World Health: the magazine of the World Health Organization: October 1987 [full issue]: the Americas

HI AITH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · OCTOBER 1987 The Americas Eighty-five Years of Dedication by Dr Jorge Osuna riginally, international coop- eration in the health field was aimed at protecting the populace from the risk of illnesses brought in from other countries. Thus, in the United States during the nineteenth century, several episodes of cholera broke out, traceable mainly to European im- migrants, and yellow fever was in- troduced through maritime contacts with Central and South America. The first efforts to arrive at interna- tional quarantine agreements re- garding cholera were initiated in Europe during the 1851 meeting in Paris of the First International Sani- tary Conference. By 1901, the etiology and method of transmission of cholera, yellow fever, and plague had been clarified sufficiently to permit the testing of methods of control, as was discussed at the Second Inter- national Conference of American States, held that year in Mexico. The conferees decided that the Ad- visory Board of the International Union of American Republics (to- day, the Organization of American States) should convene health administrators from all over the hemisphere to formulate "agreements and regulations " to assure that "the requirements of quarantine be reduced to a minimum" in relation to cholera, yellow fever , bubonic plague, and "any other serious epidemic". This group was also asked to "designate an executive committee of not less than five members" to be called the International Sanitary Bureau and headquartered in Washington, DC. That is how the First General Inter- national Sanitary' Convention of the American Republics came to be held in December 1902, at the Wil- lard Hotel in Washington, DC. This was the first in a series of meetings which later came to be known as Pan American Sanitary Confer- ences and which were held every four years. It should be pointed out that, during the early beginnings of the 2 Pan American Health Organization (PAHO), the political process was what gave birth to the technical process. Policy first grew out of humanitarian and economic con- siderations targeting control of cer- tain infectious diseases that not only produced high morbidity and mortality, but interfered with inter- national commerce as well. This approach has been sustained by PAHO throughout its long history. Prepared at WHO's regional office in Washington, World Health this month looks at the history of collaboration in pub- lic health in the Americas . Although cooperation in the fields of science and technology has often influenced policy decisions at the national level, the Organization has always promoted health develop- ment as part of economic progress and social welfare. During recent years, the Director of the Organiza- tion, Dr Carlyle Guerra de Macedo, has added a very important compo- nent which is the contribution of health towards establishing peace among peoples. The recommendation that the International Sanitary Bureau be located at the International Of- fice of the American Republics (Panamerican Union) was approved at the Fourth International Confer- ence of American States, held in 1910 in San Jose, Costa Rica. The Fifth International Confer- ence of American States, meeting in Santiago, Chile, in 1923, decided that from henceforth the meetings should be called " Pan American" rather than "International", a change which would apply also to the International Sanitary Bureau. The Seventh Pan American Confer- ence was held under this new name in Havana, Cuba, in November 1924. The Pan American Sanitary Code signed at that meeting set international quarantine regula- tions for air and maritime travel among countries of the Americas and specified the "functions and duties " of the Pan American Sani- tary Bureau. These included collect- ing and analyzing data about trends in illnesses prevalent in the region and informing member govern- ments about scientific advances and the results of experiences in health development. In 1947, the XII Pan American Sanitary Conference decided to firmly establish the identity of the Pan American Sanitary Bureau through the creation of the Pan American Sanitary Organization consisting of four bodies : the Pan American Sanitary Conference, the Directing Council, the Executive Committee, and the Pan American Sanitary Bureau. In this way, the Bureau became the headquarters and secretariat of the regional or- ganization. In 1949, the Second World Health Assembly ratified the agreement signed between the Di- rector-General of the World Health Organization (wHo), Dr Brock Chisholm, and the Director of the Pan American Health Organization (PAHO), Dr Fred Lowe Soper, ac- cording to which the Directing Council and the Pan American Sanitary Bureau would act, respec- tively, as WHO's Regional Commit- tee and WHO's Regional Office in the Western Hemisphere. Over time, concern for infectious diseases gave way to a more gener- al focus on international health ac- tivities, and improving the health of all the people became the main goal. From there, it can be said that the Americas became a world van- guard in developing international cooperation on health matters, achieving important progress in many fields: protection of the envi- ronment, especially the physical en- vironment; strengthening health service systems at the national and local levels; improving the institu- tions involved in training health personnel; and promoting col- laborative research aimed at broadening scientific horizons and W oRLD HEALTH , October 1987 A young Colombian boy symbolizes the hope for the future of the people of the Americas. PAHO/WHO Photo by Julio Vizcarra stimulating information exchange. Furthermore, the countries have been fostering technical coop era- tion through Specialized Regional WoRLD HEALTH, October 1987 Centers and advisory assistance to governments. In an editorial in the May 1972 Pan American Sanitary Bureau Bul- letin commemorating a half cen- tury of publication, Dr Abraham Horwitz, then Director of the Or- ganization, stated that "Health as science and art has become diver- sified over the last fifty years, Cover: A Guatemalan woman from the Lake Atitlan region reminds us of the colorful diversity to be found i.n the 'American continent. PAHO/WHO Photo by Carlos Gaggero IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor : Christiane Viedma Editor: Peter Davies News Page Editor : ·Peter Ozorio World Health appears ten times a year in English, French, Portuguese. Russian and Spanish, and four times a year in Arabic and Farsi. The German edition is obtainable from: German Green Cross. Scnuhmarkt 4, 3550 Marburg. FR·G. Articles and photographs not copyrighted may be reproduced provided credif is given to the Worlcl Health Organization. Signed articles do not necess· arily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Eighty-five Years of Dedication by Jorge Osuna . . . . . . . . . . . . . 2 Health as a Bridge for. Peace by Mark L.. Schneider . . . . . . . . . . 5 The Need to Know by Jose R. Ferreira . . .. ....... , 7 Health Prpblems Old and New by A. Alleyne . . . . . . . . 9 Water, Source of Life by Horst Otterstetter and Alberta Flores . . . . . . . . . . 11 Children of Latin America and the Caribbean Eisa M. Moreno, Nestor Suarez and Giro de Ouadros . . . . . 14 Health for: All in the Americas . . . . . . . . . . . . 16-17 Disaster Preparedness in the Americas by Claude de Vi lie de Goyet , . 20 Health Services for All Jorge Osuna . . . . . . . . . . . . . 23 The Challenges Ahead by Carlyle Guerra de Macedo .. . . . 26 30-31 3 Eighty-five Years of Dedication extending its reach from molecular biology to social biology. We be- lieve the root of life as well as the destiny of every human being is to engage in work; we understand it as the framework for happiness, as a stimulus and component of economic development; we experi- ence it as the goal of every indi- vidual and a means to social wel- fare. " The breadth of his conceptu- al framework and the dynamism of his remarks are characteristic of the historic evolution of cooperation among the countries of the Americas, as they searched to- gether for ways to improve the health and well-being of their popula tions. According to the basic premises of the Punta del Este Charter, which was signed in 1961, " public health programs are essential and complementary to economic ones." Member governments approved the Ten-Year Plan for the 1960s, in which they pledged to establish na- tional health plans and recom- mended to PAHO that it undertake the responsibility for advising coun- tries on how to best prepare their plans and implement them. The Ten-Year Health Plan for the Americas, formulated for the Third Special Meeting of Health Ministers in Santiago, Chile in 1972, repre- sents the culmination of a series of coordinated efforts undertaken by countries of the region to improve their citizens' health. This plan is more detailed than the previous one and includes concepts, mea- surable objectives, methods of achievement, and implementation programs. At the IV Special Meeting of Health Ministers of the Americas, which took place at PAHO Head- quarters in September, 1977, the 28 member governments of the Or- ganization reported on national health service coverage, and of- fered strategies for further expan- sion and improvement based on a document made available by PAHO entitled "Expansion of Health Ser- vices Coverage, Strategies for Prim- ary Care and Community Participa- tion". The national strategies that emerged in the reports indicate a realignment in terms of internation- al cooperation, and the reports express unanimous agreement to share experiences and resources within the region. 4 To meet the agreements and mandates coming out of the World Health Assembly of 1977, when the goal of Health for All by the Year 2000 was set, PAHO's Directing Council - in 1982 - approved a plan of action to implement corres- ponding Regional Strategies. More recently, in October 1986, the XXII Pan American Sanitary Conference approved a document entitled " Orientation and Program Priorities for PAHO for the Period 1987-1990", which offers several focal points for the reorganization of national health systems: - development of a health ser- vice infrastructure, emphasizing primary care ; - attention to priority health prob- lems appearing in vulnerable human groups by establishing specific programs to deal with them; and - information management to bring about the foregoing, mak- ing optimum use of the resources of PAHO/WHO. The Director of the Pan Ameri- can Health Organization, Dr Car- lyle Guerra de Macedo, summarizes the significance of this resolution as follows: "At this turning point in the history of the countries of the Americas, marked as it is by pro- found economic and political crises, the role of international organiza- tions becomes even more crucial. The Pan American Health Organi- zation, through increasing involve- ment in consultation and participa- tion with governments of member countries and increasing awareness of the challenges implied, has been able to define the main criteria and priorities underlying its policies of technical cooperation to fit with the current developmental stage of the countries and their needs, within a framework for collective decision making for the region. " Despite economic recession, along with structural readjustments, explosive population growth, and extreme diversity-geographic, cul- tural, and epidemiologic-the prin- ciples and methods espoused by PAHO still manage to address preva- lent health problems, offer modern techniques to reduce their impact, concentrate resources on groups at greatest risk of illness and death, and provide prevention and prim- ary care as part of an organized system of health service delivery. • "rs entral America" conveys an image of internal violence, in- ternational conflict, and hu- man misery. Those images unfortu- nately are all too real ; but there also is another reality in the field of health, one of international cooper- ation, intrasectoral collaboration and intersectoral coordination. It is called "Health as a Bridge for Peace". This subregional initiative was launched three years ago by the seven nations of the Central Ameri- can Isthmus working together with the Pan American Health Organiza- tion, the regional arm of WHO in the Americas. PAHO/AMRO was asked by the governments of Belize, Cos- ta Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama to help coordinate this joint effort. Four examples will demonstrate some of the consequences of that decision: - Each of the past three years, a temporary cease-fire has been de- clared in El Salvador between gov- ernment and guerrillas to permit a three-day nationwide immuniza- tion campaign to be carried out throughout the country. More than 200,000 children and mothers have been vaccinated each year as the church, private voluntary groups, the press, PAHO/AMRO, UNICEF, Rotary International, and several donor nations joined in these cam- paigns which were led by the Minis- ter of Health. - For more than three decades, the Ministers of Health in Central America and Panama had met each 1 year to share common concerns -but Belize had never been in- cluded, nor had any other entities from the health sector participated. Through this subregional initiative, Belize was included and the annual event also matured from a gather- ing of the ministers of health to a meeting of the health sector, with the full participation of the directors of the Social Security Institutions. WoRLD HEALTH, October 1987 llth as a Bridge for Peace by Mark L. Schneider - Although recent conflicts had strained international dialogue, the initiative spurred cooperation be? tween all countries of the region, including formal agreement be- tween the Ministers of Health of Honduras and Nicaragua to conduct joint border monitoring to prevent the spread of malaria and other tropical diseases, mutual spraying in malaria endemic areas by Nicara- gua and Costa Rica, and dozens of training and technical cooperation exchanges among the countries themselves and also with their neighbors. - Last year, in the first joint pur- chase from the revolving fund for the procurement of essential drugs sponsored by the initiative, the countries obtained some 17 drugs more than 300 per cent cheaper than each had purchased the same drugs separately the previous year. The five-year initiative was a product of the spirit of Contadora, the cooperative venture by other Latin American nations to try and promote peace and development in that strife-torn subregion. Conta- dora found the underlying causes of the political and ideological conflicts to be the conditions of social and economic injustice, them- selves the bitter legacy of undefdevelopment. AMRO Regional Director Carlyle Guerra de Macedo, who is also PAHO Director, said, "Health was the one area where everyone could agree, the one goal which overrode ideological . differences, the one field where there wasan impressive tradition of Central American coop- eration and the one sector where a, common long-term ideal, Health for All by the Year 2000 already was shared''. The subregion<il initiative an- nounced in September 1984, spur- red a series of Central American technical meetings with PAHO/AMRO. UNICEF was brought into the pro- cess. Other sectors were advised and involved. The seven Ministers W oRLD HEALTH, October 1987 met and decided that the initiative, whose formal name is "Priority Health Needs in Central America and Panama" would concentrate on mothers . and on children aged under five, on refugees and dis- placed persons, and on the urban and rural poor. Its seven priority areas of action would be strengthening health ser- vices, developing human resources, essential drugs, food and nutrition, control of tropical diseases, water and sanitation, and child survival. A refugee camp in Central America, where the "Health, a bridge for peace " initiative is promotingcooperation to improve health. PAHO/WHO Photo by Carlos Gaggero Objectives, strategies and ac- tivities were defined in each area, and then two kinds of projects de- veloped-subregional projects and complementary national projects. The Ministers voted that the sub- regional projects were the highest priority because they carried the dominant theme, in addition to health development, of subregional . integration, promoting internation- al understanding and solidarity, and through those results, it was hoped, advancing the cause of peace. Some 30 subregional projects were designed along with 293 na- tional projects as each nation estab- lished a national intersectoral com- mission to work on each priority area. A second round of review refined the projects, established priorities and developed the first package of 123 national projects and 29 subregional projects to be presented to the international com- munity for support. Endorsements in the Americas came from the Presidents and For- eign Ministers of the participating countries, as well as from the Con- tadora countries and the Contadora Support group. Formal approval was certified by resolution of the Directing Council of P AHO which is the Regional Committee of WHO. In the global arena, the World Health Assembly heard the plan presented by a unified Central American delegation, and adopted resolutions of support and exhorta- tion to its members to translate that political commitment into material and technical support. President Felipe Gonzalez of Spain responded immediately by agreeing to host an international pledging conference for the Plan in November 1985. The conference was attended by thirty-two nations from Europe, as well as Japan, the United States, Canada, the Holy See and a host of international and regional organizations. In the narrow sphere of mobiliz- ing external resources, more than US $100 million has been commit- ted by a dozen donors, including Scandinavian and Western Euro- pean countries, the US, the EEC, the Inter"American Development Bank and UNDP for 19 multi-year subregional projects; another $255 million was approved by those and other European and North American donors for nation- al projects. More than 90 projects are underway with that external financing, and with national and TCDC support. Perhaps even more important, the initiative has sparked an array of technical cooperation links throughout the region. The Presi- dent of Colombia sponsored a re~ 5 Health as a Bridge for Peace gional gathering of Contadora and Contadora Support Group coun- tries which yielded new commit- . ments for the sharing of training, research, and collaboration with the countries of Central America and Panama. PAHO/AMRO has selected subreg- ional initiatives like the five-year Central American endeavor as a flexible and powerful vehicle to convey the Organization's manage- rial strategy for the optimum use of P AHO/WHO resources to the countries. It has concentrated on the coun- tries as the key participant in the design of the Organization's techni- cal cooperation and enhanced the role of the Ministries of Health in defining national health priorities, in setting national social objectives, in coordinating external resources, in promoting national awareness of health goals, and in mobilizing na- tional resources to meet those goals. P AHO/ AMRO also has become a far more active and involved actor helping to mobilize national and external resources to respond to the subregional and national needs con- tained in the overall Plan. Also, both the nations and PAHO/AMRO have garnered new knowledge in the design, promotion and exe- cution of health development projects. The Central American initiative already has become the inspiration for the launching of a similar Carib- bean subregional initiative, "Carib- bean Cooperation for Health", and Andean and Southern Cone pro- jects also are being planned for the countries comprising those subreg- ions of the hemisphere. This imaginative venture has also cloned a similar endeavor in the areas of education and housing .. Under the aegis of the Organization of American States (the Western Hemisphere's regional political body), the Inter-American Devel- opment Bank and PAHO/AMRO, a program for social investment in Central America and Panama has come into being. As was done with the subregional health initiative, national coordinators have been named, subregional meetings have been held, and both subregional and national development projects are under preparation. • 6 WoRLD HEALTH, October 1987 The Need to Know by Dr Jose R. Ferreira ~ m proving the health of the population as a whole requires the delivery of services based on mastery of already available know- ledge, whether scientific and tech- nical or political, social, and economic. This statement is neces- sarily broad because of the com- plexity represented by the multiple efforts of research, dissemination, and transmission of knowledge, a process which, in the health con- text, has been called "information management". Outcomes and Research The information management process requires countries to take charge, first of all, of diagnosing their own situation and organizing to improve their information sys- tems and their capacity for analysis in overall socio-economic terms, as well as in relation to health care in particular. More specifically, there is a need to strengthen capacity in the areas of analysis of national policy and the financial sector and to probe in depth the factors pro- moting efficiency and efficacy in health interventions in order to bet- ter serve the whole population. Other priorities include biomedi- cal research related to hygiene and public health, as well as studies on nutrition, infectious diseases, en- vironmental protection, and the problems of high risk groups, such as children, women of childbearing age, workers, and the elderly. Re- search in the area of child survival is another priority. Efforts so far have come out of the universities and national re- search institutes charged with fos- tering scientific development. The Pan American Health Organization (PAHO)-the regional office of the This young Central American girl may be the ultimate beneficiary of joint health action by the seven nations of the Central American isthmus. PAHOIWHO Photo by Carlos Gaggero WoRLD HEALTH, October 1987 World Health Organization (wHo)-has pulled together all these initiatives, supporting national in- stitutions and projects in specific fields and developing such multina- tional centers as the Institute of Nutrition of Central America and Panama located in Guatemala, the Caribbean Food and Nutrition Insti- tute in Jamaica, the Pan American Foot and Mouth Disease Center in Rio de Janeiro, the Pan American Zoonosis Center in Buenos Aires, the Pan American Center for Sani- tary Engineering and Environmen- tal Sciences (CEPIS) in Lima, the Latin American Center of Perinatology in Montevideo, and the Caribbean Epidemiological Center in Port of Spain. The Organization's efforts have been concerned mainly with carry- ing out research, as well as lending support to particular projects and training specialized personnel, in- cluding strengthening the capacity to stimulate development of new knowledge and to critically analyze it, always with reference to the actual situation of the country in- volved. A case in point is the cur- rent effort to foster countries' capacities to evaluate new tech- nologies applicable to health care and therapy which are sometimes of disputable value, contributing unnecessarily to the high cost of health care. Data Collection and Dissemination These provisos notwithstanding, essential health information, whether produced in more de- veloped or developing countries, will be useful only to the extent that there are adequate mechanisms for its documentation and dissemina- tion. With exponential growth in the order of 6 to 7 per cent per year, the body of biomedical and health literature and data will dou- ble every 10 or 15 years, providing an immense challenge in terms of information management. The United States, through the National Library of Medicine, has made a landmark contribution in bringing together the largest collec- tion of medical literature in the world and developing an efficient reference system, the Index Medicus. In addition, through the application of modern technology, it has created MEDLARS, a corn~ puterized system for analyzing and retrieving the entire biomedical bibliography. PAHO, with the support of that library and national libraries, has been able to establish a Regional Library of Medicine (BIREME), de- signed to serve all of Latin America, and located in Siio Paulo. This lib- rary, by incorporating the same computerization system, was able to develop a Latin American Index Medicus and create an information network with more than 400 par- ticipating libraries. In addition, two specialized information systems have been created: the Pan Ameri- can Network of Sanitary Engin- eering and Environmental Science Information and Documentation, headquartered at CEPIS in Peru, which represents about 200 centers, and the Latin American Cancer Re- search Project (LACRIP), an inter- national computer network con- cerned with collecting and dis- seminating up-to-date information on cancer. So far these technologies, which permit on-line utilization of inter- national data banks, are accessible only through satellite telecommuni- cations networks, such as is the case with LACRIP, which usually in- volves considerable cost. The Or- ganization is working on an alterna- tive which will initially rely on the facilities of BIREME and CEPIS, eventually going to other general information sources. The new sys- tem uses compact video disks hooked up to a personal computer to gather and manipulate large vol- umes of information and dissemi- nate it cost-effectively throughout the affiliated network. This system 7 A network consisting of more than 1,500 Latin American institutions helps the countries carry out training pro- grams, such as this laboratory course in Trinidad and Tobago. PAHO;WHO Photo by Jul io Vizcarra also offers the advantage of large capacity, since each compact disk may contain the equivalent of one thousand books of 200 pages each. This mechanism is designed to open access tci sources of knowledge, not only to the health library network, but also at the level of health ser- vices and, eventually, to the profes- sional caregiver. In order to facilitate the exchange of information between countries, the language barrier must be over- come. To deal with this situation, PAHO came up with another innova- tive initiative to promote the devel- opment of a computerized English/ Spanish translation system. The process, now in full operation, overcame the dilemma of different 8 interpretations by incorporating a dictionary of phrases which shows the multiple meanings of each word. Transmission and Training The creation of effective informa- tion management mechanisms al- lows the possibility of further trans- mission of this knowledge and of stepped-up staff training efforts. A network has been formed consisting of more than 1,500 Latin American institutions engaged in training pro- grams for 100,000 specialized per- sonnel each year in various health fields. The Organization's efforts range from the promotion of human resource planning and surveys of the health care job market to setting standards of operation for the train- ing network as a whole and lending institutional and program support. The focus has been on promoting the design and establishment of The Need to Know new educational centers, the revi- sion and upgrading of professional courses of study, faculty training, and methods development, along with the collection, production, and distribution of educational material. Professional training is being reor- ganized according to the goal of Health for All by the Year 2000, with an emphasis on the expansion of primary health care. Regarding this educational effort, it should be pointed out that the public health training approach has been adopted by 24 US and 13 Latin American schools of public health, in addition to 16 graduate programs in community and social medicine, as well as several short- term core courses and specialized residencies in health administra- tion. More recently, in Latin Ameri- ca a series of ten Regional Programs of Animal Health Training have been established which combine the resources of public health training centers with those of health care training facilities, reinforcing their strategic planning component. Most of these programs, mindful of the commitment to Health for All, have stressed the need to reor- ganize health delivery systems as well as leadership and advanced training in order to strengthen the decision-making process. Special emphasis has been placed on what has been called "the multidimen- sional focus of epidemiology", which covers not only traditional monitoring and control of infectious diseases, but also everything rela- tive to health analysis and evalua- tion of health services to serve as a basis for health planning and monitoring in all aspects of disease control, both acute and chronic, infectious and degenerative. In this advanced formulation, it is important also to elaborate on in- terdisciplinary relationships in or- der to treat health within its broader social context, considering the implications for other fields in terms of responsibilities and out- comes. Therefore, all aspects need to be considered: educational, ad- ministrative, legal, economic, and political to assure future leaders the knowledge they need to enlarge the dialogue in favor of health develop- ment, reduction of dependency, and promotion of an attitude of confidence and determination to move ahead. • W oRLD HEALTH , October 1987 Health Problems Old and New by George A. 0. Alleyne 11 he developed countries of the world have passed through three distinct stages of health problem evolution and resolution. The first saw a concerted attack on infectious diseases, the ravages of severe under-nutrition, and poor sanitation. This was the golden age of dramatic health breakthroughs when progress could be seen, mea- sured, and appreciated. Antibiotics, immunization, water purification, and improvements in diet con- verged to produce a generation of healthy children, most of whom survived to adulthood. The next stage focussed on chronic, non-contagious conditions such as heart disease, cancer, and diabetes. A sophisticated, tech- nologically-based health industry arose, more concerned with saving individual lives than with promot- ing health. The third and latest phase has been marked by attention to life- styles and environment. National health planners have become in- creasingly aware of the health ef- fects of social pathology, such as substance abuse and traffic accidents. Movement through all these phases may have taken developed countries a century to accomplish. However, an accelerating rate of change has now forced developing nations to confront the problems of all three stages simultaneously. Traditional scourges remain ram- pant, while instant worldwide com- munications about new or exotic ailments create panic in areas where health resources might be better devoted to more basic needs. Demographic trends Apart from infection patterns and environmental influences, economic difficulties and shifts in a population's age composition both have substantial impact on the type and frequency of health problems encountered. In Latin America, par- ticularly, decreased infant mortality W oRLD HEALTH, October 1987 and longer life expectancy have increased the proportion of both adolescents and the elderly. These trends, coupled with rapid urbani- zation, have further taxed the capacities of existing health care facilities. Within the burgeoning cities, three major problem groups emerge. Malnutrition remains a problem in many developing countries, while sophisticated, technologically-based facilities form part of an industry more concerned with saving lives than with promoting health. PAHO/WHO Photo by Jul io Vizcarra 1. Youth-In 1985, the 15-to- 25 age group comprised fully one- fifth of Latin America's population, the majority living in urban areas. In countries where as many as 85 per cent of this youthful group are city residents, accidents are their leading cause of death. While it is normal for adolescents to ex- periment, their involvement with sex, alcohol, and drugs can have serious health repercussions. Un- wanted pregnancy remains very much a problem, with pregnancy rates for women aged 15 to 19 running as high as 86 per 1,000 in certain countries. In at least three nations of the region, abortion is the leading cause of death for this group. Suicide and homicide also take a large toll among youth. 2. The urban poor-Like other parts of the world, Latin America is experiencing considerable popula- tion growth, mostly in urban areas. In several Latin American countries, over half the population now lives in municipalities with more than 100,000 inhabitants, compared with only 15 per cent in Asia. This Latin American urbanization has a predo- minantly youthful character. While theoretically a concentra- tion of people in urban settlements should facilitate delivery of health care services, this is not always the case. Inhabitants of large cities suf- fer from high rates of malnutrition, violence, poor medical care for mothers and children, and illnesses associated with unsatisfactory wa- ter and sanitation services-in short, from all the health problems of social marginality. Cities are not just concentrations of people, but of health problems. 9 Health Problems Old and New 3. The elderly-Whereas expo- nential growth among adolescent and urban populations is mainly characteristic of Latin America and the Caribbean, an increase in the number of senior citizens is occur- ring throughout the Americas. In the period from 1980 to the end of this century, the number of persons aged 60 to 69 in Latin America and the Caribbean will rise from 14 million to 23.5 million. In 1900, only 4.1 per cent of United States' residents were over 65, whereas by 1980 the figure had risen to 11.3 per cent. This rapid "greying" of the population affects patterns of dis- ease as well as of health care deliv- ery. Since the elderly are more prone to chronic ailments, most countries are gearing up for higher expenditures and a different mix of health services. The high cost of caring for the aged in developed nations, due partly to expensive technology, has provoked alarm in developing countries. While these cost concerns are understandable, the social aspects of changing na- tional age profiles also need to be considered. To get a better handle on all aspects of the situation, the Pan American Health Organization is promoting collaborative research on the needs of the elderly in ten nations of the region. However, all countries in the region will have to make long-range policy decisions about what services to provide, and how best to care for those elderly institutionalized for medical or so- cial reasons. The countries of the Americas also have to address a phenomenon occurring with in- creasing frequency, that of elderly people burdened with the care of their very old parents. Vector-borne diseases A health problem dating back to Biblical times is that of insect-trans- mitted-or vector-borne-diseases. Of these, malaria in particular has been a persistent plague which shows no signs of abating. Coun- tries in the hemisphere accept that wiping out malaria in the foresee- able future is not feasible, and have opted instead for a strategy of con- tainment based on epidemiological approaches which examine people in their environment over time in 10 order to focus interventions where they are likely to be most effective. The situation does appear to be stabilizing somewhat, with 884,000 cases of malaria being reported in 1985, compared with 830,000 in 1983. However, Brazil and Guyana are still showing steady increases and the outlook for eradication or even a reduction in overall inci- dence is bleak, in the light of di- minished national and international resources being allocated to the problem. What is more, too little attention has been paid to indirect influences on patterns of disease transmission, whether the introduction of new systems of mining and agriculture or stepped-up migration within and between countries due to social and political upheavals. How people live, their income level, and where they travel all are factors affecting the spread of malaria. Although a vaccine may be in sight, the best near-term strategy is one based on sound epidemiological methods, in- cluding the incorporation of now- separate malaria-control efforts into general health services. The difficult question is how to do this when general health services are already overextended in areas where the disease is most rampant. Drug resistance presents another dilemma in malaria control. A number of strains are now resistant not only to the usual chloroquine, but also to dehydrofolate reductase inhibitors and even to potentating compounds of these with sul- fanamides or sulphones. There- fore, the search for new drugs or drug combinations has very high priority. Dengue fever, another tenacious insect-borne disease, has increased steadily over the past 20 years -with no end in sight. In the great pandemic of 1977-80, approxi- mately 700,000 people were af- flicted in the Caribbean, South and Central America, Mexico, and Texas. Cuba alone recorded 340,000 cases in 1981, 24,000 of these developing the complications of dengue hemorrhagic fever (DHF) with 158 deaths. And in a more recent epidemic, Brazil reported 200,000 cases. A frightening spec- ter for the future is the combination of a high frequency of DHF with dengue shock syndrome, as has oc- curred in Asia, with a consequent surge m hospitalizations and deaths. Flavivirus infection is another malady beginning to receive more attention as the result of the arrival in the Americas of aedes albopictus. This mosquito, widely distributed around Asia and the Pacific and once native to the forest, has be- come quite at home in the city, breeding not only in tree holes and leaf axils, but in bottles, vases, abandoned tires, and other man- made containers. Remarkably har- dy, it can even survive in hiberna- tion. This creature has been associ- ated with many dengue epidemics in the Far East and can transmit all four forms of the virus. Yet, a far more serious threat is that aedes albopictus could also become a transmitter of yellow fever. The region would then face the prospect of widespread infesta- tion with a hardy, adaptable species not only carrying dengue viruses between forest and city, but also introducing yellow fever into urban settlements. Mosquito control pro- grams need to be stepped up quick- ly to definitively eradicate this pest before it spreads further and be- comes even harder to control. AIDS By far the most important new health problem confronting the Americas is the far-flung occur- rence of acquired immunodeficien- cy syndrome (AIDS) . In the United States, the patient population has been mostly homosexual and bisex- ual men, along with intravenous drug abusers. Certain Caribbean countries have a disproportionately high incidence of cases. One of the most alarming devel- opments has been an increase of the disease among heterosexuals in some countries, notably Brazil, ag- gravating the likelihood of a much more rapid rate of transmission. AIDS not only adds immeasurably to human suffering, but takes up considerable medical resources in terms of patient care, public educa- tion, and research. If current projec- tions materialize and a commitment is made to care for those afflicted until they die, AIDS will place another enormous strain on the already overburdened and under- funded health systems of the region. • W oRLD HEALTH, Octo ber 1987 Water, Source of Life by Harst Otterstetter and Alberta Flares 11 he International Drinking Wa-ter Supply and Sanitation De-cade (1981-1990) represents a worldwide thrust to extend drink- ing water and sanitation services to the largest possible number of peo- ple. This effort targets the popula- tion most in need of these services, those living in urban slums and rural areas. For the Americas, the Decade is the third in a series of major politi- cal accords designed to improve water and sanitary services in coun- tries of the region. Following two previous agreements-the Punta del Este Charter, signed in Uruguay in 1961, and the Special Meeting of Health Ministers of the Americas, held in Santiago, Chile in 1972-the nations of Latin America and the Caribbean made considerable pro- gress toward expanding the scope of coverage and increasing national capacity on these fronts . These achievements raised hopes for even faster progress during the 1980s. However, just before the period was about to get underway, severe economic crises began undermining the ability of nations to fully realize their plans for the Decade. Member countries of the Pan American Health Organization have made important strides nonetheless. During the first five years of the Decade (1981-85), the urban population with access to a water supply went from 186 million (83 per cent) in 1980 to 226 million (86 per cent) in 1985, while those covered by sewer and household sanitary services rose from 132 mil- lion (59 per cent) to 156 million ( 60 per cent). Similar progress was made in rural areas, where water availability jumped from 40 per cent (49 million persons) to 45 per cent (55 million) and sanitary ser- vices reached the 15 per cent level. In urban areas, these gains encom- passed a large factor of population growth, especially among low in- come persons living around the fringes-in keeping with the goals of the Decade. W oRLD HEALTH, October 1987 Yet progress has been uneven and, overall, less than anticipated, especially regarding sanitation. If the same rate of growth continues for the rest of the Decade, member governments will not be able to reach their goals ; to do so would require providing drinking water to some 58 million additional urban dwellers-most of them in low income areas-and sewerage to 61 million by 1990; in short, a doubling of the efforts made during the first five years. Similar expan- sion would be required in rural areas. A large proportion of urban dwellers who live in slums Jack drinking water. PAHOIWHO Photo by Julio Vizcarra An analysis of 1981-85 expendi- tures provides clues to this relative- ly slow rate of advancement during the period. To begin with, expendi- tures came to an estimated US $5,000-$7,300 million, or between 20 and 25 per cent of the total anticipated. This means that an additional $22,500 million (at 1980 prices) would have to be spent to reach the goals set. Quite obvi- ously, given current economic pres- sures, these resources are very un- likely to become fully available and therefore adjustments will have to be made. Making the best use of resources involves identifying areas of greatest need, cost reduction, optimization of capacity, mobiliz- ing community participation, and matching technology to socio- economic conditions. Likewise, wa- ter and sewer agencies must be inspired to greater efficiency and effectiveness-for instance, control- ling water leakage to allow exten- sion of coverage to more people. These are principles which have been acknowledged since the begin- ning of the Decade, but their im- plementation has been slow and sporadic. Continued population growth and migration into cities will exert even more pressures to find appropriate solutions to chang- ing and growing needs. Of particular concern are the 40 per cent of urban dwellers who live in slums and who totally lack drinking water and sanitation ser- vices, or must rely on rudimentary facilities dangerous to health. These under-served urban areas are pre- cisely where recently arrived mig- rants are adding disproportionately to population pressures. In an effort to address the serious health prob- lems of slum dwellers, the Pan American Health Organization, in 1984, held a Regional Symposium on Potable Water Supply and Sani- tary Waste Disposal in Santiago, Chile. This conference, part of the observance of the Decade, looked at institutional, economic, technical and social barriers to the provision of water and sanitary services to urban shantytowns. The search for solutions has highlighted the im- portance of being willing to experi- ment with innovative practices. Water and Sanitation, Vital to Health Water and sanitation are basic human necessities, as well as funda- mental requirements of modern life, especially in crowded living conditions where residents may be unaware of health ramifications. 11 Water, Source of Life Nevertheless, for the guardians of the public interest, the main rationale for such services is, and always has been, public health. Water of sufficient quantity and quality for human consumption is a recognized component of preven- tive health services, as well as of human well-being and life itself. The health impact of water and sewer services is further enhanced when these are combined with other programs, such as oral rehy- dration and immunization. A number of nations of the Americas are taking a comprehen- sive approach to health, bringing together water and sewer services, immunization, oral rehydration, education about sanitation and nut- rition, and other measures to obtain the long-term, effective results that are the raison d'etre of all health services. Since health is a basic human right, access to health ser- vices is also a right. The countries of the hemisphere are strengthening all primary health services to meet WHO's worldwide goal of "Health for all by the year 2000 " . Primary health services must therefore be viewed broadly as encompassing all processes and measures affecting health and quality of life. Community participation is also essential to the achievement of health and includes water and waste disposal, along with trash removal, clean housing, and sani- tary food handling. Community participation, in the broadest sense of the community simultaneously as agent and beneficiary of health ac- tivities, requires the formulation of health projects that are-from their inception- culturally accept- able and financially feasible. Com- munity participation necessarily en- compasses the low income sector which constitutes such a large seg- ment of the urban populace. A previous tendency to ignore slum settlements is giving way to an acceptance of their existence as a socio-economic fact which must be addressed. Water services in urban slum areas are usually quite costly to the user, while leaving much to be desired in terms of supply and qual- ity. A number of projects in the region have been designed to ad- dress these problems, taking local contingencies into account. Among several successful demonstration 12 projects is that of the "New Town" of Huaycan in Lima, Peru. Lima is no exception to the popu- lation explosion sweeping the low income areas of Latin American cities. Because of this, the Peruvian Government, in conjunction with the Pan American Center of Sani- tary Engineering and Environmen- tal Sciences (CEPIS)-part of the environmental health program of the Pan American Sanitary Bureau-identified a settlement 17 kilometers outside of Lima as a good prospect for experimenting with cost-effective alternatives for water supply, sewage disposal, and solid waste management in such areas. Huaycan's Experience Unlike many unauthorized squat- ters' settlements, this one has been recognized by the City of Lima, which has been encouraging devel- opment of innovative ways to meet the housing needs of the 19,620 families living there, specifically through creation of 327 communal · living units (CLUs) on some 400 hectares (960 acres) designed for an eventual population of 110,000. Every CLU will accommodate 60 families and will occupy a lot 90 meters square. Some 4,800 families have already moved into completed CLUs (now at two-thirds occupan- cy), most of them unemployed or underemployed, which has allowed them to contribute considerable manuallabor to their own housing. The strategy proposed by CEPIS to bring water to these dwellings is a series of step-by-step improve- ments based on simple, immediate- ly available technology in keeping with the socio-economic level of the community. There are four stages of development planned for this particular community in coopera- tion with the Water and Sewer Department of Lima (SEDAPAL). In the first stage, water is distri- buted by tank trucks and stored in metal drums or bottles next to or inside each house. In the second stage, the trucks, instead of making deliveries door-to-door, deposit the water in a storage tank constructed for each communal living unit and connected to a public faucet. The third stage consists of individual water hook-ups, and the fourth stage will see the installation of minimal sanitary services within each unit. The first stage is being im- plemented now, while some CLUs have gone on to the second stage of building their own storage tanks. At the same time, to free the communi- ty from dependence on water deliv- ery trucks, SEDAPAL has con- tracted with a local firm to drill a well to be connected with storage tanks and has engaged another firm to develop a complete drinking wa- ter project. · To improve water quality during the first phase of the plan, it was considered advisable to chlorinate the water first in the tank trucks, then again in the individual house- hold drums. Since community par- ticipation was recognized as essen- W oRLD HEALTH, O ctobe r 1987 In some Latin American slums water is trucked in, left, while many cities, above, have sophisticated water ser- vices. Left photo by Julio Vizcarra. above photo by Carlos Gaggero tial to reduce costs, CEPIS staff came up with the idea of giving householders small bags of pre- measured calcium hypochlorite to add to the truck tanks and to their individual water drums, similar to the little bags of rehydrating salts for diarrhea with which they were already familiar. Also, in collabora- tion with the Health Ministry, a very simple calor-coded calibrator was developed which housewives were taught to use to detect re- sidual chlorine before adding new bags of chemicals to their water supply. The team brought together by CEPIS to develop the basic sanita- tion program consists of an en- gineer from the Health Ministry and one from SEDAP AL, a physician specializing in disease control, a social welfare aide, _students of sani- tary engineering and social sci- ences, and eight sanitary technol- ogists working directly with the community. W oRLD HEALTH, October 1987 Their achievements to date in- clude the following : - Reduction in the incidence of diarrhea and other illnesses caused by contaminated drinking water and by the inadequate dis- posal of sewage and solid waste. - Active participation by the peo- ple in the chlorination and re- chlorination of water, as well as in the construction of latrines and small sanitary landfills . - Preparation of educational mate- rials for purposes of local instruc- tion and training of community health advocates, who will be able to pass along basic informa- tion on sanitation to residents. - Formation of school-based youth brigades to transmit sanitation education and stimulate support and participation by local lead- ers, family heads, and students in the basic sanitation programs of the community. Community participation has been a key element in the success achieved so far; however, this par- ticipation has never been automa- tic. Instead, it has had to be nur- tured through patient teaching and motivation. The program continues in operation and is in the process of developing an evaluation of the extent to which each stage of im- provement in basic sanitation has been reflected in a reduction in the incidence of disease. Outlook for the Year 2000 No reversal of the trend toward increasing urbanization in the Americas appears in sight; the cities remain magnets for rural families . By the year 2000, 80 per cent of the population will live in cities, a large proportion in urban slums and in low income areas around the periphery. This situation cannot help but further aggravate the pre- carious conditions of health, water, sanitation, and garbage removal services in such areas. Pollution of air, water, soil, and the whole envi- ronment will create even greater challenges in the future to the creation of economically viable, healthy communities. Giving priori- ty to low income areas is urgently needed to prevent or reduce these negative effects. Most importantly, the effort to mobilize the community on its own behalf involves citizen education-especially among the young-to insure that proper health concepts become firmly grounded and that people understand their own essential contribution to the solution of environmental health problems. This effort also needs to be tied in with institutional changes which encourage active community involvement. Equally essential is the search for new urban planning criteria which can shape city development and stimulate the necessary correlates of economic growth, and work to solve the problem of the uncontrol- led growth of urban slums. The health sector has an indis- pensable role to play in this whole process. Agencies charged with re- sponsibility for health and sanita- tion must be able to anticipate the impact of urban development and guide it toward health improve- ment. Standards need to be e~tab­ lished to govern daily life and to bring the vision of "Health for all by the year 2000" to full fruition, especially among low income citi- zens. As the year 2000 draws near, health must go beyond mere plan- ning and strategizing to become a palpable reality for the people of the Americas and of the world. • 13 Children of Latin America and the Caribbean by Dr Eisa M. Moreno, Dr Nestor Suarez Ojeda and Dr Ciro de Ouadros Within the Western Hemi-sphere live more than 200 million children and adoles- cents afflicted with a variety of health problems. Significantly, these problems are always related to some aspect of underdevelop- ment deriving from one or more of the following: - unequal distribution of income; - accelerated population growth, especially in the poorest areas ; - large-scale voluntary and in- voluntary migration from rural areas to the cities. The interaction of these factors has led to a result appalling beyond any doubt: the deaths of more than a million children under five occur annually in the region; deaths which, in many instances are due to perfectly preventable illnesses-a cost in lives which could be sub- stantially reduced through tested strategies and technological appli- cations. The experience of the last few decades with the development of high efficiency and low cost tech- nology clearly demonstrates that health care's ability to reduce child- hood deaths has grown accordingly. The efficacy of health interventions in this area has held up across differences in social strata and levels of development. Through optimum application of health ser- vices, several countries of the re- gion have been able to reduce in- fant mortality to less than 20 per thousand over the past ten years, a dramatic decrease, especially given the lack of a significant rise in per capita income during the period. Mortality Rates for Young Children Childhood deaths in Latin Ameri- ca and the Caribbean have plunged 14 W oRLD HEALTH, October 1987 over the last decade, but are still excessive in comparison to more advanced countries. Children's mortality rates vary considerably among countries. In 1984, for ex- ample, infant mortality ranged from 15 per thousand live births in Cuba to 117 per thousand in Haiti. Among one- to four-year-olds, Bolivia registered a mortality rate of 23 per thousand compared with only one per thousand in Costa Rica, Cuba, Panama, and Trinidad and Tobago, equivalent to the rate · in the United States. These differ- ences occur not only between coun- tries, but also between different areas and localities of the same country. The Risk Factors If all the countries of the region could achieve, as some already have, infant mortality rates of 20 per thousand, then more than 500,000 children under one year of age could be saved annually. Al- though most countries have reached infant mortality rates be- low 50, more than 60 per cent of Latin American children live in W oRLo HEALTH. October 1987 geographic areas where mortality is higher than that. Children of illiterate mothers face a risk of death five times that of children whose mothers have completed at least five years of formal education. In most countries of Latin Ameri- ca and the Caribbean, the main causes of deaths of young children are birth problems, diarrhea, acute respiratory infection, and infectious diseases subject to vaccination. Malnutrition underlies many pre- ventable deaths, although it is rare- ly recorded on death certificates. Typically, countries with high rates of infant mortality, such as Guatemala and Honduras, show diarrhea as the principle cause, while those with low rates, such as Chile and Cuba, have birth defects in first place. This change in the It is estimated that 60 million children lack access to basic health services. But primary health care reaches out to these young Peruvian children, left, and this Costa Rican volunteer, below, in a community improvement project. PAHOIWHO Photos by Jul io Vizcarra structure of morbidity/mortality seems to be a trend in most coun- tries and should be taken into account in any reorganization of services. Strategies for Change According to current estimates, some 60 million children lack access to basic health services and, if this situation continues unchecked, these numbers could reach 100 mil- lion by the year 2000. This prospect indicates the need for a fundamen- tal change in health care delivery and in the orientation of providers. Clear policy direction is needed to pull together efforts within and be- tween disciplines and to promote the active participation of families and communities in the improve- ment of their own welfare. Expanding coverage no longer means the classical solution of set- ting up more physical plants to await the arrival of patients. Rather, the only acceptable avenue now is to recognize the communi- ty's key role and the impact of popular mobilization as the last stage of a decentralization process empowering decision making and problem solving at the primary care level. That is why, in the Americas, primary health care has become an action strategy and the leaven for change throughout the health sys- tem as a whole . The growing, developing young child always belongs to a given family and a given nation. Improv- ing health conditions for the chil- dren of the Americas depends on a process of identifying priority prob- lems and searching for solutions through the combined efforts of individuals, families, and neighbor- hood organizations. Innovative Approaches All countries in the region recog- nize that improving the quality of life for the children of the Americas requires mobilization of a wide range of resources. The health sector lacks sufficient funds and staff to do the job alone. Meeting the challenge of Health for All by the Year 2000 requires talents and resources from many sources, in- cluding international agencies, non- governmental organizations, and Continued on page 18 15

Children of Latin America and the Caribbean national institutions outside the health field . As important as resource mobili- zation is, it is not enough by itself. A more comprehensive form of mobilization is now gaining momentum; this is social mobiliza- tion, which involves calling on all sectors of society to work toward common goals. For instance, in- stead of being passive consumers of health services on behalf of their children, parents are being encour- aged to actively seek care, to par- ticipate in carrying it out, and to pass along the word to their neigh- hors. In addition, modest instruc- tional materials are being produced for the general public to enable educational, charitable, and religi- ous enterprises to disseminate in- formation about major childhood illnesses and preventive measures (vaccination, oral rehydration, prompt treatment of acute respirat- ory infections, influences on growth and development) . The mass media are lending their support, with magazines and newspapers making health-related announcements and recruiting volunteers from all social strata. In this way, many talents and resources are brought together. A Hemisphere freed from Polio These new approaches have spe- cial meaning in relation to a goal adopted by all the governments of the hemisphere in May of 1985 : to eradicate the natural transmission of the polio virus by 1990 in the whole hemisphere. Between 1969 and 1977, the average number of polio cases in the Americas reached 4,000 per year. Since 1980, this figure has fallen to 1,000. The number of countries recording any cases at all fell from 19 in 1975 to 13 in 1986. Encouraged by this progress, but aware that greater efforts would be needed to reduce the incidence to zero , the coun- tries of the region agreed on the common goal of eradicating polio completely. At the international level, a number of organizations have joined in the battle. The United States Agency for International De- velopment (usAm) has committed US $20 million to the effort, the Inter-American Development Bank has pledged $5 .5 million, and the 18 International Rotary Club has raised its contribution to the world- wide Expanded Program of Im- munization to $23 million so far , assigning a large portion to the Americas. UNICEF is continuing its support, which is now in the order of $12 million. In order to coordinate this whole effort, the Pan American Health Organization (PAHO) has formed an Interagency Coordinating Commit- tee representing each of the above- mentioned agencies, along with PAHO itself and the Task force for Child Survival, a group which meets periodically to review pro- grams and coordinate the effective use of resources . Another application of these strategies and approaches can be found in the Child Survival Pro- gram within the Health Plan for Central America and Panama, " Bridge for Peace " . The plan was originally conceived as a consensus project, intented to promote dia- logue among heads of state and among countries diametrically op- posed ideologically to the point of military confrontation. In a region convulsed by armed struggles, political violence, and forced migra- tion, the theme of health care priorities still had sufficient pulling power to bring together top health authorities from seven countries of the Central American isthmus, who together designed national and sub- regional programs aimed at improv- ing health and living conditions for their 25 million inhabitants. In this overall plan, measures for child sur- vival and maternal and child health held special prominence. It was rec- ognized that children are highly vulnerable due to their social and physical dependence, especially in an area undergoing such economic and political upheavals as Central America. The health situation of children in the region has been identified as a most pressing prob- lem, not just because of the mag- nitude represented by more than a million children under five who die annually, but because so many of these deaths could have been pre- vented by available technology. This initiative was very successful in mobilizing international re- sources and promoting the com- bined efforts of technical coopera- tion entities. On the one hand, the European Economic Community, the Italian Government, and USAID have promised additional financial support amounting to $39,582,100 for a five-year period; on the other, PAHO, UNICEF, and the Institute of Nutrition of Central America and Panama have improved collabora- tion by augmenting technical coop- eration capacity and strengthening the exchange of experts and tech- nologies among countries of the region. With the participation of all the governments and agencies included in the Health Plari, a Technical Coordination Committee was formed to supervise health ac- tivities in the region and assure the complementarity of national pro- grams. A total of 39 projects have been developed, 38 of them nation- al and one subregional. Each coun- try has also formulated its own Child Survival Integrated Plan, which not only covers additionally funded activities, but encompasses all national-level measures of ma- ternal and child health, such as personnel training, technical man- agement, critical inputs, informa- tion systems development, and health services evaluation. The most important activity so far has been immunization. Four countries-Guatemala, Honduras, Nicaragua, and El Salvador-spon- sored two to three campaigns of one or two days each, Belize held three five-week campaigns, and Panama and Costa Rica zeroed in on local areas of least coverage, while promoting immunization among the population as a whole. All the countries have achieved significant progress in terms of vac- cination coverage, especially Be~ lize, Guatemala, and El Salvador. Nevertheless, 33 cases of polio were reported in Guatemala, 15 in El Salvador, and 4 in Honduras. As for oral rehydration therapy, all the countries make oral rehydra- tion salts available. About 7.3 mil- lion envelopes of salts were distri- buted through health services. In El Salvador, this program was ex- tended through 1986. The main problem in Guatemala has proved to be an insufficient supply of salts. Two countries produce their own salts, Costa Rica and Honduras, and two more will begin production in 1987. All children's hospitals and university pediatric departments use oral rehydration units in train- W oRLD HEALTH, October 1987 W oRLD HEALTH, October 1987 Innovative approaches are needed to bring health services to children such as these residents of a refugee camp in Central America. PAHO/WHO Photo by Carlos Gaggero ing medical, nursing, and graduate pediatric students. The control of acute respiratory infections was another effort initi- ated by PAHO/WHO between 1984 and 1985 in nearly all the countries. During 1986, progress was achieved in rev1Slng and dis- seminating technical standards, the training of medical and auxiliary personnel, and the production of educational materials. Five coun- tries have established programs for control of acute respiratory infec- tions in one or two health regions. Lack of antibiotics has been the major obstacle to carrying out this program. In the area of breast-feeding, all the countries have national commit- tees working in conjunction with other institutions outside the health arena. All have completed surveys on breast-feeding over the last two or three years, either nationally or in particular geographic areas. This will serve as the basis for a follow- up evaluation of trends in infant nursing in each country. All the countries have mothers ' milk banks available for ill and low birth- weight newborn babies. The area of growth and develop- ment presents difficulties in terms of the ability of existing statistical systems to monitor what is being provided. All countries use height and weight growth curves to evalu- ate nutritional status. In two coun- tries, Costa Rica and El Salvador, the health identity card given to the mother shows the growth curve. While it would be premature to judge the impact of these interven- tions, they do seem to represent an increased effort to control and pro- tect children's health. The theme has also been adopted by the mass media, with the result that families are beginning to express greater concern for the optimal growth and development of their children. Without any doubt, the Health Priorities Plan for Central America and Panama, as well as the Bridge for Peace, represent a significant policy commitment to the survival and improvement of the quality of life for all of Central America's children. • 19 Disaster Preparedness in the Americas by Dr Claude de Ville de Goyet eventeen years ago, a power- ful earthquake killed 66,000 people in Peru. In 1972, just two days before Christmas, 10,000 Nicaraguans lost their lives under similar circumstances. Then in Feb- ruary, 1976, another devastating temblor left 23,000 dead in Guatemala. The Guatemalan quake, no less than the others, brought a realiza- tion that natural disasters posed a continuous threat to the region. This led member governments of the Pan American Health Organiza- tion (PAHO)-which serves as WHO's regional office for the Americas- to ask the Director to establish a spe- cial unit at the Washington, DC, headquarters. Called the Emergen- cy Preparedness and Disaster Relief Coordination Program, this unit was charged with a variety of re- sponsibilities, including preparing guidelines, formulating plans of ac- tion, training emergency personnel, and establishing effective coordina- tion among non-governmental and international agencies. Today, more than ten years later, the Americas' vulnerability to natural disasters is as great as ever. The last two years alone attest to this. Major earthquakes have occur- red in Chile, Ecuador, Mexico, and El Salvador. Colombia's snow-cap- ped Nevado del Ruiz volcano erupted violently, killing more than 23,000 and almost completely burying the city of Armero under volcanic mudflows and tumultuous streams of debris and ash. Although less widely publicized, slow-onset disasters such as floods .periodically hit many parts of South America and the Caribbean. Emergency Preparedness Rapid and effective response to post-disaster health problems is a major goal of PAHO's disaster pro- 20 Rescuers search for survivors among the rubble of a Mexico City hospital, above, while patients being evacuated, below, point up the need for adequate hospital emergency preparedness. PAHO/WHO Photos by Julio Vizcarra gram. This is accomplished by as- suring the existence and vitality of a national emergency preparedness program in the health sector of each member country. To meet differing needs and priorities among coun- tries, the PAHO program offers a variety of approaches : technical as- sistance in formulating national dis- aster plans, support for multidisci- plinary workshops at national and local levels, promotion of close cooperation between the ministry of health and other organizations, and training and fellowships for health leaders. Special emphasis is placed on sharing examples of suc- cessful programs from around the world. Within the limits of human and material resources, national health services must be ready to respond appropriately to mass casualties, both at the scene of a disaster and in hospitals where victims are cared for. PAHO helps member govern- ments develop preparedness sur- veys of key hospitals, increase per.- sonnel training, and factor local earthquake and hurricane prob- abilities into the early planning and design phases of hospital construc- tion. Wherever possible, educa- tional materials and training pro- grams are formulated to be passed along, thus multiplying their im- pact. The availability of publica- tions and audiovisual programs covering all types of disaster and issue promotes a common philoso- phy and approach to disaster man- agement in the region. Relief Coordination The second prong of the P AHO program is coordination of the re- W oRLD HEALTH, October 1987 Volcanic mudflows left more than 23,000 persons dead in Armero, Co- lombia, above, with rescue by air, right, the only way out for survivors. PAHOIWHO Photos by Julio Vizcarra lief that usually pours into an af- fected country in the wake of a disaster. Thanks to modern com- munications, word of global tragedies often reaches the interna- tional community within minutes and, in just a matter of hours, relief is on its way. This generous out- pouring can be of immense benefit to a disaster-stricken country as long as it meets real needs. But charity can quickly become a bur- den when it is unsolicited and based on false perceptions. Although diverse strands contri- bute to international aid problems, some common patterns are evident the world over. - Competition among donor coun- tries eager to be "first" in re- sponding to an emergency may mean that inappropriate assist- ance arrives before needs have even been identified. - Disaster publicity fanned by media overemphasis often results in the wholesale dispatching of mobile hospitals, medical person- nel, and drugs, blood, and vac- WoRLD HEALTH, October 1987 cines-all generally unneeded or actually counterproductive. - Developed countries increasingly airlift emergency response teams to disaster sites, but usually too late to save lives. They end up vying with each other and local personnel for visibility, meaning well but only adding to the confusion. How can the requirements of a disaster-stricken country be better matched with international con- tributions? Correct information is obviously a key to proper emergen- cy management and precious time spent gathering and disseminating the facts is not wasted. Unfortu- nately, political expediency and public pressure may lead donors to jump the gun before a situation can be properly assessed. Governments and private organi- zations should consult their own country's disaster relief experts, the ministry of health of the affected country, or PAHO/WHO before send- ing off any supplies or personnel. Common pitfalls to avoid are ex- cess donations of food and clothing, unneeded blood and plasma, vac- cines to combat imaginary ep- idemics, and field hospitals and medical teams which often arrive in time for good public relations but too late for emergency relief. Individuals who want to assist should consult their national health authorities, the Red Cross, or the P AHO/WHO office in their own coun- try. They should not travel to the location of a disaster until they have made sure they will be useful and welcome. Finally, they should 21 Unsolicited pharmaceuticals such as those in a Mexican warehouse must be sorted, classified and labeled, diverting health personnel from more pressing tasks. PAHO/WHO Photo by Julio Vizcarra consider giving cash-the most flex- ible and versatile form of assistan- ce- through a reputable agency. A good rule of thumb for the donor is : offer the same type of help you would like your own community to receive in the event of a disaster. Dispelling Common Myths Inappropriate disaster responses are based on misconceptions widely held by the public, as well as some people in the scientific community, and perpetuated by the media. 22 What are some of the persistent myths behind well-meaning but misguided disaster efforts? An accumulation of dead bodies will lead to catastrophic outbreaks of exotic communicable diseases. Indeed, it has been common for self-appointed experts to predict more deaths from these secondary epidemics than from the original calamity. This is simply not the case. Human bodies, especially when buried under a landslide or earthquake debris, pose no particu- lar threat of disease. The problem is one of fear, not of actual danger. Mass vaccination is required after a disaster. Improvised vaccination campaigns are inadvisable for a number of reasons. Many vaccines, such as that for typhoid, are not very effective in last-minute appli- cation because they require more than one dose and several weeks to become fully operative. Emergency mass vaccinations are wasteful of money and manpower, benefiting the politicians who advocate them while lulling the populace into a false sense of security. The affected population and local authorities are too shocked and helpless to take responsibility for their own survival. Disaster sur- vivors are not necessarily depen- dent or immobilized. Many find new strength during an emergency, as evidenced by the thousands of volunteers who spontaneously un- ited to sift through the rubble in search of victims after the 1985 Mexico City earthquake. And most Latin American countries have sophisticated and farflung health services, plus a good supply of physicians. Natural disasters create severe food shortages. This is not so, yet the belief is so common that it has led to many post-disaster food gluts. Earthquakes, for instance, usually have little immediate im- pact on food supply. Food relief decisions always should be made with care, since food distribution relies on transport and personnel perhaps better deployed elsewhere. Everything is needed and needed now! Again, the haste-makes-waste mentality spawned by many catas- trophes may produce assistance that harms more than it helps, thereby aggravating disorder and contributing to a secondary disas- ter. Foreign medical personnel ar- riving too late for emergency help must still be met, housed, oriented, and provided with interpreters. Similarly, unsolicited pharmaceuti- cals take up needed space and must be sorted, classified, and labeled, thus diverting health personnel from more pressing tasks . Yet, there are many instances of genuine assistance whose common de- nominator is response to needs clearly identified by national health authorities. When it comes to disaster -whether natural or man-made-all nations are at risk. Many national health systems have recognized that emergency preparedness must be an ongoing process of testing, critiquing, and updating. Mean- while, PAHO's disaster unit stands by, supporting measures to prepare for tomorrow's disasters today. • W oRLD HEALTH, October 1987 Health Services for All by Dr Jorge Osuna 11 he evolution of systems to provide health services to the countries of the region has reflected the processes of economic and social development experi- enced by national societies from the time of the 15th century discovery to the present day. During the European conquest, the first hospi- tals sprang up to meet the military needs of the conquerors; later, as colonies, almost all the countries set up public aid hospitals to care for indigents. During this period, in tandem with the establishment of services, came the founding of reg- ulatory bodies and of medical train- ing centers allied from the begin- ning with the universities that blos- somed in the colonial capitals. About the end of the nineteenth century, along with independence and national governments, national health departments began appear- ing, frequently as part of ministries of the interior. These departments, which were designated differently in different countries, were con- cerned above all with protecting foreign commerce by controlling "quarantinable illnesses" through health campaigns quarried out primarily in the main seaports. Na- tional health departments rose to the ministerial level in most Latin American countries during the 1930s and 1940s, with the early exceptions of Cuba, 1907, and Chile, 1924. This period also saw the emer- gence of mandatory social security programs, which now play such a crucial role in the region. In succes- sion, such programs were adopted by Chile in 1925, Brazil in 1934, Ecuador in 1935, Peru in 1936, Venezuela in 1940, Costa Rica and Panama in 1941, Mexico in 1942, Paraguay in 1943, Argentina in 1944, Colombia and Guatemala in 1946, the Dominican Republic in 1947, and Bolivia and El Salvador in 1949. Since their establishment, social security programs have de- voted approximately 50 per cent of their resources to financing person- W oRLD HEALTH. October 1987 al health services and the rest to benefits for illness, retirement, and death. Meanwhile, health ministers cre- ated ever more complex organiza- tions to both regulate and carry out massive campaigns against epidemics rampant in local areas and programs to deal with collec- tive health problems, while also providing- in varying degrees -public medical care. The rapid acceptance of a broad concept of health as a fundamental human right and a basic function of the state was reflected in the name change made by many ministries which went from being "Public Health Ministries" to merely "Health Ministries". Human resources: A nurse cares for a sick child. PAHO/WHO Photo by Jul io Vizcarra In 1972, at the Ill Special Meet- ing of Health Ministers of the Americas, held in Santiago, Chile, the countries of the region collec- tively adopted the Ten Year Health Plan for the Americas, in which an "operative nomenclature" was proposed, along with the setting of priorities, budget allocations, and the performance of specific ac- tivities. These were contained in the General Programme of Work for PAHO/WHO for the 1973-77 period, approved by the XVIII Pan Ameri- can Sanitary Conference. This sys- tem differentiates problems directly related to health from those of quality, quantity, and organization of resources and of methods and procedures to improve health. The former are grouped under the title of personal health services and en- compass maternal and child health, nutrition, treatment of infectious and chronic diseases, and anything regarding the environment. The lat- ter fall under the rubric of infra- structure development and include human, technical, and auxiliary re- sources; the processes of adminis- tration, planning, evaluation, and information; legislation and regula- tion; basic and applied research; and financing. The World Health Assembly of 1977 determined that all member governments should have as their primary goal to achieve by the year 2000, a level of health that would allow their citizens to enjoy an economically and socially produc- tive life. The goal is now known as "Health for All by the Year 2000" (HFA/2000). The 1978 declaration of Alma- Ata identified primary health care as the avenue for achieving these objectives within a framework of general development and in a spirit of social justice. In 1980, the gov- ernments of the region agreed, through the XXVII PAHO Advisory Board, on the strategies and re- gional objectives of HFA/2000. Since then, important efforts have taken place to restructure health systems and activities to meet the proposed goals and objectives. The concept of primary health care as an integral health strategy that encompasses and affects the whole population and the health system at all levels is expressed in the following statement from a document on regional strategies : " Once it is accepted that the goal is reduction of inequalities among countries and among human 23 Health Services for All groups, this strategy should be con- sidered valid and applicable to the population as a whole and not re- stricted to backward or marginal groups, although satisfying the basic needs of the latter is still one of the primary objectives. It is not possible to conceive of basic health care as a program limited in any way to meeting only the minimum needs of those who live in extreme poverty. " In the process of reforming health systems to meet the goals of HF AI 2000, countries are facing the need to make substantive changes to sol- ve two problems common to exist- ing health systems in the region. First, the systems are already inade- quate to meet the growing demands of a large proportion of the popula- tion and, second, such systems tend to be inefficient in their use of the very limited resources available. In terms of lack of resources, it has been estimated that nearly one third of the population of Latin America and the Caribbean enjoy no regular access to health services. That means about 130 million peo- ple in the region are still without health coverage. To this uncovered population would have to be added projections from now until the end of the century totalling another 160 to 170 million persons. Thus, over the next 13 years, Health for All presents a serious challenge to achieve what countries in the re- gion have never been able to achieve since the discovery of America. Other dimensions are added by the aging of the popula- tion, the population concentrated in urban areas, and the growing adop- tion of patterns of health service consumption common to developed countries and more favored classes, which further increase health costs. Of the almost US $40,000 million spent annually for health services in Latin America and the Caribbean, it can be fairly estimated that 25 per cent is wasteful in cost-benefit terms. At the same time, the health system suffers from chronic man- agerial deficiencies causing losses whose true dimensions are un- known, but which certainly contri- bute to overall inefficiency. Expansion of health service coverage to unserved or under- served populations was the princi- pal goal of the Ten Year Health Plan for the Americas, which as 24 I have said was formulated in San- tiago, Chile in 1972. In general, member countries made important strides in expanding basic health services · and organizing them ac- cording to the size and concentra- tion of population groups. Informa- tion available at the beginning of the decade gave rise to assumptions that people living in settlements of more than 2,000 inhabitants had relatively satisfactory coverage. Consequently, the main efforts were directed toward improving Satisfying the needs of marginal groups is vital. PAHOIWHO Photo by Julio Vizcarra the organization of health service systems and increasing the number of units devoted to primary care in health locations and centers, primarily in rural areas where they would be tied together by a referral system. Thus, the population gained access to more complex facilities- hospitals and specialized cen- ters-generally available only in the cities. This trend is reflected in the con- siderable growth of outpatient clinics, estimated at 64,000 in Latin America and the Caribbean in 1983. Even though there is no up- to-date information on the geo- graphic distribution of these facilities or of their relation to population distribution, it is esti- mated that increasing availability of this type of facility has helped in- crease coverage principally in terms of the care of mothers and children and of educational activities and environmental health programs geared to families and to outlying rural communities. As for the avail- ability of facilities for more compli- cated care, estimates are that, as of 1983, there were 22,493 hospital facilities in the region, of which 45 per cent were public and 55 per cent private. When the current number of beds per thousand in- habitants is compared with the 1970-72 period, a reduction has occurred overall, attributable for the most part to population growth with which hospital physical plants have been unable to keep up, given the costs involved. In North Ameri- ca and some Caribbean countries, a general upgrading of living stan- dards and shifts in health service delivery, mostly to outpatient care, have reduced the need for hospital beds. Within the general context of health service systems develop- ment, all the countries emphasize strengthening diagnostic support services, such as laboratory and radiology. The enormous tech- nological expansion in these fields over the last few years has meant considerable cost increases for med- ical care, which has further cut into the chances of extending the be- nefits of complete care to the popu- lation as a whole. There is an increasing trend in the region towards establishing nation- al laboratory networks based on high-quality, simplified technology to support various health activities in the war against infectious dis- eases. These national laboratory systems have proved most success- ful where they have been tied in with an already existing central laboratory which sets standards, trains staff, provides supervision, and maintains and repairs equip- ment. In radiology, the main con- cerns have been to bring basic diag- nostic systems to rural and urban slum areas, provide backup for diagnosic and therapeutic radiology referrals, develop human resources, reduce equipment costs through use of simple, good quality technology, and establish national systems for protection against radiation. Another area of concern for all the countries is the availability of medicines needed for the adequate treatment of health problems. In a dizzying upward spiral, total phar- maceutical expenditures in Latin America and the Caribbean have risen to more than $5,100 million annually. Yet there is still consider- able disparity between the avail- ability and cost of basic drugs and the abundant supply of specialized drugs for the urban population of means with access to private care. W oRLD HEALTH, O ctober 1987 There is limited access to basic medications for all the people under equitable conditions. Countries are also confronted with the need to carry out policies and programs to increase service networks in geographic areas not currently being served and, at the same time, to upgrade their methods of organization, financing, and administration to make a reasonable effort to reach the goals of Health for All. Genuine oppor- tunities to expand service networks are seriously hampered by the se- vere economic conditions affecting -to a greater or lesser degree-all the countries of the region. Conse- quently, efforts are aimed primarily at improving the maintenance of installations and of equipment and making prudent investments to re- novate and modernize existing facilities to meet pressing needs. Modest efforts are being made to replace deteriorated facilities which have become totally inadequate. The improvement of health sys- tems represents an extraordinarily complex task which cannot be put off any longer because of the pro- gressive accumulation of "social debt" and the poor utilization of available resources. Almost all the countries of the region are looking into three main strategies. First, there is the search for new ways of inter-connecting health sec- tor institutions and of meshing the goals and operations of each institu- tion with overall policy and nation- al objectives. This is where the idea of health ministries comes in, taking on the broad task of guiding, lead- ing, and mobilizing national and international resources and analyz- ing progress toward the goals of HFA/2000. Second, all the countries have tried hard to offer better alterna- tives for service financing to permit better and fuller health coverage, including equitable access by all people to the level of care required by each case and elimination of unnecessary procedures that raise costs and contribute nothing to sol- ving real health problems. As part of this strategy, the countries are developing projects to improve staff utilization and to rationalize the use of health technology, espe- cially where it can reduce costs in terms of either service or equipment. W oRLD HEALTH, October 1987 Implementing efficacious me- thods of planning, administration, and evaluation of health services opens up a third important avenue for health improvement. All the countries have shown a renewed interest in decentralization, since experience indicates that too much centralization and lack of local par- ticipation contributes to inadequate service. The establishment and strengthening of local health sys- tems serving a given population in a defined geographic area offer a clear example for the re-design and reform of the health system at all administrative and care levels. At the same time, the efficient opera- tion of local health systems is essen- tial for bringing resources together to improve utilization and assure wholehearted community participa- tion by creating empowering instru- ments and channels of expression, including such activities as educa- tion, information, dissemination, social organization, interdiscipli- nary coordination, and adoption of new styles of decision making. Better Services In the United States, there has been extraordinary growth in the health sector through the expansion and improvement of hospital ser- vices, increasing availability of health insurance and pre-paid plans, greater access to care by new population groups, and substantial- ly improved information systems. Nevertheless, the problems of rising costs and rational resource alloca- tion remain. Because social organi- zation and economic development in the United States favor private sector activity, open competition and decentralized government reg- ulation, the new health service ap- proach of the country can be characterized as a strategy of de- centralized intervention. This re- quires state and local participation in comprehensive health planning, revision of standards of hospital care, development of measures to prevent duplication of facilities, promotion of pre-paid systems as an alternative to conventional pay- ment practices, and creation of new planning entities at local, regional, and state levels. The Canadian health system is a product of a long tradition of co- operation between government, health professionals, and voluntary organizations. Besides contributing to national health insurance, the federal government plays a leader- ship role in public health, promot- ing and financing research and the adoption of healthy lifestyles. Pro- vincial governments are in charge of health service delivery, including organization, administration, and financing of public health activities. Provinces sometimes delegate some of these functions to local and re- gional governments or they may provide direct service, usually on a regional basis. Professional groups have played an essential role in the design of the national health insur- ance system and in the implementa- tion of standards. An outstanding aspect of the Canadian system is National Health Insurance which· covers medical and hospital services for all the people, under shared financing between federal and provincial govern- ments . Community participation has been the rule ever since munici- pal health advisory bodies were organized to control epidemics at the end of the last century. Today community participation is express- ed through various mechanisms ex- tending from the local level all the way to Parliament. The organiza- tion of the health system has shown satisfactory results in terms not only of the care provided, but also in its democratic and equitable form of delivery. Among future needs of the system, some of the most im- portant are strengthening inter- disciplinary cooperation, increasing training on critical aspects of health policy at the user and provider level, and targeting resources to areas of greatest need. Within this broad context, the cooperation of PAHO/WHO with member governments is expressed in joint activities designed to im- prove individual and collective understanding of the health field and trends, promoting and facilitat- ing the exchange of experiences regarding the development of na- tional health policies, improving in- formation and techniques for basic health services, supporting training and instruction, administering staff resources, supplying information and data on the health technology process, and strengthening analysis of economic/financial processes im- pacting on health development. • 25 The Challenges Ahead by Dr Carlyle Guerra de Macedo dozen peasants file in proces- sion along the side of a dirt road in a country in the Americas. One of the men carries a small, crude coffin on his shoulder. It holds the remains of one of more than 700,000 persons, mostly chil- dren, who die annually from com- pletely preventable causes. This sad, grim scene, which is repeated a thousand times a day, provides a searing commentary on poverty and is a tragedy that offers a pro- found challenge. In still another country, health workers hold a sit-in at health cen- ters and hospitals, seeking higher salaries and more fringe benefits. Here we get a glimpse of the conse- quences of the . financial and economic crisis Latin America is currently undergoing and of the failures in health systems' operation and leadership. We are also re- minded that the challenges we face sometimes have their roots in our own backyard. In a third country in the hemi- sphere, health professionals spend their days rushing from one job to another. We see them in a mad race that doesn't let them ·carry out any of their multiple functions with the degree of professionalism their pa- tients deserve and which their self- respect · demands. This rushing around doesn't afford them the ele- vated socio-economic status that some believed would be their di- vine right after graduation from medical school. They find them- selves in a constant struggle to maintain a modicum of dignity in an urban environment super-saturated with health professionals and with specialties that neither the popula- tion nor the institutions can even afford. What can be done about this poor use and unequal distribution of such valuable resources? Here is another challenge which the health field must face in the years and decades to come. These familiar vignettes, well known to all those involved in the everyday struggle for health in the 26 · Americas, remind us of another challenge we face daily: how to avoid the tendency to intellec- tualize and distance ourselves from what can be a day-in and day-out bitter fight for life, for health, and A health worker checking blood pressure, above, and a rural medical team making its rounds by boat, below, illustrate the consensus view that health is the fundamental right of every human being. PAHO/WHO Photos by Julio Vizcarra for justice in our continent. We must be clearly aware that if we do not address the practical goal of changing and improving the bitter realities that many of our people live, then we are part of the prob- lem, not of the solution. The Americas in general and the field of public health in particular will face serious challenges in the remainder of this century and for the years to come. These challenges are both quantitative and qualita- tive in nature. The quantitative challenge in- volves the extraordinary effort of making real the global and regional strategies of Health for All, satisfy- ing the health needs of tens of millions of people now lacking those services and, as if this were not complex enough, of the millions of new people who will be added this century. The magnitude of this challenge is evident when we con- sider that historically, in Latin America and the Caribbean, ·health services have reached the point of providing · coverage for about W oRLD HEALTH, October 1987 270 million persons. The 135 mil- lion people who live in extreme poverty do not have regular access to health services, and it is esti- mated that another 160 million per- sons will be added by the year 2000. In other words, we must provide services that will cover 300 million persons in addition to the 270 million already covered. Sim- ply stated, in the next 13 years we must create, organize and set in .motion health services that will double the coverage of what we have been able to reach today. \ t The qualitative challenge is a re- flection ofthe changes now occur- ring in Latin America and the Caribbean in social and economic terms ; in terms of the ecology ; and in terms of the patterns of morbidi- ty and mortality. W oRLD HEALTH, October 1987 Health services must be prepared to deal with a population in which the proportion of elderly persons is increasing each year, and which is becoming increasingly urbanized, both geographically and culturally. The needs which the health services must fill will be more complex, and the demands greater. Dealing with this situation under optimum condi- tions would already represent a notable effort; dealing with it under current conditions, in which the external debt crisis demands that countries devote 30 to 50 per cent of their export earnings to pay only the interest on their debt, leads inexorably to the search for new approaches. We can only face these chal- lenges if we initiate a process of profound change, which must be promoted in each of the countries of the Region of the Americas. The health systems and their relation with the social, economic, and polit- ical environment in which they op- erate must change. This need is obvious since, if current approaches The caring hands of health workers, left and below, demonstrate the unifying potential of health among all peoples. PAHO/WHO Photos by Julio Vizcarra and trends continue, they will guarantee a disaster with incalcul- able repercussions. It is indispens- able that health services be or- ganized and administered in ac- cordance with the principles and values of Health for All and pri- mary health care: equity, universal cov~rage, participation, and effi- ciency. Extreme poverty and the disparities in access to health ser- vices among different social groups must be reduced. Health services must be reoriented to allow each individual to live a socially and economically productive life. The need for community participation in health goes beyond the use of community members as workers in health campaigns and programs, to involve the community in decision making and control of activities. Efficiency demands that we halt the waste in health systems of Latin America and the Caribbean, which is estimated at 10,000 million US dollars. This waste involves the un- coordinated and duplicative ser- vices offered by different institu- tions, delays in decision making, organizational deficiencies, the use of inappropriate technologies, and the idleness of costly equipment rendered ineffective because of lack of maintenance. There is also ineffi- ciency in the recruitment and man- agement of personnel with obso- lete, feudal attitudes which gener- ate underground resistance or open confrontation. The values and prin- ciples outlined in the goal of Health for All are just as pertinent, if not more so, than when they were ap- proved a decade ago. In order for health services to be in accord with those values, there must be a revision in the way health is integrated into socio-economic development. Health can and must change its role and image as a "non-productive" sector, tolerated and given resources for pragmatic political reasons, for reasons of charity or philanthropy, or as a result of trade union pressures. We must be able to show the positive social, economic and political reper- cussions that a tangible improve- ment in health conditions can bring. Societies, governments, and indi- viduals cannot avoid the question of how to reshape the processes of . socio-economic development ac- cording to new models. As the twentieth century lurches fitfully toward a close, the models of devel- opment which have been debated and put into practice over the last 150 years are beginning to show clear signs of weakness, fatigue, and even obsolescence. Theoretical orthodoxy, when applied to the 27 The Challenges Ahead infinitely complex variables of hu- man living, has propelled govern- ments, societies, and individuals to- ward the ruin of pyrrhic victory. In Latin America and the Caribbean, even before the current economic crisis, as for example during the growth period of 1972-80, the num- bers of people living in extreme poverty still went from 95 to more than 130 million. Yet, the high cost of the little progress made so far, added to stagnation and popular discontent, have led us toward experimenta- tion and away from orthodoxy. On all sides, then, there is a gradually growing socio-economic flexibility and a thrust toward economic and political planning performed "as if people really mattered." Thus, this quantitative and qual- itative challenge we face requires mobilization of political will. It re- quires the search for opportunities and ways to deliver a clear, precise message, in a spirit of collaboration, 28 to all political and social sectors of each country. This message is that health is the concern of everyone for everyone; that health is not the last car in the train, but the locomo- tive which can lead us effectively on the track to development. The challenge of redefining and modernizing health systems cannot be met without leaders who will promote and cultivate the search for excellence. The efficacy and efficiency of socio-economic pol- icies, particularly those pertaining to health, are determined in any country by the capabilities of those charged with the conception and execution of those policies. Leader- ship has many facets. It includes the patient and persistent struggle to form coalitions within and among institutions and sectors. It includes the challenge of orchestrating per- sonal agendas and interests in search of a different vision and of the common good. It encompasses the need to express, define and reiterate new concepts and values, and to revive others that have been forgotten. It requires understanding of the interdisciplinary character of health and of the political process and its repercussions for health. Leadership goes beyond accepting a mandate and begintiing to carry it out. It is the indispensable basis for the search for excellence. And with- out this continuing search for ex- cellence the perspectives for the health sector, and particularly for the peoples of the Americas, are dimmed. However, probably the most seri- ous crisis and greatest challenge of the coming years and decades is Primary health care must include not only community based services such as the immunization visits in Peru, below, but also health education of the public, right, to deal with priority health problems among the most vulnerable groups. PAHOIWHO Photos by Julio Vizcarra W oRLD HEALTH, October 1987 that of solidarity. We might become aware of different and better av- enues, be willing to change direc- tion, achieve new heights of institu- tional and personal efficiency, and produce the best national and inter- national leadership; but if we fail to act together, we will have made little headway beyond manipulat- ing resources in a hit-or-miss fash- ion or on a case-by-case basis. The human . race unleashes ever more spectacular scientific and technological pyrotechnics, almost on a daily basis. Meanwhile, hu- manity's ethical evolution, of which solidarity forms a part, leaves much to be desired. The lack of solidarity takes many forms. We see it when international ·organizations are criticized-sometimes for reasons that are justified, and other times for ideological reasons-and attack- ed politically and economically. We see it in a growing preference for bilateral cooperation among coun- WoRLD HEALTH, October 1987 tries. We see it in the short-sighted mentality that erroneously divides sectors according to .production or consumption of resources. We suf- fer from it when localism and institutional chauvinism impede reaching agreement, even within the health sector. And we promote it when in our daily conduct, perhaps because we suffer from fatigue and frustration, we are guided by petty goals and personal interests. Rejection of humanistic values and a lack of unity bring about world conflicts and impede human advancement. Nonetheless, the broad consensus ,that physical and mental health is beneficial and the right of every human being- together with the widely accepted fact that illness knows no border, race, or ideology-show that health can become, increasingly with each passing year, the catalyst for the solidarity among people which we all seek. The truces held in El Sal- vador to allow vaccinations for wo- men and children and the initiatives of the Pan American Health Or- ganization PAHO/WHO in Central America entitled "Health, a Bridge for Peace" constitute a dynamic demonstration of the unifying po- tential of the health field. Over the past few years, after some successes and a number of frustrations, PAHO moved to meet these challenges, expressed by the unmet needs of daily life in the countries of the region, and by the unacceptable social debt that brings about so much suffering and so many preventable deaths, and so much injustice and inequality. But despite these frustrations, we have achieved considerable progress. And the clearest demonstration of this is the strong support that the Organization has received from its member countries. The approval in 1986 by the Pan American Sanitary Conference- the highest policy or- gan of PAHO/WHO in the Western Hemisphere-of program priorities for the 1987-1990 quadrennium has provided us the tools to con- front these challenges in a systema- tic and pragmatic way. This political decision established the quadren- nial frame of reference for the Or- ganization's cooperation in trans- forming health systems, with its activities now underway in three related areas of priority: the devel- opment of the health infrastructure with emphasis on primary health care; specific programs to deal with priority health problems among the most vulnerable groups; and the process of information management needed to carry out these programs. By targeting these three areas, the member countries have given the Organization a mandate to move effectively against the human catastrophe that would be rep- resented by the prospect of having 300 million people lacking health services by the end of the century. This is a regional approach, de- veloped on the basis of the particu- lar socio-economic and health con- ditions of the Western Hemisphere. But it is also an approach that fits perfectly within the universal prin- ciples which the Member States of the World Health Organization ac- cepted when they approved in 1977 the universal call for Health for All by the Year 2000. • 29 '' Pre-Emptive Ban'' Sought Against Smokeless Tobacco By World Experts A group of experts meeting under the aegis of WHO has cal led for a "pre-emptive ban" on smokeless tobacco wher- ever this product has not been introduced to "prevent a new public health epidemic from a new form of tobacco use". As the basis for its recom- mendation, the experts stated that smokeless tobacco is "now being promoted cynical ly and aggress ively around the world despite its known harm- ful health consequences". Thus, governments "shou ld as a matter of urgency, pre- emptively ban the manufac- ture, importation and sale of smokeless tobacco products before they are introduced into the market." Dr Gregory N. Conno lly, Di- rector of Dental Health, Depart- ment of Public Health, Boston, who chaired the week-long meeting said, " lt is vita l that we do not repeat the mistakes which have led to the massive health problems caused by cigarette smoking ." The experts were from Aus- tralia, Hong Kong, India, Ireland, Pakistan, Sweden, the United Kingdom and the U.SA. The use of forms of smoke- less tobacco- that is, tobacco not smoked but chewed, dip- ped, or just left in the mouth, even overnight between gum and cheek- has already been prohibited in Hong Kong, Ire- land, Israel and New Zea land. Although promoted as an al- ternative to cigarettes, smoke- less tobacco is described by WHO PHOTO!Tibor Farkas Free samples : A need to pro- hibit them. 30 "AIDS: A Worldwide Effort Will Stop lt" Above: The theme of a worldwide health education and public information pro- gramme launched recently by WHO to increase awareness of how AIDS is spread, and, just as importantly, how it is not. At right.· The symbol. Through them. the aim is not only to "communicate the severity of the AIDS threat," as Dr Jonathan Mann, Director of WHO's programme on AIDS, explained during an unveil ing ceremony, but also to make it plain that "only a global strategy can control it. " There is good reason for mounting such a concerted attack against AIDS, the dreaded acquired immuno-defi- ciency syndrome. According to figu res received by the end of Aug ust. 144 countries reported cases and, in the six years since the disease was first identified in 1981, the total number of victims reached some 57,000. That f igure, whi le high, is stil l estimated to be less than a half of all actual cases worldwide. The need for a globa l assault was endorsed by the leaders of the world's seven major industrialised countries - Canada, the Federal Republic of Germany, France, Italy, Japan, the United Kingdom and the United States. At their meeting last June in Venice, according to Dr Halfdan Mahler. WHO's Director-Genera l, they sing led out WHO as the "best forum for drawing together international efforts on a world wide leve l to combat AIDS." In exp laining the symbol, its U.S. designer, Milton Glaser, said he sought an image with the "power to persist in the memory." The result of this work- two red hearts that converg e on a blue fright mask. • ...... ....... ... ... ... ...... ...... ..... . .......... . ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• ••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••• • • •••••••••••••••••••••••••• ... ... ....... ... ... ... .... . . ......................... . ••• ••• ••• ••• ••• ••• • • ••• • ••••••••••••••• ... ... ....... ........... ..... . ... . ................... . ... ... ....... ........... ..... . ... . .................. . ... ... ....... .......... ..... ... . ................ . WHO as a "new threat to society" - particula rly to young males who are. thus far, the major targets in promotiona l and advertising campaigns. Studies have shown "bey- ond any reasonable doubt." ac- cording to a WHO working paper, "that its use has led to leukoplakia, white patches on gums, which in turn may de- velop into cancer. and to gums that recede from the crowns of teeth thereby leaving roots ex- posed. Its addiction is "similar to that produced by cigarette smoking and by other addictive drugs such as morphine or cocaine". In another major recommen- dation, the experts urged coun- tries where smokeless tobacco is already in use to subject the product to legislation that is as strong as that for cigarettes. The primary aim. however. should be ending its use. Among measures ca lled for are the prohibition of sa les to adolescents, as we ll as a ban on promotion in the mass media. Among promotional techniques are offers Gf free samples of tee-shirts, and of " introductory" pouches pack- aged in look-alike tea-bags. Also recommended are a series of regularly rotated health warnings on smokeless tobacco products and adver- tisements . In Western nations. smoke- less tobacco is sold as : • Moist snuff, tobacco finely cut and marketed loose. or in pouches, which is avai lab le in different flavours. This form is preferred in the United States and in Sweden. • Chewing tobacco, wh ich is coarsely cut tobacco. • Dry snuff, tobacco in a dry and finely powdered form, which is sniffed or taken by mouth. In the United States alone, a form of smokeless tobacco is used by an estimated 12 mi llion people, three mill ion of whom are under age 21. In India and Pakistan, it is estimated that least 100 mill ion people use smokeless tobacco, often combined in the bete l quid w ith lime and flavouring agents. • Enforcement Alone Is Not Enough to Fight Drug Abuse Measures aimed against traf- ficking and at law enforcement are essentia l in the fight to curb drug . abuse around the world. but by themselves are not enough. Because drug abuse is a health problem too, health measures are needed also. Drug abuse is both a symp- tom and a cause of psycho- social deterioration, accord ing to Dr Norman Sa rtoriu s, Direc- tor of WHO's Division of Mental Health. " it strikes at youth, a most vulnerable section of the popu- lation, " who need help, not punishment. he said in ad- dressing the recently con- cluded UN Internationa l Confer- ence on Drug Abuse and Illicit Trafficking in Vienna. The development of "de- signer drugs," made in laboratories by tampering with legally permitted compounds, has also added to the "catas- trophic health consequences of drug abuse." These synthetic formulations have an addictive impact as much as a thousand times more than natural, plant- based substances. And AIDS, "infesting and kill- ing not on ly those injecting drugs but also spreading from them into a far wider popu la- tion," has raised the threat to health to new heights. The UN Message: Say Yes to Life; No to Drugs. Prevention, treatment and rehabilitation are preferable to measures that might alienate already confused young drug users. In large part. a country's anti-drug programme shou ld be based on prevention. "No country can claim it is dealing with the fearful threat of drug abuse unless the health sector is intimately involved in demand-reduction." he said. To reduce the demand, there is the need for countries to pro- mote healthy behaviour, to W oRLD HEALTH , October 1987 make health and wel l-being possible and enduring, and drug abuse less likely. Above all, there is need for an international all iance aga inst death, disease, socia l deterioration and misery which drug abuse is bringing to the world ." In al l countries narcotic and psychotropic drugs are be- ing misused and abused. The number of cocai ne abusers stands at 4.8 million, of opium abusers at 1.7 million, and of heroin abusers at 750,000, ac- cording to figures reported to the United Nations. • A Step Forward In Protecting The Ozone Layer By 1990, world production of chlorofluorocarbons wi ll be frozen at 1986 levels. Over the two fo llowing yea rs, production wi ll be reduced by 20 pe r cent, and from two to four years later cut by a possible 30 per cent. That is the gist of a draft proposal that is likely to form the basis of a "meaningful in- ternational ag reement to pro- tect the ozone layer " from the sun's destructive ultra-vio let radiation, according to Dr Mos- tafa K. Tolba, Executive Di rec- tor of the UN Envi ronment Pro- gramme. Evidence over the past de- cade shows that use of CFCs, fo r instance, in aerosol cans, refrigerators and cleansing agents, thins the ozone and as a consequence raises the planet's temperature, as well as accelerating the so-called "green-house" effect that cou ld alter the earth's cli mate. One health effect of ozone depletion is an increase in skin cancer. "There was no dissent at all about the fact that we are fac- ing a rea l problem of the deple- tion of the ozone," the top UNEP offic ial sa id during a 31-nation conference held in Geneva in May, " but because of economic factors, industry needs to have time to adjust to change." About a month later, in a related development, U.S. and Soviet scientists agreed to ex- pand a pact between the two nations on research in the at- mosphere, in particular the ex- change of information. If their studies show that a "hole" in the ozone layer over Antart ica is widening, UNEP is committed to ca ll ing an emergency conference later this year. • WoRLD HEALTH, October 1987 News brief • Awards: Candidates are being sought for the second A!bert Dubois Quinquennial Prize for Tropical Pathology. The prize, of a half million Belgian francs, is named for a scientist regarded as a founder in tropical medicine, and who began his life's work at age 24 in the Congo combating sleeping sickness and leprosy. Candidates are asked to submit a summary, in Dutch, English or French, at least ten pages long, of studies carried out and published within the past five years. Deadline is 37 December 1987, with the award to be made in 1988. (For more details. write Academie Royale de Medecine de Belgique. Palais des Academies. 1 rue Oucale. 1000 Bruxelles). - Next month, Or Fe del M undo, a pioneer in the development of family planning programmes in the Philippines, will receive the triennial IAMANEH-Bourguiba Award in recognition of her life- time's devotion to maternal and child health. it will be presented on 7 November during the 3rd International Congress of Maternal and Neonata! Health to be held in Lahore, Pakistan. Given by the International Association for Maternal and Neonatal Health, Geneva, and the Tunisian Association for the Health of the Mother and the Newborn, the award is named, in part, after Tunisia's President Habib Bourguiba. UNFPA. UNICEF and WHO are on the selection committee. - For "sustained contribution made to the cause of refugees in their country, and throughout the world over the years," the people of Canada have been awarded the Nansen Medal by UN High Commissioner for Refugees, Jean-Pierre Hocke. The award is named for Norwegian scholar and explorer, Fridtjof Nansen, who was the first commissioner, under the League of Nations, for refugees. • Calendar : Of more than usual noteworthiness, the Interna- tional Conference of Ergonomics, Occupational Safety and Health, and the Environment, to be held a year from now- from 24 to 28 October 7988- in Beijing, China. The Chinese Society of Metals, and the Darling Downs Institute of Advanced Education, Australia, are joint sponsors of the conference aimed at making workp!aces safer and healthier. The event, they say, will be " the biggest of its kind yet staged in China." (For details. write ICEOSHE Administrator. P 0 Box 44. Darling Heights. Toowoomba. Queensland 4350, Australia). • Still Playing, but Only When Safe: Hollywood has responded, at least in part, to a call by the US. Department of Health and Human Services for AIDS education programmes that stress abstinence and "sa fe sex." The first AIDS-influence films, which reached movie houses last summer, show that while heroes still play, they play it safe. In the latest James Bond film, "The Living Daylights," Secret Agent 007 practices monogamy. While in previous adventures he has been required to go to bed thrice with three different women, he frolics now thrice with the same woman. And in a police thriller, "Dragnet," the hero, albeit reluctantly, passes up a liaison with a blond on discovering that his stock of condoms has run out. "We have to conform to what's going on in the world. We have to be responsible, " the New York Times quotes the producers as saying. • Turning to Nutritious Fast Foods. The message of a current advertising drive by McDonald's Restaurant is that the worldwide hamburger chain is cutting back on fat and salt, thus in effect striving for more nutritious content in the "fast food" it serves. i t has lowered the sodium content of pork sausages and pickles. it is frying fish and chicken in pure vegetable shortening, instead of animal fat. thereby helping to lower cholesterol levels. In the next issue WHO has long been in the forefront of efforts to find and develop new and better methods for fertility regulation. Some of the exciting developments in the field of research into human reproduction are discussed in the November issue of World Health. Authors of the Month Dr Jorge OsUNA is Area Direc- tor of Health Systems Infra- structure at WHO's Regional Of- fice fo r the Americas, PAHO. Mr Mark L. SCHNEIDER is a Technical Officer in the Analysis and Strategic Planning unit at WHO's Regional Office for the Americas, PAHO. Dr Jose R. FERREIRA is Program Coordinator, Health Manpower Development, at WHO's Regional Office fo r the Americas, PAHO . Dr George A. 0. ALLEYNE is Area Director, Health Programs Development, at WHO's Regional Office for the Americas, PAHO. Mr Horst 0TIERSTETIER is a Sanitary Engineer in the En- vironmental Health Program at PAHO, and Mr Alberto F'LORES is Director of the Pan American Center for Sanitary Engineering and Envi ronmental Sciences in Lima , Peru. Dr Eisa M. MORENO is Program Coordinator of the Maternal and Child Health Program; Dr Nes- tor Suarez OJEDA and Dr Ciro de QuADROS are both Medical Officers in the same program. Dr Claude de V ILLE DE GO YET is a Medical Officer in PAHO's Emergency Preparedness and Disaster Relief program. Dr Carlyle GUERRA DE MACEDO is Director, Pan American Health Organization, and Re- gional Director fo r the Americas of the World Health Organi- zation. WORLD HEALTH For readers everywhere 1987 Subscription Rates US$ Sw. fr . One year Two years Three years 14.- 25.- 24.75 45.- 33.- 60._: ORDER FORM Please enter my subscription to " World Health" as follows : One year 0 Two years 0 Three years 0 I enclose cheque/international postal order in the amount of: Name: __________ ~------ Street: _______________ __ City: -------~-­ Country:--- ----- World Health, WHO, Avenue Appia, 1211 Geneva 27. Switzerland World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies. please contact your usual bookseller. 31 A young boy suffering from a rash is checked by a doctor in a rural hospital in Guatemala. PAHOIWHO Photo by Carlos Gaggero . ., > ,., c Q) t9