WHO priorities [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JULY 1976 • USA $1 2 4 Strengthening of Health Services by A. Anderson Cover design by Peter Davies Contents Top Priorities 3 Environmental Health by L. Thapalyal 8 Health Manpower Development by J. Bland 14 Expanded Programme on Immunization by G. Levi ......... 20 Research Leprosy by H. Sansarricq 26 Cholera by D. Barua & L. Thapalyal 30 WHO News in Brief 32 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • JULY 1976 • USA S 1 WHO PRIORITIES TOP PRIORITIES I Ho's work covers a wide spec-trum of activities, ranging from the fight against most of the world's diseases to the award of fellowships, from the monitoring of envi- ronmental conditions detrimental to health to the collection of international statistics, from the training of health per- sonnel to multifaceted research endea- vours. In a single issue of World Health it is quite impossible to describe exhaustively all the work of WHO. Many important activities—such as the expanded pro- gramme of research, development and research training in human reproduction, or the seven-nation programme to con- trol onchocerciasis (river blindness) in the Volta River Basin—have been fea- tured in previous issues. So too have the important research programmes into can- cer and cardiovascular diseases. Given our limited space we have had to be selective, just as developing nations with limited resources have to concentrate on their most pressing problems. This issue of World Health has none- theless tried to focus on some of the most far-reaching aspects of the Organization's work—activities which are all of great social relevance. Fundamental to the efficacy of any health service is its infrastructure. In far too many developing countries the prog- ress of health, which in turn affects the quality of life, has been hampered by inadequate health services. Usually the pattern of existing health services reflects a heavy concentration of resources in the main cities for the benefit of a privileged few and the neglect of huge numbers of people living on the land. WHO in conse- quence sees as its top priority the streng- thening of health services. To this effect it has developed a simple, easily applicable methodology called country health pro- gramming which is described in the next < One of WHO's top priorities is to promote the immunization of children in the devel- oping world who risk death or disablement from common infectious diseases. (Photo WHO/UNACR/J. Mohr) article. One way of strengthening health services is by developing primary health care, principally in rural areas. However, any health system depends primarily on the personnel available to run it. Therefore the training of all categ- ories of health workers is of paramount importance for the effectiveness of health services. Equally important are those problems which concern the environment and have a direct bearing on health, such as safe water supplies or hygienic waste disposal. The availability of safe water in a commu- nity or of a waste disposal system can influence its health more dramatically than the presence of several experienced physicians, who could only treat the effect without getting to the cause. Though research may bear fruit more slowly than environmental measures, it too plays a major role in protecting health or in checking disease. Quite often, research provides the real means to a "breakthrough" and rapidly solves a longstanding socio-medical problem. In this issue we deal with research in just two of the communicable diseases, leprosy and cholera, in which advances have recently been made. Leprosy is one of the six tropical diseases for which new means of protection are being sought under a massive research programme launched by WHO. The other five, which afflict more than 500 million people throughout the world, are all parasitic infections : mala- ria, schistosomiasis, filariasis (including river blindness), trypanosomiasis (sleep- ing sickness and Chagas disease) and leishmaniasis. Another specific WHO activity de- scribed in these pages is the expanded programme on immunization. Each year some five million children in the develop- ing world are killed by common infec- tious diseases which are preventable by immunization. With the lives of all these children at stake, the programme repre- sents an enterprise of great magnitude which should alleviate untold suffering. These are some of the main WHO priori- ties in 1976. Progress at a sustained pace in all these areas is essential if the goal of health care for all by the year 2000 is to become a reality. ■ 3 STRENGTHENING OF HEALTH SERVICES ADAPT DON'T ADOPT Country health programming, applied to a developing nation, invariably leads to identifying the needs of the underserved as a matter of high priority by Alastair Anderson pa eople who live in most of the I world's industrialized countries tend to take their health services as much for granted as the water that comes from the tap, the electricity that gives them light at the press of a switch, or the public transport that gets them to work or school. For the less privileged countries, a health service is far from being one of the accepted facts of life. It tends to concen- trate on urban areas and caters in particu- lar for the wealthy sections of the big cities. Frequently in these countries the rural masses are deprived of adequate health care. One of WHO's top priorities is to offer technical cooperation to the less favoured nations who want to build up their health services. For obvious reasons, this takes time as well as money. Personnel have to be trained, equipment must be bought, a network of rural and suburban health centres has to be started and maintained. There can be no question of simply graft- ing on to a struggling and largely agricul- tural economy a high-powered medical care system, with ultra-modern hospitals, specialist surgeries, and general practi- tioners making house-calls. But what is the most effective and ac- ceptable form of services for these people? The accent has to be on encou- raging the community itself to determine its own priorities and goals, and to initiate effective action. The community will then have taken the first and most significant step in the national health planning process. Many countries have already shown that, given the right will, sensitivity and imagination, action on these lines is pos- sible. Community-based services drawing upon locally available manpower—which may sometimes include traditional heal- ers—are already being developed, and people with only limited resources at their disposal are contributing effort and know-how to the kind of services that will best benefit them. Instead of pro- moting health structures which require a high level of investment, these services make the maximum use of resources already available in the community. Since each country differs from the next in its needs, the concept is being encouraged of "country health pro- gramming", that is, a pragmatic ap- proach which tailors the services precisely to the national situation. Dr Halfdan Mahler, Director-General of WHO, said in his preface to the Annual Report for 1975: "Such programming is a long-term process, not a one-time intensive plan- ning effort. In order to attain the syste- matic development of health programmes and services, countries that have not al- ready done so will need to set up per- manent mechanisms for formulating health policies and translating these poli- cies into operational programmes. This implies a continuing process of planning, implementing, monitoring, controlling, evaluating, and replanning—a truly new approach for most countries—and the need for appropriate mechanisms to launch the venture and maintain its dynamism will continue for the foresee- able future. It is clear, therefore, that a trend has been initiated which, if it achieves its purpose, will have far-reach- ing consequences for the organization of ministries of health throughout the world. A number of countries that have begun country health programming are already engaged in formulating major and detailed operational programmes covering areas identified as deserving priority attention." The concept of country health pro- gramming which can be applied in deve- loping as well as developed countries was evolved a few years ago from WHO's early efforts to single out the elements neces- sary for the successful development of health care, and from the need to over- come the constraints that have impeded such development in the past. Country health programming invaria- bly leads to identifying the needs of the underserved as a matter of high priority. Frequently the primary health care ap- A busy clinic in the New Hebrides. Pri-D mary health care involves helping people to help themselves. The local community should be asked what their needs are, rather than having solutions imposed upon them. (Photo WHO/Takahara) 4

proach is the key to meeting these needs. Sometimes primary health care activities have been made an integral part of com- munity development activities, especially those directed to rural populations. Sometimes existing health service pro- grammes have been reoriented to incor- porate the primary health care concept. Primary health care integrates at the community level all the elements neces- sary to make an impact on the health status of the people. It calls for measures that are simple and effective in terms of costs, technique and organization, that are easily accessible, and that improve living conditions. It should use available local resources including manpower, material and funds generated within the community itself as well as strictly essen- tial resources allocated by the govern- ment. It should be fully integrated with the national health system and with the other sectors involved in community development—agriculture, education, public works, housing, communications. Primary health care activities should be carried out by trained health auxiliaries and should reflect real problems and community concerns, and should be based on practicable, modern, scientific knowledge and health technology, as well as accepted and proven traditional heal- ing practices. The treatment of everyday minor injuries, advice and instruction to pregnant and nursing mothers, childhood immunization against common infectious diseases, provision of safe water supplies, building of latrines and waste disposal systems—all these come within the pur- view of primary health care. At the same time, a higher echelon of medical care should be available to which serious or dubious cases can be referred. Here are a few random examples of the successes achieved by some countries in strengthening their health services : In Burundi, a project for integrated rural development has been established in the demonstration area of Gitega, with the collaboration of the ministries for agriculture, health, national education and social affairs. In Togo, 85 per cent of the population of Pagouda health district is now covered by primary health care services that are within reasonable reach. In Thailand, the Government's pro- gramme for the strengthening of rural health services received WHO technical cooperation in the training of traditional health workers, the printing of manuals and the provision of teaching aids. In Pakistan and Southern Sudan, dur- ing the country health programming Above : Medical assistants in Mongolia discuss health services in relation to town planning. Efficient planning is one of the keys to the strengthening of any nation's health services. (Photo WHO/D. Henrioud) Right : A health assistant at a rural health centre in Venezuela treats a child's injured leg. In choosing what kind of services should be available each country should bear in mind the slogan: "Adapt, not adopt". (Photo WHO/J. Littlewood) process, emphasis has been placed on pri- mary health care in order to extend health services to underserved populations. WHO has offered further technical cooperation to health services develop- ment in Western Samoa, where members of the village women's committees are being trained to play a larger role in the delivery of primary health care. These are just a few examples of the ways in which primary health care becomes an essential element in the process of country health programming, which in turn forms a keystone in the strengthening of health services—itself one of WHO's top priorities. ■ 6

ENVIRON VENIAL HEALTH SOURCE OF LIFE by Lalit Thapalyal ife began in water. Billions of years later, the organism reached out towards land and learnt to survive in air out of water. The stream of life flowing through the laby- rinths of time brought countless crea- tures into being culminating in the ad- vent of man, essentially a land-lubber. But the bond with water, the mother element, remained. Not only does the human individual start life's journey in the embryonic sac of fluid but the body cannot survive without water more than a few days. Alluding to the bloodfilled mammalian body consisting nine- tenths of water, a biologist has whimsi- cally pictured human beings as "walking bags of sea water". These "bags" must be replenished with intakes of water throughout our lives to maintain the body's fluid balance. Two of man's most important life-sustaining activi- ties—agriculture and industry—are dependent on water. Water is thus vital to human exis- tence, but so is it to other forms of life. Many of these, seeking moisture and food, find devious ways of entering the human body and bring disease and death. The life cycles of the organisms responsible for water-borne diseases vividly demonstrate the inter-depen- dence of life, from the microbe to man. From water, which sustains life, also comes the threat of death and disease. In order to survive and maintain good health, man must remain on guard against• poisoning one of the most im- portant elements of his environment— water. This applies also, though to a les- ser extent, to the two other elements of the biosphere, land and air. In addition to the air we breathe, the soil we walk on, the water we drink, the food we eat is also our direct link with the environ- ment. These are links with health as well as disease. The study of man's relationship with the various elements in his surround- ings, and the use of this knowledge to prevent disease and promote health, are the major concerns of environmental health. It seeks to ensure that human beings live in harmony with their envi- ronment, drawing sustenance from it and using it for social and economic needs without endangering their health or disturbing the ecosystems. In many cases man himself is the agent of the environmental pollution that threatens his well-being. With the advance of civilization have come rising popula- tions and overcrowded cities and shanty- towns choking in poor environmental sanitation. Industrial growth has con- tributed to air, water and soil pollution. Life began in water. Earth's seas still teem with life firms which, at least at the intel- lectual level, have not advanced very far along the evolutionary ladder. Amphibious creatures testify to the half way house, when organisms began to venture on to the land. Although aeons have passed since man's earliest ancestors emerged from the primeval seas, man still retains his bond with water and his need for regular, un- polluted water supplies. ( Photos Len Sirman ) The use of various sources of energy yields gases and other effluents that can pose serious hazards to human health. The increasing use of chemical substances and powerful machines in the factory and inside the home has added to the dangers of man's environment. The various aspects of the problem are reflected in WHO's programme on environmental health. The Organization collaborates with Member States in developing basic environmental sanita- tion and particularly hygienic water sup- ply systems and waste disposal facilities. Criteria are established on the exposure of populations to physical and chemical agents, and guidelines prepared for health protection standards. The levels and effects of such exposure are moni- tored and interpreted in cooperation with leading institutions and scientists in the world. The information obtained and methods developed for protecting human health by the use of environmen- tal control are disseminated to the Member States. Close cooperation is maintained with governments in streng- thening the services and institutions required for environmental health activ- ities and in training workers in this field. Heading the list of priorities in this programme is provision of basic sani- tary measures, of which the main ele- ments are safe water supply and dis- posal of human excreta and other wastes. In 1975, more than 57% of a total of $20.5 million allocated to WHO's environmental health programme was spent on activities aimed at providing basic sanitary measures and services. The reason is obvious : some of the lead- ing causes of death and morbidity in the developing world are water-borne dis- eases such as cholera, typhoid fever, diarrhoea, dysenteries and intestinal worm infection. The vectors of dengue haemorrhagic fever and filariasis breed in insanitary, stagnant water in areas where the drainage is inadequate or non-existent. This applies also to some varieties of the anopheles mosquito, vec- tor of malaria. Schistosomiasis, an in- fection borne by a water snail, perpetu- ates itself in communities lacking sani- tary facilities as the eggs of the disease organism discharged in the urine or faeces of the sufferers are washed into rivers, canals or lakes to start a new chain of infection. It has been estimated that the burden of sickness in the world could be immediately cut down by 80% if it were possible to supply safe water to people everywhere. But to make this a practical proposition requires not only large resources but a determined effort on the part of the governments directly involved to free the poorest sections of their people from the vicious grip of dis- ease and poverty. The grim fact is that more than 1,200 million people of the developing countries have no safe water supply and more than 1,400 million no sanitary waste disposal facilities. These are inhabitants of areas with the highest rates for infant and child mortality and deaths and sickness caused by communicable diseases. While it has not been possible—mainly owing to lack of data and a variety of complex factors that contribute to dis- ease prevalence—to establish an exact numerical correlation between poor san- itation and disease, it is not difficult to see that no community can free itself from the grip of enteric diseases if its drinking water, polluted by human wastes, is a constant pathway for disease organisms travelling along the route : man-faeces-water and/or food-man. By contrast, in communities where water supply and excreta disposal have improved, many enteric diseases have ceased to be public health problems. The outbreak of cholera is a case in point. Even a few cases in an Asian or African community lacking a protected water supply system often explode into an epidemic; in countries of Europe where waterworks and waste disposal- systems have been perfected, imported cases of cholera have been reported ev- ery year since 1970 but without similar consequences. The principle was vividly demonstrat- ed during a cholera outbreak in the Mulanje district of Malawi in 1973-74. A study of the distribution of the dis- ease showed a striking difference between areas receiving piped water and those served by unprotected surface water. Moreover, the victims in the area receiv- ing piped water were shown to have either caught the infection in villages other than their own or to have been using the contaminated surface water owing to the distant location of the standpipes. The lack of basic environmental health facilities for over one-third of mankind and the resulting cost in terms of sickness, deaths and thwarted economic growth cannot be ignored in any effort to promote development and raise the quality of life. The provision of safe water and sanitary waste disposal facilities to the urban and rural populations of the developing countries is therefore being pursued by WHO as a major objec- tive during the present decade, designat- ed by the United Nations as the Second Development Decade (1971-80). The goals set at the start of the decade were modest enough : 60% of the urban population to have house water connections and 40% access to stand- pipes, and 25% of the rural population to have safe water by the end of 1980. Even while the targets were adopted it was felt that they might be difficult to achieve owing to population growth and other factors, such as shortage of funds and trained manpower. However, a mid-decade review (1971-75) has shown that at the rate of the progress achieved so far, these goals are likely to be rea- lized in most of the developing world. All targets are being revised upwards with the exception of that for urban population to be served by standpipes. Targets for the provision of excreta disposal facilities have been set for the first time ever. The total global invest- ment in the proposed new targets for community water supplies in 1976-80 is estimated to be in the region of $21,000 million — an approximate an- nual investment per head of $1.81, tak- ing the estimated 1980 population of the developing countries as the base. The es- timated global investment in excreta dis- posal projects is $14,500 million, or $1.25 per head. The community water supply programme will directly benefit 479 million people and the waste dis- posal programme 432 million. Where does all this money come from? Not from WHO, with an annual regular budget of about $140 million, nor from any other single member of the United Nations system. The major contri- bution must come from the countries benefiting directly. Additional resources are expected to be generated thanks to the close collaboration between WHO, UN Children's Fund (UNICEF), UN Develop- ment Programme (uNDP) and the Inter- national Bank for Reconstruction and Development (IBRD), the support of bilateral agencies, and long-term loans by regional banks once they are convin- ced that to invest in waterworks is justified on socio-economic grounds. The funds available are utilized in various ways, depending on the state of development of the country, and its immediate and long-term needs. In a typical case, WHO cooperation may begin with helping the national health'authori- ties organize a nationwide technical and institutional study of the water supply and waste disposal facilities. The investi- gation will reveal areas where demands are not being met, what are the main hurdles, and what the government and international agencies can do about it. 1 0 This will enable the government to asses the country's water supply and sanita- tion needs within the context of the total health programme and of other develop- ment activities. It will be possible to choose realistically the type and size of the population to be covered, decide the type of services to aim at and determine the level of the governmental and inter- national action. In the case of projets requiring a large financial. outlay, WHO helps further by identifying viable invest- ment projects and informing potential donors and lending agencies. As recent examples of investments following such studies may be men- tioned : India : IBRD appraised a $78 mil- lion water and sewerage project that will benefit 6.2 million people; Oman: a uNDP-assisted water supply project cost- ing $435,000 was formulated; Republic of Korea : a uNDP-assisted project for sewerage was drawn up for the city of Seoul. In Latin American countries, the total investment in programmes of water supply and sewerage over the period 1961-75 reached $5,000 million. A large number of projects have been carried out by WHO in close collabora- tion with the Inter-American Develop- ment Bank, IBRD and the Canadian In- ternational Development Agency. The focus of the programme has been shifting increasingly to the rural poor, for it is in the rural areas of the develop- ing countries that the magnitude—and the glaring injustice—of the problem is most strikingly evident. About 80% of these people have no access to safe wa- ter and even more are without sanitary waste disposal facilities. And yet, these The provision of safe water and sanitary waste disposal facilities is a major objective of WHO during the present decade. < An Indian sanitary engineer explains to a rural health team the design of a simple and cheap latrine slab which can be produced locally with local materials. Above right : Laying sewage disposal pipes in West Africa, part of a project due to be completed this year with WHO's technical cooperation. Right : This woman in South-East Asia used to walk several miles daily to fetch and carry water. The sinking of anew well, with a raised platform around the pumps to protect the well shaft against surface drain- age, gives her easy access to safe water. (Photos WHO) are the people who as farmers, cattle raisers, village craftsmen, forest workers and fishermen, contribute the major share of the gross national product in the primarily agricultural economies of the Third World. In recent years, more and more governments have accorded a high priority in the national health plans to the environmental health needs of the rural communities. A water supply programme especially aimed at rural areas of the developing countries is being carried out with sub- stantial material support from UNICEF. The construction of tubewells with handpumps is a major goal of this pro- gramme, and good progress has been made in some countries. Bangladesh, for instance, constructed 100,000 new tube- wells and repaired 40,000 within the past four years. Pakistan hopes to install 35,000 tubewell handpumps by the end of this year under a scheme launched three years ago. The Republic of Korea over a period of three years (1972-75) has succeeded in ensuring easy access to safe water to 50% of its rural popula- tion. Nearly 4,000 simple rural water supply systems have been installed and thousands of dug wells constructed or repaired in a programme which is also supported by the World Food Pro- gramme. Notable progress has been made in the Region of the Americas particularly in Argentina, Chile, Mexico and Uruguay in terms of the number of rural people having access to safe water. One of WHO's tasks is to collect, deve- lop and disseminate information on wa- ter supply and waste disposal technolo- gy that could be adapted for use in deve- loping countries. Last year, for instance, a considerable amount of information was collected on certain types of hand- pumps and other methods of extracting water, which will be used in preparing guidelines on the subject. In many rural areas the village pond is the main source of water—and infec- tion. A method has been developed to use the water without risk to health by providing an infiltration gallery in the bed of the pond that filters the raw water and delivers it into a well at the edge of the pond. A planning guide for rural water supply that could be adapted to varying local conditions is being prepared by WHO for use in rural development projects. These are examples merely of what can and is being done to improve water supply and waste disposal in the rural areas of the developing countries. What has been achieved so far barely touches the fringe of the problem. But valuable lessons have been learnt for the future. The best results have been achieved where the governments showed a firm determination to carry the programme through and were able to ensure com- munity participation. This experience has confirmed a number of principles that WHO regards as basic to the devel- opment of environmental health pro- grammes. According to this approach environ- mental health projects and activities should be regarded as an integral part of the national socio-economic plans, and should be allocated national resources in consonance with the country's other priorities. A major goal should be provi- sion of basic sanitary facilities to the largest possible proportion of the popu- lation as a means of improving health, with a marked emphasis on underserved communities. Particular attention should be given to community participa- tion, utilization of local resources and development of self-reliance among the people served. Programmes in key fields WHO will continue to collaborate with Member States, dealing through minis- tries of health as well as other ministries and national agencies involved in pro- moting environmental health. As an in- terim measure, WHO's emphasis will be on national programmes in key fields, such as water supply and waste disposal, food sanitation and healthy housing. Later comprehensive environmental health programmes will be promoted. Some 200 professional environmental health staff employed by wHo and a large number of short-term consultants drawn from various countries of the world will continue to be at the disposal of the governments to assist in various ways from planning to the operation and management of specific projects. In recent years the public has become sharply aware of the dangers of the en- vironment being polluted by chemicals and other man-made substances, and asked for action to stop it. The sources of pollution, however, are the great achievements of the modern age : indus- try, the automobile, the aeroplane, in- secticides and herbicides, and the various sources of energy. So startling was this discovery that prophets of gloom in the last decade began to fore- cast that man's destiny was not to disap- pear in an atomic cloud but to smother under the debris created by him in an oxygen-less planet. These dire warnings have become less fashionable with the realization that technology can prevent a good deal of pollution that it gener- ates and that there is a promising area of research yet to be explored. However, there is a real threat to human health from modern pollution, and the need for constant vigilance and monitoring of the biosphere is imperative. WHO's programme in environmental pollution control has two major aspects : developing methods of assessment of the effects of environmental conditions on health, and monitoring of the environ- ment. In addition, cooperation is given to member countries in controlling pol- lution. Carried out in collaboration with 30 national scientific institutes and with the support of UNEP, the programme develops information and specifications on which national administrations can base their health-related environmental quality standards. Last year, for in- stance, six meetings of experts were con- vened to evaluate the health risks from exposure to mercury, lead, cadmium, manganese, and other contaminants. The WHO air monitoring programme links major urban and industrial sta- tions in 13 Member States and gathers aerometric data with particular refer- ence to sulphur oxides and suspended particulate matter as indicators of air quality. The Pan American Air Pollu- tion Sampling Network now includes 88 stations in 30 cities in 15 countries and will be integrated with the more wides- pread monitoring network. A pro- gramme for water quality monitoring was formulated last year under which information on hazardous water pollu- tants of international significance will be collected and disseminated. WHO and UNDP are collaborating in more than a dozen pollution control projects in Europe, Latin America, and parts of Asia. The activities are concerned mainly with the control of air, water, and soil pollution, and in some cases, as in Greece, with noise abatement. In Poland, support is being given to a pollution control centre in the highly industrialized zone of northern Silesia, which serves as a research facili- ty, reference laboratory and training centre. A large-scale collaborative pro- ject on pollution monitoring and research in the Mediterranean, involving all the coastal countries and several in- ternational organizations, was initiated by the United Nations Environment Programme (uNEP) last year. WHO is the executing agency for a part of this pro- ject. Since food like water sometimes becomes a medium for harmful organ- isms or chemicals, food hygiene and safety have an important place in WHO's 12 environmental sanitation programme. Primarily the work lies in developing microbiological specifications for foods and the acceptable tolerance levels for substances that may be intentionally or unintentionally added to food. Much of this work is carried out in close collabo- ration with the Food and Agricultural Organization (FAO). Last year, for instance, the Codex Alimentarius Commission, the principal organ of the joint WHO/FAO Food Stan- dards Programme, recommended nine international standards on processed foods and vegetables. After a joint con- sultation by voio and FAO experts, two documents were prepared, one suggest- ing guidelines for an effective national food control system, and the other dealing with food hygiene in catering es- tablishments. Other topics taken up un- der the joint Food Standards Pro- gramme included pesticide residues in food; food additives, such as food colours, preservatives, thickening agents, etc; chemical and biological con- tamination of food during storage or transportation; viruses in food; and specifications for egg products. The new knowledge about environ- mental quality and its effect on health has found expression in the expansion and restructuring of the health adminis- trations in many countries. It has also underlined the importance of the inter- disciplinary approach to health, and of health as a basic element in the quali- ty of life. WHO has contributed to this process through meetings, seminars, ad- visory services and programmes for training of personnel and for developing techniques for environmental health planning and management. It is a well known dictum of public health that disease is the interaction be- tween the environment, the agent and the host; with today's awareness of the biosphere itself as man's environment, that equation takes on an infinitely big- ger dimension. In order to survive and to remain in good health, man must know his environment and use that knowledge with wisdom and foresight. ■ <A laboratory assistant tests air samples at the Bulgarian Hygiene Institute in Sofia. The air is examined for levels of dust, lead, sulphur and a variety of other potential pollutants. In recent years, the public has become sharply aware of the dangers of the environment being polluted by chemicals and other man-made substances. (Photo WHO/P. Almasy) 13 HEALTH MANPOWER DEVELOPMENT BASIC SKILLS The aim of WHO's concept of health manpower is to produce the right "mix" of medical personal, in quality and quantity, to meet the health needs of all the people by the year 2000 by John Bland j 1 health evvilo a lt h si to oi c erse afcbhr its bo yb j etchtei v ey e aorf 2000, a reorientation of personnel training is essential, while whole new categories of health workers must be trained and sent into action. Millions of people still have no access to health— in some rural areas they include more than 80 per cent of the population. Vil- lage health workers, nursing assistants, auxiliary midwives: all these will be needed—and more. Remote country areas will need environmental health workers, dental auxiliaries, primary health workers and many other trained personnel. Many countries already recognize that the greatest returns will come from increased investment in these middle- and peripheral-level health workers. Training them and using them effective- ly will be vital for improving health ser- vices and reducing the costs of health care for all. Unfortunately there is still a huge imbalance between the expensively trained physician and the more cheaply trained assistant personnel. Not the least of the problems is the chronic shortage of the necessary teachers and teaching aids. As a country develops socially and technologically, with its average life- span increasing and its living standards steadily rising, the health needs multi- ply. The doctor is obliged to delegate to other health technicians many of the duties which he can no longer carry out himself, duties which may not in fact require the services of a fully qualified doctor of medicine. Although there is frequently a short- age of doctors, it is also often true that they are badly used. The doctor's role has to be reconsidered, taking into ac- count the services that the community needs and the tasks that can be entrust- ed to other hands. Eventually the doctor should no longer be regarded as a one- man factotum in the health field, but as the leader of a team in which each mem- ber has his or her appropriate place. (See "The Case for Medical Assistants" in World Health, June 1972.) The fact is that more doctors do not necessarily raise health standards. Indeed it might be better to produce more personnel who do not have an exportable universi- ty degree than to over-produce at great expense doctors who are exportable. Medical education is a costly and long-drawn-out process, so that cost becomes a paramount factor to be con- sidered when a comparatively poor country plans to set up a medical school. The outlay involved in training a medical graduate can be estimated by multiplying the annual expenditure on him by the number of years—four to six—that his course will last, and then taking into account investments wasted on students who "drop out" before graduating. Using this formula, a study some years ago showed that it cost Nigeria US$33,600 and Uganda $26,000 to train a medical graduate. The size of these figures may be seen even more clearly when they are compared with the per capita annual income of the two countries at that time, $68 and $83 respectively. Nor are these the only costs to be considered. When graduates leave medi- cal school, there have to be supporting facilities for them, such as hospitals, equipment, medicaments and other sup- plies, as well as the supporting staff— nurses and health auxiliaries for in- stance—without whom the doctor can- not work effectively. Starting a medical school therefore becomes a major in- vestment decision, raising the question of whether the costs can be justified by the likely benefits to the country. Developing countries in particular have to bear in mind the "brain drain"— the outflow of trained health manpower to other countries where perhaps the financial rewards may be higher. A \NTH() study showed that around 1971 there were at least 140,000 physicians in coun- tries other than those of which they were nationals or where they were born or trained. Such numbers clearly repre- sent a heavy economic loss to the coun- try of origin, and various forms of in- In Western Samoa, members of the village women's committees are being trained to play a greater role in the delivery of pri- mary health care. A district nurse is seen instructing an attentive audience in the process of birth. There is still a huge im- balance between the expensively trained physician and the more cheaply trained assistant personnel. Not the least of the problems is the chronic shortage of the necessary teachers and teaching aids. (Photo WHO/ R. J. Gobius) 14 0'7 Mir A medical assistant's duties may range from simple treatments for common diseases to a variety of diagnostic, cu- rative and preventive practices. Above : The forerunner of the modern med- ical assistant was the barber-surgeon or feldsher, whose name is still applied in the Soviet Union. (Photo WHO) <A health auxiliary in Colombia efficiently bandages a small patient at a rural health centre. Health workers of tomorrow attending a N training course in Kenya. Training centres should reflect the requirements of the com- munity they serve. ( Photos WHO/ P. Almasy) ducements have been introduced to limit such a drain. However, a country unable to make the services of physicians available to its entire population may still be able to provide a nationwide service in which the initial health contact of the people is a person trained at much lower cost. Many countries have found it practical to promote the training and use of "medical assistants" and primary health workers—like the feldshers of the Soviet Union, the "barefoot doctors" of China and the auxiliares de enfermeria of Venezuela. At least ten French and nine English terms exist for the same job of medical assistant whose duties, in WHO's defini- tion, "may range from simple curative procedures for common diseases to wid- er care including a variety of diagnostic, curative and preventive practices. Per- sonnel in this category have not studied medicine at university level." Such a medical assistant will take a full share in promoting the community's well-being, and will have the experience necessary to advise local health planners and to guide a health team towards promoting the physical, mental and social well-be- ing of the community. There is even a long historical prece- dent for this new emphasis. The forerunner of the modern medical assis- tant was the barber-surgeon, a military man who in past centuries tended the wounded in Europe's wars. (See "Forerunners" in World Health, June 1972.) Tsar Peter the Great introduced feldshers (from the German for field- barbers) into the Russian army in the 17th century. Today the principle is beginning to be universally recognized that basic health needs in developing countries can be catered for by the village health worker, a man or woman living locally, chosen by the village community and paid by them in cash or kind, and given a few months of training by the coun- try's health services. He or she can dis- pense rudimentary treatment, make sim- ple diagnoses, undertake basic preven- tive measures to safeguard health, and offer some degree of health education. More complex cases are referred to a higher level. These village health workers or pri- mary health workers may be selected, appointed and administered by the local community. From an education base which may be bare literacy and after three to four months of local training, they can undertake many fundamental tasks plus primary health care for com- mon illnesses and family planning. They may not be what has in the past been recognized as "health workers" yet they have proved capable of dealing with 85 per cent of a village's health needs. Of course, they also need continuing practi- cal education directed towards the sort of problems they are likely to encounter. This continuing training is not con- fined to the primary health worker. All 16 public health workers need to be alert to new findings in medicine or develop- ments in public health techniques. So how is the health professional, once out of school, to remain in touch with the rapidly growing knowledge in his field? A WHO expert committee in 1973 recom- mended that WHO should support governments in developing national sys- tems of continuing education for the health professions and integrating these programmes with the national health care systems. New style schools will be needed to train the health workers of tomorrow, patterned not on existing schools or for- eign models but reflecting the needs of the community concerned. There will be a need to train more students with fewer teachers, which in turn demands the use of new educational techniques and eval- uation tools. Such techniques exist—au- diovisual methods, simulation devices, self-instruction and so forth—but they are sometimes complex and often costly in terms both of buying the materials and of operation and maintenance. The University Centre for Health Sciences at Yaounde, Cameroon, found- ed in 1969, was the first of its kind in Africa in pioneering a new type of medi- cal education for equatorial Africa. Its main educational function is the train- ing of physicians and other health work- ers, with emphasis on health care for defined communities in Cameroon, and the promotion of the "health team" concept. One of its aims is to turn out leaders of multi-purpose teams capable of dealing with nutrition, sanitation, mother and child care problems, and to train them so that they work well with other team members such as nurses, technicians and so on. The emphasis is on a good fundamental scientific edu- cation with practical clinical training in a country where large numbers of skilled specialists are not available. WHO itself foresees the development of national "health services and man- power development" (HsMr) centres replacing existing teacher training cen- tres, which will train teachers for all categories of health personnel, pro- vide technical support services (in- cluding producing and testing learn- ing materials), undertake educational research and ensure the relevance of the training to the needs of the services. These centres would become the institu- tional bases for—and the main promot- ers of—changes in the health services and in the education of all health per- sonnel. One of the most important services that the Organization has rendered to its Member governments since its inception has been to provide assistance, guidance and teaching staff for training physi- cians, nurses and other categories of health workers. In 1974, about 15 per cent of WHO'S budget was devoted to programmes which could clearly be labelled education and training. It has long been apparent that the most effec- 17 Above and opposite : A team of auxiliaries making their rounds in Ethiopia. From an education base which may be bare literacy and after some three months of local train- ing, primary health workers have proved capable of dealing with 85 per cent of a village's health needs.. . . . .but back-up hospital and specialist ser- vices will still be needed, to which serious cases can be referred. The operating thea- tre in a urological clinic in Azerbaijan, USSR. (Photos WHO/E. Schwab & Novosti © ) Left : At training centres like this one in Burma teachers are prepared for service in all the categories of health personnel. (Photo WHO/J. Mohr) tive way in which WHO could make use of its slender resources was not by un- dertaking to fight diseases, like some kind of international fire brigade, but by helping governments to develop the health manpower system best suited to their own resources and needs. In addi- tion, WHO makes available a great num- ber of fellowships each year—a total of over 50,000 between 1947 and 1975. But the Organization is already fos- tering the concept of integrated develop- 18 ment of health services and health man- power. This aims at producing the right "mix" of health personnel, both qualita- tively and quantitatively, to ensure full coverage for the entire population in the coming decades. A study group on the planning of schools of medicine, con- vened in 1974, recommended methods of organizing and administering new schools. It also underlined that the num- ber of physicians trained must be related to the total health manpower require- ments of a country if a balanced "mix" of health personnel is to be achieved. That same year, following studies of the role of traditional birth attendants, WHO began to look into the practi- cability of using traditional healers and other practitioners of traditional medi- cine. After proper training, it should be possible to associate them in health care delivery programmes. In many rural parts of the developing world, official health services are lacking, yet the local health services that do exist are poorly used because the local population pref- ers the services of traditional healers. Frequently they find it easier to commu- nicate with them than with the staff of the health services. It clearly makes sense to tap this substantial resource of manpower for the purposes of primary health care. All these developments represent as- pects of "health manpower planning" ; this has been described as a process of estimating the quantity and type of knowledge, skills and attitudes needed to introduce predetermined changes into the functioning of a health system. The object of the exercise is not merely to promote health in the widest sense, but to provide the appropriately trained staff who will, as far as possible, treat diseases, prevent their onset and meet the community's demand for services. "The health .auxiliary has come to stay", declared Professor V. Ramalin- gaswami of India when he received the Leon Bernard Foundation award in Geneva in May. But he stressed that this system of community-based health ser- vices employing auxiliaries must not be interpreted by the people as "providing inferior medicine to the rural poor". He went on : "An auxiliary is a health edu- cator, a rudimentary physician, a social worker and a preventive person, all in one . . . The education and training of auxiliaries is the most challenging task that medicine faces today. Auxiliaries serve to bridge the catastrophic separa- tion between hospital-based, fragment- ed, episodic medicine and mass public health. The principles of educational science and technology must diffuse into their training programmes. It is on our willingness and ability to experiment with auxiliary training programmes that the chances of success will depend. The moment modern medicine penetrates the social veil in developing countries— that is the moment of triumph for mod- ern medicine. Here is medicine in the raw, medicine rooted in the reality of rural life." Even in the training of the classical types of health workers, primarily physi- cians and nurses, changes have been all too slow. But conditions for a major breakthrough to solve the manpower problems of the developing world are accumulating rapidly even if no such breakthrough has yet been achieved. Hence the concept and mechanism of integrated development of health ser- vices and health manpower which, as we have seen earlier, WHO calls HSMD or Health Services and Manpower Devel- opment. The setting up of such a mechanism is not an end in itself. It should result in health services that cover the entire population of a country and meet their promotive, preventive, curative and rehabilitative needs; health services that are staffed in sufficient numbers by personnel whose skills have been developed in answer to health problems. If the bulk of this ambitious work remains to be done, at least the foundation stones have already been laid, and have already won the whole- hearted backing of delegates to the Twenty-ninth World Health Assembly held in Geneva in May. ■ 19 EXPANDED PROGRAMME ON IMMUNIZATION YOUNG LIVES AT STAKE by Gino Levi n the rich countries of the world today there is protection against most diseases of childhood. Clean water flows freely from gleaming chromium taps. Babies are born in spot- less sterilized clinics and soon after birth they are vaccinated and immunized against a number of common infectious diseases. For a majority of people in the indus- trialized world and for a tiny minority in the developing world—for the lucky ones who regard motor-cars and refrigerators as standard equipment, not as undreamed of luxuries—immunization is a routine procedure whereby their children's health can be systematically safeguarded. Many of these lucky ones are well-meaning peo- ple, good citizens who would probably shudder at the thought of maiming or killing a domestic animal or even an in- sect. Yet how many of these people who comprise the affluent societies of today know that each year about five million children in the developing world are killed by common infectious diseases pre- ventable by immunization? Other infec- tious diseases, such as malaria and intesti- nal disease, kill millions more but they are preventable by other measures, not by immunization. Even the technological revolution in mass communications, the advent of the television era, and the pro- fusion of radio or film documentaries and illustrated magazine stories, have not brought home this grotesque fact. Yet these millions of tragic deaths could be prevented if the children were protected by immunization. Millions of other children survive but are disabled through brain damage, para- lysis, stunted growth, chronic lung illness, deafness and blindness. No precise figure can even be guessed at because basic sta- tistics on life and death are difficult to obtain in countries struggling with almost insuperable problems of inter-related poverty, hunger, disease, unemployment and ill-planned population growth. Some 80 million children are born ev- ery year in the less privileged parts of the world. Not even ten per cent of them are ever seen by health workers who could immunize them against the debilitating and deadly diseases of childhood. By contrast, in the rich countries well over 90 per cent of the children are immuniz- ed against diphtheria, whooping cough, tetanus, polio and measles. Ironically, the very success of immun- ization programmes in the rich countries over the past 20 years has sometimes removed the fear which motivated parents to have their children protected and immunized against diseases whose names and characteristics are often for- gotten or mistaken for one another. The wHo smallpox eradication pro- gramme has helped to bring this deadly disease—for which there is no medication or cure—to the point of no return. However, this should not prevent coun- tries from including smallpox vaccination in their health programme if local circum- stances warrant it. For the complete erad- ication of smallpox to be certified, two full years must elapse after the last case has been identified. Measles—far more infectious than smallpox—poses a serious public health challenge in Africa and elsewhere. Among malnourished children, this high- ly contagious virus disease can kill as many as one in ten of its victims. And yet one dose of the live vaccine gives 95 per cent protection for at least 15 years, and probably for life. Diphtheria, an acute infectious disease of tonsils, pharynx, larynx or nose, also has a fatality rate of about ten per cent which has changed little in the past 50 years. The only effective control is by active immunization with diphtheria tox- oid. Vaccines of different bacterial species may be administered in combination as, for example, diphtheria and tetanus. Such a "cocktail" can also contain pertussis (whooping cough) vaccine, thus making up the well-known DPT vaccine which is used for the multiple immunization of children from the age of two or three months. Tetanus, also known as "lockjaw", because it is characterized by painful con- tractions of the jaw muscles, can have a fatality rate of up to 70 per cent. Tetanus of the newborn usually occurs through infection of the unhealed umbilicus and is a particularly serious public health prob- lem in developing countries. Poliomyelitis is an acute viral illness causing "infantile paralysis". Severe epi- demics now occur with increasing fre- quency in less developed areas and mainly affect children. Paralysis of muscles of respiration and swallowing may threaten life, and the fatality rate, which may reach ten per cent in epidemics, increases mark- edly with age. Yet another challenge comes from childhood tuberculosis, a slow, insidious disease affecting a small percentage of Mothers waiting to have their children im- r> munized at a village dispensary in Zaire. Each year about five million children in the developing world are killed by common infectious diseases preventable by immun- ization. Millions of other children survive but are disabled through brain damage, chronic lung illness, or blindness. (Photo WHO/H. Page) 20 •

These parents (left) are watching their chil- dren receiving oral administration of polio- myelitis vaccine at a village centre in Colombia. Their journey was possibly a long one to the clinic—but it was worth while. Their children will avoid the fate of the little boy (above) who must struggle throughout his childhood with leg-braces, reinforcing muscles which a polio attack has crippled. (Photos WHO/H.Page) children. BCG vaccination protects against it. So successfully have the teeth of these deadly diseases been drawn by the mass immunization of children that minor problems stemming from the opposition to vaccination on ethical or even so called "health" grounds by minority groups can be discounted as trivial and unimportant. The real problem lies elsewhere. Cold stark figures tell us that 97 per cent of all deaths in children under five years of age occur in the less developed countries. This is clearly where the priority lies, since the contribution of the six diseases to that mortality is substantial. Much can in fact be done to reverse this tragic situation and it is precisely with this aim in mind that the World Health Or- ganization has given priority to an "ex- panded programme on immunization". Experts agree that additional funds and improved planning and administration are the major priority for this pro- gramme. They are relatively much more important than the need for further scien- tific knowledge, if the existing difficulties in the way of vast and successful immun- ization campaigns are to be solved. There is, however, also an urgent need for vac- cines which are stable to heat and there- fore no longer require refrigeration, as in the present smallpox vaccine. The United Nations Children's Fund (uNicEF) and the World Health Organiza- tion are jointly determined to develop the expanded immunization programme as rapidly as possible, to turn it into an effec- tive vehicle of collaboration with the developing countries and to make effec- tive child immunization possible even in the remotest rural areas. Potential donors to the voluntary fund bringing additional substance to the ex- panded programme must be made to real- ize that children can be protected for life against all these diseases for little more than one US dollar. The biggest stumbling blocks to suc- cessful immunization programmes are not medical. They derive directly from the practical difficulties facing field opera- tions in remote rural areas. Maintenance of transport and fuel supplies, keeping the vaccines safe and effective through refrig- eration from the time they leave the manufacturing laboratory right up to the moment when they are administered to the child, supervision, administration— these are the real problems with which public health authorities have to grapple. Only experience will tell whether they are easier or more difficult to solve than scientific or medical research problems. The training and development of national personnel to effectively bring im- munization as close as possible to the home of every child is the only safe and sound way of giving firm foundations to programmes whose ultimate success depends on their continuity. Immunization services will expand as fast and as far as the basic health services of any given country—and no faster. The two are intrinsically linked. In order for them to be financially feasible and for them to last as a long-term—indeed al- most indefinite—operation, immuniza- tion services should be part and parcel of maternal and child health services. The basic "strategy" suggested by WHO is a pragmatic, step-by-step approach. The programme should be developed geographically by adding new areas, tech- nologically by adding more complex vac- cines requiring special handling, and socially, by including the most needy por- tions of the population. Only in this way can viable programmes be built up and consolidated. There are of course marked social, eco- nomic and cultural differences between the developing countries, and it is precise- ly one of WHO's major tasks to make it possible for all countries to benefit from the sum total of experience gained from dealing with the same problem in dif- ferent latitudes and in different circum- stances. Efforts are being made by WHO to draw up guidelines on the planning, manage- ment and evaluation of programmes which are being tested in collaboration with a number of national authorities. The situation varies widely from Soma- lia, for instance, where 70 per cent of the population is semi-nomadic and immu- nization planning must be drawn up on the basis of meeting the tribes at water- holes in order to immunize the children, 23 The Target Areas At present not more than 5 per cent of the 80 million children born in the developing world are being immunized against six dangerous diseases : Diphtheria: In parts of the developing world faucial diphtheria (involving the tonsils) is still a rare disease because immunity is developed early from diphtheritic skin infections. But the incidence is in- creasing with urbanization. Diphtheria is, however, a common disease in other parts of the develop- ing world where the reported mortality is 10- 20 times greater than in the developed countries. Tetanus: The incidence and mortality vary greatly in different parts of the world. In some areas rates of 60 per 100,000 have been reported in the total population. For the first month of life, statistics show death rates of '100 per 1,000 births. These high rates are from developing countries, where tetanus is one of the major causes of death from infectious diseases. Pertussis: Children are seldom admitted to hospital with uncomplicated pertussis (whooping cough), but surveys not only show that the disease has a high incidence but that it also carries a high mortality, particularly amongst the very young. Poliomyelitis: In the years before vaccination became available, the United States of America, Canada, Australia and New Zealand between them were reporting an average of about 50,000 cases annually: now they report less than 100. Yet in Ghana two years ago a survey of schoolchildren revealed that 7-8 per thousand had paralytic disabilities typical of those of poliomyelitis, a rate higher than in the USA in the pre-vaccination period. In Uganda where only 100 cases were notified in four years, a survey of hospital records showed that 983 cases were treated in one four-year period. In one year in only one city in India over 1,000 cases were diagnosed. Measles: Practically every child in the world who survives for the first few years develops a recognizable clinical attack of measles and is liable to develop one or more respiratory, neuro- logical or ophthalmic complications. But the mortality of measles varies greatly in different parts of the world. In developed countries the attack is usually mild; so much so that in many European countries vaccine is used on a very small scale. In some countries in the Western Pacific it is also rather mild, whereas in West Africa it is one of the principal causes of death in children below five years of age. It is also a killing disease elsewhere in Africa and in many parts of Latin America and South-East Asia. Tuberculosis: World mortality figures range from 1 to 50 deaths per 100,000. In a study of death rates in groups of developed and developing countries the reported death rates from tubercu- losis were at least three times higher in the devel- oping than in the developed countries. Since we know that reporting is as poor in tuberculosis as in other diseases in the developing world, the incidence is probably at least ten times greater. 24 A A routine check-up for a young patient in Venezuela. The health assistant looks for telltale symptoms of diphtheria, an infec- tious disease of the tonsils, pharynx, larynx or nose against which the only effec- tive control measure is immunization. (Photo WHO/J. Littlewood) <Childhood tuberculosis is a slow, insidious disease. This Vietnamese boy is getting his BCG vaccine protection against it. (Photo WHO/UNICEF) to Malaysia where there is one trained midwife or nurse for every 2,000 people and routine immunization can be plan- ned quite differently. A major common denominator to en- sure the success of any immunization campaign—or any public health action in general—is the imperative need to obtain the understanding and cooperation of the people who are directly involved in the project. More than in any other aspect of public health programmes there is a need here for intimate knowledge of local ways of life, customs and beliefs to reach opti- mal results. No health information cam- paigns can be improvised from a distance. Television and radio programmes might provide the right approach in one com- munity, while elsewhere health educators may find it much more valuable to reach the people directly through religious lead- ers, local story-tellers, or village elders. Elsewhere pantomime or theatre groups might be used successfully. One of WHO's major tasks in connec- tion with the expanded immunization programme is to encourage national health services in the belief that even the limited means they have at their disposal now—in certain developing countries— can be harnessed into efficient small groups capable of raising the standard of living and life expectancy of the poorest among the poor. Health services, in collaboration with international agencies such as WHO, can for instance establish simple control labo- ratories to keep under constant check the safety and potency of vaccines used for immunization. It may not always be eco- nomically sound to start manufacturing vaccines from scratch but as much as 50 per cent savings can be made by countries if, as a first step, they start importing concentrated vaccines in bulk from abroad and develop their own bottling, labelling and filling. The encouragement and strengthening of national activity in this field could also have an important side effect in certain countries where private practitioners are demanding vast sums of money in urban areas to vaccinate children often with vac- cines that have lost their power to protect. Government action would then succeed in putting an end to such harmful mal- practice. Some of these private practition- ers may not even be aware of the fact that because of poor refrigeration facilities they are giving "dead" and therefore completely useless vaccines. The problem does not only arise with negligent private practitioners in towns. Much depends on the "cold chain" em- ployed in the transport and storage of the vaccine used for immunization. The "cold chain" is still grossly inadequate— both technically and managerially—in rural areas to keep the viruses in measles and polio vaccines alive all the way from manufacturer to child. Epidemics of these diseases are in fact frequently reported among children known by the authorities to have received the vaccines at the cor- rect age and in the correct quantity. Such unfortunate occurrences have serious ethical and social implications— particularly in Africa south of the Sahara desert—where measles is greatly feared as a deadly disease. More effective managerial monitoring of vaccine transport and storage is of primary importance with frequent labo- ratory tests of vaccines returned from the field to make quite sure that they have lost none of their potency. These essential aspects of programme management are under constant study by the World Health Organization, which is ready and eager to develop national eval- uation systems capable of measuring progress towards ultimate objectives. It should be possible to institutionalize ef- fective systems in the monitoring and control of public health activities. These would ensure the success of expanded child immunization programmes, as well as that of many other activities carried out by national health services in the best interests of the people. ■ 25 RESEARCH INTO BATTLE AGAINST LEPROSY A strange little animal, armoured like a primitive tank, is playing a vital role in the search for a vaccine against the centuries-old scourge of leprosy by Hubert Sansarricq he disfiguring disease of leprosy, feared throughout the recorded history of mankind, is one of six tropical diseases for which new remedies are being sought under a mas- sive research programme launched by WHO. The other five are all parasitic infec- tions—malaria, schistosomiasis, filariasis (including onchocerciasis or river blind- ness), trypanosomiasis and leishmaniasis. More than 500 million victims suffer from these scourges throughout the world. Now WHO is stepping up research and intensifying the training of personnel so as to tackle these diseases more effectively and check the public health problems which they pose for many countries of the developing world. Leprosy itself is not a parasitic disease but a chronic ailment caused by the bacil- lus Mycobacterium leprae. Its effect is to trigger off lesions in the skin tissues and the peripheral nerves. Untreated, some 40 per cent of victims show some form of disfigurement. It affects people at all ages and of all races. wHo estimates suggest there are today between 11 and 12 million cases, most of them living in the tropical and subtropical regions of Asia, Africa and the Americas. The symptoms may take a variety of forms, depending on the degree of the patient's resistance to the bacillus. At one extreme is the tuberculoid form, when the human body has strong defences which prevent the bacillus from reproducing, and at the other extreme is the leproma- tous form, where the bacillus reproduces unchecked because any defence reaction is lacking. It is the latter form which is contagious. But in both forms of the dis- ease, unless treatment starts early, lesions begin to appear at the fingers and toes, on the face and in the eyes. For more than 30 years we have had an effective drug against leprosy, dapsone, which is cheaply and easily administered. Unfortunately it is far from being a per- fect solution. It acts extremely slowly, and treatment has to be continued for two or three years as regards the tuberculoid cases, and for five, ten or fifteen years— perhaps even for a lifetime—when the lepromatous form of the disease is in- volved. It requires a great deal of will- power to take a drug regularly over such long periods and many patients become discouraged. Others may stop taking dap- sone as soon as they notice a superficial improvement, and in such cases relapses are frequent. If the treatments available so far are not perfect, the progress that has been made is far from negligible. In some coun- tries where it has been possible to mount a well-organized compaign against leprosy, it has proved possible to reduce the total number of cases by as much as 75 per cent, after 15 year of efforts. But in many coun- tries where leprosy is endemic much re- mains to be done, particularly when there are many other public health problems to be tackled and resources are limited. This situation has therefore prompted new lines of research aimed at finding new weapons against leprosy, particularly specific skin tests, more efficacious drugs and, in the long term, a vaccine. Recent findings in the field of leprosy immunology have already suggested ways in which specific skin tests may eventually be developed. One type of test would enable carriers of the disease to be identi- fied who harbour the leprosy bacillus without showing symptoms, just as a reaction to tuberculin can indicate the carriers of a tuberculosis infection. An- other type of test—and this would be even more useful—would permit the diagnosis of leprosy at the onset of the disease, long before the clinical signs are clear enough to be detected. This would have the spe- cial advantage of enabling lepromatous cases to be recognized at an early stage when they are already contagious. With this aim in view, preliminary researches have already been carried out. One preparation has already been used in Venezuela, in regions where the endemici- ty of the disease is either high or average, and in Chile, in an area where leprosy is almost unknown. In Venezuela, 45 per cent of the people tested reacted positive- ly, while in Chile the positive response was observed in only three per cent. Simi- lar studies have taken place in Burma too. These results have yet to be confirmed, The age-old disease of leprosy is more p easily cured if detected in its early stage. Children whose parents already suffer from the disease are given special attention so that they can be assured of early treatment, like this West African boy. (Photo WHO/P. Pittet) 26 ~~ : into battle against leprosy Left: A small, healthy boy sits beside his mother whose feet and legs show the ugly lesions of leprosy. Early treatment, better drugs and eventually a leprosy vaccine should ensure that boys like him avoid the same unhappy fate. (Photo WHO/P. Pittet) Right : The quaint little armadillo, a native of the Americas, at last offers research workers a possible "breeding-ground" for the mass cultivation of the leprosy bacillus. This in turn at last gives the scientists a better chance of discovering an effective vaccine against leprosy. (Photo WHO) but they do suggest that skin tests can and will be developed which will infallibly show up leprosy infections and thus strengthen the hand of those who are fighting this disease. However, scientists are looking for a still more powerful weapon : an anti- leprosy vaccine. Recent developments al- ready suggest that it will not be long before this weapon too will be added to the armoury. A vaccine is a substance which, when injected into the human body, triggers off a defensive process to ensure that, in the event of a pathogenic microbe being en- countered, it will be prevented from caus- ing disease. Methods for preparing such vaccines vary widely according to the microbe concerned, but invariably the first step is to ensure that the microbe exists in large quantities in the laboratory. The same is true for the kind of skin tests referred to above : before they can be put into effect, appreciable quantities of the leprosy bacillus have to be available. Usually, large quantities of a microbe are obtained by cultivating it in the labo- ratory. Unfortunately, in the case of leprosy, nobody has yet succeeded in cul- tivating the bacillus. Since 1960 it has proved possible to obtain limited quanti- ties of Mycobacterium leprae extracted from the paws of mice, but this method of production is totally inadequate as a basis for producing vaccines or substances for use in skin tests. Since mass cultures of the leprosy bacil- lus proved impossible, the problem had to be tackled in another way. This bacillus is similar in certain respects to the causative agent of tuberculosis, and efforts have therefore been made to establish whether the BCG vaccine effective against tuber- culosis would also give protection against leprosy. Tests carried out in Burma over a ten-year period, with the technical coop- eration of WHO, showed that the protec- tion conferred by BCG against leprosy did not exceed 15 to 20 per cent. Nevertheless, the problem of obtaining large quantities of the leprosy bacillus is about to be overcome, thanks to a little animal of strange appearance and habits —the armadillo. In the wild, this animal lives only in South and Central America, and in the southern United States. It is not rare, and in many Latin American countries its flesh is regarded as a tasty local dish. It is a toothless mammal, about 12 inches in length, with pointed ears, an elongated head and sharp claws; but its outstanding feature is the brown- ish carapace or shell which covers its body like the armour of a primitive tank. The shell is interrupted at intervals by hooped bands varying from three to nine in num- ber, according to the species. Around 1971, when the zoological peculiarities of this animal were the sub- ject of a study in Louisiana, USA, resear- chers recalled the hypothesis that the leprosy bacillus reproduces more rapidly in certain parts of the human body because the temperature there is lower. It happens that the armadillo's blood heat is lower than that of man. A number of armadillos were accordingly inoculated with the leprosy bacillus. After one year, four in ten of the animals were found to have severe symptoms of the disease, and the bacilli had multiplied at an enormous rate in many of their organs. These findings aroused considerable in- terest, but all the problems had not yet been overcome. Not the least of these is raising sufficiently large colonies of the animals in order to inoculate them. The armadillo does not breed in captivity, and special precautions have to be taken to help ensure that it adapts to being caged. In spite of this, a number of centres in the United States, South America and even 28 Europe have succeeded in rearing colo- nies of a few scores of animals. If a start has been made, the road which it is hoped will lead us to the development of a vaccine is still a long one, and there are many obstacles to be dealt with. The bacilli have first to be extracted from the organs of infected armadillos, and then various substances will have to be pre- pared whose effectiveness on the immu- nological mechanisms of laboratory ani- mals can be evaluated. Only if these preli- minary studies prove conclusive can tests be started on the human body. The quest for an anti-leprosy vaccine is not limited to the use of products derived from the bacillus. Other microbes belong- ing to the same large family of mycobac- teria and more susceptible to being culti- vated may turn out to have the requisite properties to serve as a basis for vaccine preparation. Research is continuing into these possibilities too. All told, a great many hurdles remain to be crossed before the final goal of a valid leprosy vaccine is reached. But, thanks to the little armadillo, we now possess an abundant source of bacilli; a start has already been made on extracting the bacilli and preparing a few of the antigenic substances whose biological properties are being studied. The process of developing the vaccine and putting it into action will be long and slow, because of the complexity of the methods used and the need for carefully checking at every stage. Without doubt between five and ten years will elapse before the first tests can be made on man. But for the first time in the long history of leprosy we have embarked on a plan of research with a foreseeable chance of eventually develop- ing a vaccine. Meanwhile research is continuing into ways of treating the disease more effec- tively. We have seen that dapsone acts too slowly on the bacillus. In addition, relapses still occur among leprosy cases who have undergone regular and long- term treatment with this drug. There are two reasons for this: in some cases the bacilli develop their own immunity to dapsone, while in others they survive and remain active in parts of the organism where the drug cannot reach them. Ef- forts are therefore being made to find new drugs or therapeutic formulae which will prove better than dapsone. Two drugs have been put forward as being biologically more effective against the leprosy bacillus in recent years- rifampicine and clofazimine. However both of these have certain important drawbacks, and there is every reason to suppose that, if each is administered in isolation, the same problems of immunity and the survival of bacilli not reached by the drug will still arise. On the other hand, there is a reasonable chance that, if used in association with dapsone, these drugs might make the treatment more effective. Tests are now being carried out to deter- mine whether this is so. A number of other products whose chemical composi- tion suggest they might be useful against Mycobacterium leprae are also being test- ed to see whether, after the necessary preliminary studies, they might prove suitable as anti-leprosy drugs. Besides collaborating actively in the campaign against leprosy in the endemic countries, WHO is stimulating and coordi- nating research on a vast scale, aimed mainly at finding more effective drugs, skin tests which will identify infected indi- viduals—with or without symptoms—at an early stage, and the eventual develop- ment of an anti-leprosy vaccine. In this great effort, which has the backing of leading scientists from many countries, a strange little animal from the New World has a vital role to play. ■ 29 RESEARCH ORAL REHYDRATION New Weapon against Cholera and other acute Diarrhoeas by D. Barua and L. Thapalyal s the Sixth Cholera Pandemic pet- ered out to a finish towards the end of 1923, the disease seemed to lose its public health importance except in a few countries where it was endemic. Then in 1961, cholera reappeared in a big way catching much of the world by surprise and unprepared. That was the beginning of the Seventh Cholera Pan- demic which is still continuing. Caused by an organism designated El Tor vibrio, it spread rapidly from the Far East to parts of Europe, and established itself in Africa where it had not been reported for nearly a century. Prevention and control of the disease depends on safe water supply, proper ex- creta disposal and other sanitation facili- ties. While these long-term undertakings requiring heavy financial investments and skilled manpower were continuing in many countries, research was under- taken to improve immunization against cholera and develop better methods of treatment. Today, while cholera remains a serious and internationally important disease, it has lost much of its ancient dread, thanks to some treatment techniques developed as a result of recent researches. A typical case of cholera left untreated has no more than a 30 per cent chance of survival, and in the past a large propor- tion of its victims died. The main cause of death is dehydration—loss of body fluids and salt depletion. When the lack of fluid resulting from repeated discharge of watery stools equals one-tenth of the patient's body weight, dehydration becomes severe and, unless corrected, leads to death within a few hours. A highly effective technique of manag- ing dehydration was introduced in the early sixties, which resulted in bringing down the case-fatality rate among cholera patients in well equipped hospi- tals to as little as one to three per cent. But it is only recently that a simple and practicable method has been developed to make the treatment available to communities not served by hospitals. Cholera, typhoid and bacillary dysen- tery readily come to mind when one men- tions serious enteric diseases, but one is apt to forget sometimes that they cause fewer deaths than many other acute diarrhoeal diseases that are widespread in the tropical parts of the world. A number of these infections, grouped under the general heading, "diarrhoeas of child- hood", rank among the first three leading causes of death in the developing coun- tries, particularly among children. The high death toll is the result of loss of body fluid in children already debilitat- ed by inadequate feeding and nutritional deficiency. Diarrhoea aggravates nutri- tional disorders, and in turn, malnou- rished children become more susceptible to diarrhoea. The vicious circle thus perpetuates itself. It is against this background that one can see the immense potential of the new simplified technique. For although origi- nally developed as a tool against cholera, it is being applied equally effectively against the other acute diarrhoeas. WHO, therefore, through clinical trials, training courses and other means of communi- cation, has been propagating its adoption in communities in the grip of endemic diarrhoea. Simple, inexpensive and easy to adapt to local circumstances, the new method consists basically in successfully replacing the body's fluid loss by a solution which the patient can drink. Whereas until recently dehydration could be corrected only through the intravenous route, an expensive process and beyond the reach of populations not served by adequate health services. Treatment by oral rehydration has not only proved effective for both cholera and other acute diarrhoeas, but oral fluid of the same composition can be given in all of these diseases and to patients in all age groups. This is a major breakthrough. It is now possible for these diseases to be treated simply and inexpensively in many parts of the world not only by nurses and auxiliaries, but also by volunteers and mothers with a few days' training. The solution for oral rehydration recommended by WHO consists of sodium chloride (table salt) 3.5 grams; sodium bicarbonate (baking soda) 2.5 grams; potassium chloride 1.5 grams; and glu- cose 20.0 grams dissolved in one litre of potable water. Glucose is an important ingredient since it helps the salt and water to be absorbed in the body. UNICEF has launched a programme to make this formulation available in aluminium foil packages under the name "Oralyte", and to assist its local production. The more expensive intravenous fluid treatment can now be limited to patients in shock as a result of dehydration or those who are too weak to drink. Ex- perience shows that about five per cent of the patients that are brought for treat- ment are in a state of severe dehydration, and therefore require intravenous treat- ment. But after the initial treatment, the patient can be given the oral fluid to drink, reducing the need for expensive intravenous fluids by about 75 per cent. 30 Starting the patient on oral rehydration at home at an early stage of the disease can prevent severe dehydration and may also help in breaking the diarrhoea- malnutrition cycle. The efficacy of the technique was vivid- ly demonstrated in a calamitous situation in India in 1971 when its severely strained health services were confronted with an extensive outbreak of cholera and other acute diarrhoeal diseases among refugees who had entered the country from its eastern border. Faced by an acute shortage of intrave- nous fluids and of persons trained in their use, the responsible health officer in one of the refugee camps decided to switch to rehydration by mouth, reserving intrave- nous fluid for patients in shock. The deci- sion paid off handsomely. Nearly 4,000 patients were brought to the treatment centre within a period of eight weeks, two-fifths under age five. Of these 135 died (half of them before intravenous fluids could be administered) giving a case fatality rate of three per cent while the rate for the refugee population as a whole was 30 per cent. The new technique was developed in the Calcutta Infectious Diseases Hos- pital and the Dacca Cholera Research Laboratories as the fruit of years of research, in which a number of visiting scientists, particularly those from the Johns Hopkins University and the Centre for Disease Control in the USA, collaborated with local experts. WHO has just published a guide on the management of dehydration in diar- rhoeas explaining in detail the technique of oral rehydration. It is being given wide distribution as part of wHo's programme to develop and disseminate simple and effective health technologies that could be adapted by Member countries en- gaged in extending primary health care to their underserved rural and urban communities. The exact manner of introducing the new measure at the local level will be governed by the available health facilities and the cultural beliefs and traditions of the communities concerned. ■ Cholera and other diarrhoeal diseases> cause rapid dehydration of the victim's body fluids—a condition which, unless checked in time, can prove fatal, especially for small children. Where formerly an in- travenous drip had to be given at a clinic (inset), today there is increasing use of fluids which can simply be drunk from a cup. (Photos WHO/D. Henrioud and B. Cvje- tanovic) WHO NEWS IN FRO VI THE 29TH WORLD HEALTH ASSEMBLY 1,000 population) to 175,000 (8.2 per 1,000). Expenditure on such items as malaria, exanthematic typhus, typhoid fever, poliomyelitis, diphtheria, tetanus and pellagra has been either cut back to nothing or reduced to levels which no longer present a public health problem. Now we are faced to an increasing degree by non-communicable diseases and problems related to accidents, espe- cially on the roads. The birth rate is holding at 19 per 1,000, the overall mor- tality rate is 9.3 per 1,000 (less than half what it used to be), infantile mortality is 34.7 per 1,000 (compared to 179 per 1,000 in the past), and life expectancy is now 69 years compared with only 42 in 1938." Romania Dr M. Aldea — Vice-Minister of Health Director of the Institute of Hygiene and Public Health Dr H. Mahler, Director-General of WHO, with Sir Harold Walter, President of the Assembly. (Photos WHO) Learning from the healers The World Health Assembly held in Geneva in May brought together some 730 delegates from nearly all of the 151 Mem- ber countries of WHO. Here are some excerpts from the ad- dresses delivered by delegates at the Assembly. They indicate the variety of health problems still facing Member States today. Positive balance-sheet "Romania's budget for health care is now 18 times greater than it was in 1952... Over the past 30 years, the number of doctors and chemists has increased more than fourfold. We had 7,664 doc- tors in 1938, and today we have more than 28,000... Where before there were 1,300 chem- ists, now there are some 5,200, and from 11,360 health auxiliaries we have in- creased the total to more than 120,000. Today there is one doctor for every 630 inhabitants and a health auxiliary for every 178 inhabitants. We have 5,200 medical dispensaries, including 3,200 in country areas (against a total of 1,239 in 1968); and 4,279 oral health clinics- 1,444 of them in rural areas—compared to only 540 such units in 1938. The number of specialist surgeries now ex- ceeds 4,200, a great many of them run by two teams who alternate with each other in the polyclinics, of which there are more than 400; there were only 37 in 1938. The number of hospital beds has risen from only 30,800 in 1938 (1.98 per "Our health needs are so enormous and our resources so small at the pre- sent time that it can be said, without fear of contradiction, that the majority of citizens in the developing countries are still treated by traditional cures practised in the villages, and according to the knowledge and practical ex- perience of the healers. However that may be, our aim is not to transform our healers into salaried workers or bureau- crats. In this first phase, we are in fact learning from them, because they are the repository of an important share of medical knowledge in our country. In this field, however, experience has shown us the need to be on our guard against mere quacks, motivated only by greed... In fact, instead of creating an associa- tion of healers and local midwives, we 32 plan first to make a census of the genuine practitioners of traditional medicine, on the understanding that they will form themselves into an asso- ciation later. Our objective is of a very practical nature and consists of utilizing all the available means to care for our people... As for the herbalist healers, I have asked them to offer specimens of their potions to the Ministry of Public Health. The specimens will be sent for study in the laboratories of our national university. If they are not toxic, they will be used in the course of our health training. Contracts will be made be- tween the Ministry and the healers in the event of industrial manufacture of these drugs. We have been literally over- whelmed by the response. As regards the midwives, they will receive official recognition in the same way, but they will also have to undergo a two-month preparation stage after which they will receive a diploma. The villages will then be required to build "childbirth cabins", the equipment for which is already being sent by UNICEF, to whom I want to express our grati- tude." Benin Dr M. I. Bouraima Minister of Public Health Meningitis epidemic stifled "The epidemic of cerebro-spinal meningitis was the great challenge of 1975. The number of cases exceeded 130,000. We decided on vaccination de- spite the limited information available on the bivalent AC vaccine. Research enabled the public health authorities to develop a new operational methodolo- gy; as a result they distributed vaccines kept at 20 degrees below zero to the most remote communities of the coun- try, and vaccinated 81 million people in the space of nine months. At Sao Paulo, in a single day, 23 March 1975, 3,200,000 people were vaccinated. The epidemic was immediately stifled and research is now going on into the epide- miology, frequency and nature of the sequelae, the treatment, the immunolo- gy and the effects of vaccination. While the frontier populations were being vaccinated, citizens of neighbour- ing countries who came voluntarily to our centres also received the vac- cine without discrimination. More than 300,000 people were thus immunized, representing an investment of 160,000 dollars which may have contributed to protecting our brother nations against the intrusion of the epidemic into their territories." Brazil Professor de Almeida Machado — Minister of Public Health Integration of traditional and western medicine ..."Priority is given to the work of helping the medical and health workers understand better the importance of tra- Professor V. Ramalingaswami, Director of the All India Institute of Medical Sciences, who received the Leon Bernard Foundation Prize. ditional medicine, a valuable cultural heritage. We organized the private prac- titioners of traditional medicine to work in hospitals with an equal social status to doctors of western medicine. Doctors of western medicine are encouraged to learn traditional medicine and doctors of traditional medicine, for their part, learn the strong points of western medi- cine. In addition to the setting up of hospitals of traditional medicine, a department of traditional medicine is formed in most general hospitals. Medi- cal and pharmacological schools of senior and medium grades and research institutes for traditional medicine are es- tablished. In order to inherit and systematize the experience of veterans—of traditional doctors and pharmacists—who are ad- vanced academically or with special ability and skill, young and middle- aged doctors of traditional medicine, or doctors of western medicine with train- ing in traditional medicine, are assigned to assist and learn from them. All these measures inspire greatly the revolution- ary zeal and initiatives of the doctors of traditional medicine and pharmacists to contribute to the integration of tradi- tional medicine and western medicine and to the creation of a new school of medicine. In rural areas barefoot doctors (more than one million in number), fighting at the forefront in the prevention and treatment of disease, constitute the main force in the integration of traditional and western medicine. Our rural labour- ing people have accumulated much ex- perience in combating diseases. The vast plains and mountains in rural areas are rich in medicinal herbs and resources. Taking the rural areas as an important base, we have a strong force of man- power and inexhaustible material means to promote the rapid development of the integration of traditional and western medicine." China Professor Wu Chieh-ping — Chinese Academy of Medical Sciences Towards prevention and Primary Health Care "In the two years since the February 1974 revolution, important steps have been taken to develop prevention- oriented basic health services in the rural areas of the country: an important aspect of the Devel- opment through Cooperation Campaign was health education, with a view to preparing the population to participate actively in health as a community affair; the Ministry of Health and the Development through Cooperation Campaign have built over 250 health stations in two years. This is more than 50 per cent of what was built in the last 30 years; 33 From the 29th World Health Assembly — a modified, more preventive- and community-oriented training pro- gramme has been run, for what used to be called "elementary dressers", and this has more than tripled the yearly output in this category of health worker. The fast development of peasant asso- ciations and urban cooperative associa- tions has opened an important avenue for the development of primary health, care. The Ministry of Health has set up a study group to work out possibilities and alternatives. At present, the basic curriculum and other preliminary studies have been completed." Ethiopia Dr Y. Kitaw — Head, Health Section, Development through Cooperation Campaign and Head Department of Preventive Medicine Rebuilding the health network "In North Viet-Nam, the Health Ser- vice has made great efforts to recon- struct and strengthen the medical net- work built up over the years, and this network already ensures quite a broad nationwide coverage, from the capital to the remotest villages. We are trying to start more polyclinics and extend the dispensary system step by step in the towns and rural areas. We have suc- ceeded in restoring 4,500 hospital beds, representing 63 per cent of the total number of beds destroyed during the war. Today we have 24 hospital beds available at state cost for every 10,000 inhabitants, which is 20.7 per cent more than in 1973. Since peace was restored, the massive displacement of populations in both the North and South of Viet-Nam obliged us to take appropriate measures to pre- vent and check epidemics. Anti-malaria work is intensifying : in 1975, DDT powders have helped to protect 2.4 mil- lion people in the endemic areas. We are trying to improve the quality of health work in controlling such diseases as tuberculosis, trachoma, leprosy, endem- ic goitre and mental disease, as well as in treating the sick, scientific research, training of health personnel and so forth. In South Viet-Nam, health work has to face countless difficulties in trans- Dr N. Ramzi, Vice-Minister of Health of the Syrian Arab Republic, who won the Dr A. T. Shousha Foundation Medal and Prize. forming the health organization of the former Saigon regime—concentrated as it was in the large towns—into a new health organization which must serve all the people and must progressively be ex- tended to cover the entire country. We also have to liquidate as quickly as pos- sible the major endemic diseases like plague, cholera, dengue fever and ade- nopharyngial conjunctivitis, and must draw up battle plans against the other communicable diseases. The work start- ed a year ago has already given promis- ing results, it seems, but it is certainly a heavy task which will call for titanic ef- forts in the future." Viet-Nam Professor Hoang Dinh Cau — Vice-Minister of Health Malaria control means more food "The recrudescence of malaria is a source of deep concern not only to India but to many countries in the developing world. It is sometimes forgotten that the "green revolution" in India, which has produced this year enough food to feed our 600 million people and also build up some buffer stock, would never have been possible had it not been for the virtual eradication of malaria in the areas where the agricultural break- through took place. A major recrudescence, therefore, will not only be bad in itself but could well endanger the entire economic viability of a country. There are three major problems in this regard : the first con- cerning an adeqUate and continuing supply of insecticides at reasonable prices, the second the setting up of national organizations to ensure the optimum utilization of these insecticides, and the third the provision of antima- larial drugs for the treatment of the growing number of people suffering from this disease. I wish to stress that the wHo has to be far more effective in its assistance of the first and third elements that I have outlined if we are going to succeed in reversing the present alarming trend. Seminars and conferences on malaria are useful, but will prove sterile unless accompanied by concrete measures on the insecticide and antimalarial fronts." India Dr Karan Singh — Minister for Health and Family Planning Village health committees "We are very well aware that the elimination of communicable diseases is first and foremost a Congolese problem. The struggle against pollution of the en- vironment, water and food has to be un- dertaken by each and every individual. This is why we have set up our village health committees. At this level, the health officer tries to explain to the villagers how essential the sanitation work expected of them is, and from that point the community decides on the public health measures that are required. Our aim is to give the rural population access to the pri- mary care which will give the quickest results in safeguarding health. The fact is, in view of the lack of good rural communications, going to the dispensary 34 Authors of the month Mr ALASTAIR ANDERSON iS a journal- ist based in Geneva. Mr LALIT THAPALYAL, Mr JOHN BLAND and Mr GINO LEVI are infor- mation officers at the Geneva head- quarters of WHO. Dr HUBERT SANSARRICQ iS Chief of the Leprosy unit in \vim's Division of Communicable Diseases, and Dr D. BARUA is a medical officer in the Bacterial Diseases unit of the same Division. WORLD HEALTH HEALTH and the aiakty of ife -";11 - • 11 oil, , ' -14 lli Ii' LA SANTE et la quahte de la vie ,''' V"'' VOW ........ the quality of depends on a decent shelter... Le sante est function d'un logis dkent... ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* One year 10.— Two years 18.— Three years 24. 25. 45 — 60 One year : Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: "or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Poster display at the Assembly depicting health and the quality of life. often constitutes an insurmountable problem for the peasant. This has convinced us of the need to develop the health agent appointed from his own settlement or from the local co- operative farm, and who thus becomes a very valuable auxiliary. The Congolese Government appre- ciates the position taken by our Organ- ization as regards the upgrading of tra- ditional medicine ... Our medical and pharmaceutical colleagues are in the process of taking a census of Congolese healers and organizing them with a view to drawing up a national herbal register. A centre for research into traditional medicine is being created to undertake pharmaco-dynamic studies of all the plants that the local healers. use." Congo Dr Kouka-Bemba — Minister of Public Health and Social Affairs Self-reliance "In the field of public health as in all other fields of economic development, the principle on which we base ourselves is that of reliance on our own efforts. The People's Republic of Albania today produces electromedical apparatus: pharmaceutical and immuno-biological products are sold in large quantities, and in a few months' time the first Alba- nian antibiotics will be available. Health protection in our country is well developed and year by year it ex- pands in both town and country. This expansion has been constantly accompa- nied by improvements in the quality of the services, made possible by the train- ing of cadres at all levels and by increas- ing the numbers of basic specialists... These measures have in turn permitted us to resolve the most complex of prob- lems in the medical field. Under the laws of the People's Republic of Albania, all the costs of health and social institu- tions, whether in the rural areas or the towns, are covered by the State. Fifty- five per cent of the hospital units and 95 per cent of the ambulances in our coun- try are located in rural areas... Among the general prophylactic mea- sures we have to undertake... the battle against contagious diseases has a special place. The efficacy of these measures has enabled us to keep these diseases under complete control, with the result that they are declining from year to year." Albania Professor S. Capeli — of the Faculty of Medicine, Tirana for readers everywhere Gne of WHO's prior sties is to ensure tha basic heath care eople even rural