Health for all by the year 2000 [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • NOVEMBER 1979 IIVORLb HEALTH

What is health for all? by Dr Halfdan Mahler Director-General of the World Health Organization L t is only four years since the idea of health for all by the year 2000 was first put forward at a number of WHO's Regional Committees. Since then it has fired the imagination of peo- ple throughout the world. It has also given rise to severe scepticism. "How do you define health? What do you mean by all? Will no more babies be born with in- born diseases ?" When the Thirtieth World Health As- sembly in 1977 decided to adopt health for all as the main social health target of governments and WHO for the coming decades, it referred to it as a level of health that will permit people to live a socially and economically productive life. Such a life is also not easy to define pre- cisely. Yet it is those who live such a life who tend to be the sceptics and who demand explicit definitions, whereas those who live an inferior life, or repre- sent people who do, have become in- spired by a new hope and a new determi- nation to work towards better health. If health for all meant medical repairs by doctors and nurses for everybody in the world for all their existing ailments, much in the same way as mechanics repair faulty motor-cars, it would cer- tainly not be a realistic proposition. But it does not mean that. Nor does it mean that nobody will be sick or disabled. It means a different approach by which health is considered in the broader context of its contribution to, and promotion by, social and economic development, so that all people will be able to lead socially and economically satisfying lives. It means that people will use better methods than they do now for preventing disease and alleviating unavoidable disease and dis- ability, and better ways of growing up, growing old and dying gracefully. Today nearly one thousand million people, living mainly in rural areas and urban slums, certainly do not live satisfy- ing lives, since they exist in a state of The provision of safe drinking water—one of the fundamental elements in primary health care. (Photo WHO/M. Jacot) social and economic poverty. This is a pernicious combination of unemploy- ment and under-employment, economic poverty, scarcity of worldly goods, a low level of education, poor housing, poor sanitation, malnutrition, affliction by disease, social apathy, and lack of the will and the initiative to make changes for the better. Taken together these create a vicious circle, and improvement of any one of them could contribute to improvement of all of them. 6 6 We must succeed. The chil- dren of today, and those who have not yet been born but who will comprise more than one- third of the people living in the year 2000, will never forgive us if we do not. 99 It is for these people first and foremost that the concept of health for all is so im- portant. However, it is not for them ek- clusively. No people can be entirely satis- fied with their social and economic pro- ductivity. As they move forwards along the road of social and economic progress they strive to improve their lot; they would not be human beings if they did not. But in the past, in trying to do so, they have committed gross errors in their relationships with their environment. In this way they have brought on them- selves retributions in the form of slowly developing but insistent ill-health, such as lung cancer and cardiovascular dis- ease as a result of over-smoking, high ac- cident rates, mental illness to the extent that vast numbers live on tranquillizers, and high suicide rates in those countries that consider themselves among the most socially advanced. In short, health for all aims at all peo- ple whatever their present level of social and economic development, but social jus- tice demands that greatest attention be paid to the underprivileged, so that they become able to extricate themselves from the poverty equilibrium in which they are Cover: Health for All by the Year 2000. The four-month-old human fetus is already getting to grips with life. (Photo Lennart Nilsson ©, from "Behold Man" published by George G. Harrap, London) 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 What is health for all? by H. Mahler 3 An attainable target? by A. El Carnal 6 The health revolution by M. Toure . 10 Helping people to help themselves by P. Tuchinda 14 The UN answers the challenge by K. S. Dadzie 18 Life in the Americas 21 Health for all by the year 2000 by J.J.A. Reid .. 22 Vital links in the health chain by B. Petrovskij .... 26 Starting from scratch by E. M. Samba 32 News Page 36 Young World Health 38 Top: Youngsters all over the world are knocking at the gates. Will they gain access to the better life they seek? (Photo WHO/R. Rouleau) Above: A health visitor brings advice on family planning to the home—rather than waiting for overburdened mothers to visit the clinic. (Photo WHO/J. Mohr) Upper right: Life holds no joy for the malnourished. If re- sources are to be more evenly distributed, this means giving top priority to the socially under-privileged. (Photo WHO) Lower right: "Health begins at home, in fields, in factories. It is there, where people live and work, that health is made or broken. - (Photo WHO/P. Almasy) What is health for all? trapped. As they do so, they will be wise to progress in a way that does not lead them into another trap—that of exces- sive medical consumption as part of a consumer society. Health for all is thus a moving target. As a certain health status is reached, people will try to reach a higher level, and so on. The approach that is being adopted to attain health for all is based on the fun- damental understanding that health begins at home, in schools, in the fields and in the factories. It is there, where people live and work, that health is made or broken. People must therefore under- stand what health is all about, and it is the duty of those who know to help oth- ers to understand. People must grasp that ill-health is not something that is in- evitable, and that to bring about better health proper account has to be taken of a number of factors of a political, eco- nomic, social, cultural, environmental, and biological nature. Strengthened by this understanding, people will be in a better position to exploit those factors that are favourable to health and to com- bat those that are detrimental. But to gain progressively such an understanding a minimum level of health is essential. So health and social awareness must go hand in hand, the one leading to the oth- er and each progressively reinforcing the other. The process I have just briefly de- scribed is known as community involve- ment, or as somebody has expressed it, "health as if people mattered". Such community involvement can have a broader influence than the local organization of health care. It can be in- strumental in bringing about the commit- ment of community leaders to support the health reforms required, and through them can stimulate the political commit- ment of their government to introduce and sustain these reforms. For, in the final analysis, governments do have re- sponsibility for the health and socio-eco- nomic development of all their people, and not only of the elite in the main cities. This implies distributing resources for health more evenly, and to do so means giving top priority to the socially under-privileged. This applies within countries, but it also applies internation- ally, since the more fortunate countries have a double responsibility—to their own people and to those in countries in less fortunate circumstances. Government decision and popular in- sistence are also necessary to ensure that many sectors in addition to the health sec- tor take the necessary action to promote health. For example, the education of the masses on health matters, the provision of safe drinking-water and adequate sanita- tion, adequate supply of the right kind of food, and housing that shelters against ex- cessive sun and rain and wind, and gives protection against insects and rodents, usually depend on actions in other sec- tors as well as in the health sector. The involvement of people in ensuring this action is just as important as their invol- vement in action within the health sector. The latter has to ensure maternal and child health care, including family plan- ning. It has to deal with the provision of immunizations against the major infec- tious diseases and to take other measures necessary to prevent and control impor- tant local diseases. At the same time, it has to deal with the treatment of common diseases and injuries as well as with the rehabilitation of those left with disability. Rehabilitation also requires action in sectors other than the health sector. So does the provision of essential drugs. This calls for industrial and commercial action in addition to the careful selection and quality control of those drugs that are really essential. For most purposes these could be reduced to far less than 200 in most countries. How much will it cost? The above describes the minimum requirements for moving forward in the direction of health for all by the year 2000. Are the costs exorbitant? Recent small-scale studies have shown that con- siderable improvements in people's health can take place for as little as 0.5 to 2 per cent of the yearly gross national product per person—or what amounts to a few dollars a year. This is by any standard a reasonable cost, around a hundredth of what is spent on health by people in many rich countries. So cost factors should not hinder governments when they consider if, and to what extent, they should commit themselves to the target of health for all by the year 2000. So this, in a nutshell, is what is meant by health for all through primary health care. If countries strive towards health for all in this way, and avoid creating the kind of medical consumer society that exists in the developed countries, they will be able to make progressive im- provements in their provisions for health at a cost they can afford. This must in- clude support for primary health care from the more central tiers of the health system. In too many countries today, resources are first allocated to central medical in- stitutions that provide sophisticated and costly medical care to the privileged few, only a small fraction trickling down to people where they most need them—in their homes and in their communities. The education of health workers too is concentrated in these central medical in- stitutions, producing health workers who are quite divorced from most health problems of most people. The correct ap- proach to attaining health for all there- fore includes training health workers to be socially attuned to the needs of the people they are to serve, and technically equipped to help these people understand what health is all about and to provide them with the care they need, where they need it and when they need it. The developed countries too will require enlightened community involve- ment as well as government commitment to introduce the health reforms required to reshape their health systems. These reforms will have to include adequate measures to combat over-smoking, over- eating, over-drinking, over-driving, over- using and abusing drugs, over-pollution of the environment, and over-stressing and over-alienation of people in gigantic urban agglomerations. At the same time they will also have to include giving up the attempt to provide everybody with every type of medical technology cur- rently in vogue, which even the richest countries cannot afford, and which would not be of real benefit to their peo- ple even if they could afford it. In September 1978 the International Conference on Primary Health Care that was held in Alma-Ata in the USSR is- sued a Declaration calling for urgent national and international action to at- tain an acceptable level of health for all. No time has been lost by WHO in setting this action in motion. The Member States of WHO are about to embark on the development of strategies for attain- ing health for all, individually as far as their own countries are concerned, and collectively for regional and global strat- egies in support of national strategies. The involvement of the world commu- nity and the commitment of the world's political bodies are crucial for ensuring the success of these endeavours. For we must succeed. The children of today, and those who have not yet been born but who will comprise more than one-third of the people living in the year 2000, will never forgive us if we do not. ■ 5 An attainable target? dt o many people, including some political leaders, health services are synonymous with medical ser- vices, and good health is the out- come of good medicine. They cannot be more mistaken. Health, as stated in the WHO Constitution, is the "state of com- plete physical, mental and social well- being and not merely the absence of dis- ease or infirmity". The International Con- ference on Primary Health Care, held last year in Alma-Ata, stressed this fact in clear terms in its Declaration when it stated that "Health ... is a fundamental human right... whose realization requires the ac- tion of many other social and economic sectors in addition to the health sector". This definition of health and how to attain it is of vital importance if we are to understand and fulfil the goal of Health for All by the Year 2000. In its quest for this goal, humanity faces many predictable and yet controll- able factors. First among these is the present state of health of the community—the pres- ence and extent of endemic diseases, for example. The community's state of mind is a more subtle, though no less impor- tant, consideration. It can not only affect the mental and social well-being of indi- viduals, but can also reflect on the physi- cal condition of the population in the form of high blood pressure, heart at- tacks, peptic ulcers, and a high rate of conscious and subconscious suicide at- tempts. The environment in which the commu- nity lives is another factor that requires study and analysis. The quality of air is an important element at a time when in- dustrialization and means of transport are polluting the atmosphere in an ever more dangerous way. Sources of drink- ing water too are subject to pollution by domestic and industrial waste water which is not effectively treated before by Dr Amin El Gamal Under-Secretary of Health, Egypt discharge, while noise, excessive heat, cold or radiation impose a further bur- den on the human environment. The population increase is another factor for consideration. Apart from determining the size of the health ser- vices required, the rate of increase gives an indication of the age pattern of the society, which in its turn is an indicator of the health and social problems. Besides these activities with an obvious relation to health, there are other fields of action where the effect on health may not seem so apparent. Among these is the urgent need for universal literacy. The degree of literacy in any country can be shown to relate directly to that country's health status. 9 Finally, the type and distribution of the health services available, together with the access the entire population has to them, will obviously have a significant bearing on the present state of health of a community and its future improvement. If we review these factors and analyse them, we can determine some of the ac- tivities that are needed to attain our goal by the year 2000. First and foremost among these activi- ties is the universal supply of safe drink- ing water and sewage disposal systems. This is so vital and so urgent a matter that the United Nations arranged an in- ternational conference in Mar del Plata, Argentina, in March 1977 specifically to discuss it. The conference came up with resolutions which were subsequently adopted by the UN General Assembly. These resolutions included the attain- ment of safe drinking water supply and sanitation services by the world's popu- lation by the year 1990. To achieve this, the period from 1978 to 1980 was to be devoted to studies and pilot projects. This was to be followed by the Interna- tional Decade for Drinking Water and Sanitation 1981-90, during which every effort will be made to make safe potable water and efficient sewage disposal avail- able to all as a human right. To attain such a goal, governmental, intergovern- mental, and international efforts are be- ing coordinated and funds will be raised and made available for projects accord- ing to the priorities laid down once their feasibility has been studied. Another important activity that has to be considered is the provision of special nutrition services for mothers and chil- dren. The period of pregnancy and lacta- tion is a very critical one, with far-reach- ing effects on the health, mentality and life expectancy of the infant. For the growing child, nutrition means not only the quantity of food but also its quality, and the inclusion of essential vitamins and minerals besides animal and vege- table proteins. Immunization against such diseases as smallpox, diphtheria, tetanus, poliomye- litis, tuberculosis and measles has strik- ingly reduced the incidence of many dis- eases and has considerably lowered the mortality rate, particularly among chil- dren. The list of diseases is fortunately increasing, and the effectiveness and safe- ty of the vaccines is improving. In recogni- tion of this, WHO has launched its Ex- panded Programme on Immunization. In the light of increased communications between countries, it is clearly imperative to plan a universal approach to vaccina- tion if we are to follow up the example of smallpox, which is on the point of being declared eradicated from our planet. 6 Top: Stress, pollution, overcrowding, noise: the conditions of daily life in Cairo, as in other great cities of the world, bear directly on the state of health of the community—and on the community's state of mind. (Photo WHO/M. Jacot) Left: The waters of the Nile are the life-blood of Egypt. But without careful control they can harbour dangers, such as the water snail that carries schistosomiasis. (Photo WHO/D. .Henrioud) Above: Learning to read. The degree of literacy in any country relates directly to that country's health status. (Photo WHO/M. Jacot) An attainable target? Left: Waiting at the family planning clinic. The better controlled the population's rate of increase is, the greater the chance of securing Health for All. ( Photo WHO/M. Jacot) Right: Victory will be won, not in lavish con- sulting rooms but in settings like this, with the health worker visiting homes and spreading his equipment in the village street. ( Photo WHO/D. Deriaz) Besides these activities with an ob- vious relation to health, there are other fields of action where the effect on health may not seem so apparent. Among these is the urgent need for universal literacy. The degree of literacy in any country can be shown to relate directly to that coun- try's health status. This has been proved by many surveys and is a fundamental prerequisite for ensuring that the public has access to health education. If we review the services mentioned above, we find that they can be grouped under the heading "improved standards of living". This is attainable provided we have the resources and the know-how to use them. Economic development is therefore another essential factor in our endeavour to attain the accepted stan- dard of health. The better controlled the population's rate of increase is, the more chances we have of securing Health for All. This makes family planning a key-stone in health strategy. Besides improving the health of mothers and children, it helps to ensure that a country's health and social services are not overburdened. The world situation would have been easier to understand and more predict- able had it not been for certain uncon- trollable and to a large extent unpredict- able characteristics of human society. These factors have the effect of impeding many of our initiatives in the right direc- tion, while putting an increased strain on national finances. Economic crises are becoming a stan- dard feature of modern societies. Even in developed and well industrialized coun- tries, the alternation of depressions with periods of prosperity and the continued increase in prices of vital commodities— apart from their effect on inflation— cause rising unemployment and make it harder for new generations to find suit- able jobs. They may also contribute towards swelling the ranks of the under- privileged migrant workers. Such crises impede all efforts to improve the health situation and, even where good inten- tions and feasible plans are available, may provoke the deterioration of an al- ready unacceptable situation. Political upheavals too can hamper the implementation of good health plans. The very countries that most need politi- cal stability are the ones that are plagued by drastic and frequent changes of their political systems. Unfortunately it is a common experience that every regime brought to power by a coup d'etat tends to try to change the policies and plans adopted by the previous regime. It is ob- vious that plans for development need to be followed through and evaluated over the years if they are to fulfil their targets; it is also obvious that frequent changes in the political system are inimical to such an orderly pattern. Political change does not always stem from internal unrest but may be brought about by external military hostilities, which in turn result in devastation, famine, epidemics and other forms of human suffering. The loser from all this is clearly the physical and mental health of large communities and nations. The occurrence of cases of smallpox in Soma- lia and Ethiopia after this disease was wiped out from all other countries may have been due in part to the hostilities that broke out between those two coun- tries. A further factor which is not man- made but which can cause desperate situ- ations is the natural disaster. Droughts, floods and earthquakes can have a far- reaching effect on the health of the peo- ple and on any plans to improve it. Uncontrollable and unpredictable though some of these factors may be, yet humanity is able to do something to off- set the calamities they bring in their train. The Universal Declaration of Human Rights, the Geneva Conven- tions, and international public opinion itself can and do help to diminish the human suffering resulting from military hostilities, oppressive political regimes and natural catastrophes. It is in this respect that the interna- tional organizations are today more than ever required to play a leading role. Bringing about peace for all peoples, im- proving the lot of refugees and solving disputes between countries by negotia- tion will spare humanity a great deal of suffering and in the long term will help to improve the living conditions of mankind. Is the goal of Health for All an attain- able target? From the foregoing it is clear that attaining this goal will not be merely the prerogative of the health ser- vices, but will depend rather on a willing collaboration between a great many sec- tors of human activity. Given such will- ing collaboration, Health for All by the Year 2000 can certainly be achieved. ■ 9 The Health Revolution by Dr Madiou Toure Director of Hygiene and Health Protection, Ministry of Public Health, Republic of Senegal he literature of the Year 2000 is already very much with us; what is surprising is that it has not yet attracted the attention of those who award the big literary prizes—or even the Nobel Prize for Literature. For it offers a rewarding prospect. The planners dream of a harmonious and in- tegrated unfolding of events that will bring about by the end of this century a world that is more just, more humane, more imbued with brotherly love. voio itself has launched an optimistic call for Health for All by the Year 2000 and has started a vigorous political offensive with this target in view. The developing coun- tries aspire to enter the industrial age by the end of the century. But why such zest for such a goal? President Leopold Sedar Senghor of the Republic of Senegal gave an appropriate reply when, in the context of our Third Four-Year Plan for Social and Economic Development, he wrote : "Why embark upon long-term planning and why choose the Year 2000? First of all, in a world of rapid change it is best to look as far as possible into the future, if only because it is harder to foresee things at short term.... If, on the occasion of the Third Plan we have chosen the Year 2000—or 2001 to be precise—it is because it marks not merely the end of a century but the end of a millennium, and as such it has already captured people's imagination and braced their efforts. What is more, there already exists a whole literature of the Year 2000 in the form of forward-looking studies." We have never before been so close to realizing that ancient dream of "the whole man", in this age of wonderful scientific discoveries and incredible tech- nological breakthroughs. And yet, neither has humanity ever been so close to the apocalypse through the stupid application of those dis- coveries. Ever more refined weapons of destruction pose a permanent threat to our entire planet; people seem unable to live at peace with one another and slaughter each other in the name of ab- surd ideologies; the highly developed countries grow ever richer at the expense of the two-thirds of humanity who grow still poorer. The medicine of tomorrow will be shaped by the people for the people, because the people themselves will determine their own condition, their own destiny. 9 9 But in time, self-reliance and the awakened social conscience will be the hallmarks of development. They imply the participation of the community in the major political choices that will assure its future. Medicine itself will no longer be sim- ply a matter for doctors, trained in the cloistered lecture-rooms of the medical schools. As Ivan Illich says so eloquently in "Medical Nemesis", the health profes- sion of the future will be shaped by a progressive reduction in medical expen- diture and by a rapid "de-professional- ization" of health care. The eradication of diseases such as smallpox will set free large amounts of money and energy which can then be reinvested in other health sectors for the general good of humanity. Village health workers, on the lines of China's barefoot doctors, are in effect a response to the arguments of Illich. Tra- ditional practitioners and healers were aware, long before our modern doctors, that the pathological condition of human beings is directly linked with the social group in which they live and is deter- mined by the structure of their social sys- tems and cultures. Once again everything comes back to culture. The new bourgeois industrial society with all its internal contradictions—on the one hand invididualism and personal success and on the other hand the demo- cratic ideal which demands the same basic living standards for every individ- ual—has shaken the entire social struc- ture and its values to the core by admit- ting the mass of the people into that soci- ety, with all the force of law. Health, like well-being, has become a basic right and everyone can aspire to reach the highest possible level. The nations of the world admitted this when, on 10 December 1948, at the seat of the United Nations, they signed the Univer- sal Declaration of Human Rights. Thirty years have passed and the situa- tion has not changed for the better. It proves therefore all the more essential and urgent to revise the present health system and to adopt an entirely new ap- proach. It will involve integrating the system within the general framework of development, defining operational stra- tegies, and ensuring dynamic technical cooperation between countries as well as community participation in the public health effort—all of this underpinned by a resolute political will. What this amounts to is a veritable health revolu- tion that we are living through, a revo- lution that strikes the dominant note of medicine today. 10 How far can it carry us towards WHO's social goal of Health for All by the Year 2000? Some of the new development strategies already launched in Senegal al- ready go a long way towards it. African realities Immediately after Senegal gained its independence, in 1960, the authorities set the country's general economy on a new road; this new direction was based on an original form of socialism that cared for the individual, was democratic and de- centralized, and took account of African realities. One of its main innovations has been to implant a unit charged with responsibility for development at the heart of each territorial administration, backed up by machinery for consultation and participation. The principles of our health policy are based on the idea that health action and the right to health of every citizen are in- divisible. At the operational level, this calls on the one hand for the integration of medical action with social action, and on the other hand for the broadening of health coverage. What is really needed is to bring about preventive, curative, educative and social medicine; to develop efficient services in the rural communities; to organize a rational system of primary health care based on effective community participa- tion; to devise means of educating peo- ple in universal health care; to steer a course resolutely towards social ad- vancement; to define a population poli- cy, including family planning, which will have both medical and humanitarian ob- jectives and services, and will be integrat- ed within the maternal and child health services; and to lay stress on medical and paramedical training. The government intends to devote nine per cent of the national budget to the health sector in the near future, that is, over the next three years. However, the needs are so pressing that the participation of the population is essential, as well as a perfect under- standing of the organizational techni- ques and methodology required to make the services operational. This is why a training course in administration is being offered to heads of health posts so ... We have never been so close to realizing that ancient dream of "the whole man", in this age of wonderful scientific discoveries ... (Photo WHO/M. Jacot) as to spread around all the available resources. Ever since the first years of our inde- pendence, there has been some sporadic involvement of initiatives by the local community in support of state action in the health field, for instance in building dispensaries and rural maternity clinics or setting up village pharmacies. But it was the administrative reform of the 1970s that enabled an effective system of community participation to be started. Two basic projects have proved partic- ularly encouraging and deserve special attention in the context of WHO's great goal for the Year 2000. The primary health care experiment in the Sine Saloum area is certainly the most successful of all those that have been developed in regions subject to admini- strative reform. 11 The blueprint for the test-zone of Sine Saloum, drawn up on 30 November 1977, envisaged the village pharmacy as a practical expression of the local vil- lagers' desire for health care to be as ac- cessible as possible; the pharmacy was to be run by a member of the community, trained quickly by the health service and equipped with a box of basic medi- caments. The following prior conditions were laid down : The community itself should un- dertake to build a "health house" from locally available materials; this would then be dependent on the local health post. The person in charge, designated by the community, would be trained at the departmental health centre, then at the health post, before assuming the run- ning of the community health house un- der the supervision of the health post chief. Financing of the health house is the responsibility of the rural communi- ty, which must set aside part of its budget to this end; and the villagers must agree to contribute towards the running costs by paying a small sum for each consulta- tion. The funds thus collected should be handled by a communally-appointed management committee. An initial contribution should be provided by UNICEF, WHO and US AID funds. In this way Sine Saloum found itself well on the way to putting primary health care into action, and always with- in the framework of the action pro- gramme of the nation's Fifth Plan for economic and social development. ... What is really needed is to organize a ratio- nal system of primary health care based on effective community participation ... ( Photo WHO/D. Henrioud) The second example is the basic health service scheme at Pikine, with Belgian and Senegalese backing. It relies on a network of urban or suburban health posts, ensuring a satisfactory coverage of the population and an even distri- bution of services throughout the whole prefecture. The aim, again, is to develop a cura- tive, preventive, educative and social ap- proach using means that are at the same time simple, inexpensive and effective. They should be easily accessible, in the geographic, economic and cultural sense, and should rely from start to finish on local resources of materials and man- power. To attain these objectives, it was necessary to win people's confidence at once by creating an official health asso- ciation, self-managed and self-financed, which was given effective powers to train health personnel, both professionals and volunteers, so as to ensure the broadest possible in-depth coverage. We are well aware that not everybody thinks as highly as we do of our system and our activities. But what matters is that the guidelines are being laid down that will enable us to keep pace with cur- rent trends in developmental theory. Thanks to administrative reform, the development of basic health services and community participation, Senegal today seems well set to win its pledge for the Year 2000—"Health for all in a socialist society". We have already said, and it is worth repeating, that the entry of the mass of the people into the new industrial society, with all the force of law, has fun- damentally stirred the social structure and toppled its values. The medicine of tomorrow cannot escape from this phenomenon; it will be shaped by the people for the people, because the people themselves will determine their own con- dition, their own destiny. That health which conditions the sta- tus of the individual, the family and the community clearly constitutes an impor- tant element in the well-being of a nation. The global approach to health problems must therefore be placed with- in the framework of integrated develop- ment, and the final goal is the advance- ment of mankind as a whole. In tackling this approach, one hears much talk about human structures and societies. But the problems will not be solved under the present system. That will require a systematic new cultural and economic order, an international ad- ministration on a planet-wide scale, standing above all petty prejudice. It will need a new science whose symbols have yet to be formulated. Within such a frame the medicine of the Year 2000 will be a symbiosis of all the health sciences, rooted deeply in the positive values of ev- ery culture and assimilating every fertile invention of the modern age in its quest for universality. Once this new order is attained, thanks to the present efforts of the developing countries, the new medical science— stripped of human foibles and failings— will be able to devote itself in all con- science to the quest for the perfect being, that is to say, the integrally balanced in- dividual, redolent with all the values of all the world's civilizations, capable of facing the future with confidence. To do this, the health revolution will have to set its course towards finding the common ground between widely differ- ing health service structures, between the widely differing abilities of health per- sonnel. Between the hospital and the "health house", between the physician and the village health worker, the rational approach will recognize the need for a single unified system. Health for All by the Year 2000—a dream or a reality? It could go either way when we look at the state of our planet. All will depend on the conscience of mankind. If we are truly to attain this social objective, it will only be by engag- ing that human conscience in all our endeavours. ■ 12 ... We have to define a population policy, which will be integrated within the maternal and child health services ... (Photo WHO/UNICEF/J. Ling) Helping people to help themselves by Professor Prakorb Tuchinda Under-Secretary of State for Public Health, Thailand and President of the Thirty-second World Health Assembly Li ealth is a fundamental human ' right. All human beings have a right to the necessities for the en-joyment of good health. For over 30 years, WHO has tried to promote and support health—in the sense of complete physical, mental and social well-being— within all its Member States. However, there is still a gross inequali- ty in the health status of the people, par- ticularly between developed and devel- oping countries as well as within coun- tries. The gap is widening between the health "haves" in the affluent countries and the health "have-nots" in the devel- oping world; and this gap is also evident within individual countries, whatever their level of development. Despite phenomenal advances in scientific disciplines in general and medi- cal science in particular, three-quarters of the world's population still has no ac- cess to any permanent form of health care. Basic necessities which may be con- sidered as measures of a reasonable qual- ity of life, such as proper housing, safe drinking water, education and a proper food intake, are denied to the vast major- ity of rural communities and to the urban poor. Infectious diseases—many of which are preventable—continue to take a heavy toll of human life in most developing countries. Infant mortality remains at an unacceptably high level, with millions of children not living to see their first birthday. Many more millions are handicapped for the rest of their life following the ravages of malnutrition and associated conditions. Being fully aware of this world health situation, the World Health Assembly in 1977 resolved to make Health for All by the Year 2000 the main social target of WHO in the coming decades. In turn, the historic Declaration of Alma-Ata, in September 1978, called upon all govern- ments to have a responsibility for the health of their peoples which can be ful- filled only by the provision of adequate The emphasis of primary health care in Thailand is re- flected in a variety of efforts aimed at involving local resi- dents in restoring and main- taining their own health status within the framework of rural development. 9 health and social measures. Affirming that the primary health care approach is essential to achieving an acceptable level of health throughout the world, the Alma-Ata Conference also urged each 14 nation to make a strong and continuing commitment to primary health care at all levels of government and society, and to ensure that primary health care is an in- tegral part of community and national development and does not develop as an isolated peripheral action. The Confer- ence emphasized the importance of full and organized community participation and ultimate self-reliance, with individ- uals, families, and communities assum- ing more responsibility for their own health. The , services provided by primary health care will vary according to the country and the community, but will in- clude at . least : promotion of proper nutrition; an adequate supply of safe wa- ter; basic sanitation; maternal and child care, including family planning; immu- nization against the major infectious dis- eases ; prevention and control of locally endemic diseases; education concerning In Thailand, the traditional medical practi- tioner is recognized as a potential resource for primary health care and is given his due place in community welfare work. ( Photo WHO/A. S. Kochar) prevailing health problems and the methods of preventing and controlling them; appropriate treatment of common diseases and injuries; and provision of essential drugs. The Thirty-second World Health As- sembly this year endorsed the report of the International Conference on Primary Health Care, including the Declaration of Alma-Ata, and adopted a resolution on "Formulating Strategies for Health for All by the Year 2000" which is of momentous importance. All govern- ments are called upon to formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in co-ordina- tion with other sectors. Collectively these policies will be a basis for formulating regional and global strategies. The World Health Assembly also appealed to all agencies and organizations within the United Nations system, and in par- ticular the United Nations Children's Fund (uNicEP) and the United Nations Development Programme (uNDP), as well as to all bilateral agencies and non- governmental organizations concerned, to give full support to formulating and implementing national, regional and global strategies for achieving an accept- able level of health for all. In my country, Thailand, for some decades in the past, the health service has unfolded mostly in the form of hos- pitals and clinics for treating diseases. This kind of health system, using 15 conventional medical care, has benefited only a small group of privileged individ- uals in the main cities. Later on, under our Fourth Five-Year Economic and Social Development Plan, the National Health Development Plan was drawn up on a more scientific basis through country health programming and project formulation. WHO and other UN Agencies as well as bilateral agencies were closely associated in the prepara- tion. The main emphasis was laid on im- proving the health status of the rural population, especially at the village level. In 1977, the Ministry of Public Health launched the Primary Health Care Pro- gramme, with five general objectives : to expand the coverage of health services, particularly among the under- served rural population, as quickly as possible, and to help the people to help themselves; to utilize community resources and encourage community participation so as to solve individual health problems and eventually to establish self-help pro- grammes at the village level; to promote the dissemination of health information to local people, as well as collecting all the data reflecting the needs and health problems of com- munities; to make basic health services avail- able, accessible and acceptable to the people; to decrease malpractice, especially in medical care. Involving local residents For health manpower development there has been a re-orientation of the training concept towards primary health care workers. The emphasis of primary health care in Thailand is reflected in a variety of efforts aimed at involving local residents in restoring and maintaining their own health status within the frame- work of rural development. The Ministry of Public Health has realized that there are untapped manpower resources exist- ing in the villages—people who can serve local communities as Village Health Communicators (vHc) and Village Health Volunteers (law). Appropriate projects were formulated under the pro- gramme, and the guidelines were laid down for training viics and viivs. Those who are interested in health activities in the villages will help their neighbours and communities after they have been properly trained in simple medical care, disease prevention and health promo- tion. They can serve their communities and relieve the shortage of government health personnel in rural areas. wics and viivs are volunteers who are willing to help their communities without any remuneration. They only ex- pect a gain in recognition and respect from the villagers. This programme will help the people by promoting communi- ty health services with community partic- ipation and the use of community resources. 16 Helping people to help themselves Left: A traditional midwife examines a mother- to-be. Given training to ensure that she does not perpetuate any unsafe practices, the traditional midwife too can help to meet the basic needs of her community. Right : The old-style hospital-centred health service used to benefit only the privileged few in the main cities. Today immunization against the major infectious diseases is safeguarding children's lives even in the remotest rural areas. ( Photos Thailand Ministry of Public Health) The Government of Thailand, through the Ministry of Public Health and other health-related ministries and agencies, has already begun a series of steps to develop national commitment, strategies and action plans in order to reach the goal of Health for All. Following Thai- land's participation in the International Conference on Primary Health Care held at Alma-Ata, and based on its recom- mendations, the Ministry of Public Health made an analysis of the present situation of primary health care schemes and of the obstacles to their success in the country. Recommendations and a policy statement were then made and submitted to the Cabinet for considera- tion. In March 1979, the Cabinet approved the principle of primary health care as a National Health Development Policy and supported the allocation of resources and administrative mecha- nisms to ensure the achievement of the programme objectives. As a consequence of this national commitment, the Minis- try of Public Health is currently prepar- ing to set up a new Primary Health Care administrative unit within the office of the Under-Secretary of State for Public Health. This unit will be responsible for co-ordinating, organizing and support- ing activities relating to primary health care, and will also serve as the focal point for a national inter-sectoral co-ordinat- ing mechanism. Initial steps have been taken to formu- late strategies and plans of action for achieving Health for All. A series of national inter-sectoral workshops are planned to analyse the issues relating to long-term planning. Joint ventures in regional, provincial and local develop- ment planning are being conducted un- der the auspices of the National Eco- nomic and Social Development Board and the Ministry of Interior, in which the Ministry of Public Health is closely col- laborating. A national seminar on "Ap- propriate Technology for Health in Sup- port of Primary Health Care" was also held in April 1979 in co-operation with WHO, UNICEF and other international agencies. In the area of technical collaboration, Thailand is participating in inter- regional consultations sponsored by wixo with a view to drawing up national case studies in country health pro- gramming. Member countries will ex- change information, share experiences, and prepare for collaboration in formu- lating regional and global strategies for Health for All. While we are making ev- ery effort to mobilize all available national resources for overall health development, technical and financial as- sistance from international sources will continue to be quite essential. Finally, I want to end on a note of hope and sincere optimism. Although the path to Health for All by the Year 2000 will be steep and difficult, with enormous obstacles which we must sur- mount, provided all of us have the will and commitment, the goal of Health for All should be reached by the end of this century—or even before. ■ 17 The UN answers the challenge by Mr K. S. Dadzie United Nations Director-General for Development and International Economic Cooperation gehe United Nations General As-sembly decided in January this year that a new international development strategy for the Third Development Decade should be launched during 1980 for the purpose of promoting the accelerated development of the developing countries. It estab- lished a Preparatory Committee, open to all Member States, to draw up such a strategy and invited all the organizations of the United Nations system to make contributions to the preparatory process. In doing so it affirmed that the new strategy should be formulated within the framework of the New International Economic Order and be directed towards its objectives. This affirmation has great significance, for it denoted that the new strategy, un- like the current one, would not be built around a centre-piece consisting simply of quantified growth and aid approaches. It meant, rather, that these approaches would be only one element in a wide range of policy measures aimed at far- reaching structural changes in the system of international economic relations— changes which would make the system operate in more equitable fashion and be more supportive of the development process. Development is increasingly seen as a process that should be geared to the human factor both as the agent and the beneficiary of development; should be endogenous, involving the autonomous definition by each society of its own values and goals; should rely primarily on the strength and resources of each country; should encompass the transfor- mation of obstructive structures, both national and international; should be in harmony with the environment and re- spect ecological constraints. In short, the final aim of development must be the constant increase of the well-being of the entire population on the basis of its full participation in the process of develop- ment and a fair distribution of the bene- fits therefrom. These perceptions correspond to the stress given in the concept of the New In- ternational Economic Order to the need to reduce the excessive dependence of the developing countries and to re-orient their national policies towards develop- ing strategies based on the principle of self-reliance. In short, the final aim of development must be the con- stant increase of the well-being of the entire population on the basis of its full participation in the process of development and a fair distribution of the benefits therefrom. 9 9 Taking past experience into account, the task of translating these perceptions at the national level and also of reflecting them at the international level in terms of specific and operationally meaningful policy measures will be far from easy. But the Member States of WHO, individu- ally and collectively as an Organization, can play a unique role in ensuring that health and health-related issues of social development are given due consideration and a proper place in the preparation and implementation of the new interna- tional development strategy. We have over the years witnessed within the international community the declaration of solemn intentions and lofty goals which failed in their imple- mentation largely because they did not command the required political commit- ment and popular support. It is, there- fore, gratifying to observe that, in defin- ing its social target, WHO intends fully to explore and take into consideration all the political, social, economic and tech- nical aspects of the strategies required to reach Health for All by the Year 2000. In the Declaration and the recommen- dations of the Alma-Ata Conference, strong emphasis is given to community participation in the planning, pro- gramming and implementation of the health care systems destined to serve the people themselves. Closely linked to community participation, and indeed in- separable from it, is the principle of self- reliance, both at the community and at the national level. As was forcefully stressed at the Conference, the principle of self-reliance implies, in addition to the notion of primary reliance on a country's own human and natural resources, the absence of imposition from the outside of alien concepts and approaches; com- m-unities and countries are thus free to decide themselves how to tackle their problems in a manner that is best suited to local conditions. In emphasizing the contribution of the health sector to the formulation of a new international development strategy, per- haps I have not laid enough stress on the benefits that will accrue to the health sec- tor from accelerated development of the developing countries. So let me conclude by associating the United Nations with the central WHO tenet, most recently ar- ticulated at Alma-Ata, that "economic and social development based on a new international economic order is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of de- veloping and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace". ■ 18 Life is full of fun and games today. What will it be like for them—and for their children—in the Year 2000? (Photo WHO/J. Mohr)

Life in the Americas From the frozen tundra of Alaska and North- ern Canada to the windswept Tierra del Fuego in Argentina, the vast land masses and count- less islands that make up the Americas com- prise a confusing variety of life-styles. The message of Health for All is going out to every country, whether rich and industrialized or poor and struggling. Each country faces the challenge in a different way, but already the initiatives that have put primary health care on the world map are beginning to have an impact on some of the most far-flung com- munities of the continent. Farm lads in Ecuador proudly follow their yoked oxen over the difficult ground which will produce good food for their Pundit's. ( Photo WHO/ P. N. Acha) Further north, in Colombia, farmers are learning to grow maize and beans together so that the two crops complement each other in the local diet. ( Photo P. Harrison ©) A voluntary health auxiliary brings primary health care to a family in the Lake Titicaca area of Peru. Even where levels of education are low, a new aware- ness ofhealth and how to improve it is gaining ground. ( Photo WHO/ D. Henrioud) A nutritive drink helps to build up growing school- children in Guatemala. ( Photo WHO/T. Webb) On this page, two photographs that remind us how the forces of nature can cancel out all man's puny striving towards a better A hurricane—like that which devastated whole areas of the Caribbean in August—boils viciously out of the Atlantic. Oil tanks ablaze in an Alaskan town in the wake of a devastating earthquake. ( Photos Len Sirman ©) Health for All by the Year 2000 by Professor John J. A. Reid Chief Medical Officer, Scottish Home and Health Department United Kingdom, and former Chairman of WHO's Executive Board In 1977, the Thirtieth World Health Assembly in Geneva drew attention to the vast health problems which still exist throughout the world and to the inequitable distribution of resources to deal with this continuing human tragedy. As a result of its discus- sions the Assembly adopted a resolution which, among other things, decided that the main social target of governments and of WHO in the next two decades should be the attainment by all the citizens of the world, by the year 2000, of a level of health which will permit them to lead a socially and economically pro- ductive life. By this decision, WHO em- barked upon the most ambitious task with which it has ever been faced. The Organization's objective is com- monly shortened to the words used in the title of this article; but it is important to bear in mind what was actually decided by the World Health Assembly, since ex- pectations must be realistic. No country will ever achieve a state in which all peo- ple enjoy perfect health, but every nation has scope for striving to ensure that its citizens achieve the highest practicable level of well-being. The magnitude and nature of the problems facing different countries vary enormously; in all too many, health facilities are still totally inadequate, whilst in others they are unfairly distrib- uted in the sense, for example, that par- ticular sections of the populace or geo- graphical areas have inadequate access to health facilities. Some nations are faced with gross problems of malnutri- tion, inadequate or impure water sup- plies, poor or non-existent sanitary facili- ties, and substantial prevalence of com- municable or parasitic diseases. Else- where the problems lie at the other end of the spectrum, in the form of the grow- ing occurrence of diseases attributable directly or indirectly to affluence. This diversity of problems clearly points to the conclusion that the strategies for achieving the desired objective must pri- marily be generated within individual countries, and that regional and then global strategies should subsequently be built up from these. A basic necessity is that there should be clear political commitment at the We must strive to ensure that, by the year 2000, most citi- zens of the world can look back over two decades with a keen appreciation of what has been achieved partly by their World Health Organization, partly by their governments, but mainly by their own individual efforts., 9 national level; and governments must appreciate that the attainment of an ade- quate level of health by their people is not dependent solely on health services. The economic state of the country, its educational system, and its agricultural potential and policies are just a few ex- amples of other parts of the social fabric which are highly relevant. It is equally important that there should be clear pub- lic understanding about health matters and that individual citizens should be ac- tively involved in the promotion of their own health. These are vital tasks, which are as necessary in the more developed countries, where illness is all too com- monly self-induced, as they are in devel- oping nations, where public participation in attaining and maintaining a satis- factory standard of health is essential over a very wide range of activities. As a result of the 1977 Assembly reso- lution, a large amount of preparatory work has been, carried out by WHO towards formulating possible strategies for achieving the desired goal. An oppor- tune and important initiative took place in 1978 in the form of the International Conference on Primary Health Care, held at Alma-Ata in the Soviet Union, and sponsored jointly by WHO and UNICEF. This was preceded by a range of national, regional and international meetings on primary health care, and the Conference itself was attended by delega- tions from no less than 134 governments as well as by representatives of 67 United Nations specialized agencies and of non- governmental organizations in official relations with WHO and UNICEF. The full scope and importance of pri- mary health care was spelt out, and the Conference called upon all governments to launch and sustain this approach as part of their comprehensive national health systems. It also stressed the im- portance of international action and, in the historic Declaration of Alma-Ata, af- firmed that primary health care is the key to attaining the desired level of health throughout the world. The initial empha- sis is therefore on community involve- ment and community services rather than on the more specialized and expen- sive aspects of health care which are of less relevance to the immediate health problems of much of the world. Following Alma-Ata, the Secretariat and Executive Board of WHO prepared a paper on the principles and major issues involved in formulating strategies for health for all by the year 2000. The 22 Water for washing the clothes, water for drinking—and perhaps it is the village sewer too. Health for All will only be achieved when governments, communities and individuals make a concerted effort to solve the problems of inadequate or impure water supplies. (Photo WHO/UNICEF/B. Wolff) Health for all by the year 2000 compilers deliberately described this document as a preliminary one, and laid emphasis on the fact that it constituted only the beginning of a long process which will call for unprecedented efforts by all countries of the world, both indivi- dually and collectively, over the next two decades. The fundamental principle on which the proposed strategies are based is that each country should develop its own health policies in the light of its particu- lar health problems, its social and eco- nomic structures, and its political and administrative mechanisms. Experience has shown that, in addition to political commitment and community participa- tion, administrative reform and legisla- tion may well be required in relation both to health and to other related matters. There will also be substantial financial implications, although it is worth noting that a growing number of countries have made impressive progress, particularly in the development of primary health care, at a remarkably low economic cost. The Executive Board's report dis- cusses the evolution of national plans of action in the health field. It goes on to describe how these, in turn, should lead to well-defined country health pro- grammes and organized health systems to deliver them, based on primary health care but including an appropriate refer- ral process for people requiring more specialized services. The targets of various kinds will have to be defined and periodically updated in the light of the circumstances of individual countries. These might, for example, involve the reduction of deaths from particular causes, the extension of effective health care to certain vulnerable groups of the population, or the achievement of a bet- ter geographical distribution of health and related services. Targets will not be approached by the same methods, at similar speeds or in identical order in dif- ferent countries; but it will be important to try to ensure that the early steps in the development of services are consonant with what it is hoped ultimately to achieve over a period of two decades. A process of evaluation should be an integral part of the evolving system, sup- ported by appropriate means of gather- ing health information. Here again, the type of information to be collected will vary from country to country; it must be remembered that, in many cases, ele- mentary statistical information on births and deaths are either lacking or quite in- adequate. It may often be more sensible to begin with an unsophisticated system that provides basic data, of a kind that primary care workers themselves can col- lect, than to evolve elaborate machinery which works better in theory than in practice. Moving on from the national level, regional strategies should be arrived at through a collective decision of the coun- tries in each of the six WHO regions, their main objective being to ensure the promotion and support of national strategies, and to facilitate technical co- operation amongst countries within the regions in preparing and implementing them. The final stage in the process in- volves working out a global strategy which, in turn, would support the national and regional strategies. An im- portant aspect will be to strengthen the mechanisms for attracting support funds from the international community, and for ensuring that these funds are chan- nelled into activities considered to have a high priority in recipient countries. All this will call for the expenditure of much time and effort, since a period of little more than two decades is not long in order to achieve what is required. The 1979 World Health Assembly agreed a timetable which will lead, through a cy- clical planning process, to the evolution of the initial global strategy in time for the Thirty-fourth Assembly to consider it in May 1981. This article is no more than a brief outline of a wide subject, and I will con- clude with a few general remarks. First of all, it should be recognized that this is a matter for every Member State of WHO, irrespective of its stage of development or of any other factor. We can all learn from each other and, whilst developing countries may benefit from seeing the successes (and failures) in health service matters of their more developed fellow- states, the reverse process is equally true. Developed countries not uncommonly find that their systems of health care have been inhibited in their evolution as a result of inbuilt and irrelevant attitudes and prejudices, whereas certain develop- ing countries have demonstrated what can be achieved by having to start the process of building up their health ser- vices virtually from scratch. Secondly, it is important that there should be no misunderstanding about what we all hope to achieve by the year 2000. There is no question of a state of affairs in which disease has been abo- lished, but several things are clearly desirable. Preventable illness should be prevented; there should be early diagno- sis, treatment and, where necessary, rehabilitation for those conditions which are treatable; there should be continuing care for patients with maladies which are not treatable; and increasing regard should be paid not merely to the length but also to the quality of life. Next, it is desirable that there should be a diversity of approach in the evolu- tion of health care systems not merely between countries but, where appro- priate, within countries themselves. Such diversity, if accompanied by suitable monitoring, may be of greater value than a totally unified national approach; al- though this will clearly depend on the size, political constitution and other as- pects of particular countries. There will be a need to exchange information about national case-studies in primary health care and its relation to a comprehen- sive health service, and also about how best to secure co-ordination between the health and other sectors at national and at local levels. WHO and its Member States have em- barked upon a great and challenging ad- venture. It will involve international or- ganizations and governments; but if it is to succeed it must also involve the partic- ipation of individual human beings throughout all countries of the world. Nothing on this scale has ever previously been contemplated, but health is a human right and something which directly affects all of us. We must there- fore strive to ensure that, by the year 2000, the overwhelming majority of citizens of the world will be able to look back over the comparatively short period of two decades with a keen appreciation of what has been achieved partly by their World Health Organization, partly by their governments, but mainly by their own individual efforts. ■ 24 _„.-.404ettkOr- 4*- "... And increasing regard should be paid not merely to the length but also to the quality of life ..." Left: Compare this picture with the one on the previous page. No doubt this woman would gladly trade her dried up water-holefor the abundant lake water—however polluted. ( Photo WHO UN) Top: It was famine, rather than drought, that set this little family' on the move. Such migrant communities pose special problems for the health planners. (Photo WHO! UN) Below: At the other end of the spectrum, diseases like obesity and high blood pressure may be direct- ly attributable to the affluent society". ( Photo WHO/M. Jacot) Bottom : Disease will not be abolished by 2000 AD. But preventable diseases should be prevented, and there should be early diagnosis and treatment for those conditions that are treatable. (Photo WHO/E. Schwab) r . rt • 4 k • • • • r. Vital links in the health chain by Professor Boris Petrovskij Minister of Health of the USSR, and Member of the Soviet Academy of Medical Sciences very country tackles the problem of health care in its own way, as its economic resources and social values dictate. From its very earliest days the Soviet State recognized health as one of man's basic and inalienable rights and under- took to respect it. Everyone, no matter where he (or she) lives or to what social class he belongs, should have access to whatever medical care he requires, whether it be an injection to protect him from infectious disease or surgery to cor- rect a heart defect. In setting up our state health services, we chose to use what has been called the district principle of medical care, in ac- cordance with which the country was divided up into administrative areas called rayons, and these in turn into med- ical districts (urastoks) of approximately equal population. Each medical district is assigned a doctor and a middle-grade medical worker, or feldsher. Of course, the way in which this prin- ciple is applied in practice depends on the circumstances. In rural areas the medical district generally covers a num- ber of population centres. As a result the first link in the chain of curative and pre- ventive care is the outpatient clinic which has a few beds for inpatients and is run by a physician. Remote villages that are difficult of access are provided with feld- sher-midwife posts. These are staffed by feldshers, who work under the supervi- sion of the physician of the rural medical district in which the post is located. In In other words, the coun- try dweller in the Soviet Union has the same access as the town dweller to the very best in medical care. 9 towns, the initial link is formed by adults' and children's polyclinics, wom- en's advisory centres and dispansers- centres for prevention, case detection, treatment and follow-up of specific dis- orders or groups of disorders. The district principle brings medical attention very close to the local popula- tion; no one is overlooked, everyone is under the watchful eye of the district physician, who is a real family doctor, knows his patients' backgrounds and is able to understand how their illnesses are linked to biological and social factors. This is especially necessary where people are exposed at work to any risk, however slight, of occupational disease. In such cases a dual system of health surveillance has been set up conducted by the district physician and by the workshop physician attached to a health post in the enterprise concerned. Health care in the USSR forms an in- tegral part of a single state system. As economic resources have grown, so the amount spent on health has increased and extends to environmental protec- tion, to making working and living con- ditions healthier, to providing for rational nutrition and recreation, and to maintaining the health services them- selves, which are in a state of continuous evolution. At present the district physician has on average 2,000 adults in his care and the A feldsher-midwife and a nurse admire a new- born baby in a Tashkent health post, and a health worker visits a factory in Leningrad to give routine vaccinations to the work staff (Photos WHO/Novosti) 26

district paediatrician not more than 1,000 children. Polyclinics have become large diagnosis and treatment centres, where the treatment of approximately four-fifths of all patients is begun and completed, since it is found in practice that only 20 per cent of the sick require treatment on an inpatient basis. The number of works' health posts has in- creased and they have expanded into medical departments staffed by hygien- ists and occupational physicians. I should like to draw attention to the fact that in the USSR there are close links and a continuity of action between all curative and preventive establish- ments. This is particularly clearly illus- trated in the system of medical services provided for the rural population. These operate in three stages, starting with the initial care given at the feldsher-midwife post, the outpatient clinic staffed by a physician, or the rural hospital staffed by specialists in various branches of medi- cine, such as general practitioners, pae- diatricians, surgeons, stomatologists or obstetrician-gynaecologists. Patients can next be referred for treatment at a central rayon hospital, or finally—when care in a specific "narrow" branch of medicine is required—to a clinic at regional (oblast) or higher administrative level. The cornerstone of rural medicine today is the central rayon hospital with its attached polyclinic. This has special- ists in all branches of medicine on its Above: A heart-attack victim receives emer- gency treatment from a mobile first-aid unit in Baku. Right: Eyesight check for a young girl in a Leningrad polyclinic. (Photos WHO/Novosti) staff and includes an emergency health care department, with medical aircraft at its disposal so that in emergencies a med- ical team can be brought by helicopter or aeroplane to a patient living in some in- accessibly remote place. There are now over 3,000 such hospitals in the country, and they have every facility for providing treatment up to the highest modern stan- dards. In other words, the country dwel- 28 ler has the same access as the town dweller to the very best in medical care. At the same time the initial link in the rural medical service has been changing. We have been reorganizing small rural inpatient units located near central rayon hospitals into outpatient clinics or reha- bilitation units. Rural medical staff working in such clinics and at feldsher- midwife posts thus get an opportunity to devote more attention to preventive care for healthy people. Regular medical checks are made on pregnant women, children, the war dis- abled, industrial workers exposed to health risks and persons with chronic diseases. There are now more than 40 million people on the dispanser regis- ters—almost every sixth or seventh per- son in the country. Nearly 160 million people a year undergo a preventive ex- amination, expenses being paid by the state. Although the problem of providing the population with qualified medical care has in principle been solved, this does not mean that there is nothing left to do. In order to ensure that the Soviet citizen's constitutional right to health care is met as effectively as possible, fur- ther massive capital investment, social measures and scientific research are needed. The scope of medical achieve- ment is increasing and science is finding new and more effective methods for the treatment, prevention and early detec- tion of diseases and of conditions likely to lead to disease. These new techniques have to be mastered quickly, brought widely into practice and made accessible to each of the nearly 900,000 Soviet physicians. New problems keep arising in an era of scientific and technological revolu- tion, and, develop as a result of changes in working practices and the exposure of the human body to environmental fac- tors it has not encountered before in the course of its evolution. In other words, life calls for a flexible approach from the medical service. One way of improving this approach in the Soviet Union has been to strength- en the initial links in the medical district 29

Above: A feldsher-midwife uses her outpatient clinic "on wheels" to call on tea-pickers in the plantations of Georgia. Left: Flying doctor service in the Soviet Far East. Local families flock to welcome the arrival of the regular helicopter. ( Photos WHO/Novosti) service, the "family doctor institution", on which the effectiveness of preventive care primarily depends. Another has been to develop specialized types of med- ical care, by setting up large treatment and advisory centres providing both curative and preventive care for the population of a specific area. These centres and the large compre- hensive hospitals at regional and higher levels have instituted polyclinics and out- patient clinics "on wheels", using special cross-country vehicles. They carry spe- cialist medical teams into remote rural areas to carry out comprehensive preven- tive examinations of the local popula- tion. There are now about 2,000 such mobile units and their numbers are steadily increasing. As the health care system has devel- oped, so new forms of medical care have grown up and establishments of a new type have been introduced, such as specialized kindergartens and board- ing schools where children with chronic diseases receive both treatment and schooling. Six decades of Soviet rule have elimi- nated the sharply contrasting levels of health formerly seen in persons belong- ing to different social strata. The mortal- ity rate has fallen by a factor of three and the infant mortality rate by a factor of almost ten. Life expectancy at birth has now risen to 70 years. But the organiza- tional bases and the principles of the Soviet health system—such as the provi- sion of health care by the state, the emphasis on prevention, and the close links with medical research—remain unchanged, for they have stood the test of time. ■ 31 • Starting from scratch by Dr E. M. Samba Director of Medical Services, Ministry of Health, Labour and Social Welfare, Gambia 4 he world is crying out for social justice. There is a universal state of flux—conflicts between black and white, between the haves and the have-nots, between North and South. Even within any one country there is a great divide between the lucky few and the underprivileged masses. Health for All by the Year 2000—the most momen- tous decision ever taken by the World Health Assembly—is a noble attempt at bridging this gap. It is universally accep- table; the general mass of humanity is hungry for it; above all, unlike many dreams, it is achievable. The question is therefore how? How can we clearly define, plan, programme and successfully bring into function this noble social objective? Alma-Ata gave us the instrument with which to achieve it. Primary health care (PFic) when properly applied will, more than anything else, help us towards this goal. The principles of primary health care are universal, but the details have to be tailored to suit the individual country and indeed individual tribes or commun- ities within the same country. The cus- toms and traditions of different social groupings have to be taken into account, while the political colouring of the government must, of necessity, influence the implementation of such care. Until now, the medical care system of The Gambia has been available to less than 20 per cent of the population (those living largely in urban and periurban centres), while the emphasis has been on the curative side. With primary health care we focus on over 80 per cent of the country. This is easier said than done. It requires a complete reorientation of the attitudes of medical personnel, adminis- trators and politicians. Many questions have to be answered : how can we obtain and maintain political commitment at the highest levels? How can we reverse the curative/preventive ratio? How can we shift the concentration of facilities in order to give the peripheral section of society its fair share of the cake? How can we start from scratch to initiate and maintain the correct impetus up to the year 2000 and beyond? In The Gambia we almost take for granted the political commitment. The majority of the voters come from the rural areas and, for all practical pur- poses, all our Cabinet ministers are from the provinces. Over the years they have been struggling to redress the urban/rural imbalance in all fields of socio-economic development. When we Teaching schoolchildren to wash their hands regularly—this too is primary health care. (Photo WHO/D. Henrioud) Starting from scratch Left: "... The agricultural masses contribute the lion's share of our total national budget and it is only just that they should have a fair share of the budgetary allocations." ( Photo WHO/E. Mandelmann) Right: Taking a blood sample during a survey into the incidence of disease. Health workers like this young man have to be properly trained; the Gambia is intensifying its local training facilities so as to provide one village health worker for every 500 population by the year 2000. (Photo WHO/J. Marquis) returned from Alma-Ata preaching the gospel of primary health care, all politi- cians welcomed it as the very idea they have been trying to put forward all these years. My primary problem was to convince my senior medical colleagues. As a surgeon, with many years of urban hos- pital practice in a senior capacity, I thought exactly like them a few years ago—that taking health to the country- side was tantamount to lowering stan- dards or dishing out cheap medicine to the rural masses. Now, as a fervent believer in the principles of primary health care, I am convinced that making health available to the majority is not cheap medicine. Indeed, it is much more expensive, but definitely more effective than what we have been doing hitherto. The agricultural masses contribute the lion's share of our total national budget and it is only just that they should have a fair share of the budgetary allocations. We had long been convinced about the broad principles of primary health care, but what Alma-Ata did was to help us define and crystallize our ideas and focus them on the right channels—channels which will lead to Health for All by the Year 2000. We returned from Alma-Ata with our heads bursting with ideas. The field is vast, the target is daunting, one priority cries out for precedence over an- other, and the resources are very limited. So where do we start? The first move was to put down our ideas on paper, detailing the present health service situation, the justification for primary health care, the priority areas—proper nutrition, water supply, sanitation, mother and child health, ex- panded programme of immunization, family planning, health education, and so forth. To facilitate this exercise, the Alma- Ata documents were circulated and dis- cussed at a series of meetings in the Department of Health, which included representatives of the staff as well as WHO personnel. We organized joint meetings with the Ministries of Econom- ic Planning, Agriculture, Education, Finance, Works and so on. As we had no 6 6 In The Gambia we almost take for granted the political commitment. The majority of the voters come from the rural areas and, for all practical pur- poses, all our Cabinet ministers are from the provinces. When we returned from Alma-Ata preaching the gospel of primary health care, all politicians wel- comed it as the very idea they have been trying to put forward all these years. time to sit down and write up a docu- ment, we invited a WHO short-term con- sultant who visited various parts of the country to familiarize himself with the existing local conditions. With this exhaustive background he was able to prepare a detailed draft PHC document. Once this had been modified so as to be consonant with the country's political, social and economic realities, it was sent to all ministries and interested parties for their comments. Further meetings were held before a final draft was presented to the Minister of Health for consideration in Cabinet. While this exercise was in progress, one of the WHO directors from Geneva was on leave in The Gambia. He was a good PHC salesman. He contributed im- mensely towards making the top brass in this country aware of Health for All by the Year 2000. We had a meeting with him in the National Planning Committee chaired by the President of the Republic, Mr Dawda Kairaba Jawara, and attend- ed by all the permanent secretaries and heads of departments in the civil service. The President was highly impressed and gave his blessings and full sup- port to PHC. Subsequent events demon- strated that this support was extremely important. In conjunction with the Ministry of Economic Planning, which is the coordi- nating ministry, we invited representa- tives from the Federal Republic of Ger- 34 many, the United Kingdom, USA, WHO, UNICEF, UNDP, UNFPA and other bodies to discuss PHC and Health for All by the Year 2000. We expounded on our plans and programmes and invited them to contribute in the various fields which in- terest them. We made it quite clear that, from now on, programmes will cease to be donor-oriented; that we the Gam- bians will decide what we want, how and where we want it; and that we would ap- preciate it if donors would collaborate and supplement our efforts. A coordinat- ing committee was formed to minimize waste and duplication. Without excep- tion all the donor agencies welcomed this policy and pledged their full support. We intensified the countrywide consul- tations, visiting various villages, having discussions with health personnel, and making use of radio and local news- papers. During these consultations we learnt as much as we informed, and had to continually review and adjust our ideas. Even though The Gambia is a small country with less than 750,000 inhabi- tants, there are at least six different tribes. These have different traditions and languages, and each, therefore, requires a slightly different approach. We selected 12 representative sample villages and vis- ited them for detailed discussions with the traditional and administrative lead- ers. We explained PHC as best as we could and said we were now reviewing our strategy. Instead of the previous em- phasis on disease, hospitals and doctors, we were now focussing on positive health for all the people. We underlined that health must be sustained by nutritious foods containing carbohydrates, proteins, fats, vitamins and minerals. Mercifully, we can pro- duce all these, but our people have to be made aware of the health aspects of food. Many gardens up-country produce fruits and vegetables but these are taken to the markets for sale; we stressed the point that poor farmers need these fruits and vegetables even more than rich town dwellers. We discussed water supply, water- borne diseases, the maintenance of wells, and the effect of sanitation on health. And we explained government inputs such as maternal and child health ser- vices, immunization, family planning, and so on. All these will be organized and coordi- nated by the community committee, chaired by the traditional chief or his representative and including the local government officials in agriculture, health and rural development as well as school headmasters, police, village per- sonnel, youth leaders and local business- men. The committee will select from the village its own Community Health Workers whom we in the Ministry of Health will train in PHC. District com- mittees will support the work of the village committees. Thus we have inter- sectoral committees at various levels of society—village, district, interministerial and finally the National Planning Com- mittee presided over by President Jawara. It has been very exciting but tough going since this PHC exercise began in October last year, but gradually health is being accepted as an integral part of socio-economic development. PHC is not cheap. Already 9.5 per cent of our national budget is allocated to health and there is no hope of improving on this in the immediate future. We therefore have to make a drastic reallo- cation of funds and facilities in order to do justice to the underprivileged popula- tion and to give preventive health ser- vices the emphasis they deserve. This is easier said than done. There are formid- able pressure groups both within the medical fraternity and outside. We are redoubling our efforts to tap resources from the international bilateral and mul- tilateral agencies. We need their support, especially in the early stages. A detailed study of the cost implica- tions of the PHC document made it quite obvious that we were over-ambitious; we could never pay all the village health workers as scheduled. We therefore decided to get the village committees to provide their remuneration in cash or kind. The number of supervisory staff was also drastically reduced. In a nut- shell, this exercise requires a great deal of improvisation and adjustments to suit local realities. Manpower development is another critical factor. It is becoming increasing- ly obvious that overseas training is not always relevant, and besides, it is expen- sive. We are intensifying our local train- ing facilities to provide one village health worker for every 500 population by the year 2000. We are retraining traditional birth attendants and community nurses to support the village health workers. Auxiliary nurses will in part relieve nurses from the hospitals, who in turn will be given refresher courses and re- deployed up-country to keep up the dis- pensaries and health centres. Nurses with 15 years experience are being retrained to lead the health centre teams. Thus we are gradually building up our service from the grass roots in the village and through the dispensaries and health centres to the hospitals. We are going through a very exciting phase in the history of our national development. The appetites of the under- privileged have been stimulated and must be satisfied. The problems are al- most daunting, and yet we cannot afford to fail. We must succeed. ■ 35 4100 00 • 0.0 000 000 000 000 000 00000* 11 00 000 0011 0541000 041411 000 *00 000 0011 4100 000 0 00 SO . 000 *410 000 0 00 000 000 0 0* 000 S OO 41 0 0 00* 000 0110 000000 0 010 00 0 000 000 000 oo• 0041 000 00 00• e 11lo••410 1111. 000 *Se• .11..0. 000 000 ***Mo• 000000 Caribbean countries use audio-visual aid to push breastfeeding: UNICEF support The Caribbean Food and Nu- trition Institute (CFNI) has pro- duced with UNICEF support an audio-visual teaching package, "Breastfeeding your baby", for use as a tool in nutritional edu- cation programmes in CFNI's 17 member countries. Developed in response to the need for audio-visual materials felt by health and nutrition workers in the Caribbean, the slide-sound set has been de- signed to appeal primarily to pregnant and lactating mothers and for use with community youth groups, family life educa- tion classes, and training courses for teachers, nurses, midwives, physicians and other health workers. Photo WHO/J Huddleston Breastmilk: best food in first 4-6 months of life. The package features a num- ber of key concepts related to breastfeeding, and to a lesser ex- tent, weaning. An understanding of these concepts is expected to motivate mothers to want to breastfeed, and to encourage them to breastfeed up to one year or longer, discontinue the use of expensive breastmilk substitutes, and wean their babies properly. A collaborative venture be- tween CFNI, UNICEF and the Pan American Health Organiza- tion ( PAH 0), the project is aimed at creating a receptive environ- ment for the introduction of good nutrition practices from birth onwards. The sound-slide presentation is in three parts, each consisting of more than forty 35 mm colour transparencies linked to a 7-min- ute sound recording on cassette. Part I focuses on preparation for breastfeeding, Part II on the suc- cessful management of breast- feeding, and Part III on the intro- duction of solid foods during the breastfeeding period. The entire presentation takes 25 minutes, but each segment can also be shown separately to meet specific audience needs. A teaching guide goes with the set with suggestions for use, an outline of objectives, back- ground information on breast- feeding and discussion ques- tions. Also included are a poster and two postcards, one for evalu- ating the package and the other for requesting additional mate- rial. To reinforce the learning, members of the audience at the presentation are given some printed material to take home. This includes four fact sheets with additional information about nutrition, and a mother's booklet with black-and-white reproductions of the visuals seen in the show, flanked by the words heard on cassette and explanatory teaching notes. In areas without electricity or pro- jection facilities, the booklet alone can serve as a pictorial teaching aid. The presentation was pre- tested at a number of health centres in Jamaica to determine that the medium chosen was ap- propriate for the audience and that the content and messages were clear and simple. Another evaluation will be carried out to find out how far the teaching package has contributed to the promotion of breastfeeding and improvement of the knowledge of nutrition in the region. Developed as an undertaking of the International Year of the Child (IYC), the package was launched last June at a CFNI technical group meeting devoted to "Techniques to Promote Successful Breastfeeding". The CFNI, located in Kingston, Jamaica, has the following membership: Antigua, Bahamas, Barbados, Belize, British Virgin Islands, Cayman Islands, Domi- nica, Grenada, Guyana, Jamaica, Montserrat, Saint Kitts-Nevis- Anguilla, Saint Lucia, Saint Vin- cent, Surinam, Trinidad and To- bago, Turks and Caicos Islands. High sodium levels in drinking-water: blood pressure risk The presence of excessive amounts of sodium in drinking- water can have an adverse effect on blood pressure, according to a report* recently published by the WHO Regional Office for Europe. The report, based on the de- liberations of a working group convened in The Hague last year, comes to the conclusion that there is a link between sodium intake levels and hypertension, and recommends reduction of sodium salt consumption. The report also makes the fol- lowing points: Sodium in drinking-water can arise naturally or as the result of human activities. A general tendency for sodium levels in drinking-water to increase has been reported in many countries. This may be caused by increased pollution of sources or by water treatment processes. Until recently, little atten- tion was paid to the possible health effects of high levels of sodium in drinking-water. In the WHO European and Interna- tional Standards, dated respec- tively 1970 and 1971, sodium is not listed as a possible hazard. Interest in sodium increased when its association with hyper- tension was observed. The Working Group recognized that there is strong evidence of a rela- tionship between sodium and hypertension. * Sodium, chlorides and conduc- tivity in drinking-water: report of a WHO Working Group. Copenhagen, WHO Regional Office for Europe, 1979; 63 pages; Sw.Fr. 7.—. Since drinking-water is an important ingredient in food, it is essential that sodium levels be maintained as low as prac- ticable and trends towards in- creasing sodium levels in water supplies be discouraged. The intake of sodium chlo- ride (common salt) should be reduced. In the case of an adult in normal health it would be rea- sonable to aim for a progressive reduction of salt to 6 g per day. A long-term goal of 3 g per day may well be desirable, but fur- ther research in the matter is necessary. Assuming that the contri- bution of drinking-water to the total intake of salt in the diet is 10 per cent, the concentra- tion of sodium, on the basis of a consumption of 2 litres per day, would be 120 mg/I to cor- respond with a total intake of sodium chloride of 6 g per day. For patients with hyperten- sion or congestive heart failure there is a need for further restric- tion in the total dietary intake to a maximum of 500 mg of sodium per day corresponding to 1.3 g of sodium chloride. As it is not practicable to provide food with less than 460 mg of sodium per day, corresponding to 1.2 g of sodium chloride, the contribu- tion from drinking-water should be limited to 40 mg per day. Thus, again assuming a con- sumption of 2 litres per day, the concentration of sodium should not exceed 20 mg/I. In the case of water supplies where this figure is exceeded, health au- thorities should be notified. Schizophrenia linked with cultural styles A relationship between the course of schizophrenia and the cultural background of the pa- tient has been underlined in a newly published WHO report entitled Schizophrenia, an Inter- national Follow-up Study. The 420-page publication de- scribes the latest findings of the International Pilot Study of Schizophrenia which began in 1966 as a large-scale cross- cultural psychiatric investigation carried out simultaneously in nine countries: China, Colombia, Czechoslovakia, Denmark, India, 36 Nigeria, the USSR, the UK and the USA. The nations were chosen for their wide variety of social and cultural characteris- tics, and the study looked deeply into the differences in prognosis in developing and in developed countries. Schizophrenia is the name given to a large group of mental disorders believed to be widely prevalent throughout the world. On the basis of previous studies, it has been estimated that schiz- ophrenia affects 5 to 10 persons per 1,000 in any population. The main symptoms are gradual loss of contact with reality, distur- bances of thought and emotions, delusions and hallucinations, and social withdrawal. More than 90 per cent of the 1,202 patients investigated in the study were traced two years after the initial examination, and on an average over 75 per cent of them were re-examined, using standardized instruments and methods. Broadly speaking, schizophrenic patients in the centres in developing countries had progressed considerably better than patients in the de- veloped countries. Photo WHO/P. Almasy Mental illness, a problem of increasing importance. A series of hypotheses gen- erated by the pilot study may now be tested during the five- year follow-up at present in pro- gress, the report says. These in- clude the view that "culture has an important effect on the course and outcome of schizophrenia", and that "the course and out- come of schizophrenia may be less favourable in socio-cultural settings characterized by a high level of economic development, vertical social mobility, small average family size, social isola- tion of psychiatric patients and well-crystallized community ste- reotypes of the mentally ill, and may be more favourable in socio-cultural settings charac- terized by mainly agricultural economy, little vertical social mobility, extended families, psy- chiatric services which include the active participation of the family, and the absence of spe- cific community stereotypes of the mentally ill". The report, priced at $35 (£16), has been published for WHO by John Wiley & Sons, Chichester, UK. India's victory over smallpox chronicled In April 1976, a WHO In- ternational Commission an- nounced to a somewhat scep- tical world that smallpox had been eradicated from India. The 16-member Commission, com- prising experts in epidemiology and infectious diseases from as many countries, had arrived at that conclusion after carefully reviewing all smallpox data in Government records and visiting a number of states, districts and villages for an on-the-spot as- sessment of the validity of the data. That the achievement has been hailed the world over as a public health miracle is under- standable when it is recalled that in 1974—only two years prior to the declaration—smallpox in India claimed 188,000 cases with 31,000 deaths. The Indian subcontinent was known to be the world's principal focus of en- demic smallpox since earliest history, and since 1900 a major epidemic had been recorded every five to seven years. In 1951, 11 years before the Indian National Smallpox Eradication Programme began, more than 250,000 smallpox cases and 64,000 deaths were recorded, and it is now known that these figures probably reflected less than 10 per cent of the actual toll taken by this disease. The story of this magnificent success and of the tremendous feat of planning, organization and national and international coordination and collaboration has been set down in detail in a publication issued by WHO's South-East Asia office in New Delhi, entitled "The Eradication of Smallpox from India". Photo WHO Saiban Bibi: last case of smallpox in India. International assistance play- ed an important role in this achievement, explains Dr Donald A. Henderson, formerly Chief of WHO's Smallpox Eradication unit, in his preface to the book, and adds: "But it must be point- ed out that even during the in- tensive final phase of the pro- gramme more than 75 per cent of the costs were borne by the Government of India. Interna- tional staff numbered less than 250 in a staff of the more than 150,000 workers who partici- pated." In his foreword, Dr V.T.H. Gu- naratne, WHO Regional Di- rector for South-East Asia, de- scribes the achievement as "an event which is truly historic in the annals of medicine and pub- lic health". The book is pub- lished in the hope, Dr Gunaratne says, that "many of the strategies and tactics used in the Indian programme can be applied for the control of other communi- cable diseases in any country". Priced at Sw. Fr. 30.—, the book can be obtained from WHO sales agents, the Regional Office in New Delhi or the Distribution and Sales service, WHO head- quarters, Geneva. In the next issue The December issue of World Health will look at acupuncture—as a treatment and as an anaesthetic—as used in China and elsewhere, and at aspects of traditional medicine. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* 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 WORLD HEALTH Red diagram: Gamma-g obulin o -otection. Another way of protecting babies, at least for a short period of time, is to extract serum from an adult 'who has been subjected to repeated vacc nations (7 and 8) and who therefore has a very strong immunity to most infections diseases. This serum (9) is tan processed to extract gamma-globulin (10) with which the baby can safely k-e vaccinated. The gamma-globulin encourages antibody activity and will protect the child from disease for about three weeks (11). Vaccination: a weapon against disease Infectious diseases are passed from one person to another by simple contact or just by being nearby. They have scourged mankind for centuries, and a single epidemic of cholera, for example, used to kill hundreds of thousands of people in a very short time. Then it was discovered that it was possible to stimulate a defence, system within the human body. A person can only catch measles once in a lifetime because the illness gives rise to tiny antibodies which, the next time round, will attack the virus. All one had to do, therefore, was to provoke a "disease in miniature", that is to say, to make the organism sick enough to create its own natural defence system but not sick enough to show the actual symptoms of the disease. So, in the eighteenth century, the practice of "variolation" began. A small quantity of the virus of smallpox (variola) introduced into the body was enough to protect it from later attacks of the disease. In the course of the same century, Jenner invented vaccination. He had observed that the vaccinia virus, which attacked cattle, was related to smallpox, and it was from this virus that he created the anti-smallpox vaccine. Since then, vaccines have been made from viruses and from bacilli for an ever-increasing number of diseases. Today, some of these have to all intents and purposes disappeared from many parts of the world. Smallpox itself is soon to be declared entirely wiped out from the face of the earth. Why then, when we have such a magnificent instrument for preventing infectious diseases, do so many children in the Third World still die from them? The problem is largely one of means and of organization. This is why WHO has launched its Expanded Programme on Immunization with the aim of encouraging and helping countries to vaccinate all children without exception, between now and 1990, against the six most deadly diseases of childhood: diphtheria, whooping- cough, tetanus, measles, poliomyeletis and tuberculosis. But how can this be done? Only action by the entire com- munity can reach every child, even in the smallest and most remote village. The whole society has to be fully aware and fully involved. If everybody does their social duty, the day will come when we can say for other illnesses what we say today about smallpox: that this disease is about to cease for ever to menace our lives. In blue in our diagram: Protecting babies from infection. If the mother- to-be contracts a disease before her pregnancy (1) or during it (2), the immunity—shown as blue signs—which she acquires against this disease—red arrows—will be transmitted to the fetus (3). The new- born baby will then be protected by the antibodies which it has re- ceived from the mother (4) but not against new infections which she has not encountered (5). Early vaccinations (6) are therefore essential to ensure that the baby is safeguarded against all the common infec- tions of childhood. Uninvited guests No living thing exists in isolation. All creatures depend on what they find around them, and share their existence with other creatures. Their bodies harbour other species, which sometimes feed on their host—and the human body too may support unwelcome guests. Some of these other species, or parasites, stay on the surface of the body (1, 2, 4 and 13), others infiltrate the tissues (14, 16, 17 and 18), while still others make for the internal organs (5, 6, 8, 9, 10 and 12) or circulate with the blood (7, 11 and 15). The mosquito (3) is not strictly speaking a parasite. It feeds on human blood and through its bite can transmit various diseases; it can inoculate humans with blood parasites, such as plasmodium, the malaria parasite. Many of these forms of life cause illnesses, of varying severity. In the drawing opposite, you can see the main species that live on mankind; we have listed some of the diseases they cause. Louse (typhus) Bed-bug Mosquito (transmits malaria and yellow fever) Flea (plague and typhus) Lung-fluke Liver-fluke Plasmodium, the malaria agent H ookworm Roundworm Tapeworm Schistosome (schistosomiasis) Threadworm Crab louse Guinea worm (dracunculiasis) Trypanosome (trypanosomiasis or sleeping sickness) Trichina (trichinosis) Itch mite (scabies) Onchocerca (transmitted by the blackfly, these tiny worms cause skin nodules and eventually "river blindness") The vaccination and parasite diagrams are taken from "Le livre de la Sante", published by Andre Sauret, Monte Carlo 1967. They are reproduced by kind permission of the author, Joseph Handler. p ri m er ie s H eu m e s S .A . La Primary healtt. care in action in Gt.a- temala (Photo WHO/P. AlmaFy)