WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • NOVEMBER 1976 • USA $ 1 eating better 2 WORLD HEALTH T HE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • NOVO., ,,, , Cover: The anguished face of malnutri- tion: a child in an African squatter settlement showing symptoms of the calorie-deficiency disease, marasmus. (Photo WHO/B. Seitz) Contents Earning more, eating better by R. Seitz 3 The scourge of Venus by D. Gould 8 What are the real needs? by K.L. White 12 Madhubani shows the way by P.K.J. Menon . 18 A link with the outside world by H.M. Cerni 24 WHO News in Brief . 30 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. earning more, eating better The Nutrition Centre in a squatter suburb of Nairobi had to overcome a widely practised tradition that "children don't need special food; they can get by on anything" BY RUTH SEITZ 17 he small Nutrition Centre in Kenya's Mathare Valley buzzed with the usual Tuesday activity. Young toddlers gathered on the benches for a nutritious gruel. A few listless babes whimpered in their mothers' arms. Two who were already satisfied romped on the floor. In the kitchen corner three women prepared a demonstration meal. As one cleaned fish, another deftly cut up kunde—cowpea leaves, a nutritious green vegetable. The third refueled two small charcoal stoves known as jikos, the basic cooker in East Africa, poured on some kerosene and kindled the charcoal with a flaming paper. As the fish sim- mered, tomatoes, onions and chilis were added. A savoury aroma filled the room. Waiting for the 10 o'clock discussion about the menu, small groups of women chatted. Some sat stitching wall hang- ings. Others compared finished pieces, which they would sell to buy more nutritious food. Jane Kirui, director of the Nutrition Centre, used to fix the weekly demon- stration meals herself, carefully choos- ing the cheapest nutritious foodstuffs from Mathare's markets. At first her efforts didn't seem to make an impres- sion; the women merely listened quietly. The wall sampler which this woman is com- pleting in Kenya's Mathare Valley will earn her enough money to ensure that her family eat better. The Mathare Nutrition Centre has encouraged sewing as a means to break the sad cycle of poverty and malnutrition. ( Photo WHO/B. Seitz) But now each demonstration stirs a hearty discussion. The women view the experience as an opportunity to exhibit their culinary skill. The cooks began by explaining what they were cooking and how it was pre- pared. When the audience was asked about the merits of fish as a food, one woman enumerated several points : "It gives your child strong blood and keeps him free of diseases. His hair can't go red (from protein deficiency). It is such a beneficial food that you can give it to your child when he has diarrhoea." This woman has lost four children because of malnourishment. She attributes their death to some unknown mistake she herself had made. The staff at Mathare Valley Nutrition and Family Education Centre are confident that re-educating her about proper food will save her fifth child. "Mothers here are well-acquainted with the country's health services", ex- plains Mrs Kirui. "When their children weaken, they take them to dispensaries and clinics far and wide. Sometimes they are admitted and with nourishment improve after a few days. But with the constraints of poverty, the children just don't get adequate protein and calories at home. Many survive, but their physi- cal and mental development is stunted. If their systems weaken to the extent that their bodies reject food, they die. The mothers who have experienced this syndrome often believe that their chil- dren are constitutionally frail and ill. We believe education can bring changes", says Mrs Kirui, who has had training in both nutrition and social work. At the demonstration, several women protested strongly about some of the cooking practices. When talk about the best method of cooking vegetables reached the level of an argument, Mrs Kirui intervened with a poignant illustration. "When the traditional doc- tor asks you to prepare medicine from herbs, do you drink the steaming liquid or eat the cooked leaves?" No one doubted that the ngumu or strength of the medicine was in the liquid. "A similar thing happens when you cook vegetables. The water in which they boil has a lot of substances that your body needs. Never throw it away." And the discussion turned to the various ways of making vegetable broths. I noted that the one-year-old Centre must be having an impact on the eating patterns of some of Nairobi's poorest women. The Mathare Valley Nutrition and Family Education Centre is situated in a squatter area four miles northeast of central Nairobi, Kenya's capital. The three-mile stretch makes up 40 per cent of the city's uncontrolled housing, ac- cording to a survey made in 1969-70 by the Housing Reasearch Development Unit of the University of Nairobi. An estimated population of 80,000-100,000 live on the slopes of the Mathare River valley. Sub-divided into ten villages, the area absorbs many migrants from the rural areas. According to a 1967 municipal coun- cil census, at least 45 per cent of Mathare's residents are single women— widows, divorcees, unmarried mothers or deserted wives. Many are landless 3 earning more, eating better because in most Kenyan ethnic groups it is customary for women to inherit land only through their husbands. Without land, a rural woman is totally without resources. For self-support, an urban setting offers more options. A woman with some education may attend a secretarial school or be employed as a shop assis- tant. A woman without schooling must engage in a bitter struggle for few jobs. If she is fortunate, she may become a domestic servant. The jobless rely on the limited generosity of clansmen. The notion persists, claims Jane Kirui after talking to hundreds of Mathare women, that life is easier in Mathare—if one can manage to get a little money. Instead of carrying firewood and water in the countryside, they prefer the uncertain urban struggle for shillings. Brewing buzaa, a maize beer, is a common occupation of Mathare wom- en. While they work at home and main- tain a regular income, they can care for their children. But this self-employment is risky because brewing is illegal. Wom- en in Mathare are frequently harassed by police raids. All who are involved— those who fry flour, the brewers, the wholesalers and retailers—form a sup- portive network. If the police pour away one woman's brew, a friend will sell her some so that she won't disappoint her customers. In order to protect themselves and their friends, the women are very suspi- cious of outsiders. When the National Christian Council of Kenya's Urban Squatter Programme opened the Nutri- tion Centre in September 1975, nobody would come through the door. Director Kirui began walking the dusty paths of Mathare to discuss the clinic with moth- ers, but "for two months, only children would talk to me". "Then I learned that many older chil- dren were absorbed by the constant search for food. When they see that no fire is cooking at home, they rummage in groups, stealing from a boiling pot or doing odd jobs to get a bit of chakula (food) in payment." Interest in nutrition education began because N.C.C.K. scholarship recipients from Mathare Valley usually failed or dropped out. The development workers felt that the children's performance might be affected by hunger. The Centre was opened "to study the present eating habits of children under five; to advise mothers to improve these habits nutri- tionally and to educate mothers on all matters affecting family growth and development". Dismayed by her lack of success in the alleys, Mrs Kirui took up lecturing to a captive audience at a church clinic which has been operating for at least five years. Using visual aids, she talked in Kiswahili to the 50 waiting mothers about the signs of malnourishment and invited anyone with such children to come to her office a few yards away. Her invitation was soon accepted by mothers with children who resembled the photos in the standard malnutrition charts on her wall. Some had symptoms of severe kwashiorkor and/or marasmus. Dr John Adams, the clinic physician, examined and dewormed all malnutri- tion cases. "The most extreme cases of malnourishment occur because of early weaning. If a six-month-old child trans- fers from breast milk to maize porridge made with water, he suffers." After each child had been examined, the mother would tell Mrs Kirui of her difficulties; later, a visit would be arranged to the mother's home. "After a month of talking about the value of milk and beans, I realized that my advice wasn't being practised. They were willing, but they didn't have the money to buy better foods. A banana cost 20 Kenyan cents; they could buy five bananas for the price of a half-litre of milk." Their priority was the most filling food for the least money. An original principle of the nutrition programme was "No handouts". After finding six severely marasmic children in one village, Mrs Kirui altered this edict. A kilo of whole powdered milk was dis- tributed weekly to each child. More children enrolled. Two new staff mem- bers began assisting with home visits. Demonstration meals were made regu- larly each Tuesday. "But the condition of the children did not improve", explained Emma Obun- ga, a nurse at the Centre. "We feared that the milk was being used for tea. We asked the women if there was a better way to improve their children's health." "We need money", was the response. "Let us learn to sew and sell what we make." They remembered such success- ful enterprises in their rural areas. The staff pursued this idea, but Mrs Kirui recalls her dismay when the emphasis seemed to be shifting from nutrition. "In my frustration, I tried an- other idea." Mixing one part of ground beans and two parts of millet meal and adding powdered milk, Mrs Kirui ex- perimented with a porridge. Fortunate- ly, the mothers and their children were pleased with the taste. The Nutrition Centre distributed this mixed meal in- stead of milk powder. Within two months, all children receiving the meal improved in strength and appearance. In the meantime, the sewing pro- gressed. A designer from Cottage Indus- tries, an N.C.C.K. crafts cooperative, encouraged the women to draw on cloth, cut out scraps and appliqué them on to the design. The product was a wall sampler. The designs were creative illus- trations of Mathare life. More than half of Mathare's women have had no schooling. The women learned to write their names so that with thread they could autograph their work. The unique samplers are marketed in Nairobi. As their popularity increases, sales have risen. Twice a week the wom- en hand in a finished sampler and receive materials for another one. A woman earns 20 Kenyan shillings for a small one and 80 for a large one. Thus far over 18,000 shillings (US$ 2,142) have been paid to the women. The Cen- tre adds 25 per cent to the wholesale price for programme expenses. The effect of this income on the lives of these women and their children has been remarkable. Buying a kilo of beans or a daily carton of milk is no longer a problem. Their families eat eggs twice a week and meat more frequently. One staff member says that they now hear talk about going home for lunch. In Mathare one meal a day in the evening is the general rule. Recently a man inquired of Mrs Kirui, "Why do all the women who go to the Centre look so rich?" The effects of being able to buy soap and food regularly are obvious. The mothers coming to the Centre now number 104. A recent decision indi- cates their dedication to improving their families' nutrition. Fifty-year-old Kadija Duba suggested that they organize as a self-help group. Ninety-two agreed to give four shillings each to a selected committee. As a result, four im- poverished women each receive 92 shill- A member of the Mathare Nutrition Centre's I> "self-help group" displays the nourishing local foods which she is now able to buy for her family. ( Photo WHO/B. Seitz) 4 _ t • ,66*-66.6-66 Mrs Jane Kirui, director of the Nutrition Centre (right), inquires about Mrs Margaret Mumbua's new job at a weaving shop. A widow, Mrs Mumbua's new skills will help to ensure that her four children thrive on more and better food. While a demonstration meal is cooking on the simple stoves at Mathare Valley Nutrition Centre, a family life educator discusses methods of family planning with the house- wives. As their economic situation improves and they learn better ways of feeding their families, they usually prove more receptive to ideas about spacing their children. (Photos WHO/B. Seitz) ings to make major purchases that week to improve their children's health and welfare. It was decided that the commit- tee should visit each recipient's home to ensure that the money was spent properly. Many women use this sizable sum to buy a 45-kilo bag of whole-grain maize flour wholesale. Buying in bulk means a saving of 41-50 shillings over 22 two- kilo packets. Besides, unrefined maize flour, which is more nutritious, is not available in small packets. Maize flour is used to make ugali, a thick porridge that is a staple dish in Kenya. With that ingredient on hand, a woman can use her sewing income to buy a variety of nutritious relishes—tomatoes, fish, meat and Mung beans. All these foods were too expensive for most of the women eight months ago. Filling their chil- dren's stomachs with ugali was a strug- gle—and costly to the mothers' health. The Centre emphasizes mixing foods, e.g. beans and potatoes, bananas and beans, spinach and ugali. The women are told, "If you eat only beans, your system uses the nourishement for ener- gy; there's little left for body-building protein." They are introduced to a vari- ety of beans haricot, green grams and njahi, a black and white bean that was traditionally given to mothers after childbirth. Mrs Kirui says that the Centre has to overcome a widely practised tradition that "children don't need special foods; because they're little, they can get by on anything". In the rural areas, children fared well because there was plenty of milk which was not considered a food for adults. In the city, because milk is expensive, children don't even get that. Children often get the minimum—the equivalent of leftovers. A few children have come to the Cen- tre nearly dead. One three-year-old was too weak to sit; his bones popped out of his fleshless skin. Two children died because their families were unable to follow Dr Adams' instructions. Since then, Mrs Kirui immediately takes a severely malnourished child and his mother to Kenyatta National Hospital for ten days of surveillance and body- building. At that point, Mrs Kirui says, a wom- an's self-esteem is low. "I emphasize the positive factors in her life. Sometimes they are so few, perhaps only the fact that her child is alive." From there on, individual re-education takes place— through home visits, interviews, group activities and the possibility of an in- come. As her knowledge and her situa- tion improve, her aspirations rise. "And so does her self-confidence", points out Mrs Kirui; "this change in attitude was basic before the Mathare women could be persuaded to practise nutrition prin- ciples". ■ 7 the scourge of versus The sexually transmitted diseases, syphilis and gonorrhoea, were known to medicine for many centuries but defied most methods of treat- ment until the advent of the penicillin drugs BY DONALD GOULD Il yphilis seems to have been first recognized as a distinct disease about 500 years ago. The infec- tion began to make its mark on life in Europe during the Middle Ages, when it was the cause of a chronic sick- ness, chiefly characterized by sores and ulcers, which afflicted the residents of some towns and districts, but left others unaffected. Sometimes the local people gave the condition a name of its own, but more usually it was confused with leprosy. Then, towards the end of the fifteenth century, the character of the contagion suddenly changed. The disease increased in virulence and became epidemic all over Europe, killing many of its victims. Syphilis began to generate serious public interest and alarm around 1494, when an outbreak among French soldiers in- volved in the siege of Naples caused havoc. Because of this well-publicized occur- rence, syphilis was often known there- after as the Neapolitan disease. But no nation liked to claim the newly ac- knowledged plague as its own, so it was also labelled the French disease (malus Gallicus) by many people outside France, and the Spanish disorder by many people outside Spain. Others, per- haps less jealous of their national pride, simply called it the Great Pox. Christopher Columbus was common- ly blamed for importing syphilis into Europe, largely upon the strength of an assertion made by a Spanish physician in 1505 that a number of the sailors in the explorer's service were suffering from the disease when they returned to Spain and Portugal from Haiti in 1493 at the end of his first voyage. The pro- ponents of this theory claim support from the fact that skeletons of bodies buried in Europe before Columbus and his sailors returned from the New World, rarely show evidence of syphilit- ic bone damage—a condition which became common from then on (together with many other destructive lesions in all parts of the body which the infection then began to cause). Other medical historians have declined to blame Columbus, both because of evidence of the disease's presence in the Old World long before the fifteenth century, and because of an unwillingness to believe that a group of fewer than 50 sailors, even if every one of them had been infected, could have passed on a newly imported germ to so many people, so rapidly, that within 18 months it had spread throughout the entire European continent. A more prob- able explanation (say the critics of the Columbus theory) is that a change in the nature of the "old" or "European" syphilis germ, rather than the intro- duction of a virulent spirochaete from the Americas into a Europe hitherto free of the infection, was responsible for the far more serious form which the disease so rapidly assumed. It was not a new plague, but an old one which developed a suddenly fiercer and more dangerous nature. There is, in fact, a record of a local European epidemic pestilence break- ing out in 1484 (nine years before Co- lumbus returned from his voyage), which appears to have had all the characteristics of "modern" syphilis. This dispute about the origins of syphilis is made more complex by the age-old presence in many parts of the world of other closely related tre- ponemal infections—endemic syphilis, yaws, and pinta. The spirochaetes re- sponsible for these three conditions, and for venereal syphilis, are indistinguish- able under the microscope from one an- other. There are slight serological differ- ences between the four (that is to say, slight differences in the structure of the antibodies found in the blood of infect- ed patients), but their extremely close 8 Boy meets girl today in far more relaxed and permissive circumstances than used to be pos- sible only a few decades ago. For most parts of the world, this is an age of rapidly chang- ing sexual mores ; for better or worse, tradi- tional notions of arranged marriages, the vir- gin bride, and chaperoned meetings of a betrothed couple are fast being eroded by the winds of change. But the price — "the scourge of Venus" — is a huge increase in the incidence, in many countries, of the sexually transmitted diseases, notably syphilis and gonorrhoea. (Photo WHO/E. Mandelmann) relationship is shown by the fact that they produce a cross-immunity to one another. This means that yaws, for ex- ample, makes the sufferer far less sus- ceptible to venereal syphilis. Wherever it arose, modern venereal syphilis was quickly acknowledged at the turn of the fifteenth century as a dis- tinct and recognizable pestilence among the several which were commonplace at the time. It took rather longer for the fact that it was usually spread by sexual contact to be appreciated. The term "syphilis" was coined for the new pla- gue in 1530 by Girolamo Fracastoro, a physician of Verona, who in that year published a poem describing the adven- tures of a wealthy young shepherd named Syphilis who foolishly insulted Apollo. To punish him the angry god visited upon him a horrible contagion. The poem describes in detail the suffer- ings of the shepherd, which were exactly those of the syphilis victim. Mercury presently became a popular remedy for the disease, and was admi- nistered externally either in the form of an ointment or as a lotion prepared from the mercuric salt, corrosive subli- mate. This rapid resort to mercury, in- cidentally, lends supporting evidence to the idea that a milder form of syphilis was commonplace in the Old World in ancient times. The Crusaders set great store by the " 'Saracens' ointment", which was mercury mixed with lard or some other fat, and was commonly used for treating leprous sores. Mercury has no effect upon leprosy but does destroy spirochaetes, and it is a fair presump- tion that the Saracens' ointment owed its reputation to the fact that it cleared up many of the chronic skin ulcers from which these mediaeval adventurers suf- fered because they were syphilitic. Mercury (which happens to be in- tensely poisonous) was still being used by western physicians in the treatment of syphilis as recently as 30 years ago, either as an ointment or an injection or a pill to be swallowed. Throughout the sixteenth century a warm decoction of guaiac wood was regarded as a foolproof treatment for the disease. Patients were kept in bed for a month, fasted and made to swal- low quantities of guaiac "tea", which made them sweat. The reputation achieved by guaiac was probably due to a circumstance which has led to many folk remedies and patent medicines be- ing given the credit for curative proper- ties they do not, in fact, possess. Many afflictions are self-limiting, or go through phases of exacerbation and remission, so that a remedy which the patient happens to be using at the time of any such natural remission gets the credit for having effected a cure. Both the sores of primary syphilis and the rash and general feeling of illness of secondary syphilis are self-limiting, and disappear without any treatment. So any course of therapy lasting as long as 30 days is bound to encompass an ap- parent improvement or "cure" in most sufferers from the early disease. It was not recognized that the infec- tion persisted after the original, obtru- sive and unpleasant symptoms had died away, nor that the disabling and eventu- 9 ally fatal damage to the heart, brain, liver and other vital organs (possibly occurring only after many years) were the end results of the same disease. Syphilit- ic tumours of the brain, for example, were first described by Morgagni, pro- fessor of anatomy at Padua in 1770. Another century elapsed before Sir Sa- muel Wiles of Guy's Hospital in London pointed out the effects of syphilis on the viscera, including the fact that the infec- tion could produce a weakening and ballooning of the body's main artery, the aorta (an aortic aneurysm). One of the grimmest manifestations of late or tertiary syphilis, general para- lysis of the insane, in which an invasion of the nervous system by the spirochaete produces personality changes such as ir- responsibility, slovenliness, and delu- sions of grandeur, and which causes memory defects, speech difficulties, muscular weakness, and, finally, death, was first recognized as a distinct disease in 1822. However, its true cause was not seriously suspected until the end of the century, and was not conclusively proved until 1913. At that time two workers at the Rockefeller Institute for Medical Research in New York, Hideyo Noguchi and Joseph Waldron Moore, reported finding the spirochaete of syphilis in the brain tissue of 14 out of 70 patients who had died of the disease. The essential fact that syphilis is in- deed caused by a spirochaete was estab- lished in 1905 by Fritz Schaudinn, a zoologist, and Paul Hoffmann, a derma- tologist, working together in Germany. They demonstrated the presence of the corkscrew-shaped organism which they called Spirochaeta Pallida in material obtained from the skin lesions of syphi- litic patients. The heavy involvement of the skin during the early stages of the disease led to Hoffmann's special in- terest in the infection, and until quite recently it was common for one man to fill the double role of skin specialist and venereologist. Syphilis has earned a major place in medical history not only as one of the major killers in the western world dur- ing the past few centuries, but also Harmless fun for the majority of young peo- ple. For the few, the permissive life-styles of the 1970s mean the nagging fear that too easy and too many sexual contacts may entail the risk of infection. The sexually transmitted diseases pose a growing public health problem in many countries today, particularly the most common contagion, gonorrhoea, whose causative bacteria are proving increasingly resistant to antibiotics. (Photo WHO/P. Almasy) 10 because, almost by accident, it played a central role at the birth of the therapeut- ic revolution which was to change medi- cal practice and the pattern of human disease beyond recognition. Toward the turn of the century, a German bacteriologist, Paul Ehrlich, achieved a breakthrough in the treat- ment of the disease by using organic arsenicals, the first of the synthetic chemotherapeutic agents, which pre- ceded by over a quarter of a century the next great generation of such com- pounds—the sulfonamides. For this work Paul Ehrlich was awarded the Nobel Prize in 1908. But great though Ehrlich's achievement was, the length and inconvenience of the course of treatment needed to effect a cure meant that a high proportion of patients failed to stay the course, and syphilis remained a major killing disease until 1943, when penicillin was tried with striking success, rapidly replacing the arsenicals altogeth- er. Before the introduction of penicillin, syphilis had killed half the people who caught it. Although gonorrhoea is by far the commoner of the two principal venereal contagions, occurring 10 to 50 times more frequently than syphilis, its history is far less well documented than that of syphilis. Most authorities believe that the in- fection was known in biblical times, and that references to it occur in the works of Galen and Hippocrates. Others main- tain that the earliest certain records belong to the fifteenth century. Early in the sixteenth century, when the venereal nature of syphilis was becoming recog- nized, the two infections were common- ly confused, and were regarded simply as different manifestations of the same sexually transmitted plague. John Hunter, the great eighteenth century English surgeon and anatomist and one of the founders of modern pathology, attempted to demonstrate that gonorrhoea and syphilis were in- deed one and the same affliction by in- oculating himself with gonococcal pus. Unfortunately the patient concerned did have both diseases, and both were con- tracted by Hunter, and were probably the cause of much of the illness which dogged his later years. The germ responsible for gonorrhoea was discovered by Neisser in 1879 and named Neisseria gonorrhoea (more com- monly known as the gonococcus). Neis- ser, who evolved the blood test for syphilis in conjunction with August von Wassermann, was director of the Derm- atological Institute at Breslau. His career, like that of Hoffmann (the co- discoverer of Treponema pallidum), again shows the close association which has existed in modern times between the study of sexually transmitted diseases and the study of skin ailments. Only in 1935 was an effective treat- ment for gonorrhoea found, with the discovery of the sulfonamides by the German chemist and pathologist, Ger- hard Domagh. Until then attempts were made to get rid of the gonococci from infected tissues by using antiseptic solu- tions, of which the most popular was Condy's fluid—a solution of calcium permanganate and sodium permanga- nate in water. Originally a syringe was used to irrigate the urethra in men with the antiseptic. Then, at the turn of the century, the French venereologist, Jarat, popularized the idea of introducing large quantities of the wash-out fluid into the urethra through a nozzle at the end of a rubber tube leading to an ele- vated reservoir. Women were sat in hip baths containing the antiseptic, and were given vaginal douches. These tedious and unpleasant proce- dures were commonly undertaken once or twice a day, and the treatment might last for weeks. Whether the wash-outs indeed influenced the course of the dis- ease to any significant extent is a matter of opinion. Sulfanilamide, the first of the sulfona- mides, made a dramatic impact by rapidly curing previously grave infec- tions caused by streptococci, and it was soon tried out on patients with gonorr- hoea, but with less gratifying results. The great advance came a couple of years later with the introduction of sulfa- pyridine. This drug proved capable of curing 90 per cent of infections within a week. But the triumph was short-lived, for within six years so many gonococci had developed a resistance to sulfapyri- dine that around 50 per cent of patients were failing to respond. Fortunately penicillin then became available and for a time an even higher cure rate (virtually 100 per cent) than that originally achieved by sulfapyridine was commonplace. But, in its turn, penicillin too began to produce resistant strains of gonococci. Reports of infec- tions failing to respond to penicillin began to appear in 1958, and within the next 10 years the situation had deteriorated to the point where some authorities believed that up to 80 per cent of gonococci had developed peni- cillin resistance. However, new forms of penicillin and other antibiotics have since been developed which can today cure virtually all cases of gonococcal infection. ■ Resistant Strains Only in September, it was reported by the Center for Disease Control in Atlanta, Georgia, USA, that gonococci producing penicillinase had been isolated from sick per- sons. Penicillinase is an enzyme produced by certain bacteria—in this case Neisseria gonorrhoeae- which converts penicillin to an inactive product and thus increases resistance to the antibiotic. De- scribing this new development as "of the utmost clinical and epi- demiological importance", the Center for Disease Control re- ported on several patients who had contracted gonorrhoea outside the United States and who still presented symptoms after treat- ment with doses of penicillin that were usually effective (4.8 million units of procaine penicillin pre- ceded by one of probenecid). The patients were subsequently cured with other antibiotics. Since the Atlanta Center's report, a number of other laboratories have also recorded similar cases. Doctors and laboratories have been asked to exercise the utmost vigilance. It is recommended that every pa- tient with gonorrhoea should be given a further clinical and patho- logical examination seven to 14 days after treatment. Patients from whom a positive culture is obtain- ed after that lapse of time will have to be treated with an anti- biotic other than penicillin. It is also recommended that the strains thus isolated should be studied for their ability to produce penicillin- ase or else sent to a laboratory where such studies are carried out. Procedures for the surveillance of penicillinase-producing gonococ- ci, recommended in consultation between the Center for Disease Control (Venereal Disease Control Division) and the WHO Colla- borating Centre for Reference and Research on N. Gonorrhoeae, Copenhagen, were detailed in WHO'S weekly Epidemiological Record dated 17 September 1976. The WER's report on this develop- ment concluded: "In order to assess the epidemiological im- portance of this discovery and determine the measures to be taken, it is important that every new case of gonorrhoea caused by N. gonorrhoeae producing penicillinase should be reported to the Venereal Diseases and Tre- ponematoses Unit, WHO, 1211 Geneva 27, Switzerland". 11 what are the real needs? A seven-country WHO study focusses on the needs of the sick and on what health care personnel actually do, rather than on traditional counts of the dead and diseased BY KERR L. WHITE le he only justification for organiz-ing health care systems that pro-vide services is to meet the needs of people as they perceive them. Yet few social services are as costly, as uncertain in their benefits, or as difficult to plan as health services. To allocate scarce and expensive health care resources so that realistic services can be distributed fairly to all who can benefit from them is an increas- ingly complex task in any society. While the variety of purportedly useful medi- cal services is proliferating on the one hand, the essential contribution to health of non-medical influences is being more widely recognized on the other. The needs of people in all lands for fundamental, primary health care as the point of access to a balanced and inte- grated array of truly beneficial health services is now generally recognized. And limits are being set to how far tech- nological imperatives in medicine can be allowed to bring about a situation where any test or procedure that can be carried out is carried out without regard to how many people it benefits or to how much it benefits them. From all these pres- sures has emerged a widespread interest in comparing different health care sys- tems and their achievements in balanc- ing needs, resources, and the use of health services. To confront these problems in both developing and developed countries, a practical base of information and a rea- listic appreciation of fundamental rela- tions among the components of the health care system is essential. How are the perceived needs of the population related to health care resources and their organization, and how are the ser- vices to be planned and used? For the most part, these relationships have been seen as unique manifestations of a par- ticular locality, country, financing mechanism or political ideology, rather than as differing responses to universal problems of interaction that can be eva- luated and that have some measure of "generalizability" and predictability. The World Health Organization/In- ternational Collaborative Study of Med- ical Care Utilization (wHo/tcs-mcu) was a large-scale study directed at increasing our understanding of these fundamental relations and interactions so that the al- location of health care resources and the planning of health services can be guided by information that is population- based and problem-oriented, rather than institution-based and disease- oriented. Although the study was con- ducted in industrialized countries, it em- braced rural and semi-rural areas as well as large urban centres, and the concepts, methods and results are seen as practical and useful for countries and regions at all stages of social and economic devel- opment. The study shows that simple epidemiological and statistical surveys can provide useful information about health care systems and their use that is not available from other sources. It is such information that is fundamental for two of WHO's major initiatives, i.e. national health planning and primary health care. Fifteen million people living in twelve study areas in seven countries were represented by some 48,000 respondents interviewed in their homes by fieldwork- ers trained in the same way and using identical questionnaires, translated into the five major languages of the study (English, Finnish, Polish, Serbo-Croat and Spanish). Small populations as well as large conurbations were included in the 12 study areas, four in Canada (Grande Prairie, Saskatchewan, Fraser, Jersey), two each in the United States (Northwestern Vermont, Baltimore) and Yugoslavia (Banat, Rijeka), and one each in Argentina (Buenos Aires), Fin- land (Helsinki), Poland (Lodz) and the United Kingdom (Liverpool); their pop- ulations varied from 11,000 to almost 8 million persons, but the sample sizes (and hence their estimating power) were approximately equal, and the rate for those responding was unusually and uniformly high (i.e., over 90 per cent in all study areas, with an overall average of 96 per cent). Final error rates were low and a variety of different methodo- logical studies conducted by all study groups provided standards for the credi- bility of the data collected. Perhaps even stronger evidence for the validity of the findings is to be found in the similarities of the patterns of use within countries or geographic regions, and in both the similarities and differences observed Village health workers attending a course on I> primary health care at Tillaberi, Niger. The need for primary health care as the point of access to a balanced and integrated array of truly beneficial health services is now more generally recognized. ( Photo WHO/R. da Silva) 12
a) 2 a' Ca CO U- D C C 2> PHYSICIAN MANPOWER—RATIOS PER 10,000 POPULATION STUDY AREAS Total Physicians Physicians in Clinical practice I 11 among countries and types of areas (e.g. rural, semi-rural and urban). These were all based on data collected independent- ly but simultaneously during the four consecutive quarters of the household survey in 1968-69. To achieve these levels of comparability, reliability and validity, an enormous amount of pre- parative work and of coordination was necessary. The wHo/tcs-mcu has extended over a decade; three years were spent on feasi- bility study (in three areas in the United Kingdom, United States and Yugoslavia), and seven years in the main study. About 16 months of the lat- ter were spent in the design of the study and, if added to the 36 months of the feasibility study, a total of 52 months was spent in planning. Twelve months were spent on the field work, eight months in coding and local editing, and 24 months on computer editing, data reduction, data processing and tabula- tion. Another 24 months were spent on analysis and preparation of the main report, and yet another two years have been required to see the final product through the press (Health Care: An In- ternational Study, London and New York, Oxford University Press, 1976). Because of the enormous investment in time and talent (some 90 professional and 300 technical workers were in- volved), every effort has been made to ensure that both the substantive findings and the documentation of the methods are widely available. In addition to the main report, over 50 substantive and methodological papers, two Occasional Reports, and a series of nine manuals explaining the methods employed have been published. Complete archive tapes containing all of the household inter- view data (with identification of individ- uals removed), are available from a number of repositories, and a practice- How are the perceived needs of the population related to health care resources, and how are the services to be planned and used? This table, resulting from a large-scale WHO/ICS- MCU study made in seven countries, shows the ratios of physician manpower per 10,000 population, and the proportion of physicians who are in clinical practice—that is, primarily engaged in patient care. (Photo WHO/J. Littlewood) Collecting data on the health situation of a> rural community in Finland. The study has shown that simple epidemiological and statis- tical surveys can provide reliable information about health care systems and their use that is not available from other sources. (Photo WHO/D. Henrioud)
oriented planning report setting out the major concepts and relationships derived from the study has been pre- pared for publication by WHO. First, it is clear from this cross- national study that these 12 diverse pop- ulations are more alike than different with respect to their perceived needs for health care, their demands for general or primary care, and their attitudes towards care. Differences among the populations seem to arise from the way the systems are organized and the resources are planned and deployed. What has been learned from the study? First, some general findings about the units of observation employed in the study. It is important to distin- guish between measures of persons who need, seek or obtain care, and the volume of services received. Age-sex standardized rates for the former, cer- tainly at the level of physician care, vary less than the latter. Perceived need can be measured and, perhaps more impor- tantly, when expressed as levels of sever- ity or of chronicity, can be used for standardizing rates of use of services across study areas in much the same way that age and sex are used for stan- dardization. Resources need to be divided into functional categories, such as generalist (or primary care) and spe- cialist physician services, short-term and long-term hospital beds, and ambulato- ry or community nurses and inpatient hospital nurses. Simple counts of heads and beds are less meaningful for plan- ning purposes than are the ratios of types of personnel to each other, or to the types of beds (or other facilities) available to a population. Systems of health care can be compared quantita- tively; although the measures are still rudimentary and much more work needs to be done, the wHo/Ics-mcu made a beginning in this difficult area. Secondly, there is the overall realiza- tion that it is the balance among com- ponents of the health care system, rather than the ratios of resources, that most influences both the distribution of ser- vices and their costs. For example, concentration on costly, intensive care short-term beds, in the absence of an adequate supply of accessible primary care, both increases total costs and diminishes basic health care services needed for early treatment to contain disease and alleviate suffering. As an example from this study shows, the volume of ambulatory physician care (i.e. the rates for physician contacts per 1,000 population within two weeks) is inversely associated with the ratio of short-term beds per 1,000 population, and the level of unmet need for care (i.e. the percentage of those with perceived morbidity of high severity who wanted but did not obtain a physician contact within two weeks) was directly and very positively associated with the volume of hospital nights consumed (i.e. the rates for hospital nights per 1,000 population annually), regardless of the supply ratios of short-term beds. Not only physician services and hos- pital services, but also dentist services, vision services and those of selected non-physician health care personnel (in- cluding nurses) and the use of medicines were studied in the wHo/Ics-mcu. Detailed graphic displays of rates (with their standard errors for the age-sex standardized rates), ratios, and percent- age distributions are provided in the main report, so that within and between 16 what are the real needs? < Sophisticated technology may appear prestigious. But the WHO/ICS-MCU study indicated that a concentration on costly, intensive-care short-term beds in the hospitals, in the absence of an adequate supply of accessible primary care, may both increase total costs and diminish the basic health care services that are needed for early treatment of disease. (Photo WHO/D. Henrioud) A health worker advising on hygiene and maintenance of latrines in D an Iranian village. The new study lends support to WHO's efforts to encourage Member States to plan their health services rationally, and to build the fundamental infrastructure of all health care systems — namely, primary health care. (Photo WHO/D. Deriaz) study areas comparisons can be made visually as well as numerically. Some of the classifications and comparative pre- sentations that relate needs, resources and use should suggest new ways of pre- senting information for decision-makers and health planners, as well as new rela- tionships among these three components that might promote the earlier attain- ment of desirable social goals and humanitarian aspirations. Although the study has been an un- usually lengthy and complicated exer- cise, its results should encourage new ways of thinking about health care sys- tems, and its methods should be of use in diverse settings as well as for cross- national comparisons. Probability sam- ples of residential clusters based on aerial photographs of rural villages or of census maps of industrial cities are fea- sible as a basis for household surveys in which a "head-man", "block represen- tative", or "survey interview", using simple but identical questionnaires and instruction manuals, can inquire about the health status of populations. A few questions about the extent to which symptoms, problems or conditions "bother", "hurt", or "worry" the re- spondent, or about his or her efforts to seek care, or about the degree of satis- faction with the receipt of care, provide worthwhile, practical estimates of need and use. Measures of resources by func- tional categories and related to popula- tion estimates based on the sample surveys provide ratios that can be relat- ed to measures of need and use that are standardized for age, sex, severity, chro- nicity and urgency. How does all this differ from tradi- tional approaches to health planning? It focusses on the needs of people who are suffering now, on crude measures of the extent of that suffering, and on crude measures of what health care personnel and facilities actually do, in contrast to the traditional focus on counts of the dead and the diseased, and on counts of buildings and personnel. These measures are far from perfect and much work is needed, but wHo/ics- mcu has made a start at counting what counts, rather than counting that which is easiest to count. If measurement is one prerequisite for objectivity, then this study has attempted to raise the level of empiricism and to improve the climate of decision-making with respect to the allocation of scarce resources to meet desperate human needs. As such, the study is seen as buttressing WHO's major concerns for improving the capacity of Member countries to plan their health services rationally, and for building the fundamental infrastructure of all health care systems, that is to say, primary health care. For further information see: Main Report: Health Care: An Interna- tional Study, eds. Robert Kohn and Kerr L. White, London and New York, Oxford University Press, 1976. Bibliography of all wHo/ics-mcu publi- cations: Division of Strengthening of Health Services, World Health Organ- ization, 1211 Geneva 27, Switzerland. Procedural Manuals Describing the Study Methods: National Technical In- formation Services, United States Department of Commerce, 5285 Port Royal Road, Springfield, Virgi- nia 22151, USA, PB234 275-283. ■ 17 madhubani shows the way BY P. K. J. MENON wo men got down from the lorry, drenched to the skin from the sudden cloud-burst which had overtaken them five miles from Pandaul. They were Dr Jha, Medi- cal Officer in Charge of the Pandaul Primary Health Centre and his collea- gue Dr Prasad, Medical Officer. They had been to a sub-centre which is the primary responsibility of Dr Prasad, who visits it every Saturday with Dr Jha while their other colleague, Dr Sinha, holds the fort at the static dispensary at Pandaul. This serves the dual purpose of enabl- ing the medical officer in charge to feel the pulse of health activity at each sub- centre once a week, and the medical of- ficers to practise curative work at the dispensary. As they finished their work at the sub-centre, they were informed of a suspected case of smallpox in a village ten miles away and rushed there, only to diagnose a clear case of chicken-pox. After giving necessary directions for nursing and taking precautions against the spread of the disease, they were 18 making their weary way home when their jeep, "Old faithful", broke down. They finally hitched a lift from a passing lorry. "Rural health under-development" is a component part of the dilemma called "Rural under-development", as Dr K. W. Newell emphasized in an arti- cle in the April 1975 issue of World Health. The community development pro- gramme in India launched in October 1952 (on the anniversary of Mahatma Gandhi's birth) was aimed at bringing about an integrated development of rural India, covering the social, cultural and economic aspects of community life. This was sought through the fullest development of available human and material resources, on an area basis, so as to raise the rural community to high- er levels of living standards with the ac- tive participation and on the initiative of the people themselves. Selected items of activity in a community development programme include agriculture, animal husbandry, land improvement, health and rural sanitation, social education, communications and small industries. Popular participation in the programme is ensured by the local village commit- tees and by the block-level councils which include elected sarpanches (presi- dents of village committees) and a few co-opted persons representing women, the disadvantaged, and so on. Initially a development block covered an area of 1,300 sq. km. with about 300 villages and a population of 200,000. Since 1958, the pattern has been revised and a block now covers an area of about 600 sq. km . Children copying examples of the local style of painting, using materials available locally, which has already made the Madhubani Dis- trict of India famous and has contributed sig- nificantly to the District's economy. (Photo WHO/P.K.J. Menon) with about 110 villages and a popula- tion of 100,000. In April 1974, there were 5,123 development blocks, includ- ing 483 tribal development blocks. Madhubani is a district in Bihar state, carved out as recently as 1972, and is bounded on the north by Nepal and on the south by Darbhanga district. Mad- hubani and Darbhanga lay on the great routes of Aryan immigration at a time when other parts of Bihar were outside the pale of Aryanism. Madhubani district came into the limelight when the special 19 madhubani shows the way Left: A sanitary inspector takes samples of foodstuffs from a rural store during a regular check to make sure that community standards of feeding and diet are kept as high as pos- sible. Right: A table in the open-air becomes a makeshift surgery for a health worker deliver- ing routine immunizations in the Madhubani District of northern India. In the background —the jeep which ensures the mobility of the rural health staff. Below: Local children line-up for a nutritious meal at one of the health sub-centres. The feeding programme in particular requires the active participation of the community. (Photos WHO/P.K.J. Menon) local art of painting with indigenous materials caught the public imagination and became popular worldwide. This has contributed significantly to the economy and also to the local inhabi- tants' pride in their culture. With a population of 1,892,000, of whom 98 per cent live in the rural areas, the district has 18 development blocks. Literacy is low, and is estimated at less than 20 per cent. The eastern parts are flooded every year by the snow-fed riv- ers tumbling down from the Himalayas. But this brings down fertile silt, result- ing in bumper crops year after year. Communication systems are not very satisfactory because of frequent damage to roads by floods. Let us briefly consider the organiza- tional set-up in this district as regards health services. The responsibility rests with a triumvirate consisting of a civil surgeon, the district health officer, and the district family planning officer. There are Primary Health Centres in each development block with a referral hospital at district level. The civil admi- nistrator, or block development officer, works in close harmony with the medi- cal officer in charge. A detailed study of the system of integrated rural health ad- ministration in one of the blocks (Pan- daul) illustrates what has been achieved so far. The block has three medical of- ficers of the state medical service, all located at the headquarters. The static dispensary has four male and two female beds, with the usual staff includ- ing a compounder, a dresser, a midwife, and male and female ward attendants. These are complemented by a sanitary inspector, vaccinators and two auxiliary workers for public health work. Family planning There are three health and three fami- ly planning sub-centres. These usually share premises, only 30 per cent being separate. Two medical officiers share duties at the sub-centres, where all tasks of curative, preventive and promotive work are carried out by a basic health worker, a health assistant, an auxiliary nurse-midwife, female and male family planning workers and a dresser. Special workers are allocated under different projects like the control of malaria, filaria, trachoma, leprosy, tuberculosis and so forth, and they also work under the operational and administrative con- trol of the medical officer in charge, though the technical supervision is the responsibility of their own specialists. Not only in Madhubani but throughout India, the lack of infrastructure has ham- pered faster progress in establishing a strong framework for rural health ad- ministration. It is difficult to expect the primary health centre or sub-centre staff to go and live in the villages and per- form their duties with concentration and energy unless there is suitable accommo- dation. Another circumstance which delays delivery of health services is the lack of communication facilities. All India's states are making superhuman efforts to provide an all-weather road from each village to the nearest metalled road. The necessity for this has been emphasized in all the Government's planning direc- tives. Bihar has converted all the posts of medical officers in rural areas to practising posts, and they are encou- raged to provide themselves with their own transport. Eventually the building of good roads will encourage a prolifer- ation of public transport and help health workers to reach any village within their jurisdiction within one or two hours. UNICEF is also providing a jeep as well as equipment to each of the primary health centres which fulfil certain condi- tions such as completing buildings, and 21
madhubani shows the way < A medical officer examines a child at one of the static dispensaries in the Madhubani Dis- trict. Usually the permanent staff at a static dispensary includes a compounder, a dresser, a midwife, and male and female ward atten- dants; there are four beds for male patients and two for females. A basic health worker explains the advan- tages of .family planning to one of the vil- lagers. Most health sub-centres set up under India's community development programme incorporate a family planning sub-centre where both female and male health workers are available to give advice on spacing births. (Photos WHO/P.K.J. Menon) laying on electricity and water supplies. Out of 5,369 primary health centres in the country, jeeps and equipment have been provided to 3,679 and this has con- tributed in turn to the mobility of the health staff. Within the last decade, the adminis- tration has realized that providing an in- frastructure of workers and constructing centres and sub-centres cannot provide a final solution to the problem of health care delivery to the people who need it most. The oft-repeated statement that "80 per cent of the country's population live in villages and are served only by 20 per cent of the country's doctors and 30 per cent of the hospital beds, there- fore doctors must be encouraged to go and settle in the villages" will not take us very far. However, there is one redeeming fea- ture in rural India—the presence of thousands of practitioners of indigenous systems of medicine, in whom the bulk of the rural population have faith. In the Madhubani district, for instance, a survey made in Pandaul shows that there is at least one such practitioner per thousand population, many of whom are already administering drugs and giving injections from the modern systems of medicine. Registration of these practitioners is now compulsory in several states and a special strategy is being involved on how to knit them into the health organization. Similarly, more vigorous implementa- tion of the dai (local midwife) training programme is being made possible through approaches made by village panchayats, and at least two dais per village are being made available to assist the local health programmes. An alter- native scheme for training village level workers enrolled from among the local population is being taken up in selected areas, and they will in due course be able to take care of the community's minor ailments and arrange for quick referrals. These workers will be support- ed by the community in cash or kind, and their work will be supervised by the assistant nurse-midwives and multi- purpose health workers from the sub- centre. Reporting of vital statistics is expected to improve considerably. One more measure which can be ef- fected without much expenditure will help to take care of 10 per cent of the population. These are the private medi- cal dispensaries run by industrial units, missionary and other charitable organ- izations. Some attempts have already been made to entrust family planning work to them. If these dispensaries, esti- mated to number 10,000 throughout In- dia, could be made to look after 50,000 villages, they could take care of 10 per cent of the rural population. A great deal has been achieved, although much more remains to be accomplished. Nevertheless, whatever is possible in Madhubani is possible in every other district in India, since initia- tive and leadership are available in plenty throught the country. ■ 23 a link with the outside world The goal of Costa Rica's rural health programme— to reduce the mortality rate by 50 per cent in ten years—was very nearly reached in only three years BY HORST MAX CERNI V he northeastern part of Costa Rica—near the border with Nicaragua—offers a certain vacation charm to the traveller from the colder areas of the world : palm trees and other tropical vegetation, exotic flowers and birds, Brahman cattle in the lush meadows, flooded ditches and tropical downpours, and a wild river. For the scattered population living along the River San Carlos, these as- pects are part of daily life and the strug- gle against the forces of nature and iso- lation. Dona Maria Lara, mother of ten children, is widowed and her older children have left home to work on the cattle farms further up the river. Her eldest son, Jose Alejandro, comes once a month to see how his mother is doing and help fix up things about the house. Dorm Maria is trying her best to give her three smaller children a basis of good health. She has a small vegetable garden, papaya (paw-paw) grows on a tree near the house and she also has some chickens. Still, the children often suffer from diarrhoea and other sick- nesses. The nearest health post can only be reached by motor boat, and the jour- 24 ney involves a long ride upstream against the current. Since 1972 a regular link with the out- side world has been established and Dofia Maria is gratefully benefiting from it. Under the national programme of rural health, Dam Maria and her family are visited on an average once every three months by Health Assistant Marvin Carmona Chavez. Marvin, now 23 years old, finished his fifth year of secondary school and then took a train- ing course in basic health practices of- fered by the Ministry of Health under an agreement with the World Health Organization and UNICEF. Marvin want- ed to work in the rural areas, but he was also looking for something more excit- ing than just tending cattle or working in one of the sawmills. When a doctor from San Jose came to his High School in Quesada and explained the rural health programme, Marvin became in- terested and applied for the training course. After several tests, including vocational and psychological ones, Mar- vin was accepted and he signed a con- tract with the Ministry of Health to work for at least two years in any part of rural Costa Rica, once he finished the course. Should he resign from the ser- vice before completing two years, he would have to repay the full amount of the stipend offered by UNICEF for the training course. The reason for putting special empha- sis on rural health derives from the Government's recognition that 58 per cent of Costa Rica is rural and the rural population had received only very spo- radic medical attention, provided during occasional visits by mobile health teams. The great majority had no access to any type of health service before 1972. The Ministry of Health, therefore, proposed to amplify the coverage by establishing health centres and health posts and at- taching to each health post an auxiliary nurse and a health assistant, both of whom visit the families in the area. The auxiliary nurse is part of the pro- fessional medical establishment and is required by the School of Nursing to complete an 11 month course, which en- ables her to work in any hospital in Costa Rica. According to Dr Carlos En- rique Valerin, Director of the Rural Health Programme, this training is too The little motorboat carrying a health assis- tant across the River San Carlos represents a vital link with the outside world for this iso- lated community in Costa Rica. The young man brings the rural population not only practical medical care but also some degree of health education. The child objects to the immunization process, but health assistant Luis Francisco Gutierrez has explained its value to the mother. ( Photos UNICEF' H. Cerni) extensive and exceeds the needs of the rural health posts. "Besides, it is too costly", he adds, "and we are presently discussing with the Nursing School a revision of this training programme to adapt the curriculum more to the actual needs". The assistant receives a training of four months. Usually men are chosen for this job, since it involves travelling in difficult areas. Dr Valerin is in constant touch with the health centres and posts, not only because of the official reports he receives, but because he tries to visit most posts twice a year. "Through per- lavengene" - ;if'. Left: The health assistant and one of the aux- iliary nurses from a health post near the River San Carlos check on the makeshift but essen- tial clean water supply. Above: He is already a familiar face in this household, and his rou- tine check on the family's health is friendly and informal. ( Photos UNICEF/H. Cerni) sonal observations and discussions we can correct mistakes and adapt the pro- gramme to the practical needs. This was especially important during the first two years of the programme, when almost 20 per cent of the Health Assistants resigned. We had made the mistake of recruiting people who had previously worked in the malaria eradication pro- gramme and who had not necessarily the disposition or the interest to work in difficult rural areas. Our new admission tests have corrected this and we now take mostly rural people, who are in- terested in working for their people. Now fewer than two per cent leave the service before completing two years." Marvin has been working along the River San Carlos for one year now, serving the scattered family groupings as well as three major communities with a total of some 350 people. "Continuously for about two and a half weeks I make home visits with the help of the Tanga' (the UNICEF-provided motorboat), inter- viewing the families, taking their health records, examining the children and vac- cinating them", explains Marvin. "But in addition I find out what the mother cooks, how their water is, if they boil it, and if they have sanitary facilities and a clean toilet." This aspect of Marvin's work—educational conversations—often takes the form of larger community meetings, where the development com- mittee of the community organizes those activities which are needed to improve living conditions. The participation of the villagers is essential to make the best use of the help offered by the Ministry of Health—be it materials for latrines, supply of pipes and pumps for potable water supply, or medical equipment for a health post—if the community wants to build one. "When in 1972 we did a nationwide study of health problems in Costa Rica we found that the infant mortality rate of 65 per thousand was due mainly to the lack of health care in rural areas and that this rate could be reduced by estab- lishing rural health and vaccination pro- grammes", explains Dr Valerin. "The major mortality causes, such as diph- theria, tetanus, whooping cough, tuber- culosis, measles, and so on, can be fought with proper vaccinations. In ad- dition, the health auxiliary and assistant can keep a control on malaria and other diseases and refer the cases to the health centres or for special medical atten- tion." Naturally, most Costa Ricans in rural areas do not have the problem of isola- tion as the river communities do. Mar- vin, for instance, spends most of his time travelling by motorcycle to the other 15 communities of his sector, where he has to attend some 1000 families. One of his fellow health assistants, Luis Francisco Gutierrez, working in the health post of Florencia, has to at- tend to the needs of 14 communities with a total of almost 4000 inhabitants. While the auxiliary nurse, Mrs Emilce Cruz Artavia, deals with visitors to the 27 1 -, f .'..) li.r i -,.. a ,f et-, 1----, , ..! , i ‘.- i .,-, ,,z,3 y 1 . 1 r ., - - ,-, : . ., .,.., , ... . • . te , i .---,, ;t "'" if , -° ..'.'.... .. ,. ft, e 4 Orn '11741 q !Th r 1 Left: For a while the teacher takes a break while the health assistant tells the children about the value of hygiene and the importance of immunization. Above: Luis Francisco Gutierrez takes leave of the schoolchildren and continues his rounds, this time with the help of his UNICEF-supplied motorcycle. ( Photos UNICEF' H. Cerni) health post (about 550 during the last six months) and also calls on nearby families, Luis Francisco helps out in the post only on Friday afternoon and Saturday. The rest of the week he travels on the UNICEF-supplied motor- cycle to remote communities—visiting families, vaccinating children in schools, and helping to establish community development committees or assisting in their activities. "A very important aspect of our Rural Health Programme", explains Dr Valerin, "is first of all the emphasis on keeping good records because before, while many children got vaccinated, their mothers didn't remember when and against what. Secondly, we con- stantly supervise and evaluate the pro- gramme. Some health assistants, who have proved their abilities and interest, have been promoted to become supervi- sors of health posts. These are active supervisors, taking medicines and other supplies to the health posts and sharing their experiences with the assistants in improving their services." These health services are partly financed through the regular budget of the Ministry of Health, plus contribu- tions in the form of equipment and sti- pends from UNICEF and other interna- tional and bilateral sources. More recently a special "Social Development and Family Subsidy" programme has started, which benefits especially the school feeding programme and the sup- ply of potable water. The impact of this Rural Health Pro- gramme can best be seen by the interest the communities take in asking for more of these services and helping to improve existing facilities. "At present we work out of a private house with limited space and it is inconveniently located", says Luis Francisco. "But the community of Florencia is already clearing the land for the construction of a new health post in the centre of the town. In addition, the people are raising funds through dances and bazaars to buy additional medical supplies." The goal of the Rural Health Pro- gramme was to reduce the mortality rate by 50 per cent in ten years, but this goal was almost reached already within three years: from 65 per 1000 in 1971, the mortality rate in 1974 had fallen to only 37 per 1000. In the rural zones, specifi- cally, the success story is even more im- pressive. For example, in 1969 the dis- trict of San Carlos had an infant mortal- ity rate of 106 per thousand, while in 1974 this figure was reduced to 25.3— less than the national average. In addi- tion, while in 1965 almost 50 per cent of all deaths were of children under four years of age, this percentage dropped to 26.8 per cent in 1974, and the majority of these deaths occurred before the age of one. Deaths due to measles in 1969 amounted to 322 while in 1974 there were only 12 deaths. Diphtheria caused 19 deaths in 1969, and 22 were caused by poliomyelitis, but none was caused by these two diseases in 1974. These dramatic changes cannot solely be attributed to this programme, but better health services in rural areas, and the educational work of the health aux- iliary and assistant, have played a major part in improving and modernizing liv- ing conditions in rural Costa Rica. ■ 29 UNRWA in need UNRWA, the United Nations Relief and Works Agency for Palestine Refu- gees, has been in action since May 1950, bringing assistance to the refugees in the three fields of foodstuffs and upkeep of camps, general and technical education, and health services (in conjunction with WHO. At that time there were still a few cases of smallpox in Jordan and in the Gaza Strip, and malaria was endemic throughout the camps. Vigorous cam- paigns of vaccination and anti-insect vectors and malaria control ensured that typhus was eliminated from the camps by 1952 and smallpox in 1957. Cholera remained a more stubborn problem: there were 177 cases among the refugees in 1970 during a general epidemic in the Middle East, eight cases in 1972 and the same number in 1975. Since 1966 there have been only a few isolated cases of malaria. Maternal and child health constitutes an important aspect of UNRWA'S health activities, and the special health needs of pregnant women and new-born babies are catered for in 84 dispensaries run by the agency. The agency also has 21 spe- cial rehydration and nutrition centres, with 240 beds, for babies suffering from gastro-intestinal infections and conse- quent dehydration. Last year, these centres treated 1,917 infants. The budget of UNRWA depends entire- ly on voluntary donations, notably those from governments. Around 60 countries support the work of the UN for the Palestine refugees in the shape of money, material goods or services. These contributions have steadily in- creased year by year, but have been out- stripped by increases in costs, affected by inflation, the effective devaluation of the dollar and the pound, and the steady rise in schooling costs. Between 1950 and 1967, the annual budget of UNRWA slowly increased from about 30 to about 40 million dollars. In 1972 it exceeded 50 millions, nearly reached 86 millions in 1974 and stood at 121.5 million dollars in 1975. The estimated budget for 1976 was 129 million dollars, of which 15 millions are allocated to health services. Conse- quently, by early August this year, the agency's deficit had risen to 31 million dollars. Since there are no available reserves and unless substantial contribu- tions are received very soon, the agency could face the possibility of ceasing its activities in the course of the current year. Such a step would not only involve the cessation of food distribution, which ensures a basic subsistence for about half of the registered total of refugees, and the closure of schools where some 9,000 teachers are in charge of around 300,000 Palestinian boys and girls; it would also put an abrupt end to health services which for over a quarter of a century have protected an uprooted population. The repercussions that all this would inevitably have in the coun- tries of the Middle East—already severely affected by the Lebanese tragedy—would be incalculable. safe use of pesticides Accidental poisoning of humans from pesticides nearly always results from im- proper use and failure to follow precau- tions, according to the First WHO Regional Seminar on the Safe Use of Pesticides which took place recently in Manila. The Seminar, which was op- ened by Dr Francisco J. Dy, WHO Regional Director for the Western Pacific, concluded that, from the health point of view, an outright ban on pesti- cides was not the answer. In his opening address, Dr Dy said there had been comparatively little dis- cussion of this subject in that Region. He went on: "The dramatic benefits of Palestine refugee children tuck into a meal in a Middle East camp. For over a quarter of a century, UNRWA has guaranteed a proper food supply for most of the region's displaced populations. (Photos UNRWA/M. Nasr) 30 chemical pesticides in increasing food production and improving human health have been well publicized over the years. But recently concern has been expressed over the harmful effects these substances may have on man and his environment, and a number of pro- posals have been made for effective safe- guards." He emphasized that wHo had long been promoting the safe use of pesti- cides, generally in response to the ex- pressed wishes of Member Govern- ments. He mentioned the February 1975 pesticide management workshop orga- nized for Philippines workers in Manila under the Bureau of Plant Industry and the University of California/usmo pest management project. Seminar Director Dr J. Copplestone, from the Division of Vector Biology and Control at wHo headquarters in Gene- va, said the number of pesticide poison- ing cases in the world was "substantial", amounting to 2.5 to 5 per cent of all accidental poisoning cases. It has been estimated that 500,000 cases of acute accidental poisoning from pesticides occurred in the world every year, resulting in more than 9,000 deaths per annum. Dr A. V. Adam, Pesticides Officer at the Rome headquarters of the Food and Agriculture Organization (FAO), told the seminar that official control regulations constitute a first step toward ensuring safety, regardless of whether a country has the facilities to monitor these con- trols. The mere existence of regulations could have a distinctly beneficial effect in reducing the improper use of pesti- cides. Sloppy or inefficient application of these chemicals may result in poison- ing and other problems, he said. During the three-year period from 1971 to 1973, the rate of increase in the use of pesticides was highest in Asia, reaching 35 per cent. However, the sub- _ A Japanese farmer sprays his fruit-trees. Pes- ticides are invaluable for food-producers — provided the users take due health precau- tions. (Photo WHO/T. Takahara) sequent energy crisis resulted in a dras- tic cutback in the increase rate, from 35 per cent to 8 per cent between 1974 and 1976. Stressing the relationship between reducing pesticide use and harming a country's harvest potential, Dr Adam said that this cutback in the usage of such chemicals was followed by losses estimated at between 30 and 50 per cent in the potential crop yield in Asia. Twenty-two participants and ob- servers from the health and agriculture departments of 15 countries and areas attended the week-long seminar. investing in health "Productivity in a population which is not healthy is low", warned Dr V.T.H. Gunaratne, WHO Regional Director for South-East Asia, in his Annual Report presented to the 29th Session of the wHo Regional Committee at Srinagar, India, in September. Dr Gunaratne went on: "Similarly there can be no health and well-being in a static economy. Therefore I fervently appeal to the governments of our Mem- ber countries to consider seriously the urgent need for adequate investment in health as an important component of socio-economic development. Failure to so invest is bound to perpetuate ill health and retard productivity and eco- nomic progress." In order to solve the problems of the still under-served millions of people in countries of the Region, attitudes to health development must undergo a change. Dr Gunaratne said in his report: "We must develop down-to- earth, broad action programmes, rather than isolated projects, to meet basic health needs within the limits of avail- able resources..." He added that there was also "an urgent need to apply mod- ern management methods and scientific techniques of planning Furthermore, in many cases, health programmes should not only be for the people but also of the people and by the people." The report confirmed an unprecedent- ed success—the elimination of smallpox from the South-East Asia Region; Ban- gladesh, India and Nepal became small- pox-free during the past year. Unfortu- nately, in other fields the health picture in the Region was far from encouraging. Malaria, for example, continued to show an upward trend and estimated deaths from this disease in 1975, though still low, were almost double those of 1970. ■ Authors of the month RUTH SEITZ is a freelance journalist based in Nairobi. Dr DONALD GOULD, himself a Lon- don-trained physician, is a leading medical journalist and writes regular- ly for a number of specialist and non- specialist publications. Professor KERR L. WHITE is Professor of Health Care Organization at the Johns Hopkins University, Baltimore, Maryland, and Chairman of the WHO/ International Collaborative Study of Medical Care Utilization. Mr P.K.J. MENON was until his retire- ment in 1974 Chief Secretary to the Government of Bihar State, India. Earlier, as Secretary to the Indian Government's Department of Person- nel, he was responsible for recruit- ment, promotion and morale of most of the All India and Central Services. Mr HORST MAX CERNI iS UNICEF'S Regional Information Officer for the Americas. 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