Aging; Water decade; Youth; Contraception [full issue]

• * • At" 11.1111111111.111111 aging • water decade • youth • contraception WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION MAY 1982 t is now 25 years since oral con- traceptives and intra-uterine devices (iuDs) revolutionised fertility regula- tion for many women all over the world. Some ten years later, hormonal contraceptives which could be given as an injection started to become avail- able. They had to be given only once every two or three months and con- tained only one hormone, a proges- togen, whereas the pill contained both an estrogen and a progestogen. The popularity of injectable con- traceptives has been due to their particular advantages: they are highly effective in preventing pregnancy, their administration is simple and relatively infrequent, they can be used while breastfeeding, and they can be offered to women who are unable to use the pill because of its estrogen component. However there are probably only 1.5 million women currently receiving in- jectable contraceptives in both de- veloped and developing countries, compared with about 40 times that number who are using the oral pill. Why is that? First, let us consider what drugs are available for injectable contraception. There are two such drugs marketed. Depot-medroxyprogesterone acetate (DMPA) or Depo-Provera, when injec- ted in a dose of 150 mg, gives protection from pregnancy in 99.8 per cent of women for at least three months. The other, norethisterone enantate (NET-EN) or Norigest, has a chemical structure slightly different from DMPA and, when injected in a dose of 200 mg, gives a slightly shorter period of pregnancy prevention of two to three months. Although DMPA is licensed for con- traceptive use in some 84 countries and NET-EN iS now being marketed in 40 countries, DMPA probably accounts for about 98 per cent of the total two- to three-monthly injectable contracep- tives being used world-wide, since NET- EN is only just being introduced into many national family planning pro- grammes. In addition to its contraceptive use, DMPA, given in different dosages, is also employed to treat a variety of gynae- Injectable contraception Peter E. Hall and Susan E. Hoick 2 Cover: The vigorous face of old age in the s Soviet Union. , (Photo L. Sirman C)) _ ''`'..- IX ISSN 0043-8502 World Health is the official 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 in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Injectable contraception by Peter E. Hall and Susan E. Holck . . 2 Health technician in Turkey by Peter W. Jolly 5 Keep death off the road! by D. Paul Sondel 8 Accidents can be prevented by Joseph Fux 12 International Youth Year, 1985 by Asha Singh Williams 14 A new look for health services by H.J. H. Hiddlestone 16 Weather ship to the rescue 20 Family support for the elderly by G.M. Ssenkoloto 22 The biology of aging by Dmitri Chebotarev 27 News Page 30 A community midwife in northern Thai- land advises her audience about the alternative forms of contraception avail- able. Injectable contraceptives are a popular method in Thailand. ( Photo WHO/ S. Surin) cological and other medical problems, including certain abnormalities in physical growth and development, and various types of malignancy such as cancer of the uterus, breast, kidney, testis, and bone. In spite of the much greater use of the pill, we have undeniably seen a demand for injectable contraception, whether it be among the women in the Chiang Mai province of Thailand awaiting the arrival of the mobile clinic, or those queuing in a pharmacy in Mexico, or those waiting in their physician's office in New Zealand. If the drugs currently in use are so popular in such diverse places as these, why has injectable contraception not been used more widely around the world? Why has it been one of the most controversial subjects in discussions of health care? One reason is that the United States Food and Drug Administration (usFDA) has not yet approved either DMPA or NET-EN for use as a contraceptive. Another stems from reports of its use without the informed consent of the woman, a concern which has also been raised about IUDS and sterilization. Thirdly, a lack of accurate information about the drugs, especially in places where they are not easily available to potential users, has contributed to misconceptions and the dissemination of erroneous information. One of the major attacks on DMPA was published in the summer 1980 issue of a US consumer magazine "Women and Health". This article was largely inac- curate, and in part misrepresented the data found from studies on DMPA. Regrettably it was circulated to govern- ments and newspapers around the world, creating an adverse climate for the use of injectable contraceptives. Partly as a result of such attacks, injectable contraceptives, in particular DMPA, are one of the most extensively studied group of drugs available, and are mentioned in more than 1,000 published scientific articles. The poten- tial short-term side-effects have been thoroughly studied and reported. The most common side-effect, and the most frequent reason for women discontinu- ing these drugs, is the disruption they often cause in the normal menstrual cycle. Most women who use these drugs experience either episodes of bleeding over and above their usual menstrual bleeding, or no bleeding at all (am- enorrhoea). Although neither the ir- regular bleeding nor the amenorrhoea have known adverse effects on a woman's health, unpredictable bleed- ing can be very inconvenient and can be particularly disturbing for women for whom regular menstruation has impor- tant cultural and religious associations. No serious or irreversible long-term effects of these contraceptives have been found thus far, but studies in animals as well as the known car- cinogenicity of other hormones have aroused concern about a possible increased risk of cancer with the use of either DMPA or NET-EN. Cancer of the endometrium has developed in mon- keys who received DMPA or NET-EN, but only when dosages of 50 times the human dose was given for most of their adult life. Unfortunately, most of the human studies that have tried to find any affect of DMPA or NET-EN on the development of cancer have been poorly designed and therefore do not provide much useful information. Be- cause of the importance of this issue, and the lack of well-controlled studies on it, WHO is currently conducting a major project in 11 countries, to exam- ine the relationship between the use of steroid contraceptives including DMPA and NET-EN and the development of cancer. Many experts consider, how- ever, that if either DMPA or NET-EN were liable to cause cancer, a large number of cases would have already been reported around the world. The other main area of medical concern is the possible effects on children who are exposed to one of the drugs, either via breast milk, or while in utero, when a woman who is already pregnant inadvertently receives one of these drugs. From studies of such children, it appears that physical growth and development proceed normally, at least up to 13 years of age. A limited amount of information suggests that there is no increase in the incidence of congenital abnormalities among children exposed in utero to contraceptive doses of DMPA or NET-EN. Nevertheless, long-term studies must be continued to be certain that no adverse effects develop in these child- ren later in life. Individual governments have res- ponded quite differently to the information available to date. For example, New Zealand has used DMPA for many years and Sweden has recent- ly approved its use as a contraceptive. Yet, as mentioned previously, the U.S. Food and Drug Administration, the decisions of which are often used as a guide by many countries in the world, has not given approval, despite the fact that the FDA'S professional advisory committee on Obstetrics and Gynae- cology twice recommended approval of the drug. This situation may change in the near future as the FDA has appoin- ted three experts to again review the information about DMPA and to con- sider, in public hearings, whether DMPA should be licensed for contraception in the United States. The Administration has just agreed to allow a study to be conducted using NET-EN in the USA. The possibility of abuse is an issue that has been raised repeatedly with injectable contraceptives. It is unques- tionably important to ensure that either DMPA or NET-EN—indeed any drug—is given only to women who choose it voluntarily, after being fully informed of its expected side-effects and the other options available. This issue has been highlighted in the case of DMPA because of its use—and alleged abuse—in such situations as refugee camps and in countries practising racial discrimination. Because of these concerns and pro- blems, there has been a continuing demand on WHO's Special Programme of Research in Human Reproduction from various sources—governments, UNFPA, technical assistance agencies and other bodies—for guidance on the use of both DMPA and NET-EN. As part of its continuing assessment of the safety of long-acting injectable agents through research coordinated by wHo in many countries, the Programme convened a meeting in October 1981 involving members of the Programme's Toxicology Review Panel, represen- tatives of the Drug Regulatory Agencies of India, Mexico, Sweden, Thailand, the United Kingdom and the United States, representatives from the pharmaceutical industry manufactur- ing these products, and scientists working in this field. A review of the most recent data available from both animal and human studies was prepared and has subsequently been published by WHO. The concluding section of this document states: Injectable contraceptives—both DMPA and NET-EN offer several advantages as a method of contraception, and have been shown in a number of clinical trials In Sweden, DMPA has recently been approved for contraceptive use, and in the rest of Europe too, injectable contraception is becoming a more widely available method of family planning. (Photo WHO/ E. Mandelmann) to be effective in preventing pregnancy and acceptable to many women. Al- though animal data have raised concern about the safety and long-term side- effects of DMPA and NET-EN, certain animal models and the doses used appear not to be appropriate for studying human effects of these steroids. Extensive clinical and epidemiological studies among women using these drugs have thus far demonstrated no life- threatening side-effects, including any increase in the risk of neoplasia. The most common side-effect is the disturbance of normal menstrual cycles, which occurs in the majority of women using injectable contraception, and is the primary reason for its discontinuation. Women frequently report irregular bleeding, spotting, and amenorrhoea, but heavy or prolonged bleeding is uncommon. Studies thus far have not shown any serious short or long-term effects of DMPA or NET-EN. However, both DMPA and NET-EN have been used for a relatively short period of time, and the potential long-term effects (more than 15 years) are not yet known. With regard to metabolic effects, the areas in which research should continue are on the effects and physiological conse- quences of long-term use of DMPA and NET-EN on carbohydrate and lipid meta- bolism. In addition, further research is needed regarding the risk of neoplasia among women using DMPA or NET-EN. Finally, the effects on the later develop- ment of infants who are exposed to DMPA or NET-EN in utero or through breast milk are not known. Research should continue in these areas. In summary, DMPA and NET-EN appear to be acceptable methods of fertility regulation. Clinical evidence from more than 15 years of use as contraceptive agents shows no additional and possibly fewer adverse effects than those found with other hormonal methods of con- traception. The particular advantages of DMPA and NET-EN as highly effective, long lasting and reversible contracep- tives make them important as options for women desiring a method of fertility regulation. WHO's Special Programme has ad- dressed and will continue to address itself to actual or theoretical problems associated with the existing injectable contraceptives through clinical and epidemiological research, health ser- vice research and research on animal models. Furthermore, it has a major programme for the development of new injectable preparations and im- plantable devices with the aims of reducing the amount of drug received, and decreasing menstrual disturbances and other side-effects. It is expected that by the 1990s such new long-acting contraceptives will be available, and will play an important role in providing safer, more effective and more accept- able options to existing injectable methods of fertility regulation. ■ 4 Health technician in Turkey A special group of primary health care workers in Turkey, called Environmental Health Technicians, are helping that country to meet the challenges of the Water Decade to provide safe drinking water and sanitation for all by 1990 by Peter W. Jolly U he Turkish authorities long ago acknowledged the impor-tance of environmental san- itation in the control of communic- able diseases. In the early sixties, with the assistance of WHO, the government started on a project to develop basic environmental services. A training college for Environmental Health Technicians opened its doors in the capital, Ankara, and today some 800 tech- nicians are working throughout the country's 67 provinces; other colleges are already functioning or are planned. One such technician is Fahrettin Altundag, aged 30, who qualified in 1971, and lives in the small seaside town of Karatas in the Adana province of south-eastern Turkey. Fahrettin's rural district contains 21 villages with a total of some 10,000 people. He works at a Health Centre in Karatas and is supported in his work by the Cukurova Medical Faculty of Adana Univer- sity, which has created in the area a training project for community medicine. The government has very recently chosen this part of Turkey to develop, with wHo's assistance, its Primary Health Care (Pm) ap- proach to the control of communi- cable diseases. A key activity here is the control of endemic malaria, which flared-up in 1978 to epidemic proportions and required massive efforts to bring it under control. Activities in the context of the International Drinking Water Sup- ply and Sanitation Decade also form part of this PHC approach, especially in the village setting. And a typical village named Dogan Kent has been chosen in Fahrettin's area to demonstrate what can be done in environmental sanitation by com- munity participation and a multi- Environmental health technician Fahrettin Altundag inspects the dis- play of meat outside the village butcher's shop. (Photo WHO/P. Jolly) sectoral approach to problem- solving. With all these things going on, Fahrettin is a busy man, and this is reflected on the work plan fixed to the wall in his office. It is well worth while to look in some detail how his time is taken up, the problems he faces and how he, as a member of a team, sees the solutions at the beginning of this new approach. The village of Dogan Kent has a population of 2,400 persons, with 408 dwellings. Because of the im- portance of demonstrating here in practice the theoretical planning behind the Water Decade, at least two days of Fahrettin's time each week will be devoted to work in this village. The Malaria Control Service has done excellent work in making sketch maps of the villages, and he makes good use of the one for this community. Every house must now be surveyed. The hygienic state of the toilet is recorded on the map; the water supply is checked and it is noted whether it comes from a private well or the village distribu- tion system, or both. The solid and liquid waste disposal systems are inspected, the manure storage from the farm animals is noted and the density of the fly and rat problem is determined. The Malaria Service will have already mapped breeding sites for mosquitos, since malaria is a serious cause of illness in the village; Fahrettin will add his 5 Health technician in Turkey The Turkish village of Dogan Kent has been chosen as a pilot area where the theoretical plan- ning behind the Water Decade can be shown in practice. Left: The environmental health tech- nician studies a plan of the village with the rural midwife. Right: A local boy and his sister get a drink from the ancient pump. The close proximity of a manure heap does not inspire confidence in the purity of the water. Far right: Even more hazardous is this well, only a few yards from a brick and currugated iron la- trine; yet the villagers continue using the well rather than invest- ing in a piped water supply. (Photos WHO/P. Jolly) weight in persuading the villages to eliminate small breeding places close to dwellings. Water supply for domestic use is more complex than it appears at first sight. Turkey is fortunate in possessing an excellent agency for rural development, called YSE (Roads, Water and Electricity) in the Ministry of Rural Affairs and Cooperatives. A high percentage of villages have been provided with a piped water system by the YSE, which is also responsible for roads and electricity, but not for solid or liquid waste disposal, nor for main- tenance of water distribution in- stallations once they are handed over to village committees. Here in Dogan Kent the distribution system exists, but unfortunately fewer than half of the village families use it for domestic purposes; the rest prefer to continue to use their shallow wells, where the risk of contamina- tion is very high. Fahrettin knows that water from the distribution system is measured at the tap near the house and costs 10 Turkish Liras for 1,000 litres, a cost that is not negligible where the incomes of some of the poorer village families may be only 3,000 Turkish Liras per month. Another obstacle is that the consumer must pay the considerable costs of install- ing the pipes and the tap, including labour costs. He knows too that, to overcome this, the Water Decade planning aims to provide the pipes free, or at very low cost, and to train the villagers to form an installation team themselves. This will involve a wider approach to solving village problems, bringing in other state organizations, and involving all parts of the Water Decade planning at central level. However, there is more to finding the solution than merely arranging financial and organizational ap- proaches. Fahrettin is aware that the attitudes and values of the traditional rural population need changing, and he feels that he is not qualified for this work. He seeks support here from the health educa- tion service at the Provincial Medical Director's office, because he knows that, if active participa- tion of the population in solving their own multiple environmental health problems is to be achieved, it will be through the educational approach. Already during the planning and pilot area selection stage of the wFTo- assisted Primary Health Care Project, the UN Children's Fund (UNICEF) had funded social studies made in the village by a national con- sultant anthropologist. The pop- ulation's knowledge, attitudes and practices had been surveyed, and one of the findings directly concer- ned the use of water for domestic purposes. The villagers often prefer- red water from their shallow well, and not only because it was cheaper. It was cooler in summer and warmer in winter, they said. It made a better tasting tea and looked clear and good to drink. Apart from that, the piped supply was cut off when there were village electricity cuts and the main pump ceased to work. All these are formidable arguments to overcome, and require solid educa- tional techniques, if one of the objectives for the village—to have 100 per cent of the houses supplied from the distribution system is to be met. 6 The village midwife works together with Fahrettin to improve the quality of life of the villagers. She lives in the village and is a great fund of knowledge on local matters. She has told Fahrettin that by the end of each summer a majority of the village children aged up to six years will have been ill with diarr- hoea although, fortunately, good health care has prevented fatalities. Another objective will be to reduce this figure by as much as two-thirds. At the moment, no accurate statistics exist for the number of cases of diarrhoea in the village. A method for collecting this data that would closely involve the Commun- ity Health Workers is being considered. A simple form would be left at each household and a mem- ber of the family would record who in the household has had fever, diarrhoea or a heavy cough recent- ly, and which children have had ear infections. Improved environment- al health conditions could then be correlated with the health of the villagers themselves. Food hygiene plays a big role in checking the spread of gastro- intestinal infections, so the local health workers advise families on nutritional and hygienic aspects. In the local butcher's shop, for exam- ple, Fahrettin finds the meat hanging outside by the main high- way to attract customers. But it also attracts flies and is exposed to dust and heat. Yet inside the shop, the owner is proud of his large and shiny cold store. Again it is a matter of education and persuasion, both of the public that buys the meat and of the local butcher. Locally slaughtered meat is not inspected for disease. There are too many butchers' shops in the villages and not enough meat inspectors. How- ever a tax is paid to the village Muhtar, or headman appointed by the government. So one solution being considered under the self-help approach is to train the Muhtar to recognise the main animal diseases when he collects his official tax from the butchers. Fahrettin has 20 other villages in his area and most of the problems are similar. He tries to divide the rest of his week so that he can take a water sample from each village for analysis in the laboratory at least once a month, and follow up with remedial action if the sample is contaminated. For the individual wells, he provides the owners with chlorine compounds and instructs them in how to sterilise their own wells. The village schools are inspected in their turn, small defects being made good through the Muhtar's village account, and large works such as toilet construction or drink- ing water provision being funded by the Ministry of Education. Discuss- ions with the teachers encourage them to teach health subjects to their pupils. The lessons to be learnt from the pilot village of Dogan Kent, where planning will be translated into action in a primary health care approach to the objectives of the Water Decade, will have direct application to the overall extension of improvements to village sanita- tion. Community health workers like Environmental Health Tech- nician Fahrettin Altundag have a key role to play in the many tasks that lie ahead. ■ 7 Keep death off the road! by D. Paul Sondel ET-§ SALIM' RINCAILLERIE MAIM UP; 240 OUACADOU How can we say that we are vitally concerned with the quality of life if we accept as inevitable that every year around a quarter of a million people must die and millions more be injured? ID he basic facts about road accidents are that each year they kill at least 225,000 people and injure uncounted mil- lions, leaving tens of thousands crippled or maimed. Quite apart from the loss in human terms, the financial costs involved are incalcu- lable. For the engineer and the econo- mist, the disruption in transport and in the supply of services, and all the other consequences of traffic ac- cidents, are viewed as disruptions of, and aberrations within, the system. They have called for techni- cal remedies within favourable cost benefit parameters. We have tried to build safer cars, and we have succeeded, though many say that the cost has been excessive. We have made our roads better, both by design and through improved facilities. After we have built in or allowed certain con- ditions to develop which make injury or death likely, we go out and identify such "black spots" and do something to correct the situation. We try to make it reasonably safe for children to get across streets. We use a painted crosswalk, a traffic light, a crossing guard, or a police officer. In extreme cases, we might put up an overpass, or dig an under- pass. In California, some 40 years ago, the State authorities built a major highway which split a com- Dangerous signs of wear on a juggernaut lorry's tyre in West Africa. Transport systems should be tailor-made to suit the communities they serve—not to crush them out of existence. (Photo WHO/E. Mandelmann) munity. They built a fine underpass for sheep, but made no provision for the children—the fact sticks in my memory because a close friend of mine witnessed his child being killed there on her way home from school. We also try education. Toddlers may not be able to learn traffic skills well enough for their lives to depend on those skills. School age children learn many useful ideas and prac- tices concerning traffic and we think that these sometimes have an effect on their behaviour. But we could do better. For instance, when we teach people to drive, we could put much more pro- fessional skill, time, and effort into bringing home to learner-drivers the significance of that activity on our lives. We ought to reconsider the basic assumptions which we accept about traffic, because it is these basic assumptions which have created problems in the developed countries and are rapidly doing the same in the Third World. It is not the vehicles, or the drivers, or the roads. It is what we assume to be true about them, and about the systems in which they interact, that has got us into trouble. Cars, drivers, and roads are just the symptoms. We have to think about the system as a whole. Most people accept, almost with- out question, that cars and trucks are essential for transport and services; that roads must facilitate the rapid flow of motor vehicles; that death, crippling and a great deal of less severe injuries naturally result from the interaction of motor vehicles with people, but this is the price that must be paid for a modern transport system. We have been conditioned to accept the first two assumptions and to ignore the third—not to see it at all—though it has become a fact everywhere in the world. When a two-year-old toddles into the street and is instantly killed by a passing car, we accept the idea that the toddler should not have been in the road. The accepted penalty for the two-year-old being in the wrong place is death. Roads are built for cars. The driver has the right to drive, at reasonable speeds, along residential streets. Nobody ques- tions the driver's purpose in getting about swiftly and comfortably; speed and ease of transport are understood to be essential in a modern society. Time spent getting from here to there is time which costs money. Our traffic systems must facilitate the swift, uninter- rupted flow of traffic. It is not eco- nomic to be slow. It is backward. In a "modern" society, there is no place for the slow. Pedestrians are slow, especially little children and old people or the handicapped. Push carts, animal carts and cyclists are slow. They get in the way. They impede the flow of traffic. They clutter up the lovely four-lane highways, spoil the statistics and make computer models useless. Human beings are a nuisance! Why don't they have the decency to climb into motor vehicles, or keep out of sight so that our road networks can hum with productive activity? Even the crashes-94 per cent of them—are basically caused by hu- man error, in spite of these great machines, operating on our mar- vellous roads. We are authoritatively told that 9 accidents "only" cost one per cent of a nation's gross national product. Isn't that a wonderful figure—so neat and simple? But questions keep popping up: does it cost more to mangle a young professional person in a sports car than to kill the driver of a donkey cart? Which costs more, to kill a pregnant young woman, or an old and barren one? How much of the GNP does it cost to paralyse, say, 400 children under 10 years of age? We need not accept massive death and injury as the price for progress. We have the right to hold that life is of greater value than speed. Con- sider what is important—truly important. Drop the socio-political theories. Stop thinking of the bil- lions of people on this planet. Focus, instead, on any one person whom you love. How is the purpose of life fulfilled when the life of one whom you love, or your own life if you'd rather, is lost in a motor vehicle crash? Is it any different for each anonymous human being on earth than it is for you? We have been duped. We are on the verge of being swindled out of the only inheritance worthy of the name: our fundamental respect for human life. Our cultures either have been or are being subverted by the insidious notion that speed and ease of transport are of greater value than human life. Throughout the world, roads are laid out on patterns developed in the United States and Europe. Traffic is controlled by standards established in the industrialised world. Vehicles roll on these roads which were engineered for another culture, another land, for people living wholly different lives; they include cars with speedometers measuring 240 kph and lorries carrying 70 tons gross vehicle weight. The result is the same (or far worse) slaughter which has been produced elsewhere in the world. Never mind; this developing country can take pride in having a modern road transport system! What can we do about this? We can start by setting the stage for the Keep death off the road! Left Again in West Africa, a huge lorry thunders along a road that was engineered for another cul- ture, another land, for people living wholly different lives. Right Three people died when this truck plunged into the roadside ditch in Bangladesh. Transport practices which have been de- veloped elsewhere are not to be superimposed on the developing countries: life is too important to be sacrificed on the altar of speed. ( Photo WHO /E. Mandelmann and WHO/A. Khan) development of systems which will be uniquely appropriate for the societies and cultures which de- veloping nations want to preserve, and toward which they want to move in the next few decades. We can state, clearly and forcibly, that mechanical and civil engineering practices which have been de- veloped elsewhere are not to be superimposed on the developing nations, because we know that there can be something better. Life is too important to be sacrificed on the altar of speed. Goods and people can be moved, and services provided, with effi- ciency appropriate to the cultures within which they exist. Transport systems can be fitted into existing communities, so that people can continue to live in neighbourhoods and villages, sharing the traditional values built on their religious beliefs and cultural mores, and can still be "modern". Following the guidance of the World Health Organization, we can stop categorising traffic death and 10 injury as a transportation problem and dumping it in the hands of the engineers. We can look at it for what it truly is: a major public health problem. We can attack it— through the entire community—as we would if it were cholera, typhoid, plague, yellow fever, enteritis, or birth defects. The object should be to relate the values of the culture to the problems of road death and injury. To help people to perceive that what they cherish most in life is directly related to, and threatened by, what is happening on the roads. To en- courage them to reject the notion that road casualties are inevitable. To help them to understand that driver behaviour and motor vehicle use are subject to their social mores and can fit into their traditional value systems; that it is not neces- sary to accept the slaughter for the sake of modernising their transport system. We can improve the way we get about, move goods, and receive services without killing one another to do this. What must be done is to adapt improvements to the life style which people want to maintain, rather than remould their lives to accommodate the machines. Start with people, then fit the systems to their needs. Bring essential services to the people rather than force each person to travel to acquire necessi- ties. Allow vehicles to supply residential areas at perimeter points, or through protected cor- ridors and at controlled speeds. Provide clean, efficient, low-cost or even no cost public transport to reduce the need for individuals to consider themselves disadvantaged if they do not own a car and we're not talking about multi- million dollar subway systems but about owner-operated mini-buses, ridesharing systems, and other neighbourhood-oriented systems. Let us stop ignoring the real social, economic, health, and environ- mental costs of the private car when considering the alternatives to it. When we train and licence drivers, let us put in the level of effort which is consistent with the significance which driving has on our lives. When we enforce the law, especially against driving under the influence of alcohol, let us do so impartially and thoroughly, ensuring that drug- impaired drivers are kept off the roads. People are still more important than the machines they make and use. All our tools, our machines, our economic models, our computers —of what use are they if they do not enhance the quality of our lives? How can we say that we are vitally concerned with the quality of life if we accept as inevitable that each year at least a quarter of a million people must die and tens of millions must be injured, so that we can have progress? What kind of idiocy is that? What sense is there in saying that we are trying to improve the quality of people's lives when we impose traffic systems on them which are built on the assumption that life itself is worth less than the economic necessity for rapid transport? ■ 11 ne way of looking at accidents is to consider them as the result of an inadequate response to a normal chain of events. The causes of this inadequacy vary, but may be ascribed to extreme youth or extreme old age, organic or neurological di- sease, minor psychic disturbances, or an abrupt change of environment. Accidents at home or in school may seem a trivial matter, yet the statistics show otherwise. A study made 20 years ago among 1,000 inhabitants of the United States found that in a given period this group had suffered 144 domestic accidents compared with 28 traffic accidents and 48 accidents at work. The figures may be rather old now, but all the same they do underline the dangers that can lurk in the daily environment, whether in the shape of staircases, lifts, doors and windows, slippery floors, insufficient lighting or electrical devices. Certain groups of the population are more at risk than others. Particular examples include old people who may suffer from impaired sight, hearing or smell, and immigrants who are sudden- ly plunged into a new social and cultural setting, which generally tends to be more advanced than the one they are used to. Then there are children, who are specially accident-prone in their homes or at school. In Tel Aviv, Israel, an average of seven accidents a day occur in the schools of that city alone. It was also found that certain children suffer from recurrent accidents of the same type within a short space of time, presum- ably for some psychological reason. Take, for instance, the girl in her early teens who suffered from fractures in two consecutive years, because she was in permanent competition with her three brothers and wanted to prove she was capable of the same physical activities as they were. Is there anything we can do to prevent such accidents? One of the most important factors underlying accidents is that of age, at the two extremes: infancy and the start of adolescence on the one hand, and old age on the other. Children are curious. They want to know everything, they touch every- thing, and their ignorance and lack of experience stops them seeing the risks they take in handling objects, instru- ments and gadgets whose action and mechanism they don't understand. As a result, they get burnt or injured in some other way. As for old people, their exposure to accidents increases as a result of illnesses which affect their senses, attacks of giddiness, over-slow reactions, or failing eyesight, and sometimes simply as a result of isola- tion and loneliness. The Japanese have invented a kind of mini-siren which can be attached to an old person's arm if he or she is left alone, when the rest of the family is at work or at school. If any sudden change in the vicinity of the old person is recorded—a violent action, an inexplicable increase in temperature and so forth, the siren emits a warning signal audible over an area of 800 square metres. But obviously this system depends on very high technol- ogy, and is of little value in countries where people cannot afford such lux- ury gadgets. In Israel, whose population stems from no fewer than 117 different countries, the most important causes of accidents arise from the difficulties that new immigrants face in acclimatising themselves to conditions of life quite different from those in their countries Accidents can be prevented! The very young, the very old, immigrants newly arrived in more developer countries these are among the groups who are most exposed to the risks of accidents. How can we protect them? by Joseph Fux 12 Children at risk, in Sri Lanka (above) and in Israel (right). Curiosity, ig- norance and lack of experience prevent youngsters from seeing the potential dangers that surround them. ( Photos WHO/F. Dupuy and WHO) of origin. The same situation arises in all countries of the world which have a large number of foreign workers, most of them coming from less developed countries. They may be confronted by domestic utensils and gadgets which are quite unfamiliar to them. In this context, the immigrant reception centres ought to give serious attention to arranging a series of instruction courses. At this stage, it is even desirable to look very carefully at the state of health of newly arrived immigrants, some of whom may well be suffering from disorders that are not very obvious—eyesight problems, cardiovascular diseases, neurological conditions and so on. Therefore any accident prevention campaign activity should involve not only doctors but also teachers, engi- neers, and the manufacturers of tools, kitchen apparatus and heating equip- ment. It goes without saying that these activities should also be accompanied by publicity campaigns in the news- papers, radio and television. As for the prevention of accidents at school, Israel's Ministry of Education has set up a special service which records all accidents, investigates them and tries to devise ways of avoiding such mishaps in future. The Ministry also publishes training material on the same subject. Headteachers and their staff deserve special praise for their sustained vigilance and for the meas- ures they have already taken to prevent such accidents: close surveillance in class, in the playground, during school excursions and so forth. Special efforts are called for in schools where there are likely to be children of recently arrived immigrant workers. Among all these steps that have been taken it is worth mentioning that, if an accident occurs, a teacher takes charge of the injured child, accompanies him or her to the polyclinic or hospital, and only leaves when it is quite clear that the patient is receiving the best possible attention. In technical training schools, where pupils might be at risk from the machines they are learning to use, the staff draw their attention to possible hazards and show them how to avoid them. The more advanced electrically- operated machines are equipped with special devices which automatically cut the current if any defect or mishandling occurs which could cause an accident. The only other thing that remains to be done is to reinforce all the measures that have already been taken. In Israel, teams of schoolchildren are trained to help in traffic control, and their num- bers are being increased. Radio and television broadcasts are used inten- sively to encourage drivers to respect these "junior policemen" who help the traffic flow. Even closer collaboration is encouraged between school doctors and the medical staff at polyclinics and hospitals, to ensure rapid and effective first-aid treatment for the victims of accidents, and to analyse the causes of such accidents. Finally, the problem of recurrent accidents deserves more in- tensive study, so as to discover the pathological causes underlying them, to help us understand the mental state of their victims, and to find remedies for them in the future. ■ 13 International Youth Year, 1985 A scant 15 years will remain from International Youth Year (1985) until the year 2000. By the end of the century, the World Health Organization aims to achieve its ob- jective of Health for All. Do the two concepts complement each other: on the one hand, the designation of a specific year to focus international and national atten- tion on young people (aged from 15 to 20 years) and their potential contribution to human well-being and, on the other hand, the aspirations of attaining an accept- able level of health for the peoples of the world — of which youth constitute a large proportion? The answer would certainly appear to be a strong affirmative by Asha Singh Williams Cy he General Assembly of the United Nations recognised the "... profound importance of the direct participation of youth in shaping the future ...". In the wHo global strategy for Health for All by the Year 2000, one of the key factors to reaching this goal is described as "... community in- volvement in shaping its own health and socio-economic future, includ- ing mass involvement of women, men and youth ...". It is obvious, then, that there is an explicit appeal to young people to be actively involved in all aspects of development, of which health is an integral part. However simple this concept may be, the implications are multiple and complex. An essen- tial prerequisite is the political and social acceptance of young people as equal and responsible partners in the process of development. But circumstances differ, not only from country to country but even from locality to locality, and there can be no blueprint for a plan of action that will have universal application. Notwithstanding some percept- ible progress in global development, the total number of poor people is increasing, and existing conditions of poverty are becoming worse, not better. Slums on the outskirts of large towns are also a growing phenomenon, with enormous so- cial, economic and health problems. The largest proportion of in- dividuals most severely affected in this population group are children and young people. What then, in the light of this awesome challenge, can be pro- posed in general terms that will both encourage and enable young people to act as promoters and stimulators of health, to take better care of themselves, their families and their communities? What kind of mo- tivation is needed? One of the most urgent require- ments is relevant information to foster self-reliance in all sectors affecting health and development. Existing systems and forms of communication are not adequate, nor—in many cases—are the messages that are communicated. With the recent advances in com- munications technology, innovative and cost-effective methods of chan- nelling appropriate information have to be sought and utilised. Information that seeks to impart some form of learning needs to be closely related to productive and socially beneficial activities using, whenever possible, networks of existing community structures. The production of low cost teaching/ learning materials about health and social problems for and by young people would be an important step in raising the general level of health awareness. Such information should focus not only on the specific needs of young people, but also on how they can contribute to promotive activities to bring about improve- ments in health for all. Health does not exist or maintain itself in isolation. People need to be made aware of the interplay bet- ween health and factors such as the availability of clean water, adequate housing and sanitation, adequate nutrition and basic health services. Therefore, parallel to and comple- menting the dissemination of in- formation are training activities. These include not only the relevant training of those who provide health and social services for the young but, more important, the training of young people them- selves. Especially in the rural areas of developing countries, youngsters can be trained to develop and promote community-based primary health care activities for education in health, family life, literacy, family 14 These Indonesian villagers know and trust the primary health workers who visit them. Health for all by the year 2000 is a challenge to young people to come forward as promoters and stimulators of health in their families and their communities. (Photo WHO! A. S. Kochar) planning, child care and other welfare activities, with the aims of encouraging and facilitating self- care. As I have said, there can be no general plan of action that will be fully applicable to all the varied situations. However it can be stated with some certainty that, if con- centrated and relevant action is taken, the outcome will be positive. It can be expected that there will be a rise in the general level of awareness about health and, therefore, an improvement in the general health status of a given population. There will be an in- crease in the number of young people actively involved in primary health care at the community and village level, both as promoters and stimulators as well as providers of health. An increase in knowledge about and acceptance of family planning will affect the demograph- ic pattern and will have a positive impact on socio-economic develop- ment. Also to be expected is an enhanced awareness among young people about health and develop- ment issues and, through education in health-related issues, a decrease in the abuse of drugs, alcohol and tobacco. At first glance, the period of youth marks the stage in life which is probably the healthiest of all. But such a view is based almost ex- clusively on an unrealistically narrow definition of "good health". Psychosocial and physical problems occurring during this period of growth and development can have a very negative impact later in life if left untended. This is even more true for young women, due to their reproductive functions. It is an accepted fact that the status of women closely interacts with their own health as well as that of their children and families. This interac- tion is strongly influenced by physiological and psychosocial fac- tors present during adolescence. Cultural practices and attitudes determine adult behaviour. If, then, the future status of women, includ- ing health, is to be improved, immediate priority will have to be given to changing these practices and attitudes. Especially important is the delaying of pregnancies, in order that women's educational, social and employment potentials and opportunities are not limited. There is, therefore, an obvious need for action programmes related to health problems that have a significant effect on young people. For example, educational activities should be available to prepare the adolescent for parenthood, and there should be accessible informa- tion on, and services for, the treatment of sexually transmitted diseases, and the excessive use of drugs, tobacco and alcohol. Much needs to be done both for and by young people. It is not sufficient merely to have activities directed towards youth. If the aims and objectives of International Youth Year, 1985, and of the wHo Global Strategy for Health for all by the year 2000 are to be achieved, serious efforts of collaborative ac- tion by everyone—young and old —are needed. The youngsters of today, with their capabilities, en- ergy and commitment, represent a vital resource; they must be partners in the quest for a just future. ■ 15 A new look for health services Dr Hiddlestone, Director-General of Health for New Zealand and the current Chairman of WHO's Executive Board, described the reorganization of his country's health ser- vices in an address to the Medical Society of WHO earlier this year. The following is a slightly shortened version of this speech by H.J.H. Hiddlestone 2ngp±j§6--- n is. the rather cu- ous acronym for the Special Advisory Committee on Health Services Organization. Appointed by the New Zealand government, it has—to use a nautical metaphor—steered the barque of pro- gress through the seas of indecision and is fast reaching the haven of achievement. I should stress that this achievement has been made against a background of gale force winds and mountainous seas of contention and disagreement in the recent past. Because of this achieve- ment, I suggest that our recent experience may have value as a plan- ning model suitable for adaptation and application in other countries. The reasons that call for health services reorganization are common to many countries. First of all, it is obvious that changing problems need changed solutions. In many parts of the world such things as the conquest of infection, the remarkable advances in anaesthesia, and the application to everyday practice of aspects of bioche- mistry have all brought about such marked changes in the problems we 16 now face that obviously the organiza- tion to deal with them has to be a very pliable and changing one. But there are rather more intense reasons for looking at reorganization, such as the constraints of finance and manpower. In my little country of only three million people, we are now devoting 11 per cent of our government expenditure to health, and many people feel that this must be about the upper limit in hard terms. There seems to be an almost insati- able demand for increased manpower in our health services, and our reor- ganization must take account of this too. If we just take one simple example in New Zealand, until two years ago the requests for our laboratory services were increasing in a compound way by 17 per cent per annum. One of my colleagues did a projection forward and was able to show that, by the year 2008, every adult and every teenager in New Zealand would have to be a laboratory technician, this despite the advances of automation. And so it is quite obvious that financial and manpower constraints are very real things in requiring health ser- vice reorganization to take account of them. Next, we have the impact of technol- ogy and treatment. It is apparent that, even if the problems haven't changed, the methods of coping with them oblige us to make substantial changes. And to take the very simple case of myocardial infarction and make it relatively per- sonal, when I returned to New Zealand as a reasonably trained and qualified specialist physician in 1954, such un- fortunates as came under my care with myocardial infarction ended up in a ward of 30 patients. They had regular electrocardiograms, they had a lot of tender loving care, they were half poisoned with anti-coagulants and they tended to stay in hospital—if the Almighty didn't decree otherwise for a period of about six weeks. But as far as their nursing care was concerned, this involved being one of 30 patients overseen by two qualified nurses and about four trainee nurses. Contrast the situation in 1982. The same patients, on being admitted, would go into a coronary care unit where the fully qualified and very specialised trained nursing staff would A veteran sheep farmer in New Zealand, with a younger novice alongside. When a major reorganization of health services was tried out in a pilot area, in North Island, it was a typical local farmer who became a surprisingly successful chair- man of the new Health Services Advisory Group. ( Photo L. Sirman C)) outnumber each patient by at least a two-to-one ratio. They would be under constant electronic monitoring, and face a battery of regular laboratory tests at least three times a day. Apart from the increase of staff who were directly related to care, they would have the back-up of technologists looking after the equipment, and a substantial package of laboratory tech- nology. Provided they successfully survived the various forms of therapy, they would invariably, if they were of a suitable age-group, have coronory angiography and possibly by-pass sur- gery. So in that simple, common condition of myocardial infarction, it is plain " that health service organization has to take account of changing technology and treatment. Of course we have to respond to life- style diseases. Everyone who works for WHO is well aware that the changing impact of these in terms of cardiovas- cular disease, cancer, accidents, and alcohol and drugs, to name the four major aspects of life-style diseases that plague mankind everywhere, require an organization to take account of them. We have to mobilise that new form of therapy which is not based on drugs or technology, but rather on the more subtle effect of therapeutic social pressures which are aimed at changing people's attitudes and activ- ities. As a convert of some standing, I believe these have been effective with smoking. Archaic structure Then, in my own country we had a rather archaic hospital board structure. We had hospital boards run by an elected group of the populace of the area they served, and they were elected every three years. New Zealand had 29 of these boards and a population of only three million, so that some of them looked after 800,000 people and others after only 8,000; something obviously had to be done to change the organization. There was a need for coordination. Voluntary agencies and private agen- cies play a very important role in the health services, and there is no point in each of them going their several ways. In 1973, the people of New Zealand elected a new Labour government which felt there should be political emphasis on health. So the emphasis was put on health services reorganiza- tion. A government White Paper (policy document) was produced in a fairly short period of time, and was at once subjected to great criticism. At the same time, seven Advisory Committees were charged with looking into various things—personnel, finance, legal as- pects and so on. The government proposed legislation to produce a universal plan based on a series of Regional Health Boards which were to take over the total functioning of public health, public hospitals, private hospitals, private practice and volun- tary agency activities. However, the 1976 election saw a National government elected, at least 17 in part because of the fear engendered by the White Paper on Health Services Reorganization. The new Minister of Health took stock of the situation and said "This can't all be wasted: there is an enormous amount of good here." So it was agreed that six of these seven Advisory Committees should be aban- doned; but one, the legal and administrative consultative group, which had been working in a very positive and constructively critical manner, should go ahead for another year and produce something of a modern phoenix out of the ashes of this White Paper. And so it happened that a year later SACHSO was brought into being, the Special Advisory Committee on Health Services Organization. It has been a very effective group, because it is multi-disciplinary. It's not just doctors, not just health department officials, but has a wide range of members. These include five profess- ors, among them professors of socio- logy, political science and medicine. There are representatives of the three major health groups through their associations—medicine, dentistry and nursing. And there are people re- presenting the voluntary and private agencies in the health service and several officials from my department. They were charged by the government with producing the skeleton outline for a new health services organization. They foresaw the integration of public, private and voluntary agencies, the abolition of hospital boards and their replacement by area health authorities, and the introduction of some appointed members to these authorities. They then selected two areas of the country as pilot areas, one a large provincial area, the other a metro- politan area. So first we went to Northland, the provincial area in the northern part of North Island, and there we had a most extraordinary experience. Several of us made a whistle-stop tour, travelling rapidly from one location to another. In one place the mayor even declared a half holiday so that everyone could come and hear the nonsense these bureau- crats from Wellington were going to foist on them. It was strange to sense the hostility that came back from the audience. The first job was to reassure them that we were not trying to impose a Central Plan, but were putting forward a skeleton of ideas for a better service, and inviting them to set up their own committee. So it became a local initiat- ive, and they appointed a committee of local people to look at our ideas and flesh them out in detail. By one of these strange chances of fate, a farmer with no knowledge of health—he knew a lot more about cows than about human beings— became the chairman of the Northland Health Services Advisory Group. He proved to be absolutely fantastic; he brought about the involvement of the public in this whole exercise and much of its success was due to him. One of the first things he did was to ensure that the people of this district were fully infor- med about what was going on. He used the radio, he used television, he used the press, and if any small group invited him, he or others among his 15-strong committee would go along and speak to them. No fewer than 195 groups were developed in a widely scattered rural area, and each group regularly met to discuss what was going on—an extraordinary involvement of the population. So discussions went on right through the year, and what emerged were Shadow Service Development Groups, 18 A new look for health services Left An air view of Wellington, the capital of New Zealand. When a shake-up of provincial health services was planned, one mayor declared a holiday "so that everyone could come and hear the nonsense these bureaucrats from Wellington were going to foist on them." Right Many of the farmers whose meat production contributes significantly to the country's economy are descendants of the original Maori people who populated New Zealand. ( Photos L. Sirman so-called because the real Service Development Groups could only arise when this new organization came into being. The shadow groups covered areas of concern such as childrens' health, the health of elderly people, dental health, mental health—notice the emphasis was on health not illness. It all seems beguilingly simple, yet it has been most effective. These groups have undergone an evolution. They met each other at first with very obvious suspicion; the doctors eyed the technicians, the technicians eyed the officials, and so on. Then they started to realise they all had "tunnel vision", and were looking too narrowly at the situation. So they began to seek outside help. We set up a small professional group to help in planning, and in identifying the true problems not just the surface expression of problems through ill health. We found areas of overlap, and of deficiency, and these were corrected. So in Northland, the groups that were initially antagonistic to the whole idea are now its strongest supporters. The next stage was Enabling Legisla- tion; not legislation that said "thou shalt" but legislation that said "you can if you wish". This is the stage we are in at present—the enabling legislation is included in the present government's legislative programme for 1982. What are the lessons to be learned from this exercise? The first is the multidisciplinary approach to plan- ning, which ensures expert advice but does not just depend on the health professionals. That is very important. We learnt such a lot from having a political scientist, an economist, or a sociologist involved. This is quite essential. In many countries of the world, when they are looking at health services organization, people tend to look only at the major health profess- ional groups to do the planning. The second lesson is that govern- ment initiative and encouragement are essential but NOT government direc- tion. The third is to have consumer involvement. It's easy to say but difficult to do. Use every possible medium for publicity—radio, televi- sion and the press—but also make sure that you engender local interest and feedback, by forcing the people who are doing the planning to go out and listen to what people are concerned about. At the same time the changes have to be explained. Our reorganization would never have got off the ground if we had not gone out and met people and told them what it was about; if we had simply allowed it to filter through the press and radio, nothing would have happened. The next lesson is the need for enabling legislation. Instead of putting up authoritarian legislation, you make it possible for people to come into it from choice. I have mentioned only one area, but this same thing has caught on throughout the country and we now have a great number of service develop- ment groups starting in areas without any central initiative. But even more important, there is no doubt that the old illness-oriented approach to health care has changed remarkably with this whole process; that people really are much more health-conscious, and the concepts that wHo has preached for so long are starting to get a response as a result of this process. Finally, whatever value this ex- perience in New Zealand may have for other countries, I am sure it must start from the basis of an adaptation of any of the ideas outlined here, and not the rigid adoption of those ideas. ■ 19 Weather ship to the rescue It is not often that WHO's sister agency, the World Meteorological Organization, finds itself directly concerned with health. So we take a special pleasure in reproducing extracts from the log of the French weather ship France I, one of a network of such vessels which feed data into the WMO's "World Weather Watch" system, and which enable this United Nations agency to maintain a rapid exchange of meteorological information between its member states. In September last year, France I —one of two vessels which take turns in going to "tramp water" at the lonely spot in the Atlantic known as Station Romeo suddenly received an SOS call from an unknown vessel with a seriously ill boy on board. Captain Bernard Hamon's marine log-book takes up the story. 4 September 0810 Request for medical assis- tance heard on the distress frequency 500 kHz coming from the sailing vessel Outlaw, flying the Maltese flag, which estimated its position at about 110 nautical miles West North West of Station "Romeo". Weather conditions good. 0830 Since France Iwas the nearest ship with a doctor on board, we set off in the direction of the Outlaw on one engine, while the other two engines were being warmed up. 0900 Contact again established, by radio-telephone, through the British- registered ore-carrier King Charles, which relayed the first medical con- sultation between our doctor and the captain of the Outlaw. The first diag- nosis, subsequently confirmed, was appendicitis with a probable risk of peritonitis. 1035 Our three engines are turning at maximum speed. King Charles sight- ed the Outlaw, and informed us that she was a 45-metre schooner. 1530 Spotted King Charles dead ahead, and shortly afterwards the Outlaw, which gradually took on the magnificent silhouette of a sailing ship of bygone years, with jib, staysails and spanker set, although her engine was turning. 1643 We stopped one cable to the lee of the Outlaw which was hove to under staysail. Launched our inflatable dinghy and set off with the doctor. What we had been observing through binoculars now became clear: the Outlaw is certainly no ordinary sailing boat. It serves as a kind of youth hostel. At least 20 youngsters (the youngest was 12) greeted us. The captain im- mediately took us to see the 16-year-old patient, Michael, who looked to be having a rough time. While the doctor examined him, I was invited for coffee in a saloon which smelt intriguingly of hemp rope and dried fish. Seeing my astonishment, my hosts explained. While flying the Maltese flag, the schooner and most of its unusual crew hail from the Federal Republic of Germany. These youngsters had been unhappy drop-outs whom some kind philanthropists had wanted to divert from delinquency. They had sailed from the Western Mediterranean last April on a six-month voyage. By the time they had visited Madeira and the Azores, they had become real sea-dogs, ready to face the Atlantic crossing directly from the Azores to South- ampton. The captain, a strapping, bearded seaman, was not yet 30; two women teachers, a chief engineer, a specialist in child psychology, and two other men made up the Outlaw's complement of officers, while the 16 young people formed the crew. The doctor told me things looked serious, and we would have to take Michael with us. As we talked amid the decor of a bygone age, we noticed a proverb carefully painted on a beam: WHERE THERE'S A WILL THERE'S A WAY. 1740 We returned slowly in the dinghy so as not to jolt the tired- looking patient too much. We also brought back Norbert, a German psychologist, who could speak English (because Michael could only speak German). 1755 France I, whose three engines had been kept idling, set course for Brest. There was that very special atmosphere on board that we always have when assistance missions inter- rupt the daily routine. I know of no comradeship more spontaneous or more binding than that which unites seamen engaged in helping others. 5 September 0830 Michael had a very bad night. Without asking questions, everyone could guess as much from the drawn features both of our young medical officer and of the sick-bay attendant, 20 "We spotted the Outlaw, which took on the silhouette of a sailing ship of bygone years..." Facing page: The weather ship France I speeds to the rescue. ( Photos WHOI Meteorologie Nation- ale, France and WHOIWMO ) neither of whom had slept at all. The French port of Brest was still a long way away, more than 400 nautical miles Would Michael make it? What if our medical officer had to operate? The operation itself did not seem to worry the doctor, but the anaesthesia seemed risky since the ship's hospital was totally lacking in control equipment. 1242 Brest called us up to confirm the helicopter operation for tomorrow morning by which time France I would be within flying range. The theoretical rendezvous was fixed 130 nautical miles out from Brest. In order to avoid the helicopter wasting any time, a plane would first come to locate us and would then give the departure signal for the helicopter. 6 September 0500 At the prearranged time for the aircraft's take-off, France I put its radio-beacon into operation. This dear old obsolete radio-beacon had been of invaluable service in its time, when the frigates had served as beacons for transatlantic aircraft flights. Our chief radio officer was justly proud when, on pressing the red button, our call-sign C7R went out clearly over the waves. 0552 The bridge announced that a plane answering to the call-sign Whisky-Juliet was flying overhead. In the sick-bay they started to prepare Michael. 0630 We were informed of the helicopter's departure. France I, in no need of being woken up, was a hive of unusual activity. Only the cook was chagrined because Michael had turned down his specially-made vegetable soup. 0720 There it is! A Super-Frelon seen in action close by is really quite something, and when it hovers 20 metres above the bridge creates a tremendous draught. We saw the door of the helicopter open, and shortly after a diver swinging at the end of a thin steel wire which our sceptical boat- swain could not resist examining later on. The diver guided his descent by making signs to his winch operator. He was visibly amused by the flurry of extended hands trying to catch him in mid-swing. The helicopter swallowed up its cable again to unwind it a few moments later with a naval doctor on the end. The two doctors held a quick consultation on the state of the patient, who had been brought out at the last minute smothered in blankets. In order to gain time, we decided to do without the stretcher, and Michael left the France I in the arms of the diver. Those few seconds were full of intense emo- tion which cannot be described, only imagined. The diver came back down to us, still as unruffled as on his first trip. He methodically checked the harnessing of the other "packages" to be transferred; namely the helicopter's doctor and Norbert from the Outlaw. 0740 Our assistance in the emer- gency was completed. We immediately turned to head back in the direction of Station "Romeo" in order to resume our meteorological mission. Epilogue Michael was admitted immediately to the Maritime Hospital at Brest and underwent an emergency operation for peritonitis. The following day we learnt that he was out of danger. That was the green light we were waiting for to drink to his health as well as to the successful voyage of the Outlaw, whose name I shall no doubt forget one day, but never the proverb "WHERE THERE'S A WILL THERE'S A WAY." ■ 21 xperts who work in the field of aging constantly underline the importance of strengthening the capacity of the family to prevent and cope with the problems of the elderly, and to provide them with economic, psycho-social, emotional or psychic security and other care support. This is true in both de- veloped and developing societies. Of course, all people in the Third World, despite modern ideological and technological influences, still have a special significance for other family members. Particularly in the rural areas, we can observe their crucial and central role as a unit of society, a basic economic unit, a source of physical and social secur- ity, a starting point for lineage and kinship relations as well as a durable basis for order and discipline in a community. Although it remains true that there is "no retiring age" for elderly people, the drift to cities and urban centres is fast altering the "extended family" way of living. Many elderly are being left in villages to fend for themselves at a time when they most need care. Emphasis on the nuclear family and the ever increasing burden of providing accommoda- tion, food, clothing, education and health care for children pose a problem, not only for the parents of the self-isolating family, but also for the aging women. This is at a time when their waning strength and ability to earn make it difficult for them to obtain basic necessities of life, and deprive them of the help and company of those who under the traditional extended family system—would have seen to all their needs. The plight of aging women in the urban centres may even be worse. So if both aging men and women need certain services in common, women have some unique needs as a result of being more dependent and more lonely. There is "no retiring age" for elderly people. An ancient farmer tills his land in Uganda. (Photo WHO/J. Mohr) Family support for the elderly In much of the Thirc Worlc ,thee rift to cities anc ur oan centres is fast altering the - extencec family - way of living. In a personal expression of his viewpoints, the author suggests that family support for the elderly offers the oest possiole opportunity for fulfilling the slogan of World Health Day 1982 "Acd Life to Years. - If the cuality of life is not to remain static or even to recline for the world's olc people, they must continue to be assured of help, encouragement anc positive action by family incivicuals anc by the family unit as a whole by G. M. Ssenkoloto

Traditionally in most African countries, and indeed in most of the Third World, every family looked after its old women. A woman who had no children to care for her was looked after by neighbours or by the village as a whole. The aged in Ghana, for instance, formed an integral part of the family unit, holding definite and high ranking positions; they were men or women of wisdom whose opinion and advice seriously mattered and whose consent and blessing on ventures by younger people were eagerly sought. They were all- knowing experts on social pro- blems, folklore and tradition, sitting in family councils to settle disputes and officiating at marriage, birth and death ceremonies. Today, there are limitations and constraints due to changing pat- terns of living. But all hope is not lost. Families in developing coun- tries have always differed because of variations in environment, culture, social change, and the general level of development. It is within this diversity that family support for the elderly can be reinforced to the advantage of the aging population. And while negative attitudes to- wards family support for the elderly may be identified, the family is still the key unit through which such attitudes can be rectified, primarily by educating younger people about the elderly. Even where outside institutions or agencies have proved useful in caring for the aging in certain aspects, they are only bridg- ing the gap created by the diminishing role of the family. Areas of concern If we enumerate such main areas of concern to the aging individual as health, housing, social welfare, in- come security, education, transport, recreation and employment, on close examination these too prove to hinge on the family, and it is through family support that they need to be tackled. Family support for the elderly Left The elders of the family can continue to be productive for many years, like this old man making a bamboo mat in ay. Ivory Coast. Creating new roles for the aging helps them to continue to be accepted as useful members of the family. Right But for many old people, this is a time when their waning strength and ability to earn make it difficult for them to obtain the basic necessities of life. A family in Upper Volta submits in resignation to the rigours of a drought. ( Photos WHO/National In- stitute of Public Health, Ivory Coast, and WHO/FAO) The various concepts of the family that exist in the Third World have been labelled as the nuclear family, extended family, corporate family, joint family or experimental families. All these are forms of a household, defined as a domestic group sharing common residence and housekeeping, regularly cook- ing, eating or drinking together. However, all households are not families. In Africa in particular, the concept of family has to be extended to other kinship groups, such as a compound or house defined as a group comprising all persons who bear a common ancestral name, or who share a common ancestral origin. Cultural groups like clans and tribes can also play a part in supporting the elderly. What type of family support should be provided and who should provide it? In most cases, family support is required to satisfy sur- vival needs of food, shelter, clothing and affection all of which em- brace physical, social and emotional 24 security. Other necessary forms of support must ensure continued health, sources of income (including employment and facilities for self- employment), transport, recrea- tional facilities and the general psychological well-being of the aging. While it is easy to say that support must be provided by the family members, this is not specific enough. We need to stress the idea of the corporate family which is organized around a number of important activities, such as per- forming important rituals, rearing its children and "supporting" its aging. In this context, therefore, each member of the family has to play a particular role in supporting the elderly materially and non- materially, though in varying de- grees and employing various means. Jointly, members of a family can and should provide psychological security, physical security and cul- tural satisfaction. These are tremen- dously treasured among the aging population in the Third World. Those who are better able to offer economic support to the aging should be willing to transfer some of their wealth, income or resources to the elderly or, better still, to invest it for the benefit of the aging. Age-old values are changing. Adverse economic forces, the mis- allocation of resources, the yearning for material things, the struggle for self-esteem and status all these factors are overtaking the tradition- al positive values as regards support for the elderly. How can this trend be checked? Particularly in the Third World, the extended family with all its ramif- ications should be upheld, valued, respected, preserved in terms of its positive aspects; and it should be provided with the means and back- ing it needs to take care of its old people. Through a process of learn- ing, both informally and formally, the younger population need to acquire knowledge, skills, accept- able beliefs, values, customs or practices that emphasise how valu- able and admirable it is to support the aging. Provided each family member plays his or her role effectively, untapped resources of the family and kin network can be identified and put to use for the benefit of aging members of the family. New roles should be created for the aging within the family so that they continue to be accepted as useful members of the unit. It may even be possible to create and encourage a demand for the labour of old people within the family circle. Since human aging is a result of the complex interplay of physiologi- cal, psychological and social fac- tors, these can be best learnt, analysed and assessed within the family system, provided the appro- priate knowledge, skill and time are available. If only we can lend realistic, valued and timely support for all various aspects of the life of the aging, "more life will be added to years". ■ 25

The biology of aging What is important is that, in extreme old age, people should not lose interest in the joys of life. It is equally vital that they should still do intellectual and physical work within their capacity, and that society should continue to benefit from their experience. by Dmitri Chebotarev n any country today, the aging of the population greatly influences the structure and functions of the family, the economy, the goals and organization of the public health system, education and the social services. The progress that has been achieved by biology and medicine, as well as the study of social gerontology, can play an important part in solving the problems of the elderly. In turn, the advances made in geriatrics, the science that deals with the diseases of the old, are linked with the achievements made in studies of the physiology and mechanisms of aging, and their relationship with environmental factors. Were it not for the diseases that accompany old age, we may be sure that mankind would, on average, live 30 years longer and would have a life-span of 100 to 110 years. Since the frequency of many diseases increases with age, many scientists speak of cancer, athero- sclerosis and diabetes as pathologi- Well past 100 years of age, Shirali Muslimov is still firmly in the saddle in the hills of his native Azerbaijan. ( Photo L. Sirman C)) cal conditions typical of old age. We do not think so, and we do not regard aging as a disease in itself. It is a physiological process which causes greater instability, more sen- sitivity and more susceptibility to pathological processes. At the same time, certain compensatory mech- anisms start working in elderly people. Without a profound knowledge of the process of aging and of the diseases suffered by elderly people, the modern physician often makes mistakes in both diagnosis and treatment of patients, and of course is inhibited from taking radical prophylactic measures. The biology of aging not only allows us to comprehend how and why the main human diseases develop, but also sets us on the road towards the prolongation of human life. Studies made by the genetics laboratory at the Institute of Gerontology of the USSR Ac- ademy of Medical Sciences suggest that people grow old as two dif- ferent population groups—one with a tendency towards a long life and the other towards a short one. The establishment of a biological rather than a calendar age will make it possible in the future to determine to which of the two groups a person belongs, and to choose the necess- ary preventive measures and meth- ods of treatment. In all the developed countries, women tend to live from four to ten years longer than men. Obviously this is not due solely to social factors, but is a purely biological phenomenon as well. Our investiga- tions found striking differences in the date of change of lipoid meta- bolism due to age around the years 45 to 55; men seem to be ten years ahead of women in this respect. The leading mechanisms of aging seem in many respects to depend on neurohumoral changes which deter- mine mental changes, changes in behaviour and human working capacity, and deviations in the control of many organs. Experi- ments have proved that changes due to age in the mechanism regulating the nervous system regulation can weaken the nervous control of tissues, change their sensibility to hormones and in the end cause secondary disorders of tissue meta- bolism and function. A key role in the process of aging is played by changes in the hypothalamus, par- ticularly during the male and female climacteric period (menopause). Disorders of the neuro-hormonal control system, and a pathological climacteric period as a consequence, seem to be a prologue to the rapid 27 development of atherosclerosis, ischemia and hypertension. Our studies of 5,000 family trees prove that heredity considerably influences longevity. The frequency of family longevity in the group of people aged between 80 and 84 years is 52 per cent, while in the group of people aged 105 and over it increases to 71 per cent. Those who enjoy long lives and their relatives show a certain bio-electric activity of the brain which distin- guishes them from the rest of the population. They have a higher frequency spectrum of the electro- encephalographic rhythm, while the rate of change due to age in terms of the bio-electric activity of the brain is slower. This is yet another con- firmation of the existence of a biologically "optimum" type of human. On the other hand, many social and biological factors are at work as well as heredity. The possibility of choosing con- ditions for slowing down the rate of aging, and of preventing diseases in old people, justifies our studies in this field and our efforts to draw up recommendations for an optimum life regimen. It also offers good prospects for experimental work on prolonging life by removing those external factors which tend to shorten it, and eventually for the artificial control of the biology of aging. Our experiments have succeeded in increasing the longevity of ani- mals by 25 to 50 per cent, by means of certain physical, chemical and biological factors which prolong the active period of life when the animals produce offspring. It is quite feasible to apply some of these factors to humans, thus opening the possibility of postponing the development of pathological con- ditions to a later period of life. We have also created a number of The biology of aging Left The advancing years do not mean that people's pleasure in the simple things of life declines. Scientists at the Soviet Institute of Gerontology do not regard aging as a disease in itself, but as a physiological process which causes greater instability, more sensitivity and more susceptibil- ity to pathological processes. Right Centenarian Khadicha Bakh- turazovaie can claim an "exten- ded family" of more than 200 children, grandchildren, great- grandchildren and even great- great-grandchildren. ( Photos L. Sirman C)) preparations which slow down the rate of aging. Research is still going on in this field, and the search continues for means to prolong the active period of life. Forecasts of a new longevity for the people of the future have been popular for several decades, many of them being quite unrealistic. In our view, the next stage in geronto- logy will involve a synthetic approach to the cognition of the mechanisms and biology of aging. Geriatrics The task of geriatrics is to study the peculiarities of development, diagnosis, treatment and preven- tion of diseases in old people, to find ways of normalising the physiologi- cal processes in the aging organism, and to learn how to prevent prema- ture aging. Any medical specialist is obliged to develop a special approach to the 28 treatment of patients belonging to older age groups. As a rule a patient over 60 undergoing the usual medi- cal examination at a polyclinic in the Soviet Union is given not less than three diagnoses. Pathology in old people can be compared to an iceberg, more than six-sevenths of which are hidden under the water. This requires a physician to know not only the peculiarities of the course of internal diseases connec- ted with age, but also the symptoms of some diseases of the nervous system, of the motor apparatus, and so forth. Medicinal intoxication develops more easily in an aging organism, and this must be always borne in mind by the doctor. In addition, the restoration processes following a disease develop more slowly. Social Gerontology The advances made by geronto- logy can only be successfully put into practice in a society which regards people of the older age groups (75 years and more) as their "creditors", that is, people whose efforts have ensured economic, so- cial and cultural progress and are therefore worthy of the all-round care taken of them by society. In the space of a little over 60 years, the life-span in the Soviet Union has increased from 32 to 70 years, and the proportion of old people in the total population is increasing. Thus in 1939 people aged 60 and over formed 6.7 per cent, in 1975 they formed 13.2 per cent, while by 2000 the figure will have reached between 17 and 18 per cent. These circumstances help to ex- plain the rapid development of gerontology. The first Institute of Gerontology of the USSR Ac- ademy of Medical Sciences was founded in Kiev in the 1950s. There are now dozens of such institutions. Among the problems they are looking into is the improvement of people's social adaptation to the pensionable age. What is very important is that, in extreme old age, people should not lose interest in the joys of life. It is equally vital that they should continue to engage in intellectual and physical work within their capacity, and that society should continue to benefit from their experience. A wide ranging comparative epi- demiological investigation of the position of old people and their need for medical and social aid is at present being conducted in a num- ber of European countries, under the guidance of WHO's European Regional Office. The planning of similar investigations in the developing countries too will undoubtedly prove of value to those countries in the years to come. ■ 29 Beer Production Up World-wide by 124% But Rates Higher for 3rd World Nations 000 000 0.0 000 000 000 0410 000 000 000 0410000 000 000 000000 000 000 0 00 0000 0 0 0410 41 00 0 00 10011. 0100 000 000 *00 000 000 000 000 000 000 000000 000 0,0 000 000 00 0000 000 000 000 4100 000 000 00• 00• ••• • 0 0000 000 0 00 000 000 000 000 000 000 00• 000 0•0 Over the past 20 years, people have been taking more and more to drink. In some cases, moderately, and in other cases excessively, they imbibe spirits and wine. But mostly they down beer. The consumption of alcoholic beverages has risen largely be- cause the supply—of both home and imported brews—has in- creased. In the developing world in particular, beer production has soared. According to a report presen- ted to WHO's World Health Assembly meeting in Geneva this month: "Well-stocked supermar- kets are springing up all over the developing world," often selling alcoholic beverages at lower prices than elsewhere. In some places, the report says, "alcoholic beverages are being sold through automatic vending machines." Almost everywhere alcohol is promoted energetic- ally. Photo WHO/Paul Almasy In Africa, beer production in- creased by 400 per cent. Rather than the other way around, therefore, it has been largely a case of supply creating demand, and with it a host of alcohol-related problems. Foremost among them are the health problems of the drinker—alcoholism, liver cir- rhosis, cancer of the mouth and throat—leading in turn to heavy burdens in health services. To take but one example: in virtually all countries for which statistics are available, cirrhosis, which is often used as an index of the extent of alcohol damage, now ranks among the five leading causes of death among males aged 26 to 64. There are, as well, severe social and economic problems, such as family breakdown, crime, traffic accidents and absenteeism. The production of beer com- mercially shot up by leaps and bounds over the two decades; the report says, increasing by 124 per cent world-wide. High as that is, the rise registered in the Third World has been still higher. Production jumped by some 500 per cent in Asia, by 400 per cent in Africa, and by 200 per cent in Latin America. For the years 1975 to 1980 alone, production rose by 100 per cent in 17 countries, all but one of them developing countries, and by 50 per cent in 46 others, 43 of them developing. "Some of this increase resulted from the establishment of sub- sidiary companies, joint ventures, and licensing agreements with foreign corporations," the report says, adding that "the rate of beer production—and in some cases, wine production—has far out- stripped population growth over the last 20 years." All these factors present governments with a dilemma. On the one hand, alcoholism and alcohol-related problems take a heavy toll on health. "The human costs are incalculable," the report says. On the other hand, the production and sales of alcoholic beverages create jobs. Above all, taxes on drink are a source of revenue. "Economically," the re- port states, "alcohol is an important commodity." As a result, "only a few coun- tries have attempted to face this situation squarely." The report asks governments to do so—by drawing up national policies and programmes that put health ahead of economic interests. For Zambia's Rural Communities, the Play's the Thing Zambian health officials had long felt the need to take the message of primary health care in different ways to rural com- munities, since the majority of the population in those areas are illiterate or semi-literate. They did so with the help of a group of performers who were, coincidentally, seeking to drama- tize themes relevant to the daily lives of citizens, particularly those in the countryside. The two groups joined forces and created the Theatre for Development in Zambia. According to Bwino, a publica- tion of the Ministry of Health, a typical theatre workshop runs along these lines: Photo WHO/Bwino Through theatre in the village, dramatizing health problems. Workshop participants, both health workers and performers, go into market-places and homes to determine what problems vil- lagers face. These become the subjects of the next production. In one case, though villagers knew it was wrong, they dumped garbage out in the open. Why? Simply because everybody does it, participants were told. These real-life situations are dramatized through mime, dance-drama, puppet shows or plays. After about a week of rehears- als, the show is put on, usually in the village square, and invariably to enthusiastic audiences who see in the unfolding drama a reflection of their own lives. They may even identify characters por- trayed with persons they know. A group discussion follows, centring on the solution to the problems offered at the end of the performance. The aim of this type of popular theatre is to raise the consciousness of communities in the part individuals must play in improving their own health. "You should have come a long time ago," one villager said to the departing troupe, who left behind them a community motivated to help themselves. Success Against Schistosomiasis In the Sudan Systematic use of chemicals to destroy snails has prevented the spread of schistosomiasis two years after the species Bulinus truncatus and Biophalaria pfeif- feri were found in irrigation canals of Rahad, one of three areas that form part of an am- bitious agricultural scheme along Sudan's Blue Nile. "The Sudan has the potential to become the food basket of the world," says the country's Health Minister, Sayed Khalid Hassan Abbas. However, the risk of schistosomiasis, a debilitating parasitic disease, increases as more land is put under irrigation. Snails are the disease's inter- mediate host, which, if allowed to breed, can turn a development project into a health disaster. According to the first annual report of the Blue Nile Health Project, an examination of stool and urine samples, carried out in 1980 and taken from 628 persons in eight Rahad villages, showed 11 per cent infected with the S. mansoni, and about 1 per cent with the S. haematobia forms of the disease. The propagation was checked by the end of 1981 through use of the molluscicide, Bayluscide- 437 litres to treat 313,200 cubic metres of excanal—and Hudson Xpert sprayers. In addition, those infected with the disease were given a new drug, Praziquantal. The project covers not only Rahad but Gezira and Managil as well, an area 2.1 million acres in size. Together they form one of the largest farming areas in the world, with a population of two million. Plans developed by the Suda- nese authorities and WHO call for a concerted attack on health problems whose origins lie in the complex irrigation system— mainly schistosomiasis, but malaria and diarrhoeal diseases as well. Begun in 1979, the project is scheduled to run until 1990 on an estimated budget of $155 million, with 60 per cent of costs being met by Sudan and the rest stemming from sources outside the country. Countries Urged to Set Up Programme Against Snakebite The extent of snakebite, one of the oldest known forms of pois- oning, has yet to be fully determined, but even the little that is known causes concern, particularly among public health authorities in Asia. And for good reason too, since in that region virtually every type of poisonous snake is found, including spitting cobras able to blow venom in the face of a victim from three to four metres away, 30 WORLD HEALTH 1982 Subscription Rates US$ Sw fr . One year 15.— 25 . Two years 27.— 45 . Three years 36.— 60 . ORDER FORM Please enter my subscription to "World Health" as follows: One year Two years Three years I enclose cheque/international postal order in the amount of • Name • Street • City • Country • World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies, please contact your usual bookseller. CI CI and the Gaboon viper whose bite kills instantly. Some 10,000 deaths from snakebite are reported from Asian countries each year, according to figures presented during a semi- nar on epidemiology and medical treatment of snakebite sponsored by the Japan Snake Institute and by WHO. As that figure is based, almost without exception, on hospital statistics, then it is safe to assume that true mortality is several times higher. Burma is among the countries with the highest mortality from snakebite in the world. Of the 10,000 cases reported each year, an estimated 10 per cent are fatal. During rains or floods, when snakes seek the high ground, the danger is greatest. In India, an estimated 200,000 people each year are bitten—most often be- tween 6 p.m. and midnight—by snakes. Most victims of snakebite are farmers, but sea-snake bites are also a problem among fisher- men, particularly in Malaysia and Thailand. These and other facts led a group of experts convened by WHO's South-East Asia regional office to call upon countries to set up national programmes against snakebites. Not only are reporting systems needed, experts said during their three-day meeting, but so too are studies of the clinical manifestations of bites. The experts also urged coun- tries to take steps to resolve the problem of insufficient and ir- regular supplies of anti-venoms. And they recommended pro- grammes to train both the primary health care worker and the physi- cian in first aid. Their advice: "Reassure the frightened patient, wash or wipe the bite site to remove residual venom, im- mobilize the bitten limb with a splint or sling, transport the pa- tient quickly and comfortably to the nearest medical centre. A blanket hammock slung under a pole is a convenient method which causes the patient a mini- mum amount of movement. Tourniquet, incision and suction may be harmful." In the next issue A gulf yawns between the industrialised countries and the countries still in process of development. But the United Nations recognises another category in the developing world — that of the 31 Least Developed Countries. The June issue of World Health looks at these states which, on the world scene, constitute the poorest of the poor. Newsbriefs Aging. Just five years ago, Austria, the two German Republics, Sweden, and the United Kingdom were the only five nations in the world with as much as 20 per cent of their populations aged over 60. There will be almost 40 in that category by the year 2025. Although the majority will be countries of today's developed world, according to a report presented to a U. N. advisory committee meeting in February, the others will include Barbados, Cuba, Trinidad and Tobago, Hong Kong and Singapore. By that time too, there will be just four countries—Botswana, Kenya, Niger and Rwanda—with less than five per cent of their populations aged over 60, as compared to some 50 in 1975. To raise consciousness of this demographic shift, and to meet the economic and social challenges presented by it, the United Nations has scheduled a World Assembly on Aging from 26 July to 6 August in Vienna, and WHO has selected "Add Life to Years" as its World Health Day theme for 1982. Bhutan Joins. Upon acceptance of WHO's constitution, on 8 March, Bhutan, a kingdom in the eastern Himalayas, became WHO's 158th member nation, and the 11th in its South-East Asian region. Gulf Fund. AGFUND, the acronym for the Arab Gulf Pro- gramme for U.N. Development Organizations, will finance programmes for countries designated by the United Nations as "least developed" under a US$2.5 million agreement recently signed with WHO. The fund was established by seven States: Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates. Its president is Prince Talal, brother of King Khalid bin Abdul Aziz of Saudi Arabia. Off the Press. By whichever of its three titles the album is referred to—"Eaux rares," or "Precious waters," or "Aguas preciadas"—its message is clear: more than half of the population of the world lacks pure water. Published as part of UNESCO's programme on the U.N. Water Decade, the book is economical in words, but lavish in photography—sensitive black-and-white studies by Dominique Roger, who is chief of the agency's photo service. The book may be ordered from UNESCO in Paris. Price, 45 French francs. The study "Aging 2000: A Challenge for Society" comes right in time for the U.N. Assembly on Aging, which opens in Vienna in less than two months. Published by the Sandoz Institute, Geneva, it reports the findings of a survey carried out with the United Nations in that city on aging in 16 countries. Ten are industrialised nations: Australia, France, the Federal Republic of Germany, Israel, Italy, Japan, Poland, Sweden, the United Kingdom, and the United States. Six are developing: Brazil, Egypt, India, Kenya, Nigeria, and the Philippines. The survey is based on a response to a range of questions put to three experts in each country—on national health and social programmes, politics, the economy and other factors. Since the findings could be of value to governments in developing policies and planning pro- grammes for the aging, the book's authors, Philip Selby and Mel Schechter, say copies will be distributed to delegates in Vienna. People. Appointed as Assistant Director-General of WHO, one of five such posts, Dr Lu Rushan (China). Formerly Vice-President of the Branch Academy of the Chinese Academy of Medical Sciences, Dr Lu is now responsible for WHO's divisions of diagnostic, therapeutic and rehabilitative technology, of mental health, and of non-communicable diseases. Appointed as Director of WHO's Malaria Action Programme, Dr Jose A. Najera Morrondo (Spain) a staff member since 1961. U.N. General Assembly Endorses. The U.N. General Assembly has endorsed WHO's global strategy for health, with its underpinnings of primary health care, and its aim of providing services particularly to those in rural areas. It is seen as a "major contribution of Member States to the attainment of the world-wide social goal of Health for All by the Year 2000," according to a resolution adopted at the 36th session last October. Among the milestones towards that goal: ensuring enough of the right kind of food for all by 1985; providing essential drugs by 1986; providing an adequate supply of safe drinking water and basic sanitation by 1990; and immunizing children against six common diseases also by 1990. Authors of the Month Mr Peter E. HALL is a Scientist with who's Special Programme of Research, Development and Research Training in Human Reproduction, and Dr Susan E. HOLCK is a Medical Officer with the same Programme. Mr Peter W. JOLLY is a Sanita- rian Tutor with WHO's Environ- mental Sanitation team working in Turkey. Mr D. Paul SONDEL is United Nations Adviser to the Traffic and Licensing Directorate of the State of Bahrain. Dr Joseph Fux is a surgeon with special interest in childhood accidents, and works in Tel Aviv, Israel. Mrs Asha SINGH WILLIAMS is Technical Officer with the Mat- ernal and Child Health unit at who headquarters in Geneva. Dr H.J. H. HIDDLESTONE iS the Director-General of Health for New Zealand, and the current Chairman of wilo's Executive Board. Dr G.M. SSENKOLOTO iS a spe- cialist with the Regional Pan African Institute for Develop- ment, based in Buea, United Republic of Cameroon. Academician Dmitri CI-IEBOTA- REV is Director of the Institute of Gerontology, Soviet Academy of Medical Science, and a for- mer member of the WHO Expert Advisory Panel on Organiza- tion of Medical Care. 31 New look for nealth services in New Zealand: see page 16. ( Ph Ito L. Sirman (0) Im pr im er ie s Re un te s S. A. L au