Nursing [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • DECEMBER 1978 • USA $ 1.25 NURSING ursing, like medicine, has for far too many years been predomi- nantly oriented to meeting the needs of the privileged few. It is too late at this point to argue why and how this situation came about. What is more important is the need for all health workers, especially the professionals, to recognise and confront today's reality: the fact that the urgent health problems of the majority of the people relate to poverty, to infection, to malnutrition and undernutrition, to the lack of po- table water, and to multiple environmen- tal hazards. History has shown that such basic threats to health as these are un- likely to be countered by conventional health service techniques, however sensi- tively and intensively they may be ap- plied by whatever category of health worker. If the needs of communities are to be met, the ranks of the health workers, in- cluding nursing and medical personnel, will need to consist predominantly of people who genuinely care about the health and welfare of impoverished com- munities, who want to help such com- munities, who are willing to learn what has to be done, and who can not only do it, but do it without dependence on sophisticated and costly technology. To those who ask whether the "world needs nurses", my answer is that billions of people need health services and care, no matter what we may call the respec- action for change in nursing by Dr Halfdan Mahler Director-General of the World Health Organization 2 A male nurse attracts an attentive audience of village women in Guinea-Bissau. (Photo WHO/Guinea-Bissau Health and Welfare Ministry) tive collectivities needed to promote such care. If those who are now called nurses, or will be so called in the future, are will- ing to confront the formidable challenges implicit in primary health care, and to acknowledge primary health care as the medium for achieving an acceptable level of health for all people in the foreseeable future, then the world does, indeed, need nurses. It needs nurses who can diagnose community health problems and insti- tute measures to protect, advance, and monitor the health of populations as a whole, nurses who can care for the sick or the disabled, nurses who can teach people to care for themselves. What this means is that the world needs many more nurses than the esti- mated four million now in action through- out the world. It also needs many more nursing auxiliaries, who are estimated to be about double the number of the qualified nurses. The fact that only 15 per cent of the qualified nurses of the world work in developing countries, where 66 per cent of the world's popula- tion live, is a factor to be taken into ac- count when plans for health develop- ment in the developing countries are be- ing drawn up. This issue of World Health highlights just a few aspects of the work of nurses in different corners of the globe. ■ Cover: A veil still ./ ,' hides this nurse's face. But women,' ,1:1; ' and the nursing . 11: , .. profession, are changing their im- .4' ' age in the Eastern ...... /a ,. Mediterranean. ..„,. See page 4. (Photo WHO/J. Mohr) 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: Lalit Thapalyal World Health appears in Arabic, English. French, German, Italian, Persian, Portuguese, Russian and Spanish. 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 Action for change in nursing by H. Mahler . 2 A changing image by A H Taba 4 Nursing in Africa by V. Bailey & E. Barton . 8 Community care in the Caribbean by G. Allman-Burke ...... 10 Learning to care by M. Skeet 14 Thirtieth Anniversary: Human Rights Day 16 Care of the elderly by D. Norton 18 Where there's need by J. Bland 22 New look for rural health by F.N. Aguilar 26 Red Cross nursing : born on the battlefield 29 News Page and Index. 30-31 3 a changing image Fifty years ago most professional nurses in the Eastern Mediterranean Region were expatriates. Today, the vast majority are nationals. Every country has its own Schools of Nursing and each year 30,000 nurses graduate from the 500 schools scattered throughout the Region by Dr A. H. Taba ge he antiseptic mask is replacing the yashmak in the Middle East as national health ranks swell with nurse pioneers in countries where women once made motherhood their sole vocation. Barely 25 years ago, a preliminary study of the possible contribution of women to health promotion in the area concluded that a strong commitment to any activity or career other than that of housewife was rare. Since then, educa- tors have increasingly pressed the argu- ment that girls should be educated to do more than bring up their children—and the advice, in a society already undergo- ing many changes, is being listened to. Recently, a nurse-tutor who graduated on a wHo Fellowship commented "Our mothers are just as intelligent as we are, but something was missing : they did not ask for what we are asking for. They made motherhood their sole vocation. We are looking for ways to make social contributions, in public health, as in other fields". Nevertheless, nursing as a profession is new to most Middle Eastern countries. Almost as new is the idea that women should have a vocation other than child- rearing. The pressures of tradition and custom have long denied them the right to take up a profession and to participate in society. And because women were not available for work in the health services, many nursing duties in the area were car- ried out by men. Male nurses still form part of the health manpower force in many coun- tries, sometimes being referred to as health assistants, medical orderlies or dressers. Often they work in remote areas where they cover difficult terrain to reach those families in need and where they provide continuity of health cover- age as their careers are not interrupted by marriage and motherhood. Nursing is, however, a predominantly female pro- fession and many traditions and customs had to be overcome before nursing care was to reach the majority of people, es- pecially those women forbidden by social taboo to consult male health workers. Now many young women are anxious to have a career and a large number of them are joining their country's nursing service. For some this represents the ful- filment of a life-long ambition which began when they saw a sick relative or friend nursed back to health. Others have realised that nursing education is further education. Some have entered the profession against the advice of relatives and neighbours who have "told them stories of the sort of lives girls lead at big city hospitals". These pioneering women were usually daughters or wives from emancipated families who had received their educa- tion abroad. Often they had to take their nursing training away from their own countries also. But on their return they not only became the nurse leaders in their own countries, they also helped to convince families that nursing gives young women the opportunity to help others and the chance to enrich their own lives. Thus, through face-to-face meet- ings, group discussions, through the mass-media, slowly they were able to persuade parents to allow their daugh- ters to enter the profession. wHo Nursing Advisers also were constantly in search of more recruits and more 'potential leaders'. In addition, the profession has become recognised in its own right large- ly due to the support and involvement of influential people outside the profes- sion—particularly the wives of national leaders. Now, nursing is recognised as a worth- while occupation and holds its rightful place among the health professions. In virtually every health programme—in hospitals, in health centres, in home care and school health programmes, as well as in industrial establishments, nurses perform a wide range of health tasks. Early training programmes admitted girls with the minimum of educational qualifications and in addition to learning nursing skills, these students also conti- nued with their general education. Today, in countries such as Egypt, Iran, Iraq and Lebanon, general education for girls is well established and several nursing programmes have moved to Universities. In others—Democratic Yemen, Jordan, Pakistan and Sudan—nurse training pro- grammes require that girls have nine to twelve years general education before ad- mission to Nursing School, and Universi- A veiled patient consults a nurse—in modern cap and gown—at a school of nursing in Iran. (Photo WHO/P. Boucas) 4 d .; • ty programmes are being promoted in order to prepare nurses for leadership positions. Saudi Arabia, one of the strongest adherents to Islamic tradition, has initiated two University-based pro- grammes for nurses and is well on the way to producing its own nurse-leaders. The earlier training programmes for men continue, sometimes in separate Schools or classes. In a few countries, in order to make optimal use of their lim- ited number of qualified tutors, young men and women students learn together. But these programmes can run into dif- ficulties, and families of the girls must be assured that discipline will be strict. Usually it is: in one country recently a male student who tried to hand a love- letter to a female colleague was instantly expelled. Whilst careful selection and relevant education are vital to the production of good nurses, it is through their activities that the new graduates contribute to the health care of the people, and the majori- ty are responsible and well-motivated practitioners. In one country, a little while ago, because there were no funds to pay their salaries, all nurses worked for one year without financial support beyond that supplied by their families. The traditional 'protective' attitude to women, however, means that on occa- sions leniency is shown towards less re- sponsible actions. In another country, for example, it is accepted that a nurse will sometimes find that her home duties are more pressing than those in hospital: she is not expected to come to work if visitors arrive at home! Perhaps it is because of such cultural heritage that nurses in these countries have often carried out their assigned duties conscientiously—but also without questioning their value. Now, a growing number are querying the "why" of nurs- ing rather than just repeating the "how", and, as a result, they are seeking new ways to make more effective the care they are offering their patients. In Soma- lia, for instance, nurses undertook studies to evaluate the maternal and child care provided. By systematically questioning mothers about the deaths of their children, they discovered that 40 per cent died before the age of one year Above: Ouch! Nurses at a hospital in Demo- cratic Yemen delicately adjust the traction on a patient's injured leg. (Photo WHO/N. Wheeler) Right: A community auxiliary nurse takes careful notes in the course of her house-calls in Afghanistan. (Photo WHO/Afghanistan Health Ministry) and, of these, half had died of neonatal tetanus. This had not been recognised previously and such data had a signifi- cant effect on the planning of MCH ser- vices for that country. Other projects have included studies on the utilization of nurses as well as on various aspects of health care. Some have shown that when nursing education programmes are based on patterns from other countries, often they have not pre- pared graduates for the skills they have to be able to perform and neither have they given them the knowledge they have required. For instance, hours may be spent on learning anatomy in the ab- stract instead of studying the develop- ment of children in the country itself, 6 and subjects such as hospital dietetics may concentrate on regimes never imple- mented whilst the local causes of infant malnutrition are ignored. Such examples show the need for relevant programmes in nursing education. Many countries in the Region are ex- perimenting with training programmes during which nursing students learn alongside other disciplines: such Train- ing Institutions for Health Personnal are in existence in Bahrain, Democratic Ye- men, Somalia and Yemen. In Jordan, also, nursing and medical students take some of their lectures together, and in Schools of Public Health in Egypt, Iran and Lebanon, all professionals, includ- ing nurses, study together. It is hoped that by doing so they will find it easier to work together. In Sudan, new ap- proaches have very direct and practical application. Community nurses go into the villages to learn the attitudes of the people and their leaders towards the health care being provided. The aim is to make it acceptable to the people being cared for. wHo has long felt that without well- qualified teachers no consistent improve- ment in health care can come about, and as a result has given particular emphasis to this aspect of training. The first post- basic nursing programmes in the Region were for nurse-teachers. But tutors form only one element in any training pro- gramme. Nursing education in the East- ern Mediterranean countries has long struggled with the problem of having textbooks written in English for students whose only language is Arabic. Illustra- tions, slides and films all show other cul- tures or the different situations of other countries. This is being slowly remedied. Syria, for instance, has its own closed circuit television so that students are able to watch themselves performing, whilst through tape or cassette recorders in many Schools, nurses can hear their own health education talks before they deliver them to families. A project in Cairo which seeks to prepare learning material in Arabic, based on Egyptian examples, will produce material which can be used there and in other Arab countries. Other countries are laboriously preparing their own texts or translations of well-known textbooks and in this way nursing know- ledge will be made available to their nursing students. Fifty years ago most professional nurses in the Eastern Mediterranean Region were expatriates. Today the vast majority are nationals. Every country has its own Schools of Nursing and each year 30,000 nurses graduate from the 500 Schools scattered throughout the Region. Yet there is an overall shortage of these professionals. Their distribution is uneven and there are still wide geo- graphical areas without any. More Schools are opening, but different ways of using the skills of nurses must be sought in order to meet the overwhelm- ing need. Every manpower resource needs to be used : family, friends, and colleagues: one midwife can increase the care she gives to mothers tenfold—with the help of traditional birth attendants working with her. The real hope for the future lies in the nurses who are now taking an active part in the lives of their countries and who are seeking every way to improve the nursing care they provide. ■ 7 nursing in Africa by Vernon Bailey and Elizabeth Barton he African Region of WHO stretches across forest, sea and des- ert from Lesotho and Madagascar in the East to Mauritania in the West. Health problems are many, serious and often of endemic proportions. Thir- teen of the poorest countries in the world lie in this Region, and the majority of the populations of all countries lack, to a greater or lesser degree, those basic ele- ments that permit people to grow and develop physically, socially and mentally —food of sufficient quality and quantity, potable water and basic sanitation, adequate shelter and housing, education, adequate income—and health care. Sixty-five to 90 per cent of the popula- tions live in the rural areas and from 60 to 85 per cent have no access to health services. It is against this background that the nurses go about their daily round. The health sector alone cannot im- prove health, and socio-economic devel- opment cannot take place, without health development. It is the growing recognition of this fact that is bringing about change in health programmes and in the activities of nurses and midwives. These professionals must work and col- laborate more with communities, fami- lies and other workers beyond the health sector—with community leaders, reli- gious leaders, agronomists, teachers and others at the local as well as the national planning level. Nurses are frequently the key people of the health service in rural areas, although the system also includes traditional healers and traditional birth attendants, particularly in areas not reached by organized health pro- grammes. The day begins early in rural Africa and, as soon as the sun is up, people wend their way to the Dispensary or Health Centre, often walking long dis- tances, to wait patiently for treatment, for relief of pain. This has been, and in some countries still is, the main task of the nurse—to assess symptoms and treat disease, and when necessary to refer patients to hospital. At the same time, however, the nurse has been a counsel- lor, friend and support to families even if he or she has received little formal train- ing in this field. African countries differ in their cul- tural, social and political systems; never- theless nurses face many similar prob- lems and enjoy many of the same ex- periences. It would be tempting to write of these joys and sorrows, of anxious hours spent waiting for help to transport a sick patient to hospital, of hopeless or hilarious moments digging the Land- rover out of the mud, the feeling of ela- tion when a programme is successful—as after the hard and often frustrating task of working with communities trying har- moniously to bring about change in child feeding habits and thus combat malnu- trition. But it is to the present and to the future that we must look, building on the positive experience of the past. Nurses, and indeed all health workers in Africa, are redirecting their energies, participating in national and local efforts to improve and extend health care to all the people. To educate, prepare and maintain a registered nurse is an expen- sive outlay for countries whose per capi- ta income varies from US $90 to US $250 per year. He or she must therefore be uti- lized to the maximum capacity—training and transferring many functions to other health workers as well as to families and communities, who are the most impor- tant resources in health development and health care. In the African Region, nurses have to function in a truly polyvalent way, per- haps more so than in other regions. Med- ical officers are few, and mostly located in cities. So nurses are not only carrying out the bulk of the work in all health in- stitutions, but are also to be found directing national programmes in MCH, health education and nutrition, and they form the backbone of many other ser- vices such as tuberculosis and leprosy control, mental health, medical records and health statistics, immunization pro- grammes and—last but not least—pri- mary health care. African nurses may be met on radio and television programmes, in school health services, and even on horseback visiting outlying villages where other members of the health team seldom or never go. Nurses are to the fore in every health institution and their work and influence spread wide and deep, including the health planning and evaluation processes, and they outreach to the community. They likewise play a major part in teaching programmes, not only for nurses and doctors but also for health auxiliaries and frontline workers of many kinds including social workers, teachers, community health agents and district or village officials These points may be well illustrated in the case of Botswana. There we see nurses not only as the principal actors in the development of hospitals, mcH and peripheral health services, but also as key agents in several specific fields including : mental health; general health clinics (the Francistown Town Council Health Clin- ic for instance is entirely staffed and run by nurses and auxiliaries); MCH services including family spacing (nurse-mid- wives with special aptitude are trained to carry out gynaecological examinations and Kip insertions); training of all categ- ories of health personnel, especially at the National Health Institute (where 377 registered and enrolled nurses were trained up to July 1977 and where quali- fied nationals are now being appointed as teachers to replace expatriates—a big step in the struggle for self-reliance); and health education and nutrition pro- grammes. Nutritional activities, for example, are carried out principally in the framework of MCH programmes. They include the usual individual consultations, as well as group education by discussion and food demonstrations. Some special activities of interest include a nutrition rehabilita- tion centre directed by a nurse in Gabo- rone, and the national nutrition surveil- lance system. Throughout the country children are regularly weighed in health clinics and 8 A community nurse in Ethiopia. Nurses are frequently the key health people in rural areas. (Photo WHO/E. Schwab) the results are plotted on an individual chart of weight for age. The growth curve is used to show the mother whether the child's growth is satisfactory or not. So far this is nothing new, and in the past, that was the only use to which the information was put. Since January 1978 however, under the direction of the nutrition unit (whose head is a nurse), the data are systematically collected in each health unit from all the children brought to the clinic during one week in each month, are plotted on a single chart, and are then forwarded to the Regional Health Office and ultimately to the Bureau of Statistics. The percentage of underweight children is calculated and compared with the figure for the pre- vious month. The data are consolidated and analysed by geographical zone and in comparison with previous records at the National Statistics Office. This nutritional surveillance system has already enabled the Government to pinpoint some problem areas and will facilitate identification of any emergency problem which could develop. Seeing the importance of this, the Rural Extension Co-ordinating Committee (a policy advi- sory body to the Cabinet) has requested the nutrition unit to produce a compre- hensive report on nutritional surveillance in Botswana by January 1979. Thus we see this surveillance system as a vital ele- ment in national development, and it is the nursing services which are respon- sible for its functioning. The image of the nurse as merely a provider of care and treatment is chang- ing, whether in hospital, urban health centre, or rural district. His or her role as a provider of health care remains pri- mordial, but is directed to those patients and clients whose condition or need for investigation exceeds the competence, or is beyond the resources of, a less quali- fied worker. The nurse is becoming more and more a planner of services within the local area, an organizer, a supervisor, a teacher, the supporter of auxiliary health personnel and community workers, and the collaborator with health and other workers in a concerted effort for health development. Many problems remain to be solved, and resistance to change from several quarters has to be overcome, but what is happening in Botswana can be repeated in many African countries. A quiet revo- lution has begun. Nowhere is nursing more challenging or more interesting than in Africa today. Nurses are emerging to play a political and executive role in the health system. In one country, the Deputy Minister of Health is a nurse, and in another the As- sistant Chief Planning Officer at the Ministry of Health is a nurse. In several countries, nurses are members of the National Assembly, while at district level in many countries, the nurse is frequently the senior health official, working in har- mony with the community to form the backbone of the health system. As health programme planning and management become a multi-discipli- nary process, as greater support to health workers in rural areas is ensured, and as learning is seen more and more as an es- sential component of health develop- ment and not an end in itself, and if the revolution goes far and deep enough, we will reach our goal by the end of the century of making health care available to all. ■ 9 community care in the Caribbean The Caribbean community nurse is the most accessible and available member of the health care team, and provision is often made for her to live in the community where she works by Grace Allman-Burke L ursing personnel constitute the largest category of health workers in the Caribbean territories, and therefore shoulder the greatest burden for the delivery of health care to the population. After they complete their basic nursing and midwifery education programmes, nurses are fitted for work in their communities where they have to meet the basic health care needs of indi- viduals and families. After further preparation in courses of study in community health, they are ready to take on leadership roles in the delivery of care to the wider community. This in turn prepares them to supervise the work of all categories of community health nursing personnel, who may in- clude midwives, nursing assistants, com- munity health aides (general and specia- lized), and traditional birth attendants— wherever the latter have been identified and trained. In addition, the community health nurse collaborates and coordi- nates her work with other members of the health care team, including physi- cians, dentists, public health inspectors, nutritionists, health educators and mem- bers of the community itself. As is the case elsewhere, the rapidly growing trend in health care in the Caribbean is toward strengthening of community-based care, and the develop- ment of activities related to community participation in health programmes. This trend brings the work of community health nurses sharply into focus, since they are a vital link between the commu- nity and the organized health care deliv- ery system. The community health nurse in the is- lands of the West Indies carries out a variety of functions, a major portion of which are related to the delivery of pri- mary health care. This is true, for in- stance, of maternal and child health care, which in the Caribbean context means ante-natal, childbirth, and post-natal care; family planning; child health ser- vices, including immunization against communicable diseases, attention to mal- nourished children, care and treatment of selected illnesses in children, and preventive aspects of care to infants and children of pre-school age; school health services, including screening for physical defects and medical problems, immun- ization, dental education, nutrition counselling, and family life education. Then there is the investigation of com- municable and infectious diseases, and the carrying out of programmes of care and education for their control and pre- vention. Special attention in the Carib- bean is devoted to control of gastroen- teritis (especially in children), sexually- transmitted diseases, and diseases that are endemic in the area such as worm infestation and dengue fever. The community health nurse also pro- vides health education to the public, par- ticularly with reference to nutrition, en- vironmental sanitation, and personal hygiene, and offers first-aid treatment of accidents, injuries, and other emergen- cies, particularly in rural areas. She also takes care of the adult population, espe- cially the elderly, with their attendant 10 ... If the nurse has lived in one community for a long time, she has probably delivered most of the infants in the neighbourhood. She may even have delivered the infants of those children when they have grown up ... (Photo WHO/E. Rice) health care problems of a more chronic nature. The most frequently seen medical conditions in the Caribbean area among this group are diabetes, hypertension, and heart disease. Each Caribbean territory has built up a network of health centres and health posts, to which community health nurses are attached. These dedicated health pro- fessionals are the major providers of maternity care in both urban and rural areas. They begin to care for their patients from the early stages of preg- nancy, and continue their care right through the birth of the infants, and pro- vide the post-natal follow-up as well. Several of the territories offer domici- liary or home delivery services for select- ed patients, and these services are pro- vided by district nurses and midwives. These home contacts encourage the development of warm and close relation- ships between nurses and patients. They also create the opportunity for the health of the entire family to be monitored, and for the provision of health information and counselling. If the community health nurse has lived in her work location over a long period of time, it is very likely that she has delivered the majority of infants in the neighbourhood. Many of the more senior nurses have even had the privilege of delivering the infants of those chil- dren, who have grown up to become parents in the same communities. In fact they carry out virtually all child health care, particularly the preventive aspects. They also monitor growth and development, and refer more serious health problems to the supervision of medical and social services. Caribbean community health nurses recognize that the future development of the territories is intimately linked with the mainte- nance, today, of the best possible health status among its junior citizens—the most vulnerable group within the popu- lation. So they take special care to follow up those youngsters who have been ad- mitted to or discharged from hospitals for curative care. In several of the smal- ler Caribbean Islands, there is one main general hospital, usually located in the capital city. In most cases, a community health nurse visits the hospital daily to check on the status of patients referred there, especially children. They also ar- range for their home care after discharge. In the larger countries, there are usually more comprehensive systems for main- taining close contact between hospital and community nursing services. Health care for the elderly has as- sumed much greater importance in recent years, as an increasing number of people enter this age group within the population. With improvements in the standard of living, basic sanitation, and the quality of life in the Caribbean area, and with the increased dissemination of health information and greater avail- 11 ability of more comprehensive care, the elderly have begun to take up a greater percentage of the community health nurses' time than hitherto. More fre- quent contacts with the health system, resulting from the more chronic nature of their health problems, mean that warm and sustained relationships fre- quently develop between nurses and their elderly patients. In many cases, district health centres provide more opportuni- ties for social activities among the elder- ly, and have served as focal points for group health teaching by community health personnel. In addition to caring for the elderly, the West Indian community health nurse provides major services to the other seg- ments of the adult population as well. These services include, among others, family planning care, mental health care, participation in dental and visual care, attention to medical emergencies, im- munizations, and general health educa- tion. In the context of health education, increasing use is being made of the mass media by Caribbean community health nurses so as to ensure that health infor- mation reaches the general public. Along with other health educators, they have produced and/or participated in radio and television health programmes that reach wide audiences. As members of voluntary citizens' groups and village committees, they have also been able to motivate various segments of the com- munity to participate in health-related activities. They are frequently the cata- lysts for self-help action, such as building or re-fitting health centres, and encou- raging indigenous community leaders to provide the local population with health information. The Caribbean community nurse is the most accessible and available member of the health care team. In a number of ter- ritories, provision is made for her to live in the community in which she works. She is thus available on a 24-hour basis for service, when called upon. In semi- urban and rural areas, the entire village knows where the nurse may be found and where care and advice may be ob- tained. Some nurses have organized their working hours in such a way as to enable them to hold clinics during the evening, for the greater convenience of patients who are out at work during the day. Home visits are a major responsibility of these trusted health workers, and they know almost every resident of their com- munities. They are aware of those citizens who need closer health supervi- sion, and more sustained follow-up. In most territories, the health centres tend to be located within a two- to three-mile radius of the furthest village population. However, in those countries with exten- sive rural areas, the distances may be much greater. Home visits can be made by car in many islands such as St. Lucia and St. Vincent but, in the more moun- tainous and densely forested areas of is- lands like Dominica, the nurse may have to travel by jeep or walk long distances to reach the homes of her patients. Some countries send mobile units out into their rural areas to bring health information to the public. Here nurses function as part of the health education teams, espe- cially in remote villages and hamlets. The Caribbean area does not consist solely of islands, but includes territories on the South American continent. Some of these countries have vast but sparsely populated and remote interior areas, where community nursing personnel also 12 community care in the Caribbean Left : ... Throughout the Caribbean, community health nurses have ably demonstrated their capacity to expand their role to include func- tions traditionally carried out by doctors ... Right: ... She is a trusted health worker available, accessible, and acceptable—able to motivate her community towards participating in plans for meeting its own health care needs ... (Photos WHO/E. Rice) function. These nurses are far removed from the resources available to those who are based in urban areas. The scope of their responsibility is therefore often much broader in order to meet the needs of the people they serve. Throughout the Caribbean, for several years, community health nurses, particu- larly those in the rural areas, have ably demonstrated their capacity to expand their role to include functions tradition- ally carried out by doctors. At present, educational programmes are being devel- oped and implemented in the Caribbean which will formally prepare nurses for these expanded functions. Most of these courses place special emphasis on meet- ing the total health care needs of children and families. There has been wide com- munity acceptance of these nurse practi- tioners. Today, the community health nurse in some Caribbean territories is being as- sisted by a new category of health work- er, called the Community Health Aide. These workers have been very helpful to the nurses in undertaking home visits, helping to disseminate simple health information, and referring patients to other levels of health supervision. Some countries employ these personnel in such specialized programmes as family plan- ning and nutrition. In other cases, they carry out general duties as assigned by the community health nurse, after a period of training. The training pro- grammes are usually carried out in the individual countries with a special eye towards local health.care needs, and gen- erally average 6 to 12 weeks in duration. Many territories have developed com- munity mental health services, staffed by nurses with additional educational prep- aration in this clinical field. These ser- vices have evolved in keeping with the trend towards encouraging the early return to the community of persons who have been hospitalized for psychiatric care, and the emphasis is on preventive aspects of mental health. In keeping with the move towards in- tegrating curative and preventive activi- ties, the community health services are being reorganized so as to provide more comprehensive care to their citizens. Some countries have developed networks of multi-purpose clinics or polyclinics which are sited in selected areas, often within the main general hospital, thus making available resources for meeting the total health needs of persons in one single setting. Some of the larger territo- ries have designed several types of health care facilities, ranging from the simple to very complex, depending on the prevail- ing health care needs and levels of care to be provided; community health nursing personnel are found in all of these set- tings. In summary, the community health nurse is making a major contribution to the delivery of health care in the Carib- bean area. She provides care in a variety of settings and attends to the needs of all segments of the population which she serves. This disseminator of vital health information develops warm and friendly relationships with those to whom she ministers, and often travels long dis- tances to reach those who require her as- sistance. Her focus of care is on individ- uals, families and the community at large. She is available, accessible, and ac- ceptable. She is a trusted health worker, able to motivate her community towards participating in plans for meeting its own health care needs. ■ 13 mong the many changes currently affecting the health professions, perhaps one of the most far- reaching is the orientation of training to meet the demands of emerging national health programmes in a practical and realistic way. Over a period of years wHo has assisted in organizing a number of nursing semi- nars and workshops that have focussed on the need for basic health services and for relevant nurse training. Many attempts have been made in the past to adjust the education of nurses to meet the priority needs of rural communities, but for var- ious reasons these attempts have rarely succeeded. Obstacles have included a lack of understanding of what was required and a resistance to change from tradi- tional patterns even when the needs were identified. But changes are now coming about; some of them rapidly. The health situation and problems of South-East Asia are those of many Third World countries; high infant and child mortality rates; parasitic diseases; com- municable diseases; malnutrition ; poor sanitary and environmental conditions; illiteracy and poverty. For a large propor- tion of the rural populations living with these problems, the main providers of health care are the staff of remote health centres and mai clinics, or the local private practitioners including large numbers of traditional healers. In recent years several countries have given emphasis to preparing multi- purpose personnel to work in those re- moter villages: some, for example, have broadened the training of midwives to include community health, family plan- ning and general nursing care. Throughout the Region, nurses are involved in training and supervising the many categories of auxiliary staff and vil- lage workers which have been mobilized to assist them. WHO and national nurses have worked together to prepare manuals and other learning material for this level of health personnel. The adoption of the primary health care approach has placed other new de- mands on nurses. Curricula in nursing and midwifery have been revised, giving priority to community health nursing in both basic and post-basic programmes. In Thailand, for instance, nurses are now being prepared to become nurse practi- tioners responsible for running health centres and undertaking primary health care in the country's rural areas. Experimentation with several new approaches to rural health undertaken by nurses and midwives have received atten- tion and support in Indonesia. Of parti- cular interest to teachers, and an event which greatly enhanced the acceptance of change in the nursing education system of that country, was the opening of the Cilandak Teacher Training School in 1972. The field programme, initially covering four villages in Cilandak, pro- vided students with the opportunity to work with, and learn from, the people by : helping to identify community groups; promoting community participation in planning health care; training interested community mem- bers to become health volunteers and to carry out health activities such as nutri- tion classes; improving the sanitation of the envi- ronment by assisting community mem- bers in building latrines, wells and rub- bish pits as well as in improving their homes; and teaching self-care to families so that they may safeguard themselves. The people of Cilandak, the students, and the teachers all acted together as a single community. No set theoretical course was defined for the students be- forehand ; problems and requirements in the field, as felt by the community and seen by the students, were used in decid- ing the curriculum. Thus, the theoretical part of the programme was devised to answer needs in the field and to help the students understand the activities invol- learning to care Throughout the South-East Asia Region, nurses are now involved in training and supervising auxiliary staff and village workers involved in community health care by Muriel Skeet 14 ved. Theory became relevant to future roles and tasks. The teachers planned their teaching programmes with the stu- dents, and the students evaluated the teaching they received. The climate of the school was characterized by trust and openness, and gathering and storing of relevant information, the sharing of goal- setting and of work, the improvement of technical knowledge, and evaluation—all in cooperation with the community itself. At the same time the nursing education structure and the existing nursing person- nel system were being studied in the light of the increasing value attached to health and a growing social consciousness. An analysis of the tasks and functions re- quired at the community level showed that nurses and midwives were not trained to perform these tasks and func- tions, and often had to learn them through trial and error. Moreover, they were being taught procedures which were irrelevant to their work in the community. This analysis enabled priorities to be set in terms of what needed to be done, at what level, and by whom. It also revealed that what was required was not the cre- ation of a new category of personnel but a reduction in, and an amalgamation of, existing categories; tasks and functions needed to be defined more clearly, and educational programmes had to be de- Weighing a new-born baby: a nursing class in India. Training in South-East Asia reflects the new approaches to rural health care. (Photos UN/WHO and WHO) signed to impart the necessary skills and knowledge to two categories of nurse— the primary health nurse, or Perawat Kesahatan, and the university-educated nurse. These new programmes will be continually reviewed in terms of validity, viability and significance. To achieve better planning and man- agement of nursing programmes through- out the Region, wHo has also given assistance in the field of nursing research. Activity studies have been undertaken not only in Indonesia, but also in Thai- land, India and Sri Lanka. In 1976 a nursing research project was established at the Rajkumari Amrit Kaur College of Nursing in Delhi, to train nurse educators and administrators in India in applied methods of nursing research. A follow-up workshop, sponsored by the College and wHo, took place ten months later, at- tended by the same group of senior teach- ing staff. These particular workshops provided an example of the technical cooperation and assistance which developing coun- tries can provide for each other. A subse- quent publication on Nursing Research gave guidance to health educators, nurses and others in the identification, imple- mentation and evaluation of a research problem. Its focus is research at the applied level, with emphasis on primary care settings in developing countries. It is intended to stimulate its readers to think, involving them in active participation as they read. Sample chapters were first given to the workshops' participants and then disseminated by prior publication in the Journal of the Association of Trained Nurses of India, thereby ensuring a wide feedback before publication. Contributions from nurses to the health of the people can be strengthened through such instances of technical coop- eration among countries, particularly in the form of collaboration in the publica- tion of textbooks, teaching aids and other educational materials. There is a similar crucial need for the dissemination of research findings to serve as a scientific basis for improve- ments in patient care, community health and nursing education, as well as in the organization and management of nursing services. Such exchanges—of information and personnel—and the provision of wuo fellowships for nurses, will all help to develop and strengthen national re- sources so that each country will itself be able to achieve that ultimate goal— Health for All by the Year 2000. ■ 15 THIRTIETH ANNIVERSARY hirty years ago a world groping for stability through the ruins of war proclaimed its faith in the dignity and worth of the human individual by adopting the Declaration of Human Rights. It was an assertion of hope in the future and of the confidence that mankind will survive its destructive impulses and prevail on earth. During the past three decades—marred though they have been by conflicts and injustices—the awareness of social justice and the rights of the individual has continued to deepen. who's own policies bear an imprint of this new awareness. In setting the goal of health for all by the year 2000 through a far-reaching programme of primary health care, who Member nations have recognized that without social justice in the distribution of health resources the battle against ill health cannot be won. HUMAN RIGHTS Ill' UMBER. 19Th Health is a universal human right, as who's Constitution clearly states, and its attainment an essential social goal. The just distribution of health resources is as important as their quantity and quality. To reach a more equitable distribution, it is necessary to pay greater attention to those least served, the social periphery, the disease-ridden majority. Our guiding principle should be the greatest health benefit to the greatest number of people at the lowest cost. Dr H. MAHLER DIRECTOR-GENERAL, WHO ... Health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and ... the attainment of the highest pos- sible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. DECLARATION OF ALMA-ATA All human beings are born free and equal in dignity and rights. They are en- dowed with reason and conscience and should act towards one another in a spirit of brotherhood. UNIVERSAL DECLARATION OF HUMAN RIGHTS Discrimination between human beings on the grounds of race, colour or ethnic origin is an offence to human dignity and shall be condemned as a denial of the principles of the Charter of the United Nations, as a violation of the human rights and fundamental freedoms pro- claimed in the Universal Declaration of Human Rights, as an obstacle to friendly and peaceful relations among nations and as a fact capable of disturbing peace and security among peoples. UN DECLARATION ON THE ELIMINATION OF ALL FORMS OF RACIAL DISCRIMINATION The United Nations is dedicated to the fulfilment of the rights of all mankind. Any form of discrimination is unjust, and it is the duty of the world organization under the Charter "to reaffirm faith in fundamental human rights, in the dignity and worth of the human person, in the equal rights of men and women and of nations large and small". Faith is not enough. Action is needed. The United Nations has worked un- ceasingly to advance the cause of human rights in practical terms—the right to live, the right to work, the right to health, the right to knowledge. Much remains to be done. Our goal can only be achieved when the principles of the Universal Declara- tion are fully adhered to. But our experi- ence of the past 25 years is that the ideal is worthy, and is capable of achievement. KURT WALDHEIM SECRETARY-GENERAL, UN "The Prodigal Son" by Auguste Rodin, 1889, in bronze, photographed by Bruno Jarret. By permission of the Musee Rodin, Paris c 16 International Convention on the Elimination of all Forms of Racial Discrimination Article 5 States Parties undertake to prohibit and to eliminate racial discrimination in all its forms and to guarantee the right of everyone, without distinction as to race, colour, or national or ethnic origin, to equality before the law, notably in the enjoyment of the following rights: a) The right to equal treatment before the tribunals and all other organs administering justice; b) The right to security of person and pro- tection by the State against violence or bodily harm, whether inflicted by govern- ment officials or by any individual, group or institution; c) Political rights, in particular the rights to participate in elections—to vote and to stand for election—on the basis of uni- versal and equal suffrage, to take part in the Government as well as in the conduct of public affairs at any level and to have equal access to public service; d) Other civil rights, in particular: The right to freedom of movement and residence within the border of the State; The right to leave any country, in- cluding one's own, and to return to one's country; The right to nationality; The right to marriage and choice of spouse; The right to own property alone as well as in association with others; The right to inherit; The right to freedom of thought, conscience and religion; The right to freedom of opinion and expression; The right to freedom of peaceful assembly and association; e) Economic, social and cultural rights, in particular: The rights to work, to free choice of employment, to just and favour- able conditions of work, to protec- tion against unemployment, to equal pay for equal work, to just and favourable remuneration; The right to form and join trade unions; The right to housing; The right to public health, medical care, social security and social ser- vices; The right to education and training; The right to equal participation in cultural activities; f) The right of access to any place or ser- vice intended for use by the general public, such as transport, hotels, restaurants, cafes, theatres and parks. 17 care of the elderly Nurses are not merely preventing ill health in old age. They are also helping society to recognize that old age is not a disease but the fulfilment of every individual's birthright by Doreen Norton nyone visiting the central southern coast of England (other than at the holiday season) can hardly fail to notice the high proportion of elderly people. In fact about one in every five of this area's population is at least 65 years of age-20 per cent compared with the national average of 14 per cent— and nearly half of these are aged 75 or more. It is therefore not surprising that this part of the United Kingdom is becoming known as the "Costa Geriatrica"—"The Old Folks' Coast"—even though this title perpetuates the mistaken notion that "geriatrics" is a collective term for elderly people in the frailty of their years. What is happening there, however, in terms of demand upon health and personal social services will be experienced elsewhere in the UK and in other industrialized coun- tries in 10 to 20 years from now. Advanced old age In the industrialized world, most people have tended to associate nurses and nursing with care in illness and in advanced old age. In recent years, old age has been gaining a significance hitherto undreamed of, if only for the fact that more people are surviving to experience the extremes of the elderly phase of life. In Britain, for instance, the rate of increase in the number of people aged 85 and over seems likely to reach about 42 per cent between the years 1976-1996, according to Mark Abrams in his Age Concern research publication "Beyond three- score and ten". Moreover, whereas once it was usually only fit and tough individuals who survi- ved for 80 and more years, this is not so today. Indeed, B. Isaacs and others enti- tled their 1972 study of geriatric patients in Glasgow: "Survival of the unfittest". In terms of hospital and community nursing services this means care of an in- creasing number of very infirm people with multiple ailments and commonly presenting problems of immobility, de- fects in excretory control and, not least of all, mental confusion. A fundamental change has also oc- curred in the way in which the elderly patient is nursed. That is to say, admin- istering care and attention is no longer confined to the bedside. Ironically, the founder of modern nursing, Florence Nightingale, in the second half of her life (she died aged 90), presents us with a picture which modern nursing strives to prevent. She donned the shawl of inval- idism and took to her bed (or rather, couch) prematurely and almost con- tinuously. This leads one to speculate whether she developed wastage of muscles, weakness of bones, contracture of the lower limbs and constipation, and perhaps even bed- sores during her spells of prostration, since all these are now recognized as some of the complications which can result from prolonged confinement to bed. But she was, of course, gloriously exceptional in that, by her own volition, her mind was fully occupied with purposeful activity, planning in meticulous detail such revo- lutionary things as reform of the army medical services, sanitation in India and a school for training nurses. She unknowingly demonstrated by this some- thing that has only been realized rela- tively recently in relation to nursing of the aged : namely, that care of the body is pointless if it is so indulgent as to cause the mind to wither through lack of stimu- lation and opportunities to use it. As recently as 1975, a group of doctors and nurses found it necessary to stress that the old person is a unique individual "... with a need for creative activity, for privacy and fellowship at appropriate times, and with a right to be consulted and to choose in all matters affecting his health and welfare". 1 In the institutional setting, we have to bear in mind that the "unique individual" correlates with having personal clothing and retaining belongings which are "uniquely individual". Such possessions are not easily tolerated by those providing care, because of limited space and in the interests of tidiness and ease of domestic cleaning. One old lady on her admission to a long-stay hospital was found to have amongst her belongings a large, odd-shaped metal object, broken and green with age. Curious, the nurse asked the owner what it was. "Well," she said, after a lengthy pause, "I don't rightly know, but I've had it so long I don't like to part with it". I am bound to add that in this instance the "unique individual" was not deprived of her mysterious treasure ! Whether the old person is nursed at home or in an institution, current policy is to promote mobility and for the very in- firm to spend at least part of the day sitting in a chair fully dressed. The pur- pose is not simply to avoid the compli- cations of the bed-fast state but to retain the sense of daytime living and provide opportunities to improve the quality of life for the individual. In practice, this has meant that the nursing of old people is now physically harder and more exacting. 1 Royal College of Nursing of the UK and British Geriatric Society (1975). "Improving Geriatric Care in Hospital". The old person is a unique individual, with a right to be consulted on matters affecting his or her health and welfare. (Photo Nursing Times, London ©) 18

care of the elderly Left: Helping hands for an elderly patient in Morocco. Only now is it being recognized that post-basic courses are necessary for nurses wishing to specialize in the care and treatment of the elderly. (Photo WHO/J. Mohr) Right: Contrary to fears that the elderly might regard home-visits as an intrusion of their privacy, most of them welcome a community nurse on their doorsteps inquiring about their health and welfare. (Photo WHO/D. Henrioud) Heavy lifting, for example, is often invol- ved, dressing is difficult due to crippling of limbs, and assisting a handicapped person to the lavatory is more time- consuming and arduous than providing a bedpan, as used to be the case. In this connection, it is an undeniable fact that it is far quicker and easier to "take over" and do things for infirm and handicapped people than to provide the necessary time and means whereby the individual can accomplish tasks unaided. As time is usually of the essence, because of other pressing demands, it is under- standable how the care-giver—whether a relative caring for the patient at home or the nurse working in the community or in an institution—can become an uninten- tional thief of independence and, by so doing, risks reducing the life of the indi- vidual to one of mere existence. Collectively, therefore, it is not enough that the care-giver acquires skills in "helping the patient to help himself". More hands are required to share the caring of those elderly patients for whom rehabilitation is no longer possible, as well as providing furniture, equipment and clothing which have been specially designed to promote self-help. Less than 40 years ago, the term "reha- bilitation" was rarely, if ever, used in rela- tion to old people. When an old person developed health problems and could no longer get about and attend to his or her own basic needs, the medical response was to attach the label "chronic sick" and delegate responsibility for care to the nurse. With the discovery by a few pioneering doctors that people with chronic disease and the irreversible effects of ageing could be helped to regain abilities in self-care, the term "rehabilitation" took on a new meaning—and the speciality of geriatrics was born. A positive approach A new philosophy (for that is what it was) can seldom be explained in a few words and, when its message has to filter through the vast network of human com- munication, it is bound to become dis- torted or lose its vital essence on the way. The message that we must adopt a posi- tive approach to the health and welfare problems of those elderly patients gener- ally regarded as "irremediable" was no exception. "Get them up and get them going" was how most nurses received it. The response was one of dismay ("it's cruel to make these old dears get up") and chaos followed, since all nursing tech- niques and routines had evolved from the care of patients in bed. Moreover, the physical environment and facilities were totally unsuitable to practise rehabili- tation. With the dawning of realization that the needs of elderly patients usually arise from a host of inter-related problems— multiple ailments interlaced with the ageing process, residual disabilities, emo- tional and psychological disturbances, environmental and social difficulties—it became apparent that rehabilitation could only be achieved by having a multi- disciplinary team. This includes the doctor, nurse, remedial therapist and social worker, and embraces those who work in hospital and in the community. The building up of such teams, with each member learning to complement the others, is the current activity in most countries with a rapidly expanding el- derly population. The development of modern geriatrics in Britain began in hospital with the set- ting up of special departments, and at first patients were admitted wherever there happened to be a bed available. It soon became clear that it was necessary to have wards specially for assessment and reha- bilitation, and others for those patients requiring long-term nursing, probably for the remainder of their lives. This group- ing assisted nurses in a better under- standing of what was expected of them. Working with patients assessed as having a potential to regain sufficient indepen- dence to be discharged meant, in essence, to gradually withdraw nursing care. This is a hard discipline for nurses to learn; it comes hardest of all when the patients are old people. Working with patients who were found to have little or no potential to be discharged provided the opportunity to give tender, loving care in the tradi- tional sense, but at the same time pre- sented the challenge of maintaining the last vestiges of independence for each old person in their charge. Unfortunately, basic nursing educa- tion did not keep pace with developments in the care and treatment of the elderly, and it is only now beginning to be recog- nized that post-basic courses are neces- sary for nurses wishing to specialize in this field of work. Developments in the field include re- cognition that a thorough clinical and social assessment is the essential prelude to the equally essential plan for tackling the problems which bring the old person to the team for help. 20 The nurse, whether working in hospital or in the community, is in a key position to obtain information for an accurate assessment; to ascertain the old person's accustomed and recent life-style, excre- tory habits, diet and behavioural charac- teristics. Indeed, it is not an exaggeration to say that the nurse requires to be a skilled detective—a collector of "evi- dence" by deliberate observation, percep- tion and purposeful talking with the patient and any relatives. The nurse also has to be able to observe and assess with a refinement of judgement, because it often has to be made without aids like the patient's voluntary declaration of how he or she feels. To illustrate this point, I recall an el- derly man who had no relatives and who had been in hospital for several weeks following a stroke which had robbed him of speech. A passing nurse suddenly stop- ped in her tracks, looked at him thought- fully and said "I bet you usually wear spectacles". A hunt through his belong- ings brought to light a pair of thick- pebble glasses of the kind worn by very short-sighted people; the joy on his face as she put them on for him defied des- cription. The case-conference is the occasion when all the information collected by members of the team about a new patient is discussed, immediate and long-term objectives are decided and action plans agreed. The old person and any relatives then have to be told of these decisions and the reasons for them explained. Some- times the old person is too unwell or too disorientated to understand, and it falls to the nurse to "get through" in the course of time. Both the objectives and the plans have to be constantly reviewed, for el- derly patients are no different from others with disabling conditions insofar as the patient's future depends upon his or her total response to treatment as the various problems are tackled. Building up the old person's morale—and that of any relative who has been struggling to cope—is as much a part of the rehabilitative process as clinical and technical treatments, and here again the nurse is in a strategic posi- tion to do this through a close, and often affectionate, relationship. Nursing care plans for promoting maximum independence in the basic ele- ments of self-care—the ability to feed oneself, wash, dress and excrete in the appropriate place and at the desired time —are central to the rehabilitation plans made for an individual. They are also the ones most likely to break down, due to insufficient staff. Characteristically, col- lective routines dominate when there are too few staff, since this is the only way of ensuring that all patients receive the basic essentials of attention. Nevertheless, countless numbers of handicapped old people have been returned to their own homes and sustained there—which is the dearest wish of most—and countless others have been rendered sufficiently fit to live in residential homes. None of this would have been possible without multi- disciplinary teamwork and tremendous hard work on the part of the nurse. Care in the community "Rehabilitation" in its accepted sense will apply less with the predicted rise in the number of people over the age of 84, with its associated higher prevalence of mental infirmity. It will be necessary to think more and more in terms of "reable- rnent" to maximum independence and enjoyment within a supportive nursing environment. Insufficient nurses to care for the el- derly and too few trained in its parti- cular skills appears to be a feature com- mon to most industrialized countries with a high proportion of the population over the age of 65. That this is now beginning to be recognized gives hope for the near future. Greater hope lies, however, in the growing recognition that care of the el- derly includes the promotion and main- tenance of health. The wHo Regional Office for Europe recently published a report of a working group set up to study nursing aspects in the care of the elderly which includes consideration of "the well elderly". It is therefore appropriate to quote from this report. "A person should be regarded as healthy if he can remain socially and intel- lectually active, even though he suffers some disability or discomfort. Care... should therefore be directed to helping the individual to maintain adaptive be- haviour and promote wellness..." In pursuit of this, the working group suggests that there should be preventive and supportive programmes for the well elderly similar to the long-established programmes for the healthy young (the new born, under-fives and schoolchil- dren). Nurses have been responsible for implementing the latter and are increas- ingly involved in planning schemes for care of the well elderly. Where schemes are already in operation, the general expe- rience appears to be that the vast majority of well elderly people have welcomed the opportunity for health surveillance and the chance to discuss and obtain advice on matters concerning their welfare. Systems to identify people over the age of 75 and "at risk" groups (for instance, the recently bereaved and those living alone) were also advocated by the work- ing group. Where these exist, a com- munity nurse visits to assess needs and arrange for help to be given, and also takes the opportunity to give health advice. Contrary to earlier rears that el- derly people might regard this as an intru- sion of their privacy, most of them have welcomed a nurse on their doorstep enquiring about their health and welfare. Nurses working in the community are particularly well placed to promote the health of the elderly, but their activities are not only preventing ill health and social breakdown in old age. They are also helping society to recognize that old age is not a disease but the fulfilment of every individual's birthright. ■ 21 : Jet •• • _ . -if where there's need It was all in a day's work for Nurse Ana—scrambling down a steep and slippery slope to bring her nursing skills and care to a needy urban community in Bolivia by John Bland rf L1 uite the most exciting way to ar-rive in La Paz, capital of Bolivia, is to go overland from Puno in southern Peru. Overland means in part over water. A bumpy bus-ride across dirt roads brings the traveller to Juli, and from there a hydrofoil skims across the sometimes choppy waters of Lake Titicaca, calling at different points before reaching Huanajata in Bolivia. The next stretch is a two-hour journey by bus across an immense plateau, the high Andean altiplano, lying some 12,700 feet (3,900 m) above sea-level. To the east, this plateau tilts gradually up- wards until the horizon is blocked by a splendid range of snow-capped peaks, glowing in the declining sun. Presently the bus enters the outlying suburbs of La Paz and passes the airport; the traveller might reasonably expect a straight run in towards the Bolivian capital. By now the streetlamps are casting pools of lights, in which can be seen knots of people in bright-coloured wool- len clothes, waiting for buses or grouped around market stalls. From street signs, one learns that this suburb is called El Alto. A moment later the bus takes a sharp left turn and a spectacular panorama swings into view on the right. It is as if the plateau itself has crumbled away into a vast crater. One looks down into a bowl of twinkling lights, growing brighter as they converge on the bottom of the bowl—the heart of La Paz, fully 900 feet (300m) below. And beyond the city, where only a rare cluster of lights marks distant villages, rises the massive bulk of Mount Illimani, over 21,000 feet (6,500m) high, its snow cap glowing in the last sunset light. Now the bus is dropping rapidly down the inside rim of the bowl, descending in great zig-zags. The traffic grows denser and the street-lighting brighter. Narrow crowded streets give way to tree-lined avenues with multi-storey buildings. De- spite this long descent, the thin, chill air in the city centre reminds the traveller that he is still 11,800 feet (3,600m) above sea-level. Some days after arriving, I was riding back up the inside of the bowl to El Alto suburb, to see the work of nurses at the Health Centre there. This time it was broad daylight. The city lay far below, its outer suburbs sprawling untidily up the slopes, until the angle became too steep, 22 A ilrikliht 4 1. r,. , ;eV • • 41 - '41 e. a. a,... -1 • %41 , 111 ...r.,.. . a .-. ;iellit.'' *# i. (4 ...,. 1 .. A , ' ...; . , , . 'it e,,* ,F. • t.''''' , tr 1 .. .. .1101i f . ...4 Olia' ..400 - . gbpoilfa. 41.1116.- • • • I4. .0, . a., L. 401. ' .• A • I '' . ,,.. i„,.__#•W' . --- / • 147-5-'-' • , • ' 1 4* hit 4 'Ara* 4 •tr katirr alt zi 00* .4.41116 , ti‘ .' 4 Ir■rb:114, i • . . . - 4.4. I -4,-- i-- , , , -4 •- "1". .., IL ' ,h6:6117 —ki:dial. IL ----4;', :7;l'ib?,7-3:111:: ..‘ 46:1":1111161hr. • 4' -. .''''. ' v., ai, ii* sii . Iowa , . ' • ' - ' . A _ ' ...7.--, . •• ,11k. - •-• -- , ,. • ....,. I - :limo: - - _ice e- . "7 . . ' . . 4' IC 6 ' I; . .* i 4 . 4 $ 1, 44 6 " 4./E0/111r 1 Nurse Ana follows the recently bereaved mother down the steep and slippery slope to her home high above La Paz. (Photo WHO/D. Henrioud) and the mud-walled houses gave way to parched brown soil or rocky outcrops. The road reached the rim of the bowl and swung away among a maze of houses and dusty streets. The Health Centre of El Alto was having a busy morning, and dozens of patients waited patiently inside and outside the single- story buildings. Most of the women wore the bowler hats that are traditional wear throughout the high Andean regions. The staff consisted of three doctors, three nurses and six auxiliary nurses, who share out the work into two shifts, morning and afternoon. The supervisor, Sefiora Luisa Saldaria de Guzman showed me the work plan for the nursing staff, and told me that after four years study to qualify as nurses they undergo eight months training as public health specialists. Sefiora Mary da Sanz, who is 34, showed me how she carries out inter- views at the Centre, both individually and in groups. She examines and treats babies brought in by their mothers, and offers ante-natal advice to pregnant women and post-natal counselling to mothers of infants. She gives vaccina- tions too, but these are more frequently carried out during home visits in the neighbourhood. In one of the consulting rooms, Mary examined a child who was suffering from infectious diarrhoea. She explained to the mother that she should give the child regular spoonfuls of medicine every six hours. The infant should have no breast- milk for the next three hours, but warm rice-water instead. She emphasized the need to wash hands, spoon and feeding bottle. All this was said both in Spanish and in the local language, Aymara. Then the mother was made to repeat it all back to the nurse,•to guard against any misun- derstanding. Mary meticulously recorded the interview and the recommended dosages on one of the forms on her desk. Later there would be a follow-up home visit, to check on the baby's progress and ensure that the mother was following instructions correctly. Mary herself lives here in El Alto. She knows the district's problems and the in- 23 habitants know and trust her. The most common problems are respiratory dis- eases—no doubt the altitude plays a part in these—and gastro-intestinal disor- ders; each day there are many cases of infectious diarrhoea. Adults and children alike frequently suffer from tuberculosis, and some have to be referred to a labora- tory or the city hospital for further tests. That month there had been two cases of whooping cough and several of measles. Mary told me : "There are a surprising number of emergency cases too—traffic accidents, accidents at work, burns, inju- ries in fights, and various incidents in- volving broken bones. Only this morning a boy of ten was brought in who had fal- len off a bridge on to a truck. He was lucky; he may only have suffered a bro- ken hip." Two days a week she visits the Moth- ers' Centres (Centros de Madres) to talk about their various problems. Otherwise her afternoons consist of four or five house-calls to check on patients under treatment or to respond to appeals for medical care. "We try as much as pos- sible to explain what has made them ill, if they are ill, and why the doctor has given them pills or medicine," said Mary. And of course we check that they are really taking the medicine. There is no social worker at this Centre, so we in- clude social work in our duties—for in- stance, seeing that the old people are taken care of." The Centre is in action on every work- ing day and on Saturdays too. But since it is a small Centre with a limited staff, it cannot deal with major emergencies or night calls. One unusual aspect of the nurses' work here at El Alto is the running of four-month training courses for tradi- tional midwives who live and work in the neighbourhood. Often, but not always, elderly women, they are being taught the vital need for hygiene when they attend births. The nurses instruct them how to spot difficult cases that should be referred to a clinic or hospital, and help to kit them out with more modern equip- ment than they would normally possess. It had just been arranged that I would go out on house-calls with another of the nurses, 33-year-old Sefiora Ana de Vega- briel, when a woman entered the Centre with a baby slung in her poncho and holding the hand of a little girl. There had been a tragedy. Only the day before, the little girl's brother had died of coque- luche—whooping cough. Now the little girl too has a cough. Ana decided that she must visit the house to check on the health of all five surviving children. Over the edge The mother, Sefiora Susana Botello Alarcon waited resignedly until Ana pre- pared her classic black bag of basic equipment and medicaments. At first we drove for a short distance, and found ourselves just beginning the descent from the lip of the La Paz "crater". At a word from the mother, the driver stopped. But there were no houses in sight. To my as- tonishment, the mother—her bowler hat firmly in position and the little girl's hand still clutched in her own—stepped over the edge and hurried rapidly down the slippery slope that fell away to the city suburbs far below. Unperturbed, Nurse Ana followed her, though more circumspectly. There was nothing else for it; I too stepped gingerly over the edge. We were in sunlight and the city shone below us like dull copper. Beyond the city towered the snow-cap of Mount Illi- 24 Left: At the El Alto Health Centre, Nurse Mary explains how a baby's diarrhoea should be treated. Above: The surviving members of the family look fit and strong. Nurse Ana impresses on the mother the need to boil all drinking water. (Photos WHO/D. Henrioud) mani. But this was no time for sightsee- ing. The hillside fell away at a critical an- gle, with a treacherous surface of brown dust and loose pebbles which rolled from under our feet and skittered away out of sight. The mother was now skirting the top of a ravine whose walls and sides were mere crumbling mud. It all looked most unsafe. At last the topmost houses appeared below us, constructed from wood, corru- gated iron and sun-baked mud. They perched on tiny terraces hacked out of the unyielding soil. Seriora Botello Alarcon walked surefootedly, perfectly used to finding her way on this slope in all weathers. Now we could see that she had reached the roof level of the upper- most house. From there she stepped with care along an inclined plank bridge which brought her over her neighbour's yard and down to a second, identical house. In this tiny two-roomed home she was bringing up her surviving family of five. The sixth child she had found dead in his bed when she awoke the previous day. He was buried on the morning of our visit. He had been one month old. Nurse Ana went into action. She donned a spotless white apron, produced a roll of newspaper which she always car- ries to spread on tables, and briskly ex- amined the sad little survivors. The mother brought her a cupful of water to wash her hands. Water is a perennial problem here; at this height above the normal services of the city, the residents are dependent on rainwater caught on their corrugated iron roofs and trapped in water-tubs. Failing that, they have to buy it, at four pesos (about 20 cents US) for a small pot. One of the children had suffered a fall not long before—an accident that hap- pens all too frequently in this airy sub- urb. His cuts had been sewn up and he had been badly bruised. Nurse Ana took off his bandage, checked that the wound was healing well and dressed it again. She was satisfied that the surviving chil- dren were in good health. Seriora Botello Alarcon's husband, a policeman, was away at work in the city, despite that morning's little funeral. Ana delivered a short talk about the need for nutritious food, and how important it was to boil the water before drinking—especially before the children drank it. We said goodbye to the little family on the hill, and began the long climb back, first up the plank bridge, then painfully up the slippery scree slope. Gasping a lit- tle from the effort—though she was bet- ter attuned than I to the rarified atmo- sphere at these altitudes—Ana comment- ed as we stepped nervously round the top of the crumbling gully : "People some- times commit suicide by throwing them- selves down there." For her, this was all in a day's work. For me, it was an insight into the way so many people in the world have to live— close to a thriving and spectacular city yet cut off by sheer geography from its services and comforts. For such families, it is Nurse Ana and colleagues like her who provide the bridge, bringing the comforts of their nursing skills and care to a needy and deserving urban community. ■ 25 new look for rural health Three years ago the Philippines restructured its rural health care delivery system. Nurses today contribute more positively than ever before to individual, family and community health care by Francisco N. Aguilar 11 hen, a few years ago, studies were undertaken into the effi-ciency and effectiveness of rural health units in one pro- vince of the Philippines, it was realised that before any improvement could be achieved, radical changes were needed in the whole rural health care delivery sys- tem. In deciding to implement such changes, the health planners were ac- knowledging that there were better ways to deliver health care and that in order to make it more cost- and goal-effective, orientation towards the patient, his fami- ly and the community, was necessary. Steps were undertaken three years ago to completely restructure the health care delivery system of the rural health ser- vices. What are the main features of this res- tructured system today? By identifying the independence and the inter-depen- dence of the services provided, a re-defi- nition of the key roles of the personnel running the rural health units was under- taken. Changes were introduced in work methods and procedures and in the sys- tem of delivering patient care. In order to facilitate the patient's entry into the health system, the midwife became the provider of basic health services at the first level: the "gate-keeper" of the ser- vice. Patients who present health prob- lems outside her area of competence are referred to the multidisciplinary and multilevel health care system. In this, the public health nurse provides care at the second level and the municipal health of- ficer at the third level—both still operat- ing within the rural health unit. Effectiveness of supervision was in- creased by setting up a mechanism for monitoring activities, developing stan- dards and performance criteria and devising methods for quality control. At the same time by deploying the midwives to provide basic health care services in specific catchment areas, a step up in the coverage of health care services for the whole rural population was achieved. Every effort was made to involve the community in the planning, implementa- tion and maintenance as well as the as- sessment of their health services, and to step up collaboration and coordination among all health care providers, whether government or private, whether profes- sional or non-professional. The services of the health units were planned to reflect better the health needs and requirements of the community and to take into account all available and potential resources. These plans ensured the continuity of patient care by catering for all possible situations, including the transfer of a patient from one level of the health care system to another and also the eventuality of his moving outside his original geographical area. Emphasis was placed on prevention-oriented health care, providing what is called care-cure services. What are the implications of these changes for the public health nurse? The main objective of any community health service is to provide the best possible care to individuals, their families and the community in the fields of prevention, treatment and, when possible, restora- tion to health. Coordination of all these aspects of care requires communication and cooperation with other members of the rural health team, as well as with the patient and his family. These are essen- tially the responsibility of the public health nurse. Her role and function in these major areas of community health work, in relation to the roles and func- tions of other team members, include identifying strategies, setting targets for activities, participating in planning, and discussing the overall health plan with the community and with the health au- thorities. These responsibilities are, of course, in addition to her work in pro- viding patient and family health care, teaching self-care, reporting cases of notifiable diseases, preparing for emergency and disaster situations, super- vising staff, monitoring programmes, keeping the community informed of all health matters and participating in com- munity development plans. The management of such a service requires a variety of knowledge and skills. The public health nurse needs to be: a planner: analysing and interpreting facts and thus foreseeing the future requirements and needs for nursing ser- vices; an efficiency expert : getting the best possible results from the allocation and utilisation of resources; a "Houdini" : bridging the gap be- tween the unlimited demands upon the service and the scarce or limited resources available; a personnel manager: dealing with the various professional and personal needs of the health service staff; The public health nurse must be a planner, an efficiency expert, a personnel manager, an educator and a super-clerk all in one. (Photo WHO/J. Mohr) 26 ir hi "AI .4° 01.11■1 13- 21.F, ' 1 , 47.! an "ombudsman" : acting as a spokesman or negotiator for the mid- wives as well as for the "consumers" of the health service; a "super-clerk" : overseeing the com- plex process of paper work and keeping tabs on the activities of other members of the rural health unit; a facilitator: providing positive in- terest in health and the health services within the rural health unit and in the community; an educator and trainer : developing the potential of other members of staff to the maximum; and a clinician : assessing, planning, im- plementing and participating in the health activities required of her and her team. The expansion of the midwife's role to include the routine management of high priority problems has meant that nurses have had to relinquish some activities which traditionally have been part of the personal and professional identity of nursing and medical practitioners. To some, this has been a painful reality slowly accepted; others saw quickly the necessity to delegate. Perhaps the main challenge to these nurses has been in guiding and supporting the midwives as they adapt to their new responsibilities and in proving their own personal com- petence in the management and supervi- sion of patient care. For the midwives themselves, the focus is on recognising the signs and symptoms of diseases and the patient's response to them. The kind, method, quantity and frequency of interventions are closely spelled out for them by poli- cies and by standard procedures. The public health nurse also sees her patient's symptoms as a consequence of his re- sponse to problems. She recognises that life-styles, environment and family all affect the way in which health problems are manifested, perceived, interpreted, and therefore must be taken into account when dealing with them. The increased mobility of people and the consequent variety of ethnic groups in a rural population, for instance, means that the nurse must plan, provide and evaluate care to patients whose values, concepts and practices concern- ing health and health care may differ widely from her own. If her care is to be relevant and effec- A patient receives her prescribed medicine from the nurse in charge of a district dispensary in the Philippines. (Photo WHO/J. Mohr) tive, she must be familiar with her patient's culture, and value systems. She must also maintain a kind of inventory of language and symbols, concepts of health and disease, folk health practices, social norms and values, socioeconomic factors and religious considerations. And she must be aware of those environmen- tal factors which are associated with in- creased risks or vulnerability to specific diseases. The restructuring of the rural health care delivery system of the Philippines represents a big step in the direction of a positive response to the needs of the Phil- ippine rural population. Three years lat- er, the public health nurses working in it are making their own special contribu- tion to the efficiency and effectiveness of the system in general and, in particular, they are, independently or with other members of the health team, contribut- ing more positively than ever before to individual, family, and community health care. ■ 28 Red Cross nursing: born on the battlefield ust 150 years ago—on 8 May 1828—was born a rare and remarkable man who left his mark on international events and onthe nursing profession. Henri Dunant, a native of Geneva, was already a convinced pacifist when, in 1859, he chanced to be present at the Battle of Solferino in Northern Italy. The battle marked a major step towards Italian unifica- tion, but the 31-year-old Swiss was not interested in the political reper- cussions. What he saw was the pitiful sight of some 40,000 injured and dying soldiers—Austrian, French and Italian—abandoned on the battle- field. For eight days Dunant busied himself in tending the casualties, recruiting girls and boys from nearby villages to carry them to shelter and offer what nursing and medical care was available. Returning to Switzerland, he published at his own expense an account of this experience, and sounded a call for an international body to be set up "to give care to the wounded in time of war". At an international conference in Geneva in October 1863, the foun- dations of such a body were laid down. It required an easily recognis- able and neutral emblem. What more natural than the inverse of the Swiss flag, which is a white cross on a red field ? The symbol and the name were chosen : on a white background the Red Cross. Later, in response to Moslem wishes, the Red Crescent and the Red Lion and Sun (Iran) were adopted as parallel symbols. Dunant himself subsequently lived an obscure life, but his achievements were eventually rec- ognised. He was honoured with the award of the first-ever Nobel Peace Prize—shared with French pacifist Frederic Passy—in 1901. He died nine years later, at the age of 82. Today the idea that was born at Solferino can count on nearly two and a half million members in 125 countries. On average every 20 days, the Red Cross comes to the aid of victims of natural or manmade disas- ters. It also maintains a card index file on some 50 million missing or im- prisoned persons. Red Cross workers today are familiar figures around the globe. ( Photo League of Red Cross Societies) Among the many people with whom Dunant corresponded during his campaigning was Florence Nightingale—"the Lady with the Lamp"—who made her own mark in the world's history. Since her work during the Crimean War, (and her even more important contributions after that date), the nursing profession and the Red Cross have developed their roles and changed many of their ac- tivities, but they are still guided by common principles and inspired by common ideals and common objectives: improvement of health, prevention of disease and mitigation of suffering. Today, nurses every- where are helping in the develop- ment and disaster relief programmes of Red Cross societies. For many of them their training began when they were members of Red Cross Youth —which has become a global incu- bator of tomorrow's doctors and nurses. The Red Cross "Health in the Home" programme is known throughout the world and provides (for the public in developed and Third World countries alike) guid- ance and information on parent- hood, family care, nutrition and the essentials of elementary nursing. Most sessions are the responsibi- lity of Red Cross nurses who also participate in social welfare and first aid programmes of many societies. Health and social factors are inex- tricably linked, and the current emphasis on primary health care brings together the many disciplines involved in a concerted effort to improve the quality of life for mil- lions of people. Today's social prob- lems are the concern of nurses, doc- tors and other health workers throughout the world, and the Red Cross recognizes this. In Regional Nursing Seminars held in Asia, Europe, and Latin America, subjects for discussion have ranged from individual care of the elderly and handicapped person to national pro- grammes of disaster preparedness, family planning, drug abuse and community health. Self-help and self-care are also recent trends in the health field, and nurses are aware that yesterday's slogan that the Red Cross is com- posed of "people helping people" may require an additional claim that they are "people helping people to help themselves". But the caring continues, for the Red Cross has extended its role far beyond that of those first stretcher bearers at Sol- ferino who gave the little nursing care they knew. Today, in all corners of the globe, the Red Cross has a network of pri- mary level workers—accessible, acceptable, well motivated and for the most part—trained by nurses: the potential is great. ■ 0 00 000 041 0 000 000 0** 000 0 00 *410 0*• *90 00000* 0 0* 000 *00 40* 00• 00,000 000 000 000 00 0 000 000 *00 00* 000 SO* 00 0 OOOOOO 000 0 4* 00000* 0 00 000 000 000 000 0 0 0 000 0110 000 oeo *eon: Mee* 0000. . 00* ... .4• 00• 0 0• 00* SO• 004 000000 **0 000 Botulism outbreak reported from USA The second largest out- break of botulism in the USA since recording began in 1899 and one of the rare large outbreaks ever recorded any- where has been reported from a town of 40,000 population, in the State of New Mexico. Thirty-two persons, ranging in age from 10 to 72 years and including 21 males and 11 fe- males, were taken ill. There were no deaths. WHO Photo/Spooner Inspector examining a food consignment. Botulism is a serious form of food poisoning character- ized by weakness, extreme dryness of the mouth and cranial-nerve paralysis. The patient complains of visual difficulty and sore throat. Vomiting and diarrhoea and, occasionally, constipation may be present. About one- third of the patients die with- in 3 to 7 days, usually from respiratory failure or from superimposed infection. The disease is caused by toxins produced by a microorganism known as Clostridium botu- linum in foods improperly processed during canning, and eaten without subse- quent adequate cooking. The toxins are destroyed by boil- ing, but inactivation of spores requires higher temperatures. Ordinary refrigeration does not necessarily prevent toxin production. The reservoir of the bacillus is soil, water, and the intestinal tract of animals, including fish. In the USA, the illness is associated mostly with home-canned vegetables and fruits or fish, and infre- quently with meats. In Europe most cases are traced to sau- sages and to smoked or pre- served meats or fish. Information concerning the first case in the New Mexico outbreak reached the US Center for Disease Control (CDC) on 10 April last. A further two cases were re- ported on 15 April, and in the next 48 hours an additional 29 patients were admitted to hospital. An epidemiological inves- tigation revealed that the first patient was a part-time em- ployee in the restaurant of a private club. It was soon es- tablished that all 32 patients had eaten at the club. Two items served at a salad bar on several days—potato salad and three-bean salad—were identified as being associated with the illness. Type A botulism toxin was identified by CDC in serum specimens of two patients, and by the Food and Drug Administration in potato salad obtained from the res- taurant. Although two foods were incriminated, they could not separately account for all the cases as neither had been eaten by all the patients. This suggests either cross-con- tamination or the addition of a common contaminated ingredient to the two foods. Yaws and endemic syphilis re-appear Yaws and endemic syphi- lis, brought under effective control in the sixties through WHO-UNICEF mass treat- ment programmes with long- acting penicillin, have be- come rampant in many parts of Africa, according to data accumulating at WHO head- quarters. In 1976-77, 17 countries in Africa reported an increase in yaws and endemic syphilis —endemic treponematoses—in populations that had been the targets of mass treatment campaigns. Fourteen of these had reported over 100,000 cases of yaws while low to high endemicity in endemic syphilis continued to be re- corded in 6 countries—pri- marily in the Sahelian zone of Africa. It is feared that if the treat- ment of these diseases is left to casual penicillin treatment, there will be a grave risk that endemic treponematoses may increase until it becomes a serious health hazard within a few years, at most a decade. WHO Photo A young victim of yaws. Control of the diseases re- quires adequate surveillance through rural health services with community help and prompt treatment of the pa- tients and their contacts. Action must be planned in keeping with the resources and manpower available. WHO is collaborating with a number of governments in the planning, implementation and evaluation of their pro- grammes to control endemic treponematoses. Smallpox watch ends in. U.K. Nearly 300 persons were brought under surveillance, including in many cases quarantine measures, after an outbreak of laboratory- associated smallpox infection in Birmingham, in the U.K., in August and September. There were two cases, in- volving a single family. The first victim, Mrs Janet Parker, a 40-year-old medical pho- tographer, died in hospital. Her mother, Mrs Helen Wit- comb, aged 71, who had nursed her during her illness, contracted a mild form of the disease and has since re- covered. The containment and sur- veillance measures taken by the U.K. health authorities quickly brought the outbreak under control. Contacts with Mrs Parker who later trav- elled to the U.S., the Nether- lands, Spain and the Federal Republic of Germany were also kept under surveillance, and no further cases oc- curred. The precautions have now ended, and WHO has been informed by the U.K. authorities that Birmingham is no longer an infected area. The U.K. episode con- firmed the warning, already issued by WHO on several occasions, that the greatest risk of smallpox infection today comes from stocks of smallpox virus maintained in laboratories. To reduce this danger to a minimum, WHO recommends that virus be re- tained only by WHO Collab- orating Centres, under max- imum security. The outbreak, which was of "artificial" ori- gin, will not affect the overall programme for worldwide certification of eradication. No case has occurred in any formerly endemic area for more than a year despite in- tensive surveillance, and if this situation continues, the official announcement of final victory over the disease is scheduled for 1980. 30 FEBRUARY- MARCH WORLD HEALTH MAY Honoured for leading smallpox drive Two physicians whose ef- forts led to the apparent eradication of smallpox from the face of the earth have been named the 1978 recip- ients of the Joseph C. Wilson Award for achievement and promise in international af- fairs. Dr Donald A. Henderson directed the global campaign against the disease as chief of the World Health Organiza- tion's smallpox eradication unit, and Dr William H. Foege developed and demonstrated the surveillance/containment Dr Donald A. Henderson. strategy which was the key- stone of the smallpox eradi- cation campaign. He was personally involved in WHO's field activity in both Africa and India. The last-known naturally occurring case of smallpox was recorded on Dr William H. Foege. October 26, 1977 in Somalia. (The laboratory accident in Birmingham, U.K., just men- tioned, is seen as of "arti- ficial" origin.) The award, which carries a $10,000 honorarium for each recipient, is offered as a me- morial to Joseph C. Wilson, late chairman of Xerox Cor- poration and a leading figure in humanitarian, civic and educational affairs. It is given to an American citizen in mid-career whose sustained contribution to the quality of life and to inter- national understanding in- cludes recent achievement of unusual and lasting signifi- cance. Dr Henderson is now Dean of the Johns Hopkins Uni- versity School of Hygiene and Public Health, and Dr Foege is now Assistant Surgeon General and Director of the US Public Health Service's Center for Disease Control. Dr Aculia Reelected PASB Director Dr Hector R. Aculia has been reelected Director of the Pan American Sanitary Bu- reau for a second four-year term. The Bureau is the Sec- retariat of the Pan American Health Organization (PAHO) and serves as WHO's Re- gional Office for the Americas. The election took place du- ring the XX Pan American Sa- nitary Conference which was held in Grenada, West Indies. Dr Hector R. Acuna. WHO Photos Dr Acuria was born in the State of Sonora, Mexico, September 1921. He re- ceived his medical degree in 1947 at the Faculty of Medi- cine of the University of Mexico and a master's degree in public health at Yale Uni- versity in 1951. In 1971 he became Director of Interna- tional Affairs in Mexico's Ministry of Health and Wel- fare, a post he held up until his election as PASB Director in 1974. Authors of the month Dr H. MAHLER is the Director- General of the World Health Organization. Dr A.H. TABA is the Regional Director of WHO'S Eastern Mediterranean Region. Dr V. BAILEY is the Regional Officer, Nutrition, in WHO's Afri- can Regional Office, Brazzaville. Miss E. BARTON, formerly Regional Nursing Adviser in WHO's African Region, is now in the Division of Family Health at wito headquarters, Geneva. Mrs G. ALLMAN-BURKE is the Caribbean Area Nursing Adviser to WHO'S Regional Office of the Americas. Miss M. SKEET, now a consultant to WHO in Geneva, was formerly Chairman of the Advisory Com- mittee to the League of Red Cross Societies. Miss D. NORTON was formerly Liaison Nursing Officer to the Metropolitan Regional Board, Greater London, UK. Mr J. BLAND is the Editor of World Health. Dr F.N. AGUILAR is Executive Director of the Project Manage- ment Staff, the Philippines Department of Health. Manila. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* WORLD HEALTH INDEX 1978 January Towards a better tomorrow Cooperation among Developing Countries February - March Down with high blood pressure World Health Day issue April Thirty years of service WHO Anniversary issue May Primary Health Care Justice in health June Man and the Environment Cause and effect July Human Rights — Influenza Medicinal plants Tropical disease research Malaria August - September Research in family planning Fertility control methods October Animals and Man A balanced relationship November Sport for a lifetime Sports medicine and health December Nursing Action for change in nursing One year 12.50 25 — Two years 22.50 45 — Three years 30.— 60 — One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country • * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Po l IT O O r :M ifg er la ria I m p ri m et ie u Ru u nl uu S .A . La u& al m e Above ad, nursing means the offer of loving care and attent'o7 when it is most needed. (Photo WHO a Mohr)