Healthy mouths; Smallpox; Radiation; Water; Blindness; Guinea worm; UNRWA; Accidents [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • NOVEMBER 1984 Cover : Open-air lesson in good care of the teeth, photographed in the Swiss Alps by Monique Jacot. ,Jo, 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, German, Portuguese, Rus- sian and Spanish, and four times a year in Arabic and Farsi. 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 Smallpox: a happy ending by John Wickett 3 Water that goes to waste by Martin Abraham 6 Safe water for every family by Julio C. Duran 8 Radiation watchdog by Russ Manning 10 From darkness to light by Jitendra Tuli 13 Healthy mouths for all by the year 2000 16 Rinse Wednesdays by Peter Ozorio 18 The right people for the right jobs by Viatcheslav Alexeev and Igor Rozov . 21 Guinea worm and the Decade by Donald R. Hopkins 22 Saving young lives By Stephen Badzik 24 A scourge of modern times by C. J. Romer 27 No vaccine against road deaths by Akin Adebayo 29 News Page 30 Smallpox: a happy ending by John Wickett Avast international campaign spearheaded by WHO between 1967 and 1979 rid the world of smallpox. The disease was eradicated; it won't come back. The fact was certi- fied by the best scientific experts in the world in 1979. Smallpox vaccination no longer appears in the International Health Regulations nor in the Inter- national Certificates of Vaccination. Nevertheless WHO still receives ru- mours of suspected cases of smallpox. Every single one proves to be false. Smallpox struck a . small village in Bangladesh in 1974. The village chokidar or watchman knew what to do. He reported the cases to the health centre and set about isolating the cases in their homes and vaccinating the village. Everyone entering or leaving the village was vaccinated. When the smallpox team arrived they were im- pressed by his conscientious work. The outbreak was quickly contained and very few deaths occurred. There was only one thing the chokidar for- got—to vaccinate himself. He got smallpox and died. There is no moral to this story. The international consultant had tears in his eyes as he recounted it. I guess we both worked even harder afterwards. The following year the last case of smallpox in Asia, the virulent form which killed one in four of its victims, occurred in Bangladesh in October. It was a two-year old girl and she sur- vived. The world's last endemic case was in Africa in October 1977 ; this was in Somalia where the disease had a milder form. The programme to globally eradicate smallpox was hailed as a public health miracle. For the first time in the history of man a major killer disease had been eliminated. The dreams of a great many inspired people had been realised. The eradication of smallpox is now a part of medical history ... almost. You do not forget such a disease in just a few years. Large numbers of people still wear the disfiguring scars of small- pox. It was a disease which terrified people for thousands of years and decimated entire populations. Vast sums taken from scarce health resources had been spent on smallpox vaccination. The cost of producing and A sight the world will never see again—a young woman dying from smallpox. Facing page : wHo keeps a global reserve of smallpox vaccine, sufficient for 300 million persons. Photos WHO/Herrlich and WHO/M. Vanappelghem administering the vaccine, the mainte- nance of quarantine measures, and the treatment of complications (albeit rare) from vaccination came to an estimated US$ 1,000 million a year worldwide. The elimination of small- pox vaccination and smallpox vaccina- tion certificate requirements for inter- national travellers was obviously de- sirable. And what a return on invest- ment ! The eradication effort under- taken by who together with the amounts spent by Member States was estimated to total only US$ 300 mil- lion between 1967 and 1977. Plenty remained to be done after 1977. It was one thing to eliminate the disease, but quite another to convince the world that it had gone for ever. In order to free the world from smallpox vaccination regulations, national au- thorities had to be absolutely sure it was gone and could not come back. So WHO initiated procedures for the cer- tification of smallpox eradication by international experts from all over the world, independently even of WHO itself. The first international commis- sion certified eradication in South America as early as 1973. Subsequent commissions reported each time that large, previously endemic geographic areas became smallpox-free. These in- dependent experts examined detailed reports and records and visited areas of their choice in a given country. Their role was to make 100 per cent certain that no smallpox case had occurred during the previous two years, and that the existing surveil- lance system would have detected a case had it occurred. At the end of 1977, a Global Com- mission for the Certification of Small- pox Eradication was formed. This panel of experts reviewed the results of previous Commissions and set up a stringent programme for global certifi- cation which would be so convincing that no one would hesitate to cease vaccination. At the end of 1979, two years after the last case in Somalia, the Global Commission submitted their final re- port. Since 1973, 77 experts from 49 countries had participated in 22 inter- national commissions, 79 countries had undergone special review either WORLD HEALTH, November 1984. 3 In 1979, members of the Global Commis- sion rode for hours on muleback in Ethiopia to verify that eradication of smallpox was indeed total. Photo WHO through commissions, expert visits or special reports, while the remaining countries in the world had submitted declarations of their smallpox-free status. The Global Commission was con- vinced ; but in their recommendations they also provided for continuing as- surance for the world community. They said the number of laboratories retaining variola (smallpox) virus for scientific study should be severely re- duced to limit the risk of any possible escape ; WHO should establish a global vaccine reserve ; WHO should continue to investigate rumours of suspect smallpox cases which would inevit- ably continue to be reported ; human monkeypox, an exceedingly rare dis- ease which clinically looks like small- pox but is caused by a different virus, should continue to be investigated ; and, of course, smallpox vaccination and vaccination certificates should be done away with. Solemn declaration In May 1980, the World Health Assembly adopted the Global Com- mission's report to WHO's Director- General and endorsed its recommen- dations. The Assembly resolution " de- clares solemnly that the world and all its peoples have won freedom from smallpox, which was a most devastat- ing disease sweeping in epidemic form through many countries since earliest times, leaving death, blindness and disfigurement in its wake and which only a decade ago was rampant in Africa, Asia and South America." It was an intensely satisfying moment. At that time only 64 countries had stopped routine vaccination. On the other hand, only 12 countries still demanded vaccination certificates from all travellers. There were still six laboratories retaining stocks of variola virus, and WHO vaccine reserves stood at only 44 million doses. As predicted by the Global Commission, rumours of smallpox cases continued. At present, all but one of WHO's 165 Member States and Associate Members have officially discontinued routine smallpox vaccination. Only in Albania is vaccination being con- tinued. No country in the world re- quires smallpox vaccination certifi- cates from international travellers. In May 1981 the World Health Assem- bly formally struck smallpox from the International Health Regulations. As of 1983, smallpox vaccination does not exist in the new edition of the International Certificates of Vac- cination. WORLD HEALTH, November 1984 4 Information for physicians Vaccinations may be performed by a nurse or medical technician if under a physician's direct supervision. The dates on each certificate are to be recorded in the following sequence: day, month, year—the month in letters. Example: January 1, 1981 is written 1 January 1981. If vaccination is contraindicated on medical grounds, the physi- cian should provide the traveller with a written opinion which health authorities should take into account. Vaccination certificate requirements of countries are published by WHO in Vaccination Certificate Requirements for International Travel and Health Advice to Travellers. The list of designated yellow fever vaccinating centres is published by WHO in Yellow Fever Vaccinating Centres for International Travel. This information is usually also available from local health offices. Please be sure to always consider that your patient may have a travel-associated illness. c■V Renseignements destiv 2;•• Les vaccinations peuvent etre :' 2 d'autres membres du personnel pa .c.',, c. le contrelle direct d'un medecir b 2< 4/4k 4,, * o La date doit etre portee T *44, c4,,, OF I, 444 jour, mois, armee — le mois 2 44k., c, Rzi,, 4 c CA, CO3:14,4 4 40,pri°,1;44, .1)744-* 004. atteint janvier 1981. ce'sr Si le vaccinateur esti/ pour raison medicale, iP indiquant son opinion, tenir compte. Les exigences de' l'OMS dans la bra Voyages internat' (;.. 447, Voyageurs. La l? • ,Z.v 44, contre la fievre de Vaccination naux. En ge, renseignements. 4.1/41„,„. /fool .1 es tio- ces Tenez toujours comp.. d'une maladie lice a un voy., WHO declared on 8 May 1980 that smallpox had been eradicated. Smallpox vaccination is there- fore no longer justified. It may even be danger- ous. L'eradication de la variole a ete proclamee par l'OMS le 8 mai 1980. La vaccination antivarioli- que n'est donc plus indiquee. Elle peut meme etre dangereuse. Can smallpox ever come back? The virus which causes smallpox can only live in man. Once people are infected, either they die and the virus dies with them, or the immune system of the body kills the virus and the victim survives, or one infected person infects another. Smallpox vaccination with vaccinia vir- us (which is not the same as variola virus which causes smallpox) protects against infection. Thus, if an infected person is surrounded by vaccinated people, the vir- us has nowhere to go and dies out. In isolated populations, the virus runs out of victims and dies out. In larger populations the virus dies out when it is isolated by being surrounded by vaccinated persons or by survivors who have had the disease and have become immune. There are no subclinical cases of small- pox—you either have it or you don't. It must be passed on from one person to another at least every three weeks or it dies out. That would mean an absolute minimum of almost 20 cases per year, and smallpox just doesn't go unnoticed. So when competent worldwide surveil- lance systems cannot detect anyone with smallpox, we can be sure it doesn't exist. And if it doesn't exist, it cannot come back. Only two maximum security labora- tories in the world now retain variola virus for scientific purposes. Reserve stocks of vaccine held in Geneva are sufficient to vaccinate more than 300 million people. Reports of suspected cases of smallpox continue to be re- ceived at the rate of about 20 per year. Each one has been thoroughly investi- gated. Each one has been proved false and turned out to be chickenpox, measles, some other rash or a record- ing error. The other day a woman telephoned me from France. She was going to join her husband in one of the countries of West Africa and he had told her to get their young son vaccinated against smallpox. She was a little concerned as she thought that smallpox had been eradicated. "Yes, Madame, that is ab- solutely correct " I replied. " Small- pox vaccination no longer even ap- pears on the International Certificates of Vaccination." She was still uncertain since her husband had insisted, and she still had an old edition of the certificate. Yet she wanted to avoid unnecessary discom- fort for her child. She decided to check with the West African country's embas- sy in Paris. We agreed she should do so ; if there should be any problem what- soever, she would phone back and WHO would take up the matter. She didn't phone back. It gives me a good feeling to compare this story with the first one in this article. wHo can reassure the world with 100 per cent confidence of the success of the elimination of smallpox. It is quite an adventure story, and there were some pretty dramatic moments. Preparations are well under way for a definitive work, " Smallpox and its Eradication ", to be published by WHO in 1986. It may never reach the best- seller list but parts of it read like a novel. And in the best classic tradition it has a happy ending ! ■ WORLD HEALTH, November 1984 5 Water that goes to waste With a humid tropical climate and high mountains in the interior, Malaysia has a great many large rivers, streams, gullies, creeks and lakes. But over 85 per cent of the water runs off into the sea, leaving all too little for the thirsty inhabitants to drink by Martin Abraham W ater is an indispensable commodity which should be easily accessible, ad- equate in quantity, free from contami- nation, safe, inexpensive and readily available throughout the year. How- ever, only about 60 per cent of the people in Peninsular Malaysia are sup- plied with piped drinking water, and 90 per cent of this fortunate group live in urban areas. Among the rural popu- lation, it is disheartening to note that less than 50 per cent have access to potable water. Prolonged droughts in recent years have further complicated the situation, leading to outbreaks of water-borne disease, decreased agri- cultural production, frustration and a deteriorating quality of life in general. Among the factors that contribute to the scarcity of potable water are poor management, misguided prior- ities, deforestation, land development, dwindling catchment areas and indus- trial pollution. With at least one region in the country experiencing water scarcity at any given time, Malaysians can ill afford to regard water problems as sporadic or isolated phenomena to be blamed solely on climatic aberrations. Judging from recent trends, such an- nual fluctuations in the climate as solar radiation and the severity and dates of the annual monsoons are secondary factors. And it is becoming increas- ingly apparent that Malaysia's bur- geoning water woes, especially the water crisis in rural areas, primarily stem from failure to undertake intel- ligent management of existing water resources. Malaysia's humid tropical climate, coupled with a mountainous interior, sustains a great many rivers, streams, gullies, creeks and lakes. But over 85 per cent of the copious surface water resources runs off into the coastal seas, besides being channelled for economic enterprises such as hydroelectric power generation, fisheries, agricul- ture, industries and pollution abate- ment. Eventually, only 10 to 15 per cent is actually available to meet the needs of the 12 million people residing in Peninsular Malaysia. As the population steadily in- creases, the concomitant demand for water for domestic, agricultural and industrial purposes would undoubted- ly exert severe additional stress on Malaysia's already stressed " finite " water resources. Consumption of water, which shot up by 424 million gallons per day between 1959 and 1980, is projected to escalate by another 133 million gallons per day in 1983. Experts speculate that, at cur- rent rates of consumption, the water situation in Malaysia would attain gravely critical proportions within a relatively short time-span of 10 to 20 years. Poor management, pollution and ineffective conservation measures would lead to a further reduction in the availability of clean, sustainable water. The increased momentum of de- forestation, for instance, has resulted in vast tracts of lush, virgin, tropical forests being indiscriminately cleared to pave the way for "progress and development. " Out of a total land area of 50,806 square miles, only 52 per cent is still covered with some sort of forest. At current rates of deforesta- tion, through land development and logging for timber, it is projected that Malaysia's forest reserves would be completely depleted within a couple of decades. The effects would be to erode agriculturally invaluable top soil, speed up desertification, destroy watershed areas, reduce the flow of water to catchment areas, silt up the rivers and provide a vicious combina- tion of extended droughts and flash floods. Crisis point The simple and tranquil day-to-day lives of many rural communities in Malaysia have, in recent times, been repeatedly disrupted by the acute scarcity of water suitable for drinking and meeting other basic needs. Sahabat Alam Malaysia (sAm) or Friends of the Earth, a non-profit- making non-governmental organiza- tion, is engaged in research, documen- tation and dissemination of informa- tion on human health and environ- mental issues, with a view to improv- ing the quality of life and evoking ecological consciousness among the masses. The plight of residents caught in the coils of water crises in rural areas of Peninsular Malaysia is lucidly portray- 6 WORLD HEALTH, November 1984 ed in three case studies, monitored by SAM since 1979. The first of these is Kuala Ketil, a village in Kedah, with a population of 3,000. Since 1976-1977, the village has witnessed an inade- quate and inconsistent water supply, a result of the vast distance separating Kuala Ketil from the reservoir in Kulim, 25 miles away, which resulted in extremely low water pressure. For most days, water supply was restricted to half an hour per day, enabling villagers to collect only 8 to 10 gallons of tap water for daily use compared with their estimated needs of about 30 gallons per day. Some villagers drew water from their own wells, while most residents, without their own wells, were largely depen- dent on the generosity of relatives or neighbours. To compound the prob- lem, the only public well in the village had silted up and wells in the more elevated areas of the village frequent- ly dried up during periods of drought. As a temporary relief measure, drinking water was conveyed by lor- ries ; but the villagers contend that the quantity of water supplied was inade- quate. Consequently, the entire vil- lage was forced to draw water from the nearby river, even though it was confirmed to be contaminated with cholera vibrio. Ironically, despite the fact that taps ran dry, the villagers were still served with water bills. When the villagers unanimously agreed to stop paying them, the au- thorities concerned threatened to cut off all water supplies and to impose heavy fines. Eventually, the villagers were promised that a new pipe would be connected to the much closer reservoir at Pinang Tunggal. In mid-1982, a pump was installed to bring water from the river, but the supply is far from being satisfactory and may be interrupted, without prior warning, for days at a time. What little water flows through the taps is of extremely poor quality, being turbid and yellowish. The villagers have re- sorted to storing water in large, rusty, tin containers, thereby accentuating the public health hazards arising from the lack of clean drinking water. Two neighbouring and identically named villages, Kuala Sanglang (Kedah) and Kuala Sanglang (Perlis), have been confronted by a water crisis for the past seven years. In 1980, over 250 households (80 per cent) had taps but no water, while the other 20 per cent had no taps at all. The 3,000 villagers received drinking water from lorries, twice a week. The river was the principal source of water for bath- ing and washing, and sometimes even for drinking. SAM was informed that the taps had run dry because of a broken connec- tion from the main water pipes. Vil- lagers expressed their disappointment that nothing was being done to rectify this pressing grievance. By mid-1982, only half of the in- habitants had access to potable water, and the water supply was still insuffi- cient for meeting day-to-day needs. As at Kuala Ketil, the Kuala Sanglang villagers were expected to settle monthly water bills despite the non- availability of tap water. Kuala Kedah (Kedah), a fishing hamlet, has also suffered since 1977 from serious irregularities in the sup- ply of potable water. Although no water flowed through the taps for two years, the 2,000 residents dutifully paid the minimum charge each month for fear that the water meters would be disconnected if they stopped pay- ing. The situation was so severe that the villagers stayed awake the whole night, often in shifts, to collect about four gallons of water from a point one Water-carrying may occupy a large part of the working day for many Malaysian housewives. Photo CIRIC mile away. Irrigation canal water was the primary source of water for bath- ing and washing, and people lived in constant fear of contracting cholera from the unclean water. Even though there was water in the taps by 1980, the supply was inade- quate and unfit for human consump- tion. On occasions the flow was com- pletely cut off without warning. The dismal feelings of the afflicted residents are summed up by one indi- vidual comment : "Pre-election prom- ises of settling our water woes have not been fulfilled. We, the unfortunate rural folks, do not even have adequate drinking water, while the urban dwel- lers can afford to wash, bathe, water their gardens and flush their toilets with clean water. " These few examples underline the pressing need for the authorities at all levels to re-evaluate their priorities, and to formulate and implement a National Water Policy. The objectives of the UN's International Drinking Water Supply and Sanitation Decade offer a basis for ensuring that an adequate supply of clean potable water reaches a significant proportion of the rural community in Malaysia by the year 1990. ■ WORLD HEALTH, November 1984 7 A small community in Paraguay took the initiative in starting a drinking water project some two years ago. Today every family has access to safe, clean, drinking water at the turn of a tap W hile millions of people need only turn a tap with their fingertip to get drinking water, many others have to spend considerable time and energy to ob- tain a little of this life-giving liquid, and the chances that it is not safe for drinking are very high. Almost half the world's population are deprived of the benefits of drink- ing water and adequate sanitation which they need to attain socially and economically productive lives. About 15 million children under five years of age die every year in developing coun- tries from diseases connected with a lack of drinking water. In Latin Ameri- ca and in the Caribbean, more than 200,000 persons suffer from water- related gastro-intestinal diseases. The International Drinking Water Supply and Sanitation Decade, be- tween 1981 and 1990, aims at ex- tending these services to as many people as possible. Attainment of this objective will constitute an important step towards the goal of " Health for All by the Year 2000," since clean water and good sanitation are key- stones in the global concept of pri- mary health care. In Latin America and the Caribbean, the objectives amount to the provi- sion of water and sanitation to some 338 million persons living in the towns and about 147 million living in the countryside. It will be an arduous task since it means bringing these services to twice or three times the population that enjoys them today. Achieving this goal will entail an enormous effort. It will require the participation of all the countries of WHO's Region of the Americas, who will have to allocate every resource at their disposal, undertake immediate planning and feasibility studies, and train the qualified staff needed to operate, administer and maintain exist- ing systems as well as new ones. Many projects have regional sup- port from such international institu- tions as the World Bank, the Inter- American Development Bank, WHO it- self, the Pan American Health Organ- ization (PAHo) and others, which have offered technical and financial cooper- ation to drinking water and sanitation supply activities in the countries of the Americas. What is essential is that projects of this type should be initiated in the countries themselves, whose govern- ments have to make a political com- mitment to identifying their needs, suggesting appropriate strategies and evaluating their own financial and hu- man resources. Only in this way can they find solutions to their own prob- lems through concrete programmes implemented for the benefit of their inhabitants. The drinking water supply problem is usually more acute in urban-fringe areas (variously called " pueblos jovenes", "villas miserias" or "favelas") which spring up outside the cities as people are attracted by uncertain hopes of better living condi- tions, and in rural areas where the populations are too small or too re- mote to be properly provided or planned for. Driven by their own needs, and despite the obstacles and disadvan- tages which they face, many such communities have participated ac- tively and on their own initiative in projects and works which otherwise would never have been carried out. One such example is the Caacupe- mi district, some 22 kilometres dis- tant from Asuncion, the capital of Paraguay. Its population, slightly over 1,000 people, lives mainly from dairy farming and the sale of a few other farm products. This typical tropical area, where the main language is Guarani, did not have any drinking water supply. The inhabitants had to fill their jugs and containers at springs and wells and carry them back to their homes, a task made much more difficult during the torrential rain season. One day the members of this com- munity asked the National Environ- mental Sanitation Service (SENASA), a technical agency of Paraguay's Minis- try of Public Health and Social Wel- fare, to do a study of a drinking water project for the community. The re- quest was granted and the study became a part of the Drinking Water Systems Programme. Two years later the project was completed, and every family had ac- cess to water taps. Two reinforced concrete water storage tanks rose alongside the houses, one with a 8 WORLD HEALTH, November 1984 Villagers in this small Paraguayan commu- nity worked together to build their own safe water supply. Photo WHO/PAHO/M. Montecino capacity of 100 cubic metres and the other of 60 cubic metres. Each had its own pipeline and pumping system. The materials were provided by the inhabitants of Caacupe-mi, in addition to the labour, the costs of which were estimated at 20 per cent of the total value of the project. It was a difficult job, performed with pick and shovel, and in some places the ground was so hard that it had to be soaked before it could be excavated. The work was financed by a World Bank loan, and this is being amortised in payments of which 60 per cent is contributed by the Sanitation Board and 40 per cent by the Paraguayan Government. The Sanitation Board is the community's own management body, which channeled the popula- tion's participation in the different stages of the work and now manages and maintains the system. PAHO—WHO's Regional Office of the Americas—provided technical advis- ory services (in the organization of projects and training), as it has done in other programmes of the Govern- ment of Paraguay. SENASA was responsible for the technical guidance and execution of the project. This included sending in plumbers, who taught the new own- ers how to make their installations using their own resources so as to reduce the cost of connecting the water supply to their houses. SENASA also saw to it that the women of the community attended courses on the virtues and benefits of drinking water. The results were excellent. The interest awakened in the population of Caacupe-mi in undertaking the pro- ject and in maintaining the drinking water system remained high. Today, the sanitary conditions, the improved outlook on basic hygiene, and the saving of time afforded by having water at arm's reach have freed the inhabitants to give their attention to other concerns, enabling them to im- prove their production, widen their knowledge, and participate more ac- tively in tasks in the home for the benefit of the family. Communities the world over are participating in similar projects. Experi- ence has shown that local initiative, effort and determination have been decisive factors in solving problems. Apart from the benefits obtained, the communities have developed a greater sense of responsibility, and their members a greater sense of unity, so that in turn they are well- prepared to undertake new ventures with greater chances of success. ■ WORLD HEALTH, November 1984 9 Radiation watchdog Designated by WHO as a Collaborating Centre, the Radiation Emergency Assistance Center/Training Site in Oak Ridge, Tennessee is on call to all the countries of the Americas by Russ Manning L ate in 1981, a technician at a hospital in Kingston, Jamaica, tried to remove radiation sources of radium-226 from a stainless steel therapy needle. The needle was slightly bent, and the technician dam- aged the sources. Spread of radioac- tive contamination was a possibility, but how much was not known. Concerned hospital authorities notified the Jamaican Ministry of Health, which sought help from the Pan-American Health Organization in Washington, D.C. PAHO in turn called the Radiation Emergency Assistance Centre/Training Site (REAc/Ts) in Oak Ridge, Tennessee, whose staff advised sending a health physicist to the hospi- tal. PAHO concurred, and in February 1982 a REAC/TS physicist arrived in Jamaica to survey the hospital. The therapy needle and sources were damaged in the radiation treat- ment area of the hospital, where such needles are used to implant radioac- tive sources for the treatment of solid tumours. Health physicist James D. Berger took samples from the floor and laboratory benches in the area thought to be contaminated. He found some radium contamination but not enough to warrant a medical check of the persons involved. Berger advised the hospital staff on what clean-up was necessary, and suggested an improved health physics programme for the hos- pital, with more attention to safe stor- age and the use and quality control of radiological monitoring devices. Expert reassurance As with most radiation accidents, the incident turned out to be minor and with no health consequences for the people involved. But it was reas- suring for the hospital to have qual- ified personnel to call on in such an emergency. For that purpose, wHo approached REAC/TS in 1980 about providing as- sistance in the management of radia- tion emergencies in the western hemisphere. Such emergency response centres had been designated for other parts of the world. REAC/TS had been in operation for several years. It was established in 1976 by the Medical and Health Sci- ences Division of Oak Ridge Associ- ated Universities (oRAu), a private, non-profit making research institution under contract with the U.S. Depart- ment of Energy. Since then, it has acted as the radiation emergency centre for the United States, ready 24 hours a day to assist U.S. government nuclear facilities and private nuclear power and nuclear fuel reprocessing plants in the event of nuclear emergencies. When WHO designated it as a Col- laborating Centre for Radiation Emergency Assistance, that responsi- bility was expanded to include Cana- da, Mexico, Central and South Ameri- ca, and the Caribbean. PAHO, acting as a WHO regional office, fields requests for assistance from western hemi- sphere countries and passes them to REAC/TS in Oak Ridge. The staff there then recommend a course of action. As Dr Gerald P. Hanson, Radiation Advisor in the Division of Disease Prevention and Control at PAHO ex- plains : "The role of PAHO is a catalytic one of providing technical cooperation 10 WORLD HEALTH, November 1984 Visitors to the Radiation Emergency Assist- ance Centre/Training Site are shown proce- dures for decontaminating victims of radia- tion accidents. Photo U.S. Department of Energy @ and coordination for its member gov- ernments on request. " REAC/TS helps in one of the principal functions of PAHO's Radiation Health Programme, which is "protection against excessive or unnecessary exposure to radiation, including protection of workers, the public, and patients ". As a medical emergency response team, REAC/TS does not get involved in equipment failures or clean-up opera- tions unless there has been possible human contamination or exposure. Following an accident at the Three Mile Island nuclear power station at Harrisburg, Pennsylvania, in 1979, for example, the REAC/TS staff was on an alert status for several days. But since no human contamination or overexpo- sure occurred directly from the acci- dent, the staff was never called in. The response to requests for help varies with the situation. The staff WORLD HEALTH, November 1984 might respond by sending someone to the scene of an accident, as in the Jamaican incident. But most requests for assistance are handled by consulta- tion over the telephone. " We prefer to locate medical assistance for the requestor at the local level ", says Dr Robert C. Ricks, Director of REAC/TS. If necessary, persons possibly ex- posed to radiation may be sent to Oak Ridge for evaluation. In August 1980, a broken radiography source, used for examining pipe welds and high- pressure vessels at a refinery near Maracaibo, Venezuela, released a small amount of radioactive iridium, contaminating several workers. The U.S. company involved brought in a U.S. physician to examine the work- ers. The physician suspected that the workers had not received a large con- tamination, but he did not have the radiation counting equipment to vali- date his impression. Once it was confirmed that there was no medical emergency, the work- ers were flown to the REAC/TS base in Tennessee for whole-body counting, in which radiation detecting instru- ments recorded any radiation emitted from their bodies. As a second diagnostic procedure, chromosome analyses were also car- ried out on the workers. The staff of the cytogenetics programme of ORAU's Medical and Health Sciences Division use this biological method for deter- mining the extent of radiation expo- sure. The cytogenetists use blood sam- ples, which may be drawn at the site of the accident but then must be kept cool and sent to REAC/TS within 24 hours. Once the samples arrive, the researchers set up cultures of lympho- cytes, stimulating these human blood cells to divide. Slides of the dividing cells are prepared and are examined under a microscope. "Our standard protocol ", says Dr L. Gayle Littlefield, director of the cytogenetics programme, "is to ex- amine about 300 mitotic lymphocytes and record every time we see evi- dence of specific types of chromosome lesions. To estimate the radiation dose, we then compare the frequency of the lesions observed in the patient's lymphocytes with lesion frequencies 11 Handling hazardous radioactive wastes in southern England. REAC/TS only gets involved in clean-up operations if there has been possible human contamination or exposure. Photo UK Atomic Energy Authority © in appropriate dose-response curves. " Much of this work is still basic re- search, adds Littlefield, " so we con- stantly work on refining or evaluating variables that might affect the results, hoping to make the system more precise". Although the procedure does not identify low levels of exposure, it can determine whether an accident victim has received a clinically significant dose. In the case of the Venezuelan workers, the cytogenetics tests con- firmed that the workers had not re- ceived a radiation exposure requiring medical care. Such radiation accidents as the Ven- ezuelan incident are entered into the REAC/TS registry system, which serves as a medical data base on radiation accident victims. At present the regis- try contains data on nearly 6,000 individuals involved in some 600 inci- dents. The data include the kinds of radiation accidents that have occur- red, the number of persons involved in each accident, the number of fatalities due to radiation exposure, and refer- ences to studies of these accidents. In contrast to the accident response services provided by REAC/TS, the cy- togenetics studies and the accident registry are research programmes. " So the work we do here is not only directed to the medical assessment of some accident situation and the person or persons involved ", says Director Ricks, "but also there is a research interest in radiation biology and radi- ation pathology that is part of the REAC/TS mission. " From this research perspective, the staff watch for unusual cases that may add to their knowledge of radiation effects. A recent accident involved several workers exposed to the radioactive element americium at a private company in Houston, Texas. Since there is very little data on americium, "we're keenly interested in the case ", says Dr C.C. Lushbaugh, chairman of ORAU's Medical and Health Sciences Division and a member of the REAC/TS staff. "We are consulting with the physician involved to aid in the decontamination of the workers. " Although REAC/TS responds to any request for help with a medical radia- tion emergency, its primary assistance to wHo is in training. It conducts courses in radiation emergency re- sponse for health professionals from throughout the world, usually medi- cal, paramedical, and health physicist personnel who need to know how to manage a radiation accident where they work. The courses include con- sultation with REAC/TS personnel, the study of case histories, and the oppor- tunity to practice techniques in drills designed to test a person's ability to handle an accident victim and to meet the victim's medical and decontamina- tion needs. The REAC/TS faculty also participates in workshops and conferences on radi- ation emergency response. At the re- quest of PAHO, the teaching staff par- ticipated in a two-week training course held at a conference centre near Rio de Janeiro, Brazil, in De- cember 1981. The conference partici- pants included physicians, nurses, and health physicists from Mexico and var- ious South American countries. It is through such training pro- grammes and accident response that REAC/TS fulfills its commitment as a \NTH() Collaborating Centre for Radia- tion Emergency Assistance, a designa- tion that was recently renewed for another three years by WHO. With this renewal, REAC/TS will continue to be available to all countries of the west- ern hemisphere, to assist with radia- tion emergencies and to train medical and health personnel in the care of radiation accident victims. ■ 12 WORLD HEALTH, November 1984 From darkness to light by Jitendra Tuli B holu's day starts early. At the stroke of seven, come rain or shine, he is at work at New Delhi's bustling inter-state bus ter- minus. Except for a brief break for lunch at mid-day, Bholu is busy till six in the evening. It is a long day for a nine-year-old boy. And as he admits, "It seems much longer, because I cannot see." Incurably blind from the age of four, as a result of what doctors later diag- nosed as acute xerophthalmia, Bholu has a fierce determination not to let his handicap bog him down. When he first came to the bus terminus a year ago from his native Madurai in south India, the shoeshine boy's kit that he carried with him was the object of many taunts from the other boys. Soon, however, the taunts gave way to admiration when the boys realised that Bholu "meant business ". He wanted to be treated as an equal, and was willing to prove that he was as good, if not better. Today, but for the white walking stick by his side, no- body would guess that he is blind. Of course, young Bholu is an excep- tion when it comes to determination and willpower. He asserts that it would be very easy for him to take a bowl and beg for alms, as many other blind people do, and perhaps make more money. " But I would much rather starve than do that", he says with burning pride. Surprisingly, for a nine-year-old, Bholu is rather well-informed. He knows, for example, that his eye condition —xerophthalmia — could have been prevented with the proper diet and timely and regular doses of vit- amin A. In fact, whenever he gets an Above : Shoeshine boy's-eye-view of life in the streets of New Delhi. Photo WHO/J. Tuli WORLD HEALTH, November 1984 13 From darkness to light Left : An old man shows his delight at the prospect of regaining his sight after a cataract operation—part of India's massive programme for the prevention of blindness. Right : These men and women patients are also among the lucky ones whose sight will be restored. Over two-thirds of the blind people in South-East Asia suffer from either preventable or curable blindness. Right, below : Recovered from her eye oper- ation and fitted with spectacles, this woman can once more make her contribution to the community, rather than feeling that she is a liability to it. Photos Stern Magazine, Hamburg C) opportunity, he tells his young col- leagues how important it is for them to eat green leafy vegetables, a source of vitamin A, and to see to it that the young ones at home also eat them regularly. He tells them that, in his native Madurai, an ambitious pro- gramme has been launched to educate people, especially mothers, about the vital role that greens play in prevent- ing blindness in children. He also knows that this is part of the Indian government's massive programme for the prevention of blindness in the country. What Bholu is not aware of is the real extent of the problem. Of the 40 million blind people in the world, an estimated 80 per cent are in the developing countries. The South-East Asia Region of WHO, with a population of over 1,000 million, accounts for almost 50 per cent of the world's blind. Of these, India alone has nine million. What adds to the poignancy of the problem is that over two-thirds of those affected suffer from either preventable or curable blindness. In Bangladesh, it is estimated that about 20,000 children go blind every year—as Bholu did—due to xeroph- thalmia. The problem is being tackled by the regular and widespread dis- tribution of vitamin A capsules among children, along with the control of diarrhoeal diseases and other infec- tions. In addition, compared to the 5.5 million cataract patients who can be cured with an operation in India, Bangladesh has more than 800,000 cases awaiting operative re- storation of sight. Infections including trachoma, xerophthalmia and occupational hazards to the cornea are the main causes of preventable blindness among the rural population in the Region. Considering the cost of main- taining the blind, and the consequent loss of production, India alone esti- mates the cost at over US$ 1,890 million annually. Of course, there is no way in the world that the anguish of those forced to live in darkness can ever be measured, assessed or quantified. The dimensions of the problem are further highlighted when one takes a look at the acute scarcity of trained ophthalmologists in the Region. While India is estimated to have nearly 6,000 eye specialists and 2,000 eye assistants for a population of over 680 million, Thailand has 60 ophthalmologists for a population of 45 million, which works out at 1 per 125,000 in Bangkok and 1 per 2 million in rural areas. Indonesia has 175 ophthalmologists for 130 mil- lion people, and Bangladesh has 66 qualified ophthalmologists and 122 ophthalmic trained doctors for over 80 million people. It is not surprising, therefore, that there is a long waiting list for cataract operations, even though pioneering efforts have been made, particularly in India, in arranging eye operation camps. Some of these camps are legen- dary, with a team of surgeons at times performing hundreds of operations. Such are the skills and the care that patients come from hundreds of miles to be attended to. According to pre- sent estimates, nearly 1.3 million eye 14 WORLD HEALTH, November 1984 operations need to be performed every year in India, but the capacity is only 800,000. As in other countries of the Region, efforts are being made through voluntary and international agencies to extend these services to more areas and more people. More attention is being given to setting up eye banks, and here, the success of the programme in Sri Lanka is a shining example. Bearing in mind the many con- straints, as well as the urgent need to tackle the problem on almost a war footing, most countries in the South- East Asia Region have formulated national plans for the prevention and cure of blindness. These programmes basically aim at intensifying efforts for eye-health care, using the mass media and encouraging community partici- pation. The programmes also seek to extend eye-care services to rural areas, and establish permanent facili- ties for eye-health care as an integral part of the general health services. At various seminars and workshops run by the WHO South-East Asia Re- WORLD HEALTH, November 1984 gional Office, it has been recognised that blindness not only constitutes a priority health problem but that the technology and the resources can be mobilised to achieve effective control. It is also realised that, to be truly effective, the programme would need to devote more attention to basic and applied research, at the regional and national levels. For instance, consider- ing that there are millions suffering from cataract in the Region, it would be of immense value to discover an alternative to surgery for the treat- ment of cataract or a new technique for the prevention of cataract. By the very nature of the problem, there is no dearth of potential donors for programmes to preserve sight or restore vision to the curably blind. Perhaps what is needed above all else is the mechanism of health care deliv- ery. Once that mechanism is de- veloped, children like Bholu will not have to work in darkness, relying on misty memories to visualise the splen- dour of a monsoon sky or a flowering shrub in bloom. ■ 15 DECAYED TEETH MISSIN3 TEETH FILLED TEETH PLAQUE ON TEETH Fh]tos : Societe Sjisse d'Odontostomatologie Healthy mouths for YESTERDAY TODAY TOMORROW Oral disease The DMF-Tooth Index measures the state of a country's oral health—or oral disease. It is simply a count of Decayed, Missing and Filled teeth. The global goal for the year 2000 is a DMF-tooth index of no more than three in 12-year-old children. Twenty years ago, the index averaged less than one for most Third World countries, and up to 10 for industrialised countries. But figures reported in 1982 show a sharp reversal of trends : 4.1 for developing and 3.3 for developed countries. The two most common oral diseases are : Dental Caries: Our mouths always harbour bacteria, which are generally not harmful. But when they combine with foods con- taining a lot of carbohydrates—especially sugar—acids form which eat away at the enamel of our teeth, leading eventually to cavi- ties. If extractions are to be avoided, cavities must be filled. Dental caries are the major oral health problem for children and young people. Inflamed or Bleeding Gums: Gingivitis, or inflammation of the gums, is caused by bacteria which feed upon decaying food particles to form plaque. A sticky colourless substance, plaque clings to tooth surfaces and lodges between your teeth, causing the gums to swell and bleed. If not removed, plaque hardens into calculus or tartar deposits and causes gum diseases that lead to bad mouth taste, abscesses and tooth loss. Diseases of the gums are the major oral health problem for adults. WORLD HEALTH, November 1984 A World Health m i by the year 2000! 111. r Oral health It's your responsibility... Clean your mouth Preferably right after each meal, but at least once each day, wash out your mouth thoroughly. To remove plaque from your teeth and gums, use a toothbrush or a chewstick—with or even without tooth- paste. It is the cleaning that removes the plaque. If you can, also use dental floss to clean between your teeth. These are the basic measures of oral hygiene. 2 Use fluoride (F) Fluoride is a mineral found naturally in many foods and in most sources of drinking water. It inhibits the ability of bacteria to produce acids, strengthens the enamel on your teeth, and makes them more resistant to decay. Use fluoridated toothpaste. In addi- tion, either drink fluoridated water, or use fluoridated salt in cooking and have it available on the table for use with food. If none of these is available, use fluoride tablets or rinses. Fluoride protects throughout life, but especially protects the teeth of children. 3 Eat less sugar You can safeguard your teeth by eating less sugar-rich food. If you must eat sweet dishes, it's best to do so only at mealtimes. Immediately after eating sweets or sugary snacks, clean your mouth out thoroughly. Don't let snacks take the place of a well-balanced diet ; nutritious foods are essential for oral health as well as for overall health. If you really need to nibble between mealtimes, the best snacks are those that contain no sugar. Education Poster WORLD HEALTH, November 1984 Rinse Wednesdays by Peter Ozorio 1 W ednesday is a day with a difference throughout pri-mary schools in St. Chris- topher-Nevis, a newly independent nation of 52,000 people in the Eastern Caribbean. Before classes begin, children aged from six to ten are given cups filled with 10cc of fluoride mouth rinse. On a signal, they take the rinse into their mouths and swish it thoroughly over their teeth. Some do it silently, others gurgle a little. All are enthusiastic about it. Exactly one minute later they squirt the rinse back into the cups, which are then collected, emptied and disposed of in plastic bags. " Wednesday is ideal for the rinse because it is the day of highest school attendance," explains Dr Julian Mitchell, an expatriate Londoner and now a ten-year resident on the island. "After rinsing, classes begin. This means the kids are kept away from snacks, and particularly sugar cake or drinks, till about mid-morning break —making the effect of fluoride last a little longer. " Sugar cake is generally sold by ven- dors outside schools. It is almost neat sugar, to which is added some coconut and a small amount of flour. Small wonder it is then that a child develops a "sweet tooth" very early on in life in St. Kitts-Nevis (St. Kitts is the usual abbreviation of St. Christopher). Dr Mitchell is "the Government Dentist." As such he is expected to pull teeth and fill cavities, and so he does. But as head of dental services, he is also called on to be health educator, persuader and advocate of preventive oral health. On a recent trip to primary schools at Lodge Valley and Sadlers, he was the delivery man—taking cases of paper cups and plastic bags to the teachers. Sadlers is on the Atlantic side of the violin-shaped island, some 15 miles (24 kilometres) around the Main Island Road from Basseterre, the capital, which lies on the Caribbean side where his clinic is located. "Fluoridating the water supply is not yet possible," he observes as we drive along a road flanked by palm trees to seaward and by cane fields on the land-side, "because St. Kitts-Nevis is without a central water supply system. " Sponsored by the Canadian Dental Association and the Canadian Inter- national Development Agency, the rinse programme is estimated to re- duce decay by about 30 per cent. While rinsing is not as effective as fluoride in water or in salt, it does have one decided advantage—the ex- citement about Rinse Wednesdays that children enjoy fixes the idea of oral health on their impressionable minds. The rinse programme is one aspect of the government's expanding oral health services. There is also a morn- ing programme for six-year-olds, and 18 WORLD HEALTH, November 1984 an afternoon programme for ages se- ven to 16. But the six-year-olds com- mand most attention ; not only is that an age where children are beginning to cooperate with their elders, it is also when permanent teeth—the teeth for life—are developing. The clinic at New Town in Basse- terre, which opened in 1976, can take up to 30 children each morning—ten for each of the three dental chairs—for their first "charting", an examination by a dentist followed by polishing and cleaning by a "chairside ", or dental assistant. The school bus does double duty—taking the children to school first, and those who need care to the dental clinic later. About 80 per cent of children come back for treatment after the first visit; in the worst cases as many as nine decayed teeth may need filling or extraction. Usually appointments are spread over three or more days, with fillings done first to reduce fear as much as possible. Extractions follow. As the aim is to save permanent teeth, a decayed primary tooth that is likely to affect a permanent one is taken out without compunction. Auxiliaries, after two years of train- ing, are equipped with the skills needed to care for virtually all dental problems of six-year-olds—the filling of primary teeth worth saving, and of new cavities, along the top surface for example, of first permanent molars. They stop short of extractions. But an auxiliary in Nevis removed a perma- nent tooth in an emergency case after calling St. Kitts and receiving instruc- tions from Dr Jerome Peister, the island's other dentist who used to practise in New York. One of the two dentists makes the two-mile boat trip to the sister island of Nevis once a week. The population of St. Kitts is about 40,000 and that of Nevis about 12,000. In all there are ten staff in the government service. They include three auxiliaries who are graduates of the School of Dental Nursing in Trinidad and Tobago, while a fourth is still studying, and three chairside assistants. There are posts for three dentists. The service was not always so well staffed. When Dr Mitchell arrived in 1974, he found he was the only dentist in service—in fact there had been no treatment for the previous 15 months. The out-of-date equipment at the clinic was beyond repair because re- placement parts were no longer manu- factured. At that time, he estimates that 70 per cent of children were without tooth brushes. "There was little awareness of pre- vention," Mitchell says. " When a tooth hurt, it would be yanked out —that was the common idea of dental health." Oral health poster at a clinic in St Kitts in the Caribbean. Facing page: A dental auxiliary shows chil- dren how to brush. Photos WHO/P. Ozorio A comprehensive oral health pro- gramme was built up painstakingly over the years, with new and sim- plified dental equipment, the introduc- tion of auxiliaries, and, most impor- tant of all, health education : a "Health Week" featuring poster and calypso competitions, a " Weekly Hot- line " going out over the radio, and, on the opening of the New Town Clinic, a television programme demonstrating the uses of equipment. In addition auxiliaries visit schools with an over-sized tooth brush to show youngsters how to clean their teeth, and one auxiliary, Barbara Edwards, runs Basseterre's Cavity Fighters' Club. At Sadlers, brushes are kept in school so that teachers can make sure that children are indeed brushing and are doing so properly—a responsibility that many parents fail to discharge. It is a practical decision since most chil- dren live in wooden houses without running water. In the school days of their parents, dental care was virtually non-existent, or, at best rare. From time to time, a dentist made the round of schools, setting up shop—a table for a wash basin and instruments, and a stool for the patient—under a tree. A child with a puffy face came out, was instructed to open wide, and had aching teeth pulled without the benefit of anaesthe- tic. It was a terrifying experience. Much time and thought is now given over to dispelling fear at an early age. On a first visit to the clinic, six-year- olds are allowed to play with the polishing brush, feeling it vibrate on their fingers. And taking advantage of their natural curiousity, they are en- couraged to watch during the exami- nation of a class mate before it is their turn for the check-up. Children used to show alarm and cry even before sitting in the chair. That is a rare occurrence now. The prevalence of dental caries is a chief indicator of oral health, using an index based on a count of "decayed," "missing," and " filled " teeth at age 12. A DMF-tooth index of 1.1 is rated very low and above 6.6 very high. The Health for All goal is an index of 3 for all countries by the Year 2000. In 1979, a survey undertaken by wHo's regional office for the Americas with the Caribbean Epidemiology Centre, Port-of-Spain showed that St. Kitts- Nevis had an index of 9. However, between 1979 and 1982, the number of six-year-olds without cavities on their first visit to the clinic increased from 16 per cent to 22 per cent, and those without cavities in permanent teeth rose from 50 to 62.57 per cent. Furthermore, of 543 extrac- tions during the school year 1981-82 only eight were of permanent teeth. The ultimate aim, of course, is a caries-free society, or at least one as near to that goal as is practical. Pre- vention will depend on the use of WORLD HEALTH, November 1984 19 If children can watch what goes on in the dental chair, it helps to dispel their fears when their turn comes. Photo WHO/P. Ozorio fluoride as a measure against, decay. Fluoride strengthens teeth, making them more resistant to decay, and inhibits the effect of bacteria in the mouth, thus diminishing decay-caus- ing acidity on the tooth enamel. When fluoridated compounds are added to diets, cavities are generally smaller, making possible even the treatment of nine-year-olds by dental auxiliaries. With fluoride in table salt or water, for example, a reduction in decay close to 70 per cent is possible, according to estimates by WHO's regional office for the Americas. This is now a top priority for St. Kitts-Nevis. The idea of preventive hygiene is catching on, Dr. Mitchell says "I have seen a child at 6.30 in the morning scrubbing his teeth at one of the stand- pipes in the street just down the road from where I live." Brush, use fluoride, and don't eat sugary foods outside meal times are the health mes- sage that need to be transmitted. " Success has been seeing pretty well every child in the state at the dental clinic ", he adds as we head back towards New Town. "It is our aim to have one age group—the six-year-olds —free from decay, and then to say to them : 'You are now caries-free, and it's your responsibility to look after your teeth and keep them that way'. " ■ 20 WORLD HEALTH, November 1984 Health Manpower Development The right people for the right jobs by Viatcheslav Alexeev and Igor Rozov ii ealth manpower is a limited resource in many countries today, at a time when having the right kind of people in the right job is crucial if WHO is to attain its goal of Health for all by the year 2000. Conse- quently, health manpower develop- ment is itself undergoing a process of change. At the Thirty-Seventh World Health Assembly in May, it was repor- ted that most countries now have a manpower policy, and include man- power planning in their general schemes for their national health services ; at that date, 118 of WHO's 162 Member States were putting these plans into practice. But while there has been some progress in health manpower training, in the area of manpower manage- ment—that is, setting the right pri- orities for available personnel and making the best use of them—the progress may be described as only modest. At a time when we might expect a national resource as valuable as trained personnel to be used most economically and most rationally, it is this very aspect of manpower work that is weakest. It would be incorrect to regard the problem as a "neglected area". Most countries have the best of intentions when they try to solve the problem of making better use of their available manpower. But either the right skills are lacking to use health personnel properly, or the situation is bedevilled by circumstances beyond the control of the health care system. Political, social, economic, cultural and other factors are usually involved, so that success in this field calls for both intersectoral cooperation and positive political support. The problem of the rational use and allocation of manpower stands a good chance of being effectively solved in a national health care system. There may be more hurdles in the way when the private sector predominates, but a well-organized manpower manage- ment system can achieve positive results. With these considerations in mind, WHO's Division of Health Manpower Development (HMD) convened an inter- Health promoter in Mexico City. Trained personnel represent a valuable national resource. Photo WHO/J. Bland regional consultation on the improve- ment of manpower management sys- tems. Organized in cooperation with the South-East Asia Regional Office and the Indian Management Institute, it was held in Bangalore, India, late last year and attended by represen- tatives of 13 countries from five of WHO's six regions. The consultation first discussed the basic concepts underlying the best possible use of skilled health workers. Each of the participants then drafted a series of measures aimed at improv- ing the situation in the particular circumstances of his or her country. Comparison of these draft plans sug- gested the following "common ground" : available health manpower must be distributed within a country and within the different sectors of the health services in direct relation to the needs ; no member of the health team should carry out activities that could be performed by less qualified per- sonnel ; the right kind of motivation and incentive needs to be offered to all health personnel to ensure that each person has a feeling of responsibility, appreciates that the work is effective and useful to the community, and has opportunities to undergo continuing education with a view to improving performance. Other incentives should include an appropriate system of so- cial security, moral and financial reco- gnition of achievements, job satisfac- tion and security of tenure for staff at all levels within a properly organized career structure, possibilities for pro- motion, and constant technical sup- port and supervision—again, at all levels. If all these criteria are met, the Bangalore consultation concluded, the right conditions for the proper management of health personnel will be present. At the same time, health personnel in sufficient quantity and of sufficient quality will be attracted to posts in the health services where they are needed, and will stay as long as their skills are required. ■ WORLD HEALTH, November 1984 21 Guinea worm and the Decade Dracunculiasis is an "ideal" disease for showing how the provi- sion of safe water can result in dramatic and important benefits — benefits, moreover, which are directly related to development by Donald R. Hopkins I f, by the end of the International Drinking Water Supply and Sani-tation Decade in December 1990, the goal of providing safe drinking water to all has been achieved, dracunculiasis, or guinea worm dis- ease, should no longer exist, or should be on the verge of extinction. The disease is spread only by drinking water contaminated with infected cyc- lops, a small crustacean. There is no animal reservoir, and when clean wa- ter is introduced into affected villages, and is used, the disease disappears in one or two years. Guinea worm disease is a dramatic affliction. About one year after a per- son has drunk contaminated water, one or more adult female worms —each up to 1 metre (over three feet) long—emerge through the skin, usual- ly of the lower limbs. When the af- fected part is immersed in water, the worm expels hundreds of thousands of tiny larvae, which are then ingested by cyclops to continue the cycle. The adult worm emerges slowly over sev- eral weeks. The irritation from the emerging worm and from secondary infection of the site is so painful that victims are often unable to walk or work, depending on which part of their body is affected. The disease can cripple a large pro- portion of a village's working popula- tion, and, because the transmission cycle is often confined to the rainy season, the victims are put out of action during the very time of year when they must plant or harvest their crops. Therein lies much of the dis- ease's economic and social signifi- cance. Crippled children often cannot walk to school. Sometimes the ulcer which surrounds the emerging worm is secondarily infected by tetanus, and the victim dies. Victims do not become immune. The overwhelming majority, who do not contract tetanus, live to suffer the infection year after year. Dracunculiasis still afflicts millions of rural villagers in India and Pakistan and in a broad band of African coun- tries from Mauritania and Senegal in the west, through Mali, Niger, Bour- kina Fasso (formerly Upper Volta), Ivory Coast, Ghana, Togo, Benin, Nigeria, Cameroon, and Chad, to Su- dan, Uganda and Ethiopia. Fewer than five per cent of the cases are routinely reported. There is still a widespread errone- ous impression that this is not an " important " disease. One must ask, not important to whom? For those who suffer from it annually, there is no doubt about its importance. A few years ago, Dr Joshua Adeniyi and his colleagues at the University of Ibadan asked a group of Nigerian villagers about their priorities for outside assist- ance. The villagers listed electrifica- tion first, and elimination of guinea worm disease second, ahead of roads, hospitals, jobs, water, and several other critical needs. Transmission of dracunculiasis can be prevented by motivating villagers to filter their drinking water through a clean cloth, or to boil it before use, and by educating persons with the disease not to enter ponds or other sources of drinking water (see April/ May 1983 issue of World Health). Larvicides such as Temephos or Abate can kill the cyclops without causing harm to humans if they are applied periodically to ponds, wells or other stagnant sources of drinking water. But the most secure, and also most expensive, intervention to interrupt transmission is the provision of a pro- tected source of drinking water, such as a tube well or even piped water, where persons with emerging guinea worms cannot contaminate the source. Treatment, including chemotherapy, is only a palliative. The USSR eliminated dracunculiasis from residual endemic foci in the southern zone of that country in the 1930s by means of a systematic cam- 22 WORLD HEALTH, November 1984 An abscess caused by guinea worm lamed this ycung man in a small Ivory Coast community so that he could no longer work. The disease can cripple a large proportion of a village's working population. A traditional and simple solution is to wind out the emerging worm on a matchstick. Photos WHO/B. Weniger and WHO/H. Zaiman paign of providing piped drinking water and filling in step wells. In recent years, similar improvements in rural water supplies and environmen- tal hygiene have apparently elimi- nated the disease from Egypt, Iran, and some other countries of the Eastern Mediterranean. In April 1981, the Steering Commit- tee of the International Drinking Water Supply and Sanitation Decade endorsed the idea of making the con- trol or elimination of dracunculiasis a sub-goal of the Decade. The following month, the World Health Assembly adopted a resolution on the Decade which also took note of the oppor- tunity afforded "to eliminate dracun- culiasis as a public health problem in affected areas, where the prevalence of the disease could serve as a uniquely visible and measurable indi- cator of progress for the Decade ". Since 1980, India has undertaken a Guinea Worm Eradication Programme with the target of eliminating dracun- culiasis from India by December 1986. The Indian programme emphasises a coordinated approach of active sur- veillance, health education, temporary chemical treatment of unsafe water sources, and provision of safe drinking water, all in the context of the coun- try's primary health care system and activities planned for the Decade. India's Tamil Nadu State, which has had an aggressive anti-dracunculiasis programme for some time, has appa- rently already interrupted transmis- sion of the disease. Consultants to Benin, Ivory Coast, and Togo on be- half of the African Regional Office of WHO, and to Uganda on behalf of UNICEF, have made recommendations for developing national plans in those countries. In Nigeria, a national meet- ing is planned, to be held in late 1984, to consider what is known about the extent of dracunculiasis in that coun- try, and what can be done about it during the remainder of the Decade. In the meantime, various opera- tional research studies on the disease are also under way in Ivory Coast, Nigeria, and Bourkina Fasso (formerly Upper Volta), with funding from WHO, the United States Agency for Inter- national Development (usAID) and the Organisation de Coordination et de Cooperation pour la lutte contre les Grandes Endemies (occGE). One of the most acute needs is to document more exactly the agricultural impact of the disease in one or more affected communities. In June 1982, an international meet- ing on dracunculiasis took place in Washington, D.C. under the auspices of the U.S. National Research Coun- cil, USAID, and WHO. More than two dozen experts from Ghana, India, Ivory Coast, Nigeria, Togo, the Un- ited Kingdom and the United States attended. The workshop participants agreed that the disease is easily diag- nosed, and that effective methods for controlling it are already known. They concluded that the obvious next step is for endemic countries to start immediately implementing con- trol activities suited to their needs and resources, and for international and bilateral agencies to assist them, especially in view of the special op- portunities presented during the De- cade. The full report of that meeting is available from the National Re- search Council in Washington. For the Decade, dracunculiasis is an ideal disease for demonstrating rapid- ly that a dramatic, important and di- rect " health benefit " can be derived from providing safe water—a health benefit, moreover, which is directly related to development. Since the areas where dracunculiasis is endemic constitute less than ten per cent of the unserved rural communities in Africa and Asia, the goal of eradicating this disease is theoretically achiev- able—even if the Decade is unable to meet all its goals by 1990. ■ WORLD HEALTH, November 1984 23 Saving young lives Pioneering efforts by the medical personel of UNRWA in treating dehydration and diarrhoea! diseases have proved a major factor in improving the survival chances of young Palestine refugees by Stephen Badzik Concerted efforts over the past 34 years by the Health Depart-ment of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (uNRwA) are credited with reducing the infant mor- tality rate by more than half among the Palestine refugee population under its medical care. The Agency operates 98 health centres/health points in five areas ; Jordan, Lebanon, Syrian Arab Republic, and the Israeli- occupied territories of the West Bank and the Gaza Strip. The infant mortality rate is gener- ally considered to be one of the most sensitive and informative indicators of a given community's health status. The rate is determined by the number of deaths of infants under one year of age, in one year, per 1,000 live births. The director of UNRWA's Health De- partment, Dr H. J. H. Hiddlestone, on secondment to the Agency along with four other senior medical officers from WHO, has pointed out that, in some fields where the Agency operates, the decrease in deaths among children under one year old has been quite significant. For instance, in the early 1960s the infant mortality rate in the West Bank, where such studies have been extensively conducted, was about 140 out of every 1,000 live births. Today that rate has dropped to less than 40 per 1,000. One of the major factors which has led to this dramatic improvement in the survival chances of young Pales- tine refugees has been the pioneering efforts of UNRWA's medical personnel in treating dehydration and diarrhoeal diseases. The number of reported cases of diarrhoeal diseases among refugee children, newborn to three years of age, has dropped from 86,703 in 1967 to 49,706 in 1982—a reduc- tion of 43 per cent. The effective, simple and low-cost rehydration therapies pioneered by This 8-month-old baby, a victim of gastro- enteritis, weighed less than it had at two months. Another infant death seemed likely in the Palestine refugee camp near Jericho. Photo WHO/UNRWA UNRWA have saved the lives of many Palestine refugee children, and now serve as a model for international efforts to reduce the heavy toll that dehydration from diarrhoeal diseases claims in many regions around the world. Rehydration therapy is just one of the many successful services de- veloped by UNRWA's maternal and child health care (max) programme to ensure healthier lives among the refu- gees. The MCH programme represents UNRWA's strong commitment, evident since the Agency's inception in 1950, to devote particular medical attention to the especially vulnerable members of the refugee community. Starting with 46 clinics and sub- sidies for 700 hospital beds, UNRWA's medical service has grown to include 98 health centres and 1,432 subsidised hospital beds. At 86 of these centres specialised MCH activities are in opera- tion. The MCH programme annually serves over 30,000 refugee mothers and more than 100,000 children under three years of age. Back in the 1960s, the MCH opera- tion had recorded some progress in reducing the incidence of various dis- eases, but infant mortality rates still remained very high, due in part to low education levels and substandard liv- ing conditions. During this period, 40 per cent of the programme bene- ficiaries lived in overcrowded camps and tiny shelters. Typically, an aver- age family of five shared a one-room concrete dwelling of about 10 square meters. Although UNRWA had insti- tuted basic environmental sanitation procedures in the camps, it was dif- ficult to reach a satisfactory level of cleanliness because public latrines, the presence of domestic animals and limited sewerage facilities added greatly to unhealthy conditions and provided prime breeding grounds for insects. Safe drinking water was avail- able in most camps, but only in limited quantities. Such undesirable environmental conditions persist in some areas but 24 WORLD HEALTH, November 1984 there have been major improvements. Also contributing to the current de- crease in illness attributed to environ- mental factors has been the improve- ment in personal and family hygiene stimulated by health education pro- vided through the mai programme and in UNRWA schools. Since the introduction of the mai programme, mothers have been en- couraged to make five visits to one of the Agency's health centres during pregnancy for routine check-ups, guidance and supplementary food rations. It is estimated that the Agen- cy's maternity services reach about half of the eligible refugee population, mainly the camp inhabitants who make up one-third of the 1.9 million refugees registered with UNRWA. In 1982, there were 30,478 deliveries to women in MCH, and of these 41 per cent were attended in the homes by Agency-supervised dayahs (traditional midwives). The number of hospital deliveries has increased over the years as more of the refugee women living in urban areas follow the modern trend of having their babies in hospi- tals. The Agency's programme for supervision and guidance of the tradi- tional midwives, many of whom were illiterate or semi-illiterate, has had a direct impact on the care of mothers and children. Child care The infant health care programme has also been upgraded over the past three decades, but the programme's basic objectives have always been to reduce preventable deaths and illness and to improve prospects for normal and healthy development. The pro- gramme calls for all children under three years of age to undergo regular medical check-ups. This includes re- cording height and weight on a growth chart and administering various vacci- nations. In 1982, 103,917 children up to three years old received health care in Agency clinics, and were immun- ized against tuberculosis, diphtheria, whooping cough, tetanus, poliomy- elitis and measles—the six target dis- eases of WHO's Expanded Programme on Immunization. While at the clinics with their babies, mothers receive A nurse at the UNRWA health centre in the Gaza Strip shows refugee mothers how to prepare rehydration salts for children suffer- ing from diarrhoea. Photo WHO/UNRWA/M. Nasr advice on breastfeeding, weaning, bathing, clothing and prevention of infection. In addition to declining rates of infant mortality, the decreasing num- bers of underweight babies reflect the positive impact of the MCH pro- gramme. In 1966, 17 per cent of the children under one year and 33 per cent of children between one and two years attending the MCH centres were below the normal weight. In 1982, the percentages of underweight children were respectively 7.1 per cent and 6.3 per cent. When a refugee baby's growth chart indicates a lower than normal weight, the child may be referred to a nutri- tion/rehabilitation clinic. During the 1950s, refugee children with diar- rhoeal disease would suffer a rapid loss of body fluids from diarrhoea and vomiting. If the body fluids were not quickly replaced, dehydration would soon be followed by death. UNRWA's first step in tackling this major baby killer was to set up a rehydration centre in the Gaza Strip's Maghazi Camp for a five-month trial period, beginning in August 1961, under WHO's technical supervision. The Centre's four objectives were : to treat dehydration by replacing the lost fluids ; to treat the diarrhoeal disease with appropriate medication ; to im- plement nutritional rehabilitation so that the child's diet could include food normal for its age ; and to educate the WORLD HEALTH, November 1984 25 The child on the left is the same as the one shown on page 24. Rehydration treatment restored her health, and supplementary feeding provided extra nourishment. Photo WHO/UN RWA mother in various health practices such as greater cleanliness in prepar- ing meals. Dr Adib Jabra, the Maghazi Camp medical officer during the ex- periment, said the mothers were quite receptive to the staff's advice and teaching because they saw such a rapid and dramatic improvement in their children. Since the mothers stayed with their infants during the daily treatment, there was ample op- portunity to give them health educa- tion on other matters too. The experiment was a great success. UNRWA eventually opened many more rehydration/nutrition centres and pro- vided instructions and equipment for rehydration therapy to all UNRWA health units. By the late 1960s, the centres had fewer cases of severe dehydration from gastro-enteritis, so their mission was expanded to handle a wider range of illnesses that were often associated with malnutrition. Since the cases were less severe, the nasal-gastric method of rehydration was replaced by oral rehydration therapy ; each mother is given pre- pared packets of salts to be diluted in water and then spoon-fed to the sick child. Until the child recovers, it also receives the post-diarrhoea menu con- taining easily digestible foods of high protein and high calorie content. Since 1980, the packets of rehydration salts have been provided to UNRWA by the United Nations Children's Fund (UNICEF). Dr Jabra, who has been chief of UNRWA's Division of Nutrition and Supplementary Feeding since 1966, commented : "Today's clinical picture is almost solely a nutritional one, with cases of dehydration becoming very rare. " To reflect this current need, the rehydration/nutrition centres have been renamed nutrition rehabilitation clinics, and they can operate at any of UNRWA's 98 health units. " With this network, we can easily reach more children, " said Dr Jabra, "and, I hope, achieve even greater success in the treatment and control of diarrhoea) disease. " ■ WORLD HEALTH, November 1984 26 A scourge of modern times Question: Which epidemic causes tremendous suffering and countless disabilities, is a major cause of death at all ages, entails vast cost to society, is found in all countries, yet rarely figures in medical school curricula or research projects? Answer: Accidents. Despite their frequency and gravity, accidents are the poor relations of teaching and research. People are in- terested in their immediate conse- quences, death and various traumas —broken bones, external or internal injuries, haemorrhage, skull or verte- bral damage, burns, poisoning. A lot less is known about such long-term results as invalidity, and partial or total disability, whether temporary or permanent, and practically nothing is known about " accidentology, " the study of the pattern of accidents. How do they happen, how do health and other public services deal with them, what are the physical, mental and social consequences for the victims and their contacts in the family or community? And how can they be prevented? Everywhere, accidents are a major and increasing cause of injury, hos- pitalization, disability and death, espe- cially among young people and the elderly. Their socio-economic cost —and the suffering that follows—is beyond measure. In 1974 there were an estimated 250,000 deaths in two million traffic accidents. It is a safe bet that the figures have gone up since then. For lack of statistics, the amount of sick- ness resulting from accidents can only be guessed at, but many experts be- lieve that for each death there are several hundred non-fatal accidents, and maybe ten or so permanent dis- abilities. Many seemingly trivial accidents, such as falls, turn out in fact to be more serious, particularly in the case of old people. In New Zealand, 28,000 people are injured each year in vari- ous types of fall which cost the insu- rance companies about 12 million Dangerous ages In industrialised and "newly indus- trialised" countries, accidents are now the main cause of death among women aged up to 34 years and among men aged up to 44. Women again become a high-risk group after the age of 65. Young women mostly suffer in traffic accidents, and men in work accidents. Older women are prey to domestic accidents, usually falls resulting in fracture of the thigh. Socioeconomic costs In many countries, 20 per cent of hospitalisations on average are con- nected with accident injuries. In the USA—as in most industrialised coun- tries—accidents are the main cause of death during the first half of life, killing 150,000 people each year and injuring about 75 million. Of the in- jured, about 90,000 suffer head-injury in a car accident and require hospital treatment. Many are left with a perma- nent mental disability. Many others become juvenile disabled with some form of motor handicap—paraplegia or quadriplegia—and are marked for ever by their experience. Apart from the purely human aspects, the cost to society of road accidents in the USA in 1980 came to 2.6 per cent of the gross national product (GNP). Not lagging behind A recent WHO study shows that deaths from motor vehicle accidents are increasing in the 15-24 age group. Between 1955-59 and 1970-74 they increased by over 600 per cent in Mexico, 250 per cent in Venezuela and 210 per cent in Chile—a much greater increase than in the developed countries. On the other hand, deaths from other kinds of accident are rising quite slowly, or even standing still. dollars. Old people have a slower reaction time and are weakened by various chronic health problems (osteoarthritis, respiratory difficulties, cardiovascular disease). It is less easy for them either to avoid an accident or to get over it. The numbers of old people are of course increasing, especially in de- veloped countries but also elsewhere. They are faced with an environment —in town, on the road or at home— which is ergonomically suited to a population of young adults, and which involves risks that the elderly cannot always avoid. Home accidents account for about 75 per cent of injuries to people over 65 in the industrialised countries. Children, whose physical, sensory and psychomotor capacity develops only progressively, are also a vulner- able group. The other prime victims are adolescents ; the taking of ill- considered risks is normal behaviour for their age. Although accidents are linked to a certain extent with socioeconomic growth, they are not the prerogative of developed nations. They happen at least as often in developing countries, where their share in the general mor- tality is shooting up, both in absolute terms and in proportion to other causes of death. So far accidents ac- count for only a small percentage of total deaths in the Third World, but as other causes of death and disability —such as malnutrition and communic- able diseases—are gradually over- come, accidents will come to the fore. The developing countries are up against an additional problem, too. Whereas the industrialised world has had more than a century to adapt, more or less successfully, to the devel- opment of transport and other indus- trial technologies, the Third World is confronted with a much faster speed of change. In some countries the number of car-owners is doubling ev- by C. J. Romer WORLD HEALTH, November 1984 27 ery five years : improvement and ex- tension of the road network and maintenance facilities are incapable of keeping up with this diabolical pace. The same phenomenon of rapid increase can be seen in the often un- controlled commerce in hazardous substances (medicines, fertilisers, pes- ticides, cleaning products) which are now invading Third World markets, even in the remotest places. The in- adequacy of first aid, emergency, treatment and rehabilitation services aggravates the situation. For the same injury, mortality is often higher in developing countries. Accidents are more endemic than epidemic, and far from easy to stop. They are the product of many factors —physiological, psychological and social—originating as often on the per- sonal level as in the human or material environment. Psychological and social factors weigh heavily in the matter, as in the case of adolescent risk-taking. Cars, it has been said, come second only to firearms as instruments of violence. Whether or not this is true, the natural history of accidents—the sur- rounding circumstances, predisposing and determining factors—reveals no- thing but complexity and confusion. The accident is a multifactorial pro- cess. It calls for an intersectoral ap- proach to both prevention and care, hence WHO's global research and action programme on the prevention of acci- dents, begun in 1976. Under this programme, covering ac- cidents of all types, WHO has promoted data collection, country studies, re- search into the organization of pre- ventive and curative services, and manpower training activities. Many countries and other agencies with similar interests, national and interna- tional, collaborate in the programme. WHO's main objective is to help coun- tries integrate accident prevention into their primary health care policies, looking forward to Health for all by the year 2000. The accent is on partici- pation by individuals and com- munities ; collection and analysis of data on health or health-related tech- nologies ; use of these technologies in various cultural contexts ; inter- institutional cooperation for better use of national resources ; and tech- nical cooperation among developing countries. wHo encourages countries to set up national accident prevention and care Childhood is the age most vulnerable to accidents. This little girl had no idea that a plastic bag could asphyxiate her. Photo WHO/E. Mandelmann programmes. They should be based on sound epidemiological data that will not only indicate the true extent of the problem, but can be used to evalu- ate programmes and to make inter- national comparisons. Community health action has been defined as a professional, social or geographical group of people consid- ering their health problems together, deciding on priorities, and helping to identify, set up and apply the services that are most likely to resolve the problems. In accident prevention, community action—by employees or factory workers, schoolchildren, or neighbourhood families—is not only possible but quite irreplaceable. A community survey into the frequency and severity of accidental injuries, for example will show up the most com- mon risk factors, "black spots," the circumstances, and the long-term effects—details that a hospital investi- gation rarely provides. Safety instruction also begins in the community. The child assimilates it gradually, as its social circle widens from the family to relatives, district, village and school—the milieu of com- munity life, embracing both the hu- man and material surroundings (a bal- anced prevention programme must deal with both). The school, a com- munity where the child spends much of its time, is an ideal place for learn- ing " safety first ". In such a complex field as accidents, wHo needs support from other quar- ters. It supports and cooperates active- ly with innumerable governmental, inter-governmental and non-govern- mental organizations that share its preoccupation with accident preven- tion and care. Their capacities and interests vary widely, which is an extra advantage. Working together, coordinating our efforts is difficult, and it will take a long time to bring accidents, that scourge of modern times, under con- trol. WHO's concern is to ensure that accident prevention and care are inte- grated into primary health care. There is much to do, but much is at stake. For there will be no Health for all, neither in 2000 nor in 3000, if humankind cannot learn to master the sometimes dangerous consequences of its inven- tive genius. ■ 28 WORLD HEALTH, November 1984 LIFESTYLES No vaccine against road deaths by Akin Adebayo H istorically, epidemiologists have investigated the multitude of factors and conditions that de- termine the occurrence and distribution of such diseases as cholera, yellow fever, measles or tuberculosis in many developing countries. This approach has helped public health officials and organizations to control epidemic and infectious diseases in the developing countries through the application of modern medicine, better sanitation and immunization campaigns. In Nigeria, the last decade witnessed a dramatic decline in the number of deaths from communicable diseases (especially among adults)—but also an unprecedented increase in the number of people dying from automobile ac- cidents—a "disease of development". Accidents on Nigerian roads have reached such epidemic proportions that adults are more liable to die on the road than to perish from communicable dis- eases. Unlike communicable diseases, there are no immunizations against road accidents, and they do not respond to the antibiotics. Nigerian government statistics show that automobile fatalities climbed from 29,000 in 1979 to 32,000 in 1980 and 34,000 in 1981. Many thousands more people suffer permanently disabling multiple injuries or temporary dis- abilities resulting from traffic mishaps. Some years ago a group of experts compared motor vehicle accidents in tropical countries. Based on each 100,000 population, they found that Egypt had a motor vehicle accident rate of 0.1, Nicaragua 1.2, Burma 3.5 and Nigeria 13.7. In 1973, another study suggested that Nigeria and Uganda had the highest automobile fatality rates in proportion to automobile registration in the world. The preponderance of peo- ple in the middle-age group (31 to 40) involved in fatal road accidents makes the problem a grave and challenging one. It creates an enormous brain-drain on the productive resources of the country. A quick perusal of the obituary columns of Nigeria's newspapers underlines the alarming rate at which productive adults are massacred on the roads. The causative factors in these acci- dents can be explained in terms of the "epidemiological triangle "—the host, the agent and the environment. These three factors, namely the vehicle, the driver and the road, interact together to produce the road accidents. In Nigeria, the rapid increase in the frequency of accidents corresponds closely with the increasing number of motor vehicles (the host). The total Buses and trucks are more frequently involved in ghastly road accidents than private cars. Photo WHO/A. Khan number of cars in Nigeria in the early 1950s was 10,000. By 1977, it had reached 633,655. The driver (the agent in the "epidemiology triangle") plays a key role in the accident frequency and sev- erity in Nigeria. Commercial drivers, including chauffeurs, taxicab drivers, bus drivers, and truck operators are more frequently involved in ghastly road accidents than private car drivers. They are accident-prone for many reasons. They are relatively younger, single and less educated (if not completely illiter- ate); they often drive under the influ- ence of alcohol, manifest more nega- tive attitudes toward safety, and oper- ate vehicles which are unroadworthy. In contrast, private car drivers are a low- risk group because of their positive attitudes toward safety, and because their passengers are likely to be rela- tives and children. The distance travelled by the average Nigerian driver has increased tenfold since the last decade. Increasing mobili- ty results in the congestion of cars on our limited and narrow roads. Road construction has not kept pace with the unprecedented rate of automobile own- ership in Nigeria, and conspicuous road safety signs are rare. Young people of secondary school and college are more liable to die on the road than to be killed by communicable diseases. Not many years ago, a lorry full of university students plunged into a river, killing 15 of them and injuring many others. The toll of pedestrians (adults and children) has risen sharply in the past decade. Highly urbanised, thickly populated cities such as Ibadan and Lagos account for the great bulk of pedestrian fatalities. Accident rates are higher at night and at weekends. The automobile death toll reaches a peak in December, be- cause of increased driving at night, larger numbers of commercial journeys as a result of the Christmas rush, and the likelihood of less experienced and unlicensed drivers on the roads. Since Nigeria does not have a legal drinking age, the chronic drinking problem among teenage drivers exacerbates the situation. In an attempt to reduce the motor- vehicle death toll, the authorities are considering certain drastic measures. They include mandatory safety educa- tion for all drivers, stricter traffic laws, and a clampdown on drunken drivers, perhaps including random breath tests by the police. Drivers may be obliged to have health examinations, including eye tests. The inability of many drivers to see long and short distances explains the high incidence of head-on collisions in Nigeria. Regular medical examina- tions would also enable the authorities to spot those health problems that tend to increase accident risk, such as anaemia and tuberculosis. ■ WORLD HEALTH, November 1984 29 Photo WHO/J. Abcede Painful—but the blood sample is a vital test for sleeping sickness. ooe 000 000 000 000 se e 000 000 000 000 eee oeo OOOOO 0 000 • •• 000 *sow ••• ••• DG speaks out on population " It is people who matter", Early diagnosis of sleeping sickness African human trypanoso- miasis remains a permanent risk to the health and well-being of some 45 million people who live in the tsetse-infected re- gions of Western and Central Africa. Between 10,000 and 20,000 new cases of sleeping sickness are detected each year. One of the biggest prob- lems associated with the con- trol of the disease is that of identifying individuals who may be infected by the parasite, which is transmitted from per- son to person by the tsetse fly. Last November, an inter- national symposium on the diagnosis of African sleeping sickness was held in Antwerp (Belgium) under the auspices of the Antwerp Institute for Tropi- cal Medicine and the Biological Division of the pharmaceutical company Smith Kline—RIT. The two-day meeting was attended by specialists from 15 African countries where sleeping sick- ness is a persistent threat to the health of the populations, and from Belgium, France, Switzer- land, the United Kingdom and WHO. Researchers and clinicians successively reviewed the characterisation of Trypanoso- ma antigens, serological sur- veys and parasitological diag- nosis, and the detection of trypanosomes. They also ex- amined the experience gained in the field with newly de- veloped diagnostic tests such as the Card Agglutination Test (cArr) and the test based on indirect haemagglutination. The former is the simplest and easiest to perform. Devised and developed at the Antwerp Institute, it was subsequently modified by the producer with a view to its commercial diffusion for use in mass screening. It is easily carried out, on whole blood, plasma or serum, in the laboratory or in the field. Results are obtained within five minutes and are easy to read. The indirect haemagglutina- tion test was developed in Brus- sels several years ago and, in a modified form, produced com- mercially. It is used in the Re- public of Cameroon and Angola on a large scale. It requires a certain amount of laboratory skill and takes approximately one hour between sampling and results. Comparative trials of these tests under field conditions in six different countries proved prom- ising and seemed to suggest adequate sensitivity and reliabili- ty in both cases. Pilot trials by national health services are cur- rently under way in Cameroon, Central African Republic, Congo, Ivory Coast, Mali, Nigeria, Sudan, Togo and Bourkina Fasso (for- merly UpperVolta). ■ Dr Halfdan Mahler, Director- General of WHO, told the UN In- ternational Conference on Population, held in Mexico City in August, "Yes, people who can make or break their own development as well as the de- velopment of the community, the country, and for that matter the whole world in which they live. And to make that develop- ment they will need healthy bodies, healthy minds and healthy attitudes." According to Dr Mahler, a vital factor is all too often forgot- ten : people's energy. This ener- gy is needed in a world where 1,000 million people are still trapped in a nightmare of scar- city of goods and education, primitive housing, poor sanita- tion, malnutrition and disease, in a world of poverty and under- development where the death rate for women in childbirth may be 160 times higher than in the most privileged countries. In these conditions, the poorest countries cannot afford to wait to achieve the quality of life that industrialised countries reached in about 100 years and that resulted in a progressive decline of fertility. They must act now. Wise policy, national and in- ternational, is necessary to help people improve the quality of their lives. For the balance be- tween population size and the world resources is not just a matter of quantity, it is a matter of quality. And life would not be of quality without health. Dr Mahler went on : "Since we last met in Bucharest ten years ago a process has begun to take place in the field of health that could have a power- ful influence on human develop- ment, and that is what is popu- larly known as " Health for All by the Year 2000". This is a major policy decision of WHO•s Member States—representing virtually the entire world population—which declared in 1977 that a main social goal in the coming decades should be "the attainment by all the people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life". The Director-General stressed that family planning through the use of technically and cul- turally appropriate contraceptive means, complementing other culturally accepted means such as breast-feeding, "can lead to striking improvements in the health and well-being of mothers and children and in- deed of the whole family. For in all societies, the family in one form or another is the central nucleus for people, for their lives, their loves, their dreams, their health and their develop- ment. In keeping with this, the strategy for Health for All aims at ensuring that every child born is truly wanted and enjoys the best possible opportunity to grow into a healthy member of a decent and just society". ■ Simple books for solving problems Two recent publications from the London-based Appropriate Health Resources and Tech- nologies Action Group (AHRTAG) are How to look after a health centre store, by Anthony Bat- tersby, and How to work and Photo WHO/D. Henrioud The cold box keeps vaccines chil- led from laboratory to patient. make a cold box, developed by Anthony Battersby from mate- rial originally prepared by Paul Janstad. Their objective is to present the reader with clear and concise information, so that it may be easily understood by those for whom English is a second language. The choice of subject arose from observed problems. Once these problems were identified, the next step was to decide who was likely to be the person most able to use information to solve them. The first book is aimed at the manager of a health centre, which may range in size from a simple dispensary to a large health centre with some in-patient accomodation. In either case, the manager is responsible for all aspects of primary health care. 0.• 000 41 00 000 000 000 000 000 000000 *00 0041 000 000000 000 000 000 000 000 041411 000 000 000 *00 000 000 000 000 01,0 0041 000 000 00e 000 OOOOOO 000 *00 041000• 000 000 410• OOOOO• 000 000 WORLD HEALTH, November 1984 30 By contrast, the second book seeks to answer the questions raised by a programme man- ager in a country, and by those working in aid agencies who may be asked to donate cold boxes for the safe storage of vaccines. In each case, the as- sumption has been made that, firstly, English will be read as a foreign language and, secondly, the subject matter is not likely to be the Number One interest of the person reading it! For example, health centres are often the responsibility of doctors who are primarily in- terested in health. But they may also have to take responsibility for supplies—a job they are neither very interested in nor have any training for. The books aim to keep it simple, while at the same time making sure that all the major points are included. The clarity of the message is at least as important as the mes- sage itself. A good message that is not interesting is useless. These books use various means to make sure the message is understood. First, the language is kept simple, and where tech- nical words are used they are explained in an annex. Second- ly, pictures which are stylisti- cally consistent throughout are used to illustrate points, either to give them emphasis or to explain them more clearly. Thirdly, the density of print is low; there is not too much small print on each page and maximum use is made of sim- ple charts and text headings. Both books concentrate on how to do the tasks necessary to tackle the problems con- cerned. They are intended to be practical publications which will stand up to being used again and again. The simple but sound preparation of a store is essen- tial if supplies are to be safe- guarded in places where they will not be spoilt by the climate, eaten or contaminated by ver- min, or stolen. In the case of cold boxes, one of the most daunting tasks is to choose the right one, in terms of cost and performance. Both books are sold through Teaching Aids at Low Cost (TALC), P.O. Box 49, St. Albans, Herts., UK, at £3 per book plus £1.50 per book for airspeed postage and packing. The stores book can be supplied in a form that is directly reprintable by cyclostyle machine. ■ WORLD HEALTH, November 1984 Newsbriefs UNDP chief speaks on African crisis: Mr Bradford Morse, Adminis- trator of the UN Development Programme, has announced a package of proposals to help alleviate "the unprecedented economic and social crisis and unimaginable and unacceptable human suffering" in many African countries. The package calls for expenditure of more than US $90 million on about 100 projects in 31 countries. Widespread drought has devastated crops and livestock herds, caused famine, accelerated the spread of deserts and drastically reduced hydro- electric capacity. This move by the UNDP Administrator is in response to the special initiative on Africa launched by the UN Secretary-General, Mr Javier Perez de Cuellar. Setting the seal on the UN Decade for Women : The culminating conference of the UN Decade for Women, 1975-1985, will take place in Nairobi, Kenya, next July. Its main purpose will be to review and appraise the achievements of the Decade and to formulate strategies for the coming years up to 2000. The Decade has already played a significant role in encouraging women all over the world to become more fully integrated into national and international activities, planning and policies. Recession leans hardest on the Third World : The severe strain imposed on the social fabric of developing countries by the current world economic recession poses a serious challenge to the Interna- tional Labour Organisation (iLo). Mr. B. G. Deshmukh, Secretary of India's Labour and Rehabilitation Ministry, gave this warning earlier this year on being elected Chairman of the ILO Governing Body for a one- year term. ILO must help to ensure that policy packages which developing countries are obliged to accept do not result in massive retrenchment in the social sectors, Mr Deshmukh said. It must also contribute to the avoidance of social tensions, strikes and conflicts. Experts meet on viral hepatitis. A WHO Technical Advisory Group met in Geneva in July to review the Viral Hepatitis Programme and advise the Organization on priorities in services and research. The group comprised experts in clinical medicine, virology and epidemiol- ogy from each of the six WHO regions. The experts noted that safe and effective vaccines against hepatitis are already available and vaccines against hepatitis A are under development. Vaccination of high risk groups against hepatitis B is at present practised in many industrialised countries. Since the vaccines on the market are still expensive, the Technical Advisory Group stressed the need to increase the production of hepatitis B vaccines, to reduce their cost to a level which developing countries can afford, and to support research into alternative methods of vaccine production. More research is called for in the fields of information exchange, training and the production and distribution of diagnostic reagents. And pilot studies are needed in countries where the disease is common, in order to develop the best possible vaccination strategies and to evaluate whether vaccination can eventually be incorporated into WHO's Expanded Programme on Immunization. The Technical Advisory Group recommended that WHO should develop programmes to stimulate the local or regional production of vaccines and diagnostic reagents, should assist in training the person- nel required, and should seek extrabudgetary funds to accomplish these objectives. The Group plans to meet next year to review progress. In the next issue Schistosomiasis, a parasitic disease, is second only to malaria in terms of its impact on socioeconomic conditions and on the health of poor agricultural families in 74 tropical and sub-tropical countries. Recently, however, the development of simplified diagnostic 'tech- niques and of safe and highly effective drugs has opened the way to a new realistic strategy for schistosomiasis control, to be reviewed in the December issue of World Health. Authors of the Month Mr John WICKETT is a Consultant with WHO's Smallpox Eradication pro- gramme and was formerly a Technical Officer with the programme. Dr Martin ABRAHAM is a Research Officer with the Sahabat Alam Malay- sia (Friends of the Earth), a non-profit- making nongovernmental organization, in Kuala Ketil, Kedah, Malaysia. Mr Julio C. DuRAN is a Bolivian free- lance writer currently working for the Spanish community in the Washington D.C. metropolitan area, USA. Mr Russ MANNING is a writer and editor with Oak Ridge Associated Univer- sities, Tennessee, USA. Mr Jitendra 'Tut,' is Information Officer for WHO•s Regional Office for South- East Asia in New Delhi. Mr Peter Ozomo is a Programme Sup- port Officer and News Page Editor of World Health with WHO's Division of Public Information and Education for Health in Geneva. Dr Viatcheslav ALEXEEV is Chief Medi- cal Officer for Health Manpower Man- agement, in WHO•s Division of Health Manpower Development, and Igor Rozov is a Programme Support Officer with the Division of Public Information and Education for Health. Dr Donald R. HOPKINS is Assistant Surgeon General of the USA and Assistant Director for International Health at the Centers for Disease Control, Department of Health and Human Sciences, Atlanta, USA. Mr Stephen BADZIK is an information officer with the Public Information Di- vision of UNRWA (the UN Relief and Works Agency for Palestine Refugees) in Vienna. Dr C. J. ROMER is Manager of the Global Programme for Accident Pre- vention at WHO's Regional Office for Europe in Copenhagen. Mr Akin ADEBAYO is Research Assis- tant with the Department of Sociology, Kansas State University, USA. WORLD HEALTH For readers everywhere 1984 Subscription Rates US$ Sw. fr. One year 12.50 25.- Two years 22.50 45.— Three years 30.— 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 sub- scription agencies. For payment in national cur- rencies, please contact your usual bookseller. a 7,, or, like Smallpox is de, • m , a we • • y li this woman in Zaire, are totally blind. See page 3. Photo WHO/C. A,gan