(WP/RC16/Min/3 Hev.l) "--
MJNtJl'ES OF THE THIRD MEmrING
Centr.aJ. OfficiaJ.s r Training Institute Friday, 17 September 1965 at 9.00 a.m. CHAIRMAN: Dr Youn Keun Cha ~
'-
1 2
CONTENTS
Addre ss by incoming Cha1rm.an •.••.••••.....•......•....•.•..•.
137
HeaJ.th in relation to demographic questions .••••••••••••.•.•• l<8teriaJ. support of the programme for global eradication of smallpox by countries in the
139
3
Western Pacific Region ••••.•••.••..••••••••• &................
158
4
Statements by representatives of non~governmentaJ. organizations in officiaJ. relations with WHO •.••••••••••••••
168
5
Poliomy-elitis ....••........•......................•..........
169
.- 133 -
l34 Third .!eeting
Friday. l1 September 1965 at 9.00 a.m. PRESENT
I.
Representatives of !ember states Dr H.E. Downes Dr Aka Toua Dr C.J. Ross-Smith
CAMBODIA
Dr In Sokan Dr Keo Pbann Dr C. K. Chang Dr T.C. Hsu
CHINA
Medecin GeneraJ. M. Orsini ..... Medec1n Co1.one1 Thenoz . JAPAN
Dr N. Tatebayashi Dr J. Urata
IAOS MALAYSIA
Dr Koukeo Saycoc1e Dr L. W. Jayesuria
Dr R. Dickie
NEW ZEALAND PHILIPPINES
Dr C.N. Derek Taylor Dr C. S. Gatmaitan Dr T.A. Gomez
Dr A.N. Acosta Dr N. C. de Andrade Dr M.F. Matias REPUmJ:C OF KOREA Dr Youn Keun Cha Dr Yang Won Pak Dr Sang Tae Han
Dr Taek n Kim Dr Chang Dong Min Dr !fyang Jong Park
REPUBLIC OF VIm'-NAM
Dr Ie Cuu Truong Dr C.H. Gurd
MtNtm:S OF THE THIRD MEm'ING
135
UNITED STATES OF AMERICA
J. Watt R.K.C. lee J. Iewis D. W. Ruthig Dr H. A. Tucker Lt. Colonel H. W. Fleming Dr Masashi Makabe Dr Dr Dr Dr Dr J. C. Thieme
wES'l'ERN SAMOA
II.
Observers of Non-Member states
SINGAPORE
Dr Thong Kah leong
III. Representatives of the United Nations and Specialized Agencies UNITED NATICl'TS CHILDREN'S FUND IV. Mr A. E. McBain
Representatives of other inter-governmental organizations Colonel Eu1 Shik Kim SOUTH PACIFIC COMMISSION Dr G. IJJison
V.
Representatives of non-governmental. organizatiOns INTERNATIONAL COUNCIL OF NtJRSm3 IN'l'ERNATIONAL FEDERATION OF SURGICAL COLI.JlX}ES INTERNATIONAL HOSPITAL FEDERATION INTERNATIONAL UNION FOR CHILD WElFARE IN'l'ERNATIONAL UNION FOR HEALTH EDroATION LEAGUE OF RED CROSS SOCIErIES MEDICAL WOMEN'S IN'l'ERNATIONAL ASSOCIATION
Miss S. Y. Hong Mr P.W.C. Mao
Dr V.R. de Ocampo Dr M. Chua Chia.co Dr J. Ortane z Dr J. Franklin-Adams
Dr G. IJJison Dr Y.C. Kim Dr C.H. lee Dr C.T. Kim
136 THE WORLD MlIDICAL ASSOCIATION WORLD vmERANS FEDERATION VI. WHO Secretariat Dr C. J • Ross-Smith
Vice-Admiral S.H. Lee
Dr M. G. Candau SECRErARY Dr I.C. Fang Regi0naJ. Director
and Dr A. C. Reyes
Assistant Director of Health Services
KrNUTES OF THE THIRD MIllIlIrING
137
1
ADDRESS BY INCCMmG CHAIRMAN:
Item 5 of the Agenda
The CHAIRMAN extended a warm welcome on behal.f of the President and the people of the Republic of Korea to all representatives and to Dr Candau, the Director-General. Dr Candau's visit and his attendance at the meeting
were proof of his deep and abiding concern for the health and welfare of the peoples of the Western Pacific Region. The duty of the Regional Committee was to review
WHO activities in ~mber
the Region, to discuss the problems encountered and to explore how countries could help each other to improve health conditions. The
Fifteenth Annual Report of the Regional Director showed that WHO had greatly contributed in the last fifteen years to the development of health services. The overall situation was much better today than it had been fifteen years ago. However, a tremendous amount of work still remained to be done.
Environmental health was still of paramount importance in developing health services. Communicable diseases would, for many years to come, TyphOid, Japanese encephaJ.itis and pol1o-
be a major health problem.
myelitis had long been recognized as important diseases in the Region. Smallpox had been eradicated, but its re-introduction should be prevented by immediate measures. El Tor cholera showed signs of becoming endemic It could be
and this situation should not be allowed to continue.
prevented by strengthening national control and by mutual co-operation in the application of the International Sanitary Regulations. The SUbject, "Health in Relation to Demographic Questions ", was included in the agenda. This was very welcome because the problem In man's past history, a period
of population was the problem of the present.
growth of population might have meant a national power,
138
RIDIONAL COMMITTEE: SmEENTH SESSION
-. of-.Pz:-O~per-ity.and.
individual well-being.
Today, however; there Were: many
areas in which a rapid increase in numbers threatened a reduction in levels of living and eventually reduced the health of the :people. The
Eighteenth World Health Assembly had unanimously agreed that programme activities in the health aspects of world population might be undertaken by WHO. Korea was now carrying out an active family planning programme
and he would bring this matter to the attention of the Member countries during the discussion of this item. Public health work, in the same way as work in other fields, could not be successful without the interest, understanding and co-operation of the people. They must be equipped with a proper knowledge of health
and should assume responsibility for their own health betterment as individuals and as members of families, communities or governments. topic of the Technical Discussions at this session was E;ducation services in National Health Progr~s ".
The
' 'l:'h.e
Use. of HeaJ,th
-.
He hoped the .discus.
sions would encourage and support government efforts to develop health education services at national, provinCial and territorial levels. t~
The
had now come when it was essential for each country to embark on
long-term national health planning which should form part of the overall national effort to obtain the desired economic and social development. In closing, the Chairman referred to the election of a new regional director and the departure of Dr I. C. Fa.'lg, who would retire on 30 June 1966 after a long and successful service as regional director. He had
been the found.er of the WHO Regional Office for the Western Pacific and had devoted himself to the inlProvement of regional health.
He deserved
the heartfelt respect of all the peoples of the Region.
The Chairman
M:rnUTES OF THE THIRD MJm.rING
~39
hoped that the deve~opment of health services,which
Dr Fang had stimulated,
would continue and that what he had. achieved would progress even further in the future.
2
HEALTH IN RELATION TO DElroRAPHIC QUESTIONS: (Document wp/Rc~6/7)
Item
~4
of the Agenda
The REGIONAL DIRECTOR referred to the reso~ution ad~ted at the ~ast
session of the Committee to demographic questions.
e~hasizing
the
~ortance
of health in relation c~y had
Following the meeting, a
been sent to
countries and territories in the Region, with a letter asking for information on: (a) studies carried out on demographic problems,
especially as regards the effects of population changes on health programmes; (b) training programmes on demography that had been or were
being organized by educational institutions and Whether or not these had been incorporated in the curricula of public health training pro-
grammes;
(c) their opinion as to what further action should be taken
in the near future. Twenty out of thirty-two goverrments to whom the resolution vas sent had rep~ied.
A summary of the replies received was contained in Also attached to the document were annexes showing
document wp/Rc~6/7.
the various studies which had been carried out by the regional office secretariat. The Regional Office would welcome further information
from goverrments concerning population stUdies in relation to health
.
conducted in their countries, with a view to facilitating the free exchange of information on the subject.
140
SIXTEENTH SESSION
. The
DIR.ECTOR-~'ERAL
stated that during the discussion of the
resolutions of the Assembly of regional interest at the first meeting, the lRepresentative from the United States of il.merica had mentioned the resolution approved by the World Health Assembly on the subject of health aspects of wor1d:population. It he.d then been suggested t~at
any comments on this resolution would be nade under this item.
It
would be reoalled that at the request of the Exacutive Board hd had presented a report to the Eighteenth Horld Her,lth Ass;;;m'bly on progra'l".me activities in the health aspects of world population which might be developed by WHO. The report (document itlS/F&B/4),which contained IIp
information about what WHO was doing
to the present and on what
might be planned for the future, had been discussed during the Assembly. As indicated in the report, th0 research on human Teproduction. progl'n:Yl;~C
so f·!ir deve1op(;d related to
It listed a certain numb.;:.r of
scientific groups, to be precise: eiCht, that had been or would be convened ly the Organization in 1963, 1964 and 1965, to study t.'1e different aspects of human reproduction. subjects: They dealt with the following
the biology of humanrepl'oduction; the physio10gy.9f lacta-
tion; the effects of labour on the foetus and the newborn; neuroendocrinology and reprodUction in the human; mechanism of action of sex hormones and analogous substances, especially the orally active progestogens; the biochemistry and microbiology of the female and male genital tracts; the immunological aspects of human reproduction and the chemistry and physiology of the ~~etes.
The last two subjects
mentioned would be considered at meetings to be held towards the end of 1965, one in Q::tober and the other in November. The first five
MINUTES OF THE THIRD MEEl'ING
141
subjects had been considered by scientific groups in 1963 or 1964 and their reports had already been published. In the report he had sub-
mitted to the Eighteenth Horld Health Assembly, reference had been made to the q'_lsstion of a bibliogra:r;hy of the ethnic and geographical variations in hurn:m roproduction and r~
critical review thereof.
Under
the heading of services to research mention had been mdde of the establishl11',mt of collecti0r,s of h'.l.'Tlan pituitaries and the possibility of estD.hlishing an information centre on steroids and polypeptides.
... "
Under this heading also i t hlld been stated that the advisability of establishing iln information cuntre on human cell lines held been studied and t!1"t viOrk 1.wuld shortly be beginning on an inventory of res02.rch institutions anci research scientists engaged in research on human reproduction. Among the studies that had been carried on by
the Organization were the "valuation of available data on safety of orally active gestogens gnd their dose-r~nge;
the possibility of
establishing an inform·3.tion Rn1 supply centr" for new and existing laboratory ccnimals to fa.cilitate the stl.dies in human reproduction; and the health aspocts of population dynamics. \>IHO's programme of
research in human reproduction had been previously considered by the Advisory Committee onM-Jdical Rese3.rcn. This year the Advisory
Committee on Iledical Research hetd again considered the subject from the point of view of the health '3spects of population dynamics under the follmlL,g headings: th," medical and social factors of fertility;
future mortality and fertility trends and their effect on population change; and the inter-relationship of population trends and health services.
142
RIDIONAL COMMI'I'rEE: SDI.TEIImI SESSION
He thought that this gave a general idea of the type of the programme
up to the end of 1965.
In the· same document, he bad proposed some eJq>anIn this part,
sion of the programme under the title "Future Programme n.
reference was made to a documentation centre for biomed.ical litarature on all aspe~ts
of human reproduction; the studies to be carried out on
medical aspects of sterility and its relief and on the medical aspects of fertility control methods; the health aspects of population dynamics; and finally, advisory services to governments. TIlis document had Deen discussed in the Assembly in what ·might be described as an extremely constructive way. the previous day, there had certainly been a As Dr Watt had mentioned consider~Gle
change in the
Health Assemblyls attitude to discussing problems rel8.tedto population and human reproduction. The Eighteenth World Health Assembly had shown There were, however, many diffi-
a great understanding of the problem.
culties related not only to the medical aspects but to the cultural background of the different countries. Assembly had adopted resolution which read as follows: IIConsidering that the changes in the size and structure· of the population have repercussions on health conditions; Recognizing that problems of h~~ reproduction involve the family unit as well as society as a whole, ruld that the size of the family should be the free choice of each individual family; Bearing in mind that it is a matter for national administrations to decide whether and to what extent they should support the provision of information and services to their people on the health aspects of human reproduction; After a long discussion, the the most important part of
~\18.49,
MINUTES OF THE THIRD MEEl'ING
143
.Accepting that it is not the r0sponsibility of WHOt.o endors" or promot,; any p3..cticuLr population policy; cmd Fot:',.ng that the sci(mtific knowledge with regard to the biology of human reproduction and the medical aspects of fertility control is insufficient, 1.. li.PPRCJvES the report of the Director-General on Programmd Activities in t.he H'3o.lth Aspects of vJorld Population lIihich might be dsvdoped by liHO; 2. REQUESTS the Director-General to develop further the programme proposed:
(a) in the fields of reference services, studies on medic:!l asp3cts of sterility and fertility control methods and hGalth aspects of population dynamics; and (b) in the fi,ld of advisory services 3.S outlin",d in Part III~ paro.graph 3, of his report, on the und2rstanding th:"t such services are related, within the responsibilities of WHO, to technical advice on the h3alt.h aspects of human reproduction and should not involve operational activities; and 3. REQ,lJiSTS the Director-General to report to the
Nineteenth Tlorld Health Assembly on the programme of WHO in the fL.lld of hu.-nan reproduction. II Following the Ass,,::mbly, he had, as he had stated earlier, presented to the Advisory Committ'Je on M<:1dical Research three papers for considc-;rnotion 'lnd'~r
the
g8D<3r9.1
heading of the health aspects of population
dynamics.
Th8 Committee had recommended that more work be done in this Some preliminary action
field in accordance with the reports presented.
had also been taken to establish a documentation centre for biomedical literature in all aspects of human reproduction. The entire matter
was extremely complicated and rather difficult because it was WHOIS duty to mo.ko available information that was as unbiased as was humanly possible. .As far as advisory services were concerned, it was quite
clear that tho Organization must be prepared to give advice, on
144 ~mbers
request, to the health administrations of its Members.
and Associate
There were plans to have annual meetings of scientific groups
on the use of gestogens and of inter-uterine devices to review the available information. countries. The results of these reviews would then be sent to all
Dr Watt had been the chairman of the working party that had
drafted the Assembly resolution.
He knew'that the statement regarding
the development of a programme in the field of advisory services ;ias to be interpreted by the Director-General as he thought fit. The Director-
General then stated that after a meeting held in Geneva by a private . organization to consider questions of human reproduction, he had had the opportunity to talk with representatives of several countries attending that meeting and one of the things they· 'Were all wor:t'ied about was the question of the evaluation of the different programmes. This was a
field into "Which WHO could go without any restriction and it was his impression that this would be one of the first activities that WHO would undertake. He believed that this matter was now open for discussion in
all forums of WHO, that was in the Regional COmmittees, the Executive
Board and the Wcirld Health Assembly.
Such discussion would no longer
be inhibited by the emotions ~t some' twel~'Years' ago, when the matter' had first been raised in the Health AsseiDbly.
It was now a purely
technical. one which could perfectly legitimately be· discussed by technical. people. Dr HSU (China) stated that the rate and pattern of population
growth would directly or indirectly affect the type and quantity of health and medical care programme that was needed for the community. In most
ot the countries in the
Region~
the maJor demographic concern
· MINUTESOF' THE: THIRD MD1'ING
seemed to be.wi.thfertility, wh.ich still remained high,.anct. its alJ,.ied health problems •. He was pleased to report that the Chinese Government had made an effort in this field during the period under review. First
of all the crude death rate in Taiwan had dropped further from 6.1 per 1000 in ·1963·to 5.7 in 1964, a reduction of more than 6 per cent. One .
.....
,
of the most rapidly expanding programmes ,ras that of family planning, which had started in January 1964 in one county only , but which now covered tho entire province. The health authorities had assumad
responsibility for the education and motivation of the people and actual service was provided by the Haternal and Child Health Association, which ,ras the Lippes loop. 0.
voluntary organization.
The main method used was
By the end of June 1965, 104 112 married women,
against a target of 600 000 for six years, had already accepted this device. This number was equivalent to 8.1 per cent. of the total Th·:; 'faiwan Population
married women in the age-group 20 to 39 yours.
Studi8S Centre of tha Provincial Dl;)partment of Health was conducting related demographic surveys and stuclic,s, and making evaluations' 'to ensure th", wise use of money and manp01ier • Seminars in pUblic' health
demography had be~:;n or;~nized by the· C:"r,t::.'u in three medical colleges.
-.
~1e
Centre also provided training opportunities for students from More than two hundred visitors in
110m3 and ·;t')road on the subject.
fifty groups f:roffi f1ft3en countries had been racei ved by the Centre last year. Bet',isen 1963 and 1964, thGre had been a 5 per cent. The actual This
red1lction in tho crudE.: birth rate, from 36.3 to 34.5.
number of births had also decreased from 424 250 to 416 609. had happened for the first time in the past twelve y"ars. His
Government was very much concerned with the question of health in
146
relation to delOOgraphic questions, particularly the relationship oet-ween high 1'ertUity and the heal.th of mothers and children. To answer this'
question, .an effort was being made to include a few questions in the 1966 cenf!US schedule on the number of births and deaths of children. The information thus obtained would be anal.yzed by the socio-economic
status of the respondents.
In conclusion, it was desired to make the
following recommendations in .connexion with the topic:
(1) that a seminar
on population problems and family planning should be organized by the Regional. Oi't'ice for the Western Pacific to exchange information and knowledge on the subject and to promote related studiesj (2) that the Regional.
Office might consider establishing a post of adviser in public heal.th delOOgraphy to stimulate, promote and co-ordinate related research and other activities. Dr laM (Korea) stated that he would make brief comments on two
factors only:
infant IOOrtal.ity and induced abortion.
The infant mortal.ity rate had declined rapidly during the last
few decades.
According to Population Bulletin No.6 of the United
Nations, issued in 1962, the percentage changes in crude death rates and infant mortality rates between the periods 1935-1939 and 1955-1958 for Asian countries with complete statistics showed. that a remarkable decrease in infant and general. mortal.ity had talten place. The percentage
decreases in .crude death rates ranged from 43.5 to 73.1 and in infant mortal.ity rates, from 48.4 to 76.2. !vbch of the decline in general.
mortality between the two dates was due to the decrease in infant mortality. However, in Korea the infant mortality rate was stUl
MINU.rES OF THE THIRD MEEll'ING
147
high, especial.ly among the rural population.
It was estimated at about
70 in 1962, as compared to 26.5 in Japan and 31.4 in China (Taiwan) in the same period. A study in rural. Korea bad shown that the infant
mortal.ity rate bad increased sharply among children in the seventh order of birth and nearly doubled among children in the ninth order of birth. Further, while the average rate was 83 per thousand during 1954-
1959, the crude rate was over 40 per thousand during the same period. Another study bad ShOrnl tha.'1 94 per cent. of the total. deliveries bad been helped at hone by untrained attendants, such as grandmothers, other relatives or neighbours. Only
3 per cent. bad occurred in hospitals or
maternity homes and the remainder consisted of supervised domiciliary deliveries. From these studies it was assumed. that the high birth rates
and the lack of a maternal. and child health service were major factors related to the high infant mortality in Korea. To bring this down, it
was necessary to have adequate spacing and limitation of childbirth by mothers and the improvement of the general maternal and child health service. Induced abortion was an illegal procedure in Korea. However, it
had been reported that this was being practised for socio-economic reasons. A survey recently undertaken in Seoul had reveal.ed that the
incidence of induced abortion was apprOximately 25 per cent. among married 'WOnen between tvrenty and forty-four years of age. tions for the last three years showed a rapid upward trend. ObservaThus, for
the tine being, this upward. trend would probably continue until contraception was known and successfully practised by married couples in the
.....-
child-bearing age group.
In the same study, it bad been noted that
SIXTEENTH SESSION
the induced abgrtionrates
wer~
1.6 per ·cent. and 3.9 p,'r cent. during. rospect~vely,
the first and second' pregnancies,
and 29.1 per cent. •
and 34.6 pel' eent. during the sixth and <;eventh pregnanCies, respectively. During the ninth pregnancies, the rate was ne:3.rly 60 per cent.
Nost of the unwanted pregnancies were terminat.cd in induced abortion under illlilgal and insanita.ry conditions. Unwant"d pregnancies sho'Il1d
be' prevented and the necessary induced abortions should be performed under sanitary conditions. The government h.Ja.lth 'starr fully realized that 1 t was their responsibility to provide as soon as possible the necessary information and services to the people about family planning, in order to reduce both the rate of population increase and the rate or induced abortion. mot~ersl
Conc(;lption control'::wa6 a' prel1eui;..};'I,,<e
_~ .:bo- 'p!"O"bec1:;.trnr-
health and, as such, was an integral part of the maternal
and cr..ild health programme. His national Goverr~~nt polic~
had adopted a
f~
planning service as its s~rvice
,and the maternal aDd child health ~.1962.
had started action
to impl.emen t .thr.:: progralTl!l1e programme vms
As the rallily ev.id~nce.
.plan~g
only thrEJ8 years old, valid
indici).ting a downHowever, it was •
ward trend in the birth rate was not yet available. hoped thc~t
if the progr3mme was successful, the annual population
increase wauld decline from the rate of 2.9 per cent. in 1962 to a level of 2 per cent. by the end of 19'71. In closing, jjr Kim re>ld a summary of an article written by Dr JOtUl Zveratt Gordon, Professor of Preventive Medicine and ~idemio
logy, Harvard School of Public Health, entitled "Public Health in an
MINUTES OF .nm .TlURD. WSEn'ING :
-
OVar-PopillatedWorld" in which it has st'.l.ted that:
liThe solution to
the population problem w~e to increase production of material resources and to limit numbers of births. among health problems. Tho latter is cl",arly to be recognized
Being in large part responsible for population
growth through success in lowering death rates, public health has a moral obligation to aid in and his environment. ~chi~vinb
an p.cologic balance.
betwe~n
man
It h<lS the faciliti03 for an active part in
research, services and education directed toward lowering birth"rates. Public h€alth centres exist. More must be provided and traditional
services expanded to include a control of births as well as deaths." Dr SAYCOCIE (Laos) noted on page 4 of the t'rench text of the document, that data on population for some countries ,lere not avz.ilable. His Government had intend;;;dto undertake ,'1
population census, Only a partial
but the present political situation did not permit it. censUS could be made in areas which were secure. . , '
Studies concerning
population growth, mortality, fertility, distribution of population, etc. 'according to age groups had--beenmade bY'-srrrng-:experts attached to international organiz'.ltions operating in Laos. The I"aotian popula-
tion had been estimated by tho statistical services of Laos at about 2 635 000 inhabitants; however, t;w real population was i:)stimated to be 2 450 000 in 1962. crude birth rate The last population survey had indicated the .. ~
as 4.7 per cent., the cr1,ldc death rate 2.3 per cent • For the next
and. the crude population growth rat.e 2.4 p('r c~nt.
fifteen years the population growth rate should not be over 4.4 ~r cent. On this basis the Laotian population around 1980,muld be
about 3 760 000.
A fellowship had been awarded by i-!HO to penni t a
150
REnIONAL CGlMI'l'TEE: SmEENTH SESSION
Laotian doctor to study in France. this fellowship set up.
It;res hoped that with the help of
a special service for health population studies would be
Dr ANDRADE (Portugal) provided the Committee with figures that -were
lacking in the table on pages 5 and 6 of document WP/RC16/7 in respect of Macao and Portuguese Timor. The census of 1960 had established the
population for Macao as 187 772 and that of Portuguese Timor as 517 079. In 1964 the population of Macao ;res estimated to be about 300 000 and in
Timor, 552 000.
He admitted, however, that there ;res an under-registration In Macao, there -were difficulties in providing more
of births and deaths.
preCise information because of the great number of people coming from the continent. Dr TRUOOG (Viet-Nam) thanked the Director-General for giving the Committee a complete picture of the population problems in relation to health and the work carried out by WHO. This tluestion had been examined
in all possible aspects during the Eighteenth World Health Assembly in Geneva. He then stated that he would provide the Secretariat with
additional information on percentage age distribution of the population and on the nedical and paramedical force in Viet-Nam to bring the document up-to-date. The population of Viet-Nam ;res estimated at about
14 000 000 in 1960 and in 1970 there would be over 18 000 000. The question of birth control did not arise at the monent in
V:i.et-Nam, although this problem was ;Uiij;>ortant because it ;res linked to socio-economic, health and political questions. There;res legislation
•
prohibiting any propaganda for birth controi although a doctor in special cases could proceed with abortion or even try and advise certain
151
physiologicaJ. methods. The NationaJ. Institute of. Statistics bad carried out certain stud.ies and released figures, which, due to the war conditions, were not quite accurate. His Government fully realized the importance of
the population problem but at the moment the question of birth control would have to be left to the future. However, the 'WOrk being carried out
by international bodies in this field was being followed with interest. Dr ORSINI (France) stated that the NationaJ. statistics Bureau in
Paris had released information on the 1963 census in New Caledonia, after the WHO document had been distributed. He 'WOuld give these figures to
the Secretariat later so that the tables in the document would be complete. At this stage, there was no quef1tion of birth control in New Caledonia alt~ugh between the 1956 and 1963 censuses the population had increased
from 68 000 to 86 500 and in 1964 the estimated figure was 88 899. Bet'Ween the two censuses the total increase had been about 26 per cent. As indicated in the table annexed to the document, New Caledonia had a population density of 4 inhabitants per square kilometre. Manpower was On the
needed and for the time being there was no population problem.
other hand, New Caledonia was part of the French Republic and all decisions to be taken concerning population questions must be initiated by the ~tropolitan
Country.
The relation of the birth rate to public heaJ.th
was realized, but there 'Were practicaJ. reasons for not undertaking birth control in New CaJ.edonia at this time. Dr Orsini added that the state-
ment he had made in the last session· remained vaJ.id •
•• Dr GATMAITAN (Philippines) said that the population of the
Philippines was baSically young, as evidenced by the fact that 45.63
REGIONAL COMMITTEE: SIXTEENTH SESSION
per cent.,or almosb one-half of the total population, consisted of children below fifteen years of age. Infants alone represented about The
3 per cent. and children under five years about 20 per cent. Philippine population at presen~was
characterized by a phenomenal ';"t this rat", it "ns Forces favourable to a rise
rate of growth of 3.06 per cent. per year. expect",d to double in twenty-three years.
in the fertility rate, such as those that came about through thd
improvement of health conditions, ware presently at work.
In 1963
the fertility rate had been eomputed to·be almost 136 live b~ths per thousand in the fifteen to forty-four-year old females. The
recorded birth rate in 1963 had been 27.7 per thousand population. However, as the registration of births in the Philippines was incomplete, it was thousand. calculat0.~Lthat.
th;:; birth ra.to lTOuld not be.. less 50 per
There was a steady and significant declining trend in the In 1963
mortality, the crude infant and maternal mortality rates.
the recorded crude and infant mortality rates had be5n 7 per thousand and 66.6 pJr thousand, respectively. However, because of under-
registration, not only of births but also of deaths, these were calculated to be about 10 per thousand and 51.6 per thousand, respectively. l'he h8alth implications of' these demographic statistics
were important. because in the planning and programming of health s ervices consideration must be given to age composition and rate of growth. Attention must be directed to the two most vulnerable
•
segments of the population, the children and the mothers, with a view to the development and implementation of a rounded programme of maternal and child heal~h.
MINUTES OF THE THIRD ME:EI'ING
153
Nention h:.d been made.of the r\3so1ution adopted by the last World Health Assembly. The Director-General had discussed in detail the
health aspects of world population and emphasized trB need for research in the medical aspects of human reproduction, fertility, population growth, etc. The Philippine delegation .rished to put on record that
it was in full accord with the contents of the resolution, since it believed that discussions on the medical ~spects
of population growth i t could not
would help solve this very important problem. go beyond that for hlO r'3asons:
P~wever,
(1) the Philippines was a highly
religious and predominantly Catholic country and therefore any discussions on family plar~ing
or population growth might be objectGd to by
the women of the country; (a) neither the Department of Health nor the Philippine Government had any official stand on the matter. As a matter
of fact, his delegation had had no official instructions and therefore could not make any official comment on population growth other than the medical aspects referred to. Dr TATEBAYASHI (Japan) asked that Japan should be added to those countries mentioned on page 3 of document HP/hC16/7 which were conducting training courses and research in derrDgraphy since these were part of the regule.r activities of thG Institute of Public Health, which ..las a government organization. Dr viAT·r (United States of Americo.) said t hat the mernb"rs of the drafting committee previously referred to had worked very hSlrd and very long; eight hours had in fact been spent on the production of this resolution. It might be useful to mention that the word
154
RmlcmL CCHU1'rEiS: SIXTEENTH SESSI<W
"operational activity", Wichhad been discussed at length by the drafting committee was used in the context at the work of WHO. The example of an
operational. activity which was given, and which was expressly forbidden in this resolution, was when WHO, upon the request of the United Nations, had actually become the operating health .organization in the Congo. The
Committee unanimously believed that WHO should not operate any form of population control activity but that this function must· be carried, on by the country concerned. particular words. all the duction. Two points had been mentioned during the morning discussions which ~mber
This was the reason for selecting those
The :r:esolution provided, the opportunity for WHO and
States to consider the medical aspects of human repro-
were significant.
The Philippine Representative had referred to the
importance of the women I s groups in creating the attitudes of the government and of the people as a 'Whole. He believed it was equally. important
to cite what the Korean Representative had said about induced abortion. It was quite clear that in Korea the women were playing a major role in deciding wh~t should be done about the children and about the size· of the family. The youn~r women, those with their first and second childrell. 1
obviously wanted them as the resort to illegal. abortion was verY, rare. On the other hand, when the family had clearly reached a size which ., made it difficult for the parents to provide adequate shelter, food and clothing, the women resorted to the illegal and very dangerous procedure of induced abortion. A conscious risk which they took because
of their love of the children and not because of their dislike of them. There should be more understanding of the f~elings, the desires and .
MINUl'ES OF THE THIRD MEm'ING
155
the needs of the women, who are concerned not only with the needs of bringing up the children, but of providing them with the supporting features so necessary to make them grow up as full partiCipating members of the social world into which they were born. A better Ym.y of communica-
ting with them was required so that they knew of the opportunities which existed for them to plan seriously for, and raise, that size of family which could be most effectively a part of the sociaJ. order in which they lived. There were available methods of sampling of population growth and trends which could be ad.apted to and used by the various countries. The
census taken once every ten years, or whatever the period might be, was necessary in order to continue the flow of information which had existed in the past. It had, however, been brought to,:his attention by people
working in the demographic field that this was not enough as it did not clearly differentiate the problem areas sufficiently. It seemed there
was need to develOp a way of study -which would differentiate within a population group between those who required information about family planning and those who already had it.
In the United States, a high percentage of the people were vlell aware of bow to plan the size of the family and follow the techniques available which were consistent with their religion and family background. There
were, bo"Wever, significant segments of the population which did not have this information. Many of these people lived in areas where the actual
.
land mass available was quite large, but the amount of land and resources available to them as a family was very limited. There was, therefore,
the paradOxical situation of overcrowding within the confines of the
156 family. The same problem existed 1hthe cities where there 'Were many .'
people who had moved in from the rural' areas and who had neither the resources nor knew how to get- them •. -The whole matter concerned the .subject of the technical. discussions. How to ·bring about the public
dialOgue Which would make it possible for the people to live consistent with the resolution which had been passed during the last World Health Assembly •.. It Was clear that in the final. analysis the family was the ilqportant area for decision. The families should know what was avall-
able to them SO that they would be able to guide their actions in
accordance with existing knowledge..
The stimulation of public dialogues
'WOuld make tbebig difference and it was hoped that' WHO and other groups would somehow be able to find the ways and means by whicb. this public dialogue could be realized. There was nm. betorethe Congress of the
United states a bili, which provided for the convening of state conferences, which would develop state discussions on tbe question of family planning, and on what activities 'Were to be carried out within the state and the component parts of the state. The United states Government believed it·
was impOrtant that the people should become involved in the development· of a public policy, and was doing everything possible to brin:g about understanding within its own people and, hopefully, with otbers, of what action should be taken on the question of human reproduction- and the health aspects .of human :population. The DIRECTOR-GENERAL said that he did not share the optimism of Dr Watt who had been the Chairman of the group which had drafted the
resolution.
There bad been fourteen Mllmbers in that group.
When the
Assembly by unanimity of more than liO Members had approved the
MINUTES OF THE THIRD MEm'ING
~57
resolution it had not sought any interpretation and each Member had interpreted the resolution in its own way. .After the Assembly he had, The
in fact, received many different interpretations from delegates. Assembly would discuss the matter again next year and another step forward would certainly oe taken then. It was i~ortant
to remember
that no mass programme or campaign could have any permanent effect unless there was a minimum health structure within the country undertaking them. T'wenty years ago people had believed that DDT spraying would solve the problem of malaria, but the problem of malaria still eXisted, because it could not be solved by mass structure to support it. c~aigns
unless there was a basic health to bear this lesson in mind.•
It was
~rtant
Dr GURD (United Kingdom) remarked that it had been stated that one
of the Pacific territories, New Caledonia, had no population problem. This did not mean that no population problem existed in the Pacific Islands. blem. Fiji and the surrounding territories had a considerable pro-
The figures indicated in the table attached to document
WP/RcJ.6/7
showed an increase of 2.9 per cent. for Fiji, Samoa and 2 per cent. for Cook Islands.
3.3 per cent. for Western
He believed, however, that the In American
figure given for Cook Islands should be very much higher.
Samoa, the figure was 10vT, only 0.6 per cent., but this was an exception which was certainly due largely to the people migrating from Samoa, as they had in fact a very high birth rate and a problem of population explosion. It might be of interest to the meeting to know that in Fiji Famil.y clinics were
family planning was a declared government policy. run by the ~dical
Department and propaganda supplied by a voluntary
organization, the Family Planning Association, and these two organizations
-,
worked as a team; There had been produced only recently a booklet, a· manual. on family planning, a copy of which would be provided the Chairuian. This manual gave information on all aspects of both the medical. and lay people interested in the problem. with a copy on his return to Fiji. He was willing to provide anyone else That there was a problem in the
territories .surrounding Fiji could be gauged by the fact that at the recent South Pacific Health Board meeting in Apia, a resolution had been passed urging Member governments to set up family planning services as an integralllart of their public hea.lthprogrammes. Dr ORSnU said that he had not meant to say that there was no
population problem in
Ne~l
Caledonia, since the population had increased What he 'Wished to say was that there
by 26 per cent. in eight years.
was no birth control problem at the moment and there would be none as
long as the Territory had sufficient resources to coPe with the demographic e:x;pans:j.on. (For consideration of meeting, section 2.) draf~
resolution, see minutes of the fifth
MATERIAL SUPPORT OF THE PRCGRAl1ME FOR GLOBAL ERADICATION OF SMALLPOX BY COUNTRIES IN THE WESTERN PACJFIC RIDlON: Item 17 of the Agenda (Document WP/RC16/11) The CHAIRMAN drew a.ttention to document wp/RCl.6/11 from which it
would be noted that this item had been proposed by the Government of the United states
of
America.
ImruTES OF THE THIRD MEEl'ING
l5Q
Dr WATT (United states of America) referred to the resolution of
the Eighteenth World Health Assembly which was attached to the document. This resolution, among other things, had set a terminal date - a date at which it was hoped to achieve global eradication of smallpox. His
Government, in asking that this item be placed on the agenda, had also asked that the same action should be taken by all the other regional meetings, in order to obtain expressions from the various governments as to what their thinking was about the ways and means of assisting in this global campaign. ~-
His Government felt strongly that the first and
most ill!Portant step to be taken was for the Secretariat to develop a global plan, which would not only take into account this terminal. date of ten years from now, but contain an effective and systematic anaJ.ysis of where the difficult areas lay, as "Well as the areas where eradication had already been achieved.
The countries in the second group could,
and should, analyze their resources in terms of assisting those other countries where smaJ.lpox still remained. In his country a serious
analysis of what smal.lpox was costing the Government today had just begun. He was not sure how long it would take to get precise figures
out but would try to give some idea of the situation. In the United states of America many hundreds of thousands of people travelled each year, all of whom required a valid vaccination certificate. The normal operating expense
to an individual. to get a vaccination was
about Us$5.00.
Multiplying the number of people travelling outside of
the country, and. needing this, would give a sizeable figure to begin with. school. Mmy of the states required vaccination before children entered
l.ru.ch of this was done through the local health services, the
160
actual. .cQst per individue.l. :being somewhat less, but even so it added u;p
to a goOq III8.llY millions of dollars each year.
Tbere were al.so III8.llY
Americans s.tationed overseas in areas where smallpox was endeinic and wbere . vac.cination tberefore was practised much more frequent·ly. Here
again a large ,amount of money was involved.· Large sums were being spent for the exist. s~
purpose in virtue.l.ly every country where smallpox did not·
Countries had to do this in order. to protect themselves against
re.,invasion and to protect their citizens 'When they went aWay from home and became exposed to this disease, their ow. A.S
they had no natural immunity of
When added u;p, the amount of money invested each year in If' eradication
maintaining a protective device was quite considerable.
were achieved, this would mean the release of a tremendous 'amount of money f.or many other programmes. His Government felt that those countries
which had, in fact, eradicated smallpox should be encouraged to make an analYSis of what it was actuall.y costing them today, just to maintain tbeir peoples. free of the disease. They should also' recognize that in
doing so they were in fact many times bringing about a disease in their ow people, because there was a complication t.) smallpox vaccination, small though it might be •. Dr watt then referred to the fact that a vaccine against measles . had recently been developed.
This too ws a disease which seemed quite It was a
clearly to 'be that of human beings with no animal reservoir.
terrific killer and crippler of children in many parts of the world. but i t was believed that it could uso be eradicated. Anything that
was done to organize and' ca:rry' out a systematic eradication' campaign for smallpox' would mean that trained manpower and tra1ned::resources
MINUTES OF THE THIRD MEmING
'WOuld exist so that the problem of measles could be tackled later, when experience with the new vaccine was sufficient to determine how to use it and. when to apply it. Countries should decide 'What they could afford to invest, through the World Health Organization, in a global campaign against smallpox. Once eradication was achieved they would immediately begin to recover the money invested through the World Health Organization, and in a very short time the amount invested in this international collaboration 'WOuld be repaid several times over, as it would no longer be necessary to continue this annual cost within their own boundaries. So far as he
knew, no systematic analysis of these costs had been made, but the information could be obtained, and the United states Government was now systematically beginning to make this appraisal. It was hoped that
other countries would do the same, and thus be able to sit down at the next World Health Assembly, or as soon as WHO had been able to develop a global campaign, and to commit in a very serious way the resources that were necessary to finish this job in the limited sections of the world where smallpox still existed.
While the number of people living
in areas where smallpox was endemic was very large, it was relatively small when the total population of the world and the total a.n:ount of eradication achieved were considered. He was personally convinced that s~ler
once this plan was made, it would be a much
and more satisfying
operation than any of those which had been tackled so far in terms of getting rid of this disease. There was every reason to believe that
eradication was completely possible. As a final comment, Dr Watt stated that he had been some'What
surprised to find that one of the earlier presidents of the United states
.. .162 ot ~rica 1l8d.e.nt'fc1p&tecl MrJobrisonquite' considerabiy •. Mr Johnson calledfortheglobsJ. eradication or'Sinalipox. Ho'Wl!ver,1iha second .
bad
President of the United states of .America, Mr Jefferson; iIi a J.etter to . .
Dr Jenner, bad stated ·'that. his discovery Of a vaccine against smaJJ.pox
would lead to'i'tseventUal extirpation from the World and that thus his place in bistorywould be far greater than that of lli8nyothers. '.
It was
rather remarkable that· even so far ago ·'this; vision could be seen and it was possibly a ratber sad conmentary 'tha't it bad 'taken so long 'to begin to do it seriously on a global basis. Dr HSU (China) 1 on bebalf of his de1ega'tion, expresf!ed full sUJ)pOrt
of the proposal made by the Unite,d states Representative.
He also
expressed his Government's support of the global eradication .of smallpox. This project was poSSible, provided all . . . ~er ' . "
countries supported it. .. -
In the Director-General's report to the last World Healtb Assembly .it bad . "." , ' ".. . :,_t', . .' been stated that there had not. been any cases of smallpox in the Pacific Region for a number of years.. :(n Cb1~a, Wes~rn
bo:wever, scbool:cbildren "
still had to be immunized every year and a great amount .was . . of lIlOIley . .. ',.
spent on the prevention of smallpox. tion made by the . . ... Asse~ly) ",
:(n .
accordance witb the recommend&-. . .. .~
.
his GOvernment
inte~ded .
too start :producing .
freeze-dried smallpox vaccine next year.
The .equipuent bad . . .beell provided
by UNICEF and technical assistance bad beenrequestedfroIll t.he WHO .. Regional Office. His Government bad informed the last HeE!l.tbAssembly "
that it would donate freeze-dried vaccine to the global E!radication , '!
.'
campaign Wen it bad been successful in .producing it.
Dr Hsu drew
attention to the fact that, in the Director-General.' s report to the last WOrld Healtb Assembly, it had been stated that half ot.the vacC;1nes
MmUTES . OF THE THIRD MEEl'ING
donated bad been found to be below the standard of the assay in respect of safety and. potency. He considered it necessary for the Horld Health
Organization.to study this problem before countries.were persuaded to donate smallpox vaccines to the global c8ll!Paign. Dr TRUONG (Viet-Nam) expressed his sUJ?J?ort of the global c8ll!Paign • Sma.llpox was a very inlPortant problem for all countries. In Viet-Ham,
.. j...:
there bad been a serious epidemic during the last century and also between 1935 and 1959. There had been 62 713 cases and 18 013 deaths;
however, since 1959, thanks to compulsory vaccination promulgated in 1954, his country had not had a single case. Every year, a smallpox
vaccination c8ll!Paign, using the vaccines produced by the Pasteur Institute in Saigon, bad been carried out. Some ten million doses -
nine million doses of dry and one million of fresh vaccine - had been used each year. The cost involved was enormous but was necessary in He believed
order to maintain the absence of smallpox in the country.
that the proposal made by the United states Representative deserved everyone's attention • . Dr DOWNES (Australia) stated that in principle his delegation supported the views expressed by Dr Watt. Many of the representatives
present wuld be aware that Australia had the strictest control on the importation of smallpox in the world and for that reason it had a reservation to the International Sanitary Convention and was not a signatory of the International Sanitary Regulations. In fact, it had
insisted. that all inward passengers by air should be vaccinated if they were above one year. If not, they were
164
col;l:1'~d a:!:thQ~
1'9.r the incUbation period to a qU8.ra.ntine station so that i llj,s CO\l!ltry·.was small, tliecost otvaccinationand of' qua.:rarit1rie HOlIever, the primary objective of such 'a campaign
was" co~tively. high.
should not be to save the. costs of vaccination in those countries which did not have smallpox; it should be to save human lives in the big As far as Australia was
countries with reservoirs of infections.
concerned, liquid vaccines 'Were now being produced and there were very rarely any co~lications
of encephalitis.
The production of 1'reeze--dried
vaccines was now being tried out and once a commercial scale of production was reached, his country would be able to give earnest consideration to
helping the less fortunate neighbours in this region and the other endemic areas of the world. Dr GATMAITAN (Philippines) said that the last cases of smallpox in
the Philippines had occurred in 1948 and 1949 as a result of "a sma.ll. localized outbreak in one of the islands." While no cases had occurred in the country since' that time, mass sma.ll.pox vaccination and quarantine measures "Were being carried out in accordance with the International Sanitary Regulations. The Bureau of Research and IAboratories of the
Philippine Department of Health was engaged in the production of smallpox vaccine. During the :fiscal ;year 1962-1963, a total of 10.8 The
million doses of dry powder sma.ll.pox vaccine bad been produced.
necessary facilities were being acquired for the production of 1'reezedried smallpox vaccine which, from all indicatiOns, was the more practical vaccine to use. Infants over six months 'Were vaccinated and
the total susceptible population was vaccinated every three months. This programme was intensified when there "Were lmown foci of infection
I>fiNUTES OF THE THIRD MEm'nl'G
surrounding the country.
All. unusual cases of varicella were routinely The Bureau
investigated so as to preclude the possibility of vaccinia.
. -.,...
of Quarantine strictly pertaining to smallpox.
~lemented
the International Sanitary Regulations
Smallpox vaccination and other anti-smallpox
measures bad constituted an activity of the Philippine Department of Health ever since its establishment in the early 1920s. It was regretted
that the actual figures representing the cost of preventing this dreaded disease could not be given, but it surely ran to several millions of pesos every year. Definitely, the cost of prevention was much less than
that of curing patients who might suffer from it, if and when preventive measures were relaxed. The Philippine delegation therefore supported
wholeheartedly the proposal of the American delegation and would like to request other countries and delegations to ® the Sam:!.
Dr ORSTIU (France) said that there must be adequate legislation
which should be strictly followed. the French territories.
This was the case in France and in
The incidence of smallpox in France and its
territories was very low, following the measures that bad been taken to control it. These measures were vaccination of children at birth and
at the age of eleven, and of adults at twenty-one •. There were also other opportunities which allowed for revaccination against smallpox for certain groups of people. AI;
France had conscription, men who joined the forces It
had to be revaccinated regardless of the dates of their previous one. could therefore be said that the male group had a good protection. Mention had been previously made of the increase in international travel. Certainly the application of the International Sanitary
Regulations was an excellent opportunity to increase the number of
166 His Government had' 'never felt, that the cost for the
vaccinations.
protection of' smaJ.l.pox was too large and'outof proportion to the results.
If' the incidence of smallpox was to be reduced in a country existed, strict measures should be enforced.
where
it still
The eradication of smallpox
would certainly free funds for the control of other diseases, but he doubted that, this could be acco~lished
for a very long time.
He did
not know who was' going to take responsibility for certifying the eradica.tion of' smallpox from the whole world, in view of the fact that there 'Were certain groups which would not be reached by health action. One had to
be reaJ.istic and it was primarily within each country that responsibility had to be taken.
Dr GURD (United Kingdom) wished to add his personaJ. support to the
case presented by the Representative of the United states.
He would
certainly report back to the United Kingdom Government favourably.
He
agreed with what Dr Downes of Austral.ia had said about the puxpose of' a mass eradication campaign but he thought that Dr Watt ws presenting one fact of the overall case for such a campaign. The financial. aspect would
be a very telling one when it came to persuading the larger governments
to produce the money to pay for the campaign. Dr Gurd then referred to the new possibilities 'for vaccination. A team from the Corrmrunicable Disease Center '1n Atlanta, Georgia, United states of America, had carried out a trial of' a new high-pressure gun for vaccination about a year ago in Tonga.' ' He had learned from the United states Representative that considerable developments bad taken place in this field and there was now a gun, which held five doses end was a little bigger than a pencil. The advantages of such a piece of
MINUTES OF THE THIRD MEEn'ING
apparatus 1-Iere at least twofold. mass vaccination.
First, it stepped up the process of
Second, the dose was approximately 1/50 of that used He had also been told that a
in the ordinary vaccination technique.
one--dose vaccination point had. been developed which would pair off with the standard gun in a mass campaign to pick up the individual people that had been missed by the use of the gun. Dr WATT informed the Committee that the
small jet injector to which It was a French develop-
Dr Gurd had referred held fifty doses, not five.
ment.
Some of the ones in the United States 1-Iere somewhat larger and used This particular one was
a different type of po1-ler for obtaining pressure.
very simple and he had been told that it had been used over a hundred thousand times in a ma.ss campaign vdthout breaking down. This development was
going to make it a great deal easier to carry out mass campaigns because the gun could be carried in one I s pocket. Dr liatt also stated that the
single dose of freeze-dried vaccine was an interesting technical development. The work was still in the experimental stage but it indicated real
possibilities that this would be available as a 1-Ieapon in the future. Referring to the statement made about the certification of global eradication, he was sure that WHO could, and would, develop with the assistance of its Member nations a basis whereby certification could be determined. There 1-Iere preced.ents for this - the certification of freeOne
dom from malaria, the certification of freedom from Aedes aegy;pti. of the first things that would have to be done was to develop those standards which would represent freedom from smallpox. matter for an Expert Committee to decide. This was a
Experience clearly sho1-led
that adequate vaccination on a mass basis would ensure that smallpox would be non-existing in the territories to which it was applied.
168
The, CHAIRMAN requested the RaPPorteurs to prepare an appropriate'
resolution on the points·that had bE!I!ndiscUssed.
(For consideration
of draft ~soiution, see ininutes of the' fifth rreeting, section 2.)
4
STATEMENTS BY REPRl!SENTATIVEs OF NoN-GOVERNMmTAL ORGANIZATIONS IN OFFICIAL RELATIONS WITH WHO Representative of the World Medical Association At tbe invitation of the Chairman, Dr ROSS-SMITH conveyed the
4.1
greetings of the secretary-General of the World Medical Association, Dr Harry Gear, and t'he thankS of the Association for the Committee's kind
invitation to be represented once again. The World Medical Association, which
had
for its rrembers the national
medical associations of most countries of the world, represented the voice of the practising medical profession. ' The Association would hold its Nineteenth World Medical Assembly in London next lIeiek and he was confident that WHO would be fully represented. Anilz!portant I:IIa.tter to be discusSed
in London would be the arrangements for the Third World COnference on Medical mucation to be sponsored by the Association in New Delhi in November 1966. of this meeting.
WHO bad rendered considerable' assistance in the planniD.g There could be no doubt that progress in the fieid of
medical educatfon,&s Well as in other related areas, including the strengthening of national health programmes, required the full support ' of governments, through the World. HeoJ.th Organization; as well as the practising medical profeSSion, through the national. medical associatiOns, and the World Medical. Association itself. '!'be 1966 World Medical.
Assembly 'WOuld be held in Men1la and it was hoped that it -wOuld af:f;'ord
MINUTES OF THE THIRD MEETING P.
an excellent opportunity for e. free and useful exchange of medical information between the doctors in the Region and those from other parts of the world. All members of the profession in the Region were cordially invited
to join the Assembly. He 'Wished on behalf of the medical profession in the Western Pacific to pay a special tribute to the outstanding and devoted service rendered by the retiring Regional Director, Dr Fang. The great achievements of
WHO which had been made in the Region under his able direction were fully recognized. He wished Dr Fang and his charming 'Wife continued good health, (For further statements
good fortune and happiness in the years to come.
presented, see minutes of the fourth and fifth meetings, section 1.)
5
POLIOMYELITIS:
Item 15 of the Agenda (Document WPjRC16j8)
Dr REYES, Assistant Director of Health Services, drew attention to two specific points. It was evident that the lack of adequate virus
diagnostic laboratory facilities in many areas hindered the study of the prevalent virus infections, including poliomyelitis. consultant virologist v~uld
In 1966 a WHO
visit selected countries to observe and It was boped
advise on the development of virus laboratory services.
that this would contribute to the more effective study of these infections. UNICEF had accepted the recommendation of the UNICEF-WHO Joint Committee on Health Policy that it should provide assistance to poliomyelitis under the follOwing conditions: c~aigns
against
(i) there was evidence
that the incidence of the disease had increased greatly or was likely to do so in the near future, (ii) the government concerned gave high priority to vaccination of the susceptibles (which in most cases would be young
170
.ch:1l~n),
(11i) that the. country bad adequate medical· services- tor this
purpose, except in emergencies. Dr DOWNES (Australia) said that in Australia there had been a continuous fall in incidence since 1955, except for the epidemic years 1961-1962. In 1955 there bad been 874 cases and 30 deaths;
in 1956, in 1958,
1144 cases and 57 deaths; 100 cases and 4 deaths; cases and 2 deaths; and 25 deaths; deaths;
in 1957, 125 cases and 8 deaths; in 1959, 56 cases and 5 deaths;
in 1960, 116 in 1962, 259 cases
in 1961, .450 cases and 21 deaths;
in 1963, 33 cases and 1 death;
in 1964, 19 cases and no Sixty-five per cent. of all A significant feature
in 1964-1965, 2 cases and no deaths.
cases b8.d occurred before the age 01' fifteen years.
of the 1961-1962 epidemic bad been the protection given to those vaccinated and the high incidence of cases in the unvaccinated. The protection rate
for children under fifteen years 01' age had been calculated to be 96 per cent. in these years, 3.05 cases per 100 000 occurring in those vaCcinated -~
and 85.6 cases per 100 000 occurring in the unvaccinated.
It would appear
that vaccination had greatly reduCed the incidence of the disease in this epidemic and prevented possibly 2000 cases. Salk vaccine had tirstbeen introduced into Australia in 1956 and iargescale vaccination had commenced ·1n June of toot year. . The vaccine was
produced by the Commonwealth Serum Laboratories and was made available tree of charge by.the Commonwealth to sJ.1 states. Originally vaccination
had been undertaken solely by state instrumentalities 1n large-scale
c8lli>aigns but in later years the vaccine had also been made available to private medical. practitioners. A great deal of credit must be given
to the individual state Governments which administer the poliomyeiitis
MINUTES OF THE THIRD MEm'ING
In
vaccination campaigns in their respective States. The
recommended dosage schedule was four intramuscular injections of
0.5 ml. each at intervals of four weeks between first and second, seven months between second and third, and at least twelve months between third and fourth doses. the end of 1964. Approximately 23 million doses had been issued up to At present, apprOximately 1 500 000 doses were used
annually but it had not been possible to obtain exact figures on the percentage of population immunized. However, it was estimated that
approximately 80 per cent. of children under :fifteen years of age and
50 per cent. of adults
had received at least three doses of Salk vaccine.
The Commonwealth Government accepted responsibility for ensuring that adequate stocks of Salk vaccine were available at all times and in addition, 'With the co-operation of the Commonwealth Serum Laboratories, maintained a reserve of 1 000 000 doses Of Sabin oral vaccine in case of emergency. During the latter part of 1964, the Tasmanian Government had carried out a pilot Sabin vaccination programme, administering two doses of trivalent vaccine to over 60 000 children injections of Salk vaccine. who
had already received three
Serological and virus isolation tests
carried out indicated a highly successful response and the complete absence of polio-like disease in the whole population of Tasmania since the Sabin commencement date further confirmed the safety of the vaccine. The
Tasmanian Government was now about to embark on a large-scale Sabin
vaccination programme in which the vaccine VIOuld be given to all, irrespective of previous immunization status. It was estimated that some
300 000 persons VIOuld receive tVIO doses of trivalent vaccine later this year.
172
Wbether or not there wou1dbe a gi'8duaJ. or a rapid· Sab~
cbil.nge
over
to .
or '¢ethex: Sal.k. would continue to be used 'as before was a matter The COllJlllOnwealth was prepared to make either In aJ.l decisions· of this nature, the Common-
for the states to .decide.. or both vaccines available.
walth laws sought the view of the National Health and loedical Research Council. The states already bad been asked by the COllJlllOnwealth Health
Departlll!ent to give preliminary advice on their proposed pOliCies for the next two years. The situation would be under constimt review by the ,. :
National Health and M!dical Research Council.
. With ·the proven. efficacy of both Salk and Sabin vacCines, it seellEd that an ap,swer had been found to one of the most crippling diseases of man;· :provided there w.s continuing awareness by the public and the health
authorities of the need for vaccination, it seemed possible that polio~litis
might become a rare disease in Australia.
Dr TRUWG (Viet-Nam) said that all countries in the world were
interested in this disease.
There had been poliom;yel1t1s .in Viet.-Nam
for a long time and it was considered to be a public health problem. statistical data indicated that there had been 177 cases in 1961, 119 in 1962, 341 in 1963 and 325 in 1964. Saigon but also in the provinces. It was prevalent not only in
l-i:>rtality was not too important but In Saigon there was
the sequel was a serious medical and social problem.
~ orthopaedic centre which dealt with the rehabilitation of cases and ...
there· were more than 2000 under treatllEnt.
There was. also a large number
of cases of paralysis, facial paralysis, lymphocytic meningitis, m;yolgic syndrome, and of infections of the u;pper respiratory tract. Investiga-
tions carried out by the Pasteur Institute in Saigon had revealed that
MlNUTES OF THE THIRD MEm'ING
173
Type 1 was more frequent, followed by Type
3 and then Type 2.
In 1962,
91 per cent. of the cases had been Type 4, 5 per cent. Type 3 and 0.5 per cent. Type 2. As to age, the youngest patients 'Were two-and-a-half Fifty per cent. of
months old and the oldest, thirty-five years old. the cases among the two-year old Type 1 disease.
appeared to have some immunity to the
Vaccination against the disease was being undertaken
on a larger scale and at a recent meeting it had been decided that it must be carried out among all children less than five years of age. HO'Wever, at this time, mass vaccination was not recommended. of epidemics, oral vaccine was recommended. In the case
There had been many discus-
sions on whether the vaccine should be given orally or by injection. Dr Truong then raised a specific question with regard to vaccination. He gave as an example a situation where half of the children in a given area had been vaccinated orally, the other half not. years later there was an epidemic. be related to the inco~lete
Then, one or two
He wondered'whether this would Mass vaccination would be too
vaccination.
expensive with a Salk vaccine. Dr Truong then stated that he would like to have the Organization's
opinion as to whether or not there was complete safety in the oral vaccinat~on
of a part of the child population.
Dr LEE (United States of America) recalled that at the fifteenth
session of the Regional Committee, the Representative of China had asked the assistance of the Committee in connexion with the Government's poliomyelitis problem. His delegation was pleased to note the action taken in
the past year, particularly in connexion .lith the work of UNICEF, and asked if the Government had already received the desired assistance from UNICEF.
174
Dr BSU (China) replied that his Govel"lUlent
'WaS'
particularly happy
that the UNICEF-WHO ,Joint COIIIIIIittee on Health Policy at its last meeting had .recommended to the UNICEF Executive Board that UNICEF assist 'in
campaigns against poliomyelitis, particularly in the supply of vaccine. As Dr lee bad stated, last year at the Regional Committee leeting the
Chinese delegation had recommended that the WHO Reg:1.onal. O1'f'ice should assist !-Ember countries in their c8lJU)aigns against poliomyelitis, . especially in obtaining the vaccine. Last year his Government had
received a donation of 1.2 million ce. of Salk vaccine from the American Christian Welfare COIIIIIIittee and also one million cc. from the Japanese Biological Producers Association, in addition to 200 000 doses of Sa.bin .vaccine. With this supply, it had been possible to
immunize children below the age of three; . 1. 2 million children had been covered. By this time, 900 000 children had been immunized with the first
dose, al:lout 800 000 with the second, and the third dose of Salk vaccine would be g:1. ven in October. Dr Hsu thanked the Reg:1.onal Director and his
Reg:1.onal. Adviser for their assistance in obtaining the vaccine I as 'Well as the associations in the Uliited States of America and Japan which had contributed it. He also thanked the Government of Japan for its
help in obtaining this valuable donation, without which it would not have been possible to undertake the campaign. His Govel"lUlent had decided to submit a request to UNICEF for assistance in a poliomyelitis campaign.
He understood that this was
~cept8.ble to UNICEF wbich 'WOuld submit it to the next me~ting of the Board in June 1966.
He hoped that the Regional Director 'WOuld continue
to pay attention to this programme, particularly in connexion with the
MlNU'l'EZ OF THE THIRD MEErING
175
survey of poliomyelitis outbreaks in the Region and would make every effort to assist Ilj:mber countries to obtain supplies of vaccine. His
Government had no exact figures of the number of poliomyelitis cases annually. Hovrever, available data indicated .300-700 cases. Assuming
that the morbidity in poliomyelitis was 10 per cent. of those infected, local experts estimated that there might be 3000-6000 children suffering from the disease. This was a big problem and with his country I s limited
financial resources the supply of vaccine was very difficult. Dr GATMAITAN (Philippines) said that his delegation appreCiated the
inclusion of poliomyelitis on the agenda and was glad to learn about the characteristics of this disease in the various countries in the Region. Poliomyelitis was endemic in the Philippines. Hammon, in a very
limited serological survey of Filipino children in 1955, had reported an antibody prevalence of 77 per cent. for Type 1, 70 per cent. for Type 2 and 80 per cent. for Type 3. in typically rural areas. An even higher prevalence rate was noted
A review of the reported cases and deaths In 1954 only 386 cases had been
through the years indicated an increase.
registered, a case rate of 1. 7 per hundred thousand population, and 73 deaths or a death rate of 0.3 per hundred thousand population. In 1963,
the number of cases registered had been 527, or a case morbidity rate of
1.7 :per hundred thousand population, and 166 deaths, or 0.5 per hundred thousand population. Recently a change in the age distribution of cases Previously the cases had. manifested a
and deaths had been observed.
typically infantile pattern but lately more than one-half of the total deaths had been in children under five years of age. The incidence of
poliomyelitis had always been correlated with the infant mortality rate.
:aEQlOOAL COMMI'l'TEE:·
As the latter declined, the poliomyelitis incidence
was expected to·
increase.
Tbe infant 1IJ:)rtal1ty rate in the PhiliPPine s had. demonstrated
a significant ·declining trend; an increasing incidence of poliomyelitis -was therefore to be expected. Tbe incidence ba.c1 also been correlated
with the state of sanitation in the area.
As environmental sanitation One of the
iDi>roved, the poliomyelitis incidence was expected to increase.
proved .control measures against poliomyelitis -was active immunization, tw types of vaccine already having been introduced.. In view of the
increasing trend of poliomyelitis in his COWltry, Dr Ge..tmaitan believed that immunization was in order, beginning with the priority grou,ps. There being no further discussion, the CHAIRMAN asked the Rapporteurs to prepare an appropriate resolution. .(For consideration of draft
resolution, see minutes of the fifth meeting, section 2.)
The meeting rose at 12.25 ;p.m.