Blind village: onchocerciasis! [full issue]

THE MAGAZINE OF THE HEALTH ORGANIZATION • OCTOBER 1973 • UK 30 p • USA i►0.70 Blind village: onchocerciasis! •*' N DAY The cover picture shows a village in Chad, abandoned by most of its inhabi- tants because of onchocerciasis, or river blindness. Of a population of 400, only nine are left, all of them blind. (Photo WHO) Contents Onchocerciasis Poverty and blindness by J. Hamon and L. Kartman . . 3 Facts about river blindness . . 10 Immigrants in Europe Paradox in Britain by D. Gould 12 An impact on health by N. H. Fisek 18 A Spaniard abroad by H. Loskant 26 Glimpses of everyday life . 30 World Health appears in Arabic, English, French, German, Hindi, Portuguese, Russian, and Spanish. Articles and photographs not copyrighted 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 2 Onchocerciasis POVERTY AND BLINDNESS by DR J. HAMON, entomologist, WHO and DR L. KARTMAN, parasitologist, WHO October 24, 1973 is the first World Development Information Day, designated by the United Nations to stimulate a world interest in development questions. Diseases and poor health can be strong barriers to development, a striking example being onchocerciasis. More than 20 million people are victims of onchocerciasis in various parts of the world. It is a relatively little known disease which frequently leads to blindness and can force people away from fertile agricultural valleys in an attempt to escape the disease as well as the flies that carry it. Because onchocerciasis occurs near running water, it is also known as "river blindness". Onchocerciasis is a parasitic disease caused by a filaria, a tiny worm whose scientific name is Onchocerca volvulus. The infection is carried from person to person by small, bloodsucking blackflies belong- ing to the genus Simulium. At the present time the disease is estimated to affect more than 20 million people. Onchocerciasis is particularly widespread in tropical Africa but is also found in limited areas of tropi- cal America. Extensive concentration of the disease has been discovered in moun- tain regions in tropical America and East Africa and also in certain parts of the Congo forest, but it is in the savannahs of tropical Africa that its most severe effects are felt and that it frequently constitutes a major obstacle to economic development. The adult worms have an estimated life of 15 years in the human body. They are found principally in the subcutaneous tis- sue, where they form more or less volumi- nous nodules. These nodules can usually be felt through the skin and this provides one of the standard ways of detecting the disease. In certain regions, systematic ef- forts have been made to eliminate the dis- ease by extracting the nodules, but the results were poor because some nodules were too deep to be felt, and because of the existence of numbers of free filariae in the tissues. The female worms throughout their lives produce millions of microscopic microfi- lariae which, it is estimated, live about two years. These microfilariae are mostly found in the epidermis, where they cause itching and may give rise to characteristic patches on the skin. They are also found in the eyes, where they can have more or less serious effects and may cause progressive loss of sight culminating in blindness. Recently, microfilariae have been reported in the urinary tract and in other internal organs, but the clinical importance of these findings remains to be established. Onchocerciasis can also be diagnosed by the microscopic examination of a fragment of skin, called a "skin snip", by examina- tion of the eyes and, in some cases, by urine examinations. The disease may also be suspected in persons who present aller- gic reactions after small doses of a drug , diethylcarbamazine, which kills the micro- filariae. The transmission cycle The disease is transmitted by the female flies of certain Simulium species. They become infected when they pierce the skin of an onchocerciasis sufferer and suck in microfilariae along with the blood. Most of the microfilariae thus absorbed are digested together with the blood meal, but a few succeed in penetrating the wall of the fly's stomach and these settle in its thoracic muscles. There, after passing through three larval stages, they finally become free lar- vae capable of infecting a human host. The time required for this development cycle in the fly varies with the temperature—under average tropical conditions it takes about one week. At the end of this period the fly may transmit the infection to any person it bites. However, the probability of such trans- mission seems to be slight, and in practice An old Mall in Ghana blinded by onchocerciasis. (Photo WHO/J. Abcede) 3 I. Nodules or lumps in the skin produced by the parasitic worms are one of the early signs of onchocerciasis. (Photo WHO/ P. A. Pittet) In a village near the Senegal river: ex- amination of skin samples can reveal the presence of the disease. (Photo WHO/ P. A. Pittet) They are bound to become infected. . . (Photo WHO' P. A. Pittet) an individual must receive a considerable number of infective bites before one or several couples of adult worms can deve- lop. It follows that people who remain for only a short time in an area where the disease is endemic run very little risk of becoming infected. In the human organ- ism, the transformation of infective larvae into adult worms is fairly rapid, and the microfilariae produced by the adult worms may be found in the epidermis less than a year after a person's arrival in an area where the disease is endemic. Simulium flies, fortunately, are able to breed only in certain, well-defined ecologi- cal situations. Their larvae need running water to live and develop, and the flies are therefore found only in the neighbourhood of particular reaches of rivers and certain types of watercourses in tropical Africa and America. The larvae of one group of carrier-flies in east Africa fix themselves to the shells of freshwater crabs. Those of the carrier-flies found in west central Africa have a strong preference for rapids and are often found also in sluices, dam overfills and the watergates of irrigation canals. When, in the course of economic develop- ment schemes, a series of small dams is built for agricultural or pastoral irrigation, one result may well be a considerable in- crease in the areas suitable for Simulium flies to breed in, and the appearance of onchocerciasis in new areas. A slowly accumulating infection Most of the clinical manifestations of onchocerciasis are caused by the microfi- lariae, whose numbers increase with those of the adult worms that develop following repeated bites by infected Simulium flies. Thus the infection is cumulative in effect, which is why tourists or foreigners on tech- nical co-operation missions rarely acquire the disease during the relatively short time they are exposed to the infection. For the same reason, onchocerciasis does not ap- pear in epidemic form. A slight infection produces very mild symptoms that gener- ally pass unnoticed. A heavy infection, on the other hand, is acquired only after a long period of exposure to bites by infected Simulium flies, and always has very serious effects, especially on the eyes. This can occur only where there are considerable numbers of infected vector flies and where Simulium can breed plenti- fully and live for a long time. For people living in places where the disease is well established, the severity of infection in- creases with age. Children are generally free from infection or are not seriously affected by it; adolescents are more fre- quently and more severely infected, while the most crippling effects of the disease appear in adults, that is, in the most im- portant age group from the economic point of view. Deserted lands In those places where the local Simulium species is long-lived but has a short flight range, people living in villages near the water where the larvae develop are very heavily infected, while those in villages further away may be entirely free from the disease. In such situations, onchocerciasis has a characteristic distribution in patches or strips that corresponds exactly with the fly's breeding-places. This occurs typically in the dry savannah regions of west Africa, in certain parts of the Congo and in moun- tain areas of east Africa. Where the vector fly has a short life and a long flight range, almost the whole popu- lation will be infected, but less severely and with only rare or slight involvement of the eyes. This is usually so in the forest areas of west Africa. More complex situations may arise when two different Simulium species exist together in the same region, or when the habits of a given species change according to the season. It frequently hap- pens, for instance, that Simulium flies travel longer distances from their breeding places in wet than in dry seasons. In suit- able climatic conditions, certain species of these flies are able to cover distances rang- ing from 20 or 30 up to 100 km in their first days of life. At best, almost the whole of the popu- lation in places where onchocerciasis is prevalent are carriers of the parasites without being seriously incommoded by the disease, but in areas where the infec- tion is more severe the majority of the villagers will suffer from eye troubles, and 20 per cent or more of them may be blind. Onchocerciasis has therefore very serious socio-economic effects. Affected families are more poverty-stricken than the others, and affected villages much poorer than those that remain free of the disease. Over wide areas of the African savannah the productivity of the population is thus reduced, and agricultural land is often abandoned over distances of 10 or 20 km from the rivers. Only the driest and least fertile lands can be cultivated, and the drier the climate the more capricious the rainfall on which the farmers depend for their meagre crops. It frequently happens that, as a result of population pressure or of land development operations, migrants come and settle on unoccupied territories in the neighbourhood of Simulium breed- ing-places. Sometimes the savage attacks of the flies and the discomfort caused by their bites chase the newcomers away before the disease becomes serious. If they stay, they become onchocerciasis victims and when, 15 or 20 years later, they are finally forced out, they are even poorer and in far worse physical shape than when they arrived in the fertile but accursed valleys. This chain of events has been recorded several times in the past and tends to recur as a consequence of population pressure, which drives numbers of peasant families to settle on unoccupied land far from their native villages. It is thus no exaggeration to say that the economic development of very extensive areas, particularly in the savannahs of tropical Africa, cannot reasonably be un- dertaken without first controlling on- chocerciasis. The situation is most serious in certain west African states such as Mali and Upper Volta, where the greater part of the fertile land is in areas where the disease is firmly established. In these areas, outside assistance provided by wealthy countries and international organizations should be used initially to attack onchocerciasis, con- sidered a major obstacle to economic development as well as a social catastro- phe. Drugs for treatment A number of drugs may be used to treat onchocerciasis. The two principal ones are diethylcarbamazine, which destroys only the microfilariae, and suramine, which acts mainly on the adult worms. Because of the 6 The sticks of the blind are prominent at a consultation in Mali. (Photo WHO/P. A. Pittet) ' products formed by the dissolution of the microfilariae, the former drug often pro- duces rather severe allergic reactions in heavily infested patients; moreover its ac- tion is only temporary since the adult worms, on which it has little effect, will gradually reinfest the organism with microfilariae. Suramine is not well tolerat- ed either by some people and, to be effec- tive, must be given in the form of weekly injections under medical supervision. In the present state of the health services in most countries where onchocerciasis is widespread, neither of these two drugs can be used in mass treatment campaigns. Even with better health services, they could never produce more than a tempo- rary improvement among people who are bitten hundreds or thousands of times each year by infected flies. No drug is known that might prevent the disease. Campaigns against onchocerciasis there- fore rely at present on efforts to control the carrier flies by using insecticides to kill the larvae in the rivers and watercourses. The aim is, as far as possible, to eliminate the flies by applying insecticides at their breed- ing-places at intervals shorter than the time required for full development of the larvae, and over a period longer than the maximum life span of the adult female flies. The insecticiding is carried out only on those particular stretches of water where the larvae can live and develop. To have a lasting effect, these operations should cover either the whole of one isolat- ed focus of the disease or else a territory wide enough to ensure that the female flies, with their enormous flight range, will not rapidly repopulate the treated areas. Protecting dam construction workers Some anti-onchocerciasis campaigns concentrate on protecting workers on eco- nomically important sites such as that of the Inga dam at present being built on the Congo river. Others were designed to give protection from the disease during the con- struction of the Akosombo dam on the Volta and the Kainji on the Niger. Insecti- ciding operations have completely elimi- nated Simulium flies from certain areas in Kenya, while a campaign at present under way in parts of Ivory Coast, Mali and Upper Volta has achieved effective control of the breeding-places over a long period. As a result of such operations, the disease has either disappeared or has been consi- derably reduced in severity. Larval insecticiding campaigns are needed on a scale wide enough to cover the vast areas where onchocerciasis occurs and over a period long enough for the parasites to disappear completely from their human hosts without other treatment. In accor- dance with the recommendations of a mis- sion of preparatory assistance to the governments concerned, an operation on Eye-testing in a village in the infected zone. This is a practical way of assessing the seriousness of damage to the eyes. (Photo WHO) 8 these lines is planned to begin in 1974 in the Volta river basin in West Africa. It would benefit Dahomey, Ghana, Ivory Coast, Mali, Niger, Togo and Upper Volta. In principle, these are very long-term operations, but there is a possibility of shortening them to some extent by the use of available drugs to eliminate the para- sites from the last people to remain infect- ed a certain number of years after interrup- tion of transmission of the disease. There is also a probability that as soon as insecti- ciding of the breeding-places is initiated throughout the Volta basin, very little risk will remain of their becoming repopulated by females flies coming in from a distance. If that proves to be so, surveillance opera- tions will be sufficient, without recourse to drug treatment. Up to the present, most campaigns against the Simulium fly in onchocerciasis foci have been based on the spraying of DDT from the ground. Because of the risk of lasting environmental contamination, it has been decided that, in future region- wide campaigns, less long-lasting insecti- cides should be used, and that they should be sprayed from aircraft. This represents a simplification from the logistics point of view, and a research programme has been under way for some years to determine what products and what quantities will be most effective in destroying the Simulium larvae while doing the least harm to the rest of the fauna. Best techniques Trials have been made to discover which aerial spraying techniques are best adapted to conditions in the Volta river basin and the results obtained so far make it possible to envisage widespread campaigns in the very near future. The experience thus gained will be of value also in attacks on onchocerciasis foci in other tropical regions. However, the spraying techniques may have to be adapted to local situations, particularly in Africa. Longer-term re- search work may succeed in perfecting bio- logical methods of controlling the carrier- flies, thus reducing or even eliminating the need to use insecticides. A large number of national services and various United Nations bodies and regional organizations have also contributed con- siderably to limited campaigns to control the disease, thus establishing scientific and technical bases on which region-wide on- chocerciasis control operations with socio- economic objectives can be established. Enough is already known to make it pos- sible to set up such campaigns on quite short notice. The most difficult problems are those of long-term multinational finan- cing. For their solution, concerted action by both wealthy and developing countries will be needed. ■ In the endemic area of the Volta river basin it is estimated that there are 70,000 blind. (Photo WHO/P. A. Pittet) 9 Facts about RIVER BLINDNESS Onchocerciasis or river blindness is an infestation with Onchocerca volvulus, a filarial (threadlike) worm. Each female lives 15-16 years and produces about one million larvae (microfilariae or mf) annually. A free-living period is followed by confinement in fibrous nodules under the skin of the scalp, ribs, etc. A heavily infested person may harbour hun- dreds of worms. Mf live for up to two-and-a-half years. They circulate in the skin, and several hun- dred may be found in one milligram of skin. They also penetrate the eye, where they can be seen swimming in the anterior chamber and are found in the cornea, retina and optic nerve. The ill effects of onchocerciasis are due mainly to host reaction around dead mf. In the skin, the elastic layer is destroyed, giving an appearance of premature old age, and this may cause itching so severe as to lead to suicide. All parts of the eyes, alone or in combination, may suffer damage resulting in blindness. Recently, mf have been found in other parts of the body too. Onchocerciasis is not a fatal disease and even blind persons may survive for decades. But lowered life expectancy is seen in hyperendemic areas, in which more than 10 per cent of the entire population, and more than 20 per cent of the adult males, may be blind. The disease is widespread throughout tropical Africa, and in the Americas in Guate- mala, Mexico and Venezuela; recently it has been found in Colombia and Yemen. It may have been transferred across the Atlantic with the slave trade, but there is some evidence that it existed in Guatemala before the arrival of the Spanish. It is estimated that 20,000,000 people suffer from onchocerciasis. Blindness rates vary, but in the endemic area of the Volta river basin in west Africa there are thought to be about 70,000 adults with "economic blind- ness" out of a population of 10 million. How is it transmitted ? Onchocerciasis is transmitted by the bites of several species of Simulium. These are small sturdily built flies, 2 to 6 mm long, whose immature stages, egg to pupa, live in running (and therefore highly oxygenated) water. Because of the breeding habits of its in- sect vector, onchocerciasis is distributed in river valleys, hence name river blindness. In Central America the vector breeds in small streams, particularly on coffee estates. Simulium species bite superficially and pick up mf, which then undergo development in the fly before becoming capable of infecting other human beings bitten later on by the same fly. Simulia often breed rapidly and form enormous swarms, specially in areas where breeding is seasonal. For this reason, and because of the irritating nature of their bites, they are probably the worst insect pest in the world. In many areas of Europe and North America, their breeding has to be controlled to protect human beings and domestic ani- mals from bites. In hyperendemic areas, blindness in 20 per cent or more of adult males often lowers farming capacity below survival level. Partly because of farming failure, partly because of the intolerable nuisance of Simu- lium swarms, river valleys eventually become deserted. Upland areas, which usually have less fertile soil, become overcrowded. This process has direct economic effects, especially in sub-Saharan west Africa. Fishing in rivers infested by Simulium may be impossible or may lead rapidly to blindness. Thus a valuable source of protein is lost. Labour forces engaged in activities such as dam-building in Africa have had to be 10 Fishermen are especially exposed. Some rivers are so heavily infested with flies that fishing is practically impossible. (Photo WHO/P. A. Pittet) protected against the attentions of Simulium, at considerable expense. Is it curable ? Two drugs are available for the treatment of onchocerciasis. Suramin, given by intrave- nous injection, kills the adult worm but must be used with caution because of toxic effects. Diethylcarbamazine kills mf but not adult worms. It may give great relief by killing the load of billions of mf, even if they accumulate again. Established blindness is usually un- treatable, by drugs or surgery. Loss of vision can often be arrested, and spectacular im- provement sometimes occurs, with drug treat- ment of selected patients. However, only a minute proportion of all cases of ocular on- chocerciasis are seen by doctors and offered treatment. Research to discover safer and more ef- fective drugs is proceeding on a small scale, but needs to be increased (which means, of course, that much more money must be devoted to it). In Central America, excision of nodules has been practised by specially trained teams for more than 40 years. Transmission has scarcely been affected, but blindness is now rare. Because of the sheer size of the prob- lem, this measure would not be possible in Africa. The only effective method of control, at present, is to attack the larval stages of the flies by adding insecticides to the water in which they breed. Biological control is still in a very early experimental stage. Because breeding takes place in running water, in ideal circumstances the same dose of insecticide may kill the larvae for over 160 km along a steadily flowing river. Normally, runnels in small streams have to be found and dosed individually. Simulium larvae are intensely susceptible to insecticides. DDT has been used for many years in Kenya, Uganda (the Nile), Zaire (the Congo) Nigeria (the Niger), Ghana (the Volta) and Canada, without causing ill effects to other fauna. Biodegradable insecticides are now available in place of DDT, without the risk of lasting contamination of the environment. In Kenya, the vector, Simulium neavei, was actually eradicated, river by river, and transmission was stopped permanently. This species has a short flight range. The predomi- nant African vector species, Simulium damno- sum, easily flies great distances from one river to the next. If the control of Simulium damnosum is to be permanent, it must be planned as a co- ordinated operation over a complete river basin which can be isolated from neighbour- ing basins. Following requests for assistance by the governments concerned, the Volta river basin, an area of 700,000 square kilometres comprising parts of seven countries — Mali, Upper Volta, Niger, Ivory Coast, Ghana, Togo and Dahomey — has been chosen as the first area for control. A special mission, financed by the United Nations Development Programme (UNDP) with the active interest of the World Bank and carried out by WHO with close co-operation from the Food and Agriculture Organization of the United Nations (FAO), has recently reported in detail on the Volta basin control project. The work is likely to take 20 years, but is regarded as perfectly practicable. The economic benefits in terms of money alone will justify the cost; moreover, the report emphasies that a country such as Upper Volta cannot support its population without a return to valley farming. Control methods developed in the Volta basin will be applicable, directly or indirectly, to the other endemic areas in the savannah regions of Africa. ■ 1 1 IMMIGRANTS IN EUROPE "The number of migrant workers and their families in the countries of western Europe is thought to be 11 million and the total number of such workers in seven of these countries is estimated at about 7 million, distributed more or less as follows: Federal Republic of Germany: 2,350,000; Belgium: 220,000; France: 1,700,000; Netherlands: 125,000; United Kingdom: 1,560,000; Sweden: 220,000; and Switzerland: 900,000. The pattern of this migratiOn is highly varied as regards ethnic origin, cultural background and language." These filets and figures are taken . from a report of the International Labour Organisation. The immigrants come from many countries—Italy, Greece, Spain, Portugal, Turkey, Yugoslavia, North Africa (mainly Algeria), Africa south of the Sahara, Pakistan, and the West Indies. Large-scale migration is nothing new. Between 1846 and 1915, more than 31 million inunigrants settled in the United States, but these earlier movements were of a different character; then, immigrants were more rapidly integrated into the host country and many of them began their active life on almost the same footing as their new compa- triots. It often happens today that onlv the lowest job is available to the immigrant worker. Immigrants in fact form an underprivileged group with health problems of their own. Their housing conditions may encourage disease, especially tuberculosis. In theory they have the same access to the host country's health services as anyone else. In practice, because they are ill-informed, because of the language barrier and because of a xenopho- bia they fear to come up against, they may use the health services only as a last resort. Three articles in this issue deal with health aspects of immigration.Their aim is to draw attention to a health situation that has its international aspects. WHO's Regional Office for Europe is to hold a meeting in Algiers in November 1973 to suggest action to protect the health of migrant workers. PARADOX IN BRITAIN by DR DONALD GOULD Native Britons have managed to find a wide variety of reasons for arguing that the inflow of immigrants from the former British Empire should be drastically reduced, or halted altogether, or even reversed. One of the sticks commonly used to beat the unwelcome immigrant is the assertion that he brings with him serious and peculiar health problems, which not only pose a threat to the indi- genous population but also place a heavy burden upon the country's National Health Service. How far are such fears justified? Immigrants do have medical problems of their own. Some of these are certainly due to the environment in which they lived before coming to Britain. A very few may even be due to a genetic weakness, peculiar to a particular ethnic group. However, the ma- jority appear to spring from the special dis- advantages the immigrants experience as second-class citizens in their new homeland. The incidence of tuberculosis among im- migrants, for example, is enormously high- er than among British-born citizens. A few years ago a survey among Pakistanis living in the North-of-England industrial city of Bradford showed that they had 30 times the tuberculosis rate of native Yorkshire- men. Very similar figures have been estab- lished for both Pakistanis and Ceylonese in Birmingham. West Indians in Britain, on the other hand, have only twice the tuber- culosis rate of the native-born, a figure exceeded by the immigrant Irish, who are three times as prone to the disease. How many of these immigrants bring the disease in with them, and how many develop the infection after arrival, is un- known. A quarter of century ago tubercu- losis was still widespread in Britain, and was among the major causes of morbidity and death. It is now a far less serious disease in the prosperous countries for three reasons. The first of these is BCG vaccina- tion. The second is effective anti-tubercu- losis drugs, which make it possible to bring an infection under control and make the patient safe to other people within a matter of weeks. The third is the huge improve- ment in housing, nutrition and hygiene (including the hygiene of dairy cattle). Because of this virtually complete control of tuberculosis in some countries, Alan Woodruff, Wellcome Professor of Clinical Tropical Medicine in the University of London, now calls it a tropical disease. A number of immigrants are likely to have a tuberculous infection when they arrive in Britain. But, perhaps even more importantly, those infected upon arrival are likely to pass their infection on to their families and their fellow immigrants, since they so often have to live in overcrowd- 12 The onset of winter—an added hardship for the immigrant from a hot country. (Photo Camera Press ©) ed conditions, malnourished and in a state of poverty of a kind none but the most unfortunate native Britishers have known since the beginning of the Second World War. Moreover, certain immigrants, such as those from the rural areas of Pakistan, lack any natural immunity to the disease, so that if they come to Britain and are ex- posed to infection they are likely to deve- lop the illness in an acute form. A further proportion of immigrants may have an old tubercular infection which has become quiescent, so that they are apparently well at the time of their arrival, only to have the disease reactivated by the rigours of a sub- sistence-level existence in an all too often cold, wet country. BCG vaccination of young adolescents against tuberculosis is routine in Britain, and in his latest report "On the State of the Public Health", Sir George Godber, Chief Medical Officer to the Department of Health and Social Security, stated the off- icial view that the children of Asian immi- grants, being at special risk, should be vaccinated as early in life as possible. Leprosy is another disease of the tropics occasionally imported by immigrants, at the rate of about 50 or 60 cases a year, but with modern treatment almost all the suf- ferers can be quite rapidly rendered non- infective, so that at present only one insti- tution in Britain needs to provide beds for the few leprosy patients requiring hospital treatment. There have been no authenti- cated cases of the disease being contracted by anybody in the country because of con- tact with an infected immigrant. Perhaps the health problem which causes the most emotional reaction among native Britishers is venereal disease. The conservative British working man, grum- bling about the invasion of his community by strangers whose ways and attitudes he does not understand, is apt to tell and hear tales, as he drinks with his mates in the local pub, of the sexual prowess of his new West Indian neighbours. The locals, who may feel their mating rights and territory threatened, swop scandalous accounts of the manner in which these dark-skinned Lotharios have come into the country, rid- dled with VD, and have then set about ravishing the island women like the Viking invaders of old, spreading their infection through the land. Myths of this kind are readily estab- lished, and are next to impossible to dispel. It is, of course, true that some immigrants will be suffering from a venereal infection when they arrive. It is also true that many of then come from societies in which pro- miscuity is far commoner than it is imag- ined to be in this country. To this extent some immigrants may indeed make their contribution to the current and growing epidemic of venereal disease, but as one British epidemiologist has pointed out, the overall incidence of VD among the new- comers is appreciably lower than that among British troops stationed abroad. 13 :!.." 4-f , Paradox in Britain However, as this same authority reminds us, "any male, without family and friends, finds loneliness on an alien shore a great trial. The social approach to venereal disease in immigrants, by encouraging family immigration, ensuring satisfactory housing and other amenities, would reduce any influence that immigrants have on the in- cidence of venereal disease in this country." Other health troubles which afflict the immigrants more harshly than the native population can often be attributed to the conditions under which the new arrivals live, rather than to any naturally greater susceptibility to particular diseases. The newly arrived Asian or West Indian family finds it difficult (or impossible) to rent decent accomodation at a reasonable or any price at all. Since 1968, when Par- liament passed the Race Relations Act, it has been illegal for any company or organi- zation or private individual (from the vil- lage publican to the Bank of England) to discriminate against anybody on racial grounds. Genuine attempts have been made to enforce the provisions of the Act, and to achieve the egalitarian society which our legislators so piously planned. A Race Relations Board was established and charged with policing the observance of the law, and it went to work with a will. There was the actual and now legendary occasion upon which the Board instituted legal proceedings against someone who had put an advertisement in a local paper inviting Scottish cooks who could prepare authentic porridge to apply for the job of chef. The Board maintained that under the terms of the Act the advertiser had been guilty of an offence by specifying that ap- plicants must be Scottish. This ludicrous charge appeared a hilarious joke at the time, but it did lasting damage to the credibility of the Race Rela- tions Board, and illustrated the impossible consequences of attempting to control pre- judices, tribal attitudes and human rela- tionships by legislation. So the law has not succeeded in enabling coloured immigrants to find the sort of home their white contemporaries, earning the same kind of money and possessing the same kinds of skills, normally occupy. The result is that the immigrants are forced to find refuge in ghettos—whole districts of towns and cities taken over by landlords (sometimes immigrants themselves) who make a rich living out of letting single rooms in large old houses to entire families at rents commonly exceeding the sum a native Britisher must pay for a whole municipal house or flat. Why can't immigrants get these muni- cipal apartments? No local authority could afford to admit openly that it active- ly tries to keep immigrants out of its area. But it is easy for the officials of unwelcom- ing communities to increase the difficulties facing the newcomers who try to settle inside their boundaries. There is never enough housing for everybody, there never has been, and perhaps there never will be, so the demand for municipal housing always exceeds the supply. There has to be some way of working out priorities, and the commonest method is simply to estab- lish waiting lists. As homes become avail- able, they go to families which have been on the books for the longest period of time. But you can only get your name on the housing list of an area in which you already live, and in some places the waiting period may be as long as nine years. Clearly it is extraordinarily difficult for an immigrant family to establish the neces- sary residential qualification. They prob- ably have no family connections in a neigh- bourhood—people who might be willing to share a home with them— and the very nature of the lodgings they are forced to take means that they are likely to have to move every year or so when the house where they rent a room is condemned, or when the landlord finds he has an opportu- nity to do it up and sell it at a high profit, or let it at a higher rent to a wealthier client. So immigrants tend to have to move quite often, frequently into a new district, where they may add their names to the bottom of yet another housing list. The local authorities find it easy to ensure that few coloured families become their tenants, and they can do so without in any way offending against the provisions of the Race Relations Act. Thus a majority of immigrants—not simply those newly arrived, but even young second-generation settlers—have nowhere to go but the ghettos. This has an important effect upon their health. Their isolation from the rest of the community means that they tend to be out of touch with the medical and social services so familiar to the native Briton. A study con- ducted by two paediatricians at St. Mary's Hospital in London, which serves an area heavily populated by West Indians, showed that West Indian mothers make far less use of the clinics and other medical services provided for the benefit of their infants than do other mothers in the area. This happens despite the fact that the West Indians have, on average, much more need of the health services available. The principal cause of this anomaly seems to be a lack of effective communica- tion between medical and social workers and the mothers concerned. In a figurative, if not indeed a literal sense, the two sides just don't speak the same language. Many 15 Immigrants have their own particular medi- cal problems but, isolated from the rest of the community, they tend to be out of touch with the medical and social services. The agents of the welfare state also remain largely ignorant of the difficulties facing their immigrant clients. (Photo ILO) The Race Relations Act has not made it possible for coloured immigrants to find the sort of home their white contemporaries, earning the same kind of money and possess- ing the same kinds of skills, normally occu- py. For the majority, the only choice is the ghetto. Colour prejudice is a continued emo- tional strain, while subsistence-level exis- tence in a cold, wet country' makes immi- grants particularly susceptible to tuberculo- sis. (Photo ILO) of the agents of the welfare state remain largely ignorant of the peculiar difficulties facing their immigrant clients; and the cli- ents, for their part, have little understand- ing of either the extent or the limitations of the services to which they are entitled. This has two unfortunate results. In the first place the social and medical services are under-used by immigrants because of the shyness and disillusionment that lack of effective communication engenders. Secondly, those who do persevere and seek help are sometimes given wholly inappro- priate advice. The authors of the St. Mary's study cite these instances : "If a mother has an infant with diarrhoea, for example, advice about hygienic precau- tions is not likely to be effective if the lavatory has to be shared with 15 others; nor can advice about activity and play be well received, when four children live with parents in a 12-foot-square room." Severely sub-standard housing, and lack of proper contact with the health and wel- fare authorities, also account for the fact that the complications of pregnancy (such as toxaemia and anaemia), stillbirths, and deaths among the newborn are all appre- ciably commoner among West Indian and Asian families than among their British neighbours. Ill-housing is also a principal cause of another complaint commonly made against the newcomers. A few British poli- ticians seek to bolster their arguments for stopping or even reversing immigration by claiming that African and Asian settlers in this country put an undue burden on the already overstretched National Health Service, to the grave disadvantage of the islanders. They back their claim by quot- ing the number of maternity beds occupied by immigrant mothers, and suggest that the strangers are pampered at the expense of the women of the country. Almost every British mother now has her first baby in hospital, but a large number have to bear subsequent children at home, simply because there are not enough obstetrical beds to go round. However, most immi- grant mothers (and some of them are pro- lific) have all their children in hospital. There is a simple reason for this apparent inequity. Too many immigrant families live in one room, and a roomful of people cooking, eating, sleeping, arguing, wash- ing, sneezing and watching television makes a pretty poor labour ward. Apart from their greater susceptibility to certain physical complaints, there is also a strong suggestion that immigrants may be more liable to mental illness. This is hardly The British National Health Service depends to --> a considerable extent on immigrant doctors and nurses. (Photos ILO and Keystone (D) surprising if it is accepted that emotional stress plays any part at all in the genesis of diseases of the mind. Dr John Griggs, a lecturer in urban geography at Notting- ham University, decided to map the dis- tribution of schizophrenia in Britain when one of his relatives fell ill with the disease. He found that immigrants are five times more likely to suffer schizophrenia than the indigenous population. According to his survey the greater incidence of the dis- ease among immigrants cannot be solely due to the continued emotional strain which must result from living in a commun- ity where colour prejudice exists, because only 35 per cent of the schizophrenic immi- grants in his study were, in fact, coloured. It seems more likely that the general strain of adapting to life in a community with different habits and attitudes is the preci- pitating factor that triggers off an overt psychiatric illness in those of us unlucky enough to have a genetic disposition to such a disease. Finally, there is the tragic situation which faces a small minority of the chil- dren born to coloured immigrants in Brit- ain. All such children, as they grow up, have to face the humilation and distress of discovering that they are the members of a minority and a socially underprivileged group. They are therefore more hard put to it than most of us to sustain their confi- dence and courage. But most immigrant children at least have the support of their families and the fellow members of their ghettos. This support does not exist for the immigrant orphan, and a West Indian or Pakistani infant is just as likely to be or- phaned (or to be the unwanted child of an unmarried mother) as his lighter-skinned cousin. It is difficult to find couples willing to adopt coloured babies, so a number of parentless immigrant infants end up in the care of local authorities or are looked after by one of the well-intentioned but rather impersonal voluntary organizations that care for orphans. Perhaps this is the sad- dest plight that can befall anyone trans- ported from their motherland. Many of the problems sketched out in this article are common to other countries, but in Britain there is a unique and piquant counterpoint to the story of medical prob- lems of immigrants and the special difficul- ties their presence may pose for the medi- cal and social services. About half of the junior doctors staffing British hospitals, and at least as high a proportion of the nurses, are either permanent or tempo- rary visitors from the countries of the former Empire. If they all went home tomorrow, Britain's National Health Ser- vice would collapse. ■ 17 AN IMPACT ON HEALTH by Dr NUSRET H. FISEK Professor of Community Medicine, Hacettepe University, Ankara In 1971, the author studied the health aspects of labour migration in Europe as a member of a team of consultants for the European Region of the World Health Organization. He is well acquainted with the situation of Turkish workers and their families both at home and abroad. A last goodbye at the main railway station in Istanbul. (Photo WHO/T. Mohr) Very little specific and systematic epide- miological information is available about health and disease among foreign workers in Europe and this is also true of Turkish migrants. However, we do know some- thing about the health situation of Turkish workers in the Federal Republic of Germany, who face three main prob- lems : a slightly higher than average inci- dence of tuberculosis, a high rate of occu- pational accidents, and difficulty in obtain- ing psychiatric care when needed. Tuberculosis is a problem not only for Turks but for all foreign workers. It is mainly an outcome of the poorer living conditions of foreigners and the hardship they go through in adapting themselves to new working conditions and a different society. Also, although foreign workers given permits to work in the Federal Republic of Germany pass a strict medical examination and a great many applicants are refused because of abnormal chest X- ray findings, the percentage of foreigners with positive tuberculin tests is higher than among German workers, and this may be another reason for the higher tuberculosis incidence. In the case of occupational accidents, the frequency rate is generally higher among foreign workers than among Ger- mans. It was 129 and 72 per thousand respectively in 1969 in building and civil engineering industries. (In the same year, the ratio of accidental deaths from all causes was 4.2 times higher among male foreigners and 2.0 times higher among female foreigners than among Germans.) These higher accident rates among foreign workers are attributed to their failing to understand safety regulations, to their seeking hazardous jobs to earn more money in a shorter period of time, and to their not being familiar with factory work- ing conditions. Accident and death rates for Turkish workers are, however, lower than for many other foreign workers. The third and perhaps major problem is the difficulty in obtaining proper psychia- tric care when needed. The reason for this difficulty is the language barrier. Although no statistical information is available, Tur- kish physicians practising in Germany report a high incidence of psychiatric problems among Turkish workers and their dependents. This is perhaps to be expected in view of the social and psycho- logical stress caused by adaptation difficul- ties. The above observations, of course, do not mean that Turkish workers have no other health problems or that their new life has no positive effect on their health situa- 18 tion. Since environmental conditions, medical care facilities and health services in the European countries are far better than those in Turkey, and since Turkish workers and their dependents enjoy the same rights and privileges as native work- ers, they and their dependents run less risk of being ill than in their own country and have a better chance of obtaining medical care when they need it. Nevertheless, the language barrier is a serious limitation. It is not possible to ignore the fact that those workers or their dependents who cannot speak and understand the language of the country in which they reside and work are unable to use the available services proper- ly. This is especially true of psychiatric cases, and utilization of health services for periodic preventive check-ups is also poor. Turkish workers and their dependents in Europe are in great need of health educa- tion in nutrition, child care, personal hygiene, family planning, and so on. Such education is either not given to them at all or given very rarely, the main reason again being the language barrier. The groups at greatest risk are those working illegally in Europe. They enter the European countries as tourists, seek em- ployment and are hired illegally. In such cases, they are not insured and have no right to the privileges and security other workers enjoy. They also live in fear of deportation, should they be discovered by the police. As a consequence, they usually avoid going to a doctor or to the hospital when they are ill. Since they are paid a lower salary than workers with legal per- mits their living conditions are also poor. However, we should not underestimate the positive impact of migration on the health of migrant workers and their fami- lies left at home. The socio-economic changes (the most fundamental determi- nants of health level) caused by labour migration go deeper and wider than its immediate effect on health. In 1971, I met a Turkish worker in Brussels. He told me that he had been working in a coal mine in Belgium for eight years and that he had become a foreman. Here is his story, in his own words—it exemplifies the effects of social change on the life of a worker and his family and on their health : "I was born and brought up in a small village in eastern Ana- tolia. I married after completing my mil- itary service. My land was small and poor. I had to leave my village and find a job to support my family. I worked in Istanbul as a porter. I could not earn much, but I had to save some money to send my wife. When I had saved enough, 19 I Group medical examinations in Istanbul for prospective workers in the Federal Republic of Germany. The entire series of tests takes two days. Left and right, on the second day, exami- nation of fingers, joints, shoulders, backs and feet, including a search for hernias and scar tissue. Below, a sight test. Eleven doctors ex- amine a total of 800 applicants per day. The doctors are German. Their assistants interpret into Turkish. (Photos WHO/J. Mohr) I went back to my village and lived with my family for a month or two, then went back to Istanbul to work. Many a day, my family and I could have only one meal. "I was told that the Government was sending workers to Europe and that wages were very much higher than what I was earning in Istanbul. I applied for a job in Europe and I was sent to Belgium. While working in Belgium, I was able to send more money to my wife and save more as well. Within two years I had enough money to buy a house in Istan- bul for my family. "I went back to my village and took my family to Istanbul. My dream was to educate my children. I am happy my dream has come true. My children are going to school and the eldest is attend- ing the university. I shall keep working in Belgium until I retire. Then I shall go back to Istanbul. I shall buy some pro- perty with my savings and open a shop." There is no need to say that this worker and his family have a healthier life than before. Peker, a social scientist who has studied the effects of labour migration in a pro- vince in western Anatolia, has pointed out that butter, cheese, and eggs are not sold in the town market any more. They are bought and consumed in the villages by the families of workers working in Europe. These families have also become the best customers of the town shops. Peker also studied the possession of household com- modities. He found that 84 per cent of the families of workers working in Europe have radios, record-players, and tape- recorders; 95 per cent have butane-gas stoves; 17 per cent have refrigerators. The other families had far fewer of these items; there was no comparison. Yet not all the families left behind are so fortunate. The husband of A.T. has been working in Germany for ten years. She lived in the home of her parents-in-law. Her husband sent 1,000 Turkish pounds (approximately 70 US dollars) every four months for three years, but this was not enough for her to live on and she had to work. Her husband has been back to Tur- key for a vacation only two or three times The German Recruitment Bureau in Istanbul. Applicants lake practical and theoretical tests for the various professions. Skilled workers are in greater demand than unskilled and can leave almost immediately. for the Federal Republic provided they are in good health. Left, brick- layers take an aptitude test. Those who fail can re-apply for jobs as labourers. Right, successful applicants receive their air tickets and 300 DM. Their families wait outside to hear the result. (Photos WHO/J. Mohr) during the ten-year period. Now he is not sending money any more, and she has heard that he is living with a German woman. She has applied to the court for a divorce and has gone back to her parents' home, with her children. Children, whether their father supports the family or not, are those most affected by labour migration. The difficulty of bringing up children without the authority of a father is the most frequent complaint of the women left behind. Labour migration is not limited only to men. Women, married or single, go to Europe to work as well. The number of Turkish women working in Europe is esti- mated to be around 90,000. A married couple usually apply for a job abroad at the same time. The woman, however, may find a job before her husband. In this case, she has to leave her children to the care of her parents or relatives. This deprivation of the care and affection of their mother may interfere with the children's mental and emotional life. The above case histories, though they illustrate the effects of socio-economic changes caused by labour migration on the health situation of families, give no idea of the magnitude of the problem. Today, Turkish workers in Europe are one of the largest groups, together with Italians, Spa- niards and Portuguese. Their number has risen from a few thousand in 1963 to over half a million now. They are spread through all the European countries, though the great majority-85 per cent—work in the Federal Republic of Germany. According to a study of 24,600 workers returning to Turkey for their vacation, conducted recently by the Turkish Labour Employment Agency, most are married but living alone in the country in which they work. The percentages of male and female workers abroad living with or away from their families, or living alone, are as follows : Male Married and living with Female their family 17.8 46.7 Married, family in Turkey 75.7 32.7 Single, divorced or widowed 6.5 20.6 It should be mentioned that the coal- miner in Belgium is not an exception in wishing to give a better education to his children. A study of Turkish workers in Germany made by Prof. N. Abadan demonstrated that the percentage of the workers who wish to send their children, both sons and daughters, to a university is very high-69 and 39 per cent respec- tively. According to the same study, 80 per cent of the workers are saving money to buy land or other property in their country, or to start a business when they return to Turkey. Thirty-five per cent stated that they are sending money to their families regularly, which implies that the socio- economic status of the great majority of the families left behind has not improved considerably as yet. However, since most Turkish workers do not plan to work in Europe for more than five years, and since they save money to improve their social and economic status when they return home, this may not be as serious a problem as it now appears. It should also be added that in 1972 workers sent back 740 million US dollars to Turkey, which amounts to 1,500 US dollars per worker. These obser- vations tend to show that the beneficial effect of socio-economic change on the health of the workers' families will not be a limited one. However one must also bear in mind that those who leave are the most skilled and the healthier, and of these a fair proportion are likely never to return to their homeland. The overall effect of labour migration on Turkish economy should also be consid- ered as a determinant of the health level of the country. The rate of population growth was not a serious problem in Turkey until the fifties because of the high death rate. Birth and death rates were estimated to be around 45 and 3.5 per cent respectively in the early forties. The death rate dropped to L6 per cent in the sixties as a result of the socio-economic development of the coun- try, and particularly as a result of malaria eradication and tuberculosis control pro- grammes run by the Turkish Government with the assistance of WHO and UNICEF. There was then a rapid increase in popula- tion which aggravated the employment problem, so that today the number of un- employed or underemployed persons runs to over a million. The possibility of send- ing half a million workers to Europe has certainly increased other workers' chances of finding jobs in their own country and of securing better living conditions for their families. The second positive effect of labour migration is seen in the foreign exchange balance. The foreign exchange reserve of the Central Bank of the Turkish Republic has now reached around a billion dollars. The availability of enough hard currency has facilitated efforts for the development of industries and the modernization of agriculture. The third positive effect is the accumula- tion of capital. It is estimated that the savings of Turkish workers amount to around 2,000,000,000 German marks. The workers are interested in investing their savings in industrial enterprises, and indus- trialists are also expanding their enterprises by establishing holdings open to the public. It may be concluded that labour migra- tion from Turkey has had a positive effect on the health status of the workers in Europe and their families, but their greatest problem remains under-use of the services available. In 1971, a health officer in Germany told me he had been horrified to hear that a Turkish worker had helped his wife deliver her baby at home. The man did this because he did not know enough German to ask his neighbours for help, nor where the maternity hospital was, nor how to take his wife to someone qualified to assist her. This is a good illustration of the fact that even though a service may be available, not everyone is equally likely to use it. This is certainly true of many of the migrants' families left behind in Turkey, who are insured for health care by the administrations of the countries where the migrant works. The administrations are prepared to pay their health bills submit- ted for the rest of the family, yet the num- ber of families who avail themselves of this privilege is still very low. ■ An impact on health Turkish women at the German Recruitment Bureau in Istanbul. They are asked if they speak any German and whether they have a relative already working in the Federal Repub- lic. Those who have worked abroad before are easily distinguishable by their dress. Women from the countryside still wear the traditional headscarf Men and women alike have a num- ber attached to their wrist for identification purposes. Later it is stuck to the jar containing their urine sample. The Bureau's laboratory deals with up to 800 blood and urine tests per day. About 2-3 per cent of the women are pregnant and have to be refused for this reason. X-rays are processed in 24 hours, usually in small format unless they reveal anything abnor- mal. Up to 6 per cent of the applicants have tuberculosis. (Photos WHO /J. Mohr) A CS. KAHI/ E .6 k liVF A SPANIARD ABROAD by Dr HANS LOS KANT In the autumn of 1964, Fernando Lopez decided to try his luck in a foreign country. In Spain, he applied to the recruitment centre of the Federal Repub- lic of Germany's Labour Institute, lthere he was tested and found suitable. That is how he became one of the 65,000 Spaniards who entered the Federal Republic as migrant workers in 1965. A new loneliness... (Photo WHO/J. Mohr) He came to a country that was already employing some 1,300,000 foreigners. Today, almost ten years later, about 2,350,000 non-Germans are working in the Federal Republic, and make up 10.8 per cent of the total labour force. There are considerable differences between the various Lander in the proportion of foreign workers they employ, which ranges from 16.9 per cent of the total labour force in Baden-Wurttemberg and 13.9 per cent in Hesse to 5.9 per cent in Lower Saxony. With the constant rise in the total num- ber of foreign workers, there have been considerable changes in their distribution by nationality. For many years, the Ita- lians provided the largest contingent, but were then dislodged from top place by the Yugoslays, who in turn have recently had to give way to the Turks. Today, Turks make up 22.4 per cent of the foreign labour force, Yugoslays 19.9 per cent, Italians, 17.5 per cent, Greeks 11.4 per cent, Spa- niards 7.7 per cent, Portuguese 2.9 per cent, and North Africans 1.2 per cent. Other countries account for 17.0 per cent. About 700,000, or 30.1 per cent, of the foreigners employed in the Federal Repub- lic are women. Fernando Lopez arrived in Frankfurt early in 1965 after a long journey with 40 of his fellow-countrymen. He was met by a representative of the personnel department of the chemical firm which had engaged him. He and his fellow-migrants were in- stalled in one of the "men only" hostels run by the firm. Fernando Lopez was surprised to find that, although he shared a room with two Spaniards, there were Germans, Italians and Yugoslays in neighbouring rooms. Bringing the nationalities together in this way was decided on after a great deal of thought. When the authorities realized that the labour shortage in the Federal Republic could not be met from a single country and that workers from many countries would have to be recruited, the question arose whether to accommodate each national group separately or to pro- vide mixed quarters. Accommodation by nationality was op- posed on the grounds that it was impos- sible to apply the same principle in the factory. Furthermore, there was the danger of the development of ghettos. It was believed that mixed accommodation would promote mutual acquaintance and understanding, and also encourage the workers to learn German more quickly. Fernando Lopez remembers the trouble he had at first in communicating with oth- er hostel residents in the washroom and in 26 the kitchen. The latter was a particular surprise for him and his workmates, as well as a relief. During working hours they ate the factory food—plentiful, but pre- pared in the German way. On each floor of the hostel they found a communal kitchen equipped with electric hotplates and a refrigerator with lock-up compartments. Here they could prepare their own food in the evenings and at weekends. At a briefing session on the first working day, the new arrivals were told about the nature of the company, the kind of work they would be doing, their rights and duties under the staff regulations, safety questions, and the way of life in their new country. The factory medical officer ex- plained to them how to adapt their diet and clothing to the different climatic and working conditions of the Federal Repub- lic of Germany. Before Fernando Lopez started work he was examined again by the works medical officer, though he had already been screened by the Federal Labour Institute's German doctor in his own country. The regulations make it compulsory to ex- amine workers again in the Federal Republic with a view to their fitness for certain tasks in the factory. The doctors employed in the recruitment commission are not authorized to do this. Because of shortage of time, they are unable to carry out the special examinations sometimes required, and temporary illnesses that im- pair fitness may appear during the journey. The many types of work in the chemical industry make very different demands on health. For instance, shift work is often necessary, and the operation of units and machines whose controls are normally ad- justed to standard German or North Euro- pean sizes imposes a strain on the skeletal and muscular system of workers from Mediterranean countries, who are general- ly shorter. The examination by the indus- trial medical officer makes it possible to decide on the most suitable work for each person. Fernando Lopez was found to have no health problems restricting his employ- ment but since he works in a factory that processes toxic substances he is subject under the regulations to regular health checks. Many foreign workers, despite their more favourable average age, have higher sickness rates than their German counterparts. Several explanations have been advanced for this, such as a greater susceptibility to nostalgic feelings during the settling-in period and the change in diet. Also, large companies have a greater turnover of staff and a larger number of 27 new arrivals, all of whom need an adapta- tion period. Other factors are the greater anonymity of large companies and the bet- ter social insurance they provide. Like most of his foreign workmates, Fernando Lopez was first employed on simple labouring jobs—carrying materials, emptying presses, and so on. He had an accident, though not a serious one. For- eigners are at greater risk than German workers owing to their imperfect knowl- edge of the language and their unfamiliari- ty with industrial procedures. They receive their first instruction in accident preven- tion as soon as they start work, and safety signs are posted in each language. Although most foreign workers can read, some have received very little school- ing. According to a survey conducted by the Federal Labour Institute, about 6 per cent of foreign men and 9 per cent of foreign women employed today in the Fed- eral Republic have never attended school. About half of them have had at least six years of schooling. In accident prevention campaigns, in- creasing use has accordingly been made of symbols. In the factory itself, the situation in general has improved because the core of long-serving foreign workers is con- stantly growing and many of them have a good knowledge of German. This makes it much easier to integrate the new arrivals. According to the Federal Labour Institute, some 22 per cent of foreigners now have a good knowledge of German, 35 per cent a reasonably good knowledge, and a further 31 per cent know at least a few words. By the spring of 1972, about half of all foreigners had been in the country for four years. Many have sent for their families to join them, and about a million dependants must be added to the 2,400,000 foreign wor- kers at present in the Federal Republic. Fernando Lopez also decided to bring his family. In 1967 he found an attic with a small adjoining room in an old house. Here he lived as best he could with his wife and two children. His living conditions were much worse than in the hostel, but he had his family with him. He was also act- ing on the belief—as many others did and still do—that his official application for accommodation was more likely to be favourably received if he could demon- strate a serious accommodation problem. This problem soon became very acute when the third child arrived. Fernando Lopez turned to the foreign workers' rep- resentative on his factory council —an Ita- lian who under the industrial relations code was released by the firm for council activities—and to the company's advisory centre for foreigners. With their assistance he filed an application and after a time was assigned a three-roomed flat with bath- room and kitchen. A number of Germans and Italians lived in the same building. Here again the fact- ory follows the same principle of mixed accommodation, although it sometimes leads to difficulties. For example, the poli- cy is that children of foreign workers should be integrated in German schools, but divided up into separate national groups for tuition in their own culture and language. However, this is possible only if sufficient children from the same country live within a reasonable distance of each other. Such problems have to be taken into account when accommodation is assigned, as also must the question of rent. Further- more, despite the severe housing shortage it is often difficult to persuade people to leave their old rooms and move into mod- ern accommodation. The provision of housing and the prevention of slum devel- opment constitute one of the most difficult tasks the Government faces. Pre-school and school health care for children of foreign workers is a task for the authorities. Out-patient medical care could be improved, perhaps by employ- ing more foreign doctors authorized to practise under the compulsory insurance schemes. The valuable efforts of churches and charitable organizations, which have set themselves the task of providing foreign workers with social care and assistance in all areas of life, need considerably more material assistance than they have so far received. The integration of first-genera- tion workers could be speeded up by in- cluding more foreigners in local adminis- trative bodies and in the social insu- rance agencies. In industry, this policy has already proved effective, with the appointment of foreign workers as works council representatives and as security officers. Both industry as a whole and the Feder- al German authorities consider it their re- sponsibility to keep a constant watch on the problems that result from migration, and to see that social services everywhere in the Federal Republic are the same for all. ■ A Spaniard abroad Some 2,350,000 foreigners work in the Federal Republic of Germany, about 11 per cent of the total labour force. Turks make up the largest contingent (22 per cent), followed by Yugo- slays, Italians, Greeks, Spaniards, Portuguese and North Africans. About 700,000 of the "guest-workers" are women. (Photo WHO/ J. Mohr) Foreign workers undergo two medical check- ups, one in their home country and a second on arrival in the Federal Republic. They have a higher accident rate than German workers, largely due to their poor knowledge of German and their unfamiliarity with work in industry. (Photo WHO/J. Mohr) 5 4 I. Wash-day at an immigrants' hostel. (Photo Comet CO Pizza is popular everywhere. ( Publi- foto ©) Italian workers at a social centre in Zurich. (Photo Comet Prayer in an airport. (Photo Ca- mera Press ©) A news-stand in Wolfsburg, Fede- ral Republic of Germany. (Publifoto (0) Training course for workers in Switzerland. (Photo Comet ©) 3 6 74 M M M _. Immigrants in Europe, page 12. (Photo WHO/P. Almasy)