Women in white [full issue]

WORLD HEALTH The magazine of the World Health Organization September-October 1969 UK:416d USA:0.75 Amsou Maiga, a nurse-educator at the National School of Nursing, Niamey, Niger. contents Page 3 Towards equality by Germaine Tillion Page 12 Her name spells hope by Rehane Repond Page 20 Mountain doctor by John Taylor Page 25 Pioneer nurse, Niger by Monique Jacot Page 30 Friend and pharmacist by Julie Con tat Page 34 Tropical midwives by Karl Frucht Page 38 Laboratory technician, an un- known quantity, by Noel West Page 42 Guardians of the smile by Mariam Tigrane Page 46-47 Books—Letters All over the world, health services depend on the devotion and patience of the women in white. ► This issue of World Health is devoted to women health workers who, with their capacity for devotion and their gift for teaching, are essential to the improvement of health the world over. However, in spite of woman's increasing participation in a variety of professions, it would be premature to believe that her emancipation is being rapidly or easily accomplished. Germaine Tillion aptly emphasizes the constraints still imposed by certain social structures. women towards equality by Germaine Tillion* Foreign residents in Egypt have often been heard to observe: "In this country, women are more intelligent than men." Personally, I do not believe for a moment that it is so, but I am not much surprised by this statement, because, when in countries around the Mediterranean women aspire to high-level posts, they have great obstacles to overcome, much greater than those with which men have to contend, and only a very small number of women manage to climb to the top. As competition is severe, it is not astonishing that lesser lights are eliminated, with a consequent rise in the average quality of those that remain. The same phenomenon may be observed wherever selection is unequal: during the colonial period, there were more remarkable people to be found among native-born officials in high posts than among similarly placed foreigners; after independence, for the same reasons, the proportions were reversed. Statistically, the endowments of all human beings average out, and women are, after all, a part of mankind. If they are to develop, endowments call for education. Educational equality for women does not exist even in highly- developed countries, and much less, of course, in countries where women are systematically excluded from anything that might strengthen character and quicken the mind. Inequality of educational oppor- tunity actually leads to inequality in human worth and, so, in a random group of people there are considerably fewer intel- ligent women than men, in fact the contrary of what was observed by the foreigners who had associated only with a highly educated section of the population. No doubt, in every country and within all kinds of societies, among women as much as among men, outstanding human beings may be encountered, whose imag- ination, judgment and generosity attract an increasingly large circle of persons, who in turn broaden their outlook. Indeed, I have personally known a number of old ladies who were totally uneducated, who had never left their family circle, yet whose imposing authority rested on penetrating judgment. Although deprived of learning and with limited experience because of their seclusion, these beings influence their surroundings and strengthen our belief in a special vocation of the human race. But it must be admitted that they are not numerous. In fact, they are so few that they cannot be expected to bring about nation-wide progress. Lacking as they are in learning, with little opportunity for talking to well-informed persons, not making the mental effort entailed by even modest trades, the beam of the revolving beacon we call intelligence is irrevocably narrowed. Considering the nation as a whole, the inequality in intellectual worth between men and women is obvious. But it must not be imagined that women are unimportant in societies where they are set apart; on the contrary, their role grows greater the more, as individuals, they are crushed, maimed and repressed. Mama's influence In the traditional families of the Mediterranean area, a girl has neither the means nor the right to express a personal opinion—which would of course have to be subjected to critical examination—but she may always refer to the fiats of tradition, which are more or less immut- able. On attaining womanhood, she need no longer keep silent and is allowed to take part in family decisions, but that does not mean that she is identifiable as a "person": her thoughts, opinions and decisions are not really her own but are formed, as it were, outside her; they are the expression of a featureless, nameless entity that might be called "womanhood", a redoubtable entity solidly anchored in age-old customs and maxims which in the * Head of studies at the Ecole pratique des Hautes Etudes, Paris, and author of numerous social and political works. 3 Mother- in - law. long run are transformed into absurdities and which she is instrumental in keeping alive. She will crush without hesitation her personal tyrant, were he to try to think for himself and find an original solution to a particular problem, or were he to seek to abandon the odious role which usage has forced upon him. The decisions taken by Mediterranean mamas are all the more compelling in that they conform to those that would have been taken by their own mothers and grandmothers, and are vin- dicated by the almost unanimous approval of their contemporaries; for, at that same moment, in other villages, other old women are taking identical or similar decisions to which the whole family must bow down. This acquiescence is no longer, however, a foregone conclusion, and conflicts do sometimes arise. Love and force of habit tend no doubt to obscure the seriousness of family disagreements but, when they do break out, it is more often than not the man who knuckles under and the old woman who has the last word. She fre- quently prevents the young people in the family from continuing the studies for which they have a liking (not only the girls but the boys too); she chooses spouses for her descendants and interferes at every turn in the matrimonial incidents of the young couples. As for the "emancipation of women", she is obviously its principal opponent. The development of an entire family can be obstructed by her but such obstruc- tion has much wider implication, for it affects the nation's destiny. In areas where all the women are actu- ally secluded from the rest of society, so-called "feminism" is not the concern of women, just as the abolition of slavery (in regions where it still exists, i.e. espe- cially in the Sahara) is not the concern of slaves. I have come across many slaves in all the countries bordering on the desert, in spite of the fact that slavery, as everyone knows, has been abolished in these countries. The abolition is by no means a legal fiction. Slaves who no longer want to be slaves are perfectly free to leave their masters, and the authorities will prevent their being pursued. Yet only a small number actually leave, despite the fact that they are completely deprived of rights : they figure in wills, and are divided up among the heirs as if they were date-palms or cows; their children may be disposed of by the master, who often gives them away while they are still quite young to distant members of his family; they receive no pay and may be given physical punishment. How can one explain the survival of a practice that is in such violent conflict with present-day moral principles? In the first place, obviously, slavery survives because of economic necessity: slaves have no means of livelihood; they own neither land nor flocks and have no possibility of obtaining paid employment. The second reason might be called "envi- ronmental pressure" : all around them, people believe, including the slaves them- selves, that slavery is lawful and is willed by God, and that those who escape from their masters, by depriving them of a "thing" belonging to them, commit an act of "robbery". Thirdly, there are senti- mental ties : since a slave has no father, it is his master who fills the paternal role. Stagnation is reinforced by ingrained habit and lack of information. In the subjection of men as in that of women, only the State, if it so wishes, is in a position to intervene. But such inter- vention, it must be admitted, would be difficult, for in both cases the State would come up against its own national public opinion, including the opinion of the downtrodden themselves. It has been observed for many years now that men must already be almost free in order to want to be free . . . The emancipation of women, which is simply part of the liberation of human kind, is no exception to the rule, but on the shores of the Mediterranean few are the women who have moved forward on the path to freedom. In Egypt, however, there are a number of such women, especially in intellectual circles, and they may be found in appreci- able numbers in the medical and allied professions. Comparatively speaking, Egypt developed early among Arab nations and, from the beginning of this century, has had an educated and thriving urban middle-class with access to world currents of thought. Today, it can boast of an intelligentsia that is well informed of the country's major problems and aspira- tions and to which a large number of intelligent, educated and influential women belong. Many active members of this elite today feel disturbed that the great efforts recently made by the Government for an all-out family planning policy have produced such meagre results. They also deplore the delays of jurists and legislators in moving towards the normalization of the status of women. The lack of momen- tum in these closely linked programmes represents a serious danger in times when technically and economically the world is changing. Like a falling body, such change accelerates . . . The contrast between the speed of technical development and the delays of social development is a matter of concern because, basically, it is a source of danger. Governments know it and those who think about such matters know it. Why then is official action so slow and ineffective? Because there are considerable difficulties, greater than elsewhere. In order to under- stand them, we must go back to the remote origins of human society. Structures of kinship All elements of a society are inter- dependent, and just as one cannot speak of the status of women without relating it 4 Mrs Hikmat Abou Zeid, the first woman minister in the U A R, works easily with male colleagues. to the status of men, so, when the general development of a particular region is investigated, it is necessary to examine the interactions between man and the material conditions of his existence : man influences the conditions for sure, but it is very much a two-sided game. Man modifies his environment first by means of technical discoveries, of which the earliest, the discovery of fire, goes back perhaps seven hundred thousand years. Today, as in the past, he applies some new invention, and later the invention draws him on in its wake ; entering a new dis- covery-determined milieu, he has to adapt to it. Willy-nilly, he is compelled to concoct those laborious social inventions which today are called "structures". When the ethnologist speaks of "structures", the reference is, as here, to patterns of kinship. It may fairly be stated that these "structures" are persistent, for in the whole of the human species only two series are known : one of them is characterized by the rigid prohibition of marriages between boys and girls belonging either closely or distantly to a common lineage (exogamy), and the other permits and even encourages this kind of marriage to the exclusion of all others (endogamy). Exogamy, practised by the so-called savage inhabitants of the globe, appears on large-scale maps as small scattered dots, at tremendous distances one from the other, and is today apparently doomed to extinction. Endogamy, on the other hand, can be clearly seen in that part of the world where civilizations first arose; here, very long ago, it was invented (or re-invented), and here it is still practised. On the map, the area is homogeneous and centres on the eastern Mediterranean; it extends, spindle- shaped, from the Atlantic Ocean to Japan. Endogamy has been established for a very long period in the regions where it is still encountered, for historical documents lead us to believe that it was already practised here at the dawn of history, and it was precisely here, five thousand years ago, that history started. For purposes of establishing a "natural history of man", it may seem ludicrous A new profession for women in the U AR: laboratory technician ( Research Institute at Qalioub). • .... , ... , .44. • a ..,„.„ ••• ' , • ... . a -.A.:" .04; - .- X • ' • '''). a ...." , ,•:. _.''' 4 ... • • .„ s• , • ' , , 6.- , ,:., ' ■ .: . at at" ' ■ II li • . a , .. ..t • , . 1 : "; • ' 411L:,' . .110441 4 • r, •0 ' . • - .7 ' ' - • 1, ..- ' ilk' i , ;,,,.' . : . . „,... ‘.. -.„..44 tv, * . . ,r' , • •-• - " 04,47- • -4. „. - • ato. 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It was perplexing to observe that all the groups of "savages", scattered widely in the four corners of the earth, and obviously quite unable to transmit patterns of be- haviour to each other, should have invented, each group apparently inde- pendently of the others, one and the same rule that can be related neither to instinc- tive behaviour, nor to any custom in our own historical and populous area. These enigmatic "savages" in their isolation stubbornly keep alive a custom which is neither natural nor expedient, and which they themselves consider troubleseome. By showing that the prohibition of marrying a woman within one's own family means marrying a woman from abroad or, more precisely, being obliged to give in marriage a kinswoman to a foreign clan (even an enemy) which will provide or has already provided you with a wife—Claude Levi-Strauss explains in his Structure elementaire de la parente (Ele- mentary Structure of Kinship) the scope of the mechanism : the mainspring of the system consists in the established law whereby groups are compelled to give their girls in exchange; this barter, or exchange of gifts, is thus the motive force behind much in their way of life. A different kind of coherence, almost the exact opposite of the previous one, but which is also "structural", is operative in endogamous societies. Here observers have been struck by the fact that men have to marry one of their cousins on the father's side. Can this be interpreted as a prohibition to marry the girls of a family to strangers? If it is forbidden to "export" women, it follows that they must not be allowed to be "idle", and the young men of the family have to do their duty . . . The way of life of Egyptian women is still largely determined by age-old custom. 6 Between the obligation of the "savages" to barter or make gifts, and the reluctance to exchange that characterizes the "peoples of history", it appears to me that there is a common element: the dictates of demography. These have changed, as we know; at present they are changing once again, and maybe it is changes of this kind that impel human society in new directions. Technical innovations are as sudden and, in a way, premature as social innova- tions are slow in satisfying the needs that gave rise to them. The former are the result of actions by one man or by a group of men, and do not encounter any partic- ular resistance in establishing themselves wherever they are useful; once they are installed, they act directly on their sur- roundings, on the ecology. The latter, on the contrary, arise in this modified envi- ronment, which slowly but irresistibly acts upon society and eventually compels it to change, to accept innovations. In other words, a reform of the "structure" is not the consequence of a demographic crisis but rather of a crisis in the "philosophy of demography". Demography of "savages" If "elementary structures" (exogamy) preceded "historical structures" (endo- gamy), as I believe they did, then exogamy is not an invention of contemporary "savage" tribes but, as many ethnologists think, constitutes a step in the general evolution of man, and for Mediterranean peoples is an aspect of their prehistory. My belief in the correctness of this theory is strengthened by having observed traces of it among members of a Mediter- ranean linguistic group, the Touareg. By comparing their vocabulary related to kinship with that of other Berber-speaking peoples, it is possible to follow the trans- formation of an endogamic society step by step. If this is really so, a number of questions arise. Why did the transition Women of the Upper-Xingu tribe in Brazil where exogamy still is the rule. This tribe is in danger of becoming extinct. Dr A. Selim studying schistosomiasis in her research laboratory at the University of Cairo. take place? Why did it take place at the junction of Asia, Africa and Europe? The answer to the second question is perhaps that it was here, some seven or eight thousand years ago, that there occurred a radical transformation of man's economy caused by a number of almost simultaneous inventions : the cultivation of cereals, the domestication of animals (especially cows), the earliest means of transport, urban communities, etc. Until then, groups of human beings had subsisted only by hunting, fishing and gathering. Apart from a rich fund of tradi- tion, their only possessions were circum- scribed hunting territories and their women. That in the long run they tried to use the latter in order to secure the former may be inferred from a study of the customs of peoples untouched by civilization. Human beings who have preserved exogamous structures have this in com- mon : they eke out a precarious existence in tiny groups over an extensive area; should they reduce their capital or should their numbers increase, they are con- demned to famine. Some observers who have visited them have noted that their customs include infanticide and abortion, and that contra- ceptive methods are not unknown to them. They are also very much concerned with nature conservation the protection of game and pastures. That palaeolithic man was obsessed by the necessity of maintaining a certain relationship between the number of mouths to be fed and the amount of available food is, of course, only a hypothesis, but it would explain how through hardship exogamy was evolved. Secondary structures One day, somewhere between Nile, Euphrates and Jordan, man invented bread. From then on, the complicated, tortuous schemes to arrange marriages with avowed or potential enemies became unnecessary: to secure the frontiers, all that was needed was to have large numbers of children, who moreover could now be fed. Consequently all the girls must be 8 kept for the boys of the clan . . . and women should be imported, if at all possible, but on no account should they be exported, except to those who are more powerful, as a token of defeat and submission. This no doubt explains the relative ease with which a daughter-in-law from abroad is accepted in these same regions and the resentment that is caused when a girl marries a man who is not a kinsman, especially if he is no higher placed than his brothers-in-law. The new watchword was growth: growth of the economy and of the popula- tion. Increase and multiply, says the Bible. This injunction, the motto of the new sys- tem, is still today inherent in all our industrial enterprises. Of course, sooner or later population reaches saturation point, but this only happens in areas where population is dense, and where the death rate is so high that the age-old precautions of the previous era regarding the number of mouths to be fed are no longer applicable. From the beginning, urban civilizations have had a means of population planning: microbes. During our historical past, when in rural areas there were more child- ren than could be fed, they were dispatched to the towns. There, amid typhoid, typhus, plague, cholera and tuberculosis, carrying water, wood, coal or sedan chairs, they survived or they succumbed. Thus man- kind, without any violent revision of its "secondary structures", hobbled along its ruthless path. The time came when the great medical discoveries of modern times were gradu- ally being disseminated in the region where the oldest civilization of the world had thrived, and which consequently was the most "natalist" in outlook. From then on, a larger proportion of the children coming into the world would be able to survive, but at the same time the barbarous methods which "savage tribes" had employed in order to feed their people had become abhorrent. Starting in the nineteenth century, some countries were able—not Visiting hour at the Institute of Medical Research, Alexandria. without upheavals and crimes—to achieve industrialization and to adapt demo- graphically. In this way they achieved a number of advantages which in time became overwhelmingly great. The other countries, which evolved a civilization very early in history but which for geo- graphical and historical reasons were late to industrialize, are now up against their own "structural revolution", and have to adopt a new "philosophy of demography" (which we might call "tertiary structures of kinship"). Let us now see how they are facing the challenge. Poverty and population growth In 1952, at the outset of the Nasserian revolution, Egypt had 22 million mouths to feed or 8 million more than in 1927. Today she has 32 million. The popula- tion, which in twenty five years increased by eight million, is now rising at the rate of one million a year, and will of course continue to increase in proportion to the population and also because of the drop in mortality. Infant mortality is still high (over 100 deaths from 0 to 1 year of age per 1,000 live births) but is continually decreasing: medical services in Egypt are well organized, progress in public health is swift and, while today there is one doctor for every 5,000 inhabitants, it is planned to have one for every 1,000 by 1972. The increase in the number of babies, which at the dawn of history was the "striking force" of civilization, has become a cause of concern in many developing countries today. The high birth rate all around the Mediterranean seems to me to be closely linked with the "secondary structures of kinship", the workings of which we have tried to explain. If in these countries adaptation to modern structures is not accelerated, it may be feared that the ancient Stone Age philosophies will entail widespread misery ensnaring the inhabitants for a long time to come. Such is not the case for Egypt which, except perhaps in certain limited sectors, has chosen the path of change. The country is to be admired for having managed to maintain and even to slightly raise its standard of living despite an excessive increase in population. From 1960 to 1965, the growth rate of the Egyptian economy has averaged 6 per cent a year. Taking into account population growth, the gross national product per head has risen 3 per cent a year, equivalent to an increase of nearly 16 per cent in five years. Unfortunately, the 1967 war brought many problems again to the fore. In 1961, I travelled all over Egypt. I visited the country again in January 1969, from Aswan to Alexandria. After a period of eight years, what struck me most about everyday life was the undeniable progress, particularly the way in which the scale of wealth had narrowed down : ostentation and luxuries in dress, in the shops and in social life had disappeared, but the face of misery, of wretched, ragged poverty was also absent. In towns and villages, numerous shops now offer for sale a variety of goods, manufactured in Egypt, of tolerably good quality and low in price. Industrial production on a large scale is proceeding apace : automobiles, lorries, railway equipment in part, all the cus- tomary household goods for the modern town-dweller — cookers, refrigerators, radio and television sets are assembled in the country from parts only some of which are imported. Finally, mention must be made of an achievement on the heroic scale : the building of the Aswan High Dam. Unveiled This grandiose initiative has already brought an increase in Egypt's gross national income. It is to be hoped that as a consequence private incomes will also rise, for this is essential if families are to adapt themselves to the new structures of 9 Face of the past. kinship, to those "tertiary structures" which are already partly established in some Egyptian homes. Throughout the whole of rural Africa, including Egypt, the birth of a son is an occasion for great rejoicing, not only in obedience to age-old tradition, but also because, even today, social mechanisms favour the father—and the mother—of a large number of boys. Contrary to what might be supposed, this advantage is reinforced, at least in the countryside, by modern developments. Let us look first at the traditional advantages of fertility. A woman, as we know, has only very few rights in the households of her father or her brothers, and even fewer in her own husband's home; by contrast, in her sons' it is she who gives the orders—she may even abuse her privilege. As for aged women who have no sons, they may well be reduced to begging. For the father, who is more likely to be an agricultural worker than a landowner, the benefits are even more immediate, for even when the boys are still quite small, they can earn more than they eat. Not- withstanding the law on compulsory primary education, many children, even in the towns, may be seen to leave school in order to earn a few pennies and some food. In matters of prestige, the advantages are obvious. The division of the community into two rival factions is characteristic not only of the Kabyl region, of the Aures mountains and the Moroccan Atlas, of elections in Corsica and the Italian relatives of Romeo and Juliet, but is also very prevalent in Egypt. In villages, today as in the past, the most lucrative and prominent posts are monopolized by the strongest party; in modern times, sticks and rifles have simply been replaced by ballot papers. Far removed from the demands of agriculture and village rivalries, in cities or in suburbs, where dwellings cannot easily be extended but where higher salaries allow young fathers to nourish ambitions for their children, there the signs of family evolution may multiply. The following are some which have been observed recently: In circles where qualifications are re- quired in order to obtain employment, whether in government service, in the liberal professions, in trade or in technical jobs, the young man today who wants to marry and settle down prefers a girl who has been to secondary or vocational school, or better still, who is employed. This is a recent development; ten years ago, it was quite the opposite. But the change is appreciated by families that have profited by it and that all of a sudden have given in to their daughter's desire for education and independence. This surely is the explanation for the large number of young women who now attend specialized classes and the universities. Eight years ago, I had already observed that women wearing the veil could be seen on the outskirts of the towns but not in the more elegant quarters. During my last visit, in the course of a journey that took me through the whole of Egypt from south to north, I saw only one veiled woman in all. The veil, of course, is not a cause but a consequence; it is not by discarding the veil that a woman becomes a student, a doctor, a shop-keeper or a nurse, but in none of these occupations can she wear a veil. In the modern world, a family can only just survive on a single salary; with two wage-earners in the family, it is possible to make dreams come true: to buy or to improve one's dwelling and let the children have an expensive education. For the two "structures" hinge on the children. Children have always been loved, but modern boys and girls are more exacting than their predecessors : in order to be equipped for life's struggle, they need their full share of calories, doctors, dentists, teachers . . . It is these claims —expressed by the mothers—that regulate populations much more than any pill. ■ Today the veil becomes rare as more and more women find jobs. This laboratory employee works in a pharmaceutical plant near Cairo which employs 3,000 people; 60 % of them are women. 10 11 The Filatov Institute, Odessa. her name They call it the "last-chance hos-pital"—an extensive building surrounded by a large park in the outskirts of Odessa on the Black Sea. From all over the Soviet Union and even further afield, the sick and the injured come here to regain their sight after having been written off as hopeless cases. This last chance for the hopeless is the Filatov Institute, so named in memory of the eminent scientist who made revolutionary discoveries in corneal transplantation and tissue therapy. His tradition is being con- tinued by his best student, who now heads this famous Ukrainian hos- pital, one of the most impressive research institutes in ophthalmology in the world. Nadejda Putchkovskaya is a large, dynamic woman with a warm smile and intelligence sparkling from her green eyes. She greeted us in Professor Filatov's old office where everything that might recall his memory has been piously preserved. His white smock still hangs from a peg in a plastic bag and the clock has been stopped at the hour of his death. "He was over 81 and yet remained the youngest of us all," Professor Putchkovskaya said. "He left as a legacy a large school and many fol- lowers, who continue his work throughout the country." The Filatov Institute is divided into two main sections—the clinic, which has 450 beds and is being enlarged, and the research department. In addition, there is a large out-patient clinic where some 120,000 visits are recorded each year. To deal with patients and to do further research —clinical and research science are closely associated here—a large team of 605 doctors, ophthalmologists, opticians and engineers are at work; 130 of them hold the highest rank in their respective professions. Before heading the Institute, Pro- fessor Putchkovskaya was in charge of its keratoplasty service, where she distinguished herself by pioneering surgical operations on the cornea. The cornea is like a small trans- parent window that fits into the structure of the eyeball, a little like the glass of a wristwatch. Its fragility, and the fact that it protrudes, expose it to all sorts of accidents and infec- tions, to foreign bodies (metal splin- ters are especially dangerous), burns and various illnesses; all or any of these may endanger sight. Injuries, whatever their origin, have the same effect—the cornea, instead of being clear, becomes clouded like a misted- over window : the eye has gone blind. This explains the extraordinary importance of corneal grafts which allow light rays to penetrate to the retina once again and thus restore vision. It was in this sensitive and delicate work—following in the foot- steps of Professor Filatov and invent- ing new operational procedures — that Professor Putchkovskaya won 12 Professor Putchkovskaya examines a patient. ► spells hope by Rehane Repond External examination of the eye. worldwide renown. Her advances allowed successful work to be done on cases that had formerly been considered hopeless. Since the war, more than 7,000 corneal operations have been carried out at the Filatov Institute. Opening the window on the world For a long time, the idea of repla- cing an opaque cornea with a "clean window" was but a dream. In the 19th century, some surgeons actually attempted to insert a piece of glass or crystal in the eye; but the foreign body was rejected. Animal corneas grafted into human eyes were equally unsuccessful. As a result of the immune response, the body's prim- itive form of self-defence, the graft was invariably rejected. However, in 1931 Filatov had the brilliant idea of taking human cor- neas from corpses and was thus able to perform the first successful corneal transplantations. These operations became current practice after the Second World War, and eye banks were set up all over the world to receive donations of people who bequeathed their eyes at death. Since then, about twenty countries have adopted legislation to cover the use of tissues and organs from deceased persons. Today, with the dramatic spotlight on heart transplantation, it is worth remembering that the legislation under which they are being performed was originally adopted to regularize corneal transplantations. The name of Nadejda Putch- kovskaya is closely associated with a number of operating techniques in corneal transplantation, particularly for transplantations necessitated by burns. In such cases, called symble- pharon (from the Greek syn—to- gether, and blepharon—eyelid), not 14 Examining the interior of the eye using an ophthalmoscope, which allows the entire region to be scanned. only is the cornea damaged but the eyelid has melted and is welded, so to speak, to the eye. Formerly no treatment seemed possible and such cases were abandoned as hopeless. Yet Professor Putchkovskaya man- aged to perfect an operation to undo the adhesions between the eyelid and the eyeball; the eyelid is then replaced by tissue taken from inside the patient's mouth. Another operation permits stretching the eyelid, which often shrinks or is shrivelled by the scars from the burn. After this, a corneal transplantation is performed using yet another technique per- fected by Professor Putchkovskaya. Professor Putchkovskaya holds weekly briefing sessions with the heads of services. A =The eye is illuminated by a "spot" to guide the laser beam. Women physicians in the URSS Number of total Year of women number of physicians physicians 1940 96 300 62 1950 204 900 77 1960 327 100 76 1968 438 000 70 The complex eye operation that humanity owes to her knowledge and skill has given excellent results and offers a 96 % chance of success; thanks to her, thousands of people have regained their sight. Transplants for children The team at the Filatov Institute scored another success in perfecting transplantation for children. For a long time it was believed that the earliest age at which this operation could be successfully performed was 14 or 15. Today the specialists at the Institute operate as early as possible. Their youngest patient was 18 months old. Professor Putchkovskaya has re- cently demonstrated that speed is all-important in transplantations sub- sequent to burns : immediate trans- plantation avoids allergic reactions or inflammations, which in turn may cause irremediable lesions in the cornea. Burns caused by jets of che- mical products (particularly ammo- nia and quick-lime) or by a stream of burning liquid or molten metal are all too common among workers. An operation performed within hours of an accident can restore sight to the injured person, as many opera- tions have proved. Once the operation has succeeded, the Odessa school places great em- phasis on exercises to strengthen and develop the eyesight, especially for children. Nadejda Putchkovskaya operates about twice a week now, consider- ably less than hitherto. She devotes most of her time to research and to the running of the Institute. At present she is in charge of a team carrying out research on corneal transplants and burns. Research also continues on glaucoma, detachment of the retina (treatment here involves use of laser beams), and ultrasonic waves for the diagnosis and treatment of various illnesses. The preservation of children's eyesight has the highest priority at the Institute. The Institute forms the hub of a large network of clinics covering the Ukraine. For a population of 46 million, the Republic has 2,500 oph- thalmologists. In the Soviet Union as a whole, there are more than 13,000 ophthalmologists, many of whom received their training at the Odessa Institute. Not only the Institute itself but many of its most important depart- ments are run by women. This is hardly surprising when one reflects that 70 % of the Soviet medical pro- fession are women. One of the eminent physicians of the Filatov Institute, Professor Zinakla Skrip- nichenko, became head of the traumatology service after having served as a doctor in the armed Biomicroscopy of the eye. The instru- ment also measures eye tension. OP- 16

The director of the "last-chance hospital" gets ready to operate. She wears a magnifier over her spectacles and has slipped on rubber gloves. The operation is a corneal graft. 18 forces during the Second World War. In the entry hall of the Institute, a roll of honour with photographs commemorates the members of the Institute who served at the front. One of the photographs shows a young woman, Putchkovskaya, who as a captain was head of the ophthal- mological service of an army hospital on the Ukrainian front for three years of the war. This modest woman holds the highest scientific and military honours the Soviet Union can bestow : Heroine of Socialist Labour with a Gold Star, Order of Lenin and Cor- responding Member of the Academy of Medical Sciences of the USSR. Flowers and Music It was hard to get her to tell any- thing about herself and her life outside the Institute. "My life," she said, "is the Institute." However, she does admit to loving roses and described growing them around her dacha with her husband. As far back as she can remember, as a very little girl, she had always wanted to become a physician. She also played the piano when she had time. She has a small dog who now is seven years old. "But the children in the hospital think seven is so old that it frightens them. So I have rejuvenated him simply by knocking off a few years and for a long time now he has been Her Sunday walk. just four years and not a day older," she explained triumphantly. Her optimism and serene gaiety are the most characteristic traits of Nadejda. After all, her name means "hope". The entire Institute is im- pregnated with her calm optimism. The aim is to fight with every means to preserve each ray of light, to restore each possible tiny fraction of sight to the patient. "The last chance" She explains : "They call us the last-chance hospital because we take the cases no one else wants. We often fail; there is still so much to be known, so many problems to be solved. Corneal transplants don't always work; sometimes the new graft becomes opaque like the old. The operation may have to be done over and over again, and sometimes it fails each time. We go on trying. Glaucoma may appear on a graft to block our efforts. The problems of immunology in transplantation and the causes of rejection are still far from being solved. That is why ophthalmologists all over the world must combine their efforts to find new techniques to protect eyesight and help those who have lost their sight: much remains to be done but I don't feel things are hopeless. Each year brings some progress, some new success." ■ 19 Vlasta Pertot is a woman of deceptively fragile appearance who crams more activity into her days than many men. A doctor in a mountain valley in Yugoslavia, she is up and about at 6 a.m., and in the dispensary by 7 a.m. At midnight you are still likely to find her on a sick call. Her regular round includes a weekly visit to a village so inaccess- ible that she can only get to it by walking for an hour along a steep mountain path. Dr Pertot takes it all in her stride. So many demands are made on her time that she frequently eats only one meal a day, yet she still manages to have a home life. It is not a question of being overwhelmed by the job of caring for the sick: Dr Pertot main- tains a keen interest both in public health and politics. She is a member of the Communist Party, and has AI A hurried breakfast. Every Monday, Dr Vlasta Pertot ► clambers up the steep path leading to the village of Borovica. mountain doctor by John Taylor T• In the dispensary, Dr Pertot begins her consultations at 7 a.m. represented Vares-Majdan, the town where she is in practice, in the Sarajevo Parliament, with a public health portfolio. Fifteen years ago Vlasta Pertot came to Bosnia-Herzegovina in res- ponse to a call for 16 young volunteer doctors. In her area she was the only doctor. She had to cope not only with an average of 100 patients a day in the work of general practice, but with minor surgery, industrial injur- ies, burns. A patient who needed hospital treatment had to be taken by narrow-gauge railway to Sarajevo, because the road was not open to vehicles. At that time Dr Pertot had to make all her rounds on foot, winter and summer, yet she has always made it a rule to return home, no matter how late the hour. To run a home and family in such circumstances requires co-operation. Dr Pertot's husband, a mining engineer, has learned to be a useful cook. Their two daughters are now in Slovenia, in the north, with her parents. This will enable Dr Pertot to continue with the special training she requires to complete her qualifications for internship. Time has brought her the profes- sional satisfaction of seeing the med- ical services in Vares steadily develop. The dispensary is now adequately staffed, and there are two small hos- pitals in the area. The one in Vares has 20 sick beds and as many again for maternity cases. Dr Pertot has The doctor treats workers from the local iron mines. To confirm a diagnosis, Dr Pertot uses the microscope. 1,800 patients on file in her con- sulting-room at the dispensary, but is also able to give attention to preven- tive medicine. Twice a year she tours the surrounding villages to vaccinate against diphtheria, smallpox and poliomyelitis, and she regularly in- spects the local mines and factories, the food in the canteens, the working conditions of logging teams in the surrounding forests. But life is not only work, it is also relaxation. Dr Pertot and her hus- band can afford to run a car on their combined salaries, so there are excur- sions in the mountains, a holiday once a year. A gay, talkative person- ality, Dr Pertot also finds reward in her social contacts with the people of Vares. A cup of Turkish coffee is always waiting for her in their homes, and they know, without asking, that she likes it without sugar. Such moments help to blur other memories that shadow Vlasta Pertot's face occasionally—memories of a con- centration camp and the war years with the partisans in the mountains. ■ Especially if there is only a pitcher and a tin basin on a stool to wash in, hygiene must be respected. A child brought in for treatment is given a first examination. pioneer nurse, Niger by Monique Jacot She was talking softly and insist-ently to a recalcitrant mother as I entered the Maternal and Child Health Centre in Niamey. Foure—her name means 'flower' in Hausa—was trying to find out the true name of the child the mother had brought in for treatment. According to local custom, the name of the eldest male child should be kept secret. So the mother had been making up a name each time she visited the centre. Since she usually forgot the product of her imagination by the following week, she was forced to invent a new one each time, causing Foure to search laboriously through her new card index to locate the child's record. The index was started in November of 1968 but already had 776 names in it. Finally the goumier, responsible for maintaining order in the waiting room, was asked to "confess" the mother; he eventually succeeded and, scarcely breathing, she whispered the boy's real name in the goumier's ear. This is only one of the problems —many of them are far thornier— that Foure has to solve every hour of the day. She is 21 years old and is the first graduate nurse of Niger to be given such extensive duties. She begins the day by looking after the premature babies. Every morning the mothers come with their tiny off- spring, who are too weak even to nurse at the breast. Foure obtains breast milk and then feeds it, a tea spoonful at a time, to these tiny creatures, whose weight is far below normal. At certain times there is a flood of patients: measles and pulmonary illness during cold spells, malaria during the winter months, and di- arrhoea in hot weather, when the thermometer usually rises above 45°C (110°F). Foure finds the educational part of her work most rewarding and at the same time frustrating. Twice every morning, using a big black flannel- board to illustrate her talks, she tries to convince mothers of the impor- tance of diet and hygiene. Then she gives a practical demon- stration, for example, on how to make gruel for children from millet, how to add an egg-yolk to the mixture, and so on. Local customs must of course be respected, which means cooking over a wood fire and using certain local vegetables and grains. Foure talks to the mothers in the Djerma language and this adds to her difficulties as her own mother tongue is Hausa. But how did this shy daughter of poor rural folk get to the capital in the first place? Foure was lucky to be able to go to school; only one of her six brothers and sisters did likewise. Her parents were small farmers at Tibiri, a village located at the foot of a high cliff about three hundred kilometres from Niamey. At the centre of Tibiri there is a huge baobab tree. From this focal point the four main streets of the 25 I village radiate, each of them lined with clay houses. Thanks to a lot of hard work, Foure Wonkoye and three boys from her village obtained scholarships to go to high-school in Niamey. The four children waited in Doutchi, a small town in the neighbourhood, to take the bus to the capital. Rolled up in her pocket-handkerchief Foure was clutching 3,000 francs CFA,* a small fortune to her parents. They had patiently accumulated this sum so that she would be able to dress like the other girls in the city and have a little pocket-money as well. She was going to live as a boarder at the school in the capital. At the end of Foure's third year, the headmistress of the school asked her what she wanted to be. Without a second's hesitation, Foure replied "a social worker". But openings were few in that field for a girl of nineteen in Niger, so the headmistress persuaded her to begin by training as a nurse. Foure passed the entrance examinations with flying colours and joined the National School of Nursing. This school was set up in 1965 with assistance from the United Nations Development Programme and the World Health Organization. Such an institution was vital: the country, with 3.3 million inhabitants, has a proportion of only one doctor for 65,000 people, plus a total of two dentists and three pharmacists. Con- sequently, nurses are called upon to assume far greater responsibilities than in places where doctors are more numerous. However, although nurses are desperately needed, the profession in Niger tends to remain the province of men. When the school was set up there was not a single registered female nurse, and the proportion of qualified midwives was one for 200,000 inhabitants. Two white blouses When they arrive at the National School of Nursing, the girl students receive three dresses and two white blouses. The girls choose the material in the market with the school admi- nistrator and have two local costu- mes made and a short European-style skirt. Each month they receive 3,000 francs as pocket money. Foure finished her examinations in September 1967 with good grades. 26 * One dollar is worth about 250 francs CFA Health education forms a prominent part of Foure's work. On the flannel board, she explains baby care. Later, she gives advice about feeding and shows how to prepare meals. Foure consults the card file she started herself. 2 1. A child's first visit. Foure makes out a card. She reassures an anxious mother. Once a baby is weaned, it needs a balanced diet. A well-made gruel will contain all the necessary elements for good nutrition. The nurse explains how to make a millet gruel. She was seventh in a class of twenty- two, of whom four were girls. The school reports noted her extreme timidity and stressed the difficulty she might encounter professionally in trying to impose herself and her ideas on others. Yet she quickly showed a first sign of independence by marrying Amadeus Nignon, a fellow-student whom she had met in class. Today they are the parents of little Nathalie who, at twenty months, rai- ses baby-sitting problems; fortunat- ely, these are largely resolved by Ama- deus' mother and by a neighbouring fourteen-year-old girl, Azumi. How does the young couple make ends meet? Amadeus and Foure each earn about 35,750 francs a month. Her husband pays for food (10,000 francs) and fuel (wood costs them about 350 francs a month). Foure contributes to the cost of their car, a small Citroen, and pays the two boys who help around the house (3,450 francs each). One cooks and does the shopping, and the other washes up after meals and waters the garden. The fact that the nearby house of her father-in-law has run- ning water makes it easy. Foure's husband is a football enthusiast and plays for the national team. She likes to spend a lot of her spare time reading—a nursing review, her instruction manuals and richly illustrated novels. She also loves the cinema. Though Foure recognizes that she is materially better off than her mother (who does not own a car or a refrigerator), she nevertheless in many ways follows the traditional way of life. The shyness of her nursing school days has made way for a sweet seriousness that is accentuated per- haps by the Hausa tribal marks she bears on her face. Soon there will be other nurses to help Foure, the shy girl from Tibiri who started the health centre's card index. ■ Local wine-growers on the main square in Rust, Austria. friend and pharmacist by Julie Contat Neatly arranged around the main square of Rust, a small town in Austria 75 kilometers from Vienna, are the Fishermen's Church, the Rural Credit Office, the odds-and- ends store, the inn where everyone forgathers and the St. Hubert Pharmacy. Mrs Margaret Jandl is in charge of the pharmacy; a graduate of the University of Vienna, she is called by her official title "Magister". This large, fair-haired woman with a broad smile seems much younger than her sixty-odd years because of her liveli- ness and bustling activity. She was born on Lussinpiccolo, a small island in the Adriatic. The daughter of a pharmacist, she was content to follow her father's footsteps. She went to school in Merano and studied phar- macy in Vienna. After four hard years of study and two more of apprenticeship, she was ready to become her father's assistant and she eventually replaced him at the head of a pharmacy in the centre of Austria's capital. But country life was more appealing than the crush of the city, so, in 1953, Magister Jandl and her husband left the city behind and moved to the country, to the little town of Rust, remote from the life she had been leading. She has never regretted her decision. Rust has 2,000 inhabitants and is a place of some importance in this pleasant wine-growing part of Bur- genland, the castle country, where Haydn and Liszt were born. Magister Jandl's pharmacy is the only one for twenty kilometres around; the nearest one is located in Eisenstadt, the capital of the region. Her pharmacy serves a number of villages and hamlets, some 8,000 people in all. The St. Hubert Phar- macy is therefore a busy place. In fact, Magister Jandl is on call day and night, weekdays and holidays ; she has been summoned during a film showing and roused from sleep to handle an emergency. "Fortunately that doesn't happen too often," she said, "because not only are people around here healthy but they have a lot of common sense and tact as well, and they wouldn't bother me just for some minor ache or pain. "What are the most frequent ail- ments? Oh, I guess the same as almost everywhere else : childhood diseases—and families are large in this part of the world—old-age com- plaints which require medicines ; and, frankly, the fact that 99 % of the cul- tivated land here is used for growing vines creates a problem or two." 30 •;: , APOTH, 11,,tr" ....' . , ; , '''',•,i7 :, ...., . i ::',,, ", ,. ;A., ,..,, , . . • . • . • -. ' i'... .4 4: . . , ^ • ' .1.,, ..„,,,, , ; . ,,,- , L, , ,, , ,,, -1 , ^„ • , • ii.ve. , ,e,,, '!.4 - " ' . 't ''-'4 " . . A - ., _.:,:k , ..... . . .4 , , TrIN ,.. ,, . .,r,„ • i , e 7,a,P , Wf., ,,.' ■ PIO ' .* •., '' ,1‘ .4. 1...:,.t . .II' \.41.• i;0 II . . . The pharmacist makes sure that the patient understands the physician's instructions. 31 Everyone knows Magister Jandl and likes to have a chat with her now and then. Magister Jandl rises at six and has the pharmacy door open by eight. She works until noon, closes for lunch and then works from two until six. On Sundays the pharmacy is open from nine to eleven in the morning. It stays closed on Thursday afternoons. Actually the pharmacist remains on duty all the time, because in Aus- tria it is considered that she renders a public service and thus cannot absent herself when she is tired or not in the mood. She can only be replaced by a properly qualified pharmacist and is in any case responsible for what her substitute does. Magister Jandl admits that the restrictions are beginning to wear her down and she is looking forward to the time when her niece will help run the pharmacy ; at last she will be free to go on vacation with her hus- band and swim in the Adriatic. Afterwards, when she returns to work, there will be two of them to face it together. There are varied responsibilities in a small-town pharmacy. For example, the pharmacy has an annex where the local vintners buy the chemicals they need for wine-making, sterilizing the bottles and curing the vats. The pharmacy proper has more than 2,000 different preparations in stock, and simply by telephoning to Vienna Mrs Jandl can order any others. The five doctors of the region, two of them in Rust itself, rarely write prescriptions to be made up by the pharmacist, but usually rely on stand- ard preparations. Only elderly doctors still occasionally write their own prescriptions. The pill age "We live in the pill age . . . not to mention The Pill," said Mrs Jandl smiling. "People are no longer wary of medicines. In fact, they are so enthusiastic about them as to be greedy, especially when it comes to tranquillizers. Personally, I avoid medicines whenever I can, and, if everyone were like me, the pharmacy would go into bankruptcy." In case of accident, Magister Jandl is on the spot; her husband, who was a medical orderly in the army, knows all about first aid. However, neither is called very often since Austria has an excellent emergency service, fully equipped with rapid ambulances. Though she may complain about being tied down, Magister Jandl's life has a great deal of charm which she admits to enjoying. Rust was rebuilt in the 17th century after a series of invasions. Today, - Big and small, they all have confidence in their pharmacist. 32 this prosperous and friendly town has many historic monuments. In addition, there are 46 stork nests on its chimneys, one of them on top of the St. Hubert Pharmacy itself. Every year, the storks arrive in March, first two or three at a time to scout out the land. When the main body arrives it takes possession of the chimneys. There they lay their eggs and hatch before going to raise their young at a nearby lake. In August, they fly off to Africa. The year 1969 was hard for them; several baby storks died of cold this April. Magister Jandl is enthusiastic about the storks and the aquatic birds that visit the banks of Lake Neusiedel only a few kilometres from the town. This lake has been declared a refuge for wild life, and its fame has brought experts from all over the world to observe the fauna. The pharmacist herself raises birds and has a dog and a number of cats. She looks after the plants on her terrace and has it bright with daisies, her favourite flower and emblem. Two thirds are women This smiling competent woman is a fitting representative of the 2,500 pharmacists now practising in Austria. In the three universities, Graz, Innsbruck and Vienna, 1,000 students are engaged at the moment in the study of pharmacy. As many as 66 % of them are women, an even higher percentage than the 60 % at present working in Austrian pharma- cies. One reason why this profession appeals to women is that they can marry and bring up a family while continuing to work professionally. In Austria, it takes at least three years of study to obtain the degree of Magister Pharmaciae. State exam- inations are held at the end of the second and third years of study. The second year exam (first Rigorosum) covers anatomy and physiology of plants, botany, physics, inorganic and organic chemistry. The second Rigorosum covers espe- cially natural drugs, pharmaceutical chemistry and hygiene. Passing the second Rigorosum is equivalent to graduation. In order to obtain a licence to practise, holders of the Magister degree must work in a public pharmacy as an "aspirant" for two years and then pass an examina- tion. However, this period of practical training and the subsequent examina- tion are not required of those who wish to work as pharmacists in research or industry. In Austria, it is considered that the country lacks pharmacists, yet Austria ranks among the highest in Europe according to the statistics that appear in the World Directory of Schools of Pharmacy (1963). At that time, Austria had one pharmacist for 3,000 inhabitants, whereas in the Netherlands the ratio was one to 10,900. Bulgaria had one for 4,300; Romania and Switzerland one for 4,000; Yugoslavia one for 5,400. The Directory showed that there were about 600,000 pharmacists in the world as a whole, and that its 472 schools of pharmacy train about 20,000 new pharmacists a year. ■ More than 2.000 preparations in stock. Wine-growers need advice concerning their work. tropical midwives by Karl Frucht Women in white in the pro- vince of Phitsanulok spend one afternoon a week on house calls. We are in a part of Thailand in which homes are built on stilts and preceded—defended as it were—by tiny "spirit-dwellings" perched on top of poles. At the house, shoes are left at the foot of the ladder leading up to an artistic and functional stage-like wooden structure making up a large room wide open to the landscape and giving the impression that one is nestling among the tall branches of tropical trees. It is ritual for young mothers here to heed the age-old advice of local midwives and "lie by the fire" immediately after delivery. This custom is well respected in the home we enter despite the fact that the baby was born with the assistance of a midwife who completed a WHO training course and is well versed in modern methods of delivery. When the health team we were accom- panying entered the room on a post-natal visit, the young mother rose from her bamboo-woven bed near the fire and opened what looked like a tent hanging from the ceiling to reveal a basket with a well-wrapped baby inside. Why the tent and blankets did not suffocate the infant in the stifling heat of the summer afternoon was a mystery. There was in fact what sounded like a deep sigh of relief from the baby when Mrs Penom, the midwife, brought it out into the open air to weigh it in a very practical scale net made of woven straw. All was well, and after a few words of advice to the mother, the baby was put back into its basket and we followed Mrs Penom on her rounds. Another home visit, another newborn taken care of by Mrs Penom while the provincial public health nurse, Miss Invi- thaya, and the district midwife nodded their approval. It was only between one call and the next that the three women engaged in lively conversation with each other and with the villagers who crossed our path. They took notes on everybody's state of health. Pregnant women were asked to come to the health centre for pre-natal care, and appointments were jotted down on little note books. A foreign observer is immediately struck by the earnestness, the good will and the optimism of Thai midwives, nurses and health assistants working in the Province of Phitsanulok. This first impression is confirmed all along the visit. It augurs well for health since we are in a pilot-area to which the 34 35 Mrs Penom, midwife, gives ad- vice on child-rearing to a young mother under the attentive eye of Miss Sateet Invithaya, the public health nurse in charge of Phitsanulok province. The baby is weighed. Following the advice of the health team, pregnant women arrive at the centre for pre-natal examination. Between house-calls, women in white strike up a conversation with local inhabitants met on the way. A living symbol of an age that is swiftly passing into history : an old dai (midwife) recalling memories of her long, active life. 36 Thai Government attaches particular im- portance and where great attention is given to the work carried out by the "women in white". Miss Sateet Invithaya, the public health nurse responsible for the entire Province of Phitsanulok, accompanies us on this visit to the district of Wat Bote which alone is inhabited by 20,000 people. We are in the very heart of this tropical country of 22 million inhabitants, about 500 kilometres north of the capital city, Bangkok. The district we are in had only one so-called "first class" health centre in 1965, but the pilot project made it possible to bring the number of these centres up to six by 1968. The same goes for "second class" health centres the number of which grew from 19 to 33 over the same period, while the number of midwifery centres rose from 13 to 16. In the very first centre we visited we were greeted by one of the five young doctors who run the health services of Wat Bote. Beside him stood the district pub- lic health nurse, a nurse midwife, a midwife and several village-level health workers. No clinic was held that summer after- noon at the health centre but the public health nurse attached to the centre and Mrs Penom, the midwife, were preparing to make a few house calls when we arrived. The last visit of the day was a courtesy call on the old dai, the village midwife who never in her life had donned a white blouse: gentle image of the past now slowly fading away. Toothless, with knotty hands and a warm heart, she smiles and brings old memories back to life. She laughs off a question on her age by saying she's so old she's forgotten .. . With evident pride she displays a mid- wifery kit provided by UNICEF and thinks aloud: "How can I have done without it for the past 50 or 60 years?" This one-day visit to the Wat Bote district in the heart of Thailand leaves one with memories of smiles, handshakes and human warmth. It also enabled us to see the public health situation in the field, to realize at first hand the progress ac- complished and to appreciate the efficiency of nurses and midwives at all levels of the public health services. ■ 37 laboratory unknown Al around us rose modern buildings dominated by spotless chimneys reaching hundreds of feet into the air plumed with puffs of smoke. In this chemical complex is one of Switzerland's largest pharmaceutical research establish- ments as well as a school which gives on-the-job training to apprentice labora- tory assistants and technicians. The former require only a six months' course but to become a laboratory technician three years of hard work are necessary. "Although the number of girls at work in research has risen," the Director of the school said, "they are still only a handful of the thousands who work here. Today, there are 20 girls following the course out of a total enrolment of 210." "Is this because they aren't interested or because you don't encourage them?" "A little of both, perhaps. Not too many present themselves at the entrance examination when they are fifteen years old, which is the usual age. However, some take the test during the next year or so. Frankly though, we do make it a little harder for girls to enter than for boys. For example, if a passing grade of 700 points suffices for boys in the entrance exam, the required number of points for girls will be 800. But you must understand, our experience has made us cautious. Too many girls lose interest, particularly in the long hours of theory. Others get married or drop out for a variety of other reasons. For instance, of twelve girl students who began three years ago, only four followed the complete course this year. Of these, one failed her finals, one was average, one exceptional, and one hasn't yet taken her examination." Girls who are just looking for some extra money while waiting to get married can find many easier ways of doing it. This may explain why there are such large numbers in production (where training is simple) and so few in research. In other countries the situation is similar. A WHO Expert Committee on laboratory services called attention to the problem and spoke of the "great confusion in titles, responsibilities and qualifications, and a marked feeling among technicians that they are neglected and their efforts are unrecognized". As an unfortunate result "the profession is unattractive and recruit- ment is lagging far behind needs". Jacqueline, a 20-year-old laboratory assistant born in Basle and now doing research in analytical chemistry, said: "Don't look for large numbers of girls in white smocks working side by side in huge research laboratories. The only place you'll find them in the pharmaceutical industry is out at the plant, doing pro- duction work. What is more, research today, although it is based on team work, tends to take place in small laboratories, with only a dozen people or so at work." In another laboratory nearby, we found Anni hard at work. She was doing research on the quality control of biological sub- stances used in medicine. "How did I get into this field? I was always interested in chemistry. Maybe the fact that my father was a chemist had something to do with it. I much prefer to do work that is constructive and helpful to humanity, like medicine, than to perfect chemical means of destruction, for example. One thing I certainly didn't want to be was a schoolteacher." Another girl who had come by smiled her agreement. In fact, the group of young women who had gathered in the laboratory all agreed that they had in some measure chosen the hard road of becoming labo- ratory research technicians because they didn't want to follow the typical "women's" professions such as secretary or schoolteacher. "My father teaches physical education," said Heidi. "All my family were teachers, generations of them, and I decided to be the exception. I am certainly glad that I did, since I met my husband in a university chemistry course. At present, he is con- tinuing with his studies towards a doctor- ate. I am able to help him, not just with money, but by understanding what his work is about, although, like many hus- bands, he is not so interested in mine. I These girls from different countries form part of the small community of highly-trained laboratory technicians (Basle, Switzerland). ► 38 technician, an quantity by Noel West The day passes quietly within a small, well-equipped laboratory, weighing, pouring, measuring and examining with infinite care ( Basle). think the real reason I wanted a job like this, however, was that I felt it would force me to be organized and exact. Basically I am rather disorganized," she laughed. "I think more women will be going into this work," affirmed Karen, a Danish woman who referred to the experience of her country. "Women will enter profes- sions not traditionally reserved for women when they are given the choice. In fact, the farther north you go the larger the proportion of women you find in research work. This may be a measure of social progress." A Swiss girl, Verena, agreed with her, but said wistfully, "Still, it will take a long time. Men aren't going to give up their prerogatives so easily." The head of the pharmaceutical develop- ment section, aged about fifty, mentioned that only a quarter to a third of his staff were women. Moreover, there hadn't been any numerical increase in the past ten years, though the proportion of highly trained girls had gone up. Yet the work is interesting. It consists in finding and perfecting the most practical ways of mass-producing newly discovered phar- maceuticals in order to make them avail- able to the large numbers of people who need them. This means putting the medicine into pills or ointments or am- poules for injection and then checking back to see that the potency and quality remain the same. "When the stuff goes into production our job is over. We don't want to hear about it again, unless of course reports from the field indicate that the drugs require adaptation to new conditions. The work is interesting, certainly, but when you think that after three years of hard work and study these girls earn about as much as those who learn how to type and then take a trip to London to polish up their English, it isn't surprising there are so few. The day begins here at 7.30, there is an hour for lunch and we all go home at five. You really have to like this work to do it." Susan, a biology research worker, looked up from the microscope. She was investigating enzyme changes in liver sections as part of a study of controlled dietary variations. "The work is fascinat- ing, and I like the calm and quiet of the laboratory. I follow the animals' diets and then study the changes and reactions in specimens. There are so many new laboratory methods and techniques now- adays that I have great difficulty in keeping abreast. However, my boss not only allows me to read up on my field in office time, he encourages me to do it. "Yes, I am married. My husband is 40 It is necessary to distinguish between laboratory technicians in medical laboratories and those in industrial laboratories. There are about 2,000 medical laboratory workers in Switzer- land. Of these about 10% work in the chemical industry, the others in hospitals. The proportion of men and women is as follows: Among medical laboratory techni- cians there are 100 women for one man; in industrial laboratories one woman for 100 men. studying for a doctorate in chemistry. We have been married for only two months; I will go on working until he has his doctorate and then we can think of starting a family." Irene, Rya and Verena all confirmed that their marriages had not interfered with their careers, but having a baby certainly would. All of them had gone to school or shared laboratory work with the men who later became their husbands. Though keeping up with developments in their field may be difficult, most of them felt that they would like to go back to work when their children were grown up ; but that was far in the future. "Most girls just don't have the sustained interest needed for science," said Martha, a senior research worker. "They find the laboratory too quiet and often a bit lonely, and I must say it often bothers me to think that a typist can make as much as a girl who has sweated through years of study and work in a profession dominated by men." "Yes," said one of the laboratory workers, "but I can understand the girls who prefer a job where you meet more people. Another drawback is that today everything tends to be teamwork, and this means you aren't going to make a spectac- ular breakthrough by yourself." Talking with these well-adjusted, com- petent young women made it seem strange that despite the drawbacks so few girls enter this challenging profession. ■ This technician follows changes in samples of dyed materials, which the machine dips end- lessly into various liquids, to determine if the colours are fast and won't irritate the skin. 41 guardians of the smile "Pick up your brushes ... Dip them into the water ..." Twenty toothbrushes poised aloft swoop down into twenty small water-filled card- board cups. "Now brush—one, two, three, four!" For a group of small Norwegian boys and girls in the Godlia school in Oslo, the clear young voice of Berte Bjornsen marks the beat of the exercise. The nine-year olds are well accustomed to the drill. In her left hand Berte holds plastic models of two enormous jaws filled with perfect teeth ; in her right, a massive toothbrush with which she demonstrates the toothbrushing procedures to the children. She is doing more than teaching the correct way to brush teeth, something the children already know well. The card- board cups, into which their well-trained hands dip the brushes, contain a fluoride solution, and Berte is making sure that all of the children's teeth are well protected with fluoride against tooth decay. The brushing is done carefully, methodically, in a relaxed atmosphere. No one laughs or nudges his neighbour. This little com- munity is convinced of the importance of the work they are doing. At the start of each tooth-brushing lesson, Berte enters the classroom carrying two paper bags containing the materials for this preventive exercise. On each child's desk she places a paper napkin and two by Mariam Tigrane cardboard cups. In the smaller cup she pours the fluoride solution ; the other is for the children to spit into when they have finished. The "good" students have all brought their own brushes. There are only a few forgetful ones, two or three at most, and for them Berte picks some new brushes out of her paper bags. As she pours the fluoride liquid, she questions the children : "Why do you brush your teeth?" "How many times a day?" "And how about candy, do you eat a lot of it?" All the children proudly proclaim that they brush their teeth at least twice a day, but they do admit to a certain fondness for sweets. Berte repeats the maxims that are prominently displayed on posters through- out the school : the apple and the carrot are your tooth's best friends ; bite and chew your food carefully; avoid sweets and cakes between meals; rinse your mouth after meals. When Berte is satisfied that all the children's teeth have been thoroughly exposed to the fluoride solution, she dis- poses of the cups and napkins, thanks the teacher who has granted her this quarter of an hour and goes back to her own office where a group of smaller children await her. They are too young, too easily dis- tracted, to derive much benefit from collective exercises. Instead, in small groups of five or six, Berte teaches them to apply the fluoride solution themselves. First they practise on a large plastic model; then they use their own small brushes in their mouths. The task facing Berte and her colleagues is not confined to distributing the fluoride solution. She also teaches general dental hygiene and has many brightly coloured visual aids at her disposal to help in this task. Fierce lions, snarling tigers and cheerful squirrels all proudly display their superb teeth; they are the standard- bearers of dental hygiene in the Oslo schools. Tand-Ola (01a-with-the-beautiful- teeth) is the hero of comic strips, where he is usually seen munching an apple or a carrot. Parents also take part. The mothers of the youngest children are invited to come to school, where they follow the first lessons together with their children. Parents' permission must be obtained before fluoride applications are given ; refusals are rare. Oral hygiene, prophylaxis and teaching occupies about half a dental hygienist's working time, the rest being taken up with cleaning teeth and removing calculus (tartar). Dental cavities, troubles in the spacing of teeth and poor conditions of the gums are referred to the school dentist. He also treats the children in the school, though more complex forms of treatment are provided in a central clinic. 42 2 I. The children carefully imitate the hygienist's move- ments. They make serious work of brushing their teeth under the supervision of Berte Bjornsen. The children are taught not to neglect inner surfaces of the teeth. '4 At Tveita school, another dental hy- gienist, Ester Dahl, is at work cleaning and removing calculus from Frode's teeth while Susanna waits her turn. Mrs Dahl explains each action to the boy, who can see what is going on in a mirror he holds in his hand, and she takes advantage of the opportunity to give some additional lessons in oral hygiene. Since Frode and Susanna are both adolescents, her most telling argu- ment is that healthy teeth make a smile attractive, for boys as well as for girls. (The fact that Ester Dahl and Berte Bjornsen both have beautiful teeth proves far more convincing than any number of sermons. What is more, their enthusiasm and conviction are contagious.) Afterwards, Mrs Dahl fills out her patient's card where all the dental care throughout the school years is regularly recorded by dentists as well as by hygienists. Ester Dahl has been practising her pro- fession for twenty years now; she began in Bergen before coming to Oslo after her marriage. She is responsible for three schools and cares for about eleven or twelve children a day, working from eight in the morning to three in the afternoon. She alternates cleaning sessions with lessons on brushing and dental health. Berte Bjornsen has had the same educa- tion as Ester: a year at a school for a diploma as a dental assistant followed by a year of specialized instruction to become a dental hygienist. There are 19 dental hygienists in Oslo, each responsible for about 2,000 school- children. About a dozen of their colleagues work in other Norwegian cities. Dr Olav Engh, head of Oslo's dental service, emphasizes that dental hygienists are indispensable for his service. His only regret is that there are so few of them. With a population of about half a million, the Norwegian capital has 50,000 children between the ages of 7 and 15, all of whom are entitled to the dental care they may require. By the time they are three years old, 70% of children already have caries. At age eleven, the proportion reaches 95%. By fourteen years of age, nearly all suffer from caries. In addition, many cases of malocclusion (teeth in irregular positions) occur and Dr Engh estimates that nearly 40% of school children need treatment for this type of defect. These figures are by no means exceptional and the same situa- tion prevails in many countries. Preventive measures to protect children's teeth are of primary importance for good dental health. In many cases, the damage has already been done by seven years of age, which is why Oslo has begun to organ- ize a dental programme in kindergartens where children start at the age of four. Eleven thousand children already benefit from this service that will help protect their primary teeth, which are of vital importance to the health of the permanent teeth to come. But what exactly is a dental hygienist? Her functions were described by a WHO Expert Committee which reviewed various categories of auxiliary dental personnel. Dental hygienists work under the close supervision and direction of the dental practitioner. They provide services in preventive dentistry by cleaning the teeth and removing calculus, teaching oral hygiene to individuals and groups, per- forming topical application of fluorides or other prophylactic solutions, and con- ducting screening examinations of groups such as schoolchildren in order that they may then be referred to qualified dentists for treatment. The total number of dental hygienists is nearly 20,000, currently practising in over twenty countries. The United States has 14,000, Japan more than 3,000. Both Canada and the United Kingdom have 400, Thailand about 900, and there are smaller numbers in another 16 countries. Dental hygiene attracts men as well as women, and this profession certainly will grow in the future as humanity faces its enormous dental needs. These vital "guardians of the smile" lighten the dentist's load and allow him to concentrate on those tasks for which he alone is qualified. The dental profession is grad- ually accepting the concept of providing preventive and early operative dental care for children to help control dental diseases. Other types of auxiliaries who participate in the provision of dental services have been established in several countries. School dental nurses were first introduced in New Zealand some forty years ago. Today, they are providing dental care for nearly all schoolchildren through regular dental examinations, early treatment of dental cavities by placing fillings in both permanent and primary teeth, and extrac- tion of teeth under local anesthesia. The dental nurses combine these operative procedures with preventive measures sim- ilar to those performed by dental hygienists. New Zealand alone accounts for more than 1,200 of the estimated number of 4,000 dental nurses in the world, as indicated by a rather incomplete statistical survey. Czechoslovakia has about the same number, the United Kingdom more than 200 (where they are called "dental auxiliaries"), Malaysia over 330, Indonesia 250 and small numbers are also reported in Africa (Ghana and Sudan), Asia (Ceylon, Hong Kong and Thailand) and Oceania (Australia, Singapore and Papua- New Guinea). If it is true that more physicians are needed throughout the world, dentists are in even shorter supply. According to the WHO Directory of Dental Schools (1967) there were only 432,000 dentists in the world in 1963, with 371 dental schools which graduate approximately 15,300 new dentists a year. Here too, the contrast between develop- ing and developed countries is flagrant. In Africa there is only one dentist for 81,000 people, in the Americas one for every 2,600, in Asia one for 17,000 and in Europe one for 3,000. The increasing demands placed on the existing number of dentists to care for the needs of growing populations throughout the world can be greatly facilitated where dentists are helped by dental auxiliaries. The surgeon-dentist as head of the dental team, in private or public practice, benefits as well as his patients by the competent assistance of auxiliaries. Thanks to them he can provide dental treatment to a larger number of people and render more service to the community. ■ Cleaning and removing calculus (tartar) are also part of the hygienist's job. Thanks to her, the dentist has more time available for specialized work. 45 The pharmacy at the St. Elizabeth Hospital in Vienna, Austria. Medicines, by Jean-Marie Pelt. Le Seuil, Paris, 1969. 192 pages (in French). Man's use of herbs, salves and concoctions is as old as doctoring, as old as man himself. Every family medicine chest contains a variety of medicaments, which for most people, however, have lost none of their mystery. While breakthroughs in surgery are widely reported in the press, radio and television, pharmaceutical research and development tend to remain unrecognized. Modern pharmaceuticals co-exist with traditional medicines, some of which are very ancient. All of them, however, have a story behind them, and some of these stories are told in Pelt's attractive book. Formerly, drugs were directly derived from natural sources, but with the growth of organic chemistry synthetic materials have become available in ever greater numbers. At present the number of pharmaceutical preparations has grown so large as to be criticized by pharmacists, physicians and public health workers. A standing committee which surveys pharmaceutical developments in France showed in 1966 that there were 3,911 preparations on the market presented in 9,000 forms. Nevertheless, at the present state of knowledge, a basic list of about 200 med- icines should be sufficient, it is claimed, to treat any patient. The excessive use of pharmaceutical pre- parations creates a new set of problems that are causing considerable concern. A drug may also have dangerous side effects, as thalido- mide so dramatically proved. In other words, progress brings its own dangers. Medicines should be carefully prescribed and their effects scrupulously determined. The author highlights the importance of pharmaceutical research, which, however, is not very productive. Of 2,000 compounds submitted to systematic biological and phar- macological testing, only 50 may be selected for more intensive investigation; of these, 12 may be tried clinically and perhaps only one will actually be introduced into therapy. The book stresses the true role of the phar- macist and of pharmacy generally as "advance aspects of the colonial period. Determining the level of health of a population is difficult, and Professor Aujoulat warns against hasty conclusions. "Neither a lowering of mortality nor an increase in life expectancy necessarily reflects an improvement in the standard of health. In certain diseases, such as tuber- culosis, mortality drops much more rapidly than in others. Furthermore, an increase in life expectancy is accompanied by an increase in degenerative diseases. Nevertheless, serious cases of tuberculosis tend to become rare, and improvement of diagnosis and therapy has an influence on the recorded frequency of illnesses associated with ageing. Longevity and the improvement of health thus do have a certain correlation, which can be used as a basis for comparisons, provided the limita- tions are not lost sight of." Beyond present problems and solutions, the author, in a chapter entitled "Prospects for the year 2,000", proposes a programme for the future. He defines a series of steps by which the health services could be improved in accord with the country's general rate of development. Hopefully, these suggestions, which follow the main lines of WHO's thinking, will be acted upon. This book will be most useful for all those who wish to inform themselves rapidly about health problems in Africa. It is only to be regretted that the author has given French- speaking Africa a predominant place at the expense of east and south-east Africa. A half-century of fighting infectious diseases in the Soviet Union, and certain problems of epidemiology, by 0. V. Baroyan. Published by Medicina, Moscow, 1968, 303 pages (in Russian). Eradication of communicable diseases depends upon adequate knowledge of their epidemiology in the world. Since the second posts of public health" and the last chapter describes some of the complex reactions which occur when medicine is taken into the body. The author concludes that the action of a medicament is to a large degree deter- mined by the person who takes it and that medicine should consequently concern itself more with the individual than with man in general. Thought-provoking and easy to read, this book deals agreeably with an important subject that so far has not been given much prominence. Health and Development in Africa, by Louis- Paul Aujoulat, A. Colin, Paris, 1969, 285 pages (in French). Here is a clear, precise book about the health problems of Africa in their broadest sense. Before describing Africa's present state of health, the author sets out to give an objective account of the positive and negative 46 Photo credits WHO-MONIQUE JACOT : Front cover, back cover, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29 WHO-JEAN MOHR: 2, 10 wHo- Rom ROULEAU: 5, 11 WHO-DIDIER HENRIOUD: 5, 8, 9 WHO-PAUL LAMBERT: 7 WHO-BEATRICE ZEPPILLI : 30, 31, 32, 33, 38, 39, 40, 41, 46 WHO-PHILIPPE BOUCAS : 6, 43, 44 WHO-KARL FRUCHT: 34, 35, 36, 37 half of the nineteenth century, scientists have been at work describing the patterns of disease in various parts of the world, including pre-revolutionary Russia. Although public health information was regularly published in the Soviet Union for ten years after the Revolution, the flow stopped in the thirties. Thus a large gap developed. This book by 0. V. Baroyan has the considerable merit of filling this gap by providing information for the first time in almost forty years about communicable diseases in the USSR. The work is divided into two parts. The first gives the history of epidemics in Russia before the Revolution and the subsequent fight against infectious diseases during various stages in the development of the Soviet State. The second part of the book discusses con- temporary problems of epidemiology. Before 1914, millions of cases of malaria and hundreds of thousands of deaths as a result of typhus, plague, cholera, smallpox and other diseases were reported yearly. The First World War and the subsequent civil war worsened the situation ; between 1918 and 1920, for example, 20 million people in the Soviet Union were victims of louse-borne typhus. Malaria was prevalent in parts of central Asia, the Caucasus and the Volga valley. By 1950, only 780,329 cases were reported for the entire territory of the Soviet Union and in 1966 the number of cases had dropped to 290, most of them brought in from abroad. At the beginning of the twentieth century, more than half the population of Russia suffered from trachoma. In 1956, there were still 911,463 cases but, by 1965, this number had been reduced to 2,500. Today, plague, cholera, smallpox, louse- borne typhus, relapsing fever and malaria have been eliminated throughout the USSR. The number of cases of whooping cough, tetanus, typhoid fever and dysentery have been very much reduced, and the nation is now engaged in eliminating diphtheria and poliomyelitis. Control of intestinal and respiratory disea- ses is also being pursued relentlessly. This monograph contains numerous charts and diagrams, and is a valuable contribution to systematic knowledge of communicable diseases. It also illuminates a chapter in the history of disease on which information for the medical profession has long been lacking. readers write Dear Editor, On page 10 of the February issue of "World Health", Dr Hoffmann suggests that hypoglycaemic shock is an explanation of some obscure traffic accidents, and again on page 18 the writer of the story on "Dangerous Remedies" includes the drugs used in diabetes among many others which may cause dangerous side effects for drivers. There is no doubt that all persons taking drugs or suffering from chronic diseases which might interfere with driving skills must be well educated about the potential difficulties in their case. But we wonder if these claims can be really substantiated. Most diabetics are extremely careful. We get many requests for guidance and I think it important to point out to you that the British Diabetic Association provides detailed advice to diabetics who wish to drive. Prof. W. J. H. Butterfield Chairman, Executive Committee British Diabetic Association Sir, In the past fifteen years or so, considerable progress has been made in the development of inexpensive drugs in the fight against tuberculosis. However, less progress has been made with the reorganization of tuberculosis programs relevant to treatment, which these drugs have engendered. For instance, according to WHO's Expert Committee on Tuberculosis a patient living under the poorest circumstances can now be successfully drug-treated at home without endangering the health of other members of the family. The new trend in the treatment of tuberculosis is decentralization. In short, treatment is available at home under supervision of the local physician, who is assisted by visiting tuberculosis specialists. The main disadvantage to home treatment is that the patient is less likely to take his drugs regularly. But, since many patients are recipients of social welfare, financial assistance from the government should be conditional to taking the drugs regularly, and this can be proved by simple urine testing similar to the diabetic urine tests. WHO's close study of home treatment in a number of countries has shown that "a year's well-supervised domiciliary treatment with drugs is as effective as a year's hospital treatment with the same drugs, and does not expose the patient's contacts to any special risks." Home treatment costs as little as one-tenth of sanatorium treatment. This means saving millions of dollars and requires less staff. Perhaps what I am trying to say in this letter is that if governments in all countries would adopt WHO's recommendations on tuberculosis control programs, the present expenditure would be more than adequate to eradicate the disease from the world. In the developing countries, the disease still kills three million people annually and causes untold suffering to fifteen million others. For the most part, the developing countries are without trained doctors to treat the disease, while we in Canada are over-supplied. In view of the great advances made in our own country, shouldn't we be prepared to release our trained staff for the developing countries even if only on short term assignments? Only the politicians can make these decisions and we, the people, should keep them informed-that's why I write to the papers about this grave problem in the developing countries. Walter H. Davis 24 Poplar Avenue St John's (Canada) 47 A corneal transplant carried out by Professor Nadejda Putchkovskaya.