Rural health [full issue]

WORLD HEALTH The magazine of the World Health Organization July 1970 UK:2/3d USA:0.50 Farmers, fishermen and foresters are all part of rural life but in the countryside today a much richer variety of professions are found; in some European countries, for example, industry is moving to the countryside and thus factory workers become involved in rural health problems. Climates and ways of life vary; there are tropical farmers working ankle deep in the mud of rice fields and fishermen farmersharvesting seaweed along a cold and windy North Atlantic shore. This issue of World Health uses the term rural in its largest sense to include anyone who lives outside a heavily urbanized area. Contents Doctor for the island, by Nedd Willard 3 Dr Nikitina of Toissi, by Alexei Striganov 10 Indonesia: making villages healthy, by K. Frucht 13 Help comes up the river, by W. Muckenhirn 1 8 All correspondence should be addressed to The countryside goes industrial, by Dr Walter Best 24 World Health, WHO, Avenue Appia, Where doctors never went before, by R. Plant ... 27 1211 Geneva 27 Around the world 34 doctor for the island by Nedd Willard The doctor took a last hurried sip of tea and finished off the small sandwich. The village clock had just stopped ringing for noon and it was time to get into his car and make for the port. He was soon riding over the treeless hills and down winding bends through country that looked like a tourist adver- tisement for Connemara. There were flocks of black-faced sheep grazing behind the grey-green blotched stone walls laid out in irregular lines on the brown turf. On top of a small mountain one or two of the Connemara ponies were standing, peaceful, alone, untroubled. He swerved sharply to avoid four hulk- ing black cows grazing "on the long acre" as they say, meaning alongside the road on public land. Somehow the grass seems to taste better to cows there, even when the pasture is high in the fields. There was little reason to hurry, he reasoned with himself ... just routine calls on the island, but for the past two weeks the sea had been too rough to cross over so it was just as well to try again today because the islanders were expecting him. Besides, he was always glad to visit the place. At the small seaport he pulled up in front of the one pub and left the car, carrying a bundle under his arms. The woman inside greeted him warmly. "Good afternoon, Doctor. A bit cold, surely, but that won't bother you. Have a little stimulant." While she poured a glass, the doctor stood in front of the turf fire putting on his waterproof trousers; by the time he had slipped the unwieldy top of his water- proof on, the trawler had been sighted, so he hurriedly downed the drink. "Don't forget these, Doctor," said the woman, handing him several days' news- papers. The quay itself was quite short, just room enough for the few fishing boats that used it. The trawler, a lobster-fishing boat, served as mail service and throughout the year delivered food and other necessities to the island as well as a handful of adven- turous tourists in the summer. "Afternoon, Doctor. Mind your step." The crew, both of them, welcomed him aboard. The captain was a young man, son of the captain before; the rest of the crew consisted of one sailor in water- proofs. "We'll be off in a minute. Not too much to take on today." The cargo, such as it was, soon found its way below decks and they cast off. The sky was clear but a cutting wind was blowing from the sea. That wind had come a long way uninterrupted. There was a saying in the county, "the next parish to the west is America." Once past the shel- tering shoulder of a hill that ran its fields down to the sea, the trawler got the full force of wind and waves. The doctor was unalarmed; he had seen worse. Yet he hoped it wouldn't keep mounting for then the waves would be even larger when he took the trip back. Not that he didn't like the island, but he couldn't afford to be forced to stay on it when he had dispen- sary and hospital duty tomorrow. A little less than an hour later, the island appeared, low with a few ridges which looked as if they had been trying to be mountains but had given up the attempt because of fatigue, halfway there; a ruined abbey sprawled on the stoney arm that sheltered a small bay. The trawler anchored inside the bay and the crew brought the dinghy alongside. They loaded the cargo aboard the little boat—sausages, hundreds of them in plastic bags, some tinned goods, and a few cases of good beer and a bottle or two of whisky. Then it was the doctor's turn. He sat in the stern and the two men rowed him ashore, using the stiff and clumsy oars. The mayor of the island, and proprietor of its main hotel, was standing on the rocky beach waiting for him. "Nothing much today, doctor, a few regulars, some colds, some babies, a few pixillated [not too right in their minds], and that's about it, except that we are glad to see you." The mayor and the doctor climbed the beach to the hotel; a hot lunch was waiting for the doctor, and the mayor's wife, a trained nurse, brought him up to date on the situation in the island. When he couldn't cross over from the mainland she was responsible for everyone there. Luckily, with the exception of the 'flu, which had laid everyone up, things seemed all right except for that poor young man who ran a small hotel on the other side of the island. His wife was very concerned, for the last time he had had a heart attack it was necessary to use a helicopter to get him off and away to the Galway hospital. But there was little that could be done; in fact he had arrived on the island from England with a life expectancy of only a few months and he had weathered four winters since then. The island must be a healthy place. "There is something healthy about County Connemara, generally," said the doctor. "If I bury a patient under eighty years of age, then I rack my brains to find where I have failed. Most live long past." 3 The doctor comes aboard the trawler which will take him, with a number of essential supplies, to the island. It is a cold day in March and the wind is rising. "Yes, but here on the island a lot are so bored that they begin imagining things. And, like everywhere else, the young are going," the nurse added. "We are a funny sort of region : babies, schoolchildren and old people. So many still emigrate. It's almost expected of them. Boston and Brooklyn seem closer to many here than Dublin." The hotel owner and mayor broke in. "The land can only hold so many. We have about 250 people on the island but 1,000 sheep. Too many sheep for grazing and even then we don't sell any of them, just shear the wool and kill what we need for meat. Fishing brings in a little and fuel is almost free for those willing to dig it out of the turf, but that's not enough to keep young people, especially today when they want so much more than their grandparents." "Doctor," the nurse interjected, "they are beginning to arrive at the dispensary." Doctor and nurse walked the few yards along the path to the dispensary, past an old boat house where a few men stood in the lee, sheltered from the wind and en- joying a desultory ray of sunshine. "After- noon, doctor. Lovely day." Behind the combined grocery store and pub was the dispensary, a small room but large enough for the purpose. Only a few patients had arrived, mostly old people and regulars, with rheumatism or the remains of a bad cough, so that an hour or so later the doctor was able to start on his rounds. In one of the two cars on the island, doctor and nurse jolted up a hill to a farm where an old man had suffered a heart attack and lived in fear of another. He was a sturdy old fellow, former sailor and fisherman, who had spent years pulling oars in the open sea and his spare hours watching over a few cattle and a flock of sheep. There was nothing wrong, and the visit ended with the doctor pronouncing the ritual phrase, "All right, Mick, you'll be here when I come back on the next boat. And probably long after that, too." Waiting on the strand near the rowboat was a woman wrapped in a shawl, her face pained and her whole body drawn in upon itself. "Doctor, my tooth is abscessed, like I told you, and I need to have it fixed." The doctor and nurse exchanged glances. They both knew that the trouble bothering this woman was more a result of her husband wandering off the island in the direction of England than of any physical aches and pains. But if a visit to the local hospital, an X-ray and dental examination would make her feel better, then that was the best that could be done. The sun was low on the horizon as the dinghy came alongside the trawler, and the wind had been blowing steadily. Even the captain seemed glad to get going and only the woman, huddled beside the small wheelhouse, appeared indifferent to the weather. Past the ruined monastery, the trawler, its sail raised for stability, hit the full force of the sea and began to pitch and roll. Soon the decks were awash and the only comfort on that cold evening was the steady, though unemphatic, throb of the motor putting one stroke after another. The island was out of sight and the main- land seemed far away. The doctor felt his sixty odd years as he clutched the railing and rolled with the ship. The sea kept giving the hull nasty wet slaps and an occasional push; once, the waves coming broadside, the vessel took two and heeled over with one rail under water. "Hope another one doesn't come too close after it," the doctor thought. "It's too cold for swimming and not another boat in sight." But the old trawler rolled heavily like a drunken man, unsure of his feet but sure of his destination, and leaned into the wind. By dark they were moored alongside the pier and soon the doctor was having a drink close to the turf fire. "Hard day, doctor?" asked the woman behind the bar. "Wouldn't care for it any worse," he replied. After stripping off the waterproof gear, he got back into the car. He had no calls to make on the way and was glad to be heading home. His wife met him and joined him for a cup of tea and something warm to eat. Then the telephone rang. A sick baby. "I hate to see you go out, particularly tonight when it's raining and blowing like that. Probably nothing to it." "Probably right, but I'd rather go on twenty useless calls than miss one that was important." Twenty miles out and up a stony lane was the cottage. Sturdy and white on the outside but bleak within. A small turf fire Late in the afternoon the crewman unties the mooring line of the dinghy from the huge anchor left behind by some sailing ship wrecked offshore hundreds of years ago. 4

didn't dispel the cold and the children sleeping together were lending each other some warmth as well as comfort. The father was a part-time farmer, getting financial assistance from the government, farming a little, fishing a little, a making an odd pound here and there. The family had four cows, enough for milk; they would be sold off for meat in the years to come. Pasturage was stony or bog, enough for a few sheep. Surprisingly enough, next to the great stone boulders potatoes grew best. At least the year's routine was varied. Cutting turf for the year's fuel took about a week. This the man and his son attacked with special spades, cut great brown hunks of the solidified mould that had stopped short About the Republic of Ireland 1966 Population: 2,884,000 50.8% in rural areas: 54.5% of persons engaged in farming are small property holders with farms of less than 50 acres. Life expectancy for men is 68 years and for women 72 years. Number of physicians: 2,952. 105 physicians per 100,000 popula- tion. 1 dentist per 5,000 population. Number of nurses and midwives: 15,230 (1961). There are 74 hospitals with 11,246 beds. of becoming coal, and then stacked the pieces on end, "footing it", so that the turf would dry a bit more. At the end of the week they took the donkey and carted the fuel home. The community charged them only a pound a year for cutting the turf from the common bog, so fuel was a slight problem and no economic drain. But where could they find money? Seaweed was a partial answer. Off their rocky strip of land a few sections of shore- line were allotted to them and every few years they could harvest seaweed which was fetching a good price. Seaweed went into fertilizers, plastics and even ladies' hand cream and cosmetics. When the tide was low, the men cut the weed and bundled it into piles weighing tons. The weed was hauled ashore and carted away. As this could only be done at certain times, when tides were right, every tractor in the region was commandeered. The doctor found little wrong with the baby and chatted a bit with the family. This old sailor looks forward to the doctor's visit every week or so. His days of pulling an oar 6 are over but he is concerned about his heart. The nurse is listening to the doctor's instructions. "How are you getting on?" he asked the father. "Hard, doctor, it's hard. But at least my son here won't know it." "Oh, why not?" "He's going to America. To live with a brother of mine near Boston and have a good life." "But it's sad to see them go." The doctor remembered all the roofless, de- serted farmhouses he had passed on the way out. The major part of each genera- tion grew up here sturdy and happy, then left to go half round the world; some might return as pensioners to end out their lives. Where an old farmhouse was being re-roofed the chances were that a tourist or retired man was having the work done. Irish health patterns Most frequent causes of death in 1966 (death rates per 100,000 population): Cardiovascular diseases 613.0 Malignant neoplasms 179.4 Acute upper respiratory infections 127.3 Accidents, including motor vehicle accidents 40.5 Influenza 33.1 (Source : World Health Statistics Annual for 1966, Vol. I) A bit stiff in the legs, the doctor got up and took his leave. It seemed a short ride home and there was just time for another cup of tea before going to bed. Next morning on the way to the dis- pensary he met the veterinarian. They were good friends and each in his way saw the same people and travelled the same stony roads. The veterinarian was concerned about a number of abortions taking place among the cows. "Hope it isn't brucellosis again. As soon as I hear of abortions that's my first thought." "Perhaps not this time. Are you very busy otherwise these days?" "Well the ewes are dropping lambs now. I should even be busier, but only some of the farmers take good care of the newly born. On the island, where your friends are, they don't get up at night to look for lambs, nor the next day. Those that wander in with the ewes are all to the good and the ones that fall off cliffs or are eaten by foxes, well, that makes less of them for the commonage (common pastureland) The veterinarian gives one of Connemara's famous ponies a looking over. 7 4°1 1.61,1 *!iiiild.64.4"V‘‘ _2* - 1111. - - _,:,..„±„,....._ 2 . ,. -Attr,_• -,---*- .:,-- ---a.01,'Itit • .. --...._ ' _ At, The tide is low and there is a fresh crop of seaweed. The nurse on her rounds looks after many. where there are already too many. The biggest farms take the best care, and some good farmers, like that young fellow Boyle, who goes out gathering in lambs each day." "Don't be too harsh, Pather; I had a patient who wouldn't stay in bed with a high fever and when I insisted he said, `But, doctor, the ewes are dropping now'." "Well, there are all kinds of people and all kinds of farmers. If you see the Boyle lad ask how his cows are doing." "Right enough. Come round for tea soon." "I'll try." They parted in different directions, the veterinarian off to cover his hundred odd miles of territory, aiding, advising, keeping close watch on diseases, the doctor to the dispensary where almost every farmer of the district came. In Ireland everyone in the lower income group receives free medical care. Well over 90% of the people in this poor rural area are in that category but they are well provided for medically. The doctor holds dispensary almost every day, receives calls at his home, and gives out medicines, without charge, as people need them. Cases that require hospitalization or a specialist's opinion are sent up to Galway where they are fully treated without charge. Even people in slightly higher income brackets pay only a nominal sum for medical services. The Irish medical system is in for some changes though. Patients in the lower income group will be given a choice of physicians. People here are fortunate to have as doctor a man who comes when they need him, and often when they don't, who likes and knows them all. But else- where it was felt an imposition that people in lower income groups have no choice but are obliged to use the one medical officer paid for by the Government. Also the system for distributing drugs will be changed and they will eventually be dispensed through the pharmacies rather than, as now, by the district medical officer. The changes will not affect this doctor much: in his area he is the only doctor—almost everybody is his patient— and he won't mind being rid of the bother of dispensing drugs. What was best in the Irish medical system would remain, complete and ex- cellent coverage for everyone in this rural area free of charge. Western Ireland: a poor land, but a good and healthy one. Before receiving patients the doctor stopped for a chat with the nurse. They worked closely together. He assigned cases for her to check on, injections to be given, backs to be rubbed, babies to be looked at, and she reported upon those that needed his attention. Among others, she mentioned that Boyle's mother would like a visit sometime soon. The old lady was sorely troubled with rheumatism and concerned about her heart. The cases that day were hypertension, an ingrown toenail to be cut off under local anaesthesia, and one more serious case, a cancer, but curable he thought. The doctor locked the dispensary door and visited the small hospital built on the brow of the hill behind the dispensary. There were about thirty beds and most were occupied by the very old. The sisters who were on duty had nothing special to report so the doctor merely made the rounds shaking hands and letting each old person know he was not forgotten. Boyle came to meet the doctor as he got out of the car. Like most of the young men in this region he was unmarried, although 29 and with a good bit of property. No one knew why there were so few marriages or why they took place so late, but everyone had a theory. Women didn't want to marry farmers since life was so hard. The girls went away to England and America where pay was good and living a good bit easier. Many of the boys were too tied to their mothers. They were shy. In any case the region was sown with unmarried men. On the farm But Boyle had the intention of being married "as soon as I get both these properties well under way." He was young, strong and a hard worker; if anyone could succeed at this frugal type of farming he could. "How are your lambs doing?" "Brought in twenty so far. The foxes got a few, but less than last year. Unfortu- nately, someone put out poisoned bait for the foxes and I lost my best dog. Now I only have this loveable fool puppy. Hope he turns out all right." The puppy leaped and bit and ran about as if to show that eagerness and willingness to serve were his best qualities. Boyle would need a dog to round up the sheep scattered over forty acres of rocky and boggy hillside, mountain and valley bottom. It was near sunset and the ewes were making their way to the top of the hills to sleep. Why they went there was uncertain but they seemed to feel more sheltered on top. Boyle kept the ewes that had suckling lambs in a field below his house where he could keep an eye on them. About twelve miles away he owned another property, from an inheritance on his mother's side, and there he kept another forty sheep or so. In addition, he cut seaweed, rented the old cottage, refur- bished, to summer tourists and even acted as fishing guide during the summer. The doctor had finished checking Boyle's mother and gave her a little something to ease the rheumatism and reassurance about her heart. "You'll be still baking bread for many a long year." They both saw him to the gate. "Thank you for coming, doctor." The doctor drove off feeling good about it all. Here was a sturdy young man working hard, good to his mother, good with his neigh- bours, and rooted into this old, hard and stony land. Connemara was still a good place to live in. ■ 9 Dr Nikitina of Toissi by Alexei Striganov Don't try to find the village of Toissi in an atlas : it is only a small village somewhere in the huge steppes of the Soviet Union. How far is it from Moscow? In this age of space travel everything has become rela- tive, but it still takes fifteen hours in the train from the capital, plus an hour in a car and a ride on horse- back for two hours to reach the village. It is part of the autonomous Soviet republic of Chuvashi in the northern part of the Volga river basin. This region, traditionally agricultural, has almost a million inhabitants. Since the war, however, industries have been implanted. For example, in Cheboksary, capital of the republic, there are large tanneries as well as pharmaceutical factories. According to the 1968 figures, Chu- vashi has 1,705 doctors, or about 170 for 100,000 inhabitants, which is less than the national average of 210 per 100,000, so it is not surprising that Dr Vera Nikitina is the only physi- cian in Toissi. But how did Dr Nikitina happen to choose such a place for her practice? "I was born and grew up in Chu- vashi," she said. "My father was a small farmer, busy with his live- stock. I still remember that part of my life because it was so painful. My family, like almost everyone in the village, including myself, suffered from trachoma. My eyelids were swollen and when I woke up they would be stuck together with pus. It is a horrible feeling to have to unstick your eyes and even then to see everything distorted. I made a vow to myself that when I grew up I would become a doctor and try to help those who were suffering as I had suffered." Fortunately, trachoma has now disappeared, and Vera Niki- tina can devote herself to other tasks. Her medical studies were paid for by the Toissi kolkhoz (collective farm), for already during her secon- dary education her gift for medicine was so clear that the head of the kolkhoz called her into his office. "Vera," he said, "we have confidence in you, and since we need a doctor 10 The village of Toissi: winter. we are going to send you to the medical school at the Kazan Insti- tute. Your studies will last six years, but when you return not only will you be a physician but you will find a new hospital here waiting for you." The head of the kolkhoz kept his word, and the hospital for the village was built and equipped with kolkhoz funds. Vera is a paediatrician and is still today the only physician; two places remain to be filled, one for a general practitioner and one for a neuropathologist. Doctors to fill these posts should arrive within the next few months. Meanwhile, Vera does the work of three. Her day begins with a visit to the hospital. Next, she receives out- The doctor is here! L patients in a clinic situated in a wing of the hospital. The waiting room is usually full, mostly with women and children but with the occasional man. By the end of the morning Vera has examined twenty-one patients. Afternoons and evenings, Dr Niki- tina goes on her rounds. There are nine villages around Toissi which are entirely dependent upon her for me- dical care. Today she is going to visit five people scattered in four different villages. In summer, transport is no prob- lem, since Dr Nikitina can use the hospital automobile, but in winter, when the countryside is one huge unbroken field of snow, the best means of transport remains the horse. In fact, in very isolated areas, the doctor has to use an aeroplane for bringing a patient rapidly to hos- pital. Regardless of the weather—snow, sleet or hail —Dr Nikitina sticks at her job and unceasingly devotes her- self to the welfare of her patients. Beloved by all, she is known to everyone in Toissi as "our doctor". ■ On sledge or on foot, Dr Nikitina makes her rounds. Indonesia: making villages healthy by Karl Frucht Scattered over 3.5 million square miles (9 million km2) of the Pacific Ocean between Asia and Australia, 3,000 islands and islets, most of them inhabited: the Republic of Indonesia is the largest archi- pelago in the world. However, the actual land mass consists of only half a million square miles (1.9 million km 2), on which 118 million people are living. An annual population growth rate of 2.8 per cent makes the efficient use of land even more important. Rich as Indonesia is in natural resour- ces, it must still import food at an annual cost close to 100 million US dollars. Understandably, in government planning high priority has been given to agriculture, in which rural health is a vital factor. Seventy per cent of the population still live in rural areas, so the first industries to be developed under the Five Year Development Plan begun in 1969/1970 will concentrate on fertilizers and products related to agriculture. The Indonesian Government is aware that, in addition to being an end in itself, public health will raise the level of productive working capacity and speed development. It rightly considers the improvement of public health as a form of development investment. A master public health plan has been drawn up. In rural areas the aim is to provide everywhere some form of medical treatment and to stimulate sanitation pro- grammes, with the emphasis on water supplies and evacuation of waste. How necessary this is may be indicated by the fact that 73 per cent of all houses in Indonesian villages have dirt floors, only 32 per cent have their own wells, and only 12 per cent private toilets. Communicable diseases still present the main health problem in Indonesia but great progress has been made. Yaws was chosen in 1950 as an example of what could be accomplished with relatively simple means. "It is now difficult to find a case of yaws in Java to demonstrate to students," says Dr Sulanti, Director of the Communicable Disease Division of the Department of Public Health. But other major diseases must be attacked. Outbreaks of plague still occur; in 1968 there were 95 reported cases and 38 deaths in central Java. The latest epidemic occurred in January 1970. Immunization and control measures undertaken by the Ministry and the local authorities with expert advice from wHo and other sources succeeded in containing outbreaks in a limited area. Smallpox cases for Indonesia as a whole numbered 17,300 in 1968. The figure rose to 17,800 cases in 1969 with 1,452 deaths. In order to cope with flare-ups of the 13 4 disease, a new method of attack at focal points has been devised : smallpox "fire- fighting" teams are rushed to any region to reinforce provincial health workers when necessary. Hard-hit village The village of Parungserab, with 1,300 inhabitants, was hard hit in January 1970. Eighteen cases of smallpox occurred during one week and resulted in four deaths. Actually, only a handful of cases had been reported to the authorities, but a house-to-house search by the specialist team revealed the rest. It was late after- noon when the team arrived at the village, and work in the fields had stopped. One new case of smallpox was detected at a collection point for vaccination, and two more cases—infants dying of the disease—were found in their homes. By now the villagers were so alarmed that they were rushing to the collection points. Hundreds of children and old people were vaccinated the same day, the technique used being that of multiple puncture with a bifurcated needle, which requires only a fifth of the usual amount of vaccine. On the following day "backlog" fighting of smallpox continued in the village of Tjiurgaruga and in the Regency of Bandung, where four cases had recently occurred. Scabs were collected from patients for laboratory analysis. Houses marked with "backlog" notices were visited and people were vaccinated who had been missed out earlier. Such opera- tions should help to halt the spread of smallpox, which in this area had resulted in 1,500 cases and 100 deaths in 1969. Another important communicable dis- ease in Indonesia is malaria. At the end of 1963, as many as 64.5 million people in Java, Bali and Lampung had been protected against malaria attacks by DDT- spraying. Later, however, the situation deteriorated because of lack of funds and the interruption of foreign assistance which had provided DDT and other supplies. As a result the incidence of malaria increased in certain areas—in Java and Bali, for instance. In September 1969, a plan to integrate the malaria programme with the general health services was adopted; eradication schemes at various levels will now become part of the communicable disease control network. Local administration will be ensured by chiefs of regional health ser- vices, while the central authorities will be responsible for overall guidance, super- vision and evaluation and for the procure- ment of supplies and equipment. The difficulties in the field are evident in a malarious area north-west of Bandung. There is a certain resistance of the popu- lation to DDT-spraying; in addition the terrain and climate often hamper eradica- tion activities. The collection of data on malaria cases during epidemiological surveillance is also a time-consuming and demanding job. In the village of Tykalong Wetan a team of case-finders works on despite a violent downpour. An examination based on symptoms alone shows more than 2 per cent of the population to be suffering from clinical malaria. The maternal and child health (Mai) services constitute one of the best organ- ized branches of the general health ser- vices in Indonesia. The health and welfare of mothers and children is of prime concern to the government. The mai section of the Ministry of Health was established as early as 1952; the number of mai welfare centres increased from 350 in 1950 to more than 5,000 in 1968. The old and the new Ketapang is a village south of Bandung, shaded by trees and surrounded by rice paddies whose irrigation canals reflect the sunny sky. It has a co-operative mill where villagers bring their maize crop to be ground. New motor-cycles are parked 14 In the paddy fields. e The word has been passed: smallpox is in the village. People cluster at Smallpox scabs are collected for laboratory analysis. collection points in spite of the rain. in front of shacks, side by side with straw- covered bullock carts with wooden wheels. A cock is spruced up for a fight by its proud owner. Women relax in the door- ways of the houses, greasing and combing each other's hair. The mai staff of the combined poly- clinic and welfare centre consists of a public health nurse, a midwife, a home visitor and an assistant. They also look after four other villages with a total population of about 40,000, providing ante- and post-natal care for mothers and babies and giving family planning advice. A walk with the home visitor gives a good idea of the conditions of rural life. Water, for example, has to be drawn from wells; it is alive with bacilli, but is actually drunk without the addition of chlorine, even though the rate of intestinal infection is known to be high in Indonesian villages. In the villages of Bali, ferocious-looking dogs announce all comings and goings, but otherwise life goes on quietly enough. The villages line the roads, but are hidden from sight by massive stone walls; a few portals lead into the courtyards of homes, and half of each village is reserved for multi-storeyed shrines and temples whose thatched roofs rise high above the sur- rounding countryside. In Bali the women not only do the housework but are also to be found ploughing the waterlogged rice paddies, up to their knees in the rich mud and followed by trails of ducks. The villagers breed black pigs of Australian origin, and the proprietors of the fruit- stalls sell custard-apples, durian and also a rich assortment of vegetables. Other 16 produce, however, comes from the major towns, .some of it from as far away as Djakarta. All kinds of plastic goods, textiles and straw baskets are to be found in the village markets, but few of them are manufactured locally. A school health programme at Klung- kung, also in Bali, bears witness to the enthusiasm with which health workers as well as pupils are pursuing the goal of complete physical, mental and social well- being. The children's gleaming dark eyes belie the considerable amount of night- blindness to be found among them, and their white, flashing teeth give a false impression of the true picture of dental health in the area. Mr Umar Hassan, a sanitarian in the rural health service, is responsible for a programme of school health begun in 1969 and already encompassing 100 schools. He travels by motor-cycle to supervise 50 trained health workers and the 150 tea- chers who have already received training in school health. During check-ups at the schools, high priority is given to environ- mental and personal hygiene, compre- hensive immunization programmes, nutri- tion and dental health. Fifteen of the 280 children examined at a school in Klungkung were found to be suffering from malnutrition or nutritional anae- mias, the former being diagnosed by height/weight comparisons. Each pupil receives a spoonful of vitamin-rich palm oil, washed down with another spoonful of water, ladled out from wash-basins. No milk is available for distribution to schools, but an applied nutrition pro- gramme is to be started in Bali in 1970. The health worker is very important to such a community, and confidence in Indonesia's health services is increasing among the villagers. The health of over 8 million children of school age through- out the country will eventually be safe- guarded by teams of health workers in the 36,000 elementary schools of the area. ■ Water, essential for health.> On the road is an "ambulance"—two porters carry a fever-stricken man; the blanket spread over the patient protects him from the weather, which in the monsoon season alternates between blin- ding sunshine and torrential rain. Strung out like beads for thousands of kilometers along the Amazon River and its tributaries, the open-sided, thatched- roof houses of the Peruvian ribereilos * dot the river banks, up- and downriver as far as a canoe can penetrate. Pressed to the very water's edge by the nearly impene- trable rain forest, isolated from each other and from civilization, self-sufficient to a high degree on his little plot carved out of the dense jungle, the riberefio looks to the river as his lifeline. The river represents his only link with the outside world. Living up to a full day's journey from the nearest village, the dug- out becomes his sole means of transport. * Peruvian term for a dweller along the river banks. It is from the ambulatory merchant, travelling up and down the main water- ways, that he learns the latest news. It is to him that he sells whatever surplus he has managed to produce and from him that he buys his meagre household items. And the river, with its abundance of fish, provides him with his main source of protein. Lying practically astride the equator in a hot and moist climate, this Amazonian region is plagued by almost every tropical disease known. Unfortunately, like most underdeveloped regions, the situation is greatly aggravated by the average fiber- 's ignorance about the importance of nutritional balance. Although the Amazon is a rich source of fish, and thus of protein, fishing is only possible during the " dry " season, roughly June through October, when the water is at its low level. As soon as the great rains set in, the waters rise tremendously, transforming what was a placid river into a treacherous and seeth- ing flood, twisting with crosscurrents and undercurrents. Since it is too hazardous to fish, the ribererio and his family fall back on the main staples: yucca (a root, not unlike potato), green bananas, beans and rice; these are all rich in carbohydrates, but poor in protein. The result is a nutri- tional drain on the health of all concerned. Fortunately, the ribereflo is blessed with a great variety of vitamin-rich fruits which are his for the picking, but these do not supply the essential elements of protein. Until as recently as 15 years ago, the whole region was ravaged periodically by epidemics of infectious diseases, and the 18 help comes up the river by Werner Muckenhirn The river is the lifeline. populations, their bodies weakened by protein-calorie deficiency, had little resis- tance to offer and succumbed in great numbers to the diseases and the accom- panying complications. For example, almost yearly, epidemics of measles claimed the lives of up to 30 % of cases and regular epidemics of whoop- ing cough proved fatal in almost 10 % of cases; 20 %-30 % of the young contracted infectious polio; malaria, yellow fever (selvatica), tuberculosis and leprosy were also ever-present threats. And every des- cription of parasite thrived under the favourable conditions. So when, in 1953, the Peruvian Ministry of Public Health, in cooperation with wHo and UNICEF, went at the task of organizing a public health service for the Peruvian part of Amazonia, it faced the formidable problem of providing medical and dental service for a population of almost half a million people, spread out thinly along more than 10,000 kilometers of waterways, over an area of almost 500,000 km2 (or about the size of France), a region without a single road. There was no standard model in opera- tion elsewhere for the Peruvian authorities to copy. Amazonia is unique not only in its dimensions and strung-out settling pattern, but also in its almost total inaccessibility. Before the advent of the aeroplane, the only way to get from Lima, on the Peru- vian coastal plain, to Iquitos was on foot across the giant Andean range—or by boat, around the Straits of Magellan or through the Panama Canal, then all the 19 4 Jammed up close to the river by the thrust of tropical rain forest, these villagers have only the rivers as links with the world outside. Children scan the waterfront waiting for the arrival of the boat that will bring medicine and care but also a welcome break in the weeks' monotony. V way around the continent and up the Amazon, 3,700 km from the Brazilian port of Belem. Even now, the most practical way of reaching Iquitos is to take an aeroplane. In view of these tremendous obstacles, a visit to the area today shows an organi- zational achievement of impressive pro- portions. Headquartered in Iquitos, the capital of the Department of Loreto, the Servicio Civico Fluvial del Amazonas has grown into a solid network of health centres all over the region. Strategically located facilities within the region provide the necessary health care on a permanent basis : the central hospitals in Iquitos and in Yurimaguas stand fully equipped to take care of major or complex medical problems. The six "postas medicas " (health centres) in outlying communities like Nauta, Laguas, Caballococha serve as centres for their immediate regions. They consist of a small hospital, with a maxi- mum of 10 beds; one to three doctors take care of all medical needs, including simple surgery, dental service, etc. Flotilla of boats An extensive network of "postas sani- tarias" (health sub-centres, 50 are pre- sently in operation in the area) staffed by local auxiliaries, administer first aid, attend to everyday ills and give advice on nutri- tion, hygiene and maternal health care. However, since this still would leave a great portion of the river population with- out any medical attention, the Servicio Civico Fluvial took to the water. Using an extensive flotilla of boats, ranging from small outboard speedboats, medium sized motorlaunches, to Navy gunboats, teams of doctors and nurses go out daily on Less than a village—a tropical hamlet scraped out of the jungle with a few head of cattle and small gardens. The people welcome the boat which brings drums of insecticide. journeys lasting anywhere from one day to four weeks. Three motorlaunches, acting as floating health centres, travel from settlement to settlement. In addition, immunization teams travel the full length of the rivers, reaching into every nook and cranny, in an attempt to stem the spread of infectious disease. Malaria eradication teams, for instance, continue to attack the breeding grounds of the mosquito over the entire region. Even the four Navy gunboats, making their routine patrol tour up and down the rivers, carry a team of doctor, dentist, educator and auxiliary. They stop at every settlement along the way in order to treat the sick, pull teeth and teach the rudiments of sanitation, health care for babies and their mothers, nutrition, etc. One Navy boat, the "NAPO", is a fully equipped hospital ship, where simple surgery and dentistry can be performed, 1 with beds for post-surgical patients. The latter stay on board for recuperation and are brought back home on the vessel's return trip. The success of the Servicio Civico Fluvial is impressive. Deaths from measles were brought down, through vaccination, from 30 % to approximately 1 % of cases; immunization against whooping cough has reduced the case fatality rate to appro- ximately 1 %. Malaria, yellow fever, polio and leprosy are now seen only in isolated cases. The fight against parasitic diseases continues and is increasingly based on an intensive programme of education for the public. The rivers which isolate the riberefio and link him, though distantly, to other men, the rivers which bring him food but serve as carriers of illness, are being made to serve as avenues of aid now that human solidarity takes new forms. ■ I. Dentistry on deck. A small malaria patrol arriving with stocks of insecticide at a remote location. There is a lot for the doctor to do in a short time: check the children's health for a variety of disorders and ensure that they have whatever protection vaccination can provide. 2

the countryside goes industrial by or Walter Best `If health is "not merely the absence of disease or infirmity, but a state of complete physical, mental and social well-being," as the WHO definition has it, one can only infer that people in rural communities to- day often live in conditions that cannot be described as "healthy".' This remark was made in June 1966 by Franz Klose, President of the German Green Cross, in a lecture attended by the President of the Federal Republic of Ger- many. He thus drew attention to one of the most urgent problems concerning our regional planning and a constructive health policy. There is talk of "social rearmament on the land" in Federal Germany today and if this process really gets going, then we are beginning to be serious about putting the wHo health definition into practice in this country. A few indications, however, will show how complex this task really is. The totalitarian system in Germany, which was overthrown in 1945, pursued an intensive agricultural policy as part of its attempt at national self-sufficiency; in doing so it strengthened traditional social structures and way of life in the country- side. The end of World War II set in motion human migrations on a scale un- precedented in recorded history. Eleven million persons coming from eastern Europe were resettled in the West and this changed the old population structure. Between 1945 and 1949, immigrants having moved west numbered 24 % of the total population in Bavaria, 14 % in Hesse, 14.7 % in Baden-Wiirttemberg, 36 % in Lower Saxony, 8 % in North Rhine- Westphalia and as much as 58 % in Schleswig-Holstein. The newcomers had to be housed; since the villages and small towns in Federal Germany, as opposed to medium and large-sized towns, were still largely intact, the main burden of the task devolved on the countryside. This develop- ment greatly influenced social structure, for not only did the small towns and villages increase in population but the non- farming community increased, as did the number of trades and professions not usually found in rural areas. Economic recovery and swift industrial development led to additional structural changes; industry had to go further and further afield to meet its manpower re- quirements : workers travelled ever-increa- sing distances to the city factories, the trip in each direction often taking as much as two hours. The word "Pendler" was coined for the commuting worker on account of his daily pendulum movement between home and factory. The big towns in industrial areas grew apace and spread far beyond their limits Satellite cities were created in the country. So the villages ceased to be agricultural dwelling places and provided accommodation for a mixed community. As a further development, industry, in order to meet the manpower shortage, transferred its factories as far as possible to rural areas in order to pick up any workers who might be available before they move into the towns. Industry up to the present has continued to grow and has yet to reach saturation point with regard to manpower require- ments; efforts have been made to satisfy the need by attracting workers from countries where economy and industry are less strong. In agriculture, however, 24 labour will be released continually over the coming years. The stabilization of German agriculture within the framework of the European economic community will ultimately release hundreds and thousands of workers for industry and trade. It is quite clear today that agriculture and the countryside are becoming industrialized, but also that it is necessary in the small towns and villages to create social condi- tions that approximate at least to what the large towns offer their inhabitants. Civilizing influence The "social rearmament" of village and countryside has been launched, but it is not yet effective and in some places it has only just started. This gives point to Pre- sident Klose's remarks quoted at the beginning of this article. The most effective way to set spurs to this rearmament is to take action in the health field. It seems clear that, aside from territorial planning and general questions of administration, a health policy actively pursued can exert a strong civilizing in- fluence and determine the cultural status of a country; it can also be of great value in promoting an equilibrium between con- urbation and rural area. The task devolves on the public health service, which, depen- ding on the Land, may operate either as a state or as a local service. The organs of this health service are health offices whose duties are uniformly prescribed and result from the 114 paragraphs in the health ordinance together with other legal pro- visions. In broad outline, the tasks of the public health service can be said to consist in supervising and controlling the observance and execution of health legislation, chan- nelling all legal and voluntary preventive measures, and being responsible for certi- fication in the social and therapeutic field, including rehabilitation. In practice, the various functions often overlap and thus cannot be classified as schematically as I have done here. The long list of duties are carried out by health offices that are normally staffed by a medical officer who has one or two part- time physicians at his disposal, a health inspector, a medical technical assistant and several public health nurses. The effective- ness of a health office obviously increases with the number of full-time medical staff. Good co-operation between the medical officer on the one hand and general prac- titioners and specialists on the other is essential to maintain a satisfactory health status of the population within the area covered by the health office. The only compulsory preventive meas- ure, imposed by law in the Federal Republic, is vaccination against smallpox. The state offers all other vaccinations as voluntary measures via the health offices. In rural areas, the health officer has the task of convincing his public of the useful- ness and effectiveness of presently avail- able vaccines and must take every oppor- tunity to provide health information and to further the health education of his public. For these purposes he has at his disposal such organizations as the German Green Cross which develop methods and media for health education. The psychological approach in health pro- paganda, if properly applied, can effective- ly promote understanding of the need for preventive measures. Well-baby clinics, under medical supervision, are available free of charge on certain days of the week to all mothers with children less than twelve months old, and are one of the most effective means of furthering broad progress in prevention. Mothers are ap- proached when they are most receptive to means of ensuring the healthy development of their child. I spoke to a number of medical officers and it appears that they are satisfied with the protection being provided by vacci- nation. Rickets and nutrition problems are their main worry. A condition seen among infants appears again in more pronounced form at school health examinations (among entrants as well as among school-leavers): overfee- ding, the cause of most nutritional troubles. "Our preventive effort in the nutritional field," a school doctor told me, "is to fight obesity." Several doctors emphasized that manufacturers' advertisements for baby foods unfortunately convey false ideas to mothers anxious to leave nothing undone when it comes to looking after their children. The apple-cheeked roly-poly cherub seems to have become the ideal image of a baby in the Federal Repub- lic. Oral vaccination against poliomyelitis is now being increasingly accepted and sessions at which combined vaccination against diphtheria, tetanus and whooping- cough is offered are well attended. Sight and hearing tests for school entrants and for pupils in their eighth year of school, tests that have been carried out for some time now by the school health service, make possible the early correction of many defects of sight and hearing and condition the choice of occupation by young people. The school doctors' fin- dings are forwarded to the vocational- guidance department of the labour office. Young people can thus avoid choosing an occupation for which they are physically unsuited or which would impair their health. Tuberculosis work continues, alas, to occupy an important place in the work of School bus for handicapped children in rural areas. 25 "Roly-poly apple-cheeked cherub." But overfeeding may be a menace. When the worst of the city comes to the > country in the form of waste products, new means of disposal must be found. - - s - - the health offices. The main accent is on treatment and rehabilitation, but the work is also preventive in effect when cases liable to spread infection are detected early. The health offices are well equipped for tuberculosis work. Various forms of X-ray equipment are available and the health offices have their own laboratories for developing and interpreting X-ray films Tuberculosis consultations take place re- gularly . Structural changes in country districts entail problems which, although they figure already on the list of tasks facing the health offices, have now to be viewed afresh : the supply of drinking water and the disposal of waste water and refuse. While the rural areas in the Federal Republic at present still have adequate sources of hygienically acceptable water, there is an urgent need to bring a pres- surized water supply into each house- hold. Piped water is subject to health office supervision. The water is treated where necessary. In one locality I saw a plant for removing iron and manganese from water taken from a deep well. The provision of sewers and sewage treatment plants serving a number of villages is a task now being pursued more intensively. The increased demand for fresh water and the larger amounts of waste water result from the changes in social structure. The sooner these problems are solved, the better will be the protection of health. Two problems are still to a large extent unsolved: the removal and destruction of refuse, and, as the number of large stock- raising establishments grows, the disposal of dung and animal droppings. It is to be expected that the much greater population density in rural areas will necessitate priority for the hygienic disposal of manure. The administrative framework for prac- tical and efficient health protection in rural areas in the Federal Republic exists. Those responsible, however, need to think far ahead when it comes to staffing problems. One way of making rural areas more attractive is to extend the network of indoor and outdoor swimming-pools. Swimming today is no longer simply a way to stop yourself from drowning: it is part and parcel of leisure-time occupation, for which much remains to be done within the framework of village social rearmament. There is considerable scope here for pre- ventive work in mental hygiene. One often reads, on entering our villages, such slogans as "We want our village to look better still". Such initiative on the part of the inhabitants is also a guarantee that the health situation will develop favourably. ■ 26 where doctors no never went before by Robert Plant Far below us, no more than a hint of green on the endless plain, was Maralal, the tiny settlement which serves as the head-quarters of Samburu District. The Samburu are a nomadic people, whose land stretches, a desolate wilderness, across a high plateau in the Great Rift Valley, a crack in the earth's crust more than 3,000 miles long running from the Red Sea to the Zambesi. At this point it is some 200 miles wide. From the air, I had the impression of an immense, silent solitude, abandoned by man and beast alike. Near Maralal, however, there is water at certain times of the year. The scattered buildings stand among the trees. "Rift," as everybody calls it, is the largest of Kenya's four provinces, reaching from the Tanzanian border in the south to Ethiopia and Sudan in the north. It covers 69,000 square miles, an area equal to that of Oklahoma, and is thus much bigger than England and Wales, about one-third the size of France, five times the size of Holland. The map, however, gives little indication of the vastness and remoteness of the region, most of which is sparsely populated, with few tracks or other signs of human life. Yet across the middle of the province, straddling the rift like a giant barrage, are the former "white highlands", some of the richest lands in Africa. When we landed at Maralal, the District Medical Officer, Dr Green, was perform- ing an operation, so I spent a little while observing the hospital from the outside; I saw two low buildings, little more than sheds. The ward contains 25 beds and usually 40 patients, so that those who have not got a bed have to lie on the floor. The other shed contains the office, the dispensary, the laboratory and a room where a mother can have a baby or a patient an operation, all very cramped and rather improvised. In the small compound surrounding the buildings, a number of people stood or sat on the ground, occasionally chatting but more often silent. They were mainly women. In spite of their manifest poverty they looked rather fine, with band upon band of glittering bracelets on their arms, about their necks magnificent collars of concentric metal hoops fringed with beads or shells, and ear-rings that truly were rings, some of them dangling almost to their shoulders. Along the side of the nearer shed, a queue of about 20 out-patients stood in line, hugging the wall for protection against the sun. They constituted the tail- end of the 200 or so treated at the hospital each day. Women predominated in the queue, many of them carrying babies or holding children by the hand. They were more animated than the people out in the sun. There was a general hubbub of conversation and even laughter, mingled with the whimpering of babies. Occa- sionally, however, a child would sing, in those sweet pure tones children have. By now it was very hot. I sought out a tree under which to sit, and when I looked up there he was, a young Samburu warrior, moving rapidly towards us with 27 A medical assistant giving the immediate care which so many need. a high, loping stride. He was not remar- kably tall, but he was exceedingly slim— nobody is fat in Samburuland. His hair was done in ringlets close to the head and was coloured with ochre, which gave it a metallic appearance. He gripped a spear in his fist, holding it vertically away from his body in an elegant, fastidious manner. His only costume was a red blanket knotted above one shoulder, leaving the other shoulder bare. Slender as a pencil, he strode in a perfect straight line through the compound, looking neither to left nor to right. His eyes seemed fixed on some faraway object, as if the hospital with its throng of people did not exist or was beneath his notice, merely chancing to be in his line of march. In a matter of minutes, he had disappeared into the distance. Such sights are common enough on the African savanna, but to see him suddenly appear within that tiny outpost of modern science, sweeping past it all with such utter disdain, was a startling experience. Yet he and thousands like him are as much a part of our world as the men who went to the moon. He has his medical needs, and he has his attitudes to modern ideas, much influenced by tradition and pride. Pills and potions In the wall at the end of the nearer shed was a small square opening, well above the ground, below which a group clus- tered, their eyes set intently on the aperture; they were waiting for medicine. From time to time an arm emerged from the blackness within, handing down a bottle or a twist of paper. The recipients of these packages always seemed to make off in a great hurry, backing away from the hole and turning the corner of the building almost at a bound, while clutching the prize in a firm grip, as if no time should be lost before pill or potion was put to the test. What mysterious cures for what mys- terious diseases were thus being dispensed? According to the figures on drugs used, the bottles most likely contained a remedy for diarrhoea and the bits of paper a few aspirin tablets. The complaints which afflict the great majority of the out-patients who every day trek for miles across the African bush, setting off from their simple homes as the sun rises, or even before, to join the throng outside some primitive rural hospital or dispensary, are generally commonplace ailments from which most of them would not suffer at all if they were properly nourished, housed and educated. A last I caught a glimpse of Dr Green. Still wearing his mask, he suddenly emerged; with an assistant, he was carry- ing a stretcher on which lay the person on whom he had just operated. He carried the motionless form across the open ground to the other shed, where a bed had been prepared. In its way, the white-robed mas- ked figure presented as bizarre an appe- arance as the painted warrior who had passed across that same space only a few minutes before. When Dr Green had completed his operation, he had barely an hour before he was due to leave by Land-Rover to join the hospital's mobile clinic, already in the field about 50 miles away. A former mis- sionary, Dr Green, like so many of his pro- fession in rural Africa, is doing the work of two, if not three, men. Without prompting, he broke into an enthusiastic account of the mobile unit— "a huge thing" he called it. In fact, it is a specially built ten-ton truck, virtually a travelling mini-hospital, which was pre- sented to the hospital by a British charity. The doctor had recently performed a Caesarian operation in this "huge thing", out in the wilderness 53 miles from Maralal. Dr Green divides his time more or less equally between his little hospital and the 28 Even before the dispensary opens, a crowd has gathered. mobile clinic, driving out about once a week from Maralal to head off the lorry wherever it may be and travelling with it for two or three days. When he is at Maralal, the clinic is manned by a medical assistant or a nurse. The large map behind the doctor's desk—with its plethora of small flags indicating the points where the travelling clinic was to call—plotted the orbit of Dr Green's artificial satellite, endlessly circling the mother hospital at Maralal. Two other points were marked on the map : Baragoi and Wanda. These are settlements where health centres have been started under Dr Green's supervision. Each has 200 beds—almost as many as the district hospital itself—and is manned by a single nurse. Dr Green visits them once a month. "Is that enough?" "It is all I can manage. But the nurses are very good. I have the utmost confi- dence in them." Staffs to be doubled The individuals in charge of Baragoi and Wanda are what are known as "enrolled nurses". The principal grades of medical personnel in Kenya, apart from doctors, are the following: Medical Assistants, these might be thought of as a kind of junior doctor. They have generally had a secondary school education and have received four years' specialist training, including one year in a hospital. In many places they perform the same function as the general medical practitioner in Europe—seeing the patients in the first place, treating most of them and passing on the special cases to the hospitals. The Ministry of Health plans a big training drive for medical assistants in the next two five-year plans, because it is problematical whether the U.N. minimal health recommendation of one doctor per 10,000 population can be achieved. They know the medical assistant can be relied upon to fill the gap. At pre- sent, there are 304 in government service in Kenya. Health Assistants are at about the same level as the medical assistant, but they have been trained in preventive rather than curative medicine. Where the medical assistant runs a dispensary or even a small hospital, the health assistant might be in charge of a health centre. At present the Ministry has 105 on its payroll. Kenya Registered Nurses are fully qualified nurses of the same standard as those in Britain. At the last count they numbered just under 400. Kenya Registered Midwives have qualifications equal to those of Britain's. There are at present about 300 in Kenya. Enrolled Midwives have been trained in the same way as the enrolled nurses. The work of a midwife being more specialized than that of a nurse, they are generally highly competent at their job but cannot always take the same amount of responsi- bility as a registered midwife in, for example, prenatal and postnatal care. Within ten years, the government plans to double its staff of medical auxiliaries, and within five years it will have trained 72 new medical assistants, 93 health assistants, 542 registered nurses, 305 registered midwives and more than 1,000 additional enrolled nurses. These figures reflect in part the numbers now in training. The new school for medical assistants will show results chiefly in the subsequent plan period. The medical staff at Maralal comprises one doctor, one medical assistant, one registered nurse and four enrolled nurses. They all work hard. Even if the hospital's meagre facilities were expanded, it is doubtful whether the present staff could do much more for their patients. I asked Dr Green how big a complement his pre- sent little hospital really needed. Before 29 A mobile WHO-assisted vaccination unit against TB in a remote area where life is hard. answering, he thought very carefully, evidently anxious not to exaggerate, then replied : "Another doctor, another regis- tered nurse and three more enrolled nur- ses. Then we could have a trained staff on duty day and night". Apart from staff, one of the hospital's biggest needs is an X-ray unit. "Think of it ! A month ago we were away up at South Horr, which is about 150 miles north of here over an atrocious road. A man had been brought to us on the back of a camel from a village 35 miles away, over an even worse road. He had broken his leg falling out of a tree. All we could do was splint him and bring him down to Maralal in the back of a landrover. And then, having got him here, because I've no X-ray, I had to send him on in the landrover to the provincial headquarters at Nakuru, another 150 miles over a road little better than the others. Six days were lost before he obtained proper treatment." "Are there people in such circumstances who get no treatment at all?" "There must be. We simply do not hear of them." Medical supplies have to be carefully rationed, and these too are often held up by transport difficulties. "We've only got three cylinders of oxygen. When one runs out we have to send it to Nairobi to be refilled, which can take anything up to six weeks. So we have to be very careful how much we use. We cannot afford oxygen for every patient; it's kept for real emergencies. Otherwise, we'll find we've emptied all three cylinders and then... "Again, infusion solutions, intravenous solutions for treating shock—we have three boxes that go down to Kenyatta Hospital in Nairobi to be refilled. We daren't use them liberally because we might not get a box back before we've finished the other two. This is also true of other things." The operation Dr Green had performed that morning brought his total for the year, at Maralal alone, to 612. By the end of the year, it would be approximately 700. Surgery is additional to his many other duties—almost a sideline. A tale of two women He had operated on a woman who had been married for 10 years without con- ceiving a child and had followed Dr Green from hospital to hospital in the hope of obtaining treatment. He had already oper- ated on three other members of her family who subsequently had borne children. This lady first sought him out at Tumutumu, near Mount Kenya, only to find that he had moved to Kikuyu, on the outskirts of Nairobi. She followed him to Kikuyu, but he had moved on to Maralal. She made the difficult journey to Maralal, and here at last she received the treatment she had 30 travelled so far and so persistently to obtain. This, then, was the inert figure I had seen carried on a stretcher between the two sheds. "Female sterility is widespread in many parts of Africa," explained the doctor. "In the six or seven years I was at Tumu- tumu I investigated over 350 cases, and, after treatment, quite a number were able to have children. Here at Maralal I have had 25 cases in the last 10 months. At Kikuyu Hospital I was averaging 90 new cases a year. The trouble is often that the oviduct is blocked because of gonorrhoea. The operation is not particularly difficult, but of course what we should be treating is the gonorrhoea. We get hundreds of the young men coming with it, but we can very, very rarely get hold of the women. At one time, we were instructed not to treat the man unless he brought his partner." "So what happened? Did both come, or did neither come?" "It caused great ill feeling, and now we really have little choice but to treat the men." Much farther south in Rift Valley, about 400 miles from Maralal, I visited the district hospital at Narok in the land of the Masai. These renowned herdsmen mostly occupy the vast Masai Plain, but here their country climbs into the hills more than 6,000 feet above sea level. The hospital, bigger than Maralal's, has 90 beds. The two districts are about the same size but Maralal is the more thinly populated. Here, I found a young Dutchman, Dr Robert Van Ee, who had volunteered for service in Africa and was now, like Dr Green, an employee of the Kenya Ministry of Health. There are still several district hospitals in Kenya without a doc- tor, and until Robert Van Ee came up the rough mountain road to Narok this had been one of them. Now he was in charge of an area more than half the size of his own country, with a population of 200,000. For their everyday needs, Dr Van Ee is their only doctor. At the district hospital, Dr Van Ee has two medical assistants, one registered nurse, seven enrolled nurses and two midwives. He has another midwife out in the field, making three for the whole district. Only one of his 20 outposts is manned by a medical assistant; all the others depend on enrolled nurses. Trans- port is one of the biggest headaches. "Let's face it," he remarked, "there are no roads !" He spoke of expectant mothers walking 60 miles to the hospital to deliver. But the " Flying Doctors " organization helps. Twice a month one of their pilots lands an empty plane on Narok's tiny airstrip; Dr Van Ee climbs in with a Masai "dresser" to serve as assistant and inter- preter. (A dresser is an ungraded auxi- liary who does simple nursing.) And so for a while he becomes a flying doctor himself. If a case at Narok called for specialist surgery, the Flying Doctors would fly out a surgeon, but Dr Van Ee is versatile —and very confident. "If any emergency comes up, I'll deal with it. We do all obstetrics here. We do all acute abdominal operations. We do all traumatology, we even open up skulls—without an X-ray." An X-ray machine, however, has been promised. In the men's surgical ward, I was astonished to discover that every case was either a burn, injuries sustained in a fight or wounds inflicted by wild animals. The man nearest the door had been savaged by a buffalo : he had a hole in his lungs, several broken ribs and bad abdominal wounds. Another had had his skull cracked in a quarrel. A third was an epileptic who had rolled onto a fire, burning 70 per cent of his body. These were typical cases. One patient had killed a lion. He was a big-boned fellow with a massive grin. Leaning back on the pillow with his hands behind his head, he described his duel with the lion in Masai, and this was translated for me. The lion had attacked one of the man's goats, and he had unhesitatingly gone for it with his spear. A fight to the death ensued, and he was the winner, but the bandages in which he was swathed testified to the ferocity of the struggle. The modest hero watched my face intently during the translation. "You're a brave man," was all I could say. "They must be grateful to you," I remarked to the doctor. "Not at all! Why should they be ?" shouted the young Dutchman. "They're entitled to hospital care and they expect it. They have the correct attitude !" The same story Njoro, a village about 110 miles from Nairobi, was interesting because the sur- rounding country is farmland and forest, unlike the greater part of Kenya, more than three-quarters of which is unsuitable for cultivation. I reached the little building early in the morning, before the doors were opened. At that hour, it cast a long shadow, but this would quickly retreat and already the narrow verandah was packed with people. Others waited in the field outside. Many carried empty bottles, and some had umbrellas, to be opened when the sun rose high. Evidently, they were prepared for a long wait. It was a Saturday, when the centre is normally open from 8.30 to 12.30, but it was nearly one o'clock when the last patients finally departed, their bottles now 31 The Flying Doctors arrive in the land of the Masai. containing a small quantity of medicine or with fresh bandages on arms or legs. During the intervening time the small staff, brisk and cheerful in their white uniforms, had worked at astonishing speed without a moment's rest. They were headed by Mr Isaac Mwendwa, who described him- self as an assistant enrolled nurse grade two, aided by another enrolled nurse, Mahungo Yahuma, and a midwife, Han- nah Tiba. They normally had also the help of a dresser, but she was on maternity leave. Isaac Mwendwa is typical of the many enrolled nurses in East Africa whose wide experience enables them to shoulder con- siderable responsibility. After his three years' training, he served one year at a big government hospital in the highlands, seven years with an industrial company and three years at various village dispen- saries before coming to Njoro. That was six years ago. He sees all the patients personally-156 that morning alone. When she is not required for maternity cases—she had delivered a baby early that morning—Miss Tiba helps in the dispensary. To watch these three devoted workers disposing of cases hour after hour at an average rate of two every three minutes is a lesson in swift decision-taking, utter concentration, high dexterity, good humour and perfect team- work. What were the ailments of the 156 villagers Mr Mwendwa has seen that morning? " The cases we usually get are pneumo- nia, diarrhoea and vomiting for children — that's the commonest—and cuts, wounds, burns and something like that. Also, we often have difficulties with malnutrition— the children who live in the forest; they don't get much." "What can you do for them?" "We can only give advice on what food to eat, because we don't geet nough milk Sometimes the parents are too poor to buy the food, then we can do nothing. But sometimes it is, you know, ignorance. Then there is some improvement." His voice lightened as he said this. Njoro is classified as a health centre, but the demand for curative treatment is so great that in practice it is able to do little preventive medicine or health educa- tion. And neither of Dr Green's health centres at Baragoi or Wanda was in a position to concentrate on preventive medicine. At all these places, overworked per- sonnel struggle desperately to cure ills and injuries from which many of their patients 32 BCG vaccination against tuberculosis, a widespread disease in Africa. WHO helps set up com- bined BCG/smallpox vaccination campaigns. would not be suffering if there were adequate staff—and finance—for public health duties. Short as they are of hospi- tal accommodation and other facilities, the existing provisions might be enough if only there was time to turn aside, as it were, and give more attention to preven- tive measures. A neat example of a vicious circle. At present there are about 160 function- ing health centres in Kenya and over 300 dispensaries. The government has plans for one health centre per 20,000 people, which would require another 450 to be built. The staffing problems involved are severe, and on this account it may be ten years or more before the target is reached. "Physical structures only will not be regard- ed as constituting health centres, "says the Ministry's report, sternly but realistically. That means a health centre will in future only be classified as such if it disposes of at least one medical assistant, one health assistant, an enrolled nurse, an enrolled midwife, a health inspector and, whenever possible, a laboratory assistant. Like all African countries, Kenya is very short of doctors, especially in the rural areas. At present there are rather more than 250 in government service and between 50 and 100 employed by the missions, making 300 to 350 serving the mass of the people. The top men at the Ministry, Dr Likimani, Dr Munimo and Dr Onyango, are of course African, but the doctors in the field are mostly expa- triates. The new Nairobi Medical School will eventually take 105 medical students a year: they will receive part of their train- ing in the rural areas and will be required to give a period of "bonded service" to the government after graduation. The greatest need is for general practitioners. One medical superintendent said jokingly, "I'll swap you three specialists for one G.P. !" The Flying Doctors Against this background of immense distances, meagre communications and lack of qualified men, the East African Flying Doctors perform notable service. It would be more precise to call them surgeons, because that is what they are. Their leader, Tanzanian Michael Wood, a noted plastic surgeon, heads a regular team of five in Nairobi, which includes an American surgical consultant, a Dutch eye surgeon, a German general surgeon and a second plastic surgeon, also an American, while two other plastic surgeons, one Pakistani, one American, have recently helped out. They have five aircraft. In 1968, in Kenya, they flew 191,936 miles, saw 6,197 patients, performed 866 operations and provided an air ambulance on 174 occa- sions. In Tanzania, where the service has been introduced more recently in collabor- ation with one of the missions, they flew 43,500 miles. Plastic surgeons predominate because the Flying Doctors, too, have found that burns and wounds are their most common cases. There is still a fair amount of resistance to modern medicine. One mission doctor told me that he believed 30 per cent of the patients admitted to his hospital had pre- viously been treated by the village medi- cine-man. This was confirmed by several other experienced men. Winning the battle Here, again, the need for health educa- tion is obvious. It will come in time, of course, by example rather than precept; the first hospital in East Africa was erected only 73 years ago. A young medical assistant in charge of a village dispensary in Uganda said "Certainly, we have witch- doctors here, but it seems that I am winning. Many of their patients come here and some of them say to me they like to come to the dispensary because they have seen that those witch-doctors, the treat- ment they give doesn't cure them. So the witch-doctors are losing the battle." Yes, he is winning the battle, he and all the other young men and women who are fighting Africa's war against disease. They are winning because in the end their enthusiasm and dedication will surely break down every barrier. ■ 33 Students at the Federal High School of Agriculture near Yaounde, Cameroon, learning to weigh cattle. They receive a four-year course aimed at giving them a scientific education in all aspects of tropical agriculture. wound the world Mobilizing against hunger "The exciting fact that mankind can now —if it chooses—create a society in which every man, woman and child has a reason- able chance to build a decent life has not been grasped. The fact that man's most ancient enemies—hunger, disease and ignor- ance—can be banished in a generation has aroused no enthusiasm, and created no sense of exhilaration." (Background document presented to the Second World Food Congress). The Second World Food Congress, convened by the Food and Agriculture Organization of the United Nations from June 16 to June 30, 1970, represents an attempt to mobilize world opinion for positive action towards ending hunger in the world. More than a thousand people met in the Netherlands to discuss how agriculture can make its contribution to world progress and overcome hunger and malnutrition. Developing and developed countries together must pool their ideas and enthusiasm and technology to join in the exciting adventure of constructing a world society without poverty. The first need of every human is to find enough to eat. For a large part of the world's population this means a perpetual struggle to obtain enough of one or two of a relatively small handful of staple foods which deliver the carbohydrate, or energy- yielding part of the diet, along with some amount of proteins, vitamins and miner- als. About 70 per cent of the world's supply of edible protein comes from vege- table sources. Cereals provide almost 50 per cent of the whole supply; grain legumes, oilseeds and nuts another 12 per cent; starchy roots, vegetables and fruits about 4 per cent each; and the remaining 30 per cent comes from animal sources —meat, milk, eggs and fish. Priority, therefore, should be given to developing new high-yielding cereal varie- ties. So far these varieties are grown in only about 5 per cent of the croplands of developing countries today. Yet, according to FAO, they could be successfully grown on about a third of these lands and wipe out hunger and malnutrition in a decade. But many problems remain : how to improve the new varieties to make them resistant to disease and easy to store, and how to have them win acceptance among the people as a substitute for tra- ditional grains. Youth must be enlisted in this drive. By the turn of the century there will be over one billion rural youth in the less developed countries. Even now most of these countries count more than half their population under 20 years of age and, of this number, 80 per cent live in rural areas and are dependent upon agriculture in some form. People on the land must work together to create new resources. New jobs must be created and people, willingly, should be enlisted to raise production and bring new amenities to the countryside. Ways must be found to give people in rural areas the means to build themselves a society which not only supplies their minimum needs but offers the chance of a new and better life. Health is important since, at the moment, the life and outlook of poor people in the contryside is hemmed in by poverty and a lack of vitality. Good- will unaided by strong hands won't go far. Developed countries also have a vital part to play. Often with restrictive policies to protect their home markets, they are out-competing developing ones in the field where the latter are most vulnerable. Al- though agriculture represents the most important export, hence source of revenue, developing countries' exports have dimi- nished while their imports, both agricul- tural and industrial, have risen sharply in the past ten years. Developed countries, then, must contri- bute more than technology : they must be willing to sacrifice some immediate, short- term benefits to help construct a healthy world society. As one commission put it, "if we wish that (future) world to be secure and prosperous, we must show a common concern for the common problems of all peoples . . . We live at a time when the 34 ability to transform the world is only limited by faintness of heart or narrow- ness of vision." The Second World Food Congress points the way to a more hopeful tomorrow. A new university in Africa About 60 per cent of doctors and more than 70 per cent of teaching staff in the WHO African region are foreigners and the region depends on outside institutions for training 43 per cent of its medical students. This makes it a matter of extreme import- ance to enlarge and improve the training facilities for health personnel. At the present rate, "none of the African countries will achieve the rate of one doctor per 1,000 population by the end of the 20th century," according to Dr Alfred Quenum, WHO's Regional Director for Africa, quoting a prospective study under- taken by his office. "Nine countries with about 8.9 per cent of the total population of the region will have one doctor for 5,000; 11 countries will have one doctor for 10,000, the objective set by the Second UN Development Decade. Thus, even in the year 2000, 64 per cent of Africa will have less than the minimum amount of cover- age." For this reason, innovation is necessary in order to improve health training in Africa. In the words of Dr Quenum : "We must take account of the new approaches to the education system. "The most urgent matter will be to improve the present output of the medical training establishments, replacing tradi- tional education by training better adapted to the conditions in Africa. "Training of auxiliary staff will have priority but training of the health team must be envisaged as an entity." A good example of this new approach is the first University Centre for the Health Sciences for the region, just opened in Yaounde, Cameroon. It is a new type of training and research institution specially designed to meet local health needs. It is not another attempt to transplant into Africa a European system—costly and inadapted to African conditions. In this centre, it will be possible to develop high quality multi-professional programmes for joint training of all members of the health team. "On the success of this Centre will depend the quality and number of the future medical and paramedical staff in Africa," says Dr Quenum. Measles, a dangerous disease Measles remains a very dangerous dis- ease for children in the Americas. In 1966, nearly 450 thousand cases were reported (excluding Brazil, Canada and Surinam), and nearly 21,000 deaths were registered in areas containing about three-quarters of the population of this region. The high number of deaths indicates the severity of the disease; the part played by malnutrition in increasing the death rate from infectious diseases such as measles is under study by WHO. Poliomyelitis: thousandfold decrease in North America Poliomyelitis has declined steeply in Europe, North America, Australia, New Zealand and a few other countries includ- ing the USSR. However, in Africa, as in Central and South America and in Asia, the frequency of outbreaks is increasing and countries there may have to face extensive epide- mics at any moment. In a statistical enquiry covering a period of 20 years, WHO shows that in Europe, the annual polio incidence in recent years has dropped to between one twelfth and one thirty-fourth of the average for the period before polio vaccine was introduced. Decreases would have been even greater had it not been for large outbreaks in Poland in 1968 and Spain in 1969. In the United States and Canada, in Australia and New Zealand, the reduction can be considered to be a thousandfold in 1969, compared with the averages for 1951-55. The situation is less cheering in develop- ing countries, where data however, are apt to be scanty. Altogether, of the 71 tropical and semi-tropical countries in Africa, America and Asia, 45 showed increases, which were, in general, threefold in the 10-year period between 1951-55 and 1961-65. The World Health Assembly has called for international surveillance of polio- myelitis similar to the present WHO pro- gramme for influenza. Such surveillance should have similar practical benefits in guiding the production and distribution of polio vaccine throughout the world. Poliomyelitis reported to wno from some major regions of the world Area Europe . . USA Canada . . . Australia . . . New Zealand . Africa (34 count ) Central and South America (20 countries). Asia (17 count.) * Approximate first nine months for most countries. Photo credits WHO/J. MOHR, front cover, pp. 2, 4, 5, 6, 7, 8, 9, 33 AGENCE NOVOSTI, pp. 10, 11, 12 WHO/K. FRUCHT, pp. 13, 14, 15, 16, 17 WHO/W. MUCKENHIRN, pp. 18, 19, 20, 21, 22, 23 WHO/E. MANDELMANN, pp. 24, 25, 26 WHO/E. SCHWAB, p. 27 WHO/AFRICAN MEDICAL RESEARCH FOUNDATION, pp. 28, 32 WHO/R. PLANT, p. 29 wHo/D. HENRIOUD, back cover, pp. 30/31 FAO, p. 34 Average annual No. of cases 1951-55 1961-65 Anual reel ports of cases 1969* 28 359 6 665 475 44 378 852 21 3 660 3 932 3 726 4 639 3 903 1 527 4 718 4 647 758 Mobile vaccination units in Africa (see p. 27).