Summary reports on meetings 1983

Summary Reports on Meetings WHO Regional Office for Europe SUMMARY REPORTS ON MEETINGS 1983 WORLD HEALTH ORGANIZATION Regional Office for Europe COPENHAGEN 1984 ISBN 92 890 1024 X © World Health Organization 1984 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto , of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen q, , Denmark. The RegioI16l Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory , city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in these reports do not necessarily reflect the deci- sions or the stated policy of the World Health Organization. PltlNTED IN DENMARX This collection of summary reports is intended to provide health administrators and other health professionals with a convenient guide to the proceedings and findings of meetings organized by the Regional Office for Europe in 1983. Separate editions in English, French , German and Russian are available. The Regional Office will be pleased to supply additional in- formation on any of the activities described in the reports. ACCIDENTS APPROPRIATE TECHNOLOGY FOR HEALTH BASIC SANITATION CHEMICAL SAFETY COMMUNICABLE DISEASES ENVIRONMENTAL HEALTH FAMILY PLANNING FOOD SAFETY HEALTH ECONOMICS HEALTH EDUCATION HEALTH LEGISLATION HEALTH OF THE ELDERLY HEALTH PLANNING AND EVALUATION HEALTH SERVICES RESEARCH HEALTH MANPOWER INTERNATIONAL WATER DECADE LIFESTYLES MENTAL HEALTH MODEL HEALTH CARE AND QUALITY ASSURANCE NUTRITION OCCUPATIONAL HEALTH ORAL HEALTH PRIMARY HEALTH CARE PUBLIC INFORMATION SELF-HELP AND HEALTH SOCIAL EQUITY AND HEALTH WASTE MANAGEMENT WOMEN AND HEALTH CONTENTS page 1 9 17 25 35 45 57 65 75 91 97 103 115 121 129 143 151 161 177 185 189 197 201 205 20~ 217 227 231 - 1 - ACCIDENTS Symposium on Accidents in Europe Newcastle-upon-Tyne, 12-16 September 1983 Introduction - 3 - ICP / ADR 030(5) 2519E 18 Octobe r 1983 ORIGINAL ; ENGLISH The Symposium was hosted by the City a nd University of Newcastle-upon-Tyne, and the Department of Health and Social Security, London . There were 35 participants from 21 European Member States. They were joined in a work ing partnership by 20 represent a t ives of other o r ganiza ti ons , and by 31 temporary advisers. Over the five days, 25 papers were presented . They began with a general review of accide nt s in Europe and continued with papers on road traffic accidents, the effect of alcohol and drugs on driving, home accidents, sports accidents, accidents and their prevention in children, accidental poisoning, accidents to the elder l y, the biomechanics of injury, the acciden. trauma process and its long-term effects, the relationship of design to accident s , standards in the design for safety , educati on for safety, intersectoral coordination, the role of nursing in accident prevention, envi r onmental o r behavi ou r modification, and the political will. One of the most valuable as pects of this Symposium was the fact that so many disciplines and professions were represented, including e ngineers, socia l scienti s t s, eco nomists, urban designers and planners, politicians, administ rators, and members of th e health profession, such as nurses, clinical and community doct o r s, a nd psychologists . Conclusions l. More comp r ehensive and comparable methods of data collection are essential for the prevention and management of accidents . This is of paramount impo rt ance in justifying the need for a proper allocation of r esources . In this connection , WHO's search for a basic da t a se t that recognizes all aspects of the accident/injury process is to be welcomed. This data set s hould include the measurement of the long-term consequences of acciden ts, t o aid the rehabilitation of individual victims and to assist in defining preventive st r ategies. This will involve inco rporating the revised ve r sion of the International classification of impairments, disabilities and handicaps, and Chapter 17 a nd the E codes of the International classification of diseases . 2 . Modifications of the e nvironme nt and of behaviour are complemen t a r y not alternative approaches to preventing the continuing carnage on the roads. They will involve improving safety in the design of vehicles and the e nviro nm e ntal infrastructure , and modifying personal behaviour by r estraint s o n s peed, control of alcohol when driving and the correct use of safety devices. Where chi ldre n are concerned wo rk in the United Kingdom ha s shown that drivers ex pect children to exercise restraint: this points clearly to the drivers' need for education . Yo ung adults on mo t o rc ycles and mopeds appear to be a t particular risk of death or se ri ous injury in many countries and strenuous efforts need to be made to reduce this toll . Lo ng- distance drive rs crossing state bo unda ri es are a special problem as they appear t o be overrepresented in accident statistics. It has been sugges t ed that their working conditions or desire for maximum remune rati on may lead to ove r-tire dness and the taking of stimulants . The speed of vehicles is a crucial e l ement in traffic accidents and its restric ti on is clearly indicated . The presc ribed limits may vary between Member States but they should be effec tively e nfo rc ed; and the education of the public i n the be nefits of s peed limits shou l d also be pursued . Nevertheless, well-planned sta t e highways have ac h ieved a ce rt ain measure of safety, and attention has now moved to smaller road s in urban areas . - 4 - 3 . Accidents in the home are less conspicuous than those on the road and have consequently received less attention. Both the young and the aged are commonly involved, and as these groups are less able to voice their own needs they have had low social priority. Yet, home accidents are far from trivial. There is a need for epidemiological research, comparable to that carried out for road accidents, to establish the facts. Modification of the home and domestic facilities and the education of parents with young children should be the main approach to their prevention. 4 . In contemporary society there is, and will increasingly be, more time for leisure pursuits. In addition, exercise appears to be beneficial for health and the two processes have led to a massive increase in participation in sport and consequently in sports-related accidents . Only a minority of such accidents occur in high performance sports, the majority affecting the beginner without the necessary training . The study and subsequent prevention of ski injuries should act as a model for other sports. Health personnel should be educated in the recognition and management of sports injuries . S. The prevention of sports injuries should begin in schools, but there is a paucity of data not only on school sports accidents but on accidents in the classroom and school grounds . This is in part due to the low prestige of school health and the school health services in many countries. This is an area that warrants further study. 6 . Alcohol is known to be a major causal factor in road accidents and it may also have a significant role in home accidents. This is another area where careful epidemiological studies are called for. It is clear that the control of this problem will involve legal sanctions; and an important issue is that, whatever restraints are chosen, both the public and the government should be well prepared so that the measures are accepted. Alcohol in relation to driving is one facet of the much deeper problem of alcohol dependence in the lives of many individuals. 7. The effect of drugs on accidents both on the road and in the home is virtually unknown. Although many drugs are known to affect "driving-related" behaviour, extrapolation of this finding is not justified with our present state of knowledge. Further investigation is urgently required. 8. There is a stubborn resistance in developed and developing societies to face the full costs of accidents and their prevention, pointing to a continuing need for education . The basic reason is that accidents are regarded as the unfortunate side-effects of a congenial lifestyle to which we have become deeply attached. Preventive programmes should be related to the developmental stage and specific hazards of each age group, from infancy to old age. It is essential to heighten and maintain an awareness of accidents in all communities so that active preventive measures will not only be acceptable to the public but demanded by them. The main target groups are young children and the aged in the home, and young adults on mopeds and motorcycles. Educational programmes need critical evaluation, but the time scale of human change is such that instant returns cannot be expected. The targets for teaching should include the parents of young children, school teachers, medical students, doctors, nurses, the designers and maintainers of the environment, the police and politicians. In view of the special educational role of teachers and examination should be made of what they are currently taught necessary. The provision of modern teaching aids will help. and health education is desirable. health visitors, a critical and proposals made for improvements if A closer collaboration between safety 9. In view of the increasing passage of goods across state boundaries, which is one of the principal aims of many intergovernmental organizations, the search for equity in product safety standards is essential. 10. Safety must be bought and the available resources are limited. The costs and benefits of the preventive measures used must be assessed as precisely as possible . This assessment should include human suffering as well as social and economic disadvantage, and damage to property . 11. Most accidents have multiple interrelated causes: environmental, personal and social. Their prevention calls for multidisciplinary collaboration, an approach that is not easily accepted and that needs to be learned. The first step is to create "windows" between the disciplines so people can talk to each other . This intersectoral dimension raises the question of wider coordination. Several Member States have set up national bodies for this purpose. They can be both government initiated and independent of government, but it is important that they are accepted by both the public and the government and have the authority to act. - 5 - Coordination at the national level should go hand - in- hand with a local community-based approach because· the success of any programme depends on strong involvement at the local level . 12. Accidents are a worldwide problem and it is clear that international cooperation is required in the coordination of research and the dissemination of knowledge. 13. There is a continuing need for fundamental research into the nature of accidents. Nevertheless, if the best is not to be the enemy of the good, then acceptable knowledge should not wait too long before it is translated into preventive policy. Thus the sceptical researcher and the reforming politician must find common ground by working together and finding a common language. 14. The biomechanics of injury and protection from it are now well understood. Accidents occur only very rarely in terms of the number of observations or actions undertaken by road users, i . e . 30 million actions for every injury-producing accident . Vulnerable groups can now be clearly identified and the stage has been reached when limits for "acceptable" severity of injury must be defined. 15 . Elderly road users appear to be at significantly greater risk than those in the 25-64 year age group. It seems that countries that have energetically tackled the road accident problem in general have done so to the relative disadvantage of the elderly. Pedestrians are at particular risk, although cyclists are also a major problem in some countries . Home accidents to the elderly are a significant cause of trauma and long-term disability . Existing studies indicate that falls are of prime importance. Any further work should take account of the environment in which the elderly live, their degree of adaptability to changing situations and their increasing fragility. It is especially ~mportant that there should be a multiprofessional approach and that health service personnel should be included . 16. Nurses have a fundamental role to play in accident prevention. In many countries, they are an integral part of the primary health care team, and are often the first contact point with families . They should participate in all activities in accident prevention at all levels . 17. Acute poisoning especially in children gives continuing cause for concern. The use of child resistant packaging on medicines appears to be an effective means of prevention and the extension of the use of such devices to certain dangerous household products is indicated . Accident prevention programmes in Member States should include this . 18. Community participation is essential in both the development and the implementation of accident prevention programmes . The voices of the consumers and their representative bodies must be listened to . Reconunendations 1. Multisectoral coordination There should be a central State. This may or may not be and have the authority to act. complement this mechanism. coordinating mechanism for accident prevention in every Member goverrnient initiated but should be strongly supported by goverrment Conununity based multidisciplinary groups should be developed to Its area of responsibility should eventually include progranunes for the prevention of accidents of all types at all ages, and cove r both human and envirormental factors. Such programmes shou ld not be developed in isolation but should be an integral part of a state programme for the prevention of disease and the promotion of health and well-being within the framework of the strategy ~o achieve health for all by the year 2000. 2. Comprehensive infonnation systems WH0's work to develop a minimum data set should be supported as it is fundamental to the determi nation of the size of the problem and the definition of vulnerable groups within Member States. Member States should take part in this development by participating in field trials of the minimum data set that will begin in 1984. - 6 - 3. Epidemiology Further work in the epidemiology of accidents should be undertaken in conjunction with existing epidemiological studies in related fields, such as those that follow (though there will be others). Alcohol is clearly a major problem and further investigation of this factor in accident research should be encouraged with a view to supporting Member States in whatever measures of restraint seem appropriate and for which the community has been prepared. The elderly. Accidents to the elderly are also an area of major concern a nd further s tudies should be undertaken by multiprofessional teams including environmental scientists, gerontologists, road safety expe~ts, nurses, social workers, geriatricians, urban planners and the police . Drugs and medicaments. There is general concern that the large number of drugs that are now in common use in medical practice may be involved in the genesis of accidents both in the home and on the road. This is a matter that should be considered internationally. Long-distance drive r s. Investigations should be made into the special problems of long-distance drivers who cross state frontiers and who appear to be overrepresented in accident statistics . Young adults . The high mortality and morbidity among young adults riding motorcycles and mopeds gives rise to serious concern in many Member States and calls for urgent measures to reduce this alarming toll . 4 . Research There is a need for the wider dissemination of research and its findings, both completed and in progress. The possibility of producing a directory of such re search should be examined as part of the proposed WHO study of institutions and activities concerned with accidents and accident prevention i~ Member States. 5. Education We recommend that education for safety become an integral part of the general education, public information and health education programmes in Member States. There should also be an increased effort to include education for safety in the curricula of pre-school and school education programmes. The training programmes for all personnel involved in the multidisciplinary group activities mentioned in recommendation 1 above should include education for safety. 6 . Accident and emergency services We recommend the further development of comprehensive services for both immediate and long-term care with particular emphasis on the use of appropriate technology and the primary health care services, including first aid . 7 . Accidents to the elderly Increased multisectoral research (including a contribution from health service personnel) is needed into the special problems of the elderly . All safety programmes should take special note of the elderly and all studies should take account of the effects of the aging process. 8 . Accidenta 1 poisoning Programmes s hould include the prevention of accidental poisoning and take into account the success of child resistant co nt aine r s in decreasing thi s problem in young children . 9. Community participation An integral part of programmes for accident prevention should be the active involvement of consumer organizations. - 7 - 10 . Safety standards Safety standards should be widely applied to prevent accidents of all types and c ontinual efforts should be made to reach common international standards . 11 . Developing countries There should be special arrangements for accident prevention programmes in developing countries that take account of their special needs . 12. Background papers The papers that formed the basis for the discussions and recommendations of this Symposium should be compiled and made available as further reference for the goverrments of Member States. - 9 - APPROPRIATE TECHNOLOGY FOR HEALTH - 11 - Workshop on the Organization of a Health Technology Assessment Network in the European Region The Hague, 30 May - 1 June 1983 Introduction ICP /ATH 010(4)(S) 23481 10 October 1983 ORIGINAL: ENGLISH The use of high technology eq uipme nt and methods in health care is rapidl y expanding. But it is threatened by national cutbacks, the international recession and the rising costs of sophisticated equipment and specialized personnel . There is also g rowing concern about the undes ired s ide-effects of these technologies. Objective asse ssments must be made of their cost-e ffective ness and their likely benefit to the health of individuals and the ove rall popu lation. On l y then can policy-ma! r s make informed choices about which equi pment o r method to i nvest in a n d which th ey can do without. Becau se of this need fo r technology assessment, it was dec ided at a WHO meeting in Budapest in 1982 that an international network o n h e alth technology assessment o ught to be set up. A WHO me e ting was then held in The Ha g ue on 30 May - 1 June 1983 to decide: how technologies should be assessed; how they should be selected fo r assessment; how to ensure that the assessment re aches policy-makers, physicians, patients and the public; a nd how to ensure they understand it . How to assess technologies The assessment of health tec hnology is a complex mu l tidisciplinary task. Methods of a ssessment and the whole idea of technology assessment are by no me a ns widely accepted . Many medical technologies in use today have neve r been evaluated a t all a nd there a re more new t ech nologies appearing e very year . Te chnologie s should be assessed fo r their effects o n healt h , th ei r risk s, their costs a nd th ei r social acceptability . As an exampl e, here are some .of the ques tions that ought to be asked about controversial technologie s used in pre gnancy and childbirth, s uc h as electronic fetal monit o ring , amniocentesis, ultrasound a nd Caesarian section: does the technology detect pro blems that have a serious effect o n health ? will the condition be g reatly improved by treatment? is the technology safe? i s it acceptable to th e woman? can we afford it? The assessment of technologies should also be continuous. Just as drugs undergo "post marketing surveillance" in the sense that doctors continue to feed back information on the effects of the drugs they prescr ibe even after they have been officially tested and launched o nto the market, so feedback on the utilization of technologies should continue even afte r the original assessment has been made. It is impor t a nt that this feedback s hould be used to e nc o urage i ndustry to readjust and improve the t ec hnologie s, as needed, and to help users towards a better understanding of them. How to select technologies for assessment Once an acceptahle method for assessing technologies ha s been worked out, the next problem is decidin~ which technologies need to be assessed first, since it would be impossible to assess every one available . There is no formal s y s tem for assigni ng priorities to them. One of the most important criteria s hould be that of cost, not just the cost of the individual technology, but its overall cost in the health se rvi ce bud get. Many s mall cheap technolog i e s c an cost the health services very much more overall than a few large and very expensive ones. Another important c riterion is of course their effectiveness. - 12 - The best way of identifying technologies for priority assessment is to set up a c lassificat ion system that can also be used for disseminating the assessments as they are made. This system should not be set up in isolation, but in collaboration with bodies such as the International Organization for Standardization and the International Electrotechnical Conunission. It should take into account the availability of the technologies and for whom they are intended . How to reac h policy-makers, physicians, patients and the public To disseminate the health technology assessments, this data bank of classified medical devices must be c r eated in a form that is readily retrievable. This involves deciding what should be stored, how data should be entered and retrieved, and who should run it (an international agency or various national organizations). The international network has a vital r ole to play in coordinating all this work, Members of the network could ensure that information is exchanged on how to assess technologies, what priorities have been given to pending assessments, how technologies have been assessed and how the assessments have affected policy decisions. They could also e nsure that gove rnment officia ls and experts are kept in touch with each other and that policy issues are discussed when necessary. The network should he open to all individuals and institutes who are actually engaged in health technology assessme nt as well as to anyone with an interest in the field . It would then be in a position to coordinate clinical trials, arrange collaborat ive studies among its members and follow up on the use of the technologies. What WHO can do The leadership of WHO is essential. It should e ncourage the appointment of a national ce nt re in eac h participati ng country . These centres could support the network in its job of collecting and disseminating information, and collaborate in te s ting new technologies in the fields of r adiology, laboratory and bioinstrumentation. WHO could also, fo r instance: maintain an address and telephone list of members of the network and a directory of the government age ncies involved in technology assessment; participate in the dissemination of cur rent information on health technology assessment; arrange periodic meetings of the network members and sponsor appropriate bodies to organize semi nars on technology assessment; purlish a newsletter for the memhers of the network or participate in existing ones such as The Sorcerer's Apprentice or the European Communit y journal Effective Health Ca r e and disseminate exis ting information on technology assessment through professional bulletins such as European Medical Physics News and the newsletter of the International Federation for Medical and Biological Engineering; and e ncoura ge the establishment of an international prize for excellence in sc holarship or scientific achievement in the field of technology assessment. What European Member States can do The countries of the Region have a particular role to play where the complexity of technologies would benefit from international collaboration. There are already a number of countries concerned with the problems of medical technology assessment. Expe rt committ ees are studyi ng the rising costs of health care with specific reference to the expense of hi gh technology equipment and others are considering the r ole of manufacturers, the possibility of increased standardization, and how to influence the behaviour of physicians as the prime consumers of medical technology . Education The final stage is convincing decision-makers and health professionals as well as the public , the media and industry to use the results of health technology assessments and to ensure that technologie s are allocated and operated correctly. To do this in an unbiased and informed manner they have to understand what the assessment means . The international network could assist by developing ed ucational programmes for everyone concerned with technology assessment. It could also develop a questionnaire to identify what is already being taught about the uses and effects of health technologies . - 13 - What is also very important is the context in which these technologies are chosen and applied. The education of decision-makers, producers, and professional and lay users should therefore also cover: the allocation of medical resources throughout society; the choice of appropriate medical treatment; collaboration among health care teams; the organization and coordination of health services; and the goals of the health care system. Consultation on Biosafety in the European Region Copenhagen, 25-26 November 1983 - 14 - ICP/ATH 005(S) 2819E 17 May 1984 ORIGINAL: ENGLISH The Consultation was convened by the WHO Regional Office for Europe and the special programme for safety measures in microbiology of WHO headquarters to ascertain the status of biosafety programmes in the Region and to propose a plan for the development or support of country-level programmes. The participants gave accounts of the biosafety programmes in their respective countries, including the resources available and the administrative arrangements. Some of the Member States, although having a sophisticated administrative and microbiological network, had only the beginnings of a biosafety programme. Where such programmes did exist, their activities tended to fall under one department or ministry, but occasionally came into conflict with other similar administrative structures with overlapping responsibilities. In recent years many individuals with different disciplinary backgrounds have moved into the field of microbiology as a result of developments in biotechnology, and these people need training in the safety aspects of their work. The production of the WHO Laboratory biosafety manual has given authority to local demands for action, but legislation may be needed in some countries before the recommendations can be appplied. The genesis and activities of the safety measures in the microbiology programme were described. The first phase had been confined to basic issues: shipments of specimens, safety cabinets, isolation techniques, all leading to the publication of the WHO Laboratory biosafety manual. Stress has been placed on procedures , not on buildings. Other efforts have been directed to training courses in various parts of the world . Biosafety collaborating centres are being set up and the next six-year WHO programme has been agreed on, Conclusions and recommendations Biosafety collaborating centres and their role Biosafety collaborating centres should be developed in every country to act as a focus for biosafety information and expertise, To balance their present geographical distribution, more collaborating centres are needed on mainland Europe, particularly in the south, A list of suggested responsibilities for collaborating centres was developed and discussed as follows, 1. Coordination is required between centres and national laboratories in the identification of biosafety needs by means of continuous data collection. 2 . There are considerable obstacles to international agreement on methods for exam1n1ng equipment in the European Region, but all equipment should at least be capable of simple decontamination, cleaning and handling without danger. 3, Countries should find out where potentially harmful biological substances are handled and where the expertise exists to deal with them. They should also ensure the classification of organisms and the registration of laboratories before they are permitted to handle organisms in risk groups 2, 3 and 4, 4, There may be a need to teach basic techniques, to train health inspectors and to "train the trainers". 5. Assistance to institutions in establishing biosafety programmes includes the provision of a consultative service, particularly for institutions with special problems or proposed new activities related to biosafety. - 15 - 7. The impo rt ance of establishing programmes to record laboratory infections and accidents cannot be overlooked . Experience has shown that recording such information leads to improvements in laboratory safety . 8. There are difficulties in collecting statistically reliable data, particularly on those who suffer subclinical infections. The activity is nevertheless worthwhile in spite of the problems. 9. The coordination and pooling of res ources and studies were discussed, as was research into biosafety technology and engineering and into laboratory-associated infection. 10. Not all centres would be involved in all aspects of the development of minimum requirements and standards for biosafety equipment. European biosafety congress Holding a congress in Europe to create a forum for equipment manufacturers, laboratory staff, workers in biotechnology and other disciplines related to biosafety could be of value, and some of the details of arrangement were discussed. Training Courses in biosafety have been held in various WHO regions, but more training courses should be established in the European Region. Material that combines the cont ent of these courses (as detailed in the Laboratory biosafety manual) with notes on the teaching/learning strategies needed to teach them could be produced and distributed to centres teaching laboratory workers. Three methods of presenting courses were suggested and discussed; a visit by students to a large centre; a visit by instructors to the country requesting a course; the incorporation of lectures on biosafety into the programme of other courses/meetings. Testing and certification There appears to be a need for the training and certification of people to test biosafety cabinets. The approaches to certification in various countries were outlined, and it appeared that the testing of filters, for example, ranged from nil to a programme of semi-annual testing. Even where there was testing, there was often no certification progrannne and manufacturers were relied on to provide a proper service. Spot checks by independent experts are therefore needed. Information gathering and sharing Few laboratories wish to report accidents and incidents, as this is often considered a reflection on their competence. Nevertheless, this information should be collected and distributed, as it can be used to illustrate pitfalls to others, especially where new and untried equipment and procedures are concerned. Epidemiological studies These are useful as training examples. Reference was made to the work on the incidence of hepatitis in the United Kingdom, showing how proper handling of infected material can reduce or even eliminate a hazard. Surveillance on the epidemiology of infections in laboratory workers should be established. It was noted that there is no recorded incident of man being infected from specimens in transit. - 17 - BASIC SANITATION Workshop on Housing Hygiene in Mediterranean Countries Split, 9-13 May 1983 Introduction ICP/BSM 002(5)(S) 1689D 29 June 1983 ORIGINAL: ENGLISH The Workshop was convened to review housing hygie~e problems in human settlements in the Mediterranean and Balkan countries. Particular attention was paid to the public health aspects of the size, density, stability and soundness of dwellings, to the occurrence of accidental injuries in and around them, to their heating, lighting, ventilation and insulation, to their sanitary equipment and related facilities, to noise control, to the prevention and control of vermin infestation, and to the toxic effects of indoor air pollutants. Discussions were held on the epidemiology of various classes of diseases that are or may be influenced by housing conditions, such as respiratory and enteric diseases. Consideration was also given to slum eradication, to the existence of shanty towns and squatter housing, to the inspection and control of existing housing and to the rehabilitation of older dwellings that are substandard. There were 34 participants and lecturers at the Workshop from 16 different countries including 11 in Southern Europe and the Mediterranean coastal area. The United Nations Centre for Human Settlements sent one representative and the International Union of Architects showed great interest in the Workshop and sec three representatives from three Mediterranean countries. A review and examination were made of the housing programmes of the following organizations: the Regional Activity Centre of the Priority Actions Plan (part of the United Nations Environment Programme's Mediterranean Action Plan), the United Nations Centre for Human Settlements, the World Health Organization and the Committee for Housing,"Building and Town Planning of the United Nations Economic Commission for Europe (ECE), and its sub-committee for Southern Europe. Particular emphasis was placed on the role of housing in WHO's strategy for health for all by the year 2000, and on activities of the WHO Regional Office for Europe aimed at developing healthy and decent housing which is a basic element of primary health care as defined by the International Conference on Primary Health Care convened by WHO and the United Nations Children's Fund in Alma-Ata in 1978. Conclusions The participants in the Workshop reached a number of conclusions that were widely shared and pertain to the elimination of many of the hazards to health associated with housing and town planning, particularly as related to the conditions that prevail in the Mediterranean area. 1. If the goals of WHO's strategy for health for all are to be reached, increased emphasis must be placed on programmes for housing hygiene by all governments and public and private agencies, and greater cooperation will be needed among public health professionals, architects, town planners, financial management experts, economists, sociologists and others concerned with urban housing and human settlements. 2. Housing hygiene programmes embrace various aspects of health including the physiological, psychological and mental health needs of occupants. These programmes should aim at creating an enclosed environment that will minimize the transmission of infectious agents and the occurrence of accidental injury; provide protection and security from external natural and man-made hazards; create and maintain a favourable indoor microclimate; and provide an adequate amount of living and sleeping space and a safe and healthy residence for the occupants. 3. The problems of housing hygiene in the Mediterranean area are influenced to a high degree by rapid industrialization and urbanization changes that are putting great pressures on society and governments alike. - 20 - 4. In the development and implementation of prograunnes i nvolving housing hygiene and town planning, it must be acknowledged that irreversible ecological changes may ensue. Special consideration must therefore be given to this possibil i ty, and solutions to existing housing problems must be sought that will not have adverse effects on ecological or other biological systems. 5. Housing hygiene problems are extremely diverse and depend on many factors, but they can be divided into three general classes of housing and health problem, depending on population size and location: totally urban problems are those f ound in urban centres, usually involving older housing, overcrowding and lack of modernization; suburban problems are those associated with housing located on the outskirts of towns and cities , where some or all of the basic amenities are lacking, and where buildings may have been constructed in conflict with the existing codes, standards , norms and/o r guidelines that pertain to land use and to the methods aod materials of construction; rural housing problems are those associated with isolated dwellings or with small villages that tend to be extremely substandard . 6. Overcrowding is one of the major problems of housing aod health io the Mediterranean area, and increases the vulnerability of the occupants to the rapid spread of infectious agents . 7. The minimum conditions that ought to apply to all housing in the Mediterranean area are the following: a s uf fi c ient number of rooms and an adequate amount o f floor space to minimize the transmission of disease agents and to meet the basic need for privacy and for freedom from the stress created by overcrowding; the separation of domestic animals f rom the areas of housing used for human habitation, preferabl y in distinct structures; a potable and palatable water supply piped under con t inuous pressure by sanitary plumbing into each dwelling or courtyard, or to a standpipe in the immediate vicinity of the dwelling; a sanitary means of collection, treatment and/or disposal of sewage and human excrement (with particular emphasis on the nec essity of ensuring that an ecological balance is maintained); a sanitary means of storage, collection and disposal o f garbage, rubbish and other solid wastes; suffic ient a nd conven i ent facilities for washing and bathing; appropriate facilities f or cooking, eating and storing f ood ; protection from insect and rodent vectors and/or reservoirs of disease; adequate lighting , insulation, ventilation, heating and noise control; an atmosphere inside the dwelling unit that is reasonably free of biological and chemical impurities . 7 . Greater emphasis is needed in most housing hygiene prograunnes in the Mediterranean area on th e reduction of morbidity and mortality from home accidents, particularly those involving the very young, the elderly and the handicapped. 8. According to reported data, falls, burns and the i ngestion o f toxic substances are the main types of injury sustained in home accidents in the Mediterranean countries . 9. Structural damage to dwellings c aused by seismic forces is a major public health concern in many areas o f the Mediterranean. This concern is based oo the knowledge that in certain areas of the Mediterranean many buildings were not designed and constructed to withstand seismic forces. - 21 - 10. Greater attention should be paid to the design and construction of new residential structures in areas where the potential for seismic acti vity is great, to give greater protection to the health, safety, and wellbein g of the occupants. 11. Many Mediterranean cities and towns seem to lack adequate green space and recreation areas, particularly in or near the centre. 12. Insufficient attention has been paid to the height of buildings and to the proximity of one building to another, with the result that dwelling units on the lower levels of some buildings are devoid of direct sunshine and natural light. 13 . The health a nd wellbeing of many occupants in the Mediterranean area are threatened by apparently undesirable microclimatic conditions in a considerable number of dwellings. 14. Existing indoor air pollution is intensified in many dwellings by the continuing use of tobacco products by some residents and is a hazard to the health of all the occupants. 15. Some of the most serious and widespread housing hygiene problems in the Mediterranean invol ve shanty towns and squatter settlements. 16. To resolve the problems associated with shanty towns and squatter settlements, new approach - s must be developed by governments and other agencies to deter their further growth and development; to rehabilitate existing substandard housing as far as is economically possible; and to demolis h those housing units that are grossly substandard . Such programmes will involve a great deal of healthy reconstruction to rehouse those who are displaced. 17. WHO and other specialized agencies of the United Nations are not directing sufficient re sou rces towards solving the acute health problems found in shanty towns and squatter settlements. Recommendations l. A code of practice should be developed for, the sanitary inspection of dwellings in the Mediterranean area to determine the quality of the dwellings, and to evaluate the progress made in housing improvement programmes, in the plan ning, design and construction of new houses, and in the renovation and r ehabilitation of existing dwellings. 2. Criteria and guidelines should be formulated specifically for the hygienic requ irements of housing in the Mediterranean area, taking into account such local conditions as climate, lifestyle, patterns of living, availability of building materials and the conservation of heating, cooking and lighting· energy. These criteria and guidelines should be developed cooperativel y by public health specialists, architects, town planners and other specialists and should be coordinated with the housing standards developed by EGE. 3 . The housing materials and methods of construction used in the building of new dwellings and in the rehabilitation of existing structures should provide adequate, safe and healthy housing not only fo r the immediate future but also for a long time to come . 4. Special attention should be paid to the position of dwellings in relation to the sun and to prevailing weather patterns to maximize the beneficial uses of solar energy and to prevent the creation of undesirable indoor microclimates. 5. Existing technology should be utilized by architects, builders, construction experts and others to upgrade existing substandard dwellings and make them safe, healthy and decent at a low cost. Research should be initiated into the most economical ways of doing this. 6. Within the Mediterranean coastal areas there is an abundance of historical, c ultural and picturesque sites. Methods should therefore be developed and programmes initiated to restore, rehabilitate and protect them, particularly when they are endangered by urbanization. 7. Some epidemiological studies have indicated an association between housing conditions and health. Further studies should therefore be initiated and conducted to identify the causal relationships, which could then be made use of in remedial programmes. 8 . Those Mediterranean countries with building and construction legislation that is inconsistent with the standards of EGE should review and revise their legislation to reach a greater degree of uniformity with the practices in other countries. - 22 - 9. Building research institutions in the Mediterranean area should initiate a research programme into the increased use of locally available building materials and traditional working methods. 10. The Mediterranean area is subject to much seismic activity and many residential structures are in the immediate vicinity of faults in the earth's crust. Courses should therefore be developed for public health specialists, architects and other housing specialists to acquaint them wi th the hazards associated with seismic activity and with the means of making existing dwellings more resistant to seismic forces. Special emphasis in such courses should be placed on protecting the life and safety of occupants of older buildings. 11. One of the causes of migration of people from rural areas to urban centres is substandard housin g in the rural areas without necessary amenities. Health, architectural and town planning agencies should therefore investigate in cooperation with other specialists various practicable and economic means of improving the quality of housing and of life in the rural areas. 12. Among other standards to be developed, consideration should be given to adopting 12 m2 per inhabitant as the standard of minimum indoor space for existing housing in the Mediterranean area. If and when such standard is adopted, periodic in-depth reviews should be conducted to determine its adequacy. 13. Present research being conducted on the effect of noise and other physical factors on the hea lth and wellbeing of occupants and on practicable means of preventing and/or controlling these factors should be continued. The results should be made available to architects, builders and others involved in the physical planning, design, construction, repair, remodelling and/or rehabilitation of dwellings. 14. Current studies of the effects of indoor climate and of exposure to indoor air pollutants on the health of occupants should be continued, expanded and accelerated, and the results should be incorporated into the planning, design, construction and maintenance of residential stuctures. 15. The smoki ng of tobacco products in dwellings ca uses a rapid deterioration in the qualit y of the ai r and has c learly been observed to cause or contr i bute to the ill health of the occupants. Over t methods of health education should therefore be initiated and continued to make occupants aware of the consequences of smoking in dwellings to the health not only of themselves, but also of other occupants such as children. 16 . Investigations should be initiated to evaluate objectively the nature and degree of public health hazards created by the present widespread practice of building water c losets without an outside window, or with limited ventilation and natural light. 17. Since accidents in and around buildings cause much human misery, suffering and death, the importance of the e nvironmental aspects of accident prevention as pertains to children, the elderly and the handicapped, should be taken into account i n the planning and construction of residential structures. 18. As a means of preventing squatter settlements or shanty towns, legal research should be initiated to determine whether or not legislation may be used as a deterrent to the use of these places for human habitation . 19. A more vigorous attack should be initiated by all governments in the Mediterranean area and in southern Europe to prevent the spread of squatter settlements or shanty towns; they should investigate all the causative forces that bring about these living conditions, and identify practical means of preventing this type of housing. 20. Progarmnes of cooperative effort should be undertaken to develop practical plans of action that are consistent with the principles of urban planning, to limit the growth of existing squatter settlements or shanty towns and to eliminate those already in existence where the housing is deemed hazardous to the health and wellbeing of the occupants . 21 . Owing to the presence of many squatter settlements and shanty towns in the Mediterranean area a workshop, seminar or conference should be sponsored as soon as possible to discuss practical ways and means of eliminating, or drastically reducing the serious hazards to the health of their inhabitants. - 23 - 22. A vigorous campaign of health education in basic sanitation should be launched through various media to teach urban residents, particularly newcomers to urban areas and residents of squatter settlements and shanty towns, that they have a responsibility to maintain their home and its environs in as clean and sanitary a condition as practicable, in order to reduce the hazards associated with the transmission of infectious agents and with accidental injury. 23. Owing to their importance as preventive measures and as a basic step towards the achievement of the goal of health for all by the year 2000, programmes of housing hygiene should be given high priority. 24. Public health officials, architects, town planners, builders and others concerned with or involved in housing and health activities should be constantly alert to new technology as it becomes available, and should apply it as quickly as practicable. 25. Parks, recreation areas and green spaces with a variety of vegetation should be increased i n size and number in all urban areas. Policies should be promulgated and implemented that will preserve and protect the existing natural environment in and around urban areas. - 25 - CHEMICAL SAFETY - 27 - UNDP-supported project "European Cooperation on Envirornnental Health As pects of the Control of Chemicals" (RER/82/002) Third Meeting of the Steering Committee Varna, Bulgaria, 16-19 February 1983 Introduction ICP/RCE 903(24)(5) 13181 6 April 1983 ORIGINAL: ENGLISH The third meeting of the Steering Conunittee of the UNDP-supp-orted project "European Cooperation on Envirornnental Health Aspects of the Control of Chemicals" was convened by the WHO Regional Office for Europe at the invitation of the Government of Bulgaria. The meeting was attended by representatives of 10 participating countries from the European Region, and participants from UNDP, ILO and WHO. The objectives of the third meeting were: to present and evaluate progress reports on project activities during phase I; to present and discuss the work plan _for phase II of the project; to disc uss intercountry cooperative arrangements for implementation of items of work of conunon interest. Conclusions and reconunendations 1 . At the request of UNDP, countries that took part in phase I of the UNDP-supported project should provide data on priorities and current nat~onal activities. 2. The reports on implemented activities should give as much information as necessary to assess the significance of the findings in the light of the existing circumstances, such as types and location of sources, types of processes used, etc . Full and adequate reports on all activities, both in progress and completed , should be made according to the pattern received from the Chief Technical Adviser, who will contact those focal points whose reports do not fulfil the above criteria. The reports should be sent promptly to the focal points for information and initial evaluation . 3 . To facilitate utilization of the output , reports should contain precise terminology; health surveillance studies should be clearly marked as such, and differentiated from epidemiological studies. 4. At this stage of the project focal points will provide, to the best of their ability, basic information on informal international conununications within the network. During the early stages of the second phase this informal conununication network will be strengthened, and at the mid-project review full information will be provided on the volume, scope and subject matter of this exchange of information. 5. Focal poin ts that have special interest and expertise in any aspect of the project work should assume the role of lead institution on that aspect. This would involve maintaining up-to-date information on current activities in other participating countries, disseminating this information to focal points, evaluating and disseminating the results, and acting as an intercalibration and quality assurance centre. The work may· involve periodic publication of a special bulletin on the subject. The Chief Technical Adviser will approach the focal points within the next 2 months to ascer t ain t heir interest in assuming the role of lead institution. It is expected that agreements would be reached in principle within 4 months and that the network of lead institutes would become opera t ive within 6 months . This network would form a structural basis for permanent cooperation after the termination of the project. - 28 - 6. Quality assurance and intercalibration are an essent i al component of act1v1ties implemented under the cooperative programme. The partic ipating institutions should take on the task of coordinating internationally the various components of ep i demiological studies, assisted as necessary by outside experts and institutions. The cost of any external assistance required for this purpose would be charged to the contracts granted to these institutions . 7. It was agreed that focal points would take responsib i lity for the distribution of guidelines to appropriate government agencies in their country, and arrange that these agencies be fully informed on the content of these guidelines . 8 . All focal points and the Regional Office are to be supplied, by the end of April 1983, with the Field Paper Test developed in Bulgaria, and a preliminary evaluation, providing data on limitations, use and methodology, should be sent to the Regional Office. 9 . The activities carried out in phase I are valuable for strengthening and expanding national programmes on chemical safety, not only on subjects directly related to project objectives but also on i ndirectly related subjects. The achievements in phase I of the project form an adequate basi s for work directed towards the accomplishment of the tasks stipulated in phase Il. 10. The final report on phase I of the project will be pr epared in 6 weeks, and will include as appendices the technical reports of implemented act1v1ties. It will also show activities on subjects relevant to project objectives, financed from other sources, implemente _ within the f ramework of the pan-European programme. 11. It was agreed that studies of the envirorunental or occupational exposure of hospital personne l to drugs and other chemicals would be included within the work plans of the projects being discussed. 12. A basic course in toxicology within the context of tra1n1ng approach 1 will be held in Portugal for Portuguese speaking countries, with the collaboration of ILO. A course on the toxicity of pesticides should take place in Bulgaria in late 1983 or early 1984, provided that a sufficient number of candidates is available. 13. The ILO representative said that the Organization intended to participate in the planned course on general aspects of toxicology and control of exposures to chemicals, and that its role would be that of training in industrial exposure control. It would also provide background material and one lecturer. A sum of US$ 3500 has been earmarked from project funds for ILO participation in this activity. 14. The riparian countries of the Danube participating in this project will consider the feasibility of monitoring chemical pollution in the river resulting from the var i ous discharges. 15. Considering the great interest shown by the participating countries in the i mmediat e objective related to emergency respons e systems, the survey of existing emergency response systems conducted in 1981 should be repeated in 1984 t o determine progre s s . It was also noted that not al l countries could provide detailed information in this area because of national constraints. 16. The next meeting on collaborative activities relating to monitoring and health effects of exposure to pesticides should be held in Turkey subject to goverrunent approval. 17 . The next meeting of the steering committee would be held in Hungary in May or June 1984 . The steering committee will concentrate more on the outputs of the performed activities and follow-up actions. All reports should reach the Chief Technical Adviser by the end of February 1984, and will be transmitted to the committee members at least one month before the meeting. The absence of FAO, UNIDO and UNEP in the current meeting were noted and regretted, because of the valuable contribution these organizations could have made and the relevance of some of their activities to the project. 18. The meeting discussed, reviewed and amended the draft project document for phase II , with emphasis on expected outputs, follow-up actions and related material needs, and approved the amended version for re-submission to UNDP for prompt consideration. - 29 - International Workshop on Manpower Development and Training in Toxicology and Chemical Safety Luxembourg, 28 Nov~mber - 2 December 1983 ICP/RCE 903(25)(5) 32591 11 April 1984 ORIGINAL: ENGLISH The growing significance of the adverse health effects of toxic chemicals and the increasing need for chemical safety in both industrialized and developing countries have resulted in a greater demand for education and training in this area. Manpower development and the training of various categories of personnel in the control of chemicals is one of the main components of the UNEP/ILO/WHO International Programme on Chemical Safety (IPCS) and of the WHO European regional programme of chemical safety. In the European Economic Community, a number of directives have been adopted requiring the health risk evaluation of chemicals, the implementation o f safety measures, and the toxicological testing of new chemicals. Thus manpower development and training in the various areas of toxicology merit a high international priority for action . The Commission of the European Communities (CEC), specifically the Directorate General for Employment, Social Affairs and Education, and the Directorate General for Science, Research and Development organized this Workshop jointly with the WHO Regional Office for Europe, acting on behalf of IPCS, to better assess manpower needs in toxicology and to evaluate and recommend training and education programmes , thus helping to harmonize and improve the approaches and avoid duplication of effort. The Workshop was attended by 146 participants from 35 countries in all six WHO regions. The participants embraced a wide range of professional backgrounds, including pharmacology, veterinary medicine, chemistry, biochemistry, e pidemiology, occupational medicine , and public health. They came from poison control centres, university departments, government agencies and institutions, labour unions, and industry. The Workshop reviewed and evaluated five general areas: a methodology for estimating the need for various pro fessional ca tegories ; occupational profiles and career structures in toxicology ; training curricula for toxicologists and professionals requiring a toxicological background; the development of a s trategy for implementing training programmes at various level s ; and criteria for the recognition of qualifications. Of particular concern were the special needs of both industrialized and developing countries to train chemical safety personnel at the primary health care level, and the possible national and international actions needed to implement appropriate training programmes. Discussion 1. Current status of training programmes A variety of systems already exist for training in toxicology. In Europe, the most advanced are 4-year postgraduate courses in toxicology, producing f ully-fledged scientists and professionals whose competence is mainly in experimental toxicology. Shorter courses also exist. In many countries, training in toxicology is limited mainly to professionals and scientists already employed in one of the areas of toxicology and existing training facilities in closely related fields such as analytical chemistry, biochemistry, pharmacology and occupational hygiene are often used. 2 . Current employment of toxicologists and surveys of need In Europe, experimental toxicologists are employed mainly in universities and industry, and graduates in clinical toxicology are employed entirely in hospitals and poison centres . The estimated need for toxicologists by 1988 ranges from 20-40 in countries such as the Netherlands and Poland to 130-260 in Italy. In the United States, there is a shortage of specialists in inhalation - 30 - and reproduction toxicology and graduates in environmental toxicology easily find posts in research and training. In Japan, as in many other countries, there is a clear need for clinical toxicologists. 3. Professional profiles in toxicology Toxicology has a multidisciplinary character, with professionals coming mainly from medicine, veterinary medicine, pharmacology, pharmacy, biology, biochemistry and chemistry . Toxicology can be divided into three basic areas: clinical, analytical and experimental toxicology. Clinical toxicology should go beyond acute poisoning to include chronic and subclinical effects, as well as clinical and epidemiological studies relevant to toxicology. Analytical toxicology, based mainly on chemistry , deals with the environmental and biological monitoring of toxic chemicals and with the interpretation of data in terms of dose, exposure level, exposure assessment and risk estimate. Experimental toxicology combines the elements of dosage or exposure and those of effects in a single experiment . 4 . Curricula for training The curriculum for training toxicologists, contained in Manpower development for control of chemicalsa matches the requirements of the experimental toxicology pt -~ ile. The research component should be strongly emphasized, as even applied toxicology usually contains elements of research . The curriculum should develop an understanding of the various factors , such as climate , nutritional s tatus and genetics, that can influence toxicity findings and evaluation. Detailed curricula need to be developed for clinical and analytical toxicology using the same approach and , where possible, the information already available in this interim document. 5. Career patterns in toxicology The framework presented on careers in toxicology is an acceptable basis for identifying career opportunities for toxicologists. There was concern about the current status of clinical toxicology and the absence of toxicology from the undergraduate medical curriculum. 6. Recognition of qualifications Any sys tem of training must have some recognition of educational attainment as the endpoint. Recognition may depend on formal examination or on a review of experience and achievement by people eminent in the field. Recognition of the "senior" or "evaluative" toxicologist can be accorded only by peer review of experience, achievement , and on ability to cope with the broad spectrum of the subject, and may lead to the award of an advanced degree in toxicology or to appointment to a chair in the subject. 7. Assessing the need for toxicologists The model for assessing the need and demand f or trained toxicologists was accepted as a reasonable approach to the problem. While there i s an "ideal" need for toxicologists , what really matters is the effective demand. Toxicological training should be included as part of the undergraduate curriculum in medicine, agriculture , chemical engineering and chemistry, and this would , of necessity, produce a demand for appropriately trained university teachers . 8. Need for professionals with toxicological background Those involved with the regulation of chemicals, particularly administrators responsible for preparing regulations and organizing post-regulatory control, need a background in toxicology. Also needed are educators who can ensure the proper dissemination of knowledge throughout the popula t ion . Of perhaps the greatest impact would be the i nclusion of the fundamentals of toxicology in the training of chemists, whose main concern is with the manufacture and use of chemicals, and at various educational levels. 9. Problems of special relevance to developing countries Lack of awareness on the part of the public and policy-makers of the health problems posed by toxic chemicals is one of the major reasons for the inadequate number of trained manpower in the a Interim document No. 2, issued in 1981 by the WHO Regional Office for Europe, Copenhagen . - 31 - developing countries. Training prograunnes from industrialized countries may not be suitable and an international workshop would be an appropriate way of tackling this problem of manpower development. Conclusions and recommendations General 1. A working definition of a toxicologist is a prerequisite for adequate communication on the subject and the following is recommended: a toxicologist is a university graduate in medicine or one of the branches of science relevant to toxicology who has a general knowledge of the theory and practice of toxicology and the knowledge and practical experience of a specialist in at least one area of toxicology. Toxicology relies on methodologies developed in several branches o f the basic sciences. Hence, competence is achieved mainly through the cooperative work of different specialists within a team. The concept of the toxicological team should therefore be further developed. 2. Toxicology is a relatively new discipline whose foundations are in an early stage of development. At present, research is needed to transform toxicology into a more predictive science and to solve practical clinical problems. Research is also an essential element in the training of toxicologists. Funding for research should be encouraged at the national and international levels. 3. The development of toxicology should also be accelerated through an exchange of information at the international level. Governments should be encouraged to create, as far as possible, the basic conditions for toxicology to develop as a discipline in its own right by establishing departments of toxicology in schools of medicine, pharmacy, veterinary medicine, agriculture and science. This would also constitute a step towards the institution of academic careers in toxicology. Wherever possible, the foundation of toxicological societies and professional/scientific journals at the national or regional level should be encouraged. Furthermore, toxicology should be recognized as a discipline at the university level, or if already recognized, upgraded, to provide adequate coverage in appropriate curricula and enhance awareness of the toxic potential of chemicals at all levels of education in°chemistry, chemical engineering and in pure and applied sciences in general. This can best be achieved by teachers of chemistry and biology, provided that their own curriculum at the university level is amended in an appropriate way . 4. Toxicology as a discipline has a place in several occupational profiles, of which three seem to be essential. These profiles, defined by both area of activity and type of qualifications required, are experimental, analytical and clinical toxicology. Clinical toxicology is open to medical graduates only. The two oth~r fields are open also to graduates of veterinary medicine, natural sciences and chemistry. Specialists in any one of these fields could be engaged, within the limits of their competence, in a number of applied fields of toxicology, such as industrial, environmental, forensic, agricultural and regulatory toxicology and cl i nical diagnosis and treatment. The occupational profile and curriculum developed in Manpower development for control of chemicalsa are considered appropriate, with possible minor revisions for the training of experimental toxicologists. This document could also be used to develop target curricula for both analytical and clinical toxicologists, and should be updated. 5. Clinical toxicology is the discipline that studies the harmful ef f ects of chemicals on humans. It deals with the diagnosis, treatment and prevention of acute and chronic poisonings. In most countries, it is not yet fully recognized as a medical specialty and efforts should be made to ensure that it is. In developing curricula for physicians who specialize in toxicology, emphasis should be placed on the need to diagnose chronic effects and on the use of preclinical effects for purposes of evaluation and prevention. Training in toxicology and chemical safety should be included in t he curricula of general practitioners and various medical specialists such as internists and paediatricians. They are not always sufficiently aware of the possible role of chemicals in human pathology. Cases of chronic intoxication are not always diagnosed, appropriate treatment is not always provided, sound advice is not always given about the adverse effects of exposure to chemicals, unhealthy situations are not always rapidly identified, and preventive measures are not always taken. Interim document No. 2, issued in 1981 by the WHO Regional Office for Europe, Copenhagen. - 32 - 6. Current toxicological testing depends mainly on the use of laboratory animals . Clinical and epidemiological studies are of special value for the detection of toxicity. In addition, the handling and disposal of chemicals requires guidance. The toxicology curriculum should include an ethical code that deals with animal welfare and abides by the Proposed international guidelines for biomedical research involving human subjects.a 7. Precise information is not available regarding the qualifications required for professional activities in experimental, clinical and analytical toxicology. Surveys should be conducted in selected countries to establish the current qualifications required in the field of toxicology in government, industry, universities , etc., and to develop general criteria for these qualifications in the future; the development of these criteria at the i nternational level would help provide a common approach for risk management. When recognition of qualifications is adopted by a country, the self-trained professionals already working in the field, with long experience and of high standing, should be given due credit. 8. The theoretical model proposed for assessing manpower needs in toxicology, based on the production, use and degree of control of chemicals, was considered valuable and worth validating. The practical assessment of the need for toxicologists made in Italy and Ireland should be used to evaluate the adequacy of the model. 9. Career models of different degrees of sophistication were proposed in experimental, analytical and clinical toxicology. The assessment of the manpower needs model and the career models should be combined and developed into strategies for manpower development that are appropriate for national and regional needs. 10 . It is not known to what extent additional training programmes in toxicology are currently needed. This should be estimated when the real demand for toxicologist s has been assessed. 11. The poison control and clinical toxicology centres already active in a number of countries play an increasing role in informing physicians and the public of the risks of chemicals, and this should be developed further. 12. Safety and hygiene committee representatives have an important role to play in preventing occupational expos ure to industrial chemica ls; appropriate training programmes and short-term courses should be developed for them. Workers, management representatives, occupational health personnel, safety engineers and labour inspectors are not always given proper training in the risks to health of exposure to and handling of toxic chemicals . An awareness of the need for such training is growing, as shown by specific requirements in recent European Community legislation. National and international authorities should ensure that all those responsible for health and safety at work receive adequate information about chemical risks . 13. The flow of communication and information between the toxicologist and consumer groups and the media has not always been adequately conducted, and adequate educational programmes are needed to facilitate this exchange. 14. The proposed training approaches in toxicology and chemical safety may be used as a model in the manpower development programme . International organizations should organize or support international seminars and workshops to facilitate the establishment of harmonized training approaches and provide training opportunities to candidates from countries lacking the necessary facilities . Of special relevance to developing countries 15. The successful control of infectious diseases in developing countries, combined with the increasing use of agricultural and industrial chemicals, has led to an increase in the death rate and in ill health resulting from both acute and chronic chemical poisoning . Nevertheless, most developing countries have inadequate facilities and personnel to deal with such problems, and substantial resources should be made available for manpower development in these countries. Issued in 1982 in Geneva by the Council for International Organizations of Medical Sciences. - 33 - 16. Different degrees of industrialization and agricultural development exist within developing regions. It is therefore impossible to make general recommendations about manpower needs and training requirements that are applicable to all regions. A workshop should be organized as soon as possible in a developing country to assess these needs so that appropriate programmes and priorities can be planned. 17. It is likely that many instances of harm due to chemicals in developing countries are not brought to official attention because of a lack of public awareness of the hazards involved . International organizations should try and increase awareness on the part of the public and policy"'"11lakers of the health problems posed by toxic chemicals, as this ignorance is one of the major reasons for the lack of trained manpower in the developing countries. 18. Training received in industrialized countries may not always be suitable to the socioeconomic framework of developing countries. Facilities and materials for education and training should be made available in the developing countries, addressed to local problems and written in the appropriate language. 19. Successful short courses on specific topics in toxicology, such as those held in Brazil and Egypt in 1983 with the support of IPCS and the individual governments, satisfy an immediate and urgent need to disseminate information. They should be continued, and extended to other countries as needed, with the support of appropriate international agencies and programmes. 20. A particular problem in developing countries that are dependent on agriculture is the use of pesticides by farm workers who are ignorant of their toxic properties and the safety procedures to be observed. An adequate supply of manpower is urgently required, trained in chemical safety, registration and regulatory control. 21 . The idea of a day devoted to chemical safety and the impact of chemicals on human health and the environment should be launched. 22 . To ensure that manpower development in toxicology proceeds as quickly and effectively as possible, with optimum use of all available resources and worldwide harmonization of approaches, the well coordinated efforts of IPCS, CEC and other international bodies should be reinforced. - 35 - COMMUNICABLE DISEASES - 37 - Working Group on the Immunization of the Elde rly Zagreb, 5-7 September 1983 Introduc c ion ICP/ESD 008(5) 0278G 15 December 1983 ORIGINAL: ENGLISH Immunization programmes have largely been designed to protect children against childhood diseases. With the change in age structure of the population, more emphasis has been placed o n the health ca re of the elderly, particularly in developed countries, and there is therefore now a need co study the rationale for an effective immunization prograame in this age group . The frequency of various communicable diseases in the elderly in different European countries is not well known and has not been properly analysed, but it is clear that morbidity and mortality from i.nfec t ions increase markedly with age. Influenza I pneumonia and o ther infect ions account for a large proportion of deaths in the elderly. Chronic diseases increase the risk and complicate many infections in older persons. The prevention and treatment of infections in nursing homes and other long-term. care settings present problems and require study of age-related factors on the occurrence and ou tcome of infections. Among the infectious diseases that are preventable by immunization, the most important are influenza, pneumococca l pneumonia I hepatitis 8 and, in certain countries, typhoid and tetanus. The improvement of the quality of these vaccines and their proper use in the elderly were discussed. The optimal application in the elderly of new vaccines for viral and bacterial agents depends on understanding age-related factors affecting pathogenesis and host immune response. Immunization schemes suitable for the elderly were discussed. New tech niques for pc-oducing antibodies suggest an increased potential role for passive i mmunization of the elderly, whose immune systems are often slower to react: The possibility of preventing infections in the elderly by replacement therapy to correct immunological deficits remains unexplored. The available data indicate that immunization against influenza and pneumococcal infections (wi th newly developed polysaccharide vaccine) would be beneficial for the health of the elderly because it would lower morbidity and mortality due to these infections and their sequelae. However, detailed epidemiological knowledge on groups of elderly people at highest risk (e .g. people with chronic lung or cardiovascular affections, those institutionalized, etc.) should be improved in order to determine priority groups and time of immunization. Immunization of the elderly against influenza and pneumococcal infections seems justified. That against influenza should be carried out annually, and documentation should be improved. It is not known how often iR1DUnization with pneumococcal polysaccharides should or can be provided. On retirement, people often take up activites (e.g. gardening, mushroom collecting, animal rearing on a small scale) which may bring them into contact with soil, and some of them may be more exposed to tetanus and require tetanus toxoid boosters. In view of the vi rtual disappearance of tetanus among children, relatively more cases of this disease are now found in adults. Combined influenza pneumococcal tetanus vaccine can be prepared for logistic and practical reasons, but the effectiveness and reactogenicity of such a combination have to be studied. There is Little information on any adverse reactions to such vaccination in the elderly. Although antistaphylococcal vaccine is still controversial, since staphylococcal infections are important sequelae of influenza outbreaks, the methods of production and the safety testing and effectiveness of this vaccine should be studied further. - 18 Recommendations Hea 1th po 1 ic ies l. WHO should encourage health authorities in M.ember States to develop and implement immunization policies to prevent prevalent infections in the elderly. 2. Health authorities in Member States should promote educational programmes to increase professional and public awareness of the dangers of infection in the elderly, especially those with card1ovascular 1 pulmonary and ocher chronic conditions. They should promote the use of vaccines, particularly against influenza, pneumococcal infection and tetanus, as a part of rou tine health care fo r people over 60 years of a ge. I nfluenza 3. High priority should be given to ensuring that elderly persons receive annual vaccination prior to the influenza epidemic season. 4. Inactivated influenza vaccines containing antigens r epresentative of recently isolated strains are recomme nd ed for people over the age of 60 years, particula rl y those in the high-risk groups listed above . 5. Antiviral drug (e.g. rimantadine) prophylaxis should be considered as an additional control measure against outbreaks of influenza A in institutions for the erderly, irrespective of previous influenza vaccination . 6. Research ins t itutions should be encouraged to pay urgent attention to critical issues related to the vulnerability of the elderly co influenza. Pneumonia 7. Pneumococcal pneumonia in the e lderly should be prevented by immunization with polyvalent polysaccharide vaccine followed by booster doses. Those at high risk should be particularly protected. 8. The booster dose of tetanus toxoid should be given ac ten-year intervals co the elderly, particularly co those who take part in gardening and other open-air activities. 9. Combined vaccines for immunization of the elderly should be developed and applied accordin~ to a well established immunization pr ogramme . - 39 - Working Group on Tickborne Encephalitis and Haemorrhagic Fever with Rena 1 Syndrome in Europe Baden, 3-5 October 1983 Introduction ICP/BVM 018(5) 0279G 15 December 1983 ORIGINAL: ENGLISH The meeting, attended by 16 research workers in virology, epidemiology and ecology, was held to review the geographical distribution and prevalence of tickborne encephalitis (TSE) and haemorrhagic fever with renal syndrome (KFRS) and their public health importance in Europe. The meeting also set out to identify the research needed for a better understanding of the pathology, epidemiology and ecological aspects of control measures, with a view to preparing verified and accurate maps of the occurrence of natural foci of these two diseases. The maps will appear in the final report of the meeting and will show not only spa tial distribution but also as much as possible of the ecological factors. With recent advances in virology and se rological techniques, new oppor tunit ies have arisen for improving diagnostic procedures and for carrying out epidemiological and ecological investiga tions and geographical mapping of these diseases. Epidemiological patterns can now be more precisely defined and this knowledge used to develop more effective control programmes. Tickborne encephalitis The results were reviewed of epidemiological and ecological studies carried out using virological, se rological and other techniques in determining the presence and extension of the natural foci of TBE in Austria, Czechoslovakia, Finland, the German Democratic Republic, the Federal Re pub lie of Germany, Hungary, Po land, Sweden, the USSR and Yugoslavia. The presence of the natural foci of TBE in these countries was confinaed by isolating virus from ticks and by positive serological findings in man and animals. The well defined natural foci in hilly and mountainous areas of central Europe extend f rom the northern parts of Yugoslavia to the southern parts of Finland. In these natural foci, virus circulates between ticks and animals; people working in the fields and fores ts are occasionally infected by tick bites, mainly in central Europe where these foci occur. An inactivated vaccine has recently been developed from local virus st rains, and certain high-risk groups, such as professional hunters and forest workers, have been successfully immunized. The vaccine is well tolerated and 98% of those immm.unized developed antibodies. I n Austria, no cases have since been observed among immunized forest workers. Fu rther investigation , using monoclonal a ntibody techniques, is under way to identify the most immunogenic virus strains from which highly effective vaccine against local strains of TBE will be made. Research is also being carried out on purifying the vaccines to make them less reactogenic . Since the control of ticks over large areas is difficult and not very effective, immunization represents an important tool in protecting individuals exposed to infection. Haemorrhagic fever with renal syndrome The disease has been found in south and centra l Europe, Scandinavia and the USSR, and recently in Belgium . It is also prevalent in East Asia, including China and Japan. The role of rodents as the reservoir of the virus is being investigated. It appears that HFRS is a disease of increasing public health importance in many countries in Europe. Its apparent absence in other countries might be due to the lack of serological investigations and active surveillance. The number of human ca■ es within- the natural foci may vary considerably from year to year . There is no evidence, however, that the size and location of endemic areas have undergone changes in recent years . - 40 - Cone lus ions 1. TBE is present in a number of European and o ther count ries where the ecological situation favours persistence of natural foci of this disease. The relative public health importance of TSE is realized only in countries where extensive investigations have been made , but probably the disease is under-reported and/or overlooked in other countries. Fu rther epidemiological, ecological and virological investigations are, therefore, required to ascertain the presence of TBE and any dynamic changes that may have occurred. To obtain more information on the distribution of TBE, it was felt desirable to consider TBE in all cases of suspected viral infection of the central nervous system and to perform laboratory tests accordingly. 2. Haemorrhagic fever is at present a disease of considerable public health importance in a number of countries in Europe and is likely to be recognized in an increasing number of them as facilities for viral diagnosis become available . The presence in Europe of at least two antigenic types of HFRS virus has been indicated. The number of rodent species reported as positive in Europe has increased. However, the main European host still appears to be Clethrionomys glareo lus. Outbreaks have also been traced to infected laboratory rats. Recomme ndations l. Mo re accurate information is needed on the distribution, incidence and prevalence of TBE and < HFRS in Eu rope. Such information is necessary if effective control programmes are to be planned. Attention should be directed to the problems of disease surveillance which should be done on a routine basis. Epidemiological or geo-ecological investigations should include anthropogenic changes in landscape, intensified recreational activity and mobility and, in particular, activities in border areas which may be of international importance and require transfrontier coopera t ion . Surveillance shoul d include that of laboratory rat colonies for HFRS infection . If for any reason it is necessary to maintain an HFRS-infected rat colony, it must be done under appropriate containment conditions. Such ra ts or materials from them should be handled and notified as infectious. 2. Health workers must be made more aware of the possibility of TBE and HFRS in diagnosis, especially the mild form of HFRS. Wide ci rculation of information on the clinical characteristics of HFRS should be made and the irupo~tance of acute nephropathy as a discriminating feature should be emphasized . ). It is essential that for both diseases clinical diagnosis should be confirmed by appropriate virological methods. Efforts should be made to ensure comparability of results obtained in laboratories in different countries . Techniques should be promot·ed to ensure rapid differentiation among TBE, HFRS and other viruses causing encephalitis, in particular herpex simplex. This implies an efficient international collaborating network and the designation of at least one laboratory in each endemic co untry with the ability to carry out accurate virological diagnosis . l ~. There is a need to standardize available laboratory tests for the detection of antibodies and antigens. S. In areas where both Crimean-Congo haemorrhagic fever and HFRS are known to appear 1 use of rapid diagriostic techniques is desirable. The development and evaluation of IgM specific antibody tests is there fore recommended. 6. Fu rther emphasis should be placed on the isolation and eventu~l establishment i nto cell cul ture of HFRS-related viruses. This will facilitate the further characterization of this virus ~roup. 7. Inactivated virus vaccines against tickborne encephalitis , which are bein~ used in some areas 1 are well tolerated and protect against overt disease. It is recommended , therefore , that they be used to protect high-risk groups in the population. Working Group on Mycotic Diseases Hamburg, 26-28 October 1983 Introduction - ... ICP/BVM OlO(S) 0280G 6 January 1984 ORIGINAL: ENGLISH The meeting was attended by 15 eminent mycologists (physicians, veterinarians, biologists, serologists, allergologists and epidemiologists), mainly from Europe but also from the United States of America. The reasons for the meeting were the current significance of mycoses, their tendency to increase in frequency and severity, the fact that various epidemiological and nosological aspects need to be clarified and better surveyed, and because several fields in diagnostics and therapeutics need to be improved. Moreover, the classification and nomenclature of mycetes should be improved, since at present they constitute a labyrinth in which it is dif , icult not only for laymen but also for mycologists to find their way. The basic condition for planning effective control of mycotic infections is knowledge of their distribution and the ecology of the respective causal organisms, of the ways and mode of their transmission, and of the environmental factors influencing their persistence and spread . Modern epidemiology has developed methods that allow the exact assessment of these. The majority of all European mycoses consist of secondary infections based on certain predisposing factors. The latter, which can be exogenous or endogenous, play a basically important role in the development, nosological character and prognosis of mycoses, and they therefore need to be studied in a more detailed manner as well. Dealing with mycotic infections requires, as· perhaps with no other infection, extensive education in schools, in the military, in old people's homes and in hospitals, as well as simple recommendations on the selection of therapeutic agents and on the prevention of mycotic disease in general . The purpose of the meeting, therefore, was to evaluate the public health importance of fungal diseases according to the above-mentioned points, and to put them into their proper perspective. The meeting discussed the following topics: mycotic diseases as a public health problem; ecology of pathogenic fungi; epidemiology of fungal infections in the European Region; importance of mycotic infections in ambulatory practices, schools, old people's homes and public baths; mycoses as an important problem in hospital infections; importance of mycotic diseases in the rural population and as a professional risk in defined population groups; fungus infections as a zoonotic problem ; clinical immunology of mycotic diseases; diagnosis of fungal infections; therapy of mycotic infections; prevention and public health importance; and training in the diagnosis of mycotic infections and the identification of pathogenic fungi. Conclusions and recommendations Fungal diseases comprise not only the common mycoses (invasive fungal infections) but also allergic diseases (mycoallergoses) and intoxications with fungal toxins (mycotoxicoses, mycetism). The common mycoses were the main points of interest in this meeting. The public health significance of mycoses is evident from their worldwide distribution; their extraordinary frequency (which is the highest of all infectious diseases); their etiological and nosological heterogeneity (more than 100 causative organisms; lesions ranging from superficial and innocuous to severe and life-threatening, and covering all medical disciplines as well as - 42 - veterinary medicine); their therapeutic resistance (partly because most of them are secondary diseases, and the primary diseases are difficult to cure, partly because only four or five really effective systematically administrable Rntimycotics exist); and their tendency to recur (because there is more or less permanent exposure to organisms that are almost ubiquitous in the human environment) . . An important role in the spread of European mycoses is played by public facilities such as swimming pools, saunas, showers, sports grounds and schools, where superficial dermatophytoses, mainly of the feet, groin and toenails, are caused by such organisms as Trichophyton rubrum, T. mentagrophytes and Epidermophyton floccosum. Contact with farm animals and materials used on farms and in stables, as well as with pets and laboratory and zoo animals, can result in acute kerion-like dermatophytoses of the pilous skin (mainly the scalp, neck, beard area, extremities and trunk; the most common causal organisms are Microsporum canis, Trichophyton verrucosum and T. mentagrophytes) . Door handles, sanitary facilities, taps, towels, etc., in hospitals, nursing homes and old people ' s homes can harbour Candida spp., resulting in candidiases of the skin and the mucous membranes of the mouth and the genitals, in some cases also in systemic candidiasis. The increasing number of treatments and conditions (open heart and other thoracic surgery, grafts, immunosuppression, and recently also AIDS) that predispose for systemic fungal infections, especially with Candida albicans, Cryptococcus neoformans and Aspergillus spp., has led to a dramatic increase in t · ,se life-threatening mycoses. Certain non-European mycoses may be imported, e.g. coccidioidomycosis and histoplasmosis from the south of the United States, and this is made ever more likely by the increasing intercontinental traffic. For the diagnosis of mycoses, culturing and, especially with the systemic forms, serology are the basic methods; experience has shown, however, that in certain cases histopathological examination leads to the most rapid identification of the organisms concerned. Skin tests are of only limited value for the diagnosis of mycotic infections, especially the candidiases, but they are useful for fungal hypersensitivity disease. Current Candida albicans "antigenic" preparations are very varied and contain little protein, and are therefore unsuitable for testing cell-mediated immunity. Standardized protein reference materials, free of polysaccharides, are needed. Mixed "delayed" type skin test antigens are not desirable , since they could modify the manifestation of type IV allergy by eliciting type I and III reactions. Candida albicans, for example, contains "polysaccharide" mannan antigens; it also increases the level of circulating antibody and the capacity to elicit type I and III reactions on retesting. In skin tests with histoplasmin and coccidioidin for type IV allergy, positive reactions in 80-90% of cases are common in endemic areas , most often without current clinical disease. Negative reactions in the acute stage do not, however , exclude the existence of the disease. Since skin te s ts can modify the antibody response, serum should be taken beforehand. Candidiases of the genitals are often, especially in younger people, transmitted by sexual contact, and several authors have suggested that they be classed among the sexually transmitted diseases . This, however, would inadmissibly generalize the epidemiology and could cause juridical problems. The main source of Candida albicans for systemic infections in compromised hosts is the digestive tract , especially the intestine. Regular quantitative assessment of yeast in faeces of such patients and consistent decontamination are therefore necessary. The treatment of mycoses should be performed only on the basis of a firmly established diagnosis, especially on the result of a culture. Antimycotics should be applied specifically as required; the use of "broad-spectrum drugs" and "combination drugs" (e.g. antimycotics plus antibacterials plus steroids) should be restricted as far as possible. New antimycotics should be fully evaluated against existing drugs, whenever possible in prospective double-blind control studies. Special attention must be paid to adverse effects, and standardized methods must be used to assess them. Mandatory reporting of the occurrence of the principal mycoses in Europe, especially of the systemic forms of candidiases, cryptococcosis and aspergillosis, to the respective national ministries of health should be encouraged. The collection of data should also be aimed at determining the occurrence of mycotic infections that are not endemic in individual countries. The data so collected should be disseminated to all interested countries and also to health ministries in European countries. - 43 - The establishment of national and international mycological diagnostic centres should be encouraged, Such centres should be staffed by individuals trained to provide mycological diagnostic services. Adoption of preventive measures against allergic pulmonary diseases to control atmospheric contamination and prevent exposure to fungal material , together with appropriate clinical, epidemiological and immunological studies, is recommended. Wider dissemination of knowledge about the various forms of fungal diseases to the medical profession is desirable. Regional workshops, seminars and short courses for clinicians, pathologists and laboratory workers on medical mycology in general or on specialized aspects of medical mycology, such as serodiagnosis, mycological diagnosis and his topathological diagnosis, need to be encouraged. Moreover, the public should be better informed on the most important sources of fungal infections and their potentially long survival in the human environment and in animals, especially domestic pets. - 45 - ENVIRONMENTAL HEALTH Working Group on Health and Energy in Europe Monaco, 19-22 Jul y 198 3 - 47 - ICP/RCE 803{l)(S) 21791 6 September 1983 ORIGINAL: ENGLIS H The Wo rking Group wa s convened t o review present a nd potentia l health i ss ues related to the produc t ion and consumption of e ne r gy . The Gr oup consi sted of 29 temporary advisers and participants f rom IAEA, UNESCO and WMO . They r eviewed the current ene r gy patterns in the European Region and discussed some of the changes in th ese patterns that might have implications fo r health . They a l so discussed present and projected fossil fuel use, nuclear e ne r gy, renewable and other sou r ces of energy and conse rvation i n terms of occupational and public health, and analysed the adver, ~ effec t s on health of the diffe r en t fuel cycles, from extraction t o use and disposal . The par ticipant s then focused on practices in the use of energy that have a n impact on human health, particularly t hose practices that a re changing or involve new technology. The development of improved scienti fic methods in e nvironmental health scie nce was disc ussed in t erms of the tools that a re either available or needed t o be tt e r r ecogniz e impacts on healt h that may be r e l a t ed to e ne r gy . Finally, the Group attemp t ed to relate significant health issues associated with past and present ene r gy practices to trends and op tions fo r the future use of energy . It developed r e commendations for new operational trends, policy options and necessary research . Se veral specific topics we r e studied in subg r oups and then reviewed by the complete Wo r king Group . Energy trends Energy tec hnologi es have changed r apidly over the pas t t e n yea r s in Europe, primarily owi ng to th e inc reases in energy prices (especia lly oil ) . Alternatives to a major dependence on o il were reviewed . It was not ed that the use of coa l and nuclear power had i nc re ased in some countri es while the consumption of natural gas was expected to remain fairly steady, with increasing domestic use and declining industrial use . Natural gas was also expected to come from different sources than before. Sources of renewable ene r gy such as the sun, the wind, ocean tides, water, the earth's internal heat, the burning of wood o r the fermentation of agricul tural products are attrac t ive , bu t they a r e unlikely to have much collec t ive impact on Europe's energy balance . They are cost-intensi ve at present and some have majo r technological impediments . The conversion of coal int o fluid o r gaseous fuels has a grea ter potential, as does the improved combustion of coal (e.g. fluidized bed combu s tion ) and they a l so have significantly reduced ef fects on health a nd the environment. Energy conservation is having the most significant and i mmed ia te effect at seve r al levels. Fuel ef ficiency and the r es ultant decrease in consumption is to some extent accompanied by a reduction in emissions and in exposure to byproducts and consequent l y in effects on health. While major industrial and commerc ial conserva t ion measures have been taken, much more progress is possi bl e in the comme rcial a nd domestic sectors . Fossil ene rgy The effects on hea l th of fossil energy were reviewed and it was noted that its demonstrated and doc umented effects we r e mainly immediate or acute, occu rr ing soon after high levels of exposure. The effects on health of low levels of exposure at intermed iate or very long intervals are widely distributed, d if fuse and difficult to prove . The effec t s of concern, however , suc h as canc er and birth defects, a re of greater severity . Health scientis t s have begun to develop methods fo r population and labo ratory studies of these effects. It was noted that many of the documented ac ute effects on health, associated with the uncontrolled burning of fossil f uels, have been la rge l y e liminated by modern contro l practices of dispers ion and aba t eme nt. The Group was conc e rned that intermedia t e and lat e effects should not be downgraded in import a nce because of their delayed appearance and the apparent lack of urgency . - 48 - The effects of fossil fue l use on the biosphere were discussed since they can affect human health. For exampl e, when acid rain acidifies water supplies this may accelerate the release of heavy metals that can cause problems for health as well as for the environment . The new technology used to produce liquid a nd gaseous fuels from coal generates organic compounds that ma y put workers at risk of developing canc er. Finally, mixtures of low levels of effl uents from many sources may act adversely and synergistically on people within a common region or "air shed". This tends to affect the lungs in particular. Nuclear energy The impact of nuclear energy on health was reviewed in the light of current apprehension about radiation exposere during normal operatio n or after accidents . The major concerns are cancer and genetic effects, and considerable research, evaluation and assessments of these risks have been ca rr ied out . The Group noted that the public concern about these issues was not borne out by the scientific da t a now available on levels and effects of r adiat ion , a nd that radiation exposu r e f r om nuclear plants was lower than from medical radiation or natural background radiation. The Group concluded that education of the autho r ities and the public was needed to increase their understanding of the health hazards of nuclear energy. The Group felt that the issue of deep geological or deep ocean disposal of nuclear waste would receive increased attention in the future. It also concluded that cu rrent projections of the number and type of future nuclear power reactors could not be relied upon. Alternative energy Ene r gy al ternatives, which usually means a ll sources of energy ot her than fossil or nuclear f uel, were reviewed and it was found that they had a limited effect on Europe's e nergy balanc e and that each had some real or potential impact on health . Fur thermore their c urrent high cost per unit of energy produced is a serious disincentive and th i s is not likely to change unless economic measures are taken to alter the costs. Hydropower, now largely exploited, does have additional potential for pumped sto r age (to relieve peak demand) and for some small-scale electrical generation. The creation of large storage reservoirs can alter salinity, reduce the productivity of fisheries and local ag r iculture, and enhance the spread of waterborne disease . Wind energy, where appropriate , can provide local but intermittent additions to the electrical grid, and in some coastal areas can be used for seawater desalination. Local noise pollution can be a serious annoyance. Solar-generated electricity requires large land masses and costly converters, and the devices often use potentially hazardous materials such as cadmium or arsenic. Owing to the diluted intensity of solar energy on the earth's surface, large collectors are needed and the costs are high. Solar collectors based on satellites would be more efficient but involve the possibility of microwave exposure. The solar heating of water for domestic use and industrial purposes is viable, benign and cost - effective with virtua ll y no effects on health. The increased burning of wood for home heating raises seriou s problems of indoor air pollution, with increased leve l s of carbon monoxide and potentially carcinogenic volatile and condensable organic compounds . Geotherma l energy has been a useful addition to the energy mix i n a few places but its potential is limi ted and the extraction of the underground fluid stream can release toxic substances such as boron, arsenic and radon. A matrix of the effec t s on health A matrix of the effects on health of each ene rgy fuel cycle from extraction to use and disposal was discussed, and a preliminary one was developed that highlighted the following observations. Smal l scale and individual users of fossil fuels are at highest risk and in largest numbers . No fuel cycle is free of health risk . Alternative or renewable e nergy sources may carry risks at the point of use but not during extraction, processing and transport. - 49 - A preliminary ranking of increasing health risks for each energy source began with water at the bottom and ran through gas, sun, oil and nuclear energy to coal at the top, but these rankings were not quantified. Energy conservation It was felt that where energy conservation caused reductions in fuel consumption, there were also reductions in emission levels and, hence, in health risks. A policy of end-use analysis, where the choice is the e nergy-demanding task rather than the energy source, can improve the cost-effectiveness of decisions on energy and integrate conservation into the planning process. Inappropriate conservation measures, however, may be detrimental to health. For example, energy - efficient sealed buildings may, through inadequate ventilation, increase the concentration of air pollutants such as radon, formaldehyde, tobacco smoke and carbon monoxide. The Group concluded that conservation policies should include the use of the best ava ilable technol ogy . Furthermore, major health advances were still possible with light duty but safe vehicle design, lower exhaust emissions and the further development and use of mass transport. Regional options and cooperation The emphasis was on the transboundary transport of energy-related pollutants. Interest in and attempts to solve environmental problems related to energ~ have not been paralleled by a c ommensurate programme of research and action on the impacts on human health. It was noted that the costs of prevention were invariably much lower than the costs of correction and amelioration of adverse effects on both health and the environment . The curr ent reduction in energy demand should be considered an opportunity for timely regional anticipatory planning on these health and envi ronmental issues. Recommendations Opera tional tasks 1. WHO should continue its commitment to and responsibility for dealing with health and energy. This should include the compilation of pertinent health information to be used in making energy-related decisions, and the provision of guidance on real and potential impacts of energy activities on health. This responsibility could be undertaken in co llabora tion with other concerned organizations such as the United Nations Environment Programme. 2. Meetings should be sponsored on specific issues such as acid rain, coal and biomass, related to health and energy. 3 . A retrospective review of the effects of e nergy-related protective measures on human health should be made, to determine and evaluate the effectiveness of past actions to improve the health of workers and the gene ral public. 4 . The imp rovements and, where possible, the harmonization of methods and working protocols for epidemiological monitoring should be coordinated and made more compatible. Policy options 5 . Energy-related health protection policies and princ i ples should be developed that are analogous to those applied in the radiation protection field. 6. Where they do not already exist, appropriate methods should be developed to monitor the exposure of the environment and of biological systems to physical and c hemical agents to provide a better understanding of the impact of energy-related pollution on human health. 7. Support should be given to the use of the concept ''best available control technology'' (BACT) in recognition of the need to consider cost-effectiveness. 8. There should be stronger incentives to conserve energy and use renewable sources, with particular emphasis on health protection and cost-effectiveness. 9. Clean fuels such as gas should be re se rved as much as possible for individual and small users who are more likely to neglect or abuse environmental and health controls, and fuels that are more potentially polluting such as coal should be increasingly confined to large-scale concentrated use where control, monitoring and economy can minimize their adverse impacts on health. - so - 10. Effective and safe mass transport as opposed to private commuting should be further developed to reduce the effects on hea lth of vehicle exhaust and accidents. Research needs 11. Well-founded and cost- effective epidemiological and experimenta l studies are needed on pot e nt ia l energy-induced effects on man's health. 12. Expanded research is needed on e nvironmental pathways as they relate to exposure and population doses. 13 . Research is ne eded on the genetic and teratogenic effects of energy-related pollutants a nd the conditions of expos ure . Intercalibration Exercise and Consultation Meeting on Microbiological Methods for Coastal Water alit Monitorin: WHO/UNEP Joint Project MED POL Phase II) Barcelona, 7-11 November 1983 Introduction - 51 - ICP/RCE 2ll(3)( S) 27901 11 January 1984 ORIGINAL: ENGLISH The activity was convened jointly with the United Nations Environment Programme (UNEP) and was held at the School of Civil Engineering in Barcelona. It was attended by 22 temporary advisers from Spain, four from other Mediterranean countries, two from non-Mediterranean countries, two representatives of UNEP and one staff member of the WHO Regional Office for Europe. Within the overall framework of the Mediterranean Action Plan, and particularly under the terms of the 1976 Convention for thP Protection of the Mediterranean Sea against Pollution , the majority of Mediterranean countries .,ave now submitted, or are in the process of submitting, their national monitoring programmes as part of the long-term programme for Pollution Monitoring and Research in the Mediterranean Sea (ME D POL Phase II). The programmes include monitoring of bacteriological parameters in recreational and shellfish-growing coastal waters. A number of reference methods for sampling and analysis of the main microbiological indicator organisms have been prepared for use by Mediterranean laboratories as common methodologies for such determinations and were reviewed during the WHO/UNEP intercalibration Exercise and Consultation Meeting on Methods for Monitoring Selected Pollutants in Sewage Effluents and Coastal Recreational Waters, held in Rome from 22 to 26 November 1982. To ensure comparability of results and quality control at both country and intercountry levels, a series of intercalibration exercises in a number of Mediterranean countries was planned. These exercises were designed to involve mainly participants in the home country engaged in the monitoring programme, and also a number of participants from other selected Mediterranean laboratories taking part in the same programme. In addition, as a preliminary step towards the future extension of the use of the methodologies in other Regions, participants from non-Mediterranean countries would also take part. The first exercise in this series was held at the School of Civi l Eng ineering of the Universitat Politecnica of Barcelona and was preceded by an interlaborator y t es ting exe rci se on the reference methods in Catalonia, Spain, during the s ummer of 1983 . The purpose of the activities was twofold: to enable participants to conduct actual laboratory determinations of bacterial parameters, using the same samples of seawater and the same methodologies; and to review the results of the laboratory exercise and to make appropriate recommendations in future exercises in the series, as well as on any other related matter. Discussion and conclusions During the laboratory sessions, participants made actual determinations of three bacterial parameters (total coliforms, faecal coliforms and faecal streptococci) in each of three different seawater samples (one clean, one polluted and one medium). In all cases, the membrane filtration culture technique , as discussed in the appropriate reference method, was used. During meeting sessions, participants discussed the progress and results of the laboratory exercise, as well as draft guidelines for statistical evaluation of results obtained. The results of the intercalibration exercise held in Rome in November 1982 were given further statistical evaluation and disc ussed by the meeting. A number of technical points regarding equipment and media to be used in future work were raised. It was also recommended that studies on pollution indicator organisms, as well as on parameters and factors likely to affect the validity of bacteriological determinations, should be further encouraged. - 52 - The results of the interlaboratory exercise held in Catalonia during the summer of 1983 were also reviewed in the light of their statistical analysis. The results of the intercalibration exercise proper were statistically analysed and comprehensively reviewed. It was found that even using identical samples and standard methodologies , there was a wide divergence in the results obtained by different participants on the basis of bacterial counts. This was partially explained by (a) the heterogeneous composition of the group as a whole , where "individual" techniques played a significant role, and (b) the abnormally heavy rainfall in the region just before the samples were taken, which led to heavy bacterial concentrations in the samples, rendering a large series of dilutions necessary and possibly resulting in variations between individual subsamples . This variation factor was considered extremely important in comparing results submitted by different laboratories, as variations in results could be due to the operator rather than to differences in the actual state of the beaches. Recommendations The meeting recommended that: in view of the importance of ensuring comparability of results and quality control, the series of in tercalibration exe rcise s on bacteriological parameters within the framework of the monitoring component of MED POL Phase 11 should be regularly co, ucted ; it was important to develop reference methods for the determination of pathogenic organisms in seawater as early as possible; the preparation of a manual on microbiological laboratory quality control should be started; in this respect, material accumulated during the current and previous exercises should be taken into considera tion ; within the framework of the research component of MED POL Phase 11, laboratories should be encouraged to participate in activities conce rning (a) co rrelation between seawater quality and health effects, and (b) survival of pathogenic organisms; in the former of these activities, examination of sand in heavily frequented recreational beaches should also be included. Working Group on Health and the Environment Vienna, 12-16 December 1983 Introduction - SJ - ICP/PPE 009(2)(5) 29211 10 January 1984 ORIGINAL: ENGLISH The Working Group was organized on the reconnnendation of a Consultation on Health and the Environment convened by the WHO Regional Office for Europe in Copenhagen in March 1983. It was attended by 24 temporary advisers from 18 Member States as well as 4 representatives from other international organizations. The Working Group was convened with strong support from the Austrian Federal Ministry of Health and Environmental Protection. The Working Group was given the task of reviewing the present status of environmental health within the Region together with likely forthcoming trends. It was asked to identify shortcomings in existing research, monitori1 ~ , risk evaluation and control strategies, bearing in mind the need for a multisectoral and coordinated approach. Finally, it was to make recommendations for the benefit of Member States and to guide the development of the prograunne of the Regional Office. Discussion The discussion centred around four main themes: the current status of health in Europe in relation to the environment; the problem area of risk assessment and its related research components; the question of the administrative setting of environmental health in European countries; and the role of the WHO Regional Office for Europe. During the discussion on the present status of health in Europe, emphasis was placed on differences in health cond itions among countries. The recognized differences in infant mortality, life expectancy and age-specific mortality are particularly attributable to environmental conditions. In addition to the effects of inadequate water supply and sanitation, mainly felt in the less developed countries of the Region, new chemical, physical and biological stresses are increasingly likely to become significant. Progress has been made in containing some of the factors responsible for environmental pollution but others are still being aggravated, and both national and international efforts are required for continuing action. Among important environmental factors influencing health, particular mention should be made of emissions from internal combustion engines as well as many types of accident. As an example of conditions requiring international action, the transboundary pollution of air and water is specifically emphasized. During the discussion on risk assessment, a review of recent biological research findings was given. There are indications that advances in knowledge may, in the relatively near futu re , lead to a better understanding of environmental health problems with the possibility of establishing new avenues of prevention. The report on the Planning Consultation on Risk Assessment and its Use in the Decision-Making Process for Chemicals Control held in Ulm in November 1983 was also reviewed, and it was felt that the approaches taken by the Consultation, although specifically addressed to chemical problems, could be more generally applied. It was emphasized in the discussion that the perception of risk in the population at large differs both individually and according to socioeconomic conditions and cultural background. The importance of the role of the media in informing the public, as well as the interactions between the media on the one hand and the professions and administrations on the other, were also discussed. During the discussion on the administration of environmental health, it was stated that complex contemporary society tends to lead to complex administrative structures. This in turn may lead to problems of counnunication, although these could be remedied by improved cooperation and adequate coordination. It was considered that the Regional Office had an important role to play in advancing environmental health policies both nationally and regionally. - 54 - Conclusions and recommendations Data There are gaps in fundamental data related to environmental health. These include lack of linkage between morbidity/mortality data and environmental exposure. If already existing data were proper ly collated and disseminated, many of the existing shortcomings could be overcome, but there is a need for a more comprehensive and well structured approach at both national and international levels. It is important that available expertise for this task should be identified and the efforts of these experts effectively harnessed. There is a need to develop the means to obtain more comprehensive environmental health data and to make optimum use of existing data by exploiting modern information technology. Efforts should be made to ascertain where specific environmental health-related data are located. In some cases these data will need to be substantially augmented. A system enabling the effective linkage of existing knowledge on human health and biological effects, derived clinically, toxicologically or epidemiologically, should be established. Information from all possible sources of health-related data, including health services and other public services as well as industry, should be effectively utilized . National environmental health policy A multisectoral approach to national environmental health is essential . Although government structures differ throughout the Region, there is nevertheless an essential need for appropriate coordination to ensure the integration of health considerations into all relevant sectors of government. National environmental health policies should be developed. The primary preventive dimension and the need to develop mechanisms for systematic priority setting were stressed. Coordination in all sectors of gove rnment that could have an impact on environmental health should be strengthened. Risk assessment The question of risk assessment is of utmost importance . The principles of the recommendations and the description of the risk assessment process and model, as contained in the report on the Planning Consultation in Ulm, are endo rsed. The risk assessment process should take account of all routes of exposure, including water, air, food and the working envi ronment, and s hould consider microbiological, physical, chemical and sociological risks. Attention should be paid to s tudying the potential health impact of new technologies - including biotechnology - and new products . The importance of evaluating combined risks and indirect risks was stressed and the interdisciplinary nature of risk assessment recognized. A holistic approach to risk assessment is required, taking into account economic, social and other factors with their beneficial as well as detrimental aspects. The scientific basis fo r risk assessment should be strengthened. Measures should be adopted for a more systematic identification of the potential health r isk from new environmental hazards. Research Ongoing work in the biological sciences will have a fundamental significance in environmental health. In addition to exposure from the general environment and workplace, factors such as lifestyle, nutrition, housing, stress and genetically derived individual sensitivity can have an i nfluence on environmental health. An essent ial factor in the protection of health against insults from environmental hazards , is the body's defence mechanism. Some availab le information supports the view that this defence mechanism is greatly fortified by correct and adequate nutrition. - 55 - Research should be encouraged into identifying the factors related to lifestyle, nutr1t1on, housing, stress and genetically detennined defence mechanisms against toxic substances that contribute to environmental ill-health. Efforts should be made to expand and coordinate clinical and epidemiological investigations to assist in the identification of environmental hazards with a view to enhancing prevention. Collaboration between the medical and biological sciences in the field of the environment should be strengthened at both the national and international level. The use of industrial resources to support research should be carefully considered. Education, training and counnunication An interdisciplinary approach to environmental health is important. There is a lack of sufficiently trained personnel in many areas. The public needs better infonnation on matters concerning environmental health problems, including the role of factors such as lifestyle, housing, stress, etc., especially with regard to the perception of risk and risk prevention. Environmental health should be given more emphasis in medical training curricula. Training in toxicology, epidemiology and appropriate biological sciences needs to be strengthened . Specific training prograunnes in the methodology of risk assessment should be established. The counnunication of infonnation on risk assessment to the public by public agencies should be encouraged, without causing unnecessary alann while increasing infonned public awareness. International cooperation and collaboration The WHO Regional Office for Europe has a fundamental role to play in relation to environmental health in the European Region, and this holds true particularly in relation to data collection, evaluation and dissemination. A WHO European advisory group, multisectoral and interdisciplinary in character, should be established and should meet regularly to advise the Regional Office on all aspects of environmental health. It might be advantageous for the advisory group to hold meetings in different countries of the Region on a rotating basis. Interest . was expressed in the concept of establishing a WHO European interdisciplinary centre for environmental health. In studying the further development of this suggestion, however, more detailed infonnation should be collected by the Regional Office on the main tasks to be accomplished and on the administrative mechanisms, together with an inventory of related efforts at present in progress within the European Region. The increasing importance of environmental health warrants the allocation of increased financial and personnel resources to this prograunne area in the Regional Office. The Regional Office for Europe has an important role to play in stimulating, both at the country level and within international agencies, increased efforts to solve problems related to environmental health. All activities related to chemical safety carried out by the WHO Regional Office for Europe should be implemented in full coordination with, and where appropriate as part of, the International Prograunne on Chemical Safety, in order to give optimum assistance to worldwide efforts within the field of environmental health. - 57 - FAMILY PLANNING Meeting on the Development of Teaching Modules on Various Aspects of Family Planning Copenhagen, 7-9 June 1983 Introduction - 59 - ICP/MCH 025(9)(S) UNFPA RMI/79/POS 14 June 1983 2011F ORIGINAL: ENGLISH The aim of the Meeting was to review a series of modules on various aspects of family planning that had been developed in 1982; to develop strategies for testing the effectiveness of these modules; and to identify new modules to be elaborated . The 13 participants discussed the lack of relevant teaching material dealing with sexuality and family planning, with particular emphasis on the psychosocial aspects and the needs of migrants . They considered four of the five modules that had been prepared and made r ecommendati~~s to bring them into a uniform educational structure prior to field testing. A list of subjects for future development was prepared and there was some discussion on their possible educational objectives. Recorrmendations 1. The modules should be as flexible as the subject allowed, to enable trainers to select the appropriate parts and devise their own teaching programmes . 2 . The modules should be accep~able in all areas of the Region: trainers should be able to adapt them to local needs and resources. 3 . The modules should include or refer to materials already in existence in order to avoid duplicat ion or omission. 4. The modules should be aimed at people whose work involves: (a) sexuality and family planning at all levels in teaching and service; and (b) the psychosocial aspects of family planning. 5. The modules are designed to be used for the training of health or social workers. They should be suitable for both basic and refresher training . 6. The modules must make it clear that the subject is important enough to justify their inclusion in existing curricula . 7. Although the modules are for use in training the family planning worker, the ultimate goal is the needs of the client. 8. The existing two modules on sexology and migrants, and two on psychosocial aspects of family planning, should be revised by the authors before 1 October 1983. Copies should be ready for field testing by 1 January 1984. 9 . All modules should contain sections on objectives, subject content, teaching methods and evaluation. 10. Each module should outline the assumptions it makes about the prerequisite knowledge and skills of the user. - 60 - 11. Evaluation of the modules will be carried out by the British Life Assurance Trust Centre in London based on field testing of all the specified types of audience in institutions to be identified by WHO and located throughout the European Region. 12 . Seventeen topics were identified for which future modules could be developed. Some of these were considered as priority areas, for example the male role in family planning and sexuality of the aged, Conclusion The participants were asked to provide continuing support and motivation for the development of the series of modules . Their past and future help was much appreciated by WHO. Consultation on Sexuality Copenhagen, 9-10 November 1983 Introduction - 61 - ICP/MCH 026(5) RMI/79/POS 3016F 15 December 1983 ORIGINAL: ENGLISH The meeting was attended by five experts in psychology, sociology, psychiatry, neurology and family planning. One of the issues likely to receive increased attention during the coming decade is sexuality and sexual health . When it is said that sexuality is likely to become a salient issue of the future, this is neither a denial of the importance of sexuality today (or yesterday for that matter) nor an attempt to claim that sexuality in the future will be that much more important. Rather, it is a claim that sexually related problems in the future will more often be add r essed as such. With a reduction in taboos, which can already be witnessed today when comparing young people with previous generations, people will be able to allow themselves to enjoy sexuality more. In expecting to enjoy sexuality, people will attach greater importance to this aspect of life and thus facilitate an increase in the number of complaints that can be addressed in terms of sexuality . Greater expectations will lead to more "problems" to which the health system must react by reformulating present health concepts to take into account their sexual dimension. This change on the part of health systems is to be facilitated and supported by the World Health Organization, and at the WHO Regional Office for Europe this is signified by the launching in 1984 of a new programme on sexuality and family planning (previously called simply family planning) . The purpose of the Consultation was thus to discuss the scope of sexology and its contribution to the new programme, to the WHO regional target on sexuality, and to the overall objectives of health for all by the year 2000 (HFA2000). In particular, this implies identifying present problems, and the resources and strategies to overcome these problems, with a view to raising awareness about the sexual dimension of many health problems and to improving people's c hances of leading emotionally fulfilling sexual lives. The discussions covered the following areas: the development of a programme on sexuality and family planning; sexology, a science with many parents (presentations were made by participants on different contibutions to our understanding of sexuality); the joint identification of the most urgent problems; teaching strategies; available resources; and new directions. Conclusions and recommendations At present, it is not possible to define the totality of human sexuality in a form that would be acceptable to all countries, but every person has a right to receive sexual information and to consider accepting sexual relationships for pleasure as well as for procreation. l. Various personnel have close contact with people with sexual health problems, including gynaecologists, psychiatrists, psychologists, social workers, general practitioners, nurses, counsellers, teachers, community and youth workers, the clergy and rehabilitation counsellers . This requires them to have a much broader knowledge of sexuality than before and calls for the education of a greater variety of health professionals. 2 . Organized sexual training can be given at several levels and should be given to most cat egories of health and other personnel involved with sexual education and sex counselling. Sexual training should enable personnel to sanction sexuality or, on another level, to give limited information. A more advanced level of sexual training should enable them to give specific advice - 62 - as in a family planning office, which requires specifi c tra1n1ng and a knowledge of medicine and family life as well as of sociology. More advanced sexology involves training in intensive therapy, which should be given by professional therapists. Sexualit y should be taught as a discipline in its own right as part of the education and training of health professionals and become a recognized component of genera 1 health services, particularly famil y health. 3. Sexuality starts at birth, if not earlier in the foetus . Masturbation and sexual play in children are normal and healthy activities, but children in most countries suffer from sexual repression. The attitudes and reactions in the environment of the child have an impact on his/her sexual development and will influence to what extent sexual problems will develop. Children as well as adult s require support to be able to feel enjoyment as sexual beings. 4. Sexual problems have long been avoided by health professionals with regard to somatic medicine and drug treatment. There are many somatic diseases that directly or indirectly have an influence on sexual functioning. Surgery and drug treatment can have an impact on sexuality, either directly or by interacting with already existing sexual problems. It is important to stress the interaction between psyc hological and s omatic aspects in a broad way and its impact on human sexuality as well as its relation to self-esteem . Psychiatric medical treatment often affects sexual functioning, and patients s hould be carefully informed about its consequences. 5. Contrac eption is closely linked to sexuality and therefore also linked to the relationship between men and women. Yet, family planning services still have a tendency to discourage any association with a fuller enjoyment of sexual relationships and concentrate mainly on contraceptive techniques . As a consequence, those men and women who turn to family planning services for help other than of a purely contraceptive nature are often disappointed. When they discontinue their visits, they are unjustifiably regarded by the services as "drop-outs" and as putting themselves at risk, yet in many cases they are coping perfectly well with famil y planning as such. An unavo idable dilemma in family planning is the contradiction between the rationality of planning and the irrationalit y of sexualit y . It is therefore important to emphasize the enjoyment of sexuality in the context of family planning. Although sexual health is of concern to both sexes, in most of the existing health and family planning programmes the approach is directed mainly at women. 6. Within the framework of increasing the level of knowledge about sexual matters, the media (radi o , tel evision, newspapers and popular magazines) should be used. These are valuable resources fo r b ringing information t o a wider audienc e . 7. This r eport has underlined some aspects of sexuality in relation to family planning and health care. Although this is a new trend in health care, most of the problems have been known for decad es. It is not the new trend that is the problem in itself, but the requirement from people that these problems should be dealt with in conjunction with sexual matters. Targets The part1c1pants reviewed the programme structure of the famiy planning unit in the WHO Regional Office for Europe for 1984-1991, and concentrated on objective 5.1 dealing with sexuality: " to stimulate the development of policies, programmes and services for ensuring a healthy and satisfying sexual life". They agreed to the following planned targets . 5.1.l Review of existing definitions, concepts, principles and conditions for a healthy and satisfying sexual life by 1987 . 5.1.2 Assessment of current status of satisfying/non-satisfying sexual life by 1989. 5.1.3 Analysis of sexuality and/or partnership among the disabled and the elderly at home or in an institutional setting by 1989. 5.1.4 Analysis of existing sexual counselling programmes by 1988. 5.1.5 Guidelines on appropriate legislation related to satisfying sexual life by 1991. - 63 - The group then suggested four new targets. Study of the segregation trends in modern society regarding sex roles and sexuality. Study on the impact of occupation on sexuality and family life. Review of homosexuality, prostitution, sexual abuse and violence. Study of the sexual climate and the conditions under which children are brought up and how it affects their sexual development. The participants also reviewed target 41 in support of the regional strategy for HFA2000 related to sexual behaviour. By 1995, in every country at least 80% of the people - including vulnerable groups such as those in institutions, the disabled, the elderly, etc., will have an opportunity of leading an emotionally satisfying sexual life in harmony with the needs, beliefs and values of the individual and society. The participants felt that the topic covered by this targe t was of great importance. Owing to the very special character of sexuality and great differences in the cultural expression of sexual sentiment, however, it appears to be more appropriate to indicate the direction of the change intended and the importance of this subject rather than to quantify it. - 65 - FOOD SAFETY Working Group on Denatured Rapeseed Oil Toxicology Syndrome Madrid, 21-25 March 1983 - 67 - ICP/RCE 905(l)(S) 13771 21 April 1983 ORIGINAL: ENGLISH From early May 1981, an outbreak of a previously unknown syndrome occurred in Spain, mainly in Madrid and in areas north-west of Madrid. The epidemic reached a peak by mid June, when more than 600 daily hospital admissions due to the disease were recorded. Illegally sold denatured rapeseed oil was announced as the most probable cause, and on 30 June the authorities began to exchange all suspected rapeseed oil with pure olive oil. After this time, hospital admissions concerned intoxications in a chronic stage , the majority being readmissions. Many cases were severe and needed intensive care. By December 1982, a total of 336 deaths had occ urred, the total number of cases recorded had reached 20 178, and a small number of patients were st ill in intensive ca re. Treatment with corticosteroids showed significant effects in the early stages, but various treatment regimens during later stages proved unsuccessful. The severi t y of this epidemic and the associated important medical and toxicological aspects revealed a need for an international collaborative effort to establish precise diagnostic c riteria, mechanisms of pathogenesis, epidemio logical characteristics and the identit y of the etio l ogical agent or agents. In addition, the implications for preventing similar incidents need to be assessed . The Working Group reviewed and evaluated available environmental data related to the outbreak of the poisoning, as well as the results of extensive clinical studies and toxicological and chemica l i nvestigations in several countries. On the basis of the evidence reviewed and detailed discussion in subgroups, the Working Group adopted general conclusions concerning the cu rrent level of understanding and recommendat i ons for future investigations necessary, mechanisms for collaboration and future preventive measures. The material examined epidemiologically covered five general categories: data from national case surveillance systems; results of analytic epidemiological investigations; studies of spec i fic cases or case groups; information regarding sources and dis tribution of suspected toxic oil ; data regarding an etiological hypothesis other tha n edible oil. From these data the evidence pointed to the toxic syndrome being not an infectious disease, but one that had to be attributed to an article of diet and, above all, to that form of rapeseed oil offered for sale illegally by itinerant vendors i n Spain during the early part of 1981. The data , however, were not sufficientl y precise to incriminate any particular batches or cons ignments of that oil , and less still to any distinct component of the oil . Suggestions that some agent other than the oil, such as food crops or agricultural chemicals, might instead be to blame did not with stand c ritical epidemiological evaluation . Conclusions 1. Nine separate case-control studies, which compared patients with toxic oil syndrome (TOS) or their families with controls (pe rsons without TOS or their families), showed a remarkably strong and consi stent as sociation between development of TOS and consumption of food oil purchased from itinerant markets o r salesmen. 2 . A series of s tudies performed in Navas del Marques (Avila Province) starting on 10 June 1981 found, in add ition to the strong link to oil use, a dose-response pattern indicating greater oil consumption by affected patients than by their una ffected relatives or controls. 3. No strong or consistent evidence was found in these studies to suggest inhalation rather than ingestion as the route of oil exposure. - 68 - 4, Repeated clinical-epidemiological evidence suggests that the latency period between ingestion of oil and developme nt of the first TOS symptoms was 7- 10 days in adults. 5. From an epidemiological point of view it is not yet clear whether aniline and aniline reaction products in the rapeseed oil were present only in case-associated oils, or whether denatured oil was in fact more widely distributed and consumed in Spain both before the epidemic and during the epidemic in parts of the country unaffected by TOS. 6. In contrast to the findings with respect to food oils, no convincing alternative hypothesis has been put forwa rd. 7. The toxic oil syndrome consists of acute and chronic phases resembling those of well known disease entities, but the combined clinical picture and the pathology a r e unique and suggest that this syndrome is new, 8 . Characteristics of the acute phase include fever, eosinophilia, skin rash, pruritus, malaise, myalgia, arthralgia, dispnoea, non-cardiogenic pulmonary oedema, and nonspecific gastroint estinal symptoms . 9. The mechanism transient aller~ic endothelial lesion of the acute phase "the syndrome seems to be primarily toxic with possible features superimposed. The pathogenesis appears to involve a systemic with the most severe effects in the lungs . 10. The chronic phase, developing insidiously over a period of months, is characte ri zed by peripheral neuropathy with muscle atrophy and deformity of the upper limbs, skin tautness of schleroderma type, xerostomia and xerophthalmia (sicca svndrome), pulmonary hypertension and, less frequently, Raynaud's phenomenon, oesophageal hypomotility and the occurrence of auto-antibodies. 11 . The mechanism of the chronic phase has not been established . There are some features of toxicity a nd some of autoimmunity. The observed progression of the endothelial lesions suggests that the total perspect ive of chronic effects has yet to develop. 12. Fewer than 2% of patients with TOS have died. The clinical course of the majority of cases so far has been that of a slow, spontaneous resolution . In a small proportion of patients the severe chroni c changes desc ribed above have developed , and i n a few patients these have not r esolved . In addition, in a significant proportion of patients an almost stable reduction of diffusion capacity of the lungs and/or increase of liver enzyme levels remain. 13. Corticosteroid therapy was beneficial and sometimes life savin~ in the acute phase, a nd subsequently speeded the improvement in lung function. There is no evidence of either a beneficial or a harmful effect of steroid therapy on the development and course of the neuromuscular syndrome. Although any harmful effect of steroid therapy has not been detected, long-term treatment is not recommended. 14 . Conce rnin g other therap ies, no overall benefit has been established from any other drug treatment and it is unrealistic to expect any specific antidote. Physical rehabilitation has been the most effective symptomatic remedy prescribed so far . Trials of other measures are s till under way. 15. Owing to the emergency nature of the situation in 1981, proper organization of the collection of case-related oils and proper coordination of chemical and toxicological studies were not carried out. 16 . Available evidence from owing to the fact that: (a) (b) uncertainty prevails as chemical analyses and animal experiments is difficult to evaluate different oils were examined in different laboratori es, and to whether or not truly case-related oil samples were examined. 17. Attempt s to reproduce TOS in animal model systems have given man y ne gative results. Moreover, the positive results obtained in one centre could not be rep roduced in others. The reasons for these discrepancies may be due to the following factors in addition to the two mentioned above: (a) the relevance of the animal models has still to be proved; (b) experimenta l designs and processing of histological samples have, in some cases, been inadequate; (c) insufficient attention has been paid to nutritional and other factors; and (d) coordination between different groups of scientists has been insufficient. 18. Although an ideal model system should reproduce all aspects of the disease, a number of in vivo and in vitro models may he necessary to piece together a combined model system. In - 69 - particular, promising preliminary results have been obtained with the human fibroblast system, chick embryo and in vivo systems using the mouse and the rabbit. All systems require validation, however. 19. The evidence that fatty acid anilides are the cause of the disease is still inconclusive, but they may nevertheless be useful markers for toxic oil. 20, Samples of aniline denatured rapeseed oils at the customs authorities, and samples of case-related oils kept at the National Centre of Foods and Nutrition in Majadahonda and those kept in connection with the national plan, may become available for further study. In addition, technical details on the denaturation and refining operation at the ITH plant i n Seville have just been released, thus perhaps making simulated toxic oil production possible. Specific recommendations 1. Existing national and provincial TOS case surveillance files should be verified, coordinated, and made accessible for active and continuing epidemiological analyses. 2. Existing case registries should be maintained so that TOS cases and family members can be followed up for possible lat 0 health sequelae . 3. To implement the first two recommendations and to allow adequate analysis of other epidemiological data, Spain should give high priority to developing a greatly strengthened national epidemiological programme . The ongoing availability of such a national resource would not only benefit studies of TOS but would also provide significant support for general activities in public health. 4. In view of the crucial importance and strength of the epidemiological evidence linking oil exposure to TOS development, it is strongly urged that all data in the nine case-control studies be promptly prepared for international scientific publication. 5. Although initial studies of birth defects in relation to TOS have shown no evidence of abnormal patterns, periodic re-analysis should be carried out, using national case files if possible, to take advantage of the increasing numbers of observat ions and to exclude the concept that evolving illness in patients with TOS may be accompanied by altered risk of reproductive abnormality. 6. Clinical epidemiological data, particularly regarding specific kinds of oil and latent periods, should be published in full where such data seem on a firm footing and involve repeated observations. 7 . A thorough re-analysis of all data on the time and place of distribution of aniline/anilide-containing food oils should be carried out, so that this difficult point can be resolved as far as possible. 8. It would be of critical importance for a more precise epidemiological and toxicologica l understanding of the epidemic and its cause if information now held by judicial authorities could be shared with scientific i nvestigators. 9. As long as the exact toxin remains unidentified, all confiscated oil samples should be kept in storage. Such samples should be clearly ca talogued by source, and their use as a foodstuff in the future should obviously be completely prohibited. 10. Any evidence suggesting the role of particular risk factors in TOS, as in any disease problem, needs to be fully presented for open scientific evaluation in the published scientific literature. If alternative hypotheses are to be considered, particularly in the face of convincing evidence regarding oil consumption, this useful and ge nerally accepted procedure should be followed. 11 . The organization of follow-up of patients for monitoring the natural history of the TOS, and future studies of clinical research, should be concentrated on a small number of multidisciplinary units with central coordination . However, the medical care delivered to these patients, either in hospital or in outpatient clinics, should be integrated with that for patients with other conditions. 12 . A long-term follow-up programme should be set up to define the natural history and to detect and investigate deterioration. The follow-up groups should include: - 70 - (a) all patients with persistent or progressive disorders of any organ system, which should be intensively invest igated; (b) offspring of affected parents; (c) patients who have made an appurently complete recovery; and (d) exposed but unaffected individuals . 13. Collaboration in research and clinical management should be encouraged with centres outside Spain that have a special interest in related conditions or have special facilities for clinical investigation . 14. Any untried treatments should be considered entirely experimental . Such therapies should on ly be given as part of a properly planned controlled clinical study in selected units. 15 . The following general guidelines for further medical research are recommended: (a) attention should be focused on endothelial damage and repair of lesions; (b) both immunology and toxicit y studies should be continued; and (c) HLA typing of patients with acute disease only a nd of patient s with chronic disease should be carried out on a sufficiently large scale for definite conclusions to be drawn. 16. A new coordinated approach is necessary to the possible identification of the toxic agent(s) in the oil, and to elucidate the toxic mechanism and pathogenesis of TOS . 17. The selection system for case-related oils examined to date is unsatisfactory. For the present, oil samples should be selected on the following basis: (a) the s ample should have originated from the home oi a patient with TOS; (b) the rapeseed oil content should be at least 40%; and (c) the content of anilides should be at least 700 mg/1 . 18. Samples of oil collected at the time of the TOS outbreak are stored in the National Centre of Food and Nutrition in Majadahonda. After chemical analysis and initial screening on the Swiss mouse at Majadahonda ; the same samples should be sent to other laboratories, both in Spain and abroad, for repeated testin g according to agreed protocols. 19. A simulated refining procedure, as used at ITH in Seville, should be used to produce samples of oil for chemical and toxico logical characterization. Earlier agreements and recommendations in this respect should be implemented as soon as possible. 20. Research into the toxic properties of anilides and other aniline reaction products should be continued. 21 . The mouse and rabbit systems, the human fibroblast and chick embryo should be used for toxicity testing of the case-related oils as described above. At the moment, however, no bioassay system can be recommended. 22. An international steering gro up should be formed to evaluate the status of current research, to coordinate research activities, and to supply guidance for future studies and for the selection of oil samples for continued storage and further testing. In addition, the steering group should promote multicentre studies, develop joint protocols and arrange peer reviews of experimental results . 23. In cooperation with the Spanish Government, WHO should explore the possibility of funding international collaborative research into TOS. In addition, support should be sought from other international bodies because of the significance of this research with regard to human toxicology, defence mechanisms, and possible individual susceptibility related to nutritional factors. 24. The health significance of food contamination and the particularly catastrophic results of the toxic oil incident in Spain should be communicated in detail to government authorities abroad in order to emphasize the importance of food safety regulations, implementation of food inspection and strict enforcement practices. - 71 - General recommendations 1. The toxic oil syndrome resulted from the illegal manufacture and distribution of an adulterated rapeseed oil sold for human consumption, which resulted in tragic loss of life and serious illness. It is important that consideration be given by the Spanish authorities to the need for more exacting food safety services at national and local levels, with an adequate number of well trained inspectors s upported by good legislation. 2. Expanded training programmes for Span ish personnel, if possible with international support, should be developed within the fields of toxicology, epidemiology and food safety. 3. In Spain, as in other countries, there is a need for a well coordinated system for contingency planning and emergency response to all types of chemical accident, in order to limit the severity of their effects. This should be in accordance with the guidelines prepared by the WHO Regional Office fo r Europe under the International Programme on Chemical Safety. 4 . The Working Group strongly supported the recommendations concerning epidemiology and clinical observations and pathology, and emphasized that they should be implemented without delay . There is urgent need for further toxicological research i n accordance with these recommendations. This work should be carefully planned and coordinated . This task might well be entrusted to a small group of individual experts from Spain and other countries. 5 . The further activities recommended by the Working Group will require adequate funding . It is important that any progratrane to solve the problem of TOS in the cause of human health should not be constrained by lack of commitment and material resources. The commitment should not be confined to Spain, because the possibility of another catastrophe of this kind elsewhere cannot be dismissed . Working Group on Food Inspection Copenhagen, 21-25 November 1983 Introduction - 72 - ICP/FSP 002(2)(S ) 28091 14 December 1983 ORIGINAL: ENGLISH The Working Group was attended by 18 temporary advi s ers from the European Region drawn from a variety of relevant disciplines including medical officers, veterinarians, microbiologists and environmental health officers . In addition there was one representative each from the European Bureau of Consumers' Unions (BEUC), the European Food Law Association (EFLA), the Food and Agriculture Organization of the United Nations (FAO), and the International Organization for Standardization (ISO), together with representatives from WHO headquarters and the Regional Office for Europe . The purpose of the Working Group was to discuss food inspection with a view to producing suggestions for better use of available resources and improved food inspection systems. The inspection of food was described in the scope of the meeting as being carried out with the main purpose of protecting the consumer against foodborne disease. Discussion Two background papers were presented: one on the system of food inspection in the United Kingdom and one on that in the Federal Republic of Germany. In the discussion it emerged that there are wide variations in inspection systems and the qualifications of inspectors between the different countries represented . There are two broad categories of inspector: those with an academic training, s uch as medical officers, veterinarians or environmental health officers (EHOs), and those with no academic training. In Sweden and the United Kingdom the academically trained EHO actually carry out the food inspections, whereas in most other countries inspections are made by non-academic inspectors working under the supervision of the academically qualified inspectors. Most services are at local government or national level . Coordination between these services and central government is essential . Food inspection was seen as having two aspects: the inspection of the food itself , and the inspection of all stages of producing and distributing it , i.e. premises inspection. It was firmly concluded that this latter aspect of inspection is a more effective means of protecting the health and safety of the consumer than end product testing. There is much wasteful expendit ure of resources on end product testing. There are occasions when microbiological specifications for the end product could serve a purpose, but these should preferably be in the form of guidelines rather than legal requirements. Where such specifications are established, they should be in accordance with the principles established by the Codex Alimentarius. There was seen to be a case for wider application of the "hazard analysis critical control point" (HACCP) system. This was seen as the most cost-effective means of ensuring the production of safe food. This concept, embodying old established principles, is increasingly being adopted by industry and should be encouraged by food inspectors. By ensuring that the system is being properly applied, and by verifying the monitoring results and quality control programmes, food inspection could be made more cost-effective. By involving themselves in this way, inspectors could help to s t rengthen the dialogue with trade and industry, which the group considered to be of mutual benefit in achieving food safety. The role of food inspectors in educating both food workers and the consumer in food hygiene was felt to be very important. It required inspectors to be well qualified and good communicators. It was generally agreed that food inspectors should aim to advise and educate rather than to perform a rigid policing function. - 73 - Although the group did not favour end product testing, it was recognized that the control of imported food was generally dependent upon this . However, it is impracticable to devise sampling schemes in relation to the microbiology of imported foods that were capable of ensuring acceptable levels of public health protection. It was felt that a more effective approach would be to encourage importers to require their suppliers to adopt the HACCP system. This may require special arrangements to be agreed between importers and exporters, e.g. recognition of export certificates or inspection. In view of the wide range of types of food inspector it was not possible to make specific recommendations on training requirements, but it was acknowledged that in some countries the level of training of inspectors needed to be improved. This would depend on their level of responsibility within the service. Current food inspection requires a wide range of expertise supported by outside experts where necessary. However, the core of the service is likely to remain the adequately trained food inspector. Food inspectors require good laboratory support if they are to function effectively. Good communication between inspectors and laboratories is also essential. Recommendations It was recommended that: l. Food safety should be recognized as of paramount importance for the protection of the health of the c.nmunity, and it should be recognized as one of the main compo~ents of primary health care and preventive medicine. 2. Safety and hygiene can be controlled more cost-effectively by food hygiene inspection than by end product testing. Food inspection services should therefore place emphasis on inspection rather than end product testing. This inspection includes all aspects of the handling, processing and storage of food (premises etc.) from production, processing and distribution to the point of sale to the consumer. 3. The "general principles for the establishment and application of microbiological criteria for foods", as elaborated by the Codex Alimentarius Commission, should be followed when setting up microbiological criteria in national or international legislation. 4. When microbiological cri teria are set they should be used to identify non-compliance with hygiene rules and to correct bad manufacturing practice . S. The hazard analysis critical control point (HACCP) concept, already included in the Cod~x Alimentarius Codes of Hygienic Practice, should also be used in national and international food legislation so that special emphasis is placed on hazardous foods and the identification of critical control points. 6. The application of HACCP should be considered as a means of improving the efficiency of the food inspection service. The food inspector should be provided with guidance on the monitoring of these points. 7. The frequency and completeness of inspection of each food business should be related to the adequacy of its own quality control programmes. 8. Inspection services should try to achieve mutual understanding with the food trade and industry. The involvement of the food inspection services in identifying critical control points and the establishing of monitoring procedures is one means of achieving this. 9. Food importers should be encouraged to require their suppliers to adopt the HACCP system . This may require special arrangements to be agreed between i mporters and exporters, e.g . recognition of export certificates or inspection. Wherever possible, food inspection services should accept test results, certificates or marks of conformity issued by the relevant inspection service in the exporting country. In accordance with the principles of the Codex Alimentarius, foods imported into a country should be treated no less favourably by the inspection services than those of national origin. The inspection of imported food should not create unnecessary obstacles to international trade. 10. The main emphasis in food inspection should be on advice and education rather than punitive sanctions. Sanctions should be reserved for deliberate violation of the law and for instances of serious negligence. - 74 - 11. The education of food handlers in food hygiene is one of the most effective means of improving hygienic practices. It should be applied to all levels from management to food handlers . It should be recognized as an essential element in all training courses for food handling and food management personnel. The food inspector should play an important role in this. Particular effor t should be concentrated on those food handlers involved in situations known to be associated with outbreaks of foodborne infections and intoxications. 12. The education of the consumer in food hygiene is necessary to reduce the incidence of domestically caused foodborne disease. Education on basic elements needs to be introduced as ear ly as possible, as part of personal hygiene education, ideally starting in primar y school. Food inspectors should actively promote and participate in such education at every possible opportunity. Application of modern techniques of communication should be considered. 13. Coordination between food inspection services both within and between countries should be improved. The ultimate goal is mutual recognition of the effectiveness of the different systems. Inte rnationa l harmonization o f requirements for foods and of inspection procedures would help to achieve this. 14 . In some countries the training of food inspectors may need to be raised to a higher level. I t would be appropriate for i nternational bodies such as FAO and WHO to suggest suitable curricula , using the professional profile discussed in this report. - 75 - HEALTH ECONOMICS Workshop on the Cost and Financing of University Hospitals Maastricht 1 28-30 March 1983 - 77 - ICP/SPM 035(5) 217 SE 9 August 1983 ORIGINAL: ENGLISH University hospitals are the most sophisticated facilities in national medical care systems . They perform a number of functions, in particular the delivery of secondary and tertiary patient care, the education and training of specialized health manpower and the conduct of biomedical , clinical and health services research. Given the canplexity and interaction of these functions, it is difficu lt to determine how the costs of activities in university hospitals are attributed to each one . Teaching hospitals lack at present any routine costing or budgeting information by functi 1. This has made it almost impossible to: divide responsibility for the functioning of university hospitals properly between the various national and regional administrative and supervisory bodies; d istribute the costs of university hospitals among financing bodies in an efficient and just manner; and enable the management of univer si ty hospitals to deal efficiently with their multiple functions. There were 33 experts from 11 countries at the Workshop, including government offic ial s , administrators, managers, researchers and r epresentatives of financing bodies. The participants had before them eight detailed statements from various European countries and the United States on the organization, financing and management of university hospitals in these countries and on research into the allocation of costs to different functions within these hospitals. Organization, financing and management The first objective of the Workshop was to gain insight into the ways in which university hospitals in selected countries organize, finance and manage the above-mentioned functions; to explore procedures for funding and managing university hospitals in a more efficient and just manner; and to consider related policy issues . With respect to ex ternal organization it was observed that different gove rnment bodies supervise and control the operation of university hospitals in each country. In some cou ntries, for instanc e the United States, the private sector has considerable administrative power. In others, s up ervision of patient care, teaching and research is carried out by different administrative bodies. It was stressed that the administrative structure should not interfere with the planning of the university hospitals as an integral part of the health care system. University hospitals are financed from various sources and in different ways. It was observed that in a number of cases inadequate financial means were available to operate all the hospital's fuoctions or fo r investment, which made it necessary to reallocate money from other sources. It was thought preferable that the patient care function be fina nced in a similar way to all other health care functions within the health care system but that the undergraduate training of medical students and biomedical research should receive separate financing through other channels. Fur therm ore, the c lose re lat ions hip between f inane ing and planning was s tressed which sugges t s that those in charge of planning should also be responsible for financing. With respect to internal management it was observed that a whole range of organizational models apply to the relationship between university hospitals and medical schools. These models range from those where university hospitals and medical schools are one integratel unit, as in Austria, to those where they are separately administered and managed. In some cases a "matrix organization" is used to create the necessary administrative and managerial links between the two. - 78 - Specific recommendations 1. The major task of unive rsity hospitals is to provide tertiary, highly specialized medical care . They should be planned and financed as an integral part of the health care system. In practice this would mean providing specialized services to a region of 1-5 million inhabitants. 2. Physicians should not only be trained in university hospitals, but also at other levels of care with other members of the health team . 3. University hospitals should carry out research not only into the clinical and biomedical aspects of tertiary care but also into the health services, with emphasis on the cost-effectiveness of comprehensive health services . 4. To the degree that a university hospital has responsibilities in the training of undergraduate medical students, basic biomedical research and health services research, it should receive additional finance from bodies responsible for research and education. In many countries this will mean financing through central departments of education, science and/or research. 5. All the functions of a university hospital should be planned jointly to ensure that sufficient provision is made for research and training and that neither function jeopardizes the delivery of patient care. 6. Where the university faculties of medicine and nursing are not under the same management board as the university hospital, there should be close coordination between both partners, preferably by means of annual agreements. Allocation of costs to functions The second objective of the Workshop was to determine the usefulness of different approaches to allocating costs to the various functions of a university hospital, to review the system of dealing with these overlapping functions, and to consider related policy issues . At the Workshop the results of a number of research projects that attempted to allocate the costs of university hospitals to the different functions were presented. It seemed clear that it was indeed possible to narrow the area in which arbitrary decisions on cost allocation have to be made. A small percentage of the costs cannot however be attributed to any one of the functions on the basis of analytical and objective methods. The separation and identification of costs is important not only as a basis for financing and control, but also because university hospitals are thought to have a responsibility to the public to clarify the functions they perform and to identify the costs that result from them . It was suggested that multiple methods (such as residual costing by comparison with non-university hospitals, acceptance of administrative rules, and detailed activity and time analysis) should be used to identify costs and to confirm the various results. Sensitivity analysis should be used to show how much the results depend on the availability of certain information and a priori assumptions. Specific recol!Dllendations: 1. University hospitals, and indeed all other hospitals, should review their financing/payment systems (fees for service, salary, and income from private patients) to ensure that they do not conflict with the objectives of the cost-effective delivery of health services. 2. To ensure an effective and equitable level of staffing and operation in university hospitals, information systems should be developed with the emphasis on the patient (grouped according to diagnosis, severity of condition, stage of disease) and on the cost of consuming resources. 3. As many of the services of a university hospital provide patient care, research and training all at the same time, an effort should be made to allocate their joint costs to each of the different functions to promote a better division of labour and better coordination between them. - 79 - General recorranendations It was recommended that Member States should: determine the role of university hospitals in promoting cost-effective medical care; study the impact of different hospital financing systems on the effectiveness, efficiency and equity of health care; and promote the training in health economics of members of medical and nursing faculties. Planning Meeting for the Study on the Cost- Effectiveness of Managing Chronic Psychotics Mannheim, 2-4 May 1983 - 80 - ICP/SPM 035(2)(5) 0070A 24 November 1983 ORIGINAL: ENGLISH This meeting was held in close collaboration with the Central Institute for Mental Health, Mannheim, and included an equal number of psychiatrists and of economists and social scientists. The followi ng presents the conclusions they reached about the content and methods of the multinational study on the cost-effectiveness of managing chronically psychotic patients planned for 1984-1986. 1 . Five research iss ue s There are five major research issues for the study and the appropriateness of different research methods was discussed . Regional differences Why do mental health services for chronically psychotic patients differ to s uch a large extent from one European country to another, and what are the economic and social consequences of these differences? Of special interest are the economic determinants (such as economic recession or cost containment) and economic conseque nces (cost-effectiveness or the economic burden on families) of these differences. The method of research is the description, and then the comparison, of care centres or regions with opposite mental health care strategies. Where possible, these macro studies will include information from c entres that have already participated in related WHO pilot studies. While the emphasis here is on c ross-sectional research , it may also be interesting to view the shi fts in mental health services over long periods of time within countries, either retrospectively or by non-concurrent prospective cohort studies. Patterns and pathways of care Are there different patterns and pa thways of recruitment and care ("patient careers" ) of chronically psychotic patients even within one region? Are there differences in the de-institutionalization o f patients? Can these differences be explained in terms of different case-mixes (patient needs) or in terms of differing diagnoses? If not, what are the implications of these differences in terms of cost-effectiveness ? The method of research is path or cluster analysis, followed by a cost-effectiveness appraisal of the balance of care for speci f ic groups of patients. The cost of research depends on the strictness of data protection laws and the existence of case registers . Psychiatric treatment When does the cost-effectiveness of treatment improve? When outpatie nt (rather than inpatient) care is made the norm? When different locations, forms and dosages of medication are involved? When social (rather than medical) assistance is given? When the patient is seen by a general practitioner r ather than by a psychiatrist or psychologist? When long-term care rather than repeated short-term treatment is applied? Does cost-effectiveness vary with different psychiatric schools or supply structures? The method of research is (quasi) experimental, using matched-pair comparisons and occasionally randomized clinical trials. This type of research is usually quite costly. - 81 - Special patient and target groups What kinds of economic problem are associated with undiscovered and/or untreated cases of chronic psychosis? Those associated with an increasing dropout rate due to rapid change from inpatient to outpatient care? Problems associated with medical treatment that disregards family and community factors? What groups are most affected by the observed shift in care policies? The de-institutionalized? The discharged? Psychotic patients without families? Psychotic already at a social disadvantage? The family? Welfare organizations? Social workers? vagrants? patients City The method of research is explanatory-empirical, with the aim of shedding light on these questions by means of interviews, press reviews, participant observation, etc. In many instances, qualitative answers will suffice. Optimal solutions Are there optimal pathways, treatments, strategies and sequences of psychiatric care for chronically psychotic patients? What is the optimal mix of primary, secondary and tertiary prevention? The method of research is a formal cost -e ffectiveness or cost -benefit analysis, i.e. the maximization of effectiveness or benefits under economic (cost) constraints, even where this means chall enging existing norms and standards. Markov chains for modelling sequences, sensitivity testing and various operational research techniques may be required as well. The information requirements for this type of research can be quite large. 2. Schizophrenia as trac e r for psychoses 3. The focus of the study should be chronic schizophrenic patients, in view of the: relatively unambiguous diagnosis; possibility of validating the diagnosis by means of psychiatric scales; rough consensus on management; great variation i n the management strategies (14% to 92% of schizophrenic patients are hospitalized, depending on the country); better availability of information than, for instance, in the case of organic and affective psychoses; relatively high incidence, ranging from 0 .1 5 to 2.5 per 1 000; economic significance , given that a large percentage of all hospitalized mental patients are diagnosed schizophrenic; great burden on the family and the social environment ; long duration of illness (varying for the different subtypes of schizophrenia); and satisfactory accessibility for research. Review, rehabilitation and redirection of research The study should have a threefold aim, in relation to the above-mentioned five research issues regarding chronically schizophrenic patients. Review of completed and ongoing research This part of the study will identify, revi ew critically and summarize completed research studies, ongoing research activities and definite proposals for future research. The review of each project will include its scope (objectives, rationale, issues tackled), methodology (economic, epidemiological and statistical methods employed) and any findings (for health and related action, education and training, and future research) . Rehabilitation of completed research This part of the s tudy will take up any completed research that lacks an adequate health economics component . Some research, for example, might not have inc luded cost information at all; others might have disregarded costs to the family, the community a nd society ; and again others might have used expenditure and average cost figures when opportunity and marginal cost concepts would have been appropriate . - 82 - Where feasible and useful, the study will attempt to rehabilitate these research projects retrospectively by adding economic aspects and information , by recalculating the research findings within the cost-effectiveness (cost-benefit or other appropriate economic) framework, and by reformulating any implications for health and social policy. Redirection of ongoing and planned research This part of the study will run in parallel with the rehabilitation of completed research. Contact will be made with institutes that have current research activities in this field or have recently developed detailed research proposals. The aim is again to include economic questions and information whenever appropriate. In addition, it is hoped that some study part1c1pants may find it possible to initiate original research themselves, although these projects need not be finalized within the time frame of the study. 4. Participation in the study It is hoped that research teams from at least five countries will participate in the study in 1984-1986 . Each national team should consist of at least two experts: a health economist and an expert in research methods. Psychiatrists, psychologists and social workers could be associated in an advisory capacity or be included in the team. Depending on the national scope of the study, sociologists, biostatisticians, comput er scientists and o ther experts may have t o be consulted as well. Access to patients will have to be gained through primary health care and other services, unless case registers or past surveys already include pertinent information. The team of the Federal Republic of Germany will be asked to act as the reference group and develop a more detailed study outline. Queries, comments and suggestions are most welcome, and should be addressed direct to: Dr Oetl ef Schwefel WHO Coordinator of the Study on Chronically Psychotic Patients Institute for Medical Informatics and Health Services Research (MEOIS/GSF) Ingolstadter Landstrasse 1 D-8042 Neuherberg Federal Republic of Germany Second Meeting of the Study Group on the Development of Health Economics Training Funchal, Madeira, 20-22 October 1983 - 83 - ICP/SPM 030(3)(S) 1 December 1983 0524e ORIGINAL; ENGLISH The Study Group began by confirming the approach towards the development of health economics learning materials suggested at the first meeting of the Study Group in Florence in June/July 1982. This approach uses problem-solving actions to construct a modular framework for the development of training materials and activities for health care providers, managers, and policy-makers at different educational levels and in the context of different health systems. It was agreed that the intent of the modules and the description of their content was to serve as a vehicle for the communication of economic concepts and tools to target groups in practical, relevant and innovative ways. The Study Group then reviewed the current state of development of the content of the learning modules; discussed both the appropriateness of the modules for different target groups and levels of training, and the teaching methods considered most effective for each group; and identified the gaps in existing training material and programmes. Finally, a unique opportunity was afforded to illustrate the concepts and tools under discussion in the context of the Autonomous Region of Madeira. The participants were invited to discuss the local organization and financing of health services and forwarded a summary of their comments to the Regional Secretary for Social Affairs. Conclusions Content of the modules Taken as a set, the eight modules developed so far provide a reasonably complete framework for the teaching of the core concepts and other important economic topics identified at the Florence meeting. While one or two new modules discussed below were suggested, the most common suggestions for improvement concerned the rephrasing of module statements, for instance to render them less assertive or to widen the scope for instructors to introduce or illustrate concepts. Additional statements were also suggested to allow a wider range of concepts to be introduced or to allow more thorough development of concepts currently suggested by existing statements. Each of the eight modules benefited from discussion in one or both of these ways. The module "responding to external economic influences on the health sector and health policy" was deemed highly appropriate, but three main suggestions were made. The existence of different goals among different groups in the economy and their effects on the health sector should be made more explicit. A clearer development of the relationship of health care to health status is also needed prior to the linkage of health status to economic growth. Issues in the measurement of health status, which some thought might warrant a separate module, could be included here. The module "mobilizing health care resources" was seen as one of the broader modules, encompassing issues of financing and payment methods at both the micro level (individual provider/institution) and the macro level (design and operation of national health care systems). A primary concern here was that it should be made clearer that the mobilization of health care resources begins with human resources and includes their efficient operation and allocation. A comprehensive approach must take into account the knowledge, abilities, rights, attitudes and motivation (including payment systems) of the personnel involved. The module "influencing other sectors of the economy to take health-promoting action" generated considerable discussion. Views were expressed that it encouraged . students to "stray" from a consideration of economic concepts and that it was closely related to the module "responding to external economic influences on the health sector and health policy". It was suggested that these two modules be offered and taught together since they both clearly demonstrate the interrelationship of the health sector and the larger economy, and the economic role played by health workers and their institutions. - 84 - The modules "setting health care priorities" and "choosing among alternative strategies of care" were also viewed as natural neighbours, Suggestions emphasized that the purpose of the former was to describe the context of choice while the latter introduced the types of analyses done within economic appraisal and evaluation. The latter was also considered an exception in that a rich body of i llustrations exists from the economic appraisal literature . Within another already broad module "introducing incentives for efficiency", two further important themes should be developed, First, incentives (or o ther methods of encouraging efficiency) must be adapted to the roles played by various actors in the health care system and the understanding they have of what efficiency is. Second, the efficiencies of the component parts of a health care system are i nterrelated; one cannot analyse or attempt to adjust the efficiency of any given componen t in isolation. The module "strengthening the role of the consumer and patient" was another one that generated lengthy discussions, most of which focused on potential expansions of the module. The possibility of strengthening the role of consumers collectively, such as through community involvement, as well as the role of the individual consumer/patient , should be included. Also, the nature of the process of using health care should be elaborated, beginning with the special nature of health care as an economic commodity, continuing with the distinction between need and demand, and finally linking patient demand to actual use through the agency role of physicians. Finally, with respect to the module "reducing inequalities in health and health care" suggestions were made that further emphasis should be put on the difficulty of defining various notions of equity and that exploration of the relationship between equity and efficiency should be encouraged. Consideration of the gaps in the existing learning materials resulted in three ca tegories of suggested expansion. First, it would be useful to add new modules on "what is health economics?" and, possibly, "measurement /valua tion of health". Second, several top ics and concepts were identified that exist in modules/statements developed so far but that should receive more emphasis or elaboration (such as the nature of costs; the economic interpretation of norms, standards and guidelines; consumer participation in public choices; and the macro-economi c analysis of supply and demand in the context of manpower planning, technology assessment , and the assessment of the appropriateness of national levels of utilization). Third, some topics or concep t s were not explicitly mentioned in the modules/statements, but could be worked into material developed to date without great difficulty (such as uncertainty, and health accounting for administrators), With respect to the collection of illustrations for the economic concepts and module statements, several concrete examples were offered. They ranged from descriptions of situations , through published demonstrations of economic concepts , to already developed case studies for specific modules. Illustrations are still lacking, however, for many cells of the matrix defined by target group and type of health system or country context. Moreover, the view was expressed that it would be preferable to develop initially a few detailed illustrations (including annotations of their main economic concepts and messages) for each module/target group/health system cell, rather than numerous thinly worked examples that might focus on module coverage without sufficient concern for the needs of different target groups and the contexts of different health systems. Teaching of different target groups While the longer term goal is to improve training in health economics for health care providers (e.g . physicians and nurses), administrators/managers, and politicians/policy""1Dakers, at this stage it is still important to ensure that the trainers are themselves well trained. More effort could be usefully applied in expanding the supply of competent health economics instructors. Two general points were made with respect to the selection of modules for different target groups, and the tailoring of courses for different groups at various levels of education. First , although not all modules will be equally important for all groups, and the ordering of modules may vary according to group needs and instructor preferences, the objective in develop ing learning materials should _be the creation of a series of interchangeable parts, each of which can be used alone . Second, although the tailoring of courses will often result in homogeneous groups of students , it may on occasion be preferable to have multidisciplinary groups of students from different target audiences. This is especially true if the objective is to change attitudes rather than to develop skills. - 85 - "1hen considering the tra1n1ng of policy-.uakers, a distinction should be made between elected politicians and senior planners as target groups, Owing to the pressures that politicians work under, they are unlikely to participate in or respond to training programmes organized or taught in a "traditional" manner. Although some scepticism was expressed regarding the cost-effectiveness of attempting to train elected politicians in health economics, it was agreed that if such training is to be possible it must occur in a seminar environment where they are not required to adopt the usual student role. Alternatively, it may be more effective to focus training efforts for elected politicians on situations where they have initiated requests for advice and consultation from health economists. More optimism was expressed with respect to the tra1n1ng of senior planners, and the modules on mobilizing resources and setting priorities were seen as particularly relevant to their work; it is difficult to develop a unique set of useful material for training due to the variation in planning contexts from country to country. The same difficulty confronts those developing and/or selecting training material for administrators and managers. In addition, the materials appropriate for "lay" managers (health care providers who have moved into administrative and management positions) will not be the same as those for managers coming fro m a business-oriented training background. Subject to these qualifications, however, it was suggested that the modules on setting priorities, choosing among strategies, and introducing incentives for efficiency should be among the first to be included in training prograomes for this target group . Furthermore, the packaging of training materials should concentrate on simulating operational decision-making situations that students can easily relate to. The highest payoffs from the creation of international training materials may come from materials aimed at providers such as physicians and nurses, since the nature of their work varies less from one health system to another. With respect to physicians, it is useful to distinguish those who are still in some form of training programme (e.g. undergraduates, residents) from those who are established in practice and are seeking continuing education. For both groups, however, the modules on setting health care priorities and choosing among alternative strategies of care are strongly recommended. These modules afford ample scope to change attitudes toward health economics and health economists by clearing up misconceptions. Furthermore, the modules allow a demonstration of the difference between a clinical approach and an economic approach that suggests expansion only until the additional benefits are offset by additional costs. Furthermore, the module on strengthening the role of the consumer was recommended for both levels of training of health care providers to remind them of their important role in affecting the demand for care . With respect to teaching methods for training health care providers, it was suggested that health economics materials be incorporated into clinical courses whenever possible. This type of approach underlines the overall feeling of the Study Group that the development of innovative teaching methods deserves substantial attention . It was also suggested that leaders of medical op1n1on and physicians and nurses currently teaching in clinical departments should be prime targets for initial training, to create a climate for reaching undergraduates in particular. Interactive teaching, prograomed learning, simulations (both quantitative exercises and role-playing), debates and audiovisual methods were suggested as worthy of further consideration, It was recognized that the teaching methods are often specific to and determined by the nature of the teaching materials themselves, and this was thought to be one reason for the lack of innovation to date. Another factor was that trainers themselves often have little experience with methods other than the traditional lecture and seminar format. Nevertheless, the Study Group reconfirmed its desire to attempt to match the development of relevant learning materials with appropriate, yet innovative teaching methods. The discussion among the part1c1pants and an analysis of background material on existing training programmes indicated that the existing prograomes in most, if not all, Member States fall short of providing adequate training to the above""11lentioned target groups. Seldom does adequate case study material exist for even one target group within particular health systems. Often, the individuals instructing providers, managers and policy""11lakers are themselves not properly trained in health economics. Moreover, much of the existing health economics training could benefit from closer cooperation between health economics instructors and instructors from other disciplines, notably epidemiologists, through the formation of multidisciplinary training programmes. - 86 - Future directions of the Study In view of this gap between the characteristics of desired and existing health economics training programmes, it was recommended that the Study on the Development of Health Economics Training be continued, with future efforts to be made in two complementary areas. First, increased emphasis should be placed on the collection and/or development of concrete teaching material for each module. The next goal of the Study should be the production and assembly of a few illustrative case studies per module (with the essential messages and concepts highlighted and annotated) for each target group within each health socioeconomic system of the European Region. AJJ an initial step toward achievement of this goal, the Study Group participants should be asked to contribute materials from their own training activities; where necessary, further production of case studies should be commissioned to complete the range of desired cases . Advantage should be taken of existing materials (e.g. the international Training Workshop on Health Economics in Copenhagen in 19828 ) whenever possible. AJJ teaching material accumulates it should be tested in training workshops whenever appropriate. Meanwhile, any dissemination of existing module development and training material should be accompanied by a careful commentary explaining the intent of the modular framework and providing guidelines for its appropriate use. With respect co the case studies themselves, it was suggested that whenever possible more attention be paid to the development of cases built around the advisory role of economists and the specific service tasks or medical decision-making of managers and providers . Once the illustrative material has been assembled, or perhaps once it has been tested in "representative" settings reflecting the different target groups and health systems, a third meeting of the Study Group should be convened to assess the materials and/or the learning experiences and to recommend the extension and completion of training materials. As regards the review of learning experiences it would be highly desirable for the cases to be evaluated by the target groups themselves, through some appropriate mechanism . The second area for continuation of the Study is the facilitation of information exchange on existing health economics training programmes. The view was expressed that, even though the most recent updating had improved the pool of instruction available, the descriptions of courses and programmes often do not contain sufficient information to allow assessment of the utility of the teaching material in other contexts. Consequently, it was suggested that if surveying of those involved in health economics training is to be continued, it should be done in a standard reporting format. The view was also expressed, however, that some participants may be feeling "oversurveyed" and that future effort should concentrate on facilitating contacts between individual trainers who might then discuss in some detail an appropriate exchange of materials. Of course, as new training programmes develop, these should be added to the catalogue. There was agreement that, in any case , only those training programmes that conformed to a set of criteria for health economics training , should be considered. Recommendations 1. Member States should put resources into the development of suitable case study material by target training group, within the context of their own health systems. 2. Member States should monitor and evaluate the development, adequacy, and impact of their health economics training programmes and develop a policy for health economics training, including for example a national centre. 3. As health economics is one of the essential disciplines used for solving health problems, Member States should support the creation and functioning of national or multinational working groups of health economists and acquaint them with national strategies for attaining health for all by the year 2000. 4. The WHO Regional Office for Europe should continue the Study on the Development of Health Economics Training through collaborating centres that will act as clearing-houses for information on health economics training programmes and materials . 8 WHO document ICP/SPM 030(1). Advisory Committee on the Health Economics Programme Funchal, Madeira, 20-22 October 1983 - 87 - ICP/SPM 033(S) 2776E 15 December 1983 ORIGINAL: ENGLISH The first meeting of the Advisory Committee on the Health Economics Programme was held from 20 to 22 October at Funchal in Madeira, Portugal, with the participation of 22 experts from 18 countries. It was noted that the existing programme had been built up from humble beginnings since 1978 and contained not only a large number but also a wide range of activities . There was also considerable horizontal integration with other programmes within the WHO Regional Office for Europe. It was noted that the regional strategy for health for all by the year 2000 (HFA2000) contains many topics to which economics has an important contribution to make. It is important to ensure that this contribution is sought by other programme managers at the stage when problems are defined. As regards working methods within the health economics programme, more frequent exploratory meetings and studies by a smaller number of people who are knowledgeable in the area would be useful in the early stages of projects. On some occasions country-specific or subregional approaches to the study of topics would be desirable, for instance in the development of training activities in health economics. A network of collaborating centres in health economics should be set up as soon as possible. The Committee felt that the secretariat was already fully s tretched. In this connection, the usefulness of voluntary contributions from countries (on some topics) and the secondment of economists from Member States were mentioned. Pro·ect 1: Economic evaluation of health care strate ies in collaboration with health science and technology programmes) It was thought that the title of this project should be changed to "Economic evaluation of health strategies" to reflect the need to consider a broader range of health-promoting strategies and not just medical ones and to strengthen the contribu tion of economics to broader policy questions. A number of new topics were suggested. The economics of nutrition This would be a multidisciplinary study considering the healthiness of different types of food, strategies for changing behaviour and the costs of those strategies, especially spillovers to other sectors of the economy. Occupational hazards This topic could be studied in association with the programme on workers' health and could focus on particular incentives. Economic assessment of medical technologies Important topics would include the development of guidelines for the evaluation and diffusion of new technologies, the study of how biomedical research policy affects the emergence of new technologies, and the role of regulations and incentives in the use of medical technology. As . regards the cost-.,ffectiveness of alternative strategies for health care of the elderly and chronic psychotic patients, it was felt that a broad view of what "care" was, including both health and social care , should be adopted in both activities. There was also a role for more methodological discussion. Finally, it was thought that these were good areas in which to examine more closely the costs and benefits of community care or primary care strategies. - 88 - As regards the cost-effectiveness of selected strategies against tobacco, alcohol and drug abuse, it was felt that this presented a good opportunity to think more broadly about the role of economics in health. For example, there could be an examination of non-health care strategies, the costs of legislative change, tax and subsidy policies, and agricultural policies. The impacts on other sectors of health policy could also be examined, e . g. the costs of restructuring industrial production following the imposition of a health promoting measure . The establishment of a collaborating centre on these broader aspects of the economics of health might be considered . Project 2: Evolution and distribution of health care expenditure and related policy measures (in collaboration with the programme on health planning and evaluation and the information systems programme) This project was originally called cost-consciousness and cost-containment measures in the health field. It was felt important to change the title to reflect the central role the programme might play in helping countries attain HFA2000 targets, especially as this is the main vertical project in the programme. It was important to remind governments that they should be concerned with cost containment, and particularly in redirecting resources in line with social priorities, i n essence mobilizing financial and other support for HFA2000 . A number of new activities were suggested . Equity in health and health care There is much that economists can do, and have done, to clarify the concepts of need and demand for health care, to measure health and to estimate the distribution of public expenditure by socioeconomic group. Economic aspects of medical demography This is the study of medical manpower planning, including the increased incentives for specialization , migration and employment . already interesting literature on this topic . consideration of total numbers, It was thought that there was As regards cost -containment polic i es, it was fe l t that many changes are currently being made within European Member States (such as in health insurance legislation, deregulation and privatization). Therefore, a new survey shou ld be conducted soon. Although studies by OECD and other intergovernmental organizations were of use, Committee members felt that many new dimensions could be added to the WHO study, especially: the role of competition in health care in both the public and private sectors; the impact of policies on the d i stribution o f expenditure by socioeconomic group; and aspects of the administrat i on and organization of primary and se condary care and the potentia l for increased efficiency in these managerial , as opposed to clinical, areas. As regards economic information on health systems performance and the evolution and distribution of health care expenditure , it was felt that a closer look should be taken at the usefulness of compiling international health statistics (e . g . expenditures, performance indicators, health accounts). In particular, it was important to consider t he following points . Why the information is needed. If it is for estimating the proportion of health care expenditure spent on primary care, a more direct method of surveying might be preferable. The problems of definition (e.g . what is primary care, what constitutes a hospital ? ) that severely limit comparability. The amount of expenditure that goes outside the health care sector on health promoting activities. The enormity of performing this task correctly and the resources that would be involved . What is our willingness to pay for this kind of information? Whether more can be done in comparing individual countries' experiences through time (in expenditure and performance indicators) rather than standardizing national health accounts , etc., and making international comparisons. - 89 - Pro·ect 3: Education and trainin in health economics in collaboration with the programme on health manpower development) This project was formerly called development of the skills of health workers in health economics, and promotion of the use of health economists in health service management. This was regarded by the Committee as an important activity. The reasons for this were that health economics is an emerging subject and many of the health economists in Europe feel "short-handed" compared to the amount of work that needs to be done. It was felt that the training of the trainers was being given too low a priority and that this should be brought forward from 1990. It was suggested that this might be one area where WHO could make special efforts in some parts of the Region, by holding seminars on special topics, providing help with the development of materials and holding country-specific or subregional meetings of health economists. As regards international health economics tra1n1ng workshops for health care providers and managers, these should concentrate on opinion-formers and key individuals, who might be able to sensitize others to the importance of health economics or take actions based on their training. In addition, short seminars in health economics for WHO programme managers should be considered. Other activities of the health economics programme It was felt that liaison with the relevant intergovernmental organizations needed to be maintained and further strengthened, while links needed to be established with national and international economics associations. As regards health economics information, it was urged that efforts be made to: overcome the language barriers by more frequent and quicker translation of health economics documents; issue more material in the form of documents when it becomes available rather than waiting for publication of a book; and designate a suitable health economics topic for technical discussion at a future Regional Committee. The meeting considered that a period of three years would be about right before the next Advisory Committee meeting. It was suggested that a consultant study be commissioned in advance of the meeting, on the extent of support given by the programme to aspects of the regional strategy for HFA2000, and new areas and directions of health economics as a discipline. The contribution of health economics to target 78 in support of the regional strategy fo r HFA2000a It was felt that it was important to leave the target in, as it restated the worldwide minimum for expenditure on health strategies (5% of GNP). Furthermore, the main purpose of the target is to ensure that resources are allocated to agreed objectives and priorities and to deve l op a management system that is not fragmented and brings planning in line with resource allocation. It was felt that monitoring of the 5% figure was possible without a major data co l lection effort, although there were problems of comparability between countries and severe problems in defining health care activities. Ad hoc surveys could be carried out if there were some major doubts, but a comprehensive attempt to standardize and improve the accuracy of such data in all countries would not be worth the resources involved. The Advisory Committee felt that if resources were available for such a purpose, these would be better spent in collecting data on the distribution of health care expenditure by socioeconomic group. Monitoring trends in health care expenditure, particularly the balance between primary and secondary care, was considerably more important. Again, it was felt that a major data collection effort would not be required if the aim was simply to ascertain that countries were moving in the right direction. If further resources were available, these would be better put into the stimulation of programme budgeting exercises. These would have direct policy relevance within Member States, since they would enable health ministries to ascertain where money had been spent, e.g. whether or not there was an increase in expenditure on the high priority groups. The role of WHO in this field would be to compare experience, not to devise common indicators to be applied to all countries. a Document EUR/RC33/9. - 90 - Recommendations The Advisory Committee believed health economics to be one of the crucial support measures for health for all by the year 2000. This support should not be confined to questions of financing or deploying and managing resources for health care . Health economics has a major part to play i n the development of health policies in their widest sense, including those concerning social equity , the prerequisites of health, changing lifestyles, creating a healthier social and economic environment, and the reorientation of the health care system. The programme of health economics should be further developed over the medium term, in terms of both activities and staff. Health economics is under-represented in the Regional Office compared with the other social sciences. The major field to be developed is economic analysis and support to assist in the achievement of HFA targets outside the health care field . Very high priority should be given to the training of trainers in health economics, providers and administrators, particularly in countries where the subject is currently under-represented or seen in too narrow a scope, and to the reinforcement of health economics research in Member States of the Region. - 91 - HEALTH EDUCATION - 93 - Workshop on Training in Health Educa ti on ICP/ HEO 022(4)(5) 1565F Cologne , 28- 29 March 1983 27 May 1983 ORIGINAL : ENGLISH 1. Introduction The Workshop was attended by 18 experts from 9 Member States . Each participant was concern ed with hea lth-related educa tional and tra ini ng activities. The aim of the mee ting was to r ecommend new directions for training in health education bas ed on th e new health education programme of the WHO Regional Office fo r Eur ope . The three main goa l s of the health educa tion and lifestyles programme a re: to raise i ndividua l comp e tence and knowledge about health and illness, abou t the body and its fu nction s , and about prevention and cop ing; t o raise comp etence and knowledge about how to use the hea lth car e sys t em and to understand its f uncti oni ng; to raise awareness about social, political and env ironment al factors that influence health. In its discussions the Wor kshop drew on the expe rience of the International Union for Health Education (IUHE) working group no . 2 on professional training in health educat ion and took account of the initiatives developed by the health education programme of the Regional Office since Sep tember 1981 . It also benefited f r om the experi ence gained in national and int ernat i onal educa tion and training co urses in the European Region. A ma j or concern of the Workshop was to explore the feasibility of estab lishing a European summer schoo l on health education and health promotion as a f irst step in the developmen t of a core c urri c ulum that would serve to ac tively promote health education and heal th promotion train ing in the European Region . Such a c urriculum s hould emphasize a soc i al concep t of health and the promoti on of li fes t yles conducive to health. It was es pecially import ant to examine ways in which curricular innovations resulting from these developments might be disseminated to Member St a t es . With the gu i dance of the Workshop, a provisional plan of work would event ually be drawn up co f urth er develop the training aspects of the health educa t ion programme of th e Regional Office a nd the r o le of a r esourc e and informati on centre fo r training. 2 . Discussion t opics European s ummer school in health educ ation and health pr omo tion A proposed summer school or study seminar received detailed consideration. The feasib ility of such an operati on and the principles on which it should be based were carefully examined. Discussion drew heavily upon the evaluation of the four international postgraduat e courses chat had been organized by the Federal Centre for Health Education (FCHE) in Cologne in collaboration with WHO . This included r eport s of the f irst -hand experiences of course participants who wer e present at the Workshop. In addition , the Workshop's deliberations were guided by re port s on the c urrent training s ituation in Member States. Relevant data from the IUHE working group no. 2 were also discussed; info rmation on i nterna ti onal programmes of educa ti on and training in health educa tion had been co llected since 1978 and was still being assembled . It was recognized that this source of expertise would need to be continually updated and r egularly disseminated . The main aim of the summer school would be to promote the new public health approach in health promotion and health education . It should inc r ease knowl edge and understanding of the personal, social and political d imensions that impinge on health education programmes and interventions. It should above a ll make programmes developed in Member States mor e effective . The summe r school programme would adopt an eco logical approach to health and health education; it would foc us on - 94 - core concepts of health education and health promotion; and it would aim to familiarize participants with the state of the art of interdisciplinary research relevant to education prograrmnes and interventions. Problems associated with international postgraduate courses The planning of training activities associated with the proposed summer school should take account of th e difficulties experienced by those running existing courses of this kind. International courses pose particular problems, as illustrated by the fou r international training courses organized by the FCHE: participants should be sufficiently conversant with the course language to enable them to handle abstract concepts and principles; attendance a t international courses will prove a greater problem than at those held nationally; the inherent problem of heterogeneous student intake will be exacerbated; the politically contentious nature of the lifestyles programme may be more difficult to handle in an international context; funding may be an important issue. lt is therefore important to differentiate between the goals of international courses and national courses; the latter should constitute a network based on detailed WHO guidelines . ln addition to the problems posed specifically by international courses, the diffuse and multidisciplinary nature of nealth education is itself likely to engender difficulties. Particular problems experienced by advisers and consultants have centred on the heterogeneity of the studen t s. When ke y decision-makers from different disciplines are deliberately selected for such courses communication problems arise in both cognitive and affective areas . Methodological issues have also been identified as problems. It is especially important to avoid a cognitive overload and to meet the affective needs of participants by using appropriate methods, and to use visiting expertise wisely. A particularly important problem is that of recruiting key decision-makers who have heavy professional commitments . 3 . Recommended approaches and guidelines for the summer school General organization I t was agreed that the course should not emulate existing national courses. It should last for 14 days and thus be more accessibl e to participants. The country house or boarding school principle was e ndor sed as a valid way of producing changes in awareness and attitude. Target group It was essential that the course be systematic and have clearly defined objective s. A contract should be es tablished with the studen t s to minimize processing problems. Students would be key decision-makers and planners. It was envisaged that they would subsequently act as multipli ers and form mutually supportive "cells" after completing th e course. They would be drawn from various disciplines but, to avoid the problems associated with a heterogeneous intake, students shou ld share certain common characteristics in relation to needs, cultur al/political background or experience. lt would, however, be important to avoid unproductive categorization. Student s should receive preliminary preparation for participation in the course. Eighteen participants from six different backgrounds might make up a course. Content Course conte nt would be designed to consolidate existing developments such as primary care and health promotion, whil e at the same time fosteri ng the lifestyles programme. Three major areas might be developed . - 95 - The first would examine incentives for healthy lifestyles including public policy aspects, public participation and social networks . The second would be concerned with fostering healthy individual behaviour including lifeskills, diet and exercise, creativity, stress management and the development of social and sexual relationships . The third area would be concerned with the reduction of harmful activities such as smoking, drug and alcohol abuse and traffic accidents. Methodology It was clear that methodology should be flexible and student-centred. There should be a balance between task and process. An undue emphasis on didactic methods and cognitive overload should be avoided. Group methods, participation and experiential work would be extensively employed . Visiting experts should be used judiciously; ideally they would act as facilitators and resource people, and wherever possible work alongside groups rather than supplying fragmentary input. It should be recognized, however, that expert input - including that of a cognitive nature - would frequently be necessary . Dissemination Effective dissemination should be a major feature of the proposed summer school. It was envisaged that this might happen in the following ways. Training network. A training network should international health education training courses in summer school and be guided by an advisory board. countries with no training facilities . be established in order to provide national and the European Region. This would derive from the This in turn should stimulate activities in Resource handbook. A handbook or "kit" might be produced to facilitate further developments in Member States and consolidate the work of the sunrner school. This could be used by the training network. Collaborating centres. Both existing and newly established WHO collaborating centres could have a major part to play in the dissemination process. 4 . Conclusion and future activities The summer school proposal received support in principle from Workshop part1c1pants and the UIHE . Although some concern was expressed at the potential problems of international recruitment, there was general agreement that an international course could provide particular benefits that supported national activities . A timetable of activities was outlined, commencing in April 1983 and ending with a pilot run for the proposed summer school in July-August 1984. Activities would include the identification of the core curriculum and methodology; a questionnaire on training activities within the European Region; applications to Member States to finance a pilot run; workshops of training representatives; invitations to Member States to participate in the summer school; and a pilot course for staff at the WHO Regional Office. - 97 - HEALTH LEGISLATION Working Group on Health Leg is lat ion Infonnation System Uppsala 1 8-10 November 1983 Introduction - 99 - IC? /HLE 003(1)(5) )947L 3 l January 1984 ORIGINAL; ENGLISH This Working Group was convened by the Regional Office to evaluate the progress of the co mputerized health legislation information system developed by the health legislation uni t in cooperation with the Uppsala University Data Central (UDAC), a WHO collaborating centre. The meeting brought toger~er 17 experts from 11 countries, including senior staff of ministries of health, public lu,.a lth administrators, senior staff from unive rsities, directors of national research institu tes for computers and law and fo r computer linguistics, as well as observers fro m European in tergovernmental organizati ons . The solidarity and interdependence of Eu r opean countries creates a need for Member States of the European Region to ob tain rapidly from othe r countries available information on health legislation for comparison and decision-making purposes. In 1977 and 1980, the World Health Assembly requested WHO t o strengthen its role in this respect. In 1977, the European Member States appointed a network of national count erparts for the exchange of information in the field of health legislation. Their regular input led to the progressive build-up of a body of information on health legislation in Europe. In 1979, in collaboration with UDAC, work was started to computerize the information in o rder to speed up its ci r culation among Member States. In 1980, a fur ther step was the creation of a pilot system of notification of new legislation with the use of a standard form designed for computerized processing. In 1981 the Advisory Committee on Health Legislation noted that this pilot system was giving satisfactory results and recommended i ts progressive extension to every country in the Region. Objectives The purpose of this Working Group was to allow a representative g r oup of users of the info rmation system together with a group of experts in computers and law to : - express their views on the usefulness of the system; - confront their expe rience on its utilization; - discuss questions of concern to Member States in the field of the exchange of information on health legislation; - examine the present possibil i ties offered by the use of computers in the legal field; - reflect on what future technology in the computer field could bring to health legislation information retrieval; and - make suggestions about the role and task of the Regional Office for Europe in this respect. General considerations on legal information retrieval The expe rts on computers and law presented a thorough and comprehensive picture of national and international compu terize d legal in format ion services, including the ea r ly e..¥pe..rin1.~nta ~ the developments of nationwide computerized services, the. international services, -:: trA · &urope.,a.n- t..r-ends the re.search and development. - 100 - The discussions centered around the followin g main issues; the demand for legal infonnac1on retrieval for decisions, planning, statistics, evaluation and research; the types of document treated such as laws , explanatory materials, ordinanc es , re commendations, official reports, administrative decisions , legal literatu re , court rulings; the relative performance o f different retrieval approaches; and the different steps in establishing an operational information retr ieval, such as the goal-setting (main goals, sub-goals), the data input (i nternal sources, external sources), the technical solutions ( the selection of the information retrieval software, the software adjustments in building the data base), the data base control, its operation , the training involved, the development and evaluation of the system and its coordination wich other existing systems. Emphasis was put on the three following crucial points: the data base conten t , its quality and its updating. The experts in computers and law and in computer linguistics also clearly stated what can and ca nnot be expected from the machine. They explained what are the most important facilities available, which facilities will become available in the future and what service the machine will never be able to P,erfonn. The hea 1th leg is lat ion in format ion svstem A demonstration was made of the computerized health legislacion notification system . The objectives of the system and its present utilization were described, its technical characteristics explained and its functioning demonstrated on screen so that the national counterpart s could experience direct interplay with the machine, searching for and reading data themselves. The health legislation notification system is an initiative geared at strengthening the reporting of new legislation to the Regional Office . It is based on the use by national counterparts of a standard notification form designed for computerized p ce ssing. Its t wo main initial objectives are to support and s trengthen the intergovernmental exchange of information on health leg is lat ion fo r comparison and dee is ion-making purposes I and to provide Member States and the Regional Office with constantly updated information about the evolution of national health policy and legislation in Europe. The system is used as a current awareness system, and a -regular -report is made once a year to governments on changes in health legislation in Europe. Collaboration is also ensured for the selection of texts for publication by WHO headquarters in the International digest of health legislation. The discussions centered around the following main issues; the usefulness of the sys tem and the expe rience of the participants in its use; the objectives of the system and in particular its importance fo r the monitoring of progress toward the goal of health for all; the functioning of the system, the various output s expected a nd the various possibilities of access by users to the information 1 given the development of the computer technology. The Working Group unanimously shared the view that'the pilot project was giving satisfaction, that it had considerable practical potential and should be developed further. ) Experience shows that the health legislation system is used in health ministries for two main purposes ; - to promote the interest of the various policy-makers in the health department in what actions other coun tries a re taking in health legislation; - to obtain information when revising or initiating legislation in a specific field, to know about and possibly use the work other coun tries are doing or have done in this field , and to know about recent changes that parallel their own efforts. Certainly a key feature of information retrieval is a continuous reflection on the objectives of the system and the influence of its organi~a tional context. In this respect , the Working Group discussed the relevance of the health legislation system to the regional strategy for health for all by the year 2000. The Group's firm view was that the system was relevant to this strategy and would increasing l y be so because the systematic monitoring of health legislation was seen to have benefits. First, it is an excellent indica tor of shifts in health and social policy and, second, it ca n act as a stimulus fo r governments in their thinking over social issues. To put this in context, it was the view of the Working Group that the system would pr ovide three thi ngs : - a general overview of health legislation developments in Europe; - a valid indicato-r of policy developmen t in health for all by the year 2000; - a browsing facility for policy-makers and regulators. - 1()1 - ";Jith regard to the functioning of the system, the Working Group was of the opinion that the focus of the system is more on innovation in heal th legislation and dynamics than back-listing, as ocher health legislation projects provide the background for the evolution of health legislation in the past. The question of the access of users to the information was discussed in detail, and the Working Group expressed great interest in three types of possible reporting: - printed reports with diversified listing (e.g. by technical subjeccs, by WHO programmes, by countries); - on-1 ine cormnunication with terminals; - on-line or off-line communica t io n f rom and co local da ta bases. Every participant indicated which type of access to the information would suit best his or her country's needs. Some participants announced their interest in participating in tests oi innovation of the system in this respect. Co ne lus ions and recommendations l. The health legislation notification system is g iving satisfactory re sul ts and its development should be pursued because it has considerable practical potential. 2 . Close collaboration with the UDAC, a WHO collaborating centre, should continue in o r de r to ensure that the system takes advantage of innova t ions in computer technology. 3 . The relevance of the system for monitoring the progress of the European Region towards the goal of health for all s hould be increasingly taken into account by the Regional Office . 4. The notification form now in use is satisfactory. So me minor changes could be incorporated to make the best of the form without o verburdening the users. 5. Providers of infonnation are encouraged to g ive as much straightforward descriptive information as possible according to the report forms, to enable the health legislation unit to furthe r differentia te its internal analysis. 6. To enhance direct intergovernmental coll aborati on after the information is received frorn ',,IHO, the form should mention the address and telephone number of the national r esponsible aut hority. 7. Attention should be given by national counterparts in health ministries to contacting, ...,hen necessary, ocher ministries that could usefully participate in the notific ation sys t em. In this connection, the health legislation unit should prepare g uidelines for standard repo rting . 8. In reporting to Member States, use should be made of different printed reports as well as on- line communicatio n with term i nals and/or on-line or off - li ne communication with local data bases, while taking into account the resource implications for the unit of health legislation. 9. Regular evaluation meetings should be held every three year s to monitor the evolution of the health legisla tion information sys tem. - 103 – HEALTH OF THE ELDERLY Advisor~ ~ommittee for Health Care of the lderly - 105 - Dun Laoghaire (Dublin), Ireland, 22-25 March 1983 ICP/ADR 017(2)(5) 1945E 13 June 1983 ORIGINAL; ENGLISH The Cormnittee consisted of 22 experts in ge rontology, ge riatric medicine, epidemiology, rehabilitation, nursing, psychiatry, social research and health care administration. The meeting was also attended by five staff from the Regional Office. This was the second meeting of the Committee, which met for the first time in Octo ber 1978 in Munich. On that occasion, the Cormnittee made recommendat~ons about the priorities to be given to the act1v1ties of the newly established Europea n regional programme on health care of the elderly for the period up to the end of 1983. The purpose of the second meeting was to reexamine the programme on health care of the elderly, and to plan projects of technical cooperation among Member States within the framework of the medium-term prograrmne for 1984-1989. During the last three years there has been an increasing interest in aging among Member States. This interest was particularly enhanced by the United Nations World Assembly on Aging, held in Vienna in 1982, and the reorientation of WHO policy towards health for all by the yea r 2000, an approach that should be reflected in the future prograrmne on health care of the elderly. Therefore, the objectives of the meeting were: 1. to review progress so far in the programme on health care of the elderly 1978-1983; 2. to reexamine the medium-term prograrmne on health of the elderly 1984-1989, with particular reference to: the regional strategy for health for all by the yea r 2000 the primary health care approach the Inte rnational Plan of Action on Aging; 3. to consider recent developments and future trends in selected areas of concern in health care of the elderly; 4. to make recormoendations on the planning of act1v1t1es to be undertaken at intercountry and national levels within the framework of the medium-term programme on health of the elderly, 1984-1989. The Cormnit tee received encouraging reports on progress under the following headings: development of operating models of services and systems of ca re attitudes and behaviour towards elderly people information (and a minimum data set for service planners) medication and prescribing prevention, case-finding and health education manpower development and training rehabilitation and aftercare research and evaluation, including the development of simple indices of effectiveness. It was noted that there had been an impressive level of activity under each heading, but five particular future needs were recorded: to develop a more effective exchange of models of services and systems of care that work; to develop (and collaborate in) simple systems for the evaluation of effectiveness, particularly _of innovative approaches; - 106 - to share information about interventions (for example, education, prevention, case-finding, medication, treatment and rehabilitation) that seem valuable; to promote accurate perceptions of, and positive attitudes to, aging and older people among professionals, policy-makers and the pu blic and to encourage their greater involvement in working with older people; and to clarify t he extent to which il lness or impairments affecting the quality of life may be prevented both before and during late r life. It was recognized that financial constraints on governments present a difficult challenge at a time when the older population (and particularly the populations in very old age-groups who are most likely to need mor e intensive health a nd social care) is growing in all countries. The Committee considered, however, that this increased the need among governments and health planners for mutual dependence and exchange, self-criticism, creativity in innovation, and the evaluation of effectiveness. Despite its own resource limitations, WHO was recognized as ha ving a particular capacity for stimulating collaboration, dissemination and the development of simple indicators of a kind that can be used and promoted by local health and social ser vice planners. To do this, it must build and maintain close links with collaborating centres and individuals in each country. This was seen to be particularly important in the context of the recent United Nations World Assembly on Aging, which signified world concern about the problems and opportunities inherent in worldwide demographic change. The Assembly showed that governments shared a wish to interact with experts, academics and care-providers to formulate the International Plan of Action to ensure that quality of life is seen to be as important as long life. The Committee welcomed this as a statement of intergovernmental recognition of the centrality of health care and health promotion in emerging policies fo r an aging population. It also saw the promise of practical action in t he collaboration that has occurred between policy-makers, scientists and nongovernmental organizations, forming a "troika" of effort. This " troika" has the capacity to reac h and involve elderly people themselves, informal, voluntary and family care- providers, and policy-makers and service-providers. The Co111111ittee received detailed reports on the World Assembly and on other meetings and studies initiated as part of the programme on health care of the elderly. It also heard papers outlining trends and developments in research, information gathering, medication and drug compliance, prevention , assessment, health education, and systems of care, including primary health ca r e, rehabilitation and nursing . It focused its recommendations particularly on responding to the needs identified above . It listed seven priorities for the WHO programme on health of the elderly fo r 1984-1989 ; 1 . the exchange of i nformation between providers and policy-makers; 2, the development of simple evaluative tools; 3 . the dissemination and implementation of existing research findings; 4, the development of effective systems for identifying and assessing the elderly "at risk"; 5. efforts to focus attention on prevention , health promotion , comprehensive home care , t he creative use of i nstitutions and cost-effective improvements; 6 . the identification of the extent to which conditions associated with aging are preventable and treatable; 7. the promotion and evaluation of health education programmes, incorporating up-to-date knowledge, and using the mass media, professionals, and academic and other existing authoritative sources of knowledge. To achieve these goals it was agreed that the WHO Regional Office should consider: identifying and making contact with collaborating national institutes, nongovernmental bodies, researchers a nd health administrators who could devise and perform the key tasks listed ; reexamining its system of publicising and distributing WHO documents in order to reach more effectively all t hose who would benefit from receiving them; - 107 - revising and promoting the glossa r y of terms in social ge rontology prepared fo r the meeting; promoting the publication by collaborating institutions of simple guides, flo.,..charts, directories of model schemes and other useful materials for practitioners; and developing close links with key groups such as librarians, journalists and computer information systems experts for the furtherance of these tasks. Working Group on Studies on Health Care of the Elderly Goteborg, 24-27 May 1983 Introduction - 109 - ICP/ADR 046(S) 3032E 16 January 19 84 ORIGINAL: ENGLISH Many studies have already been carried out on the health care of the elderly, both clinical and e pidemiological . These traditional studies will continue in the future . The Member States of the European Region have nevertheless expressed a wish that WHO follow up the further development of sys tems in health care of the elderly and present models of community based services . The present meeting was the first to be held on these i ssues . It was based on demonstrations of primary health care services, supported by various types of institution (medical and social) and the links between them. The demonstrations were followed by discussions . Conce rning research, ongoing studies / re sea rch projects were presented on health care of the elderly, particularly with regard to continuing ca re. Other presentations were made on fundamental ag ing projects now being researched and on demography and the planning of services. Conc lusions and recommendations I. Clinical studies l. Overdiagnosis is an important problem in old age that results in iatrogenic disease due to inappropriate drug therapy . Equally important is underdiagnosis as a result of which old people with disease may be denied effec tive treatment. It is essential that doctors and others concerned with the health care of the elde rly should have a better understanding of normal and abnormal function in old age . 2. The terminal phase of life when organ and system functions are significantly reduced and the ability to maintain normal homeostasis is severely impaired requires special study. This phase of human life has been much neglected and its s tudy assumes greater importance as more and more people survive to a great age. 3. Further research in oral and dental health in old age is required and should be encouraged a t the national level. Particular attention should be directed towards the causes of root exposure and the need for optimal prosthetic provision . Educational programmes in o ral and dental health should be developed that are directed at : (a) the general public, to make old people (and their carers) aware of the benefits of good dental care even at an advanced age; (b) the dental profession, to encourage dentists to take a greater and more positive interest in 11gerodentistry 11 ; (c) caring staff in residential homes and in home care programmes, to make them more aware of the benefits of dental care in the aged . 4 . The re is now incontrovertible evidence of the ill-effects of smoking on health in old age, including effects on the skeleton . Campaigns against smoking and inactivity in old age should be vi goro usly encouraged. There is also a need to determine the optimal dietary calcium intake as a means of reducing the loss of skeletal tissue with advancing age. 5 . The available evidence suggests that the deliberate mental stimulation of elderly subjects may improve their performance both in the community and in institutions . It is now necessary to conduct experiments to determine whether mental functions can also be improved by stimulation and - 110 - techniques of reality orientation in subjects not showing any signs of mental de terioration. If this is shown to be the case then this knowledge should be incorporated into su itable educational programmes. 6. There is still doubt about the prevalence and incidence of senil e dementia (of the Alzheimer typ e) in old age and well designed studie s are now required to elucidate this important sub ject especially in the over 80 age group. II. Epidemiological studies /health statistics 1. Physio l ogica l aging s hould now be accepted a s a primary c ause (a l ong with d i sease) of handicap in advanced old age . The r e is now a need to conside r whether physiological cha nges due to advanced age require spec ial classification i n the In ternational c l assif ication of impairments, disabili ties, and handicaps. 2. The traditional medical diagnosis has been confined to purely path o log i ca l considerations but thi s needs to be widened to includ e social, environmental and emot ional factors . It is also necessary t o include in the diagnosis, the health and welfare of the ca rer s of the elderly person. It is s ugges ted that the routine use of problem-orientated records would be one simple and inexpensive way of encouraging thi s broader approach . 3 . There are important differences between cohorts of aging people and these require detailed study to i dentify th e fac t ors that have led to bette r (or in a few cond it i ons poorer) health in those born more recently. 4 . The r e is an urgent need for national re searc h council s (and other grant -g iving bodies) to give priority to s tudies of normal ( physio l og ical ) aging . 5 . Atte ntion s hould be directed t owaras the identifica tion of significant risk factors that are specia l dangers to the elderly . These risk f actors s hould encompass social, environmental a nd i atroge nic ca t egories. 6 . Bet t er mortality and morbidity sta tistics are needed among the elderly (i . e. better medical records) as is a more accura t e de t ermination of the causes of death from autopsy s tudies. 7. There is a need for accep ta ble c lassi f ications of mental disorders in old age and for th e production of rating scales and inventories fo r their diagnosis which are suitable for c ross-n a ti onal use and comparison. 8 . Health sc reening of the e lderly should be the subject of thorough investiga tion. Although studies in younger subject s have not shown any di s tinc t benefits for the screened subjects as compa red t o controls, it is necessary t o keep an open mind in relation to older age group s, especia l ly those in whom significant functional reductions are associated with the changes of age. The value of screening should be judged on several levels: its effec tiveness in r ed ucing mortality and morbidity; its effec tiveness in reducing o r altering the use of health and social se rvices; its effec tiveness in avoiding functional decline due to agi ng and disease and hence increasing life satisfac tion for the elderly . There is an urgent need to define the nature and extent of the sc reening process, to determine who s hould car ry it out ( if a doctor, which doctor; if a nurse, which nurse, etc.) and which g r o ups of o ld people should be offe red s creening . The outcome of sc reening requires evaluation (possibly by f ull- sca le controlled trial). The cos t-e ffective ne ss of screening procedures also requires e valuation, 9 . Until full-scale evaluation has been carried out, case finding among the elderly should be encouraged t o identify th ose with import ant unmet needs . Case finding should include the hea lth and welfar e of the carers. Ill . Policy in health care of the elderly 1. Authorities should be aware o f the need to provide social conditions and phy s ical environments su itable fo r the increasing numbers of aging and old persons. - 111 - 2. In order to achieve thes e aims, suitable education is urgently needed on nonnal aging and the disease of old age for all those concerned with the care of the elderly. Crucial in this context is the nursing profession whose members are frequently intimately concerned with prevention, and the treatment and care of the elderly both in the community and in institutions. - 112 - Working Group to Assess the Contribution of Balneotherapy to Health Care of the Elderly Abano-Montegrotto (Padua), 15-17 June 1983 Introduction ICP/ADR 019(S) 2515E 3 October 1983 ORIGINAL: ENGLISH The meeting was attended by 16 temporary advisers from 10 countries. They included public health administrators, directors of research and therapeutic institutes of balneotherapy, epidemiologists, and clinicians from the fields of cardiology, rheumatology and medical pharmacology. (The sad news of the sudden death of Professor von Manger- Koenig 10 days before the meeting was received by participants with deep regret. Professor von Manger-Koenig had been greatly respected, not only for his distinguished international career, but also for his personal interest in balneology.) Modern health services in many countries recognize that balneology has developed as a specialty of medicine, with a multifactorial content. The Working Group met to discuss the benefits of balneotherapy with particular emphasis on its social role. Other associated areas, such as the use of saunas and the place of dietetics and diet, were also considered. After consideration, the participants agreed to consider two documents as background material to their discussions; a document prepared for the twenty-seventh session of the Regional Conunittee held in 1977, International travel for health reasonsa which was still relevant to the deliberations of the Working Group; recommendations formulated during the United - Nations World Assembly on Aging in 1982, which included the important question of the possible prevention, or at least postponement, of the negative functional consequences of aging. It was also agreed that when considering the role of balneotherapy in the prevention of disability, the Working Group should bear in mind the possible benefits for other age groups, as well as for the elderly. Terms of reference During discussion of the working papers, the should be defined to clarify further discussion . they should not be interpreted as definitions. consensus was that clear terms of reference The following were agreed, with the proviso that The Group agreed to limit itself to consider naturally occurring resources, such as mineral water (for internal or external use), derivatives of mineral waters (gas, vapours, etc.), thermomineral mud and climatic factors. These natural resources are often given different names in different countries. Balneotherapy is the use of naturally occurring resources at the place of origin, in support of health care. It follows, therefore, that the use of such resources must include curative, preventive and promotional progranunes, aimed at improving the quality of life of the individual. a Document EUR/RC27/10. - 113 - It should be recognized that other physical and educational methods, such as physiotherapy, electrotherapy, dietetics, gymnastics, re-education, medical rehabilitation and health education, could equally be associated with the use of such natural resources. Conclusions 1. Balneotherapy has an important role to play in the maintenance of health and possibly also in the prevention of disability in later life. Dietetics is an inseparable part of the discipline and nutrition should cater, as closely as the condition of ill health allows, to the physiological needs of a healthy subject of the relevant age group . 2. It is necessary to emphasize not only the medical, but the social role of balneotherapy in the overall s ystem of health care. 3 . There is a need for further evaluation and study of the processes involved in balneotherapy. 4 . Balneology as a discipline has many components and their interaction is essential to the full application of balneotherapy as a process. 5. As balneotherapy involves a multidisciplinary approach, it would seem suitable for further study to incorporate it into some of WHO's existing programmes: for example, primary health care, health care of the elderly, disability prevention and rehabilitation. 6. It becomes extremely important when developing positive indicators for the use of balneotherapy in the elderly, to specify the contraindications as well. Areas of further study 7 . It is necessary to increase the scientific base of balneotherapy. To achieve this objective, empirical, experimental, medical and epidemiological methods should be used. 8. Ways must be found to promulgate such scientific information nationally and internationally . 9 . Ways must be found to use balneotherapy as a support, not only in old age , but in all ages, to the promotion of health. 10. While the Group was aware of act1v1t1es already in progress to formulate dictionaries of definitions and terms in common use in balneotherapy, there seemed to be a need to prepare an international glossary of terms. 11. The specific content of the discipline referred to as balneology still requires further study . 12. It seems essential to identify the indications and contraindications for the use of efficiency of balneotherapy as a means of changing the progression from disability to handicap in the elderly . 13. It is important to study the factors that motivate the elderly, even when they do not contact the formal medical services in their countries as a first stage, to prefer to use naturally occurring resources such as balneotherapy. 14. The use of balneotherapy could be considered as complementary or as an alternative to drug therapy and polypharmacy which could lead to a possible reduction in the side effects of prescribed drugs in the elderly. 15. There is a growing use of saunas in many countries, and it is necessary to find ways of emphasizing to those not familiar with the principles of the use of saunas, that they could have harmful effects, particularly on the elderly. 16. There appear to be two areas that need ultimately to be translated into formal action: first, the relationship of the physiology of aging to the functional response of the elderly; and second, the accepted problem of multiple pathology which is often related to old age but may or may not alter the functional capacity of the elderly. 17. The new methods of surgical intervention and their possible relationship with balneotherapy should be studied: for example, surgical technology, such as joint replacements and medical technology, such as pacemakers. - 114 - Recommended action 18, Balneotherapy could be included as a specific element in one or more of the existing WHO programmes. 19. A study should be made of the use of balneotherapy in relation to specific age groups. 20 . An information system should be developed for the users of balneotherapy, indicating both the advantages and disadvantages of the various methods available to them. 21. A network of information centres should be developed to collect and distribute scientific information on the advantages and disadvantages of balneotherapy. This would be an appropriate activity for the International Association of Balneology and Climatology and national institutes wherever possible. 22. Research should be stimulated to enlarge the base of knowledge in this field, particularly the relationship between the possible benefit of balneotherapy and degenerative processes, to include the cost-effectiveness of balneotherapy compared with other methods of therapy. 23. Ways must ~e found to identify the educational needs of the personnel, both medical and auxiliary, invu1ved in balneotherapy. 24. Existing methods should be better adapted for assessing the functional capacity of the elderly both before and after treatment. - 115 - HEALTH PLANNING AND EVALUATION - 117 - Advisory Commi t tee on Heal th Planning and Eva luat ton ICP /CHP 004(5) 27510 23 Novembe r 1983 ORIGINAL; ENGLISH San Marino, 13-14 June 1983 The Adviso r y Committee met to give advice and gu idance to the WHO Regional Office fo r Europe on the development of the pr ogramme on health plann ing and evaluation, and implicitly on the accomplishments of the Country Health Programming (CHP) unit. The CHP unit ha s a special role to play i n developing an appropriate mana ge r ial process fo r national health developme nt ( MPNHD ) as a basis fo r attaining health for all by the year 2000 (HFA2000) in Europe, within the f r amework of the Seventh Gene ral Pro gramme of Wo r k (7 th GPW) . The main objective of the meeting were to: ( 1 ) g ive advice and guidance on the relevance , validit y and feasibili t y of the objectives , strategies, targets and eva luat ion indica t ors o f the programme; and (2) review some selected issues related to heal th plann ing and management development: ( a) the 7th GPW i n relation to the CHP unit; Discussion ( b) the !iPNHD document s i n relation to the implementat ion and promotion of sound comprehensi ve planning for HFA2000 in European Membe r Sta t es; (c) the Euro pean targets fo r HFA2000 and the managerial requirements fo r implementing them; and (d) the docume nt " Scenarios fo r KFA2000 - a strategic long-term approach". The meeting reviewed the i mpli ca tions of the re gional st rategy for attaining HFA2000 and the Eu ropean targets for HFA2000 fo r health planning and management development in European Member States. Great appreciation was expr essed of the target-setting document I a lthough there was some conce rn that the targe t s seemed overly o riented towards Western Eur ope . Although the cont e nt of the document was considered good, there was hesitation about how national administrations would reac t to it and whether effort s would be made to implement it nationally, especially in times of economic recession and instability. With regard to the present formulations some experts fel t that unless figu r es and targets were expre ssed more flexibly, countries would be disenchanted. Other s were of the opinion, however, that as targe ts are only meant to be indicative, positive target setting would force authorities into discussing real health problems and present a much needed political challenge . The WHO Regional Of f ice f or Europe should pay attention to the continuous reorientat ion and imp r ovement of management systems for the implementation of HFA2000, as it is a difficult process that needs to be applied individually t o each different national administration and political se tting. It is also important to integrate this approach into the exis ting management s truc ture s and processes o f each country, thereby improving , not r ep lacing, existing sys tems and s trengtheni ng the functions of exi s t i ng planning and management or ganization. The s tructure of the programme of the CHP unit presented in the 1984- 1985 approved pr og ramme budget was s uppo rted ; mo reover it was fel t that more manpower was required i n t h e CHP uni t and tha t to function adequa tel y it shou ld continue actively to dEY«\.aD and stren gthen a network of con tacts and experts in all Member Sta t es a nd g r adua lly rei1 11 o t.ta' Oi.ei~~ -O"'t -.allaborat ing centres. This would also e nable the unit to avoid any unne4es ... Q J.W p ....u;..&.Cl.tm <if effort with o ther i nternational o r ganizations work i ng on the same issues and t-o h•v.e .a mor-e·ci:mntTY-speci fic out pu t. - 118 - As the HFA2000 movement in Europe is in its implementation phase, and bearin g in mind th~ number of activities foresee n by HFA policy guidance documents, the Advisory Committee on Healt h Planning and Evaluation needs t o meet more often: over the next few years , meetings should be held every second year . The programme structure for health planning and evaluation was considered against the background of the different obje c tives , targets and approaches outlined in the European target document. 1. Conce rnin g the objective of promoting an adequate managerial process in support of the attainment of HFA2000, stress was put on the European Conference on Management and Planning for Health, to take place in The Hague in 1984. This was seen as a useful forum for high-level decision-makers and planners to exchange information and experience on national planning systems and to help develop a common understandin g of the manageria 1 requirements of HF A2000 es pee ia l l y in its implementation stage. The survey of the health management and planning structure and processes of s elected European ~ember States , suggested fo r 4se at the Conference, 'would be a neces s ary and helpful background document. Such a do cument co uld throw light on the relevance for HFA2000 development of the present state of the art of health management in the Region. Furth~r consideration should be given to the technical 8spects of such a survey and to the administrative feasibility of its implementation and cost, paying particular attention to how best to achieve input from the different national experts in the survey . For this purpose' it was recommended that a shor t planning meeting should be arranged as soon as possible. 2. Concernin g the objective of developing more prob lem-speci fie mana ge ria l methods for heal th development in Euro pean countries, greater consideration s houl • ie given to planning the content of se r vices as well as their delivery and the allocation of their resources . There is also a real need i n the longer term to shift planning from an input and/or output ( production ) orientation t o a strategic and outcome orientation. Finally, it was felt that multisectoral planning is an area full of managerial and politi ca l conseqeuences that has not been explored well enough. Although great effort is at present required in field projects, more specific problem- oriented case studies and collaboration should be undertaken in countries where there are particular problems or experience in developing heal th services, and especially in developing primary heal th care. Further guida nce is required on key issues of health planning and management~ the balance between centralization and decentralization, and the problems of programme budgeting, of the integration of various forms of planning and management into comprehensive planning, and of p tanning and management fo r heal th under conditions of zero economic growth . Further conside rati on should nevertheless be given to the priori ties to be assigned to these issues. In this regard, whereas the last two are basic to HFA2000, the first two relate more to technical matters and could be referred for later consideration. _/ The study on the implementation of programme budgeting could usefully be turned into a study of the problems of outcome-or ient ed planning and budgeting. Furthermore, as practically no Membe r State has zero econ omic growth at present, the term "restricted economic grow th" would be more applicable . J. In relation to the objective of motivating sectors other t han that of health to become active contributors to HFA2000, the suggested targets may seem to put too much emphasis on the present. More effort should be put into what can actually be done to improve the situation in the future ~ In this respect, problem-or i ented case studies could usefully be conducted in countries where there are particular problems in achieving i ntersectoral collaboration . 4. Concerning the objective of improvin g capacity and quality in heal th management training, emphasis ought to be put in fut ure on national training courses, without detracting from the importance of international training programmes. This will allow the nat ional development of s pecific and problem-solving training activities relevant to each country and to i ts health planning and management system and situation. An effort should be made to tailor special courses, i n terms of length and content, to the needs of individual groups of decision-makers and manager s at different levels in their respective countries, particularly keeping in mind the time constraints of senior managers. Only in this way will it be possible to achieve a continuous reorientation and improvement of existing manageme nt systems and to develop an adequate managerial process for attaining HFA2000 in Europe. - 119 - The best way of achieving further motivation of politicians and senior decision-makers at th e national level would be to arrange travelling seminars and workshops in collaboration with Member States. In this way a dissemination of informa tion on WHO's policies will be attained and WHO's European regional strategies for attaining HFA2000 furthered through improvements in existing health planning and management systems. Recommendations 1. The manpower resources of the CHP unit in the WHO Regional Office for Europe need to be increased. 2. The CHP unit should continue the active development of a network o f contacts in Member Scat es and seek to reinforce the role of collaborating centres in the technical f ield. 3. Because the HFA2000 movement is in its implementation phase more frequent meetings of the Advisory Committee on Health Planning and Evaluation are needed. They should take place every second year ove r the next few years. 4. Further consideration should be given to the technical and administrative aspects of implementing the survey of health planning and management structure and processes in European Member States, planned for the European Conference on Management and Planning fo r Health in 19 84, and to the contribution of national experts to the s vey. A short planning meeting should be arranged as soon as possible. 5. In response to demand at the subna tional level, co nsideration should be given to the planning of health services , resource allocation and broadly speaking to the developmen t of relevant planning techniques and methodology. Strategic, outcome and multisectoral plann ing should also be continuously encouraged when dealing with national planners and people responsible for national policies. 6. There should be further consideration of the priorities to be given to key issues of health management and planning in the European target document, and of the problem of avoiding any duplication of effort with other interna tional organizations working on the same issues. 7. The subtarget of a study on the implementation of programme budgeting could usefull y be changed to a study on problems of outcome- oriented planning and budgeting. The subtarget of a study on zero economic growt h should be renamed a study on restricted economic growth. 8. More specific problem-oriented studies should be undertaken in countries with particular problems in developing health services, and especially in developing primary health care. Such studies should also be unde rtaken in coun tries where there are specific problems of intersectoral c ollaboration. Field pilot projects may help clarify managerial issues and initiate relevant health policy development. 9. Emphasis should be put on national training courses as an attempt to develop specific and problem-solving training activities. 10. For different levels of decision-ma kers and managers, special c ourses should be tail o red in terms of length and content to correspond to their needs. 11. To furthe r motivate politicians and senior decision-makers at the national level, travelling seminars and workshops should be organized co disseminate and further WH0 1 s policies and European regional strategies. - 121 - HEALTH SERVICES RESEARCH - 123 - Study Group on Health Services Research ICP/RPD 007(3)(S) 1593D Murren, Switzerland, 25-27 January 1983 27 May 1983 ORIGINAL: ENGLISH I. Introduction were: 2 . The meeting was attended by 10 temporary advisers from the European Region. The objectives to review the rec ommendations of previous planning groups in the light of current knowledge and developments; to consider the role of health ,ervices research (HSR) in connection with the future activities of WHO and the European Advisory Conunittee on Medical Research (EACMR); and to suggest targets for Member States in their development of HSR and to relate these to the regional strategy for health for all by the year 2000 (HFA2000) . Proceedings Discussions centred on three main areas: the reasons why previous recommendations did not appear to have been followed in Member States; the constraints experienced in the conduct and implementation of HSR; and targets for Member States and the role of WHO in association with them. The reasons why earlier recommendations did not appear to have been followed were strongly associated with the constraints experienced in mounting and applying HSR. These constraints applied at central or government level, in the academic/research conununity, and within the professions and authorities involved in the provision of health services. They ranged f rom lack of funds and interest at top level to difficulties in gainin g access to patients, and included the dominance of the biomedical research model in developed count rie s . 3 . Areas of agreement The challenge was to reorientate health services better to meet the needs of the population, and HSR was rega rded as the main tool with which to do this. Ideally, it should precede the establishment of health service programmes. By nature, it i s pluralistic and multidisciplinary. Lack of convincing evidence of the use of HSR as a tool in the planning and provision of services could be a factor in the way it is regarded at present, and action is urgently needed to overcome inertia in establishing HSR programmes and in monitoring progress towards HFA2000. General and specific measures are necessary; the former would include securing acceptance that HSR would contribute towards better services. A number of targets were identified as specific steps that countries might take. 4 . Results and recommendations Targets The main outcome of the meeting was the determination to overcome the constraints experienced, by setting up targets. - 124 - At the central and government level: the formation or identification of a focal point; the specification by 1990 of a role for HSR; the specification by 1985 of a budget for HSR. At the academic or research level: research councils to specify their budgets for HSR by 1985; HSR to be represented on national research councils by 1985; arrangements for HSR to include peer reviews at the protocol and progress stages as well as on completion; the career structure of HSR to be in line with other fields of research; the recruitment for and conduct of HSR to be improved through better training and career arrangements. Progress towards HFA2000 HSR would assist in monitoring progress, but countries would be likely to selec t their own benchmarks f rom among the many possible indicators, such as indices of health, social and economic wellbeing, environmental fac tors, and care systems and their adequacy and accessibility. Role of WHO WHO was an international focus for HSR and could assist by identifying focal points at the central level and collaborating centres at the researc h level. The training of individuals and the dissemination of information were important activities for WHO in encouraging the development and application of HSR. Working Group on the Management and Structure of Health Policy Research Rome, Italy, 18-20 October 1983 - 12S - ICP/RPD 012(2)(5) 2779D 21 December 1983 ORIGINAL: ENGLISH The working Group was attended by 18 participants from 12 developed countries, most of them physicians with a specific responsibility, either administrative or technical, for health service research, The meeting stemmed from the basic fact, acknowledged by the European Advisory Committee for Medical Research (EACMR), that effective mechanisms for setting national priorities for research do not exist in the majority of Member States, despite the generally accepted belief that the health of individuals or populations and the delivery of health services would greatly benefit from the application of research results to specific problems and areas. The meeting was convened: to consider the structure and mechanisms required to align research more closely with health care provision and practice; and to explore, from examples of problem-oriented research that have affected the practice or provision of services in the countries of the participants, and of the difficulties encountered in establishing health service research programmes, the relevance of this fact to Member States. In their discussions, the participants concentrated on: the exact definition and meaning of health service research and health policy research, and on their place vis-a-vis health research in general; why this kind of research should be encouraged, how priority fields might be chosen and the problems within them defined and how the necessary research might be commissioned; the necessary balance between undirected "free" research versus commissioned studies, and the practical problems in recru1t1ng scarce research skills for the analysis and investigation of organizational and delivery problems; how to convey and interpret results to health administrators, personnel and the public at large, and on the expected modifications in health policies and practice; and the extent to which central policy and health practices have been significantly altered by target research, and on what role WHO should have in pursuing this. The outcome of the meeting can be presented under three headings, leading to general or more specific recommendations. The nature of the problems encountered and how they have been or could be solved There is a general lack of appreciation - from government departments, the "scientists" and those responsible for providing health services locally - of the benefits and potential of research related to health policy. Sometimes, this lack of appreciation verges on prejudice on the part of the scientific community against health service research. Far too often the poor quality of health service research seems to justify this misjudgement, This might result from a shortage of suitably trained and experienced people for conducting such research, from a lack of incentives, and from the lack of a secure research base in some essential disciplines such as sociology and economics. Finally, some ethical problems raised by this type of research are still largely unexplored; the discrepancy in timing between the length of the research and the urgent need of its result, and some political difficulties linked with its application may bring health-policy-related research into disrepute. - 126 - As possible solutions, some of them already experienced in a few countries, the Group stressed: an increased dialogue between policy-makers, health care providers, scientists and health service researchers; the commitment of government departments to basing policy on research findings; the stability of financing and of proper career structure in health service research, together with arrangements to make mobility possible; and the organization of peer assessment of research applications and peer review of completed research. In addition to commissioned research, free or undirected research should continue to be unhindered by government direction or interference. Nevertheless, the scientific community should be made aware, through dialogue, of public health problems. Benefits of health-policy-related research In this very period, when most countries are trying to halt the increase of the share of the gross national product devoted to health services, and when the provision of health services and medical care is increasingly challenged as insufficiently reflecting the needs and wishes of the community at large, it should be reaffirmed that health-policy-related research is essential and is as noble as any other type of research. Among the benefits that can be expected from it, the Group stressed its usefulness for providing a more scientific and secure base for policy decision and service provision; g1v1ng a platform for improving and changing the actual practice of health professionals, including physicians; where funds are limited indicating best value for money; and assessing technology (itself a result of research) and indicating its appropriateness . Likely future developments These will most probably occur in the following areas: evaluation of results and their translation into po l icy options and descriptions of case studies of policy innovations resulting from research findings; providing more information on how policy and practice have changed as a result of research would undoubtedly attract researchers to working in policy-related fields; stronger emphasis on feeding back research results to the public, to the health professions , to policy-makers and care provi ders at various leve l s and to teachers and trainers of health personnel; possibilities (and limits) of transferability between countries of results of health-policy-related research; and collection and exchange of experiences of ethical issues arising within health service research, keeping in mind that these problems are not confined to biomedical research. Recommendations 1. 2. Basic principles The Group emphasized that: any research should be for the sake of society; the community at large should benefit f irst from health policy related research; the needs and demands of the community should therefore be taken into account when planning research; health service research is more easily accepted when it aims at improving and tends to be rejected when it pretends to change . Recommendations for the governments The Group also emphasized that: more importance should be attached to economic problems and factor s in the health field in the short and medium term; - 127 - countries should look at their own structures and arrangements for careers and dialogue, as well as for financing; governments should provide traLnLng facilities, permanent positions and career profiles in health-policy-related research, so as to encourage permanent commitment to research in this field; countries should develop the training of students and health professionals, both for research and through research. 3. Recommendations for WHO WHO should: promote health service research by acknowledging its importance for all Member States and by publicizing its potential and results; contribute, by all appropriate means, to a better definition of c oncepts and to an internationally accepted terminology ; help identify the most profitable fields fo r health service research. encourage a dialogue among policy""1Dakers, health services, scientists and the community at large through all possible channels, by structural and managerial measures; promote international training in health-policy-related research, for instance by initiating training courses, providing fellowships, etc.; help create an international network of peer assessment and peer review, especially for small countries; contribute to documenting the ethical aspects of health service research as well as the implementation of results; collect information on the counterproductive effects of measures that are too constraining in the field of legislation, regulations and policies; set up a mechanism to monitor progress in the field of health-policy-related research. - 129 - HEAL TH MANPOWER Seminar on Primary Health Care in Undergraduate Medical Education Exeter, 18-22 July 1983 Introduction .• 131 - ICP/EDS 009(5) 0484J 6 December 1983 ORIGINAL: ENGLISH The Seminar was attended by 22 participants: 19 temporary advisers and 3 WHO staff members. Primary health care (PHC) has the key role in the regional strategy for attaining health for all by the year 2000, formally adopted by the Member States of the WHO European Region. This implies "major changes in professional practice and the organization and financing of health care" and "a fundamental reorientation of medical and nursing education".a Although Member States have not yet drawn up th~ir national strategies for health for all or indicated the forms that PHC will take, it is possible to derive from the regional strategy what the main new or modified roles and functions of primary health care professionals will be if it is implemented, the corresponding objectives of educational systems, the implications of those objectives for educational policies and for the organization and management of educational institutions and curricula, and the relations between educational and health care systems. The predominant structures and forms of primary medical care and medical education in the European Region are one of the main obstacles and challenges to the widespread adoption of primary health care as the key to implementing the regional strategy. The WHO Regional Office for Europe therefore convened a meeting of representatives of health administrations, medical education, primary care and medical students to identify the steps that education and health administrations will need to take, or are taking, to adapt medical education systems to the needs of primary health care and the constraints that have to be overcome to do so. These steps and constraints include the structural, organizational and financial aspects of health care and medical education systems and different aspects of their interrelationships. The report of the meeting will be designed to be of use to national health and education authorities in determining how medical education systems may be modified and supported so as to provide the optimum conditions for training medical practitioners of primary health care . The task of medical education The focus of the Seminar was on the new or modified roles and functions for which PHC practitioners will need to be trained if the regional strategy is to be implemented, and not on preparation for primary medical care (or general practice). It became clear, however, that primary medical care, either as a discipline or as a curricular subject, cannot be taken for granted . Large numbers of vulnerable people are not receiving the care they could receive. Since primary medical care in the European Region is generally considered to be the root from which the new elements of PHC will grow, the main effort must be concentrated on raising its standards, expanding its scope and changing its structure so that the benefits of medical science and modern technology may be made generally available. One of the tasks of medical education must be to promote this kind of primary medical care rather than merely to reflect current norms of practice. The skills of the generalist physician in PHC will include educational, informational, communicational and multidisciplinary teamwork skills. In a relatively few countries, some basis exists for an evolution from primary medical to primary health care, as regards both service and education. In many countries of the Region, in view of both the structure of primary medical care and its complete neglect by medical education, radical changes will be needed on both counts. a Re ional strate Office for Europe, 1982 for attainin health for all b EUR RC30/8 Rev. 2) . the ear 2000. Copenhagen, WHO Regional - 132 - Obstacles to PHC in medical education The obstacles to the necessary reorientation of medical education include some that impede change in medical education in general and some that are specific to PHC in both practice and education. The former involve mainly the change from the predominantly academic, departmental, specialist structure of the medical curriculum to a competency-based, problem-solving, generalist-oriented curriculum. The latter include the prevailing passive pattern of medical practice in which doctors wait for patients to come to them with well established symptoms, and where there are no incentives to practise anticipatory, preventive medicine or to mobilize nonmedical means of prevention or health promotion. The predominant influence of specialized high-technology medicine is reflected in the medical curriculum, which in many countries is seen as an initial step towards specialization and has little to do with generalist principles. An obstacle at government level is the lack of a tradition of cooperation among the different sectors . One example is the independence from each other of the health and the higher education sectors; another is the inconsistency between the economic or fiscal interests of government and the policy of protecting the public health . The range of obstacles to be taken into account in attempts to reorient medical education :owards PHC include a ttitude, motivation, vested interests, lack of knowledge, communication, tradition, and structures and patterns of practice and education. These obstacles are encountered at various levels - government, university, medical school , professions and connnunity. Reorientation of medical education to PHC The conditions necessary for the reorientation of medical education to PHC include; the adoption by each country of a national strategy for health for all, indicating the form that PHC will take and commi tting to PHC the resources it needs to become the "central function and the main focus" of the health system; the development of a well defined, agreed role for medical education in support of the strategy and as a partner with government and other PHC interests in developing PHC through both research and service-based education; the education of the public and of the politicians and administrators whose decisions affect PHC, in the nature and scope of PHC; as an essential basis for curricular planning and effective learning, the determination by an authority in which PHC interests are represented by the body of practical and scientific competencies and levels of performance in PHC expected of graduating students; the use of sound educational practices from curricular planning to the evaluation of students and programmes, and the adequate representation of multidisciplinary and multisectoral interests in educational planning and during training; a formal arrangement between the medical school and the community's health care and health related services for the school's use of a sufficiently large and representative community for training and research purposes; this should permit the medical school to co-opt primary care practitioners to train and supervise individual and small groups of students; the training community ' s PHC services should gradually develop to satisfy the criteria set out in the regional strategy (item 20) with regard, for example, to community participation, multidisciplinary teamwork and helping people to assume greater responsibility for their own health; the functions and educational management skills needed by PHC faculty members must be defined in detail and training programmes for teachers formulated accordingly. PHC in the structure of the medical school While a case can be made for establishi ng professional chairs and departments of PHC, such an arrangement risks restricting to academic departmental limits a branch of health care to which many departments have contributions to make and which is essent ially a range of competencies rather than a body of theory. A form of organization was proposed that would band together the medical school departments or units, other health car e disciplines and possibly other university departments that - 133 - have substantial contributions to make to PHC, to form a strong sector of the medical faculty directly responsible for PHC in education, research and service in the cotmnunity. The appropriate medical school departments would be general practice, social medicine, occupational health, epidemiology, geriatrics and long-term care and social psychiatry . Such an arrangement should not have the effect of polarizing the specialist clinical and the cotmnunity-oriented dimensions of medical education . The structures should provide for the clinical departments to make their own contributions to enable students to master those dimensions of clinical medicine that a generalist practises. Their cooper ation should be sought, for undergraduate education purposes, in distinguishing between the generalist and the specialist elements of their subjects, so that students may attain the high quality clinical competency of generalist medicine essential to PHC, instead of having to master fragments of the unduly sophisticated technology used in specialist medicine. Part of this process would involve senior clinical teachers working in primary care facilities. Besides the preventive colDDunity-oriented and the specialist clinical groups, a third potential "power group" in the medical school could be the educational development and management group, found in the more progressive medical schools. This group could promote competency-based, problem-solving learning and reduce the departmentalism in education that is largely incompatible with education in PHC. It could also help the faculty members responsible for PHC to manage the largely decentralized, cotmnunity-based , educational progratmne that PHC requires, and in particular it could support, in their training and supervisory functions, the large number of primary care practitioners whom the medical school will need to co-opt for the practical training of students. The university and PHC Since health cannot be attained by the health sector alone, the potential of the university (or the higher education system) as a whole needs to be explored and realized. The PHC group in the medical school could have powerful allies on university governing bodies and in a wide range of faculties and departments of, for example, economics, sociology, political science, geography, bioengineering, architecture, urban planning and agriculture . University funds might be provided for cooperative interfaculty research. Recotmnendations 1. A national body should be established in each country to act as a catalyst in promoting PHC in the education of health personnel and as a clearing-house for information on national and international activities related to education for PHC. 2. WHO fellowships should be used to support national task forces promoting PHC in the education of health personnel. 3. The WHO Regional Office for Europe should cooperate closely with international professional associations in Europe concerned with medical education to reorient medical education towards PHC. - 134 - Working Group on the Evaluation of the Regional Fellowships Programme and Training Courses Zagreb, 11-13 October 1983 ICP/PTR 007(S) 0554J 12 December 1983 ORIGINAL: ENGLISH The meeting was attended by 18 part1c1pants from 13 European countries, including former WHO fellows, directors of institutions that receive WHO fellows for training, directors of WHO-sponsored training courses and national fellowships officers. There are no clear mechanisms for the evaluation of WHO fellowships and courses, despite the generally accepted belief that they have greatly contributed to the development of national health services and training institutions for health personnel. The Working Group was therefore convened: to discuss the new policy on fellowships adopted by the Executive Board resolution EB71.R6 and consider the evaluation needs that it implies; to review an evaluative study on the regional fellowships programme and training courses made by a consultant; to make recommendations on future fellowship act1v1ties in the countries of the European Region and in the Regional Office, and on how to evaluate them. The WHO fellowship policy in view of the global and regional strategies for attaining health for all by the year 2000 The Working Group reviewed the background of the Executive Board resolution EB71.R6, including the reports by the Director-General to the seventy-first session of the Executive Board on the policy on fellowships (EB71/PC/WP/4) and to the sixty-ninth session on the use of fellowships in health manpower development (EB69/26), and endorsed the new policy on fellowships. EURO fellowship activities The present fellowship activities in the European Region were reviewed in relation to fellows from both inside and outside the Region and it was clear that this Region has great importance in the global WHO fellowships programme as the main receiver of WHO fellows for training from all the other WHO regions. This implies a great responsibility. In spite of their limited size, the WHO fellowship activities also have an important role in the development of health services in the European Region, where only a few but mostly key persons benefit from WHO awards. A review of selected WHO fellowships completed during the period 1978-1982 The consultant, Professor J. Cervenka, presented the results of the study conducted according to the protocol designed by the Consultative Group in January 1983, and pointed out that the study was not intended to have scientific value but was merely an introduction to the problem to be discussed in the light of the recent change in the WHO policy on fellowships. He also pointed out the bias caused by variability between the local investigators who collected and prepared the primary data. The study was based on a total of 661 questionnaires, some of which did not contain all the data r~quested or contained unreliable data . As a whole, however, the study reflected the situation. One weakness of the study was that it did not include fellowships that had been requested but not granted, nor fellowships awarded but not taken up. - 135 - The Working Group considered the selection of fellows to be one of the most important factors in the success of a fellowship and included in this process the person to be selected, the procedure of selection and the body responsible for making the selection . The adequate choice of countries and institutions was also considered important and a knowledge of what each country and institution could offer was, therefore, essential in choosing the best possible placement for each candidate . The age of the fellows did not seem to influence the success of the studies undertaken during the fellowship but it was felt that younger candidates should be given priority as they were a better investment . The physician/non-physician ratio varied according to specific national situations. The Working Group felt that health insurance was an important factor in the wellbeing of the fellows and considered that fellows should always be automatically insured as soon as their fellowships had been awarded. The proper briefing and supervision of fellows was also mentioned as a major factor in the success of fellowships, and different approaches were studied. The usefulness of adequate information from the countries receiving fellows was stressed . Language proficiency was considered essential for the success of any fellowship, and proper assessment and certification methods were studied. Future evaluation of fellowships and training courses The evaluation study made of individual fellowships completed between 1978 and 1982 should be followed by other studies drawn on similar or different lines, aimed at identifying trends in the variables studied. Follow-up of participants in WHO-sponsored courses should also be a permanent feature of all of them. Future evaluations of each individual fellow should be done by the fellow himself, by his employer and by his training institution(s). It was suggested that a small percentage of the cost of each fellowship (l-2%) be earmarked for evaluation purposes . Simple but effective approaches to evaluation should be used such as, for example, to ask what was wrong with and what was really impressive about a training course . The questions asked of the fellows should be simple and should allow them to write about the impact made on them. Direct and indirect measurements for evaluation should be developed. For example, it was suggested that one good criterion for evaluation was whether a former fellow had trained other people, and another was whether the former fellow had been promoted. Other mechanisms of training There was not enough experience in other mechanisms of training to suggest any concrete way of evaluating them. Post-fellowship employment It was pointed out that some countries do not fulfil their obligation to employ former fellows in the fields in which they have been trained, and that this has a very negative effect on the performance and/or wellbeing of the fellows from those countries. Team training The Working Group studied the problems created by the isolated training of people who were expected to work as a team, and suggested that when possible they should be trained together as a team. Follow-up of former fellows Consideration was given to the people responsible for this task, the methods to be used, and the information to be obtained, as well as to the definition of "follow-up", which meant different things to different people . WHO should be informed of follow- up activities on former fellows by the teaching institutions that carry them out. - 136 - Follow-up activities in one country were studied as an example of what can be done. They i~luded the compulsory writing of a report for everyone returning from studies abroad, the discussion of the report in a small circle of colleagues, and its later submission to a scienti fic board for further discussion. Reports by former fellows The Working Group considered that the present WHO form provided to fellows for writ ing their reports was not fully adequate and suggested some improvements. Brain-drain The Working Group felt that as a general rule the brain-drain was not a problem in the European Region. Recommendations To Member States 1. The briefing of fellows by both sending and receiving countries should be improved. The receiving countries who have not yet done so should publish an information booklet for this pu: ,)se. 2. Mernoer States of the European Region should submit to WHO a list of institutions, activities and specializations connected with the regional strategy for attaining health for all by the year 2000 that they can offer to WHO fellows for studies. The list should include the language in which the training will take place and the names of those responsible fo r teaching/training. To the WHO Regional Office 3 . The evaluation of fellowships and tra1n1ng courses should continue. It is strongly recommended that a WHO project should be designed on the evaluation of teaching and training activities and on the outcome of fellowships and other forms of postgraduate education. This will require the active participation of Member States and technical institutions. 4 . Follow-up activities should become as an obligatory and permanent feature of any WHO-sponsored training. 5 . All WHO fellows should be covered by health and accident insurance. 6. The assistance and guidance of WHO fellows in countries of study by the national fellowships officers should be more actively supported by the WHO Regional Office . To both Member States and the WHO Regional Office 7. It is strongly recommended that WHO fellowships be planned as part of a national health manpower development programme or, if this does not exist, be based on a special agreement between WHO and the relevant country; fellows should be selected according to the new policy on fellowships established by resolution EB71.R6. 8. As a first approach, the most effective way to evaluate the impact of fellowships and training courses may be to analyse the positive changes brought about by former fellows in their activities. The joint evaluation of any teaching programme by both teacher and fellow will always be extreme ly valuable. 9 . Wherever mechanisms other than fellowships training pp. 5-7) are more appropriate, they should be e ncouraged. methods as for fel lowships. Team fellowships should also training. mechanisms (as described in EB71/4, They can be evaluated using analogous be included as alternative methods of Seminar on the Role of WHO Participating Centres in Continuing Education, Specialty Training and Educational Research London, 31 October - 2 November 1983 Introduction - 137 - ICP/~u~ 007{l)(S) 0564J 14 December 1983 ORIGINAL: ENGLISH The Seminar was attended by 22 participants from 17 European countries, one observer and four WHO staff members. The participants were mostly directors of participating centres engaged in postgraduate medical education and continuing medical education. Health education, nursing , pharmacy and child care were also represented. Scope and purpose The Seminar addressed the question: what role should WHO participating centres play in meeting the priority educational needs of the European Region? There are three goals in meeting such needs: ensuring that the specialties developed meet the real needs of the health services; increasing the amount of research relevant to health manpower development; and changing the characteristics of continuing education so as to implement the regional and national strategies for attaining health for all by the year 2000. The Seminar also set out to suggest what action on these matters should be taken by national authorities, to advise the Regional Office on the activities it would be appropriate to develop, and to provide a general forum in which the directors of participating centres could discuss areas of mutual concern. The participants worked in groups. Topics introduced by three papers l. Research The participants were asked to describe relevant and manageable research problems of health manpower development, and to outline possible methodological approaches to solving them, with a description of available or required resources. The discussion revealed concern about recognition of the legitimacy of research in medical education. Some major areas for research are the needs of the community specialist, profiles of various professionals involved in PHC, the matching of the curriculum to the health services, the evaluation of postgraduate training in relation to health needs, educational methodology i n postgraduate training, the relationship of undergraduate training to career choice and the education of lay people by health professionals. The methods for studying these topics would be comparative studies of different institutions, case studies and sample surveys. The resources for the research would be mainly in the medical schools. 2. Specialty training The ambivalent nature of specialization was noted: it promotes medical advances, but seems to be a response to unhealthy lifestyles rather than a promotion of healthy living. Points proposed for discussion were the specialized (medical) content of PHC, referral policy, the relationship of the specialist to community health services, graduate training of general practitioners, teamwork, manpower planning, the control of numbers, variety of training experiences, length of training, - 138 - continuing education and restriction of practice . The di scussion suggested that health administrators play a role in this area; training of health professionals in how to work within financial constraints is a necessary adjunct to their training; perhaps the term "medical specialization" should be rephrased as ''health specialization" to include competence, identity, status, community demand and the organization of the health services. The free market system leads to the development of specialties independent of community health needs, and this has negative effects on patients, other health professionals and PRC. A monitoring system is needed to control, steer, plan and evaluate health services, of which manpower development is a part. Health workers should be trained in environmental factors and lifestyles, but in an integrated manner rather than separately. Research areas of interest concerned the decision-making processes of specialization, the career structure for specialists, the evaluation of community demand and needs in relation to specialization, the evaluation of the effectiveness of continuing education for specialists, and the evaluation of specialist competencies. Such research would be best done through a common protocol, so that activities in different countries could be compared. The information available at present on specialization in Europe is still in an early stage and could thus be further developed. It was emphasized that such studies should come from the bottom up, rather than be imposed by WHO. WHO could help by constructing a theoretical model of medical schools (including po, graduate ones) in the year 2000, to reflect the whole system of future medical education. 3. Continuing education It was proposed that continuing education for PRC was even more important for changing attitudes than for the simple provision of updated knowledge, competencies and skills. Intercountry help was still needed, because different countries are at different stages of development as regards both primary health care and continuing education. Outside help is thus a tactical instrument in the effort to change attitudes, since the outsider is often more influential than the local teachers. The greatest need for continuing education is found in those health workers working outside the hospital context. Also, the need for continuing education for the primary health care team, as distinct from that for the individual members of the team, is important . The core content of continuing education as regards different experiences and exposure to the community should be constructed. The discussion suggested that continuing education was not only for general pract1t1oners, but also for specialists . It was thought important to have an exchange of various experiences and to establish a common policy of teacher training . Research, which would come after such an exchange , would be concerned mainly with educational methodology, the organization of continuing education , and the relationship of continuing education to undergraduate and postgraduate training . The skills and attitudes for continuing education are often negated by the traditional methods of education . Since continuing education will be mainly about attitudes, decision-making and performance improvement, the traditional methods of teaching and learning are not appropriate. An important aspect is the training of teachers in pedagogy and methods of teaching. Consideration should also be given to incentives, motivation, job satisfaction and career prospects. Ideally, continuing education should be multiprofessional, with an emphasis on teamwork, learning and teaching procedures and thinking processes. Participating centres could help in planning, researching and advising in continuing education, both nationally and internationally . They could investigate how many doctors will be needed in the year 2000 and how they will be distributed, what can be done with the present superfluity of doctors, what are the key issues of PRC doctors for geriatric care, and what are the important issues in training with regard to self-imposed risks, such as alcohol abuse. Conclusions The participants recommended to WHO the following developments: l. The training of teachers. This is the best use of resources. Teachers need grounding in educational methodology and pedagogy, including special skills for interdisciplinary group learning. - 139 - 2. Sharing of experience. A great need for pooling ideas and experiences was repeatedly expressed. This could lead to mutual support, shared information and common research projects. 3. Evaluation and/or monitoring systems. All systems of education should have an evaluation component. A first step towards this would be provision of a data base on the present situation with regard to continuing education and specialties in different countries. 4. Curriculum content. The curriculum must be matched to known health needs. 5. Management and economics. Managers are part of PHC. Should they be doctors or not? Both administrators and doctors need to learn how to work within known economic constraints; they will need education in accepting this idea and in applying the knowledge creatively to health needs. 6. The learners. We must know more about their motivation and the context in which they work and learn. Recommendations 1. Evaluation of continuing education. It was recommended that WHO develop, in different countries, case studies on continuing education in primary health care with respect to the problems of the elderly. This would provide a basis fvc subsequent evaluation. Participants from the Institute of Hygiene (Padua), the Faculty of Medical Sciences (Lisbon), the BLAT Centre (London) and the Department of Medicine (Troms,) expressed an interest in undertaking this research . 2. Decision-,naking in regard to specialization. It was recommended that WHO contact those participants who had expressed interest in this and ask them to develop a research protocol. 3. Establishment of a network of people in teacher training. It was recommended that WHO facilitate the setting up of a mechanism to provide contact between people actually working in teacher training, for the purpose of sharing information, staff, experiences, research and evaluation projects and perhaps a bulletin. Participants from the BI.AT Centre (London) showed interest in undertaking this work. 4. Specialization. It was recommended that WHO promote the planning and implementation of a specialization system best adjusted to population health needs. A first step would be to describe the present situation in various countries and to evaluate the present state of affairs from the point of view of population needs. The data for this would be both qualitative and quantitative and would be gathered through a descriptive study of the general characteristics of specialties, postgraduate training systems, administrative aspects and selected features of various specialties. A pilot study could help to refine the area and methods of study. The purpose of the study would be eventually to discover how well the specialties match the intended national strategies for primary health care. Participants from Evangelismos Hospital (Athens) and the Institute of Hygiene (Padua) stated interest in this research. WHO was asked to take up these matters with the national authorities. Fourth Meeting of the Advisory Committee on the Health Manpower Medium-Term Programme London, 3-4 November 1983 - 140 - ICP/PPM 003(3)(S) 0595J 10 February 1984 ORIGINAL: ENGLISH The Advisory Committee on Health Manpower Development was set up in 1976 to assess the programme regularly and advise on its future course, to advise the Regional Office for Europe on the relevance and priority of projects and to suggest ways of obtaining the collaboration and resources necessary for implementing the programme. The three p•evious meetings of the Advisory Committee were held in 1976, 1978 and 1981. The third meeting in 1981 made both general and specific recommendations on matters such as the rational use of health manpower planning, the reorientation of basic education, continuing education, multiprofessional training programmes and the WHO fellowships programme. At its fourth meeting, taking into account the new developments in the European strategy and their implications for health manpower development, the Advisory Committee was asked to review and assess the activities of the programme since the last meeting in November 1981, suggest practical ways of implementing WHO activities in 1984-1985, and lastly discuss and recommend suitable approaches for proposed WHO activities in 1986-1987 and subsequent biennia. The meeting was attended by 18 participants from 17 European countries, and staff from WHO headquarters and the Regional Office for Europe . They represented in general the interests of medical education at undergraduate, postgraduate and continuing education levels, nursing education, health administration at national level and specific organizations such as the Association for Medical Education in Europe, the Nordic Federation for Medical Education, the Association of Schools of Public Health in Europe and the Commission of the European Communities. Background The major topics of the meeting were: new developments i n the European strategy for attaining health for all by the year 2000 and their implications for manpower development; a review of the 1982-1983 programme activities; the proposed activities for 1984-1985 and 1986-1987 of the health manpower development medium-term programme, and some consideration of longer- term activities that would establish the framework for the 8th general programme of work. Underlying all these discussions was the regional strategy for health for all by the year 2000 and in particular the two regional targets proposed for the health manpower development programme: by 1988, in all countries, the planning, production and management of health manpower will be more closely adapted to national health needs and health for all policies with more emphasis on primary health care, promotion, prevention and rehabilitation as well as appropriate use of diagnostic and therapeutic methods (Target 79). by 1988 , education of personnel for sectors other than health will provide adequate information on health for all principles and training in the practical implications of the national health for all policy and programmes as applied to their own sector (Target 81). The rationale of the health manpower development programme for the period 1984-1989 is based on the identification of six problems being in need of urgent solutions. - 141 - Health manpower planning has not been adapted to meet the changing needs of the health care system and the communities served. Slow progress is being made in reorientation and innovation to give greater emphasis to primary health care and community needs. Systematic and appropriate continuing education programmes are not developed sufficiently for all categories of personnel within the framework of national health systems. There is a lack of community-oriented programmes that provide for multidisciplinary training and for the development of the teamwork approach to the provision of primary health care (health manpower management). The type of fellowship training sought and provided is not always relevant to the main needs of the country concerned. Manpower in sectors other than health is not sufficiently knowledgeable about the health implications of activities in their own sectors and not motivated strong l y enough to take assertive action in support of health for all developments. Discussions Attempts to solve these problems raised issues such as WHO's collaboration with other bodies, the development of links among teacher training institutions, the relevance of continuing education, the production of learning materials, the training of managers, evaluation, the development of specialties related to community health needs and the orientation of health workers towards primary health care and research. There was a strong feeling that there shoul d be an examination of the contribution that the different specia lties are making towards health for all by the yea r 2000 . This feeling had also been present at a seminar of centres participating in the health manpower development programme that had taken place prior to the Advisory Committee. Similarly both meetings shared the view that there should be a st rengthening of the links among teacher training institutions. The need for rigorous research was regarded as an obvious requirement. One area particularly urgent i n need of such research is how continuing education can be reorientated more towards the consumer and the community . There is also a need to discover how multiprofessional continuing education can be promoted. Discussion among the participants revealed that such research or experimentation is in fact taking place in many of the countries of the Region, thus demonstrating a clear need to improve the ways in which information is disseminated. There is clearly a wealth of information available on community-oriented programmes and it was suggested that greater impetus should be put into the examination of their effects in various areas, particularly their efficiency . The part to be played by WHO fellowships was also considered as they too ought to be related to the regional strategy of health for all by the year 2000. One possibility mentioned was the production of guidelines for national committees. With respect to personnel in sectors other than health, it was felt that analysing the health components of their training programmes and producing health for all teaching guidelines for key personnel needed to be done earlier than scheduled provided that finance was available. Finally, the meeting turned its attention to the way in which the contribution of health manpower development is emphasized in the regional strategy documents. It was felt very strongly that as health manpower development is in fact affected by the decisions taken in all the other programmes of WHO it should be given greater prominence, particularly in the document Targets in support of the regional strategy for HFA 2000.a Recommendations 1. There should be an evaluation of the contribution that the different medical and other health personnel specialties are making towards health for all by the year 2000 . 2. Every effort should be made at both national and local level to stimulate movements towards community-oriented programmes and to disseminate information on them . - 142 - 3. The gathering of information about multiprofessional continuing education should be given major priority, and should then be followed by a workshop to consider how best such multiprofessional training could be promoted throughout the Region. The means by which such information is disseminated also needs improving. 4. A mechanism should be established to help ensure that fellowships are related to health for all. One consideration could be the production of guidelines for national fellowship connnittees. 5. The analysis of health components in the training of personnel in sectors other than health and the related educational methodology and the production of health for all teaching guidelines and modules for selected key personnel groups should be considered for inclusion in the 1986-1987 programme. 6. In the target document, greater emphasis should be placed on health manpower development as it affects decisions taken by other units. 7. A steering connnittee/consultative group should be set up to devise a systematic research methodology for dealing with the problems involved in evaluating the effectiveness and efficiency of continuing education. a Document EUR/RC 33/9. - 143 - IllTERNATIONAL WATER DECADE Working Group on International Drinking-Water Supply and Sanitation Decade, Monitoring in Europe Copenhagen, 14-18 March 1983 Introduction - 145 - ICP/BSM 003(4)(S) 31371 27 January 1984 ORIGINAL: ENGLISH The Working Group is a direct response to the request by the 31st Regional Committee for Europe of WHO in resolution RC31/R9 for the Regional Director to take the necessary action to reinforce the Regional Office's support to Member States in their efforts to collate data relating to populations served with supplies of safe drinking-water, populations served with an appropriate network of water disposal and health-related aspects of drinking-water quality. There is also a request in the same resolution that the Regional Committee be kept regularly informed of the progress made. This cannot be done without the development of an effective means of obtaining information from individual countries in a standard form, making use of the national organizations or institutions best equipped to provide as accurate and comprehensive data as possible. Needs and purpose of monitoring system One purpose of monitoring is to enable the Regional Office to report back to the Regional Committee on Decade progress . This is important, but it is an internal management requirement of the Organization . The more important function of the monitoring system is support to Member States in their efforts to attain the goals of adequate and safe water supply and appropriate sanitation for all. There is little purpose in establishing goals within a time scale if a system does not exist for mon itoring progress or the lack of it. However, the establishment of an information system for water supply and sanitation services should not be regarded as purely or primarily a Decade information system. It is an information system for the authorities responsible for water supply and sanitation services that will: establish a common statistical base for all countries of the European Region; provide an opportunity for an interchange of information among count r ies; promote dialogue and hence facilitate cooperative research and avoid duplication of effort . The proposed information system, although stimulated by the requirement to monitor progress towards the achievemen t of the Decade goals, will be a sanitation information system that will, once established, continue as a permanent feature of the water industry. It should also be a dynamic system that will respond to the needs for improvement indicated during implementation and changing data requirements as services develop. Const r aints to be surmounted Following the United Nations Water Conference in Mar del Plata in 1977, WHO undertook what was called a "rapid assessment exercise". This was designed to determine, as quickly as possible, the levels of water supply and sanitation services in each Member State so that an overview of the status of services could be obtained before the commencement of the Decade on 1 January 1981. By nature, this exercise, although relatively simple, demonstrated the difficulties of obtain i ng statistics for water and sanitation services in the first instance and of obtaining info rmation tha t was comparable among countries in the second. - 146 - Among these practical difficulties were: first and foremost, many countries did not collect water and/or sanitation statistics; often where data were collected, it was by individual water supply or waste disposal undertakings and did not co rrespond to the need for national statistics and there was no mechanism for their central collec t ion; often at the national level, different ministries and agencies have responsibility for different sub-sectors within the sector, and in particular, it is common fo r sanitation to be the responsibility of a different agency than water; a further difficulty is that community services are ofte n left to the responsibility of municipalities rendering data collection impossible, while in rural areas there is no responsible enti t y; the ministries of health, which are WHO 's counterpart at the national level, are not the ministries responsible for water supply and sanitation services, although they usually have a surveillance and hygienic quality control mandate. When the i nformation was received back from countries during the "rapid assessment exercise" and began to be analysed, the added difficulty of non-comparability became apparent. A simple example is that some countries reported the percentage of the population served, while others used the unit of members of a household connected . Other problems were more fundamental and concerned the differences in what was classified as "rural" or "urban", and the lack of definition of what was "safe and adequateu or appropriate. Protocol app r oach It is clear that one, or perhaps the only, way of overcoming some of these difficulties is for a system of information collection and service monitoring to be developed direct ly in co llaborat ion with the authorities responsible for water supply and sanitation services in each country . The Working Group was therefore convened to prepare a protocol for doing this, with the collaboration of the International Water Supply Association (IWSA), a nongovernmental organization in special relations with WHO. The protocol contains several key elements: a questionnaire complete with explanatory notes and guidelines; an outline appr oach for the application of the questionnaire, including a proposed list of participating national institutes; a timetable for implementation, including data collection, analyses and preparation of results; a suggestion for the frequency of monitoring and reporting . Questionnaire The major part of the meeting was prepared as the main working document . circulation and completion by national identified in collaboration with IWSA. devoted to a detailed review of the draft questionnaire A consolidated questionnaire was developed, intended for water a nd sanitation information focal points, to be The questionnaire was produced in its final form to avoid unnecessary complications. This does not preclude its being amended and improved on the basis of operational experience. National information focal points The IWSA nat ional committee in each country is the backbone of the network of national information focal points. There are some countries, however, where IWSA does not have a national committee or perhaps even an individual member, and in these cases the questionnaire will be distributed to the miniseries of health by WHO with a request that they be passed on to the appropriate agencies responsib le for water supp l y and sanitation services. - 147 - The Working Group did not feel that it was an appropriate forum for the preparation of a list of focal points but that this was best done by IWSA in consultation with WHO. Frequency of monitoring After some discussion about the best frequency of monitoring Decade progress, it was concluded that every 18 months as originally suggested was not appropriate and that a round number of years should be aimed for. Finally, a two-year period was agreed on, starting in mid-1983 with the questionnaire being circulated in English and French. Conclusions and recommendations 1. The Working Group stressed the importance of establishing a water supply and sanitation service infonnation system in European countries in a unified form. 2. The Working Group reviewed the WHO headquarters publication National and global monitoring of water supply and sanitationa and agreed that this was the correct approach for gathering information for the monitoring of Decade progress on a worldwide basis . The Working Group appreciated, however, that the national and global monitoring system was primarily aimed at developing countries and that a modified approach was required for the European Region. 3. A European-instigated Decade monitoring sysL~m must be totally nationally based and implemented, since in almost all countries there are no United Nations or WHO personnel; it should be an information system principally, with Decade monitoring as just one element. 4. The European gathered national and global monitoring system should be incorporated, as appropriate, into information protocol so that the results obtained are complementary to those being in the other regions for Decade monitoring purposes . the 5. The protocol introduced in Europe should be designed so that it can be modified and developed in future. 6 . To be successful and to ensure that the information obtained is as accurate as possible, the protocol must be implemented in cooperation and collaboration with the national authorities in each country responsible for water supply and sanitation services . 7 . The most appropriate and effective means for WHO to implement such a protocol will be in collaboration with IWSA, the nongovernmental organization that represents the water supply industry worldwide, in accordance with the collaborative agreement signed in March 1983 . 8. Since the Decade has been operative for over two years, it was considered of vital importance that the protocol be finalized and put into operation as quickly as possible . a National and global monitorin of water su 1 and sanitation. Geneva, World Health Organiza t ion, 1982 International Drinking Water Supply and Sanitation Decade, Publication No . 2). International Drinking Water Supply and Sanitation Decad~ Exploratory Consultation Rabat, 19-20 April 1983 Introduction MOR/BSM 004(5) 14821 25 May 1983 ORIGINAL : ENGLISH To attract external financing for water supply and sanitation projects to be implemented within the framework of the International Drinking Water Supply and Sanitation Decade (IDWSSD), the Government of Morocco, assisted by the WHO Regional Office fo r Europe, invited bilateral and multilateral donors and international lending agencies to attend an exploratory consultation, the purpose of which was to identify what external financing resources were actually available to support I!J.,'SSD projec ts in Morocco. The meeting was held in Arabic, English and French, with simultaneous intepretation . The opening ceremony was chaired by the Prime Minister and attended by 10 other Moroccan ministers together with most of the diplomatic corps. Representatives from 20 countries attended the meeting. Also participating were 8 bilateral donor agencies, 8 multilateral donor agencies , and 11 United Nations bodies . The Consultation made use of six technical background documents prepared by the Government of Morocco with WHO assistance, summarizing the Moroccan plans and objectives for the IDWSSD and describing proposed water supply and sanitation projects des igned to achieve the IDWSSD objectives. Findings The Government of Morocco and its technical agencies involved in the water supply and sanitation sector gave full information on their plans and projects for the Decade . Morocco, being classified as a middle-income country, is mostly qualified for loans rather than for grants from international donors . However, the rural sector remains qualified for grants. The Moroccan objectives for the IDWWSD were stated in the Prime Minister ' s speech as follows; to reach in 1990, the connection of 80% of the urban population to a public water supply network, instead of the 44% connected in 1980; and to reach in 1990, the connection of 50% of the rural population to a public water s upply network, instead of the 7% connected in 1980. Morocco is also facing an acute problem of shortage of water resources in the arid and sub-arid areas of its territory, where half of its population lives. It appears that urban water supply projects may be financed by loans, the amount of the loans being, to a large extent, limited by the reimbursement capacity of the water supply agencies, the reimbursement capacity itself being linked to the rates of payment for water consumption. Therefore, the participants pointed out the need to increase the payment rates for water, in order to improve the loan amortization capacity of water supply agencies . The problem of urban fringes could be solved through equalization with the urban sector pr oper. It was also considered that urban sewerage projects could be financed through loans if the necessary institutional arrangements were decided on, ensuring financial autonomy to the sewerage sub-sector, at least in large cities . The solution to be found for the city of Casablanca would be a pilot experience for this institutional development. - 149 - It appears that there is a shortage of grants to finance the rural water supply sector, and the participants, therefore, made a pl ea to encourage generosity from the international community towards the rural water supply sub-sector . However, institutional development is also needed, in order to build efficient rural water supply agencies capable of ensuring adequate follow-up maintenance and management. This is why the participants also stressed the need for institutional strengthening of the rural sector, in order to ensure proper maintenance and management of relevant public utilities. The following donors offered to increase their assistance to Morocco in the water supply and sanitation sector: the African Development Bank, the German Bank for Reconstruction and Development, the Federal Republic of Germany, the Islamic Development Bank, Italy, Japan, the Kuwait Fund for Arab Economic Development, the Netherlands, the Fund of the Organization of Petroleum Exporting Countries, the Sultanate of Oman, Switzerland, and the World Food Programme. The following donors offered to increase the share of the water supply and sanitation sector within their global assistance to Morocco: the Arab Fund for Economic and Social Development, Canada, the Commission of the European Communities, France (Central Bank for Economic Development), the Saudi Fund for Development, the World Bank, UNDP, UNICEF, UNIDO and WHO. Conclusions and recon:unendations The participants acknowledg - 1 that Morocco is recognized as a pilo t country for the IDWSSD. The participants congratulated the Government of Morocco on its efforts directed towards rural populations, and recommended that the priority given to rural water supply again be increased . The participants acknowledged the willingness of bilateral and multilateral agencies to increase their loans to the urban water supply sector, and recommended an increase in water rates in order that the wealthy urban population contribute to subsidizing the water service for the urban fringes . The participants recommended that the Moroccan experience and achievements be used for the benetit of IDWSSD development in other developing countries. The participants recommended an accurate follow-up of the meeting's conclusions and recommendations, to be ensured both by Moroccan water supply and sanitation agencies and by bilateral and mult ilateral donors, with WHO and/or UNDP assistance when needed. Finally, the participants concluded that Moroccan IDWSSD objectives can be achieved only through closer collaboration between Moroccan technical and financial agencies on the one hand, and friendl y foreign governments, international lending agencies, United Nations agencies, and bilateral and multilateral donors on the other. - 151 - LIFESTYLES Workshop on Smoking and Health Suzdal, USSR, 13-17 September 1983 Background - 153 - ICP/HED 022(6)(S) 3418F 28 February 1984 ORIGINAL: ENGLISH The WHO Regional Office for Europe has for some time supported the development of comprehensive smoking control activities in Member States. Recently, it has recognized the need to develop a coordinated European smoking control policy. To achieve this, it is necessary first of all to gain knowledge of the prevalence of smoking and the status of smoking control activities in Europe . This has already been achieved for some western European countries, but WHO has, so far, had little first-hand knowledge of the situation in socialist countries. Accordingly, the WHO Regional Office for Europe, in collaboration with the Government of the Union of Soviet Socialist Republics, decided to hold a Workshop on Smoking and Health. The Central Institute for Scientific Research in Health Education, under the Ministry of Health of the USSR served as co- organizer of the Workshop. Scope and purpose The scope and purpose of this Workshop were to: provide WHO with a better knowledge of the prevalence of smoking in socialist countries; provide WHO with a description of the present status of anti-smoking activities in socialist countries; give the socialist countries an opportunity to exchange ideas and develop a strategy for further action; put invited experts from selected western European countries into a setting that enabled them to take part in a broad exchange of ideas on experiences between different states and subregions of Europe; provide WHO with a network of contacts in socialist countries which may be of great value for future activities within the smoking and health progrannne and a survey currently being carried out. The Workshop The Workshop delegates represented most of the socialist countries of Europe and some western European countries. In addition there were some observers from the USSR . The Workshop began with three presentations on general matters: smoking epidemiology general principles for smoking action national smoking control activities with specific reference to the USSR . - 154 - The main part of the Workshop consisted of national reports from each country represented by the participants, describing aspects of prevalence and smoking control policy . Discussion of the points raised in the papers produced broad agreement, despite the great variety of political and economic systems represented. There appeared to be greater variation, for example, between some western countries than between some western and socialist states. In general terms, the factors affecting smoking control were found to be broadly similar throughout the Region . Recommendations 1. In view of the serious effects of smoking on health, smoking control programmes should become a major component of the regional strategy for attaining health for all by the year 2000. 2 . Effective progrannnes should be as broadly based as possible, involving education, legislation, and fiscal and curative measures. Education was seen as the first priority since legislation and fiscal measures a r e unlikely to be enacted until high levels of public awareness have been attained. 3. Effective planning was seen as a prerequisite for success, and should involve both governmental and nongovernmental agencies . It was recognized that the execution of a planned programme was more likely to be successful in Member States with a state planned system of health care. 4. There was considerable discussion concerning priority groups. Some delegates believed that children should be seen as the key group, while others felt that children's smoking could not be controlled in isolation. 5 . It was agreed, however, that groups that set an example, such as health professionals, teachers and youth leaders, were of prime importance in drawing up an effective programme. At the same time, attention should be paid to educating decision-makers, especially government and other high authorities. 6. Programmes aimed at children need to include a variety of approaches, such as practice in resisting the social pressures to smoke, as well as health information . In addition, children's programmes should be conducted Ln the context of smoking in the family, in view of the role of parents to set an example. 7. Women's smoking is now a cause of considerable concern in a number of Member States. Greater emphasis on this issue is needed, in some parts of the Region at least . 8. Finally, with regard to educational programmes, the Workshop agreed that smoking education should be conducted along thoroughly scientific lines. Measurements of the effectiveness of health education were seen as essential, broken down by population group. The adoption of internationally standardized instruments was also recommended, along with the development of broader criteria of effectiveness (in addition to the standard measures of prevalence and consumption). 9 . Apart from education, various kinds of regulatory action are desirable. The substitution of other crops for tobacco, and the development of alternative uses for tobacco, were both seen as highly desirable. 10. Price increases have undoubtedly proved valuable in reducing consumption in some countries. They may well have an important role if carried out in conjunction with a sustained and vigorous educational programme. 11. Delegates also noted the need to provide support for those who want to stop smoking. It was agreed that, in spite of the fact that specialist clinics are too expensive for mass use, some of them are needed as research centres that are able to develop therapeutic techniques that can be adopted on a large scale, e.g. by physicians in primary and occupational health care. Conclusions In view of the extreme seriousness of the problem, delegates called on WHO to appeal to Member States to initiate the drawing up of national programmes of smoking control, and to develop a scientifically based model for anti-smoking education . Careful tests of smoking control methods were required on a regional or subregional basis. Delegates emphasized the need for standardized terminology and procedures when reporting results of tobacco smoking surveys, to facilitate data collection. The exchange of specialists between WHO - 155 - collaborating centres should be improved and regular workshops on smoking and health should be held to facilitate the development of action in every Member State, as there is great variation in the degree of large-scale implementation of smoking control activities. Finally, delegates believed that the whole-hearted implementation of these recommendations was essential throughout the Region if a major impact was to be made on this very serious threat to public health. They were optimistic, however, about the prospects for success, in the light of major falls in prevalence and consumption recorded in certain parts of the Region. - 156 - Workshop on Youth Lifestyles, Risk Behaviour and Health ICP/HED 021( 3)(5) 3503F Spitzingsee, 26-28 October 1983 17 January 1984 ORIGINAL: GERMAN The Workshop was the third of a series of meetings on the principles and practical applications of the concept of "lifestyles" in the field of health promotion and youth . The principal aim of the meeting was to study modifications in the lifestyles of young people in relation to changing historical and social conditions and their implications for the programme of health promotion geared to this group. As this aim called for dialogue and exchange of the findings of research on young people and experiences in the field of health education and health promotion, experts and officials in these fields, from 18 Member States of the Region, were invited attend the meeting. 1. Background For a number of years, a new approach has been emerging with regard to sociology and research on youth and to health education and health promotion. This orientation is not so much inherently scientific as a consequence of the recognition, in both disciplines, that the concepts and perspectives of the 1960s and 1970s are no longer applicable to the present social realities. This recognition is leading to a reconsideration of the historical and social context of the problem and ways of tackling it. The awareness is also leading to a search for a new paradigm that will encompass the new, complex conditions and requirements. Within the area of youth research, this process is clearly reflected in a critique of the conventional socialization or behaviour theory approaches and in an attempt to define the place of young people in the context of culturally and subculturally determined "lifestyles" as well as cormnunity, regional and sex-specific "social situations". In the area of health promotion, attempts are also being made to develop approaches in connection with the "lifestyles" paradigm that view "health" (according to the broad definition given by WHO) as a product of the influence of a series of factors relating to individual behaviour , social conditions and socioeconomic/sociological relationships and take into account the importance of lifestyles for healthy behaviours and wellbeing. This situation does not only provide a framework for valuable dialogue between the disc iplines of health promotion and youth research; it also underscores the view that youth problems and risk behaviour are a general reflection of the problems of social patterns and lifestyles. If that is so, health and youth research have a contribution to make , both individually and jointly, in explaining and exerting a positive influence on social conditions. The aim of the meeting was thus to develop approaches, within the framework of encounters and exchanges between the two disciplines, to: the definition and analysis of current historical and social trends that have raised the question of the opportunities and problems relating to the social situation of young people; the description and evaluation of regional, sex-specific and socioeconomic dif fe rences in social situations and forms of coping as well as the manifest or latent risk factors concerned; and the search for points of departure for the development of positive influences and/or support of positive factors in the social situation of young people in terms of a complex of mutua lly acceptable measures and activities. - 157 - 2. Discussion Following the introductory statements, the participants turned to the question of identification and analysis of the historical and social context and that of causes and expectations in relation to lifestyles and social situations. 2.1 Previous studies A brief report was given on the status of research on the "lifestyles concept" within the framework of the WHO programme of health promotion. This concept is not only, at the micro level, reorienting the traditional health education programme that focuses on individual risk factors (e.g. smoking, alcohol abuse, lack of exercise) towards a new socioepidemiological approach; it is also, at the macro level of organized social relationships, giving impetus to the development of a total view of health ("health scenarios"). A report was presented giving the main conclusions of a meeting on the related topic of "youth, everyday life and health; youth lifestyles in big cities" (Salzburg, 5-11 September 1982) as well as the status of research on youth and risk behaviour. 2 .2 Crisis in lifestyles and present status of youth research In the search for a "historical definition of the present problems of youth lifestyles", two points emerged. (1) In the present debate, there is clear evidence of the fragility of the image of 16-year olds. The image of 16- and 17-year olds, who used to be assured a social and professional future based on individual education, training and achievement, is now coming up against the problem of a growing disparity between educational achievement and professional opportunities, life-plans and self-realization. In this situation of uncertainty, many young people are questioning the conventional life-plans, in which earning one's living plays a central role. The growing "risk behaviour" of young people is increasing by a reflection of the search for a new lifestyle and orientation. (2) On the other hand, it is also necessary to examine the traditional concepts and approaches of youth education and research. Today youth represents more than a problem of education. To talk about youth is to be engaged in a forum of discussion, and above all to examine those goals of our social future that give rise to anxiety or awaken hope. A review of the present trends in youth research showed clearly that the theoretical and empirical aspects of such research are still very closely tied up with the new orientation that is required. The traditional orientations lie somewhere between the concept of the youth problem as a generation gap on the one hand and as a merely socially-determined phase of life on the other; these orientations generally open up new approaches to research which recognize the importance for the social situation of young people of factors such as; youth and work, youth and education, youth in relation to the family and the community, the alternative youth culture and youth in relation to the future of society. 2.3 Experiences in health education and health promotion The history of health education in recent years can be seen as a debate backed by practical experience and critical arguments that show the ineffectiveness of traditional approaches. Since then a range of new concepts and practical models have emerged, on the basis of which the value of a "lifestyle concept" in relation to youth can be critically evaluated. One common feature of these new approaches is that they no longer focus on individual behaviours or personality traits, but on the totality of community and individual life experience in the relevant economic/political, ecological and cultural context with the greatest possible involvement of those concerned. Last but not least, the applicability of the "lifestyle concept" to this new orientation was examined in the light of the practical experiences of ten pilot projects that had been presented at the previous meeting in Heidelberg. From an example of "promotion of healthy living for young people in the German Democratic Republic", it was evident that youth lifestyles are shaped by the relevant practical conditions in society. Conversely, the practical relationships of society provide the framework and preconditions for health promotion strategies. In terms of its being a complex approach - 158 - encompassing all aspects of life, health promotion above all requires "methods and forms of active involvement of young people in community measures designed to foster healthy living and health education11 • 3. Working groups The general observations concerning the present problems of youth lifestyles were further examined in the requisite detail by working groups from the standpoint of the practical and theoretical experiences of the participants, and they were defined in concrete terms in the light of the feasibility of exerting a positive influence. The "scenario method" was presented as a useful means of describing social situations in relation to the relevant trends in social development. The groups were composed of members of different nationalities and dealt with the following themes: youth and work (employed/unemployed) youth in education and training young migrants girls and women. 4 . Conclusions 4.1 The relationship between youth and school (educational system) can be analysed at two levels. On the one hand, in its capacity as a place of learning, the school is part of the life context of children and young people and thereby makes positive but also negative contributions to their wellbeing. On the other hand, as an organized learning situation, it is also a place where health education is provided. As the two levels cannot be separated, any improvement of health education in the school always involves an effort to optimize the "school" social system. It should be possible to achieve this result by ensuring that the following changes take place: the school must be aware that it has (and be ready to exercise, both internally and externally) a moral responsibility for the health of children and young people (in terms of WHO's broad definition of health); the school must create or re-create the necessary conditions for all measures aimed at improving health; the school must have freedom of action, the possibility to experiment, access to the community, and cooperation with other places of learning; and steps must be taken to improve teacher tra1n1ng and to design and develop a system of support for teachers as these are of strategic importance for improving schools and school health education. 4.2 Currently, the social situation of young migrant workers is characterized above all by three mutually exacerbating negative factors: social isolation in the host country, the fact of belonging to a low social category, and an unfavourable economic context (recession). These factors increase the overall difficulties affecting the lives of the young migrants who must endeavour to develop their own identity while belonging to two different cultures. These factors also make the host country less will ing to support and encourage the integration of this group. The consequences are insecurity, aggression and family conflicts. In this situation, it is now necessary to reduce the social and psychological tensions through compromises at several levels by different means including: the development of bilingual education for young people, in order to offer the opportunity either of integration or of a return to the country of origin; the promotion of forms of administrative autonomy, participation and cooperation in every possible area of everyday life and in the local context. 4 . 3 Work is a necessary but in no way sufficient condition for a healthy lifestyle, It is above all in terms of the significance peopl e attach to work that there is a plurality of values and lifes tyles. For that reason, the relevant national policies must develop a complete range of activities and measures. Instructors, labour unions, self-help groups, etc. have a particularly important role to play in shaping attitudes to work and therefore merit special attention when - 159 - designing health education programmes. Because of the variety of work situations and the significance attached to work, successful health education measures must be planned in relation to work openly and with the involvement of the young people themselves. The "health workshop" could serve as a suitable model for this purpose. 4.4 The specific women's lifestyle that is "created" through the socialization process and as a result of economic, legal and cultural factors has many aspects that are positive but may sometimes be used to justify discrimination. This situation leads at the same time to the specific contradiction of self-awareness and self-knowledge of girls and women on the one hand, and consequences of problems of self-esteem, denial of biophysical feminity, and attitudes to male partners, etc . , on the other. Health promotion directed to girls and women must take this ambivalence in the female lifestyle into account. The necessary conditions for comprehensive health promotion in this group are thus: encouragement of personal development, i.e. of self-awareness, self-confidence, a sense of individual responsibility, and self-esteem; development of mental and physical awareness of the body, and of one's own sexuality; and development of a new image of women, implying the same rights for all and the fostering of women's vutential in the family, at work and in society . 5. The various topics raised should be further examined in the proposed meeting on the problems of health education in the countries of southern Europe. - 161 - MENTAL HEALTH Working Group on First Contact Mental Health Care Tampere, 25-29 April 1983 Introduction - 163 - ICP/MNH 059(l)(S) 2121F l July 1983 ORIGINAL: ENGLISH The Working Group was convened as part of WHO's medium-term programme for developments in mental health care, particularly in relation to primary health care. The Working Group was composed of 14 temporary advisers from 12 Member States. There were in addition 5 observers from the host country and 3 representatives from nongovernmental organizations and WHO collaborating centres. The report of a WHO working group that met in Lysebu, Oslo in 1973a focused on psychiatry in general practice, and the role of the general practitioner in mental health services. The present Working Group was concerned primarily with the roles and functions of mental health teams operating in the context of primary health care with emphasis on the ways in which specialists in mental health could give support to primary health care workers, and work directly at community levels with self-help groups and other voluntary agencies who were already contributing to mental health. The Working Group was convened and undertook its task in the spirit of the Alma-Ata Declaration on primary health care which commits the WHO Member States to work towards the provision and evaluation of services that will meet the need for primary health care, including the promotion of mental health. Discussion Because of the wide-ranging scope and purpose of the Working Group and the large number of introductory presentations, working papers and background documents, many topics were raised by the Working Group . They can be grouped under four main headings. General policy and organization The principal aim must be to provide access to mental health care for as many people as possible by making clear all the potential contact points with the primary health care system. First contact mental health care can be provided at four different levels: by specialist mental health services including inpatient facilities in the hospital units; by specialist centres provided in the community such as day-centres and outpatient departments; by general practices or health centres in the form of primary health care; and by self-help and voluntary bodies in the community. It is deemed important at each level to provide the minimum degree of intervention that will allow individuals and their families to maintain their self-regard and independence. The nature of the first contact Various basic questions are raised: first contact with whom and by whom, where is it to be undertaken and what is its purpose? Recognizing the importance of this first contact between the services available and those seeking help, great sensitivity is required to structure and handle the potential interpersonal relationship so that there is the most favourable outcome. The role of the specialized mental health service is therefore to guide and support primary health care givers in their work at this first point of contact . - 164 - Membership and functions of mental health and primary care teams The terms of reference or job description of each of the participating professionals and volunteers defines the potential membership of each team. It will have a core group of colleagues working regularly together, and an extended group of others who will join in the work of the core group from time to time as circumstances and occasion demand. It is vital that the equality of status of all those working in these mental health care teams is fully recognized and practised. Each team should work out its own procedures for consultation among its members, and for the referral of problems and specialized tasks to each other. When many people are involved in this work at the various levels described, conununication systems require careful definition and discipline if there is not to be confusion, frustration and wasteful overlap. Training and research To enable people to work in this way, training should be extended into the conununity, using established methods that are traditionally based on the psychiatric hospital or district ge neral hospital psychiatric unit . Such training schemes should allow potential members of f uture mental health care teams to receive their tra i ning and education together as a team. The educational aims should be directed not only towards the acquisition of required technical knowledge, but also towards shaping the attitudes of the students, developing their sensitivity and providing basic management skills s uch as the establishment of priorities and the identification and utilization of resources. University departments and academic institutes have a vital part to play, but they too must become conununity-orientated and participate in training schemes located directly in the primary care set ting . Research should focus not only on epidemiological studies as such, establishing prevalence rates of disorder, etc., but should also determine indicators of change in health parameters, which can then be used in evaluating the provision and utilization of services . Conclusions and recommendations Certain basic principles emerged from the discussions: (1) that the promotion of mental health is a vital component of primary health care; (2) that the decentralization of mental health services is essential to bring them into the community where people live and work; (3) that at all times an attempt must be made to supply the minimum level of care required, according to the needs and existing resources of individuals and their communities, so as to give them back their self-regard and the c apacity to be responsible for themselves and their own futures; and (4) that mental health care skills and resources should be closely integrated into primary health care and social welfare systems, for the purposes of education, support and consultation. Conclusions l. The proper creative handling of the first contact is vital to the quality of the subsequent care of families and communities. 2. General practitioners, clinical psychologists and social workers, not at present sufficiently represented in the higher echelons of policy-making, should be encouraged to seek representation for their disciplines on government bodies so that their particular skills and perspectives can be invested in further planning of mental health services and primary health care. 3. Working together in the democracy of the primary health care team does not mean abandoning the practice of individual professional skills or the responsibilities of leadership , although at times there will be a considerable degree of sharing of skills and of the responsibility of leadership , as occasion and circumstances demand. a Psychiatry and primary medical care: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1973 (unpublished document EURO 54271). - 165 - 4. Infonnation system• contribute to and enhance the continuity of care. The principle of continuity of care does not necessarily operate in oppoaition to the principle of conaultation and referral to other more qualified or experienced member• of the teams. 5. Internationally recognized and validated inatruments of ascertainment and measurement ahould be uaed in research and evaluation atudies, to facilitate comparison• between different countries and national centres. 6. Evaluation ia a vital component of the aetting up of all new services and training progral'IDlles. It ia important to integrate qualitative evaluations into quantitative measurements to ensure that problems and difficulties are clearly defined for both helpers and the helped. Incorporation of the principle• of health economics should go some way towards enauring the cost­ effective uae of limited facilitiea and scarce personnel. 7. As specialist• in mental health broaden their intereat from the diagnoaia and treatment of disease to the organization and management of health care, their interest shifts from etiological/epidemiological research to health aervicea or health care research. A clear need is therefore emerging for the development of the mental health component of health service• research and for the training of mental health profeasionala in health services research. Recolllftendations l. A working group should be set up to study the organization and proviaion of psychiatric emergency services given their importance as points of firat contact with mental health care. 2. Intercountry training should be developed in mental health practice in the primary health care setting, based initially on deaignated WHO collaborating centres. 3. A multidisciplinary study group should be set up to examine the consultative relationship between mental health care and primary health care systems, in order to detennine what is current practice in different Member States. 4. National authorities with responaibilities for health planning should consider the effect of the population size in particular localities on the shape and form of services and the effect of this on the planning and use of mental health resources. 5. Voluntary bodies such as mental health and psychiatric patient associations in lay-care and community health programmes should examine the ways in which users of mental health services are able to find out what ia available, and what values they attach to theae services. Consideration should be given in this context to the contribution of the mass media to health education programmes. 6. To promote active mental health care in primary health care settings, links are recommended in national and international activities wherever there are areas of joint intereat and concern. Such links are already identifiable between mental health and health care of the elderly, health economics, drug utilization programmes, health information system,, and countrywide programea of preventive practice, in chronic diseaaes. European Symposium on Control of Alcohol Consumption Paris 1 7-10 June 1983 1. Introduction - 167 - ICP/MNH 027(1)(S) 2224F 22 July 1983 ORIGINAL: ENGLISH The Symposium provided an opportunity for the synthesis of a number of recent act1v1t1es carried out by the WHO Regional Office for Europe or in collaboration with WHO . It formulated proposals for future action and implementation at national and international levels . It was attended by SO participants from 21 countries and various intergovernmental and nongovernmental international organizations: economists, social scientists, public health administrators, psychiatrists and educationalists. The assistance of UNESCO in the organization of the Symposium was gratefully ; · knowledged . The prominence given to the formulation of comprehensive national alcohol policies in resolution WHA36.12 of the Thirty-sixth World Health Assembly in May 1983 served as a special focus for this Symposium. 2. Topics 2.1 Balance between economic interests and public health interests The most significant trend during the postwar period has been the general increase in the aggregate consumption of alcohol . Although the current economic problems faced by most countries are slowing down the rate of increase in aggregate consumption, the range and severity of alcohol-related problems in all countries are likely to remain at unacceptably high levels unless concerted and sustained action is taken both nationally and internationally . Of fundamental importance to the Symposium was the recognition from the outset of the basic conflict between economic interests and public health interests. It was emphasized repeatedly that alcohol is a special commodity, both because of its potential for adverse social and health consequences and because of its addictive nature. The major task of any country's comprehensive national alcohol policy has to be to achieve a fair balance between economic interests and public health interests. 2.2 Changes in patterns of problems Increases in aggregate consumption are associated with a growth in whichever problems are most common to each particular culture. In some countries, increases in problems resulting from excessive drinking have to be seen in the context of the increased use of other psychoactive drugs. In every country of the Region, it is adult males who demonstrate the largest number of alcohol-related problems. Nevertheless, some subgroups within the population, such as women and young people, are currently the subject of special concern in a number of countries. Regional differences within countries are sometimes underemphasized in national statistics. The question of unemployment requires careful consideration, although current research seems to suggest that, because of increased social passivity and reduced spending power, the unemployed actually demonstrate fewer alcohol-related problems . It is possible, however, that drinking by the unemployed may come to be seen as a different kind of social control problem from the drinking of the rest of the community. The influence of mass tourism upon drinking habits is another area of particular concern. A trend towards greater harmonization of drinking habits within the European Region has been associated with a process of addition rather than substitution of habits. - 168 - It was recognized that the special problems of migrant workers in relation to alcohol consumption had not ye t been adequately studied; nor had the impact of population movements away from rural areas. 2,3 Trade in alcoholic beverages Detailed consideration of the international trade in alcoholic beverages reveals a pattern of continuing growth, especially in beer and spirits. Wine remains, however, of particular importance because of questions relating to the disposal of the substantial surpluses caused by overproduction in the European Region. For many European countries, trade in alcoholic beverages represents an important percentage of gross national product. As consumption in some of these countries levels off, s o exports become increasingly important . The most s pectacular rises in consumption are now taking place i n countries in the developing world, toward s which are directed not only the actual beverages, but also the technology necessary to create local alcohol industries. These changes in production and distribution structures present a new challenge to the development of international controls, especially since the social and health implications of increasing consumption may be poorly understood in some of these countries. 3. Conclusions and recommendations 3.1 Comprehensive and comparable data In order to come to more definite conclusions about all these trends, real improvements in the collection of data are required. Countries that are not accustomed to gathering statistics on alcohol consumption and alcohol-related problems may need special help from appropriate international organizations. Despite repeated resolutions of the World Health Assembly, greater comparability still has to be achieved and better time-series analysis has to be encouraged to establish trends in alcohol problems. In view of the importance of an economic perspective, quantifications of health and social costs associated with alcohol consumption may require special attention. 3,2 Taxation Fiscal measures were seen to have considerable potential from a public health perspective, although it was emphasized that there existed considerable differences among countries in the scope they offered for the use of taxation to modify consumption. Existing proposals to harmonize levels of taxation within Europe could lead to a reduction in tax in some countries, with likely consequent rises in consumption . Equally, however, very high taxation levels could have unintended negative effects. One specific issue, perhaps symbolic but certainly important, is that of tax-free alcohol sales to travellers. A high proportion of such sales takes place during travel between countries in the European Region, and the practice represents an irrational example of increased public health risks. Since, however, on this issue no country can act alone, coordinated international action is required . 3,3 Advertising Although the results of research into the effects of alcohol advertising upon aggregate consumption levels remain equivocal, it is clear that advertisements all carry cultural messages that are of symbolic importance in their own right. The diffusion of electronic media across national boundaries, e . g. by means of satellite broadcasting, requires international action to restrict advertising that is contrary to public health interests. Advertising restrictions by themselves are relatively futile unless they are in harmony with other control mechanisms adopted at national and international levels . 3.4 Health promotion Health promotion can provide important support for systems of control and may even be a prerequisite for them. Its relationship to control strategies will , however , remain problematic unless its goals are consistent with these strategies and unless it is fully integrated with them . Promising approaches to health promotion should be appropriately evaluated, and information reviewing the best practices should be gathered and disseminated at international level . 3,5 Organization of services Concern was expressed that the increasing financial strains that are likely to be felt in the future in many countries could lead to competition for scarce resources within the welfare sector generally. Better integration between health services, social services and educational services is an important prerequisite of more effective responses. - 169 - 3.6 National policies Previous relevant experience gained in the development of comprehensive national alcohol policies should be assembled with a view to providing guidelines for those countries that wish to take action. It is important to recognize that some countries may choose not to act, while for those that are prepared to move in the direction of policies significant difficulties will arise. The delicate act of balancing economic interests and public health interests is perhaps the central obstacle, but it is not the only one. Cooperation between many different interest groups, within and beyond the government, will be necessary. The provision of examples from the past and guidelines for the future will be of considerable value to countries in their efforts to develop such policies. 3.7 Role of WHO Comprehensive national policies will sta nd or fall by the degree of international commitment to them that is forthcoming in terms of relevant advice and support. Within the European Region, the preparation of guidelines for national policies, the continuing improvement of relevant statistical information and the strengthening of links between the alcohol programme and other WHO programmes, especially health education, are all crucial . At the regional and global level, the role of WHO in supporting countries in their task of developing policies is important, not because WHO will necessarily always be the most relevant operational agency, but becausr WHO can give a lead through the coordination of international effort . If WHO does not take this lead, the world can look forward to further increases in alcohol consumption and to the avalanche of human misery that will follow. Health for all by the year 2000 will become a very hollow toast as glasses of alcoholic beverages touch all around the world. Working Group on Mental Health Care of the Elderly Cork, 3-7 Octobe r 1983 Introduction - 170 - ICP/MNH 063(l)(S) 2887F 19 December 1983 ORIGINAL: ENGLISH The Working Group was convened as part of the WHO medium-term programme on mental health to consider the mental health needs of the elderly in the European Region. The Group was composed of 20 temporary advise rs from 10 countries, including 7 from the host country, and 4 representatives of nongovernmental organizations. The WHO collaborating centre for research and training in mental health at the Central Institute of Mental Health in Mannheim, Federal Republic of Germany, and the WHO collaborating centre for psychosocial factors and health in Belgium were also represented. The disciplines represented were geriatrics, gerontology, health administration, nursing, psychiatry and voluntary work. The purpose of the meeting was to advise on the development of comprehensive community-based mental health services for old people and to prepare guidelines for the prevention and reduction of mental disabilities in the elderly. A working paper presented an overview of the organization of such services, and the participants outlined in a general way the organization of services in their countries. All acknowledged the growing problems of very old people with mental disorders and the increased prevalence of mental disorder in the very old. Development of services There is now clear and widespread epidemiological evidence of the rising numbers of old people with mental health problems, particularly dementia. The problems of services for the elderly who are mentally ill must always be seen in the context of services for the elderly in general, with which they must be closely integrated. The primary care and psychiatric services have a special role to play. It is clear that the extent and perception of the problem varies from country to country and that no clear blueprint can serve the different organizations and resources of different countries. There is an urgent need for each country to prepare a coherent national strategy for the development of mental health care services for the elderly. This should take account of the following key items. A statement of present and f uture need based on demographic and epidemiological information, An analysis of the likely needs of the elderly and the capacity of existing services to cope with the demand. A proposal for how a comprehensive range of services may be jointly planned and operated. Comprehensive services should provide for prevention, early detection, assessment, treatment and care in various ways. They will contain many elements from the health, social , housing, voluntary and other services. Recommendations for how educational and research strategies may be developed to promote good practices and seek innovations in service delivery. Information services A wide range of information is required to ensure the economical deployment of scarce resources. It could be collected under four principal headings, - 171 - Scientific research. Studies on the prevalence of mental illness have already been successfully undertaken in a number of countries and their findings broadly agreed. In the case of dementia, however, there is little information available on incidence or on the outcome of recognized cases and especially of the large number of so-called mild cases . Longitudinal studies will be needed to elicit this information, and they will require the use of standardized instruments for screening and the reliable recording of mental state and other data, Health services, Much has still to be learned about the outcome of illness in the elderly and the movement of patients between different facilities. Further data will also be required on manpower and other resources and economic data for cost-benefit studies of experimental services. Special emphasis should be placed on different methodologies in these and other studies on the quality control of services, including the satisfaction of the consumers and their relatives. The traditional statistical information on bed use and patient flow should continue to be provided . Co111Dunications . It will be necessary to continue to define technical terms clearly. For international comparative studies, three areas need attention: the possibility of a glossary of general health terminology; a glossary of aging itself; and the continued development of the International classification of impairments, disabilities and handicaps. Education. The training of both professional and nonprofessional workers will require an evaluation of their needs and the preparation of suitable training programmes. In some countries little instruction is given on aging to doctors and nurses or to staff working with old people in other settings. This situation will need to be improved. The types of information needed for the training of voluntary workers will also require consideration. Organization of local services It was an agreed general principle that elderly people should continue to live at home wherever this is reasonably possible and be provided with such primary care and specialized services as they require. Where life at home is no longer possible, short-term or longer-term residential care should be available locally. To achieve these aims, a planned comprehensive network of services should be deve loped to provide for prevention whenever possible, early identification of those at risk, and skilled assessment, treatment and care whenever needed. A number of key factors were identified to assist in drawing up such a local plan of action, such as the definition of the population to be served, an appreciation of present resources and deficiencies and the establishment of a local joint planning group, to include key personnel from psychiatry, geriatric medicine, primary medical care, nursing, remedial professions, social services, administration and the voluntary sector . The operation of a comprehensible and coordinated service calls for skilled planning, good working relationships and the maintenance of high morale. High standards of care must be set, taking account of what local advice is available on the provision of good practice. The achievement of these high standards must be vigorously pursued and maintained. Primary ca re The great majority of old people live at home, often alone, and psychiatric disorder plays a major role in their morbidity. All necessary statutory as well as voluntary services should be available at the primary care level to provide the domiciliary support they may need, This demands that between the primary care workers and those in the specialist services a joint working relationship must be carefully organized and managed to strengthen and enhance their interdependence. Most primary care services are based on the concept of a multiprofessional team working in the community. Here, the general practitioner is sometimes the most important professional contact, often the first point of contact, who generally deals with most problems. The local policy, however, should provide for specialist health or other staff to visit the old person's home when necessary. Self-help groups and other structured means of providing counsel and support are an important adjunct to the range of domiciliary care and provision outlined under the heading "Organization of local services". With this emphasis on domiciliary care for mentally ill elderly people, the needs of the family supporters and other carers must also be taken into account. - 172 - Education Educational and training programmes are essential for the wide range of people, both trained and untrained, who provide and work in services with the elderly with mental illness . By providing a framework for understanding and learning, they heighten personal commitment, confidence and ability. The feedback of information they provide promotes better services and facilitates their monitoring and evaluation. Meeting the mental health problems of the elderly calls for special knowledge, and some coun tries have developed specialized services for mental illness in old age in the context of existing mental health and general medical services. Most long-term care of the elderly is provided by relatives or by untrained staff. Their contributions and those of voluntary workers are enhanced where professional staff offer educational and training services as well as active intervention where necessary. Where there are insufficient trained people to provide direct care services for all who need them, their expertise should be used as a source of consultation and training for others. The spreading of knowledge through educat ion must not be confined to carers and professional workers. Education must also be aimed more widely to raise both public and political awareness and concern. In this way, society and its leaders will come to recognize the problems and the possibilities and consider its responsibility towards i ts older members . Prevention The primary prevention of mental illness in the elderly is at present limited, which suggests that research in thi s field is an urgent requirement. Secondary preventive practice - the treatment of previously undetected psychiatric disorder - is possible. Major surveys have shown a high prevalence of psychiatric disorder in the elderly . The screening and routine assessment of vulnerable groups by primary care services should result in early case finding and prompt treatment. The vulnerable groups include those aged over 75 years and living alone, those recently bereaved and those requiring domiciliary services. Tertiary prevention is very feasible and depends on the better management and treatment of known psychiatric disorders. Essential to this is early medical evaluation, a multidisciplinary approach and continuity of care. Recommendations 1. The mental health needs of the elderly must be incorporated into the development of the regional strategy for health for all by the year 2000 . 2. Health information systems at each level of health care provision should include data collection referable to mental health care of the elderly . 3. The Group endorsed the recommendations of the WHO Working Group on First Contact Mental Health Care held in Tampere in April 1983a and emphasized the importance of training in mental health practice at the primary care level. 4 . A collaborative study is recommended of intervention practices in different countries and health care set tings, with the objective of identifying effective strategies for the prevention of mental disorder in the elderly. 5. WHO should consider the feasibility of preparing guidelines for training manuals referable to various categories of health care personnel charged with the health care of the elderly. a Document MNH 059(1) (S). Working Group on Child Mental Health and Psychosocial Development Delphi, 30 October - 5 November 1983 - 173 - ICP/MNH 065(l)(S) 3417F 17 February 1984 ORIGINAL: ENGLISH This Working Group had its or1g1n in the WHO Expert Committee report on child mental health and psychosocial developmenta and subsequent interregional projects and activities aimed at promoting child mental health and psychosocial development as a priority for consideration by Member States. The meeting was attended by 16 participants from 10 European countries. The purpose of the meeting was to assess current child mental health and psychosocial development in the Region and to establish goals for trying to improve it. National case studies National case studies of the 10 countries represented at the meeting were presented . Most of the country reports had been prepared according to an outline prepared earlier and used in an interregional pr oject. In assessing the extent of the problems, the types of problem and their main causes, it became clear that the data were probably not very comparable, partly because of classification problems and partly because total population surveys are lacking more often than not . Most countries seem to have a lot of problems in common . The prevalance rates of mental retardation, epilepsy, and emotional and behavioural disorders were globally the same in all the reporting countries. Urbanization and the stress it places on traditional family life were considered to be a major cause . Other factors regarded as important causes were high divorce rates, chronically distorted family relations, failure at school, physical illness, brain damage, poor socioeconomic conditions and malnutrition . The structure of health, education and social services in the various countries was described. In the southern and eastern countries lack of resources, services and well-trained personnel appeared to be the main problem. In the northern and western countries, lack of coordination among the various services and the need for a child mental health policy were the main issues . The existing services were unevenly distributed over several areas in all the reporting countries . The reports on aspects of legislation concerning children revealed that there were great variations in the relevant legislation among the different countries. It appeared that a good deal of legislation, at least in some countries, was never or only partially enforced, mainly because of a lack of resources. On the other hand, in other countries and for some specific problems, legislation seemed to lag behind social practice. The reports on training described the amount of teaching carried out by mental health personnel and on the mental health content of the curricula for teachers, nurses, medical students, paediatricians, and others. It was concluded that child psychology was a recognized part of most curricula, but the amount of time involved was often inadequate. Besides that, some countries had no academic departments of child psychiatry and child psychology at all . It was concluded that the training of primary mental health care workers in particular (doctors as well as nurses) needed considerable improvement everywhere. Those present who had participated in the national case study exercise agreed that it had been a worthwhile venture, despite the considerable effort involved. The Group felt that the Regional Office should obtain case studies of every country in the Region. a WHO Technical Report Series, No . 613, 1977 (Child mental health and psychosocial development: report of a WHO Expert Committee). - 174 - Establishing goals In order to discuss goals in promoting child mental health and psychosocial development, the Group concentrated mainly on three topics: services and prevention, training and research. Services and prevention In considering priorities for the development of services to maximize prevention, the Working Group used the framework provided by the International Conference on Primary Health Care held in Alma-Ata, USSR, in 1978. It seems that mental health problems and deficiencies in the psychosocial development of children cannot be expected to be handled to a significant extent by specialized services only. It was stressed that a comprehensive approach is needed: education, housing, welfare, as well as the legal sector and primary health care were considered to be highly relevant to the issue . Coordination and communication at various levels between the different institutions and services active in the above-mentioned areas were regarded as being of utmost importance. In considering the possibilities for early detection and prevention, three levels were delineated. A general level: in this area preventive measures should be focused on the modification of lay care and lifestyles. For this, it was believed helpful to consider using television and radio programmes and other media, as well as the teaching of older secondary school pupils . Primary and secondary care levels: various existing systems and agencies provide for the early identification of problems, notably health centres, kindergartens, schools and social agencies. In this context it was s tressed that schools are the only institutions where the entire chi ld population is available for the detection of problems. Tertiary health care level: the Group felt that there was an urgent need to evaluate the systems of care in 1nst1tut1ons for children and to identify those care systems least detrimental to children's mental health development. Training In considering training needs, the Group used the framework provided in the section on training of the WHO Technical Report mentioned above. It was stressed that child mental health is first and foremost the responsibility of parents and the family. Consequently public education was considered to take first priority. The essential components of public education in child mental health and psychosocial development were delineated . In general the training of non-child mental health workers, who spend some, but not most of their time on matters concerning child mental health, was considered to be seriously deficient . It was concluded that child mental health professionals were better trained, but there was a lack of coordination as to their specific roles. It was recommended that in each country the various professional or ganizations concerned with training should both separa tely and together identify the various child mental health tasks to be conducted by their own particular disciplines. Once the particular tasks to be carried out by each discipline had been identified and agreed, it was expected that the means of achieving adequate training would become more apparent . Research In consider ing research priorities, the Group used the f r amework provided in the reports of previous meetings, especially the Interregional Workshop on Child Mental Health and Psychosocial Development, held in Athens, in 1982, and the Task Force Meeting, in Washington, in 1983, on biobehavioural and mental health aspects of primary heal t h care with particular emphasis on maternal and child health. It was agreed that different countries have different needs. structures and mechanisms to establish priorities that match unmet established in the context of cost-effectiveness. Priority should the research topics should be oriented to all children. Four main Every country should evolve needs . Priorities should be be given to common problems and priorities were delineated : the standardization of assessment ins t ruments and methodologies; epidemiological and longitudinal research on child mental disorder; - 175 - research on psychosocial factors and the impact of social change on child mental health and psychosocial development; health service and health policy related research, including progra=e evaluation research. Recollllllendations The European Society of Child and Adolescent Psychiatry should focus on prevention at its next meeting. Recommendations for governments l. Governments should give more importance to the training of primary health care workers in chi ld mental health and psychosocial development. 2. They should promote epidemiological and longitudinal research in the field of child mental health and psychosocial development. 3. In the more developed countries, where several child mental health and psychosocial development services exist, governments should lay emphasis on research related to health service and health policy. 4. In developing countries, governments should lay emphasis on research related to psychosocial factors and the impact of social change on child mental health a nd psychosocial development. 5 . Governments should encourage the use of television, radio and other media to make the public more aware of child mental health problems. 6. They should develop ways of monitoring effectively the development of the preschool population. 7 . They should stimulate the evaluation of the systems of care in institutions. Recollllllendations for WHO l. In considering further national case studies, WHO should encourage those who complete them to provide information on training along more standardized lines. 2. WHO should base its target approach for health for all by the year 2000, in the field of chi ld mental health, on existing scientific evidence and where this scientific base is lacking, research should be promoted to obtain valid and reliable findings on which to base its policy. 3. WHO should promote intercountry activities in such fields as the standardization of instruments and methods, intercountry research progra=es, and research training courses, on a regional level with special emphasis on the needs of developing countries. - 177 - MODEL HEALTH CARE AND QUALITY ASSURANCE Advisory Committee on Model Health Care and Quality Assurance Barcelona, Spain, 16 May 1983 Introduction - 179 - ICP/SPM 039(S) 2233E 27 September 1983 ORIGINAL: ENGLISH The Advisory Committee consisted of 15 temporary advisers, In addition, four observers participated in the discussions of the Committee. The participants, whose professional backgrounds were in medicine, nursing, economics, biostatistics and hospital administration, included government health officials, medical educators and public health educators. They came from Belgium, the Federal Republic of Germany, Finland, France, Italv, Netherlands, Spain, Sweden, the United Kingdom, the United States and Yugoslavia. The charge of the Advisory Committee was: to review WHO's suggested medium-term programme in quality assurance; and to make recommendations for the further development and implementation of this programme. Discussion One major point of discussion was the need for WHO to ensure that its interest and activities in quality assurance are not misrepresented as being excessively concerned with cost, The Committee recognized the difficulty in achieving the proper balance among concerns of efficacy, effectiveness and efficiency, Many of these concerns were further addressed by the Working Group on the Principles of Quality Assurance and will be detailed in the report of that Group. The Advisory Committee discussed the model health care and quality assurance medium-term programme document in some detail, and developed recommendations for further WHO activities relevant to quality assurance. As to the medium-term programme itself, the discussion focused on motives for quality assurance, criteria for choosing areas subjected to quality assurance and the scope and future trends of the programme. To the list of motives for introducing quality assurance were added provider dissatisfaction and increased complications from the excessive use of services as a consequence of low quality health care. Areas where quantitative or qualitative variations in the provision of care or outcomes of care are known or suspected, as well as areas where there is a known opportunity for intervention to improve care are prime foci for quality assurance. The frequency of litigation may not be a particularly good criterion as its use may reinforce physicians' fears that standard setting could lead to further litigation whenever standards are not met. The prograrmne should be broadened to ensure that it encompasses all health professions. The specific mention of nursing was urged. The programme should emphasize flexibility in the approaches to quality assurance. The importance of the components of quality based on human values, such as caring, should not be overlooked. Attention should also be devoted to the attitudinal problems in developing quality assurance programmes, as well as the methodological problems. Some of the trends that will influence the programme include the following. The tendency towards self-care will place more pressure on practitioners to practise good quality medicine. Legislation to regulate physicians may diminish their involvement in quality assurance activities. - 180 - Increasing competition as a consequence of expanding the number of health professionals increases the need for controls over the process and outcomes of care. Outcome quality assurance methods will become increasingly difficult as the portion of morbidity related to chronic disease continues to rise. As multidisciplinary teams coordinate care, quality assurance must also become multidisciplinary. Increasing economic constraints on health resources may make quality assurance seem an unnecessary "frill", but it is precisely under circumstances of resource limitation that effective quality assurance will be most important to maximize the health benefits of the available resources. Recommendations 1. WHO's role should be one of leadership in facilitating the development, promotion, implementation and evaluation of quality assurance activities among Member States. 2. An information clearing-house should be developed under WHO sponsorship to collect, translate (as needed) and disseminate information on quality assurance methods, activities and results in Member States. An overall plan for information collection and dissem ,ation should be the first see~ towards this objective. The development of a European journal of quality assurance, of motivational and technical publications on quality assurance, and of "public relations" programmes on the quality of health care would all be potential activities of such an information clearing-house . Such activities should encompass four constituencies, each of which requires different information: the public, politicians, institutions and the professions. 3. WHO should stimulate effort s to teach quality assurance in medical schools and othe r health profession schools by funding model programmes. Such programmes should be expe riential, rather than didactic, and should be integrated into the clinical activities of the teaching institutions. Such eilot ~rejects could include the development of a text on the principles of qualit y assurance, teaching guides for the faculty, case exercises, model curricula and interdisciplinary experiments . 4. WHO should convene a workin~ group to develop suggestions for the organization of quality assurance programmes at the institutional, regional and national levels. This would complement the methodological principles developed by the Working Group on the Principles of Quality Assurance. 5. Consideration should be given to developing a WHO European grants programme to stimulate quality assurance research and pilot quality assurance projects in Member States. In addition, this programme could fund studies on the costs and cost/benefit ratio of various quality assurance approaches. 6. A travelling educational programme could be developed under WHO sponsorship to conduct training seminars for professional associations, universities and provider groups in Member States. 7. The development of institutional and national data systems capable of collecting and analysing valid information on important process and outcome indicators of quality should be considered as an activity for WHO funding. WHO working groups considering the need for information systems should ensure that the use of such information for quality assurance is included in their recommendations. 8. WHO should be cautious in promoting quality assurance to ensure that unreasonable expectations of its impact are not stimulated. 9. Guidelines for structural quality control (minimum facilities, equipment, manpower, organization, record keeping) might be developed for use by Member States in the licensing or accreditation of facilities. 10. The recommendations of the Working Group on the Principles of Quality Assurance should be widely disseminated among national health authorities, professional and provider groups, certification groups and insurers . 11. Model legislation to stimulate/promote quality assurance in Member States could be drafted , but caution should be exercised in promoting such legislation as it might be counter-productive in some countries. - 181 - Working Group on the Principles of Quality Assurance Barcelona, Spain, 17-19 May 1983 Introduction ICP/SPM 044(5) 2409E 28 September 1983 ORIGINAL: ENGLISH The 15 participants and 4 observers involved in the meeting of the Working Group on the Principles of Quality Assurance had professional backgrounds in nursing, economics, biostatistics and hospital administration, and included several physicians, government health officials, medical educators and public health educators. They came from Belgium, the Federal Republic of Germany, Finland, France, Italy, Netherlands, Spain, Sweden, the Unic ~d Kingdom , the United States and Yugoslavia. Starting from the assumption that quality assurance is a new but desirable concept among the European Member States of WHO, the Working Group was charged with the responsibilit y of suggesting a strategy for introducing quality assurance to health authorities, health professionals, the scientific community and the consumers of health services . The Group attempted to analyse and answe r the following questions. Why is quality assurance needed? What are its objectives? How can it best be introduced at the national and local levels? What activities should be included in an actual quality assurance programme? How ca n the quality of services, if found defective, be improved? Background information Although the World Health Assembly and the Regional Committee have passed no resolutions ex plicitly mentioning quality assurance, the mandate to proceed is clear: quality is implicit in the WHO Constitution, the Sixth and Seventh General Programmes of Work, and in the many recommendations pertaining to the establishment of norms and standards and to the evaluation of hea lth services . There is also clearly a growing interest in quality assurance in Member States . The current WHO concern with quality assurance is a natural and logical ex tension of previous activities that have reflected this implicit mandate. If one looks at the reports and recommendations of the working groups convened by the Regional Office, one notices the concept of quality with an increasing frequency in discussions pertaining to the evaluation of health services and the effective use of available resources. Topics of discussion and conclusions The discussions of the Group attempted to define more clearly the desirable characteristics of quality assurance programmes. The need for quality assurance has become clear. As with industrial processes, effective mechanisms for evaluating and improving the quality of health care are essential components of any system for the provision of health services. As the complexity and technological sophistication of health services systems in the developed nations of Europe and other areas of the world has increased, the ability of earlier methods of quality control (such as licensing of personnel and institutions) to control adequately the quality of care has been surpassed. Accordingly, a need has arisen for new methods and mechanisms for quality assurance to ensure the accountability of the health professions, and of health care institutions, to the public they serve. - 182 - The Working Group concluded that WHO should play a leading role in facilitating the development, promotion and implementation of effective mechanisms for quality assurance in its European Member States. Although the nature of the specific activities to be conducted by each nation will vary with its social, political and professional situation, the Working Group concluded that seven major principles should serve as guidelines for WHO and its European Member States in working toward an effective and efficient approach to health care quality assurance. 1. The methods employed must lead to the identification and resolution of problems in the provision of health services and to the identification of opportunities for improvement in health care, so as to have a positive effect on the physical, mental and social wellbeing of patients. 2. Quality assurance activities should include considerations of efficiency and risk as well as effectiveness, to promote care that achieves optimal benefits, at minimum cost, with minimum risk of further injury or disability. 3. Consideration must be given to developing programmes that encompass the emotional and social aspects of health care quality, as well as the scientific/technical aspects. 4. Quality assurance activities must be integrated into the direct clinical and institutional management functions of health professionals and health care institutions, rather than be separated or isolated from them. Accordingly, quality assurance should become an operational responsit.lity of line managerial personnel, both clinical and administrative, at all levels of health care, including both primary care and institutional care. Adequate resources and suppo r t to facilitate and coordinate quality assurance activities should be provided by the administration of each health care organization . S. The appropriate locus of quality assurance activities extends across every organizational level in health care , from the individual patient-provider interaction to institutional sub-units, institutions, re g ions and nations. 6 . All health professions have a publi c obligation to participate in quality assurance activ1t1es. Because the provision of health services requires the coordinated efforts of a variet y of health profession disciplines, the evaluation and improvement of the quality of health services should also be performed through the interdisciplinary cooperation of the professionals involved in care. 7. Because health care is a rapidly changing field and health care quality assurance methods are still in a period of experimentation and development, any approach chosen for quality assurance in Member States should maintain the flexibility to change as the state of the art of quality assurance continues to evolve. Recommendations To facilitate the development and implementation of quality assurance programmes consistent with these principles, the Working Group made the following recommendations . 1. WHO should develop and implement a comprehensive plan for the collection and dissemination of information on quality assurance methods, activities and results among Member States. The development of info rmat ional, motivational and technical publications on quality assurance fo r such audiences as public health policy-makers, health professionals, health service financiers a nd educators should be included in this plan. 2. Health profession organizations in Member States should be encouraged to plan and implement programmes to increase the motivation of their members to be actively involved in quality assurance activities. 3 . Each Member State should, as a component of its national health plan, define the organization(s) responsible for quality ass uranc e activities and establish mechanisms for assuring the public that those responsibilities are met. 4. Member States should be encouraged to allocate a percentage of their financial resources for health services to quality assurance research, development, education and implementation . - 183 - 5. Educational institutions in Member States should develop programmes for training all health profession students in quality assurance, such that the attitudes, skills and knowledge necessary for effective quality control are developed in each individual. In addition, appropriate postgraduate and continuing education programmes should be developed to foster these attitudes, skills and knowledge among practising health professionals. 6. Where necessary and appropriate, Member States should develop legislation to implement the recommendations outlined above. - 185 - NUTRITION Informal Consultation with Infant Food Industries Copenhagen, 7 December 1983 - 187 - ICP/NUT 010(4)(5) 8 February 1984 3365F ORIGINAL: ENGLISH The aim of the informal consultation was to provide a possibility for a dialogue between the Regional Office and the infant food industry, to share experience, ideas and opinions and discuss future contacts . The infant food industry has collaborated with WHO and UNICEF since October 1979, but this collaboration has been almost entirely at headquarters level. In the European Region there is a need for greater opportunity for dialogue with this particular industry. The consultation was attended by 10 representatives of infant food industries from major exporting countries - Denmark, France, Federal Re ,•ublic of Germany , Netherlands, Switzerland, United Kingdom, USA - and representing four industry organizations: International Council of Infant Food Industries (ICIFI), Association of Dietetic Food Industries of the EEC (IDACE), International Secretariat for the Industries of Dietary Food Products (ISDI) and Association of Danish Producers of Dietetic Products (SEDAN) as well as representatives of the Regional Office, WHO headquarters and UNICEF, New York. The main issues discussed were: monitoring of the implementation of the International Code of Marketing of Breast-milk Substitutes, including a Draft Model Scheme for Evaluation of Infant Food Marketing Strategies in the Context of the International Code of Marketing of Breast-milk Substitutes. the question of voluntary agreements between industry and other parties; the question of in what way exporting companies are responsible for the marketing of their products in other countries; follow-up formulas (i.e. milk products targeted at infants over 4 months of age ) and their marketing. It was agreed that: (1) the Draft Model Scheme for Evaluation of Infant Food Marketing Strategies in the Context of the International Code of Marketing of Breast-milk Substitutes would be reviewed by the part1c1pants from the infant food industries and a consolidated connnent would be forwarded to the Regional Office before the end of March, 1984; (2) the secretary of ISDI would in future serve as the contact point between the Regional Office and industry; (3) it would be useful, at least for a period of some years, to have annual informal consultations between the Regional Office and the infant food industry, preferably during the autumn . - 189 - OCCUPATIONAL HEALTH Working Group on the Effects of Occupational Factors on Reproduction Tbilisi, 25-29 April 1983 Introduction - 191 - ICP/WKH 015(S) 2299E 11 August 1983 ORIGINAL: ENGLISH The meeting was convened jointly by the WHO Regional Office for Europe and the Office of Occupational Health, WHO headquarters. It was attended by 21 participants from 14 countries of the European Region and one from the United States, as well as one representative from the Commission of the European Conununities and one from the Permanent Conunission and International Association on Oc cupational Health. The objectives of the meeting were to review the state of knowledge on the effects of oc c upational factors on reproductive function; occupational factors on reproduction, in animal guidelines for the application of study results Discussion discuss methods for assessing the effects of studies and epidemiological studies; and draw up in practice. A review was made of the legislation and practices in the participating countries relating to occupation and reproduction. In particular, limitations or special recommendations concerning the empl oyment of women, especially pregnant or lactating women, were described . The effects of European Conununity legislation and of the regulations of the Co~ncil for Mutual Economic Assistance (CMEA) on national practices were mentioned. The existing knowledge on the effects of industrial hazards, particularly chemicals, on reproduction was reviewed and it was emphasized that men, women and children were all vulnerable to such influences . A comparison of the effects of metals on reproduction in animals and humans was presented. The meeting divided into two subgroups. One of them considered experimental methods for studying the effects of exposure to chemicals at work on fertility, embryotoxicity and general gonadal function in animals . It also considered the use of mutagenicity studies for predicting hazards to humans. The other subgroup discussed the design, conduct and interpretation of epidemiological studies on reproductive hazards . The value of animal and other experimental studies in the setting of occupational health standards was reviewed and it was affirmed that epidemiological studies have a role to play in confirming or modifying these standards. The new knowledge that has emerged since previous meetings and the many problems that remain unsolved are shown by the large number of conclusions, reconunendations and gaps in knowledge listed below. The discrimination against particular groups of workers, especially fertile and pregnant women, that might result from the setting of different occupational health standards for them was extensively discussed, but no easy solution could be agreed. Conclusions General 1 . The aim of occupational health in controlling reproductive hazards should be to enable parents to have as many healthy children as they consider appropriate and to prevent a deterioration of the genetic basis of mankind . 2. In the setting and revision of occupational health standards, attention should be paid to effects on the reproductive function of men and women. - 192 - 3. The reproductive system may be more sensitive to potential adverse effects than other organs and systems. This should be taken into account in the setting of occupational health standards . 4. There is a need to distinguish between hazards that have general adverse effects on health and only secondarily affect the reproductive function, and those that specifically affect reproduction. S. Legislation containing special provisions for protecting the reproductive function of people exposed to chemical, physical and biological agents at work, has been and still is rapid ly changing in a number of countries. In some countries the tendency has been to reduce the special provisions, while in others to increase them. 6. While legislation exists in many countries for the testing of new chemicals, attention was drawn t o the need to consider the testing of existing chemicals whenever a suspicion of reproductive toxicity arises. Furthermore much of the legislation on new chemicals does not require reproductive tests on mammals until large amounts of chemicals have been produced, by which time considerable numbers of workers may have been exposed. 7. More basic information is needed on fertility, pregnancy and pregnancy outcome in various groups of workers in different work categories, such as in the home, in light or heavy work, or in sedentary work. 8. There i s a need to define those general aspects of work, for example physical and mental workload, mi c roclimate, posture and hours of work, both inside and outside the occupational area, that may have adverse effects on fertility or pregnancy outcome. 9. The Working Group applauded those countries where no loss of seniority, pay or benefit was incurred by pregnant women transferred to other jobs because of a suspected hazard to the fetus or the mother. 10. When a s uspicion arises about a potential reproductive hazard, it is obviously necessary to identify the exposed populations so that they can be studied . Difficulties have been experienced in identif ying and gaining access to populations of workers exposed to specific agents or groups of agents. 11. National registers of reproductive outcomes have proved extremely useful in the investigation of suspected reproductive hazards. Nevertheless, codes of confidentiality prevent investigators in some countries from gaining access to these records, although methods are available that can ensure the confidentiality of the individuals on the registers. 12. Potential carcinogens in the workplace may present a special hazard for pregnant women. Their genotoxic potential in both male and female germ cells must also be considered. 13. In setting priorities for the agents or occupations to be studied the following factors s hould be taken into account: existing animal data, mutagenicity and carcinogenicit y data, the number of exposed workers, the degree of exposure, clinical and preliminary epidemiological data and public concern. These priorities would therefore differ in different countries. Animal and mutagenic ity studies 14. Although most attention in animal studies has been paid to the effects of chemica l exposure, the effects of physical and biological agents are also important and should be adequately studied. 15. To assist i n the recognition of potential reproductive toxicity, animal tests are usually performed on fertility and embryotoxicity/teratogenicity but other studies on gonadal function may also be necessary . These may be carried out according to the currently accep ted protocols although special consideration must be given to the route and timing used to administer the agents being tested. These should take into account the likely industrial exposure and the toxicokinetics of the materials. 16. The literature on experimental studies in animals indicates that they are valuable for predicting the impairment of specific aspects of reproductive function. For example, the adverse effects of l,2-Dibromo-3-chloropropane on the testes were reported in animals before the effects were recognized in men. 17. Comparison of the limited data available on the effects of chemicals on both animals and humans indicates that in ge neral humans are no less sensitive than animals to adverse effects on their reproductive systems. - 193 - 18. While most animal studies concentrate on single substances, occupational exposure usually consists of a combination of low levels of many agents . Knowledge of their interactive effects is very limited. 19. In general, but especially in teratological studies, the exposure of animals to single doses of chemicals such as metals that tend to be cumulative in humans may not be relevant to the setting of standards for long-term human exposure . 20. In teratological experiments in animals, attention should also be paid to other observed effects, such as embryolethality, that may be relevant to humans. In reports of such studies, these other effects should therefore also be mentioned. 21 . In embryotoxicity studies, particular attention should be paid not only to prenatal development but also to postnatal functional and behavioural development. 22. In animal experiments, complex physiological, morphometric and biochemical methods for assessing effects on reproduction can be of value. 23. When wide dose-intervals have been used in animal studies, it may be of value to establish the maximum level at which there was no effect as well as the minimum level at which there was . 24 . Mutagenicity tests do not all have equal value for extrapolation to the risk in humans and attention was drawn to the use of different levels of test systems. 25 . Of the various types of chromosome aberrations that can be observed, chromatid exchanges are the most important for predicting human hazard . Nevertheless, increases in the frequency of breaks and other types of chromosome damage are also criteria of mutagenicity . 26 . The significance for reproduction of chromosomal aberrations in somatic cells still needs to be evaluated. Information on whether compounds reach the gonads is therefore useful in the evaluation of hazard. 27 . Germ cell mutations may lead to infertility, abortions, stillbirths, congenital malformations and inherited diseases, while mutations in somatic cells may induce cancer . Both types of mutation are therefore significant in assessing reproductive hazards. Epidemiological studies 28. Data in the literature indicate that occupational hazards can have a wide range of effects on the reproductive system of males and females as well as on the fetus and offspring themselves . There can be adverse effects on the libido, potency and fertility of males, on the menstrual cycle, ovulation, fertility, pregnancy (abortion, malformation and postnatal development) and lactation in females and on postnatal development from direct and indirect exposure via breastmilk in children . In addition, there may be increased risks to the health of the mother owing to the interaction of her pregnancy with occupational factors. 29 . Information on reproductive effects may be obtained from interviews, medical records or registers. Interview data should be collected with care to avoid asymmetry of reporting in the exposed and the control populations. Efforts should be made by those responsible for medical records and registers to record adequate data on occupations. 30. It was recognized that it is extremely difficult in epidemiological studies on groups of workers, to control adequately for all the factors that can influence reproductive performance. While the Working Group encouraged a high standard of scientific work it recognized that studies on small numbers of subjects could provide useful clues to possible hazards without reaching statistical significance. It felt that statistical and other criteria should not be set so high as to impede progress in the collection and publication of information about potential hazards to human reproduction. 31. Reproductive outcomes in persons with specific exposure tend to be rare. This makes it difficult a nd expensive to conduct studies with enough statistical power to show weak effects . Thus other types of evidence, experimental and clinical, may have to be taken into account in assessing reproductive hazards to workers. International cooperation would be useful in setting up studies so that larger numbers of exposed workers could be evaluated. 32. Epidemiological studies should be based on reliable quantitative data on exposure. Hitherto, these have rarely been reported. Where possible, such data should be obtained by direct measurement or observation _in the workplace rather than by interviewing workers. - 194 - 33. In the assessment of workers' exposure to chemicals, the measurement of the chemicals and the metabolites in body fluids may be of particular value. Any other biological criteria of exposure should also be used as should measurements of ambient concentrations in the workplace. 34. Attention should be paid to the timing of exposure i n relation to the observed effects on reproduction. 35. When negative epidemiological results are reported, information should be provided on how large a risk ratio the study is able to exclude. 36. At present, cytogenetic studies on groups of workers are expensive and require special expe rtise. These studies are a valuab~e tool however for identifying hazardous exposures to mutagenic agents. Cytogenetic studies should be aimed mainly at occupational groups where some previous experimental or epidemiological evidence of potential genotoxic hazards is already available. Recommendations 1. There should be an exchange of information among Member States on which occupational factors, agents or tyo~s of work are considered hazardous to the reproductive function of men and women. 2 . There should be an exchange of information among Member Sta tes on which occupational factors, agents or types of work are considered unsafe for pregnant women. 3. A periodic review should be made of developments in legislation and administrative provisions for the specia l protection of the reproductive health of people exposed to chemical, physical or biological agents a t work. Particular emphasis should be placed on the scientific basis of these provisions and their practical implementation to assist those countries that are considering developing or changing their legislation in this area. 4. Control of occupational exposure s hould whenever possible be the primary form of protection of the he alth and wellbeing of the mother and fetus, rather than discrimination by refusal to employ women workers. In cases where exposure cannot be avoided a nd where there is evidence of a hazard to mother or fetus, pregnant women should be transferred out of the hazardous area . 5 . The occupational health services or ot her appropriate aut horities should ensure that undue exposure of pregnant and lactating women to any toxic chemical , physical o r biological agent is prevented. 6. Internationally coordinated studies should be encouraged on the effects of suspec ted chemical, physical or biological agents on reproduction. 7 . Management, trade unions and government agencies should be encouraged to cooperate in the investigation and control of potential hazards to reproduction. 8 . National or regional registers of reproductive outcomes and the occupations of the mother and father should be promoted and made available for research on reproductive hazards. 9. For occupational health studies to benefit from a multidisciplinary approach, cooperation should be encouraged among epidemiologists, occupational health staff, obstetrician s, gynaecologists and paediatricians, etc. 10. Efforts should be made to obtain more qualitative and quantitative data on exposure levels in the workplace. This may be achieved by closer cooperation among occupational hygienists, epidemiologists and other researchers. In epidemiological studies, attention should be paid to the accuracy of information on exposure and its observed effects on reproduction. 11. To assist in the recognition of occupational effects on reproduction, those responsible for the health of workers, in particular the occupational health services, should record the reproductive outcomes of male and female workers , both infertility and pregnancy outcome (including spontaneous abortions and birthweight) . 12. Efforts should be made to improve and validate methods for studying reproductive parameters, for example fertility, semen analysis, menstrual function and pregnancy o utcomes . 13. When negative results are reported in epidemiological studies, a calculation of the statistical power should be included to indicate how large a relative risk the study can exclude . This would prevent unjustified confidence being placed in small-scale studies. - 195 - 14. In mutagenicity studies, substances should be tested using a battery of test systems . 15. Workers potentially exposed to identified human clastogens should be monitored. For example, se l ected groups of occupationally exposed persons should be investigated for chromosome damage before and during employment. This would detect any increase in mutagenic changes resulting from exposure in the working envirorrnent. 16. Because of variations among individuals in the incidence of cytogenetic aberrations, longitudinal studies should be encouraged that begin before individuals start a specific job and that follow them up at intervals after that . 17 . A glossary should be prepared to help unify the terminology used in studies on reproduction . 18. Internat ional training courses should be organized and national courses encouraged on the methods used to assess the effects of chemicals on reproduction. - 197 - ORAL HEALTH Intercountry Workshop on Community Oral Health Services Erfurt(GDR), 12-16 December 1983 Introduction - 199 - ICP/ORH 008(2)(5) 40601 20 February 1984 ORIGINAL: GERMAN The meeting was attended by representatives of seven countries, two representatives of the International Dental Federation, six observers, six temporary advisers and three officers from WHO headquarters and the Regional Office for Europe . The main purpose of the Workshop was to analyse the existing dental care system on the basis of epidemiological data and the best possibl, improvements to the latter. Discussion The preliminary findings of the WHO International Collaborative Study of Dental Manpower Systems - GDR sample survey - were presented, permitting a comparison between international and national systems of care. This was followed by country reports on the present state of dental care systems in Bulgaria, the German Democratic Republic, Hungary, Poland, Romania, the USSR and Yugoslavia. Three main points were discussed: (a) What epidemiological data are needed in order to analyse existing problems in dental care? (b) National goals for oral health by the year 2000. (c) Strategy for reaching these goals . Particular stress was given to the need for and importance of a wider-ranging practical implementation of primary prevention as part of primary health care. This means including the approach in teaching programmes at dental schools, formal continuing education programmes for dentists and the programmes of dental associations. It implies the general implementation of prevention as a task involving the whole of society. In those countries represented, where dental care systems form an integral part of the public health care system and where the right to the protection and maintenance of health of every citizen is enshrined in their constitutions, good prospects already exist for creating the requisite manpower, material and financial situation . As a whole, the Workshop showed that the traditional one-sided curative alignment of dental care in all countries had not produced the desired success. This recognition presupposes, for applied research , high demands in respect of the development of new treatment models, aimed at prevention and relevant to practice. The need to devote research to problems of improving treatment systems as far as possible was also stressed . The Workshop led to a number of recommendations being made designed to reduce the incidence of dental disease and diseases of the dental apparatus and consequently to further improvements in prevention-oriented primary health care. In this connection the participants felt it was essential to bring about further promotion of international cooperation by strengthening collaborating centres and arranging workshops on manpower development. - 201 - PRIMARY HEALTH CARE Conference on Primary Health Care in Industrialized Countries Bordeaux, 14-18 November 1983 Introduction - 203 - ICP/PHC 02l(S) 2961E 16 January 1984 ORIGINAL: ENGLISH The Conference was attended by 59 government representatives from 26 countries and 14 delegates from nongovernmental organizations, representing general practitioners, medical students, nurses, the International League of Red Cross Societies and UNICEF, Observers from several countries and members of the press were also present . In 1977, the Thirtieth World Health Assembl: stated that "the main social target of governments and the World Health Organization in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead socially and economically productive lives" . At Alma-Ata in 1978, primary health care was adopted as the main approach to achieving this objective . In 1979, the European Regional Cormnittee elaborated the principles of primary health care for the Region, and in 1980 the first regional strategy for health for all was presented to the Regional Cormnittee in Fez. In 1983, the European Regional Cormnittee discussed suggested targets for achieving health for all by the year 2000, including targets related to primary health care. Meanwhile, the World Health Assembly has approved global targets up until 2000 and intermediate targets for the period 1984-1989 which, however, are not all relevant to the very complex situations in the industrialized countries . The Conference on Primary Health Care in Industrialized Countries intended: to reaffirm the Declaration of Alma-Ata as relevant health policy guidance for the industria lized countries; to take stock of national developments in the implementation and development of primary health care since Alma-Ata; to review concrete examples of the successful implementation of the Alma-Ata principles and to identify obstacles to their implementation; and to provide essential building blocks for the further elaboration of the primary health care component of the European regional strategy for health for all by the year 2000. In addition to the plenary session, the Conference also worked in two groups. Country reports on the implementation and development of primary health care were presented to half the delegates, while the others discussed basic principles of primary health care. Several conclusions were reached. While the practical application of the Alma-Ata principles has been influenced by economic, social and political realities, definite progress has been made in the integr ation of public and private medicine, the control of hospital costs and the reallocation of financial and human resources to the isolated, deprived, vulnerable, politically powerless and those at high risk. The teaching of the principles of primary health care has increased at both professional and nonprofessional levels, as have the opportunities for individuals and cormnunities to participate in the health care process. The role of prevention is recognized, and legislative support for the control of environmental and personal risk facto rs is widespread. Nevertheless, a number of constraints also became apparent. Confrontations between health professionals and lay people, the technical nature of many health issues, variations in willingness or ability to cooperate and rigid administrative structures sometimes make intersectoral collaboration and community participation difficult goals to achieve. While the integration of health services will improve the quality and continuity of care, constant attention - 204 - needs to be paid to meeting the needs of individuals and communities rather than those of health professionals. Finally, the development and application of appropriate health technology should support primary health care, which will also help to stabilize or reduce cos t s. Conclusions While recognizing the relatively high level of medical care in most industrialized countries, governments, health professionals and lay people should acknowledge the cen tral role of primary health care in improving the accessibility and quality of care by: controlling the expansion of the hospital sector, promoting the appropriate use of health and communication technology, and ensuring the allocation of resources according to need; coordinating multisectoral, communit y and individual efforts to improve the physical, social, political and economic "prerequisites of health"; and stimulati ng, in particular at the community level, health pr omo tion , disease prevention and health care activities related to the needs of vulnerable groups and the elderly. Recommendations Governments should : identify priority issues and concentrate their attention and resources on the areas of greatest need; and support the development of self-help, community participation, intersectoral collabora tion, the integration of health services, teamwork, and ed ucational and quality assurance programmes . Health professionals should : recognize that their responsibility is to provide comprehensive and continuous health care rather than just medical care; take steps to improve the undergraduate and postgradua te teaching of primary health care principles a nd increase their efforts to reorient the practice pa ttern s of licensed practitioners; acknowledge their responsibility to improve data collection, information transfer and monitoring procedures; and increase teamwork and communicate more effectively with health care users . - 205 - PUBLIC INFORMATION Working Group on Information and Kealth ( II) Liobon 1 20-22 April 1983 1. Introduction - 207 - ICP / INF 003 ( S) 2797L 9 June 1983 ORIGINAL; ENGLISH The first Working Group on Information and Hea I th, he Id in Luxembourg in November 1980, at tempted to out 1 ine a framework of i ncec-es t Chat was common to oat ion a 1 hea 1th i n forms c ion officers in the European Region. It reviewed information appr oac hes to the goal of health for all by the year 2000, taking into account such factors as the emergence of pressure g roups, the impact of increae ing cos ts on hea 1th s true tu res, and the rights of pat i e n cs to in fo nna t ion and to a say in decisions affecting their health. It focused attention on new techniques that would make public information more ef fective in the health field . The second Working Group had three main purposes: (1) to acquaint the 18 participants, who occupy key positions in the media, health ministries and international o rganizations, with the aims of WHO in respect of health for all by the yea r 2000 at the European level; (2) to obtain the professional advice of the participants o n the public in fo nuation programme of the Regional Office at the national l e vel; and (3) to examine relevant issues in the field of health informati o n , fo r instance the eme r ge nce of pressure groups and the impact of economic restraints on nati onal health information policy in such a way that the participants themselves and the Regional Off ice would benefit from the experience. The Lisbon meeting was intended to provide guid ance to WHO o n its Eu r o pean public information policy, which is to be developed in close associa tion with the Member Sta tes, and to suggest practical steps for the implementation of the recommendations adopted in Luxembourg. 2 . Discu11s ion Five subjects were adopted for disc ussio n by the second Working Gr oup. These were: - heal th themes of tomorrow - health information policy in an international context - i n formation policy and group pressure - explaining health in times of economic constraint - WHO regional information pol icy. 3. Conclusions and recommendations 1. The Working Group emphasized that a reorientation o f health policies as e nvisaged by the strategy of health for all by the yea r 2000 requires an effective mobilization of the community. The public at large will involve itself in health policy matters only if the issues are made clea r and are felt to be of personal concern . In Eu rope, health for all by the yea r 2000 should take fully into account the present health challenges in the Region. Ce rtain health problems, although unquestionably important in a worldwide context, are not of pra c tical concern to the general public in the European Region. While o r ganizational, technica l and financial problems may be of the greatest relevance for a small ~lite in Che health field, they will not mobilize interest among the general population or help significantly to enhance Che current status of health policy. Policy-makers should pres f nt policy issues in a way that will encourage enlightened public debate of the choices that have to be made. 208 - 2. The Working Group concluded that issues concernin g the lifestyle• of individuals, the enrichment of their leisure time, employment and unemployment, all of wh ich affect their wellbeing , will assume increasing impo rtan ce i n the coming years and will lead to new development s in he• l th policies and health information. ). The Worki ng Group affirmed t hat health information should emerge from, and serve as a corranentary on, previously established, sound health policy concepts and not be a substitute for them . It recommended that information office r s shoul d try to ensure that the media gi ve the eame attention to health policy as for example to education and environment policies; information activities should be directed to stimulating d iscussion of the thrust, cohere nce, relevance and o b jecti ves of health policies, "'ith the aim of ["aisi ng public interest i n he alth questions, •• the \.IH1)-sponso["ed publication lie.11th Crisis 2000 see k s to do, and s hould help the media to engage i n debate on the costs and benelits of heal th services. 4. The WiJrking Group r ecomme nde d that WHO s hould p rovide the medu with mo["e factual infonnation o n ca ncer, and cardiovascular and other diseases related to contemporary life1 tyl e1. lt noted that communicable di1eas e remains an impo rtant health p roblem in many parts of Europe and recommended that heal th information programmes should combat the danger of complacency towards immunization a ri sing from the belief that c4!rtain diseases a re no longer a threat . ) S. The Working G-r oup agreed that popular entertainment i• a powerful medium for health me1sages. Efforts should be made t o enlist the s upport of the c reator s of eotet"tainmen t in pre1enti ng positive health behaviour as the norm . 6. The Working Gt" o up noted that health issues a r e open to manipulation fo r purposes other than health promotion. Pol i cy-makers and journalists in the health field should investigate and evaluate the o r igi ns, motivation and methods of ope ration of pressure and other interest groups. To e ncourage more openness and f r an kness, a code of conduct should be formulated for these g roupa . - 209 - SELF-HELP AND HEALTH - 211 - Workshop on self-help and professional care: a comparative approach to social and economic costs in selected areas Hobr-Grenzhausen (Federal Republic of Germany), 23-25 February 1983 ICP/HED 022(3)(S) 21861 25 May 1983 ORIGINAL: GERMAN Within the framework of WHO's activities, the Workshop should be seen as a step towards the implementation of the regional stategy for health for all by the year 2000 (EUR/RC30/8). The attainment of such a goal through the regional stategy and particularly through the regional programme on health education and lifestyles, which emphasizes the role of mutual aid in the areas of rehabilitation and preventive medicine, provides the basis for WHO's information centre on research into self-help and health. The first meeting on mutual aid (Copenhagen 1980), which recommended the establishment of a European information centre on self-help reseach, and the workshop on mutual aid groups (Hohr-Grenzhausen 1982), which recommended the development of infrastructures for new cornrnmunity forms of care, provided a practical framework for the present Workshop. The purpose of the Workshop was to answer the question of whether and, if so, how professional and community lay care can be compared . Underlying this question is the present political discussion in some Member States, where essential cost reduction measures in the health sector have po .tted to the desirability of strengthening both nonmaterial and financial support for self-help groups, especially when they appear to be engaged in professional work. Thus the meeting had the task of identifying the similarities and differences of the two concepts and, as far as was possible and meaningful, to develop comparative evaluation criteria for the assessment of both economic and social costs in this field. To permit comparability, it was decided to examine two common health problem areas that are dealt with both by self-help groups and in the professional care sector, namely mental health and overweight . The Workshop was convened by the WHO Regional Office for Europe in cooperation with the WHO information centre on research into self-help and health, Hamburg, and the German Association of Self-help Groups, Giessen. The 20 participants from 9 European countries were persons either engaged in professional practice or working with self-help groups in the field of mental problems or overweight, or carrying out research within this area or within the general area of health economics. The Workshop was opened by Dr I . Kiekbusch, WHO Regional Officer for Health Education, who described the background of the self-help approach in the Regional Office and the place of the meeting within WHO's activities. She defined the "self-help continuum" as an instrument for the classification of different social and political phenomena, that emphasizes the low organizational level of lay care compared to highly organized medical care and thereby highlights the importance of supportive infrastructure. Dr K. Gretschmann of the Institute of Finance, University of Cologne, spoke on the subject of the economics of self-help groups and self-organization and its health policy implications. Study of these two aspects within the field of economics is insufficiently developed in both theory and practice . The structures and functions of the self-help sector, which operates between the State and the market, have scarcely been defined. From the economic standpoint self-help groups, because they have to establish their legitimacy once they make financial demands on the political system, will find they require an evaluation, to which the traditional approach is a cost-benefit analysis. Because of the nature of their constitutions, however, self-help groups defy simple measurement; an evaluation is therefore possible only by making a full cost-benefit analysis that takes into account the real qualities of self-help groups such as their spontaneous development, the identity of producer and consumer, their informal decision-making procedures, etc . Nevertheless the evaluation of individual elements remains difficult. In addition any comparison - 212 - of the possible relationship of self-help to professional care (substitution, complementarity, corrective and constitutive functions) requires a further cost-benefit analysis. There are examples of self-help projects outside the health sector that provide considerable evidence of economic effectiveness from the standpoint both of the national economy and of the community, in the form of social satisfaction and wellbeing and a corresponding increase in equity. On the basis of this socioeconomic presentation, three working groups were set up to discuss the following general topics in the light of their experience: - To what extent is a comparative evaluation of self-help and professional care at all possible? - What obstacles are posed by the different organizational approaches of both systems? - Where can evaluation criteria be applied in both systems? - Is a comparison of the self-help and the professional care systems possible, or should other systems of classification be used as point of reference? The disc ussion in the working groups and in plenary led to the basic conclusion that self- help and professional care cannot be assessed in terms of a comparison of two complementary sys tems. New types of socia l movemen t s, including self-help, have resulted from the development of professional and lay ca re systems. Self-help groups s hould not a priori be seen as a reflex against the inadequacy of th e professional (medica l) systems but as a new concept of and app roach to lay care The notion of th e self-help continuum proved very useful in this analysis. Thus it was concluded that a ge neral comparative evaluation of self-help and professional care would not be meaningful, and on that basis the following general recommendations were formulated: 1. Factors having a positive or negative influence on t he functioning and development of se lf-help and other community institutions should be identified. 2 . At the same time there is a need to establish intermediate forms of community organization (e.g . back-up mechanisms s uch as clea r ing houses), that would support the self-help groups and i n general c re ate a positive climate for the promotion of self-help and lay care. 3. The evaluation of all social resources for health must be based on a community mode l of hea lth (i.e. also taking into account the values of lay care sys tems) . 4. Although an evaluation should be made covering the health system as a whole (i.e . both the social and the professional aspec ts), it s eems essential to s tart with the professional sector since at present it is to thi s that all the financial resources flow in practice . In particular the evaluation should show where the professional system has developed along the wrong lines. The evaluation criteria should not refer only to professiona l values but also the va lues of the lay care sys tem. 5. In addition to the evaluation there is a need for political action aimed at disseminating general information on self-help in order to promote changes that would give the publi c more cho ice. The lay community should have its own political organization within the health care sys tem, that would put forward its views and take action to increase its options. Drawing on the practical experience of the participants, the meeting reached the conclusion that the evaluation of self-help should be applied not to individual groups but rather to support mechanisms for self-help groups . The following views were expressed concerning the evaluation : 1. As a rule individual self-help groups do not require money but rather an infrastructure that would enable them, among o ther things, to exchange experiences, establish contacts (also with professionals) and thereby have a real oppo rtun ity to develop continuity in their wor k . The infrastructure should be developed by intermediate-level support mechanisms such as clearing houses. In general, the form of organization of the infrastructure should strengthen the options for self-help (see recommendations of the 1982 workshop on mutal aid groups, regarding the possibilities for practical and political support of such groups) . 2. An evaluation of self-help support systems should address the question of whether they are orientated to the needs of the group, since this governs the degree of its acceptance and utilization . Relevant support mechanisms should therefore be evaluated at this stage, The aim should not be to evaluate legitimacy or effectiveness but to analyse and collate local or regiona l experiences and traditions in order to make them more widely known within the professional and lay care systems. - 213 - 3. The fact that a self-help group exists should in itself be regarded as sufficient proof of its legitimacy. External evaluation of individual groups should not therefore be undertaken, partic ularly as the aims and values of such groups can alter greatly over time. Groups should have the possibility of having an internal evaluation performed, if they so wish. This s hould conform to the requirements of the group, and be carried out using methods and (if necessary) professional expertise in which they have confidence. It should be in the nature of a self-teaching experience and develop into a learning process about the group's work . It should provide a basis for monitoring of the goals the group has set itself and the degree of their implementation. - 214 - Workshop on Health Promotion and Youth Heidelberg, Federal Republic of Germany, 4-6 July 1983 ICP/HED 021(2)(S) 3163F 29 August 1983 ORIGINAL: GERMAN The Workshop was the second in a series of four meetings of experts convened to discuss the topic of youth and health. The first, held in Salzburg in September 1982, was concerned primarily with assessing the present situation with regard to young people, although a number of health-promotive approaches in the areas of the school, the workplace and leisure time were also discussed. That meeting and two others that are due to . xamine the topics of the conceptual and political background (October 1983) and positive aspects i n Mediterranean countries (spring 1984) should be seen in the context of the decision of the United Nations to declare 1985 as International Youth Year. Some of the 15 participants from 9 Member States were physicians, mainly specializing in epidemiology, and the others were teachers, psychologists or sociologists concerned with health education for young people. The aims of the meeting were as follows: to describe existing programmes and projects concerned with health promotion and the motivation of young people in the school and workplace , and during leisure time; to monitor the effectiveness of such programmes with reference to their objectives, their methodology and the results obtained; to discuss the possibilities and limitations of implementing such projects with reference to the accessibility of the groups in question; to draw up conclusions and recommendations that could serve as guidelines for countries of the European Region in the development of lifestyle-oriented health-promotive measures . The introductory presentations dealt with the main differences between the health- promotive approach and conventional health education methods. In health promotion oriented to youth, it is necessary: to motivate young people to become personally involved in this field; to provide information in a non-directive and non-authoritarian way; to see the measures in the light of the lifestyle concept. "Lifestyle" in this respect refers to approaches situated between individual behaviour and its social, political and cultural contexts, which represent confounding factors. Health-risk behaviours such as smoking, alcohol abuse, unbalanced nutrition and inadequate exercise are, according to the lifestyle concept, rooted in a person's total behaviour spectrum. They are related to other behaviours, are dependent on them and can only be distinguished from them for analytical purposes. Before the participants divided into working groups to consider the key issues of health promotion in more detail and to draw up recommendations , aspects of health education in the school and workplace were discussed with reference to two projects . A youth study carried out in Oslo between 1979 and 1981 on 828 schoolchildren aged between 11 and 14 showed very clearly that health education measures have an influence on the behaviour of young people. The children in the study group who had been given suggestions about sound nutrition and physical exercise and had been informed about the possibilities for avoiding smoking or alcohol - 215 - consumption showed significant pos1t1ve results compared with a control group, i.e. during the observation period of two years; fewer subjects in the study group started to smoke or consume alcohol. Overall, an improvement in nutritional behaviour and an increase in physical exercise were observed. As emphasized in the ensuing discussion, the school occupies a particularly important place with regard to health promotion. At the same time, it should not be forgotten that basic behaviours such as those relating to nutrition are formed in the family before the child starts school. Some of the participants pointed out that it is not possible to carry out effective health education in the school without the participation of the teachers . Teachers not only have a key role to play as models, but they must also be motivated to carry out health-promotive measures themselves. It is, however, important that educators be trained for this purpose in order to counteract the lack of confidence that is revealed particularly when they are required to carry out an information transfer in the sense of a specific intervention. With regard to health education at the workplace, the "Moosham project" that has been under way in Austria since 1981 was presented. Although it is only now planned to expand this preventive programme focusing on alcohol abuse, consumption of illicit drugs, abuse of medicaments and smoking directly to the workplace, the activities have already reached about 3000 young workers (apprentices). When the latter undergo three-week rest cures in trade union hostels, they are ercouraged to discuss the problem of abuse behaviour, in addition to the regular cure programme. Through group activities, the possible causes of abuse behaviour and suggested solutions are reviewed . For this purpose, the young people have a free choice of approach (e.g. role-playing, poetry, song, collage, sketching, etc.). At the end of the exercise, the individual groups present their findings, which are then discussed by the other apprentices. This type of "activity training", which has also been developed in schools and the armed forces in a different form, has been shown by an anonymous questionnaire survey among young people to be well received. It was also found in the survey that a large proportion of apprentices reported a change in their attitude to abuse behaviour, as a result of self-discovery during the group activities. The Moosham project was welcomed as a model for health-promotive measures . The participants noted, however, that there is little interest on the part of employers to undertake health promotion in industry. It is, moreover, difficult to introduce such measures at the workplace. It was felt that one possible approach would be to develop such projects within the framework of the existing programme on safety in workplaces, endeavouring first to improve the situation at the workplace and only then initiating practical intervention measures , e.g. for the prevention of alcohol abuse at work. In all these measures, the worker should have an essential right to a say in the perspective of "workers' health". Both working groups made a detailed analysis of specific problems relating to health promotion and youth. For instance, after presentation of a project, "Health in the Association of German Scouts", one of the groups discussed the question of the evaluation of such activities. The actual project was carried out in an adventure playground, with the participation of 20-50 children aged 8-11, and involved activities such as role-playing, photo action, massage, self-discovery, etc., that were aimed at developing health promotion in a total perspective. In this respect, it is not so much a question of immunizing young people from smoking as enabling them to develop a healthy lifestyle or health culture by themselves. It is particularly difficult to monitor the effectiveness of such programmes. Above all, when endeavouring to comply with the in itself sound requirement of evaluation that must be both internal (by those carrying out the project) and external (by those not involved), one soon comes up against the limiting factor of the funding possibilities. It was also suggested that, alongside formal evaluation methods, less formal ones might be envisaged. The second working group drew up a number of recommendations relating to many different issues including: definition of the concept; identification of target groups with reference to the purpose of an intervention; i nvestigation of possible approaches; formulation of criteria for programme planning; verification of the criteria; health education in schools; health education at the workplace; health education during leisure time. - 216 - At the closing session, the participants adopted the following general recommendations. l. Health promotion should be seen as a policy of society as a whole·. 2. Motivation in favour of healthy lifestyles should not be developed primarily in the perspective of morbidity or mortality statistics, but as a component of ethical and moral education, i.e . education for life in terms of work culture as well as efficiency and the ability to experience things. 3 . The development of appropriate working and living conditions should be seen as a part of health promotion. That implies providing comprehensive education and occupational training, guaranteeing the right to work, making health care available on a continuous basis, and establishing the appropriate legislation. 4. Health promotion is a task for society as a whole, that should be carried out under the technical guidance of the institutions responsible for health policy. Above all, young people must be involved in the process of developing health-promotive working and living conditions. 5. The previous scientific studies on health promotion and health education and youth were inadequate, in many cases were not representative, had a weak theoretical base, frequently consisted of non-transferable intervention studies or focused only on certain behaviours while disregarding others. This shortcoming should be corrected by better planning and the development of a larger number of studies and well directed evaluations. 6. In the area of health promotion, one of the most important requirements is to maintain peace and especially to prevent nuclear war. This objective should be incorporated in WHO's programme for the European Region. 7. The mass media should apply ethical norms when reporting on health measures directed to young people (e.g. regarding drug and alcohol abuse, smoking, sex). 8. The group below the age of puberty should not be left out of the health promotion programme; however, it is not an essential target group and the measures should prefeTably be applied in the normal social environment (parents, school, district) . 9. More than in the past, emphasis must be placed on the study of living conditions of young people in terms of cultural aspects. In connection with the Workshop, two interesting projects were presented by the Federal Centre for Health Education, Cologne: a travelling exhibition on the theme of the working day, that is intended to provide a discussion forum for the target group of employed young people, in terms of the health problems they face in the world of work; a film, "Warten bis Lili kommt", dealing with age-specific behaviours of school-age children which play a role similar to that of alcohol, tobacco and illicit drug consumption at a later stage in coping with the day or escaping from problems; the film depicts alternative ways of facing up to everyday reality, e.g. through fantasy, activities and friendship. - 217 - SOCIAL EQUITY AND HEALTH Advisory Conmittee on the Programme on Social Equity and Health Barcelona, 26-28 October 1983 Introduction - 219 - ICP/ SPM 050(2)(S) 0584J 13 January 1984 ORIGINAL: ENGLISH The meeting was attended by 23 participants from 14 countries and 3 WHO staff members . The participants came from a range of disciplinary backgrounds, including sociology, psychology, political science, social administration, economics and different fields of medicine and public health . The purpose of the Advisory Committee meeting was to select concepts, methods and terms of research that would meet the requirements of the medium-term programme on social equ-,y and health and the regional strategy for health for all by the year 2000, while taking into account the differences in social, economic and cultural conditions among and within the various Member States . In particular, the Committee discussed important questions related to research projects. General discussion of research issues A number of papers were presented at the meeting and they raised the following important issues. 1. The meaning of key concepts and the nature of health-related disadvantage vary considerably from country to country. Any research strategy must therefore allow for flexibility in design to ensure relevance to all countries . 2. A range of sources of information, including routinely collected official statistics, ad hoc surveys and reviews of exis ting re search, should be used to develop indicators of social equity/inequity and health s tatus, including positive wellbeing wherever possible . 3 . A range of complementary research methods exists and all have a contribution to make to re search . 4 . Research on health and social services, and especially interventions, should be included when appropriate rather than only at the later stages. A research strategy The Advisory Committee agreed on a general framework within which the main questions to guide research and the important concepts involved should be elaborated; further questions within these initial ones and examples of variables and methods that can be used should also be identified; the actual choice of how relevant concepts should be put into practice, and which research methods should be used, should be left with individual countries or small groups of collaborating countries or projects . Emph asis was placed on the development of a structure for the research and work remains to be done on the development of precise questions, lists of variables, etc. Three main types of study were identified . 1. Descriptive studies: the focus would be on the distribution of social equity, health status and health and social services across a society. 2. Explanatory studies: the focus would be on the relationship between social equity and health status indicators . - 220 - 3. Cross-national studies: these would rely on a comparison of results and interpretations from different countries rather than of empirical data unless analysis revealed such a comparison to be valid. Where relevant, small groups of countries could collaborate on research on particular issues, such as migrant people or youth unemployment. This approach would allow greater collaboration over methods and the choice of variables. A case study The Advisory Cormni ttee took as an example of a topic requiring explicit cross-national study the issue of migrant people and discussed research in this area in considerable detail. Such a study would be multidimensional, looking both at migrants and at the families they leave behind in the country of origin, as well as at the direct and indirect effects of migration. It would also focus on different points of time, on the second generation and elderly migrants. Relevant variables related to health status, social equity and vulnerability were identified. One of the most important of the latter was felt to be the nature of social support networks . Studies of migrant people should also include consideration of relevant policies and health, social and other services and provide an opportunity to combine different disciplinary approaches. Concl usions and recommendations The Advisory Cormnittee assumed that relevant studies/activities associated with other WHO programmes would continue to be identified and would eventually amount to a significant part of the research, and that information would be collected about relevant research - whether planned, ongoing or completed - that already exists in Member States. Within that context, the following recommendations were made. 1. Priority within the prograrmne on social equ ity and health should be given to identifying and describing social and health inequities within countries in the Region. 2. A small g roup of experts should draw up a list of indicators of both social equity and health status as examples of those that might be incorporated into research projects . A similar exercise should be undertaken with regard to specific research methods. 3. Simul taneously, relevant groups of cou ntries should be encouraged to collaborate on specific aspects of the social equity and health prograrmne. Small groups of experts should then meet to decide on both methodology and the relevant indicators to be included, The Committee felt that its explora tion of these dimensions for migrant people illustrated the value of this type of exercise. 4. A focus on po licies and services and especially the design and eva luation of intervention to reduce health-related social inequities will most logically follow at a later stage in the programme, when causal mechanisms and directions have been further explored. I n some instances, however, it will be appropriate to include an evaluation of existing policies at an earlier stage. 5 . Special effort should be devoted to encouraging the participation of experts from the developing countries of the Region . It might also be useful to convene a meeting on the special concerns of developing countries. 6. Along with the various other agencies and networks that WHO will cooperate or liaise with in the programme on social equity and health, it would be valuable to work with the newly established European Society of Medical Sociology, in particular with the Society ' s coordinators in the developing countries of the Region. 7. Coun tries of the Region should give more emphasis to supporting research and interventions regarding some specially vulnerable groups, in particular the unemployed and migrants. Mult iple deprived groups were also mentioned as a priority target for research and intervention. 8. Countries of the Region should focus more on the social aspects of health: medical sociology and other social and behavioural sciences are of great significance. ln this context, there is a need in some countries for support through fellowships and educational programmes to develop a strength in social science as related to health issues. - 221 - Consultative Group on Ethnic Minorities The Hague, 28-30 November 1983 ICP/SPM 050(3)(S) 28160 18 January 1984 ORIGINAL: ENGLISH Health care workers and researchers from seven countries met to review the main health care needs of migrant populations in the European Region. An attempt was made to identify policies that national health care systems, and voluntary and international organizations could implement to improve the health care of migrant populations. Review The unequal distribution of health care is an i mportant issue in the European Region and the organization of health care services for vulnerable groups is a major challenge for primary health care. In this context, migrant populations in Europe deserve special attention. Mig rant groups come from different countries of the European Region, as well as from Asia, Africa and South America. Most of the countries of origin of migrants to the European Region are in the Mediterranean area, e . g. Algeria, Greece, Italy, Morocco, Portugal, Spain, Turkey and Yugoslavia. Recipient countries tend to be the more industrialized countries of western, central and northern Europe, e.g. Belgium, Denmark, France, the Federal Republic of Germany, Luxembourg, the Netherlands, Norway, Sweden, Switzerland and the United Kingdom. All migrant groups share some of the following characteristics and thus tend to have the same health care problems: they are a sizeable group and their problems concern a large number of European Member States; the overall problem of migrant populations grew mainly during the 1960s and 1970s as a consequence both of the labour needs of the host countries and of the poor working and living conditions in the countries of origin; the degree of social, economic and cultural integration of these populations with the host countries is still low, and close ties with the countries of origin are maintained; their prospects are uncertain, and at least a certain proportion of migrants is expected to return to their countries of origin in the next few years; immigrants have special needs related for instance to family planning and maternal and child health care. The provision of health care to migrant populations is of concern to the following parties. The migrants themselves: to what extent are their health care needs met by the host country's health care system? The host countries: to what extent are their health care systems responsible for the different sets of particular needs in their population, even beyond the specific case of migrant populations? The countries of origin: what is their role in assisting their migrant populations in foreign countries and should they prepare themselves for the possible return of a proportion of their migrant workers? International organizations: what can their role be in improving the provision of health care to migrant populations and in stimulating cooperation between the host countries and countries of origin? - 222 - Research policy with particular reference to ethnic groups There is a need to improve the data base for migrant groups; most of the evidence is fragmentary and cannot readil y be adapted to policy. Access to health data can be difficult , and there is a need to impr ove the methods used to collect vital statistics so that comparisons can be drawn between and within countries. To facilitate better health and social services, target groups need to be identified by a mix of qualitative and quantitative methods that can outline service and personal needs at a national and regional level. In-depth studies and small area analysis should be used to identify the characteristics and needs of ethnic populations. Evaluation research should be used to test the effectiveness of the health education programmes and general health information provided by the host country for migrants. When setting up a data base, researchers and institutions should be sensitive to the privacy of minorities and also be alert to the possible misuse of information. Health care delivery pol icy All provisions for ethnic minorities in host countries should be integrated into the existing heal th care programmes provided fo r the indigenous population. Special needs can be met by encourag ing domiciliary visits, and improving facilities for information and education. To this end , full use should be made of i nterpreters , bilingual and bicultural health workers and the migrants ' news media. Meetings with migrant groups allow their needs to eme r ge, avoiding the dangers of medicalizing the problems of adjustment. Traditional resource s should be used fully and alternatives to western medicine taken into account and recognized. In general, health planners should take into account the demographic characteristics of ethnic groups when allocating resources, paying particular attention to density, age and sex distribution. The needs of elderly and female migrants should be particularly taken into account. International aspects of migrant health care To achieve better health care for mi grants, cooperation among host countries, among countries of origin and between these two categories is essential at a governmental and nongovernmental level. An exchange of health educa tion programmes and information will overcome language difficulties and cultural barriers. It is recognized that some mig rants when elderly will return to their country of origin, and their health and welfare can only be protected if both countries take this into account when planning health policy. It has been discovered that some elderly migrants have in the past had the date of birth changed in their passports so that they appeared younger and more e l igible for immigration. Now when they reach the age of sixty-five, they cannot claim retirement benefits . The only way this dilemma can be overcome is by col laboration between the country of origin and the host. Illegal immigrants pose s pec ial health problems for both host country and country of origin because they are open to exploita tion in the work setting. The nature of their illegal status may lead to illness that the host country wil l find hard to trace and prevent, while the country of origin may for the same reason find that workers are returning ill. An international perspective and increased cooperation can combat the dangers of racism and also allow a more c ritical awareness on the part of the host country that what it sees as migrant problems could be problems of society generally. Recommendation l. International organizations and national governments should support more interdisciplinary and coordinated i n-depth studies of migrants' health, with special reference to mortality and morbidity by country of origin. 2 . The exchange of prograOJDes and information between countries should be promoted through their periodicals or by any other means, such as interdisciplinary meetings. 3. The WHO programmes on the health of the elderly, and the prevention and cont rol of alcohol and drug abuse shou ld give special attention to ethnic minorities . 4 . Illegal immigrants should be recognized as having special problems and migrants' health status should be given prior ity over any other status they may have. 5. National authorities should recognize folk medicine healers as trained workers and make an effort to integra te their skills into the ordinary health services. Seminar on Unemployment and Health - New Approaches in Research and Social Action Stockholm, 5-7 December 1983 - 224 - ICP / RPD 804(4)(S) 2909D 24 January 1984 ORIGINAL: ENGLI SH If there is one law in social and medical research, it is that if you put a group of researchers together in a room for two days they will spend at least three quarters of the time disagreeing. This Seminar was no exception. The participants approached the problem of unemployment and health from different backgrounds, with different theories, using different methods, and expressing different concerns. But behind the inevitable disagreement they reached considerable agreement, and it may help to begin by summarizing some of the key points. A broad measure of consensus existed on the following points. 1. The mismatch between the demand for, and the supply of labour is liable to persist for a long time and there is unlikely to be a return in the industrial world to the full employment known in the 1950s and 1960s. 2 . Unemployment is clearly implicated in the worsening of individual health and wellbeing. 3. This relationship reflects the particular circumstances associated with unemployment that produce stress, reinforce feelings of helplessness, and remove opportunities for individual growth and development: specifically, economic, financial and psychological circumstances. Some types of employment do the same, too, of course. 4 . The likelihood of losing a job and staying unemployed, the experience of the circumstances of unemployment, and the consequences for health of these circumstances are all related to existing patterns of social inequality. By and large, it is the most underprivileged who are most vulnerable to unemployment, and to its nega·tive consequences for health. S. There are measures that can be taken to change this situation, though the part1c1pants differed in the emphasis they placed on changing the causes of unemployment ( through job generation and reduced lifetime working hours, for example) or changing its circumstances. These types of intervention are not necessarily contradictory, indeed they may be synergistic. In terms o f long-term solutions they are certainly preferable to merely coping with the consequences for hea lth of the present state of affairs. To be more explicit about some of the different approaches adopted, it is useful to divide research strategies into three groups. The work done by Professor Harvey Brenner at Johns Hopk ins University is an example of a ggregate or macro sociological analysis: using national statistics to demonstrate, strikingly , that variations in unemployment are associated with subsequent va riat ions in mortality. This approach suggests that economic events out of the i ndividual's control do have negative impacts on health , but it does not tell us who is suffering these impacts. The second approach uses individual-level analysis , typically surveys or interviews. There has been a shift away from cross-sectional studies, comparing employed and unemployed people at one point in time, to more longitudinal studies, following individuals through their labour market experience. Several of these studies are now under way, some of them in Sweden. Almost universall y , these studies point to unemployment as being some sort of trigger for physical and psychological ill health in many people. No study has found unemployed people displaying on average better health, though several have found small numbers of unemployed people who are not so badly affected, who are making good use of their time, or benefiting from having left poor working conditions. Another shift in research has been a move away from merely describing the consequences for health of unemployment, to attempting to analyse the processes that are involved, by relating the particular circumstances of unemployment to its consequences. Economic, social and psychological circumstances have been shown to be important, and there is definite progress in the understanding of why this should be. One style of research that has yet to be developed extensively, and in a rigorous fashion, is intervention research, which aims at changing the circumstances of unemployment and thus its consequences . There are researchers and activists engaged in many interesting projects, and - 225 - proposing many more, but these social experiments have yet to be subject to a full evaluation. The discussion also suggested that there are other types of intervention, _that could benefit from investigation. These are directed at reducing or coping with the negative consequences of unemployment, because even if the aim is to achieve a situation where these are no longer produced, the problems already exist, are being produced daily, and will not disappear overnight. Let us first consider some of the shortcomings of the research discussed. First of all, most studies are too undifferentiated, and the exceptions generally prove the rule that issues that are being missed out are important. More attention needs to be paid to different social groups (such as women, the young, migrants, the elderly), different phases of the process of job loss and unemployment, and different structural features (e.g. the situations in different countries and towns, different labour markets, different periods of an economic programme). Most studies assume that what holds for one holds for all. But there are strong suggestions that vulnerability to the negative impacts of unemployment is not at all evenly distributed, just as unemployment itself is not. Second, most studies are too restricted. They focus on the unemployed individual, but the likely effects on the health of other family and even community members (other threatened workers, for example) are often disregarded. Rather few measures of wellbeing are used in most studies, and they focus mainly on ill health; the interruption of psychological development or health-enhancing behaviour should also be studied. While we are rapidly moving toward more explanatory analyses, there are still many studies just documenting the consequences of unemployment, too many simple •~ause and effect'' approaches that do not take a systems view and integrate structural factors into the analysis. There are also too few interaction studies being undertaken. Two major disagreements preoccupied the participants, although fundamentally there were few great divisions. On the one hand there was a dispute between those who stressed the negative consequences of unemployment now, and those who felt that those consequences were not inevitable and that by changing the circumstances of unemployment they could be avoided. Thus there was a contradiction between the view of the present, and the hope for the future. The second debate concerned how to move from the present to the future, and this time there were those who argued that the priority was to change the labour market so as to provide more employment , and those who argued that since unemployment is here to stay ways had better be found to help people make something out of it. Researchers find themselves on a tightrope: whatever they do, someone will say it is counterproductive and with some reason. If they show that unemployment has bad consequences for health, then they may contribute to medicalizing it so that it comes to be seen as a health problem to be handled by tranquillizers, etc. Even worse, they may add to the fatalism and despair of so many unemployed people, by leading them to expect to be ill, to believe that ill health is inescapable and they cannot do anything about it. If on the other hand they stress that there are ways of coping with at least some of the negative circumstances of unemployment and avoiding its worst consequences, then they may be accused of normalizing unemployment, of making the unbearable tolerable. Again, they may raise false hopes among the unemployed about how readily they can change their lives, leading them into ventures (such as starting new businesses or learning new skills) that do nothing for them in the end. These are real dangers, and were reflected in the disagreements in the discussion. In conclusion, it was suggested that, like many of the arguments of academics, the differences are less important than the areas of agreement. Surely the main issue concerns linking amelioration of the present with the vision of the future of work: the need to develop policies that can help transform working life in a desirable way in the long term, while providing support for the most vulnerable unemployed people today. It means providing support that enables these people to exercise more control over their lives, and to have more of a political voice in the future of working life. This will mean changing both employment and unemployment as we know them today, so that the benefits employment now offers will be much more evenly distributed in society, while the costs of both unemployment and employment will be substantially reduced . From the discussion, a number of priorities for the work ahead were identified. Ultimately, work is required on changing the circumstances of unemployment, and the ways in which it has negative consequences, so as to determine how better relations between work and nonwork, unemployment and employment can be acquired, so that economic growth can be directed towards human development, not just economic development. Ways need to be found to protect the most vulnerable from becoming the group paying the heaviest costs for the structural adjustments that seem to be inevitable. Researchers have the important tasks of expanding their knowledge and raising the consciousness of policy-makers, professionals and the public about the problems and possibilities involved. - 226 - The main conclusions and recommendations are as follows: Prospects for employment and unemployment Present Future Prospects for unemployed people, circumstances and consequences of unemployment Present Future Positive · factors The cyclical recovery is resulting in some growth in employment and a demand for new technology skills There is some trend toward reduced working hours The upturn of the "long wave" may possibly lead to renewed growth Political movements are pressing for changes in working hours, socially useful protection , and new services and infrastructure A small proportion of the unemployed benefit from free time and can redirect their lives There is more social accept - ability and less stigma for the unemployed There are a growing number of social interventions and self-help groups There will be continuing initiatives by and for un- employed people , opportuni- ties to learn from experi- ments, to increase skills, competence and the power of the unemployed There will be the possibi- lity of increasing profes- sionals' knowledge and sensitivity Negative factors The recovery is likely to be limited , and anyway confronts high levels of unemployment and deprivation There is a growing number of long-term unemployed Work is insecure and intensified There is the threat that in- formatics will mean that future growth will create few jobs There is pressure to reduce public services, and pressure on working conditions and a polarization of the occupa- tional structure Economic , social and psycho- logical deprivation is wide- spread among the unemployed There are political attacks on the unemployed and on benefits There is limited access to and knowledge of actual or possible alternatives to employment There is a maldistribution of welfare resources A lack of solidarity and the fragmentation of communities may grow There is a threat of lower benefits and services, and the medicalizing of the growing problems of unemployed people Unemployed people may be in- creasingly cut off from new technologies and processes Finally , the main recommendation to Member States is chat the i ssue of unemployment and health should be considered as a topic for the technical discussions during one of the forthcoming sessions of the Regional Committee . The intention is to put more focus on this subject and help governments in their task of overcoming and preventing the effects on health created by unemployment. - 227 - WASTE MANAGEMENT - 229 - Working Group on Hospital Waste Management Bergen, 28 June - 1 July 1983 Introduce ion ICP/RCE 401(4}(S) 19901 27 July 1983 ORIGINAL: ENGLISH The meeting was attended by 34 participants, including medical specialists, scientists, engineers and administrators from 19 countries . The purpose of the meeting was to review recent developments in the handling, transport, treatment and disposal of waste from hospitals and other health care facilities and to prepare guidelines on the subject for use by administrators, engine ers and others concerned in industrialized countries . The unique hazard of health care waste is its potential for transmitting infection . A small quantity of flarrunable and toxic chemicals and some low-level radioactive waste is also generated . Nevertheless, more than half the waste, including that from food services, is no more hazardous than general municipal waste. Discuss ion The Group agreed that three principal aspects of the subject should be considered: the health of personnel and patients in health care facilities; the risks to the health of the public arising from the transport and disposal of infectious and hazardous waste; the environmental and economic effects of waste disposal methods. The term "waste" should include any type of waste generated in health care facilities, including aqueous and other liquid wastes. Both the internal and external aspects of waste disposal should be considered, but the organizational and legislative arrangements of municipal and other envi r onmental authorities concerning waste disposal were not within the scope of the Group's deliberations . Although the original terms of reference of the Group referred to "hospital waste", it was considered that a more suitable term was "health care facility waste", as infectious and other hazardous or obnoxious waste arises in several kinds of health care facility. The Working Group considered specific aspects of its terms of reference as follows. Categories of waste Waste-generating facilities Radioactive waste Legislative, administrative and economic aspects Health care waste categorized by source Occupational hazards and risks to health Handling, storage and transport Treatment and disposal Regional planning and the planning of waste handling in new or renovated buildings Incineration and associated equipment Training and supervision The impact of health care facility waste on human health and the environment The outline of a proposed code of practice Handling, packaging and storage of chemical waste - 230 - Conclusions and recommendations 1. Waste from health care facilities should be c lassified into eight main categories: general waste pathological waste radioactive waste chemical waste infectious and potentially infectious waste sharps (any sharp waste item such as a syringe or broken glass that can cause a cut or punc cure) pharmaceutical products pressurized containers. 2. Low-level radioactive waste should be allowed to decay to a non-hazardous level and then disposed of by the method appropriate to the sort of waste it is then defined as (chemical, infectious or general). 3. Hospitals and other health care facilities should be legally accountable for their waste management practice . 4. People at risk from infectious and hazardous waste were categorized as: personnel and patients in health care facilities personnel employed by waste transport and disposal contractors the public . 5. Resea r ch and development should be instituted into automation and enclosure technology to protect these groups who should also be given appropriate information and training . 6. Was te s hould be segregated according to the required handling methods and hazard characte ristics and identified by colour-coded packaging and nationally accepted symbols. Efforts shou ld be made to develop internationally accepted standards for colours and symbols. 7. Waste dis posal policies and methods should be designed to minimize the pollution of air, water and land. 8 . Policies on the location of waste treatment and disposal sites will vary with local circumstances . Treatment and disposal can be carried out on a hospital site for a single hospital or at a central location for a gr oup of health care facilities. External treatment and disposal facilities may also be used, where appropriate. 9. Incineration is the most effective way of disposing of most non-recyc lable waste. 10. All health care facilities should prepare written policies on their waste handling procedures. Training based on these policies should be given to the personnel involved. 11. Chemical waste should be minimized by reducing as far as practicable the use of chemicals in health care facilities and by substituting non-hazardous chemicals for hazardous ones whenever possible. Chemical waste should be recycled whenever feasible. Disposal should be by incineration or, alternatively, the waste may be handled and disposed of by an authorized professional waste management organization . 12. It would be useful to draw up a code of practice on the management of health care waste, for which an outline has been prepared by the Group. 13. A follow-up activity should take P,lace directed specifically at the use of incinerators on a regional, on-site or collective basis. - 231 - WOMEN AND HEALTH Conference on Women and Health Edinburgh, 25-27 May 1983 Introduction - 233 - ICP/MCH 030(5) 1599F 11 August 1983 ORIGINAL: ENGLISH The Regional Office for Europe of the World Health Organization (WHO) and the Scottish Health Education Group (SHEG) jointly sponsored a three-day Conference on Women and Health, This international, interdisciplinary Conference was attended by approximately 150 people from 26 countries in the European Region. They included: researchers concerned with the basic conditions of women, and demographic and structural issues; activists from both the women's health movement and various community health projects; health educators and policy-makers concerned with the theory and practice of accomplishing c hange; and representatives from WHO and SHEG who played a mediating role. The Conference on Women and Health was one manifestation of the contribution of the WHO Regional Office for Europe to the second half of the United Nations Decade for Women and the United Nations World Plan of Action. The purpose of the Conference was to create a dialogue among people with different expertise on the issues of women and health in the European Region, to report on what is at present being done and to develop strategies for future action. Discussion The Confe rence s tarted with a ge neral analysis of the social, economic, political and st ructural aspects of health issues and graduall y focused on issues and strategies specific to women. The first day was allocated to the f actors in the structure of society that affect the health of women. They were discussed from the point of view of epidemiology, demography, culture, politics, society, economics and the health services. Having created a socially based context for further discussion, the part1c1pants spent the second day dealing with specific health-related issues. Some a reas of special concern were: women and medicalization, fertility control, alcohol and drug abuse, sexuality, violence and women, women and employment, women and disability, mental health and aging. On the third day the participants considered strategies for action in the future and the exploration of new and alternative approaches in health promotion/education activities. The positive approach to health and appropriate lifestyles was emphasized. Selected recollllllendations General 1 . Governments and WHO should be asked to support health education and prevention programmes for women . 2. Easily administered funding should be available to self-help groups and the networking among such groups should be developed, - 234 - 3. The decision-making process in health-related issues should include consumer participation at all levels of government. 4 . Women should be involved i n all levels of policy development, research programmes and evaluation, and the setting of priorities in all aspects of health and medical care that affect women. Specific l. Pilot studies should be ca rr ied out to test forms of health care, such as birthing centres, that offer an alternative to stand ard hospital c are. 2. The role of fathers as well as mothers in child rearing s hould be recognized a nd supported through appropriate legislation and fiscal measures. 3. Further research is needed into the fac tors affecting the health of aging women. 4. Information should be collected and disseminated for women migrants i nforming them of their rights, status, etc. 5 . Funds s hou ld be made available fo r research and analysis by women' s groups on female sexua l ity . 6. Separate fertility regula tion servi ces should be designed that a re appropriate to the particular needs of adolescents. 7 . International guidelines s hou ld be establis hed regarding the adve rtising of drugs a nd investigations ca rried out into the increasing prescription of tranquillizers and mind-altering drugs for women. 8, Research should be carried out into the long-term effects on women of various obstetric and other medical interventions. 9 . Educational prograrmnes should be supported for the entry and re-entry of women into the labour market. 10. Guidelines s hould be produced for doctors and other individuals dealing with women who are the victims of violence. 11. Housework s hould be considered an occupation and research carried out on morbidity patterns related to housework as opposed to work outside the house. A controlled evaluation should also be made of new tech nologies that affect women's health at home, at work and in health care. 12. The arbitrary censorship of health education material written by lay and professional women for other women should be eliminated. 13 . Funds s hould be made available for innovative media programmes on women's health topics.