Better health through research [full issue]

BETTER HEALTH THROUGH RESEARCH WORLD HEALTH The magazine of the World Health Organization December 1971 UK: 15 p. USA: 0.50 Purveyors of pestilence (see p. 10) Contents Good health, a basic human right by Jim Breetveld ........ 3 The purveyors of pestilence by Aaron Sternfield ....... 8 How to make the most of health services by F. J. Tomiche ........ 16 The need for a mathematical model by David Allen 22 Around the world 30 World Health appears in Arabic, English, French, German, Hindi, Japanese, Portuguese, Russian, Spanish. 2 a basic human right by Jim Breetveld UNICEF Public Information Officer UNICEF, the United Nations Children's Fund, is 25 years old on December 11, 1971. It has co-operated with WHO in many health programmes. Together, these organizations face an immense challenge. "Every half- minute 100 children are born in the developing countries. Twenty of them will die within the year. Of the 80 who survive, 60 will have no access to modern medical care during their child- hood. An equal number will suffer from malnutrition during their crucial early years, with the possibility of irreversible physical and mental damage. Their chance of dying early will be 20 to 40 times higher than if they lived in Europe or North America." These blunt facts are from a recent report by UN Secre- tary-General U Thant. Such statistics make us aware of the staggering waste of human energy and talent, drained from the very nations that need them the most. There is much talk about the economic gap, the social gap, and the political gap between the peoples in the developed and those in the developing regions. The health gap is equally serious, aggravated in many areas by rapid population growth coupled with a shortage of health personnel. In the developed coun- tries, the ratio of doctors to inhabitants ranges from one per 450 to one per 1,000. Many developing countries have a ratio of one doctor for every 20,000 to 30,000 inhabitants. Some have a single doctor for over 70,000 inhabitants. Two United Nations agencies have been working together for almost a quarter of a century to help close the dangerous health gap. Hand in hand with the governments of more than 100 countries, the World Health Organiza- tion (WHO) and the United Nations Children's Fund (UNICEF) have focused attention on programmes to help estab- lish conditions in which children can thrive and grow into healthy, productive adults. Important gains have been made in disease control campaigns in different countries (e.g. yaws control, malaria eradication, smallpox eradication, tuber- culosis control through BCG vaccina- tion, control of trachoma and conjunc- tivitis, and leprosy control). The main emphasis has been on improved health services (health centres and sub-centres, maternal and child health clinics, public health laboratories, referral hospitals, etc.), global dissemination of health information through all available means, the production of trustworthy drugs, the improvement of nutrition, and the bet- terment of the physical environment in general. WHO has as its objective "the attain- ment by all peoples of the highest possible level of health ". By virtue of its mandate from the UN General Assembly, UNICEF is responsible for helping govern- ments establish or widen programmes for the health and welfare of children. The UN Declaration of the Rights of the Child states that "mankind owes the child the best it has to give ". That "best" most certainly includes the best health possible. Good health is the most urgent need of the child. It is a basic human right, without which the other rights are meaningless. Good health is not only desirable for its own sake; it is the vital key to every aspect of a child's develop- ment and welfare. With similar and, in some cases, identical objectives, the programmes of WHO and UNICEF are carefully co-ordinat- ed to avoid duplication. Health education, which is funda- mental to preventive medicine, is an essential element of the common efforts of the two agencies. An ounce of preven- tion is worth a pound of cure, especially in the developing countries where the WHO/UNICEF partnership is most active. Providing people with the information, methods, supplies, and equipment to avoid disease or malnutrition is the most effective way to better global health. Accent on health Since its inception, 25 years ago this December 11, UNICEF has invested a major portion of its resources in health services for the benefit of children and mothers. More than half of its pro- gramme aid during the last decade went into health services. There may be vari- ations in different countries but it is An ounce of prevention is worth a pound of cure. The future of this girl may be influenced by the Nepalese health education programme, which is being assisted by UNICEF and WHO. 3 +5, likely that for UNICEF health will continue to be the single most important area. Over the past 25 years, UNICEF has helped to equip more than 12,000 main rural health centres and 38,000 sub- centres in more than 100 countries (mainly in Asia, Africa and Latin Amer- ica), along with several thousand hospi- tal paediatric and maternity wards. In co-operation with vnio, UNICEF carried out several activities which bene- fited millions of children throughout the world. More than 400 million children have been given BCG vaccinations against tuberculosis. More than 425 million children have been examined for yaws, and 23 million have been treated for it. Some 415,000 children have been discharged as cured of leprosy. About 71 million children have been examined for trachoma, a disease which causes progressive loss of vision, and 43 million were treated for it. During 1970 alone, some 27 million children were protected from malaria. Nearly 2,000 training institutions for health personnel have been aided by UNICEF. The focus of UNICEF'S assistance has been on maternal and child health, usually within the framework of a basic health service. An interesting develop- ment during the 1960's was the progres- sive integration of mass disease control programmes into basic health services. A short-term operation, such as the mass BCG vaccination campaign against tuberculosis, can have far-reaching ef- fects, and the long-term benefits are often impressive. The personnel trained, the facilities established, and the transport used can form the nucleus of a basic health service. In areas where doctors and nurses are scarce, traditional mid- wives and others may be trained and equipped to serve as auxiliary medical personnel. In a number of countries, various organizational patterns are being tested in the consolidation of health services. Comprehensive health service concepts are also being developed. The provision of child health services, family planning assistance, improved nutrition, and en- vironmental sanitation is being looked upon as a "package deal ". This is being applied more in rural than in urban areas. Most leaders in the field of public UNICEF and WHO are helping to establish conditions in which children can thrive and grow into healthy, productive adults. Too many children born in developing countries suffer from malnutrition. Their chance of dying early is 20 to 40 times higher than that of chil- dren in highly developed countries. Right a girl in a camp for Palestine refugees (UNRWAphoto). - frri , Good health requires good water. Here, in the Ghanaian village of Affiaman, the inhabitants listed running water as their first need—ahead of a school, a health centre, electricity or a cinema. health feel that the single measure that would bring about the most significant improvement in world health would be the adequate supply of clean water for the 2,000 million people of the developing countries, where many must now struggle along without it. In 1969 WHO, in consultation with UNICEF, prepared an assessment on environmental sanitation and rural water supply programmes. The study brought out clearly the importance of a sanitary environment, especially safe water, for child health. The parasitic infestations and diarrhoeas which result from a polluted environment have a devastating effect on pre-school children. These conditions aggravate the child's malnutrition and weaken his ability to survive common infectious diseases. The recent outbreaks of cholera in parts of Asia and Africa have dramatized the water problem and underlined the exis- tence of poor sanitation and contaminat- ed water sources in many countries. In many parts of the world, despite the progress that has undeniably been made, countries still face difficulties in providing adequate health services to their popula- tion, particularly in rural areas. It will take many years for most countries in Asia, Africa and Latin America to establish the basic health services, which are essential not only for the well-being of the child and the family, but also for sound national development in line with the aspirations of the UN Second Devel- opment Decade. The current child population (15 years of age and under) in the countries assisted by UNICEF is about 800 million. This number is expected to pass the thousand million mark by 1980. The task ahead In the meantime, everything possible must be done to protect the children who need help today. Every available means to supplement conventional health services must be explored to make the most of limited resources and personnel, and to compensate for the scarcity of doctors and nurses. Health education may often be indi- rect and still contribute to the improve- ment of health. Simple training in hy- giene and child care, for example, is an important element in most UNICEF-assist- ed women's programmes. Schools reach a larger proportion of children than any other organized service. Other members of the family can be reached through the children who attend school. So, health education has become part of teacher training in many countries. There is also the use of mobile health units to reach remote areas of a country. A powerful impetus for the expansion of WHO/UNICEF programmes is the knowl- edge that, ironically, there are more sick children, more malnourished children. and more uneducated children in the world today than there were 10 years ago. That is so because of the population expansion. The 3,000 million people on earth now will be doubled before the end of this century, with the consequent strain on all of our resources, including those required for health services. The tasks of WHO and UNICEF in the immediate future are clear enough, espe- cially within the context of the Second Development Decade. The progress of a nation depends first and foremost on the progress of its people. Unless the nation develops the spirit and potential of its people, and safeguards its health. it cannot effectively develop much else socially, politically, or economically. The basic problem of most developing coun- tries is not the paucity of natural re- sources but the underdevelopment or neglect of their human resources. Their first priority, then, must be the develop- ment of their human capital, beginning with their children. There will be few headlines made by the day-to-day achievements of the WHO/ UNICEF partnership in remote villages or teeming city slums. But the improved quality of life, better health, and brighter hopes of the millions touched by national programmes assisted by the two agencies will be an important contribution to the cause of global progress and peace. ■ 4 A student nurse in an infant ward in Brunei. 7 The Purvey by Aaron Sternfield Plague. The word strikes terror in the hearts of men. For centuries, man has regarded plague as retribution for his sins. He has accepted mass death and suffering as his heritage. He has sought a hiding place and despaired of finding one. Plague is an animal-borne disease. Small mammals generally rodents— carry the dread bacteria. The grisly cargo can be passed on to man by the bite of an infective flea. Iran has a recent history of plague. In the last 25 years, seven outbreaks have been studied in detail, the most recent, which began in the village of Kaderabad, in 1962. We can exterminate plague by exter- minating the animal carrier. This method was employed successfully in parts of the USSR in the 1950's. But today this meth- od is not necessarily the answer, for it is expensive. There is also the point that in the delicate balance of nature all living creatures have their roles to play. Exter- mination of a species may create more problems than it solves. The life of the predator may be as important as the life of its victim. When man tampers with the balance of nature, he must take into account the relationship of one species to another and the relationship of animal, insect and bacterial life with the environ- ment. He must act as the ecologist, •root as the indiscriminate hunter. There are some 70 diseases known that can be transmitted from small mammals to man. Plague is the most dramatic of these but far from the most common. To halt their ravages we must study the animal in relationship to its habitat, and we must study man in relationship to his environment. To control a disease, we must study its ecology. Only then can we act to maintain the health of man and preserve his environment. A rare attempt to assess the relation- ship of animal-borne infections with climate, terrain and man is taking place in Iran. The joint venture is being conducted through the Iran-wHo Inter- national Epidemiological Research Centre. Collaborating in the effort are three Iranian agencies, the Institute of 8 The Iranian landscape ranges from the tropical Persian Gulf to the alpine terrain of the north, with arid plateau and treeless hill making up a good portion of the interior. Against this backdrop of widely varying countryside, the WHO field team set out to discover the effects of the land and its creatures on the health of man. I. The field team camps at Garmeh at the base of the mountains (white tents, see circle). At the end of the day, traps are set. A field worker rises at 5 a.m. to check and collect the traps which were set the previous night. In the foreground, a basket containing traps. One method of catching gerbils by day is to flush water down their burrows and grab them when they emerge. Opposite page: A group of small rodents kept in a petrol can. To halt the ravages of diseases transmissible from animal to man, closer studies of the disease-carrying animals are needed. 2 4 ors of Pestilence Public Health, the Razi Institute for Veterinary Medicine and the Pasteur Institute of Teheran. The choice of Iran for the first study of this nature and scope was not an arbi- trary one. Few countries have as much variation in climate and topography. And few have as much recorded in- formation on the national distribution of fleas, mites, ticks and sandflies. Iranian mammal collections are extensive, as is recorded information on topography, vegetation, rainfall, soil structure and the distribution of plague and other zoo- noses. Iran contains vast stretches of desert, forested mountains, plateaus and arid hills. Climates range from the dry tropics of the arid plateaus to the alpine snow- lands of the 5,000-metre peaks. The Iranian survey, which began in 1969 and is funded through 1971, has the following primary goals: To gather information for long- range studies of specific diseases. To study the general ecology of Iran in relationship to certain animal infections. To determine if certain small mam- mal populations harbour multiple infec- tions and to determine how these infec- tions are transmitted. Iranian field team leaders in the joint venture are Drs A. Farhang-Azad and I. Mobedi. Dr Farhang-Azad, an asso- ciate professor at the University of Teheran, was a WHO graduate fellow in mammalian ecology in the USA. Dr Mobedi, a veterinarian, is an expert on parasitic infections. The WHO team leaders are Drs Andrew A. Arata and Valeri M. Neronov. The task of the joint field team is to trap animals that can serve as hosts to disease spreaders, and to study the animals and the infection carriers in field laboratories. To date some 5,000 small animals have been studied in 46 field stations. Field work began in early June 1969 in Northern Iran. By the end of 1970, the 12-man team had set up stations in the rugged Elburz Mountains in the North, in the deserts, arid mountains and pla- 9 4 I. Trapped mammals are identified and measured, and their sex determined. Refer- ence books are used to check identifications. The Iranian study covers insects as well as mammals. Insects are attracted by the lamp, then trapped in the gauze. A team member on the search. Carrots, breadcrumbs and peanut butter are used to entice the mammals to the traps. Oiled paper is used to trap insects such as sandflies. < Team members unload and set up their field camp. At nightfall, they retire to the tent. D 3 teaus of Central Iran, and in the scorched Persian Gulf area. Life in the field is hard. The men must rise at 5 a.m. to check the traps that were set the previous night. The collection must be made before sunrise to be sure to get the ectoparasites (ticks, fleas, mites, etc.), for later in the day the ectoparasites may leave the animal. The trapped animals are identified, marked and taken to the field laboratory. After breakfast at 7, consisting gener- ally of bread, butter, goat cheese and tea, the lab work begins. If the previous night's catch is light, the work can be completed in a couple of hours. But, as often happens, a heavy catch can mean 10 hours in the laboratory. The field team leads a nomadic life. The twelve men and laboratory equip- ment are carried in two Land Rovers and a lorry. Since many specimens are sent to Teheran, one of the Land Rovers acts as a shuttle vehicle. At times the trip to Teheran takes two days, over the moun- tains and across rugged desert country. Field trips last three months, with a two-to-three week break in Teheran between expeditions. In the field, the 5 men hunt, buy food in the villages, and generally live off the land. Some team members developed into surprisingly good chefs. Mutton and rice are the food staples, and various forms of kebab, following recipes not generally used in metropolitan restaurants, are served in the field kitchens. The flat Iranian bread is baked from local flour. Much of the time, the field team is a long distance from potable water sup- plies. A 150-gallon water tank, hauled by one of the vehicles, is standard equip- ment. While formal water discipline is not enforced, team members are careful not to waste water. Tea is the most common beverage, and the boiling process ensures a safe drinking supply. The work load is shared by all—from team leaders to drivers. Setting of traps and removal of the animals are a community effort. All of the Iranian drivers and tech- nicians are seasoned field workers. Most of them have worked together for many years. The bulk of the small mammals trapped are nocturnal animals. Daytime hunting is confined to digging for gerbils in burrows and seeking out bats in caves. The animals trapped are generally of the i0490:44#64. t:4‘4 ,44 44, kr ii114,414 , • - itireL ('■ wiwit 411,1). %to yrs, ' • ItIv 14(' • qkt% 41.4‘4,, it • • Nov `;' . 104/11‘k 411114, kgk toe 1 71. • ' 1,44144%, /al.. 4" • tpl., br '''''*-11N4-. \k• 40, .4%;i:Zta lbf„, , • , 11•,. ( 67* /44taft, 'so -1.111P" '14 f4SAIN• . it 1/ 41/4 48r4 %•• *110 •■•• fAilair ,"114 .444 "Or IPIVO. 414 11 11,0 1■• 411••• iri,,I, *44, 41 /5 ::4173'40.44Y. 4,4041:470 jots IN A. 41440 * • ■ **11— i• 1,40it ;41/434 *(44 s 44. s • •. .1g 4114 4 0/104:1111 14*A. 41411/4, 16* - m* tVi 4thig. Ithy 07,‘ 141 44 • f's u! 411,5 "r• • NI % -4,10.4,,idtt..„.„,, ••••■• $110111101.:‘ 70,,,10,/t 116:41t 'f.tt k°,1140'f1.444414.,A0Ilen44 3 A flock of sheep and goats graze on a hill near the field camp. Some evidence of tularemia, an infectious disease transmis- sible to man, has been discovered among them. A young hamster caught during the night. Small mammals aren't the only creatures encountered by the field team. A small mammal is removed from its quarters so that a blood sample may be taken. The traps turn up many kinds of animals, including lizards. r, Mountain goats, majestic and voracious. 12 type which would not be welcomed in most households. They are wild rather than domestic animals, and they would be regarded by most city dwellers as pests. In the first three months of operation (May-December 1969), some 14,715 spe- cimens of spleens, sera and smears were collected in 29 field stations and sent to Teheran for laboratory studies. Collection methods vary according to the species. Trapping was most effective for gerbils, a small rat-like mammal found mostly in the steppes and deserts. It took two forms--snap trapping with a large edition of the conventional domestic rat trap, and live trapping. In the latter method, a concoction with a peanut butter base was a big favourite among the desert creatures. Nets worked best for bats, while burrowing animals were taken by digging. Other mammals were collected by hand. One method—not in the standard manual—is the use of Land Rovers and spotlights. Operating at night, the drivers focus the light on the animals while their co-workers move in with butterfly nets. It is difficult work, and the sight of an eminent scientist charging after a tiny desert creature with a net has its element of humour. Once the animals are trapped, the work begins. Ectoparasites are collected. Animals are weighed and measured. Specimen collections are made of spleens. smears, blood drops, brains, sera, faeces, stomach and intestines. Liver and dia- phragm are checked for threadworms capillaria and trichinella, hydatid (tape- worm) cyst and other helminthic cysts. Reproductive features are checked— in- cluding conditions of vulva, ovaries and sperm. The weather condition, elevation and location of the station are noted, as well as various features of the animal's habitat. In the first year of operation, some of the animals were sent to Teheran live for laboratory analysis. But beginning in 1970 the laboratory work has been done in the field. To date, evidence of three diseases not believed to be currently found in Iran has been disclosed by the survey. One of them is the Crimean haemor- rhagic fever. This viral disease trans- mitted by ticks was discovered and iden- tified for the first time by Russian epidemiologists in the Crimea. It was subsequently identified in Bulgaria and in Africa. The sera of sheep showed evidence of tularemia, a plague-like disease caused 13 A Some animals, especially pikas, are caught by hand. The task requires agility considerable. Certain small desert rodents are caught by net at night, with the aid of automobile headlights. Small mammals often play an important role in the transmission chain of such diseases as leptospirosis, tularemia and tick-borne ence- phalitis. In addition to the Iranian research programme, WHO made a detailed ecological study of small mammals in Switzerland in 1970-71. Zoologists from the Station Federale de Recherches agronomiques in Lausanne caught and marked by claw-clipping more than 1,000 specimens of Apodemus sylvaticus ( common wood-mouse), Apodemus flavicollis ( yellow-necked wood-mouse) and Clethrion- omys glareolus (red-backed vole) in a wood- land area near Nyon. Capture and recapture of marked animals over an extended period provides information on home ranges, move- ments and seasonal activity under varying weather conditions. Earthworks in this field near Nyon bear witness to a huge rodent population (right). A wood-mouse emerges from its hole (far right). ..+■•• '21 .."1.-C4r -•••• s 4.• 34151.., *". 011.•■ ...1011"•• ,„;‘, 41/..'"41.1 ADO *••••■■• .4.0116. * 1ft* ...801110.40.0, - ./P• :we. , :•••• "fte. Arnie" 41116. .011111. $7641616' 4 _iiii:egew■-00111:4040 47: 4111611111Q71.4"711111Mr‘ 41.7. by microbes. A rickettsial disease which had hitherto been found only in North Asia was identified in many parts of Iran. Also identified was a species of mite that can transmit tsutsugamushi fever (also called scrub typhus). The disease used to be confined to East and South- East Asia and to parts of Oceania. During World War II, several epidemics broke out among British and American troops in South-East Asia. It was recently discov- ered in West Pakistan, and it is possible that forms of this disease exist in Iran. In each case of disease or possible vector infection, a map is drawn indicat- ing the areas where the disease or vector can be located. The map overlay indi- cates the high risk areas, and the areas which require top priority for control. This information is of prime impor- tance in the economic war against disease. As funds for any disease control project are generally limited, the money allocated can be spent in areas where it will have the greatest effect. Computerization and economics play important roles in the Iranian ecological studies. The data could be used for long- term studies by the participating groups— the Iranian Institute of Public Health, the Razi Institute for Veterinary Medi- cine, the Pasteur Institute of Teheran, and WHO. It would have been difficult for any of these agencies to bear the full financial brunt of the studies. The importance of the laboratory work can not be over-emphasized. While the field project collects the essential data, much of this cannot be interpreted without the collaboration of the labora- tory. It is long, laborious work which will, it is hoped, pay important dividends. It is an international effort with re- search workers in other countries taking part. For example, more than 2,000 blood samples were tested for leptospi- rosis by the WHO Leptospirosis Reference Laboratory at the Gamaleya Institute in Moscow, and the Iranian study is co-ordi- nated with a study of small mammals in Switzerland. Once the Iranian data is collected and analyzed, the findings are coded and placed on punch cards for computer use. Thus each agency may extract the infor- mation it requires. This information can serve as the basis for continuing studies in the various special fields. Thoroughness is one of the hallmarks of the study. After preliminary identifica- tion of the animals is made in the field, skins, skulls and fluids are preserved in the standard museum fashion for refer- ence collections in Teheran. These collec- tions are made available to specialists everywhere. The Iranian study is an attempt to determine how climatic, geographical and biological factors affect the distribu- tion of the various carriers of animal- borne disease. It is an attempt to under- stand all these factors—and their rela- tionship one to another. The knowledge gained can serve, in conjunction with data from man and domestic animals, as scientific forecasts for the distribution of diseases in space and time. While the data should prove of parti- cular use to Iran, they can also serve as the basis for similar studies in other parts of the world, particularly in arid zones. The current Iranian ecological project is due to come to an end this year. But the end will provide a beginning for many scientific research projects based on the data which have been uncovered. ■ .1447 atEh' .,1.4(watce. • , How to make the nit by F. J. Tomiche A small port in Cape Bon peninsula where fishing is done with the aid of lanterns to attract the fish. SICILY ALGERIA MALTA( MEDITERRANEAN SEA ist of health services Stretched like a hand towards Italy, Cape Bon or Ras el Tib peninsula juts into the Mediterranean from the Tu- nisian mainland. At the foot of the Cape is the site of ancient Carthage, whence Hannibal set out with his army and elephants to sow terror among the Roman legions. Today, Cape Bon is a peaceful place with city dwellers and suburbanites, rural people and nomads. Its people form a colourful chequerboard of nationalities, mostly Tunisian but also French, Italian and Maltese. The health services are also very diversified. They range from fully fledged hospitals to rural nursing centres. small dispensaries, and maternal and child health centres. In many developing countries, failure to take full advantage of facilities means wasting scarce and precious resources. A developing country seeking economic take-off cannot afford to waste its re- sources. Why doesn't the public make full use of the health facilities at its disposal? Simple as this question sounds, the answer is difficult. It involves many complex factors. In co-operation with the Tunisian Government, WHO under- took a pilot study in the Cape Bon peninsula to determine the utilization patterns of health services and the factors that influence them. The pilot study is part of a long-term WHO multidisciplinary research pro- gramme on the organization and strategy of health services. The data now being, gathered and analyzed may be used by health administrators to understand and adjust their health services. Quick and inexpensive field techniques and methods of analysis have been tested to find out how the population uses existing health facilities, and to develop the bases for information systems useful < A rural dispensary in the survey zone at con- sultation time. LIBYAN ARAB REPUBLIC in planning for health. This is of parti- cular importance to countries with few resources in the health field. The Tunisian study will provide some information urgently needed by the health administrators, but it cannot fully solve the wider problem—how health adminis- trators can make the most effective and acceptable use of their country's health resources. Many further steps are re- quired, and it is probable that the goal will only be reached by pooling the results of many studies of different types from many countries. Before beginning the study, WHO re- search workers examined the problems of programming with their Tunisian counterparts—doctors, health adminis- trators, demographers, economists, stat- isticians and sociologists. It was also necessary to train local staff to interview the users and non-users of health services and come up with clear, frank and accurate answers. These inter- views concerned not only demographic, socio-economic and cultural informa- tion, but also attempted to assess the con- ditions and factors of utilization of public health facilities. A special approach is needed to question people who associate information-gathering only with the tax collector. The community study proper began in March 1969 in Korba, in the rural zone as well as in the city itself. A preliminary survey among the population had already smoothed some of the rough edges from the questionnaire. The questions were formulated in the local Arabic dialect, and served as the basis for the survey on utilization of health services. The second phase of the study covered the Menzel-Temime area. The third included Nabeul, capital of the district and a city of about 23,000. A population sample was established and 678 families were visited by the trained interviewers. Dr A. Benyoussef, a member of the WHO scientific team, underlines an im- portant aspect of the health situation in Cape Bon. "In the study area, almost all the doctors belong to the public health services. Only rarely do they have any private practice, except in Nabeul. Fur- thermore, most people are entitled to care that is practically free; the few people who have enough money for a private physician go to Tunis or Nabeul. " The records of the health service provide information on utilizers only, but it is also necessary to know who doesn't use the present facilities, and why. The questionnaire enabled the research group to cover the entire range of people living in Cape Bon. The group CAPE BON TUNISIAN STUDY In a well-to-do household in the city of Nabeul, an interviewer asks ques- tions on the utilization of health ser- vices. The questions are designed to elicit clear replies. Nabeul is an important centre for arts and crafts. The public fountain in a Cape Bon village, where the people come to draw water. The earthenware jars which keep the water cool are carried on the backs of donkeys. 3 ote Nomads still form a very small portion of the population of Cape Bon (upper photo). WHO investigators talk at length with rural families ( lower photo), for it is essential that the people understand the study so that they may give their full co-operation. 11111111 1: ' 0411I .410111.- 4. .40110 a,40 " was not aiming to go over the same ground as the office of vital statistics, but rather to break down the population carefully into demographic, professional and social categories; to discover not only levels of income, but also spending and cultural patterns that may affect the way illness is dealt with in the family. Details count. When the bus schedules do not coincide with hospital hours, people may have to spend the whole day trudging to get there. During the tourist season, many artisans do not visit the dispensaries because the hours do not suit their working day. Many people are still sceptical about modern medicine, or simply fatalistic about illness. So they stay at home until the illness resolves itself, for better or for worse, one way or the other. The study could have been carried out in the standard way, working back from the existing records. But this would have presented two major disadvantages. Reading and handling medical records is slow and complicated; often the infor- mation cannot be correctly interpreted and is thus unusable. An even greater problem is that such records do not cover the potential users. The latter are of primary importance since the study aims at describing the patterns of health- service utilization among the population as a whole. Even if this WHO study does not result in a perfectly adaptable methodology, it has already yielded some useful results. It has disclosed, for example, that in the city of Nabeul, which has a fully equip- ped hospital, the utilization of health services is triple that of the rural zones, which only have dispensaries. One reason for this important difference can be explained by the difference in services dispensed. The study has also shown that health services cater mainly to people with infectious diseases. People with chronic diseases or gynaecological ailments sel- dom use the services. It would be interesting to find out about the excep- tional cases—people with chronic dis- eases who did avail themselves of the services and those with infectious dis- eases who did not. The study should provide a consider- able amount of information that can be used to assess why and how different population groups do or do not use health services. In this field, where data are still scanty, the Tunisian pilot study should favour the development of a new methodology and fill a number of gaps in present knowledge. ■ < The survey continues in the Korba region. The questionnaire is in the local Arabic dialect. The need fo by David Allen HOPES were high in 1955 when the Eighth World Health Assembly decided on the "implementation of a pro- gramme having as its ultimate objective the world-wide eradication of malaria". And to a large extent these hopes have been realized. By the end of 1970, of the estimated 1814 million people living in the originally malarious areas of the world, 74 per cent lived in areas where malaria had been eradicated, or where eradication programmes were in prog- ress. Of the 467 million people living in areas where eradication programmes are not yet in operation, 31 million are benefiting from extensive malaria control measures, while governments are making an organized effort to provide anti-malaria drugs to an additional 160 million people. The need for continuing research is paramount. The search for more rapid and effective techniques for the epidemiological evaluation of malaria goes on, with special emphasis on improving the microscopic examination of blood slides and tests to survey the immune response. For a while it seemed that once the administrative problems were solved malaria would become a forgotten disease. Yet despite the initial success of the malaria eradication programme, this disease is still a major health problem in Africa, South-East Asia and Latin America. Residual insecticides, sometimes combined with the use of drugs, formed the basis for eradication. But some mosquitos and parasites developed resistance (or were found resistant) to the chemicals used for their control. So new strategies had to be devised, relying on control partially of insects and partially of parasites. But what are the most efficient ratios for specific areas? How much of the effort should be devoted to insect control? How much to drugs? The need for a better quantification of the epidemiology of malaria is overriding. One approach to better quantification is mathematical. The mathematical theory of malaria has challenged scientists for 60 years. It was first formulated when Sir Ronald Ross applied a system of differential equations to the description of malaria transmission. The British malariologist identified a critical level of mosquito density below which malaria would die out automatically, and above which a specified, self- regulating endemic level would establish itself. He saw the implications of his theory for the control of infection : " One advantage of the malaria formula is that it enables us not only to name the various preventive measures, but also to obtain some quantitative estimate of their utility", he pointed out. The quest for a mathematical model for malaria eradication covers Nigerian villages and bush. The study should, eventually. affect the lives of such people as this nomadic Nigerian herdsman. r a mathematical model • A: • .11. .11\k ' -4‘4,••", 4 '• ; 704Arr'P s• ...raver prortjgar.' - Aeo;;;;.! •••■ ••7 ;•---,•••••.^ o , '' iA r „. 1 , , ,, , ,r t ,.; -: ,t: f: ' ! , . • , , i ,,, , , 4 1 ..; ' i t •", ' % I. iAt i \ i, , ,, '. !.... . ? ' , r ' , I' 1" I I ,' ■ 1 , , t ' ' 1 1 i :", " , r ;,,. \ , , - 4" ' I. : '' 1 '' * 1 1, 4 ; / . • ', ' 4 ;.! ; 1*.N-.4 - , b., ,. .t t ,I, . '',ft ' f ; ; #' 1 ) 1 f i fl • 'ft ' • 5 il . v Ns , . Further developments of the math- ematical theory of malaria were made by Martini in 1921, by Moskovsky in 1950 and by Macdonald in 1957. However, a quantative model based on figures of all the various factors and taking into What is a model? An example may help to explain. There is a need, for a variety of reasons, to find out what the popu- lation of a given country will be in twenty years from today. Certain assumptions are made: there will be no decline in the present birth rate and a decline of two per thousand in the death rate. From there it is fairly easy to calculate by how much the population will increase by 1991 under the two given assumptions. This is an extremely simple model. It can be made more complicated by taking into account the sex and age structure of the population. Certain models showing many more inter- relationships than those indicated can become very complicated. Thus a model consists of a set of equations showing different inter- relationships and taking into account specific assumptions. account their interrelation has yet to be constructed. Such a model could serve as a tool for the health planner for the selection between control alternatives, and help give him a clear forecast of the needed finance. WHO scientists, with the aid of modern computers, are continuing the search for such a mathematical model. A project Kano youngsters (photo left) display keen interest in what's going on inside the hut: with captive mosquitos, the effectiveness of the insecticide sprayed on the walls is being tested (photo right). The mosquitos are collected from the plastic cup for examination by means of a suction tube. ( See also p. 27) A I < Collections are made in the swamps where mosquitos breed. I. Larvae (left) and full-grown mosqui- tos (right) in the laboratory. Mosquitos being prepared for micro- scopic inspection. They are counted and identified as to sex, species and age. The proportion carrying malaria is noted. Plastic cones are placed inside the huts for experiments on the effectiveness of insecticides. The effectiveness of insecticides is also tested in the laboratory. 3 4 launched in October 1970 is scheduled to continue until the end of 1973. It includes both a quantitative study of the various epidemiological factors as well as a quan- titative evaluation of the effectiveness of different malaria control methods. But for a model to be useful, accurate figures are necessary. Therefore, the project has a dual task: (1) it must build the model so that it takes all the important variables into account; (2) once the model has been conceived, it must be fed with accurate figures. Parts of the two tasks can be carried out simultaneously. The project entails the following steps: To study the epidemiology of malaria in selected villages in an area of the African savanna and to construct a mathematical model. Information re- quired includes disease patterns, age groups most affected, etc. To study whether specific interven- tions using insecticides applied singly or in combination with antimalarial drugs affect the epidemiology of the disease to the extent of interruption of its trans- mission in a limited area. To assess whether this effect on the epidemiology of the disease can be predicted by the mathematical model and whether, by using this model, mea- sures compatible with operation feasibil- ity and aimed at interruption of trans- mission can be selected. To assess in mathematical terms the parasitological, entomological and im- munological changes associated with the various antimalaria measures applied in the selected villages. To establish with the help of the mathematical model the critical levels of the epidemiological variables that are compatible with the interruption of malaria transmission. To develop criteria for the interrup- tion of malaria transmission and the methods for its evaluation under ecologi- cal conditions similar to the ones prevail- ing in the study area. To make recommendations on the future technical approach to malaria control in the savanna areas of tropical Africa under the prevailing epidemio- logical and social conditions. A group of about 100 Nigerian and 11 WHO workers began assembling baseline data on October 1970. They have been collecting mosquitos, which are counted and identified as to sex, species and age. The proportion carrying malaria is noted. At the same time, the group gathers demographic and epidemiological infor- mation on the inhabitants, and takes blood samples every 70 days. The data are recorded and coded, and then sent to the data bank in Geneva. The project is divided into eight geo- graphical units, each containing two to 27 Water from swamps is collected and checked for larvae. Mathematicians at WHO headquarters in Geneva work on the data collected in the field in their search for a mathematical model. three villages. The Nigerian Federal authorities and the Kano local govern- ment both contributeAo the financing of the programme and provide staff head- quarters and laboratory buildings in Kano and Garki. No malaria eradication measures are being taken in two of the units. Insecti- cides only are used in two other units. Another two units receive insecticides, coupled with light use of antimalarial drugs. The last two units receive insecti- cides coupled with the heavy use of antimalarial drugs. All previous attempts to quantify the epidemiology of malaria have failed— probably because the immunological aspects were not considered. These pre- vious models supposed a constant recov- ery rate from infection. There was no allowance for an increase or decrease in the immunological state of the popula- tion as a function of the changing characteristics of the mosquito popula- tion. A realistic treatment of the dynamics of immunity is not only important for estimating the risk of epidemics after the interruption of control measures, but also for estimating the effects of a possible vaccine. A successful mathematical model could be a major step in the eradication of malaria. Many diseases may be conquer- ed with unlimited resources, but resources are generally limited. The mathematical model will enable public health workers to determine precisely how best to spend their money and energies for the greatest efficiency. ■ Under the guidance of a WHO nurse-educator, Yemeni assistant nurses carry out their jobs with skill. Pioneer nurses in Yemen The antiseptic mask is replacing the yash- mak among Yemeni women. Since Yemen began building up its medical manpower in the late 1950's, some 600 women have joined the ranks of health workers. This is a great step forward in a country where women traditionally led very restricted lives. Only a few years ago, the first group of young Yemeni girls left their traditional life of seclusion to serve as members of the nursing profession. Since then, they have contributed significantly to their country's health services. Of the 600 women now working as nurses and midwives, over 150 have graduated from the wHo-assisted train- ing centres in Sana'a, Hodeida and Taiz. Twenty-nine more have been awarded wHo fellowships for study abroad, and others have completed in-service training in hospitals. Progress in nursing has been paralleled by an increase in the number of Yemeni physi- cians. Barely 10 years ago, Yemen relied almost entirely on foreign doctors, assisted by a few " hakims ", local practitioners who served a kind of apprenticeship. Then, there were only two Yemeni doctors; today there are 80. Twenty of them studied with wHo grants, mostly in Egypt. As more qualified staff become available, more hospitals are being built. They range from large units in Sana'a and Taiz to small rural clinics staffed by one doctor and a number of auxiliaries trained on the spot. Ten years ago, Yemen had only three hospi- tals; today there are thirty, with 4,000 beds. Surviving natural disaster The aftermath of natural disasters floods, hurricanes, volcanic eruptions, earth- quakes—can be as serious as the immediate destruction. People are often left homeless and short of water, food and clothing. They can starve; they can die of exposure and disease. With proper sanitation, many deaths can be prevented. Yet surprisingly few coun- tries have made plans to deal with the sanitation problems that arise in the wake of a catastrophe. In collaboration with the League of Red Cross Societies, wHo has published a Guide to Sanitation in Natural Disasters*, intended to help health authorities and relief agencies develop relief plans. In the confusion and panic that follow a natural disaster, voluntary workers need simple and practical instruc- tions. The public health team doctor, nurse, sanitary engineer and laboratory technician My M. Assar, WHO, Geneva, 1971 30 must go into action as soon as possible after a catastrophe. The first job is to evacuate the injured, the elderly and the disabled. In addition to giving first aid and performing minor surgery, health workers must be on the lookout for infectious diseases that might cause an epidemic. Once shelter has been provided for eva- cuees, environmental health measures must be taken without delay. Camps of more than 1,000 are a disease risk. Mosquito breeding- places or garbage-dumps nearby are another hazard. Trees or bushes where insects, rodents or reptiles could take cover must be cleared. Water, refuse disposal, latrines and drain- age all need careful supervision. Clean water has top priority. If possible it should come from an underground source. Ground water is usually freer from contamination than surface water, and needs less treatment to make it fit for consumption. Water stored for any length of time should be covered and tested regularly. A natural disaster is nearly always followed by a food shortage. When storage and refrigeration facilities are destroyed, all food must be carefully checked for evidence of contamination. Food not fit for human consumption can sometimes be fed to ani- mals. Food handlers must be scrupulously clean. Dirty hands and clothing or careless and unhygienic habits contaminate food just as quickly as flies or dirty utensils. No one with any wound, sore or infection should be allowed to handle food. Vermin tend to multiply rapidly in a disaster area. Fleas, flies, lice, mites, mosqui- tos, ticks and rodents all carry disease. A sanitation team should be ready to destroy vermin on people, their clothes, bedding and belongings as quickly as possible. After the emergency, control efforts can be directed to general cleanliness. Mobile health teams Complete health care means more than hospitals and dispensaries. In the Demo- cratic Republic of Congo, many people live in remote areas separated from medical facilities by difficult terrain. To bring them the services they need, the Government has set up travelling health teams. The mobile teams visit people in their homes. examine the entire population regularly, and are on the lookout for diseases like trypano- somiasis, yaws, syphilis, leprosy and tuber- culosis. Besides giving treatment for illness, the two teams assigned to each area are responsible for health education and vaccina- tion. The information they gather will be used for population studies and to plot charts of endemic zones. The Government has bought enough equipment and supplies for 50 such teams, and the first units are already in action in areas where the need is the greatest. Progress in India A child born in India today can hope to live for 52.6 years, whereas in the decade 1941-50 the life expectancy figure was only 32. During the same period the death rate dropped dramatically from 27.4 to 14 per 1,000 population per year. Infant deaths in particular, usually regarded as a reliable indication of a country's health standards, have shown a noticeable fall. Shri K. K. Dass of the Indian delegation to the World Health Assembly, said that more mothers and children in India are surviving childbirth. People are becoming less disease-prone as nutrition and hygiene improve. Diseases which once took a heavy toll of human life can now be brought under control. India, the country with the world's second largest population, faces no easy task in providing adequate health care for its people. The aim is to build one health centre for every 10,000 inhabitants. Each centre is run by two doctors, one of them preferably a woman, with supporting staff led by a nurse- midwife and a male health worker. More than 5,000 primary health centres and 26,000 sub-centres have already been set up. The network will eventually cover the entire country. The results to date are encouraging. Im- provements in water supply and sanitation have reduced enteric diseases, and bring the control and eradication of cholera, for example, nearer. Significant progress has been made against malaria and smallpox. Not a single case of plague has been reported for five years. ■ World Health Contest In view of the great number of replies, the results of our competition will be published in the January 1972 issue of World Health instead of the December issue of this year. All correspondence should be addressed to World Health, WHO Avenue Appia, 1211 Geneva 27, Switzerland Photo Credits wHoo . moult, Front cover/Back cover, pp. 8, 9, 10, 11, 12, 13, 14, 15, 22, 23, 24, 25, 26. 27, 28. WHO/UNICEF, p. 2. WHO/HCR, pp. 4, 5. WHO, pp. 6, 30. WHO/P. ALMASY, p. 7. . WHO/DR A. MEYLAN (Station Federale de Re- cherches Agronomiques), p. 14. WHO/B. ZEPPILLI, pp. 17, 18, 19, 20, 21. WHO/T. FARKAS. p. 29. Nigerians gather in the market-place. Iranian women tend their sheep. Research begins in the swamps. Small mammals may harbour disease.