Telecommunications and health [full issue]

••0 • •• ••• ••41 •• • • •••41 ••0 0 0000• 0 00 000 0 0••41•• ••••• 55 5 •00000• 0• ••0 00 4100 • •• 4100•• • • 0000•• • 0041 0041•••• 000 000 0 0004100 00041000 00 0 00041 000 000 000 ••• • •• ••• 0000•• 0000••• ••• •••••41• 00 000 55 541555 5000055 000 0041541 410 000 000 41041 ••• •0• ••• ••• ••• •00 ••• ••0 ••• 0410 000 00• 41• •0• 05 •5• 50 •41• 0• •41• •0. ••• ••• 000410• 00 541 5 55 5000410• 4100000 00 00• 00 5541 041 000 0 ••• 000 •05 41 • •0• 0 0000• 0• 41• •0• 041000• 00000 41 00 505 4155 •00 500000• 000 00 0 •00 5 415 •0• 00 0000 0• 00• •00 000000 05 550 55 041000• 55 05• 055555 410• 000 •0• 0 00 0415 0041 •0• 00 0• •0• 00 •00 00• 0000041• 0• •0• 0• •0 0 00 00004100 0 041•000 41 00• 4141 • 55414100 50 00000 0• 00• 04104100 00000• 555541 50• 000 5 5• 41000000 00 • 00000 041 410• •0 0 5554155 41 0000• ••• 05• 000041 41 555 •50 00000 555 00 • 00 00000041410 5000. 00 55• 00 00• 004100 00 4100 0 00000 410 •0• 00000 5541 00 00• THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • APRIL 1981 TELECOMMUNICATIONS AND HEALTH ' t tip 1111 White wings across the moon. Art Editor Peter Davies conceived this symbol for the interlinking of telecommunications and health. IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland Many people today take for granted their ability to make an intercontinental tele- phone call or receive a televi- sion broadcast by satellite, but it does not happen by chance. Apart from the technical know-how involved, it happens because of the coordinative work of the Geneva-based International Telecommunication Union, the special- ised United Nations agency which num- bers 154 member countries. Many stan- dards must be set and maintained, and many international agreements must be reached, for the world's telecommunica- tions to function. Telecommunications play a vital role in all aspects of social and economic development. This is particularly true in the realm of health, one of the first concerns of every fellow human being. To focus on this aspect of its work, the ITU, in collaboration with the World Health Organization, has designated as the theme for World Telecommunication Day 1981 (which falls on 17 May): "Telecommunications and Health." Since many causes of illness and dis- ablement can be averted, prevention rates high among the most important as- pects of work to improve the health of mankind. Although all the media are used in health education programmes, the steadily increasing broadcasting capabilities and the spread of inexpen- sive transistor radios make radio particu- larly effective in many situations. It sur- mounts the barrier of illiteracy and can reach people in their own language. (One In Upper Volta, an imam intersperses his prayers with recorded music—and health mes- sages. (Photo WHO/UNESCO/P. A. Pittet) African country normally broadcasts in nine languages; but when there is a need to reach almost all of the population in support of a major programme, an- nouncements are made in 34 languages.) Over 80 per cent of the diseases af- flicting the developing world are water- related, and the United Nations has des- ignated the 1980s as the "International Drinking Water Supply and Sanitation Decade". In Bangladesh —as in many other countries— a major effort is under way to greatly expand the availability of tube-wells for pure water and concrete slab latrines for sanitation. But old habits die hard and community involve- ment is essential to success. Regular radio broadcasts form a key element in the campaign to stimulate popular par- ticipation and to teach the reasons for and the use of the new facilities. Good nutrition plays a vital part in enabling us to resist and recover from ill- ness and, again, broadcasts can play a unique role in explaining and teaching good nutritional practices. A working group of African journalists and educa- tors brought together by UNICEF and the wHo in Botswana in 1979 called for greatly increased, planned use of the mass media to improve health and pri- mary health care, and placed much em- phasis on radio. A special effort is being made in the Gambia to have one transis- tor radio in every household; one reason for this is so that villagers can be advised when the "Expanded Programme on Im- munization" teams will visit to vaccinate their children. Two-way radio, telex and other mod- ern telecommunications are essential to the monitoring and control of many diseases by national and international Contents Telecommunications and health by Keith E. Kentopp and Francis Zanger .. 3 Cholera can be controlled by Joseph Hanlon .... . 8 Nutrition and the elderly by M. Essam Fikry 13 The role of research by V. K. Ovcharov 16 Why are people so cruel? by Lloyd Davies ...... 20 Light in the darkness by P. K.J. Menon ........ 27 News Page ......... 30-31 Telecommunications and health On 17 May, the Geneva-based International Telecommunica- tion U nion (ITU) will commemorate World Telecommunication Day 1981 by focussing worldwide attention on the vital role that modern methods of conveying information play today — and will play tomorrow — in the realm of health by Keith E. Kentopp and Francis Zanger agencies, as well as for inter-agency co- ordination. One such tool in the fight against contagious diseases is the wHo epidemic "hotline", the "Automatic Telex Reply Service". Health workers anywhere in the world can obtain the latest official information provided by national health administrations from WHO's headquarters in Geneva, and can thus monitor outbreaks of dangerous diseases throughout the globe. Telecommunications, especially two- way radio, formed a vital factor in the dramatic eradication of smallpox, espe- cially during the final stages. In Bang- ladesh, Zaire, Ethiopia and other coun- tries, health workers went into areas searching for cases; upon finding them, they were able to bring in massive medi- cal aid rapidly to isolate and treat the in- fected patients before they could spread the disease to others. Using their radios, health workers were also able to receive supplies of vaccine, bifurcated needles and other equipment when they needed it, at a period when a delay in vaccine meant a delay in eradication and put more people at risk from the disease. International telecommunications have already helped to limit the effects of natural threats to mankind's well-being. Earth monitoring points augmented by the remarkable capabilities of weather- satellites and other orbiting spacecraft make it possible to identify, evaluate, keep track of and plan for not only hurri- canes and typhoons but also floods, drought, locust plagues and epidemics of plant diseases. A disaster may even provide a spring- board for improving health care through a major leap forward in the availability of telecommunications. When Guatema- la was struck by earthquakes in 1976, simple two-way radios were placed in a group of almost inaccessible villages as a network to coordinate disaster relief and, at a later date, reconstruction. The vil- lagers previously had no medical ser- vices, and the laborious journey to the nearest clinic was only undertaken when a sick person was virtually at death's door. They quickly discovered that, by using the radio, they could consult a doc- tor about a suspected illness, receive in- structions for medical care and perhaps summon an ambulance, a boat or a heli- copter. Thanks to radio, the number of avoidable deaths decreased substantially while, of course, the number of medical consultations with the villagers showed a parallel increase. Above: The radio room at Tamale, Ghana, is a vital link in the communications network serving the seven-nation Onchocerciasis Con- trol Programme in West Africa. (Photo WHO/D. Deriaz) Facing page: Rural education in India—an appreciative audiencefor evening classes broad- cast by radio. (Photo WHO/ UNESCO/S. Seraillier) In Zambia, the objective of a new "Health by the People" programme is to make primary health care universally available to individuals and families in the community. An early step is the establishment of telex services in the provincial medical offices to speed up the ordering of drugs from the Ministry of Health. An ambitious telecommunica- tions development programme, using microwave links and modern exchanges, will bring telephone, telex and other ser- vices to most rural areas. Radio commu- nication is also to be improved, especial- ly with rural hospitals. Radio is also the main communication link used by the Zambian Flying Doctor Service, which provides health services to rural areas and uses small aircraft to transport urgent cases from rural clinics to urban hospitals. 4 A geographically broader project can be found in the Pacific—it covers over one-third of the globe. Called PEACESAT (Pan Pacific Educational and Communi- cation Experiments by Satellite), it links institutions in 12 islands and countries through the use of NASA'S ATS-1 satellite, which was originally launched for weath- er experiments. Small ground stations, each costing about US $4,000, permit two-way voice contact. Although televi- sion transmission is not practical within this system, graphics such as X-rays, electrocardiagrams and charts are suc- cessfully transmitted by facsimile. When cholera broke out in the Gilbert Islands in 1977, the PEACESAT ground sta- tions quickly linked up to mobilise the specialised health resources of New Zea- land, Fiji and the United States. Regular conferences of doctors throughout the Pacific by way of the satellite have helped to control the spread of dengue virus. Doctors at a hospital in Honolulu were able to operate promptly on a child whose parents on a distant island sent them essential medical documents by facsimile. Hundreds of in-service medical training experiments have been effected, with satellite transmissions taking the place of many thousands of miles of travel. Doctors say that what they appre- ciate most is the opportunity to consult with other doctors or other experts at long distance. They can also make use— at long range—of expensive diagnostic equipment that each individual island simply could not afford. Year of Disabled In this International Year of Disabled Persons, accident prevention has a spe- cial significance. We take for granted the role of telecommunications in this con- text—the two-way radio in a police car or ambulance, the traffic speed sensors along autoroutes, remote and automatic control of signals, even the weather and traffic warnings on radio and television; and all of these contribute to the mainte- nance of a safe traffic flow. New technology is being introduced which will reduce still further the inci- dence of death and disablement along the highway, at work and in the home. Ambulances in some cities are now being equipped with "telemetry", a system al- lowing specially-trained medical techni- cians to maintain direct contact with their base hospitals and with emergency- room physicians. The system uses two- way radios to transmit not just voice but also electrocardiogram readouts. They can be powered either by batteries or by the ambulance's electrical system, and are light enough to be carried with one hand. Many ambulances are also equipped with cardiac defibrillators, devices which can impart a tiny electric shock to a flagging heart. Using this equipment, the technicians are able to stabilise the patient's condition while en route to the hospital, reducing the all- important time factor and the likelihood of permanent damage. Thus they are able to provide treatment previously done only by doctors; they receive direct orders from the physician who has not only a verbal description of the patient's condition. but his electrocardiogram readout as well. One spin-off from space medicine research in the United State also has application in cases of accident. This is a briefcase-sized telecommunicator, battery-powered, which can send and receive over much greater distances using a space satellite relay system. In addition to doing all that telemetry can, the new satellite system can also act as the eyes of the doctor at the hospital. A health worker on the spot using a hand-held camera can transmit slow-scan television 5 images, enabling physicians hundreds of miles away to evaluate accurately the condition of accident victims, often hours before they would otherwise have been able to do so. Even the dispatch of emergency vehi- cles can be aided by modern telecommu- nications. A single control centre can cover the whole city, directing the nearest radio-equipped vehicle to an emergency and making a central vehicle pool unnecessary. The same equipment enables the technician to call for special equipment, treatment and personnel to be ready upon arrival. The minutes saved may make the difference between a week in the hospital and a life in a wheelchair. The rehabilitation and reintegration of the disabled can be another fertile field for invention. One use of telecommuni- cations for the rehabilitation of the deaf was developed in the Soviet Union. The teachers of deaf children use micro- phone/earphone sets which let the chil- dren broadcast to themselves at volume levels they can hear. In hearing their own voices, they learn to control the sounds they make, and this is an important step in teaching such children to speak. A common type of hearing aid is actu- ally a very small receiver-transmitter set which broadcasts amplified sound direct- ly into the ear so that the user can hear almost normally. With technological ad- vances, these aids are becoming smaller, less conspicuous and more effective. In some countries, efforts are being made to include the deaf in normal television broadcasting. During news and general interest programmes, one corner of the screen is "cut away" and used for simul- taneous interpretation into the hand-sign language of the deaf. Special subtitles for the deaf, which become visible through a decoder, are also under study. Bed-ridden children are helped by television and radio broadcasting. In some cases, educational programmes, augmented by regular home visits by a teacher, ensure that such children are not left out of the educational process alto- gether. Or the child may even be hooked up by two-way broadcast directly with the classroom, taking full part in discus- sions and questions. By keeping up with their in-school classmates, such children are able to keep a temporary physical disability from becoming a permanent educational one. For those whose dis- ability is permanent, this allows them the chance to begin the reintegration process through education. Health personnel who are concerned with the integration of the blind into society as a whole recognise that radio is often blind people's primary contact with news and current events in the world around them, as well as being a major source of entertainment. Blind people can thus participate in the politi- cal and social interests of their sighted neighbours. For the near-sighted or par- Below: A stretcher-case is rushed to hospital by the Flying Doctor Service in Australia. The pilot's headphones represent the crucial communications link. ( Photo L. Sirman ©) Facing page: A closed circuit system enables these schoolchildren in Niamey, Niger, to enjoy educational television broadcasts. (Photo WHO/ UNESCO) tially blind, a device called the Television Magnification System can be of help. It acts as a giant magnifying glass, enlarg- ing written letters to fill a television screen when scanned by a small camera. One recent innovation which can help blind persons to perform jobs otherwise closed to them is an adaptor for a teletypewriter which, using a computer, can print in Braille characters instead of its normal type. Since only the adaptor need be bought and not the entire machine, it offers opportunities for the blind in the fast-growing field of telex communica- tions. Disabled persons frequently feel frus- trated when faced with an ordinary tele- phone. Most telephone manufacturers and services have developed special tele- phones for people with impaired hearing, sight or mobility. A variety of signalling systems, amplifiers, visual displays and dialling devices make it possible for almost anyone to initiate or answer a phone call. A hand-sized monitor has been intro- duced which can analyse four functions of the heart. The cardiac patient wears it strapped to his chest. If the machine senses that some heart function is irregu- lar, it emits a sound and the patient immediately telephones his doctor. He places the device at the telephone mouth- piece, while another machine is connect- ed to the doctor's telephone which diag- noses the heart condition and displays it on a screen. The doctor can then tell the patient there is nothing to worry about, or to drop by in a few days—or to stay put while he calls an ambulance. Educational programmes have been broadcast on radio and television in many parts of the world, with a view to teaching the public that they have more things in common with the disabled than differences. One series was produced by the public television network in the United States, dealing with a whole range of mental handicaps. The series ex- plained their causes, prevention and treatment, and paid particular attention to those which are more easily prevent- able. In the case of another series of four programmes about mental retardation, public attitudes about the disability were studied before and after the broadcasts. The findings indicated that the public was significantly better educated about, and less prejudiced against, people with mental handicaps after seeing the pro- grammes. The role of telecommunications in maintaining and improving health may be summed up as bringing information to people and bringing people in contact with other people—whether through public health education, illness and acci- dent prevention and treatment, response to small and large emergencies, commu- nications aids for the disabled, medical training, or consultations and confer- ences. As telecommunications networks continue to expand and as technological advances continue to be made, they will not only improve such social and eco- nomic sectors as commerce, industry, transport, education and administration. They will also make a signal contribu- tion, directly and indirectly, to "the quality of life" by helping to bring about better health for all. ■ Cholera can be controlled by Joseph Hanlon • 4. , mow 4, • •••• ..4` Town and country scenes in Mozambique. Above: The capital, Maputo, looks out across the Indian Ocean. Facing page : The main street of a typical outlying community. (Photos L. Sirman © ) Gone are the days when countries pretended that cholera did not exist. In Mozambique, public meetings and press and radio announcements told people what to do. And the campaign worked he doctor arrived at the market in Infulene and asked for a meeting. Members of the local youth and women's organizations quickly moved among the shoppers announcing the meeting. Shops closed and traders stopped selling. A queue of 200 women moved hand in hand like a line of conga dancers in order to keep their places. Within a short time, there were 500 people gathered to hear the doctor talk about the campaign to control cholera. He explained how cholera was transmitted and how it could be avoided by using latrines, washing hands, and so on. But the people did not sit passively listening. They joined in an active discus- sion and bombarded the doctor with questions, particularly about vaccina- tion. And he explained that a vaccination team would visit the market soon, but that people could come to the local health centre the next day for an anti- cholera shot if they wished. The meeting ended with songs and cheers of "Viva vaccines" and "Viva health for the people". Shops reopened and, hand in hand, the queue returned to its former position. Infulene is a suburb of Maputo, the capital of Mozambique. And the meeting was one of more than 800, attended by over 100,000 people, held during May last year as part of a campaign to control a cholera outbreak. It was a far cry from the days when many countries pretended that cholera did not exist. Not only were there public meetings, but also radio announcements and articles in the Maputo newspaper Noticias. All of them stressed the impor- tance of hygiene and sanitation, and of getting cholera victims to the hospital quickly. And the campaign worked. The outbreak was restricted to 293 cases and only 11 deaths—a fatality rate that is very low in comparison with outbreaks elsewhere in Africa. Cholera had been virtually absent from Africa for 40 years when the El Tor strain arrived from Europe in 1970. But it spread quickly, and now appears to be endemic, especially in East Africa. The first response was one of fear and shame. Fear because of cholera's reputation as a killer. Shame because it is a disease of poor sanitation and poor hygiene: al- most the only means of transmission is the cholera vibrio, transferred from the excreta of an infected person, usually by fingers or flies, to food or water which is then ingested by someone else. Fear and shame meant silence. Better not to talk about it. Yet silence guaran- teed that it would spread and kill. Cholera need not be a killer. Research in recent years has made it clear that vic- tims die of dehydration, and that simple rehydration can cut the death rate shar- ply. Oral rehydration is sufficient in most cases, with intravenous fluids for those who are vomiting too much to drink. But the key is to get the victim to hospital or health post quickly, so that treatment can start. In the Maputo outbreak, a special ward was set up in the Central Hospital for all suspected cases. Even before labo- ratory tests were completed, rehydration was started. And publicity stressed the importance of getting anyone with serious diarrhoea to a health centre or hospital without delay. This proved easy because of the nationalization of health services in 1975 ; there is no private medi- cine and health care is virtually free. The health centres were swamped with diarrhoea cases that would never ordi- narily have been taken to a doctor, and the special ward in the hospital treated more than 900 people—two-thirds of whom turned out, after lab tests, not to have cholera at all. But the death rate of under four per cent shows how effective this part of the campaign was. The most important part of an anti- cholera campaign must, however, be stopping the spread of the disease. And here, environmental efforts are central, Maputo is really two cities—the "cement city" of gleaming white high-rise blocks of flats built for the Portuguese colonists, and the "cane city" for Mozambicans, who were not allowed to build per- manent houses. Today Mozambicans live in the cement city, too. And the run- ning water and flush toilets meant that there were few cholera cases there. In- stead, cholera was restricted to the cane city, where several dozen families share each water tap. So much of the anti- cholera campaign was concentrated on education in the cane city, to encourage people to build and use latrines, to wash their hands after using the latrine, to wash vegetables, and so on. More than 500 new latrines were built during May. In addition, 1,100 garbage pits were dug and 2,500 mounds of garbage were burnt. Publicity is not the only way to break the transmission chain, however. For every confirmed cholera case, a special team went out and disinfected the house and gave prophylactic doses of sulfa- doxine to all contacts of the victim. Dur- ing the campaign, 250 houses were disin- fected and 12,000 close contacts received sulfadoxine. Ministry of Health laboratory staff worked overtime to cope with the cholera outbreak. When they discovered cholera vibrios in a water sample taken from Maputo Bay, swimming and fishing were immediately banned in part of the 9 bay. And toward the end of the out- break, the laboratory discovered the ap- pearance of a cholera strain resistant to sulfadoxine and to the tetracycline used to treat hospitalized cases. The hospital immediately switched to furazolidone, with erythromycin in reserve. The management and staffing of the campaign was done entirely by Mozam- bicans, but UN agencies did help. voio contributed some of the necessary vac- cines, tetracycline, erythromycin, and laboratory chemicals, and provided the help of a specialised sanitation techni- cian. UNICEF provided furazolidone. Undoubtedly the most public part of the campaign is the one part which makes it a bit controversial. In one month, the health authorities gave anti- cholera vaccinations to 636,426 people— that is, 80 per cent of the population of Maputo, and including virtually everyone who lives in the cane city. Generally speaking, WHO's advice is that vaccina- tion is not cost-effective, and that mass campaigns are not worth the effort. Most scientists believe that, although vaccines do reduce the severity of the symptoms in perhaps half of those who are vacci- nated and then catch the disease, vac- cines do not appear to break the trans- mission chain. This is because the vac- cines create antibodies in the blood, but these do not seem to affect the vibrios in the gut. Thus a person can have cholera vibrios in their gut and excrete them even if they have been vaccinated. This is a special problem with El Tor cholera, where for every case sent to hospital, there are 25 or more carriers who have no symptoms or only mild diarrhoea, but who still spread the disease. On the other hand, as the meeting in Infulene showed, there is a clear demand for immunization. And a mass vaccina- tion campaign does show that the authorities are doing something. In this case the campaign showed that the health authorities were going to every part of the city in the fight against cholera, and thus it provided an impor- tant back-up to the sanitation campaign. Finally, as one health official ex- plained, "the effects of vaccination are not well studied or understood. In some areas with low levels of sanitation, chemoprophylaxis and vaccination were enough to disrupt the outbreak com- pletely. Our empirical evidence shows us that vaccination works." "Ouch, that hurts!" Mass vaccination sessions at Maputo's Central Market last May helped to check the spread of a potentially dangerous cholera outbreak. (Photo J. Hanlon ©) Facing page: A shellfish hunter braves the tumbling surf beside the Indian Ocean. For a short period during the cholera outbreak, fishing and shellfish collection were banned in one area of Maputo Bay. (Photo L. Sirman ©) But if some experts feel Mozambique "went overboard" on vaccinations, they also point out that this was merely a case of doing more than was necessary. Mozambique did everything needed to curb the outbreak, and did it quickly. More than 300 people were involved full-time in the anti-cholera campaign, if doctors, nurses, and lab staff are count- ed. Many of those who held meetings and formed part of the vaccination teams were students attending paramedical courses at the Institute of Health Sciences in Maputo. Their courses were suspended and, in the words of a preven- tive health official, "we gave them a practical course in cholera control". ■ 10

Nutrition and the elderly A diet of the proper quality is the factor that lengthens the human life span, whereas an excessive quantity of all foodstuffs, whatever the quality, will tend to shorten it by M. Essam Fikry ood nutrition plays an essential role in the total well-being of the older person. It can never be con- sidered apart from the individ- ual's feelings, economic status, culture, and state of health. And it makes its greatest impact when a pattern of good eating has been continued throughout a life span, since the influences of eating practices are continuous and cumulative. Good nutrition is also a key element in recovery from illness and in the mainte- nance of well-being when chronic health conditions call for a modified diet. With the changes and crises that the process of ageing brings in its train, older people need wise support and sympathetic un- derstanding if they are to follow recom- mended dietary practices. So it is safe to say that no programme concerned with gerontology is complete if it does not pay close attention to nutri- tion in all its ramifications. And the pro- vision of adequate nutritional care is an important aspect of community pro- grammes which help to maintain older people in their own homes, as well as be- ing a vital concern for the elderly popula- tion in nursing homes or homes for the aged. Underfeeding, but not starving, of ani- mal species has been definitely shown to lengthen life and retard the ageing process. On the other hand, it is probable that overfeeding shortens life. Scientists suspect that this is due to excessive pro- duction of partly oxidised catabolites- The eating habits of the elderly need to be treated with respect. People who have lived for 60 or 70 years have a way of eating that has served them well for a long time. (Photo WHO) the products of a destructive metabolic process. Life insurance statistics show clearly that both under-weight and obesity tend to shorten the life span of humans, espe- cially in those with cardiovascular or renal diseases. In effect, the factors that decide the life span are both the quality and the quantity of diet. A diet of the -proper quality is the factor that length- ens the human life span, whereas an ex- cessive quantity of foodstuff, whatever its quality, tends to shorten it. Why should this be so, particularly in the absence of disease? Solving this puzzle is important because a consider- able number of men and women become obese above the age of 40 years. If this stoutness continues into old age, it will shorten their lives; there is a common saying that "fat people dig their graves with their teeth". Here are some of the harmful effects that may stem from obesity: Interference with respiration, because the abdominal organs together with the abdominal fat raise the dia- phragm and limit its movements ; Interference with proper circulato- ry functions, because the high diaphragm limits the cardiac movements, or because of the deposit of fat around the heart (fatty infiltration), atherosclerosis of the big vessels or coronary arteriosclerosis, with either gradual coronary arterial nar- rowing (leading to diffuse myocardial fibrosis) or sudden coronary occlusion (leading to cardiac infarction with its subsequent complications—acute and delayed); Obesity in old people, who have lost a great deal of their safety mechan- isms of adjustment (homeostasis), makes them liable to develop diabetes mellitus, especially if their insulin production has lost its margin of safety, relative hypo- insulinism. The role of endocrine distur- bances, whether gonadal, thyroid, pitui- tary or hypo-thalamic, in producing obesity in old people is negligible, and the stout person must face and accept the fact that obesity is due to excessive eat- ing. This is an essential point, since rec- ognition of this fact will help to convince the individual to take countermeasures, however irritating these may be; — An additional factor is that, apart from the tendency to eat too much, age- ing people are less inclined to engage in muscular activity. Loss of weight also occurs in old per- sons. This is not necessarily an indication of undernutrition, but may simply be one of the effects and alterations caused by the ageing process. However, individuals differ as to the amount of food they require. While it is true that, in general, the calorie requirements decrease with age as the capacities of old people are reduced and the metabolism slows down, especially the muscles, there are never- theless some individuals who, despite ad- vancing age, continue to consume large numbers of calories without suffering in any way, or without even putting on weight. The best diet for the elderly will differ from that for other age groups for various biological, psychological and economic reasons : these include loss of teeth, decreased perception, diminished taste, diminished smell, loneliness, anxi- ety, stress and depression (which may result in loss of appetite). With these fac- tors in mind, it is clearly a good policy to "plan" the diet of the elderly. 13 Old age is associated with the impair- ment, to varying degrees, of the gastric and pancreatic digestive functions. Intes- tinal absorption too is reduced with ad- vancing years. With our knowledge of these special biological needs has come an appreciation of the significance of people's habits and attitudes toward food, and the effect these have on their food intake. Eating habits need to be treated with respect. People who have lived for 60, 70 or 80 years have a way of eating that has served them well for a long time. Their choice of food may be quite different from that of their neigh- bours. Other factors, both financial and social, can influence the diet of the elder- ly. There may be few, if any, nutrition problems for the older person who is well off and who has company in old age—a wife or a husband, for example. Unfortu- nately, there are many elderly people who face financial hardship and have no companionship, and may as a result suffer from the effects of poor nutrition. Certain rules must be respected by ev- ery old man or woman in order to ensure proper health and have the best chance of enjoying a long life. Water: Adequate water intake is very essential. This is not only needed to maintain a proper healthy state of the body tissues which require water, but it is also vital to maintain the proper func- tioning of the kidneys. In this way the kidneys can get rid of the metabolites (substances produced by metabolism) which otherwise accumulate in the body and produce injurious effects. Water is needed too to keep up the secretion of normal amounts of digestive juices and to avoid constipation. Moderation: Over-eating as well as under-nutrition are equally harmful for old people, and therefore moderation is always advisable. It is better for the elderly, because of the digestive and absorption deficiencies due to old age, to have two or three small meals in between their principal meals, which ought then to be correspondingly reduced in quantity. Type of food :The type of food should be both easy to digest and appetising. Appetising food is important, since good appetite is an essential factor in good digestion, by stimulating digestive secre- Eat less live longer. The shopper with her meagre provisions and the still-active woman with her burden might not believe it, but a slender diet is better for them. ( Photos J.-M. Proust © and WHO/ILO) tions, increasing motility of the gastro- intestinal tract and helping absorption. The present tendency is to increase the amount of proteins in the diet of old peo- ple, in an attempt at least partially to correct increased protein catabolism and reduced protein synthesis by the liver. However, this increase in protein content should not result in an increase in the total caloric intake. Ideally it should be in the range of one to one-and-a-half grams per kilogram body weight. Mineral salts and trace elements are valuable, in addition to vitamins, to maintain physical tone. The energy potential of the protoplasm and the cell nucleus is believed to be reduced with age, but this loss can apparently be avoided or corrected by increasing the supply of biocatalysts, which is the ac- tion of most vitamins. In addition, folic acid deficiency is not uncommon in old people. This should be corrected not only by administering folic acid, but also by including all the B complex vitamins including B12 and pyridoxin. Special diets are required to match the particular circumstances of old people. For example, an old man or woman without dentures, or with ill-fitting den- tures, should have a soft diet that does not need chewing. Similarly, old people with atherosclerosis or coronary or cere- bral arterial disease must have as little animal fat as possible in the diet, and should eat vegetable oils instead. Those with digestive disturbances should have a diet carefully arranged as regards quanti- ty, type and times of feeding, while those with reduced renal efficiency and high blood urea must reduce their protein intake. The diet should be rich in iron to avoid the occurrence of anaemia, to overcome the reduced absorption of iron due to gastric hypoacidity, and to counteract reduced intestinal absorptive power. Anaemia occurring in an old individual is a more serious matter than it would be in the young. This is because circulatory disturbances such as atherosclerosis, hypertension or heart disease lend a more important role to the quality of the blood that flows to the tissues. Well-balanced diet:The total number of calories in the diet, their type or the way in which they are taken are not the only key factors in the nutrition of old people. Certain elements of the diet Poverty amid plenty in the developed world. Many elderly suffer badly from the effects of poor nutrition. (Photo J.-M. Proust ©) must be increased by contrast with that of young adults, namely proteins and calcium. There are many different views on the best forms of recommended daily food allowances, but they have a number of things in common, especially the general and basic principles, and only differ in the details and quantities. If we choose from what are called the "Four Food Groups" (FFG) or the Basic Four (BF), we suggest that the daily food intake for the elderly should include the following : Milk (600-750 millilitres). Meat, fish, poultry, eggs (2 serv- ings). Bread and cereals, whole grain or enriched (4 servings). Fruits and vegetables (4 servings), particularly fruit rich in vitamin, such as citrus fruit, and dark green vegetables rich in vitamin A. In addition to these basic four, other foods or larger servings can be added to maintain weight. Salt can be enriched with iodide, bread and cereals can be enriched with vitamin B compon- ents or with protein (whole grain), milk with vitamin D and margarine with vitamin A. ■ 15 Scientific research into every aspect of the Soviet Union's health services, undertaken by the Semashko Institute in Moscow, suggests how national health ser- vices elsewhere in the world can be fashioned into the most effective instruments for achieving health for all by V. K. Ovcharov The role of research he basic principles of the Soviet Union's health services were for- mulated some 60 years ago, fol- lowing an analysis of the ways in which various conditions of life, includ- ing social factors, influence the physical wellbeing of the population. This scien- tific basis, which had been prepared by progressively-minded doctors of pre- revolutionary Russia, helped after the Revolution to lay the groundwork for establishing a unified system of free health services, accessible to the entire population and putting much emphasis on prevention. Subsequently, every new stage in the development of health services was pre- ceded by major studies to evaluate the state of public health and to plan health services for the period ahead. Thus, in 1926 a study was made of the sick rate in Moscow city and region, and in 1932 the first standards were drawn up for provid- ing health services to the population when the country began to adopt five- year plans for the development of health services. In 1948 came an experiment to establish amalgamated hospital-and- polyclinic institutions, and in 1954 methodological studies of health statis- tics which made it possible for the first time to evaluate on a large scale the quality of medical care received by the population, and to establish medical data pools for use in running the health services. Most of the current researches concen- trate on the planning of medical and san- itary services, and the problems of social hygiene. These research activities are conducted by the Semashko All-Union Research Institute of Social Hygiene and Organization of Health Services (the main institution), relevant Chairs at 83 medical institutes and 15 institutes for advanced medical training, as well as appropriate departments at more than 50 leading clinical and sanitary-hygienic institutions. The sick rate and other public health characteristics are studied on the basis of registered visits to doctors and subse- quent examinations of patients by up to ten different medical specialists. The latest survey of this kind covered more than a hundred typical regions, where the frequency of illness among 50,000 in- dividuals was studied over a three-year period. Apart from figures on the mor- bidity rate, these surveys helped to deter- mine the attitude of individual popula- tion groups towards medical institutions. The results included data on the actual number of visits to doctors, admissions to hospital, prophylactic examinations and other types of medical care, all classified by disease, medical specialists consulted, categories of population, geographic districts and so forth. This work done subsequently helped to evalu- ate the increased public demand for health services. Much of this research relates to the economic aspects of health services and how to plan them : how much is spent on individual types of medical care, what use is made of beds at hospitals of dif- ferent sizes, the economic effectiveness of various health programmes. Research may be conducted at individ- ual institutions, in districts or even over whole regions with a population of up to one and a half or two million. A careful study of local trends and their subse- quent evaluation by experts can help us to develop the health services more effec- tively. Since we know the current needs for medical care, we can project the ex- pected demand for doctors of different specialties and for hospital beds per 1,000 of population in the decades to come. These calculations are made on the basis of a systematic study of public health dynamics, manpower resources, the material situation of the health ser- vices, and the rates of development of 16 Training in the use of electrocardiograph machines. Systematic study of manpower resources enables Soviet experts to foresee the future demand for doctors of different specialties. ( Photo Tass ©) specialist medical care and preventive services. The Soviet Union has, on the whole, an adequate number of medical person- nel to meet the demand. The main objec- tive now is to raise the standards and effi- ciency of all health services, so as to make specialist medical care equally ac- cessible to people in the towns and in the countryside. Hitherto, the usual medical institutions in rural areas were small dis- trict hospitals with one or two doctors on staff. Today, peasants receive in-patient and out-patient care at a central district hospital, which employs doctors specia- lising in some 10 or 12 fields, or at a regional hospital providing qualified care by specialists in 30 to 35 fields. So equal accessibility to hospital beds for both rural and city dwellers, achieved earlier, is now matched by equal quality of hospital care. In some thinly populated regions, pro- viding qualified out-patient care to all population groups involves considerable difficulties. So some of our research ac- tivities sought to develop a specialised visiting doctor service and to establish an ambulance and emergency service in the countryside. Such a service, operating within a radius of eight to ten kilometres, proved to be quite efficient. In outlying districts, doctors rely on ambulance planes in handling emergency cases. Ev- ery regional hospital in such areas has a unit of ambulance planes at its disposal. The continuity of medical care—from a first preventive examination and recog- nition of a disease to treatment, recovery and rehabilitation of the patient—plays an important role in public health studies. Such studies help to define the average periods needed for intensive treatment and ordinary active therapy for individual groups of patients, and suggest when the moment is ripe for them to be transferred to rehabilitation departments. Other lines of research have led to ev- ery district with a population of 30,000- 50,000 having its own health-and-epide- miology station which has practically all sanitary service facilities. Established with an eye to local conditions in dif- ferent economic and geographic regions of the country, this network has resulted from a great deal of research work car- ried out by 20 basic institutions under the direction of the main institution. They studied the working of the best stations, assessed public requirements for various kinds of health and epidemio- logical services, and developed quality standards for these services. Because of changing public health patterns and studies in social behaviour, the objectives of health education have changed considerably. The emphasis now is on teaching people to take care of their own health. As a result, public lec- tures, films, and school programmes on healthy living, and on family and marital life, now have a stronger sense of pur- pose. Wide use is made of radio and tele- vision programmes to convey the harm- ful effects of smoking and alcohol abuse. Major research efforts have been un- dertaken recently to draw up pro- grammes for combating cardiovascular diseases, or disorders of the endocrine system, and programmes for building up health through physical culture and sports. Such investigations include, as a rule, a profound study of the spread of certain forms of pathology, the assess- ment of factors influencing their dynam- ics, and the arranging of specialised med- ical care for this category of patients. One important aspect is to identify the population groups with the highest risks 17

Above: Young surgeons undergoing specialist training at a school of medicine in the Soviet Union. Painstaking research into medical care has helped to develop the health services more effectively. Facing page: Trainee dentists learn how to keep young patients relaxed and cooperative at a Moscow polyclinic. ( Photos Tass ©) of disease and to place them under active medical observation. More than 40 mil- lion people are now kept under such ob- servation, and over 100 million healthy people are examined each year during mass screenings whose purpose is to pre- vent diseases or to diagnose them early. A new type of health officer has emerged as a result of our research activ- ities. He is a clinician whose task is to embody the results of epidemiological investigations in a major programme and to plan this service, including deter- mining the number and composition of personnel at such an institution. All these investigations are being made in conjunction with the Semashko Insti- tute in Moscow, which coordinates scientific research in the health services. This research invariably involves looking into such aspects as social hygiene, cause-and-effect relationships in public health, the objectives of the health sys- tem in general, and the main indicators of its effectiveness. Any new developments in Soviet health services are preceded by scientific studies which make it possible to sub- stantiate theoretically and to test ex- perimentally all major medical measures before they are introduced more widely. Thus the State Plan for the Development of Health Services is increasingly becom- ing a vehicle for implementing, on a country-wide scale, as many as 150 to 200 scientific recommendations that emerge each year from these research efforts. This experience in scientific planning for the development of health services is considerably enriched through the prac- tical achievements that have been made under certain programmes of the World Health Organization. The scientific plan- ning and joint preparatory work aimed at the eradication of poliomyelitis testify to the great potential of international cooperation. No less remarkable was the scientific preparation of the international programme for smallpox eradication. Against the background of a general anti-smallpox strategy, worked out beforehand, each new stage in the cam- paign against that disease involved orga- nizational studies, to the point where a system of indicators was developed showing how effectively the individual stages of the programme were being im- plemented by each one of its partici- pants. Equally thorough preliminary work has gone into a scientific pro- gramme for combating tropical diseases, which has already been launched in African countries. An analysis of the results of these pro- grammes points to the need for broader international scientific contacts in other fields of medical research too—a need which was stressed in the Declaration and other statements of the 1978 Alma- Ata Conference. It is necessary for WHO to step up cooperation in such domains as fixing the standards of primary health care, setting the stage for achieving health for all by the year 2000, solving the economic problems of public health care, developing health services for the aged, establishing an environmental pro- tection service, and assessing environ- mental effects on public health. From the very beginning of such coop- eration, it appears desirable to publish— with WHO's participation—the most typi- cal results of research into health ser- vices, so as to popularise the methods employed and the organizational mea- sures taken. The scientific potential thus created will undoubtedly be of great value in fashioning national health services into the most effective instru- ments that can be devised for achieving health for all. ■ 19 Why are people so cruel? Nothing, not laws, not outpourings of public money, not expressions of sympathy, will help to improve attitudes towards the mentally handicapped if the mind of the public remains closed because of fear, ignorance and prejudice by Lloyd Davies The parents of handi- capped children in con- temporary society soon learn that they and their children face a hostile world. My wife and I were no exception. Our handi- capped daughter was born by caesarean section two months premature and was a placenta previa. She gave every appearance of being a bright vivacious child despite the fact that her health was delicate and she had a tendency to ear infections. One severe infection at about 18 months may have involved an undetected meningitis. For the rest of her childhood she suffered a chronic otitis or "glue ear" characterised by numerous acute attacks and lengthy periods of almost complete deafness. We noticed the first side-effects at about two years when it became plain that she was slow in picking up speech and what words she did use were indistinct. It was about this time that hostile reac- tions first became manifest. We lived in an area of new housing in Perth, Western Australia, with numerous neighbouring children. Some mothers began to per- suade others to dissociate their children from ours in case she might retard their speech. We had a two-year-old birthday party to which all neighbours were invited, including the unfriendly ones. They all came, of course. Next month, however, one of them had a party to whom everyone was invited except ours. As the party was a day-time affair in a street without gates and fences, you can imag- ine the heart-break occasioned to our lit- tle girl when she was not allowed to go and, when she slipped away unnoticed to join the others, was sent back in tears in care of an older child. Her childhood, particularly her school days, thereafter involved numerous repetitions of similar unkindnesses and rejections. Because she spent a good deal of time in special classes, we made contacts with other parents with similar problems and found such unkindness to be a common experience. I would be wrong not to mention the grace and kindness of those who did un- derstand, including neighbours, friends (and a situation like this certainly sorts out your friends), devoted school teach- ers, social workers and others. Such kindnesses make life worth living but they can never make good the damage that rejection inflicts, particularly in the early years. We have no doubt that our girl's physical handicaps were not only exacerbated but outweighed by the sense of insecurity and lack of confidence im- printed upon her by the rejection—be it deliberate or merely thoughtless—meted out to her in her childhood years by her peers and their parents. But why are some people so cruel? What causes so many people in our soci- ety not only to ignore the misfortunes of the handicapped but actually to goad and torment them? What is it that leads people to use descriptions of disability as terms of invective? We see examples of this almost every day—from politicians in particular: objects of their scorn are labelled as "cretins", "slow-learners", "morons", "geriatrics", "cripples" and so on. Public entertainers get ready laughs out of mimicking the stutterer, the lame, the blind and the deranged. At work-places the baiting of handicapped people is notorious. Children, who are always mirrors of their parents, are singularly cruel in sin- gling out and tormenting their handi- 20 capped fellows, and epithets such as "stupid", "dumb" and "nit-wit" are the most common terms of abuse. Many school teachers set a shameful example in this respect. Why is it that parliaments which have seen fit to pass legislation condemning racial discrimination have ignored this pernicious and all pervasive discrimination? In trying to answer these questions, let me quote what appears to me to be the ideal. "Civilised conduct takes many forms and has many roots but has always one thing in common : it is tolerant of deviancy and protects the weak. Any community which seeks to promote the interests of the under-privileged will succeed only if it is united in its purpose and hungry for success..." This is what David Norris wrote in "Changing Patterns in Residential Services for the Mentally Retarded". Historical and contemporary anthro- pological studies show us that it is not only civilised communities which care for the weak and the mentally retarded. Some societies in ancient times regarded the mentally deviate as holy and blessed, and some primitive societies still do today. Generally speaking, respect for Above: ...Most people who suffer from mental disorders or retardation have sensitivity and feelingwhich differ little from sensitivity and feeling of "normal" people... Right: ...What causes so many people in our society not only to ignore the misfortunes of the handi- capped but actually to goad and torment them?... (Photos WHO/D. Henrioud) 21 such people was accorded by the socie- ties of ancient Greece and Rome. Res- traint was only used when the deviate was violent. Despite the comparative tolerance of the mentally ill in such societies, there undoubtedly appears to have been the germ of what in less tolerant times leads to persecution. There was some fear, compounded with contempt and ad- mixed with compassion. The violence of some deranged people is, of course, a natural source of fear. The harmless who wandered about in a dishevelled con- dition came in for ridicule, especially from children, but generally those who were cared for by their families went unmolested. From what we know of the medieval period it seems that this comparative tolerance continued. The mentally deranged were left at liberty provided their conduct was not disorderly, in which case they were either admitted to religious hospitals or confined to prison. It was not until the late Middle Ages in Western history that the official attitude hardened. From the 14th Century on- ward there are records of whipping as common treatment for the insane (presu- mably to drive the devil out of them). In the following century began the witch hunts which are the historical ori- gin of our present day persecution of the afflicted. Like all persecution it was an endeavour by the Establishment to stamp out by violence what it regarded as a threat to society. An obvious scape- goat, an obvious repository of the stig- mata of evil, was the mentally disturbed or mentally handicapped person. The physically handicapped came in for their fair share of persecution too, but the mentally handicapped were especially reviled. Because they became objects now of evil and shame rather than of pity, they were no longer cared for, even by their families, as they had been in less disturbed times. Hence, the whippings, hence the jailings, hence the locking up in so-called "hospitals". Old prejudices and fears are very long- lasting, and over the centuries that fol- lowed, the mentally afflicted were treated as being products of "the Evil Eye" ; no differentiation was made between those who were deranged, those who were psychotic, or those who were simply mentally retarded. The triumph of the age of reason in the 18th Century did not automatically bring about a change in attitude towards the mentally afflicted. Far from it. Reason was "God" and any diversion from the norm was irrational. If reason could solve everything then all the lunatic had 22 Why are people so cruel? Left : French artist Philipp Pinal, who painted this scene in 1793, tried to show the utter in- humanity ofconfining mentally disturbed people in chains. Right : A boy with Down's syndrome helps a Belgian farmer with the harvest. Most sufferers from mental retardation benefit from association with "normal" people, and segregation is detrimental to them. (Photo WHO/D. Henrioud) to do was to be reasonable: "Confine- ment or restraint may be imposed as a punishment with some advantage and on the whole I consider fear the most effective principle by which to reduce the insane to orderly conduct." So wrote Mr Dunstan, Superintendent of St. Luke's Hospital, London, in 1812. This attitude led to an increasing ten- dency to lock up all mentally incapable persons in institutions, whether they were rich or poor. The handicapped rich were a menace to the family fortunes and the handicapped poor ended up in the workhouse in any event because they were unemployable and hence surplus population. Attitudes towards the mentally afflict- ed and the study of the causes of mental affliction stumbled slowly along in the wake of medical enquiry, and suffered even more from the kind of unscientific mysticism which has remained a fetter on medicine even to the present day. In the 19th Century, the "experts" held most unscientific theories on the causes of mental afflictions and were au- thoritarian in the treatment they offered. One theory was that masturbation was a major cause of insanity. This was so firmly held by some that as late as 1942 the us Navy psychiatrists warned against masturbation as a cause of mental illness. It is small wonder that the science of psychology and the practice of psychia- try have progressed so slowly compared with medical science and practice gener- ally. Physical medicine kept pace with the scientific age because not only did it have the scalpel of scientific research and discovery to cut away the obfuscation and mysticism of the past, but it had some degree of official encouragement. The discoveries of physical science, however, shed only an oblique light upon the mysteries of the mind and the pecu- liarities of human behaviour. Fortunately, the search for knowledge can never be completely inhibited. Not- , withstanding the fetters of the past, social scientists in recent years have es- tablished the following salient facts about mental disability and those who suffer from it : the percentage of mental patients who are actually dangerous to society and hence require restraint is minimal; the percentage of mental disorders which are hereditary is minimal; the percentage of mental retarda- tion which is hereditary is minimal; most people who suffer from men- tal disorders or retardation have sensi- tivity and feeling which differ little, if at 23

het is uan 2 zwakett u smak Above: Boys and girls at a special school in the Netherlands take turns in running the school shop. Left: Looking after a pet bird helps to develop social behaviour—a first step in "normalisation", which in turn is the way forward out of the dark ages. (Photos WHO/D. Henrioud) all, from the sensitivity and feeling of "normal" people; — most people suffering from mental disorders or mental retardation benefit from association with "normal" people, and segregation is detrimental to them. In the light of this knowledge those who work with and for the mentally han- dicapped have evolved in the last decade the principle of "normalisation", a development which began in Sweden. Put very simply, it is based upon the understanding of the concept that if you treat someone like a fool he will act like a fool. The more you embrace him into the customs and conduct of workaday peo- ple, the more he will emulate his asso- ciates and strive to become like them. Normalisation is the way forward out of the dark ages and is rapidly being adopted throughout the civilised world. It was a matter for some wonder and great admiration to me, reading the lead- ing textbooks on the matter, to note just how much of these principles my wife had evolved herself in caring for our child. Experts had told us "Don't push her". "You are being over-anxious." "You nag her too much about dress and clothes and behaviour." "Just let her find her own level." My 'wife ignored these urgings. She sought out tutors and special classes and used every available resource of educa- tion and rehabilitation. She insisted upon a proper standard of dress and a proper observation of good manners— particularly table manners. Today we are constantly being complimented upon the way our child has developed and over- come her handicaps. And this is all straight normalisation, which could have come straight out of the textbooks. Educate and continue to educate. Dress normally, behave normally and reject the fool's role. Never underestimate the capacity of learning to supplement intelligence. The reason why such a simple solution has not been adopted before is that it has meant a revolution in thinking. It has meant a rejection of all the obscurantist beliefs and prejudices I have described above. But it also means the phasing out or redesigning of most if not all of our mental hospitals and asylums. It means the retraining and educating of mental health workers. If we are to provide work opportuni- ties for the mentally handicapped, not only will governments have to provide special work shops but management will have to be persuaded to provide employ- ment opportunities. Legislative changes will be necessary to protect the rights of handicapped per- sons. Some countries are already taking such steps in line with the United Nations Declaration of 1975 on the Rights of Disabled Persons. The UN Dec- laration itself was brought into being as a result of the "normalisation" movement. A prerequisite to all these improve- ments, however, is public acceptance. Nothing, not laws, not outpourings of public money, not expressions of sympa- thy, will be of any effect if the public's mind remains closed by reason of fear, ignorance and prejudice. Not until we mount a campaign and change public at- titudes, in the same way that they have been changed—at least to some extent— as regards racial prejudice and discrimi- nation against women, will we be able to open the way for the liberation of our afflicted fellow-humans. ■ 25

Light in the darkness During this International Year of Disabled Persons, India is tackling at the community level its thorny problem of nine million blind people and 45 million more with impaired sight by P. K.J. Menon It is commonly said that sight is the most precious gift of nature, and that deprivation of sight is one of the worst disabili- ties a human being can suffer. Human suffering apart, visual impairment and blindness have also serious social and economic implications. It has been rightly said that not the least important among the human rights is the right of every man and woman to see. Yet the Indian Council of Medical Research surveys reported in 1972 that there were about nine million blind per- sons in the country, and another 45 mil- lion suffering from visual impairment short of blindness. The causes of blind- ness and visual impairment, according to this report, were cataract (55 per cent), trachoma (5 per cent), infections (15 per cent), and others (25 per cent) which in- cluded smallpox, nutritional deficiencies, injuries, glaucoma and so forth. It must be emphasised that this tragic situation had developed because of the lack of comprehensive eye care pro- grammes over the years and the paucity of trained personnel, especially in the rural areas. It has now been realised that disease-oriented programmes should have been replaced long ago by intensive health education and preventive pro- grammes, as well as phased training of available manpower to deliver the required services. India is a signatory to the goal of Health for all by the year 2000 set at the Alma-Ata Confer- ence in 1978. Consequently, national strategies are being worked out afresh towards attainment of this target. This is therefore an opportune moment to examine the National Programme for Visual Impairment and Control of Blind- ness, and its links with the concept of primary health care and community participation. The National Programme was initiat- ed in 1976 and started as a centrally sponsored programme, fully funded by the government. It envisaged curing 4.5 million persons of blindness in 20 years, with the help of 80 mobile units carrying out surgical operations on 3,000 persons each year, working throughout the year, winter or summer. The state, district and subdivisional level Above : A student nurse gives a patient an eye-test. Facing page : This blind boy, learning to mend a chair at a rehabilitation centre, will be able to earn a small income when he returns to his village. (Photos WHO/T. S. Satyan and WHO/P. Shinde) hospitals and PHC units were to set up great numbers of camps with the help of voluntary organizations, and aimed at a target of one million operations a year. There was no lack of funds, drugs or equipment so long as it was a centrally sponsored programme. But after 1 April 1979, it was converted into a centrally as- sisted programme which meant that only 50 per cent of supporting funds were contributed by the national authorities, and the balance had to be provided by the State governments. This proved to be a severe setback, since the States were giving first priority to agriculture, irriga- tion and power. The State administra- tions could not be imbued with the same enthusiasm which they had displayed earlier towards the successful smallpox eradication programme. These problems which beset the plans to control blindness are in no way unique to India, and parallel situations can be seen in a great many countries. The National Programme also visua- lised preventive work right from the village level upwards. The Community Health Volunteer (ow) would attend to "first aid" measures at the village level, and the Multi-Purpose Worker (MPw) would do so at the sub-centres. The Pri- mary Health Centres (Plics) and the dis- trict hospitals would attend to referral cases. The main proposal was to have an ophthalmic assistant at each of the 5,000 PHCS, in addition to the MPWS. But since they are not available, the aws and MPWS are doing the best they can. Last year, crash courses of six months' dura- tion were initiated at a large number of centres so as to produce 1,000 techni- cians every year. They will work for an- other 18 months as in-service trainees on full pay and thereafter qualify for their 27 diplomas. A drive has also been launched to produce 1,000 ophthalmic surgeons every year, through the country's 108 medical colleges. There are two types of organizations which can help to cure as well as to pre- vent blindness in a very big way. These are on the one hand the voluntary and philanthropic organizations, and on the other the very wide network and infra- structure already in position in the shape of the PHCS and sub-centres and cHvs. While the first can attend mainly to cura- tive work, the latter can attend to both aspects. The voluntary organizations have con- tributed to a significant expansion in eye care and curative work through cataract operations. There are many who do this work quietly and efficiently without ask- ing for or expecting any aid from govern- ment. They are well suited to stimulate community interest and mobilise com- munity resources and efforts. Surgeons come and work free. Other workers are paid out of contributions received. The most convenient period for the camps is the summer when the schools are closed, the patients are available, as harvesting is over, and there is plenty of space for op- erations. But the Rajendra Prasad Cen- tre in Delhi, for instance, has been hold- ing camps successfully throughout the year. Some of the organizations which are in need are given aid to the extent of 40 rupees (US$5) per case operated upon, subject to a limit of 8,000 rupees per camp. The Royal Commonwealth Society for the Blind in London has been making generous contributions direct to Indian organizations. The Indian National Society for the Prevention of Blindness has done excellent work. The Christian Blindness Mission, Oxfam, the Swedish International Development Authority (sIDA), the UN Development Pro- gramme (uNDP) and others are rendering assistance on the basis of mutual agree- ments. The Danish International Devel- opment Agency (DANIDA) has agreed to assist the programme with 85 million rupees over six years. These efforts are coordinated by a Central Committee. In the guidelines prepared for the voluntary organizations, stress is laid on compre- hensive eye health care, including pro- motive and preventive work, and not just operations or visual testing. All in all, the voluntary organizations and philanth- ropic institutions have made a significant and expanding contribution in the fight against blindness in India. It is very obvious that preventive as- pects need more emphasis since this will help to reduce the total cases of blind- ness, including those due to causes which may not be curable, even through surgi- cal operations. For this, the utilisation of the health infrastructure so laboriously built-up in each State is most important. The concept of building up the health in- frastructure in India has been very elas- tic. It began with the original idea of a PHC with three sub-centres in each Com- munity Development Block (or district). At present, efforts are being made to provide a PHC for every 50,000 popula- tion (20,000 in tribal areas), and a sub- centre for every 5,000 population. There is also to be a cHv and a trained dai (tra- ditional midwife) for every 1,000 popula- tion or each village. The intention is to provide a sub-centre for every 2,500 population by the year 2000. The syllabus for training the oivs and other paramedical workers at the PHCS is 28 Light in the darkness Left : A farming class for blind boys at an agricultural and rural centre in India. Community-based efforts to prevent blindness will help to reduce the total number of such cases in the country. Right : An elderly woman waits patiently for a cataract operation which will give her back her sight. India's well-planned National Programme calls for enlightened community involvement on the one hand, and a fully committed administration on the other. (Photos WHO/ P. Shinde and WHO/T. S. Satyan) elaborate. It is gratifying to record that this provides also for early treatment of eye troubles, through the allopathic, ayurvedic, siddha, unani or homeopathic systems of medicine. Whether traditional or "modern", these systems provide effective preventive measures against blindness, especially due to infections and injuries. Difficult cases are, as usual, referred to the larger and more compe- tent units. All the workers are given refresher courses in health education lasting at least 15 days in each year. This helps them to keep their knowledge up-to- date. Until these manpower development programmes become effective, instruc- tion in comprehensive eye care is being strengthened in the curriculum of all health workers, including medical students, nurses, MPWS and aws, so that they are able to detect cases of common eye ailments and injuries, and provide timely help. Further, the government is taking steps to ensure that the popula- tion in general receives health education in the care of its own eyes, and that eye care forms part of school curricula in health education. The participation of school teachers, social workers and students is considered as an important and essential part of the programme. Several brochures and folders have been brought out, as well as a Resource Book on Health enabling teachers to identify eye problems and advise parents or doc- tors in the school health service when cases should be referred. One of the highlights of the pro- gramme is to ensure community partici- pation through committees at several levels which will have the responsibility to mobilise resources, fix local priorities and ensure that what should be done is done. At the extreme periphery, the ciiv in each village is taking part in educating people in general eye care, treating minor ailments and arranging for referrals. Further follow-up is undertaken by the MPW and ophthalmic assistant. WHO made an independent evaluation of the programme in 1978, and DANIDA made an evaluation in the following year. Both of these have been extremely useful to the Indian Ministry of Health in taking follow-up action, and in reviv- ing and rejuvenating the programme. To tackle the problem of blindness in India, there is need for sustained political will, awareness of the colossal magnitude of the problem, suitable technology, and careful use of the personnel and funds available. The Indian National Programme is a well-planned and ambitious one, and requires strengthening in implementa- tion, monitoring and evaluation through a coordinated approach. To succeed it needs total commitment at every level and a realistic approach as regards targets. The top priorities are for preven- tive work through the existing health infrastructure and education of the community through the mass media. It is fortunate that the eye is a very accessible organ, since this means that the diagno- sis of many problems is relatively easy. Given a population which is chronically under-served with regard to all sectors of health, the rhetoric-implementation gap in health policy and health services de- livery can be bridged only by enlightened community involvement and awareness on the one hand, and by a determined and committed administration on the other. ■ 29 000 000 000 000 000 000 000 00 0 000 000 *00000 000 000 000000 ... .6.000 4000.Doo lipoorn 0. 0 011 0 000 000 000 000 0 00 000 000 000 000 00. 000000 000 000 4100 000 0410000 4100 000 000 000 000 000 000 000 000 000000 000 000 000 000 000 0410 000 000 000 000 4100 21 million babies born under-weight An estimated 21 million ba- bies born throughout the world in 1979 were of "low birth weight", weighing 2,500 grams (5 lbs. 8 oz.) or less, according to a first, comprehensive review of avail- able evidence of the problem on a global scale. The "vast majority"—over 19 million, or 90 per cent—of those births took place in the developing world. The infants of low birth weight constituted 17 per cent of the 122 million live births world-wide that year. "At the global level", a report in the current issue of WHO's statistical quarterly says, "this means that about one in every six infants has a low birth weight, but the incidence is not evenly spread around the globe. In some parts of Asia the ratio is one in two, while in parts of Europe it is only one in seven- teen." A child's birth weight is "uni- versally, and in all population Weight determines survival. groups, the single most impor- tant determinant of the chances of the newborn to survive", WHO experts say. Hypertension, smoking, ante- natal infections, the number of previous pregnancies, a mother's work before and during preg- nancy, are among factors that affect a baby's birth weight. The likely consequences for the child of a mother's malnourishment or ill-health, or a combination of the two, are retarded foetal growth, or prematurity of birth, or both conditions together. In the newborn, among con- sequences of low birth weight are respiratory problems, hypo- thermia, which is a state of low body temperature, and a general susceptibility to illness. Among the possible long-term conse- quences are spastic cerebral palsy, and other central nervous system disorders, hearing and visual defects, and mental retar- dation. Although survival rates have improved in many countries, to ensure that low birth weight babies grow up to lead normal lives "often requires methods which are beyond the economic and technological resources of most developing countries". Thus, the experts conclude: "The only realistic policy for such countries is to concentrate on measures aimed at reducing the incidence of low birth weight." Yet, in countries where the "proportion of low birth weight is the highest", the experts admit that "data on birth weight are extremely rare, and often non- existent". BCG: Its use urged, but studies needed Despite findings of a trial in the south of India that called into question the effectiveness of BCG vaccine, it should still be used to immunize children against tuberculosis. Such is the key recommenda- tion of experts, brought together by WHO to examine the impli- cations of the trial upon pro- grammes of immunization now under way throughout the world. The trial was launched in 1968. As planned, a first "intake" phase of tuberculin tests, X-ray examinations and BCG vaccina- tions ran over two years and a half. A follow-up phase of case- finding began in 1971 and is scheduled to go through 1981. However, seven and a half years into the second phase, public health authorities found that BCG vaccine afforded no protection against lung tubercu- losis, the most common form of the disease, and that the "pre- valence of the disease among adults, particularly among older males, is exceptionally high". In another recommendation, the experts call for new studies, after noting that there is, partic- ularly, a lack of recent scientific data on the effect of BCG in tropical climates. Virtually all that is now known of the vaccine's protective effect is derived from the experience gained in temperate countries, notably from trials carried out in Europe and North America. There have been no large- scale field trails, except for India's, the experts point out, that have taken place under "conditions mainly encountered in developing countries". And even "the south Indian trial has not provided sufficient informa- tion on the effect of BCG in infants and young children". The Indian trial covered some 360,000 people, virtually the en- tire population of 209 villages in the District of Chingleput, west of • Madras—except for those under a month old. It was designed to study the effect of BCG against the adult- type of pulmonary tuberculosis. While there is no doubting the validity of the trial's findings, ex- perts warn that the results should not be regarded as applying au- tomatically to other parts of the world. Other favourable results are equally valid, they say. Results of earlier trials have varied, with the success of BCG vaccines rated as ranging from disappointing to favourable, but, significantly, notable success occurred in trials with children, who are the "main target for vaccination". World Health Forum is launched by WHO Even though published by WHO, its new quarterly is tar- geted not only at public health workers, but also at economists, sociologists, educators, policy- makers and government officials. Fittingly named, and des- cribed as an "international jour- nal of health development", the World Health Forum was launched in March, with plans for publication in six languages —Arabic, Chinese, English, French, Russian and Spanish. According to a statement of purpose by Dr Alex Manuila, Director of WHO's Health and Biomedical Information Pro- gramme, it is aimed at readers "who are determined to do something about the dismal health status of so many people" throughout the world. The Forum is WHO's first journal devoted exclusively to the editorial viewpoint that health is a decisive factor in eco- nomic development. It is com- mitted to policies of courting dis- cussion of controversial issues —in a department aptly called "Round Table"—and of avoid- Low birth weights by world regions Asia : An estimated 15 million babies of low birth weight born, or 20 per cent of the region's total 73 million live births in 1979. Asia's average birth weight is 2,900 grams (approx. 6 lbs 6 oz). Africa: An estimated 3.2 million babies of low birth weight, or 15 per cent of 21 million total live births. Africa's average birth weight is 3,000 grams (approx. 6 lbs 10 oz). Latin America: An estimated 1.4 million babies of low birth weight, or 11 per cent of 12.4 million total live births. Latin America's average birth weight is 3,100 grams (approx. 6 lbs 13 oz). Europe: An estimated 536,000 babies of low birth weight, or 8 per cent of 7 million total live births. Europe's average birth weight is 3,200 grams (approx. 7 lbs 1 oz). North America: An estimated 269,000 babies of low birth weight, or 7 per cent of 3.6 million live births in Canada and the United States. The average North American birth weight is 3,200 grams (approx. 7 lbs 1 oz). Oceania: An estimated 62,000 babies of low birth weight, or 12 per cent of 506,000 total live births. Soviet Union: An estimated 380,000 babies of low birth weight, or 8 per cent of 4.7 million total live births. No average birth weights are available for the latter two regions. 30 1981 Subscription Rates One year Two years Three years US$ 15. 27. 36. Sw. fr. 25.- 45.- 60.— ing a "dry, academic" treatment of subjects. "It will attempt to cater to the busy reader by presenting new ideas in such sections as 'In Focus' and 'Forum Interview', and by giving information in concise and lively form", its editors say. As planned also, the publica- tion will be partly written by staff and partly by contributors. "We don't have space for a repetition of old stories, or ac- counts of well-known techni- ques", the editors say to poten- tial contributors, "but if you be- lieve you have something to say, something that will make others stop and think, some experience to relate from which a lesson can be learned, please let us know about it". Not only for health workers. The editors also seek to estab- lish a lively letters column—its "Readers' Forum"—"open to all who wish to comment on pro- jected schemes", or "to warn against possible error". Among the journal's other departments are these: "Con- densed Book", "Forum Selec- tion" and "Health 2000". Among contents of the cur- rent issue: A guest editorial by Presi- dent Jaime Roldos Aguilera, of Ecuador. "The Meaning of 'Health for All by the Year 2000 — by WHO Director-General, Dr Half- dan Mahler. "Maternal Education as a Factor in Child Mortality", by Professor J. C. Caldwell, Austra- lian National University, Can- berra. "Water Supply and Primary Health Care in Thailand", by Pateep Siribodhi. "Africa's Two Medical Sys- tems: Options for Planners", by Nguete Kikhela, Gilles Bibeau and Ellen Corin. "The Regular Medical Check-up: What Is Its Real Value?", a report of the Cana- dian Task Force on the Periodic Health Examination. Briefs River Blindness. Some 800,000 are blind, or par- tially blind, in seven countries of the River Volta Basin victims of onchocerciasis, a parasitic disease com- monly known as river blindness. Since 1975, WHO, FAO, UNDP and the World Bank have worked with the countries—Benin, Ghana, the Ivory Coast, Mali, Niger, Togo and Upper Volta—to wipe out breeding places of the blackfly, transmitter of the disease. Now the ILO has joined in the fight, with plans for vocational rehabilitation services, at first to determine —with funds from the Swedish International Develop- ment Agency—the extent of the problem, and later to train the afflicted in skills to make them useful members of their communities. World Food Day. The anniversary of the founding of FAO 16 October—has been designated as World Food Day, with the first observance set for this year. In proclaiming such a day, the aim is to create greater public awareness not only of the nature of the world's food problems but also of the measures needed to banish hunger. Among a selection of material being readied to focus on the issues are a newsletter, which began publishing in October 1980, food fact sheets, posters, and bro- chures. Available from FAO headquarters, Rome, and offices in Accra, Bangkok, Geneva, New York, Santiago, and Washington, D.C. Diarrhoea! Diseases. Over the next three years, senior staff of a country's programme against diarrhoea/ diseases will become eligible for participation in two- week training courses newly-developed by WHO. Centering on strategies of control, the course was given first in English, drawing to Bangkok recently some 40 officials from 27 nations. Now, it will be offered also in French and Spanish. Dehydration from diarrhoea claims some five million lives yearly, of children under five. In the long run, im- proved sanitation and child health practices will reduce the incidence of diarrhoea. However, by treating dehydration with ORS—for oral rehydration solution a glucose-salts replacement fluid, a dramatic drop in death rates is possible imme- diately. Water. Sudan will provide a million people in the south with safe drinking water under plans scheduled to run through the 1980s. With WHO as the executing agency, the project is being financed by Sudan, allo- cating £ Sud. 1.5 million (US$ 1.9 million), and UNDP, US$ 6 million. Funds pay for supplies and equipment, as drilling rigs, and pipes. A first order for hand-pumps has already been placed, with installation set before the rainy sea. -§bn. Health 2000. Dr Ali Fakhro, Bahrain's health mi- nister, is quoted by the magazine Middle East Health as saying his country will achieve "Health for All" by 1985-15 years ahead of the target date set by WHO of the Year 2000. In the next issue In some highly developed countries, each individual may spend more than US$ 70 a year on pharmaceu- tical products. In the least developed countries, each person spends less than one dollar on medicaments. The May issue of World Health examines what this wide discrepancy means, shows how the production of pharmaceuticals is controlled, and explains the uses of WHO's List of Essential Drugs. Authors of the month Mr Keith E. KENTOPP is a member of the Public Relations Division of the Interna- tional Telecommunication Union, Ge- neva, and Mr Francis ZANGER is a student of international affairs and freelance journalist, now living in the United States. Dr Joseph HANLON is a freelance jour- nalist based in Maputo. Professor M. Essam FIKRY is Head of the Department of Internal Medicine and Chief of the Geriatric Research Centre in the Faculty of Medicine, the University of Alexandria, Egypt. Professor V. K. OVCHAROV is the Deputy Director of the Semashko Research Institute of Social Hygiene and Organiza- tion of Health Services, Moscow. Mr Lloyd DAVIES is a lawyer practising in Perth, Western Australia. He is also a writer of both fact and fiction. Mr P. K. J. MENON was, until his retire- ment, Chief Secretary to the Government of Bihar State, India. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to World Health as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque / international postal order in the amount of• Name: Street: City: Country . World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national currencies, please contact your usual bookseller. 4- ir orb