THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • DECEMBER 1974 UK 30p • USA $ 0.70 Contents Stress without Distress by Hans Selye ..... 3 The New Guardians by Yves Maystre .. 12 The Poisoned Sea by John Bland 18 Phan Thi Khuyen by Jose Abcede A Picture of Health by Kyllikki Kauttu . Index 1974 30 World Health appears in Arabic, English, French, German, Italian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland S tress is the rate at which we live at any one moment. All living beings are con- stantly under stress and anything, pleasant or unpleasant, that speeds up the intensity of life causes a temporary increase in stress, the wear and tear exerted upon the body. A painful blow and a passionate kiss can be equally stressful. The financier worrying about the stock exchange, the labourer or the sportsman straining his every muscle to the limit, the journalist trying to meet a deadline, the patient fighting a fever, all are under stress. But so is the football or baseball fan who merely watches an interesting game, and the gambler who suddenly realizes that he has lost his last coin or that he has won a mil- lion dollars. Contrary to widespread belief, stress is not simply nervous tension nor the result of damage. Above all, stress is not necessarily something to be avoided. It is associated with the expression of all our innate drives. Stress ensues as long as a demand is made on any part of the body. Indeed, complete free- dom from stress is death! In 1925, I first suspected the existence of what I later called stress and the General Adaptation Syndrome (G.A.S.), when study- ing medicine at the University of Prague. During one of the initial lectures in internal medicine we were shown several patients in We all spend our lives under stress, which is not necessarily something to be avoided: a painful blow and a passionate kiss can be equally stressful. But the scientific study of stress may help us to lead more satisfying lives. ( Photo Len Sirman C) ) the earliest stages of various infectious dis- eases. The professor carefully pointed out that each of these patients felt and looked ill, had a coated tongue, and complained of more or less diffuse aches and pains in the joints and of intestinal disturbances with loss of appetite and loss of weight. At that time, I had only vague ideas about clinical medicine, but I had crammed myself full of theoretical knowledge and I knew that a syndrome was usually defined as "a group of signs and symptoms that occur together and characterize a disease". The patients we had just seen had a syndrome, but the pro- fessor attached very little significance to the signs that were common to all these diseases because they were "nonspecific" and hence "of no use" to the physician. Instead, he enumerated a few "characteristic" signs that, should they subsequently appear, would help the diagnosis of a specific dis- ease. These I could not see. They were still absent or at least so inconspicuous that my untrained eye could not distinguish them. I felt that instead of concentrating exclu- sively on specific manifestations of disease it would be even more important to learn something about the mechanism of being sick and the means of treating this "general syndrome of sickness" which appeared to me as being superimposed upon all individ- ual diseases. I could not understand why our professor did not pay any attention to it. However, as a student, I accepted the fact that "this is so", just as physicians had done ever since the dawn of medical history. Not until 10 years later did these same questions confront me again. At that time I was working in the biochemistry department of McGill University in Montreal, trying to 3 STRESS without distress We all live under strain. Yet the adrenal cortex thrives on it, and total freedom from stress is death ! How can we best learn to live with stress? BY HANS SELYE find a new ovarian hormone in extracts of cattle ovaries. All the extracts, no matter how prepared, produced the same syndrome characterized by 1. enlargement of the adre- nal cortex, 2. gastrointestinal ulcers, and 3. involution of the thymus and lymph nodes. Although at first I ascribed all these changes to some new ovarian hormone in my ex- tract, it soon became apparent that extracts of other organs—in fact, toxic substances of all kinds—produced the same changes. It was only then that I suddenly remembered my classroom impression of the "syndrome of just being sick". In a flash, I realized that what I had produced with my impure ex- tracts and toxic drugs was an experimental replica of this condition. This simple hunch of a connection be- tween the almost forgotten, purely specula- tive, clinical concept of student days and the reproducible, objectively measurable changes in the animal experiments at hand was the basis for the development of the entire stress concept. I was struck by the fact that, while during this reaction all the organs of the body showed involutional or degenerative changes, the adrenal cortex actually seemed to flourish on stress. I suspected this adrenal response to play a useful part in a nonspe- cific adaptive reaction, which I visualized as a "call to arms" of the body's defence forces and therefore designated as the "alarm reac- tion". However, it soon became apparent that this alarm reaction was not the entire re- sponse. Upon continued exposure to a stres- sor capable of eliciting the initial reaction, a stage of adaptation or resistance ensued, since no organism can be maintained con- tinuously in a state of alarm. If the stressor is so severe that continued exposure becomes incompatible with life, the animal dies within a few hours or days during the alarm reaction. If it does survive, the initial response is necessarily followed by a stage of resistance during which most of the initial symptoms diminish or vanish. After still more prolonged exposure to the stressor, this acquired adaptation is lost and the ani- mal enters into a third phase, the stage of exhaustion, since the "adaptation energy" or adaptability of an organism is finite. -4 The three ages of man. In childhood, swift responses to any kind of stimulus. As an adult, the lessons of life have been learned and there are fewer surprises. In old age, reactions are slower and adaptation to new conditions is more difficult. (Photos WHO/ Eric Schwab) The athlete, straining every muscle to the,. limit, is under the kind of stress associated with the expression of all our innate drives. ( Photo Len Sirman Q ) ~ : .% ~&~7 ~i _,=~.0 -, w ~ . These three stages are analogous to the three stages of man's life : childhood (with its characteristic low resistance and exces- sive responses to any kind of stimulus), adulthood (during which adaptation to most commonly encountered agents has occurred and resistance is increased) and, finally, senility (characterized by irreversible loss of adaptability and eventual exhaustion) end- ing with death. A vital part of the defence mechanism is the excitation of the hypothalamus (a nerve centre at the base of the brain), which releases a chemical messenger (CRF) that causes the pituitary—a small gland just below the median eminence (ME) of the hypothalamus—to increase secretion of ACTH, the so-called adrenocorticotrophic hormone, which in turn stimulates the adre- nal cortex to produce those hormones for which I introduced the term corticoids. Most important among the corticoids are the glucocorticoids, such as cortisone, which cause thymus atrophy and influence glucose metabolism, especially by stimulating glyco- gen formation. The autonomic nervous system sends messengers to various parts of the body, for example the gastrointestinal system (instru- mental for "stress ulcer" production) and the adrenal medulla, to stimulate catechola- mine (adrenalin, noradrenalin) secretion. Diseases of adaptation Various derangements in the secretion of these hormones can lead to maladies which I called "diseases of adaptation", because they are not directly caused by any particu- lar pathogen but indirectly by a faulty adap- tive response to the stressor effect of some pathogen. In this sense, many ailments, such as various emotional disturbances, mildly annoying headaches, insomnia, upset sto- machs, sinus attacks, crippling high blood pressure, gastric and duodenal ulcers, cer- tain types of rheumatic or allergic afflic- tions, as well as cardiovascular and kidney diseases, appear essentially to be initiated or The cells in our body have learned to work as a team, and the strength of the team depends upon collaboration between its individual units. These Bavarian schoolboys are all diabetics. (Photo WHO/T. Farkas) enhanced by the body itself because of its faulty adaptive reactions to only potentially injurious agents. Among the derailments of the G.A.S. which may cause disease, the following were the first to be recognized: An absolute excess or deficiency in the amount of corticoids and somatotrophic or growth hormone (STH) produced during stress. A disproportion in the relative secre- tion, during stress, of ACTH and glucocor- ticoids on the one hand, and of STH and mineralocorticoids on the other. Production by stress of metabolic derangements, which abnormally alter the target-organ's response to STH, ACTH or corticoids (through conditioning). 6 4. Finally, we must not forget that al- though the hypothalamus-hypophysis-adre- nal mechanism plays a prominent role in the G.A.S., other organs which participate in the latter (e.g., the nervous system, liver, kidney) may also respond abnormally and become the cause of disease during adapta- tion to stress. Indeed, stress occurs even in unicellular organisms when they are faced with demands for adaptation. Numerous studies on stress have shown that the internal stability of the human body (homeostasis) is maintained by two types of reactions : syntoxic (from "syn" = together, as in syndicate) and catatoxic (from "cata" = down, against). The former defend the organism by ordering the cells to put up with and coexist peacefully with the intrud- ers. In many cases, the aggressors (indirect pathogens) are harmless and damage is caused only by our own uncalled-for defence reactions. Hence, it is wise to sup- press this hostility. But when the agents are inherently harmful (direct pathogens), the body must protect itself by destroying them. In essence, these scientific observations show that there are two roads to survival: tolerance and fight. The former, of course, is generally more advantageous. Mutual indifference is the simplest, but by no means the best form of adaptation. It is useful because it prevents friction and con- flicts, but it does just that and no more; it cannot protect, for instance, against over- crowding, shortages of essential materials, etc. Therefore, disciplined, mutually-advan- tageous collaboration and teamwork are far more suitable. During evolution from unicellular organisms to man, the billions of individual cells in our body have learned to work as a team for the benefit of the whole person. Breakdown of such co-operation is best illustrated by the growth of a cancer, which lives off the other parts of the body until it kills its host. It destroys itself by its uncontrolled egoistic development. Teamwork between various animal spe- cies manifests itself usually in the form of an A Teamwork in the air. All on board depend on a voluntary choice of conduct which will not overstrain the aircraft nor exhaust the fuel available before the destination is reached. The living body too has comparable limiting factors. (Photo Interavia Q ) ecological group which becomes an individ- ual entity. In human society, this co-opera- tion is evident in the family, tribe, corpora- tion, federation and even in the United Nations. The strength of the team depends upon collaboration between its individual units. Work: a biological necessity Can the scientific study of stress help us to formulate a precise programme of con- duct? Can it teach us the wisdom to live a rich and meaningful life which satisfies our needs for self-expression and yet is not marred or cut short by the stresses of sense- less struggles? I think we have to begin by clearly real- 7 izing that work is a biological necessity. Just as our muscles become flabby and degener- ate if not used, so our brain slips into chaos and confusion unless we constantly use it for some work that seems worthwhile to us. The average person thinks he works for eco- nomic security or social status, but when, at the end of a most successful business career, he has finally achieved this, there remains nothing to fight for—no hope for progress; only the boredom of assured monotony. Do not listen to the tempting slogans of those who keep repeating, "There is more to life than just work", or, "You should work to live, not live to work". This sounds pretty convincing, but is it really? Of course, these statements are true in themselves, yet your principal aim should be not to avoid work but to find the kind of occupation which, for you, is play. The best way to avoid harmful stress is to select an environment (wife, boss, friends) which is in line with your innate preferences—to find an activity which you like and respect. Only thus can you eliminate the need for frustrating con- stant readaptation that is the major cause of distress. After a pilot has left the ground in a plane—unless he wants to kill himself—he cannot stop his motor before he gets back to earth again. He must complete his mission back to earth. Yet there is very much he can do, through voluntary choice of conduct, to get as far as possible with a given airplane and fuel supply under given climatic condi- tions. For instance, he can fly at a speed and on a course best suited to his machine under the prevailing weather conditions. The two great limiting factors over which, once in flight, he has no control are: the fuel supply and the wear and tear that the weakest vital part of his plane can tolerate. When a human being is born—unless he wants to kill himself—he cannot stop, ei- ther, before he has completed his mission on earth. Yet he too can do much, through voluntary choice of conduct, to get as far as possible with a given bodily structure and supply of adaptation energy, under given social conditions. For instance, he can live and express his personality at a tempo and in a manner best suited to his inherited talents, under the prevailing social condi- tions. The two great limiting factors—which are genetically fixed when a man is born— are : his supply of adaptation energy and the The crowd and the man alone. Viewed from the pinnacle of the eternal general laws governing Nature, we are all surprisingly alike. Yet each individual has his capacity for pleasure, his burden of strain. In a populous and stressful world, ought we to update the guideline "Love thy neighbour as thyself" to "Earn thy neighbour's. love"? (Len Sirman ©)
stress without distress wear and tear that the weakest vital part of his body can tolerate. So, actually, we can accomplish a great deal by living wisely in accordance with natural laws. We can determine our opti- mum speed of living, by trying various speeds and finding out which one is most agreeable. We can determine our course by the same empirical method, keeping in mind, however, that occasional deviations have a virtue of their own : they equalize the wear and tear throughout the body, and thereby give overworked parts time to cool down. Man certainly does not get the feeling of happiness, of having completed his mission on earth, just by staying alive very long. On the contrary, a long life without the feeling of fulfilment is very tedious. And yet, when (and if) they analyse their lives, most people get the feeling of merely muddling through, of drifting aimlessly, from one day to anoth- er. Just staying alive, no matter how com- fortably and securely, is no adequate outlet for man's vital adaptation energy. Comfort and security make it easier for us to enjoy the great things in life, but they are not, in themselves, great and enjoyable aims. A world in which each creature refuses to protect itself is unimaginable, but so is a world in which uncontrolled egoism with total disregard for the interests of others is the leading principle of behaviour. To my mind, the only philosophy which necessarily transforms all aggressive egoistic impulses into altruism, without curtailing any of their self-protecting values, is altruistic egoism. It has amply proved its value throughout evo- lution from the simplest multicellular organ- ism to man. In lower animals, whenever it developed, it was of considerable help but, being unpremeditated, could arise only through the power of its survival value. Wherever it developed—be it even by acci- dent—it created new strengths which in- creased resistance. Single cells combined into multicellular organisms and these into larger groups on the basis of this principle, although they were not aware of it. Similarly, individual people have formed the cooperative "mut- ual insurance" groups of the family, tribes, and nations within which altruistic egoism is the key to success. It is the only way to preserve teamwork, whose value is ever in- creasing in modern society. -4 The squirrel safeguards his own future by hoarding food. Man too has a natural drive for collecting, and the most permanent and valuable commodity he can collect is a huge capital of goodwill from those around him. (Photo Jacana ) Each person must find a way to relieve his pent-up energy without creating conflicts with his fellowmen. Such an approach not only ensures peace of mind but also earns the goodwill, respect and even love of our fellowmen, the highest degree of security, the most noble "status symbol" to which man can aspire. This philosophy of hoarding a wealth of respect and friendship is merely one reflec- tion of the deep-rooted instinct of man and animals to collect. It is as characteristic of ants, bees, squirrels, and beavers as of the capitalist who collects money to put away in the bank. The same impulse drives entire human societies to amass a system of roads, telephones, cities, fortifications, that strike them as useful means of accumulating the ingredients of future security and comfort. In man, this urge first manifests itself 'when children start to amass match boxes, shells or stickers; it continues when adults gather stamps or coins. The natural drive for collecting is certainly not an artificial, indoctrinated tradition. By collecting certain things, you acquire status and security in your community. The guideline of earning love merely attempts to direct the hoarding instinct towards what I consider the most permanent and valuable commodity that man can collect: a huge capital of goodwill which protects him against personal attacks by his fellowmen. Earn thy neighbour's love "Love thy neighbour as thyself", one of the oldest guidelines for purpose and con- duct, was propounded to please God and thereby offer security to man. Since our philosophy is based on natural laws, it is perhaps not surprising that, for centuries, throughout the world, so many of its ele- ments have turned up again and again—in the most diverse religions and political doc- trines though usually supported by mysti- cism and blind trust in an infallible authori- ty rather than by science. The people in whose cultures one or the other of these elements appeared were quite unrelated and often did not even know of each other's existence. Their creeds had only one thing in common : they were acceptable to the human brain and reflected the natural evo- lution of its functional mechanism. Perhaps we should update the guideline by rephrasing it to "Earn thy neighbour's love". In this form, it is biologically sound and cannot conflict with any religion or philosophy, in fact, ardent believers in any one of these can use our code to comple- ment their own. In it, they will find scientific support not only for one of the most deep- rooted and generally accepted religious pre- cepts of the brotherhood of man but also for that of communism, with one of its avowed goal: "From each according to his capacities, to each according to his needs", a slogan which otherwise might only en- courage laziness. The laws of Nature, which we used to construct our doctrine, apply to everybody, irrespective of his formalized and labelled creed. Viewed from the pinnacle of the eternal general laws governing Nature, we are all surprisingly alike. Nature is the fountain- head of all our problems and solutions; the closer we keep to her the better we realize that, despite the apparently enormous divergencies in interpretation and explana- tion, her laws have always prevailed and can never become obsolete. The realization of this truth is most likely to convince us that, in a sense, not only all men but all living beings are brothers. To avoid the stress of conflict, frustration, and hate, to achieve peace and happiness, we should devote more attention to a better understanding of the natural basis of motivation and beha- viour. No one will be disappointed if, in daily life, he learns to follow the guiding light of "Earn thy neighbour's love". So the whole translation of the laws governing resistance of cells and organs to a code of behaviour comes down to three pre- cepts : Find your own natural stress level. Peo- ple differ with regard to the amount and kind of work they consider worth doing to meet the exigencies of daily life and assure their future security and happiness. In this respect, all of us are influenced by heredi- tary predispositions and the expectations of our society. Only through planned self-ana- lysis can we establish what we really want; too many people suffer all their lives because they are too conservative to risk a radical change and break with traditions. Altruistic egoism. The selfish hoarding of the goodwill, respect, esteem, support and love of our neighbour is the most effi- cient way to give vent to our pent-up energy and create enjoyable, beautiful or useful things. EARN thy neighbour's love. This mot- to, unlike love on command, is compatible with man's natural structure and, although it is based on altruistic egoism, could hardly be attacked as unethical. Who would blame him who wants to assure his own homeosta- sis and happiness only by accumulating the treasure of other people's benevolence to- wards him? Yet, this makes him virtually un- assailable, for nobody wants to attack and destroy those upon whom he depends. ■ 11 SPACE-SHIP EARTH the new guardians Only by changing man's aspirations can we hope to avoid polluting our planet. Environmental engin- eering requires a brand new concept of the world. YVES MAYSTRE INTERVIEWED BY ELIE MARCUSE P rofessor Yves Maystre holds the chair of environmental engineering at the Federal Polytechnic School in Lausanne, Switzerland. An expert in rural engineering from the Zurich Polytechnic School, he held leading posts in Paris, in Geneva and in Africa before coming to Lausanne, beside Lake Geneva, to organize a new course in environmental engineering. World Health's interviewer Elie Mar- cuse found in him a person who did not need technical jargon to express his ideas. In an ironic reference to the near- by lake—which despite its idyllic Alpine setting will soon be depleted of all aquatic life if nothing is done to prevent its pollution by man—Professor Mays- tre commented : "There are still too few people who recognize as 'under-devel- oped' the Westerner who won't give up his 'whiter-than-white' biogenic wash- ing-powders." He went on : "Only when we all real- ize that we share the same Space-Ship Earth, and that there is no human activ- ity on the planet which does not affect the life and well-being of all other earth- men, will it be possible to look towards the future with confidence." How may such an attack of con- science be provoked in an age when Western "under-development" may be measured not only in detergent foam, but also by the millions of tons of oil pured into the sea over the years, and by today's ten per cent increase of carbon monoxide in the atmosphere—possibly 25 per cent by the year 2000, when we risk provoking a new Flood as the polar ice-caps melt? "By changing the aspirations of man," replied Professor Maystre. "Starting with his insatiable appetite for new consumer goods which he presently throws on the scrap-heap without thought for the cost to society." If he is hardly an optimist, Professor Maystre also has little belief in the last- ing nature of the consumer society. "Man has passed through many types of society before reaching this one," he ex- plained. "He must learn to understand that its survival depends on respect for the environment, and that defending his natural milieu is incumbent first of all on him, and only at second remove on the expert." WORLD HEALTH : What is the difference between environmental engineering and sanitary engineering? PROFESSOR MAYSTRE : The term sanitary engineering embraces the entire public or private facilities involved in protect- ing man from environmental hazards and the environment from man-made hazards. That is, the set-up which deals with examining drinking water, treating water at source and at the drain, laying on water supplies and disposing of all kinds of domestic or industrial waste. Environmental engineering, on the other hand, requires primarily an inter- disciplinary effort. At one and the same time it involves the specialists in natural sciences, such as botanists, zoologists, shanty-towns, favelas, industrial areas, suburbs—that is, the architects, town planners, sociologists, psychologists and doctors; and finally the experts in the management of wastes, whether solid, liquid or gas. So it would be no exaggeration to say that the environmental engineer is called upon to take the widest possible view of the problems that he will have to resolve. WORLD HEALTH : What do you mean by interdisciplinary effort? PROFESSOR MAYSTRE: Basically, we can- not think of a single discipline like mathematics, biology or physics. As I said, environmental engineering should be understood as a way of looking at things, an attitude to the world based on the disciplines we have just listed, with the object of grasping the interaction between man's economic activities and their impact on his environment. Man has passed through many types of soci- ► ety before reaching this one. And today's con- sumer society is doomed unless man learns to tame his insatiable appetite for goods which he does not really need and which after a time he throws recklessly on the scrap-heap. (Photo WHO/E. Mandelmann) 12
"There is no human activity on the planet which does not affect the life and well-being of all other earthmen." The little Peruvian girl (left) has to walk to the well, but the authorities ensure that the water is good to drink. The Dutch technician (right) is moni- toring air pollution as part of an international network developed by wHo. (Photos WHO/P. Almasy and T. Farkas) Thus, in the course of his specializa- tion, the physicist will join forces with natural science experts to study, let's say, the properties of material recovered from waste; the biologist for his part will study at the point of discharge the influence of waste on the natural envi- ronment (the biological treatment of waste water, for example); the engineer will concern himself with the treatment of waste, the geographer with national planning, the mathematician with sys- tems analysis. WORLD HEALTH : You spoke of pollu- tants, then of waste. What is the differ- ence between these two terms? PROFESSOR MAYSTRE: Whatever the in- dustrial sector involved, the finished product only represents a small propor- tion of the raw materials used—a half or even a tenth. This is why it is useful to establish a distinction between wastes and pollutants. When the residual by- products from a manufacturing process are not dispersed, then you are dealing with wastes, which may be solid, liquid or in gas form. On the other hand, the moment these materials escape from the control of man—gases, perhaps, or chemical substances—then we are talk- ing about pollutants. WORLD HEALTH: How have you put into practice this interdisciplinary concept of environmental engineering? PROFESSOR MAYSTRE: Simply putting together a number of lectures relevant to various subjects is not enough to create an interdisciplinary course. It is very clear that a 12-month period, even at full time, would not suffice to cover all the ground. The important thing, as I have said, is to stimulate a new way of looking at things and to train the students to work in a positive, interdis- ciplinary way so that they don't look for confrontations but for converging points of view. To do this, we have stressed both personal work throughout the three-term course and group work. WORLD HEALTH: Group dynamics? PROFESSOR MAYSTRE: Exactly. By devel- oping in each student the awareness of belonging to a well-defined group, bit by bit they appreciate the need that exists today to tackle a problem while careful- ly weighing all the data and examining all the ins and outs. It is a thrilling ex- perience to watch the process of osmosis which occurs in students belonging to different disciplines. WORLD HEALTH : What are the main dif- ficulties that you have encountered? PROFESSOR MAYSTRE : Technicians and scientists are all too often captives of their specialist vocabulary, a vocabulary which, in each discipline, can be com- pared to a screen through which they peer at reality. So it is vital to surmount the limitations imposed by specialized training and to draw up a language that can be understood by each specialist, whatever his basic discipline. It is shocking to realize that the concept of organic growth which is so familiar to the biologist is completely foreign to the civil engineer, that the shape of a piece of ground escapes the eye of a chemist, or that the architect is not aware of the effect of wastes on the natural environment. So each one of these, beyond the reality which he perceives as a specialist, must be in a position to glimpse the reality of his col- leagues. WORLD HEALTH : How have you tackled these problems yourself? PROFESSOR MAYSTRE: We started by en- couraging a practical approach : detailed visits to waste treatment plants, field trips in the course of which the students had to take samples of soil, plants, min- erals and insects. For all those who are not biologists, these tasks proved ex- tremely interesting, and transformed an abstract and philosophic interest in the defence of the environment into a real and profound love of nature. Then again, we insist on the human aspect of problems—the impact of new techniques on the social milieu, the im- portance of public opinion—and partic- ularly since the majority of environmen- tal specialists will in due course be called upon to collaborate not only with other specialists but with all levels of society. So it is essential that they should be capable of evaluating mental and social well-being as well as material well-being in the cases they have to study. WORLD HEALTH: Where do your students come from? PROFESSOR MAYSTRE: We try to attract students from as varied a milieu as pos- sible, firstly as regards their specializa- tion but also as regards their age, nationality and sex : this is the essential condition for the success of the course, which is, by the way, given in French. In 1973, we had eight Swiss and five for- eigners, and this year we have seven Swiss and six foreigners, including three women. These include a physicist, a mechanic, a chemist, a biologist, an agronomist, an architect, a mathemati- cian, a geographer, a civil engineer, a 15 111111111 11111111441111111111111 rural engineer, two sanitary engineers, and a hydraulics engineer. Their ages range from 25 to 43. WORLD HEALTH: Do you consider you have brought about all the conditions required for the success of the course? PROFESSOR MAYSTRE: In a sense, yes. But it is apparent that all the conditions can be brought about without the desired aim being achieved. It is only when the students begin to understand that their fragmentary vision of reality has to be complemented by that of their colleagues that it is possible to work effectively. That is why I insist on the interdisciplinary character of this course which emphasizes cooperation, a readi- ness to learn other disciplines, the capacity to observe and analyse from the standpoint of various criteria, rather than work of a traditional kind. You will also notice that examina- tions consist solely of "orals" on the team work done in the course of the year or of commentaries on the reading matter. All the students are present at the examination of their colleagues. WORLD HEALTH : What are the pass- rates? PROFESSOR MAYSTRE: We have found that from their arrival virtually all the students were sure of a pass. In the medium or longterm, I don't think there could be any problems on that score. What is certain is that we have to create an entire economic sector specializing in the treatment and recycling of wastes. By the same token, one can foresee that in future no decision of a technical or economic nature which concerns national planning will be taken without the effects on the environment first be- ing carefully evaluated, whether it concerns siting new towns or power plants, the means of propulsion for pub- lic transport vehicles, the discharge and treatment of waste products from this industry or the other, urban or tourist planning, or noise abatement. So I am not exaggerating when I say that environmental engineering is "a Professor Yves Maystre (left) shows his envi- ronmental engineering class one of the processes at a water purification plant beside Lake Geneva, Switzerland. (Photo WHO/D. Henrioud) profession of the future" on whose ser- vices will increasingly depend the big industrial concerns, big engineering firms, research institutes whether public or private, regional planning services, national water boards and municipal technical services, not to mention the international agencies for aid and devel- opment (particularly WHO and the United Nations Development Pro- gramme). WORLD HEALTH: Could you give us some examples of projects for treating and recycling waste? PROFESSOR MAYSTRE: The recovery of tin from old food cans, the re-use of sewage as farm fertilizer, the recycling of paper and metals. These examples in- dicate—and the rapid increase in the price of primary raw materials serve to underline this point—that tomorrow's world will see a vast economic sector engaged in the treatment and recycling of industrial and domestic waste, backed by strict legislation to protect man and his environment. So to train 13 specialists a year in environmental en- gineering is not excessive. In any case we are not alone in this. There are insti- tutes in the United States, and in Eu- rope there is a joint programme ar- ranged by the Universities of Geneva, Paris and Toulouse. WORLD HEALTH : How is WHO helping you? PROFESSOR MAYSTRE In 1973, the year the course was set up, WHO provided four environmental engineering fellow- ships which were awarded to students from Guatemala, Luxembourg, Poland and Spain. In 1974, WHO gave five, of which three went to Romanians, one to a Frenchman and one to an Italian. WHO officials also lectured and acted as discussion leaders. It was thanks to a WHO fellowship, I may add, that I could attend a refresher training course at the Johns Hopkins University in the United States. As for the conditions of admission here, candidates should have :— * a diploma from an engineering school or a final diploma from any other school recognized as the equivalent by the secretariat-general of the Lausanne Federal Polytechnic School; and * very good knowledge of French, the language of the training programme. An adequate reading knowledge of English is strongly recommended. As regards foreign candidates, preference will be given to fellowship holders. WORLD HEALTH: Protection of the envi- ronment has become a major subject for concern in society, whether in industria- lized countries or in the so-called develop- ing nations. Could you tell us, finally, whether the protection of the environment poses different sets of problems according to which group of countries one is in? PROFESSOR MAYSTRE : Not long ago I used to think, as many people did, that environmental problems in the so-called developing countries were not the same as those in the developed nations. Well, today I think the problems are fundam- entally the same; they only appear to be different. A man living in an African capital where many of the drainage channels are lined with mud, because imported cement is too dear, may not think of stopping goats and children from walk- ing on the embankments, which thus become eroded. He is regarded as un- der-developed because he declines to submit himself to a discipline imposed by technology. The Westerner living in a country where the lakes, which serve among oth- er things as reservoirs of drinking water, are polluted by phosphates declines to give up his "whiter-than-white" foaming washing-powders. Not many people would dare to call him under-developed. In this case as in the other, we are not really ready to face up to what has to be done. Proportionately there is not even much difference in the costs involved, since the environment of the industria- lized country, much more endangered than that of the poorer country, will cost much more to preserve and regen- erate. And in both countries, the reflexes of "economic man"—he who produces and consumes products which he could generally do without and has no regard for the common interest—are stronger than man's respect for nature, which is after all only a form of man's respect for himself. ■ 17 photos: takeshi shiota text: john bland T he pictures which we reproduce on these pages are shocking. But only with a shock can the fearsome tragedy of environ- mental poisoning be brought home to the greatest number of people, and the greatest possible impact be made on those authori- ties responsible for keeping the sea, the riv- ers, the land and the air healthy. The pictures show, starkly and without overstatement, the effects of Minamata dis- ease, a particularly serious form of mercury poisoning. The series won for Japanese photographer Takeshi Shiota the Special First Prize of the Jury in a World Environ- ment Photo Contest, in which entrants were invited to capture with the camera the par- ticular problems of their own environment. More than 1,500 entries from 37 countries were judged in Nairobi by a jury of leading photographers and visual experts: Tibor Farkas, Mirella Ricciardi, Monty Ruben, Mohinder Dhillon and Ray Charman. The results were announced a few months ago by Maurice F. Strong, Executive Direc- tor of the United Nations Environment Programme (UNEP). It was in the 1950s that cases of serious illness began to come to light among people heavily dependent on sea-food collected in Minamata Bay on Kyushu, south-west Japan. As early as 1953 there had been reports of convulsive deaths among such an- imals as cats, dogs and crows, but not until April 1956 was the first case notified of an unidentified disease of the central nervous system among humans. The number of vic- tims grew dramatically and by February 1971 the total of known cases stood at 121, of whom 45 had died. The survivors suf- fered a wide range of severe neurological disturbances including blindness, deafness, stupor, coma, convulsions, loss of emotional control, and intellectual impairment. What came to be called Minamata disease occurred among households heavily depen- dent on sea-food diets, mostly fishermen's families. But only slowly was the source of the illness traced to effluents from a factory producing aceto-aldehyde beside Minamata Bay. Mercury waste was picked up by algae and invertebrate organisms in the sea water, and as these organisms became in turn food for larger species and for fish, the fatal poi- son was ingested by man—the higher animal responsible for the initial contamination. Methylmercury—a waste product of the aceto-aldehyde manufacturing process in which an inorganic mercury catalyst is used—proved to be present in the waters of the Bay at an undetectably low level, but it was taken up by the shellfish and fish and biologically concentrated. Pictures that the hand of a Breughel or a Goya might have traced. But the story is a tragedy of the 20th century. Only an indus- trial society in a material age could contrive to poison the sea itself. These pictures show the results in human terms: a brain-damaged child, and a mother consoling her sick and deformed son. The total number of victims included some 25 infants with cerebral involvement (palsy and retardation) born to mothers who had eaten quantities of contaminated sea-food, but who were themselves largely symptom-free. As the scale of the tragedy in the town of Minamata (population 50,000) and neigh- bouring communities became apparent, there was a public outcry in Japan. There were demands for compensation for the vic- tims, punishment of the culpable, and guarantees that no further pollution should occur. For the sufferers themselves—some of whom are pictured here by Takeshi Shio- ta's camera—there was little relief. Methyl- mercury compounds accumulate in the human body and the damage they can inflict on the central nervous system is all too of- ten irreversible. Ten years after the first out- break, almost all the patients were reported to be still unable to live normal lives. Not until 1964 were virtually all the links in the causal connection between the fact- ory's effluents, the methylmercury corn- pounds found in fish and shellfish, and the progress of the disease in humans scientifi- cally established. But the lesson of Minamata Bay was not learned in time: in 1964 and 1965 another outbreak of mercury poisoning occurred, in the Agano River area of Niigata Prefecture in central Japan. This time 49 persons were affected, of whom six died. These tragic outbreaks served only one positive function: at least they alerted Japan, and indeed other industrial nations, to the risks inherent in permitting untreated or unsupervised chemical waste to enter riv- ers and seas. Subsequently, mercury contamination at critical levels has been detected elsewhere in Japan but also in the Baltic Sea, in the Great Lakes of North America, and in some other Canadian Lakes. No doubt there are other areas with high mercurial residues that remain undetected because of the lack of effective environmental monitoring systems. Research workers consistently found in- creased levels in places where the water is contaminated with mercury from industrial and mining processes. In fish from unpol- luted waters, comprising most of the world's total catch of food fish, the values are gener- ally low. Some of the larger predatory fish may contain high levels, but these appear to be derived from natural sources in sea wa- ter, since the same levels are found in museum specimens caught 50 to 100 years ago. The ratio of methylmercury to total mer- cury is often high (approaching 100 per cent), especially where the total mercury level is itself relatively high. But in shellfish the proportion is only 50 per cent or lower even when the total mercury level is high. Marine fish, which constitute the main bulk of food fish in international trade, have been extensively investigated for possible mineral and chemical contamination in recent years—partly at least as a result of what occurred in Minamata Bay. A 1972 report of the Joint FAo/wHo Ex- pert Committee on Food Additives warned that fish, shellfish, crustaceans and eels 20 Above—A scene as old as human history. But it was an infected catch that the fishermen of Minamata Bay brought in over a decade ago. Left—For some the suffering is not yet over. These parents watch anxiously as their crip- pled son laboriously learns to crawl. Below— Families of the victims of Minamata disease publicly display their grief in an attempt to prevent such tragedies ever occurring again. which live in polluted estuaries may contain high values of mercury, and suggested that such local fish supplies deserve more exten- sive surveying. The report added that mer- cury levels in oysters and other shellfish can be controlled by anti-pollution measures, and that levels in fish taken from some Swedish lakes and Japanese rivers have ap- preciably fallen once the contamination sources are eliminated. Takeshi Shiota's prizewinning pictures and other winning entries in the World En- vironment Photo Contest are now being ex- hibited in different parts of the world. ■ HEALTH WORKER IN VIET-NAM a day with Phan Thi Khuyen Viet-Nam's recent answer to its chronic shortage of doctors and nurses: The National Institute of Public Health in Saigon is turning out eager young health technicians vvho bring medical care to rural areas PHOTOS AND TEXT BY JOSE ABCEDE T he day was almost over when Mrs Phan Thi Khuyen got through the third household. All the seven children had scabies on their heads, buttocks, arms and legs. She had to clean each one, apply ointment and dressing, at the same time trying to calm the squealing youngsters. Meanwhile, the village worker assist- ing Mrs Khuyen had started counting malaria tablets : one woman came for- ward for the pin prick and the drop of blood on a slide. After all the children had their sores cleaned up, Mrs Khuyen talked to the mother about the youngest child who was obviously undernourished. It ap- peared that the mother had not taken the child along to the health centre. Mrs Khuyen's afternoon home visits had started soon after lunch. The first call was on a farmer who had missed getting his TB drugs from the district health clinic. The next stop was for a chat with another farmer about a latrine. It was much too near the well and the farmer had agreed to move it somewhere at the back of the house. I first met Mrs Khuyen early that morning at the primary school house of Vinh Diem Thuong, a hamlet on the outskirts of Nha Trang city, more than 250 miles north of Saigon. Mrs Khuyen, herself the mother of two little girls, is a Public Health Assistant Technician (PHAT), the foot slogger or infantry of a new "army" of health technicians gradually invading the Vietnamese countryside. That day, Mrs Khuyen's morning schedule called for smallpox immuniza- tion of first grade children at two pri- mary schools. With the help of draw- ings, she explained the disease and the protection given by vaccination. Thereafter the children filed singly from their desks, arms bared for a few gentle needle pricks. A village worker who owned a motorcycle gave her a lift to the second school. It was a full morn- ing's work. However, the afternoon home visits did not end her working day. An even- ing meeting with village chiefs had been arranged by the military commander of the district. The district health officials had to explain the next hamlet sanita- tion programme and answer questions from the elders. Mrs Khuyen joined her supervisor and other officials that even- ing in the front yard of the military commander's house. It was important for her to have good rapport with the village leaders. Health technicians are an entirely new breed of auxiliary workers in Viet-Nam. Regular training of two levels of this health staff—the Public Health Assis- tant Technicians and their supervisors, the Public Health Technicians (PHTs)— started in 1970 at the National Institute of Public Health (NIPH) in Saigon. Mrs Khuyen was among the first to complete the one-year training course; she gra- duated in February 1971, the fifth in the first batch of 35 PHATS turned out by the NIPH. During the first three years, the NIPH produced 249 PHATS. The Institute ex- pects 575 graduates by 1975 but, by then, demands for this new health aux- iliary are expected to reach 1,925. In 1980 the country is expected to need 3,150 PHATS ; the NIPH expects that only 1,150 will have graduated by that time. After her graduation, Mrs Khuyen was posted to her own district, Vinh Xuong, and promptly ran into her own pioneering problems. She wrote a report in October 1972 about transport prob- lems and suggested that PHATS were not utilized properly by the higher level staff. It is a different picture in 1974. With three years' experience behind her, the frail, 25-year-old PHAT said that her supervisors had "used our competence with satisfactory results." She went on : "I am pleased with the actual work because the people respond favourably to our activities. Phan Thi Khuyen painstakingly cleans and anoints the sores of a young patient. The care she takes, her neat appearance and her well- chosen words of advice amount to a lesson in health education for her compatriots. 22
f -4 Not yet a doctor, but the young Public Health Assistant Technician has already developed a "bedside manner" to set anxieties at rest. Phan Thi Khuyen also takes on the school- I.. teacher's role. Her simple account of the way immunization will protect the children from smallpox will make the needle-prick that is to follow less fearsome. "After three years of service at the Vinh Xuong district health centre and having worked in two pilot sanitary hamlets as well as on a school health pro- ject, we noted that the villagers are now aware of sanitation and health mea- sures." As in 1972, Mrs Khuyen expressed a wish for "an opportunity to acquire fur- ther knowledge." In the two follow-up questionnaires sent to her by the MPH, she said she had to study more nursing care by herself "in order to have more capability on duty." Completion of elementary schooling is a requirement for admission to become a PHAT. In addition, the appli- cant has to pass an entrance examina- tion and interview. During the two semesters of classroom study, emphasis is placed on preventive medicine and communicable diseases, environmental sanitation, health education and nursing practice. The students get a basic under- standing of anatomy and physiology, microbiology and parasitology, as well as nutrition and health statistics. Then for twelve weeks, they undertake actual field work at the NIPH'S field training and demonstration centres in An Giang and Tay Ninh. As a general rule the graduates are assigned to their home provinces, dis- tricts or villages. The country lacks doctors and nurses. Health services are therefore manned by sub-professionals and auxiliaries. Under its four-year national health plan, from 1972 to 1975, the Ministry of Health accorded top priority to the develop- ment of health manpower, in order to strengthen the foundation of its public health programme and to pave the way for its future expansion. The NIPH is helping the Ministry toward this goal. In addition to courses for PHATS, the NIPH has provided refresher training courses for public health staff and short postgraduate courses for physicians, dentists and pharmacists, as well as post basic courses for instructors in health sciences. A total of 979 medical and oth- er health personnel took refresher/orien- tation courses varying from 1 to 12 weeks in duration during the period from 1970 to 1973. In addition, the first batch of 31 public health technicians (PHIS) graduated in September 1973 and 112 students are currently enrolled in this three-year course. Establishment of the NIPH was one of the main recommendations of wHo in 1967, during a study of Viet-Nam's health manpower needs. WHO assisted the Government in setting up the Insti- tute and, since its inception, help has also been provided by UNICEF and the Governments of Canada, the Nether- lands, New Zealand and the United States of America. From July 1971, the Institute has been occupying a remod- elled building of the Saigon Faculty of Medicine in the Cholon district. The NIPH will shortly have its own home. The first phases of this building complex, consisting of the teaching and laboratory, administration, auditorium and library blocks, will be inaugurated in March 1975. The second and third phases will consist of dormitories for students, a cafeteria, a nutrition kitchen for teaching and demonstration, a model infirmary ward, a workshop for sanitarians, faculty housing and addi- tional teaching and laboratory blocks. Construction, however, depends on the availability of funds for this purpose. WHO is at present trying to raise more than US$2,000,000 to meet the costs of constructing and furnishing the blocks for second and third phases. In its appeal for funds, the WHO Regional Office for the Western Pacific in Manila summed up the situation as follows : "To meet the challenge, as well as fully attain its specific objectives, the NIPH urgently needs additional external assistance to complete the NIPH building complex as well as adequately furnish- ing and equipping . it for teaching, re- search, specialized public health ser- vices, and faculty/student accommoda- tion/mess/recreation purposes. The Government of Viet-Nam has consis- tently supported the NIPH generously within its fiscal capabilities as evidenced by the tremendous increase in its budge- tary allocations from VN$5,000,000 for 1970 to VN$105,950,000 for 1974. However, the Government is in no posi- tion to support financially the capital costs development of the MPH inas- much as the country's economy is barely starting to recuperate from the ravages of the war." ■ 25 a picture of health BY KYLLIKKI KAUTTU T he Baltic sea port of Turku, Finland's second largest city, planned something different for World Health Day 1974. In- stead of simply having a number of Very Important People making speeches about the theme of the Day—"Better Food for a Healthier World "—why not ask the opinions of the citizens of tomorrow? Opinions which could be expressed, not in speeches nor even in writing, but in paint and artistry? So the idea of a painting competition was conceived in Turku. Since Finland's new programme for health education in primary schools starts teaching facts about food to children in the first and second grades, the competition was declared open for young artists aged seven and eight. From February onwards, three art teach- ers drew up the competition rules, suggested seven themes on nutrition, and made sure that all schoolteachers in the area knew what was going on and were urging their pupils into action. Public health nurse Irma Laaksonen agreed to act as the coordinator of the whole campaign. So far as the paint- ings were concerned, the "rules" were sim- ple and straightforward : big pictures and lots of colours. Other public health nurses, like Aune Merikallio, toured the schools of Turku—a city of some 200,000 inhabitants—to explain to classes what healthy food means, how it helps us, and why it is important for adults as well as for growing children. This "back- ground information" helped to stimulate en- thusiasm and showed the children what a wide variety of ways were available to ex- press the Health Day theme in pictures. They were learning to understand that daily food was more than just satisfying hunger or eating what is tasty. They discovered that different foods are nourishing in different ways, and that our daily diet needs to in- clude a variety of substances in a variety of quantities. They realized that nutrition is rather more than just food. The children of Turku needed no further encouragement. Some 4,000 of them settled down with huge enthusiasm to their task of illustrating healthy, everyday food. When the paintings were completed, each class—both the pupils and the teachers— selected the three best pictures. They judged the entries not only for their artistic ar- rangement but also for their effectiveness in putting across the message of "Better Food 26 Opposite—First prize-winner Piiivi Vuorela proudly displays his painting of "Peter, the happy apple muncher." The second prize was awarded to Harry Lempiiiinen for his lively portrait of the cow, Mansikki, a confirmed eater of nourishing vegetables. Above, "Marching Carrots" are undoubtedly saying, in any language, "Eat Me." (Photos WHO) for a Healthier World." This preliminary selection reduced the "field" to 400 pictures, and from these a combined jury of health experts and teachers undertook the difficult task of picking out the best. To seven-year-old Paivi Vuorela went the first prize for his vivid painting of "Peter, the happy apple muncher," which could leave nobody in any doubt that Peter's good humour and bright red cheeks are entirely due to his consistent diet of fruit. The second prize went to Harri Lempi- dinen for his gay and colourful picture "Mansikki likes the taste," showing us how the cow keeps healthy and happy, and gives us good milk, by munching vegetables. A "short list" of 67 paintings were ac- cepted for exhibition in connection with the other World Health Day activities in Fin- 27 More entries in the Turku World Health Day painting competition relate the importance of nutritious foodstuffs to good health. Right— Three teachers—Ossi Heino, Maija Hautera and Maija Lampisuo—explain the theme of the competition, but the artistry and imagina- tion stem from the children themselves. land, and 21 of these were awarded prizes. Grown-ups who came to see the display were themselves encouraged to think what healthy food means by being invited to vote for their own choice of "best picture on show." When it turned out that many of the chil- dren's parents and friends had not had an opportunity to see the entries, one of the main banks of Turku lent its window space and its entrance hall for three weeks for the art exhibition. The children agreed to pre- sent their colourful and cheerful pictures to the city. Then the best of them were framed and distributed to health offices, health cen- tres and schools to brighten what might have been just dull institutional walls. They remain as permanent reminders that fruits, vegetables, roots, milk and rye are pure and healthy basic factors in our diet. The planning group from the Finnish Department of Health which had thought up the original idea visited the schools again to hand out the prizes and to talk again about the importance of a good and whole- some diet. Health education as envisaged by children is positive, happy and bright with colours. It does not consist of lists of restrictions and prohibitions—as perhaps adults are inclined to conceive it—but is a very positive state- ment of our bodies' priorities and the joy of eating. The painting competition amounted to a reversal of the usual roles. The children became the teachers and, without inhibition or prejudice, reminded the adults of healthy nutritional habits. One of the important messages that came across was the emphasis that young artists put on fruits, vegetables and roots—foodstuffs that are not only colourful and of distinctive shapes but also represent a rich store of vitamins, by com- parison with the Finnish people's usual heavy diet of fats and carbohydrates to see them through the long dark winters. The competition also gave a boost to a campaign by the country's dentists to declare only one "sweets day" a week: on the other days, snacks must be limited to the better alternatives of carrots, nuts, green vegetables and fruit. So World Health Day in Turku has helped to stimulate a new interest and a new outlook—not confined to this seaport alone. You could say that World Health Day in Finland is still going on. ■
INDEX - 1974 WORLD HEALTH WORLD HEALTH JANUARY . Health and family planning (World Population Year) — Benefits 40::,.), for mother and child — Food, health IV , , and the family—The socio-cultural context— Family planning research - Photo competition JULY-AUGUST Work and health — Hazards in small industries — The land worker — The trade union view — Workers in the USSR — Preparing for retirement— Ergonomics —Occupa- tional diseases and injtities FEBRUARY-MARCH Better food for a healthier world (World Health Day) — Malnutrition and brain develop ment — Fatness and food additives — The West Indies, Bangladesh, the Sahel — Defence against infec- tion — Food taboos WORLD HEALTH __ -v , ' ' SEPTEMBER WHO visits China — Nutrition: grim future prospects — Physicians, biologists and the future of man — Meningitis in the Sudan — Tracking down tuberculosis in Romania APRIL Medicines, past, present and future—The needs of developing countries — Are we overconsum- ing ? — Monitoring the effects of drugs — The future: hopes and fears — World Red Cross Day , 1 - ,, ,.0 . —s--640141 — . OCTOBER Mental health — Research — Mental health is public health — A nurse in Tanzania — Experiment in Trieste — Social stresses — South-East Asia's problems — Pre- vention and treatment WORLD HEALTH -----=-4,. MAY Ayear's work: WHO in 1973 — Manpower for health — Environ- mental health — Cardiovascular disease— Facts, figures and pointers — Onchocerciasis — A new medical reference service — 25 World Health Day themes WORLD HEALTH 4, . ..,,,, , 9... NOVEMBER In the service of health — The quality of life — Basic requirements — International cooperation — Mea- suring levels of health — Front-line workers — Replies to our ques- tionnaire _110;1RP), . ..1144.Th 4 JUNE The right to health (World Pop- ulation Year) — Land of Eagles: Albania — New Zealand : a dearth of doctors — Eradicating smallpox in India — Universal Postal Union centenary — Veneral diseases DECEMBER Stress without distress — Envi- ronmental engineering — The poi- soned sea : Minamata disease — Medical technician in Viet-Nam — Children's World Health Day in Finland — Index VIICALD HEALTH . . ..- . WORLD HEALTH STRESS 30 WORLD HEALTH DAY 1975 The February-March issue of World Health will as usual be dedicated to the theme chosen for World Health Day, 7 April. The year 1975 should see final victory for the small- pox eradication campaign launched by WHO in 1967. Built around the theme "Smallpox: point of no return," World Health will recount the history of the disease and man's fight against it, the lessons to be learnt for public health, how different countries contribut- ed to the campaign, and the tasks that remain to be done. authors of the month Professor Hans Selye, "fa- ther" of the stress theory, was born in Vienna in 1907. He is the holder of numer- ous degrees and honours. His writings, more than 1,100 books and scientific papers, deal mainly with the stress theory, stress physiol- ogy and doctrinology, car- diovascular diseases, etc. Since 1945 he has been Pro- fessor and Director at the Institute of Experimental Medicine and Surgery, Uni- versity of Montreal. Jose C. Abcede comes from the Philippines and is the Public Information Officer at the Western Pacific Regional Office of WHO in Manila. Yves Maystre has been Pro- fessor of Environmental En- gineering at the Federal Polytechnic School, Lau- sanne, since the chair was created in 1971. He has worked on wHo-assisted projects in Africa, Latin America and elsewhere. John Bland from the United Kingdom is a Public Infor- mation Officer at wHo head- quarters in Geneva. Mrs Kyllikki Kauttu is the editor of the Finnish Medical Journal, Suomen Liiiikiirilehti. She has been information officer of the Finnish Committee for the wHo, and was for several years chairman of the execu- tive committee of Finland's Health Education Council. The January issue of World Health will celebrate the start of International Women's Year, during which a series of events around the world will pay a just and perhaps belated tribute to the contri- butions made to human society by the so-called "second sex". World Health will contain articles on woman's changing role in different regions of the world, on equality of oppor- tunity, and on changing attitudes in modern society. International Women'sYear 1975 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/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland US $ * £ * Sw.fr.* One Year 5.60 2.40 16.- Two Years 9.80 4.20 28.- Three Years 14.— 6.— 40.— Health worker in Viet-Nani (see p. 22) Cl) • CC E E 0. ;