Sexually transmitted diseases and AIDS; Diabetes in youth; Nutrition; Caring care [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION NOVEMBER 1985 Cover: Infertility in Africa. Sexually transmitted diseases are often the culprit (see facing page). Photo WHO/B. Genier IX ISSN. 0043-8502 World Health is the official magazine of the World Health ,,,, i illustrated Organization. Editor: John Bland Deputy Editor and this month's Theme Editor : Christiane Viedma Art Editor : Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French, German, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be repro- duced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Table of Contents Sexually transmitted diseases by Sue Armstrong 3 Caring care by Jaswant Singh Neki 7 Harvard's Takemi Programme Lincoln Chen interviewed by Ian Steele . 10 The Joint WHO/UNICEF Nutrition Support Programme by Michael Gurney 13 Vitamin A saves sight ! 16-17 Lifestyles and diet by Carlos Marti Henneberg 18 Acupuncture: Towards a standard terminology by Olayiwola Akerele and Liu Guo-bin 20 Diabetes hits young people too by Ricardo E. Fernando 22 latrogenic disease: An epidemic of our time by Constantino landolo 26 • Departments Education for health AIDS: be informed 6 Books and publications A doctor's guide to "reading" of X-rays 25 Primary Health Care The Dogon people fight endemic disease by Mabo Kassambara 28 News Page 30 WORLD HEALTH, November 1985 Sexually transmitted diseases Syphilis, gonorrhoea and other venereal infections are already at pandemic level around the world. Control of these diseases calls for an increased sense of responsibility in the public at large by Sue Armstrong ! A Hp night with Venus ; a life- time with Mercury" was a quip familiar to the British armed forces till the early part of this century. It referred to the fact that even brief indulgence in the pleasures of the flesh could expose a person to venereal diseases (VD), particularly syphilis for which the mainstay of treatment at that time was the application of mercury ointment to the skin, or taking of mer- cury by mouth. The treatment was pro- longed, the side-effects very unpleasant, and few patients were really cured. In most people, the disease ran its course inexorably, causing ulceration of the skin, affecting bones, heart and nervous system, and leading finally to paralysis, madness and death. History is dotted with famous and less famous VD sufferers, and the stigma the disease carried could be considerable. In 15th century Scotland, prostitutes with venereal disease were branded on the cheeks with a hot iron and driven from town. And in Missouri, USA, as recently as the late 19th century, prostitutes found infected were committed to a Social Evil Hospital. Doctors generally considered VD as just retribution for immorality. Nevertheless, it was esti- mated in the late 19th century that approximately five per cent of people in the USA suffered from venereal dis- eases, while 17 per cent of the popula- tion of France, and 20 per cent of the British Army were similarly affected. Earliest efforts to control the high inci- Facing page: More than 20 pathogens are now known to be transmitted sexually. Con- trol of these diseases calls for an increased sense of responsibility in the public at large. Photo WHO/P. Almasy dence of VD concentrated on the regu- lation and isolation of prostitutes but did little for VD patients. The discovery in 1942 that penicillin could effect a cure was the start of a revolution in the treatment of VD (now more commonly known as sexually transmitted diseases, or STD). Though AIDS—aquired immune' deficiency syn- drome—is now among the most serious sexu- ally transmitted diseases. Seen through the electron-microscope, the dreaded AIDS virus resembles an exotic flower. Photo Institut Pasteur O it is as serious as ever if left untreated, syphilis is no longer considered the threat it once was. Its estimated inci- dence in the developed world at least has dropped considerably; to about one case per 10,000 in the U.K. and four to six cases per 10,000 in the U.S.A. , for example. And the focus of attention has shifted to a wider range of sexually transmitted infections which, because of their frequency and the complications they can lead to when untreated, consti- tute today a very serious public health problem worldwide. Throughout the centuries and up to this day, people often thought that gonorrhoea and syphilis were one single disease, and did not realise that there are more than 20 pathogens now known to be transmitted sexually. Their range and the frequency of the diseases they cause vary greatly from one country to another. However, on a global scale, the most talked-about STDs are still syphilis and gonorrhoea. This is not necessarily because they are more prevalent, but is due to the fact that the health profession often tends to overlook the other infec- tions, these two diseases being more easily identifiable. In developed countries today, non- gonococcal discharge (urethritis) is al- most twice as common as gonorrhoea. About 50 per cent of it is caused by Chlamydia trachomatis. Other STDs are caused by the parasite Trichomonas vaginalis, the fungus Candida albicans, and virus diseases such as genital herpes, genital warts, and hepatitis B. Chan- croid, known also as soft chancre, a painful condition once common but now rare in developed countries, is still com- mon in some tropical areas. The recently recognised acquired immune deficiency syndrome (AIDS) has been added to the list of serious STDs, and there is as yet no way to reverse this potentially fatal condition. Many factors are responsible for what some consider a " pandemic " of STDs, the most important being the social climate. In developed countries over the last 20 years, increasingly accessible and reliable methods of contraception have encouraged freedom of sexual expres- sion, particularly among young people. In many developing countries, mass migration from the poor rural areas to WORLD HEALTH, November 1985 3 In many developing countries, mass migra- tion from the contryside has increased oppor- tunities for casual sexual contact and has loosened social controls. Photo WHO/C. Viedma the cities in search of a better life has torn the old social fabric ; opportunities for sexual contact have increased, and social controls have loosened. Often, it is not so much a question of freedom as of necessity ; in the overcrowded cities, competition for work is fierce and some youngsters turn to prostitution to sur- vive. The great increase in sexual activ- ity, both heterosexual and homosexual and much of it with multiple anonymous sex partners, means that the source of any infection is ever more difficult to trace. Although hard data are often unavail- able, it seems that the incidence of STDs is higher in urban areas than in the more conservative countryside where, how- ever, complications may be more fre- quent due to the lack of appropriate treatment at an early stage of the disease. In 1924, an international effort was made, through the Brussels Agreement, to control the spread of STDs from one continent to another by providing free treatment for sailors on ships and at ports. But in the years since the Agreement, new itinerant population groups have emerged (international travellers, for instance) who, because of the vast numbers of people involved, have become a considerable burden for health services. And though sailors and prostitutes are still groups with a par- ticularly high incidence of infection, the spread of disease in the population is today so generalised that any sexually active person is at potential risk of infection—this risk increasing with the number of sexual partners involved. Moreover one infection does not give immunity against further disease. Advances in diagnosis and treatment of STDs are only half the picture of control. For many reasons sufferers do not come forward for treatment at an early stage, if at all. Despite greater sexual freedom, there is still a great deal of ignorance and misunderstanding of the possible health consequences. Many people believe venereal diseases "hap- pen to other people ". In fact, the reser- voir of infection is enormous, and the risk of a man contracting gonorrhoea on a single contact with an infected woman is estimated to be about 22 per cent (for a woman, on a single contact with an infected man, the risk is about 50 per cent or more). Moreover about 50 per cent of infected females and 10 per cent of infected males are estimated to be asymptomatic, but contagious, carriers of the diseases. All control programmes emphasise the need to treat not only the person diagnosed as having an STD, but his or her sexual contacts too. This is essential, even when the partners do not have any disease symptoms, in order to stop the disease from spreading and to avoid a possible reinfection after treatment. Furthermore, every patient who seeks treatment for a venereal infection pro- vides a unique opportunity to reach the large pool of persons who are unaware of being infected. Very often, this necessary step is ignored by busy health staff or is difficult to carry out in case of casual contacts. The international spread of STDs has serious implications. The large dose of penicillin needed to cure gonorrhoea often proved effective treatment for a syphilis infection which had been ac- quired at the same sexual encounter. However penicillin-resistant strains of gonorrhoea emerged in East Asia and West Africa in 1976, and have since been spread by travellers all over the world. Furthermore, a variety of resist- ance patterns have been observed, so 4 WORLD HEALTH, November 1985 Sexually transmitted diseases that a number of other antibiotics have become ineffective. Alternative antibiotic treatment which now needs to be applied to these penicillin-resistant strains, known as penicillinase-producing Neisseria gonor- rhoea (PPNG), may cost up to ten times as much as penicillin treatment, putting a heavy financial burden on some health services. Furthermore, most treatments for PPNG are much more disease- specific, leaving other pathogens unaf- fected, including syphilis. STDs still carry a social stigma of varying intensity, and many patients feel shame and inhibition about seeking treatment. Yet the consequences of un- treated STD can be very serious. In women the infection can travel upwards from the cervix to cause pelvic inflam- matory disease (PID), which currently affects one million women a year in the USA, and frequently results in partial or total occlusion of the fallopian tubes leading to ectopic pregnancy and infer- tility. The most frequently diagnosed causes of PID are gonorrhoea and chlamydial infections. Apart from the personal anguish of the condition, infertility in many coun- tries means terrible humiliation and loss of social identity. Yet it is more common than is generally supposed, and in some regions of the Third World, over 50 per cent of infertility is thought to result from PID. The consequences of untreated STDs in pregnant women can also be serious. Miscarriages and stillbirths are very common. Of those babies born alive to syphilitic mothers, 30 to 40 per cent may themselves be infected and may already have suffered irreversible damage in utero, though they can subsequently be cured of disease. In Lusaka, Zambia, about one per cent of newborns have congenital syphilis, and about five per cent of stillbirths and neonatal deaths in some parts of India are attributed to this. Chlamydial infections, syphilis and gonorrhoea in the mother frequently Sufferers from venereal diseases often try a treatment "recommended" by a friend. In fact these infections need to be treated by health professionals—a point that sex educa- tion for young people has to emphasise. Photo WHO/E. Mandelmann WORLD HEALTH, November 1985 cause conjunctivitis in the newborn, and genital herpes can cause neonatal en- cephalitis. So what of the future? In the absence of effective vaccines that could help to prevent STDs, there is a need every- where to increase public awareness of the problem through information and long-term health education programmes starting in childhood and aiming at changing people's health and illness be- haviour. Some people have recognised that there is resistance in healthy indi- viduals to information about the risk of disease ; it is therefore recommended that health education focus on current sufferers, who are more likely to be- come committed health promoters among their peers, the more so when one realises that about 25 per cent of STD patients are repeaters. In order to increase the competence of health services to deal more effective- ly with the STD problem in the com- munity, wHo has given priority to de- veloping methods and technologies which will enable health centres and clinicians with minimal or no laboratory diagnostic support to improve control of these diseases. In such a "simplified STD control approach", precise instruc- tions in the form of flow charts (adapt- able to the specific problems of various countries or areas) are provided to the health workers to guide them in the appropriate management of patients with suspected STDs, and of their sex partners. To bring about a significant reduction in disease transmission and the develop- ment of sequelae, these clinical activities will have to be supplemented by other control strategies, such as improved methods of diagnosis, screening for asymptomatic cases, and promotion of changes in health and illness behaviour. All these strategies should have the support of the community. To avoid the further spread of resist- ance (which is caused largely by misuse of antibiotics), patients affected with STDs are urged to comply with treat- ment provided by health professionals and to refrain from trying to treat them- selves. Preventive measures such as the use of condoms, diaphragms and sper- micides as partial barriers to infection are advised and better still, more dis- crimination in the choice of partners. In the end, successful control of this group of infectious diseases will depend as much on advances in the clinical field as on an increased sense of responsibil- ity among the public. ■ Education for Health AIDS : be informed T he key to slowing the spread of the AIDS (Acquired Im-mune Deficiency Syndrome) virus is education and information of health and social workers, individuals at high risk of infection, and the general public. Health and social workers need a basic understanding of the clinical features of AIDS, the mode of trans- mission and the associated risk of infection to be able to counsel pa- tients and those at risk. Health work- ers must be aware of the precautions to take in caring for AIDS patients and in handling their specimens. They must also develop a more com- passionate attitude towards patients. In Australia, Europe and the USA, where AIDS is most common in homosexual men, the problem may be compounded by intolerance of homosexuality. Both health professionals and the public need to know that : The spread of the AIDS virus is most often linked to intimate contact involving the transfer of blood or semen. Among sexual practices, anal intercourse is believed to be the most efficient mode of transmission. It is now clear that the virus is present in saliva, tears and urine. No one knows how easily viruses in such fluids can infect other people. Intimate kissing in which saliva is exchanged could lead to disease transmission if the uninfected person has any cuts sores, or bleeding gums in the mouth. The use of condoms may de- crease the risk of transmission but does not guarantee full protection. Any other activity involving the possible exchange of blood—such as the sharing of razors and tooth- brushes—should be avoided. Espe- cially dangerous is the sharing of hypodermic needles and the use of needles and syringes of suspect sterility. Intravenous drug abusers, in Europe and the USA, are the group at next highest risk after homosexual men, and the medical use of impro- perly sterilized or unsterilized syrin- ges and needles is thought to play a role in AIDS transmission in some parts of the world. Women suffering from AIDS or who are at high risk of infection should avoid becoming pregnant, since the infection can be transmit- ted to the unborn or newborn baby. The AIDS virus can be transmitted through blood transfusion. Most coun- tries now have legislation requiring the blood of donors to be tested for signs of the virus. Photo WHO/P. Almasy By the end of October, some 16,800 people were reported as hav- ing the disease. Information about the course of infection is incomplete, but the majority of adults will not acquire clinically apparent AIDS in the first few years after infection. In some studies, five to nineteen per cent of seropositive homosexual men developed AIDS within 2 to 5 years after a previously collected serum sample was retrospectively tested and found to be seropositive. The long-term prognoses for most persons infected with the virus is unknown. It is estimated that there are 800,000 to one million carriers who are symptom free but capable of infecting others in the USA alone. The immediate task is to provide moral support and whatever treat- ment is available to those already suffering from the disease, and to ensure that they and the "silent" but infectious carriers avoid spreading the virus still further. There is no known specific cure for AIDS but a number of antivirals are at present being tested. Scientists are not optimistic about the chances of developing a vaccine in the immedi- ate future. Early in the AIDS epidemic, the World Health Organization recog- nized the need for coordinating the research and surveillance that was going on independently in many centres, and for disseminating the information being gathered. Follow- ing the wHo-sponsored international conference on AIDS held last April in Atlanta, Georgia, USA, the Organiza- tion convened a group of experts to review the data presented at the conference and propose further ac- tion to be taken by WHO and its Member States. Similarly, the WHO European Office took the opportunity to develop guidelines for European countries on how to contain the dis- ease. WHO's role in the health educa- tion of the public and of health care workers is deemed crucial. The Organization is also acting, as recommended by the experts, to coordinate global surveillance of AIDS, assess the risk of the disease country by country, assist in the development of a vaccine, and set up a network of collaborating centres to be responsible for staff training and specialist advice as well as for epidemiological research. ■ See also WHO Chronicle, Vol. 39, No. 3 (1985) 6 WORLD HEALTH, November 1985 Caring care by Jaswant Singh Neki F Photo WHO/J.-F. ChrOtien ailing ill is an ubiquitous experi- ence. So too is the relative help- lessness that goes with it. Those engaged in providing care to the sick are often heard talking of "meeting pa- tients' emotional needs "—" giving them emotional succour"—" mitigating their emotional stress. " Such phrases have been with us for many many years. Yet they have reflected more of our inten- tion and less of our actual action. Neg- lect of patients' emotional needs is still an everyday occurrence in our hospitals. A young man was admitted to hospi- tal with abdominal pain. The consultant, the resident, the house physician, the nurses—all were busy investigating him. The doctors spent considerable time enquiring about the development of his symptoms. The nurses spent much effort making him confortable. But suddenly the interest seemed to come to a stand- still. The doctors would hurry past him during the ward rounds. The residents would pretend not to notice him The nurses would glance away from him. And all because the investigations re- vealed that he was suffering from cancer of the stomach which had already spread considerably. Just when this patient needed much more psychological care, he was receiv- ing much less. Nobody told him that he had cancer. His relatives had been in- formed, yet even they adopted a hush- hush attitude. He was perplexed, but his perplexity met only with further cold indifference. The patient felt emotion- ally deserted. Sickness magnifies one's dependency on others. One is more and more in need of " tender loving care. " In a bid to attract such care, the sick person often regresses to an infantile level, demand- ing to be handled and nursed. Yet this infantile regression is protective. It evokes other people's sympathy and tender loving care which will contribute to recovery. A young woman had her first child, but within a day her baby died for no identifiable reason. She was left alone in an acute agony of grief until the nurse who had delivered her child came to know about it. This nurse felt distressed at the woman's ordeal. She sat by her, talked to her, but—more than talking —let her talk and work out her grief. She patted her on her shoulders, applied a cold cloth to her head, wiped away her tears and comforted her in whatever way she could. With every act, she communicated to her patient how much she cared for her. Bereavement is a very severe stress and calls for tremendous sympathy and emotional succour. Luckily, it is so familiar that it generally evokes appro- priate responses. Other conditions are less easily visible, or do not evoke help- ful emotional responses. Illness-denying and illness-affirming are two such ad- verse behaviour patterns. Denial of illness has been written about quite extensively in medical literature. It is an adaptive manoeuvre for reducing anxiety generated by crippling, disabling or socially unaccept- able diseases. Denial allays anxiety by reducing the perception of the threat. Many mental mechanisms, such as dis- WORLD HEALTH, November 1985 7 The emotional needs of patients are all too often ignored in hospitals. Tender and loving care, whether from health professionals or from relatives, contributes to quicker recovery. Photos WHO/B. Genier sociation, repression, selective inatten- tion and suppression, seem to help by barring the entry of unpleasant material into our consciousness. When we cannot escape or combat a threat, 'anxiety may be reduced by denying its existence. It is a kind of "ostrich response" in the face of danger. Denial of disease can seriously inter- fere with the treatment programme. A patient came to the hospital with anginal pain. After examining him and taking his electrocardiogram, the doctor ad- vised him to remain in bed for at least a couple of weeks, since he had found evidence of a massive infarct. But the patient said nonchalantly : " Oh, doc ! this is just a mild pain in my chest and will go away soon. You don't have to restrict my activity. I assure you, I can run a mile even now. " He was denying his illness more to himself than to his doctor. And this denial exacerbated his condition. Management of denial Management of denial is a delicate affair. Health personnel must first rec- ognise the presence of denial and assess how it is impeding the patient's recov- ery. They must also determine what need it appears to fulfil for the patient. A patient who completely denies a life- threatening illness like coronary disease needs his denial to be attended to ur- gently. Still, we have to be careful. The denial may be the emergency " brake " that is preventing complete disorganiza- tion of the patient. If the denial is too forcibly undermined and the patient is brought face to face with stark reality too quickly, he may suffer an even greater upheaval. Patience and perse- verance often work better. Physicians themselves sometimes en- ter into a " conspiracy of denial, " espe- cially if the patient is a senior official, a fellow professional or a member of the physician's own family. The physicians may tend to deny or laugh off the sickness or its gravity, and thus buttress the patient's own denial of his sickness. While the denial of illness can have grave consequences, no less serious can be illness-assertion. Sickness bestows certain benefits on the sick person. It insulates him or her from a variety of 8 WORLD HEALTH, November 1985 Caring care social obligations. During the sickness, not only is he exempted from ordinary role-obligations, but is also given the right to receive care. Many patients come to like sickness for the sake of these gains, and such " illness-assertors" can even invent symptoms when there is no real sickness. To this category also belong the hypochondriacs who "keep inventing ills for their pills. " They be- come chronic grumblers, convinced that they have a unique illness which no doctor is able to diagnose or treat. One patient claimed for years that he had a cancer in his stomach. He was asked if he would be reassured if his abdomen were opened under local anaesthesia and could be shown to be normal. But the patient retorted that even that wouldn't reassure him. Illness-assertors are often written off by their family, friends, and physicians as malingerers. They begin to be spoken of disrespectfully. Yet the psychogenic complaints they have are real, disabling and disturbing. Psychological impact of technology While modern medicine has enlarged our armoury for treating illnesses, it has also opened new avenues of psychologi- cal distress. One has only to think of renal dialyses, cardiac pacemakers, in- tensive-care units and the like. Many studies have shown that these new therapeutic measures are fraught with unprecedented emotional upheavals. Reactions of depression and irritability are often found in patients who have been in intensive care and found the experience horrifying. On the other hand, some patients develop a psychological dependence on the " se- curity " provided by the unit and feel anxious when they have to leave it. The staff working in such units also face unusual stress. They have to work harder than others, frequently pass sleepless nights, and have to witness Just as psychological and social factors influ- ence illness, so the psychological component in treating physical illness offers wider op- portunities for patient care. Photo WHO/J.-F. Chretien WORLD HEALTH, November 1985 death more frequently. They too need emotional care. There is often a rapid turnover of nurses in such units, but sometimes more is needed. Strategies of emotional care that should accom- pany these " high-tech " therapeutic ap- proaches still have to be worked out. Health personnel today constantly find themselves challenged by psycho- logical and social factors which influence illness. Psychological help is recognised more as an important aspect of the care of physical illness—indeed the psychological component in the treat- ment of physical illness enlarges patient= care opportunities. It may well be said that caring care has become even more essential as a result of the changes which have occurred in health care delivery today. • Harvard's Takemi Programme Dr Lincoln Chen, an international expert on Third World health problems, has been named as the first Takemi Professor of International Health at the Harvard School of Public Health. Dr Chen has also been appointed Director of Harvard's Takemi Programme, which was named in honour of the late Dr Taro Takemi, an eminent Japanese physician and President of the Japanese Medical Associ- ation for more than 25 years. Dr Chen is the Ford Foundation's representative in New Delhi and is responsible for its work in India, Nepal and Sri Lanka. He will continue those duties until the end of 1986 when he will take up his new post at Harvard. He was interviewed for World Health by journalist Ian Steele in New York World Health: As the first Professor of International Health at Harvard, you have the opportunity to plot the course and future direction of the Programme. Do you have a list of priorities—projects you would want the Takemi Programme to pursue ? Dr L. Chen: There are two consider- ations here. The first is the rationale of Harward University in setting up the programme, and the second is what the Takemi Programme might do within the context. It seems to me that the impor- tant thing in terms of Harvard's decision is a commitment to involve the Univer- sity in international health issues—in the needs of poor people living in poor countries. We are talking here of the major health problems of the great majority of mankind ; problems such as malnutrition, infectious and parasitic diseases, and population growth. A most important part of the Takemi Pro- gramme is the manifest expression of the University's interest to involve the institution in the search for solutions to these problems from a research and educational perspective. The pro- gramme itself is structured to encourage an exchange at Harvard of ideas, ex- perience and knowledge in these areas through Takemi fellows from develop- ing countries. It has the capacity both to strengthen the role of people working in the front line against these problems and to use Harvard as a crossroads. The approach is more directly one of "let's share our knowledge" rather than of " let's teach them something. " This is an Professor Lincoln Chen (right), recently ap- pointed Takemi Professor of International Health at the Harvard School of Public Health and Director of Harvard's Takemi Programme. Photo WHO/Ford Foundation environment where different people from many different backgrounds can share and learn. The Takemi Programme in its current form is not a degree programme, which means it is not attempting to certify the professional credentials of someone from the Third World. Rather it is a research and exchange programme. I think one could argue that the Takemi fellows will get as much out of sharing amongst themselves and with interested faculty members as they would from taking University courses. WH: What kind of exchange do you envisage between doctors from the Third World and those from Harvard ? What cross-fertilization would you anti- cipate ? LC: Substantively, the areas of greatest interest are in international health poli- cy and management. In the United States, we have a revolution going on in the life sciences. Without doubt, over the next decade or two there will be major breakthroughs in the develop- ment of new technologies which may profoundly affect the capacity of societies to prevent and deal with some of the major diseases affecting mankind. These will be developed both in laboratories such as those at Harvard and also more and more in the Third World. These technologies do not oper- ate in isolation. Their delivery, the ac- cess to them by the disadvantaged, the systems that will be required to produce them, and the interaction with social organizations—community delivery sys- 10 WORLD HEALTH, November 1985 tems—are all issues which a programme like the Takemi can nurture by bringing people together from both the biomedi- cal and the social sciences. Another area of great interest is the organization and management of health care delivery. Primary health care in the Third World is clearly going through an evolution. Much of the emphasis has been placed, and should be placed, on public health systems to deliver basic services to the poor. But these systems face challenges and there are other forms of delivery systems, for example private voluntary agencies or social mar- keting, that are exploring new and in- novative directions. This could be another area of exchange and learning. WH: In a sense there has been a re- invention of the wheel in recent times. I'm thinking of the renewed focus on breastfeeding, immunization against preventable diseases, oral rehydration. Is this a revolution, and what impact has it had on health policy here and in the Third World? LC: I think it is a revolution, as is primary health care which preceded it. It is a revolution in terms of a public perception that people can take charge of their own preventive, promotive and curative health care. It's also a tech- nological revolution. This is not re- inventing the wheel. Many of the vac- cines were not available 30 or 40 years ago. Oral rehydration— scientifically- based—is not an old remedy, it's a new one. But it is true breastfeeding has been there all along. This revolution involves technological change along with social change, both of which are elements of primary health care. The revolution is affecting thinking in the Third World and I think, just as importantly, it is affecting thinking in the "First World " —the industrialised one—where we have very major prob- lems in the cost and management of technologies in health care. WH: But there are hurdles, obstacles, inhibitions ? Could you elaborate ? LC: The overwhelming bulk of govern- ment resources continues to be directed at curative services in the Third World. All too often primary health care might be just an additional programme, some- thing added on. The heart of primary health care is social change in addition to technical change. Social-technical change, if it is to succeed, will have to The Takemi Programme calls for involvement in the needs of poor people in the under- privileged countries, and the sharing of knowledge between rich and poor countries. Photo/WHO/UN/J.-P. Laffont (above) and WHO/B. Genie( WORLD HEALTH, November 1985 11 Social change, as much as technical change, is the heart of primary health care. In India, women's organizations are active in bringing about changes that favour better health. Photo WHO/UN/SEWA involve a restructuring of resource allo- cation, a reorientation of the medical profession, an increased awareness by communities that they can improve their own health through basic, simple tech- nologies which can be made available. WH: How can the Takemi Programme influence that thinking LC: I think the most important influ- ence the Takemi Programme can have is by demonstrating that these kinds of issues are important in industrialised countries as well. Having these orienta- tions at a distinguished First World University might in fact be more impor- tant than the individual products that come out of it. The primary health care movement needs First World as well as Third World support. WH: Technological medicine is rapidly outstripping the capacity of both rich and poor nations to pay. How do com- munities, governments and programmes like yours reach an accommodation be- tween the capacity to save life, and the reality for most people, which is an early death ? LC: At the first level, it appears to be a question of the cost-benefit, cost-effec- tiveness, of medical technology. At a deeper level, we are dealing basically with ethics : how much value to put on human life. How does a society value life both collectively and individually? Which parts of a life cycle are valued ? The Takemi Programme hopes to facilitate exchanges on issues as funda- mental as these—issues such as resource allocation, responses to ethical consider- ations. WH: What are the most critical health issues facing the world today? Popula- tion growth, declining mortality, rising aspirations ? What are the baseline con- cerns ? LC: There are several basic forces which I believe will shape international health issues over the next two decades. As you mentioned, the first is rapid population growth, which is creating new types of settlement, distribution and structure in developing countries that will need to be accommodated. For example, the world will have to create an additional 500 million jobs between now and the end of the century. And 440 million of these will have to come from within the Third World if we are to avoid massive, increasing unem- ployment. The second factor is something which has only emerged clearly in the last ten years. That is, there is no such thing as a Third World. Each country, each cul- ture is going through social and eco- nomic changes which will not necessarily follow the pattern of another society. We are witnessing in fact a pluralism of change, and we understand it very poor- ly at this point. It is increasingly difficult to generalise across continents like Asia, Africa and Latin America or within regions such as North Africa or sub- Sahelian Africa. We can no longer lump the Third World together as one categ- ory. We must begin to cope with prob- lems within the social units that are evolving. A third factor is the revolution in life sciences, in technology, which I believe will have a profound effect on the prim- ary health care revolution. Finally, I think this revolution is not just in medi- cal technology but in communications, and this is profoundly affecting the aspi- rations of people. They are no longer prepared to wait for some other genera- tion to have better health. Public health systems are having an increasingly dif- ficult time coping with these expecta- tions. But just as this is profoundly affecting aspirations and expectations, it also has the power to decrease the gap between those who have a technology and knowledge, and those who need it. Simultaneous processes are at work. The biggest challenge will be to en- sure social justice through this process over the next two decades and I hope that, however modestly, the Takemi Programme can contribute towards bringing this about. ■ 12 WORLD HEALTH, November 1985 The Joint WHO/UNICEF Nutrition Support Programme by Michael Gurney The world is shocked by the famine in Africa, which has cre-ated a great wave of concern. Let us consider two facts that put the emergency into its long-term perspec- tive. Even where famine does not exist, a baby born in the third world is, on average, four times more likely to die before his first birthday than one born in a rich country (infant mortality rate 85 and 20 respectively per 1,000 births). Comparative mortality is still worse among toddlers : pre-school age children in the third world are on average twelve times more likely to die before the age of five (age one to four mortality rate 50 and four respectively per 1,000 in this age group). In fact, of course, there is a wide range of death rates, with some countries being much worse than the third world averages and others better than the rich country averages, and others falling in between. Nevertheless all mortality higher than the rich country averages is theoretically preventable. Preventable mortality The fact that this "preventable mor- tality" is comparatively worse amongst toddlers than babes-in-arms is largely due to the enormous influence of mal- nutrition coupled with poor sanitation. The result is all too often severe and repeated infections which in themselves inevitably worsen the nutritional status of a child. In countries where poverty prevails, governments, communities and indi- viduals often find themselves unable to respond adequately to poor nutritional conditions, repeated infectious diseases, and lack of hygiene. Children conse- Millions of children in the Third World suffer from malnutrition, and a large propor- tion of them die before the age of five. Of those who survive, many will know a lifetime of low nutritional status. Photo WHO/M. Vanappelghem quently die from a combination of these factors. Those who survive the critical period from birth to the age of five .may have their growth and development per- manently impaired by continuing mal- nutrition and repeated infectious ill- nesses. Certainly famine deserves emergency attention. But chronic malnutrition and famine are both part of the same development problem. As Dr Halfdan Mahler, the Director-General of wHo, has said in this context, "the emotions aroused by the good cause to be sup- ported are so great that few dare to talk of tomorrow for fear of being accused of betraying today. True, empty stomachs have to filled today. But in the final analysis people have to be helped to feed themselves ; otherwise they will remain for ever a socially apathetic burden on the world, instead of con- tributing to its riches through their energy ". We must have "faith in development ". Seeking a remedy In November 1980, Dr Mahler and Mr James Grant, the head of the United Nations Children's Fund (uNicEF), met to assess the situation. The result was the drafting of a joint programme to improve the nutritional status of chil- dren and women through develop- mental measures based on primary health care. The Government of Italy agreed to fund in full the estimated cost of US$ 85.3 million. When a tripartite agreement was signed in Rome in April 1982, the WHO/UNICEF Joint Nutrition Support Programme (JNSP) came into being. It was agreed that resources would be concentrated in a number of countries to develop demonstrable and replicable ways to improve nutrition. Global ac- tivities would be included only if they supported country action, for example through management support, relevant research, training, public information, and publications. So far, projects are underway or are just starting in 17 countries in Africa, Asia, Latin America and the Caribbean. In most of these, infant and toddler mortality rates are much higher than the third world averages quoted earlier. WORLD HEALTH, November 1985 13 Breastfeeding is vital for a good nutritional start in life. Promoting this practice among mothers forms part of many JNSP projects. Photo WHO/PAHO/J. Vizcarra The nutrition objective The objectives of the Programme are to reduce infant and young child diseases and deaths, and at the same time to improve child health, growth and development as well as maternal nutrition. These objectives will not be achieved through a programme that deals with diet and food alone. The other causes of malnutrition need to be dealt with as well. Thus JNSP includes nutrition and many other activ- ities, such as control of diarrhoea. How- ever the aim of all these activities is better nutritional status leading to better health and growth and lower mortality. Just as feeding habits and family pat- terns differ from one country to another, so do the JNSP country projects. Haiti, for example, prefers to direct its main activities towards promoting oral rehyd- ration therapy and breastfeeding, while Bolivia has chosen to concentrate on eradicating endemic goitre and cretin- ism. Most countries have however adopted a much wider approach : in Burma, the project mainly extends health service coverage on a national basis ; Ethiopia works through mass or- ganizations—the Peasants Association and the Women's Association in par- ticular. But they all are based on the primary health care approach ; they are applied to local situations by local peo- ple with, it is hoped, the active involve- ment of local communities. Most JNSP projects are adopting a multisectoral approach, incorporating varied activities that directly improve nutritional status. Activities involve agriculture and education as well as health—but are only included if they can be expected to lead directly to improved nutrition. It is not automatically as- sumed for example that any agricultural activity will have a positive effect on nutrition ; a project that involves shifting from food to cash crops, can actually worsen the nutritional status of farming families, at least in the short run, and in the short run children can die. JNSP is unusual in two ways : firstly, nutrition improvement is the main objective and not just an assumed by-product of the programme ; secondly, the ways adopted to achieve this "nutrition objective" go beyond food alone. A multisectoral programme requires multisectoral management and involves 14 WORLD HEALTH, November 1985 Haiti In Haiti the JNSP works with the Department of Public Health to re- duce the high rates of malnutrition and infant and young child mortality. Malnutrition affects one out of every three or four children, and the official infant mortality rate is 125 per 1,000. Children under five represent 15 per cent of the population, but 41 per cent of all deaths. The most common im- mediate cause of child death is diar- rhoeal disease, occurring where food intake is low, weaning practices poor and personal and domestic hygiene often deficient. The two basic strategies of the project are, on the one hand, to pro- mote breastfeeding and appropriate weaning practices through public edu- cation and the mass media and, on the other, to promote oral rehydration therapy against diarrhoea by develop- ing the ability of the public and private sectors to promote and distribute packets of oral rehydration salts. Staff from the health, education and other sectors are being trained in diarrhoeal control and the promotion of oral rehy- dration therapy. So far 2,291 health workers have been trained—more than the original target figure—and a further 2,875 non-health personnel have also received training. A mass media campaign is well underway. Over 400,000 packets of oral rehyd- ration salts were distributed in 1983, and another 400,000 in the first half of 1984. Commercial promotion of the salts includes establishing sales posts to improve people's access to them ; already 596 such posts have been set up. In 1983 about one fifth of mothers in the capital city, Port-au-Prince, used ORT for their children when they got diarrhoea. Now, in 1985, four-fifths do so—a great improvement. However the amount of diarrhoea remains very high; on any one day about a fifth of children in the slum areas of Port-au- Prince have diarrhoea. JNSP appears to have reduced the effects but not yet the cause—much more needs to be done. A multisectoral Health Education Committee has assumed responsibil- ity for developing posters, pamphlets and radio and television spots. Sepa- rate committees in each of the 15 health districts are developing and disseminating messages for health programmes. A big review of the programme is planned. Promotion of breastfeeding is only just starting, but some educational materials have already been produced and a full-scale strategy and work plan are being developed. ■ Adapted from JNSP Newsletter in Nutrition Planning, Vol. 6, No 3. Another JNSP endeavour—ensuring that the community elders are involved in the decision-making process, as here in Ethiopia. Photo WHO/J. Bland coordination at all levels—district, pro- vincial and national. This has been one of the most difficult things to get going in many JNSP projects and yet one of the most important. In some countries, support for the project is provided by national nutrition institutes. As in Ethiopia and Tanzania, these already have an intersectoral outlook. In Dominica and St. Vincent this role is undertaken by an inter-country institu- tion, the Caribbean Food and Nutrition Institute (CFNI), and in Nicaragua by the Institute of Nutrition of Central America and Panama (INCAP). Most JNSP projects have led to the develop- ment of a national intersectoral coor- dinating mechanism that will have ben- efits beyond JNSP itself. In all these projects, community in- volvement is vital. Its success can only be judged as the projects unfold, but early experiences from several countries are encouraging. Mechanisms for such community participation are develop- ing. In Peru, for instance, decision- making is very decentralised, in line with ancient local tradition, and this experi- ence could yield lessons for the future pattern of social and economic develop- ment in that country. Nevertheless, will the project managers in the various countries have the courage to let com- munities run their programmes ? And will they have the knowledge and sup- port to provide the right help at the right time ? Only time will tell. ■ WORLD HEALTH, November 1985 15 Nutritional blindness occurs when supplies of vitamin A stored in the body run out, when replenishment is insuffi- cient, or when intestinal ab- sorption is hampered by infec- tion or protein-energy malnutrition. Vitamin A is obtained from animal products like liver, milk, butter or eggs, containing a preformed vitamin A called retinol, or from dark green leafy vegetables or yellow vegetables and fruit containing a provita- min A called carotene which can be metabolised by the body into vitamin A. Vitamin A deficiency strikes most dramatically at the eyes, producing night blindness (vision is impaired at night), and dryness of the eyes leading eventually to ulceration of the cornea and necrosis of the eye. Even mild states of deficiency will make children more vulnerable to gastro-intestinal and pulmonary infections, and may increase the mortality caused by these diseases. Young children are the most vulnerable, since their vitamin A needs are relatively higher and they are more prone to febrile illness that rob the body of the vitamin A. The younger the child and the more severe the deficiency, the higher the risk that corneal destruction will be followed by death. Sixty to seventy per cent of all untreated victims die within weeks of going blind. Last October WHO launched a 10-year pro- gramme to support its Member States in their fight against nutritional blindness. This programme will adopt three types of measure that have already demonstrated their efficacy : the short-term dis- tribution of two to three capsules containing an oily preparation of retinol (see inset) per year to chil- dren at risk ; the long-term approaches such as information and education campaigns, and increased production and consumption of foods rich in Vitamin A; and the medium-term solution provided by fortification of a widely consumed food or seasoning, such as sugar. These measures can be implemented within the established struc- tures and are particularly well-suited to the Primary Health Care approach advocated by WHO. ■ Vitamin Half a million children become blind every year for lack of vitamin A. Two thirds of these die within a few weeks. Six to seven million suffer from moderate forms of vitamin A deficiency. Photo WHO/FAO/S. Bunnag 44S1111e. g-3s4.-1 Facing page, above: Every day—foods rich in vitamin A. Photo WHO/Department of Information, Kenya Infections drains the body of its essential nutrients, including vitamin A. This pattern is particularly true in conditions of poverty. Preventing infections helps to prevent nutritional blindness. Drawing by J.-F. Chretien Below.: Mother's milk is rich in vitamin A, so children should be breastfed as long as possible. Lactating mothers should receive small vitamin A supplements. Photo WHO/M. Jacot WORLD HEALTH, November 1985 Nutritional blindness can be effectively counteracted by supplementing the diet with vitamin A capsules, at a cost of four US cents per child per year. Yellow fruits and vegetables such as mangoes, papayas or carrots, and dark green leafy vegetables, such as spinach, in the diet will prevent nutritional blindness. Primary Health Care workers can efficiently distribute vitamin A cap- sules. They are also well placed to provide continu- ing nutrition education and monitoring. Drawings by J.-F. Chretien 17 1 A saves sight Lifestyles and diet In some parts of the world, affluence has led to changes in dietary habits that are positively harmful to health. Correcting such habits is a major behavioural problem by Carlos Marti Henneberg In developed countries, the changes in eating patterns which have taken place over the last 100 years have probably played a decisive part in im- proving life expectancy and health. Yet excessive consumption of some foods has led to an increase in certain specific diseases. Here lies one of the paradoxes of the industrialised world. In these countries, the diseases which are most closely connected with bad diets are : dental caries, which is preva- lent in almost 100 per cent of adults in England, arteriosclerosis and coronary heart disease, obesity, hypertension, hernias of the digestive tract, and cancer of the colon. Some of these diseases require preventive control from infancy onwards. They are clearly related to unfavourable changes in the eating patterns. In France, for instance, consumption of fresh bread has fallen by half in the last 40 years, while consumption of pastries and factory-toasted bread has increased. Consumption of potatoes also halved between 1925 and 1980, but consumption of potatoes in processed forms increased. Concurrently, veget- ables have disappeared from the diets of many families. Sugar consumption has almost dou- bled in many countries since the Second World War, giving rise to the curious situation that although people now tend to add less sugar to their food or drinks, the demand for and availability of sweetened products continues to grow. Meat consumption has considerably in- creased and has doubled in some coun- tries over the last 40 years. Generally speaking, there has been a gradual de- cline in the consumption of milk as a drink, whereas consumption of pro- cessed dairy products has been steadily increasing. In broad outline, this is how a diet comprising about 45 per cent carbohy- Obesity, the result of severely imbalanced diet, has serious implications for health and can shorten the lifespan. Photo WHO/P. Almasy drates, 43 per cent fats and 12 per cent proteins has evolved and has become the pattern most commonly found in the developed countries today. One very important diet-related dis- ease is hypertension. Physicians treating adults often investigate and check for hypertension ; but it is rare for paediatri- cians to be interested in taking blood- pressure readings in children. Yet one to two per cent of the child population in industrialised countries probably suffer from essential hypertension. The most important feature of this disease is the fact that it progresses with age, and this process begins before the age of 10. When we examine possible causal fac- tors, it is obvious that the genetic com- ponent is very important, but there are doubtless environmental factors of great importance too, such as excessive salt consumption. Obesity may also be connected with hypertension, and good evidence of this is the fact that people who lose weight may also reduce their blood pressure (without any change in their salt con- sumption). Most of our considerations focus upon diet imbalance as the fundamental ill, but there is one other basically detri- mental factor which must not be over- looked. The low expenditure of energy characteristic of " western " life means that for most people in these countries their diet is too high in calories. Here again, prevention should begin in early childhood. Obesity is harder to treat in adults than it is in children. So to make health workers who come into contact with pregnant women or chil- dren aware of the risks of obesity is an important public health measure. Al- ready in childhood, and before it trig- gers such serious diseases as diabetes and coronary heart disease, obesity can 18 WORLD HEALTH, November 1985 cause respiratory and orthopaedic disor- ders. Moreover, since it is largely depen- dent on the physical sensation of appe- tite, it is often related to psychological disturbances which affect the appetite. In adults, depression often leads to obesity, but in children it has also been observed that emotional disorders, usu- ally involving the family environment, lead to obesity. We all know that the lifestyles resulting from industrialisation may involve frequent emotional and psychological upsets. Obesity developed in childhood produces biochemical dis- orders similar to those found in obese adults, and this further underlines the importance of early prevention or treat- ment. Populations which eat unrefined foods have little dental caries ; but when they come into contact with eating pat- terns involving the consumption of re- fined foods, the frequency of dental caries increases. This has been observed among populations living in areas as diverse as Southern Africa, the South Pacific and Greenland. The refinement factor is definitely likely to be relevant, particularly where carbohydrates are concerned, since unrefined sugars do not so readily adhere to the surface of the tooth, and contain carbohydrates which do not ferment there so quickly and which include enamel-protecting elements. In "western" societies, the main danger comes from the invisible sugars in processed foods, and these are difficult to combat. Arteriosclerosis and one of its conse- quences, coronary heart disease, also appear to have some connection with diet. Arteriosclerosis often starts in young people, mostly men, although its effects become evident much later, therefore preventive measures such as appropriate food habits should start early in childhood. However, there is considerable controversy as to what pre- ventive measures should be taken, as the role of fat, and in particular of cholesterol, in causing arteriosclerosis and subsequent coronary risk is not very clear. Epidemiological studies in Scandinavia suggest that a prolonged decrease in the blood cholesterol level might bring about a decrease of mortali- ty due to cardiovascular disease. In many industrialised countries, there are grounds for suspicion that many types of cancer may be diet- Sweetened drink in a Mexico City public place. Refined sugar is present in large quantities in many popular drinks and "fast foods". Photo WHO/C. Viedma Figures suggest that good health ill elderly people may start in childhood. A sound diet at every age lays a solid foundation for a long and healthy life. Photo WHO/P. Almasy Regular exercise complements a sen- sible diet. Together, they protect our health. Photo WHO/J. Mohr related. Interest was long focused on the carcinogenic toxins present in food. To- day it is also thought that dietary im- balance may be connected with cancer. There is a great deal of epidemiological information which suggests that the dietary imbalances that go with overeat- ing may be linked to cancers of the digestive tract and the breast. As far back as 1969, data collected in the United States suggested that a high calorie intake had something to do with the increased incidence of cancer of the colon and the lower incidence of stomach cancers. Weight 20 per cent in excess of normal was leading to greater frequency in the appearance of carcin- oma, particularly among women in the USA. Countries where individual con- sumption of fats of animal origin is highest, amounting to more than 40 per cent of total food intake, are also those with the highest incidence of breast cancer. Other defective eating patterns result in the paradox of specific vitamin and mineral deficiences. In all the developed countries, there are pockets of poverty where the people will be likely to live on the archetypal extremes of processed food — especially so-called " fast foods. " In addition to excessive overall calorie intake, vitamin and mineral deficiencies are found in these populations, and prove to have critical effects at specially important times in their lives — during pregnancy, growth or the childbearing years. The measures that people can take to avoid harmful dietary habits related to affluence and modern living are quite simple. For instance, breastfeeding for several months provides a balanced diet at the beginning of life. Children whose babyfood is over-sweetened tend to de- velop a "sweet tooth " ; avoiding this will make it easier to restrict or elimi- nate refined sugar altogether from the diet in later life. This will in turn help to prevent dental caries and overweight — which can also be controlled by the parents during childhood. A healthy mixed diet includes enough fibre, which is found in whole grain cereals, root vegetables such as carrots or potatoes, vegetables such as peas and beans, and fruit. Last, but not least, to keep healthy, the indispensible complement to a healthy diet is regular exercise. ■ WORLD HEALTH, November 1985 19 Acupuncture Towards a standard terminology WHO is collaborating in efforts to find a common language to facilitate teaching, research, clinical practice and exchange of information about acupuncture on a global level by Olayiwola Akerele & Liu Guo-bin Acupuncture, as a form of medical treatment, predates the first Chinese dynasties, so it is more than 2,500 years old. At different times in its long history it has been the main form of treatment used, while at others it has been virtually eclipsed. Since the founding of the new China it has once again come to occupy an important place in therapy and, in recent years, it has attracted considerable attention in other countries. The need for a common language to facilitate the teaching, research, clinical practice and exchange of information on acupuncture at the global level has long been recognised. Because of the vast- ness of China with its many dialects, and because acupuncture has also long been an important part of medical practice in neighbouring countries such as Japan, Korea and Viet Nam, considerable dif- ficulties have arisen in communication and information exchange. For example, acupuncture points have a number of different names ; consequently, different pronunciation of the original Chinese characters has caused mistakes and cre- ated misunderstanding. Acupuncturists in other countries have sometimes mis- translated the Chinese names of the points, leading to additional discrep- ancies. Efforts have been made in China and Japan to develop a uniform nomencla- ture. In 1965, a Japanese Meridian and Points Committee was established which recommended Japanese names and an international numbering system for each Acupuncture treatment In December 1979, World Health published an account of a WHO Inter- regional Seminar, held in China, on the use of acupuncture in health care. This included a list of those conditions which the participants considered lent themselves to such treatment. How- ever, it was made clear that the list was based on clinical experience and not necessarily on controlled clinical research, and also that inclusion of specific diseases did not indicate the extent of acupuncture's efficency in treating them. That acupuncture may be very valuable in some conditions is not in doubt, but an authoritative list of what diseases may effectively be treated can only be drawn up after each claim has been examined and verified or rejected. There is, so far, no such agreed list. Many institutions and modern me- dical colleges are carrying out useful investigations into the physiology and mode of action of acupuncture treat- ment. Others are studying the effica- cy of acupuncture in certain pathologi- cal conditions. We believe that the efforts of WHO to evolve a standard acupuncture terminology will go a long way towards facilitating ex- changes between these research workers, and will help to dispel prevailing myths, thus leading to a wider acceptance of acupuncture in medicine. ■ acupuncture point. In China, the All China Acupuncture and Moxibustion Society set up a Nomenclature Commit- tee, which developed a national system of names. Since then, other countries have formed their own committees, but of course important differences still exist. In October 1980, Dr Andree Nakaji- ma went as a wHo Consultant to the People's Republic of China in order to review existing nomenclature, with a view to identifying needs for uniformity and with the ultimate objective of de- veloping an internationally acceptable nomenclature. Chinese and Japanese experts met five times between 1981 and 1982 to formulate guiding princi- ples that would lead to the standardisa- tion of acupuncture nomenclature. However, because of the complexities of the issues involved, consensus could not be reached. A critical evaluation of the consul- tant's report and her recommendations prompted the initiative by the WHO Re- gional Office for the Western Pacific to organize the first wHo Regional Work- ing Group on the Standardisation of Acupuncture Nomenclature in Manila, in December 1982. The Group included participants from Australia, China, Ja- pan, New Zealand, the Philippines, the Republic of Korea, Singapore, Viet Nam and Hong Kong. The Working Group drew up criteria for determining the structure of the meridians and acupuncture points. They proposed that the standard nomencla- ture should consist of three essential elements, namely, an alphanumeric code, the Chinese phonetic alphabet (Pinyin) and the Han characters of the meridians and the acupuncture points. 20 WORLD HEALTH, November 1985 The alphanumeric code—that is, a combination of the alphabet and num- bers—would facilitate international ex- change. Since international exchange in medical science is mainly conducted in the English language, the Group recom- mended that the alphanumeric code should be derived from the English translation of the meridian names. The Han character is widely used in oriental medicine in China, Japan, Korea, Singapore and Hong Kong. It confers philosophical concepts on meri- dians and acupuncture points which often defy translation, and should therefore be an essential element of the standardised acupuncture nomen- clature. Using the Chinese phonetic alphabet (Pinyin) for names of the meridians and acupuncture points would allow accu- rate pronunciation of the Han character names. Furthermore, the Pinyin names would facilitate drawing up an alpha- betic index and thus simplify the study of acupuncture, especially the meaning of Han characters. The Manila meeting reached consen- sus on an alphanumeric code for the 361 classical acupuncture points, and also agreed on the English language names of the 14 meridians and their alphabetic codes. This was published in 1984 in a booklet entitled "Standard Acupunc- ture Nomenclature" by the Western Pacific Region of wHo, and was widely disseminated throughout the world. A multilingual comparative list of the stan- dard acupuncture nomenclature in English, French, Japanese, Korean and Vietnamese was also published in the same year as WHO Regional Publication, Western Pacific No. 1. Further meetings on standardising acupuncture nomenclature took place in Tokyo (May 1984) and Hong Kong (July 1985), and these made consider- able progress. All those involved in these deliberations recognised that in- ternational agreement regarding the path of meridians, the numbering of points and their localisation is essential. A wHo Scientific Group will be con- vened late in 1986 to review and adopt the international nomenclature that has been proposed by previous working groups and regional consultations. WHO has no official policy on the use of acupuncture in national health care delivery systems, and, in fact, the sub- A standardised system of names for acupunc- ture points and meridians has been worked out and adopted internationally. Photo WHO/P. Almasy ject has not been debated by its govern- ing bodies. There has been considerable development in the last two decades, both in theory and practice, but the exact role that it can play in primary health care has yet to be determined. Any decision to use acupuncture in national health services remains, of course, the prerogative of the Member States concerned. However, there is no longer any doubt as to the usefulness of having an Inter- national Nomenclature on acupuncture points and meridians. To put acupuncture on a firm scientific basis requires rigorous investigation of the claims made for its efficacy. This implies a regular exchange of information and communication on the subject to facilitate clinical and basic research and this, in turn, can only be achieved if a common language is utilised by all concerned. ■ WORLD HEALTH, November 1985 21 Diabetes hits young people too In this International Year of Youth, it is salutary to be reminded that diabetes does not only affect old people. In the Philippines more and more children are becoming victims by Ricardo E. Fernando Guia was an 18-year-old college student when she suffered an insect bite of a finger of her left hand. This gradually became infected ; after six days her whole hand and fore- arm was remarkably swollen. She de- veloped high fever and was taken to the hospital in a very weak condition. Diag- nosed to be suffering from severe wide- spread infection with lung abcesses, she soon lapsed into coma. Her blood sugar was found to be 594 mg per cent and she had plenty of acetone in the urine. Even though she was given large amounts of insulin and antibiotics, she was dead in 24 hours. Mike was the youngest of three healthy boys in his family. At the age of eleven he became diabetic. He went through periods of fear and anger. The first few years were very rough on him, but he eventually settled down after reluctantly attending a summer camp. He was just beginning to get over the hump when one day his older brother started to complain of signs and symp- toms much like those which Mike had experienced initially. Brought to the clinic by his worried parents, 15-year- old Nonato was immediately diagnosed as a diabetic. This left only the eldest brother unaffected. If to a once happy family the above experience was all too shocking, it was more so to a young mother and father, both dumb, to whom was born a very pretty baby girl who, after about one year, developed overt diabetes ushered in by coma. The parents now hesitate to have another child for fear that the same misfortune might recur. Lanie was five when she was found to be in a coma with a blood sugar of 1500 mg per cent. Her doctors were able to pull her through the crisis only to be confronted with exasperating fluctua- tions of her blood sugar levels which sent her frequently to hospital. Com- pliance with doctor's orders was very poor ; her brief life was characterised by rebellion against the disciplines being imposed on her. The parents were about ready to give her up when she died at the age of 21. The doctors were not sure what kind of diabetes 12-year-old Juliet had, but she was placed on insulin right away. One day her father, a farmer, had to have emergency surgery and she stop- ped her insulin to help ease the strain on the family budget. In no time at all she was rushed to the emergency ward in frank diabetic coma. She has since stop- ped going to school. Imma was an only child ; her family Even quite young children can learn how to treat themselves for diabetes, and thus con- tinue to enjoy an independent life. Photo WHO/P. Larsen 22 WORLD HEALTH, November 1985 could not afford to have another. She was eight when she developed diabetic coma. Uncontrolled diabetes led to eye complications and she went blind. Her kidneys eventually became involved and she died of kidney failure at the age of 23. Elena was a pregnant diabetic at the age of 23 ; she had been a diabetic since she was three. Unfortunately the pre- gnancy was threatened by both kidney and eye complications. She had to face the serious decision of whether to keep the baby and possibly worsen the condi- tion of her eyes and kidneys. She chose to keep the baby even with the prospect of blindness and uremia before her. Jovy, aged 17, came from a very poor family and had been diabetic since the age of nine. Many times her insulin supplies ran out. At the age of 16 she required cataract surgery but could not raise the necessary funds. Disabling nerve disease with impo- tence hit Norman, a father of two, at the age of 29 after he had suffered from uncontrolled diabetes for some five years. He had to quit a very promising job and depend on his very supportive wife for more than a year; he faces a bleak future. These ten young Filipinos dramatise the tragic incidents now occurring more and more frequently in all strata of Philippine society, sparing neither sex nor age, nor paying respect to economic status. Where diabetes used to be a rarity, affecting only adults, more and more children are now becoming vic- tims. Almost certainly the same thing is happening in the other countries of South-East Asia. The Philippines is an archipelago, mostly of volcanic origin, consisting of over 7,000 islands of which about 800 are inhabited. The total population is 50 million, most of whom live in the coun- tryside and most of whom are young. Interest in diabetes dates back to 1922, possibly prompted by the discovery of insulin. At that time, the incidence of the disease was reported to be one In the Philippines, more and more young people are falling victims of diabetes. The health authorities are actively assessing the problem and seeking a solution at the national level. Photos WHO/P. Almasy WORLD HEALTH, November 1985 23 Diabetes poses a special threat for pregnant women. For some, going through with the birth may threaten their own life. Photo WHO/P. Almasy among every 1,000 patients admitted into hospitals (1910-1921). Since then, there has been a gradual but consistent rise in incidence and prevalence. Minor surveys after the Second World War already suggested that the rates were increasing. A national survey by the Ministry of Health in 1982 placed the prevalence among the population aged between 20 and 65 at 4.0 per cent with the highest (8.4 per cent) in the region of Manila and the lowest (2.5 per cent) in the rural areas. Early attempts in the 1960s to assess the problem of diabetes among the young proved very disappointing. Li- mited surveys in public schools together with interviews among heads of pedi- atric departments in medical centres yielded negative information. The con- clusion then was that the disease was apparently rare among children and youth. However, a recent review of the rate of registration of 207 young diabe- tics in three metropolitan diabetic clinics since 1960 (25 years) shows a remark- ably sharp rise since 1970, and a very rapid increase in the yearly incidence during the last two decades. Today, young people make up 3.0 per cent of the total diabetic population attending these three clinics. The youngest was diabetic at the age of one. Two-thirds were diabetics at the age of 19 or earlier, and the majority of these were diabetics at 14 or earlier. One- third were prone to develop coma and these were mostly the younger ones. There were 10 boys for every 15 girls. There was a very strong family history of diabetes, even among those prone to coma, and overweight was a problem, particularly for the girls. The complications seen among these young diabetics are no different from those seen in other countries. Nerve and eye and kidney problems are common threats to health and life. Some 25 per cent of the mortality is caused by ad- vanced kidney disease, and around 50 per cent of deaths result from infections of all kinds. In a report on 73 pregnan- cies, there were only 38 live births. Efforts to investigate often prove frustrating. Technology is available but the logistics are not. In the face of the current economic crisis, common sense dictates that all resources should be utilised primarily for treatment and care. Attempts to educate patients are necessarily limited. Economics and ig- norance are probably the two most sig- nificant factors influencing the patients' compliance and long-term outlook. The drop-out rate at the clinics is very high. Mr and Mrs Ricardo Gonzales have a child who proved to be diabetic at the age of five, and is currently dependent on two shots of mixed insulins a day. She has to test her blood four times a day. Coma is a constant threat. The father works as a bank clerk while the mother is engaged in buying and selling. The past 12 years have been very hard on the family finances, especially with three other children in college. They have developed a phobia about going to hospital. Just one example among so many. In developing countries, where other more pressing health problems continue to vie for priority, diabetes in the young will take a long time before it attracts na- tional concern. When and if that time ever does come, a significant amount of irreparable damage may already have been wrought. ■ 24 WORLD HEALTH, November 1985 Books and Publications A doctor's guide to "reading" of X-rays In its June issue, World Health magazine presented the WHO Basic Radiological System. The Manual of Radiographic Interpretation for Gen- eral Practitioners published by WHO is an important part of this system, and is now available in English, French and Spanish. An Arabic version is in prep- aration. It is the first of a series of three practical guides for use with the WHO Basic Radiological System (WHO-BFiS), WHO's answer to the com- plete lack of radiation services in many parts of the world. The wHo-BRS consists of an X-ray unit specially designed to overcome common technical difficulties, and a shortened training programme for WHO- BRS operators. Although intended for the first-level referral hospital staffed by only one or a few general practitioners, the WHO-BRS is also being used in big university hospitals, where it can perform at least 80 per cent of all the radiographic ex- aminations required. Help for diagnosis Doctors using X-rays for diagnosis deal daily with the same common prob- lems—mostly trauma (injuries) and in- fections—regardless of where they work. The WHO—BRS Manual of Radio- graphic Interpretation for General Prac- titioners gives them better chances to interpret the X-ray pictures correctly when there is no trained radiologist to consult, which is usually the case. The 216-page Manual is comprehen- sively illustrated with more than 400 high-quality X-ray pictures. The doctor has to open it at the page relating to the part of the body in question, and con- firm the suspected diagnosis. The patient's X-ray and the corres- ponding picture in the Manual are then compared, the text reminding the doc- for what to look for. Common findings in normal X-rays are also listed. For physicians everywhere WHO recommends this Manual for physicians and medical students in all parts of the world. The diagnostic prob- lems are the same everywhere, whether in large hospitals in Europe and North America or in small ones in de- veloping countries. WHO-BRS units, developed by six leading manufacturers to the specifica- tions of the WHO-BRS Advisory Commit- A new WHO manual enables general prac- titioners without training in radiology to read X-rays, thanks to the WHO Basic Radiologi- cal System. Photo WHO/D. Gibson tee (of which the Manual's authors are members), are now installed in Albania, Burma, Colombia, Cyprus, Denmark, Egypt, Iceland, Indonesia, Kenya, Morocco, Nepal, Nicaragua, Pakistan, Philippines, Saudi Arabia, Sweden, Thailand, Yemen and Zimbabwe. Checking on the three WHO-BRS machines located in the small towns of Amaga, Campamento and Caramanta in Colombia, a WHO consultant reported : "All the doctors involved were remark- ably grateful for the new ability to treat their patients without the need to refer so many elsewhere." "The doctors also report that the community response has been over- whelmingly favourable. This is under- standable, since the state of the roads can be almost impossible in bad wea- ther, and exceedingly uncomfortable even in good weather, so that referral to a neighbouring hospital becomes an ordeal." Two WHO-BRS machines are also used regularly at the St Lars Hospital, affiliated to the University Hospital at Lund, Sweden, where the radiologist in charge says : " I have seen many uni- versity centres with the same image quality, but none with better image quality than we have with these WHO- BRS machines." Readily accessible Economical, safe and practical, the WHO-BRS unit can be set up in centres close to the homes of the 70 per cent of the world's population who at present have no access to X-ray diagnosis. The operator is trained in only a few months to take 96 different X-ray projections which are adequate for 95 per cent of radiological work at primary care level. The operator processes the films by hand, using techniques and chemicals which produce good radiographs even under tropical conditions. The second and third Manuals in the WHO-BRS series, covering operation of the unit and darkroom processing, will be published shortly. The Manual of Radiographic Inter- pretation for General Practictioners by P.E.S. Palmer, W.P. Cockshott, V. Hegedus and E. Samuel can be obtained from : Distribution and Sales, WHO, 1211 Geneva 27, Switzerland, price Swiss francs 23.—. ■ WORLD HEALTH, November 1985 25 Iatrogenic disease An epidemic of our time by Constantino landolo Some 1,700 years before the Christian era, the law of talion, or punishment equivalent to the of- fence, was instituted by the Babylonian Emperor Hammurabi, and could be specifically invoked in cases of profes- sional medical error. Twelve centuries later, Hippocrates advised : "Primum non nocere" (first do no harm), an injunction which is still repeated today in medical schools throughout the world. It has thus been realised from earliest antiquity that, in his noble endeavour to help the patient, the physi- cian may also unwittingly and uninten- tionally do him harm. Today, iatrogenic diseases (from the Greek " iatros", physician, and "genesis", origin) are rapidly becoming so widespread that they have come to consitute an important category of hu- man pathology. As an example of this development, we may mention the epidemic of " 'legionnaires' disease" which broke out in the United Kingdom last May. This disease appeared for the first time in July 1979 at a convention of the American Legion (an association of army veterans) in Philadelphia, where it killed 29 persons. It is caused by bac- teria named Legionella after this event. In the English hospital in May, the bacteria were disseminated, either by the draughts caused by aerosols or by the air conditioning system, and were inhaled by patients. Some 68 people were affected, of whom 20, mostly elderly, died. There are many statistics to show the extent of the problem of iatrogenic dis- eases in our time. In 1963, for instance, E. Schimmel spent eight months study- ing the patients in a medical ward at Yale University in the United States. He showed that 240 of the 1,252 patients had complications connected with the hospital environment or the treatments they had received. These complications included reactions to diagnostic proce- dures, drugs and blood transfusions, and infections contracted in the hospital ; 48 of these complications were considered serious and 16 proved fatal. In 1979, K. Steel and his co-workers Harmful bacteria entering a hospital's air- conditioning system are a potential threat for all the patients. Photo WHO/D. Henrioud undertook a five-month statistical study at the Boston University Medical Centre. They found that 290 of the 815 hospitalised patients had suffered some form of iatrogenic disease, with a total of 497 incidents. Serious complications occurred in 76 cases and 15 cases were fatal. Topping the list of iatrogenic dis- orders were those euphemistically known as "hospital interventions", namely drugs, with 208 complications. These were followed by diagnostic and therapeutic procedures with 175 com- plications, and lastly, by miscellaneous incidents, including 35 falls. The English medical journal The Practitioner, reporting on similar dis- quieting statistics, added the comment that these adverse effects, at times in- duced by well-intentioned and often 26 WORLD HEALTH, November 1985 obligatory attempts at therapy, can af- fect every system of the body and may mean that the last state of the patient is worse than the first. But what is the root of this sudden upsurge of an evil which has all the appearances of being absurd? Human error? Fate, as, for example, in unex- pected cases of anaphylactic shock fol- lowing the use of a drug ? Or non- compliance with advice and instructions, which makes the patients themselves re- sponsible in 30 to 60 per cent of cases ? Or can it be ascribed to weaknesses in the organization of health services or shortcomings in existing institutions ? It might be attributed to each and every one of these factors. But it is also true that we live in an age when ad- vances in technology provide physicians and health personnel with diagnostic and therapeutic tools that are extremely powerful, but not without risks for the patient. Moreover, health personnel must face the prodigious pace of devel- opment in knowledge and technology, as a result of which they sometimes have to practise under difficult material and psychological conditions. And lastly, the explosion in costs means that staffing is often inadequate. Health care at all levels tends to suffer from excessive specialisation, lack of time, and dehumanisation, especially in the large central hospitals. At the diagnostic level, for instance, clinical histories are sometimes noted very hastily. Questions are directed al- most exclusively to somatic problems while the patient's psycho-social envi- ronment is disregarded. Physical exami- nation is not always very thorough or complete, and is confined to the part of the body or the organ which is the apparent site of the disorder. Sometimes the examination is carried out without even requiring the patient to undress, or it might even be dispensed with, as if the doctor were in a hurry to move on to laboratory tests to arrive at a direct diagnosis. But such tests should only be used to confirm a diagnostic reasoning based on clinical examination ; their ran- dom use is rather like a huntsman shoot- ing off in all directions rather than using his gunsight. The clinical examination may be all that is needed for diagnosis. Unnecessary laboratory tests are ex- pensive, and their overuse might result in errors or invasive techniques which in WORLD HEALTH, November 1985 turn can lead to iatrogenic diseases. As for drugs, the available statistics show that they account for iatrogenic conditions in eight to 35 per cent of hospital patients. It must never be for- gotten that no drug is 100 per cent safe and that there is no guarantee against adverse effects, although they may be limited by rigorous application of clini- cal pharmacology and better knowledge of drug reaction mechanisms. Allergies to drugs, or certain congenital defects which should rule out the use of drugs, must also be included among the factors involved in iatrogenic disease. Prescription has an important role to play and should conform to rigorous standards, which would ensure the avoidance of certain errors, such as prescribing antibiotics for infections of viral origin. Great care needs to be Drug interactions too may cause iatrogenic illness. Elderly people, whose memory is failing often make mistakes in the amounts of drugs they swallow. Photo WHO/Zafar taken against drug interactions which may have harmful consequences. Such cases are often found among very elderly people, who have to take several drugs in the course of the day and whose failing memory leads to mistakes in the dose or dosage interval. Even human error may not necessar- ily be the result of carelessness on the part of the health personnel. Hospital costs are tending to rise exponentially and health budgets are often inad- equate. There are not sufficient staff with time to spare to give their patients all the attention they would wish. It follows that large hospitals are not the solution for the future. In many cases, patients would be better staying in their own surroundings instead of being sent to hospital. In both developing and developed countries, this approach could become general if the primary health care systems were strengthened, and if it were finally realised that prim- ary health care is the only approach by which Health for all by the year 2000 can ultimately be attained. • The Dogon people fight endemic disease Onchocerciasis, schistosomiasis, guinea worm, malaria — the people of the Dogon plateau in Mali are themselves active in the struggle to overcome these health problems by Mabo Kassambara The Dogon plateau in the Repub-lic of Mali is a large plateau of hard sandstone. In the east, steep cliffs rise to a height of 790 metres (2,400 feet) above the sandy plains, but in the south-west the hills are smaller. The Dogon people who live there are hard-working farmers who, with ingenuity and perseverance, man- age to produce millet, cowpeas, onions and so on from the arid soil. The drainage system of the Yame, a tributary of the Niger, has notched the layers of sandstone into a series of plateaux and large, steep-sided hills. The annual rainfall is around 600 milli- metres, with about 40 days of rain. The turbulent waters of the many streams and torrents which cascade into the Yame create favourable conditions for the development of Simulium damno- sum or blackfly, which transmits oncho- cerciasis or " river blindness". Last month's issue of World Health described the work of the Onchocer- ciasis Control Programme (OCP) in combating the fly and the disease. And one of the communities where the blackfly has been controlled and where human resettlement close to the river has taken place is Bandiagara, on the Dogon plateau of Mali. The Bandiagara subsector of the OCP includes four other districts of Mali and has a total population of 294,000. The blackfly no longer troubles these people, and " river blindness" is no longer a major prob- lem. What is more, the people now understand that the blindness was not caused by the spells of a sorcerer or by the baleful influence of a water spirit, but by the bites of this little fly. Other parasitic diseases The government of Mali is anxious to develop agriculture and encourage mar- ket gardening. Since 1960, with the support of friendly countries, small dams have been built across the Yame and its tributaries. At present, there are 50 of them, the largest of which is the Daga dam, holding back 1,300,000 cubic metres of water. Unfortunately, the dam spillways form potential breed- ing sites for blackfly larvae, while up- stream many pools and stretches of stagnant water form at the beginning of the rainy season and provide breeding places for snails and water fleas. Chil- dren can often be seen playing in them for hours on end. The water is usually contaminated by the debilitating parasites Schistosoma haematobium and S. mansoni, which are widespread in Mali ; they are pre- sent in almost 60 per cent of children aged between five and 15 years in the Bandiagara region. As part of the fight against schis- tosomiasis, an action promotion team visits villages to increase the popu- lation's awareness of the problem. It returns on an agreed date to treat the dam with chemicals to destroy the watersnails which play host to the para- sites. Health technicians collect sam- ples in the water near the dams, to determine the level of infestation. From the humans they collect stool and urine samples, and they use the drug prazi- quantel for mass treatment of the infection. At the beginning of every rainy sea- son in this area, a large proportion of the 28 WORLD HEALTH, November 1985 Throughout Africa, safeguarding water sources is as essential to agriculture as it is to human health. Photo WHO/B. Genier Left : Dogon farmers are well-motivated to combat guinea-worm; they know that this parasite may prevent them from working in their fields. Photo WHO/P. Pittet population is confined to the village by guinea worm disease. The economic consequences of the disease are con- siderable. When the Dogon plateau health programme was launched, it was found that in the village of Gani, for instance, more than 80 per cent of the population was affected. The fields re- mained untilled because of the short- age of manpower. In the fight against guinea worm, many villages request the help of the health service to treat their wells and ponds. One good example is the village of Pelou where, at the beginning of one rainy season and before treatment, there were 150 victims of guinea worm disease. The following year at the same time, after the water had been treated, there were only 20 patients. It is not difficult to motivate Dogon farmers to combat guinea worm, since they are constantly afraid of being in- fected and thus unable to work on their land. It is enough to explain that the disease is caught by drinking contami- nated water from ponds and wells. After sometimes spirited debates be- WORLD HEALTH, November 1985 tween the villagers and the health and community development workers, the people often ask the health workers to stay and teach them how to make simple filters, to treat and maintain the wells, to construct latrines and to treat patients. Malaria is another major problem on the Dogon plateau, and is responsible for many deaths in children up to the age of nine. Its social and economic impact is enormous, and many working days are lost as a result. At present, the approach to malaria control is the provi- sion of facilities for diagnosis and treat- ment of the disease throughout the endemic area. A new attitude A new attitude can be detected among the inhabitants of the area, who were previously of a conservative and insular nature. Today, they are open to progress and respond favourably to ac- tion in the fight against onchocerciasis, guinea worm and schistosomiasis. This action may involve constructing tracks to the most distant villages or breeding sites ; supervision of insect traps by young people ; the supply of unpaid labour to build latrines and protected wells ; provision of building materials ; and board and lodging for well-diggers, stonemasons and others engaged in community work. In many cases, the people willingly subscribe to a public works project because they have learned to rely primarily upon them- selves. The people of the Dogon plateau are committed to doing everything in their power to ensure the success of the current health action programmes. The health workers' enthusiasm for their task and the willingness of local farmers bear witness to the sincerity of this commitment. The elimination of onchocerciasis from the region and the reduction to an acceptable level of endemic diseases, especially parasitic waterborne dis- eases, will be due in no small measure to these programmes. These actions have helped to raise the level of health and increase economic and social de- velopment on the Dogon plateau. ■ 29 'Product Liability' Suits Increasing Against Tobacco The anti-smoking campaign in the United States is now turning to the courts, as evidenced by the growing number of lawsuits that seek to fix responsibility for ill- health and deaths of smokers squarely on the tobacco industry. This doctrine of "product liab- ility" is central to the increasing number of legal challenges over recent years, according to reports from the Wall Street Journal and the Los Angeles Times, and is cou- pled with mounting scientific evi- dence linking smoking to lung cancer. The number of suits have dou- bled in just a year—from 10 in 1983 to 23 in 1984—as the view that companies are not to be blamed, because smokers knowingly as- sume risks, loses ground. There has been a trend discern- ible in US court decisions to award compensation if a product is deter- mined to be dangerous. Even if the manufacturer has not been found negligent, a product is still assumed to carry an implied warranty that it is safe, courts have held. Further- more, warnings on labels do not automatically exempt manufactur- ers from liability. Photo: WHO/Zafar Attempting to hold manufactur- ers legally responsible for deaths and diseases. It is against this background that suits are being filed attempting to extend the principle of product lia- bility to tobacco. Law firms in New Jersey and Texas are pooling re- sources, or forming partnerships, as a counter to the strength of the tobacco industry, to put their cases before a jury. And in Massachu- setts, a newly-established organi- zation called the Tobacco Products Liability Project offers plaintiffs the testimony of expert witnesses. Much public interest is focused now on a case in California involv- ing a retired insurance company employee. Although he only began smoking at age 19, relatively late, he died five decades later at 68, of cancer and emphysema. By then he was smoking three packs a day of the same brand. His addiction was such that, while on his death- bed, he was caught slipping off his oxygen mask in order to smoke. The lawsuit his family is bringing holds the manufacturer of the brand liable for his death. It charges a failure to warn of the lethalness of cigarettes and of the addictiveness of smoking, which is contended to be as strong as heroin. The case is expected to be heard late this year. What has become industry's standard defence rests upon an assertion of smoker's rights, and upon a flat denial that the link between ill-health and smoking is scientifically proven. As a consequence, one Boston lawyer believes, tobacco com- panies are now in the position, on the one hand, of having to deny the causal relationship, while, on the other hand, having to claim that they are not responsible for disease and death because labels on pack- ets warn that cigarettes may be dangerous to health. "That is a very novel strategy," he is quoted as saying. ■ Immunizations Save 800,000 Infant Lives Yearly Immunizations against six child- hood diseases are now saving the lives of some 800,000 infants every year in developing countries, ac- cording to WHO estimates. This rep- resents a "major public health gain in the past ten years," says a status report published last August in WHO•s Weekly Epidemiological Re- cord (No. 34). WHO launched an Expanded Pro- gramme on Immunization in 1974 against six killers of infants—polio, diphtheria, pertussis (whooping cough) and tetanus, as well as measles and tuberculosis. The success of the programme is measured largely by the number of immunizations given against four diseases—polio, diphtheria, pertus- sis and tetanus. To protect against these diseases, a full course of vaccines—either two or three doses—is needed, thus necessitat- ing more than one trip to the health centre. Some 40 million infants received the full course of doses, a figure that represents coverage of about 40 per cent of the 100 million infants who, in 1948, survived to one year of age in the Third World. "The coverage of infants with these vaccines was less than five per cent in the countries at the time the programme started", the report says. It has thus increased eight- fold over a decade. In addition, some 33 million im- munizations were administered against measles and 48 million against tuberculosis, representing coverage of 33 and 48 per cent respectively of the 100 million in- fants. Only one dose is adminis- tered in each case. "Simply by reinforcing existing health services", the report says, "there seems every reason to ex- pect that a fully immunized cover- age level of 60 to 70 per cent will be achieved by 1990." Despite these successes, how- ever, an estimated 265,000 cases of polio, two million deaths from measles and 600,000 deaths from pertussis alone still occur yearly in the developing world. These fig- ures exclude China. And only 14 million pregnant women receive the two doses of anti-tetanus vaccine needed. As a result, some 800,000 deaths from neonatal tetanus occur each year. To protect newborn babies against neonatal tetanus, the doses are given to mothers four weeks apart. UNICEF is a major supporter of the immunization programme, not only providing vaccines, refrigeration equipment and funds, but also play- ing a leading role in promoting im- munizations. ■ Protecting Health Of Children In Bangladesh Oral rehydration against diar- rhoea and immunizations are two preventive measures that would save the lives of 40 per cent of infants—that is, those under age one—and about 30 per cent of those aged between one and four years in Bangladesh. Such is the conclusion of inves- tigators from the country's Interna- tional Centre for Diarrhoea! Re- search following a study into the causes of deaths of some 8,000 children in 228 villages in Matlab district. "Most of the technologies al- ready have been developed and are readily available at low cost," the investigators say. "The challenge is Photo: WHO/Anard Preventing deaths against diar- rhoea through oral rehydration salts. to generate the political commit- ment to mobilise the necessary re- sources, and to organize the health care providers and local commu- nities to deliver the services." Every fourth child in Matlab died before age five, their study shows. Moreover, even though those under five represent but a sixth of the total population, over a half of all deaths in the community occur- red in that age group. Diarrhoea, tetanus, and measles were the top three killers of children between one and four years. For infants, the mortality rate was 142.6 per 1,000 live births, about four times more than among the 1-4 age group. Neonatal tetanus accounted for the highest number of infant deaths, 26 per 00• 000 000 000 000 000 *0 0 OO O OOO 000 000 000 000 0 00 0 00 0 0 0 00 0 410• S o o •4114 1160 04000oo 000000 00 0 000 000 0 00 000 0 00 000 00* 000 000 000 00* 00000* 000 000 000 00 0 000000 000 000 000 000 000 000 000 000 00• *00000 000 000 000 000 000 000 0 0• 000 410• 000 000 WORLD HEALTH, November 1985 30 Newsbrief After Smallpox, Polio. The Americas was the first of WHO's regions to eradicate smallpox, being declared smallpox-free in 1973. Now the countries of the western hemisphere are setting as a target for themselves another "first"—the eradication of polio by 1990. Since the launch of WHO's Expanded Programme on Immunization in 1977, polio has been declining steadily. In 1981, for instance, 16 countries reported 1,464 cases. Last year, the figures were down to 525 from 11 countries. The aim is to "achieve the eradication of polio from the Americas in a massive, final, five-year effort, " says Dr Carlyle Guerra de Macedo, Director of WHO Regional Office for the Americas. And Amman Makes Three. A new WHO regional centre has been established, this one to serve 22 nations in the Eastern Mediterranean. It is the Centre for Environmental Health Activities, set up last January in Amman, Jordan, in part through a grant from AGFUND, the Arab Gulf Programme for UN Development Organizations. While the construction of water supply and sanitation systems is among the new centre's priorities, so also is the treatment of waste water and refuse, a topic of "particular importance for Jordan and other dry areas of the region," says Mahmood Suleiman, an engineer with WHO's Division of Environmental Health, and the centre's first chief technical and administrative officer. Such regional centres are already in operation in Lima, Peru, and Kuala Lumpur, Malaysia. 'Every Tear from Every Eye'. As India's Prime Minister Rajiv Gandhi sees it, the international system is threatened. "We are witnessing a retreat from multilateralism, " he said in addressing the annual conference in Geneva of the oldest UN agency, the International Labour Organization. "Doubt, discord and dissension are gnawing at the system". His plea to governments for a renewed commitment to the Third World is captured in these words: "We must wipe every tear from every eye." 'From Us—the UN Staff—to You'. Under this theme, UN staff members working in Geneva raised some US$200,000 to finance projects that directly aid the people of famine-stricken Africa. A year ago, some $50,000 was contributed. T-Shirts for Health. Ever since 1980, Gabon has been putting the design of World Health Day posters on T-shirts. The one seen here de- picts this year's WHO theme of "Healthy Youth, Our Best Re- source." The shirts are given to students, and to members of the health minis- try, to wear during events com- memorating national holidays, on 12 March and 17 August, during ob- servances of World Health Day on 7 April, and on other occasions, explains Dr Louis Anande Menest, Inspector-General of Public Health. He was congratulated by Dr Halfdan Mahler, WHO's Director-General, for his "amusing and non-conventional initiative" to take a health message to the public. Leptospirosis: The diagram published on page 11 of the July issue of World Health originally appeared in "Zoonoses and communicable diseases common to men and animals," by P. N Acha and B. Szyfres, published by the International Epizootics Office, Paris. In the next issue The safety, efficacy and good quality of medicines is something we all take on trust, relying on extensive testing and approval processes. The December issue of World Health looks at the "safety nets" operated by the pharmaceutical industry, national authorities and WHO, and suggests how developing countries can carry out their own quality control on imported drugs. cent ; followed by diarrhoea. To protect newborns against neo-natal tetanus, pregnant women should receive two doses of anti-tetanus vaccines four weeks apart. For children aged one to four years, the mortality rate was 34.3 per 1,000 live births. Diarrhoea caused the highest number of deaths, 44 per cent, followed by measles, 13 per cent. Measles deaths peaked during March and April, the dry months ; diarrhoea from July through Sep- tember, the monsoon season ; and tetanus from September through December, when most births oc- curred. This is also the pattern throughout all of Bangladesh, in- vestigators believe. ■ Veterinary Drugs May Pose Hazards To Human Health The increasing use world-wide of veterinary drugs in animals raised for food may pose hazards to hu- man health, experts from 125 coun- tries have warned. To prevent or to cure diseases, but also to boost growth, livestock (calves, cattle, chicken and pigs) are administered such antibiotics as pen- icillin, tranquillisers, and hormones. To cite but two examples, in the United Kingdom 50 per cent of beef animals, and in the United States 90 per cent of cattle, are given growth-promoting drugs, according to WHO estimates. The residues of veterinary drugs often end up in food. Up to 30 per cent may be retained in the car- casses of animals slaughtered soon after a drug is administered. This is particularly so with long-acting drugs. Another problem singled out by the experts is the use of prohibited substances, such as estrogenic stil- benes (DES) to promote growth in veal calves. Although veterinary drugs are be- ing used increasingly throughout the world, only a fraction of food- related illnesses are reported. WHO estimates that, even in indus- trialised countries, the figure does not exceed 10 per cent. These and other facts led the joint Codex Alimentarius Commis- sion of WHO and the UN Food and Agricultural Organization (FAO) to establish a committee on residues of veterinary drugs in food. The committee, to be located in Washington, D.C., will determine safe residual standards and develop codes of practice. ■ Authors of the Month Ms Sue ARMSTRONG is a freelance journalist based in Brussels. Professor Jaswant Singh NEKI, former Director of the Postgraduate Institute of Medical Education and Research in Chandigarh, India, is now a WHO consultant for the National Mental Health Programme in Tan- zania. Mr Ian STEELE is the United Nations Correspondent for The Press Founda- tion of Asia and the Canberra Times, Australia, based in New York. Dr Michael GURNEY is a Medical Of- ficer with WHO's Nutrition programme and Senior Coordinator in the WHO/ UNICEF Joint Nutrition Support Pro- gramme. Dr Carlos MARTI HENNEBERG is As- sistant Professor of Paediatrics of the University of Barcelona, Catalonia, Spain. Dr Olayiwola AKERELE is Programme Manager of WHO's Traditional Medicine unit in Geneva and Dr LIU GUO-BIN is Director, Environmental Health, Diagnostic, Prophylactic and Therapeutic Substances, Radiation Technology, in WHO's Regional Office for the Western Pacific in Manila, Philippines. Dr Ricardo E. FERNANDO is Medical Director of the Mary Johnston Hospi- tal, Manila, Philippines. Professor Constantino IANDOLO holds the Chair of Special Medical Pathology and Clinical Methodology at the University of Rome. He is also a Senior Medical Director of the Rome United Hospitals. Mr Mabo KASSAMBARA is Senior Assistant Entomologist with WHO's Onchocerciasis Control Programme and is based in Bandiagara, Mali. WORLD HEALTH For readers everywhere 1985 Subscription Rates US$ Sw. fr. One year 12.50 25.— Two years 22.50 45. Three years 30.— 60. 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 cur- rencies, please contact your usual bookseller. WORLD HEALTH, November 1985 31 Mother and child: prime targets for the WHO/UNICEF joint nutrition support rogramme throughout the Third World. Photo WHO/C. Viedma