.(WPR/RC33/SR/ 6)
SUMMARY RECORD OF THE SIXTH MEETING WHO Conference Hall, Manila Wednesday, 22 September 1982 at 3.10 p.m. CHAIRMAN: later: Dr Abdul Khalid bin Saban (Malaysia) Dr S. Tapa (Tonga)
CONTENTS
1.
Alcohol consumption as a major public health problem (continued) •••••••••••• • ••••••••••••••••••• Infant and young child feeding a11d International Code of Marketingof Breast-ntilk Substitutes ••.............. " .........•.........
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2.
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1.
ALCOHOL CONSUMPTION AS A MAJOR PUBLIC HEALTH PROBLEM: Supplementary Agenda Item 2 (Document WPR/RC33/19) (continued from the fifth meeting, section 3)
Mr DHILLON (Chief, Human Resource Development) was pleased to note that the representative of New Zealand had rightly stressed the importance of the role of health education in combating drug abuse. In fact, increasing importance had been given to that aspect in many countries of the Region in recent years. Preventive education on drug and alcohol abuse was being strengthened and incorporated in school education programmes. In the Philippines a national education programme for the prevention of drug and alcohol abuse and a centre for that purpose had been established. The centre, which was also serving as the ASEAN centre for the training of teachers in drug abuse prevention education, had done a substantial amount of work since its establishment in 1972, including the development of a curriculum for use in primary, secondary and tertiary education and in the teacher tra1n1ng colleges; the production of three volumes of documents for use by teachers in preparing the curriculum and discussing the topic ¥ith the schoolchildren; and a considerable amount of instructional material which had been distributed to schools in the Philippines and as sample material to other ASEAN countries. The centre had also launched a large-scale programme for the training of teachers: between 1973 and 1981 225 schoo 1 superintendents had been given one- to two-weeks' training and about 6000 school principals and senior teachers had been trained; and teams had been formed to go out t:o the provinces to train teachers in · the primary and secondary schools. So far 17 102 teachers from the Philippines and other ASEAN countries had thus been trained. In the school curriculum in Malaysia considerable emphasis had been placed on the prevention of smoking and drug and alcohol abuse. In the South Pacific . countries also an interest was developing in that aspect; collaborative programmes had been established and initial steps had been taken in developing curricula in Cook Islands, Fiji, Kiribati, Papua New Guinea, Samoa and Tonga. A consultant in the field of health education, emphasizing the prevention of smoking and alcohol and drug abuse, was at present in the South Pacific and had visited those countries. A regional workshop on school health education, with emphasis on that aspect, had been held about a year ago. Another approach had been mass education campaigns. As compared with the considerable experience of launching campaigns against smoking, experience with campaigns to prevent drug and alcohol abuse had so far been limited. However, in Singapore the previous year, in a national campaign on healthy lifestyles, one of the four subjects had been the prevention of excessive use of alcohol. Similar efforts had also been undertaken in Australia and Japan. However, much of the emphasis in the mass education campaigns had been on the prevention of drunken driving, rather than on preventing people from assuming drinking habits.
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The third approach was at the couununity level: education through ' personal communication. That was in fact rather weak; . not many health workers were as yet emphasizing this aspect in their educational effor:ts at the couununity level. But in the integrated educational approaches in the context of primary health care, it was hoped that health workers at the periphery, together with couununity workers from other sectors, would give more emphasis to the problem. The fourth area was the education of patients - to help people to give up drinking. Considerable emphasis had been laid on that aspect in the developed countries. Health educators were now becoming more concerned with "risk-resistance behaviour" and considerable research had been done on how to help people to resist pressure from peer groups to drink or smoke. Mr SUBRAMANIAN (Regional Adviser in Health . Information) . said that, although alcohol had been consumed for ages pas.t, statistics on alcohol and alcohol-related problems were mainly a phenomenon of the past 30 years. In general, surveys had become an important source of information and understanding of drinking practices and problems in the population. Data on drinking practices were now available for some countries in the Region, but data on problems related to drinking were not yet so coimnon. One problem was that the terms "alcoholism" and "alcohol-related problems" had yet to be clearly defined. Mr Subramanian went on to provide some informatfon · on · mortality frdm cirrhosis of the liver, considered as an . alcohol-related disease, as of 1976, from Australia, Hong Kong, Japan and New Zealand. As of 1981, reporting on related mortality and morbidity for the . Wor1d Health Statistics Annual had been completed by Australia, Fiji, Hong Kong, Japan, New Zealand and Singapore, showing increases for cirrhosis due to alcohol in most countries for men and women. General information of a less readily quantifiable order had been obtained from 17 countries or areas in 1976 through a questionnaire circulated to Member States of the Region. The response showed that 10 of the countries or areas returning the questionnaire considered the consequences · . of alcohol consumption to be a major to moderately important problem, and in 10 alcohol problems were reported to be increasing~ Few countries possessed precise da~a on the magnitude and characteristics of the pr:obletn, and such data as existed were rarely comparable. The level of alcohol consumption and related problems seemed to be highest, and price of alcohol related to average income lowest, in the more deve~oped countries. Traffic accidertts and harm to family relations seemed the most serious consequences of alcohol dependence; 10 countries or ar~as replying to the World Health Statistics Annual questionnaire regarded it as a health hazard. No country recommended prohibition as a solution.
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In 1980 the Working Group on the Prevention and Control of Alcohol-related Problems had produced better findings concerning consumption for th~ five countries represented, but there had still been no adequate basis for a sound policy. It had, however, appeared that the end of the economic boom in the early 1970s had been associated with a halt in the increase in alcohol consumption in Australia and Japan; but in the developing countries represented per capita consumption still appeared. to increase with economic growth. In some cases - Philippines, Republic of Korea and Singapore - increases had been <;lramatic (over 100% in 1979), although no information was available on related health or other problems. As the problems emerged, policies would be formulated and information was beginning to be generated to support such action. Definition of alcoholism still had to be determined according to morbidity or mortality, "impressional" or "operational" data, or the Eighth pr Ninth Revision of the Internationul Classification of Diseases. Data were being collected on alcohol consumption and cirrhosis of the liver as a related or non-related health problem. Simple data on household expenditure on alcoholic beverages could be a useful indicator, though they were not generally available; alcohol production and consumption data as a whole were being collected internationally by the Finnish Foundation for Alcohol Studies in collaboration with WHO, but that had not been updated since the 1970s. Consumption needed to be defined, according to type of alcoholic beverage, to provide useful indicators, as did the environmental and other conditions of its consumption, since they affected people's opinion of themselves as drinkers or abstainers. Basic studies on all these issues were required before a clear picture could emerge, and there was the added question of the effect of mothers' drinking on the foetus. There being no further comments, the CHAIRMAN asked the Rapporteurs to meet with the representative of New Zealand in order to draft an appropriate resolution. (For consideration of the draft resolution see the seventh meeting, section 1.2).
Dr TAPA (Tonga) resumed the Chair.
2.
INFANT AND YOUNG CHILD FEEDING AND INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES; Item 16 of the Agenda (Document WPR/RC33/14 Rev.l)
The REGIONAL DIRECTOR said that document WPR/RC33/ 14 Rev .1 had been issued to bring the Regional Committee up to date on the status of various actions and activities in relation to infant and young child feeding and the International Code of Marketing of Breast-milk Substitutes. There had been a number of resolutions regarding the submission of reports to the World Health Assembly, as well as requests that follow-up and review should be undertaken by the regional committees. An attempt had -been made, in paragraphs 7 to 9 of document WPR/RC33/14 Rev.l, to clarify the sequence of reporting. The World Health Assembly had called for a special report in 1983 on the International Code. The Director..,.General had already
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sent a circular letter to Member States asking for information in relation to that request by 15 September 1982. The Regional Director, in turn, had .asked Member States to copy whatever they submitted directly to the Director-General to him, in the interest of coordination. If information was sent through the Regional Director it would be sent on to the Director-General. After the special report 1n 1983, and providing the World Health Assembly did not further alter the sequence of reporting, the requirement was essentially that: (1) reports on infant and young child feeding and the International Code had to be submitted to the Regional Committee in odd-numbered years and the World Health Assembly in even-numbered years. That meant that reports from Member States should . reach the Regional Director by the end of March each odd-numbered year in order to prepare the Regional Committee document; ( 2) in even-numbered years a report on the International Code alone was required, under Article 62 of the WHO Constitution. It had been proposed, for the Committee's consideration, that it might be simpler for Member States to report routinely on both infant and young child feeding and the Code, leaving it to the secretariat to use the material as necessary, according to the requirements of the var1ous resolutions and the WHO Constitution. At the thirty-second session, the Committee had accepted guiding principles for facilitating the preparation of the reports just mentioned. The guiding principles had since been revised, taking into account the comments made at the regional committees in 1981. The revised version had been distributed to Member States of the Region in August 1982. Lastly, but certainly not least, the material that had already been submitted to the Regional Director for a report presented to the Thirty-fifth World Health Assembly in May 1982 and for the special report to the next Health Assembly - had been used to provide the Committee with a summary of activities so far undertaken. Since the preparation of document WPR/RC33/14 Rev.I, up-to-date reports had been received in respect of American Samoa, Macao and New Caledonia while Australia had included a section on the International Code of Marketing of Breast-milk Substitutes in its annual report on the progress of health activities which had been circulated to the Committee. Dr KOINUMA (Japan), reporting on implementation in his count.ry, said that, pursuant to the Health Assembly resolutions, his Government had encouraged the promotion of breast-feeding in collaboration with related nongovernmental bodies. Since 1974 every infant-food company producing breast-milk substitutes had refrained from distributing samples to consumers in clinics and hospitals consequent upon administrative guidance from the Government which had also encouraged such companies to label cans of breast-milk substitutes to the effect that breast-feeding was superior to feeding with breast-milk substitutes and that breast-milk substitutes should be used only after consulting medical doctors, pharmacists or midwives. In addition, all infant-food companies in Japan had refrained from advertising breast-milk substitutes on television, the radio and in newspapers. In statistical terms, breast-feeding of infants under two months of age had increased by 14 per cent. in Japan between 1970 and 1980.
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me~sures
Dr ZHANG YINE (China), recalling that China had firmly supported the to promote breast-feeding adopted at the Thirty-third · and Thl.J;ty-fourth Health Assemblies, said that the relevant resolutions had been implemented in China.
A seminar on infant and young child feeding and breast-milk substitutes had been co-sponsored by the Ministries of Public Health and of Light Industries in August 1982, at which standards for breast-milk substitutes and weaning foods and their production and marketing had been laid down according to the conditions prevailing in the country. Among other measures to encourage breast-feeding the Government had extended maternity leave from 56 to 70 days; breast-feeding mothers could take leave with full pay up to six months; nursing rooms had been installed in Government institutions, factories and neighbourhood kindergartens to facilitate breast-feeding by working mothers. Regular health visits · were paid to breast-feeding mothers for guidance and for medical examination of the infant. Booklets of relevant information and posters had been issued. A pilot project had been set up to popularize special breast-feeding arrangements in kindergartens and nurseries in large cities, with special meals tb ensure a proper diet for the infant. A workshop on infant and young child feeding was to be held in Shanghai before the end of 1982 under the joint sponsorship of WHO and the Ministry of Public Health. Although attitudes to breast-feeding were generally satisfactory in China, especially in the rural areas, the young mothers in some large cities were less well motivated, and propaganda had been strengthened to correct that tendency. Dr ACOSTA (Philippines) said that his Government had cooperated actively with WHO on the issue since the 1979 Joint WHO/UNICEF Meeting on Infant and Young Child Feeding. In particular, it had collaborated in the WHO interregional study on breast-feeding as well as in the volume and composition studies. A national programme on infant and young child feeding had been formulated following a national consultation meeting in 1981. Ongoing activities included rooming-in practices, in-service training for health professionals and education on nutrition. Cooperation between the public and private sectors was encouraged with the coilaboration of all social groups. A second consultation had resulted in the development of a national draft code of marketing for breast-milk substitutes. Both national consultations hadbeen supported by WHO and UNICEF. The Philippines fully endorsed the resolutions adopted by the World Health Assembly and by the Regional Conunittee on infant and young child feeding as well as the International Code of Marketing of Breast-milk Substitutes. His Government had embarked on the preparation of a new code
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based on the International Code and expected that it would shortly be adopted. It was the view of his Government that the value of the Code would programme to promote be diminished if it was not buttressed by a breast-feeding. Mr NGUYEN DUY CUONG (Viet Nam) drew attention to the summary of activities in Viet Nam contained in document WPR/RC33/14 Rev .L Breast-feeding was employed to a great extent in Viet Nam and was encouraged by the Government and by mass organizations. There were no breast-milk substitutes in Viet Nam and items used as food complements were produced within the country. His Government was making every effort to comply with the guiding principles for facilitating reporting by Member States on action taken in the field of infant and young child feeding. Dr NOIROT (France) recalled that the International Code was a recommendation and that it had been left to Member States to incorporate its stipulations into their own legislation consistent with their own circumstances. He fully subscribed to paragraph 10 of the report. It was for that reason that France had already submitted its report. Mr POLSON (Australia) regretted that Australia's summary of activities had arrived too late for inclusion in the document before them. Copies would be distributed to representatives. Much had already been done in Australia to promote breast-feeding and encouraging results had been obtained. An Australian Code of Practice for the Marketing of Infant Formulas was nearing completion as a result of consultations between the Commonwealth Department of Health and the relevant industries. The draft Standard for Infant Formula had been amended, in line with the provisions of the International Code. He supported the comments of the representative of France concerning paragraph 10 of the report. Dr LAU BUONG YAN (Singapore) said that breast-feeding had decreased alarmingly over the past twenty years and the Government was using every possible means of communication and education to reverse the trend. A Code of Ethics on the Sale of Infant Formula Products had been adopted in 1979 to ensure safe and adequate infant feeding and firms producing formulas had been most cooperative with the Ethics Committee. It was the duty of all doctors and health workers to do their utmost to promote breast-feeding. Dr KHALID (Malaysia) stated that, in his country, a code of ethics governing the infant formula industry had come into effect in 1979 and the industry's activities were regularly monitored, including all printed material and literature. Efforts were in progress to bring the Code into line with the principles of the International Code. He supported the idea of a simpler reporting system, although the one-year intervals proposed might be too short to reveal any substantial progress. Dr REILLY (Papua New Guinea) said his country strongly supported the International Code. Although the enactment of legislation tended to lag behind other national efforts, Papua New Guinea had already legislated against the advertising of infant feeding products and feeding bottles could
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only be obtained on production of a medical prescription. He supported the proposal for annual reporting, which would enable the Regional Office to collaborate with countries in formulating plans of action for implementation of the Code. Dr NAIR (Regional Adviser in Nutrition) remarked that it was little than a year since the Code had been adopted and the support voiced by the Committee was very heartening. WHO and UNICEF were closely collaborating with Member States. Since the activities connected with the Code were largely carried out as part of comprehensive maternal and child health and nutrition programmes, there was not much emphasis on additional resources. A tentative plan of activities in the Region had already been drawn up. National workshops had been held and more were planned, with full WHO support. Regular and extrabudgetary funds had been used to support studies in the Region. Italy had already offered 85 million dollars for WHO/UNICEF collaborative work on infant feeding and nutrition and it was hoped to obtain more resources, including some from the Region itself. ~ore
The Regional Office had cooperated with the Government of the Philippines in producing a national plan of operations for infant and young child feeding. In countries where breast-feeding was extensively practised the use of local food sources for supplementary feeding, as in Viet Nam, should be given every encouragement. He was grateful for the support given by the Committee to the proposals for a simplified reporting system. Dr HU (Regional Adviser in Maternal and Child Health) presented some preliminary findings of a collaborative study on breast-feeding among specific social groupings in selected areas of the world. Many mothers claimed they did not breastfeed because they did noc produce enough milk. As was known, more than 90% of mothers had the natural ability to produce sufficient milk, but there were many factors influencing the quantity. In urban areas of China, for example, factors conducive to a plentiful supply of maternal milk included: age below 24 years at time of delivery, full-term birth with normal labour, initiation of breast-feeding within 12 hours, mothers working on shifts rather than throughout the day, and primary school education rather than higher education. The CHAIRMAN asked if the Committee was in agreement with the content of document WPR/RC33/14 Rev .1, and in particular with paragraph 10 thereof recommending annual reporting by Member States. There being no objections to that paragraph, he requested the Rapporteurs to draft an appropriate resolution. (For consideration of the draft resolution see the seventh meeting, section 1.3).
The meeting rose at 4.40 p.m.