World Health: the magazine of the World Health Organization: October 1986 [full issue]: spaceship earth

2 Cover: A lunar view of our planet-still. so far as w e know. the only repository of life in the universe. Photo L. Sirman © IX ISSN 0043-8502 World Health is t he officia l illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year on Englosh, French. German. Portuguese. Russoan and Spanosh. and four tomes a year on Arabic and Farsi. Artocles and photographs not copyroghted may be repro- duced provoded credit is given to tl"le World Health Organozation. Signed articles do not necessarily reflect WHO's voews. World Health. WHO, Av. Appoa. 121 1 Geneva 27. Swotzerland. Contents Checking the pulse of the planet by Halfdan Mahler . . . . . . . . . . . . . . . . 3 A checklist of the world's well-being by Sumedha Khanna . . . . . . . . . . . . . . 5 What the Assembly said . . . . . . . . . . 7 . Twelve yardsticks for health. . . . . . . 8 The birth and growth of PHC by Hakan Hellberg . . . . . . . . . . . . . . . . 10 Information for all by Dorothy Hoffmann . . . . . . . . . . . . . 14 Spaceship Earth. . . . . . . . . . . . . . 16-17 Successes south and north - Community self-help in Burma . . . 18 - Finland : pioneer country by Steve Serdahely . . . . . . . . . . . . . . . 21 Work and health in Hungary by lvan Forgacs . . . . . . . . . . . . . . . . . . 23 Outlook for the future . . . . . . . . . . . . 26 Goitre by Philippe Stroot . . . . . . . . . . . . . . . . 28 • Department: Primary Health Care A mirror for Africa by EleutherTarimo . . . . . . . . . . . . . . . 24 News Page . . . . . . . . . . . . . . . . . . . . . 30 WoRLD HEALTH, October 1986 Health for all- from btight-eyed childhood to wise old age. Now wuo has made a first, tentative step towards taking the temperature and checking the pulse of the planer. Photos WHO/Zafar THE WORLD HEALTH SITUATION Checking the pulse of the planet WHO's Seventh Report on the World Health Situation is a global assessment of the progress made so far towards at ta ining Health for all by the year 2000 by Dr Halfdan Mahler Director-General of the World Health Organization l1 he virtually 90 per cent response rate from the Member States of WHO could be called an " infor- mation revolution " and it underlines the importance they attach to monitoring and evaluating the Health for all movement. It was a resolution of the Thirty-Sixth Worl.d Health As- sembly in 1983 that called for the Seventh Report on the World Health Situation to serve as the initial global report on the progress of the move- ment. This exciting reaction reflects the common interest that the countries have in assessing the advances made - or sometimes the ground lost-as we advance towards the years 2000. The country reports do not reflect an academic search for dramatic or utopian results , but rather a willing- ness to share positive and negative findings openly and with candour. What do we perceive on this vast canvas of unprecedented concept and scale? I believe we now have new insights into the effect of major socio- economic factors on health , on the development of health systems, on the patterns and trends in health status, and on the outlook for the future. WHO has made a first , tentative step towards taking the temperature and checking the pulse of the planet. The 1978-1984 period under review could be characterised as one of turbu- lence and change, particularly with regard to the world's economic and political circumstances. The evidence W oRLD HEALTH, October 1986 advanced by this evaluation clearly illustrates the adverse effect of these. circumstances on health and socio- economic development. A striking example was the sub-Saharan drought in Africa. "lt must be borne in mind that the tragedy of life doesn't lie in not reaching your goal. The tragedy lies in having no goal to reach. lt isn't a calamity to die with dreams unfulfilled. but it is ·a calamity not to dream. lt is not a disaster to be unable to capture your ideal, but it is a disaster to have no ideal to capture. lt is not a disgrace not to reach the stars. but it is a disgrace to have no stars to reach for. Not fai lure. but low aim is sin." Dr Benjamin Mays, former president of More- house Col lege in Atlanta, Georgia, USA The harmful consequences of self- generating and self-expanding poverty are pervasive throughout much of the developing world. People are still dy- ing of starvation, and malnutrition is regarded as the most widespread con- dition affecting the health of children. A ray of hope piercing the gloom is the increasing use of primary health care as a lever for self-development. And there have been some success stories. The growing awareness in many countries of the need to reorient health systems to primary health care has led to a consensus for change. There is renewed belief in the exten- sive advantages of primary health care, and a resolve to take the risks involved in restructuring and reor- ganizing the health system so as to establish coordination mechanisms within the health sector-and between it and other sectors. The eventual result will be to revise and expand the health care delivery infrastructure. A good many countries are making encouraging efforts in training health workers, as well as community leaders in health. New categories of health manpower-such as community health workers, village health guides and multi-purpose workers- are being in- troduced in some Member States, and these constitute a positive force in alleviating the adversity of isolation at the village level. Increased community involvement in health and greater ac- ceptance of non-governmental and women's organizations as effective re- sources are becoming apparent. New approaches to generating and mobilis- ing resources are emerging. In most countries it is still too early to measure precisely, in terms of re- duced mortality, the effect of the Health for all strategy, or the degree to which that strategy has reduced health disparities between different levels of society and between different 3 Checking the pulse of the p lanet countries. An encouraging sign, how- ever, is that a majority of countries are reporting upward trends in life expec- tancy at birth as an expression of survival prospects. This is one of twelve agreed global health indicators. On the other hand maternal mortality accounts for the greatest proportion of deaths among women of reproductive age in the developing world. I cannot , of course, comment in detail here on all the disease patterns and health trends reported by the Member States. But diarrhoea in chil- dren, acute respiratory infections, dis- eases that can be prevented by im- munization , malaria , tuberculosis and schistosomiasis remain major health problems in developing countries, as cardiovascular diseases and cancer are in industrialised countries. And now the latter are emerging in developing countries too. The sunburst of triumph following the eradication of smallpox has a less happy counterpart in the stagnation of the global malaria situa- tion. The emergence of an apparently new disease- acquired immunodefi- ciency syndrome (AIDS)-demons- trates that, in the battle to achieve health, the hostile forces arrayed against mankind are themselves evolv- ing and changing. There is a disquieting increase in the abuse and dependence on so-called " hard " drugs in many parts of the A mother yells in sympathy as a child in Yemen is immunized- another step towards global well-being. Photo WHO/M. Jacot world , accompanied by a new wave of alcohol-related problems. Other life- style and behaviour-related problems are also assuming increased signifi- cance ; it is a sinister paradox that endemic hunger and malnutrition in the developing countries are matched by the negative effects of over- consumption and detrimental eating habits in the developed world. The alarming spread of tobacco use is bringing with it a pandemic of avoid- able illness and premature death. In developing countries this means an additional burden, while infectious diseases continue to take their toll. In summary, what have we learned through this evaluation? Well, we have seen that the Member States, in assessing progress , have revealed sig- nificant strengths and weaknesses. We now realise that the evaluation process is inhibited by the absence in most countries of a statistical baseline against which to measure progress and, perhaps more important still , by the lack of information support with regard to the global health indicators. Although this is not really acceptable it is, to a degree , understandable. It has been said that statistics, after all, are people with the tears washed off. The study has shown Member States the challenges they must face in the future. These include: a true political commitment to social equity in health matters , with national policies based on reducing health disparities; inten- sive efforts to mobilise and involve professional groups, community lead- ers , non-governmental organizations and people from all walks of life; the stimulation of vigorous management of health systems, including the rein- forcement of information support sys- tems; further strengthening of the health infrastructure with emphasis on completing the primary health care network, so as to fully utilise the potential of these services; innovative and applicable research together with appropriate use of research and technology to fortify primary health care; and exploration of all viable means of improving the financing of the health system , making optimum use of available resources. WHO itself faces the challenge of providing relevant and imaginative technical cooperation to improve na- tional managerial capacities, thereby ensuring that managers have the tools to carry out and evaluate national strategies for Health for all. WHO will have to promote and support the research and development necessary to do that. Member States and WHO together will have to embark on con-· certed and intensive action to mobilise financial resources, especially in sup- port of the least developed countries. Member States in their reports have reaffirmed the validity of the basic principles of the strategy. No one has even mentioned a need to modify that strategy, which has proved equally valid for developing and developed countries. In a continuum of activities , the countries are adapting the strategy to the great array of issues that are confronting them, and are gaining a new perspective which will help them to make appropriate choices to suit their future needs. The means available to Member States to achieve the Health for all goal are as diverse as their physical characteristics, their epidemiological situation, their social and cultural pat- terns, their political and economic structures and their degrees of devel- opment. National and regional varia- tions will become even more apparent as time goes by. While the strategy might not, as yet, have reached the stage of supplying all the answers, the heartening response to the evaluation shows that it has certainly become instrumental in determining what are the right questions to ask . • W ORLD HEALTH, October 1986 A checklist ol the world's well-being The Health for all strategy is already proving effective; many countries have reported important progress in making health services physically accessible to their population by Sumedha Khanna l1 o draw together in one single, manageable document the evaluation reports from 146 countries was not a simple matter. The countries began evaluating their na- tional strategies for Health for all from October 1984 onwards, and were ex- pected to submit their national reports to the appropriate regional office by March 1985. Not all reports from the countries arrived in time, and there was a con- stant need for updating and adjust- ment of the data before the regional reports could be presented for review by the s·ix regional committees in Sep- tember and October last year. The global report was prepared on the basis of the synthesis of these six regional reports. Where necessary, the WHO sec- retariat made use of information from other sources, especially from reports of programme managers and from documents of other organizations of the United Nations system . The final document, the Seventh Report on the World Health Situation , will be div- ided into seven volumes-a global re- port and one for each region. The global report reviewed world- wide trends in social and economic development, and the potential impact of these trends on health. Besides reviewing the health status of the world's population, including major trends in mortality , morbidity and dis- ability, the report highlighted the prin- cipal actions taken by governments to develop and implement their national strategies for Health for all, and the main obstacles they encountered. WoRLD HEALTH, October 1986 After analysing the overall results of the evaluation of the Health for all strategy-and attempting to single out the various factors contributing to suc- cesses or failures , it discussed the main issues and factors which could influ- ence national, regional and global ac- tions or which could have implications for any readjustment of the Strategy. Health worker in the Philippines adds another jigsaw piece to the picture of a nation's health. Photo W HO/Zafar The report-a checklist of the world's well-being-falls into five chapters. The first focuses on the rela- tions between socio-economic devel- opment and health. It examines global demographic, economic and social trends , and their implications for so- cial policy and intersectoral coopera- tion in health. Within this context, it considers global indicators number 11 (the adult literacy rate) and number 12 (gross national product per capita). Chapter 2 reviews progress in health development processes in countries, and identifies the main obstacles en- countered and the measures taken by Member States to overcome them. Most of the global indicators are reviewed in this chapter, namely 1 (political commitment) , 2 (community involvement) , 3, 4, 5 and 6 (resources, particularly financial) and 7 (availabil- ity of primary health care). Chapter 3 assesses the health status of the world's population, analyses patterns and trends in mortality , mor- bidity and disability as well as in health behaviour and life-style, and examines key environmental factors affecting health. This chapter covers global in- dicators concerned with health status, namely 8 (nutritional status of chil- dren) , 9 (infant mortality) and 10 (life expectancy). Chapter 4 is an assessment of the progress and effectiveness of the H ealth for all strategy, and of the constraints that impede its develop- ment. Finally, chapter 5 considers the out- look for the future , and the challenges that lie ahead for the Member States and for WHO in the remaining decade and a half before the year 2000. Selected highlights Perhaps the flavour of this attempt to "take the temperature and feel the pulse " of the world is best conveyed by selecting and highlighting a few of the findings that give a broad picture of the state of the world's health. A glance at the average population 5 A checklist of the world's well-being growth in WHO's six regions during 1975-1980 shows that the growth rate was highest in the African and Eastern Mediterranean regions , averaging al- most three per cent per year. In the period 1980-1985, growth remained static in the European region but in- creased at an average of three per cent per annum in the African region , de- clining slightly in the other four re- gions. The largest decline had occur- red in the Western Pacific region. For the same first period, the high- est crude birth rates-averaging 47.6 per cent-had been in the African and Eastern Mediterranean regions while the second period was marked by a small decline in all regions except that of Africa. The crude death rate during the same periods had been highest in the African region, while the Euro- pean region showed a marginal in- crease which was most probably linked to the aging of the population. During the whole ten-year period 1975-1985, the fastest urbanisation -an increase of almost 75 per cent in the urban population-had occurred in Africa, but the region of the Americas, where 71 per cent lived in urban areas, was still the most urbanised. By the year 2000 it can be estimated that roughly one half of the world's popu- lation will be living in cities and towns, and 17 out of the 20 largest urban agglomerates will be in the developing countries. Some 55 countries, many of them in Europe and the Americas, spent five per cent or more of their gross national product on health; but 43 countries, including all those in the South-East Asia and Eastern Mediterranean re- gions, spent less than five per cent. The availability of some of the es- sential elements of primary health care is an important reflection of the ade- quacy and effectiveness of health de- velopment measures taken. For safe water coverage, 57 countries had been able to show 80 per cent coverage, while 85 countries (most of them from South-East Asia , Africa and the East- ern Mediterranean) had reported be- low 80 per cent. The urban/rural breakdown was available for only a few countries, but it was estimated that about 1,000 million more people -80 per cent of whom lived in the 6 countryside-needed to be provided with safe water. As for adequate sanitary facilities in the home or immediate vicinity, 43 countries reported access to such facilities for 80 per cent or more of their populations, whereas 73 coun- tries (mostly in Africa and South-East Asia) had access for less than 80 per cent. (A few countries in South-East Asia, Africa and the Eastern Mediter- ranean reported coverage as low as only one per cent in rural areas). Kwashiorkor case in Ethiopia. The nutrition- al status of children is one of the key indi- cators of health. Photo Relief and Rehabilitation Commission © Thirty-eight countries, including all those in the European region , reported that trained personnel attending pre- gnancies were available to 80 per cent or more of their people, while 41 countries had less than 80 per cent coverage. Roughly half of the report- ing countries had 80 per cent or more coverage by trained personnel attend- ing childbirth. As regards access to local health care, inducting the availability of at least 20 essential drugs within one hour's walk or travel , 66 countries reported access by 80 per cent or more of their population. But 65 countries had not reported, including 25 from the African region and 21 from the region of the Americas; it is possible that such information is not being routinely collected. Well over half of the countries re- porting (77 out of 123) could show that at least 90 per cent of newborn infants had a birthweight of at least 2,500 grammes ; 74 out of 155 coun- tries had an infant mortality rate for all identifiable subgroups which was less than 50 per 1,000 live births (but of the 81 countries with rates of 50 and above, 44 had rates of 100 or over; 29 in the Eastern Mediterranean). And 81 out of 144 countries had achieved a life expectancy of 60 years or more. And as regards the adult literacy rate , 75 out of 133 countries reporting had a rate of 70 per cent or more. Many countries in the Eastern Mediterranean region showed a low rate , and no information was available from 30 countries. The female literacy rate would be a relevant indicator for health , but data from many countries do not differentiate between rates for men and for women. But what figures are available show that in the least developed countries the gap between the sexes has widened. Almost two- thirds of illiterate adults in the de- veloping countries are women. One country, in the Eastern Mediterra- nean, has reported illiteracy to be 84 per cent for men and 99 per cent for women. To sum up, where the progress and effectiveness of the Health for all strategy are concerned, many coun- tries have reported important progress in terms of physical accessibility of health services to the population. Some developing countries have be- tween 80 and 100 per cent coverage with some or all of the essential ele- ments of primary health care. Among those elements, immunization has re- ceived high priority. There has been some progress in the care of women during pregnancy and childbirth, but care for children under five years of age is still very limited. And while water supply and sanitation have made gains, most of these have been nul- lified by population growth and by the effect of recent droughts. Finally, although it is still too early to assess impact , or to directly attri- bute any changes to national strategies for Health for all, an encouraging feature of this monitoring and evalua- tion effort is that infant mortality and life expectancy are showing trends towards improvement in a majority of countries. • W oRLD HEALTH, October 1986 What the Assembly said Delegates from tre 166 Member States of WHO met in Geneva to discuss the Seventh Report of the World Health Situation during the World Health Assembly in Geneva in May. Here are some of the delegates' comments (W r Kim Won Ho, Chief, Institute of Health, A~ministration Rese~rch, Democtatlc People's Republic of Korea: The report on the first evaluation of the Strategy for Health for all shows that 38 per cent of the world's population have not yet achieved a life expectancy of 60 years, that 45 per cent have not yet achieved a reduction in infant mortality to less than 50 per 1 000 live births and that, for all the indicators, considerable differ- ences still existed between developed and developing countries. If the Strategy's goals are to be attained on a worldwide scale before the turn of the century. much more work wi ll be need- ed-in particular, practical and effective assistance to the developing countries. Or B. Sadrizadeh, Under-Secretary for Health Affairs. Ministry of Health and Medical Education, the Islamic Republic of Iran: As long as developing countries suffer from war, illiteracy, poverty, hunger, ex- ploitation and injustice, the humanitarian goal of Health for all can never be achieved. Moreover, the same will apply to the affluent countries unless they are able to solve the problems of inequity and maldistribution of the resources at their disposal. Or A. Khalid bin Sahan, Director- General of Health, Ministry of Health, Malaysia: The public have become very depen- dant for their health on medical personnel and medical technologies; many have completely surrendered responsibility for their own health or that of their depen- dants to medical personnel. drugs and medical procedures. The trend w ill have to be reversed by inculcating self-re- liance, and through a more active health education programme. The medical pro- fession as a whole should refrain from giving the impression that medica l tech- nologies have all the answers. Whi le medical science can prevent certain dis- eases and alleviate sufferi ng, disease prevention and health promotion must start in the home, in schools, at places of work and on the roads. WoRl D HEALTH, October 1986 Or Z. Jadamba, Chief, Department of Foreign Relatjons, Ministry of Health, Mongolia: The information from 146 countries submitted to the Health Assembly pre- sents a rather sad picture. Only 45 per cent of States can provide 80 per cent of their population with safe drinking water ; in only 27 per cent are 80 per cent' of the population in need of immunization actu- ally vaccinated ; only 66 per cent provide 80 per cent of the population with primary Palais des Nations, Geneva, Switzerland. The 39th World Health Assembly in ses- sion, in May. Photo WHO health care; and in only 54 per cent are. 80 per cent of births attended by specially trained personnel. A more careful study is hecessary to determine accurately what further potential there is to enable WHO and its Member States to take the most effective measures and mobilise all re- sources with a view to speeding up the implementation process. Such measures should ful ly cover the 80 million home- less. the 50 million children at present obliged to work, the 1 0 per cent of the world's population that are physically un- able to work, the 1.5 billion persons living in unsanitary conditions, and all those human beings who have not yet reached the level of health recommended by WHO. Or M . Savel'ev, Chief, Department for Foreign Health Services of the Semasko All-Union Institute on Social Hygiene and Public Health Administration, Ministry of Health of the USSR: The attainment of the goal of Health for all is directly dependant on the preserva- tion of world peace. Important factors in establishing the necessary economic foundations for attaining Health for all are arms limitation and disarmament and a redl.lction in mi litary expenditures; the reallocation of resources to social and economic development activities with a view to combating economic backward- ness, hunger and disease; the develop- ment of international economic relations on a just and democratic basis; non- interference in the internal affairs of sovereign states; the solution of the developing countries' debt problems; and the optimum use of national re- sources. Or 0. R. Bowen, Secretary of Health and Human Services, United States: The voluminous report before the Com- mittee. based on the welcome responses of 88 per cent of Member States, consti- tutes an heroic undertaking. Neverthe- less, the inadequacies mentioned in the document cannot be overlooked, and the goals for many areas will not be attained unless a greater effort is made. Health for all itself will not be achieved without the careful monitoring and evaluation of pro- gress. and that exercise is meaningless if it is not taken seriously at the national level ; thus the principle of full national participation is the key element in attain- ing the Organization's ambitious goal. Or S. L. Nyaywa, Assistant Director of Medical Services, Ministry of Health, Zambia: To sum up. countries need help in gathering the essential data on such mat- ters as recurrent costs. charges for health services, and cost-effective procedures. And for that help they look to WHO, which should be prepared to devote more re- sources to this very necessary aspect of planning Health for all. As well as a greater supply of information, there is need for a systematic exchange of experi- ence. which w il l help to show which approaches have been successfu l and which have failed. • 7 Twelve yardsticks tor health In order to monitor the progress of the enti re planet towards the goal of Health for all , WHO has selected 12 global indicators for comparing each country's well-being al ow can we measure health ? As long ago as 1948 the WHO Con-stitution defined health as " a state of complete physical, mental and social well-being. " If we were to mea- sure all the criteria which make up such a definition of health , the list would be enormous. Apart from the more obvious ways of measuring an individual's health, we would have to look into social ills that have a bearing on our physical and mental well-being. We might look at the suicide rate , the number of murders committed or the road traffic accident rate . We might survey the rates of juvenile delinquen- cy, drug-taking, the consumption of tranquillisers, the number of cigarettes smoked, and the average obesity of a given population. Then there are more subtle factors that , taken together , add up to "the quality of life. " The opportunities for leisure pursuits and cultural or sport- ing activities , the length of the working day or week , even such considerations as the climate-something that humans have not yet learnt how to improve -would need to be measured. There are other highly subjective considerations such as how an indi- vidual assesses his or her own well- being: everybody has a personal per- ception of well-being, contentment, security and so forth. To find yardsticks for all these fac- tors that would be appropriate to an individual , a community or a society in a given country would be difficult enough. But to develop a set of indices that were applicable for the whole planet would be well-nigh impossible. Consequently, in its efforts to assess the health of the planet, and to monitor its progress towards the agreed goal of Health for all by the year 2000, WHO (at the 34th World Health Assembly in 1981) limited to twelve its choice of " indicators " : twelve fundamental yardsticks which will enable both countries and regional groupings of countries to be compared one with another. As WHO explained in the document Health for all series, No. 4: Develop- ment of indicators for monitoring pro- gress towards Health for all by the year 2000: " Information has to be pro- vided by all countries for the develop- ment of a global indicator to be possi- ble. For it to be useful , all countries have also to be able to use the global Breast is best. Wise feeding of babies will, eventually, be reflected in lower infant mortality rates. Photo WHO/Zafar WoRLD HEALTH, October 1986 indicator. The list, at global level, has therefore to be kept very short, though many countries may wan t to use addi- tional indicators in keeping with their needs and capacities. " The 12 global indicators are that: 1- Health for all has received en- dorsement as policy at the highest official level. This might take the form of a declaration of commitment by the head of state; allocation of adequate resources equitably distri buted; a high degree of community involvement; and the establishment of a suitable organizational framework and man- agerial process for national health development. 2- Mechanisms for involving people in the implementation of strategies have been formed or strengthened, and are actually functioning. T hat is to say, effective mechanisms exist for people to express demands and needs; representations of political parties and organized groups such as trade unions, women's organizations, farmers' or other occupational groups are par- ticipating actively; and decision-mak- ing on health matters is adequately decentralised to the various adminis- trative levels. 3- At least five per cent of the gross national product is spent on health. 4- A reasonable percentage of the national health expenditure is devoted to local health care. This includes first- level contact, including community health care , health centre care, dispen- sary care and the like, excluding hos- pita ls. The percentage considered "reasonable" will be arrived at through country studies. 5- Resources are equitably distri- buted. This means that the per capita expenditure as well as the staff and faci lities devoted to primary health care are similar fo r various population groups or geographical areas, such as urban and rural areas. 6- In the case of developing coun- tries, there are well-defined strategies for Health for all, accompanied by explicit resources allocations, and the needs for external resources are re- ceiving sustained support from more affluent countries. 7- Primary health care is available to the whole population, with at least the fo llowing: WoRLD HEALTH. October 1986 Grizzled old age in Pakistan. Life expectancy of over 60 years is one of 12 global indi- cators. Photo WHOIZalar - safe water in the home or within 15 minutes walking distance, and ad- equate sanitary faci lities in the home or immediate vicinity; - immunization against diphtheria, tetanus, whooping-cough, measles, poliomyelitis and tuberculosis; - local health care, including avail- ability of at least 20 essential drugs, within one hour's walk or travel ; - trained personnel fo r attending pregnancy and childbirth, and caring for children up to at least one year of age. 8-The nutritional status of children is adequate, in that : - at least 90 per cent of newborn infants have a birth weight of at least 2,500 grammes ; - at least 90 per cent of children have a weight for age that corresponds to the reference values recommended by WHO. 9- The infant mortality rate for all identifiable subgroups is below 50 per 1,000 live births. 10-Life expectancy at birth is over 60 years. 11- The adult Literacy rate for both men and women exceeds 70 per cent. 12- The gross national product per head exceeds US $500. The Health fo r all series, No. 4 declares: " It should be noted that the use of these global indicators implies that countries will commit themselves to use at least these and to report on them. It also implies that the WHO Regional Committees, the Executive Board and the World Health Assem- bly wi ll have to commit themselves to use them and will have to take a firm stand to make sure that the infor- mation is forthcoming." • 9 The birth and growth ol PHC Primary health care is the logical offspring of all the years of social change that have taken place since World War 11 ; and Health for al l is its own logical end-product s the world emerged from World War II , the international debate on how to tackle the looming problems of health began to emphas- ise the social aspects of well-being and disease. The interdependence of peo- ple in family, community and nation had become obvious as had the social and economic consequences of health and disease. These consequences had, of course , been recognised long before ; but in the late 1940s and the 1950s public health developed into a truly interna- tional force . In many countries pro- grammes and departments of social and community medicine were intro- duced or developed. The political pro- cesses that were forming social policy aligned themselves with those that were shaping health policy-even though political opposition too was sometimes evident. In the days of the "cold war," concepts that concerned "social" and " community " life were not universally welcomed. During the 1950s and 1960s, clini- cal and curative medicine was de- veloping rapidly , while new drugs and other tools for treatment were becom- ing widely available. This develop- ment often pushed preventive and public health measures aside; and politicians, health professionals and the public became preoccupied with the life-saving medical possibilities. But in order to make full use of the new curative and also the preventive technologies, a fully developed infra- structure was needed to reach people at the " grass roots. " This led to the planning and devel- 10 by Hakan Hellberg opment of infrastructure systems at different levels, reaching out through a basic health service (BHS) to incor- porate health centres and small hospi- tals with larger and more sophisticated institutions. More systematic planning was required, and resource allocation called for political decisions to be taken within a determined policy framework . Systems of health care A community in the Western Pacific works together to improve the environment. Photo WHO/C. Stauffer financing also had their technical and political aspects, whether they were tax-based or had important health in- surance components. In spite of the obvious benefits that derived from laying stress on social aspects of health and disease and from the development of different levels of health service infrastructure, the im- pact on the health status of people was still not sufficient. In the industrialised countries degenerative and non-com- municable diseases were increasing, with cardiovascular illness and cancer in the forefron t. By the time the pa- tient came into hospital , it was usually too late to cure him or her , or to ensure full recovery. Human behaviour and life-styles were determining health and disease in the less affluent countries too , where poverty and ignorance often predetermined attitudes and be- haviour patterns and tended to multi- ply the causes of ill-health. In both developed and developing countries , individual, social, economic and politi- cal " DIS-EASE" was often seen as the reason for disease. All this led to the search for an approach that would relate the impor- tant aspects of social and community life with the existing, fu lly developed infrastructures-right up to the sophis- ticated referral hospital. But it was also evident that one had to look outside the health / medical sector per se and consider all aspects of society which might have an effect on health and disease. Not second-rate care It was against this background, with pragmatism replacing dogma, that Primary Health Care (PHC) was de- veloped. Primary here means essen- tial, necessary and relevant to the individual Jiving in the family and community; it does not mean primi- tive or second-rate care for the poor as the term has often been wrongly inter- preted. Translation into some lan- guages still causes problems but the correct interpretation is important. In some industrialised countries PHC has W oRLD HEALTH, October 1986 unfortunately come to mean primary medical care, which is far too narrow an interpretation. In order not to lose sight of the wider aspects of PHC, the term " health promotion " was applied to all the activities that PHC, as cor- rectly understood , would involve. So what is the real difference be- tween PHC and BHS (basic health service)? In simplified terms, BHS reaches downwards from the top to- wards the bottom while PHC builds up from below with the necessary support from the top. It has been said that ideas, like less ·durable products , reach the public through a network of production and distribution. In PHC, the important ideas are community involvement, in- tersectoral collaboration and the de- velopment of appropriate technology. The emphasis on community in- volvement, or participation by people in matters concerning their own health , is the most important aspect. The notion has gained ground despite allegations in some quarters that PHC is a way to "smuggle in democracy through the back door. " PHC was developed during the late 1960s and earJy 1970s, and in the context of the health sector became the expression of the forces that were becoming significant during those years. Social and political changes (or at least upheavals) occurred in many countries. Former colonies became independent and socialist countries made their impact on global development; the winds of change affected many countries too with mixed economies or more capitalistic systems. Eventually the impulse towards Health FOR ALL through PHC be- came central to the search for better health and enhanced human welfare , for decency, equity and justice through solidarity in the sharing of knowledge and other resources. That is why community involvement be- came so essential to PHC, since both direct and indirect oppression of peo- ple is itself a sign of ill-health. In the late 1970s, the goal of Health for all by the year 2000 (HFA) Safe water on tap in the Americas-an essen- tial element in primary health care. Photo WHO/PAH0/0. Oownie W oRLD HEALTH, October 1986 Above: A rural health post in the Amazon basin of Peru typifies the first point of contact for many people with ''formal" health services. Below: Blood-pressure test for a woman in the Eastern Mediterranean. Photos WHO/PAHO/J. V1zcarra and WHO/M . Jacot The birth and growth of PHC evolved-the logical end-product of the PHC approach. As defined by the 30th World Health Assembly in 1978, the main social target of governments and WHO is the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economi- cally productive life. As people became really involved in PHC as the means to bring about HF A , the roles of professional health workers also changed. They became advisers and partners rather than dominating authorities. It also became apparent that PHC could not develop on its own but must be dependent upon the democratic and politica l pro- cesses in any society; in turn it will have repercussions on the role of women, of young people, of the under-privileged and the oppressed. lntersectoral collaboration and ac- tion became essential factors in HFA , and increased in importance as it was recognised that the reasons for good health and disease are mostly to be found outside the health and medical sector itself. People's health and wel- fare are determined by how they li ve, what they eat and drink, how human relationships are deve.loped and or- ganized, how resources a re distributed to different sectors of human en- deavour, and what governmental ac- tivity takes place. Most people easi ly understand this , but there is still a need to convince professionals work- ing in sectors other than health , and political decision-makers with re- sponsibi lity for nutrition , housing, education, industry , commerce and so forth. It is not too much to claim that the problems related to the single sector of health have been largely solved, but the remaining or emerging problems have multiple roots and require multi- faceted, coordinated action. Intersec- toral coordination , collaboration and action have both technical and politi- cal aspects, whjch can be challenging and even frightening- as new concepts always are. Development of PHC is dependent on the availability of appropriate tech- nology, whether for community or- ganization and intersectoral action or for all aspects of health promotion , W oRLD HEALTH. October 1986 Nutritional advice for a young mother in the Philippines; nourishing food for nursery school children in Turkey. The role of the health worker is changing; today they are advisers and partners rather than dominating authorities. Photos WHO/Zafar and WHO'C.Staurter disease prevention, care and cure of patients, and rehabilitation. " Appro- priate" applies equall y to the use of the most expensive and sophisticated technical solutions as well as to the simple essential tools used for basic problems anywhere. To develop and improve the use of such tools will require essential research and devel- opment. But are we asking the impossible? Are HFA and PHC an impossible dream? Experience from many coun- tries and many types of society have provided us with ingredients and ex- periences out of which PHC has evolved. Other countries and groups of people have taken up PHC-type ideas and developed them further. Others again are only now beginning to do so. This historical process has released some large global waves that touch every part of the world , but each nation or part of a nation has its own processes with its own special deter- WoRLD HEALTH. October 1986 minants; on these will depend whether smaller or larger waves of develop- ment wash their "shores." PHC, its underlying concepts and the programmatic e lements of putting it into effect, touch the very basic threads of the human fabric both fo r individuals and societies. It is not an independent nor an abstract activity, nor is it an easy path to follow. PHC represents a challenge to health ser- vice management , to a multitude of health-related activities and to the social and political processes. There may weJl be a temptation to give up on PHC and take on easier tasks. But PHC will not go away, just as the historical processes that have led to its evolution will themselves not disappear. The historical challenge to contri- bute to human development through primary health care and to bring about Health for all still confronts all humankind. • 13 Information for all by Dorothy Hoffmann 11 he existence of an informed pub-lic, who recognise their rights and responsibilities in determin- ing their own health priorities and who take part in solving some of their health problems, is vital if the goal of Health for alJ is to be achieved by the year 2000. Information and education for health have been placed fi rst among the eight essential elements of primary health care. It follows that people who work in mass media will be key actors in the drama which will be acted out in the next 14 years. So, primary health care needs the media. But, even more important, Ministries of Health need the media. A recent series of workshops , initiated by WHO, financed by the Finnish International Development Agency ~- -- 14 (FINNIDA) and orchestrated by the University of Tampere, FinJand, bore witness to the fact tha t health adminis- trators and members of the mass media are not always in harmony. The three workshops, which took place in Kenya , Tanzania and Ethiopia, brought together journalists, radio producers and health officials , and were the first lap in a comprehensive course to train journalists from East Africa in primary health care. The mass media can be an instru- ment for delivering health messages but they must be given wholehearted backing by the health professionals. The journalists complained that minis- try officials were not forthcorrting with information about health trends and policies. Their questions were passed from one person to another and they never got precise answers. When news releases were issued, they were usually too technical and incomprehensible for the lay reader. The health officials counterattacked by insisting that journalists were only interested in "sensational " news. What has been called " the silent emergency" of poverty and ill-health and the real news stories that were hidden in the health situation were never covered. A newspaper might announce the opening of a new health centre or the installation of a water pipe, but there was usually no back- ground explanation of how it might affect the disease pattern or the lives of the community concerned. "News " about some high-technology medical gimmick was often considered more important by editors than the scandal of millions dying from a preventable disease. Somehow, health officials and the media must find each other . Without the involvement of the media , the health sector cannot hope to create an informed general public. Without the health sector , the media cannot fulfil their obligation to serve the interests of the public. The media workshops concluded that, not only was better collaboration needed between the Ministries of Health and the mass media, but also intersectoral collaboration between the different ministries. Many aspects of education , food production , wate r supply and housing were dealt with by separate ministries but had a direct impact on the health situation. It was Workshops in Kenya, Tanzania and Ethiopia brough1 roge1her journalists, radio producers and health officials 10 discuss primary health care. Photos WHO/D. Hoffmann W oRLD HEALTH. October 1986 "Without the media, the health sector cannot create an informed public. Without the health sector, the media cannot serve the interests of the public." suggested that a task force comprising members from a ll these ministries should be formed in order to avoid overlapping or conflicting activities. The participants in the workshops identified the major obstacles facing effective health education. These in- cluded such problems as illiteracy, the need for material produced in many different vernacular languages , religi- ous and cultural taboos, the high cost of newsprint and difficulties in obtain- ing batteries fo r radio transistors . Health education campaigns were often felt to be badly planned and confusing. Spray your houses against malaria, said one message, while another encouraged people to keep their houses clean and to whitewash the walls twice a year. Eat more fish , said one message, but another advised that all ponds should be drained since there were breeding grounds for the WORLD HEALTH, October 1986 vectors of disease. Participants agreed that it was no good trying to introduce new dietary practices if the foodstuffs being promoted were not available or too expensive. Nor is there much point in promoting personal hygiene if there is no soap, or , even worse, no water! The workshops emphasised that, fo r health information and education to be effective, there is an urgent need for proper monitoring and evaluation of the impact. Many efforts made so far have failed through lack of plan- ning and proper research into such questions as cultural and religious influences, levels of education , local resources and environment. Radio programmes addressed to women are useless unless they are transmitted at times when women are free to listen. Information intended for men should be presented where men are frequent- ly found , such as in bars or at football games. Audience participation is a lso important, whether it be through pub- lic debates , radio programmes or question-and-answer pages in local newspapers. Issues on sensitive sub- jects such as family planning should involve those members of the com- munity who have a strong influence, for instance grandmothers , village leaders or traditional healers. Mes- sages need to be repeated frequently to achieve comprehension, acceptance and motivation leading to a change in behaviour. Training is essential for everyone concerned in the struggle for heal th . Health officials need to master tech- niques of communication, and journ- alists need to recognise their social responsibility for health advocacy. The English writer H . G. Wells said that " human history becomes more and more a race between communica- tion and catastrophe. Full use of com- munication in all its varied strands is vital to ensure that humanity has more than a history-that our children are assured a future. " Health for all is a concept of hope for the future , and for that hope to be realised, every person should have an appreciation of the value of health , know how to achieve it, and how to guard it. In order to achieve Health for all, there must be information for all. • 15 16 spaceship earth WHO's Seventh Report on the World Health Situation is the most ambitious attempt ever made to 11 check the pulse 11 of the entire globe "' ., 50 -~ 30 ~ 25 0 ~ 20 , z 15 10 Countries with safe water coverage, by WHO region Urban/Rural c:;~ Coverage of 40% or more • Coverage of 80% or more • Africa Americas South-East Asia Europe• Eastern Western Pacific • No urban/rural break~own given· Mediterranean [J o fewer than 146 out of 166 member states-virtually 90 per cent-responded to WHO's request for country reports evaluating each nat ion's health. Th is wholehearted response amounts to an "information revolution," and underlines the import- ance that the countries attach to monitoring and evaluating progress towards Health for al l by the year 2000. Compiled as WHO's Seventh Report on the World Health Situation. this infor- mation will form a vital base-line as- sessment of the advance made-or the ground lost- in the coming years. WHO has taken the first. tentative step to- wards taking the temperature and checking the pulse of the planet. On these pages we illustrate just a few of the region-by-region find ings of the report in the context of Primary Health Care- the approach chosen by the countries themselves to ensure the attainment by all cit izens of the world by the year 2000 of a level of health that w il l permit them to lead a socia lly and economically productive life. In other words-Health for all. • Above: Safe water supplies; the emptier the bottle, the more remains to be done. Left : Health education in Latin America; an essential prerequisite of better health is an informed public. Photos WHO/M . Jacot and W HO/PAHO WoRLD HEALTH, October 1986 Age groupe: Africa E. Medlter. S.E. Alii Amerlc:as w. Plcific Europe WORLD 0 Population age distribution {by WHO region• 1985} 26% 50% 76% Child dependency ratio: Number of 0..14 year okll per 100 pei'IOna of working • (16-64) 91/100 81/100 66/100 SUIOO 4111100 371100 561100 100% .. ·! c :::0 0 0 0 Top : Mother and child care in Africa and in South-East Asia keeps infant mortality low. Left : Age distribution affects overall health status; 81 out of 144 countries have a life expectancy of 60 years or more. Below: Immunization saves young lives. as here in the Western Pacific. WHO photos by P. Pittet. T Farkas and Zafar Immunization coverage of infants by number of countries OPT MEASLES POLIO BCG 41 48 Coverage under 40% Coverage 40%·79% Coverage 80% and more Healthy food for a little Burmese boy. Photo WHO/J Mohr Successes south and north by Steve Serdahely 11 he Brandt Commission report North-South * declares: "Now that both North and South are increasingly aware of their interdepen-dence, they nee d to revita lise the dialogue to achieve specific goals, in a spirit of partnership and mutual interest rather than of inequality and charity. The dialogue must aim to give every society a full opportunity to develop as it wishes and satisfy the essential needs of its people at an acceptable pace; and to create a dynamic world in which every country can achieve its own development , each respecting the other and respecting also the imperatives of a shared planet." In both North and South there is a growing awareness of the wide- ranging advantages of the primary health care approach in achieving the goa ls of Health for all by the year 2000. The fo llowing articles describe a "South " success and a " North " success in applying this approach. • Nortlz-Sowh-A Programme for Survival: Report of the Independent Commission o n International Development Issues (headed byWilly Brandt) , Pan Books. Ltd., London, 1980. 18 Burma: sell-help The way it was Ayadaw Township of Sagaing Divi- sion covers an area of 688 square kilometres and has a total populatio n of 147,000. About five per cent of the people live in the town proper and the rest in the neighbouri ng countryside. Situated in the dry zone of Burma in sandy and rocky terrain , Ayadaw (de- rived from "footprint stone of Budd- ha " ) existed as a trading centre from the time of the Burmese kings. During the 19th century and ea rly 20th century, high levels of cotton production made Ayadaw famous. But an increasing shor- tage of available water , coupled with the relative inaccessibility of the Township caused hard times to fall on the inhabi- tants. One of the first efforts of the central government to improve the primary health care picture took place in the ea rly 1960s, when the Ministry of Agri- culture and Forests dug ten wells. How- ever , the handpumps yie lded only about o ne litre of water per minute , and families had to spend most of each day in collecting sufficient water just for that day's use. At least it was a beginning. The long tradition among the Bur- mese of say-ta-na (deeds of the heart and soul without remuneration) , com- bined with a politica l decision to em- phasise rural development in a spirit of self-reliance and self-determination and in the framework of a decentralised administrative system, provided the groundwork for enunciating an overall health plan. Using guidelines suggested by WHO in its "country health program- ming" methodology in 1975, the health care delivery system was restructured so as to concentrate on priority health problems and the rural population . The result was the Burma People 's Health Plan. Although mainly conceived o n the initiative of the central health auth- orities, the Plan gave the local people an opportunity to evolve , expand and strengthen their hea lth activities in a flexible way. The Ayadaw Township People's Health Plan (PHP) really began in June 1978 with the formation of the PH P Committee. The committee was given responsibility for the following: - development of the health profile of the Township; - planning of the Township's health programme; - supervising the way in which it was carried out; WoRLD HEALTH, October 1986 - managing the community finances; - coordinating activities with rel- evant sectors; - taking the lead in motivating com- munity participation; - evaluating progress ; and - reporting to divisional and central offices. The way it is The impressive progress in health de- velopment reported since the PHP ac- tivities started eight years ago in Aya- daw Township can be measured by some particularly noteworthy achievements. Every village now has its own volun- teer health worker. The village people's council in each case is responsible for paying and supervising the VHW, the benefits of whose work are clearly rec- ognised by the people. A pilot scheme has begun to train "ten-household health workers ", whose role is to gather information for health staff and to edu- cate the ten households in their care. To date, 2,500 of them have been trained and placed in the community , and 30 volunteer nutrition workers have under- gone training. The reorien tation of trad- itional birth atte ndants has been com- pleted. - Safe water supply has received the highest priority. The Committee has provided every village with guidelines for safeguarding water , for building lat- rines and for disposing of garbage. Al- most all villages (98 per cent of the population) have access to safe water, at a per capita consumption rate of about 45 litres per day. Each household has access to o ne sanitary latrine , and properly maintained garbage facilities are in use in the households and villages. "Ayadaw Township community had been living a bard life with scarce water for many years; that's why they made their slo- gan : Need water, not gold. " Dr Than Sem - Since 1979, there have been no o ut- breaks of cholera or plague, while gas- tro-intestinal infections including diar- rhoea and typhoid have fallen dramati- cally. The active prevalence rate of trachoma dropped from 12 per cent to three per cent. Early detection and con- trol of leprosy cases has improved. There have been more immunizations, more women have access to antenatal services, and deliveries attended by W ORLD HEALTH, October 1986 Above: Cooperative health clinics are 11ow financed by village cooperative societies, which raise funds from various local sources. Below: Learning to read in a Burmese prima~y school; a literate community is much more likely to take a responsible attitude towards health matters. Photos WHO/J. Mohr trained personnel have increased from 40 to 98 per cent. Almost complete surveillance of the nutritional status of children aged three and under has been achieved, and 97 per cent of newborn babies have a birthweight of at least 2.5 kilograms. Community participation in food and nutrition activities has increased. "The people of Burma are aware and proud of the fact that a significant share of the resources expended on the health care de- livery system are contributed by themselves. Since the advent of the People's Health Plan (PHP) in 1978, contributions are being increasingly made in terms of kind, cash and labour. The driv- ing force behind such behaviour is attributed to the culture, belief and the spirit of mutual assistance which has evolved through cen- turies." Or D. Khin Hlaing - The crude death rate has declined from 4.11 per mil in 1974 to 2.36 per mil in 1984, infant mortality from 63 to 50 per mil , and maternal mortality from 0.7 per mil to zero in the same period. - Cooperative health clinics are fin- anced by village cooperative societies. Funds for health development activities, including both capital investment and recurrent costs , are raised by com- munities through local financing schemes which include proportional donations, voluntary contributions and social welfare funds. 20 An increased rate of immunizations in Ay- adaw township has been reflected in lower figures for infant mortality . Photo WHOIK. Frucht The way it will be It might seem that the shining exam- ple offered by the Ayadaw Township PHP Committee in collective leadership at the community level , adhering to the basic principles of primary health care, already represents a level of achieve- ment sufficiently high for Ayadaw to let the process develop at its existing pace. Indeed the Township was awarded a share of the 1985 Sasakawa Health Prize, offered by the Japanese founda- tion for outstanding innovative work on health development. But the commitment to change, and to further improvement, still continues. The capability already shown for or- ganizing and managing the community's health will again be brought to bear on further improvements. Among the mat- ters receiving high priority will be: bet- ter career opportunities for volunteer health workers; more efficient replen- ishment of drugs and other supplies; new ways to improve the organizational activities of VHWs; an improved trans- port system for health centre staff; es- tablishment of a proper cold chain sys- tem to keep vaccines cool and safe; and provision of health and medical care journals to all health workers and mass education materials for the towns- people. Active community involvement in planning, financing and managing resources has been the key to this success. • Burma postscript nd while the Ayadaw success story was unfolding. how did the villagers react? The fol- lowing eyewitness account de- scribes their response and invol- vement. "March 1st. 1982 was the big day when people actually started building latrines. lt began at dawn when the sun had hardly risen. Men. women and children emerged from their houses. moving back and forth to their backyards carrying picks. shovels. baskets and bam- boo. While men dug the pits. women moved the earth and chi l- dren ran around doing chores. "A tray containing a pot of hot tea and a couple of bowls was placed on a deal wood box a few feet away from the pit. Stripped to the waists and sweating from head to toe. the men would climb out of the pits and walk to the tea pot to quench their thirst. Some hummed songs to the tune of local music which blared through the loud- speaker from a nearby house. Vil- lage lanes too were bustling with activities. Committee members roamed about inspecting the work and giving encouragement. The loc- al Doh-bat (drum) group danced in procession to lend a festive mood to everything. Two male dancers. one in glittering costume and the other in comic attire. took turns dancing at the head of the proces- sion. These were followed by musi- cians playing and singing to the rhythm of the Doh-bat. backed by the wailing flute and the slap of the bamboo clappers. "The procession was followed by a crowd of onlookers. mostly children. who giggled or shrieked with delight as the comedian played the clown. Red Cross youths in smart uniforms and carrying white boxes walked about in readiness to deal with emergencies. lt was in- deed a happy occasion for both the villagers and the organizers. "These activities. although at a declining tempo. went on until April 1Oth when all householders had built their latrines. In most cases the superstructure was built of bamboo, but a few who could af- ford it built theirs with bricks. In any events. a strong effort had been made by the community to protect their own health in a manner which was w ithin their means." • W oRLD HEALTH, October 1986 Finland: pioneer count "E .!!l ~ c--~''"'""' ~ ... , ... :~ ·,·~"''' J: s ~~~~ CL.~mflill The way it was Traditionally, health care in Finland was the responsibility of central and local government. The practice of midwifery dates from the 18th cen- tury, and the system of municipal physicians was created towards the end of the 19th century. In the begin- ning of this century, the emphasis was on the prevention of infectious dis- eases. Between the two World Wars , a network of mental institutions and tuberculosis sanitariums-separate from general hospitals-sprang up. In the 1940s, municipal maternity and child care centres became statutory, offering free service regardless of place of residence or financial status. During the 1950s and 1960s the em- phasis was on building hospitals. And from the 1960s onwards, the short- age of physicians was rectified; the number of inhabitants per doctor fell from 1,100 to the present level of 500 per doctor. A re-evaluation of health policy followed in the early 1970s. At that time about 90 per cent of public health care resources were being used for special medical care and 10 per cent fo r primary services. The Finnish de- termination to face problems head-on ensured the adoption in 1972 of a Primary Health Care Act , which reoriented health policy towards inte- grated development of health services, WoRLD HEALTH, October 1986 with emphasis on outpatient care and accessibility for the whole population. Under this Act , health centres run by local authorities are in charge of the functions of basic health care. This comprises preventive care, including maternal and child health , family plan- ning, basic medical care, school health , dental care and transport for the sick. The Act also assigns to the health centres responsibility for preventing and treating infectious diseases and for the environmental health service. La- ter additions to the centres' tasks were training of health care staff (1976), occupational health services (1979) , and the provision of health care to seamen (1980). Development of the health service systems during the past ten years has been guided by national plans. As a result , Finland now has a sound prim- ary health system and a high standard of specialist care. The way it is Now available to 100 per cent of the population , primary health care re- ceives more than 40 per cent of the resources channeled into public health care- compared with the 10 per cent figure when the planning and state subsidy was introduced. In 1982, 6.7 per cent of the gross national product (GNP) was spent on health in Finland. In several critical areas , the general state of health of the population has improved. The exceptionally high mortality rate among middle-aged men is fa lling, as is the rate for women and children. The occurrence of coro- nary disease and stroke has decreased. The incidence of cervical cancer in women and of gastric cancer in bqth sexes has decreased. Promotion of healthy life-styles has proved successful. Smoking has started to decrease , and alcohol con- sumption among the young seems to be declining. There have been notable improvements in dietary habits, and more women are breastfeeding their babies. Dental care in children and young people has improved. Family planning and contraception are now more effective. Access to safe water supplies is available to 76 per cent of the total population, and 70 per cent of the population have adequate sani- tary facilities. Over 96 per cent of the newborn babies have a birthweight of at least 2 ,500 grams. Life expectancy at birth is 74.2 years for males and 78.1 for females. The adult literacy rate stands at 99.5 per cent. The percentages of children fully im- munized are: diphtheria 93.9 per cent, tetanus 93.9 per cent, pertussis 78.9 per cent , polio 82.2 per cent, tuberculosis 84.3 per cent, meastes 80 per cent. Finland has coUaborated closely with WHO in formulating its na- tional strategy. In 1982, Finland and wno endorsed an agreement whereby Finland would act as a "pioneer country " for Health for aU development, so that its ex- periences in health policy and primary health care can be shared by other nations. Prevention work during the past decade has reduced the number of fatal road accidents by half in ten years , and the number of fata l occupa- tional accidents to one-third that of 20 years ago. Despite all these benefits , there are still some challenges to be met. Exist- ing dietary factors cause one-third of the cases of cancer and cardiovascular diseases. Obesity results in a predis- position to many diseases. Smoking still causes about 4 ,000 premature deaths per year , and the number of alcohol-related deaths is estimated 21 at 2,300 per year. Accidents (some 700,000 per year) are the third highest cause of dea th , after cardiovascular diseases and cancer. The way it will be The Finns are giving high priority to the following aspects of health policy : - The promotio n of health and the primary health care approach , with emphasis on the needs of the under- privileged and those at greatest risk ; - Improving national nutrition by guaranteeing a sufficient , healthily balanced and varied food supply ; - Still greate r efforts of education , instruction, and guidance to reduce consumption of tobacco products and a lcohol ; - Restructuring the physical and so- cial environment so as to increase socia l inte rcourse and provide more opportunities for healthy physical exercise; - Environmental health measures to reduce biological, physical and chemical risks; - Maintaining genera l immunity, a high standard of hygiene and effec- tive vaccination, to bring about further improvements in the infecti- ous disease situation ; The basic aim of Finland's health policy is to promote the health and welfare of each individual. It can be summed up as: Adding years to life, Adding health to life, Adding life to years. - Increasingly more human and flex- ible health services, and additional . health care perso nnel according to changing needs; - Reallocated health care resources to meet the needs resulting from the increased proportion of elderly persons, the prevalence of chronic diseases and the introduction of new prophylactic and treatment measures; - Education of health care personnel to re fl ect the new attitudes in health policy. In opting for these new approaches, Finland has formulated its long-term planning to handle the known as well as the " what-if" occurrences of tomor- row, reflecting both innovation and pragmatism in its quest for Health for all by the year 2000. • 22 W oRLD HEALTH, October 1986 Finland postscript ne Finnish success story evolved from a bleak beginning following WHO's publication of cardiovascular disease statistics dur- ing the late 1960s which identified North Karelia as an area of high mor- bidity and mortality from heart dis- ease. Although the area was beset with other pressing social and economic problems. this added bur- den galvanised citizens' groups and women's organizations. as well as individual doctors and nurses. into action. With the backing of the provincial governor. these concerned people enlisted WHO's support for a large population study and an intervention programme to combat heart and car- diovascular disease. The North Karelia project tackled the issues of smoking. unhealthy diet and lack of exercise. Women's groups initiated "long life parties". Medical students joined in with health education activities. Other groups launched exercise pro- grammes which covered disease pre- vention as well as rehabilitation. Food industries cooperated by increasing low fat milk and healthier sausage production. and improving the dis- tribution of fruits and vegetables. Schools, youth groups and volunteer bodies climbed on the bandwagon. Five years after the project began. exciting resu lts became apparent. Cases of stroke. for example. had been reduced by almost 40 per cent. Similar reductions in cases of heart attack and high blood pressure had been achieved. An authentic "peo- ple's movement" for health had been created. In addition. a new media form-a press conference that was. in effect. a mini-seminar on health- had been generated. The entire province was motiv- ated-and that motivation spread to the whole country-while apathy and despair were replaced with pride and a universal sense of great accom- plishment. • Nutrition classes for Finnish housewives have helped to bring about notable improvements in dietary habits. Photo WHO/T. Farl<as Work and health in Hungary Since working conditions are a dominant determining factor in life-styles-which in turn are linked with many non- infectious diseases-the occupational health service has an important role to play in this eastern European country ~ ungary offers a good example of a country where the changing structure of the working popula- tion has had an important effect on the health status of the entire population. A major shift in the country's econ- omic development since 1968 resulted in a general increase of efficiency in agriculture and industry, but less growth in the service sector. In effect Hungary ceased to be a predominantly agricultural country and became a moderately industrialised one. Among the consequences of these changes were rapid urbanisation and greater geographic mobility, the em- ployment of many more women (mainly in the service sector) , greater social movement among and within generations, changes in the structure and content of education, and consid- erable modifications in life-styles and social behaviour. Working conditions are a dominant determining factor in li fe-sty les , and life-styles themselves are known to be closely linked with the main non- infectious diseases of epidemiological importance. So the occupational health service plays a big role in Hun- gary, as an essential part of primary health care. The country's population is around 10,680,000 of whom 19.3 per cent live in Budapest, 36.7 per cent in other towns and 44 per cent in vi ll ages and the countryside . The national average of one genera l practitioner fo r every 2,500 inhabitants does not reflect the true position , since a part of this population is treated by factory physi- cians in workplaces and by district paediatricians in the case of children. Since 1951 , the occupational health service has been a responsibility of the state. Today every factory employing W ORLD HEALTH, October 1986 by lvan Forgacs more than 500 persons has an indus- trial physician , fu ll-time or part-time, and the service itself deals with about ten million patients every year. Sixty per cent of the cases come for diag- nosis or treatment, 23 per cent for screening or aptitude tests related to their jobs, five per cent for fi rst aid , Health care at the workplace. The industrial physician and the nurse give first aid at the Danube iron Works. Photo WHOIMTIIJ. Feher and 12 per cent for long-term health care. (Roughly five per cent of all workers are on the lists of the occupa- tional health care teams for long-term care, usually for ca rdiovascu lar dis- eases, locomotor disorders, chronic gastro-intestinal complaints or chronic lung diseases .) Primary health care also comprises district physicians (general practition- ers), district paediatri cians, school health services, maternal and child care (including family planning, gen- etic counselling and so forth), dental services, ambulances, certain out- patient clinics which accept patients without prior referral , envi ronmental health, nutrition , epidemiology and health education. At the village level, the district phy- sicians are assisted in their maternal and child health care by nurses work- ing in the primary health care team , and by mobile specialist services staffed by experts in obstetrics and paediatrics. Pre- and post-natal mother and in- fant care is the responsibility of special primary health care teams. In 1984, some 131,000 women received pre- natal care an average of 8.6 times during their pregnancies. In the same year, the overall turnover of the ma- ternal, infant and child care dispen- saries was 1 ,300,000 infants (aged up to three years). One of the tasks of this team is to convince mothers of the benefits of breastfeeding. In the capital city, 42 per cent of the babies are breastfed, 44 per cent received mixed feeds , and only 14 per cent are on breastmilk substitutes during their first four months. In the villages, the equivalent figures are 36, 50 and 14 per cent. The school health service is com- posed of paediatricians and maternal and child health nurses. It places spe- cial emphasis on adolescents aged between 14 and 18, and ensures con ti- nuous care on the basis of screenings. Hospital services Most doctor-patient encounters take place at the in-patient or out- pati ent clinics of hospitals. Hungary has a compulsory referral system; if the primary level is unable to treat a patient-for instance , because sophis- 23 Work and health in Hungary ticated equipment is lacking-the health worker must refer the patient to out-patient clinics, which are located in the towns as integral parts of mu- nicipal hospitals. These hospitals are responsible for the out- and in- patient care of an average of 115,000 people. Cases requiring more sophisticated diagnostic or therapeutic treatment are dealt with at large county hospi- tals, where almost all the medical disciplines are represented. Where necessary, the municipal hospitals transfer their patients to such county hospitals. One important health problem for the Hungarian health services is the increasing number of adults- mainly between 40 and 59 years of age-suf- fering from such non-communicable diseases as cardiovascular, locomotor and neurotic ailments, diabetes and so on. The continuous care of these peo- ple is an essential task for health personnel. Current health policy rec- ognises that the care and secondary prevention of these chronically ill peo- ple is more effective at the community level. In 1984, some 1,400,000 inhabi- tants were registered as receiving continuing treatment at the primary health care level, thanks largely to the nurses who made more than five mil- lion visits. The object of these visits is partly social prevention and partly the care of the chronically ill or the elderly. Indeed , care of the elderly poses a special problem, since 8.3 per cent of men and 11 per cent of women are aged over 70, a total of more than one million. Roughly 70 per cent of social security spending goes on pensions, which average out at about 60 per cent of the average income of wage- earners. So the main problems of the elderly are not financial ; mostly they com- plain of loneliness, the difficulties of self-care, and chronic iJlnesses. At the primary health care level they are helped by visits from nurses and social nurses, by day-care centres and by social homes for the elderly. At pre- sent 25,000 attend day-centres, 33,000 are in social homes, and 39,000 are cared for in their own homes by the social nurses. This aspect of the health services is bound to become increasingly important as the proportion of the elderly in the com- munity continues to rise. • 24 Pritnary Health Care A mirror tor Alrica by Eleuther Tarimo !though in many African countries primary health care (PHC) was considered a revolution in health. it was also an uncharted area reflecting little real previous experience. Tackling this issue. therefore. provided an excel- lent opportunity for developing coun- tries to work together in evolving their approaches and making PHC a reality. In 1980, a group of countries met to discuss the issues and challenges fac- ing them in their attempt to implement PHC. At this stage. the emphasis was on certain particular features of primary At work in a tea plantation. African coun- tries have quickly recognised that health and economic development are directly linked Photo WHO/Zafar health care such as intersectoral collab- oration. rural development. community participation. and equity of distribution of resources. lt was apparent that vari- ous constraints would have to be over- come. The countries agreed to continue to work together. and they recognised that a clear and strong diagnostic mechanism was required. Twelve countries undertook joint PHC reviews. and agreed to hold in- depth discussions of the f indings from each country. The first such discussion took place in Gambia in June 1985. and concerned six countries- Ethiopia. Gambia. Ghana. Malawi. Nigeria. and Zimbabwe. In October 1985, a second meeting was held in Swaziland and dealt with Botswana, Kenya, Lesotho. Swaziland. Tanzania and Zambia. The joint PHC reviews held up a mirror for these African states; they sought to elicit information on policy, management and implementation at all levels. from national to household. The activities extended over a period of three to six months and involved : a planning phase; in some countries. in- depth studies prior to the field phase ; a field survey at various levels of the health service; analysis and synthesis of the findings; discussions with deci- sion-makers about the findings and re- commendations; and in some coun- tries national intersectoral workshops which debated the country's review. The general view was that the joint PHC reviews had enabled countries to see the realities of their health situa- tions. and to assess the extent to which they were putting into effect some aspects of their PHC programmes. There were several noteworthy achievements. By stepping up health facilities on the periphery of the main services. many people for the first time had access to health care. The training and· use of community health workers picked up speed. and coverage of im- munization efforts improved. Many more mothers had ante-natal consu l- tations. and the proportion of people enjoying safe water and sanitation faci lities expanded rapidly. Selected indicators from the country PHC reviews offer positive evidence of progress. In Kenya, for instance, over 92 per cent of mothers had antenatal consultations for recent pregnancy. Full WoRLD HEALTH, October 1986 immunization protected 63 per cent of the children aged between one and two in Botswana. Zambia reduced to about 24 per cent the percentage of children (aged up to five) who were under 80 per cent of standard weight for age or arm circumference. Safe water supply was available to 80 per cent of the urban and 42 per cent of the rural population of Tanzania. Botswana reported 100 per cent of the urban and 73 per cent of the ru ral households served with suitable sanitation. A total of 5.485 community health workers and 5.500 traditional birth attendants completed training in Zimbabwe in 1985. Seven of the twelve countries had established essential drugs lists. Perhaps the most important break- through was that primary health care was now taken over by the countries themselves. Several issues still cause some dif- ficulties. For example. there is a diver- gence of views over how each country interprets PHC within its own national context. This makes it hard to deter- mine just what resources are devoted to "primary health care." Collaboration with sectors other than health in the PHC field has not generally come about; clearly, high-level intersectoral mechanisms have to be developed or improved. Decentralisation of pro- WoRLD HEALTH, October 1986 gramme planning and budgeting has yet to become a reality in several coun- tries. and manpower planning needs to be more realistic and more practicable. The challenge exists for countries to develop ways of keeping PHC manage- ment at all levels fully informed, and most of the 12 countries reviewed foresaw workshops as a pragmatic ap- proach toward meeting this challenge. So. where will these countries go from here? The specific follow-up ac- tions to be taken by the countries are noted in the two reports published by WHO's Regional Office for Africa relating to the meetings in Gambia and Swazi- land (Where are we in primary health care? Countries take a close look at themselves through PHC reviews. Parts I and 11). Certainly the enthusiasm generated in this practical example of technical cooperation among develop- ing countries (TCDC) is reflected in the countries' commitment to speed up PHC programmes and to meet every two years to share achievements and problems. Pooling experiences from different countries. and enabling indi- vidual countries to use these experi- ences. provides stimulus and confi- dence to overcome the difficulties that are currently being encountered. Sub- sequent PHC reviews will focus on issues that cut across several sectors. Young African wives discuss the advan- tages and drawbacks of the contraceptive pill with the community health worker. Ph010 WHO/H. Anenden thereby reducing the risk of leaving out important elements which may not seem to concern health directly. The review guidelines need to be presented in such a way that countries can easily collect information relevant to their particular problems. and can request the assistance of WHO in draw- ing up a catalogue of common issues. Budget and financial management pro- cedures often need to be improved or reformed. The required expertise can be made available through international agencies to support country-specific approaches. thereby ensuring that all resources are husbanded to the maxi- mum degree. Finally, all the countries involved agreed that this kind of PHC review is a very useful process which has al ready evolved. and should continue to develop, in relation to the changing needs and priorities in each country. So it is not a process which can be "per- fected." but one in which the "state of the art" will continue to change in harmony with national expertise and national development. • 25 Outlook for the future !though a positive start has been made in the quest for Health for all, the prevailing and forecast economic situation will continue to challenge policy-makers as they seek a balance between economic and social goals. The health sector will face unpre- cedented demands from a rapidly growing population, especially in bur- geoning cities ringed by swelling slums. Shifting mortality and morbid- ity patterns, increased life expectancy, different social conditions, modified lifestyles and an ever-changing envi- ronment will create additional or new health care needs. Technological sol- utions to major health problems will have greater application in the future - but cannot solve everything. Solidarity among countries, at least in health matters, is expected to gain greater acceptance. But the achieve- ment of Health for all by the year 2000 in those countries that are in economic quandaries, or those facing grave environmental hazards or social and political disturbances, will indeed be a Herculean task. For WHO's Member States, political commitment to equity will remain a fundamental prerequisite for reaching the goal , and enlightened leadership will be needed to correct disparities. Support and commitment will be required from non-governmental organizations, professional groups and individuals- not least, to counteract public apathy. Limited resources will call for efficacious management of health systems based on reliable infor- mation and effective decentralisation. The integrated delivery of primary health care components, and a rational review of functions , technology and resources at all levels will serve to instill confidence in communities and professional groups. Research, par- ticularly with regard to applying health technology at the first level of contact, will need greater attention and sup- port. Financial requirements for health will have to be carefully esti- mated and wisely spent, and there will be a search for external financing . WHO itself will be called upon to furnish the right kind of technical cooperation to boost the national health managerial capacities of Member States. This will include mak- ing available all pertinent information for preparing, strengthening and evaluating national strategies for W oRLD HEALTH, October 1986 We have always been space travellers. For we are the local embodiment of a Cosmos grown to self-awareness. We have be- gun to contemplate our origins: starstuff pondering the stars; or- ganized assemblages of ten bi l- lion billion billion atoms consider- ing the evolution of atoms; trac- ing the long journey by which. here at least. consciousness arose. Our loyalties are to the species and the planet. We speak for Earth. Our obligation to survive is owed not just to ourselves but also to that Cosmos. ancient and vast, from which we spring. from Cosmos. by Cart Sagan. Copyright 1980 by Carl Sagan Productions. Inc. Health for all. WHO wi ll also face the challenge of promoting and supporting the research and development requir- ed to put the strategies into action. The Organization will need to take vigorous action to help countries to WoRLD HEALTH, October 1986 mobilise financial resources-espec- ially the least developed countries. When the ancient Greeks consulted the prophetess of D elphi for an oracu- lar statement about their future, she was not really expected to articulate clear answers to questions. Her delib- erately vague replies left room open for the choice of several options. The efforts of the Member States and the support given by WHO over the past six years clearly illustrate where their choice lay, and reflect their shared will to adopt , adapt and employ Health for all strategies. The Seventh Report on the World Health Situation reaffirms the va lidity of the strategies in both developing and developed countries and guaran- tees that the momentum will be kept up. The national evaluation reports which it contains will enable each country to define where the major emphasis should lie in the fu ture, and what changes or actions will be most essential in order to achieve all the objectives in the remaining years before the turn of the century. • Quizzical, despairing or confidently smiling - the children of today will be the young citizens of the year 2000. Health for all is their best hope for a socially and econom- ically productive life. Photos WHO/Zafar and (below) WHO/H. Anenden 27 Goitre In the industrialised world, goitre is merely an unhappy memory. But Bolivia still pays a heavy tribute to this iodine-deficiency disease. Today there is a glimmer of hope ... by Philippe Stroot [) igh on the Andean plateau and lacking any outlet to the salt Pacific Ocean, Bolivia is particu- larly hard-hit by endemic goitre. Its parched soil is critically short of iodine -one of the elements which is essen- tial to human growth. As a resu lt the daily food of its inhabitants does not meet their iodine requirements, which more fortunate populations usually derive from sea-foods and cereals. This lack results in hypertrophy of the thyroid gland. the condition known as goitre. In severe cases. the disease can result in mental retarda- tion, or cretinism . Endemic goitre is generally recognised when more than 10 per cent of a given population are afflicted. In the case of Bolivia, the proportion of sufferers exceeds 65 per cent. To combat this scourge, a preven- tive programme has been started by the Bolivian government, with techni- cal cooperation from the Joint WHO/ UNICEF Nutrition Support Programme (JNSP} and with the financial backing of the Italian government. The first and most urgent step is to deliver an injection of iodised oil to every inhabit- ant of the country. This will effectively check the progress of goitre where it already exists and prevent iodine def i- ciency in younger people not yet af- fected. The "vaccination" will supply the body's needs in iodine for roughly three years. However. the ideal solution is to maintain iodine supplies to the whole population through adding the mineral to cooking salt, and ways of doing so have already been tested elsewhere. An emergency plan backed by the international organizations is helping small cooperative plants to produce several tons of iodised salt every day, which is then put on sale in the local markets. Since the techniques used are sim- ple and cheap, it has already proved successful, particularly since Bolivia is rich in salt-mines and salt lakes . A big campaign to promote iodised salt is already bearing fruit, and the Bolivians are rapidly becoming convinced of the value of using it. Thanks to this remarkable example of international cooperation and its success in resolving a specific health problem, Bolivia has an excellent chance w ithin the next few years of shedding its unhappy burden of endemic goitre. • W oRLD HEALTH, October 1986 Photos by F. Scianna of Publ ifoto, Milan Iodised salt offers the best chance for ridding Bolivia of its high incidence of goitre. Babies and pregnant women in particular need to be protected from iodine deficiency. The campaign to identify cases of goitre and to promote the use of iodine-enriched salt starts at the vil- lage level with an announcement by bullhorn. Many who come forward already show the swollen neck which is the hallmark of the disease. Some- times (below, left), three generations in the same family may be affected. Ta 01, 1 and 2 Tend to Teeth In Thailand Oral health is generally not placed high on a list of priorities - at least not by most planners working out of capital cities in developing countries. To some extent that is understandable for, unlike communicable diseases. few people die of toothache. In villages, however, the per- ception is different. According to experts. the rural dwellers who are asked invariably rank oral health care uppermost among their needs. The reason is plain and simple-a toothache hurts and pain is immediate. lt used to be said that indus- trialised countries had cavities, while developing countries had gum diseases. Today, as a conse- quence of greater sugar con- sumption and a lack of health education programmes, cavities are a problem in the Third World too. In 1982, more people in the developing world than . those in the industrialised world suffered from toothache- for the first time ever. The answer to oral health prob- lems is not to have more dentists to fill teeth. Thei r training takes too long and costs too much. lt lies, rather, in the primary health care worker, and in prevention - as is being demonstrated in Chiang Mai, Thailand. There are only 60 dentists in that northern province of some 1.1 million in- habitants, of whom 50 are prac- tising in the capital, a city of some 100,000. Those dire circumstances- much the same throughout Photo WHO Oral health : rated a priority by villagers, not by planners. 30 Racing Against Time for Africa Some 20 million people in 285 r=:::;~=;:;;::;;;:;;==:===::l cities in 85 countries on 6 conti- nents ran five to ten ki lometers last May in the "Race Against Time", sponsored by UNICEF and Band Aid Trust the organization of Irish rock star, Bob Geldof. And in doing so they raised an estimated US $15-20 million for African economic recovery and ·develop- ment. Among pieces in the run- ners' mosaic of movement: • In New York, they ran in the heat of the noonday sun; in tee- shirts that proclaimed 'I ran the world.' • In India they ran at sunrise, a million runners in 20 cities en- couraged by Prime Minister Rajiv Gandhi. • In Australia and Japan they ran in the dead of night, their paths brightened by shop lights, .__ _________ ___J or by bonfires along river banks. • Half a million ran in London, 55,000 in Barcelona, and 1 0,000 in Budapest. In Hong Kong, 15,000 ran to raise a million HK dollars. Photo WHO/Ruby Mern United Nations: Jommg hands for the less fortunate. • More ran in Banjul (Gambia). Buenos Aires, Geneva, Helsinki, Istanbul, Nairobi, Seoul, Tel Aviv, and Venice. • In Ouagadougou, capital of Burkina Faso, President Thomas Sankara and his cabinet ran. The biggest mass-sporting and fund-raising event ever started · less auspiciously, in a Sudanese refugee camp. There, from the embers of a cooking fire, Omar Khalifa, an Olympic gold medalist. lit a torch that he would take with him as a symbol of hope while running through 12 European cities. He crossed the Atlantic in a Supersonic Concorde, courtesy of British Airways, on the eve of the opening of the u.N. Special Session on Africa. A run through the streets of New York took him, at last, to the United Nations, where he ignited a pillar of flame from the torch, and then joined hands with entertainer Harry Belafonte, and James Grant, UNICEF's Director (photo) to signal the start of races everywhere. • •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• Thailand- led the Inter-Country Centre for Oral Health and WHO to carry out a model project in two districts, Pasang and Samerng. "Dental care can be divided into ten distinct functions," says Or Thaworn Anumanrajadhon, the centre's director, so to perform three of the most basic tasks. these types of workers were re- cruited, trained and tried : - The Ta 01, or oral health ex- aminer, to recognise and to re- cord a range of dental ills on a standardised form that not only indicates treatment for the pa- tient, but also, as the information is collected and computerised, shows the state of the vil lage's oral health. A total of 44 examiners were trained in about ten days. ( "Ta" is an index system in which oral disease and care are classified on a scale from 0 to 6.) - The Ta 1, or oral health educator, to introduce the con- cept of oral health to com- munities. and to carry out school programmes. They were selected from volunteer workers and teachers and given just one day's training. In all schools now teeth are cleaned after the mid-day meal. - The Ta 2, or the scaler, to remove tartar from teeth. After tests for vision and manual skills, and interviews by vil lage leaders, 18 were selected from some 90 secondary school applicants. They were trained in two ses- sions, the first of ten days' dura- t ion, and the second of four days. Unlike the examiner and edu- cator, who are government em- ployees, the scalers are project staff, receiving salaries of 1 ,250 baht. approximately $50, a month. Plans now call for the project to move from "health mainte- nance" to a "health restoration" phase. This means the setting up of a centre easy to reach by most people in the two districts. Here cavities would be filled and teeth extracted by dental auxiliaries and dentists. But much depends on funding. The significiance of Chiang Mai, however, is that it has al- ready demonstrated an alternate system of oral health that could be adapted by other developing countries, thus holding out hope for millions. • Prospects Good for New Pertussis Vaccines Soon The prospects are good for new, acellular vaccines against pertussis (whooping cough) to be licensed and marketed w ithin the next three or four years - or even sooner. That is likely, predicts Or Roger Bernier of the U.S. Centers for Disease Control in a recent issue of World Immunization News, "as a result of intensive levels of effort in several government and private laboratories." The researchers' aim is a vac- cine as effective as the w hole-cell pertussis vaccine now generally used, but w ithout its side-effects. Adverse reactions, while rare, have been serious, leading to the suspension of routine vaccination in Sweden, to the decrease in vaccination rates in the United Kingdom, to the increase in liabili- ty suits in the United States. but above all, to a rise in the number of cases. Human trials are planned of the acellular vaccine this year or the next or are already underway. Swedish scientists, for example, have been evaluating two Japan- ese vaccines since 1984, and have begun a full-scale field trial in some 4,000 six-month children that is expected to run through mid-1987. While the vaccines under trial generally contain two antigens that confer protection against pertussis, British scientists are developing a vaccine w ith more, and U.S. scientists, at the Nation- al Institute of Health, a vaccine w ith but a single antigen. The data from trials could lead WoRLD HEALTH, October 1986 Photo WHO Whooping cough: on the rise as immunizations drop. researchers to "formulate a safer vaccine that contains only the key antigen required for protection." says Dr Bernier. WHO launched an Expanded Programme on Immunization in 1974 to protect against six killers of infants by 1990-pertussis as well as polio. diphtheria. tetanus. measles and tuberculosis. Some 700.000 children. mainly in the developing world. are estimated to have died from pertussis in 1983 alone. • Indonesian Study Shows Vitamin A Cuts Child Deaths High doses of Vitamin A given against xerophthalmia. a blinding disease. have been shown not only to preseNe sight but also to reduce mortality in children under five years of age. According to preliminary find- ings from Indonesia. the mortality rate in villages where Vi tamin A programmes are underway is 30 per cent lower than in other villages. Although studies are continu- ing, the U.N. Food and Agriculture Organization (FAO) says that "re- duction of child mortality is a reasonable expectation. and is further justification for such pro- grammes.'' Xerophthalmia is caused by a lack of Vitamin A or more pre- cisely by a lack in the diet of such foods as liver. eggs. carrots. and dark-green leafy vegetables. The name, taken from Greek. means a dryness of t he eyes. More than a half a million chil- dren in parts of Asia. Africa. Latin America and the M iddle East are blinded yearly. Yet two capsules of Vitamin A can save sight and li fe as well. • WoRLD HEALTH, October 1986 Newsbriefs • A Bad 'Big Dipper'. An American mother from Oklahoma. Betty Marsee. has brought a US $747.7 million lawsuit against the US. Tobacco Company, alleging that her son. Sean. died from cancer by use of chewing tobacco- or by "dipping snuff." This growing practice among US. youth has led the Surgeon-Genera/ to warn against it as a threat to health and is the theme of "Big Dipper", an educational video that won a blue ribbon at the American Film and Video Festival. New York. (For details. write: Caroline 8/oomfield, Independent Video SeNices. 401 E. 10th Avenue. Eugene. Oregon 97401. US.A.) • Another Pledge from AGFUND. A new pledge of $7.1 million brings up to $79.5 million the amount offered to WHO by the Arab Gulf Programme for u.N. Development Organizations (AGFUND). The funds are earmarked for a project of rabies control in Latin America. a project for primary health care in China. and projects to promote oral health in 20 developing countries. AGFUNO was established in 1981 to support the work of U N. agencies in Third World countries, and in particular the 37 designated the "least developed. " • Learning Centre for the Western Pacific. A first class of eleven- medical officers. programme officers. and administrators- from China. the Republic of Korea and Vietnam have begun a 70-month course to improve their knowledge of English and communication skills at WHO's regional office in Manila. "You will become a vital link between your countries and this organization," Or Hiroshi Nakajima. regional director for the Western Pacific, told participants at a ribbon-cutting ceremony that opened the Learning Centre. Comprising three classrooms. a language laboratory, plus audio-visual and computer facilities. the centre is staffed by instructors from Georgetown University, Washington. 0. C.. and from Ateneo de Manila University. The target for next year: 30 students. • People. Appointed as Director, Special Programme for Research and Training in Tropical Disease. Or Tore Godal (Norway}. formerly head of the Laboratory for Immunology at Norsk Hydro Institute for Cancer Research, Oslo. He is now responsible for research into filariasis, leishmaniasis, leprosy. malaria. schistosomiasis, and trypanosomiasis- a programme supported by WHO. the UN. Development Programme and the World Bank. - Appointed as Director, WHO's Division of Vector Biology and Control. Or Rudolph S!ooff (Netherlands), a staff member from 7964 until 1972, when he returned home to become chief. tropical health. at the Royal Tropical Institute. Amsterdam. He is now responsible for the following WHO units . ecology and control of vectors. pesticides development. and safe use. planning, management and operations. • ' Teeth Are For a Lifetime '. That's the main theme of a new brochure on WHO's oral health programme (see also opposite page). Its advice for developing coun- tries : aim at avoiding cavities rather than filling them; rely on primary Teeth are for a lifetime health care workers rather than on dentists alone; give oral health a higher priority in national health plans- because communities, in in- formal polls. rank this as uppermost among their needs. Its advice for individuals: "Clean Your Mouth, " "Use Fluorides," and o .. , ... ,., ... .,."""' ~ w ... "'"'" o.,.,~ ..... "Eat Less Sugar. " As more and more communicable diseases come under control, the non-communicable diseases-including oral diseases-will emerge as the major problems of the Third World. This is already happening. In the next issue Sexually transmitted diseases: not just syphilis and gonorrhoea. they include a great many conditions of varying severity, and to them today must be added the sinister Acquired Immunodeficiency Syndrome (AIDS). The November issue of World Health surveys the scene. · Authors of the Month Dr Halfdan MAHLER is Director- General of the World H ealth Organization. Dr Sumedha KHANNA is Director of WHO's office for Health for AU Strategy Coordination. Dr H c\kan HELLB):;RG is Director of WHO's Division of Public Infor- mation and Education of Health, and was formerly Director of the office for Health for All Strategy Coordination. Mrs Dorothy H OFFMANN is an Information Officer in WHO's Media Service. Mr Steve SERDAREL v, forme-rly a Senior Sanitary Engineer with the World Bank io Washington, D.C. , was Consultant Editor for this issue of World Health. Professor Iv{m FoRGAcs is Direc- tor of the Institute of Social Medicine, Postgraduate Medical School, Budapest, Hungary. Dr Eleuther TARIMO is Director of WHO's Division of Strengthen- ing of Health Services. Mr Philippe STROOT is an Infor- mation Officer in WHO's Media Service. WORLD HEALTH For readers everywhere 1986 Subscription Rates US$ Sw. fr. One year Two years Three years 12.50 25.- 22.50 45.- 30.- 60.- ORDER FORM Please enter my subscription to "World Health ·• as follows: One year D Two years D Three years D 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 sub· scription agencfes. For payment in national cur· rencies. please con\act your usual bookseller. 31 Goitre in Bolivia: a preventable disease. See page 28. Pho~CJ WHOIPublifoto. Mdanlf. Scianna I I I I !i j