(WPRlRC44ISRl6)
SUMMARY RECORD OF THE SIXTH MEETING WHO Conference Hall. Manila Wednesday. 15 September 1993 at 2.30 p.m. CHAIRMAN: Dr Ana Maria Basto Perez (Portugal)
CONTENTS
1. 2.
Nutrition in the Western Pacific Region. including follow-up of the International Conference on Nutrition ............................................... Human resources for health ..................... .............................................. 2.1 2.2 Public health training in the Western Pacific Region ............................. Fiji School of Medicine .................. ............ ..................................
190 200 200 204
3.
Regional strategy on health and environment. including follow-up of the United Nations Conference on Environment and Development (UNCED) .........................................................................................
209
- 189-
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1.
NUTRITION IN THE WESTERN PACIFIC REGION, INCLUDING FOLLOW-UP OF THE INTERNATIONAL CONFERENCE ON NUTRITION: Item 13 of the Agenda (Documents WPRlRC44J9 and Add.l) The REGIONAL DIRECTOR said that the report encompassed three important aspects
of nutrition activities in the Region. In addition to the biennial report to the Conunittee on action taken in the field of infant and young child nutrition and the implementation of the International Code of Marketing of Breast-milk Substitutes, two other items were being presented. Section 2 of the working document had noted that, as of 9 June 1993, 24 countries had reported to WHO. Since then there had been responses from two more countries, Cambodia and Singapore, giving a total response rate of 74% or 26 of all countries and areas in the Region. With the report from Singapore, there were currently 13 instead of 12 governments reporting some form of implementation of the International Code of Marketing of Breast-milk Substitutes. It also increased the number of institutions designated as "baby-friendly". That initiative was now active in Singapore where the Government reported having one accredited hospital. The working document had reported 133 such hospitals in six countries. With one hospital in Malaysia also awarded in August 1993, there were now 135 "baby-friendly" hospitals in eight countries. The joint Food and Agriculture Organization and World Health Organization International Conference on Nutrition had been held in December 1992 in Rome, attended by 159 member countries of the two organizations. One of the major aims of the Conference had been to raise awareness of the nutritional problems affecting all countries in different ways and to greater or lesser degrees. However, it was emphasized that the Conference had not been an end in itself but a catalyst for future action. The plans for follow up, which were evolving in the Region, would be described. Following the printing of the document, proposals had been received from Cambodia, the Lao People's Democratic Republic and Viet Nam for support in developing national plans of action in nutrition. The document before the Conunittee presented a review of existing nutrition activities and an analysis of how the follow-up activities to the International Conference on Nutrition
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follow-up activities would complement those. An information folder on the status of nutrition in the Region had been provided. One of the encouraging things to be noted was that there were indeed real signs of progress and improvement in nutrition in the Region. Ms GREW (New Zealand), congratulating the Regional Director on his report, said that nutrition was a public health issue for New Zealand. In 1990 one-third of all deaths were believed to have been attributable to dietary factors. Ischaemic heart disease was the leading cause of death, followed by cancer; incidence of bowel cancer was one of the highest in the world. New Zealand endorsed the categorization of countries for the purposes of funding, as outlined on page 12, paragraph 3.2 of document WPRlRC44/9, and would place itself in category (iii), among the countries developing or revising a national nutrition policy. A national nutrition policy had been introduced in 1992, nutrition guidelines had been disseminated for such population groups as adolescents and older people, and work had commenced on a national plan of action. Her Government considered that countries in category (iii) would face a challenge as they moved from policy to action to implementation. In New Zealand, for example, dairy and meat products contributed greatly to both the economy and the fat consumption of the popUlation. Innovative strategies would be required in order to involve major food with large domestic and export markets in the Region in a multisectoral approach industri~s
to
nutrition
action plans. New Zealand urged the Regional Director to provide support and guidance for endeavours to involve such industries in the formulation and implementation of action plans aimed at improving nutritional status in the Region. Dr Dong-Mo RHIE (Republic of Korea), congratulating the Organization on the success of the International Conference on Nutrition and action taken to implement the International Code of Marketing of Breast-milk SUbstituteS, said lhllt th(lse activities were important steps in the process of strengthening the commitment and action needed to prevent and alleviate nutritional problems. His country had experienced nutritional problems stemming from food shortages, but these had been overcome with the improvement of the economy. Nevertheless, there was still concern about undernutrition, overnutrition, and inappropriate nutrition. His Government was implementing programmes geared to improving health and preventing disease through compensation of nutritional deficiency and control of weight. It had drawn up national dietary guidelines, monitored dietary trends, set up a nutrition information system, promoted breast-
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feeding and school lunches, and banned the advertising of breast-milk substitutes in the media. In addition, the number of "baby-friendly" hospitals was increasing thanks to collaboration between citizen's groups and the Government. Dr LEE (Singapore) observed that although nutrient deficiencies were rare in Singapore the country was not free from nutritional problems. The principal cause of death was noncommunicable diseases related to unhealthy lifestyles and inappropriate diets. The national health policy for·the 1990s therefore gave priority to health promotion through health education and better nutrition. Her Government had drawn up a national plan of action for nutrition as part of the health promotion programme. A food and nutrition department had been established to plan, coordinate and implement nutrition policies, programmes and activities. It planned to create a demand for and supply of healthier food choices through public education and creation of an environment conducive to such choices. That would be done by both encouraging the supply of healthy food and ensuring healthy catering practices, as many people ate their meals outside the home. Unhealthy diets were also a target of Singapore's ten-year healthy lifestyle programme launched in 1992, which aimed at reducing the risk factors of chronic degenerative diseases. By the year 2000 the Government hoped to achieve specific nutrition-related goals, including reduction in obesity and the average blood cholesterol level, and healthier eating practices and diets. She affirmed that nutrition policies and programmes to improve the health and well-being of the population were firmly set on the national agenda. Dr HONG SUN HUOT (Cambodia) pointed out that Cambodia was one of the 13 most nutritionally vulnerable countries in the world, the only one in that category in the Region. His Government, including the ministries of health and agriculture, were aware that many people, especially women and children, were suffering from undernutrition and micronutrient deficiencies, and was taking steps to improve the situation. It was to prepare an intersectoral policy and national plan with the collaboration of the WHO regional adviser on nutrition. An intersectoral workshop was to be held to start formulating provincial nutrition strategies in cooperating with WHO and nongovernmental organizations. Additional technical and financial resources would be needed in order to develop nutrition programmes. Dr NOGUEIRA DA CANHOT A (Portugal) said that data on micronutrient deficiency was not yet available in Macao. problems could be identified. A nutrition survey was to be undertaken shortly so that
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Priority in all activities was given to children and pregnant women. As only 30% of mothers breast-fed their babies, measures had been taken to promote breast-feeding, including training of health workers, education on infant feeding for all pregnant women, and use of the media to provide information on the benefits of breast-feeding. Education was also provided on healthy food during pregnancy. Various educational materials had been produced, including a guide on healthy food during pregnancy, and booklets on infant nutrition and healthy food for children. In collaboration with the Department of Education, nutrition education had been promoted in nurseries, kindergartens and primary schools. Dr TEBANIA (Kiribati) said that a food and nutrition committee had been established in Kiribati to help solve nutrition-related problems. School programmes on food and nutrition had been revitalized and local nongovernmental organizations had been encouraged to conduct food and nutrition workshops for communities and young people out of school. With regard to vitamin A deficiency, a number of bodies, including the Department of Agriculture, the University of the South Pacific and UNICEF, were tackling the problem. He was glad to report that the figure of 10% given in Table 1 of document WPRlRC44/9 for the prevalence of Bitot's spots had now dropped to 2%. Although high compared with WHO norms, it indicated the effectiveness of activities. The reduction had been achieved through enhanced awareness and understanding derived from food and nutrition training programmes. The Government of Kiribati had just approved a food and nutrition policy to guide further efforts. Mr CAPELLE (Marshall Islands) commended the report on nutrition in the Western Pacific Region, which he found informative and well organized. The Ministry of Health and Development faced many obstacles to the provision of health care to all citizens of the Marshall Islands. One was the prevalence of nutrition-related morbidity, mortality and disability. A study undertaken jointly with UNICEF in 1991 indicated a high percentage of malnourished children. Reviews conducted by the Asian Development Bank and the World Bank in 1993 confirmed that preventable, nutrition-related conditions were the leading cause of morbidity and mortality among adults. The Ministry had formulated a national nutrition policy and had established a nutrition council to foster intersectoral collaboration in such areas as policy development, programme inonitoring, and the coordination of international aid. All activities were carried out within the framework of community-based primary health care, which received the highest priority.
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The Ministry had also mobilized local and international funds to host an annual national conference on maternal and child health. The conference had focused on preventable nutritionrelated diseases, disability and death. It had been attended by members of local communities, such as women's leaders, traditional leaders, educators and other key figures from the main urban centres and rural communities. The event had been organized entirely by and for Marshallese people and conducted in the Marshallese language. The Marshall Islands was seeking information that would guide its development. and would welcome any support WHO could provide in that respect. Dr GALVEZ-TAN (Philippines) reported that vitamin A, iron and iodine deficiencies were common in the Philippines among children and women. Iodine deficiency disorders were alarmingly high among pregnant and lactating mothers. Only 12% of mothers were exclusively breast-feeding up to six months. The Government had therefore launched a plan of action for nutrition involving local government, nongovernmental organizations, the private sector and communities. It aimed at eliminating vitamin A deficiency and iodine deficiency disorders by 1995 and reducing iron deficiency anaemia. Micronutrient supplementation would be given to targeted high-risk groups as a short-term measure, and food fortification, including iodized salt and dietary diversification, would form the basis of a long-term solution. The President of the Philippines had declared the Government's commitment to eliminating micronutrient malnutrition when he had launched the campaigns entitled Fortification for Iodine Deficiency Elimination and Fortified Vitamin Rice in June 1993. During the second Philippine national immunization day, a massive effort had been made to reach young children with high-dose vitamin A capsules. On a single day, 84% of all Filipino children under five years old had received a capsule. Encouraged by that success, the Government was to hold a nationwide micronutrient day on 16 October. Every child aged The between one and four years would receive one vitamin A capsule, and every pregnant woman would be given one iodized oil capsule and a packet of vegetable seeds or cuttings. provide seeds, seedlings or cuttings of plants rich in vitamins A and C and iron. A total of 103 hospitals had been declared "baby-friendly", and by 1995 all government hospitals and most private institutions should be taking part in that initiative. After signing the International Code of Marketing of Breast-milk Substitutes in 1986, the Government was paying special attention to monitoring, especially of advertising and of the sponsorship by infant formula companies of continuing medical education. initiative was interagency and multisectoral; in particular, the Department of Agriculture was to It
needed to set up mechanisms to assess problems, identify shortcomings, and document progress,
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Based on experience in national nutrition programmes, he recommended that the Secretariat should undertake the following: - vigorously pursue the baby/mother "friendly" initiative in hospitals throughout the Region, so that all babies born in those locations would have the best possible start in life; - build upon the experience of national immunization days to launch "national micronutrient days". Such action WOUld, in the short run, greatly decrease vitamin A, iodine, and iron deficiency and, in the long term enhance public awareness of "hidden hunger"; - actively involve Member States in the Region, in partnership with the private sector, in enforcing the International Code of Marketing of Breast-milk Substitutes and thus improving the nutritional status of infants throughout the Region. Dr AKE (Papua New Guinea) pointed out that in Papua New Guinea the forms of malnutrition varied widely throughout the country, and the causes of malnutrition differed from one area to another. Thus each affected area had to be assessed and strategies formulated to meet individual needs. In addition few data were available on most nutritional problems, and the public was poorly informed. His Government had established a national nutrition strategy and plan along three main lines. The first was to focus on local needs, following a local approach to tackling nutritional problems. The second was to set up food and nutrition surveillance, which called for cooperation between government ministries and nongovernmental organizations. The third was to adopt a new communication strategy - nutrition messages would be transmitted to the public in simple and easily understandable forms. Close collaboration existed with the Department of Education, and all primary and secondary schools currently included nutrition in the health components of their curricula. Breast-feeding was still the norm in his country, but a decline had been observed in urban areas, especially for working mothers. The public service therefore allowed mothers to take time off work to breast-feed. All hospitals could be considered as "baby-friendly", as all the criteria were met. Papua New Guinea planned to carry out a survey within the next two years in order to update knowledge on the nutritional status. That would provide the information on which to base the 1996-2000 health plan on nutrition. monitoring and evaluation. The Government would also be strengthening
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Mr BUILLARD (France) said that noncommunicable diseases related to dietary habits were on the increase in French Polynesia, representing a danger to the territory's health structure and increasing the cost of services. A medium-term programme had been drawn up, and a workshop on lifestyles and eating habits was to be organized in 1993; it was hoped to involve all sectors and to increase awareness among the population at large and among politicians . He thanked the cooperating agencies for their support. Dr TINIELU (Tokelau) congratulated the Vice-Chairman on her election, and the Director-General on his reappointment at the Health Assembly. Indiscriminate eating, i.e., consumption of food without awareness of or attention to the content and consequences, led to diseases that were becoming an increasing burden on the health services of countries like his own, where cardiovascular diseases accounted for 30 % - 35 % of deaths. Although the role of micronutrients was not always clear - for example, iron deficiency anaemia in children was usually but not always a factor of diet - and only clinical observation could detect vitamin A deficiency - his Government was disseminating all relevant information to improve dietary habits in accordance with recommendations of the International Conference on Nutrition. Efforts were also being made to render local natural foods more palatable where indicated, to discourage the use of unhealthy substitutes, to encourage home gardening, to enrich soil for local food production, and in particular to encourage breast-feeding of infants by such measures as increased maternity leave. Tokelau proposed to employ community nutritionists or dieticians to advise and demonstrate to the community appropriate recipes for local and imported foodstuffs. Dr ADAMS (Australia) stressed the importance of a balanced nutrient policy. It would seem contradictory, for example, to encourage households to use salt, even iodized, at the same time as discouraging the use of fats because of the risk in terms of hypertension and cardiovascular disease. Dr QI Qingdong (China) commended the report as a comprehensive account of activities for follow-up to the International Conference on Nutrition. The Chinese Government had publicized the results of that Conference, reporting thereon to the State Council and OIganizing meetings with representatives of the State Planning
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Commission, industrial and agricultural bodies, statistical bodies, consumer groups and the Women's Federation to brief them and prepare for the formulation of a national plan of action. The State Planning Commission proposed to incorporate it in China's Ninth Five-Year Plan. A National Advisory Committee on Food and Nutrition had been established in June 1993 to support the State Council and responsible departments in studies of important aspects such as food development and nutrition improvement; scientific findings; nutrition. The national plan of action was to be formulated with reference to Chinese policy documents for the 1990s and the World Declaration and Plan of Action by staff of the relevant departments such as those for health, agriculture and commerce. State Council. It was also planned to hold a national training course on nutrition improvement in midDecember with leaders of the appropriate departments, where the draft plan of action would also be discussed. A high-level meeting would be held on control of iodine deficiency disorders in September 1993 in Beijing to devise strategies and plan for international cooperation, set up networks for surveillance, nutrition education, and review of food hygiene legislation as well as preparation of a "Nutrition Law". Dr TAPA (Tonga) commended the comprehensive report and the document on the nutrition situation in the Region. Obesity and noncommunicable diseases resulting from poor or inappropriate nutrition caused avoidable mortality and morbidity. The prospects for child nutrition were better because of the emphasis on breast-feeding and the introduction of the "baby-friendly" hospital initiative, which affected two hospitals out of four in Tonga. The International Code of Marketing of Breast-milk Substitutes was followed as a recommendation. Three qualified nutritionists - two of them trained thanks to WHO fellowships - were working in nutrition education, general nutrition and diet in schools, among the general population and its special vulnerable groups in Tonga. A first draft based on a framework drawn up in June was planned for completion by the end of 1993 for review by the to provide training; to advise' on directives and draft legislation, policies and programmes for the State Council and central departments; to publicize and to promote and guide activities for food and
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UNICEF and WHO were also to be thanked for their cooperation in a current nutrition project. His Government remained committed and would give high priority to the regional nutrition programme. Dr LIN (United States of America) joined others in praising the comprehensive documentation, and the Secretariat follow-up to the International Conference. At that Conference a major initiative of USAID on "Opportunities for micronutrient intervention" was launched with a view to reducing specific nutritional deficiencies both through action in countries and support of competent international agencies. Programmes to alleviate serious nutritional disorders were under way in various countries, and USAID had a number of programmes in the Region focusing on vitamin A deficiency - both prevalence surveys and action to encourage home gardening, nutrition education and supplementation. He wished to emphasize that breast milk was the only source of complete nutrition for normal infants; mothers should be encouraged to breast-feed for at least six months. Breast-feeding was well known for its benefits to children and mothers in tenns also of infant nutrition, the infant's first immunization, in birth-spacing, and in promotion of maternal health at low cost. Nationally, a goal of the United States of America was to increase the proportion of breast-feeding mothers to 75% at hospital discharge and to 50% at six months. Internationally, USAID had undertaken to promote breast-feeding as a worldwide objective as one of the most cost-effective means of improving child survival and had adopted a related strategy as part of its child survival initiatives. Professor NGUYEN HONG NHAN (Viet Nam) said that a study of calorie intake showed that a quarter of Vietnamese families suffered from insufficient energy intake. Protein malnutrition studies based on weight-for-age in 1988 had indicated that 41.8% of children were malnourished, and animal protein accounted for only 20% of intake compared with an average total intake of 33%. Low birth weight affected 14% of newborn infants, and many women had a too-lowweight in pregnancy. Vitamin A deficiency caused xerophthalmia in 0.72% of a large sample of children under five years of age.
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Viet Nam was combating malnutrition through a plan of action to the year 2000 to create an information network, reduce prevalence of malnutrition in children under five to 30 %, increase the average weight during pregnancy, reduce low birth weight incidence to 10%, eradicate blindness caused by vitamin A deficiency. reduce goitre due to iodine deficiency by 50%, and ensure an average daily calorie intake of 2100 kilocalories. The cooperation of international governmental and nongovernmental organizations was earnestly sought for those measures. Mr WAENA (Solomon Islands) said that his country had conducted a national nutrition survey in 1989 which showed that although marasmus and kwashiorkor, for example, were not prevalent, there were unacceptable levels of malnutrition connected with weaning; the risk caused by adoption of processed-food diets was especially present in urban areas, and the national programme for maternal and child health was tackling the problem with the. help of two nutritionists, as well as promoting health education. Although breast-feeding was widely practised, the increasing employment of women constituted a potential threat inspite of the proviSion of an hour in the mornings and afternoons for those with infants to feed. institutions. Bottle-feeding was contrary to policy in hospitals and No breast-milk substitutes were imported, the other method of feeding being by
cup and spoon using expressed milk. It was intended to keep it that way. Mr PUNA (Cook Islands) said that the report gave much food for thought with no "junk". Cook Islands, which followed the principle that small was beautiful, had relatively manageable problems. He thanked WHO, UNICEF. UNFPA, SPC, SPAF and the New Zealand Research Foundation for sponsoring the family lifestyles programme and USAID for sponsoring a vitamin deficiency study in the northern group of islands which found no sufferers. Bringing up to date figures given in the WHO document. he said that the infant mortality rate for the Cook Islands was down to 9 per 1000 live births. "Westernization" where it referred to habits related to fastfood must be combated together with other causes of malnutrition in order to preserve physical. mental and social health. Ministers .of health and of finance were making a concerted effort to adjust attitudes. School lunch services were a good starting point to ensure a healthy diet for children. Nongovernmental organizations were very cooperative in that field, particularly the
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Cook Islands Welfare Association (bringing together mothers and district nurses) and the family alliance. The eradication of nutritional diseases should be seen as a realizable aim. His country's Food Act could be made available to others in the Region on request. He suggested regional cooperation for the detennination of maternity leave requirements. Premises must be provided for breastfeeding mothers that could also accommodate education for mothers. Finally, he urged health authorities to provide a good example where nutrition and exercise were concerned.
2.
HUMAN RESOURCES FOR HEALTH: Item 15 of the Agenda
2.1
Public health training in the Western Pacific Region: Item 15.1 of the Agenda (Document WPRJRC44/11) The REGIONAL DIRECTOR recalled that at its forty-third session the Regional
Committee had discussed the topic of public health training in the Region. The Committee had agreed with the Australian representative, who had introduced the topic, on the vital importance of public health training in the development of human resources to meet regional health needs of the future. The Secretariat had been requested to initiate action towards the development of mechanisms for cooperation among training institutions in the Region to maximize the Region's capabilities in that area. The interim report provided a preliminary assessment of postgraduate trammg resources. It highlighted the need to improve the relevance to regional needs of training programmes and their content, and the need to establish fonnal links between institutions. A new index to the existing directory of training institutions in the Western Pacific had been developed and would be the basis for updating the Directory in 1994. Discussion of the report was expected to elicit advice on further action needed to strengthen public health training in the Region. Members of the Committee had therefore been provided with a copy of the 1992 Directory of Training Institutions in the Western Pacific, as well as an index to postbasic and postgraduate training for use with the Directory. The index was an initial attempt to design
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more "user-friendly" packages of information on available training opportunities in the Region. It was planned to completely revise the en~ire Directory in 1994 using an extensive crossindexing format similar to the drug reference manuals used by physicians. It had been noted that the listing in the current directory was incomplete with one country's institutions forming almost 80% of the listing. and complete information on their training activities. Dr ADAMS (Australia) said that he had been heartened by the reception of Australia's proposal at the previous session of the Regional Committee and thanked the Regional Director and the Secretariat for the progress made. Hopefully the momentum would be maintained. He
He requested Member States to
collaborate closely with the Secretariat in the revision of the Directory by providing accurate
also thanked the regional training centre in Australia for the workshop organized recently and recommended study of its report. Within Australia it was proving possible to renew funding for all public health training centres; the latest budget showed welcome government support for public health training. Consortia were currently being developed to link public health schools so as to build strengths and it was hoped that that model could be extended to other countries in the Region in due course. WHO support in that regard was greatly appreciated. Dr DE LOURDES SILVA (Portugal) welcomed the review of public health training in the Region. It was most useful for Macao, where training resources were not currently
available, in selecting suitable institutions for its staff.
Macao had made great efforts to
strengthen human resources development, particularly through the training of local health personnel, to ensure continuing provision of health services beyond 1999. During the past year considerable progress had been achieved: 30 medical graduates had completed an 18-month general internship programme for professional options and 40 doctors were attending a complementary internship programme for specialization options. Since July 1993 another 25, mostly graduates from Jioan Medical University in Guangdong, China, had started a new general internship programme with a duration of 24 months. During 1993 the Macao Technical School had trained 16 general nurses, 38 specialized nurses of whom 15 were in community health, and 41 technicians for diagnostic and therapeutic services. Macao's continuing education programme was progressing successfully with the organization of in-service training and refresher courses and workshops, including one on hospital administration and planning and management for human resources for health. Study tours and technical visits had also been supported to ensure study in and exchange of
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experiences with other countries and areas.
The support provided by WHO and various
countries and areas, especially China and HO:1g Kong was greatly appreciated. In 1992-1993, 11 WHO fellowships had been granted for the training of local health professionals. Owing to the shortage of local health personnel, human resource development would be a long-term task for Macao and greater efforts were needed. It was hoped that countries and areas in the Region and WHO would continue to provide support in the future. Dr HONG SUN HUOT (Cambodia) said that Cambodia had a joint faculty for medicine, pharmacy and dental care whose main task was the training of health professionals. Training in public health was therefore related to this school and to other health institutions in the country, including centres for hygiene and epidemiology, malaria, tuberculosis, leprosy, etc. There was no specific public health school. One reason for that was the need to ensure that future doctors" and other health professionals all received a broad grounding in public health. The faculty was currently considering offering 300 hours of public health training in each of the six years of medical training, representing 25 % of the course. Postgraduate training had started on a small-scale with public health modules for public health trainers from the faculty and other institutions and for supervisors and trainers at the level of provincial health services. In addition negotiations were under way with a Philippine nongovernmental organization (ADRA) concerning the organization of another training module leading eventually to a postgraduate diploma for public health practitioners in Cambodia. External funding, especially that received from Thailand and China, had been greatly appreciated. It was felt that it should be used primarily for the training of future public health trainers and researchers as it as essential to strengthen local capabilities. Cambodia was ready to share its experiences in postgraduate training with interested countries through the exchange of training modules. Exchange of examiners would also be useful. Member States in the Region might also be interested to learn more about Cambodia's medical school. Cambodia would be grateful for support, in the form of educational materials or visits from trainers, in the further development of future trainers. It was essential to provide all health professionals with a base of public health knowledge as a first step towards the development of public health specialists. Dr MONTA VILLE (France), welcoming the report, hoped that francophone countries would participate in public health training. In New Caledonia for example there were skills and achievements that would be of interest to others in the South Pacific.
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Dr REID (United States of America) welcomed the report as a first step in addressing the appropriateness and relevance of postgraduate training in the Region. both baseline parameters and areas requiring further study and support. The United States territories in the Region had health problems that were similar to those of many other developing countries, both within and outside the Region. The United States of America was providi.ng financial support to its territories and training for their personnel at United States institutions. Other developed countries in the Region with established institutions were also providing training opportunities. In recent years WHO had provided considerable support to American Samoa in the organization of training workshops, etc. However, existing cadres of trained personnel were getting older and new younger and more dynamic staff were needed. The help received from the United States of America, WHO and other donors was therefore greatly appreciated and it was hoped that it would bear fruit in due course. Mr WAENA (Solomon Islands) welcomed the report as the Solomon Islands placed top priority on the training of qualified health workers for the delivery of health services to its scattered islands. Emphasis was given to the training of doctors and specialists to replace Training in public health was also considered essential as health doctors from overseas. It had established
services needed advice from health managers, epidemiologists, anthropologists, health economists health educationalists, environmental specialists, etc. Although training had started on a small scale, many of the training opportunities were located in the northern hemisphere far from the Region, which sometimes had adverse consequences on family life. Opportunities within the Region were insufficient to meet demands. He was encouraged to learn that Australia was setting up public health schools which would hopefully increase regional opportunities. He endorsed the conclusions and recommendations for future activities contained in the report. Dr Haji HUSSAIN (Brunei Darussalam) said that his country depended entirely on external public health training facilities and therefore welcomed the opportunities for sharing provided by the Asian-Pacific Consortium for Public Health and the Network for Community-Oriented Educational Institutions for Health Sciences. In addition to the lack of training facilities there was also a shortage of public health trainers and even candidates. There were only four local doctors with a postgraduate training in public health and they were occupying the top executive posts in the Ministry of Health. One other doctor was currently undergoing public health training in Singapore.
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Since the discontinuation of the Royal Society of Health diploma course for health inspectors, inspectorate staff had been trained in South Australia. However, current prospects in that field did not attract students. Postgraduate studies in public health, nutrition, and biomedical and laboratory sciences were undertaken mostly in the United Kingdom. The short-term on-the-job training, mostly in industrial health and safety, offered by Japan was greatly appreciated. Current priorities were for training in environmental health, occupational health, epidemiology, community health and public health practice. Dr PRETRICK (Federated States of Micronesia) commended the report and endorsed its conclusions and recommendations. Postgraduate training for his country's citizens was usually undertaken at the University of Hawaii, School of Public Health. The University had put in place several programmes designed to help students from disadvantaged backgrounds to qualify for admission to its public health master's course. One such programme was the Health Career Opportunity Program at the college in Pohnpei. In recent years the University of Hawaii had developed a graduate certificate in public health to meet the needs of interested groups, such as health practitioners. The first group of seven students from the Federated States of Micronesia would receive certificates in August 1993, and more would complete the programme in 1995. The enrolment and completion rates for the programme had been satisfactory and all States had sent participants. The programme provided a means for ensuring continuous enrolment in the future at the University of Hawaii School of Public Health. His Government was aware of the broad range of opportunities available within the Region and strongly encouraged utilization of the institutions in the Region by its citizens. The CHAIRMAN requested the Rapporteurs to prepare an appropriate resolution.
2.2
Fiji School of Medicine: Item 15.2 of the Agenda (Documents WPRJRC44/12 and Corr.l) The REGIONAL DIRECTOR said that, during its forty-first session in 1990,
the Committee had requested him to monitor progress in implementing the 1989 Plan of Action for revitalizing the Fiji School of Medicine as a centre for training health personnel for the Region. It had also requested a report on the findings within three years of the date of the resolution.
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The report under consideration complied with that mandate. emerge.
It also coincided with the year
when the first graduates of the School's ne" problem-based medical course (first tier) would
The report took note of a renewed optimism arising from the initial success of the new medical curriculum, exemplified by a significant reduction in student failure rates, and by a marked increase in interest among the island States in the Region in all the curricular offerings of the Fiji School of Medicine. In effect, the redevelopment work at the School had opened up new avenues for closer coordination of medical training in the Region. For example, an integrated primary care worker's programme recently implemented in Kiribati would soon qualify graduates for entry into the second tier (hospital-based) of the new medical course in Fiji. Similarly, the University of Hawaii-Manoa's Pacific Basin Medical Officers Training Program (PBMOTP) and the Fiji School of Medicine were seriously looking at setting up a department of postgraduate training. Parallel developments were thus occurring at many levels within the Fiji School of Medicine itself, and among related health training institutions in the Region. On the issue of the autonomous organizational structure for the School of Medicine, a paper for submission to the Cabinet of the Fiji Government had been discussed between the Minister of Health and the Council of the Fiji School of Medicine. He understood that the representative from Fiji would be able to give further details on that matter. Mr WAENA (Solomon Islands) said that the item under discussion was of great interest to the Solomon Islands which had greatly benefited from the training of its personnel at the Fiji School of Medicine for many years. His Government's health policy emphasized conununity health, so that the School's new curriculum was most appropriate. Students were being introduced to problem-based and student-centred learning, in addition to being exposed to health problems in the community, which motivated them to learn by themselves, ask important questions and find solutions. Such skills were not addressed in conventional courses yet they were most relevant for personnel who would, on their return, have to work alone in rural areas providing both health care and management. Six students were currently undergoing training at the School and, thanks to the generosity of the Fiji Government, it was proposed to send four more each year.
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The changes being made at the School were not easy and required support from the international community in the form of provision of educational and other materials and sponsorship of students. Recipient countries should also support the School where possible. He hoped that WHO would continue to collaborate with the School so as to strengthen and develop its programmes. Mr BUNE (Fiji) said that Regional Director's report summarized the progress made in redeveloping the Fiji School of Medicine and restructuring its curricula and academic programmes in the past five years. He expressed his Government's appreciation to the Regional Committee and WHO for the financial and technical support which had made the changes possible. Representatives would recall that, at its thirty-ninth session, the Regional Committee had endorsed the representative of Fiji's plea for WHO support in revitalizing the School in order to prevent its collapse and closure, which had seemed imminent at the time. The School had not only survived but had taken on a new lease of life as a vibrant and innovative health training institution at the forefront of medical education. The plan of action for the redevelopment had been a collaborative effort undertaken by the Faculty of the School and Ministry of Health officials with the support and guidance of WHO and a task force of medical educationalists and administrators commissioned by WHO in early 1989. The three-stage plan had been ratified by the Cabinet in August 1989. As the report indicated, the first phase, curricular reform and academic changes, had been implemented and the first cadre of health care workers to be designated public health practitioners would graduate by the end of 1993. It was both fitting and pleasing that the Regional Director had agreed to present the diplomas at the graduating ceremony. However much remained to be done to fully implement remaining two phases of the plan of action. The first was the desire of donor countries and WHO for the School to enjoy a measure of autonomy through the establishment of an independent council as the controlling body. WHO had appointed short-term consultants to explore mechanisms for implementation, draw up appropriate legal documents, and define the operational steps required. Documents were in the process of being submitted to the Fiji Government, which stood ready to examine them. In the meantime the Ministry of Health was accelerating efforts to identify and consolidate support from relative donor agencies to provide funding for new buildings to house teaching facilities, offices and student accommodation. The Ministry of Health had already submitted an outline plan for the project to the Central Planning Office in accordance with the recommendations of the short-term consultants.
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The Fiji Government assured the Regional Committee, the Regional Director and the other 16 island countries which depended on the School for the development of human resources for health, that the Ministry of Health was fully committed to the implementation of the plan of action. It would continue to collaborate with WHO to ensure that the 107-year-old institution remained the dominant force in training and education of health care workers in the Pacific Basin. Dr TAPA (Tonga) expressed great pleasure at the Regional Director's report. He had attended the session of the Regional Committee which had adopted resolution WPRlRC41. R 1, in response to the impassioned plea to the Regional Director and Member States to come forward and revitalize the Fiji School of Medicine, an historical institution .. As a graduate of the School himself he welcomed the successful implementation of the first phase of the plan of action and the forthcoming graduation of the first students to benefit. Although much remained to be done, the future of the institution now seemed assured as an important training centre for the Pacific islands. Tonga would continue to send students to the School. He urged the Secretariat, in the Regional Office and at headquarters, and other agencies to continue their support to the School. international collaboration in the health field. Dr PRETRICK (Federated Sates of Micronesia) said that the Government of the former Trust Territory of the Pacific Islands had started sending students to the Fiji School of Medicine in 1951 and graduates had formed the core of the medical personnel in the area until very recently. A critical shortage of staff had developed as it became increasingly difficult for students to gain admission. The Pacific Basin Medical Officers Training Program located in Pohnpei in the Federated States of Micronesia had been developed to counter that shortage. By the year 2000 at least 89 medical officers would have completed the course, resulting in at least 76 Micronesians appropriately qualified to meet the health care needs of the Pacific islands. By early 1997 all the students would have completed five-year training programmes. Following the closure of the Programme in aboUl the year 2000, future medical officer training for Micronesian citizens would have to be undertaken at the Fiji School of Medicine. With the rapid increase in population and the near retirement of senior medical officers in his country, the demand for doctors would become critical by about the year 2015. He therefore strongly supported efforts to revitalize the School. It was also hoped that the Fiji School of Medicine would provide postgraduate training for current Program graduates. Like the Expanded Programme on Immunization, the revitalization of the Fiji School of Medicine was another shining example of
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His Government respected the goal of the School - the training of highly qualified medial officers capable of providing medical care services to their own people - and he urged WHO to continue its collaboration with that institution. Dr SCHUSTER (Samoa) observed there were two medical schools in the Region to which most of the Pacific island nations had long sent their graduates and postgraduates: the Fiji School of Medicine and the Faculty of Medicine in the University of Papua New Guinea. Most of the benefits currently enjoyed had stemmed from training provided .there before students starting graduating from schools elsewhere. It was important to ensure that the two levels of training that were now going to be given would provide a balanced approach between public health teaching and clinical curative teaching. Countries had been criticized for spending too much money on costly clinical curative services rather than investing in low-cost but highly cost-effective preventive public health programmes. The Fiji School of Medicine would serve the countries in that respect. He urged donor countries to contribute generously to the School's requirements. However, he stressed that donations should not be made on a competitive basis, which might encourage the two schools to compete for financing. Rather, donors should ensure that there was solid collaboration and cooperation between the schools. Mr TEBANIA (Kiribati) endorsed the views expressed by previous speakers. Government fully agreed with the report on the Fiji School of Medicine. His
Efforts were under
way to link the programme of the Kiribati medical assistants school to the primary care practitioners course at the Fiji School of Medicine. That link should be operative by the end of 1994. Dr TINIELU (Tokelau) expressed his agreement with the support to be provided to the Fiji School of Medicine, which was an important source of health personnel to other areas of the Western Pacific. Mt HENRY (Cook Islands) observed that both the Fiji School of Medicine and the University of the South Pacific played an important part in the development of human resources. Many of the qualified health professionals of Cook Islands were working in Australia and New Zealand where they had been trained. When they came back to their country they had a different cultural outlook. He stressed that the Fiji School of Medicine and the University of the South Pacific should be used to train people of the Pacific because they would learn in the Pacific way. They would return to the country where they began their education wiser, better
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qualified and able to apply their knowledge for the benefit of their people, rather than coming back with the education of another culture. He did not wish to be derogatory, but to emphasize that the Pacific countries did loose qualified people. It was therefore important to the Pacific to maintain the Fiji School of Medicine, the Medical Faculty at the University of Papua New Guinea, and the University of the South Pacific. Mrs HOMASI (Tuvalu) expressed her full support for the betterment and improvement of the Fiji School of Medicine. The School had long been Tuvalu's main institution for training their health personnel. She joined other countries of the Region in thanking Fiji for acting as a big brother, an approach that was appreciated in Tuvalu.
4.
REGIONAL STRATEGY ON HEALTH AND ENVIRONMENT, INCLUDING FOLLOW-UP OF THE UNITED NATIONS CONFERENCE ON ENVIRONMENT AND DEVELOPMENT (UNCED): Item 16 of the Agenda (Document WPRlRC44/13) The REGIONAL DIRECTOR said that in recent years, the environmental health
problems of the Region had become more prominent and widespread.
In confronting those
problems, it had become increasingly evident how complex the interdependence was among the health, social and physical aspects of the environment, as well as between the public and private sectors. Although that interdependence was not fully understood, it was clear that a healthy environment could not be achieved by addressing health alone. At the same time, it should be recognized that WHO had some limitations. Activities must be selected judiciously, and that was something that must be worked at and planned for. Document WPRlRC44/13 was intended to serve as the framework to guide health and environment activities over the following six years. It had grown out of the work of the 1991 Regional Consultative Group on Health and Environment. Development; In addition, it complemented and was responsive to: Agenda 21 of the 1992 United Nations Conference on Environment and the recommendations of the 1991-92 WHO Commission on Health and Environment; and the new WHO Global Strategy for Health and Environment, endorsed by the Forty-Sixth World Health Assembly in May 1993. The Strategy called for a fresh look at the way traditional activities were handled. Special attention needed to be paid to pinpointing priority activities based on considerations of significance, timeliness and practicability. It must be backed up by plans of action addressing each of the identified priority activity areas. Such plans of action must be dynamic documents,
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responsive to changing circumstances. Some of the plans had already been developed by WHO in collaboration with the Member States. More needed to be developed at the national and local levels by Member States in collaboration with WHO. Such plans must reflect the priority concerns and those concerns to which key decision-makers were committed. Taken together, the Strategy and associated plans of action were intended to answer the questions posed at the Technical Discussions held in conjunction with the fony-third session of the Regional Committee in Hong Kong in 1992, on the topic "Healthy urban environment". Those questions were: What was to be done with what was available; How could they achieve a greater impact; and How could WHO best enhance Member States' effons to resolve priority environmental health problems? Successful implementation of the Strategy required improved collaboration among national and external suppon agencies involved in health, environment and development activities. It also required that WHO health professionals make themselves pan of discussions on sustainable development. They could not wait to be invited. More imponantly, it involved a renewed sense ofpannership between Member States and WHO. That must be "their Strategy", if it was to succeed. Dr PINEDA (Philippines), commending the Regional Director's timely and relevant report, expressed appreciation of WHO's pannership in tackling complex and often politically sensitive issues concerning health and the environment. She hoped the Regional Director would continue his resolute effons to ensure national action to arrest the consequences of irreversible environmental degradation in the Region. The Philippines had responded to the challenges of health and environmental issues in a number of ways. First, it had set up the Philippine Council for Sustainable Development on which eleven government agencies and some nongovernmental organizations were represented. The Council had recently identified shonfalls in resources for water supply projects, air pollution monitoring and development of a hospital waste management system. Secondly, the Health Depanment panicipated in the Pollution Adjudication Board. Thirdly, it had strengthened the Inter-Agency Committee on Environmental Health which addressed emerging and continuing problems. Founhly, the Health Depanment had adopted a radical approach to integrating health and development issues into plans and programmes, with considerable success. Regional field offices had been organized into HEAD (Health, Environment And Development) zones, grouped together according to ecological systems or bioregions. The HEAD zones had made pioneering effons to bring development issues such as industry, trade,
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energy and agriculture into health sector discussions, with a view to making risk reduction a key parameter for health interventions. A framework for continuing collaboration by the major development sectors was being constructed, in order to address the health aspects of water resource utilization, industrial expansion, pesticide use, biodiversity and food safety. It was imperative to set up a framework for regional cooperation on transboundary issues such as transit of toxic wastes, export of hazardous or toxic processes and materials and wildlife trade and the exploitation of forest resources. It was high time for the health sector of the Region to unite in condemning practices that adversely affected individual Member States and the entire interdependent ecosystem of the Region. Dr CHEN Ai Ju (Singapore) expressed her appreciation of the Regional Director's informative report. Her Government supported the regional strategy and plans focusing on priority activities with maximum impact. She urged the Regional Director to support the efforts of Member States to incorporate health and environment measures into national plans for sustainable development. In Singapore a Green Plan had been drawn up, which set out the environmental goals for making Singapore a "green city" by the year 2000. programmes: The Plan contained six action environmental education, environmental technology, resource conservation,
environmental noise, clean technology and nature conservation. Those new programmes would complement existing activities concerned with solid wastes and waste water management, control of hazardous substances and environmental management. Singapore had long recognized the need for sustainable development and endeavoured to maintain a balance between environmental protection and industrial development in its pursuit of economic growth. Great emphasis was also placed on food safety and hygiene. Mr Jeong-In SUH (Republic of Korea) thanked the Regional Director for his timely report. Since the United Nations Conference on Environment and Development in 1992 the It had introduced legislation on environmental
Republic of Korea had drawn up and implemented an environmental protection plan in order to tackle various global environmental issues. impact assessment and combated air pollution by promoting the use of cleaner fuels. Vigorous efforts had been made to increase public awareness of the importance of recycling. The Republic of Korea intended to participate in regional environmental cooperation projects such as the North-west Pacific Action Plan for the prevention of marine pollution, and would incorporate environmental factors into its industrial policy with a view to achieving sustainable development. His Government would continuously contribute to the efforts of the world community to preserve the global environment.
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Dr REID (United States of America) commended the emphasis of the repon on local involvement. response to urgent needs combined wIth sustainable long-term plans. promotion of change in attitudes. and intersectoral cooperation. The United States National Institute of Health contributed to. the latter through its collaboration with the UNEPfILO/WHO International Progranune on Chemical Safety and the Pacific Basin Consonium for Hazardous Waste Research. He suggested regional contacts should be established with these bodies. as well as the development of an interdisciplinary approach to environmental health activities. covering occupational health and maternal and child health. statistics and epidemiology
inter alia.
The same opponunities should be given to health professionals as to social and
economic development expens and politicians. He requested that the environmental health concerns of Member States in the Region should be clearly determined as a basis for cooperation. enhancing data collection and project outcome. and that the Secretariat make its services available for that process. Workshops or environmental data analysis for panicular purposes of environmental epidemiology could be \ helpful. Finally. he encouraged the Regional Director to establish a system for the recording of achievements in that field to ensure that the methods used were appropriate.
The meeting rose at 5.40 p.m.