Health for all-all for health 1 9 4 8 O~GAN!S ... TIOI'I MONOJME ot l A. SA"'lt 46); 1 9 8 8 On Thursday, 7 April 1988, the member countries of wHo will mark the 40th anniver- sary of their Organization. The outstanding public health achievement of the past four decades was undoubtedly the eradication of smallpox . Now the international effort that made that achievement possible must be harnessed to bring about Health for all by the year 2000. While governments demonstrate their political will to improve health and thus improve development, every individual and every communi- ty must also take responsibility for health. This is why wHo has chosen as the slogan for this year's World Health Day: Health for all-all for health. On these pages and the succeeding ones, we highlight just a few examples of the activities undertaken by wHo programmes. On the island of Pemba, off the coast ~ of Tanzania, bloody urine means Schistosoma haematobium infection, and it affects more than half of its 280,000 inhabitants. WHO's Parasitic Diseases Programme, with the Ita- lian Department of Cooperation and the Pharma Fund of the Federal Re- public of Germany, is helping to con- trol this disease. In September 1986, over 40 per cent of children in 34 of its 57 schools had bloody urine speci- mens, and were given a single oral dose of praziquantel, a safe curative drug in schistosomiasis. Six months later, in only seven schools were more than 40 per cent of urine speci- mens found to have blood . Parasitic Diseases Programme (POP) The diarrhoea! diseases continue ~ to take a toll of some four million deaths each year in children aged under five in the developing world. The major advance in controlling them in recent times has been the development of oral rehydration therapy, and especially of Oral Re- hydration Salts (ORS). This pro- vides a simple tool that mothers themselves can use to prevent dehydration if their chil- dren develop diarrhoea. Latest W HO estimates indicate that, by the end of 1985, at least 51 per cent of the total population of the developing countries had access to ORS, and at least 18 per cent of diarrhoea! episodes in children under five were actually treated with ORS. This treatment may have prevented as many as half a million deaths from diarrhoea in 1985. Diarrhoea! Diseases Control (COD) 16 ... A simple eight-page recognition card is now being used by community health and other workers to prevent and control nutritional blindness (above) . lt was developed by W HO in collaboration with the International Center of Epidemiologic and Preventive Ophthalmology at Johns Hopkins University in the USA, Helen Keller International, and UNICEF . The card is div- ided into what to look for when examining chil- dren and questioning their mothers, and how to act and what to advise when eye problems are detected . Its universal usefulness has been greatly enhanced by the distribution of dupli- cate sets of film containing the master illustra- ~ tions. Interested health authorities and non- ~ governmental organizations are then free to ~ reproduce the cards and insert the accompany- ~ ing text in the appropriate language. s Nutrition unit (NUT) Simple means for ensuring safe drinking-water in rural com- munities are essential in many developing countries . WHO's Guidelines for Drinking-Water Quality help such communities to maintain regular surveillance of wells, boreholes and tradi- tional water sources, and to undertake sanitary inspection, sampling and bacteriological testing. Field kits have been de- signed expressly for this purpose. Three pilot and demonstra- j? tion projects are now operational in Indonesia, Peru and Zam- s bia, and their results confirm high contamination levels. They will be followed up by technical measures to remedy the situa- tion and to improve T drinking-water quali- ty through new filter techniques, simple chlorinators, and so on. But their effec- tiveness will rely heavily in the future on community par- ticipation. Community Water Supply and Sanita- tion unit (CWS) W oRLD HEALTH , Jan ./Feb. 1988 (V E E 0 (f) ~ 0 I s ""' "' "' .'!2 :::i 0 I s ... Fifty years ago, the endemic treponematoses which in- clude yaws, pinta and bejel were rampant among children in the tropics and sub-tropics. Some 60 million people suf- fered from these disfiguring and crippling infections. WHO developed a novel approach to control these diseases, using a single shot of long-acting penicillin; 46 countries started mass treatment campaigns during the 1950s and 1960s, in close collaboration with wHo and UNICEF. Not less than 50 million cases received injection treatment, and the diseases were eliminated from many areas. For many communities these campaigns were an impressive first encounter with modern medicine, and therefore a spearhead for future rural health development. Programme of Sexually Transmitted Diseases (VDT) ~ Changes in programme strategy during the campaign to eradicate smallpox bet- ween 1967 and 1979, and a new, more potent vaccine, called for a new concept of vaccine application. lt took the form of an effective and cheap " bifurcated " needle for delivering the vaccine. lt was so simple to use that a local villager could in only ten minutes be trained to perform vaccination effectively, and it used far less of the precious vaccine. The quick transfer of this appropriate technology to all countries still affected contributed significantly to the final success. Ten years have now elapsed since the world saw its last case of endemic smallpox. t::: 0 I 3: Smallpox Eradication Programme (SME) In its first ten years, the Tropical Diseases Research pro- gramme has recruited into its worldwide network scientists of the highest calibre, whose work is already bearing fruit in the form of vaccines, drugs, diagnostic tests and other disease control tools. Many scientists in tropical countries are being trained, through TOR-supported activities, to parti- cipate in this global partnership. As these new tools emerge from basic research, they need to be put to the test of reality in the field, to assess their T work in social and economic terms as well as their effectiveness in checking the spread of diseases, in epidemiological validation and in social and economic assessment. Much remains to be done before a powerful and adequate armament- arium exists against the main tropi- cal diseases. But exciting progress is being made. uNoP/ World Bank/wHo Special Pro- gramme for Research and Training in Tropical Diseases (TOR) Signposts to Health tor All 18 51 First International Sanitary Confer-ence, Paris 1902 1923 1946 International Sanitary Bureau crea- ted - later the Pan American Sanitary Bureau Constitution of the Health Organiza- tion of the League of Nations First meeting of the Interim Com- mission of the World Health Organ- ization 1948 7 April : Consti-tution of WHO comes into being . Later, 1st World Health Assem- bly names Dr Brock Chisholm as f irst Director- General 1949 2nd Assembly confirms that Pan American Sanitary Bureau will act as WHO's regional office of the Americas 1953 Dr Marcolino Candau suc- ceeds Dr Chisholm as second Director-General 1966 Opening of WHO's C US - tom-built headquarters in Geneva, Switzerland Start of intensified campaign for smallpox eradication Dr Halfdan Mahler succeeds Dr Can- dau as th ird Director-General 1967 1973 1977 30th Assembly adopts as tar- get Health for all by the Year 2000. Last ever case of endemic smallpox located in Somalia 1978 Declaration of Alma-Ata, at WHO/UNICEF conference on primary health care 1979 1986 1988 Independent commission confirms the global eradication of smallpox Seventh report on the world health situation assesses progress made towards Health for All WHO's 40th anniversary. World Health Day slogan chosen for this occasion : Health for all-all for health 0 I 3: "' 9 0 .r:. a. Health for all- In order to achieve international agreement .,.. on just what constitutes nutritious and safe food , and thus to facilitate international trade in food , WHO jointly with FAO estab- lished in 1963 the Food Standards Programme. This programme is put into practice by the Codex Alimentarius Commission, which now has a membership of 130 countries. Among other things , the programme has developed almost 200 inter- national standards for individual food com- modities , including provisions for safe le- vels of food additives , maximum limits for pesticide residues and a wide range of che- mical compounds in many foods , and gui- delines for food labelling. And besides a Code of General Principles of Food Hy- giene, it has drawn up a Code of Ethics for International Trade in Food. Food Safety programme (FOS) ..,.. Acute respiratory infections continue to be a major cause of death among children in the developing countries and to place a heavy burden on the health services . A few years ago , WHO questioned the widespread indifference to this problem , and saw that child survival efforts would be incomplete unless they found solutions to it. Once it was determined that bacterial pneumonia was the major culprit for ARI deaths in children , WHO was able to develop and test a very simple clinical protocol which allows the communi- ty health worker to recognise and treat the one case of pneumonia that occurs for every 100 children with mild ARI. Its effectiveness in reducing mortality has been demonstrated in India , Nepal , Pakistan , Papua New Guinea , and Tanzania. Tuberculosis and Respiratory Infections programme (TRI) Devise a tuberculosis programme for developing countries : over half the population is infected , millions are dying each year and there are almost no resources . A WHO team was given these terms of reference in the 1950s, and realised that tackling the problem meant making diagnosis and treatment accessible to all , all the time. Turning its back on the classical specialised approach , the team worked out a technology that could be applied by commun- ity health workers , anywhere. This control strategy has become implemented widely, in rich countries as well as poor ones. Mor- {l tality has come down and tuberculosis has sta~ted to go away , 1 slowly but surely. A remarkable precursor of pnmary health care b3 and Health for All? That is not unlikely ; the leader of the WHO a team was a young medical officer by the name of Halfdan Mahler. I s Tuberculosis and Respiratory Infections programme (TRI) Since the beginning of the International Drink- .,.. ' .. ing Water Supply and Sanitation Decade (1981- ~- 1989), WHO has actively promoted the involve- ment of communities in water supply and ~ sanitation projects. The wHo methodology , call- ed Community Partnership Approach , starts by sensitising communities and involving them in the decision-making process, including the choice of appropriate technology , long before the physical work begins . This awareness cam- paign, linked with hygiene education , continues through the construction period and-most im- portant-for many years after the facilities have been built. Although it is too early to talk about outright success , indications are that the Com- munity Partnership Approach will lead to much better maintenance of handpumps and latrines and safer use of drinking water. > <f) "' E <( a.: 0 ' I s "' ~ 0 I Division of Environmental Health (EHE) -. ·- s 18 WHO has been at pains to make health leaders , health professionals and the ge- neral public aware of the importance of psychosocial factors in fostering econo- mic development , well-being and the quality of life. It also underlines that most so-called physical diseases, parti- cularly the major killers both in develo- ping and developed countries, could be prevented through improved life-styles. One of the positive steps pioneered by WHO's Mental Health Division has been to develop the technology to prevent and treat mental, neurological and psy- chosocial disorders (including those re- lated to drug and alcohol abuse) within the setting of primary health care. Division of Mental Health (MNH) W ORLD HEALTH, Jan ./Feb. 1988 -all for health ~ WHO's work on traditional birth attendants (TBAs) has demonstrated that " uneducated " people have the capacity to carry out a whole range of appropriate technologies if they are given the stimulus , the training, the incentives and the confidence to do so. Prior to the Orga- nization's catalytic and promotional activities , these useful health workers were ignored , mali- gned and even considered dangerous. Today TBAs form a great local manpower resource for carrying out selected primary health care servi- ces in countries where they abound. Nursing unit (NUR) Drug abuse is increasing at an ~ alarming rate all around the world . Many different sectors are working together to combat this menace-police , customs, educa- tion and health. What the health sector can offer is much more than just specialist treatment. WHO has produced a simple manual which shows how health workers can mobilise the collective will of the community to prevent the spread of drugs. The manual is already helping parents and youth organi- zations to join forces with health workers to promote drug-free life- styles. Division of Mental Health (MNH) WHO/Zafar <11111 Some people think teachers are born and cannot be trained. Of course , talent is needed to make a good teacher but even talented people have to learn their trade (less talented people should learn even harder). WHO launched a world-wide teacher training pro- gramme for health personnel schools almost two de- cades ago. Its aim was to help teachers to learn how to help adults in their turn to learn what they need to know to become competent health workers. When the programme started very few countries in the world were able to train teachers of health personnel , but even there the need was hardly recognised. Now most countries realise that need and many of them have developed the capacity to meet it. Division of Health Manpower Development (HMD) Health Learning Materials projects are already help- ing 21 countries to make important progress towards self-reliance. Developing countries in particular re- ceive technical guidance on how to produce their own teaching and learning materials for primary health care personnel. With WHO's cooperation , such train- ing materials as reference manuals , teacher guides and visual aids are developed by national staff, using local skills and resources. Community participation ensures their relevance to local health needs and con- ditions. Inter-country and inter-regional networks promote an exchange of materials and expertise in a very practical example of technical cooperation among developing countries. Health Learning Materials programme (HLM) 19 .0 ro 3: .s::: u (/) w 0 I s Health for all- ...,.. Insecticide resistance among insects that spread disease first appeared in 1947. One method of countering it is biological control , involving the use of predators , parasites or pathogens. A major breakthrough was achieved with the discovery and development of Bacillus thuringiensis H-14 to control the blackflies (Simulium) that transmit onchocer- ciasis (river blindness) . This bacillus is also used on a large scale for mosquito control in some countries with temperate climates. Fish that eat insect larvae have been used for mos- quito control since at least the nineteenth century. WHO has drawn up comprehensive guidelines on the screening and development of these fish , preferring indigenous species to exotic species which may have an adverse ecological impact. Division of Vector Biology and Control (VBC) Dapsone, the first effective drug against leprosy, was ~ introduced in the 1940s. But treatment lasted for years , so a WHO Study Group looked for multi-drug therapy that would stop the increasing occurrence of resistance by the leprosy bacillus to individual drugs , cure the pa- tient and control the spread of the disease. The com- bined therapy recommended by the Study Group in 1981 is of shorter duration and therefore more attractive to patients . Consequently more patients voluntarily report for treatment while still showing only initial signs of the disease. This prevents the appearance of deformities and disabilities, and the community's acceptance of and assistance for leprosy sufferers increases. More than 1.2 million patients have been so treated and , for the first time in the history of leprosy statistics , the number of registered cases is declining. Over the next 10 years this reduction will reach at least 50 per cent of the current 5 million registered patients. Leprosy unit (LEP) W HO/Zafar ...,.. As a result of over ten years' research on fox ecology involving 15 laboratories in 10 countries , rabies control in wildlife has become a reality in European countries. For the first time in his- tory , man has averted an epidemic in nature by using well- adapted baits to bring about oral vaccination of wild animals. At the same time the work of three Collaborating Centres has pa- ved the way for future rabies control in developing countries . Firstly , an attenuated rabies strain was shown to immunize dogs and jackals by the oral route. Secondly, a simple procedure and kit enable animal brain specimens to be shipped for laboratory diagnosis. Thirdly , a collaborative study by six European and North American laboratories on a new enzyme immuno-assay permits rapid case diagnosis without a microscope. Veterinary Public Health (VPH) Over the past ten years , the Malaria Action Programme, to- gether with TDR, has jointly developed , standardised and vali- dated test kits to assess the response of the malaria parasite Plasmodium falciparum to various drugs. These test kits have become an important tool throughout the world, and as from last year can be applied to all major anti-malarial drugs. Production is now entirely in the hands of an institution in the Philippines , and has become a self-sustained, national non-profit operation . Independent quality control is being ensured by an institution in the United States. Malaria Action Programme (MAP) W oRLD HEALTH , Jan ./Feb. 1988 .0 "' 3: £ u (}) w 0 I s -all for health <11111 Besides warning that "cancer is a Third World problem too," WHO is telling the world that enough knowledge exists to prevent one third of all cancers, to cure one third provided they are detected early and offered adequate therapy, and to provide freedom from cancer pain. Many types of cancers can be prevented, and this concept revolutionises national approaches to controlling them. This is particularly true regarding tobacco-related lung cancer, which takes a heavy toll in industrialised countries. Indeed cancer is now being considered as a new communicable disease-communicable through the rapid proliferation of unhealthy life-styles. Meanwhile WHO is showing that freedom from cancer pain is possible. An approach has been tested and published by WHO in more than 10 languages which describes a relatively simple and inex- pensive method to solve this neglected public health problem . In 1977, WHO started a peaceful revolution in..,. international public health. It asked a group of experts which drugs-among tens of thou- sands available on the market-were really necessary to take care of most health pro- blems. The experts concluded that about 200 drugs and vaccines could be considered es- sential in good medical practice. Most were no longer protected by patents rights and could be mass-produced at a reasonable cost. The list has been revised four times since 1977, but still stands at about 250 essential drugs and vaccines. More than 100 govern- ments in the Third World have adapted the model list to their requirements, as have many non-governmental organizations and other UN agencies. Action Programme on Essential Drugs (DAP) Cancer unit (CAN) <11111 The " cold chain" is the lifeline of WHO's Expanded Pro- gramme on Immunization, ensuring that potent vaccine ar- rives at the right place, at the right time and in sufficient quantity. Temperature sensitive monitors indicate whether the shipment is exposed to too much heat. The cold chain includes kerosene-driven refrigerators to keep the vaccines cool, and ice-boxes enable health workers to carry the pre- cious contents to where they are needed. Immunization against the main diseases of childhood is ensuring "a chance for every child." Expanded Programme on Immunization (EPI) "The goals of health for all Manilans can only be achieved through a partnership between the communities and the health care delivery system." wHo-supported projects in the Philippines capital show conclusively that health attitu- des and practices of the community have improved since primary health care was introduced. People cooperate with one another and with the health centre, and participate in activities for their own benefit. As a result of intensified education, immunization coverage of infants and children rose from 44 per cent to 96 per cent. Environmental sanita- tion in the area has improved and the community is more aware of the danger of insect- and vermin-carried diseases. Division of Strengthening of Health Services (SUS) 21
Health for all-all for health 1 9 4 8 O~GAN!S ... TIOI'I MONOJME ot l A. SA"'lt 46); 1 9 8 8 On Thursday, 7 April 1988, the member countries of wHo will mark the 40th anniver- sary of their Organization. The outstanding public health achievement of the past four decades was undoubtedly the eradication of smallpox . Now the international effort that made that achievement possible must be harnessed to bring about Health for all by the year 2000. While governments demonstrate their political will to improve health and thus improve development, every individual and every communi- ty must also take responsibility for health. This is why wHo has chosen as the slogan for this year's World Health Day: Health for all-all for health. On these pages and the succeeding ones, we highlight just a few examples of the activities undertaken by wHo programmes. On the island of Pemba, off the coast ~ of Tanzania, bloody urine means Schistosoma haematobium infection, and it affects more than half of its 280,000 inhabitants. WHO's Parasitic Diseases Programme, with the Ita- lian Department of Cooperation and the Pharma Fund of the Federal Re- public of Germany, is helping to con- trol this disease. In September 1986, over 40 per cent of children in 34 of its 57 schools had bloody urine speci- mens, and were given a single oral dose of praziquantel, a safe curative drug in schistosomiasis. Six months later, in only seven schools were more than 40 per cent of urine speci- mens found to have blood . Parasitic Diseases Programme (POP) The diarrhoea! diseases continue ~ to take a toll of some four million deaths each year in children aged under five in the developing world. The major advance in controlling them in recent times has been the development of oral rehydration therapy, and especially of Oral Re- hydration Salts (ORS). This pro- vides a simple tool that mothers themselves can use to prevent dehydration if their chil- dren develop diarrhoea. Latest W HO estimates indicate that, by the end of 1985, at least 51 per cent of the total population of the developing countries had access to ORS, and at least 18 per cent of diarrhoea! episodes in children under five were actually treated with ORS. This treatment may have prevented as many as half a million deaths from diarrhoea in 1985. Diarrhoea! Diseases Control (COD) 16 ... A simple eight-page recognition card is now being used by community health and other workers to prevent and control nutritional blindness (above) . lt was developed by W HO in collaboration with the International Center of Epidemiologic and Preventive Ophthalmology at Johns Hopkins University in the USA, Helen Keller International, and UNICEF . The card is div- ided into what to look for when examining chil- dren and questioning their mothers, and how to act and what to advise when eye problems are detected . Its universal usefulness has been greatly enhanced by the distribution of dupli- cate sets of film containing the master illustra- ~ tions. Interested health authorities and non- ~ governmental organizations are then free to ~ reproduce the cards and insert the accompany- ~ ing text in the appropriate language. s Nutrition unit (NUT) Simple means for ensuring safe drinking-water in rural com- munities are essential in many developing countries . WHO's Guidelines for Drinking-Water Quality help such communities to maintain regular surveillance of wells, boreholes and tradi- tional water sources, and to undertake sanitary inspection, sampling and bacteriological testing. Field kits have been de- signed expressly for this purpose. Three pilot and demonstra- j? tion projects are now operational in Indonesia, Peru and Zam- s bia, and their results confirm high contamination levels. They will be followed up by technical measures to remedy the situa- tion and to improve T drinking-water quali- ty through new filter techniques, simple chlorinators, and so on. But their effec- tiveness will rely heavily in the future on community par- ticipation. Community Water Supply and Sanita- tion unit (CWS) W oRLD HEALTH , Jan ./Feb. 1988 (V E E 0 (f) ~ 0 I s ""' "' "' .'!2 :::i 0 I s ... Fifty years ago, the endemic treponematoses which in- clude yaws, pinta and bejel were rampant among children in the tropics and sub-tropics. Some 60 million people suf- fered from these disfiguring and crippling infections. WHO developed a novel approach to control these diseases, using a single shot of long-acting penicillin; 46 countries started mass treatment campaigns during the 1950s and 1960s, in close collaboration with wHo and UNICEF. Not less than 50 million cases received injection treatment, and the diseases were eliminated from many areas. For many communities these campaigns were an impressive first encounter with modern medicine, and therefore a spearhead for future rural health development. Programme of Sexually Transmitted Diseases (VDT) ~ Changes in programme strategy during the campaign to eradicate smallpox bet- ween 1967 and 1979, and a new, more potent vaccine, called for a new concept of vaccine application. lt took the form of an effective and cheap " bifurcated " needle for delivering the vaccine. lt was so simple to use that a local villager could in only ten minutes be trained to perform vaccination effectively, and it used far less of the precious vaccine. The quick transfer of this appropriate technology to all countries still affected contributed significantly to the final success. Ten years have now elapsed since the world saw its last case of endemic smallpox. t::: 0 I 3: Smallpox Eradication Programme (SME) In its first ten years, the Tropical Diseases Research pro- gramme has recruited into its worldwide network scientists of the highest calibre, whose work is already bearing fruit in the form of vaccines, drugs, diagnostic tests and other disease control tools. Many scientists in tropical countries are being trained, through TOR-supported activities, to parti- cipate in this global partnership. As these new tools emerge from basic research, they need to be put to the test of reality in the field, to assess their T work in social and economic terms as well as their effectiveness in checking the spread of diseases, in epidemiological validation and in social and economic assessment. Much remains to be done before a powerful and adequate armament- arium exists against the main tropi- cal diseases. But exciting progress is being made. uNoP/ World Bank/wHo Special Pro- gramme for Research and Training in Tropical Diseases (TOR) Signposts to Health tor All 18 51 First International Sanitary Confer-ence, Paris 1902 1923 1946 International Sanitary Bureau crea- ted - later the Pan American Sanitary Bureau Constitution of the Health Organiza- tion of the League of Nations First meeting of the Interim Com- mission of the World Health Organ- ization 1948 7 April : Consti-tution of WHO comes into being . Later, 1st World Health Assem- bly names Dr Brock Chisholm as f irst Director- General 1949 2nd Assembly confirms that Pan American Sanitary Bureau will act as WHO's regional office of the Americas 1953 Dr Marcolino Candau suc- ceeds Dr Chisholm as second Director-General 1966 Opening of WHO's C US - tom-built headquarters in Geneva, Switzerland Start of intensified campaign for smallpox eradication Dr Halfdan Mahler succeeds Dr Can- dau as th ird Director-General 1967 1973 1977 30th Assembly adopts as tar- get Health for all by the Year 2000. Last ever case of endemic smallpox located in Somalia 1978 Declaration of Alma-Ata, at WHO/UNICEF conference on primary health care 1979 1986 1988 Independent commission confirms the global eradication of smallpox Seventh report on the world health situation assesses progress made towards Health for All WHO's 40th anniversary. World Health Day slogan chosen for this occasion : Health for all-all for health 0 I 3: "' 9 0 .r:. a. Health for all- In order to achieve international agreement .,.. on just what constitutes nutritious and safe food , and thus to facilitate international trade in food , WHO jointly with FAO estab- lished in 1963 the Food Standards Programme. This programme is put into practice by the Codex Alimentarius Commission, which now has a membership of 130 countries. Among other things , the programme has developed almost 200 inter- national standards for individual food com- modities , including provisions for safe le- vels of food additives , maximum limits for pesticide residues and a wide range of che- mical compounds in many foods , and gui- delines for food labelling. And besides a Code of General Principles of Food Hy- giene, it has drawn up a Code of Ethics for International Trade in Food. Food Safety programme (FOS) ..,.. Acute respiratory infections continue to be a major cause of death among children in the developing countries and to place a heavy burden on the health services . A few years ago , WHO questioned the widespread indifference to this problem , and saw that child survival efforts would be incomplete unless they found solutions to it. Once it was determined that bacterial pneumonia was the major culprit for ARI deaths in children , WHO was able to develop and test a very simple clinical protocol which allows the communi- ty health worker to recognise and treat the one case of pneumonia that occurs for every 100 children with mild ARI. Its effectiveness in reducing mortality has been demonstrated in India , Nepal , Pakistan , Papua New Guinea , and Tanzania. Tuberculosis and Respiratory Infections programme (TRI) Devise a tuberculosis programme for developing countries : over half the population is infected , millions are dying each year and there are almost no resources . A WHO team was given these terms of reference in the 1950s, and realised that tackling the problem meant making diagnosis and treatment accessible to all , all the time. Turning its back on the classical specialised approach , the team worked out a technology that could be applied by commun- ity health workers , anywhere. This control strategy has become implemented widely, in rich countries as well as poor ones. Mor- {l tality has come down and tuberculosis has sta~ted to go away , 1 slowly but surely. A remarkable precursor of pnmary health care b3 and Health for All? That is not unlikely ; the leader of the WHO a team was a young medical officer by the name of Halfdan Mahler. I s Tuberculosis and Respiratory Infections programme (TRI) Since the beginning of the International Drink- .,.. ' .. ing Water Supply and Sanitation Decade (1981- ~- 1989), WHO has actively promoted the involve- ment of communities in water supply and ~ sanitation projects. The wHo methodology , call- ed Community Partnership Approach , starts by sensitising communities and involving them in the decision-making process, including the choice of appropriate technology , long before the physical work begins . This awareness cam- paign, linked with hygiene education , continues through the construction period and-most im- portant-for many years after the facilities have been built. Although it is too early to talk about outright success , indications are that the Com- munity Partnership Approach will lead to much better maintenance of handpumps and latrines and safer use of drinking water. > <f) "' E <( a.: 0 ' I s "' ~ 0 I Division of Environmental Health (EHE) -. ·- s 18 WHO has been at pains to make health leaders , health professionals and the ge- neral public aware of the importance of psychosocial factors in fostering econo- mic development , well-being and the quality of life. It also underlines that most so-called physical diseases, parti- cularly the major killers both in develo- ping and developed countries, could be prevented through improved life-styles. One of the positive steps pioneered by WHO's Mental Health Division has been to develop the technology to prevent and treat mental, neurological and psy- chosocial disorders (including those re- lated to drug and alcohol abuse) within the setting of primary health care. Division of Mental Health (MNH) W ORLD HEALTH, Jan ./Feb. 1988 -all for health ~ WHO's work on traditional birth attendants (TBAs) has demonstrated that " uneducated " people have the capacity to carry out a whole range of appropriate technologies if they are given the stimulus , the training, the incentives and the confidence to do so. Prior to the Orga- nization's catalytic and promotional activities , these useful health workers were ignored , mali- gned and even considered dangerous. Today TBAs form a great local manpower resource for carrying out selected primary health care servi- ces in countries where they abound. Nursing unit (NUR) Drug abuse is increasing at an ~ alarming rate all around the world . Many different sectors are working together to combat this menace-police , customs, educa- tion and health. What the health sector can offer is much more than just specialist treatment. WHO has produced a simple manual which shows how health workers can mobilise the collective will of the community to prevent the spread of drugs. The manual is already helping parents and youth organi- zations to join forces with health workers to promote drug-free life- styles. Division of Mental Health (MNH) WHO/Zafar <11111 Some people think teachers are born and cannot be trained. Of course , talent is needed to make a good teacher but even talented people have to learn their trade (less talented people should learn even harder). WHO launched a world-wide teacher training pro- gramme for health personnel schools almost two de- cades ago. Its aim was to help teachers to learn how to help adults in their turn to learn what they need to know to become competent health workers. When the programme started very few countries in the world were able to train teachers of health personnel , but even there the need was hardly recognised. Now most countries realise that need and many of them have developed the capacity to meet it. Division of Health Manpower Development (HMD) Health Learning Materials projects are already help- ing 21 countries to make important progress towards self-reliance. Developing countries in particular re- ceive technical guidance on how to produce their own teaching and learning materials for primary health care personnel. With WHO's cooperation , such train- ing materials as reference manuals , teacher guides and visual aids are developed by national staff, using local skills and resources. Community participation ensures their relevance to local health needs and con- ditions. Inter-country and inter-regional networks promote an exchange of materials and expertise in a very practical example of technical cooperation among developing countries. Health Learning Materials programme (HLM) 19 .0 ro 3: .s::: u (/) w 0 I s Health for all- ...,.. Insecticide resistance among insects that spread disease first appeared in 1947. One method of countering it is biological control , involving the use of predators , parasites or pathogens. A major breakthrough was achieved with the discovery and development of Bacillus thuringiensis H-14 to control the blackflies (Simulium) that transmit onchocer- ciasis (river blindness) . This bacillus is also used on a large scale for mosquito control in some countries with temperate climates. Fish that eat insect larvae have been used for mos- quito control since at least the nineteenth century. WHO has drawn up comprehensive guidelines on the screening and development of these fish , preferring indigenous species to exotic species which may have an adverse ecological impact. Division of Vector Biology and Control (VBC) Dapsone, the first effective drug against leprosy, was ~ introduced in the 1940s. But treatment lasted for years , so a WHO Study Group looked for multi-drug therapy that would stop the increasing occurrence of resistance by the leprosy bacillus to individual drugs , cure the pa- tient and control the spread of the disease. The com- bined therapy recommended by the Study Group in 1981 is of shorter duration and therefore more attractive to patients . Consequently more patients voluntarily report for treatment while still showing only initial signs of the disease. This prevents the appearance of deformities and disabilities, and the community's acceptance of and assistance for leprosy sufferers increases. More than 1.2 million patients have been so treated and , for the first time in the history of leprosy statistics , the number of registered cases is declining. Over the next 10 years this reduction will reach at least 50 per cent of the current 5 million registered patients. Leprosy unit (LEP) W HO/Zafar ...,.. As a result of over ten years' research on fox ecology involving 15 laboratories in 10 countries , rabies control in wildlife has become a reality in European countries. For the first time in his- tory , man has averted an epidemic in nature by using well- adapted baits to bring about oral vaccination of wild animals. At the same time the work of three Collaborating Centres has pa- ved the way for future rabies control in developing countries . Firstly , an attenuated rabies strain was shown to immunize dogs and jackals by the oral route. Secondly, a simple procedure and kit enable animal brain specimens to be shipped for laboratory diagnosis. Thirdly , a collaborative study by six European and North American laboratories on a new enzyme immuno-assay permits rapid case diagnosis without a microscope. Veterinary Public Health (VPH) Over the past ten years , the Malaria Action Programme, to- gether with TDR, has jointly developed , standardised and vali- dated test kits to assess the response of the malaria parasite Plasmodium falciparum to various drugs. These test kits have become an important tool throughout the world, and as from last year can be applied to all major anti-malarial drugs. Production is now entirely in the hands of an institution in the Philippines , and has become a self-sustained, national non-profit operation . Independent quality control is being ensured by an institution in the United States. Malaria Action Programme (MAP) W oRLD HEALTH , Jan ./Feb. 1988 .0 "' 3: £ u (}) w 0 I s -all for health <11111 Besides warning that "cancer is a Third World problem too," WHO is telling the world that enough knowledge exists to prevent one third of all cancers, to cure one third provided they are detected early and offered adequate therapy, and to provide freedom from cancer pain. Many types of cancers can be prevented, and this concept revolutionises national approaches to controlling them. This is particularly true regarding tobacco-related lung cancer, which takes a heavy toll in industrialised countries. Indeed cancer is now being considered as a new communicable disease-communicable through the rapid proliferation of unhealthy life-styles. Meanwhile WHO is showing that freedom from cancer pain is possible. An approach has been tested and published by WHO in more than 10 languages which describes a relatively simple and inex- pensive method to solve this neglected public health problem . In 1977, WHO started a peaceful revolution in..,. international public health. It asked a group of experts which drugs-among tens of thou- sands available on the market-were really necessary to take care of most health pro- blems. The experts concluded that about 200 drugs and vaccines could be considered es- sential in good medical practice. Most were no longer protected by patents rights and could be mass-produced at a reasonable cost. The list has been revised four times since 1977, but still stands at about 250 essential drugs and vaccines. More than 100 govern- ments in the Third World have adapted the model list to their requirements, as have many non-governmental organizations and other UN agencies. Action Programme on Essential Drugs (DAP) Cancer unit (CAN) <11111 The " cold chain" is the lifeline of WHO's Expanded Pro- gramme on Immunization, ensuring that potent vaccine ar- rives at the right place, at the right time and in sufficient quantity. Temperature sensitive monitors indicate whether the shipment is exposed to too much heat. The cold chain includes kerosene-driven refrigerators to keep the vaccines cool, and ice-boxes enable health workers to carry the pre- cious contents to where they are needed. Immunization against the main diseases of childhood is ensuring "a chance for every child." Expanded Programme on Immunization (EPI) "The goals of health for all Manilans can only be achieved through a partnership between the communities and the health care delivery system." wHo-supported projects in the Philippines capital show conclusively that health attitu- des and practices of the community have improved since primary health care was introduced. People cooperate with one another and with the health centre, and participate in activities for their own benefit. As a result of intensified education, immunization coverage of infants and children rose from 44 per cent to 96 per cent. Environmental sanita- tion in the area has improved and the community is more aware of the danger of insect- and vermin-carried diseases. Division of Strengthening of Health Services (SUS) 21
Health for all-all for health 1 9 4 8 O~GAN!S ... TIOI'I MONOJME ot l A. SA"'lt 46); 1 9 8 8 On Thursday, 7 April 1988, the member countries of wHo will mark the 40th anniver- sary of their Organization. The outstanding public health achievement of the past four decades was undoubtedly the eradication of smallpox . Now the international effort that made that achievement possible must be harnessed to bring about Health for all by the year 2000. While governments demonstrate their political will to improve health and thus improve development, every individual and every communi- ty must also take responsibility for health. This is why wHo has chosen as the slogan for this year's World Health Day: Health for all-all for health. On these pages and the succeeding ones, we highlight just a few examples of the activities undertaken by wHo programmes. On the island of Pemba, off the coast ~ of Tanzania, bloody urine means Schistosoma haematobium infection, and it affects more than half of its 280,000 inhabitants. WHO's Parasitic Diseases Programme, with the Ita- lian Department of Cooperation and the Pharma Fund of the Federal Re- public of Germany, is helping to con- trol this disease. In September 1986, over 40 per cent of children in 34 of its 57 schools had bloody urine speci- mens, and were given a single oral dose of praziquantel, a safe curative drug in schistosomiasis. Six months later, in only seven schools were more than 40 per cent of urine speci- mens found to have blood . Parasitic Diseases Programme (POP) The diarrhoea! diseases continue ~ to take a toll of some four million deaths each year in children aged under five in the developing world. The major advance in controlling them in recent times has been the development of oral rehydration therapy, and especially of Oral Re- hydration Salts (ORS). This pro- vides a simple tool that mothers themselves can use to prevent dehydration if their chil- dren develop diarrhoea. Latest W HO estimates indicate that, by the end of 1985, at least 51 per cent of the total population of the developing countries had access to ORS, and at least 18 per cent of diarrhoea! episodes in children under five were actually treated with ORS. This treatment may have prevented as many as half a million deaths from diarrhoea in 1985. Diarrhoea! Diseases Control (COD) 16 ... A simple eight-page recognition card is now being used by community health and other workers to prevent and control nutritional blindness (above) . lt was developed by W HO in collaboration with the International Center of Epidemiologic and Preventive Ophthalmology at Johns Hopkins University in the USA, Helen Keller International, and UNICEF . The card is div- ided into what to look for when examining chil- dren and questioning their mothers, and how to act and what to advise when eye problems are detected . Its universal usefulness has been greatly enhanced by the distribution of dupli- cate sets of film containing the master illustra- ~ tions. Interested health authorities and non- ~ governmental organizations are then free to ~ reproduce the cards and insert the accompany- ~ ing text in the appropriate language. s Nutrition unit (NUT) Simple means for ensuring safe drinking-water in rural com- munities are essential in many developing countries . WHO's Guidelines for Drinking-Water Quality help such communities to maintain regular surveillance of wells, boreholes and tradi- tional water sources, and to undertake sanitary inspection, sampling and bacteriological testing. Field kits have been de- signed expressly for this purpose. Three pilot and demonstra- j? tion projects are now operational in Indonesia, Peru and Zam- s bia, and their results confirm high contamination levels. They will be followed up by technical measures to remedy the situa- tion and to improve T drinking-water quali- ty through new filter techniques, simple chlorinators, and so on. But their effec- tiveness will rely heavily in the future on community par- ticipation. Community Water Supply and Sanita- tion unit (CWS) W oRLD HEALTH , Jan ./Feb. 1988 (V E E 0 (f) ~ 0 I s ""' "' "' .'!2 :::i 0 I s ... Fifty years ago, the endemic treponematoses which in- clude yaws, pinta and bejel were rampant among children in the tropics and sub-tropics. Some 60 million people suf- fered from these disfiguring and crippling infections. WHO developed a novel approach to control these diseases, using a single shot of long-acting penicillin; 46 countries started mass treatment campaigns during the 1950s and 1960s, in close collaboration with wHo and UNICEF. Not less than 50 million cases received injection treatment, and the diseases were eliminated from many areas. For many communities these campaigns were an impressive first encounter with modern medicine, and therefore a spearhead for future rural health development. Programme of Sexually Transmitted Diseases (VDT) ~ Changes in programme strategy during the campaign to eradicate smallpox bet- ween 1967 and 1979, and a new, more potent vaccine, called for a new concept of vaccine application. lt took the form of an effective and cheap " bifurcated " needle for delivering the vaccine. lt was so simple to use that a local villager could in only ten minutes be trained to perform vaccination effectively, and it used far less of the precious vaccine. The quick transfer of this appropriate technology to all countries still affected contributed significantly to the final success. Ten years have now elapsed since the world saw its last case of endemic smallpox. t::: 0 I 3: Smallpox Eradication Programme (SME) In its first ten years, the Tropical Diseases Research pro- gramme has recruited into its worldwide network scientists of the highest calibre, whose work is already bearing fruit in the form of vaccines, drugs, diagnostic tests and other disease control tools. Many scientists in tropical countries are being trained, through TOR-supported activities, to parti- cipate in this global partnership. As these new tools emerge from basic research, they need to be put to the test of reality in the field, to assess their T work in social and economic terms as well as their effectiveness in checking the spread of diseases, in epidemiological validation and in social and economic assessment. Much remains to be done before a powerful and adequate armament- arium exists against the main tropi- cal diseases. But exciting progress is being made. uNoP/ World Bank/wHo Special Pro- gramme for Research and Training in Tropical Diseases (TOR) Signposts to Health tor All 18 51 First International Sanitary Confer-ence, Paris 1902 1923 1946 International Sanitary Bureau crea- ted - later the Pan American Sanitary Bureau Constitution of the Health Organiza- tion of the League of Nations First meeting of the Interim Com- mission of the World Health Organ- ization 1948 7 April : Consti-tution of WHO comes into being . Later, 1st World Health Assem- bly names Dr Brock Chisholm as f irst Director- General 1949 2nd Assembly confirms that Pan American Sanitary Bureau will act as WHO's regional office of the Americas 1953 Dr Marcolino Candau suc- ceeds Dr Chisholm as second Director-General 1966 Opening of WHO's C US - tom-built headquarters in Geneva, Switzerland Start of intensified campaign for smallpox eradication Dr Halfdan Mahler succeeds Dr Can- dau as th ird Director-General 1967 1973 1977 30th Assembly adopts as tar- get Health for all by the Year 2000. Last ever case of endemic smallpox located in Somalia 1978 Declaration of Alma-Ata, at WHO/UNICEF conference on primary health care 1979 1986 1988 Independent commission confirms the global eradication of smallpox Seventh report on the world health situation assesses progress made towards Health for All WHO's 40th anniversary. World Health Day slogan chosen for this occasion : Health for all-all for health 0 I 3: "' 9 0 .r:. a. Health for all- In order to achieve international agreement .,.. on just what constitutes nutritious and safe food , and thus to facilitate international trade in food , WHO jointly with FAO estab- lished in 1963 the Food Standards Programme. This programme is put into practice by the Codex Alimentarius Commission, which now has a membership of 130 countries. Among other things , the programme has developed almost 200 inter- national standards for individual food com- modities , including provisions for safe le- vels of food additives , maximum limits for pesticide residues and a wide range of che- mical compounds in many foods , and gui- delines for food labelling. And besides a Code of General Principles of Food Hy- giene, it has drawn up a Code of Ethics for International Trade in Food. Food Safety programme (FOS) ..,.. Acute respiratory infections continue to be a major cause of death among children in the developing countries and to place a heavy burden on the health services . A few years ago , WHO questioned the widespread indifference to this problem , and saw that child survival efforts would be incomplete unless they found solutions to it. Once it was determined that bacterial pneumonia was the major culprit for ARI deaths in children , WHO was able to develop and test a very simple clinical protocol which allows the communi- ty health worker to recognise and treat the one case of pneumonia that occurs for every 100 children with mild ARI. Its effectiveness in reducing mortality has been demonstrated in India , Nepal , Pakistan , Papua New Guinea , and Tanzania. Tuberculosis and Respiratory Infections programme (TRI) Devise a tuberculosis programme for developing countries : over half the population is infected , millions are dying each year and there are almost no resources . A WHO team was given these terms of reference in the 1950s, and realised that tackling the problem meant making diagnosis and treatment accessible to all , all the time. Turning its back on the classical specialised approach , the team worked out a technology that could be applied by commun- ity health workers , anywhere. This control strategy has become implemented widely, in rich countries as well as poor ones. Mor- {l tality has come down and tuberculosis has sta~ted to go away , 1 slowly but surely. A remarkable precursor of pnmary health care b3 and Health for All? That is not unlikely ; the leader of the WHO a team was a young medical officer by the name of Halfdan Mahler. I s Tuberculosis and Respiratory Infections programme (TRI) Since the beginning of the International Drink- .,.. ' .. ing Water Supply and Sanitation Decade (1981- ~- 1989), WHO has actively promoted the involve- ment of communities in water supply and ~ sanitation projects. The wHo methodology , call- ed Community Partnership Approach , starts by sensitising communities and involving them in the decision-making process, including the choice of appropriate technology , long before the physical work begins . This awareness cam- paign, linked with hygiene education , continues through the construction period and-most im- portant-for many years after the facilities have been built. Although it is too early to talk about outright success , indications are that the Com- munity Partnership Approach will lead to much better maintenance of handpumps and latrines and safer use of drinking water. > <f) "' E <( a.: 0 ' I s "' ~ 0 I Division of Environmental Health (EHE) -. ·- s 18 WHO has been at pains to make health leaders , health professionals and the ge- neral public aware of the importance of psychosocial factors in fostering econo- mic development , well-being and the quality of life. It also underlines that most so-called physical diseases, parti- cularly the major killers both in develo- ping and developed countries, could be prevented through improved life-styles. One of the positive steps pioneered by WHO's Mental Health Division has been to develop the technology to prevent and treat mental, neurological and psy- chosocial disorders (including those re- lated to drug and alcohol abuse) within the setting of primary health care. Division of Mental Health (MNH) W ORLD HEALTH, Jan ./Feb. 1988 -all for health ~ WHO's work on traditional birth attendants (TBAs) has demonstrated that " uneducated " people have the capacity to carry out a whole range of appropriate technologies if they are given the stimulus , the training, the incentives and the confidence to do so. Prior to the Orga- nization's catalytic and promotional activities , these useful health workers were ignored , mali- gned and even considered dangerous. Today TBAs form a great local manpower resource for carrying out selected primary health care servi- ces in countries where they abound. Nursing unit (NUR) Drug abuse is increasing at an ~ alarming rate all around the world . Many different sectors are working together to combat this menace-police , customs, educa- tion and health. What the health sector can offer is much more than just specialist treatment. WHO has produced a simple manual which shows how health workers can mobilise the collective will of the community to prevent the spread of drugs. The manual is already helping parents and youth organi- zations to join forces with health workers to promote drug-free life- styles. Division of Mental Health (MNH) WHO/Zafar <11111 Some people think teachers are born and cannot be trained. Of course , talent is needed to make a good teacher but even talented people have to learn their trade (less talented people should learn even harder). WHO launched a world-wide teacher training pro- gramme for health personnel schools almost two de- cades ago. Its aim was to help teachers to learn how to help adults in their turn to learn what they need to know to become competent health workers. When the programme started very few countries in the world were able to train teachers of health personnel , but even there the need was hardly recognised. Now most countries realise that need and many of them have developed the capacity to meet it. Division of Health Manpower Development (HMD) Health Learning Materials projects are already help- ing 21 countries to make important progress towards self-reliance. Developing countries in particular re- ceive technical guidance on how to produce their own teaching and learning materials for primary health care personnel. With WHO's cooperation , such train- ing materials as reference manuals , teacher guides and visual aids are developed by national staff, using local skills and resources. Community participation ensures their relevance to local health needs and con- ditions. Inter-country and inter-regional networks promote an exchange of materials and expertise in a very practical example of technical cooperation among developing countries. Health Learning Materials programme (HLM) 19 .0 ro 3: .s::: u (/) w 0 I s Health for all- ...,.. Insecticide resistance among insects that spread disease first appeared in 1947. One method of countering it is biological control , involving the use of predators , parasites or pathogens. A major breakthrough was achieved with the discovery and development of Bacillus thuringiensis H-14 to control the blackflies (Simulium) that transmit onchocer- ciasis (river blindness) . This bacillus is also used on a large scale for mosquito control in some countries with temperate climates. Fish that eat insect larvae have been used for mos- quito control since at least the nineteenth century. WHO has drawn up comprehensive guidelines on the screening and development of these fish , preferring indigenous species to exotic species which may have an adverse ecological impact. Division of Vector Biology and Control (VBC) Dapsone, the first effective drug against leprosy, was ~ introduced in the 1940s. But treatment lasted for years , so a WHO Study Group looked for multi-drug therapy that would stop the increasing occurrence of resistance by the leprosy bacillus to individual drugs , cure the pa- tient and control the spread of the disease. The com- bined therapy recommended by the Study Group in 1981 is of shorter duration and therefore more attractive to patients . Consequently more patients voluntarily report for treatment while still showing only initial signs of the disease. This prevents the appearance of deformities and disabilities, and the community's acceptance of and assistance for leprosy sufferers increases. More than 1.2 million patients have been so treated and , for the first time in the history of leprosy statistics , the number of registered cases is declining. Over the next 10 years this reduction will reach at least 50 per cent of the current 5 million registered patients. Leprosy unit (LEP) W HO/Zafar ...,.. As a result of over ten years' research on fox ecology involving 15 laboratories in 10 countries , rabies control in wildlife has become a reality in European countries. For the first time in his- tory , man has averted an epidemic in nature by using well- adapted baits to bring about oral vaccination of wild animals. At the same time the work of three Collaborating Centres has pa- ved the way for future rabies control in developing countries . Firstly , an attenuated rabies strain was shown to immunize dogs and jackals by the oral route. Secondly, a simple procedure and kit enable animal brain specimens to be shipped for laboratory diagnosis. Thirdly , a collaborative study by six European and North American laboratories on a new enzyme immuno-assay permits rapid case diagnosis without a microscope. Veterinary Public Health (VPH) Over the past ten years , the Malaria Action Programme, to- gether with TDR, has jointly developed , standardised and vali- dated test kits to assess the response of the malaria parasite Plasmodium falciparum to various drugs. These test kits have become an important tool throughout the world, and as from last year can be applied to all major anti-malarial drugs. Production is now entirely in the hands of an institution in the Philippines , and has become a self-sustained, national non-profit operation . Independent quality control is being ensured by an institution in the United States. Malaria Action Programme (MAP) W oRLD HEALTH , Jan ./Feb. 1988 .0 "' 3: £ u (}) w 0 I s -all for health <11111 Besides warning that "cancer is a Third World problem too," WHO is telling the world that enough knowledge exists to prevent one third of all cancers, to cure one third provided they are detected early and offered adequate therapy, and to provide freedom from cancer pain. Many types of cancers can be prevented, and this concept revolutionises national approaches to controlling them. This is particularly true regarding tobacco-related lung cancer, which takes a heavy toll in industrialised countries. Indeed cancer is now being considered as a new communicable disease-communicable through the rapid proliferation of unhealthy life-styles. Meanwhile WHO is showing that freedom from cancer pain is possible. An approach has been tested and published by WHO in more than 10 languages which describes a relatively simple and inex- pensive method to solve this neglected public health problem . In 1977, WHO started a peaceful revolution in..,. international public health. It asked a group of experts which drugs-among tens of thou- sands available on the market-were really necessary to take care of most health pro- blems. The experts concluded that about 200 drugs and vaccines could be considered es- sential in good medical practice. Most were no longer protected by patents rights and could be mass-produced at a reasonable cost. The list has been revised four times since 1977, but still stands at about 250 essential drugs and vaccines. More than 100 govern- ments in the Third World have adapted the model list to their requirements, as have many non-governmental organizations and other UN agencies. Action Programme on Essential Drugs (DAP) Cancer unit (CAN) <11111 The " cold chain" is the lifeline of WHO's Expanded Pro- gramme on Immunization, ensuring that potent vaccine ar- rives at the right place, at the right time and in sufficient quantity. Temperature sensitive monitors indicate whether the shipment is exposed to too much heat. The cold chain includes kerosene-driven refrigerators to keep the vaccines cool, and ice-boxes enable health workers to carry the pre- cious contents to where they are needed. Immunization against the main diseases of childhood is ensuring "a chance for every child." Expanded Programme on Immunization (EPI) "The goals of health for all Manilans can only be achieved through a partnership between the communities and the health care delivery system." wHo-supported projects in the Philippines capital show conclusively that health attitu- des and practices of the community have improved since primary health care was introduced. People cooperate with one another and with the health centre, and participate in activities for their own benefit. As a result of intensified education, immunization coverage of infants and children rose from 44 per cent to 96 per cent. Environmental sanita- tion in the area has improved and the community is more aware of the danger of insect- and vermin-carried diseases. Division of Strengthening of Health Services (SUS) 21