 (~20 pCi/1), on the assumption that all of the beta activity is contributed by strontium-90 in drinking-water. This level is lower than that calculated from the annual equivalent dose recommended by ICRP, but is consistent with the basic ICRP recommendation that the level of exposure be as low as practicable. The 0.8 Bq/1 concentration has as its basis that the sum of the alpha and beta gross activity levels, as calcu­ lated from the presence of radium-226 and strontium--90, will not exceed the fraction of the annual dose equivalent which may reasonably be expected to be contributed by drinking-water. Recommendations 1. Data obtained from several countries show that there are large communities supplied with drinking-water (from ground water) containing high radon concentrations (up to 106 pCi/1 at the source). Radon is a noble gas that is easily removed from the water by aeration or heating. How­ ever, it is not yet possible to make accurate calculations of the dose actually received by a person drinking water containing radon. Further investigations on actual radon concentrations in drinking­ water and on the relationship between its concentration in tap water and the resulting ingestion and inhalation doses should be carried out to aid the evaluation of this hazard. 2. In some regions, populations have been exposed for many years to exceptionally high levels of natural radioactivity in water. Consideration should therefore be given to undertaking epidemio­ logical enquiries on health effects important for the identification and evaluation of potential risks, provided that concurrent factors are properly taken into account. 3. Since a thorough knowledge of radioactivity levels in drinking-water is a prerequisite for responsible public health decisions, periodic radiological investigations of water supplies by com­ petent national authorities should be encouraged. Meeting on Environmental Health Problems in Touristic Areas Montpellier, 25-29 September 1978 Introduction - 38 - SUMMARY REPORT ICP/BSM OOl(l)(S) 27 December 1978 In pursuance of recorrnnendations made by the Working Group on the Public Health Aspects of Tourism (Torremolinos, 23-27 July 1973), the Regional Office convened the present Meeting at the invitation and with the financial support of the French Government. The Meeting brought together 36 public health physicians, sanitary engineers, ecologists, urban planners, university professors and municipal administrators in order to review the previous WHO recommendations on tourist health and to consider the impact of large seasonal fluctuations in popu­ lation, severe climatic constraints and polluting or hazardous economic activities on the design, operation and management of the environmental health infrastructure in European tourist areas on the coast or in the mountains. The 36 participants were from 12 countries of the Region, all supplying or receiving large numbers of tourists in surrnner or winter. Background European tourism involves the movement of tens of millions of people, who mostly travel in summer from northern Europe to the coasts of countries in the south and in winter from northern and central Europe to mountains with snow or parts of the southernmost countries which remain sunny. These migrations may cause the population of certain tourist places to increase as much as ten­ fold, whereas it is considered that a three-fold increase is the maximum that can be absorbed by a local health infrastructure; above this level special arrangements are needed for the infrastructure itself and the management of services. The essential services responsible for environmental health face other constraints in tourist areas, in that climatic conditions are hardest during the high season. In the mountains this season coincides with the period of winter frost, and on the Mediterranean coast the demand for water is highest during the summer drought. Finally, risks of accidents and chemical poisoning can arise from faulty area planning, whereby tourist establishments are adjacent to transport arteries or unsanitary and even hazardous industries. Discussion Attention was drawn to the publications by WHO on tourist health and to its previous recommenda­ tions on sanitation of bathing places, camping sites, hotels and restaurants, on vector control and on international control of communicable diseases. Two publications discussed in particular were the Guide to sanitation in tou:r-ist establishments (WHO, 1976) and the Guide pratique d'hygiene du tou:r>isme (Public Health in Ew'ope series, No. 9, 1978). The participants studied the impact of large seasonal fluctuations in population, climatic con­ straints and unsanitary or hazardous economic activities on essential services responsible for envi­ ronmental health, i.e. for water supply, the removal, treatment and ultimate disposal of liquid and solid wastes, and sanitary inspection especially of living accommodation. They also discussed the impact of these three factors on the administration of technical services of municipalities, on the management of water resources and on the maintenance of ecological balance and the control of toxic chemicals which could be dispersed in tourist areas. Finally, the participants discussed the specific problems of sanitation in winter sport resorts. - 39 - Conclusions The following conclusions were reached: 1. International tourist travel fosters good relations among the European peoples, economic devel­ opment of the countries of the Region, and the health and welfare of populations taking part in the migrations. International tourism should therefore be encouraged in the Region. 2. Health infrastructure in tourist places should be designed according to specific technical cri­ teria, taking into account the seasonal population as well as climatic constraints and the suscepti­ bility of the natural environment. As the infrastructure is used only a few months a year, systems involving high operating costs are preferable to those requiring major capital outlay. 3. Health services in tourist places should increase their material resources and personnel in order to meet the demand during the high season. Training should be stepped up. Health control of casual tourism should not be overlooked. 4. Development plans with particular attention to environmental health are required for new tourist establishments together with plans for renovation and provision of facilities in existing substandard establishments. 5. Above an occupancy limit which has still to be determined, it might be impossible to ensure acceptable health conditions in tourist establishments during the high season. In particular the occupancy of camping sites should be restricted and unauthorized camping prevented. 6. Despite the previous WHO recommendations, the frequency of overcrowding, inadequate facilities and unsatisfactory maintenance of health installations in camping sites and premises sublet to tourists are still the major health problems. 7. With the income from international tourism it should be possible, through suitable financial arrangements which frequently must still be determined, to amortize the cost of equipping and operat­ ing health services, and especially water supply and sanitation services, in tourist places. 8. Conventional technologies could be used for sanitation in mountain resorts, with certain adap­ tations that will be described in the comprehensive report. 9. Conservation of the natural environment in international tourist areas is the responsibility not only of receiving countries but also the home countries of the tourists whn visit them steadily. 10. Tourist activities should not be developed near the sites of noisy or hazardous transportation and industries that are dangerous or unsanitary (noise, odour, atmospheric pollution). Where such situations exist, remedies must be found. Recommendations l. The countries of the Region should promote international tourism which is positive on the balance. It is recommended that they ensure wide distribution of the Guide to sanitation in tourist e tablishments and the Guide pratique d'hygiene du tourisme. 2. Countries which supply tourists should conduct health education among their nationals; it is recommended that ministries of health in the receiving countries formulate plans of action for health control of tourist areas and places. 3. Member States of the Region engaged in tourism should speed up the application of WHO recommenda­ tions on tourist health including those of the present Meeting. 4. It is desirable that public health physicians, sanitary engineers, university investigators, urban planners, ecologists and municipal administrators meet in order to work out sound technical solutions to the specific problems of environmental health in tourist areas. 5. Member States of the Region should make the necessary arrangements to develop exchanges of in­ formation on tourist health in pursuance of the recommendations made by the Working Group in Torremolinos. 6. Member States of the Region should consider a coordinated policy to stagger vacations and pro­ mote new tourist areas, inland for instance, so as to avoid excessive concentration of tourists in a few confined coastal or mountain areas. - 40 - 7. Economists of countries engaged in tourism should work out suitable procedures to finance the construction of health infrastructure, and its subsequent operation and maintenance, in tourist areas and places. 8. European governments should step up the training of health technicians in order to meet the exceptional seasonal demand in tourist places. 9. Technological institutes should continue their efforts in developing procedures to meet the needs of tourist places, after which the Regional Office should convene a working group to study technology suitable for sanitation of places with large seasonal variations in population. Consultation on Manpower Development in Toxicology Copenhagen, 11-15 December 1978 1. Introduction - 41 - SUMMARY REPORT 1CP/EHP 006(S) 8 January 1979 The purpose of the Consultation was to review manpower development in the field of toxicology, to discuss the present position in various countries, to predict needs, and to recommend a programme for training toxicologists. The participants comprised nine temporary advisers to the Regional Office, a representative of IARC, and six WHO staff members. 2. Discussions and conclusions 2.1 Existing situation Reports were given on the eight countries represented. They showed clearly that experienced professional toxicologists are in short supply and that they work mainly in universities and the chemical and allied industries with the minority in government service. It was argued that toxi­ cology should be recognized as a specialty in its own right. 2.2 Concept of toxicology Toxicology is a distinct subject concerned with the detrimental effects of eh micals on living organisms, particularly the human organism, but also animals and plants. The aim is to reduce the risk associated with chemical substances to a tolerable level. Modern toxicology is a complex multidisciplinary science drawing together the individual expertise of medical, veterinary and science workers to identify environmental pollutants and assess their effects on health. The basic mecha­ nisms underlying the effects are studied as well as the biochemistry associated with abnormal cellular processes. The pharmacokinetics are elucidated and risk is assessed from animal experiments and epidemiological studies. Toxicological influences on ecosystems including plants are studied, and both the analytical and quantitative aspects of toxicology considered. Thus a toxicologist is one who has expert knowledge in several relevant fields and uses it to assess the hazards of chemicals for human, animal or plant life. Through this expertise, gathered over several years, effects are identified and consequences for living organisms assessed and quanti­ fied. 2.3 Prediction of manpower needs The adoption of legislation on industrial chemicals and environmental matters has created a need for a pool of professionally trained toxicologists to interpret the wide range of data. Several factors have to be borne in mind when predicting needs, but as a preliminary estimate and by way of example, it was noted that Finland would need 75 toxicologists annually over the next few years, the USA 150-200, the Federal Republic of Germany 50, and the United Kingdom 40-50. 2.4 Existing training facilities At present training is given in universities and in industrial and government laboratories. There is a need to expand these facilities. 2.5 Training requirements There is a need for training of all members of the toxicological team. The professional toxi­ cologist should be qualified primarily in medicine, veterinary medicine or natural sciences, with - 42 - training in the latter field extending beyond the doctoral level. In addition to general training in the subject there must be specialization in carcinogenicity assessment, mutagenicity, teratology and epidemiology. 2.6 lnternational collaboration Reciprocal recognition and acceptance of training throughout the Region must be ensured through collaboration and coordination of the various programmes. Larger countries should help in the training of toxicologists for smaller countries through provision of courses and exchange of per­ sonnel. 2. 7 Conclusions In the Region, and indeed worldwide, there is a dearth of experienced professional toxicologists, particularly those capable of evaluating data in terms of its practical significance to man. It is also important that administrators and auxiliary personnel working with these experts have some experience and basic knowledge of the science. There is a diversity both of practice in the training of toxicologists and the curricula However, this should not stand in the way of developing an integrated approach to the topic. could be drawn from the experiences of each Member State, to make a more rapid advance in the of mutual manpower problems. followed. Lessons solution WHO could play an active role in explaining to governments the need to employ properly trained and experienced toxicologists in any assessment of experimental and epidemiological data. Further­ more, all the recommendations given below should be carefully considered, and taken into account in developing the proposed International Chemical Safety Programme. 3. Recommendations (1) To attract high quality graduates to the field of toxicology, governments should: (a) recognize that toxicology is a specialist subject in its own right; (b) create sound career structures for toxicologists, with salary levels commensurate with those of professionals in more established fields and, particularly, comparable to those in industry. (2) The final assessment of data should be carried out by multidisciplinary teams, including medical, veterinary and science graduates experienced in toxicology, with priority given to human health criteria. (3) While there is general agreement on the shortage of toxicologists, a distinction should be made between "perceived need" and "actual demand" for such pr:-ofessional expertise. For this pur­ pose, national studies of the present and anticipated situation should be carried out in the Member States to clarify the quantitative estimates of need and assess the patterns. Emphasis should be given to such areas as behavioural toxicology, immunology, comparative pathology, and epidemiology. Countries should be encouraged to make a concerted effort to predict the number of new chemicals which will be manufactured and ultimately released into the environment, so that a realistic estimate may be made of the toxicological manpower required within the next few decades. (4) Harmonization of curricula in Member States is needed to guarantee the production of toxi­ cologists with comparable qualifications in the various WHO regions. Specialized curricula should also be developed for suitable postgraduate and postdoctoral training of toxicologists. (5) Every country should integrate the resources of all its institutions to develop the neces­ sary training schemes. A coordinating institution at national level should be recognized, but in certain situations where one does not exist as such, an institution serving several countries could be used. (6) Countries which cannot themselves organize all parts of the training should be encouraged through WHO or by other arrangements to use international training facilities or centres in other Member States. International collaboration in producing adequate manpower in this field is strongly recommended. (7) To avoid unnecessary duplication of effort, with consequent uneconomic use of manpower, the possibility of international collaboration in toxicological testing should be explored. - 43 - (8) Within industrial organizations, encouragement should be given for on-the-job training, accompanied by attendance at suitably designed toxicological courses to provide broad training and knowledge within the discipline. Governments should be encouraged to approve training courses of other countries, and there should be a mutual recognition of qualifications. (9) Attention should be paid to meeting the shortage of ecotoxicologists and developing widely accepted methods to assess the effects of chemicals on non-human fauna and flora in the environment. (10) WHO could undertake a survey of institutes in the Region which can provide training in toxicology at postgraduate or postdoctoral level. Such a survey should in particular identify institutes able to offer international courses, and should indicate the specialty of each institute. (11) WHO could prepare for the Region a list of national experts in various fields of toxicology and ensure that appropriate groups are in contact with each other. Such arrangements would ensure that regional philosophies are shared and common opinions, where appropriate, reached on particular problems such as nitrosamines, nitrites and saccharin. (12) The Regional Office should convene in 1979, or as soon as possible, a working group to discuss the design of model programmes for teaching basic toxicology to physicians, postgraduate scientists and related specialists. The group would also have to discuss in broad terms ways in which graduates in given disciplines could be retrained to become effective toxicologists. Atten­ tion should also be paid to defining criteria for the estimation of future needs for toxicologists. (13) WHO could promote further development of training facilities in various countries, stress­ ing the need for a multidisciplinary work profile. (14) Encouragement by WHO for the use of mathematics and statistics in toxicological research would stimulate the development of mathematical models for prediction and calculation of possible safe levels of toxicity and exposure. Utilization of toxicokinetics is essential, and studies of long-term effects on the central nervous and cardiovascular systems are of paramount importance. (15) As a basis for education in the principles of toxicology, encouragement should be given for use of the WHO publication "Environmental health criteria. 6: Principles and methods for evaluat­ ing the toxicity of chemicals". - 45 - FAMILY HEALTH - - - ----------------------- Meeting on Service-oriented Research in Adolescent Fertility in Europe Warnemunde, 24-27 April 1978 Introduction - 47 - SUMMARY REPORT ICP/MCH O17(S) 27 June 1978 Fourteen temporary advisers, including demographers, economists, lawyers, midwives, physicians, psychiatrists and sociologists, from eight European countries, joined by WHO staff members from head­ quarters and the Regional Office for Europe, met to discuss service-oriented research on adolescent fertility. The aim was to contribute to a better understanding of existing services related to adolescent fertility and to determine future needs for such services. Discussion Adolescence was defined as the transition - physical, psychological and social - from childhood to adulthood. It was seen as a distinctive period of life involving particular problems. In rela­ tion to fertility, relevant trends among adolescents in Europe included earlier sexual experience, earlier cohabitation and marriage and, in the more developed countries of the Region, a recent de­ cline in pregnancy rate. Service-relevant problems were identified as including deficiencies in sex and contraceptive education and counselling, psychological and financial barriers to certain types of services, unwanted pregnancies, adverse social, psychological and medical sequelae to pregnancies in the very young, and disadvantages associated with early marriages. Types of services identified as available or poten­ tially available to adolescents included the health care system (including maternity care, provision of contraceptives and school health services), the educational system, the social services system, social security programmes, informational and advisory services, the churches, and organized youth groups. Peer-groups were also seen as an important source of information, counselling and referral. Both the problems faced by adolescents and the services available were found to vary between countries and also between different groups, such as rural and urban residents. Groups identified as having special needs were migrants and physically or mentally impaired adolescents. It was felt that there was a deficiency of existing data, both statistical and behavioural, on adolescent fertility. Many studies of marriage and parenthood did not include adolescents, and vital statistics were not broken down into narrow enough age trends to encompass variances among adolescents. Vital statistics were often not presented in a form useful to those studying patterns of adolescent fertility. In addition, there was a dearth of information about the life-style and life circum- stances of contemporary adolescents. Available data were not disseminated widely enough to be of use to researchers or policy-makers. Practical and methodological aspects of service-orientated research were discussed and it was agreed that each research effort should be directed towards problems potentially solvable by policy­ makers and should be communicated directly to them. It was also agreed that such research should be multidisciplinary and involve both service providers and users. Recommendations 1. The need for service-oriented research into adolescent fertility should be recognized and em­ phasized. 2. Adolescents should not be viewed as a homogeneous group. In the fields of policy and research, note should be taken of the ways in which "adolescence" varies according to absolute age, the pace at which individuals mature physically and psychologically, and the sociocultural and legal context. - 48 - 3. All studies of fertility-related behaviour and attitudes should include adolescents, who should be identifiable as a group when the results are presented. In the design and reporting of service­ oriented research on fertility, adolescents should be divided into age intervals that are as narrow as possible (preferably intervals of one year). 4. Data on adolescent fertility, whether collected by independent researchers, nongovernmental or­ ganizations or national governments, should be continuously collated and updated by the WHO Regional Office for Europe, disseminated regularly to the governments of Member States and be made freely available to policy-makers, service providers, training institutions and research workers on request. 5. Studies should be undertaken to explore the long-term consequences of: (a) adolescent pregnancy and its outcomes, (b) the use and non-use of contraceptives among adolescents, (c) sexual activity or non-activity in adolescence. 6. Studies should be undertaken of fertility-related attitudes and behaviour among adolescents which: (a) explore attitudes to parenthood, self-images and peer-group culture among all adolescents, whatever their sexual or fertility histories; (b) explore kinship and social networks and their influence on fertility-related behaviour; (c) deal specifically with ma]e adolescents; (d) examine special groups such as the physically or mentally impaired and migrants. 7. Research should be sponsored on the processes intervening between the formulation of research and its implementation or non-implementation, in order to ensure the best means of eventual imple­ mentation. 8. The results of service-oriented research should be usable and relevant and therefore such research should: (a) be directed towards problems which lie within the power of policy-makers and service pro­ viders, and should involve policy-makers and service providers throughout the research process; (b) be communicated in comprehensible terms and through various channels to policy-makers, service providers and other interested parties; (c) encourage research by consumers, or by researchers in collaboration with consumers. 9. Since service-oriented research relies upon a body of knowledge about adolescence in general, fundamental research, whether biomedical, statistical or psychosocial, should be encouraged. 10. Service-oriented research should involve: (a) a multidisciplinary approach using the skills of physical scientists, medical scientists, social scientists, service providers and users; (b) a variety of different perspectives, research techniques and types of data collection and analysis; (c) international collaboration in order to facilitate comparative research and ensure the quality of research. 11. Studies should be undertaken of service providers' knowledge and perceptions of, and attitudes and practices relating to: (a) laws and regulations concerning adolescent sexuality and fertility; (b) the nature and magnitude of the phenomenon of adolescent fertility; (c) the scope and functioning of the services and possible improvements in them. - 49 - 12. Studies should be undertaken to examine adolescents' knowledge and perceptions of services and service providers. 13. Research should be undertaken to explore ways of communicating the attitudes of adolescents to service providers and vice versa. 14. Research should be undertaken into the relative advantages and disadvantages of integrated ser­ vices designed to meet all the needs of adolescents, as compared with services with specialized func­ tions dealing with adolescents as part of a wider clientele. 15. Research should be undertaken into the availability, accessibility, acceptability and costs of all services relating to adolescent fertility and the relationship between these factors and ado­ lescent sexual and fertility behaviour. 16. Studies should be conducted to evaluate the training given to all those providing services to adolescents regarding the psychosocial and other aspects of adolescent sexuality and fertility, and the results of such training. 17. Research should be undertaken into the content, methods and channels of sex education programmes and their effectiveness. 18. Studies should be made of legal policies and practices and their relationship to service pro­ vision and adolescent fertility behaviour. 19. Studies should be undertaken of the implications of various economic policies relating to fer­ tility and service provision, both for adolescent fertility behaviour and for society as a whole. - 50 - Meeting on the Application of Research Findings to the Development of Adolescent Fertility Programmes in Developing Areas of the Region Copenhagen, 28-29 April 1978 SUMMARY REPORT Introduction ICP/MCH 016(5) 28 June 1978 Specialists from five countries, together with WHO staff members from headquarters and the Re­ gional Office for Europe, met for two days immediately after the Warnemunde meeting on Service­ oriented Research in Adolescent Fertility with the purpose of reviewing its recommendations and ex­ amining the present situation regarding adolescent fertility in some of the developing areas of the Region. On the basis of this review the participants considered the applicability of the recom­ mendations of the Meeting on Service-oriented Research in Adolescent Fertility to the developing areas of Europe. The meeting made recommendations concerning the need for further research and service programmes in the developing areas. Discussion There was a general consensus that adolescent fertility presented a number of real problems in the developing areas of the Region, particularly where patterns of early marriage and childbirth pre­ vailed. Premarital sexual activity was increasing in large urban centres, and initiation began at earlier ages. Societal traditions frequently impeded public acknowledgement of the need for ser­ vices, particularly in rural areas. The participants concurred that adolescence was a period of gradual transition from childhood to adulthood, having diverse psychosocial and socioeconomic implications in different sociocultural contexts. Service-oriented research involved medical, psychosocial, legal and economic aspects, and required an interdisciplinary approach, special attention to reproductive health and behaviour, and an awareness of the perceptions of service users, potential users, and ex-users. Reconnnendations 1. Planners of service-oriented research in developing areas of the Region should be particularly aware of societal taboos, e.g., those related to sex education and information. Emphasis was placed on the need to work with adolescent men as well as women, and on meeting the needs for services and education for sexually active young people, whether married or not, in both rural and urban areas. 2. Service-oriented research in adolescent fertility should begin with a review of existing base­ line information (e.g., demographic, medical and school records) so as to determine which data are already available and which should be considered for collection in priority research. An inventory of the range and scope of existing medical, social and educational resources and services would be equally helpful. It would be important to ascertain the availability and accessibility of such services for married and unmarried adolescents, the pathways used to reach services, and the partic­ ular entry points. 3. Data should be obtained on the longer-term biomedical and psychosocial consequences of early marriage and early marital or premarital pregnancy for the woman, the child, the family, and society. Such studies would increase community awareness of the reality of adolescent fertility behaviour and facilitate service-oriented research leading to appropriate intervention strategies. 4. Attitudinal/behavioural studies are needed to compare the perceptions of service providers and young people regarding adolescent sexuality, fertility and pregnancy; findings should facilitate the improvement of training and service programmes for sexually active adolescents. Cultural constraints - 51 - and guidelines for service-oriented research were discussed, as were the participation of auxiliary personnel, the need for technical consultation, and the desirability of adapting research protocols to the needs of developing areas of the Region. 5. Country-specific priorities for service-oriented research should evolve from the planning phase and continuing consultations with service providers, policy-makers, young people, and others. Such research should be oriented toward recognized problems which service providers and policy­ makers are capable of resolving. There must be a realistic consideration of what is needed and what is feasible. WHO should take a more active role in strengthening mechanisms for exchanging information, providing technical consultation, and facilitating the utilization of research findings and recommendations in the Region. Conference on the Child and Adolescent in Society Athens, 26-30 September 1978 Introduction - 52 - ICP/MCH Oll(S) 8 November 1978 SUMMARY REPORT This Conference, convened by the WHO Regional Office for Europe in collaboration with the Govern­ ment of Greece, brought together 31 participants from 22 Member States, 10 temporary advisers from 9 countries, 6 representatives of nongovernmental organizations, 8 observers and 5 WHO officers. Topics discussed The topics discussed included: normal biological development and deviations; normal psycho­ social development and deviations; the effects of education on health and the effects of health on education; health services and general services for children and youth; implications for training of service providers. Conclusions and recommendations 1. While the Conference limited its deliberations to the consideration of children of school age (5-18 years), it recognized the importance of fetal and early child development to the health during subsequent stages of life, including later childhood and adolescence. It therefore recommended that authorities responsible for school-age children and adolescents should take responsibility for the integration of their services with adequate services during the antenatal, perinatal, infancy and preschool periods of life. 2. The Conference stressed that growth and development are separate concepts and that desynchro­ nization of these two processes is the main cause of many age-specific problems. In the formulation of standards of growth and development and in the assessment of individual developmental status it is important to: include asynchronous development as well as acceleration and retardation in risk groups; use normal growth and development as a positive index of health status while being careful not to misconstrue normal as necessarily optimal; include biological, sexual, psychological and social parameters; include measures of biological and psychosocial functional abilities such as physical fitness and adaptation to society; screen children at key periods of life, such as school entry and puberty, which are associated with important changes requiring increased physical and/or psychosocial output; continue to search for better methods of assessment (biological, sexual, psy­ chosocial), including simpler methods which can be administered by nonphysicians; involve children, parents and teachers in these assessment programmes and teach the principles of growth and develop­ ment to children and to all those involved with children. 3. The urgent need for more information on the newer morbidities of children and youth in more de­ veloped areas was reiterated. In this regard, the increasing prevalence of chronic conditions and handicaps (physical, psychological and social) was recognized, as well as the desirability of placing children and young people with such chronic problems in normal psychological and social environments as far as possible. Hospitals for such persons must be normalized so that stays are as short as possible, placement is determined by normal needs (peer relationships, etc.) rather than by special needs (disease category), and educational, social and leisure services are provided. Wherever fea­ sible, such children and young people should be placed in normal schools, which should receive the necessary support (special teacher training, smaller classes, multidisciplinary teams, etc.). 4. The Conference recognized the importance of the socialization process in children and adoles­ cents and the varying degree of influence of family, school, peers an<l community on this process at different ages. Although the family is experiencing profound changes in modern society it continues to play a central role in this process. The increasing tendency in most countries of the Region for women to remain gainfully employed after childbirth cannot be viewed only as negative, since it is conducive to the increased self-expression and personal development of the mother, a widening of - 53 - the father's role, and an improvement in the family's economic situation. Families with working mothers need community support, including day-care centres and paid maternity and paternity leave. The role of the school in the socialization process has to be explicitly identified and widened to produce long-term effects. Community activities outside the home and school which aid the sociali­ zation of children and adolescents (cultural, sporting, political, recreational, etc.) should be or­ ganized with families and the children themselves participating as fully as possible in both planning and implementation. 5. Since faulty socialization (social deviance) is a root cause of many of the more serious problems of children and young people today (substance abuse, accidents, suicides, school leaving), more re­ search is urgently needed on social deviance and more preventive and remedial action must be taken. Such programmes should include a risk-group approach to families and involve schoolteachers and other personnel who work with children and adolescents. 6. The rapidly changing nutritional patterns of industrialized societies produce new problems which, in turn, require new approaches. Over-nutrition (obesity) has replaced under-nutrition as the new form of malnutrition and this problem, caused by a complex of biological, psychosocial, environmental and cultural factors, needs more research. The quality of food provided in collective feeding ar­ rangements for children and young people (school canteens, etc.) is another area that deserves par­ ticular attention. 7. The Conference recognized the two-way relationship between health and education and the close link between the level of general education and the level of health. It stressed the right of all children of school age to uninterrupted education regardless of their economic, geographic or health circumstances. This education should be provided both for children who are in hospitals, other in­ stitutions or home-bound (by bringing the school to them), and for those living at considerable dis­ tances from school (by bringing them to the school with transportation, boarding schools and foster families). The role of the school in modern society needs to be reassessed. This reassessment must include: finding ways to enhance the role the school plays in the local community by establish­ ing closer relationships between children, teachers, parents and community members; finding ways to decrease the occupational stress of schoolteachers brought about by oversized classes, low prestige and salaries and performance-oriented administrative policies; identifying teaching methods conducive to better health, such as the qualitative appreciation of behaviour rather than merely labelling it "good" or "bad"; improving both the basic and the in-service training of teachers in health and the methods for periodic re-evaluation of teachers. 8. The Conference felt strongly that innovative techniques in the health education of children and young people are essential if it is to become really effective. Such innovations should: aim to improve the abilities of the child to use his own resources for his own health care by imparting the truth about health and health risks, teaching skills in identifying symptoms of ill health and tac­ tics to deal with them, including how to think in epidemiological terms; stress positive rather than negative values; teach the concept of community health by providing pupils with knowledge. skills and opportunities to tackle public health problems in their own community and by creating policies which strengthen community networks linked with the school. In developing innovative approaches to health education there is a need for more study of forms of influence on young persons which may prove effective in health promotion programmes (use of mass media, participation of actors, sports cham­ pions, well-known personalities, etc.). 9. The Conference considered at length the urgent need to improve educational programmes for chil­ dren and adolescents on sexuality, living together and parenthood. This need, accentuated by the accelerated sexual development of young people in industrialized society, is based not only on the negative aspects of this problem (increase in the number of unwanted adolescent pregnancies and cases of sexually transmitted disease) but also on the positive benefits of preparation for a satisfying, socially integrated personality and a happy life with a partner. It was agreed that these educa­ tional programmes should: be a continuous health promotional activity starting in the family with young children and continuing throughout the school years; include medical personnel to train teachers and counsel youth; be made compulsory in schools by encouraging governments to use (and enforce) legal mandates and develop undergraduate and in-service training of teachers in this subject. 10. The Conference stressed the importance of vocational education programmes for young people, in­ cluding the possibility of engaging children, while still at school, in economically meaningful ac­ tivities in industry in the local community. Because unemployment and inappropriate employment are important factors affecting the social development of youth in industrial societies, the Conference also recommended programmes aimed at increasing meaningful job opportunities for young people, es­ pecially school dropouts. - 54 - 11. Because the needs of children and adolescents in the more developed areas are not being met by traditional maternal and child health programmes, the Conference endorsed the concept of primary health care as the most suitable approach in this connexion. This approach presupposes the multi­ disciplinary participation of various sectors of society (health, education, social welfare, industry, etc.) as well as of families and children themselves in the planning and provision of primary level services. Not enough is known about services for children and young people and the Conference recommended the development of health service research in this field. Enough is known today, how­ ever, about the problems of children and youth and the more promising solutions to them; hence the Conference strongly recommended changing present services now while awaiting future research results. The innovative changes recommended in existing services are numerous (see other recommendations in this summary report and the comprehensive final report to be issued later) and the Conference stressed the importance of less traditional social and health programmes which involve young people to the greatest extent possible in the planning and management of services. It expressed the conviction that these innovative services could be funded if: outdated activities which no longer meet present needs are abolished; the favourable cost/benefit ratios of many of the proposed preventive activi­ ties are highlighted; the first innovations selected are among the many which do not call for sub­ stantial additional funds; the International Year of the Child is taken as an opportune time for planning and financing new activities in the field of child health. 12. The Conference recognized the need for changes in manpower training if the more recent prob­ lems of children and young people are to be understood and the innovative services are to be appro­ priately staffed. This manpower training should include the following: a review of present cur­ ricula of basic training for all those working with children and adolescents (teachers, social workers, doctors, nurses, etc.) in the light of existing knowledge of new problems; the principles, approaches and practices of modern sociology and social psychology during both the basic training and the continuing education of all those working with children and youth; multidisciplinary team seminars. 13. Services should accentuate the clearly dominant, positive (normal, healthy) aspects of child­ hood and youth. The basically morbidity-oriented approach to child health assessment should be gradually replaced by positive health indices. Health education programmes which focus on dangers, diseases and ''don'ts'' should be replaced by positive encouragement of self-directed behaviour which leads, for example, to satisfying occupations, fulfilling physical activities in sports and leisure, and happiness in sexual and family life. Health services which focus on the abnormality of the sick child (for example, hospitals for specific diseases) must be replaced by health services which focus on the normal needs of the sick child, which predominate in all cases except, perhaps, terminal illness, and on the integration of that child in the family, school and community. - 55 - HEALTH CARE OF THE ELDERLY Liaison Meeting with Governmental and Nongovernmental Organizations - Health Care of the Elderly Luxembourg, 4-6 December 1978 Introduction - 57 - SUMMARY REPORT ICP/ADR O16(S) (ICP /HSD OS 7) 16 January 1979 The Meeting, convened by the WHO Regional Office in collaboration with the Government of Luxem­ bourg, was attended by representatives of numerous governmental and nongovernmental organizations active in health care of the elderly. The purpose of the Meeting was to: (1) review the regional programme for health care of the elderly; (2) obtain information from the organizations on their activities, plans and current projects; (3) consider areas of possible collaboration between organizations and with the Regional Office, and the extent to which this could be mutually beneficial; and identify programme tasks for which specific organizations could be made responsible. Discussion The participants outlined the aims, structure and activities of their organizations. Although the overall aim is similar, i.e., the improvement of care for the elderly, the specific objectives vary, e.g., organizing meetings, developing information centres, establishing networks of corres­ pondents, publishing newsletters, bulletins and periodicals or providing guidelines on selected topics. Emphasis is also given to research promotion through project studies, training and liaison. In fact many of the objectives correspond to those of the WHO programme. Areas of collaboration with other organizations were also described. Attention was drawn to the need to find means of improving the dissemination and exchange of information, while noting that attempts have been made to improve the necessary liaison and avoid overlapping of efforts, with some success. In that respect the Meeting, although a modest under­ taking, was considered an important step towards strengthening cooperation between professionals and the WHO proposal for convening similar meetings periodically, possibly every second year, was fully endorsed. Reference was made to the activities of organizations not represented at the Meeting, in par­ ticular the European Committee for Gerontological Action or "Gamma Group" of individual specialists. While having no formal status with the United Nations, the Group has agreed to a pooling of the knowledge and experience of the two bodies. One important question raised was the situation of nursing personnel in care of the elderly, with particular reference to education, preparation for the new requirements of community-oriented nursing in this field, organizational aspects of nursing services, statutes and working conditions of the personnel, and incentives for them to remain in areas of nursing such as this. The problem seems to be compounded in the EEC countries by the directives which provide for free movement of health personnel across national boundaries. Another point frequently mentioned was that of training in geriatrics, which is not generally recognized as a specialty. Thus the field has too few specialists and few medical schools have a chair of geriatrics. Another crucial issue raised was the necessity to clarify the biological pro­ cess of aging and consequently to give a clear definition of the "elderly". - 58 - It was recalled that today 142 bodies are involved in the care of the elderly. Many cooperate closely with WHO, although official relationships have not yet been established with any of them. While this involvement of such a large number of bodies is gratifying, it also highlights the need for effective liaison and coordination. It was noted that until recently the Regional Office had only fragmented activities for care of the elderly and that the present structured programme was drawn up at the request of the WHO Regional Committee. In discussing future programme activities, the participants gave their views on the following five priority topics which were defined by the Technical Advisory Committee on Health Care of the Elderly (Munich, 1978) and are to be studied by ad hoe groups within a foreseeable future: (1) services and systems of care for the elderly (including arrangements for optimum coordi­ nation); (2) attitudes and behaviour, including education; (3) information (including provision of a limited glossary of terms); (4) medication in old age; (5) prevention, including screening. In relation to topic (1), attention was drawn to a number of forthcoming meetings: a symposium of the European Centre for Social Welfare Training and Research, in Warsaw in May 1979; a regional seminar on informal action for the welfare of the aged, in Denmark in March 1979; a United Nations interregional seminar on involvement of the aging in economic and social development, in Kiev in May 1979; and, also under United Nations auspices, a world assembly on aging, in 1982. Projects and studies involving WHO and the other bodies were mentioned, while stressing the need for better coordination of activities within the WHO programme and for improvement of channels of communication between WHO and the scientific world. In promoting the development of health services and the use of appropriate technical methods for the care of old people, it was especially urged that full account be taken of the social context of such action. Better defined social and health indicators were considered essential. Regarding the fairly broad topic (2), attitudes and behaviour, several examples of attitude surveys were given. Further studies would have to be initiated at the national level, but WHO could be instrumental in the exchange of valid information. In cross-national studies WHO could play a leading role as a coordinator and also catalyst in fostering international contacts and bringing together the persons actively concerned. Under topic (3), information, the Meeting felt that some priority should be given to the develop­ ment of a glossary of terms, which would be of much value, particularly for the numerous international studies carried out and envisaged. Although such a task would be complex, in view of the linguistic and conceptual difficulties, and also those involved in producing combined definitions satisfactory for both the social and the health sectors, it was stressed that there is considerable willingness to combine efforts for preparing a glossary on the basis of the existing modest beginnings. The issues raised under topic (4), medication in old age, included adverse reactions in the elderly and the methods and criteria to be used in testing them; self-medication and in particular the use of traditional remedies inherited from older generations; critical investigation of the so­ called "rejuvenating drugs" which claim to delay the process of aging; and finally prescribing pat­ terns in relation to the elderly. Some of the ongoing work in this field was reported. It was felt that a good start in further investigation might be to review the existing information with a view to eventually establishing a list of "essential drugs". Many points were considered under topic (5), prevention, which is a wide and, where screening is concerned, controversial issue. It was agreed that a major aspect of prevention is preparation for retirement and interest was expressed in a preventive programme directed to the middle-aged (persons between 40 and 50). WHO assistance would be much appreciated in selecting experts for preparing the International Congress of the Universities of the Third Age to be held in Nancy in May 1979. WHO could also encourage research to identify adverse psychological, socioeconomic and environmental factors for the purpose of screening and initiation of preventive measures. - 59 - Conclusions The conclusions reached unanimously by the participants may be grouped under the following proposals: (1) It would be useful if WHO established in the Region, persons to provide data for the WHO information system. known to be actively involved in health protection of the tion would not necessarily be a qualifying factor. at the national level, a network of contact Such persons should be selected among those elderly, although holding an official posi- (2) It would be helpful if WHO acted as a clearing house for the exchange of information, particu­ larly on studies or projects currently implemented or planned, keeping in mind that this would involve not only receipt but also dispatch. (3) As a corollary to the above proposals, WHO could explore means of producing a European newsletter on health care of the elderly, to be issued at regular intervals. Participants expressed their willingness to make their respective expertise available to WHO, and to cooperate in development of these proposals. - 61 - HEALTH EDUCATION Working Group on Health Education of Children and Young People Dublin, 23-26 May 1978 1. Introduction - 63 - SUMMARY REPORT ICP/HED 007(5) 8 June 1978 In 1974 the World Health Assembly adopted a resolution (WHA27.28) on the health education of children and young people. Among other things, it considered that WHO should pay special attention to the harmonious development and training of the rising generations with a view to the building of a healthy society. It also noted the important role played by the health education of children and young people in protecting them against the undesirable features of our era (the tobacco habit, alcoholism, drugs, etc.). In the light of the Assembly's recommendation, the WHO Regional Office for Europe arranged a Working Group on Health Education of Children and Young People, in collaboration with the Govern­ ment of the Republic of Ireland. The meeting brought together 17 temporary advisers from 12 Member States of the WHO European Region and 4 staff members of the Regional Office. The participants were asked to consider the use of agencies and services which were not direct­ ly concerned with health care but which made a contribution to the health education of children and young people, the organizational structure consequent on a multidisciplinary contribution, and the place of voluntary organizations and community participation in such a structure. They were also asked to consider the education of all those involved in the health education of children and young people, i.e., parents in the first place, but also teachers, social workers, police, clergy, youth workers and other educators. The Working Group took into account the reports of the WHO Regional Office for Europe on previous working groups, namely those concerning the evaluation of maternal and child health ser­ vices in certain European countries, problems of children of school age 10-13 years and 14-18 years, the place of health education in health administration, principles and methods of health education, and preliminary results of a study of health education in mental health programmes. 2. Discussion One working paper presented at the meeting considered the integration of health education ser­ vices and other services for children and young people. It concluded that, in addition to convey­ ing messages and influencing behaviour, health education also involves creating conditions for healthy behaviour. This is an organizational, administrative and political process, in which par­ ticipation, decentralization and planned change play an important role. In a second paper it was stated that the health education of educators needed to be reorgan­ ized. This would only be meaningful if it were in accordance with the true needs of the children. While it might seem justifiable to regard education as a means of solving society's health prob­ lems, many of the grave dangers to children's health could not simply be "educated away". 3. Conclusions and recommendations The Working Group divided itself into three subgroups which considered the health education of children and young people in the age groups 0-5, 6-16 and 17-25 years. The following conclusions and recommendations resulted: - 64 - Age group 0-5 years Educational counselling in pregnancy is infrequently provided. Clearly, both parents can ex­ ert a powerful educational influence on their c�ildren from the outset; services and economic ar­ rangements do not always attach sufficient importance to this influence. Self-identification and growth of personality of the infant and child in relation to its social environment are among the most important features of development in this age group. The integration of health education services means that various groups work alongside each oth­ er. As organizations and professions vary in relevance from country to country, no universally agreed list of these can be compiled. Since integration of services is complex in terms of organization, planning is essential. The following steps in planning are recommended: the identification, by a process of consultation, of health-related issues and of educational goals derived from these issues; the identification of the health education function of each group, organization, and profession in achieving these goals; finally, the development of a strategy for initiating and implementing health education services. The planned integration of health education services must include an exchange of views among members of different professions in order that agreement can be reached about the methods to be em­ ployed and the functions to be performed, about the dissemination of knowledge of health-related is­ sues and its relevance for health education, and about the appropriate distribution of health edu­ cation materials. Most important, appropriate education and training, and support for all those who are concerned with children, particularly parents, should be carefully planned and integrated. Age group 6-16 years A number of different services deal with the health education of children in this age group. Their number and importance increases with the child's age and the role of the parents dwindles in significance. The health education components vary from service to service and from country to country. These services, and the agencies within them, often work in isolation, in an autonomous manner, and sometimes rival each other for dominance. There is a shortage of specialist health education staff with coordinating functions at the cen­ tral level. There is also uncertainty about the appropriate methodology for teaching health edu­ cation. Measures of effectiveness and methods of evaluation are in short supply. Health education is not attracting sufficient interest and concern on the part of children, young people, the general public and governments. Those currently involved in the health education of children and young people have usually re­ ceived inadequate training initially; teachers are ill-prepared on health issues, and medical staff in general have few educational skills. This age group is not homogeneous in nature. For instance, some matters are more important before puberty (e.g., accident prevention, cleanliness, exercise and preparation for puberty), oth­ ers during and after puberty (e.g., sex education, preparation for family life, education about smok­ ing, drugs and alcohol). The potential of each service must be determined, and needs met in terms of support and training. Additional resources may be necessary. The service provided by each agency must be coordinated with other services on a consultative basis. For this an appropriate structure is necessary. Some kind of central coordinating agency would seem to be desirable. Staff dealing with health education should be appropriately trained, and satisfactory methods of evaluation disseminated. Those services which are attractive to young people, like sports clubs, youth clubs and other more informal groupings, should be linked more closely with formal education and health services. The methods and content of health education should be worked out together with young people them­ selves, according to the requirements at various ages. The multidisciplinary nature of the task must be indicated in curricula designed to train health educators. - 65 - Age group 17-25 years The range of services which can contribute to the health education of persons in this age group is wide, and includes schools of various sorts, colleges, universities, the armed services, medical and counselling services, clubs, parent education groups, police and probation services. Personal relationships, job prospects and choice of career are areas which are of particular concern to young people in this age group and for which counselling may be especially necessary; the most important aspects of health education for this age group are those which contribute to an increase of personal responsibility. Factors which inhibit the services include: vested professional and institutional interests, questions of status and autonomy; outdated and irrelevant curricula; the frequent absence of a dia­ logue between health professionals and the consumer about his real and felt needs; and the assump­ tion by service providers that the solutions they offer are seen as true solutions by the consumer. The real and felt needs of this age group should be systematically researched; curricula in schools and higher or vocational educational establishments should be examined with a view to deter­ mining their relevance to the real and felt needs of those they purport to serve. Informal influ­ ences which shape the behaviour of members of this age group should also be identified. All these factors should be taken into consideration so that appropriate changes based on con­ sultations with all those concerned can take place. A general conclusion, pertaining to all three age groups, is that governments, through legis­ lation, can play a decisive part in either promoting or limiting the integration of health education services for children and young people. Working Group on Health Education of the Public in Cardiovascular Diseases Heidelberg, 7-10 November 1978 1. Introduction - 66 - SUMMARY REPORT ICP/CVD 008(2)(5) 10 January 1979 Certain behavioural factors (e.g. diet, exercise, smoking) are related to the occurrence of cardiovascular diseases. Inducing health-related behaviour change through health education of the younger generation could therefore be an effective primary preventive measure. The Group was convened by the WHO Regional Office, in collaboration with the Ministry for Youth, Family Affairs and Health of the Federal Republic of Germany, to follow up the deliberations of similar groups which met in 1969 and 1975. It brought together directors of pilot areas of the WHO regional cardiovascular diseases community control programme, national policy-makers in the field of health education and experts in social and behavioural sciences. The pilot area directors expressed repeatedly the need for suitable guidance in health educa­ tion. The Group therefore sought to identify the most urgent problems in health education in the pilot areas, to determine guidelines for their solution and to specify practical steps to be taken in accordance with national health education policy. A working paper prepared by a consultant and statements by the pilot area directors were dis­ cussed. 2. Discussions 2.1 Health education of the public in cardiovascular diseases The discussion of the consultant's paper centred on the issue of whether health education should aim at health promotion in general or at health-related behaviour change only, or whether its target should be the prevention of specific diseases. A tentative compromise was reached in stating that health education would be more acceptable to the medical profession if disease prevention were included in the approach. However, the main target of promoting health and influencing health-related behaviour calls for the involvement of society as a whole. Undue "medicalization" of health education should therefore be avoided. 2.2 Current problems of health education in the pilot areas The pilot area directors described the problems they encounter in health education for the young generation (ranging in age from the unborn to 18 years). The problems are threefold, relating to: teamwork in health education; correct approach; and insufficient knowledge of the social and environmental determinants of behaviour of the target popu­ lation. (i) Teamwork Too often teamwork in health education continues to be hampered by lack of cooperation between health education researchers and primary health care personnel as well as between physicians and educators. Another weak point is a relative lack of collaboration with organizations and decision­ makers outside the health field. - 67 - The composition, training and motivation of the health education team are considered to be of the greatest importance especially in dealing with the young generation. Educational expertise is needed to train health personnel in educational methods, while teaching staff need to know more about health. Motivation of the health education team to carry out its tasks is adversely affected by a rela­ tively poor image of the job due to lack of academic status and career possibilities. The approach to health education varies widely among the pilot areas, its basis ranging from a liberal, dialogue-type of interaction between the community and the programme management to a pre­ conceived (although flexible) policy concerning the measures to be applied. Health-related behaviour can be changed by applying a consistent and well-coordinated policy in which administrative, legislative and educational measures are suitably blended with the informed consent and voluntary collaboration of the community. An essential requirement of health educational activities is that they should be seen as being clearly beneficial or at least harmless in terms of the proposed behavioural changes. Especially where the young generation is concerned, it is important to advocate only measures which are in har­ mony with common sense and experience and are believed with reasonable conviction to be free of harm­ ful side-effects. Even then, the results of the measures must be carefully and continuously moni­ tored. Special skills are needed in community health education and the social context in which they are deployed is of decisive importance. Informal and regular contacts with the community and team members who are fully accepted socially are essential in gaining a sound knowledge of changes in the community and ensuring its interest in the programme activities. The Regional Office will facilitate valuable exchange of experience with the health education approach in the pilot areas. (iii) Target population There is a lack of information on the following points relating to the young generation in the pilot areas: epidemiological situation; motivation; socioeconomic characteristics; urban/rural differences; knowledge and attitudes; social approaches and health behaviour; communication and social interaction; sex and age differences in health behaviour. Knowledge of the social and environmental determinants of behaviour is essential for developing a feasible health education strategy which should be adjusted in accordance with new research. It is known, for example, that the tendency to take up smoking is established well before school age, i.e. at 4-5 years. Nutritional habits develop continuously from birth (probably from conception). Moreover, as isolated nutrition education in schools has little effect on feeding habits, the whole family must be reached at an early stage of the child's development if they are to be changed. 2.3 Possibilities for progress Taking into account earlier WHO recommendations, guiding principles for health education in community control of cardiovascular diseases were recalled. Particular attention was paid to methods of intervention and evaluation, and the interaction between national policy on health education and its implementation in the pilot areas. 2.4 Relationship of the programme with national health education activities Greater involvement and possibly direct assistance by national health education bodies was advocated. Health education in the pilot areas should preferably fit into an overall policy. National resources (funds, staff, materials) and experience should be made available for the pilot areas, while experience gained in the areas could be applied on a national scale if proven effective. 3. Conclusions (1) The cardiovascular diseases control programme being implemented in pilot areas is aimed at the connnunity as a whole, although for practical and organizational reasons emphasis is sometimes put on certain groups. Health education is an important element of the programme and has three main objec­ tives: - 68 - (a) improved compliance with treatment by patients, (b) intensification of preventive measures among high-risk people, (c) promotion of healthy behaviour among the healthy population. A more specific objective under (c) is prevention of the development of faulty health behaviour among children and the younger generation. (2) Much experience has been gained and a methodology established in relation to objectives (a) and (b). However, this is less true of objective (c), which is the main subject of the Group, especially where the young generation is concerned. (3) Methods of changing health behaviour of the community should be geared especially towards children and the young to achieve significant, lasting changes. The family, kindergarten and school are the most important points of intervention for this purpose. (4) Success can be achieved only with the active involvement of the whole community, by creating a proper social background and enlisting creative voluntary collaboration at all levels. (5) Different methods of shaping the social background are now being tested and will need to be carefully evaluated. There is no ready-made, universally-valid approach: each method should be studied in the respective community. (6) Probably the most suitable method is to arouse awareness of health problems in general by imparting the necessary knowledge and skills within the everyday learning of the young generation even before the stage of intellectual awareness is reached. Equally important are study and promo­ tion of the positive forms of health behaviour in the social and physical environment. (7) There is no general agreement as to the extent and manner in which guidance should be given in promoting this voluntary, creative participation of the community, but promising experiments are noted. (8) Feedback of assorted information to all levels of the community is an important force for maintaining the effectiveness of the programme. (9) Determinants of the behaviour of a community are very complex, and at the same time changing behavioural patterns may have far-reaching consequences. It is therefore considered mandatory to monitor the reactions of the community as a whole closely both for expected and for unforeseen im­ pact of the programme. (10) Coordination between national health education policy (and its depositors) and the pilot areas should be improved for mutual benefit. More assistance from regional or national bodies is needed in the pilot areas, while experience of methodology in the pilot areas may be of value in the execu­ tion of national health education programmes. (11) Exchange of information and experience at the international level is a major task of WHO in this field. For that purpose, more regular and established collaboration of WHO with national and regional health education institutes (like the Federal Centre for Health Education in Cologne) is advocated. (12) There is a great need to train personnel at all levels in the principles of health education as well as methods for teaching the discipline. - 69 - HEALTH LABORATORY SERVICES Working Group on the Role of the Hospital Laboratory in Public Health Stockholm, 8-12 May 1978 1. Introduction - 71 - SUMMARY REPORT ICP/ATH 004(S) (ICP /LAB 006) 31 May 1978 This meeting brought together temporary advisers from 12 different countries to define the role of the hospital laboratory in public health and its collaboration with the public health laboratory network, to assess present and future trends and to consider how all types of health laboratory service might be rationalized. 2. Discussion The organization of the laboratory services in several Member States of the was described, with their many variations and facets they possessed in common. given of attempts at standardization and quality control schemes. 2. l Functions of hospital laboratories in public health European Region Some details were The hospital laboratory needs rapid, practical and accurate analyses for patient care as well as for the development of activities in the public health sector. Screening techniques should be economically efficient. Broad profile testing seems to be of little use without a specific target in mind. Furthermore, the dialogue between laboratory workers and clinicians was felt by parti­ cipants to be essential, but the means of achieving it requires further elaboration. Quality con­ trol schemes are strongly recommended. While these are relatively easy for clinical chemistry and haematology, greater difficulty is experienced by microbiology laboratories. If rapid and simple bedside tests become more frequent, reliability and safety of these investigations, and quality control must be ensured. The techniques are a difficult area for quality control; however, manufacturers are responsible for providing full information and reliable material. In addition, national laboratories should undertake quality control of manufacturers' products. The bacteriology laboratory has an obvious role in public health by providing early diagnosis, control, follow-up and treatment of communicable diseases and in screening activities. Automated analytical techniques are only beginning to be developed in bacteriology laboratories, particularly for serology and antibiotics sensitivity tests, but their development and evaluation should be pro­ moted in other domains as well. Virology laboratories also have an increasing role in public health and in the management of the patient because of the development and use of rapid diagnostic techniques. The need for close cooperation between physicians and the laboratory means that clinical. virological laboratories must be in close connexion with hospital departments. It is important to take the view of the laboratory user into account. In planning the activities of laboratories, it may be convenient to list the clinical conditions which most often lead to laboratory requests; this would establish the main users of the laboratory and so help in determining the laboratory site. The place of immunology, mycology, parasitology, serology, histopathology, and clinical physio­ logy in the hospital laboratory and their relationship to public health were also discussed. The value of mobile laboratory units in both developed and developing countries was also outlined. 2.2 Coordination of laboratory activities It was noted that hospital and public health laboratories were now tending to drop their unneces­ sary barriers and to merge their activities in providing better services for the community as a whole. Governments should encourage better communication and collaboration between the hospital laboratory and primary health care services in the community. - 72 - Quality control was felt to be important for all laboratories and should be encouraged in microbiology laboratories. Medically qualified personnel should be in charge of the laboratory in order to ensure fruitful collaboration between the clinician and the laboratory. Hospital laboratories often obtain infor­ mation that is of value to public health authorities but not sufficiently utilized. Central labo­ ratories would be able to provide several facilities, for instance reference techniques, training and perhaps, in certain cases, media and reagents. There is a strong need for standardization of equipment, which might also be the responsibility of a central laboratory. It was generally agreed that the organization of both hospital and public health laboratories should extend in a series of levels from central to regional and then to peripheral laboratories. An important aspect of such an arrangement should be that communication would be both horizontal and vertical. A rational use of expertise and equipment will necessitate an inventory of resources which will require periodical updating. Detailed information on various activities is required to prevent duplication. A central authority for training, methodologies and equipment purchase may be advan­ tageous. National institutes and university laboratories play an important role in the delivery of health care to the community. They may be particularly helpful in providing advice on the planning of research programmes and in the assessment of new equipment and in the training of personnel. 2.3 Development of hospital laboratories The developments envisaged include the introduction of new techniques, mechanization and auto­ mation, rationalization and research. A preliminary list of procedures and techniques should be considered for use at the primary health care level. These techniques might be developed and tested at central laboratories before application. The Group felt that these recommendations, however, should not be enforced since governmental backing may lead to a rather restricted approach. With regard to rationalization, the centralization of laboratories may lead to better quality con­ trol of results, more research and larger numbers of trained personnel. Counterbalancing this is a possibility of delay in reporting if collaboration and communication problems are not solved. Peripheral laboratories need upgrading in many cases and a method of ensuring this is to arrange their attachment to medium-sized or regional laboratories. Research in hospital laboratories could be undertaken under the following subject headings: (a) methodology, and in particular the clinical relevance of investigations, cost/effectiveness and new techniques; (b) the investigation of new clinical problems by laboratory methods; (c) laboratory organization and the introduction of computer and automation techniques. It was felt to be important that interest in research should be encouraged through education and training. 3. Conclusions and recommendations (1) To provide useful support to health care services in the predictive, preventive, diagnostic, therapeutic and rehabilitative fields, a rationally organized health laboratory service should be accessible to the community. (2) More effective collaboration between existing laboratory services, such as the public health laboratories, the university laboratories and the hospital laboratories is necessary. (3) Where there is no elaborate public health laboratory service, hospital laboratory services, particularly at regional level, could undertake various public health activities. (4) Coordination of various laboratory activities should be provided at national level; this will lead to a greater efficiency in the existing services. (5) More information on other types of laboratory such as veterinary laboratories, food hygiene laboratories, water and wastewater laboratories and any other laboratories dealing with public health problems, as well as laboratories working in the sector of occupational health, requires greater collaboration, but this could also be organized at national or regional level. - 73 - (6) Standardization and quality control schemes are an essential element for reliable labora­ tory results and Member States should initiate, develop and reinforce them through a central or regional laboratory. (7) Laboratory services at primary health care level need greater attention since development of them would improve community health. A list of tests and activities and basic equipment should be recommended with the understanding that these activities should be flexible and organized according to local priorities. (8) Studies on appropriate technology in the various laboratory disciplines are necessary in order to develop rational, economic but also precise and accurate techniques. (9) Mechanized and automated procedures should be carefully planned and tested for optimum cost/benefit. (10) Rationalization procedures should be encouraged, but only be permanently introduced after pilot studies. (11) The exchange of information and collaboration on laboratory techniques, as well as infor­ mation about their standardization, will be encouraged both among laboratories within individual Member States and internationally. (12) To improve the relationship between the clinical and laboratory services, as well as the quality and usefulness of biological investigations, the importance of proper initial and con­ tinuing training of medical biologists and laboratory technicians should be stressed. (13) Applied research should be stimulated in the various types of health laboratory. - 75 - HEALTH MANAGEMENT Working Group on Research on Simulation Models for Health Management Lisbon, 26-29 September 1978 Introduction - 77 - ICP/HSP Oll(S) 12 December 1978 SUMMARY REPORT The Group, convened in cooperation with the Portuguese Ministry of Social Affairs, was attended by temporary advisers in many fields including systems analysis, mathematical modelling, clinical medicine, nursing, political science, sociology, economics and health care management. It followed the European Conference on National Health Planning, held in Bucharest in 1974. Today, because of the greater diversity of health services, their rising cost and increasing concern regarding their relevance, managers of services are obliged to analyse large amounts of data on health problems and activities, and the use of resources. Traditional health planning and evaluation techniques are not suitable for this purpose as they do not give an overall assessment of services and the impact of strategies. However, mathematical models that simulate the interactions between the input, s true ture and output of services seem to off er more promise. Thus the Group was asked to consider the present development of such models and their potential for routine use in health management, including planning and evaluation. It was also asked to identify areas where further research should have priority. Discussion Functions of models For the purpose of the discussion the Group took simulation modelling to mean any scientific rep­ resentation of a real system and its functional relationships. Current European research on health management models was reviewed. It was found that although many mathematical and valid representations of parts of health systems have been constructed, the few successful applications have been confined to particular hospitals or units. Certain problems have been subject to study in many countries and indeed within several institutes in a country while many important problems common to several countries have not been modelled at all. Thus, although an impressive array of models exists, their use is limited and has by no means been accepted as a normal contribution to policy formulation and monitoring. It was noted that many useful models for a wide range of operational problems are now available to managers. Good models can give decision-makers information which clarifies the consequences of possible courses of action and thereby reduces "the cost of error" on a national scale. But it must be admitted that often the data required for using a model in decision-making are not readily avail­ able, and so estimations may have to be made at first. However, the fact that a model exists high­ lights the need for data in decision-making and thus stimulates the development of information systems. Models are also useful in identifying options for national and international policy formulation and in motivating changes in the tactics or strategy of a health system. A further valuable property of models is that they can educate managers in the formal objectives and functioning of a health system. Finally, they can be a source of new information on the behaviour of a health system under different circumstances. Model acceptability A number of problems are faced in ensuring the acceptance of models. To start with there are medical, sociopolitical and technological obstacles to the design of acceptable models. In fact the lack of motivation for routine use of models may, to a considerable extent, be due to the existence of large numbers of poorly designed, ineffective models. The modeller must have a clear understanding of the problems and constraints faced in the real world; he must reflect them in his model and be able to communicate his findings. - 78 - It is important also that models be tailored to the institutions and levels of application for which they are intended. Macro-models, for instance, serve a valuable purpose in formulating national health policy, while different models are needed for its implementation and evaluation at the level of individual institutions. More specifically, models can be identified as descriptive, explanatory or innovative and each type may be applied in a different problem area. At the national level, resources are allocated to the health sector in relation to the economy as a whole and, within this sector, to the different groups concerned. Effective strategies for the various diseases are drawn up, efficient use of high-cost technology is sought and alternative patterns of treatment are evaluated for rational development of the service units. Screening poli­ cies are highly relevant. All these strategic choices must be underpinned by sound manpower plan­ ning, involving the elaboration of supply and demand models with full cognizance of behavioural factors. Up to now, national level models for strategic planning and the allocation of manpower, funds and other resources have been tried out. Models do not at present exist for national allocation of resources between sectors but are considered feasible. At the local level, decisions are taken on the size and location of service units, these con­ siderations being highly dependent on geographical and social factors and the resources available for transportation, communication and distribution. Within the individual units, tactical decisions are made on how to ensure efficient utilization of facilities and effective treatment. Numerous local level models of proved value are available for solving problems of sophisticated medical tech­ nology, logistics, medical screening or evaluation of clinical trials. Models for resource alloca­ tion at the local level are less used but there have been some successes. Important requirements in the design of models are that they should be readily understandable by managers, logically consistent, scientifically rigorous and statistically sound. Once a satisfactory model has been designed, attention must be given to aspects of its applica­ tion if it is to be accepted. The first and most important criterion with regard to the application of models is that there should be a consensus between decision-maker and modeller on the problem faced. It was agreed that the best use of models is achieved when they are part of the negotiating process which precedes decisions. The construction of a proper model requires combined efforts by managers and modellers. From this it follows that the modelling group should be firmly established within the organization it is intended to serve, with its activities nevertheless subject to outside peer review. Moreover, continuing support by the modelling team after the model has been developed is essential for adapta­ tion of the design as appropriate. Another important aspect of application is the setting of priorities for model construction since, although sophisticated mathematical models can be developed, the cost in time and effort may not be justified. It is important to take the nature of the problem as the starting point. It must be evident that the system concerned has adequate control mechanisms which can be manipulated. For reasons of cost/effectiveness, series of interlinking submodels, each of which can be used in its own right, are preferable to large all-purpose models. A further consideration in the application of models is that of time, which may range from a matter of days to perhaps more than one decade - the planning, construction and economic break-even period for major capital investment. International cooperation In the matter of international collaboration with regard to models, it must be borne in mind that the background in which the existing ones were designed and applied was disparate. However, there are processes and functions of health systems common to all countries. Therefore, all should profit from cooperation on an institute-to-institute basis and also through WHO. Initially it may well be that most benefit can be obtained in the areas of problem identification and model design rather than the exchange of model packages. Particular attention should be paid to the sharing of experience through courses and seminars. Exchanges of modellers between institutes are also recommended. Recommendations 1. Simulation models should be recognized as a valuable tool in health care management and as an aid in decision-making. - 79 - 2. To ensure acceptance, a model must not merely be mathematical and technological but also con­ tain a clear statement of the relevant social, economic, institutional and political factors - whether or not it takes account of them. The degree of uncertainty associated with the study should be stated. 3. Successful models for health care management can only be developed through joint efforts by modellers and managers, and this cooperation must continue after the initial development of the model so that any necessary modifications in design or utilization can be made. 4. Modelling expertise should be provided as part of the management resources of the system being modelled. 5. The setting of priorities in health care modelling should depend on the priorities of the managers, the modeller's view of feasibility and the availability of necessary expertise. 6. Instruction in basic modelling principles and application should be part of specialized and continuing education programmes for managers, extensive use being made of case studies presented jointly by modellers and users. 7. WHO could directly or indirectly promote the exchange of information among Member States re­ garding new developments in health care modelling by various means, including the convening of seminars and other meetings. 8. WHO could promote training in this field by means such as the development of course modules for programmes in health care management and the exchange of fellows among countries. 9. WHO and other international bodies active in the field could encourage comparative studies of practical health care modelling, particularly in countries with different socioeconomic systems. See also: - 81 - HEALTH MANPOWER DEVELOPMENT - Cancer: - Toxicology: Working Group on Postgraduate Training in Clinical Oncology, ICP/CAN Oll(S), page 9 Consultation on Manpower Development in Toxicology, ICP/EHP 006(S), page 41 - 83 - Working Group on Training of ICP/HMP 008(S) Senior Public Health Administrators 14 November 1978 Moscow, 21-23 June 1978 SUMMARY REPORT Introduction The scope and purpose of the Working Group was to review programmes for the specialized, advanced and continuing training of senior public health administrators. A major need is to train adminis­ trators able to advise on priorities in the allocation of resources. Discussion was invited on ways of promoting communication between the public health and education and training systems in order to prepare personnel more effectively for their functions in the health services. The meeting was attended by 12 temporary advisers drawn from schools of public health, health ministries, national boards of vocational education and departments of community medicine in 10 coun­ tries of the European Region of WHO, and by 4 WHO staff members. Discussions The Group defined the senior public health administrator as a top-level professional who is in direct contact with the often nonmedical decision-makers. He is the link between the policy-maker and the community, channelling technical knowledge to the policy-maker and shaping policy decisions so that these meet objectives that are useful and technically sound for the community. The participants agreed that it was very important for all senior public health administrators to be familiar with the policy and activities of WHO in respect of health manpower development, with a view to improving international collaboration and setting up appropriate national health services. The functions and tasks of senior public health administrators depend on their categories and responsibilities. Public health administrators work at international, national, regional and local levels. A great diversity of talent is needed in public health administration. The participation of public health administrators in higher-level decision-making processes depends partly on their knowl­ edge of community medicine. Administrators of this kind must be aware of the prospects for the de­ velopment of the system, set organizational objectives, identify problems and propose ways of solving them, monitor the implementation of decisions, and seek ways of increasing the effectiveness of the system by checking the quality and effectiveness of decisions. Factors determining the managerial policy of senior public health administrators were discussed. Defining the objectives of the curriculum for training higher-level administrators, the partici­ pants reached the conclusion that they should correspond strictly to the realities of contemporary administration, and should take into account any changes which might occur in the near or more distant future. Trainee public health administrators should acquire the following skills and abilities: (1) to identify and formulate problems; (2) to make effective decisions; (3) to organize and put the administrative system into action; (4) to analyse information. - 84 - To achieve these aims during training a number of problems must be solved. Trainees are sup­ posed to acquire a good command of all sections of present-day public health management as a science. The strategic character of the work of higher-level administrators calls for a thorough knowledge of the public health system as such and its interrelation with other systems in society. The international training of public health medical officers, including in-service training pos­ sibilities, and problems of international collaboration in training of this type, was discussed on the basis of the WHO Study on Training Patterns for the Public Health Medical Officer (ICP/HMD 042) carried out in Belgium, Czechoslovakia, France, German Democratic Republic, the Federal Republic of Germany, the Netherlands, Poland, Romania, Sweden, United Kingdom, USSR and Yugoslavia. New functions and responsibilities of public health administrators in relation to future strategy and tactics in health administrations, including the monitoring and evaluation of their work and the feedback of results into the planning and production process, need to be studied and research in this field should take place in each of the Member States of the WHO European Region. This problem is directly related to the evaluation of health measures, services and performances. It is necessary to be certain that action can be taken after evaluations have been carried out, and to appreciate the difference between the evaluation of input and that of outcome. The former is to be accepted, the latter rejected. Evaluation criteria need to be developed, and choices as well as services need to be evaluated. Conclusions The Working Group reached the following conclusions: 1. The roles and functions of medical officers of health vary so much that training would have to be based on specialization in different fields of public health besides preparing trainees for special posts. The result would be a combined system of training patterns. 2. A combined system of this kind, which would harmonize with public health concepts, would be well suited to the administrative systems and to the organizational structures of public health services in most European countries. It would be based on the integration of academic and in-service train­ ing and on a systematic approach to further education. 3. The system could be used by countries as a framework within which each could develop its own training pattern to meet its own concept of public health. It would allow adaptation to the structure of its own public health services and prepare trainees for the duties and responsibilities of medical officers of health. It would permit account to be taken of the organization of its public health offices, the composition of its public health teams and the availability of other professions within the public health service. All this necessary information would, however, have to be collected first before a training pattern for medical officers of health could be evolved in any particular country. 4. Public health medical officers should be trained as resource persons to enable them to be con­ sidered for senior posts. 5. Senior public health administrators could act as part-time teachers in schools of public health. 6. In order to reduce losses from the ranks of medically-qualified senior public health administra­ tors, a good career structure should be designed, and salary scales comparable to those for senior members of other medical specialties should be assured. 7. The senior public health administrator who acts as a coordinator in the planning, monitoring and evaluation of health services should either be medically qualified or have received training in another health field. 8. WHO's policies and activities with regard to health services should be familiar to senior public health administrators starting their careers; such knowledge will assist them in the proper delivery of health services in their respective countries and will help them to achieve better mutual under­ standing and collaboration. 9. Medical teachers and administrators at medical faculties should be alerted to look for suitable candidates among medical students and young medical personnel for careers as senior public health ad­ ministrators. - 85 - Recommendations 1. The WHO Regional Office for Europe should organize and carry out research activities relating to the training and management of public health administrators and make a comparative study in this field. 2. The Regional Office should also carry out a survey of existing courses for public health ad­ ministrators in the Member States of the European Region, so as to ensure the highest standards of training and to maintain the qualifications of such personnel at the requisite level. 3. The Regional Office should play a major role in the training of senior administrators in health services by means of exchange programmes, meetings and travelling seminars by providing opportunities for senior professionals to meet, define issues and compare experience, and by helping them to seek their own solutions to problems. 4. The Regional Office should assist schools of public health to promote intercountry exchanges of senior administrators in different branches of government, and of policy-makers and experts in other fields, such as economics. - 86 - Working Group on Continuing Education of Health Personnel as a Factor in Career Development Budapest, 31 October - 2 November 1978 SUMMARY REPORT Introduction ICP/MPM OOl(S) 25 January 1979 The Group consisted of 13 persons experienced in the various aspects of continuing education (CE) and chosen with a view to developing a better interrelationship between the various categories of health personnel. The professions of nursing, medicine, physiotherapy, laboratory or medical technology and midwifery were represented. One source of the difficulty for any multinational group concerned with CE as a factor in career development is the fragmented organization and delivery of health services in many European countries. Because historical and professional developments are often based on old societal and educational structures, patience and flexibility are needed when attempting to introduce changes. It is difficult to modify the delivery of health services and especially to adapt educational policy and methods to such services. To ensure the best possible collaboration of health profes­ sionals and their assistants the type, scope and limits of the respective services must be specified in greater detail. This objective can only be achieved in a cooperative spirit and one of the best starting points for the necessary dialogue is careful programming of CE whenever possible. Strong motivation to improve CE programming, and in general to learn more and repeatedly, contributes to effective CE and is expected of course organizers and participants. Equally important is the will to develop CE programmes through joint efforts of governments and health professionals; this involves better selection of topics for courses, some of which should be structured for multiprofes­ sional attendance and if possible for evaluation. Discussion The term CE was interpreted differently by the participants, depending on the national educa­ tional policies they had encountered. In the socialist countries postgraduate and specialist train­ ing includes CE and regular attendance is required of health personnel undergoing such training. To participants from non-socialist countries CE was considered unrelated to postgraduate training, i.e., it was seen as education that is ongoing throughout the professional life and is offered to all categories of health personnel regardless of their status as specialists or generalists. In this perspective the Group agreed to interpret CE as a separate entity in educational programmes regardless of the level of specialization or professional activity. With regard to cost, quality and type of health services delivery, the Group looked at CE in a broader context and throughout the meeting attempts were made to find common denominators in the CE of health personnel in general and career development in particular. In a discussion on what is meant by career development several determinants were identified which merit consideration. They include: certification of competence in a given specialty, personal rewards when given greater responsibility or more interesting tasks in the profession, - financial incentives, - the satisfaction of learning more for the simple reason of being able to do a better job. As evident in other aspects of the organization of health services, the approach to CE of health personnel differs in the European Region. In socialist countries CE is mandatory and in non-socialist countries generally not. In Sweden, Finland and the United Kingdom there are some - 87 - categories of health professionals who must attend CE courses in order to continue serving in their current positions. The growing importance of health care research for both economic and service reasons has also been a factor influencing CE. These developments are reflected in the reports of a series of working groups and expert com­ mittees convened by WHO, a resolution of the Twenty-seventh World Health Assembly (1974) and the decision to hold technical discussions on the topic during the twenty-ninth session of the Regional Committee (Helsinki, September 1979). Conclusions and recommendations The difficulty of providing effective CE for the whole spectrum of health personnel is recog­ nized. Especially in the field of primary health care, more data seem to be needed to identify needs which can be met by one or another category of personnel. Once such information is available, criteria of care and standards of practice will provide a better basis on which to assess the quality of services and to identify the deficiencies. Planning of CE can then be better oriented and pro­ grammes with more relevant content be provided. The controversies about the organization and/or legal framework for CE led the Group to stress the importance of both voluntary and compulsory CE, with one or other factor for career development included, while not overlooking the considerable constraints in developing a more efficient and reward-oriented CE system. A consensus was reached as to the importance of the organizational and administrative aspects of CE, without which the programmes could not provide the necessary stimulus and satisfaction to both organizers and users. The motivation for further learning cannot be taken for granted in setting up CE. There is indeed no better incentive than the determination to enjoy the acquisition of additional skills and knowledge through critical and active participation in such programmes, which in itself gives suf­ ficient stimulus to look at career development within this context. Countries of the Region have taken different legal and practical approaches to licensure for the general and special categories of health personnel. The countries are also seeking ways in which to make CE more effective, and those who design and attend the courses must be concerned about their merits and weaknesses. The socialist and other countries in the Region share the wish to better assess the quality of health services. The Group recognized the importance of providing incentives to make further education of health personnel more attractive but felt that financial rewards alone are not the only or even perhaps the best mechanism for the purpose. It was recommended that those who plan, administer and evaluate CE place emphasis on life-long learning as soon as the student enters a medical or other training institution. Further, CE should be a factor in career development in the same way as qualifications and experience. CE should be made part of the responsibilities of health pro­ fessionals, with adequate provision of study leave and financial assistance to conduct and attend courses. Finally, CE should be provided at all levels and not be confined to the university, and the courses should focus on identifiable weaknesses both in the competence of practitioners and in the delivery of health care. Attempts are being made to collect data on government or professional decrees requiring one or another category of health professional to attend CE courses as an obligation to the state or their professional association and, if possible, also on career incentives or other factors of carePr development. It is hoped this will be useful for the technical discussions during the twenty-ninth session of the Regional Committee. - 89 - MALARIA - - - ----- - - - - - - - - Working Group on the Receptivity to Malaria and Other Parasitic Diseases Izmir, 11-15 September 1978 Introduction - 91 - ICP/MPD 004(S) 15 November 1978 SUMMARY REPORT Massive increases in land and air travel as well as movement of workers within and between countries and even continents have brought an unprecedented risk of dissemination of parasitic infec­ tions depending on each country's inherent receptivity to transmission. Thus it was considered timely to convene a Group to study the epidemiological status of parasitic diseases and ways to im­ prove their surveillance and control. The participants included physicians and entomologists with experience in teaching, research and field work in tropical medicine, malariology, parasitology and entomology. Main conclusions and recommendations While many countries in the Region are now free of malaria, transmission continues in parts of the Mediterranean Basin. The scene is dominated by an explosive epidemic of P. viv= malaria in three provinces of Turkey (Adana, I�el and Hatay), where the annual parasite index rose from 0.002 per 1000 population in 1968 to about 30%0 in 1977. The resurgence of malaria in this area may be mainly related to the movement of seasonal workers and broad-spectrum resistance of the main vector, Anopheles sacharovi, to insecticides. Another matter of concern is the increasing number of cases being im­ ported from different parts of the world into many European countries, about 1700 being recorded in the United Kingdon alone in 1977. There is also a serious danger of reintroducing malaria into highly receptive countries of the Mediterranean Basin. Visceral leishmaniasis, which is focally distributed in southern Europe and parts of the USSR, is increasing in certain areas that are no longer covered by residual insecticide spraying as an anti­ malaria measure; the same is true of urban cutaneous leishmaniasis. Zoonotic cutaneous disease is a serious public health hazard in some newly developed areas of the USSR and certain rural parts of the Region. It is difficult to establish the true incidence of such intestinal infections as amoebiasis and giardiasis but both pose a hazard, especially to travellers. The public health importance of toxo­ plasmosis remains to be defined also. There is a great need for up-to-date information on the epidemiology of helminthic infections. For this purpose medical geography, which involves the mapping of potentially endemic areas where con­ ditions for parasite transmission exist, can be of value - as demonstrated by studies in the USSR. Studies have in fact already been made of the distribution and prevalence of some major helminths, in­ cluding S. haematobiwn. Intermediate snail hosts for this parasite exist in some countries of Europe and the development of irrigation schemes may be a further factor in its reproduction and dispersal. Guidelines can be established to �elp governments in planning surveillance and control programmes by stratifying the countries according to the risk of transmission of a particular disease. Mathe­ matical analysis has, for instance, been used to determine the malariogenic potential of different areas. For this purpose it is necessary to collect baseline data on vector and disease patterns, ecology and community attitudes in the area (receptivity) and data on the movement of infected people into the area and its proximity to infected localities (vulnerability). This analytical approach, which is very valuable in malaria, is less useful in studying leishmaniasis and schistosomiasis. - 92 - For programme implementation specialized parasitology units are needed, but for various reasons these are lacking in most countries. They could be set up within the general health services or existing research and educational institutions. Programmes must also be backed by adequate training, which could take within child and adult education programmes; information for travellers; tion for epidemiologists, parasitologists, entomologists and sanitarians. might include direct support to institutions, the provision of fellowships specialized courses such as those of WHO. the form of instruction or postgraduate specializa­ Measures for this purpose or the organization of Priority topics for research selected by the Group include: prevalence and incidence of the diseases; vectorial capacity of insect vectors and molluscs; use of standardized techniques; identi­ fication of parasite species; distribution of the infections; environmental health measures in rela­ tion to parasite transmission; radical curative drug regimens; animal reservoirs of zoonoses; and ecologically-sound control procedures. The epidemiological status of protozoa! and helminthic infections should be further assessed throughout the Region. More specifically, studies are needed to determine the malariogenic potential in many countries and a similar approach, taking into account the receptivity and vulnerability of various areas, should be applied to leishmaniasis and schistosomiasis. For helminthic infections the medical geography approach, as developed in the USSR, should be generalized. National health authorities should give more emphasis to surveillance and control of the diseases. Specialized parasitology units are required at central, regional and peripheral levels. Specific points relating to training and research on the diseases, raised during the discussion and examined in detail in the final report, may provide useful guidance for further consideration by the responsible authorities. - 93 - MENTAL HEALTH - -------- Working Group on Changing Patterns in Mental Health Care Cologne, 27 November - 1 December 1978 Introduction - 95 - SUMMARY REPORT l.CP/MNH 044 II(S) 30 January 1979 Transition from institutional care to comprehensive community care for the mentally ill, includ­ ing those with chronic disabling conditions, is a major objective of the WHO regional long-term programme in mental health. Under this programme, the Regional Office is engaged in a series of coordinated activities to examine and stimulate new developments in the patterns of care and service provision for the mentally disordered. In pursuance of this policy, the Group was convened to examine ways in which changes are being made in the organization of mental health care in countries of the Region and to determine how far such developments can increase the effectiveness of care for the mentally ill and disabled. The Group consisted of 23 psychiatrists, public health administrators and other experts from 13 countries, appointed as temporary advisers, and 2 members of the Regional Office secretariat. Discussion Changing social and medical background Contemporary development of mental health care in many parts of the Region is taking place against a background of demographic and social change. In some countries, reduced mortality and birth rates have led to an increase in the proportion of the elderly in the population, to a point at which age-related problems of illness and dependency are becoming critical. Economic recession has multiplied the numbers of the unemployed, creating massive social problems especially among such vulnerable groups as unskilled workers, immigrants and school-leavers. The housing situation is deteriorating in many large cities, while at the same time various indices of social pathology, including rates of crime and juvenile delinquency, are on the upswing. Less dramatic, yet also of great significance for mental health care, are changes in the medical and social services. Costs of health care generally have escalated, with continuing inflation, and in some countries have reached a level at which they are difficult to support. The consequences can already be seen in a cutting-back of medical and social programmes and in shortages of skilled manpower. Simultaneously, demands for greater specialization and more advanced technology have led to the construction of huge new hospital complexes, which are often distant from the centres of population they serve. Not all current change is inimical to the principles and progress of community health care. Important favourable trends can also be discerned. Psychiatric departments have been established in many general hospitals. General medical practice in some countries is based more and more on multidisciplinary teams, in which groups of physicians collaborate with nurses, social workers and other professionals. There is a growing readiness, among physicians in all specialties, to acknow­ ledge the importance of psychological and social factors of disease. The emergence from medical schools of a new generation of physicians who have received some grounding in the behavioural and social sciences may be expected to reinforce this tendency. Changes in the demand for mental health services Against this background, it is not surprising that the nature and content of psychiatric prac­ tice are changing, even in those regions where the service structure has been little altered in recent years. Certain broad trends are recognizable across the Region and are already being - 96 - reflected in national statistics. Rates for alcohol-related diseases and for attempted suicide, especially self-poisoning, are climbing steeply, as is also indicated by epidemiological findings. The numbers of treated psychogeriatric disorders are rising, and these conditions represent an in­ creasing priority in mental health care. The frequency of alcoholism, drug abuse, delinquency and behaviour disorders appears to be on the increase among young people, while the age of onset of such problems is falling. It is seldom possible, from the available statistics, to decide if the observed trends reflect real changes in morbidity, or determine how far they are due to changes in the pattern of service utilization. Some, such as the rising rates of alcoholism and suicidal behaviour, are probably independent of service provision, whereas others, such as the increase in psychosocial ''crises'' re­ ported from many centres, may be more closely linked to the availability of care agencies. Whatever the underlying causes, there can be no doubt that the content of psychiatric practice, as well as the demand for care, is altering in ways which the psychiatrist cannot always foresee and can seldom control. It follows that mental health services must be sufficiently flexible to adapt to changing conditions, simply in order to keep pace with events in society. But this kind of response is not in itself sufficient, since in no country up to now has a satisfactory standard of provision of mental health services as a whole been achieved. The services must therefore not simply adapt to change; they must also improve. Planned innovations in mental health care A series of WHO studies have reaffirmed the goal of comprehensive community mental health care. Recently, however, the Working Group on Constraints in Mental Health Services Development (Cork, 1977) concluded that the concept was not yet being satisfactorily applied on a wide scale and that changes in public and professional attitudes, as well as in the legislation, were urgently required. The task of the present Group was to examine some possible strategies for reaching the above goal, as exemplified by experimental projects being conducted at regional or local level in Trieste (Italy), Nacka (Sweden), Leningrad (USSR) and Mannheim (Federal Republic of Germany), and to assess, on the basis of this evidence, the feasibility of effecting the transition from institutional to community-based forms of care under differing national conditions. Some of the projects were set up specifically with the goal of comprehensive community mental health care in view; others have more limited objectives, such as the provision of services for the elderly, for young persons or for crisis intervention. Scientific evaluation, or even the possibility of systematic assessment based on adequate descriptive statistics, is still lacking for many of the services in question. Taken together, the projects provide nonetheless a convincing practical demonstration that progress towards the goal of comprehensive community care can be achieved, given the will and determination, by planned change in the structure and organization of existing services. Moreover, some of the experiments suggest that such progress can be made without any large capital expenditure or increase in running costs. Conclusions The Group noted with much interest the experimental projects which were reported, based on new patterns for the organization of mental health care in the community. In the projects, which are broadly in line with the recommendations of earlier working groups, favourable results are being obtained by taking special account of the social aspects of mental illness. Such experiments should be developed and pursued in all countries, but there is an urgent need for more systematic monitoring of their results and for scientific evaluation of a number of different experimental strategies. The Regional Office can play a vital role in promoting such research and in publicizing the results as well as national changes in service structure and legislation concerning the mentally ill. No single experimental project can serve as a blueprint for change, since local projects must be planned and designed to meet local needs and to adapt to the prevailing conditions. It is there­ fore important to recall the following general principles underlying the concept of comprehensive community mental health care, since these also constitute the essential criteria by which the success of individual projects can be judged. The service should be community-based, i.e., it should provide facilities for a defined area population small enough to permit most patients to be treated within easy travelling distance of their homes. The service should be comprehensive, in the sense that it provides a range of facilities, differentiated to meet the needs of persons suffering from any form of mental illness or handicap to be found in the area population. Specialized forms of care which must be pro­ vided on a regional basis should be linked to the community-based service. - 97 - The various agencies and services engaged in mental health care for each area population should be so effectively coordinated that each part of the system can contribute to the care of individual patients, according to need, and that patients or their families do not suffer any disadvantage as a result of being transferred from one part of the system to another. This point applies equally to care given by medical and social agencies and nonmedical resi­ dential care. An equal quality and standard of service provision should be available to all persons in the service population who stand in need of mental health care, irrespective of financial or other considerations. In quality and availability, care for the mentally ill and mentally handicapped should be of a standard not lower than that provided for the physically ill. By applying these broad principles, it should be possible to monitor and evaluate the changes made in individual services, and to compare the merits and disadvantages of innovations made in different areas. The working papers presented during the meeting, together with the discussion arising from them, made it clear that mental health care in many parts of the Region is in a state of transition and pointed to certain fairly specific, practical measures which could be applied more widely in order to initiate or accelerate progress from traditional custodial care towards comprehensive com­ munity mental health care. In this situation, the Group considered it a matter for great regret that in some countries large new mental hospitals are still under construction, was of the opinion that no more such institutions should be built and urged that in future new inpatient units should be situated in, or closely linked with, general hospitals. Recommendations 1. The running down of existing mental hospitals should be phased so as to overlap with the build­ ing up of alternative, community-based services. In no case should chronically ill or handicapped patients be discharged from hospital until or unless adequate supporting services are provided in the community. 2. Facilities for after-care and rehabilitation should be developed for each service population, within the service area. Joint funding or subsidy schemes should permit costs of continuing mental health care to be met outside the hospital system, whether in residential homes, hostels, sheltered workshops or other nonmedical facilities. 3. Firm guidelines should be established in each country and region for the allocation of specialist manpower and working time to activities not directly connected with clinical care of patients, par­ ticularly consultative counselling and preventive work. Duties of this kind should, where appro­ priate, be specified in the contracts of mental health services. 4. Domiciliary visiting by psychiatrists and other members of the mental health team should be made possible, as an accepted part of the duties and responsibilities, in relation especially to pre­ admission screening and to after-care following hospital discharge. 5. In the planning of mental health services, a clear distinction should be drawn between primary and secondary levels of care. The contribution of medical practitioners, social workers and other professionals to primary care of the mentally ill should, wherever possible, be supported and rein­ forced by the formation of effective working links with area psychiatric services, as well as by the provision of opportunities for continuing education in mental health care for all the profes­ sional groups. 6. A simple type of basic documentation should be developed in each area, with careful regard for the confidentiality of personal data, so as to permit monitoring of the activities and utilization of different parts of the service and reliable computing of basic statistics on patient care in all parts of the system, e.g. for inpatients, day patients, outpatients, prevention, rehabilitation and after-care. See also: - 99 - NURSING AND MIDWIFERY - Primary Health Care: Working Group on Working Interrelationship in the Provision of Community Health Care (Medicine, Nursing and Medicosocial Work), ICP/HSP 006(S), page 121 - 101 - Third Liaison Meeting with Nursing/Midwifery Associations on WHO's European Nursing/Midwifery Programme Copenhagen, 28 February - 2 March 1978 SUMMARY REPORT l Introduction ICP/HSP 024(2)(S) 27 April 1978 ORIGINAL: ENGLISH The first and second liaison meetings, held in 1974 and 1976, recommended that regular meetings of representatives of nursing and other relevant associated organizations and the Regional Office be held to ensure that matters of current and mutual interest would be kept under review; such meetings would also stimulate action by the associations and could assist the Regional Office with programme planning in relation to the medium-term programme in nursing/midwifery in Europe. The third liaison meeting was attended by 15 representatives from 10 associations and by staff from the WHO Regional Office for Europe and headquarters. For the first time, an observer from a regional medical association also attended. Topics discussed The purposes of the meeting were the following: (1) to inform associations of the present situation regarding the development of the Regional Office's medium-term programme in nursing/midwifery in Europe, and to enable representatives to exchange views on the future planning and implementation of the programme; (2) to provide an opportunity for representatives to describe and discuss the activities of the associations which they represented as these related to nursing/midwifery; (3) to stimulate further communication and collaboration between the various associations; (4) to enable discussion of problems of mutual interest in the development of nursing/midwif­ ery services and education which are currently of major importance in the Region; (5) to facilitate interdisciplinary collaboration and the exchange of information in the field of nursing/midwifery. Statements by representatives showed a trend in the activities of most associations represent­ ing nurses and/or midwives towards an increase of emphasis on the development of the body of know­ ledge and technology in the discipline. Several associations were sponsoring research into selected aspects of nursing. There was also evidence of a growing exchange of activities and information on subjects of mutual interest between trade unions and professional associations of nurses. The group discussed the fact that the need for education of nursing personnel to meet the re­ quirements of health services in the primary care setting and the creation of posts to which such personnel could be appointed after qualifying was an urgent matter in most countries if national targets for the development of primary care services were to be met. The meeting discussed at some length and endorsed the medium-term programme in nursing/ midwifery. The fact that several countries of the Region had named a national nurses' associ­ ation as the point of contact between the country and the Regional Office in the implementation 1 The term "nursing" in this document is used in its generic sense and where appropriate is inclusive of midwifery. - 102 - of the programme was noted with satisfaction. The meeting agreed that in most instances direct input to the medium-term programme by associations was best effected through the national associ­ ations which were members of the international bodies represented at the meeting. Summary of conclusions and recommendations The participants of the meeting: (1) reiterated the need for nursing research to be developed in all countries as part of ongoing health services research; (2) stressed the need for legislation ensuring the safe practice of nursing from the stand­ point of both the practitioner and the client; (3) stressed the need for revision of legislation which restricted nurses/midwives from practising as autonomous and accountable professionals; (4) regretted the continued use, in some countries, of nursing students to staff health services instead of using qualified nursing personnel; (5) emphasized the need for health service systems to optimize the use of qualified nursing personnel; (6) urged the implementation of the ILO Recommendation and the Convention Concerning Employment and Conditions of Work and Life of Nursing Personnel; 1 (7) urged closer collaboration between organizations concerned with nursing personnel; (8) reiterated the need for immediate action to ensure that nurses are included at all levels of decision-making, whether decisions relate specifically to nursing services or to health services in general; (9) reiterated the need actively to strengthen and foster cooperation between professionals in the different disciplines comprising the health team. The representatives noted that almost all of these conclusions and recommendations had already appeared in the reports of meetings sponsored by WHO, and urged their implementation by all the national and international bodies concerned. 1 International Labour Conference, General Conference, 21 June 1977, Geneva: Convention 149 and Recommendation 157. Symposium on Nursing Services - A Meeting of National Nursing Advisers Stuttgart, 20-23 November 1978 Introduction - 103 - SUMMARY REPORT 1 ICP/MPM 024(S) 23 January 1979 The Symposium was attended by 17 temporary advisers to the Regional Office from Belgium, Denmark, the Federal Republic of Germany, Finland, Iceland, Ireland, Luxembourg, the Netherlands, Norway, Poland, Spain and the United Kingdom as well as 2 WHO staff members. The purpose of the Symposium was to: (1) introduce the participants to the WHO medium-term programme in nursing/midwifery in Europe; (2) review the present situation in the Region with regard to the organization and management of nursing services at national and regional levels, and to propose action for achieving desirable change; (3) provide technical advice on the implementation of component II of the programme (organiza­ tion and management of nursing services), taking into consideration the relationship of this component to the others. Discussion The group agreed that a system of organization and management is essential in providing effec­ tive nursing care as an integral but discrete component of overall health services. The system should cover both institutional and community health services at the national/regional level and local levels. The most appropriately qualified person in each major discipline involved in these services is logically the head of any department or unit planning, providing and controlling the services and in the case of nursing, this person would thus be a nurse. However, although WHO has for the past 30 years recommended that the organization and management of the nursing services at all levels should be the responsibility of nurses, only 6 of the 32 countries in the Region could be said to have the necessary structures for this purpose. The primary responsibility of nursing within organized health services is to provide care dir­ ectly to individuals and families which will assist them to optimize function in varying states of health. Such work cannot continue to be undertaken as a series of unplanned responses to demands for services from other health professionals. Effective nursing services require the setting of long- and short-term objectives and these are best determined, and the subsequent work controlled and supervised by nurses. In fact the lack of informed advice from professional nurses in planning and organizing services has had an adverse effect on overall health, as well as nursing services. One important factor in the management of nursing services is the supply of appropriately quali­ fied nursing personnel in sufficient numbers and mixes to meet the needs of individuals and groups. Thus there should be available at national/regional level data on the nursing needs of the popula­ tion and sufficient information about the available personnel to enable accurate manpower planning and forecasting. There is a paucity of information at national/regional level and the little that is available is often inaccurate. The unplanned proliferation of numbers and categories of nursing 1 In this report, the term "nursing" is used in its generic sense and, where applicable, includes midwifery. - 104 - personnel not only has an adverse effect on the quality of care reaching the patient/client but also makes it difficult to develop a method for the collection and compilation of data. It also hinders the exchange of information on nursing personnel between countries. The determination of effective methods for calculating personnel requirements in nursing is directly linked with the development of tools for assessing needs for nursing care. The group discussed registration systems for both first and second level nursing personnel and the possibilities of maintaining them so that they would provide up-to-date reliable information. It was agreed that such registers are desirable and that countries should establish them as soon as possible. Legislative protection of the title "nurse" and related titles is important in protecting both the public and the workers involved. These laws should then be translated into practice and enfor­ ced. There is also a need for regular review and revision, as appopriate, of legislation on the practice of nursing and the education of nursing personnel. There is a danger that monolithic oligarchies and ritualized practices in nursing and health services may militate against the introduction of desirable change. It is essential that a move be made away from participation of nursing personnel in a purely medical model of services towards patient/client and family-based nursing care. In other words, the fragmented programmes of indi­ vidual professionals should give way to comprehensive care plans under which the priority needs of patients/clients are met in such a way that they remain the focal point of all planning and services. The group considered the need to establish more university programmes for nurses at both under­ graduate and graduate levels, in the belief that the better educated nurse is able to function more effectively in diverse service situations and to provide quality care to larger groups of people. In this respect it must be emphasized that, contrary to common belief, nurses qualified through university programmes tend after graduation to occupy positions which allow them to provide care direct to patients/clients. Studies in the USA and the United Kingdom (Scotland) have produced evidence to this effect. The group further expressed the opinion that it is time that the protracted and frequently misinformed debate on whether nursing should be taught at academic level be closed: the pattern is now accepted as both necessary and desirable. Considering that management has to be taught, education in this field is needed to prepare nurses for effective planning and organization of nursing care and also for management of personnel and financial resources in all branches of nursing services. As the population's needs for health care encompass much more than nursing services, these should not be considered in isolation. Collaboration with other health personnel and with agencies providing services such as housing is essential if the objective of improving the health status of the population is to be achieved. Conclusions The group reached the following conclusions. 1. There is a need to define a pattern of organization and management of nursing services at national/regional level, preferably with a nurse heading a nursing division or team. This would ensure not only that nurses are involved in the planning of nursing services but also that they are in a position to advise on the planning of health care generally. 2. There is a need to establish and fill posts of nurse directors at hospital, health centre and domiciliary service levels. 3. If the health services management system of a country does not allow for the appointment of nurse managers, as described above, the advice of informed professional nurses should be obtained at all levels through other mechanisms. Advisory committees of nurses are one alternative mechanism which could be employed. 4. To increase the effectiveness of nursing manpower planning, nurse managers require information about the nursing needs of patients/clients both now and in the future. For this purpose relevant data collection methods must be designed and, for example, epidemiologically-based studies be con­ ducted. - 105 - 5. There is also an urgent need to establish rational nursing personnel systems and to develop related personnel information systems. Information currently produced is inadequate and often inaccurate. Without such information, the optimal use of available manpower will remain difficult as will the accurate forecasting of manpower requirements. 6. The unplanned proliferation of categories of nursing personnel militates against the establish­ ment of a system of care centred on patient/client. Every attempt should be made to halt fragmen­ tation of the profession or the addition of new professions providing direct care where the bulk of the work performed by them is of a nursing nature. 7. Nursing legislation should be reviewed to ensure that there is no legal restraint on changing practices to meet changing needs. Nurses themselves should be involved in the formulation of any laws which affect their practice or education. 8. The importance of university progrannnes for nurses at undergraduate and graduate levels should be stressed and the number of these programmes increased on a planned basis. Systems should be developed to evaluate the impact of the services of nurses prepared in such progrannnes on patient/ client outcomes. 9. In research, priority should at present be given to studies directly related to nursing prac­ tice. Such studies should eventually provide information of value in making sound decisions regarding nursing manpower and the effectiveness of different patterns of management of nursing services for patients/clients. lJ. The effectiveness of management patterns should also be evaluated using information obtained through controlled studies of nursing intervention, planned and conducted as part of the medium­ term programme in nursing/midwifery in Europe. 11. Standards of nursing care should be established in each country. 12. Criteria for assessing competence to practise nursing should be developed and applied to nursing personnel working at all levels in the nursing system. - 107 - OPHTHALMOLOGY - -- - - - - - - ------------------ Meeting on Role and Functions of National Institutes of Ophthalmology Brussels, 11-14 December 1978 Introduction - 109 - SUMMARY REPORT ICP/OND 004(S) 9 January 1979 The participants included ophthalmologists (10), epidemiologists (2), a health science teacher, an economist and staff of the Regional Office. The purpose of the Meeting was to review and pool the knowledge and experience gained so far by existing institutes, define their optimal role and functions in relation to public health and consider the research and measures required in the field of eye health care. Fruitful discussions were held on all these topics and the following recommen­ dations were adopted unanimously. Recommendations 1. National institutes of ophthalmology or equivalent bodies should play an active part in public health ophthalmology. Their role in this field can be summarized as follows: (1) Collection of relevant information and its communication to interested bodies such as national departments of health and WHO. Epidemiological methods should be used in determining the needs, priorities and strategies of eye health care through studies of the prevalence and incidence of eye diseases, case control studies in specific conditions to identify etiological factors and longitudinal studies to verify the value of new techniques and present methods of prevention, diagnosis, treatment and rehabilitation. (2) Training of all personnel involved in eye health care at all levels, while defining clearly the educational objective for each category of worker, applying known pedagogical principles and using objective methods to evaluate the success achieved. Education to promote public aware­ ness of eye care problems is important. (3) Guidance and coordination of activities concerned with the visually handicapped and evalua­ tion of new ideas in education and rehabilitation for employment. (4) Monitoring of eye health trends to predict future requirements of manpower and research. 2. Where no national institute or equivalent body exists, a small advisory committee should be formed with representatives of ophthalmological research institutes and eye departments and other experts such as epidemiologists and health economists. Such a committee would encourage interest in public health ophthalmology among ophthalmologists, determine research requirements in this field and advise and assist governments on problems of eye care. 3. It would be helpful for WHO to undertake a systematic analysis of problems in the delivery of care and health economics in this field. This could be followed by the convening of ad hoe meetings of experts to review and evaluate specific topics in order to support the national institutes or their equivalent in planning and action. The Regional Office could usefully continue monitoring the existing efforts in various countries and envisage convening a similar group, in a not too distant future, to assess the results obtained and determine additional objectives with greater precision. 4. It must be emphasized that many of the proposed activities are already being undertaken by existing services and institutions and all such collaborative efforts are to be encouraged. - 111 - PREVENTION OF ROAD TRAFFIC ACCIDENTS - 113 - Ad Hoe Technical Group on ICP/ADR 007(S) Road Traffic Accident Statistics 8 November 1978 Prague, 26-28 September 1978 SUMMARY REPORT Introduction The Group determined the objectives that should apply to the collection of statistics on road traffic accidents (RTAs), considered the effectiveness of the existing arrangements for the purpose, and made recommendations for improvements. Objectives Objectives for RTA statistical purposes were defined at the start of the meeting, namely: - to determine the nature and extent of mortality from RTAs and its distribution by age, sex and category of road user; - to determine the nature and extent of both temporary and permanent human disability from RTAs and the degree of resulting social and economic dependency, and to assist in planning for the overall management of such cases; - to determine the extent to which RTAs make demands on first aid, emergency treatment (including intensive care) and rehabilitation services, so as to facilitate the planning of such services in accordance with the manpower and economic resources available; to identify the causes of the severity of injuries sustained in RTAs and the human and environ­ mental factors1)influencing this severity, to provide a basis for introducing injury prevention measures, and to monitor the results; to identify the human and environmental factors which influence the risk of involvement in RTAs, to facilitate the introduction of countermeasures, and to evaluate their effects. Discussion The discussion centred on a number of factors identified as meriting attention with regard to collection of RTA statistics, namely: mortality; disability and severity of injury; human and environmental factors; record linkage; and the combination of data. (a) Mortality International statistics provide valuable information on the extent of mo 0 rtality from RTAs and its distribution by age, sex and category of road user. WHO receives data under the E code (cause of injury) of the eighth revision of the International Classification of Diseases (ICD); however, very few countries provide information under the N code (nature of injury), so valuable data on the exact pathology of fatal RTAs are generally missing. Countries should be informed of the importance of recording information under the latter code. The ECE also collects statistics from various sources, mainly the police, and publishes them annually; the attention of public health authorities should be drawn to the availability of these useful returns which supplement the ICD data. Validity studies should be conducted to determine the extent of any misreporting of fatal RTAs under the ICD codes. The inclusion of a special item in national death certificates, or even the ---l-)In this report "environmental factors" are taken to include vehicles. - 114 - introduction of a special death certificate on environmental occurrences including RTAs, should be considered as a possible means of improving national and hence international information in this respect. (b) Disability Data on disability from RTAs are particularly deficient at present. Social security records, for instance, are not reliable because the systems vary so widely. Pilot studies could usefully be carried out on ways of collecting this important information and on the cut-off points to be used in defining disability for recording purposes. The OECD Social Indicator Programme is concerned with this problem and its reports merit careful study. The standardized indices used by insurance com­ panies could also be considered. (c) Severity of injury Aspects of severity of injury are the extent of tissue damage, the treatment services required for the victim, and actual and prospective disability. Statistics on RTAs have not reflected changes in their severity, especially the increase in mul­ tiple injury cases. Validation studies have shown substantial under-reporting and misreporting of RTA injuries by the police, with large variations according to the different categories of road users; hence undue reliance on the existing national RTA morbidity statistics could lead to serious errors by the health, social welfare and accident prevention authorities. The view was expressed that the existing ICD rubrics are not adequate to identify the more severe injuries and it was proposed that they be re-examined with a view to making them more precise. On the other hand much experience has been acquired by hospital workers with the Abbreviated Injury Scale (AIS) in categorizing severity and there appears to be a close correlation between ratings of AIS 3 or higher and length of hospital stay. If this correlation is confirmed by studies in the countries, the hospitalization data could easily be recorded (not necessarily by qualified medical personnel) and would thus serve as a good indicator of severity. (d) Human and environmental factors In the short term it is unlikely that the national and international statistics could be improved sufficiently to enable identification of the human factors in the risk of accident involvement, apart from those such as age, sex and alcohol - and then only in the few cases where the factor is invariably recorded by a standardized technique. Necessary information on this point could best be obtained by epidemiological surveys in specific geographical areas or population groups. National statistics provide more detailed data on environmental factors, particularly where countries use the RTA reporting form recommended by OECD. Nevertheless, such statistics must be treated with extreme care as stand­ ardized forms do not permit the inclusion of all relevant information. Thus attempts to improve the forms should be continued and provision be made in them for reporting factors influencing the severity of injuries, e.g., the wearing of seat belts, as well as those influencing the occurrence of accidents. (e) Record linkage There is a need to establish record linkage as the coexistence of two sets of data is one of the main reasons for the present inadequacy of RTA statistics. Police records, on which national statis­ tics are based, give a fair amount of detail about environmental circumstances but less about as­ sociated human factors, whereas the emphasis in hospital records is the reverse. For instance, the latter records frequently do not mention the category of road user. Attempts at record linkage have been frustrated by lack of interest, failure to provide resources or objections relating to the con­ fidentiality of hospital records. Such attempts, however, should be encouraged as they could sig­ nificantly help to improve the reliability of RTA statistics; the problem of confidentiality could be overcome by using modern computerization techniques. (f) Combination of data A further matter requiring attention is the combination of data of many different tyres, e.g., police, certification of death, hospital, social security, occupational accident, sickness, absen­ teeism and insurance records. Techniques exist for the combination of data and this would be worth undertaking, even if it is possible to do no more than publish all the information available in a convenient form. In the longer term this process could be replaced or supplemented by record linkage. Meanwhile it is felt that the ECE/ILO/WHO meetings held to rationalize the accident mor­ tality and morbidity statistics of the three organizations were a welcome development, as was the convening of the European Regional Ad Hoe Technical Group on Medical Monitoring of Road Traffic Acci­ dents (Odense, June 1978). - 115 - Conclusions It is considered that the collection of national and international RTA statistics does not at present meet the objectives as defined by the Group in describing the severity of injury, disability and other consequences of RTAs. Moreover, such statistics do not permit a reliable assessment of the human and environmental factors in the risk of involvement in an accident, including severe injury and death. In the short term it is not considered feasible to modify the existing collection procedures. However certain improvements could be made, as indicated in this report; in particular much of the required information could be obtained through limited geographical and population surveys using techniques to be described in the comprehensive report on the meeting. Ad hoe Technical Group on the Influence of Alcohol and Drugs on Driving Monaco, 30 October - 2 November 1978 Introduction - 116 - ICP/ADR 009(S) 21 December 1978 SUMMARY REPORT The meeting was convened in Monaco from 30 October to 2 November 1978 by the WHO Regional Office in collaboration with the Government of the Principality. It brought together representatives of medical and other health professions to examine the situation of road safety and abuse of drugs (medicaments and illicit drugs). Discussion The Group discussed the following topics: (1) Behavioural indicators, classification of psychotropic drugs and specification of drugs with a potentiating effect on alcohol. (2) Alcohol and road accident prevention. Comparison of results obtained and existing sur­ veillance methods in the countries represented. (3) Epidemiology. (4) Psychosocial aspects. (5) Evaluation of legislation. Conclusions and recommendations The Group's conclusions and reconnnendations were as follows: 1. Research on the determination of blood-alcohol concentration in drivers should be intensified. Techniques for random tests on the road have been proved effective and it is recommended that they be increased. 2. Prevention should be strengthened, involving educational efforts, repetition of information and checks on whether it has been understood by the community concerned. 3. Clinical pharmacological studies should be continued to identify certain adverse effects of alcohol and drugs by means of appropriate tests whose value has been demonstrated for blood-alcohol levels as low as 0.15 per 1000. With regard to medicaments and illicit drugs, priority should be given to pharmacological studies designed for objective information of practitioners and of pharmacotoxicological monitoring centres in the case of preparations which have a psychotropic effect. 4. There is an urgent need to consider the development of national guidelines on safe driving and drugs, such guidelines being intended initially for prescribing physicians and road safety authorities. 5. Coordinated epidemiological studies should permit a comparison of national results. There is a need to investigate techniques for sampling driver populations, to record all fatal accidents and to study the responsibility of drivers as well as their physical state using representative samples of road accident fatalities. - 117 - 6. Medical, legal and social measures directed to the different types of drivers should be taken as early as possible, in conjunction with general education of children before the age of driving, using means which involve a personal participation and ensure proper understanding of the legisla­ tion against alcoholism. 7. There is a need to develop and apply specific and inexpensive techniques for determining in man the proportions of the main psychotropic components of pharmaceutical substances commonly employed in the Member States. 8. The legal and regulatory authorities must maintain a very firm attitude in combating the use of drugs and alcohol while driving. There is an appreciable increase in the frequency of road accidents at the level of 0.5 g/1, which is recommended as the prescribed limit for drivers. - 119 - PRIMARY HEALTH CARE Working Group on Working Interrelationship in the Provision of Community Health Care (Medicine, Nursing and Medicosocial Work) Florence, 23-26 October 1978 Introduction - 121 - ICP/HSP 006(S) 27 November 1978 SUMMARY REPORT1 This Working Group, consisting of physicians, nurses, social workers and sociologists, was convened by the WHO Regional Office for Europe at the invitation of the Italian Government and in collaboration with the authorities of the Region of Tuscany. It was attended by 19 temporary ad­ visers from 14 countries and 4 Regional Office staff members. The purposes of the meeting were as follows: (1) to discuss the situation with regard to working relations and intercommunication among health professionals employed in teams currently existing in Europe for the provision of com­ munity health care, and to examine factors assisting or inhibiting effective team work in com­ munity health services; (2) to identify areas urgently requiring attention; ( 3) to propose alternative courses of action which would assist in overcoming the identified problems; (4) to prepare guidelines for the planning of educational programmes designed to promote team effectiveness. Discussion In most countries of the Region one of the major trends in the provision of health services is the changing role of the family physician and the entry into community health services of nurses and social workers who provide services directly to the client. In many health situations indi­ viduals and families in the community do not necessarily require the services of a physician, but they do need services of a type best provided by other members of the health care team, such as the nurse or social worker. Team members need to be able to plan for and provide these services. In order to do so they have to possess knowledge and skills related to their own disciplines, an appre­ ciation of the health needs of the community, an insight into the way teams function; they must practise the principles and methods of good interpersonal relationships, have a thorough knowledge of the skills of other team members, and use the resources available to provide the care required. The extent to which health care teams in primary care settings have developed in different countries has been dependent on a number of factors, so that there is no single best or ideal model available for the organization of teams. There seems to be a need for flexibility of function in order that the team can respond to the cultural, social and economic values of the specific country and community in which it is serving. It is evident that there is a general lack of knowledge and understanding of the functions of the different members of the team and the services they are able to provide. Communication between team members and the consumer is often limited, to the detriment of services. Furthermore, patterns of health and social legislation, as well as differing structures of administration and modes of employment, frequently hamper flexibility in teamwork. Hitherto, the education and training of health workers in most European countries has been disease- and hospital-oriented. This only marginally prepares them for their roles in the ambula­ tory and preventive health services of today, where consumers are becoming increasingly aware of 1 In this report, the term "nursing" is used in its generic sense and, where applicable, includes midwifery. - 122 - their individual responsibility for their own health. It is believed that the general quality of life, taking into account the maintenance of health, the prevention of disease, and care in illness for individuals and families in the community, will be enhanced when the roles and functions of the different health workers in the team are interpreted, developed and understood by the community and by the team members themselves. The Working Group considered that it was as yet too early to make a comprehensive appraisal of the impact that health care teams would have on health service systems and connnunities. Neverthe­ less, it was convinced that working in teams would play an increasingly important role in the de­ livery of health care and that health workers generally would therefore need to be ready to function in a team setting. Conclusions The following conclusions were reached by the Working Group. 1. Working in teams to provide connnunity health care represents a dramatic change in traditional, universally accepted ways of health care delivery, since it involves various patterns of health care delivery systems and cuts across professional boundaries. This change has emerged as a response to many factors, such as conditions of life and culture, and health needs of individuals and families. 2. Health they may be be directly workers may be brought together in a variety of ways to function as a team; delegated by the central authority or by local authorities and connnunities, appointed by a central authority or by an individual interest group. for example, or they may 3. It will be important for all members of the team to have freedom to exercise their particular skills and to perform their specific functions within the team. The individual contribution of each team member which is provided by virtue of his or her special professional background and expertise cannot be taken over or supplemented by team members with different professional back­ grounds. 4. It is desirable for the team to develop a shared approach to the problems they encounter and to deploy the skills they have in common, as appropriate, to the needs of individuals and families, since it is implicit in the concept of team activity that team members should work together and help each other. 5. The relation between the team and the community should be a common concern, e.g. availability of services to the community. Thus, the working hours of the team should be decided mutually on the basis of cooperation with the community regarding needs and demands. Also, team members should have knowledge of how to work with the community in defining priorities for action needed, and the implications of such action, and to apply existing human and material resources economically and effectively. 6. It is important for teams to identify those factors that promote or hinder their effective practice in the community. 7. In order to help health workers to function in teams in the community, urgent attention should be given to the provision of appropriate education and training at both basic and postbasic levels and of progrannnes of continuing and in-service education. 8. Basic education programmes for health workers should be arranged in such a manner that students of various health disciplines, e.g. medicine, nursing, medicosocial work, apart from receiving in­ struction in their individual discipline, can take selected courses (subjects) together, as well as courses with students of other disciplines. 9. Reference material and library resources, including access to journals and other learning materials, should be readily available in training and service institutions for the respective disciplines and in shared fields of professional expertise. 10. Health workers should be encouraged to engage jointly in continuing education activities which should, among other things, prepare them for working in teams, research, teaching and counselling. 11. Thought should be given to the practicability and feasibility of requiring evidence of comple­ tion of continuing education programmes to be furnished at specified intervals by all licensed health workers as a precondition of renewal of the licence to practise. The type of such pro­ grammes, their content, duration, frequency, etc., will need to be carefully decided. - 123 - 12. Education progrannnes at basic and postbasic/postgraduate levels should utilize a systematic approach to problem solving as a teaching method and students should learn to apply this approach in planning, executing and evaluating their own work. 13. In order to change the emphasis in teaching from illness to health, students should first be introduced to learning experiences concerned with the problems of everyday life of healthy and sick individuals and families in the connnunity, prior to gaining experience in the care of the sick in institutions. 14. It is desirable that existing legislation which hinders the practice of either individual team members or the team as a whole should be changed and legislation which places restrictions on programme content should be revised.