The message of heath [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION JANUARY 1980 The message of heath - V he night is calm and warm in the courtyard of the Sheikh's house in Abu Deleig village. We sleep under the stars, and when the muezzin's first call wakes us at around four, a slim crescent moon hangs low in the sky. The cocks start to crow long before the second call. By dawn, most of the village is up and the sounds of human and animal life are all around us—cows, donkeys, sheep, goats, dogs and chanting children. Sheikh Talha Siddiq Talha, Chief of the Court, has welcomed us in place of his brother Sheikh Mohammed Siddiq Talha, who is now away at the People's Council, the Parliament in Khartoum, and is head of the 100,000-strong Bataheen, a nomadic tribe. Some of the Bataheen are now settled in Abu Deleig, some stay there for part of the year, but others still live as they always have, criss- crossing the desert for hundreds of miles with their herds in search of water and the grazing it provides for the animals. Sheikh Talha sets off with us into the desert in the project vehicle. Vast lakes appear on the horizon, yet of course there is no water here : they are only mir- ages. After about an hour we reach the hafir of Farajallah, a large reservoir dug about 50 years ago with high walls of mud to conserve rainwater. It is a mag- nificent sight. Hundreds of animals— camels, sheep, cows, goats, donkeys, dogs—and their owners crowd about the Watering the camels at the Farajallah hafir (reservoir), near Abu Deleig in Sudan. The first health messages to be transmitted in Abu Deleig will deal with better ways of collecting, protecting and using water. ( Photo WHO/D. Gibson) adjoining well, which is fed by a pipe from the hafir. The shouting, laughing boys who pull up the water in leather skins are covered in mud—there are only a few young girls here, since fetching water is the men's job. Near the well is the shop-tent of a mer- chant who sells food and household items, including aspirin. Behind the shop, a scrap of tent roofing shelters a family from the now searing midday sun (it is well over 40° C, though this is early winter). An old lady comforts a little boy of about six who lies with his head in her lap, panting. Stretched out on the ground, groaning, is a young woman with a baby of a few months. Suffering from both hepatitis and piles, she was treated briefly in the hospital at Abu Deleig, but afterwards had to make the return journey of several hours still in great pain. After this we travel another half-hour to visit the extended nomad family of Abdel Gadir Balal, the guardian of the Farajallah hafir. The family live in a group of four tents. The graceful women greet the Sheikh and welcome us with great hospitality into their homes, which are amazingly cool despite the blazing heat outside. The lady of one house shows us how she spins goat hair in the ancient fashion, with a hand spindle. Her strik- ing daughter, Selmana, aged 11, observes us with great interest. The girls marry at about Selmana's age or soon after, and go to live with a husband 20 or more years older as soon as they are adult. One lady told me that she had her first child before she had even had a period. I ask if she goes to the hospital to have her children. "No, we don't like to leave our other children alone. We have the babies here. One of Cover: How can the message of health be brought to the desert nomads of Sudan? (Photo WHO/D. Gibson) .. - IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents The message of health by Diana Gibson . . 3 Needless tragedy 8 New problems—new strategies by George C. Salmond 14 Self-help in the barrios by Ruth Seitz ......... 18 PHC in the South Seas by Seona Martin ........ 22 Floating dispensary by John Bland 26 News Page 30 The message of health The Communication Transfer project in Sudan is trying to find ways of communicating to people straight- forward messages about how to preserve health— messages that can be easily understood and acted on by Diana Gibson The message of health Left: Water from the well at Bashagra West is usually contaminated. It could easily be protected by building up the wall to keep out dirt, rubbish and animal droppings, while clean, covered containers to carry and store the water would safeguard health. The most common diseases in the area—diarrhoea, malaria and schistosomiasis—are all asso- ciated with water. Right: A nomad woman prepares coffee for the visiting Sheikh. The Bataheen tribe are anxious to have a primary health worker one of their own people—who would travel with them on their annual journeys. Women of child-bearing age would particularly benefit from the constant attention of a trained health worker. (Photos WHO/D. Gibson) the women is a traditional midwife, but the others all know what to do if she isn't here." Beneath the wooden beds lie the puppies, the kids, and the lambs, while tiny chickens scratch about with the hen. These people seem radiant and one marvels at the extraordinary powers of endurance they have developed to sur- vive. All the same, they lack any health protection and suffer very much from disease, drought and other hardships ex- emplified by the plight of the sick young woman at Farajallah. It is in an attempt to prevent such needless hardship that we are here. My companions on this journey are members of the Health Education Department in Khartoum. They are en- gaged in a project called Communication Transfer, supported by the Danish Inter- national Development Agency (DANIDA) and by WHO, which is an attempt to find ways of communicating to people straightforward messages about how to preserve health—messages that can be easily understood and acted on. Another most important part of the project will be to help the people to do something about their other urgent problems, even if these are not directly related to their health; for example, helping them to increase their income through a cottage industry or to use natural sources of energy. The third part of the project is to produce educational methods and aids for community health workers to use; these will be made locally and contain pictures that can be readily understood by people who can't read. The two sites where this project is be- ing tested are Abu Deleig, in Khartoum province, and Bashagra West, closer to Khartoum but within the Gezira agricul- tural zone. If the project is successful, it can be adapted to other parts of Sudan, and then to other parts of the world. The work has begun with a survey taken by the project's social workers and a group of nurses to find out what the families living in these two areas consider their most serious problems of health and life. At Abu Deleig, the health prob- lems come down to one thing : water. There is not enough of it, and what there is, is unsafe. At the Farajallah hafir, for instance, the water will last for only six months after the short rainy season of July and August. Another hafir nearby has water that is turbid, green, and full of insects. For the people of the village there is a well, but the inadequate water supply is contaminated by fly-attracting refuse that lies in the streets of the town, as well as by excreta both animal and human. In the houses, the water is stored in zeers, large jars that often harbour the germs of disease. It is hardly surprising that the most serious health problems that Dr Abdal- lah, the doctor, has to deal with at the simple 40-bed hospital here are gastro- enteritis in small children, malaria and hepatitis, in addition to respiratory dis- eases, anaemia in women, and snake bites and scorpion stings. "No, I can't vaccinate the children", Dr Abdallah told me. "We have no kerosene for the refrigerator to keep the vaccines, so they get whooping-cough, measles and diphtheria." Luckily there are trained midwives at Abu Deleig who give care to mothers and babies and attend straightforward deliveries in the homes. The Sheikh's son, Mr Siddiq Mohammed Siddiq Talha, is a lawyer in Khartoum but often returns to his vil- 4 lage. He told me more about the settled Bataheen at Abu Deleig. "The first prob- lem with water is getting it to the houses we carry it by animals and this is very expensive and I am sorry to say this primitive", he says. "The people who carry the water face the difficulties of the high cost of food in the market, so they try to raise the price. Water for one family for a day here costs more than for a family in Khartoum for the whole month." Another problem is nutrition ; there are no vegetables because the vil- lagers don't have enough water, and in any case have never learned how to grow them. Then, there is no industry, Mr Talha said, so that people are emi- grating to the towns and few are left to look after the animals. They need indus- tries relating to the animals—mainly for milk products and they also have the materials for a cement industry if only one could be started. The animals are of vital importance here. One might even say that to some people animal health matters more than human health. What's more, if the villagers only had electric power, they could improve the soil and eventually supply vegetables to Khar- toum. They could also have refrigera- tion and be able to store vaccines. Both Mr Talha and his uncle would like to see community health workers who would be given some training and then go with the nomads on their jour- neys, and a health visitor who could visit the village houses and offer advice on sanitation and nutrition. Though it shares many problems with Abu Deleig, the other site of the Com- munication Transfer project, Bashagra West, is a quite different village in character. It is an agricultural settlement only about an hour's drive southwards from Khartoum, not across the savan- nah but down a good road, with thou- sands upon thousands of power pylons marching across the short beige grass on the right, and the Blue Nile winding refreshingly into sight from time to time on the left. Here the people work either on farms or in the city. Our first visit is to the dispensary run by Mr Abdel Gader Idris, the medical as- sistant. He became a nurse over 50 years ago and has been a medical assistant for over 40. He tells us that malaria is his most difficult problem. He has chloro- quine to give for treatment but not enough for prevention. The next most serious problems are diarrhoea of chil- dren and bilharzia (schistosomiasis). There is also amoebiasis here. He would like to have a microscope to detect malaria and bilharzia more quickly and accurately. As in Abu Deleig, these are water- associated diseases, and due to much the same insanitary practices. Again there are heaps of refuse all around the houses and the town ; the children happily play there and the goats cheerfully eat the rubbish. There is refuse right next to the well in fact, ready to fall in. The water is dirty and contaminated, as are the buckets kerosene tins. A diesel pump—called the "don- key"—in theory supplies tap-water to about a third of the houses, but this only works for half the time since the pump is old and keeps breaking down. Mostly the water is brought from the wells by girls and boys on donkeys, using tins caked in mud or dung. It then goes into water jars, sometimes left uncovered and inviting to malaria mosquitos. The other sources of water are the Nile and the 5 canals which, besides being used for drinking, washing and cooking, serve as a swimming pool for the children and ex- pose them to the bilharzia. The animals live very close to the people, adding their own share to the contamination and at- tracting flies and other insects. The two surveys in Bashagra and Abu Deleig, the first stage of the project, show that the most pressing health messages to be communicated need to be about wa- ter: protecting it, collecting it, and using it safely and efficiently. The water mes- sage will later be followed by others, for instance on maternal and child health, personal hygiene, refuse collection and disposal, vaccination, excreta sanitation, and more efficient stoves to use less wood, thus preventing deforestation and reducing the workload of women. As a visiting social anthropologist who has advised on the project puts it, "Real- ly, what we are doing is trying to help these communities to live in a better bal- ance with their environment. Health is very largely a reflection of the social structure, of the culture, of the way of life of the people, and of their daily habits and practices." Because so many people in areas like these cannot read, the idea is to put the messages in a visual as well as verbal form, with pictures or photographs, for instance. Two designers, a photographer and a printer have followed a training course in Denmark, and are now training their other colleagues. The messages for- mulated by Dr Abu Obaida, Director of the Sudanese Health Education Depart- ment, will be put by the team into visual form—posters, picture books and so on—after being tested with the villagers to make sure they are understood and provoke the right response. One new aspect of this project is that some picture-messages will be silkscreen- printed on to cotton cloth. This is an idea that has already been used in Ghana by a consultant working on materials for training health personnel; the consultant recently visited the project in Sudan. Silkscreen-printing has the great advan- tage that the cloth is easily obtainable, durable and cheap, whereas in a country like Sudan paper is scarce and expensive. One screen gives hundreds of prints, so it is a very economical process, with an average cost of about US 60 cents a print. Almost all the materials can be found locally, and Mr Mubarak Abbas Humoudi of the Sudan Textiles factory, who will help with the project, is ex- perienced in this work and will be able to train villagers in the technique. This opens up the possibility of setting up small industries in the villages to print both the health messages and other use- ful cotton articles, as a source of local income. The same health message given in the photos, drawings and cloth pictures will be made available in verbal form on cas- settes, again made at the Health Educa- tion Department. The villagers will also be asked to put the message into their songs, stories, poems and plays so that everyone will hear it through these fami- liar means of local communication. Yet health communication is only one part of this project. For many of the oth- er problems too there is a solution that is within the villagers' own capacities. Bio- energy is available everywhere in Sudan, and the Energy Institute in Khartoum has agreed to participate in the project to devise ways of using it. The villagers, for example, can use animal and human dung to make biogas which will run the refrigerator for the vaccines, or a sterilis- er or a lighting system. They could have The message of health Left: Drawing the string tight on his skin bag, this boy is ready to carry his precious water home. But both animals and humans pollute the surrounding area, and his burden may well carry infection. Simple instruction in water hygiene will enable the nomads to avoid preventable diseases. Right: Cotton cloth being silkscreen-printed at the Sudan Textiles factory in Khartoum. Unlike paper, cotton is plentiful and cheap in Sudan, and offers a good, local medium for transmitting the message of health. The same type of printing could also be done in villages as a cottage industry. (Photos WHO/D. Gibson) a solar energy collector for a milk plant, and more efficient animal-driven pumps and animal-driven mills to extract oil from grains. All these are renewable forms of energy which do not rely on uncertain outside sources. Most people don't think of these matters as being the business of health workers, but it is a great advantage if health workers first help their clients with their most impor- tant "felt needs". Fadl El Moula Dargail, the manager of the Communication Transfer project, told me that in the long-term the aim of the project will be to strengthen the Health Education Department's skills and resources and use their experience elsewhere in the world. The short-term aim is to develop educational messages for use by community health workers that are derived from the environment and are within the villagers' frame of reference. "The old system has failed to answer the people's needs", he said. Will the health messages be put across by the community health workers? Yes, and by the council of the community: everything must first be discussed with these leaders and with everyone connect- ed with health work. Many individuals will be the tools for this health message. The sheikhs have a very strong influence, and the people believe the sheikhs know what is good for them. Then the religious leader they respect and obey him. The health personnel too they respect their advice. And in each family the grandfa- ther is revered, and so is the grandmoth- er she is very important for the young girl with a new baby, who will listen to what the grandmother says rather than to her mother. "If we can all join forces and turn our attention to prevention, all the problems can be solved very easily", says Mr Dargail. "With prevention we have a good chance of success." In both Abu Deleig and Bashagra, as everywhere in Sudan, visitors are received with a hospitality and generosi- ty which amazes and delights. I asked Mr Dargail what the people now expect- ed of us in return. "Yes, it is their tradi- tion do to all they can for strangers who arrive from distant places as their guests", he replied. "In the case of the Bataheen at Abu Deleig, they think you are coming about the water, and for these people the water is everything. If you say you are going to do many things for them and it includes water you will be welcome. The second thing is that the nomads lack a health service. A nomad community health worker who would go with them is very important to them." And at Bashagra? "They want help with their piped water scheme, more ad- vanced curative treatment, and a better preventive service, for example vaccina- tion for the children. The problems will be easy to solve with these people—they are educated, have not a bad income and have experience of working together in their cooperative farms. To get round the difficulties with the pump, we shall ask them to improve their wells—building a wall round them, covering them and using clean buckets. The well-water is fit for humans and animals if it is kept clean." In the long run, Mr Dargail explained, this Communication Transfer project is going to provide a model that can be adapted to other villages, first in Sudan, and then in other parts of the world. "This is a pioneer project", concludes Mr Dargail. "We want our results to be a sort of example that will be of value and can be used in other developing countries that are in the same situation as our Sudan." ■ Needless tragedy Three leading specialists in blindness prevention, Professor C. O. Quarcoopome, Dr. H. Pararajasegaram and Sir John Wilson, talked to World Health about the steps being taken to develop a global programme of blindness control which will contribute towards WHO's objective of Health for All by the Year 2000 WORLD HEALTH: The great majority of the world's estimated 40 million blind people live in developing countries. Two out of three of them are needlessly blind. In better living conditions their sight would have been saved. A lot of them could be cured even now except that they do not have access to the cataract operation, for instance, that could give them back not only their sight but their independence. Professor Quarcoopome, of the Univer- sity of Ghana, is Regional Chairman for Africa of the International Agency for the Prevention of Blindness. You have told me that many resources are lacking in Africa even to meet the existing problems of blindness. What exactly are these mis- sing resources? QUARCOOPOME: Well, first of all, there is a lack of basic health facilities through- out the region. The most important re- source that is lacking is technical, human resource. The other resource that is lack- ing is financial. If one is to prevent blind- ness, probably the most important single factor will be improvement in living conditions, the provision of good water supply, then better nutrition. And none of these things can be effected without adequate financial resources. WH : What are the main types of blindness that are found in the African countries? QUARCOOPOME: Probably the most im- portant single disease in the African continent is trachoma, and this is found mostly in northern Africa and in the Sahelian belt, that is, countries just south of the Sahara. The next most important is onchocerciasis, or river blindness, which again is found mostly in sub- Saharan Africa and extends from the West Coast right down to Central Africa and the East Coast. It is not often realized that cataract is also a very important cause of blindness and morbidity in Africa. And in that par- ticular regard, the problem is not so much one of diagnosis, but one of the avail- ability of treatment. Malnutrition, and undernutrition, forms another major cause of blindness and is one that prob- ably underlies most of the others. Again, another major cause of blind- ness which is not often appreciated is glaucoma. You see, the problem in Africa is that we have not only the common blinding diseases of the developed world, but these other specific endemic diseases added on top of what exists in the devel- oping world. So in other words we have super-added blinding diseases. WH: You said that the prevention of blindness depends largely on an improve- ment in the standard of living and in the economy of the African countries gener- ally. But I presume you can't wait until this happens. What are you going to do more immediately to prevent blindness? QUARCOOPOME: The first thing is to de- fine the magnitude of the problem. This is known in certain parts but, as I said before, the full extent is not known. So the first action, really, is to determine by objective surveys how many blind there are, what major blinding diseases there are, where these factors prevail, in other words in what area do you find oncho- cerciasis, where do you have large num- bers of blindness from cataract. So that, having pinpointed where the problem is, you can programme your preventive mea- sures or your curative measures to deal with the various pockets of blindness. We intend, in the near future, to fol- low the example of India and other places by having concentrated teams working to tackle specific problems. Not spe- cialists, in the sense that they will not be primarily dependent upon ophthal- mologists. This is a mistake that is very often made, that prevention of blindness is equated with the presence or absence of ophthalmologists. We can train auxi- liaries to take care of some of these things, which would relieve ophthalmologists from some of the routine treatments and diagnosis, and then they can concentrate on some of the major aspects of treatment. WH: Sir John Wilson, as President of the International Agency for the Preven- tion of Blindness, has visited blind people all over the world and studied their situa- tion for himself at first hand. Sir John, what do you see as the justification for the emphasis that WHO and other organiza- tions are giving to blindness prevention? SIR JOHN: As you know, I am myself blind and so, naturally, I start by thinking There are perhaps 40 million blind people in the world today, and of course people don't go blind by the million—they go blind indiv- idually, each in their own family, each in their own community. (Photo WHO/T. S. Satyan) 8

Left: Flies spread diseases, including eye- diseases that can cost a child like this her sight. And the blind are at the bottom of every economic and social heap throughout the developing world. (Photo WHO) Above: A trachoma control team at work in Sudan. Prevention of blindness need not be equated with the presence or absence of ophthalmologists; auxiliaries can be trained to take care of routine treatments and diagnosis. (Photo WHO/D. Henrioud) of the justification in human terms. There are believed to be perhaps 40 million blind people in the world today, and of course people don't go blind by the mil- lion—they go blind individually, each in their own family, each in their own com- munity. It is a human tragedy, very often, particularly in areas where there is no possibility of rehabilitation. It is an eco- nomic tragedy, and very often blindness constitutes quite needlessly an end to useful life. And so, in terms of human quality, quality of life, there is a human justification. Added to that, there is the economic justification in a world in which, after all, the poorer nations tend to be getting poorer, and the rich are getting richer. The blind are at the bottom of every eco- nomic and social heap throughout the developing world and we are seeking, through the IAPB'S programme, to make what I believe is a very significant con- tribution to the World Health Organiza- tion's objective of health for all by the end of this century. WH: Dr Pararajasegaram, of Sri Lanka, is Regional Chairman of the IAPB for Southern Asia. I understand that a number of countries in that area now have national plans for blindness prevention. How are they hoping to carry them out? PARARAJASEGARAM: In the Southern Asian region, Sri Lanka, India and Ban- gladesh have already prepared program- mes and plans which are in action now, while plans are being formulated in coun- tries like Thailand, Burma and Indonesia. These plans are based primarily on exist- ing health infrastructure, so that with minimum cost some of these programmes of prevention of blindness can be exe- cuted. WH : Do you mean through the primary health care services, for example? PARARAJASEGARAM: Primarily through primary health care, because 85 per cent of the population in our areas, and 85 per cent of the eye conditions in our areas, are in the rural areas. And primary health care reaches these rural areas sufficiently. This is one way in which one can deliver primary eye health care. WH: This means then that somebody who has not had a very specialized training can deliver prevention and treatment services for eye care? PARARAJASEGARAM: Part of the pro- gramme does envisage the training of paramedical personnel in eye health care and use of these personnel in situations where ophthalmologists are not avail- able. The main reason for this is that eye services suffer from a great dearth of 11 Needless tragedy Left: Her baby has been blinded by xerophthalmia, an eye disease caused by a lack of vitamin A. Cases like this are not only a human tragedy but an economic tragedy; very often blindness constitutes quite needlessly an end to useful life. (Photo WHO/H. A.P. C. Oomen) Right: Struggling to write a letter with his good eye, this patient in an Indian hospital is one of the lucky ones: a cataract operation has saved his other eye. But millions of other cases are out of reach of this fairly simple technology. (Photo WHO/T. S. Satyan) qualified personnel. It will be a long time before these personnel become available because it is expensive to train them, and they are few and far between in most of these countries. Unless one is able to start these programmes with paramedical personnel, we are going to lose a lot of precious time. WH : What sort of conditions can they deal with? What types of blindness? PARARAJASEGARAM: Much of the blind- ness in the Southern Asian region is pre- ventable by simple eye care or early detec- tion. The primary health care worker, who is the front line health worker, very often is able to identify these cases and treat them early before they lead to blindness. WH : This would be things like vitamin A deficiency? PARARAJASEGARAM: Vitamin A deficien- cy, simple infections which take a very heavy toll of eyesight in Asia, and also conditions like cataract which they could identify and refer to specialized centres. All of this would help to prevent blind- ness and clear the backlog of blindness. WH: And if you can operate on cataract, you can reverse it, you can restore sight? PARARAJASEGARAM : Cataract really forms the bulk of the blindness in the Asian countries. It is estimated that in India alone, there are 3.5 million people with cataract. The only reason why they remain blind is not because we don't have the technology to restore sight. It is be- cause we have not been able to devise adequate delivery systems of this technol- ogy to reach the people in the rural areas. WH : Let me return to you, Sir John. Have many countries followed your lead so far and set up their own plans to prevent blindness? SIR JOHN: Yes, many have. Our objective over the next three years is to try and bring it to the point where 30 countries have in progress national plans for the prevention of blindness. That was an aim we formulated a few months ago. Already a great deal is being done, if I may give you just a few examples. A most interest- ing arrangement has already started in Singapore, where they are planning to train the first group of ophthalmic cata- ract operators for work in the eye camps in Bangladesh; this is a multidisciplinary effort in which many countries are collab- orating. There are other national plans in Asia, in India (the outstanding one), Bangladesh, Sri Lanka, Afghanistan, Burma. Going to Africa, that is an area which is crying out for development. But even so, there are plans for the prevention of blindness in Kenya, in the Sudan, and in a number of other countries. And Africa is obviously an area where there is a great need for development and where I believe national planning is now beginning in many countries. WH: What basic resources do you need to have in a country before you can start a blindness programme? 12 SIR JOHN: The first resource you need is a political will—the will of the govern- ment to do something about it, and that must be based on a credible technology. You must be able to show that you can eradicate the causes of blindness in that area or control them at a cost which is within the ability of the local budget to bear. It's no good having million-dollar programmes in villages whose entire harvest is worth perhaps a hundred dol- lars or something of that sort. You've got to adjust the programme. The third thing you need is the personnel ; personnel ca- pable of applying a fairly simple technol- ogy at a local level, but an increasingly sophisticated technology as you get higher up. And obviously you need money. Not an astronomical amount of money. Not a great deal of money in relation to the cost of blindness. In India, for example, it costs about five dollars to restore sight to someone in an eye camp. You need money. You need people. You need poli- tical will. You need awareness, though it may have been a human problem since the beginning of time, that it is no longer a tolerable thing. That in a modern world, it is not reasonable. And that, in an industrializing world, it is not profitable that there should be so much needless blindness. WH : Sir John, do you think that the international programme for blindness prevention that WHO is at present coor- dinating could expand still more ? SIR JOHN: Oh immensely. It must ex- pand more. Let me put it the other way. What will happen if it doesn't expand more? Well, if it doesn't expand more, blindness is going to continue to increase with the speed of the population growth. There may now be 40 million blind people in the world, but there will be at least 80 million by the end of this century, and it is estimated that by the year 2030- 50 years from now the number could well increase three or four times. Now that is an intolerable prospect. Even in the most advanced countries, blindness is linked with ageing and so, from various diseases such as glaucoma and things of that kind, and cataract, people are increasingly going blind at the upper age limit. Here is a very interesting fact that came out not long ago. In the United Kingdom, there is a very low amount of blindness, but amongst the older age group over 65 years—there is almost as much blindness as there is, shall we say, amongst the population of Bangladesh. The conditions amongst the older age group are the things we must look at, because that is the group which is going to increase. Unless we control blindness, therefore, we will have a tightening limitation on the life style and expectation of an ageing population even in the most advanced countries. And so we must develop this programme, not merely in the countries where we have done it already, but as a global programme. And that means regional action, it means countrywide action, and it literally means action in every village. ■ 13 ir Int Tr—Tr IrRIPITMIME 1 r:f7-ri • ..*Are ret "s"""15 ,froieRT I&Ion t ti New problems -New strategies by George C. Salmond A community health survey in a New Zealand city showed people that they as individuals and groups could improve their own health—and also proved the value of health services research de o many people the word "research" conjures up visions of laboratories, mathematical for- mulas and scientists in white coats. The work is thought to be com- plex, difficult to understand, and of little interest or concern to ordinary people. Health services research is not like this at all. It is best characterised by relatively simple studies of practical health prob- lems, carried out in the community with the wide involvement, not only of those who organize and provide care, but also of those who use it. Health services research can be defined as the systematic study of the means by which basic medical and other relevant health knowledge is brought to bear on the health of individuals and communi- ties under a given set of conditions. Its aim is to provide new information and insights which will : permit a better understanding of health problems and the role and in- fluence of health services ; — assist in more rational health planning; result in more effective and effi- cient health care, which at the same time is better attuned to the cultural and emo- tional needs of people ; and, by actively involving people in the study of their own problems, will encourage greater personal, family and community self-reliance in health matters. The scope of this research is very wide, and may involve scientists and health workers from many disciplines. Research projects may range in size from major multi-national collaborative studies to small studies involving one or two work- ers in a village or urban neighbourhood. But, regardless of the size and type of op- eration, the success of health services research must be measured not by the mere production of results but by wheth- er those results are used to good effect to promote health and improve health services. Similarly the contribution which may be made by research to health services development is not confined to the provi- The transition from shack to high-rise apart- ment can be a painful one. Changing lifestyles and environmental changes call for fresh research by national health services. (Photo WHO/ T. Takahara) sion of information. Research provides opportunities to involve policy makers, the providers of care and the people themselves in a general strategy aimed at health and health services development. Involvement in the research process of- ten brings about increased insight and changes of attitude which in turn result in a greater willingness to consider change. This can therefore have a cata- lytic effect on the development of health services. As much depends upon the involvement of people in the research process as it does upon the output of research results. Research has a particular contribution to make towards the development of strategies for primary health care. If sys- tems are to be designed providing the es- sential care that people need, wide cover- age and the people's full participation, all at a cost the community and country can afford, then research is needed to ex- plore the possibilities, and to cost and test the various options. It is important for research efforts to focus on all points of the spectrum of services provided, and therefore the effectiveness and efficiency of the whole referral system up to the big and specialized hospitals must also be considered. All countries, East, West and Third World, have an urgent need to acquire competence in health services research. Some "developed" countries already have considerable competence in this area ; but the topics selected for study are often unrelated to the priority health problems. And often the strategies adopted do not ensure that the research results will be used to improve the deliv- ery of care. Despite the increasing expen- ditures on health services in "developed" countries, health status is not improving and in some instances may be on the decline. National research efforts need to re-focus on the effects on health of envi- ronmental change and changing life- styles, on the changing nature of health problems, and on the changing role of health services. In Third World countries, the prob- lems are different. Here the potentials of health services research need to be better exploited so as to make an efficient use of the scarce available health manpower, to mobilize and involve those additional health manpower resources that exist in the communities and, by strengthening the cadres of research workers, to minimize the dependence on external support. The thrust of WHO's initiative in pri- mary health care is mainly directed at the needs of the developing world, but the principles apply elsewhere. An obvious failing of the health care system in most developed countries is the unsatisfactory balance among the different components of the health system and the exaggerated attention being paid to expensive hos- pital care. Health services research is one of the strategies which may be used to promote health and the balanced development of health services in the community. New Zealand survey An example from New Zealand may serve to illustrate the point. Porirua is a satellite city of 40,000 people, 12 miles from the centre of Wellington. The city falls neatly into three areas. In the north is a new, fast-growing middle- to upper- class suburb. The western area is a mix- ture of substantial tracts of state housing and older privately-owned homes from the township days. In the east are large tracts of state housing, mostly poorly planned and often badly drained. Because of the sudden growth in the 1950s, community facilities continually lagged behind the growing town's needs. In 1972 a research group from the Department of Health carried out a survey of the use of maternal and child health services in the greater Wellington area, which included Porirua. Five hun- dred mothers who gave birth in a given six-week period were interviewed about their use of services from the time of conception until the infant was five months old. All those involved in the delivery of services were consulted and their co-operation was obtained. The findings of the survey were widely publi- cised by the news media. Compared with mothers in other parts of Wellington, the study showed, those in Porirua particularly Porirua East were gravely disadvantaged with respect to the care received. As a group they were shown to be in greatest need of care, there being more mothers without a husband living at home, more mothers with large families, more mothers who were poor and badly housed, more mothers with little formal education, more mothers with cultural problems in their use of health services and more 15 . • ; • . r • 4.! 4 The Porirua "health van" is funded and operated by the community. ( WHO/G. C. Salmond) mothers with a history of previous obste- tric problems. The research clearly showed that the health services available to and used by these women were inade- quate and inferior in comparison with those available to less needy mothers res- ident in other parts of the city. In its presentation of the study, the news media over-dramatised the results and presented Porirua East as a blot on the health care landscape, a medical slum and a social disgrace. This caused an im- mediate public outcry, both from those responsible for organising and delivering the care and from the local people. While generally agreeing with the findings, the providers of care claimed that their best efforts made under difficult circum- stances were being unfairly criticised. The people complained that such adverse publicity discouraged the efforts of the local health workers, made recruitment difficult and generally demoralised the community. They also said that, despite the advance claims of researchers, the community had in the past never bene- fited significantly from the findings of health services or any other form of social research. The publicity did, however, have one useful outcome. It helped to prepare the climate in which the Porirua City Coun- cil was prevailed upon to call a public meeting of all persons interested in trying to improve health and health services in the city. Politicians, administrators, peo- ple from religious and welfare organiza- tions, health workers and representatives of the various cultural groups came to the meeting, along with members of the health services research group. After much discussion the meeting resolved to create a community health project. A steering committee, representative of the groups present, was charged with the fol- lowing tasks : to supervise the collection of back- ground information on the existing health services in the city; to supervise a community health survey; — to identify problems with the exist- ing health services and seek solutions ; to establish links between the interested community groups and to provide a focus for continuing health discussions. The research group placed their skills and resources at the disposal of the com- A survey into the prevalence of disease in a village of Senegal. As much depends upon the involvement of people in the research process as it does upon the output of research results. ( Photo WHO/J. Marquis) munity health project. The proposed community health survey was discussed and then carried out with considerable collaboration on the part of the local people. This survey, like its predecessor in 1972, identified problems well. But whereas the earlier report did not receive community support, the 1976 survey results were differently handled. Draft reports were shared, through the com- munity health project, with community leaders and health workers in the city. Deficiencies in the availability of services were identified, and the results were used by community representatives in present- ing their case to the local health authori- ty for improved services. As it became available, information from the survey was published in serial form in the local newspaper. As well as producing a "tech- nical" report on the survey, the resear- chers prepared a "popular" report which set out the relevant findings in a form understandable by and useful to local people. Incorporating community interests in health services research has brought benefits to both the researchers and the community. From the researchers' view- point, the priority health problems were identified and studied, and the results used to promote health and improve health services. Some compromises did have to be made. The research design was changed on a number of occasions to meet the requirements of the steering committee. The researchers grew in their understanding of the ways of communi- ties, and in their sensitivity to people's need for self-definition. Without these in- sights such research must be limited in its successes. The community's benefits have been far-reaching. In large part a consequence of the 1972 research study, the Porirua Community Health Project has grown from a fragile, artificially-nurtured be- ginning into a strongly-rooted com- munity resource. In response to ex- pressed local need, the Project has evolved from a simple opportunity for "providers and consumers" of health care to meet and talk together, into a resource and support organization. Two principal areas of activity have resulted. Firstly, the gap was bridged be- tween people in the community on the one side and health agencies and other institutions on the other. Secondly, indi- viduals and groups received support and coordination in their efforts to identify and alleviate problems as they saw them in their community. For example, the problem of transporting people to where they had access to health care was identi- fied and dealt with in a variety of ways, one of which was the acquisition of a "health van", funded and operated by the community through the Project. For Porirua people involved in the Project, it has brought opportunities for personal betterment at many levels. It has opened to them the possibility that information can be used to good effect in support of efforts to improve health ser- vices and other public amenities. By showing people that they as individuals and groups could improve their own health, the Project strengthened self- esteem, that prime requirement of health for all people. The Porirua people and the researchers continue to benefit from this experience and continue to build upon it. Most countries have expressed the political desire for effective primary health care. In health services research, we have a powerful tool to use in work- ing towards this goal. ■ 17 Self-help in the barrios Community programmes of primary health care in the Philippines are trying to tackle problems in all areas of life—environment, food, water, mental outlook and housing, as well as disease prevention by Ruth Seitz ach year, after the people of Pagadian on the Philippine island of Mindanao had shucked the ears of corn from their hillside plots, there was a period of food shortage. Families watched their children grow weak from a lack of nutrients. And when the rain started, they easily fell prey to gastro-enteritis. But one year the community sought a solution. They asked the Government midwife to help them to find edible plants among the sturdy ones that survived the rainless heat. They identified several growing in their fallow corn fields, which they used to supplement their diet. "We had overlooked vegetables like the ground vine, mote-mote", one resident said. "Besides, our pigs were eating these wild plants." Now that Pagadian has found a way to produce more food and improve its health, its people say, "We understand why we got malnourished and our pigS got stouter." The resourcefulness of the people of Pagadian stems from their community- based health programme (cBHP), a prime example of primary health care (PHc) in action. The main thrust is to help the poor to provide for their own basic health needs through community cooperation. Introduced to the Philippines by the Catholic Church in 1975, community health programmes now exist in more than 200 barrios or communities. As they multiply, they bring Filipinos closer to reaching WHO's ambitious aim of "Health for All by 2000". "You can't talk about health until people have food, water and shelter", says Dr. Gunawan Nugroho, who advises on primary health care efforts from WHO's Western Pacific Regional Office in Manila. That is why primary health care is holistic in approach. It recognizes that health is not a state that can be attained solely by medical treatment but by boost- ing all areas of life—environment, food, water, mental outlook, housing, liveli- hood and protection from communicable diseases. And it gives the participants a structure—community organization— for tackling problems in any of these areas. Health problems have always loomed large for the poor in the Philippines. The ingredients of their life do not readily support a state of mental, social and phy- sical well-being. When sickness strikes, the urban poor, for example, jeopardize their family welfare to pay for medical care; a bottle of expectorant costs what a labourer earns in a half day. In rural areas where the majority of Filipinos live, medical services are scarce. Primary health care, therefore, is a vehicle for helping those who are still unreached by the health delivery system to meet their own basic needs. But change can only begin when it is desired. For this reason, diocesan leaders only introduce the programme to com- munities that have pinpointed health as a felt need. Then a CBHP facilitator calls together all interested citizens to analyse the community's health situation. If the prevalence of a disease is hampering pro- ductivity, for example, the residents dis- cuss the causes and determine an approach to defeat the disease. But before any strategies can be imple- mented, each area ideally between 10 and 15 households chooses a health worker. These volunteer workers receive intensive training in body function, herbal medicine, simple treatment and promoting group action. These sessions are led by health professionals who are skilled in soliciting ideas from the people and building on those that are scientifi- cally sound. Instead of lecturing, the doctors, nurses, midwives and medical experts try to graft new and useful health data on to the understandings of the health workers, who may have had little or no formal schooling. For instance, after Nurse Luningning Viray asked health workers at Carmona how air reached the lungs, she compared a blackboard drawing of the respiratory system to an upside-down tree, with the trachea as a trunk and the alveoli as the leaves. The lesson grew out of a community concern : the frequency of respiratory infections in their hilly settlement. The discussion included a herbal solution for cough—a compress of fresh oregano leaves. The medicinal plants and herbs that thrive in the tropical climate of the Philippines put natural cures for simple ailments within reach of the poor. Hand- books have been published which sub- stantiate the scientific value of age-old practices. For example, "Philippine me- dicinal plants in common use : their phytochemistry and pharmacology" lists over 200 plants, their healing components and methods of collection and prepara- tion. The handbook also gives a warning about any possible side-effects. It rejects treatment by trial-and-error methods and recommends only confirmed plant remedies. "We have had no cases of over- doses from herbal medicines", said one nurse. "There are few toxic or poisonous ingredients in the commonly used plants." Top left: A health worker shows how to crush seed pods of the ipil-ipil tree to make a de-worming medicine for children. Top right: A tuberculosis patient receives her one-month supply of tablets part of the community-based programme of primary health care. Below: An informal training session on the detection of tuberculosis for health workers in Carmona. One woman joined the team after her father contracted the disease other members are themselves undergoing treatment. ( Photos B. Seitz © ) 18 , Some barrios cultivate herbal gardens, and several prepare cough syrup from tamarind leaves, water, ginger root and the juice of calamansi, a small lemon-like fruit. After a preservative is added, the essence is sold. (CBHP programmes attempt wherever they can to offset the high price of essential commercial drugs by selling home preparations.) Estelle Divinagracia, a nurse who heads the CBHP Information Centre at Maramag in Mindanao, encourages the preventive use of medicinal plants. "Ginger root aids stomach digestion", she explained. "We are urging farmers to drink ginger tea instead of coffee." People infected with intestinal para- sites can minimize the painful effects by gulping a breakfast drink made from boiling three or four avocado leaves in a cup of water. Prevention is one of the solid strengths of the new approach. "But instant pri- mary health care is impossible", observes Dr. Nugroho. Health concepts, he feels, must be firmly rooted if people are to ini- tiate the environmental changes that will raise the level of health. 20 Some Filipino health workers have translated their understanding into action. In one village in Bukidnon Prov- ince, the people built 20 water-sealed toilets after they recognized their value in preventing the contamination of their drinking water. In a crowded seaside town, local people mobilized themselves into working parties to dig drainage ditches. Other communities besides Pagadian see a relationship between a steady food supply and health. After a drought, farmers in Sinanglanan set up a rice pool so as to guard against future grain shortages. Breaking the back of such public health diseases as malaria, schistosomiasis (known here as snail fever) and tuber- culosis, takes community cooperation. A community control programme fits that need as a glove fits the hand. Thus the church organization AKAP, a Tagalog acronym that stands for Help- Your-Neighbour Movement for Health, is using this approach to fight tubercu- losis, the number 2 killer disease in the country, in more than 40 barrios. Its effectiveness has been demonstrated at Carmona, a resettlement area for Manila squatters about 60 kilometers from the capital. Within a population of 1,750 fam- ilies, AKAP identified 175 tuberculosis cases by examining the sputum of 628 adults complaining of chronic cough. "After six months of continuous treat- ment with anti-tuberculosis drugs, 90 per cent of the victims achieved sputum conversion", says AKAP'S Direc- tor, Dr. Mita Pardo de Tavera. Treat- ment continued for one year and was accompanied by appropriate health education. From health workers who had had an additional six weeks' training in tuberculosis control, Carmona residents learned how the disease is spread and made sure that their infants were vacci- nated with BCG. "Also case-finding is more thorough within the community than from static centres", points out Dr. de Tavera. Gloria Ramos, a Carmona health worker, explained the procedure. "I approach a coughing person in my neigh- bourhood and ask him to spit into a paper cup." She showed me how she folds any PHC in the South Seas by Seona Martin I Self-help in the barrios Left: The community health workers learnt at a short seminar how to 'find the red dashes in a sea of blue"—the tell-tale streaks of blood in a patient's sputum that suggest tuberculosis. Since this microscopy seminar was held, they are able to tell their neighbours immediately if their sputum registered positive. Right: Having access to safe drinking water means that the village takes an important step forward towards health for all. Water is just one of the areas in which community-based health programmes are helping rural communities in the Philippines to help themselves. ( Photos B. Seitz © ) non-absorbent paper to make an impro- vised container. take three sputum samples." Improvisations like this help to keep health care within the means of the com- munity. "Instead of an applicator stick, we use a fresh coconut midrib to stir the sputum", Gloria demonstrated. "When the phegm is scrambled throughout the saliva, I transfer it to a glass slide and spread it over an area the size of a thumb- print. Then I hold the slide over an alcohol flame for ten seconds to dry the saliva." Communities make their own drying lamp by soaking strips of cotton cloth with denatured alcohol and stuffing this wick into the narrow neck of a bottle before lighting. The final step in slide preparation is staining it with a commercial dye. Last March, when a microscope was donated, health workers met to learn how to "find the red dashes in a sea of blue" —that is, the tell-tale streaks of blood in the sputum. Since this microscopy seminar was held, they can tell their neighbours immediately if their sputum registered positive. Health worker Marita Muiloz keeps the microscope in the cupboard in her two-room house. Another person cleans it. Effective health workers, as the com- munities soon learn, render services rather than promises. They give sputum examinations regularly to patients who are on drugs and willingly accompany a sick patient to the nearest hospital. Per- sonal interest often spurs commitment. One Carmona health worker joined AKAP when her father contracted tuberculosis. "I wanted to learn all about the disease." Other workers may even be under treat- ment for this disease themselves. "Social commitment between the patient and community is essential", says Dr. G. V. Saturay, who advises Carmona health workers. He points out that this social constraint restrains a tubercular patient from spitting in public and en- courages a health worker to keep a close check on whether the right drugs are being taken. When the patients feel that others care about their improvement, they anticipate returning to productive work. Within the first three months after treatment began, all the patients in Carmona were engaged in profitable employment. Hitherto these people could not keep a job because of general malaise, frequent fever and a disturbing cough. This syndrome is typical. The Philippines is believed to be losing millions of pesos annually because of tuberculosis. AKAP stresses that drug treatment necessarily takes higher precedence over nutrition for breaking the chain of infec- tion. "Many of those who get well eat only one low-protein meal a day", Dr. de Tavera says. "They simply can't afford more." Because health is related to social, cul- tural, economic and political issues, any programme that promotes human well- being must deal with these factors holisti- cally. The community-based programmes of primary health care in the Philippines are tackling the problem at the grass- roots level. The process is a slow one, but as a direct result some of the country's poor are exercising dormant strengths and tasting the benefits of health that all too often have seemed to be the preroga- tive of the rich. ■ 21 Although there may be no dramatic, overnight changes, primary health care has arrived in the South Pacific. The islands are tackling it at their own pace, and in their own — Pacific — way own amongst the palm-fringed is- lands of the South Seas, there is a method of doing things known as "the Pacific way". It has a lot to do with quiet co-operation and commu- nity consultation. It is a way of working that is ideally suited to the promotion of primary health care in the region, with its Polynesian and Melanesian village popu- lations living on small islands scattered over huge areas of ocean. While there are burgeoning urban cen- tres, most people in the South Pacific is- lands still live in traditional thatched grass huts in small, often isolated, rural villages. These are controlled by the tra- ditional system of village chiefs, and life is based on subsistence agriculture and fishing. In short, this is a tropical para- dise—but there can be problems in para- dise. The primary health care campaign is tackling these problems where they begin—with the people, at the grass roots. Fiji's Permanent Secretary for Health, Dr Jona Senilagakali, explains : "We are not looking for high-powered political commitment, we are looking for a com- mitment from village people who want to improve things in their own village for their own reasons." So the campaign in Fiji has begun quietly in a scattering of villages, but the influence is spreading. Dr Jona is confi- dent that, during the next few years, all villages will become involved and the ef- fects will spread throughout Fiji. Eventu- ally, he says, "we will make the tremen- dous achievement of health for all by the year 2000". Primary health care in the South Pacif- ic islands had its beginnings at a series of national seminars in 1977, assisted by WHO and UNICEF, which included Fiji, Samoa, the Solomon Islands and Tonga, and at a Western Pacific regional semi- nar in Manila involving more countries of the area. Fiji was amongst those which opted to work through a system of vil- lage committees to promote primary health care—committees like the one at Natogadravu, about 20 miles from the island capital, Suva. The village lies in an often waterlogged river delta, where life can be a muddy misery in the wet season when mosquitos carrying Ross River fever and dengue fever breed prolifically. It used to be a soggy sore spot for the divisional health officer who was based about five miles away, at Nausori township. But about six months ago, after seeing improve- ments at a nearby village, the people of Natogadravu decided to set up their own primary health care committee. Dr Jona and the World Food Pro- gramme project director, Dr Filimone Wainiqolo, paid a surprise visit there recently and found a well-drained, well- cut village green surrounded by neat homes and gardens and dry pathways. The turaga-ni-koro, or village head man, proudly showed the doctors the new water-seal latrines and covered rubbish pits, neat gardens and well-repaired homes. He also took the doctors to see his biogas plant and piggery, perhaps the only pigsty in Fiji that is surrounded by a neatly trimmed lawn. The gas supply runs to his home through non- corroding plastic piping. ...Most people still live in traditional thatched grass huts... ( Photo WHO/T. Takahara) Left : ...In short, this is a tropical paradise but there can be problems in paradise. Primary health care is tackling these problems where they begin with the people, at the grass roots... (Photo WHO/D. Steele) The efforts of the health committee have already had a considerable effect on such common health problems as infantile diarrhoea, which is a hot season killer, malnutrition and mosquito- transmitted diseases. "Fewer people getting sick means less demand on our more costly medical ser- vices", says Dr Wainiqolo. He describes the quiet, but increasingly effective, pri- mary health care campaign as "guerilla warfare in the fight to have health for all by the year 2000". But he and Dr Jona are emphatic that the thrust must come from within the community, with nothing imposed from without. As Dr Jona puts it : "We could go in and tell people that the problems are this and that and what they have to do to solve them ; we could give them the things they need to improve matters. And the minute we withdrew our pres- ence and support, the whole scheme would very likely fall down flat." In common with administrators in many developing countries, he has seen it happen before. He remembers a socio- economic development project in one of the isolated islands where people were fed with ideas, equipment and experts— the women were even given sewing ma- chines. But when the project people finally left, the whole thing flopped. Primary health care in Fiji is not an extension of the Government health services, Dr Jona explains. It is self- generating and self-financing. "In fact, we health people do not have the legal power to go into a village and tell people to clean up or to make better latrines." Years ago, there were such by-laws un- der the colonial administration. Villagers had to set aside certain days for commu- nity work under the direction of the vil- lage head-man. People could be prose- cuted for not complying, for instance if they let their pigs run loose. But the by- laws lapsed when the administration of native Fijian lands changed. "When we began discussions on pri- mary health care in 1977, I considered re- introducing them", Dr Jona says. "But I decided against it. I wanted to avoid at all costs imposing things on people or even getting them to do things just to please us. It has to come from them, for their own benefit." His first step was to inspire the medical officers and district nurses working in the field, those in contact with the villages. "Then we ran seminars for the villagers, not high-powered things but community gatherings conducted in the vernacular language." The villagers were encou- raged, but not told, to set up their own committees and to decide their own priorities. Most of Fiji's primary health care committees are composed of women, and much of the impetus for health im- provements and information about nutrition and health care is circulated through national women's organisations, including Soqosoqo Vakamarama and 23 In some of the South Pacific islands, the horse is still the best available form of transport. A district nurse and her assistant ride together on a health mission in Viti Levu, the main island of FM. In the foreground: The face of youth in the islands of the South Seas. Primary health care holds out new hope for a more assured future. (Photos WHO/Fiji Ministry of Information and WHO/T. Ta- kahara) PHC in the South Seas the YWCA (Young Women's Christian Association). Dr Jona comments : "They say if you want things done in the South Pacific, go to the women." Western Samoa took a similar ap- proach, and turned to the women a long time ago to promote village-level health care. Like Fiji's Melanesian culture, Samoa's Polynesian population has a highly developed and still influential system of village chiefs in which some women have considerable authority and power. Dr Wainiqolo points out that it is ex- tremely necessary to recognise who has the respect and power in the community because South Pacific people are by tra- dition conservative and slow to accept change. "The missionaries found that out when they were able to influence the young people—who had however no power to promote or control change in their own communities." In Samoa, the women's committees are strong organizations, led by influen- tial women. These committees are asked to select a representative to be trained and supervised by district health officers and nurses. For this purpose, the stan- dard WHO village health aide manual has been adapted in both Samoa and the Solomon Islands to assist workers in the field. More than 150 villages health aides have already been trained and 150 tradi- tional birth attendants have been educat- ed in hygienic and modern birth methods in Western Samoa. The women's committees remain the main tool in generating community par- ticipation in primary health care, while improvements are brought about mainly by active community participation and group effort. Development authorities in such fields as agriculture, education and public works meet frequently with the women's committees and village chiefs, who are best able to express community needs. Health staff maintain constant dialogue with these organizations and provide technical help when the deci- sions are made. Financial participation is kept at a minimum. Such matters as the development of rural water supplies and the construction of latrines require the community to provide the labour, while money for buying materials is raised from community contributions and government grants. Dr Wainiqolo sees primary health care as the bridge between the people and their first contact with a health worker, medical officer or nurse. "Of course pri- mary health care was around a long time before we gave it the label", he adds. In the South Pacific this meant "witchdoc- tors", traditional herbalists and tradi- tional birth attendants. Today the Solo- mon Islands, like other island groups, are taking a close look at the value of traditional medicine and how it can be used to promote health for all. In the past, Solomon Islanders regard- ed death as caused by bewitchment, and sickness as the result of black magic. Many of the materials used for treating sick people were subject to secrecy and magic ritual. But this has not prevented the spread of knowledge of traditional herbal medicine, particularly for com- mon ailments such as boils, sores, coughs, fever and malaria—the latter be- ing one of the Solomon Islands' major health problems. The treatments may in- volve boiling leaves and drinking the juice, or applying the leaves to the body, or crushing leaves and bark and applying the sap. Trim nursing stations, like this one in Fiji, offer a focal point for community health care. (Photo WHO/D. Steele) While belief in traditional medicine remains still strong in the Solomons, the rural communities are slowly accepting village health aides. A VHA trainers' seminar held last year reported that Gua- dalcanal, the main island, had accepted the aide scheme and had appointed six such health workers. The aides use a carefully adapted WHO handbook for VHAS, which deals with health problems ranging from crocodile bites to rubbish heaps. Fiji and Western Samoa too are planning to train their own VHAS for iso- lated areas which have no nearby nursing station or health centre. In some places, area councils have taken on the responsi- bility for paying a small salary to the aides, and then expect them to be avail- able to the community at all hours. Oth- ers call for specific hours to be set aside for health work, and for villagers to con- tribute similar hours to working for the aide or giving goods in kind. Initially the aides receive free medical supplies for a simple stock of drugs, and the councils are unwilling to bear the cost of drugs unless village people pay for them. WHO itself has helped to equip 50 boxes of medical supplies for aides. A strong health committee system is already working in one area of Fiji, a densely wooded peninsula where many villages are accessible only by "put-put", long open wooden boats powered by outboard engines, or by horseback or walking. Two health stations in the area serve a population of about 5,670. "The committees have even appointed their own 'health inspectors' who make week- ly visits to neighbouring villages and report to village councils", says Dr Jona. The inspectors can order cleaning up to be done or certain improvements to be made. There was an instance where a particular village failed to comply with a request. "The health committee imposed a penalty on the villagers—to raise money and buy a lawn-mower to help clean up the village." Dr Jona envisages that the committees will select people to be trained as VHAS, who will return to their communities armed with fundamental knowledge and a very basic cupboard of medical equip- ment and simple drugs. "When their sup- plies need replenishing, it will be up to the community to raise the money to buy them", he explains. "The Ministry of Health will not pay any sort of salary to VHAS; they will not be ministry extension workers but people working for the com- munity. It will be up to each community how they recompense the VHA, in pay- ments for treatments, or in kind through working in the garden or on the aide's house." Primary health care is on its way in the South Pacific, but there are unlikely to be any dramatic, overnight changes. As Dr Jona says, "It is a slow, quiet cam- paign, but it will be more effective for all that." Once he is assured that primary health care has taken off in the Fijian vil- lages, he will turn his attention to the more fragmented and individualistic In- dian community, which comprises about half of Fiji's population. This will be a more difficult task ... "but we have until the year 2000 to achieve health for all, and I think we will do it." The other islands in the South Pacific too are tackling primary health care at their own pace and, more importantly, in their own way—the Pacific way. ■ 25 FLOATING DISPENSARY Moth' STORY BY JOHN BLAND PHOTOS BY DIDIER HENRIOUD he Motor-vessel Chee Hong is a stubby little vessel with a dumpy yellow funnel, all of 80 feet in length; a highly functional ship, festooned with old car tyres to fend off incautious mariners in the busy waters of Hong Kong harbour. But the Chee Hong—her name means "Kindness to all sailors"—is a wel- come sight on many of the small islands that spatter the South China Sea around Hong Kong. She serves as a floating dispen- sary or floating clinic, bringing health care to tiny communities which would otherwise lack the services of a doctor, a nurse or a pharmacy. For six days of each week, the little ship, built in the colony in 1958 and donated that same year by the Royal Jockey Club to the Medical Department, plies to and fro be- tween Kowloon, the mainland half of the city, and the outlying islands. Visiting no fewer than 19 clinics on seven islands, she also pulls in at little pierheads where patients wait to come aboard for diagnosis, treatment and prescriptions. Her sister-ship Chee Wen maintains a similar schedule among a different set of islands, and the two vessels form an integral part of Hong Kong's efficient and virtually free health service. The day we boarded the floating clinic, the colony brooded under rapidly-dispers- ing morning cloud, with a soaring tempera- ture and humidity to match. We were wel- comed aboard by the Medical Officer, Dr Chen Sing-Man, and by the nurse, Mrs Lam Sui-Kuen. The crew included the master, the engineer, the assistant engineer and four sailors. Our first stop, after per- haps an hour of chugging through the busy shipping lanes past grubby tramp steamers, hydrofoils and stately junks, was the North Lamma Island Clinic. The ship nudged in to the deepwater pier jutting into a small bay. A short walk in the now fierce sunshine brought us to the clinic, where for just over an hour Dr Chen lis- tened to and dealt with the health problems of the local residents. An elderly man want- ed a check-up on his eye, which was giving The Chee Hong chugs across Hong Kong's busy harbour to tie up at Kowloon Public Pier. Dr Chen Sing-Man has sailed with the float- ing dispensary among the scattered islands for three years. The radio-telephone keeps the ship in per- manent touch with on-shore emergency services. The master of the Chee Hong threads his way through the busy harbour traffic. Nurse Lam Sui-Kuen dispenses pills, ointments and, if necessary, injections in the ship's small "Clinic Office". An elderly patient leaves the floating clinic, well-satisfied with the treatment for her aching back. At the North Lamma Island Clinic, the doctor decides a little girl's sore throat and rash signify a budding case of measles.

some trouble four years after his operation for cataract; an anxious mother brought her little girl, suffering from a rash and a high fever which proved to be measles. Presently two men approached pushing a four-wheeled trolley on which an old man sprawled, obviously in very poor shape. Dr Chen and Nurse Lam examined him together. There seemed to be a possibility of meningitis. At once a radio message went out to Kowloon. Soon afterwards, when we sailed on the Chee Hong into the bay, a swift police motor-launch passed us head- ing for North Lamma to pick up the old man and conduct him with all speed to a city hospital. In short, many of the ingredients of pri- mary health care were there. Here was com- munity care being brought to far-flung rural populations. Dr Chen and Nurse Lam—both of whom have sailed in the Chee Hong for over three years—were clearly well-known and well-liked in this and other small villages on the islands. In addition, a referral system enabled them to send more serious cases direct to hospital in the city. This primary health care aspect was even stronger at our next stop, again on Lamma Island but this time at a little township called Sok Kwu Wan. Many of the residents live in ageing houseboats and sampans moored hard alongside each other at the end of a narrow sea inlet. The ship pulled in at the pier and, sharp at 12.30, the master sound- ed the ship's hooter. A handful of patients began making their way along the pier and aboard the Chee Hong. Soon the little "Clinic Office" was crowded with waiting people. Each patient was seen by Dr Chen and then, usually armed with a prescrip- tion, went to the back of the office where Nurse Lam dispensed tablets, pills, oint- ments and antibiotics. The ship is equipped with a wide range of medicaments, oxygen apparatus and dressings for all but the most serious injuries. Dangerous drugs such as morphine are kept safely locked in a medi- cine cabinet. With the "score" of patients standing at 18, including two small children, it became clear that nobody else was venturing out on to the little pier. At 1.30 the Chee Hong gave a resounding blast on its hooter, the engines began to throb again, and the float- ing dispensary set out once more on its mis- sion of health among the outlying islands. ■ Brought to the clinic on a makeshift trolley, this elderly patient was clearly in poor shape. Nurse Lam and Dr Chen concluded this was a case for intensive care. Called up by radio, a police launch rushed the old man to a city hospital. Sea-borne primary health care: the Chee Hong lies in the little harbour of Sok Kwu Wan. The ship's "Clinic Office" fills up rapidly as patients come aboard for diagnosis and treatment. 000 000 0410 000 4100 000 000 4100 0 0* 000 0 00 000000 000 000 000 000 000::: 4141. 4141 . 000 0419 000 000 000 6 41 000 000 000 OOOOOO 0 0* 4100 000 000 0.0 000 0 00 0•0 000 000000 000 4100 000 *00 4100 000 Orb, 0410 0410 0411O 0.• 0,0 *110 OOO ••• ••• 000 0410 Scientists concerned over health hazards of mineral fibres Some 240 participants from 25 countries, represent- ing research, clinical medi- cine, public health and in- dustry, examined the health risks associated with mineral fibres at a symposium held last September in Lyon at the Headquarters of the In- ternational Agency for Can- cer Research (IARC), WHO's cancer research arm. Organised jointly by IARC, the French National Insti- tute of Health and Medical Research and the Medical Research Council of UK, the symposium was devoted to the biological effects of mineral fibres, natural and manufactured. Photo WHO/P. Larsen X-ray picture of patient's lungs shows asbestos fibres. Several epidemiological studies cited during the meeting confirmed the risk of lung cancer and meso- thelioma (a cancer of the pleura or the peritoneum) following exposure to as- bestos dust. The experts agreed that chances of getting lung cancer are multiplied if a person exposed to asbestos dust is also a smoker, but both agents are separately capable of producing the disease, the risk due to smok- ing alone being usually con- siderably greater than that due to asbestos alone. References were made to statistical studies which show that there is a simple linear relation between the amount of exposure to asbestos dust and the level of risk, so that reduction of exposure should result in a proportionate reduction of risk. The epidemiologists at the meeting were virtually unanimous that even very small exposure entails some risk, and there is no evidence of a threshold of exposure below which there is no risk of cancer. Since the asbestos-asso- ciated cancer cases being studied today are the result of exposure to the fibre 20 to 30 years ago, the question arises about the possible long-term effects of other manufactured fibres (such as glassfibre, rock and slag wool) in common use today, often as substitutes of as- bestos, since its potential for harm is well known to public health authorities and industry (see World Health May 1977). Experimental evidence was reported to the symposium showing that synthetic and mineral fibres other than asbestos are capable of pro- ducing the same harmful effects in experimental ani- mals and in test-tube studies, as do asbestos fibres. Al- though there is no evidence to date of disease resulting from exposure to mineral fibres other than asbestos, scientists and industry are collaborating to keep a close watch on the health of per- sons producing or using these mineral fibres. The need to continue experi- mental studies to determine the types of fibres that are particularly dangerous was stressed by several speakers. A new development in this field—since the previous meeting held at the Agency Headquarters in 1972—has been the discovery that in several parts of the world. mesotheliomas have been found in people who have never apparently been expo- sed to asbestos dust. In the small village of Karain, in Central Turkey, for instance, 51 cases of mesothelioma have been recorded since 1975 in a population of less than 800 people. Geologists and physicists are coopera- ting with epidemiologists in an effort to identify the causal agent of this epidemic, which may be a fibrous silicate present in the soil. Scientists are on the look-out in other parts of the world for areas where there may be similar exposure to naturally-occur- ring fibrous minerals. WHO launches new programme on Chemical Safety Between 200 and 1000 new chemicals enter the world market—and the hu- man environment—every year. They find their way, acci- dentally or by design, into our water, food, and con- sumer products, and are sometimes found in high concentrations at places of work. What are the effects of exposure to these chemicals— some 60,000 in common use—on the health of this and future generations of mankind? That they can be potentially hazardous is sus- pected by the scientists, but very little information exists on their toxicity or possible role in causing such serious conditions as cancer or birth defects. WHO has accordingly launched an International Programme on Chemical Sa- fety in collaboration with a number of national labora- tories and institutions. The cooperation of other agencies of the UN system is also being sought. Within WHO's Division of Environmental Health, a central unit has been created to coordinate the global programme. The unit will develop plans and programmes of work and provide technical and scien- tific support to the global effort. It will evaluate the effects of chemicals on human health and dissemi- nate the results. Guidelines will be developed on expo- sure limits and tolerance levels, on methods for toxi- city testing, epidemiological and clinical studies, and on hazard identification. As more information be- comes available, procedures will be devised to cope with chemical accidents, and technical cooperation will be given to Member States in training scientific workers in this field and in adequately controlling toxic substances. Photo WHO/ILO New chemicals are tested for safety at research laboratory. The WHO Regional Com- mittee for Europe—where half the world's chemical industry is located—at its annual meet- ing in Helsinki last September adopted a programme on health risks of toxic chemi- cals, which will form part of the global programme. It will include collaboration with the governments in the Region in contingency plan- ning for, and emergency response to, industrial ac- cidents. Asian workers face lung disease threat Workers in the jute mills of Bangladesh, miners in India, plantation workers in Burma, and residents of the cold, ill-ventilated dwellings in the remote hilly tracts of Nepal, all have one thing in common : the threat of respiratory diseases. 30 Photo WHO/M. El Batawi Inspector measures thermal stress in small-scale foundry. The peculiar working and living conditions of these people, which make them susceptible to disorders in the heart, lungs liver and other systems of the body, were mentioned at a seminar held last October at the WHO Regional Office for South East Asia in New Delhi. One category of people who face this threat irres- pective of where they work or live, it was pointed out, are heavy smokers. The seminar, attended by 18 participants from nine Asian countries and some internationally known ex- perts, drew pointed attention to the seldom-recognized fact that chronic lung dis- eases can be one of the important causes of heart failure, and that these con- ditions are preventable. Dr V. T. H. Gunaratne, Regional Director, stressing the need to collect base- lined data, told the group: "We still do not know enough about the reversible stages of the disease to enable us to institute intensive treat- ment rationally. The cultural and social factors need to be understood so that we can highlight traditional values that promote respiratory health". Referring to the use of certain herbs and Yogic practices, which were claimed to be beneficial in respiratory functions, Dr Gunaratne said: "If these methods are found useful, we should invest in promoting such simple re- medies and encourage per- sonal efforts to keep oneself free from respiratory ail- ments." Fish poisons in the South Pacific In a comment on an item which appeared in the News Page of the July 1979 issue of World Health, under the heading "Poison fish abound in French Polynesia", the Louis Malarde Institute of Medical Research in Papeete, Tahiti, points out that not all fish in this area are toxic. The poisonous ones are not those of the deep sea, such as tuna and bonito, but those which live close to the coral reefs. Apart from the ciguatera type of poisoning referred to in the News Page item, many other types of fish poison have not been mentioned, such as tetrodotoxin, cl upeo- toxin, scombrotoxin, and substances with hallucino- genic or histamine effects. Some of the grouper family, such as loach, sea- bass or snappers, may have a high degree of toxicity, and so have certain barracu- das, horse-mackerel and moray eels. It is also true that the ciguateric risk in- creases with the size of the fish, and whether or not the liver or the head is eaten; it is well-known that the liver may be toxic while the muscular fillets are not. Moreover the official tally of nearly 800 cases of fish poisoning reported in certain years is without doubt less than the full total, since the many mild cases that occur in remote islands never come to the attention of medical records and studies. However all these factors are not specific to French Polynesia. They are common to all tropical island regions where ciguatera poisoning may occur, that is to say, throughout most of the Pacific Islands, the West Indies and many islands of the Indian Ocean. In the next issue "Smoking or health: the choice is yours." The cho- sen theme for World Health Day 1980 (7 April) will be reflected in the February-March issue of World Health. Our writers will look at all aspects of the use and abuse of cigarettes—a twentieth century "plague" which threatens the health of rich and poor countries alike. Authors of the month Ms Diana GIBSON is a Public Information Officer at WHO head- quarters in Geneva. Professor C.O. QUARCOOPOME, of the University of Ghana, is Regional Chairman for Africa of the International Agency for the Prevention of Blindness, and Dr R. PARARAJASEGARAM, Of Sri Lanka. is the Agency's Regional Chairman for Southern Asia. Sir John WILSON is the President of the IAPB. Dr George C. SALMOND is Director of the Management Services and Research unit, Department of Health, Wellington, New Zealand. Mrs Ruth SEITZ is a freelance journalist specialising in develop- ment topics. She is based in Manila. Miss Seona MARTIN is a senior journalist on the staff of The Fiji Times, where she specialises in health matters. Mr John BLAND is the Editor of World Health, and Mr Didier HENRIOUD is the Photo Editor with WHO's Division of Public Infor- mation, Geneva. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows: US$ Svv.fr * One year 15.— 25 — Two years 27.— 45 — Three years 36 — 60.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City : Country: " or equivalent in local currency. World Health, WHO, Avenue Apple, 1211 Geneva 27, Switzerland 0 0 ',t ad i n S w ib er la n d Im u ri m er ie s R eu ni es S .A . La u sa n ne Community self -help it the Philippines— see page 18. !Photo B. Settz 0)