EM/UR/G-E Distr: RESTRICTED
contents of this restricted document may not be to persons other than those to whom it has been originally addressed. It may not be further distributed nor reproduced i n any manner and should not be referenced in bibliographical matter or cited. The divulged
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN 1988
TABLE OF CONTENTS
. I1. I
....................................... IMPLEMENTATION OF REGIONAL PROClRAEmE BUM;ET WLICY .......... INTRODUCTORY ADDRESS
1
4 4 5 7 7 8 9 9
Discussion (a) Intersectoral collaboration ( b ) Fellowships ( c ) Consultants (dl Supplies and equipnt .............................. ( e ) Joint P r o g r m Review Missions ( f ) Health for all leadership developrent colloquia ( g ) Reprting back after meetings of governing bodies ( h ) Other issues TTT
......................... ......................................... ........................................ .................... .....
.
....................................... EXPANDED PRGRAkPE ON IPlWN?ZATION ......................... ............................................
...
9
11 11 12 12
I m i z a t i o n coverage The cold chain mliomyelitis eradication ( a ) Achievement and maintenance of high immmization levels ( b ) Effective surveillance to detect and study all new cases (c) Rapid and comprehensive res]?onse to all cases........
...................................... .................................. ................................ .................................
13
13 13 14
plans of action Discussion rV .
........................................... ................................................. H I ? A T . T E T HAZARDS OF RADIATION ............................... ...................
14 16
..................................... ................................................. V . THE DTSTXICT t 3 3 L T H SYSTEM ................................. Discussion ................................................. VII 1
Biological effects of ionizing radiation Radionuclides in food Discussion
16 16 17
17 18
.
BUDC. ET AND FINANCE AND INIKEMATICS SUPPORT TO WR'S OFFICES . COMPUTERXZATXON OF THE EM MANXERIAT., PROXSS
.....
22 23 24
VIfI
.
PERSONNEL MA'JTERS
...........................................
............................................... IX . ACTIVITIES CELERRATINC; WHO'S 40th .WNIVFRW Y .............. Discussion ANNEX ANNEX ANNEX
25
I 11:
.............................................. 1 1 1 .................................................
............................................
28 31 32
PROCEEDINGS OF
THE SIXTH MEETING OF
h F D
REPRESENTATIVES
1. D r Hussein A. Gezairy, t h e Regional D i r e c t o r , a f t e r welcoming t h e WHO R e p r e s e n t a t i v e s ( W s ) , t h e new m s and e x p r e s s i n g a f a r e w e l l t o W R s going on pension, reviewed t h e a c t i v i t i e s of the p r e v i o u s y e a r .
2. which his
At
t h e f i f t h meeting twelve recomwndations had been m d e , t e n of required s p e c i f i c a c t i o n from WRs. The Regional D i r e c t o r expressed
w i s h t o h e a r f r o m WRs on t h e i r implementation, p r t . . i m l a r l y i n t-he l i g h t of t h e Regional Programne Budget Policy. I n t h i s s i x t h m ~ t e t i n ga new approach had been t a k e n ; i n a d d i t i o n t o one m j o r t o p i c f o r d i s c u s s i o n , s e v e r a l t e c h n i c a l s u b j e c t s were a l s o to be p r e s e n t e d and d i s c u s s e d . I n order t o allow for t h i s the d u r a t i o n of t h e meeting had been extended t o t h r e e days. A t t h e end of t h e meeting s e s s i o n s WRs would have two days t o d i s c u s s i s s u e s of importance t o t h e i r country of assignment with t h e various technical units.
The major t o p i c on t h e agenda w a s t h e e x p e r i e n c e of W R s in implementing the Regional P r o g r m Budget P o l i c y a t c o u n t r y l e v e l . The v a r i o u s i s s u e s r a i s e d would be d i s c u s s e d and feedback recelved from c o l l e a g u e s ; t h i s p r o c e s s would h e l p t h e Regional O f f i c e t o m n i t o r i t s implementation.
3.
4. The Thirty-fourth Session of t h e Regional C o m n i t t e e had convened i n O c t o k r 1987, and two meetings of t h e Regional C o n s u l t a t i v e C m i t t e e , two meetinqs of t h e Executive Board and t h e F o r t y - f i r s t Session of t h e World Health Assembly had t a k e n place. Resolutions and d e c i s i o n s t a k e n i n these meetings were d i s t r i b u t e d . The Regional D i r e c t o r noted t h a t technical' discussions were forming a n i n c r e a s i n g part o f Regional Cornnittees h u s e
it
wds
i n p ~ t a n t to
bring
the attention of k m b e r
S t a t e s , i n p a r t i c u l a r t h e p o l i c y makers, t o c e r t a i . n topics, new o r o f s w i f i c : concern, and t o impress upon them t h e need f o r a c t i o n i n t h e s e areas. and aspects w h l c h might h e l p them i n thelr d ~ i s i o n - m a k i n g . T h i s e of use t o WRs i n keeping them u p t o d a t e type of d i s c u s s i o n could a l s o b w i t h d e v e l o p n t s and able t o a d v i s e g o v e r m n t s ; hence t h e a d d i t l o n of t e c h n i c a l d i s a l s s l o n s t o t h e agenda. 5. The 40th Anniversary of WHO had t a k e n place and there would be a r e p o r t of g l o h l a c t i v i t i e s t h a t c e l e b r a t e d t h e e v e n t . 6. The Regional D i r e c t o r h i g h l i g h t e d s a w a s p e c t s and d e c i s i o n s of t h e F o r t y - f i r s t Session of t h e World Health Assembly. Considerable time had been devoted to discussion of t h e a n n i v e r s a r y c e l e b r a t i o n s . The s e s s i o n had, f o r t h e first time, ended on t h e u w i r ~ y Lu L l ~ e elhuri~-ratiun of regional. p r e s e n t a t i o n s and it was hoped t h a t f u t u r e (non-budget) s e s s i o n s might a l s o be shortened somewhat. A new Di.rector4&neral, D r H. N a k a j k , had k n appnint-r.d and Dr H. Mahler had k n voted D i r e t o r - G e n e r a J Writus.
t
.
7. The Reg]-onal Di.rector expressed t h e f e e l i n g t h a t it was i q x x - t a n t to havc-1 good delegat-es t o t h e WHA from t h e Region, p?rtict:ular3y w i t h r e g a r d to t h e c h a i r m a n s h i p of Cornnittees A and R. He ho@ t h a t W R s might raise t h i s i s s u e w i t h governments s m 4-5 months p r i o r t o f u t ~ r r e A s s e m b l i e s so t h a t w i l l i n g and e x p e r i e n c e d d e l e g a t e s m i g h t k proposed.
8. The Assrmbly had t a k e n Constitution regarding f a i l u r e p d s s t x ] d
strong action t o apply A r t i c l e 7 of t h e t o meet f i n a n c i a l o b l i g a t i o n , and had dLd
1t
i
i
r
w.i Lhdrdwir~y vuLir~y r i g k l L s
t,lie r ~ t : x tA s s m h l y i ~ f
Member S t a t e s t h a t d i d n o t m e t such o b l i g a t i o n s d u r i n g t h e comi.ng year. (WEE443 . 7 , WHA41.20). I n a relat-Ftd a r e a a r ~ s o l u t j k mhad h e n pxssed whjch would be a n i n c e n t i v e t o M e m b e r S t a t e s t.o pay t h e i r assessed c o n t r i b u t i o n s e a r l y on i n t h e f i n a n c i a l y e a r , by p r o v i d i n g f o r a p e r c e n t a g e decrease i n and a p e r c e n t a g e i n c r e a s e for t h e c o n t r i b u t i o n s o f t h o s e t h a t paid e ~ r l y t h o s e that. i d toward t h e end o f t.he f i n a n c i a l y c ~ i r . T t would be worthwhile WKS d i s c u s s i n g t h i s i s s u e w i t h governments t o m3ke s u r e t h a t it was c l e a r l y ~ m d e r s t d( ~ ~ 4 1 . 1 2 )
.
9. The Rfqinnal D i r e c t o r reminded WRs t h a t a format had been e s t a b l ished for f o l low-up o f a c t i o n s i n m p l anent-ing t h e r e s o l u t i o n s and d e c i s i o n s o f t h e governing bodies. One o f t h e major r o l e s of t h e wR was t-o f o l l o w I I t~h e s e a c t i o n s and a d v i s e governments on how best t-o mplenent t h e d e c l s l o n s and resolutions that had been t a k e n and t o a d v i s e EMRO on their e x p e r i e n c e i n t h i s area. H e e x p r e s s e d a wish t o r e c e i v e such f e e d b a c k on a s i x - m n t h l y basis.
10. The Regional D i r e t o r u r g c t d W R s t o s p e c i f j . c a l l y f o l l o w u p o n t h o ~ e resolutions o f p a r t i c u l a r i n t e r e s t t o t h e Region s u c h as WHA41.11 r e g a r d i n g i n f a n t and c h i l d n u t r i t i o n , hkIA41.15 r e g a r d i n g t h e environment, and WHa41.25 r e g a r d i n g t o b a c c o o r h e a l t h . I n r e l a t i o n t o t h e l a t t e r r e s o l u t i o n t h e r e w a s need for c o u n t r y a c t i o n p r o g r a m s which might., f o r example, be p r m t e d t h r o u g h t h e school h e a l t h c u r r i c u l u m a n d d j ~ s c l l s s i o n i.n t-he w a r k p l . a c e . WRs shouI d a l no e n c o u r a g e gnt7ermnt;s t-o consider d i r e c t i n g some of t h e proceeds from t o h a c c o t a x a t i o n toward t h e m i n i s t r y of h e a l t h and i n f o m t j o n and 4 u r ~ t i . o n f o r henlt-h, and even t-oward compensating t h e media for n o t a d v e r t i s i . n g tobacco. The r e s o l u t i o n s on t-he rolc! of epi.dem.iology i n a t t ~ i . n i . n g H ~ ~ lf t ohr A1 I ( W 4 3 - 2 7 ) and t h e g l o b 1 e r a d i c a t i o n of polio (WHA43.28) were a l s o s i g n i f i c a n t . Global e r a d i c a t i o n of p l i o by t h r y c ~ r 2000 was best rqarded a s a s l o g a n r a t h e r t h a n a realistic k a r g e t at this s t n g c but would encourage nuppurt to t h e EPI p r o g r a m a s whole.
11. The Regional O f f i c e would be c o n t r i b u t i n g a r e p & t o t h e E x e c u t i v e b 3 r d on t e c h n i c a l c o o p e r a t i o n a m n g d e v e l o p i n g c o u n t r i e s i n t h e Region (WHA41.30). 12. Thc Regional Office had 1-quest-d, at the World Health A a s r d l y , llS$10 000 for a frasibl lit-y s t u d y o n ways of e x p n d i n g the O f f i c e .
13. The Regional DirecCox nated the i t q x x - h ~ e of a d v m t i n g f u r HFA and primary h ~ a l t b c a r e a m n g medical p r a c t i t l o n ~ r s . If t h e goal of HFA was t be achieved i n t h e next twelve years it was e s s e n t i a l t o e s t a b l i s h p r i o r i t i e s w i t h i n t h e procrcurmes, t o t a r g e t f o r HFA and t o a c c e l e r a t e efforts tc, m e e t t h e set t a r g e t s . Medical p r a c t i t i o n e r s w e r e In a position to take t h e lead and r e s p o n s i b i l i t y i n d i r w , t . ~ n gand d e t e n i u n i n g t h e course of HFA s t r a L e y y but tlley tliemselves had first to be reached and convinced. Unfortunately m n y medical p r a c t i t i o n e r s , as well a s o t h e r h e a l t h p r o f e s s i o n a l s , were n o t we1 1 motivated towards HFA and had n o t y e t developed t h e c o n m i t m n t t o play a n a c t i v e r o l e i n i t s s u p p r t . T h i s was an area of g r e a t concern and had k e n d i s c u s s e d by t h e last s e s s i o n of the Regional Consultative C o r n n i t t e e which had made v a r i o u s recannendations. The Regional Director emphasized the role a£ t h e wR i n i n v o l v i n g d i c a l p r o f e s s i o n a l s i n t h e HFA mvement. H e would welcome i n n o v a t i v e s u g g e s t i o n s and experiences regarding such involvenent. 1A h t - i n n ing t h e role of W s i n thejr c o u n t r y of assj g m n t . , t h e Regional D i r e c t o r sought of them a more a c t i v e park i n a s s j - s t i n g i n cases o f accident o r problems encountered by WHO s t a f f . T h i s was a n agenda itm.
15. The Regional Director urged WRs t o t a k e cdre L l u t t h e y d i d not u n i n t e n t i o n a l l y m i s l ~ a d n a t i o n a l s by appearing tea c m i . t WHC) t o provj cling funds without being s u r e of a p r o v a l from t h e Regional O f f i c e ; he also reminded WRs that nationals werp not permitted t o see conmumications from IMto t o t h e WR.
16.
The
HFA were
Regional D i r e c t o r painted o u t t h a t t h e n a t i o n a l s t r a t e g i e s f o r laid down almost a decade ago. Since t h e n many new apprudcI~ra
and t&mologies had been r e a l i z e d and t h e i r p l a r e n t a t i . o n of t h e strategies had c r e a t e d a wealth of experience i n t h e cowtries, a l l of which now n e c e s s i t ~ t e d t h e updating of t h e xlational s t r a t e g i e s . CIp3at.ing should, however, be a regular process following reviews and whenever new knowledge and e x p r i e n c e i s a q l i r e d ; unfo&unate.ly such updating w a s n o t being done. A c o n s u l t a n t had now been ass5.gned t o v i s i t some c o u n t r i e s o f the Region and assj-st them i n u@ating t h e m n a t j o n a l strategies; n e v e r t h e l e s s , s i n c e t h i s was a slow p r c e s s , W R s w e r e urged i n d i v i d u a l j y t o work with nat-iomIs t o p a r r y out u p 3 a t i n g w i . t h o u t waj.ti.ng f o r a consultant ' s v i s i t
.
17. The WR information framework, ref letting t h e f u n c t i o n s o f a hR had h e n deve1.op-d and t e s t e d by Headquart.ers. A t t h e end of 1.987 a p;.lot e x e r c i s e had been undertaken i n t h e o f f i c e cf t h e WHO r e p r e s e n t a t i v e i n &ni.la to s t u d y t h e p r a c t i c a l a s w t s of t h e framwork. The protxx.01 and results o f t h e s t u d y were combined i n document PM1/88.4 Program Managerent, I n f o m t i o n Study Phase I - W a Information. This, t n g ~ t - h e r with t h e r e p o r t of t h e Programrr: M a n a g m n t Information (PMI) Task Force w i t h its reccmwndations for implementation were circulated. The rezomndatjons of t h e lat-t-er had been endorsed hy t h e P r o g r a m k v e l o p n e n t Working Group. WRs w e r e u~rgedt o s t u d y t h e s e reports w ~ . t ha view t o t a k i n g steps t o implement t h e jtem i n t h e i r o f f i c e s and t o i d e n t i f y any su~rp0r-t they might. r e q u i r e of t h e R e g i o n a l O f f ice. Of course, cir-cun~sLcrrrues diffr r EX^ fr-iun one country to anothcr and the Regional. D i r e c t o r , t h e r e f o r e , I.ooked forward t-o heari.ng from WRs on t h i ~ s mtter i n due course.
I n t-he f i r s t quarter of 1988 l 3 R O had rccc:vd senior nat-ionals from almost a11 c o u n t r i e s of t h e R q i n n . WRs had prticip?t-eil and t.he v i s i t s w e r e f e l t t.o have bcen v e r y useful However, t-hej r r e ~ l value could and by t h e u l t i m 2 t e o n l y h judged by thc- a c t i o n s taken f o l lnwing t h ~ n impact o f t h o s e act-lons a t country l e v e l .
18.
.
19.
Tht-
R e y Ir n r d l
Drr ~ i : ~ u r r e p ~ r L r i 3 . the
develu~pt~er~ of t
~ ~ rc p , vrd
guidelines f o r .Tomt P r o g r a m Review M i s s ~ o n s and statxxfi t h a t t h e r e should bf. more mphsl s on t . h c p r o g r a m e v a l u a t i o n component-. J o j nk P r o q r a m Review Missions w e r e not hudgetlng e x e r c l scs but represent-ed a r m s t impnl-t-ant n g r t o o l f o r planning, PI-ogranming, monitoring and e v a l u a t i n g WHO'S col l a b o r a t l v e a r t l v i t I P S with M e m b e r Stat~s. Rrgarding t h e r o l e of the WR i n the e x e r r l s c , t h e Regional D l r r ~ t ; o r r e ~ t e r a ~ what d h e had said i n t h e f i f t h m t i n g , "If a WR w e r e involve3 from t h e e a r l y s b g e s of p r e p r a t i o n of a Review, h e should n o t c o n s i d e r hjmseIf s o l e l y a s e i t h e r helonging t o t h e nat-ional o r t-o t h e WHO t e a m and shoul d n o t t a k e s ~ d e sI n the d i s c u s s 1 on". 20. Following t h e a d d r e s s , t h e meeting e l e c t e d Dr H. Wassef a s chairman and Dr A. Abdul Hadi and D r M. R a h n a s r a p p r t e u r s . The list. of participants and agenda are included as Annexes T and 11 respectively.
21. The main purpose o f t h e Regional P r o g r a m Widget. P o l i c y j s t:o attain o p t h l u t i l i z a t i o n by Member States of WHO r e s o u r c e s i n suppnrt; of n a t i o n a l h e a l t h development i n t h e i r countries. The main tools f o r its ~ m p l e r e n t a t l o n are c o u n t r y p r o g r a m s t i k e m e n t s , .Joi n t P r o g r a m Rcvl e w Missions, p l a n s o f a c t i o n , meetings of s e n j o r government o f f i c i a l s and the General Programne o f Work. F ~ Z l o w i ncountry ~ reports by W R s on t h e i r experi.ences in hplmtenting t h e Reg; onal P r o g r a m Budget Policy, d i s c u s s i o n s took place.
22. It was agreed t h a t t h e pol i c y docurrent p r o v i d e s g o d and broad guidelj nes f o r i.mplerwnt~t.iono f W ' s p r o g r m budget,. Tn some i n s t a n c e s good deal of t-he Flicy had been imp1 e r w n t d , however, f e w count.r.ies had u n d e r h k e n i d e n t j f i c a t i o n of p r i n r j t y p r o g r a m areas and targeti.ng f a r HFA. Health f o r a17 s t r a t e g i e s should be r e g u l a r l y revised and uqx3ated t.o m e e t changing needs. Certai.n topics of s p c j f.ic concern a r o s e . a
( a ) I n t e r s e c t o r a l col l a b o r a t i o n A number of points w c r c raiscd. Ministries o f h c x ~ l t harc o f t e n r e l u c t a n t t o involve o t h e r s e c t o r s in h ~ ~ l t ph rograming f o r various reasons i.nc1uding r i v a l r y , non-coordination between m i n i s t r j - e s , a wish t o monopol izcr WHO, and lack of clclar p 1 . j r . y on -i nt:ersectot-a1 planning and Some n a t i o n a l NGOs thj-nk t h a t WHO should s u p p r t t-hem. financing. I n t e r n a t i o n a l and b i l a t e r a l agencies a r e general I y c m p r a t i v e h ~ have t t h e i r own ~ 1 j ~ c i which .e~ somtj~ms o v e r l a p i n a r e a s of WHO mandate, making
23+
.
coordinrntinn
dj.fficult;.
Tnte1-sector-a1
ccll lntk>~ra.tion w a s often easier a t
the p e r i p h e r a l t h a n a t t h e c e n t r a l l e v e l .
M 'WRC16-F Eng" 5
a
nirecimr p,i nt-ad oi~t. t.ha t i t was up tm t h e WR t,o the Regional P r o g r m Rudget P o l i c y , a s l a i d d m t k~yt h e Regiondl Cormlitl:m? and agreed t-0 by t h e W r States themse2ves. Ttrey sho~rldm3ke i t c l e a r t o m i n i s t r i e s of health W W O w a s not l i m i t e d t.o working w ~ t h them a l o n e and t h a t o t h e r m i n i s t r i e s and s e c t o r s could be involved to t h e benefit of a 1 1 I t was j m p r t a n t t o make them understand why t;h.is w a s so. If governments w e r c not jropl.mnt-ing m~p l i c y , was the o n e that had f a i l e d i n not. explaini.ng it t o thpm properly. ~n t h e other- hantl, j f gover-nmnts d i d not 1 i.ke p l icies such as this, it was up to t h m 1 n : change t-he rules through t h e governj rlg bodies i .e. the E x e c u t i v e Board and Regional C m i t t e e . W W was n o t a supranat:ional M y but the sezreLlriat of a c l u b j n which t h e members made t h e rides.
24 .
The Reg i.ona 1
explain
.
-
25. It w a s n n t d that governments ~omctimcscould not; undcrst,xnd why WHO w a s slower t-o respond to reguests for ass1 s t a n c e khan o t h e r agencies, UNICEF xas ci t d as a n example. T h i s , on mfixsinn lead tn l o s s of pl-est.j gc. on t h e p3r-t- of W10 s l n r e WRs have f.o r e f e r h c k t o Regional O f f l c e every t ~ w fat- d e c ~ s i o n s .
26. Replyjng, Dr A. Khogal i , Direct-or, P r o g r a m Management, s t a t e d thdt orlc:e pldrt ( I T w l r k w,-ib d y l m2x1 1 1 p 1 1 1 i-11ert- w a s 110 ~ - ~ e r to d refer h c l z t o t h e Regional O f f i c e f o r d e c i s i o n s . W R s should go ahead and implement t h e approved p l a n . 27. D i f f i c u l t y i n o h t a i n i n g sticker m&rs was mnti.oned. The Regional D i r e c t o r stat& that. sticker n r m b r s could ! x g i v e n along w i t - h the approved plan of work.
With regard t o WHO'S p s i t i o n i n r e l a t i o n to other agencjes, one avoid entering i n t o any sense of c a n p e t i t i o n or i n f e r i o r i t y . I t w a s implrt~3nt n mint o u t t o governments t h a t it %as better f o r them t o have a clear p o l i c y and n o t to accept t h i n g s outside the p l i c y , for example from a b i l a t e r a l agency, which might appear b e n e f i c i a l i n t h e short run but might end up c o s t i n g wre i n t h e long nu?. O f course, unplanned activities could n o t be agreed t o a s quickly as planned d c : t i v i L j e s . 28. must
{b ) Fel lowships 29. tkspj.te t h e c r i t e r i a l a i d down hy t h e Regionai Corrmn t-tee and j.rx t h e P r o g r m B u d g e t Policy, iC: w a s rzoted that countries w e r e sti 1l nmnjnating unsuitable candidates for f e l l o w s h i p s and request-j-ng cairses which \$ere n o t i n i.inc wlth WHO p l l c y . Thxs occllrred for v a r i o u s resisons i.ncluding: t h e f a c t t h a t details o f fellnwshjps and courses w e r e n o t c i r c u l a t e d beyond t h e c e n t r a l level c l r , o f t e n , beyond a s i n g l e dcpnrt--writ i n m i n i s t r y of health; f a v o u r i t i s m ; a d e s i r e a n t h e part of governments to c o n t i n u e t o emphasize curative a s p c t s of h e a l t h care r a t h e r than health promotion and primary h e a l k h c a r e ; lack of s u i t ~ b l e national p r s o n n e l i n a n area of t r a i n i n g ; Sack of personnel i.n g e n e r a l ; and t h e f a c t that, smtires, the mrini.stry of nea1t.h 1tseJ.t w a s n o t r e s p n s j b l e for nominating f e l l o w s .
m
30. Same c o u n t r i e s suffered from non-rcturn o f fel lws f ran c o u r s e s whi l e , very o f t ~ n , a ret-urning f c t lw was assigned t o an a r e ; , o t h e r than t h a t i n which he had undertaken t h e c o u r s e rendering its effect. u s e l e s s . %me f e l l o w s attended c o u r s e s and meetings which w e r e n o t i n t h e i r area of s p e c i a l i z a t - i o n . T t was p i n t 4 o u t t h a t t h e r e was v e r y I j t t l e WHO could do a b u t t h e s e kinds of problem; it could only a d v i s e c o u n t r i e s a b u t t h e tu s keep ftllcfws in n e c e s s i t y of having a c a r e e r s t r u c t u r e arld i r i c e ~ ~ t i v r the countxy or i n t h e s u i t a b l e area of eiqloyment. I t was suggested that mre funds might k d i r e c t e d towards s t r e n g t h e n i n g n a t i o n a l t r a i n i n g i n s t i t u t i o n s r a t h e r than towards f e 1 l o w s h i . p ~ s o that coimnkries whose f e l l o w s do n o t r e t u r n w e r e helped t o keep s t a f f i n t h e country.
31. With regard t o t r a i n i n g i n t h e Region it w a s suggested t h a t a nore comprehensive d i k e c t o r y compiled of U ~ tC l L J U l S C 5 available i n the R e q i o n extending beyond t h e b a s i c academic courses. T h i s would h e l p c o u n t r i e s t o plan their fellowship p r o g r a m s b e t t e r and might a l s o encourage ~ n n p rI nn ~ t k t - . w w r r count.ries.
32. I t had k e n recomnended t o g o v e r m n t s a t t h e n a t i o n a l f e l l o w s h i p s o f f i c e r s meetings i n 1985 and 1987 t h a t t h e WR be a member of n a t i o n a l fellowships s e l e c t i o n c m i t t e e s but j n mst c a s e s this tldd nut b e e 1 1 heeded. E f f o r t s should continue t o persuade governments t o accept t h i s principle. problem of language p r o f i c i e n c y w a s still a n i s s u e i n most and had been d i s c u s s e d a t t h e r e c e n t f e l l o w s h i p s o f f i c e r s meeting. The Department of Health and S o c i a l S e c u r i t y ln R r i t a i n had explained t h a t t h e B r i t i s h Cavernment was u n w i l l i n g t o be more f l e x i b l e i n t h e requirements which were, i n any case, t h e p r e r o g a t i v e of the i n s t i t u t i o n concerned; a l l t h a t could be done w a s t o try t o develop a sel f - l e a r n i n g package with t h e a s s i s t a n c e of i n d i v j d u a l governments and t h e B r i t i s h Council.
33.
The
countries
34. Fel lowship application forms were o f t e n endorsed by s e v e r a l d i f f e r e n t people. I t should be p o i n t e d out to governments that a maximum of t h r e e persons should be d e s i g n a t e d to endorse £ o m and t h a t a l l such persons should be known t o WHQ. I t w a s t h e r e p n s i b i l i t y o f t h e WR t o see that a l l forms canplicd to the criteria laid d m by the Exem1tiv~R M r d and t h e P r o g r a m Budget Policy; forms. should not be forwarded t o the Regional O f f i c e u n l e s s a l l t h e criteria were f i l l e d . Regional D i r e c t o r sum& up t h e t o p i c by p i n t i n g o u t t h a t , Eas up t o t h e WR t o make sure t h a t t h e f e l l o w s h i p s p l i c y w a s and understood by govermnts. Since a l l fellowship dpplicatiuns fvims went through thc WR's office and w e r e checked f o r f u l f i l l m e n t of c r i t e r i a there was nothing t o stop t h e WR from adding h i s own comnents regarding s u j t a b i l i t y of c a n d i d a t u r e . A t t h e same time it was important to persuade q o v e r - m n t s of t:he irnprtlance o f s e n d i n g the correct and mst s u i t a b l e persons t o c o u r s e s a s w e l l a s t o meetings, Regi.ona1 Cormittees and World Health Assemblies. The Regional O f f i c e had t h e r i g h t , which it d i d e x e r c i s e on occasion, t n r e f u s e d e l e g a t e s nomj~natedt o m t i n g s b u t it: wuuld p r e f e r n o t tu have to do so. T t was not thc role of WHO to d i c t a t e to its own M e m b e r S t a t e s ; persuasi.on w a s consider& t o be a better approach.
35. The a g a i n , it successful
. *
(c)
Consultants
36. Governments o f t e n failed t o meet t h e i r agreed c o m n i t m n t . ~ to provide a n a t i o n a l c o u n t e r p a r t , t r a n s p o r t , off ice a c c ~ a t i o nand support. Thj.s might occur through negligence o r l a c k o f r e s o u r c e s . The burden of provfision t h e n usual. l y £ e l 1 on t h e WR' s off ice. 37. S m countries were unable to i m p l e n t consultants' recomnendations beca~lse of l a c k of resources and y e t follow-up o r even r e p e a t c o n s u l t a n t s continued t o be s e n t . 38. C o n s u l t a n t s w e r e o f t e n not s e r i o u s ahout wnrking w i t h n a t i o n a l c o u n t e r p a r t s ; t h o s e from developecf c o ~ m t r i e s were often not, i n t u n e w i t h thc local situation and nccds dcspitc thcir cnt-husiasm.
39. The Regional Director pojnted o u t t h a t t h e best c o n s u l t a n t was, of c o u r s e , a n a t i o n a l one, i f available. I f n o t , then ~twas x ~ r t a n tt o t r y and f i n d a s u i t a b l e c o n s u l t a n t from a country wlth a s l r n i l a r e c o n m l c and developoent status. The f i r s t duty of the c o n s u l t a n t should be t o t r a i n t h e national counterpart. ( d ) S u p p l i e s and equipnent
40. Governments w e r e still sendinq i n long lists f o r s u p p l i e s which were n o t covered by WHO c r i t e r i a . This w a s o f t e n because of complete l a c k o f n a t i o n a l r e s o u r c e s o r because a planned p r o j e c t had been p a r t i a l l y unimplerwnted and t h e government wished t o mke use o f t h e remaining Jlurids. At prrserlt ddtqudLt: ~-3f;al~ptls w e L e IIUL d v d i l c f b l e ~ U I :FJRs tu enable them t o check on s u i t a b l e s u p p l i e s and p r i c i n g . This encouraged
governments t o over-order and over-estimate c o s t s . U p t o - d a t e and a n adequate number of catalogues would be s e n t t.o WRs. There w a s no wav o f e n s u r i n g t h e o p t i r ~ l u t i l i z a t i o n o r maintenance of equipnent i n many cases.
M r R. Re3rnhol2, D i r e c t o r , Support Programre, p i r i L e c 3 CXJL L j i d L j L up t o WRs t o apply t h e criterla from t h e Regional P r o g r a m Budget Po1j.q t o a1 I c o m p n e n t s of a p r o g r a m . I t was asst& t h a t WRs were doing t h i s b u t , on t h e o t h e r hand, p r o p o s a l s and r q l e s t s f o r W F J O assishnce from governments d i d n o t c0nfi.m it. Before forwarding r e q u e s t s e.g. f o r supplies and equipoent, t h e WR should c o n s i d e r how r e l e v a n t the request was to t h e prcgramne a c t i v i t y or its o b j e c t i v e , whether t h i s was a r e c u r r e n t expenditure, and whether use o f local p r o d u c t s o r expertise d been explored. This kind of s c r u t i n y would considerably facilitate t h e R e g i o ~ O l f f i c e ' s work. 41. was
42. The Regional O f f i c e continued t o receive open-ended requests for basic off i c e supplies, audio-visua 1 equj.pnent, fel lowships and supplementary r diem payments, none of which were i n l i n e with WHO p l l c y . hRs should a n a l y s e and r e v i e ~such r e q u e s t s . It w a s suggested that a c e i l i n g be a p p l i e d t o t h e p r o j e c t a l l o c a t i o n f o r s u p p l i e s and e q u i p n t . For example UNDP a p p l i e d a c e i l j n g of 20% t o p r o j e c t a l l o c a t i o n s of t h i s
tw-
The R q i o n a l D i r w . t u r rrrmnded W s t h a t -lies and e q u i p n t were r e q u i r e d t o k ordered before t h e end of f i r s t year of t h e biennium and should, l o g i c a l l y , IF ordered be for^ prograne i r r p l m n t a t i o n started at all.
43 -
44. Lack of f o r e i g n exchange i n some countries w a s c r e a t i n g p r o h l m s , p a r t i c u l a r l y with regard t-x, o r d e r i n g of s u p p l i e s and equipnent. It w a s ,suggested t h a t W R e might be emh1-d t n h a w power over some kind o f f l e x i b l e funding i n o r d e r tr, assist governments i n t h i s area. (el J o i n t P r o q r a m Review M i s s i o n s
45. Several c m n t s w e r e mde i n r e l a t i o n t o J o i n t P r o g r a m Review Missions. It-. w a s felt, f o r ex<ample, t h a t the d u r a t i o n of t h e JPRM w a s t o o s h u l - t to allow for the true evaluation o f p m g r a m s : advance p r e p a r a t i o n for JPRMs by WRs and m t i o ~ l sdid n o t a d q l a t e l y d e t a i l f i e l d implementation a c t - i v i t y; t h e r e was no permanent o r appropriate q o v e r n m e n t / m c o o r d i n a t i n g mechanism t o p l r s u e t h e JPRMfs work on cert;aln issues; high turn-over of government d e c l s l n n l ~ k e r s had a n adverse r : f f t r c t on such reviews; p r o v i s i o m l a l l o c a t i o n of programne funds f o r t h e n e x t biennium sometimes led to i l l - f e e l i n g on t h e part o f t h e government when changes were m d e a t a later s t a g e , even though such changes might he according to r e v i s e d needs. 46. I t w a s f e l t that t h e r e was a need f o r 3PRM m e m b e r s t o follow up a t a time subsequent to t h e i r mission i n o r d e r t o assess t h e e f f e c t i v e n e s s of the mission, whether implementation was t a k i n g place, and t o make adjustments where necessary. W h e r n a t i o n a l involvement i n reviewing HFA 5tratqies through JPFtMs W d 5 felt to be desirable. It w a s also felt- t-hat WED-supa c t i v j t i e s were not s y s t e m t i c a l l y m n i t o r e d and e v a l u a t e d , e s p e c i a l l y a t t h e implementation phase and t h a t t h e r e w a s no specific c o p n p n t a l l o c a t e d f o r m n i t o r i n g and e v a l u a t i o n of p r o g r a m s and t h e i r impact on n a t i o n a l h e a l t h p o l i c i e s .
47. The f i n a n c i a l a u d i t was a formal tool which had been developed i n o r d e r t o review implementaLiori uf P*-uy~-amrre b d g c t Policy in prcrgramne and policy terns. Al.though, i n p r i n c i p l e , JPRMs were now tn be preceded by a n annual. a u d i t , obviously t h e Regional Offj.ce could n o t do an annual a u d i t for all c n l l n t r i e s . I t was suggested, t h e r e f o r e , t h a t t h e r e should be some s o r t of i n t e r n a l system f o r e v a l u a t i o n of projects i n a p r o g r a m . M r Helmholz p i n k e d o u t t h a t now t h a t a pmtacol for t h e a u d i t s had been f i n a l i z e d and was a v a i l a b l e f m t h e Regional O f f i . c e t h i s might provide a framework for self-anafysi.~. I n orie cc3untry where t h e sudi.t had been c a r r i e d o u t t h e r e a c t i o n of t h e government had n o t been very p o s i t i v e b u t t h i s w a s perhaps due to lack of coordinatj.on. There was no doubt t h a t an a u d i t p r i o r fa a .TPRM was o f w r t a n c e f o r i d e n t i f y i n g a r e a s requiring a t t e n t i o n . Monitoring and evaluatj.an of p r o g r a m q l m e n t a t i o n should be a n i n t e g r a l part of t h e p l a n s of work.
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48. It was suggested that the Regional P r o g r m Camnittee might clarify changes in programning before the JPRM report was finalized in order not to upset govemnts. M r ~elmholz indicated that the JPWvl report format was under revision in accordance wjth reconmendations f x m the KCRPC. It was felt that there ought to be a focal point for fnl 1 m - ~ r p tr, ,TFRMs i n the Regional Office. Dr Khogali paint4 out that the RPC was, in fact, the focal point in EMRO for JPlWs and that proceedings o f RPC meetings should be circulated to WRs. (f) Health for all leadership developwnt colloquia A number of WRs reparted good j.nvolvement and response to the HFA leadership develn-nt 1 a hut t h e r e w a s as yet no means of following up. WRs were asked to suggest suitable means for this.
49.
50. The question was also raised of how to get dedicated prsons involved m advocacy and HFA leadersh1.p. WKs might, for example, come across suitable people in meetings but were unable to nominate such people for leadership developoent colloquia training formally while i-nfoml nomination was neither appreiated nor effective(q)
Reportinq back after meetinqs of qoverninq bodies
51. The Regional Director suggested that ~t mlght be worth convening meetings between a WR and the government to which he was assigned in order to discuss resolutions of governing bodies after the relevant meetings had i x k n place. This would overcolne the problem of delegates who were notsuitable or who did not reprk hack to the government proprly. It was also suggested that WRs might hold a meeting, for example a month after the WHA, Regional Cormuttee or Executive Board, with ministries, relevant sectors and the media in order to inform them about resolutions taken and .to raise awareness about WHO and its policies. (h) Other issues
52. Governments still tended to djspute provision of local costs for training within a country despite the fact that the criteria laid down for assistance in this area were quite clear. 53. Despite the stated codtment of governments to Health of All by the Year 2000, jxrplwntation of HFA stratcgy and policies was often hindered in practice by a lack of willingness on the part of governments or by mid-level administrators to make serious efforts at integration of p r o q r m s into primary health care.
54. It was noted that health situation and trend analysis continued to be weak in mny countries. 55. Many senior offj-cials failed to read the P r o g r a m Budget Policy and, as a result, failed to follow the guidelines laid down for them in planning national strategy. Moreover, programne budget statements for the
biennium 1990-1991 rev-led that there had been less change in approach to programw budgeting than had been hoped for. This was despite. WR's enthusiasm concerning the use of the Regional Prograne Budget Policy hooklet in helping them to advise governments; the latter had, ultimately, paid little attention to the &icy. Translation of the d o c m n t into local languages and the holding of workshops constituted the best approach and should be pzrsued by WRs wherever necessary.
5 6 . High turn-over of tap-level officials in ministries of health, sanetimes accmpanied by no permanent planning structure, was a problem in same countries. The Regional Director pointed out that WRs should concentrate on working with mid-level and owrational level personnel sincc these might be expected to be more long-term and particularly sincc the gap was ktween pliticzll corrmitment to plicy and implementation of it. At the same time it was, of course, up to the WR to inform each new minister or senior level official concerned of WHO policy and keep the government up to date. Ignorance on the part of the government should be considered as a failure on W"'s part to explain plicy properly. Affluent countries had a tendency to pay too little attention to Budget Policy because their collaborative resources were mainly supplied through the national budget and funds in trust. 57.
the Programne
The flexibility of the Regional Office in assisting governments to changes to agreed plans of action might encourage governments not to d l ~ e ~ t LU j Lllebe pld113 ii~ L11e f u t u t e . Tlie R q i u l l a l D i l e c t u r pi]-rtd uut that there was no harm in flexibility provided that it stayed within priority lines. Pakistan and Somalia provided exanples of flexibility that had been exercised within the special budgetary lines laid down by WHQ. WHO had also tried to exercise some flexibility in allowing countries to pay their contributions according to different schedules, in line with their own financial year. The Regional D i r ~ t o r rqiested WRs to meet concerned offj.cials and explain tu them the i n c e r ~ t i v e sTor tjnely p y m e n t of their contribution.
58.
make
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59. It was suggested that WRs might encourage governments to create their own national program budget policy along the lines of the Regional Programre Budget Policy; the latter would be a stimulus for them. Such a move would assist them in planning expnditure of their own resources as well as external donor resources. It would also lead to other advantages such as: improving inter-agency collaboration and preventing overlap; providing countries with the opportunity to set priorities and targets within national prngra-4: and t ~ s t i n gt h m ~ n m i tm-nt. of ~ n ~ ~ n tt r n iHFA ~ s through the allocation of the resources in the partjcular areas of a c t i o n . . Also, there was a general international trend towards p r o g r m budget policy making which W O must keep up with in order to ensure that its own pollc~eswere adhered to by governments. 60. hklet
Finally, j . t was suggested that the same s u m r l a l approach, in form, used for the programw h ~ d g ~ pnljl-y t might he amlied t o t h e
Eighth General Program of Work so that the job of brlefing governments by W R s might be facilitated. However, the Regional Director pointed out that it would be difficult to condense thjs p r t ~ . m l a r document further it was rqulrPct tor pol~cy-rrraking. Instead, W R s mlght o b t a ~ n slnce copies of medium-tern programs from Regional Advisers if they wished.
111. EXPANDED P
m ON I ~ I Z A T I O N
bmnmization coverage 61. on t h e cnrrent.
Dr L . A1 Kindi, STC, Expanded Programne on Imization, reported R+A~.-I~S nf imrnlnization coverage in the Region.
62. A number of countries had continued acceleration of t h e i r EPI activities to meet the set targets, by means of caqeigns and by promoting and strengthening existing basic health services providing jmrrunization. A special meeting had been held in Khartoum in February 1988 for five countries lagging behind in achievement of coverage rates, in order to help them solve p r n h l m s facing t h e i r EPI programnes. 63. Regj-owl coverage rates by various antigen for children under one year old has reached RCG 67%, DPT/plio 64%, measles 56% and tetanus t o x o l d ( 2 doses) 2 2 % . Some of the daZa replrted by c0untrj.e~ was incomplete, inaccurate or delayed; however, Regional vaccination trends had shown an appreciable increase over the period 1983-1987. For DPT3/OPV3, fifteen conntries had reachpd nver 70% coverage and for measles nine countries had reached such a level. One country was below 20% coverage for DPT3/OPV3 and two countries for measles. 64. The targets set at the 1986 meeting of managers of national EPI programnes were exceeded by four count:ries while three countries almost reached their t a r g e t s and the remaining countries were still below the set --targets. Since imnunization cnverage had increased, drop-out rates were expected to decrease. Indeed this was the case although drop-out rates were still in the range of 10%-40%, with the exception of the five countries that lagged behind.
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65. Neonatal tetanus continued to be a major killer. Since national policies for tetanus toxoid imnunization differed, the final analysis of data for 1T2 coverage w p r e not r?nrrg?arable. However t h e figure of 22% for estimated Regional coverage was very low. 66. In
The real measure of success of any EPI programoe is the reduction sncldence of the six target diseases. The repeed figures indicated d decreasing trend i n the incidence of these diseases. The apparent increase in reported cases of neonatal tetanus was probably due to improved levels in r e p r t i n g *
67. The Regional Office had contj.nued to conduct comprehensive reviews of EPI programnes and to provide intercountry training courses and workshops. Since the last meeting o f national EPI nwnayers, r i i r i e s a l r reviews had been carried out and faur training courses had been conducted, 5-ntohealth j n addition to one workshop on integrating EPI/CDD mterj.a.1~ di~r~tio c~ n l r r i c u l a ,considered to be an hmrtant topic at this time.
68. Dr M. Wahdan, Director, Disease Prevention and Control, noted that same coverage rates were thought to be underestimated since the latest figures were based on data receive3 from the governments on routine vaccination, which did n a t include private practice, rather than on EPI sweys.
The cold chain G9. M. Haghgou, STC, CFI, statcd t h a t t k r c cold chain w a s a cold s t o r a g e system which aimed to maintain t h e temperature required f o r EPI vaccines from t h e production site, through t r a n s p o r t a t i o n t o t h e imrnuzization site. Like a l l systems, it reguired c e r t a i n components in o r d e r t o be e f f e c t i v e and e f f i c i e n t : a system design t h a t works f o r the country i n question; e f f e c t i v e mmgernent; s u i t a b l e eguipnent; and t r a i n e d personnel. I n the areas of e f f e c t i v e management and t r a i n e d personnel t h e Rcgion w a s lacking.
70. Mr Haghgou noted t h a t cold chain eguipnent w a s develop& and t e s t e d by WHO f o r almst every condition. H e s t r e s s e d the hnpcrtance of supervision and e f f e c t i v e c h e c k l i s t s and demonstrated use of t h e cold chain monitor as a managerial tool. The c o l d chain monitor indicated vaccine potency a t any t i n e a t any p i n t i n the chain and a t p i n t of delivery s o t h a t it could be determined exactly w h e r e an error had occurred i f t h e vaccine f a i l e d . One cold chain monitor could be attached to 3000 doses each of DM', O W and measles vaccine.
71. The question of i n j e c t i o n policy was an important one slnce ~t had been c a l c u l a t e d t h a t use of r e u s a b l e p l a s t i c s y r i n g e s r a t h e r than disposable ones would save the Region S1lm over four years. However, e n s u r i n g sterilization of rcusjblc syringes w a a ~ constant problem w h i l e t h e r e was no guarantee that disposable syringes w e r e n o t used mre t h a n once o r that they d i d not f i n d t h e i r way i n t o less f o m l h e a l t h s e r v i c e s . Auto-destructive i n j e c t i o n equipnent which cannot be reused -had been developed and would soon be a v a i l a b l e b u t a t p r e s e n t its c o s t was prohibitive.
72. D r hhhdan r e p o r t e d on t h e f e a s i h i l j - t y of polio e r a d i c a t i o n i n t h e Reqion i n l i g h t of t h e WHA r e s o l u t i o n on t h e subject. H e stated t h a t p o l i o m y e l i t i s was still causing a considerable burden of m r t a l ~ t y , p a r t i c u l a r l y i n developing c o u n t r i e s . I t was est.imated t h a t over a quarter of a rnjllion c h i l d r e n , mostly under three y e a r s of a g e , kcmw p l a l y s c d as a result of polio annually, yet the number of repart4 cases w a s one-tenth of t h a t figure. The n & r of cases reprted i n t h e ENR ranged between 3 and 5 thausand per year. The high p r c e n t a g e of lameness i n t h e Region, a t a n average r a t e of 2-5/1000 population, i n d i c a t e d that among p o l i o survivors some one m i l l i o n suffered from permanent sequelae from which it may be deduced t h a t t h e number of new c a s e s is i n t h e range of 20 000 per year - some t e n times higher than t h e reported f i g u r e .
The i n j e c t a b l e vaccine a p r e d i n 1953 and t h e o r a l live vaccine i n 1956. These w e r e introduced i n t o t h e Region i n t h e e a r l y 1960s b u t coverage l e v e l s remained low i n most countrj-es u n t i l t h e EPI programne was e s t a b l i s h e d i n t h e 1970s. Regional coverage had increase3 f r ~ m 5%-10% i n 1.978 t o nearly 70% i n 1988 and, i n f a c t , a l m s t 80% of i n f a n t s i n t h e Region now received a t least one dose of polio vaccine.
73.
74. Polio had been brought under control or eradicated i n developed countries using polio vaccines, as a r e s u l t of which i n t e r e s t i n e r a d i c a t i o n of the disedse I d i r ~ c r w s d a11J h e n a c c e p t 4 as a t a r g e t by t h e European, Rmerican and Western P a c i f i c Regions. The d e f i n i t i o n to be adopted f o r t h e term e r a d i c a t i o n was "the i n t e r r u p t i o n of transmission of p l i o v i r u s e s i n t h e country with l o w r i s k a£ reintroduction". Eradicatj-on was felt t o be f e a s i b l e because: (i) infection/vaccination r e s u l t s i n permanent imnunity; (ii1 t h e r e are no long-term carriers; t iii) human beings are t h e only reservuirs; ( i v ) the vaccines are very e f f e c t i v e . There w e r e t h r e e e s s e n t i a l s t r a t e g i e s f o r eradication. 7
levels ( a ) Achievement and maintenance of hiqh ~ i z a t i o n
76. The l e v e l of e f f e c t i v e coverage needed t o achieve i n t e r r u p t i o n i n transmission w a s not precisely known but was c e r t a i n l y above 80% f o r i n f a n t s . Vaccination coverage rates i n c o u n t r i e s t h a t had shown such i n t e r r u p t i o n i n transmission (Bahrain, Cyprus, Kuwait) w e r e i n t h e range of
90%.
Of
the
two
typs
of
~ r a c r i n e avai ?able t h e n r ~ fvacrine was
p r e f e r r e d because: it is r e a d i l y available; it is inexpensive (1-/30 t h e cost of IWI; i t is simpler to administer and does not r e q u i r e e q u i p e n t ; it spreads t o close c o n t a c t s of t h e r e c j p i e n t , inrnunizing t h o s e who m y not have been vaccinated; it produces local lntestmnal m n u n l t y which lmpedss a b i l i t y o f t h e r e c i p i e n t to spread t h e wild polio virus i f expsed to it; it can i n t e r r u p t transmission of t h e w i l d v i r u s i f a l a r g e number of people arc vaccimt;cd at the same t i m e , as on v a c c i n a t i o n days- . -
77. The injectable. -polio vaccine b d the advantage of d e f i n i t e post vaccination sera conversion and t h e r e was no risk, as with O W , of vaccine-induced p a r a l y s i s . 78. A cornbined OW/IW s t r a t e g y might be o f use i n s o m p a r t s of t h e 1-egion where evidenced failurcs of O W irrespective o f a good cold c h a i n
and good vaccines a r e persj-stent.
fb) Effective s u r v e i l l a n c e t o detect and s t u d y a l l new c a s e s Thorovgh cl j-nical , epidemiologica 1 and laboratory surrvej.1lance were i m p r t a n t elements of e r a d i c a t i o n . Special efforts would be needed to: i d e n t i f y a l l cases; determine whether such cases w e r e due t o f a i l u r e of t h e d e l i v e r y system o r of t h e vaccine i t s e l f ; undertake laboratory s u r v e i l l a n c e t o determi-ne t h e typ~: of p l i o virus c i r c u l a t i n g and t o d i f f e r e n t i a t e between t h e at-t-enuated vaccine virus and t h e wild virus. 79.
extremely
( c ) Rapid and comprehensive r e s p n s e t o a1 l cases
80. Since t h e case t o i n f e c t i o n r a t i o w a s a t least 1:100 t h e appearance of one c a s e of paralyI2.c p1j.o w a s equivalent t o a n epidemic of i n f e c t i o n . Therefore every case o f pol i o required tharongh, f u l l -scale i n v e s t i g a t i o n and control measures covering t h e areas around it. T h i s included searching f o r a d d i t i o n a l cases, assessment of .imnunization coverage and rapid vaccinatj.on of a l l c h i l d r e n under f i v e j.n the a r e a .
81. S e v e r a l c o u n t r i e s i n t h e Region had s u c c e s s f u l l y adopted t h e above s t r a t e g i e s , Kuwait i n particular. Plans o f a c t i o n
Regional D i r e c t o r had e s t a b l i s h e d an a d v i s o r y c o m n i t t e e eminent l e a d e r s from the Region who have c o l l e c t i v e experience i n t h e s e s t r a t e g i e s . The camittee w a s expected t o s t u d y t h e Regional p l a n of a c t i o n bej ng prepared i n EMRO and a d v i s e on m d i f j c a t i o n s necessary. The main p o i n t s i n t h e p l a n included: t i ) o b t a i n i n g plitical c o m i t m e n t w l t h l n t h e Kegion, p a r t i c u f a r l y through a R e g i u r l d l C w n r u t k resulutiun, and s w i n g f i n a n c i a l and s o c i a l support. Financial support had, t o a l a r g ~ extent,, t a k n a t i o n a l and only s ~ ~ p p l ~ m by nte dx t e r n a l s o u r c e s from m, m1ICJ?F and int-eresked NGOs who i n many cases w e r e a l s o dependent on national contrjbutions; ( i i ) s t r e n g t h e n i n g ongoing i m n m i z a t i o n prograrrmes, p a r t i c u l a r l y hy developing manpower through t r a i n i n g i n managrmcnt and c o l d rhaj n maint,enance and repair, and hy ensuring v a c c i n r a v a i l a b i l i t y and eff l c a c y , including c o n s i d e r a t j on o f type o f vaccirie Lr 1 be used; ( i i i ) d e v ~ l o p n t of a n adequate system of s u r v e i l l a n c e .
82.
The
compsd
nf
83. In oonclusion, Dr Wahdan s t a t d +-hat t-he n e c e s s a r y a d d i t i o n a l investment r~lguired t o a c h i e v e pol i o eradj c a t i o n w a s more t h a n j u s t i f id and t h a t t h e r e was no q u e s t i o n as t o t h e p s s i b i l i t y o f a c h i e v i n g s u c h a target.
Discussion 84. Thc main issue which arose from thc prescntatinnc. the f a c t t h a t although some c o u n t r ~ e sstill had very low EPI coverage rates, the a v e r a g e rate f o r t h e Region w a s around 70% and a p r e d t o have reached a plateau; the prablem n3w was haw t o r r a c h the remaining 308 of t h e p p u l a t - l o n - t h e unreachable. I t w a s p i n t d o u t however, that I n calculating t h e Kegional coverage rat-r t h e i m p r t a n t fact-or was p p u l a t i o n , n o t camtry, s l n c e t h r e e c ~ m t r i e s (Fgypt, I s l a m i c R e p u b l i c of I r a n and P a k j s t a n ) account& for t w r ; t h i I-da 05 thc p p u l st inn of thr Rcg3-n and sn dot-rrmi ncd t h r average. It was also p a i n t e d o u t t h a t reachjng such a p l a t e a u was a cornon feature of I ong-term t r e n d ana 1y s i s and sho111d not. cause o v c r - d e s p n d c n r y Sane countries u n d ~ ~ l h t c d l y o v e r - ~ s t m t e dt h e i r r e p r t d rates. Coverage rates wcrc ktt.t.cr jn rc111ntrics which hod an effective PHC system.
.
85. EPT and t h e h e a l t h manpower d e v e l n p e n t p r o g r m were warking togrthcr to p r d u c e a R F ~ ~ o M ~ s t r a t e g y a i m d a t t r a i n i n g and t o cover t h i s u n r c a c h d s e c t i o n of r e o r i e n t a t i o n of h e a l t h care ~ r s o n n e l t h e p p u l a t i o n ; s u g g c s t j o n s i n t h i s area would hc welcome. as e s t ~ b l j s h ~ t dh a t t h c two groups m s t csncerned w e r e t h e and t h r s o c i a l l y drprivtd. Wjth r r g a r d tn n s m d s t h c Rcgjnnal D i r e c t o r suggested t h a t one s u i b b l P m a n s nf r ~ ~ 3 c h 1 n this g group might he to a s r r r t a j n t h r a p5LLc .r I is rif m v e m n t h i thj n +-he count-ri ec and t . h ~ r i f a i r l y r c q l a r attendance at: mrkets f o r 511ppI7~ s Thesc . mrkrt-s might t h e ~de;,l g a t h c r ~ ng p l a r r a t w h i r h t o r r s r h n ~ m d cj fami 1.ics. pr~vidr
80.
it
norads
_
groups operational research was needed to social variables affecting them in order to reached and why they did rrut atterd hiwl Lh or irregularly. This might be done by means analysis. It was necessary to pay attention tn the psycho-social and bPhavionra1 a-ts in this type of research.
87. In the case of both establish the dermgraphic and establish why they were not facilities, whether regularly of small surveys for in-depth
88. An essential component in reaching these groups was to have dedicated health workers who were vigilant in follawing up vaccine schedules. Dedication was something that could be Inculcated in a worker and did not have to be an individual characteristic. It was also impartant to ensure vaccinators were properly trained to safeguard vaccine potency at the end of t h e c o l d chain. There s h o i ~ l da l w a y s he nt-her h e a l t h workers available in a health facility who had been trained to administer vaccine, to cope with occasions when the vaccinator was absent.
8 9 . There was some discussion as to the f e a s l b l l j - t y of actually going out and searching for the unreached since there were logistic problems involved. o r example, in one country the mobile teams were not mobile because of pcr d i m problem^ and petrol availability.
90. The private sector was felt to be an obstacle very often and efforts should be made to convert the unconverted i. e . to convince general medical practitioners of the necessity of inmmizatian for the country as a whole and of follming imrmnization schedules. 91. Witlr
rcyai-d to polio e r a d i c a t i o n it was agrccd that suah a strategy
should remain part of the expanded programne on imunization with additional mphasis on clinical identification of cases through .improved surveillance and on laboratory diagnosis of the different types. The essential factor was to gain political comnitment to eradication, through a Regional Cormnittee resolution, and national, financial and social support. Assistance from other international agencies, especially UNICEF drlr3. AGFUND, l r ~ i y l i tLE: s u u g l ~ t .
92. It was agreed that finding and following up all cases of polio posed sore problems since data collected by countries was usually based on patients attending comamicable disease centres while many cases did not turn up until after paralysis had occurred, and then in paediatric or rehabilitation centres. Health education of the public regarding the necessity of r e p r t i n g suspected cases would be an important strategy but at this stage surveillance could not realistically cover non-paralytic cases. I
93. The problem of excessive dosj-ng of tetanus toxoj-dwas noted. Five doses w e r e considered t o give permanent jnanunity but with each dose t h e risk of local reaction increased considerably. It was essential to m i n t a i n a vaccinat-ion tiisLury fur the &he*-, even though t h i s was mre d i f f imlt to achieve in practj-ce than it w a s for children, and not to indiscriminately vaccinate her each time she attended the health clinic, pregnant. A new history card had now been desiqned but the ultimate ajm was for countries to adopt a policy of giving two doses of tetanus toxoid
during secondary school years.
Iv. m T H HSWLRDS OF RADIATION biological effects of ionizing radiation
technical paper on the health hazards of radiation was presented Wjt~hai, Regional Adviser, Non-cmicable Diseases. The following is an abstract of his presentation, the full text of which is in 94. hy
nr
A
A,
Annex 111.
5. The term "radiation accident" means an unexpected and unintentional event occurring in a nuclear or radiological installation, during transportation of radioactive material, or in other circumstances which gives rise tn ovPrexpnsure (internal or e x t e r n a l ) of personnel or pawlation to radiation. Overexposure means expsure which exceeds defined regular limits.
96. With the rapid rise l n the peaceful uses of atomic energy in medicine, industry and power generation, concurrent efforts are being m d e to protect workers and the general -lation from exposure to bath external and internal
radiation
sources.
There
are
two
main types of
radiation accident: ( a ) external expsure due to a source of radiation outside the body and whereby ionizing radiation passes through the tissue, depositing energy by direct or indirect phenomena; this is the most frequently encountered type; Ib) internal exposure due to the presence of radioactive elernents in the body; these elmnts m y enter the body through inhalation, ingestion or cutaneous absorption. .
-
-
97. The mechanisms of the biological effects of ionizing radiation are described in annex 111. From the health protection point of view, certain hazardous somatic effects that may appear long after the time of expsure are of particular interest. These may, at a later stage, turn into biological effects. Radionuclides in food
98. Following Dr Modj.tabails paper, r I. Sheikh, Chief, Enviromntal Health Programre, presented a statement on radionuclides in food, a sumnary of which follows.
99. of
After the Chernobyl accident in April 1986, there was a great deal uncertainty as
to
how to proceed w i t h food control mcasurcs
for the
protection of the plblic. The available guidelines on the management of the consequences of a nuclear accjdent did not adequately cover action to be taken to protect the popllation in areas far removed from the accident site. Thjs prompted WHO to produce guj-delineson Derived Interventjon Levels for Radionuclides in Food. The guidelines relate to the post-accident situation and deal solely with appropriate intervention levels ful c u i i t l u l l i n y expasure
1
to radiation through contaminated food and
drinking water. 100. In relation to the guideljnes references were made to radiation accidents and near-field and far-field situations. Also individual dose criterion and the use of food consumption data to arrive at derived intervention levels were highlighted. The recent resolution M41.29 on radionuclides j.n food w d s d l s u L r o u y l ~ tLo t11e atterltiuin of tile meeting.
EY/WRC/6-E page 17
101. srmng
Following
t h e Chernobyl
a c c i d e n t t h e r e was
considerable conhlsion
c n n c ~ r n d natinnal
2nd i n t . ~ m a t . i n n a l a g e n c i e s a s t.o hnw t n p r r ~ d
w i t h i n t e r v e n t i o n a c t i o n t o p r o t e c t people from t h e h a z a r d s of r a d i a t i o n . Several c o u n t r i e s o f t h e Region requested urgent information on t h e radiation, particularly with regard t o p o s s i b l e contamination of countries nei~ghtmuring t h e accident s i t e . f m d s t x t t s m p r t d from r1~;1vemments at.so requested t e c h n i c a l a s s i s t a n c e i n developrent of national. c a p ~ b iities l for radiat-ion p r o t e c t i o n . To a r r i v e a t a consensus and provide p r o p r guidelines t n the cnl.mt r i e s , st.vpr,3l i n t ~ r - a g ~ n c y w t i n g s and group c o n s u l t ~ t i o n sof experts had been h e l d a t g l o b a l l e v e l . I n t h e ccluntri-es o f t h e Region, governments wished t o know when t o i . n t r o d u c ~ p r o t e c t i o n masurcs and p a r t i c u l a r ] y w h a t level, o f r a d i a t i o n i n f d s t u f f n e c e s s i t a t e s intervention action. It w a s a g r e d t h a t t h e r e w a s a need for W R s t o hc able t o a d v i s e g o v c r m n t s on p ~ : r m i s s i b l e levels o f r a d i a t i o n i n f d . The Regional O f f i c ~ wou1.d prewre a l i s t of pcrmissi-ble leve 1. s and send i t t o WRs .
102. The basic s a f e t y s t a n d a r d s f o r r a d i a t i o n protect-ion, based on t h e r m o m n d a t i . o n o f t h e I n t e r n a t i o n a l Cnmnission on Radi.ologi.ca1 Prot.ecti.on (ICRP) , set t h e e f f e c t i v e d o s e - q i . v a l e n t l i m i t f o r a n indi.vidua1 mrsnher of khe p u b l i c a t 5 mSv. Therefore, r e s t r i c t i o n s on d i s t r i b u t i o n of f o o d s t u f f s should be c o n s i d e r d i f a d o s e - q i v a l e n t of 5 rnSv w i l l k cxcccdcd i n
thc f i r s t y c a r nftcr an nncidcnt.
3073. N a t l o m l a g e n c l e s which monitor r a d i a t i o n l ~ v e l s i n f o o d s t u f f s would b e mrc i n t e r e s t e d i n a p e r m i s s i b l e l e v e l of r a d i a t i o n p r kilogram t h a n I n l i m i t s of dose-equivalent radiat-ion e x p s u r e per p r s o n per ypar. The WHO g i l i d ~iln e s a n Derived Tntervcnt-i on T P V C ~ s f o r Radionucl j d e s i n F d were brought. o u t i n order t o assist McmbPr S t a t e s by u s l n g l m a l food cons~mpt i o n data and refr r r i n g t - 7 n t c r v c n t ion lrvr 1 o f dosc-cqulvalcnt ( 5 -v) t o d e r i v e a p r m i s s i b l e l e v e l o f radiation I n foodstuEfs I n t-crms o f Rn[l>rrrl prr kilogram of food c a n s d (l?q/lcg) . Of c o u r s e i t w a s u p t o t h e n a t l o n a l a u t h o r i t i e s t o go k l o w 5 rnSv prr y e a r hut this had t o be justified by n e t g a i n i n tern of the c o s t - h P n e f i t of r d u c t i m i n h e a l t h p r o b l m s versus t h e Pcnnomic and social impact o f i n t c w e n t i o n masurcs. 104. Whl l c 1 is a
l o * . of
infn~rrratian a v a i I a h l e , n clear cut. and
C
simple d n c m n t whj c h can be easi ly understood by nati nna 1 s t a f f dors not. m t j o n d arc a n attempt i n t h i s d i r w - t i o n ; howrvcr, c x i s t . Thp g w i d ~ l i n c s icatd. W R s might usefully i - h ~ rrrt h d o l a g i e s rmpl o y d are somewhat c-1 advise governments n o t t o hpxt foods from sources where there w a s p o s s i b l e contamination i n the f i r s t place.
105. Dr f!omjni t y systm.
Rejeb, Regional Adviser, N u t r > t i n n , Acting Regional Adviser, 1 paper on the concept of t h c d j s t r i c t he3 I h ' Hcnl t.h , p r e s ~ n t , c d; H.
EM/WRC/6-E page 18 106. Evaluation of n a t i o n a l h e a l t h s t r a t e g i e s continued t o reveal t h a t t h e mljor o b s t a c l e t o achieving HFA/2000 lay in t h e planning, organization and matzaganent of h e a l t h systems, e s p e c i a l l y a t t h e d i s t r i c t l e v e l . o k 1irni t.4 IJnderstandi ng of t h e primary ha3 1t h c a r e approach continued t in scope; two pillars of PHC, i n t e r s e c t o r a l a c t i o n and romnunity i n v o l v m n t , had not received t h e r q ~ i r c d att~ntion and t h e s y n e r g i s t i r e f f e c t s of f a c t o r s such a s inproved food d i s t r i b u t i o n , n u t r i t i o n , housing and snnj t a t i o n , wjder availability of s a f r water, and r s s e n t i a l h ~ a l t h c a r e w e r e o f t e n not understood nor r e f l e c t e d i n t h e h e a l t h s t r a t e g y . Tnsuff i c i c n t e f f o r t s had been made t a involve p p l i ~ n improvj ng t h e i r own h m 1t-h thrnllgh t h e USP of simple technology o r t o involve t h r conmuni t y i n planning, imp1 m e n t a t i o n and e v r l l ~ mion t of h e a l t h and p heal t h - r e l a t e d p r o g r a m s . The problem s t i l l facing WHO was t h e s e t t i n g u of a h e a l t h s y s t m based on p r i m r y health r e . In 1986 t h e WHA reconmended that aphasis be placed on the d l s t r i c t i n order t o o p r s t i o n a l j 7 e t h e PHC concept through a learning-by-doing process. 107. The Clohal P r n g r a m P m m i t t ~ (19FIC;) ~ d~find th~district health syst-m based on primary h p a l t h c a r e as "...a mrr o r l ~ s s s~ l f - c o n t a i n c d s~gmrtnt of t h e national h e a l t h system. I t comprises f i r s t and f o r m s t . a w ~ l l defined p o p l a t i a n l i v i n g within a c l c a r l y defined a d m i n i s t r a t i v e and g w g r a p h ~ c a J area, whether urban o r rural. I t 1ncludt.s a l l l n s t l t u t l o n s providi ng health care in t.he d i s t r i c t whcthcr and ind i v i d m 1s g o v e r m n t a l , snci.al, s e c u r i t y , n o n - g o v e m m n t ~ l , p r i v a t e o r t r a d i t i o n a l . The diskrict hesxlth system t h ~ r ~ f n rnnsists r ~ nf r? v a r i ~ t ' y rlf inter-relatd ~ l e n t st h a t m n t r i b n t e t-o h e a l t h c a r e , workers and i 1i t up t o and inclurfing t h e hospital at. t h f ~i r s t r e f e r r n l lcvcl and t h e a p p r o p r i a t e laboratory and o t h e r d i a g n o s t i c and l o g i s t i c support T t s c m p n c n t , P 1 m n t . s n e d t;cs bc w e l l c m r d I n a t . d by a n off]c c r scrvl c r s a l l these ~ l e m n t s and assign& t n t h i s function i n order t o draw t o g ~ t h e r in s t i tut-ions i n t a a fr11l y cr~rRpr-ehenaive brand of p r m t i v r , prrvcntive, c11r;ltiv~ and rehabilitativ~ectivit.ies".
.
108. Howrvcr, a much sirclpler d e f i n i t i o n was to d c w c r i k t h e d i s t r i c t . as "an a d m i n i s t r a t i v e area where a local government; structur~r e p r e s e n t s c c n t m I g o v c r m n t sccltors and i s r r s p n s i b l P f o r s e c t n r a l a c t i v i t y , and where a ref prral hospital xi sts"
.
100.
Thc:
grncral
principles
of
the ddint,rict ha3lt,h systcm b o d o n PHC
( a c c e s s i b i 1 it-y , ~ q u i t r y , h e a l t h p r m t i o n and prevention, cornunity i nvol v m n t . , i n t r r s w k o r a l act-inn and dec~nt-.ra 1 i 7 a t i on) w e r e t h r saw a s t~huse f o r PHC s i n c e t h e d i s t r i c t h e a l t h system w a s not a new concept h ~ t r a t h r r s changr i n thr t,,wt.-ics of implmrnt-ing PHC by p ~ t t i . n g mp?It3sis on the district 1 1 Thr csse.ntiaT i d r a w a s t h a t s i n c e t h e d i s t r i c t - w a s m ~ c h rloscr t o t h r c o m ~ m i t y , t h r p p l e working a t d i s t r i c t l c v r l ~ m d r r s t d mlch b t t e r t h e problems of day t o day hcatkh c a r e . A1 so, s i n c ~ a1 1 thr? t r c h n i c n l s e c t o r s r q ~ rcvl i w r r r reprrsmnkrd, i t w a s t h c most. appr-opri a t e I r v e l f o r organi zing support t+o conrm~nit,yinvolvement.
.
110. Two mst i.mprtA3nt corrrl l a r i e s t.0 t h e concept. of d i s t r i c t h m l t h systc~m were pol i ti ca l cnmnitmmnt and s\~px-t.,and d m c n t r a 1i 7 a t i on. 1 i t i1 comnitmnt should hr t r a n s l a t x d intx, a n ovcr-all nationa 1 plan i 3 a t a s s ~ i r i n g q l i k y and focusing on t_he df-privcd groups. Thc plan cl-ta~~ 1d show comi t m n t of h t h .t-.hr m i n i st.ry of hrZ3 l t h and of o t h e r s w , t o r s
I34/'WlC/6-E
Page 19 and their contribution to national health develomnt should be well understood and clearly defined. In order to develop fully the district. needed a certain autonomy in decj-sion-makingand in the health system management o f resources, wiL11in the framework of national policy and strategy. Although decentralization had been effected in m n y countries it was, in most cases, merely administrative deconcentration. Effective decentralization and mlitical cmitment would eventually result i n k h ~ developent of functional district health systems which had the managerial capacity to interact with the national health system and to efficiently contribute to health development and social equity.
111. The elements required to establish the skeleton of the district health system were: organization, planning and management; operational research; fi nanci a 1 r ~ s o ~ ~ r r r ~csm ; l n i t-y i nvnl v m n t ; i n t ~ r s w t n r 1 a action; and manpower developcent. 3.12. Problems in organization, planning and management were the most c m n w~akness In a health system. Therefore, the objective here would be to build up district capabilities to understand the national health strategy and goal, to ensure all district level workers have a clear idea ahnil+
their
rnlp
nnd
are
a h l ~ t n plan and mnagP p r n p r l y the health
programnes they are in charge of. They should be able to provide appropriate supervision to, and assist the comnunity in, developing self-reliance. A district health system could not develop without the existence of a natlonal supportive network that brings about this transfer of technology from the institutional level down to that of the district and the camunity
.
113. Operational research had not, so far, h n considered part of health developnent but should be an integral part of the district health devehpwnt process. It should be a means to overcome weaknesses in the health system and should generate innovative approaches. Those in charge of mplmnting programning at the district, national or Regional level should develop a kind of partnership with the national research institutions so
that these
are
brought
into the
mainstream of health
developnent levels.
and contribute to developnent of national capabilities at all
-
114. Since equity in allocation of resources did.not exist, with most o medical care in urban areas and especially to tertiary resources going t care hospitals, an appropriate financial strategy had to be developed to meet PHC r e c p i r a n k a .
115. Camunity involvement was a process of collective organization and involvement which led to increased h w n and material resources at the local level being channelled into developnent efforts. It required some supportive mechanisms which would help to build up the capacity for self-managent at the cormunity level. Intersectoral action was also essential
.
116. M a n p e r developnent should aim at narrowing the gap between training and managent o f services,
117. A framework f o r t h e d i s t r i c k health s y s t m , covering a l l t h c s e aspects, w a s developed jn t h e Declarat.jon of Harare. The way Ln which c m i t y invo1varr:riL d l ~ di i l l t e r sm-tol-al a c t i o n jnterlinkcd was i l l u s t r a t e d by t h e Thai experience i n implementing PHC through an o ~ e r a t i o n a l approach. The HFA s t r a t e g y i n Thailand w a s q 1 3 ~ e d with achieving bft-er q i a l i t y of 1 if^ by w t i n q t . h ~hasic: m i n i m needs of t h e less p r i v i l e g e d groups and w a s aimed a t ensuring The h e a l t h sector had, d i p l ~ t i c a l l y , taken a back spat. i n social -lit-y o r d e r t o o b t ~ i n i n t e r s e t o r a l s u p & . C o m n i t y i n v o l v e m n t here had w a n t rhanglng t.he role of t h e g o v c m m t from I-lidt- of prt~vidt.:~ facilitator and the r o l e of t h e comnunity from r e c i p i e n t to a c t n r thmugh t r a n s f e r of technology and managerial ski1 1 s tfi the comrnlnity so t h a t it beam self-reliant. Xn thjc: w a y +he r n m i n i t y a r q l i r e d t h e c a p a b i l i t y t o deal with g o v e m m n t swtars o n an q u a 1 hisis; c m m i t y financing kids e f f e c t e d through c o o p r a t i v e and revolving funds.
118. were
Discussion raisedwas the conf~~sio tn hat r ~ s u l t d betweenthe Tt. was mndc c l ~ a r that t h r disttrjc;t h e a l t h system w a s n o t a npw s y s t m o r vertirA31 p r o g r m i n i t s e l f but a n approach tx, st,r~ngt.hening PHC a t t h ~ distrirt 1 ~ ~ 1 , same p r i n c i p l e s . H ~ at lh c a r e p r o v i d d a t t.he d i s t r i c t Ievel applying the had a degrre of a l t o n o w , operating w l t h n ~ a d~finwl g m g r a p h i c ~ larlr3 a d m i n i s t r a t i v e u n i t of l o c a l government which v a r i e d i n si7e from one country t.o another. The d i s t r i c t h c a l t h systcm ccffnprmi s d a1 I t h p Je s o u r c e i r s i n t h a t area w h i c h could be mnbiliwd f n r h ~ a l t h ;it was m111 enough tx, be manageable and l a r g r enough t o allow f o r d ~ v r l o p w n t of f u r t h e r m m g e r j a l and administ-rative wtt-ups and t o i n c o r p o r a t ~ m o w of t h e othcl- s e c t o r s of the c n m n i t y . Tt also provided f u r t h e r s~imrt to t h e c o m l n i t y level of health c a r e e s p e c i a l l y In relation t o s ~ ~ p r w i s i o n of h e a l t h workers, r e f e r r a l of c a s e s , l o g i s t i c sr~pprt and s u p r w i s i o o and conti nui ng d u c a t j on f o r a1 1 h e a l t h wclrkers. ronccpts
119.
The main of
i
s
PHC
and
dintrid hmlth systm
.
120. Tt w a s felt-. t,hat t h e s~hjcct need& rsreful explanation t n g o v e m n t s t o o b t a i n t h e i r 1mdcrsi;anding and slipport s i n c e i t was clear that. most q o v e r m n t , ~ found t h e t ~ r m i n o 1 q - y conFusing. The kcy issl~p was how t o go about implementing t h e di s t r i c t h e a l t h s y s t m I t . was s11gg~stA t t s i n PHC was i t s e l f f a c i n y difficult-irs i n iqlrmnf~tion, the d i s t r i c t h e a l t h system would p r ~ h i b l ys u f f e r the? saw f a t e and t h a t f e w govc?rruruer~kb would takr thc initiative to nnt- up tho d i fitrict health system. WHO might encour.lge governments t o sS;lrt with what was a l r e a d y a v a i l a b l e , t o set up a h e a l t h care f n c i l i t - y n e t m r k at t.hp level of t h e comrnulity and support dec:r?ntrali7ation by a c t u a l l y giving t h e cominity t h e respnnsibi 1i t y and a i ~ t h o r i t y t o mohi 1 i 7r and u t i 1i 7e resources. I n mst c o u n t r i e s t-he basis of t h p d i s t r i c t h e a l t h svstem had k e n i n e x i s t e n c e f o r nuny y e a r s and developrent, o f t h e c s s ~ l n t i a lrl c m n t s had a l s o been i r l t r d i n for some t h e as pjrt of PHC) d e v o l o p n t .
.
121. npde
Thp d i s t r i c t h e a l t h system w e r e f u l f i 1 1d first, f i e a
that health
developtent
. was
was of no valur imlcss basic mi nirnrm roach must not. l ose sj g h t o f t h e fact. a pa% of overall soci opconomir devel n p n t
and should go hand in hand with that, through intersectoral cooperation. The most m r t a n t aspect of the a~rclach was that it was the m s t effective mans of attaining cormrunity involvmnt, self-reliance, ~ the h ~ e d t hsystem intersectoral action, decentralization, r e o ~ i e n t c i t - i u rof and manpower developrent within the PHC system. This was because the district level is the first referral level and nearest to the comclunities. The district health system approach was not about developing health services b u t : about effective iqlementation of the health system based on primary health care. VI. DIRECT FINANCIAL COOPTBtATION
122. Mr R. Helmholz, DSP, outlined the principles of direct financial cooperation (DFC). He described it as a resources participation (sharing budgetary costs) in defined national p r o g r m s in which WHO'S resources were used to m ~ p o r t the government in attaining defined health objectives, targets and outputs. This support might, fot-example, take the rurr~r uf pruvidiriy funds to allow a government to undertake health policy or resource stud.ies or to carry out a broad group of activities designed t~ inprove the national health system. e w 123. Direct financial cooperation occurred within the context of the n Managerial Framework for the Optima1 use of WHO Resources in fllpport of Member States, ircrplmnted in the Eastern Mediterranean Region via Joint ~/C;overment P r o g r m Keview Missions and perlodrc revlews between the senior national health officials and the secretariat of the Organization.
124. The conditions governing direct financial cooperatjon, which were formalized 4 agreement, were outlined. DFC should not be confused with local cost subsidy. e concept reflected the orientation of WHO collaboration away from thtrd pafly donor s t a t u s to the collaborative partnership in support of national priorities. It was a financial participation in a national programne as opposed to financial assistance whirh f a r i l i t ~ t d national involvement in a WHO progranme125. Direct financial cooperation might caexist with other € o m of local expenditure (and for this reason its implementation was not well tmderstood) but In practical t e r n ~t might be sirplest to review, first, to determine if any the more traditional mechanisms of local e ~ n d i t u r e would fit the program requirement and, if not, to then consider DFC. A guide was handed out to assist in determining which mechanism to apply. &fare deciding on DFC, the extent to which a country was able and willing to accept the accounting responsibilities involved in the management of DPC m i s t b determined. Obviously the awlication of the DFC mechanism must be cons~stent with the Organization's overall policies as they related to financial or programing matters. 126Dr N. A1 described their Pakistan it had and in Sudan jn rehahj.1itation of
_ -
Tawil, WR Pakistan, and Dr M. J. Khan, WR Sudan, briefly exprience with DFC in their countries of assignment. In been used in relation to the EPI and Malaria programes relation to the Blue Nile Health Project and the physical ten hospitals.
127. The Regional Director gave a background explanation of how WiW had home involved in this approach based on the Thai experience in developing basic m i n h needs. Despite the fact that direct financial coopexatlon had been started qulckly and the ground rules laid down lat2r on according to the experience gained, the experience had been a good one although accountability had proved a problem. The ventures in Pakistan and Sudan were EMRO's first into khis type of financing and wcre regarded v e q
much as ~xperkntal.The experience gained so far was not as positive as had been hoped. However the approach taken by DlRO in t h h i s regard was it had been a means of somewhat different to the Thai case; for solving certam inherent problems in projects, in particular that of salaries that were too high by local standards and caused ill-feeling as we11 as being inappropriate. 128. Direct financial cooperation had so far been used, mainly, as a way of helping a government to recruit local technical staff that it would not otherwise have k e n able to afford, since it had inherited the cost of a post that had previously been funded by a donor agency and may have been filled by expatriate staff. It was an intediate arrangement only, to . n the program, and as such help the government toward self-sufficiency i the agreement m e k look to thc ncxt s h g c and ensure t h k the gm1-1vce1-rt: would be able to absorb whatever salaries and staff were agreed upon. Salaries were still higher than local standards but mre realistic than previously and the Regional Director suggest.& that in future -salaries should be not m r e than double the local level and that WRs should be involved in recruitment prmedures, either by assisting in selection or by advising on suitability of a number of candidates. Such financial coopcrcltion
should only
focus on WHO priority areas.
I . BUDGET AM3 FINANCE AND INEt3IWiTICS SUPPORT M WR's 03MPUTERIZATION OF THE E M MANAGERIAL PROCESS
OFFICES
-
129. Presentations, including demonstration of the budget query system and development of workplans, were given by ~r N. Sharif, Informatics system Suppol*.
130. Introduction of computers into the Regional Office and WR's offices would, in the long run, facilitate: ti) introduction nf a cnmmn system of budget control and financial mnitoring ; ( ii introduction and use of a p r q r m management information system; implementation of a local area network for the Regional Office and developnent of shared &hbses U I ~ vdrivus PER rosters etc.; and (iii) migration of different hardware-based software i n b a database with c m n compatible software. rt was, of course, also an efficient tool in routine office management. 131. Mr Helmholz requested those WRs with recent experience of the introduction of micro-ccmpters to comnent on the problems sc, far encountered and to give their reactions to the provision of country budget infomtion on disk. The main issue was getting used to the idea of o computer utilization, with all its possibilities, and to having access t infomation at speed. Training was needed in various areas, both of WR's
-
s t a f f i n word p r o c e s s i n g and datahasr c r ~ a t i o n and o f WRs i n i~sagc? for work plans, budgeting, p r o g r a m m n i t . r i ng and day-ko-day office mnagmnt I t was f e l t t h a t a s e l e c t i v e approach w a s n c d d t o t r a i n i n g of seaf f , arcording to office n e e d s and avai labi I it-y o f a grxsi3 standcard of l m l trajning. If local t r a i n i n g was not a v a i l a b l e a c o n s u l t a n t ( p o s s i b l y peripatetic) might be s e n t or sub-regional courses might be arranged.
.
132. I t would be u s e f u l f o r those WR's offices which are t o r e c e i v e micro-computers i n f u t u r e i f the a r r i v a l of t h e computer w a s accampanied by an expert to assist in inshllakion and initial instruction and f a m i l i a r i z a t i o n , where such was n o t available l o c ~ l l y . . 133. W R s were requested to provide the R e g i ~ O ~f f l ice w i t h s p e c i f i c requirertrents f o r t r a i n i n g of staff and develapnent o f database and other programnes for affice use. Requests for Arabic keyboards and software should be forwarded to ISS. One c o ~ m t r y 1 - c p n t t 4 d i f f i c i ~ l t - y with t h e p r i n t * e r w h i c h would be l o o k d i n t o . 134. It prinkouts
was agrecd khxt khe R q i o n a l O f f ~ c e woilld crsnt-inlle sending of budget s t a t u s reports a l n n q w i t h {-.he d i s k s t o cmollntrirs f o r d bc r: t,o fami 1 i ~ r7c i t h e n e x t s i x m n t h s , d u r i ng whi ch t. im WRs wo~rl themselves f u l l y w i t h t h p computer and t h e rlsc of t h r d i s k s .
135. In cases where a consultant's r e p r t m s Ly+ or1 ccmpter i n t h e WR's o f f i c e it was suggested t h a t W s could facilitate t h e work o f Regional O f f i c e staff by sending t h e diskette w i t h t h e report on it w i t h the c o n s u l t a n t when h e r e t u r n e d f o r d e b r i e f i n g . T ~ C P- ' X F C . I I ~ ~ V act-ion ~ d c x ~ m e n t , consill t a n k s ' c o r r w t i nns and R r g i nnal Advi wrs' ch3ngcs coi11d t h e n k done wit-hout. any part. having t o be r e t y p r d and b e f o r e t h e c o n s u l t a n t l ~ f tht. t office.
_ -
I*2r W. W i t h e . Personnel O f f ic~r. d e s c r i l d t.he proc.e&ires tr, hc. followed i n t h c event a€ t h e d e a t h o f a s t ~ f w f m b r r and ci.rculnt& ,3 r e Was t o follow. I n p r t i r u l a r he drew a t t - c n t i o n c h e c k l i s t and p r m d ~ ~ for t o t h e p m p h l ~ t " m a t h of a s t a f f nwdx-r"; t h e deakh g r a n t which i s not payable j f j ndemnj t y payment f rm t h e U r g a n i z a t l o n ' s a c r d ~e n t and 3 l 1n e s s i n s i ~ r a n c : ~policy i s m d ~ , or i f t h e r e is no wi Fe or chi lclren; f i ~ n c r a l expenses payable by WHO; t h e d l l c a t i o n grant which i s payah1 e jn f u l I f o r t h e r m i n d ~ r nf t h p arad~mic yPAr; and t h e r ~ p = t t r i a t i n n rjr.snt which reqrii res proof o f r e p a t r i at.ion. '
136.
137. M r E . Nakhla, A d m i n i ~ ~ r a ~ i and o n Finance O f f i c e r , o i l t l i n e d t h e f i n a n c i a 1 i m p l i c a t i o n s which m-ight arise from khe denkh of a s t a f f m h e r including p n s i o n fund, a c c i d e n t and i 11ness i nsurance, grotlp I -i f e i n s i ~ r a n c : ~ , s t - ~ f f h e a l t h insllrance and c o m p n s a t i on ftsr dwtt-.h a t - t r i b ~ ~ t ac! hl t n the p e r f n m n ~ e of official daties. T n part-jc~~la hr e not.& that* pension forms should he forwarded t o W ~ a d q l a r t e r s v i a P~rsonnel,EMRO, t o g e t h e r w i t h t h e death certj f i c a k e , and t h a t rw:ei pt. of b c n e f i t.s through t-he I ' l n i M Nations ,Joint S t a f f Pension Fund would t e w i t h i n 2 - 3 months provided t h a t a l l the relevant. farms and d m ~ m n t s wlhmit;tr?d w e r e completed c n r r ~ t l y . Tf t h e r e was more t h a n one w i f r the w n s i o n benefit d ~ i e wo~lld be shared between t-hm, provided that p r m f was given t h a t t h e d~wenod staff
mebr
was; m a r r i e d t n them at, khe t i m e o f h i s
death.
For
EM/WRC/6-E page 24 dependant c h i l d r e n under Ule ~ i g e of 21 yttdrs, Lkie k r l d i L wc~.~ld, urilesti t h e r e w e r e exceptional circumstances, be p a i d t o t h e surviving parent., who must suhmjt proof t h a t he/she is providing t h e main and continuing supiport nf the c h i l d ( r e n ) . If t h e b e n e f i t i s t o be paid t.o a legal guardian t h e n proof of legal guardianship must be s h i t t e d . If dep~fndantswish to continue p a r t i c i p a t i o n i n t h e Staff Health Insurance s c h m ~ aplication must be made within ninety days of t h e s t a f f e r ' s death. The Group Life Insurance 1s a voluntary schcme and accordingly b e n e f i t s a r e payable i f t h e staff member is a p r k i c i p a n t a t t h e time death occnus; a death c e r t i f i c a t e mst be submitted along with t h e r e l e v a n t d i c a l report-. from a physician ( a v a i l a b l e from IMS/HQ). Contribution t o t h e group personal l l n e s s j nswance is cnmpll sory and shared between t h ~ staff accident and i mmber (0.2%) and WZIO (0.4%). Campensati-on might be payable undPr e i t h e r t h e Accident Insurane Policy o r i n accordance with t h e Staff Rules ( i f t h ~ of a f f l c l a l d e a t h is recognxzed as havlng oc:curred d u r m g t h e p e r f o m n c ~ d u t i e s ) , b ~ not t hoth - t h e choice t o be made by t h e surviving d q x n d e n t s . 138. Mr Helmholz indicated the need for diplnmacy in dealing w i t h d e p n d e n t s ' claim.;, s i n c e k n e f i t s might be e x p c t d which w e r e not i n f a c t payable; s i m i l a r l y , t h e need f o r a f a c t u a l descripkion of events i n case o f accident. I f t h e dependent was pursuing an ins~aranceclaim l a c a l l y , WRs shoilld inform hRK3 of t h e settlement expected and est~rcrated c o s t s of obtaining t h i s s i n c e it might a f f e c t t h e e n t i t l e m e n t due through WNO and might not be worth pursuing; WHO could n o t advise unless it had t h c Facto. If the accident is rwognirecf as service-incurred, t h e m u n k due under t h e insurance p o l i c y would be r e t a i n e d by WHO o r would be used f o r a d d i t i o n a l conpensation b e n e f i t .
Discussion
139. The main issues which a r o s e daring t h e discussion concerned: ( i 1 how a f m i l y might bc o3sicrt.d until t h e f i r s t p e n s i o n p p n t i s received; (ii) t h e c o n f l i c t between payment of t h e a c c i d e n t insurance and w p n t of any o t h e r type of insurance he1.d by t h e deceased.
Since it might take up to t h r e e months before t h e f i r s t pension i n s t a l l m n t is received sotw advance a g a i n s t o t h e r en&itlemnt;s might hF3 made t o t h e family; however, t h e Regional O f f i c e would have t o c o n s i d r r srlclt d p b ~ i hLity i in light of a J 1 c; ircumstance. W R S r&ndcd t h 3 1 . onc o f t h e r B s o n s it took so long t o make payrent_ was t h a t t h e legal beneficiary d it r ~ a l d not assumed t h a t t h e surviving had t o be ~ s t ~ b l i s h and d e ~ n d c n t s w e r e t h e h n e f i c i a r i e s . The only payment t h a t could be mad^ f a i r l y quickly t-x, t h e dependents was t h e death g r a n t s i n c e it d i d not have t o go through t h e estate; t h e Regional Director s t a t e d t h a t t h i s should be paid imnediately. The Regjonal O f f i c e would n o t normally be a b l e imrdidtely t o i n f n ~ m t.he depzndents of exact entitlements duc sincr khis is determined by Headquartrrs who a r e a l s o r e s p n s i b l r : f o r w r i t i n g t o t h e dependents on t h i s matter.
140.
-
141. Death under n o m l c i rcumqtances i n c u r s not accident insurrmce cmqxnsation but t h e death g r a n t , repatriation g r a n t and any life insurance held a r e payable. 142. I f death occurs a s a r e s l ~ l t of an a c c i d e n t not a t t i b u t ~ b l e to the p r f n m ~ n c e of off i c i a 1 d u t i e s , th 2 death g r a n t , rep&-riaf-ion g r a n t , and accident insurance a r e payable.
-
1411. If deatrh as a r e m i l t of an accid~nt ici attrih11t;rhle t n t h ~ pc?rformance of o f f i c i a l d r t i es, t h e d e a t h g r a n t , r ~ p t - . r i . a t ;on i grdnt , accident and i I l n e s s .inmrance and, pssi hly, r o m p ~ n s n t i o n hy t,hr Organization (SR 730) are p y a b l e .
3 44. Compensation by khe Organi z a t i on ensrrrps t h a t srwv-iv i ng d e p n d r j n t s r e c e i v e a c e r t a i n mininxm 1ev~:l of benefits and t h e r e f c ~ r c ,p p n t s m d e From o t h e r schemes t o which the Organization cont ri b r t - r s ( including t h e a c c ~ d e n t and i 1 l n ~ s si n s u r a n c e and t h e UN,T.C;PF) are t ~ k e ni n t o a c c n ~ m twhcn f i x i n g t h e l e v e l of rcxnpensation due. Tn a d d i t i o n , any t h i r d p3rt.y l i a b i l i t y payment ( b u t e x r l u d i n g s r t t l m n t of any p r i vat^ l i f e i nsr~r~hnce held by t h e s t a f f m e m b e r ) may also be t a k e n ~ n t o c o n s i d e r a t j a n when fi x j ng t h e l e v e l of compensation. 'It was suggested t h a t silch c o n s i d e r a t i o n of t h i r d party payments was ~ m r e a s o n a h l e ; however, Mr FIelrnhol z r lrirj f i d t h a t such reduction a w l ied to ccmpnsatinn fnr s ~ r v i r - P inr~irrcvlr v p n t s o n l y , a coverage which does n o t j nvolvp s t a f f c o n t r i butj ons.
WRs were authorized t o spend inmediat~lyw h a t c v ~ r w a s r q ~r i~ d to arrangements w h ~ c h i t was known would hp p a i d for by the O r g a n i z a t i o n ( 1i s t e d i n t.he p r m d u r ~) s They shmj I d , h o w e v ~, r seek authorj zat-ion regarding repatriatjan and a d d i t i o n a l p a p n t s s j n r ~ WRs m y cover
145.
.
the place of repatr La+ ion or t h ~~ x t ~ n nf t ~ ni t t 1~rnPn* and l i a b i l j t i e s due. Rineral expenses w e r e n o t p i d i n tzhe rase o f I w a l l y r e c r u i k d s t a f f . Non-staff e - g . fel lows and t h n s ~ I I ~ ~ P Ispw-inl sprvirr agreements were not. e n t i t l e d t-CJInsurance and g r a n t brief j t.s and t h i s should be made clear t o t h ~ m 3 n i t i a l l y t.0 avold d ~ f~ fc u l t > r l sa t e r . not. l m w
146. Wli
If was
there
was no WR j n t h e c o ~ m t r ya t t.he t.im o f a d e a t h or i f t-hp no
ir~volved and
czthrr
staff
w m b r
was
avail.ahl~ to
mak~
a r r a n g c m n t s , the r m r e p r ~ s e n t a t i v ewc~uldn n m l l y be a s k 4 t n at-t; i f t h i s was nrk pxsi b l t-he ~ Rr*g ir~na 1 Off i r e wtnrl d , of rorlrsc., scnd someone t o m k e t.he necessaty a r r a n g m n t s .
147.
W R s should observe t h e pmm<ulures nut1 i n d f o r d icnl evacuat: ion.
348. Copics of the procedures to be followed in the event nf thp dp3t.h of a staff m e m b e r should be made available to a l l staff m e m b e r s including General S e r v i c e s t a f f . I X
.
ACTTVTTTES CEJdE8flATTNG WHO'S 40th A N N I ~ ~ Y MIA. which
149. Region
~ a l a h i , P I ~ b t i r ;Cnformation, toc>l< pl.>ce j n
s t ~ m r i z p d activit:ir..;
In khe
celebration a f She 4Ot-h a n n i v e r w r y nf WHO.
Tndividual c o u n t r i e s whose a c t i v i t i e s were n o t covered i n gave reports.
presmkation
-
3.50. A l o t of j nnovation was e v j d e n t I n t h e a c t l v l t l e s whlch had t a k e n place i n t h e d i f f e r e n t countries and p r e s s and media coverage had been y d . ,%LIE d i f f i c u l t i e s had also h e n encourrtered jn c e r t a i n c o u n t r j e s including clashes between krld Health Day and nt-her* mt i n n a l celebrations. 3 60. M r J. Ljng, former Director, T n f o m t i o n and F d u c ~ t i n nfor f3ealt.h R s on t h c i r e f f o r t s and hog& t h a t the D i v i s i o n , W D / H Q , congrakulatxd W SITCIC:PSS W S had achieved i n involving t h e media i n h e a l t h advocacy r e g a r d i n g tobcco and health wcl~lld conti-nue throughout t h e year and i n
EM/WRC/6-E page 26 o t h e r programe a r e a s a l s o . He remind4 W R s of the agreement "Winners f o r Hea1t.h" that e x i s t 4 between WHO and t;he International Olympics Conmitte~ under which WHO w a s able t o cooprate with national 02ympj.c~~ o m i t t e e s . i s o ) p e l ~ d up a cl~anrrel to ut.he~s m t i i c s dnd rwans uf cur lvry iriy 11-d I t.h messages. 3 63 I n the subsequent discussions t.he Regj.onal Director expressed h j s pleasure a t the activities that had taken place and h o p 4 that; t-hr momentum would continue. W R s i n countries where World Health Day clashed w i t-h n a t i o n a l events should t- ly to p?ssimde g o v e r m n t s o f the k n e f il-,s o f a varied day's programne. H e i~rged a l l W R s t-0 give lip smoking, take exercise and take care of their g e n e r a l health.
'
.
1.
WRs
should follow up on any previous recomnendations that have not yet k n implemented. Subsequent meetings should start by reviewing rcc~tm~ndatiwns of
thc
the last meeting and shmld make Uleir owr~
r w m r t d a t i o n s during the discussion sessians.
2 .
W R s
should help countries to develop the t ~ p e of plan necessary t n impleirent decisions and resolutions of governing bodies which are applicable to it, and repart on a six-monthly basis to the Regional Office.
3.
A
nat ional intersectoral HFA coordination cornnittee should be formed i n thase countries which have nok yet done so and efforts made to make this c m i t t e e functional. Similar cmittees may bF? fomxtd at various levels of administration.
4 .
WRs are Pruyrdmrtc
requested t a promate understanding and use of the Regional RuilyrL Pvlicy by n d t j o n a l s . In so doing, translation of the document into local languages should be made whenever npcessary. Workshops and seminars shollld be conducted to orient nationals to the content of the d = m n t . The Regional O f f i r e will translate it i n t ~ French. should initiate implementation of a plan of w r k as soon as j u t been approved and sticker numbers should then be attributed as soon as possible.
5.
WRs has
6 .
Technical divisions should continue to keep WRs informed of short training courses available, especially in the Region, which do not appear in the Dirwkory of FAucation and Training Prqrannes of Health Personnel as a regular entry. W R s
7.
should apply the Regional P r o g r m Budget Policy criterja when screening government requests for s~elies and quipnent, , and in d i t a t ~ that t h i s screening has occurred. In
consi~lt.ants
instances where these criteria cannot be satisfied and the proposal is still to be submitted, t h e reason for mhitting it should be given. 8.
approval by t h e Minister of Health and the Regional rep& of the Joint P r o g r m Review Mission, which has h n agreed u p n and initialled by the head of the national team and the WR, any changes propasd by the Regional P r o g r m Cornnittee or by the Govermnt should be mutually agreed by both prties. Refore final Director of
9 .
WRs will take steps for the jmplementation of the information f r a m r k in kheir offices and identify any s u p p r t required from the Regional Off iae .
1.0.
The Regional Office will prepre a list of permissible levels of radiation in f d s and send it to Ws.
EM/WRC/6-E page 28
LIST OF PARTICIPANTS
Dr Abdul Majid AWul Hadi WHO R e p r e s e n t a t i v e for Jordan and Syrian A r a b R e p b 1 i c Damascus SYRIAN ARAB REPUBLIC
Dr Zamil S . A 1 A l a w y WHO Representative S a m 'a
w D r M . I . A1 Khawashky Egypt Desk and WR Designate Cairo
m
D r Nabil S . A 1 Tawil WHO Representative
Dr A. Arnini W H O Representative
Aden WHQ
DITXCFKCIC JTNEN Dr M.A. Barzgar Representative Mcqadishu SoMKLIA D r Nosrat El Gerbi National WHD Representative Tripoli LIBYAN ARAB JAMAHIRIYA Dr M. Are£ El Yafi
WHO Representative Riyad SAUDI AFUEiIA D r P.L. Ciacometti WHO Representative Muscat
m
Ds H.J.H. Hiddleotone D i r e c t o r of Health and lnJHO Representative UNRWA/Vienna D r J. Jirous hMO Representative
D r A.A. Khan WHO Representative Teheran IST2NIC REPUBLIC OF IRAN
D r M a h 4 LJmi.l Khan WHO Representative
Dr M. Rahman WtK3 Representative
Kabul
AFGHANISTAN D r A.M. Rahmani WHO Representative
Dr H. Wassef WHO Representative
M r T. Z e r i b j . WHQ
Representative
WI-K3 R Z I O N A X J OFFICE
Dr Dr Mr Dr
Wsein A . GP-zairy, Regional Director
A. Khogali, Director, Pwyramne M a n a g a n t R. Helmholz, Director, Support Programne
M.H. Wahdan, D i r e c t o r , Disease Prevention and Control m r , Director, Health Manpower &velapent and Acting Director, Health System Infrastructure Dr M.H. Khayat, Director, He-alth P r o t e c t i o n and Promotion Dr M.I. Sheikh, Chief, Environmental Health Programne Dr A.M.M. Aly, STC, H P A ~ ~ - h and B i o m e d i c a l Informztion (Acting Manager) Dr 0. Sulieman, Regional Adviser, Health Progranme Developnent and HFA Strategy Coordination D r O.I.H.
Regional Advisers Administrative Assist~nts
ANNEX I1 '
1.
Address by Regional U i r e c t o r
2.
Implementation of the Regional Programne Rudget Policy at rniintry I ~ x n = l [ R e p r t hy W R s )
3. 4 . 5,
The Expanded Programw on Irmunization and the 1990 Target Radiation Health Hazards D i s t r i c t Health Systems
6.
RFI
System and Informatics Support to WRs' Offices
7.
Discussion of programne jmpl~_mentati.on wit-h Divisions
EM/URC/6 -E
page 32
A N N E X 111 H E A L T H HAZARDS OF RADIATION
Biological e f f e c t s of i o n i z i n g r a d i a t i o n There are v a r i o u s t h e o r i e s of t h e b i o l o g i c a l e f f e c t of r a d i a t i o n , t h e f o l l o w i n g b e i n g t h e most f a m i l i a r :
1. Holthusan's photo-chemical t h e o r y , which assumes t h a t t h e b i o l o g i c a l effects consist of multiple chemical micro-reactions of a n i n t r a - c e l l u l a r and inter-cellular nature. 2. L i e c h t i ' s p e r m e a b i l i t y t h e o r y , which is based on t h e belief t h a t t h e b i o l o g i c a l e f f e c t o f r a d i a t i o n i s due t o c h a n g e d p e r m e a b i l i t y . bessauer 's point-heat theory, which believes t h a t t h e r a d i a t i o n a c t i o n 3 c o n s l s t s of "point-heat", t h a t i s t o s a y o f a v e r y m a r k e d i n c r e a s e i n t e m p e r a t u r e o f m i c r o s c o p i c a l l y s m a l l parts of a cell.
-
4. The " d i r e c t - h i t t h e o r y propounded by Blau, A l t e n b u r g e r a n d o t h e r s , lmplying t h a t a c e r t a i n number of " d i r e c t h i t s " a r e n e c e s s a r y i n a cell t o cause biological damage. A "direct hit" is regarded a s t h e compound effect of a group of ions. The chance of a biological e f f e c t being produced i n a cell i s t h u s d e p e n d e n t o n t h e c h a n c e o f it b e i n g " d i r e c t l y h i t " I. INTRODUCTION
I n principle, two t y p e s of r a d i a t i o n c a n be i d e n t i f i e d i n t h e environment: ionizinq and non-ionizing radiation. Non-ionizinq r a d i a t i o n , o r radiation of longer wavelength, i s less e n e r g e t i c and usual1y i n t e r a c t s with human t i s s u e , p r i m a r i l y by g e n e r a t i n g heat. A b e t t e r c o l l e c t i v e term, non-ionizing radiahon (NIR) is used t o encompass t h e group of e l e c t r o m a g n e t i c rd(;iidLiv~ls d11d ~ L L ~ S U U L K In ~ . recent years there has bern an increase in the development and use of equipment t h a t produces non-ionizing r a d i a n t e n e r g y , and t h e question has been raised as t o whether a d e q u a t e measures a r e being taken t o g u a r d both t h e u s e r a n d t h e q e n e r a l p u b l i c a q a i n s t i t s p o s s i b l e adverse effects. I o n i z i n g r a d i a t i o n comprises (a) r a d i a t i o n of t h e electromagnetic *
spectrum that is chal-acterized by rrtlatively short wavelength a n d high
frequency, and (b)electrons, protons, neutrons, a l p h a p a r t i c u l a t e s a n d o t h e r parlxdar r a d i a t i o n s of v a r y i n g masses a n d charges. When s u c h r a d i a t i o n penetrates any matter, it loses energy t h r o u g h i n t e r a c t i o n with atoms i n i t s path, r e s u l t i n g i n t h e formation of i o n s and r e a c t i v e r a d i c a l s .
~
11.
SOURCES OF I O N I Z I N G RADIATION
11 .I-N a t u r a l s o u r c e s
The g e n e r a l p o p u l a t i o n is exposed t o i o n i z i n g r a d i a t i o n from v a r i o u s sources, man-made a s w e l l a s natural. Natural background radiation comes from (a)cosmic rays, (b) t h o r i u m , radium a n d o t h e r r a d i o n u c l i d e s i n t h e e a r t h ' s c r u s t a n d ( c ) p o t a s s i u m 4 0 , c a r b o n 14, a n d o t h e r n a t u r a l l y o c c u r r i n g radloactive elements i n t h e body, Collectively, t h e a v e r a g e d o s e s r e c e i v e d from t h e s e s o u r c e s by a p e r s o n l i v i n g a t sea l e v e l is almost 0.80 m S V per year, however, doses a t least t w i c e a s l a r g e a r e r e c e i v e d by p o p u l a t i o n s at higher elevations where cosmic r a y s are more i n t e n s e o r i n a r e a s where t h e c o n t e n t of r a d i o a c t i v e m a t e r i a l i n the s o i l a n d s u b t e r r a n e a n r o c k i s increased. Measurerrents m formed in reccnt years have shown considerahl P r e g i o n a l v a r i a t i o n s which a r e d u e t o e s s e n t i a l d i f f e r e n c e s i n t h e concentration of natural radioactive substances i n s o i l and i n a i r . The u s e o f building materials with increased amaunts of natural radioactive s u b s t a n c e s as well as t h e concentration of houses o r b u i l d i n g sites with h i g h e r radium content cause an increase i n the exposure of populations t o n a t u r a l r a d i a t i o n sources.
11.2.
Man-made e n v i r o n m e n t a l r a d i a t i o n
Man-made sources a r e estimated t o deliver an average of 100 t o 140 m r e m per year t o each member of any given population ( f o r example i n U.S.A. it 1s 106 mrem/person). The l a r g e s t man-made contribution comes from medical applications. Smaller c o n t r i b u t i o n s c o m e from " t e c h n o l o g i c a l l y enhanced" s o u r c e s , s u c h as t h e u s e of p h o s p h a t e f e f i ~ l l z e r s a n d b u i l d i n g materials containing small amounts of r a d i o a c t i v i t y , g l o b a l f a l l - o u t from a t m o s p h e r i c t e s t i n g of a t o m i c weapons, n u c l e a r power, h i g h - a l t i t u d e j e t f l i g h t , o c c u p a t i u r l d exposure, and consurncr products (e.9. colour TV q p t s , s m o k e detectors, luminescent clocks and instrument dials).
page 34
T A B L E I: ESTIMATED ANNUAL WAOLE-BODY THE POPULATTON TN U S A S O U R C E O F
RADIATION DOSES T O
R A D I A T I O N
Average d o s e r a t e s (mSV/year)
Natural
Environmental Cosmic r a d i a t i o n Terrestial radiation I n t e r n a l Radioactive Isotopes SubtstrlT Man-Made
Environmental Technologically enhanced Global f a l l - o u t N u c l e a r power Medical Diagnostic Radiopharmaceuticals
Occupational Consumer p r o d u c t s and m i s c e l l a n e o u s !hbtotal
Total 11.3. E x p o s u r e routes due to atmospheric c o n t a m i n a l i o n :
The exposure of man due to t h e atmospheric contamination by r a d i o a c t i v e s u b s t a n c e s occurs by a number of r o u t e s . T h e most i m p o r t a n t are:
-
-
e x t e r n a l e x p o s u r e from a r a d i o a c t i v e c l o u d ; internal exposure from r a d i o a c t i v e s u b s t a n c e s t a k e n inl-ralatiun J u r i ~ l y L l l e pawvayc u1 s u c h a c l o u d ; e x t e r n a l exposure from radioactive substances internal exposure from r a d i o a c t i v e s u b s t a n c e s taken i n g e s t i o n of c o n t a m i n a t e d f o o d ( i n r a r e c a s e s .
i n t o t h e body by on t h e g r o u n d ; i n t o t h e body by water).
For example, d u r i n g t h e Chernobyl a c c i d e n t more t h a n 17 r a d i o a c t i v e mter~s were released. Most of them w e r e i s o t o p e s of r e l a t i v e l y v o l a t i l e elements. Amongst them I 131, (2,134, C,137, had h e a l t h s i g n i f i c a n c e a n d had t h e greatest potential f o r c o n t r i b u t i o n t o t h e human dose. (2,137 with long li£e (half llfe of 30 years) was present i n r e l a t i v e l y h i g h e r p r o p o r t i o n s t h a n i o d i n e 131 d u r i n g t h e f i r s t f e w days. Among r a d i o a c t i v e m a t e r i a l s with s h o r t l i f e , t h e i o d i n e i s o t o p e s , dominated by iodine 131, are t h e most important. The half l i f e i s 8 days, and t h e e x p o s u r e r o u t e i s through milk a n d a l s o by i n h a l a t i o n .
EH/WRC/6-E page 35 *
11.4.
U n i t s of i o n i z i n g r a d i a t i o n (doses)
,
L e v e l s a n d d o s e s o r r a d i a t i o n are measured i n v a r i o u s u n i t s IICRU, 1980). The Roentgen (R) is a u n i t of exposure. The u n i t f o r e x p r e s s i n g absorbed doses is t h e r a d (1 r a d = 100 e r g s per gram of t i s s u e ) a n d t h e Gray (1 Gy = 1 J o u l e p e r k i l o g r a m of t i s s u e = 100 r a d ) . The d o s e s i m p a r t e d t o t i s s u e by exposure t o one Roentgen approximates one rad. Because o n e r a d o f particulate radiation g e n e r a l l y p r o d u c e s g r e a t e r i n j u r y t h a n o n e rad of X-rays, t h e rern and t h e S i e v e r t (St.)have been i n t r o d u c e d t o e n a b l e d o s e s o f b f f e r e n t radiations t o be normalized f o r biological e f f e c t s . One r e m i s t h a t dose af any radiation t h a t produces a h i n l o g i r ~ l effect equivalent t o o n e rad of X-rays o r gamma rays. One Sv is t h a t amount of any r a h t i o n t h a t produces a b i o l o g i c a l e f f e c t e q u i v a l e n t t o o n e G r a y o f X - r a y s o r gamma r a y s (1 Sv = 100 rems). The m i l l i r e m ( m r e r n ) (1 m i l l i r e r n = 1/1000 r e m ) is a l s o used. The units used for expressing t h e collective d o s e s t o a p o p u l a t l a n are t h e person/rem and person/SV w h c h denote t h e product of t h e number of people exposed multiplied by t h e a v e r a g e d o s e p e r person, e.g. 1 rem t o e a c h 1000 people = 1000 person/rem = 1 0 peraon/Sv. Boquerel ( E l q ) is used f o r d n s e equivalent rate i n a workplace, r a d i o n u c l i d e c o n c e n t r a t i o n i n air, water a n d f o o d a n d c o n t a m i n a t i o n o f s u r f ace, etc. Almost all international s c i e n w i c bodies h a v e now recommended t h e u s e of t h e S I units (Systhme i n t e r n a h o n a l d t u n i t C s ) d e v e l o p e d by t h e c o n f & r e n c e g6ngral d e s poids et mesures (GPM); t h e u s e of t h e s e u n i t s w a s e n d o r s e d b y t h e t k t i e t h World rlealth Asscmbly in 1977. Table I1 shows SI derived units and t h e c o r r e s p o n d i n g non-SI u n i t s and t h e c o n v e r s i o n f a c t o r . T a b l e 11. S I DERIVED UNITS A N D NON-SI UNITS
SI unit and
Non-SI u n i t curie, ci rad
conversion f a c t o r 1 c i = 3.7 x 1QZBy
Q U A N T I T Y Radioactivity ~bsorbeddose
symbol
Besuerel, Bq G r a y , GY
( 3 7 Bq) I rad = 0,01 G y Doses e q u i v a l e n t Sievert, Sv
rem
1 rem
= 0.01 Sv
BM/uEC/~-E page 36
111. HEALTH HAZARDS OF RADIATION 111.1. R a d i a t i o n a c c i d e n t
-
Biological Effects of I o n i z i n g Radiation
The tern "radiation accident" means an unexpected and unintentional e v e n t
which occurs i n a nuclear o r radiological i n s t a l l a t i o n , d u r i n g t r a n s p o r t a t i o n nf t-adirmc+-ivc. m k ~ r i a lnr in nther ~irrlirmtancs,givinrj rise t o overexposure
(external o r internal) of personnel o r t h e population. Overexposure means a n y e x t e r n a l o r i n t e r n a l exposure exceeding r e g u l a r l i m i t s . with t h e rapid rise i n t h e p e a c e f u l u s e of atomic e n e r g y i n medicine, industry and power generation, concurrent e f f o r t s are being made t o p r o t e c t workers and t h e general population from exposure to both external and i n t e r n a l r a d i a t i o n sources. There are two main forms of radiation aocidentar (a)
External exposure which is due to a radiation s o u r c e o u t s i d e t h e human body and is t h e most f r e q u e n t l y e n c o u n t e r e d form. When i o n i z i n g r a d i a t i o n is passing through t h e t i s s u e , t h e y d e p o s i t e n e r g y by d i r e c t o r i n d i r e c t i o n i z a t i o n phenomena. (b) I n t e r n a l e x p o s u r e i s s o c a l l e d b e c a u s e o f t h e presence of ra&oact;ive elements i n t h e body. These e l e m e n t s c a n e n t e r t h e bady by inhalation, ingestion o r cutaneous absorption. T h e mechansirns of t h e hinlngical effects of ionizing radiation have been f air1y w e l l clucidatcd.
From t h e health protection p o i n t of view, c e r t a i n hazardous somatic e f f e c t s whch can appear long after t h e t i m e of e x p o s u r e a r e of p a r t i c u l a r i n t e r e s t . T h e s e e f f e c t s may l a t e r t u r n i n t o b i o l o g i c a l e f f e c t s . ( a 1 External a c c i d e n t a l e x p o s u r e ( radiation9 are u s u a l l y d i v i d e d i n t o two categories: acute partial i r r a d i a t i o n h i ) a n d a c u t e whole-body i r r a d i a t i o n a .
(Acute radiation means irradiation t h a t m a y bc inskantaneous but may
a l s o be prolonged over a number of hours o r days.) Acute p a r t i a l i r r a d i a t i o n refers t o i r r a d i a t i o n a f f e c t i n g o n l y p a r t of t h e organism. T h i s i n v o l v e s , e.g. r a d i a t i o n of t h e l i m b s a n d t h e h a n d s . Whole-body radiation is a relatively rare condition a n d develops u s u a l l y after a nuclear accident with powerful sources. The h e a l t h e f f e c t s of a c u t e radiation and its clinical symptoms are u s u a l l y manifested a s immediate and
late biological e f f e c t s , 111.2. Immediate b i o l o g i c a l e f f e c t s ( c l i n i c a l s y m p t o m s ) (a.i) Acute partial irradiation normally h a s no immediate c l i n i c a l symptoms. However, it has t w o s t e p s :
local disorders: When t h e doses are r e l a t i v e l y v e r y h i g h a n d e x u d a t i v e , immediate erythema may o c c u r with o r without pain. Dry a n d e x u d a t i v e e p i d e m t i t i s can a l s o be seen. Tlns critical phase may last from a number of d a y s t o s e v e r a l weeks.
-
of
Functional disorders which a r e caused by radiation b u r n s are e s s e n t i a l l y a circulatory and neurological nature. D e p t h hyperemia and pain w i l l
c o n t i n u e t o a l a r g e e x t e n t with congestive and inflammatory s t e p s . Penetrating photon radiation not only i r r a d i a t e s t h e skin and t h e subcutaneous t i s s u e s but a l s o t h e e n t i r e conjunctival and vascular h s s u e , t h e s k e l e t o n a n d t h e muscles. Destruction of subcutancmus t i s s u e a n d s w e a t glands, n e c r o s i s , and bone f r a c t u r e s which w i l l end wit0 s c e l e r o s i s of c o n j u n c t i v a l t i s s u e a n d d i s o r d e r s of bone growth, can a l s o b e seen f r e q u e n t l y .
EM/WRC/6-E page 37
( a . i i ) Whole-body i r r a d i a t i o n The immediate biological e f f e c t s a p p e a r o n l y a f t e r a n a c u t e whole body exposure t o high doses. Certain c l i n i c a l a n d biological s i g n s and symptoms appear very early. The time of appearance of t h e s e parameters is p a r t i c u l a r 1y important f o r t h e e v a l u a t i o n of s e v e r i t y a n d s u c c e s s i v e management of t h e paticnt.
Clinical syndromes develop i n f o u r phases:
Pradromal phase of initid shock: i n t h e 24 hours following the a c c l d e n t 1. w h i c h i s c h a r a c t e r i z e d by t h r e e t y p e s of m a n i f e s t a t i o n s : - n e u r o l o g i c a l s i g n s : marked a s t h e n i a f r o m t h e f i r s t h o u r o n w a r d s ; -
-
vasomotor signs; c r y t h e m , sweating from t h e first few hours onwards;
g a s t r o - i n t e s t i n a l s i g n s : nausea, vomiting and diarrhoea. L a t e n c y p h a s e ( f r o m n i n e day t o t h r e e w e e k s )
2.
The s i g n s d e s c r i b e d above diminish. Only a s t h e n i a a n d h e a d a c h e s p e r s i s t . This phase i s marked by c u t a n e o u s m a n i f e s t a t i o n s : t h e i n i t i a l erytlie~umcan be f o l l o w e d
by drying and d c s q u m t i o n of t h e skin.
B e t w e e n 12
t o 20 days, after t h e accident h a i r l o s s c a n occur. A regrowth of h a i r a n d n a i l s o c c u r s f r o m t h e f i f t h week a f t e r t h e a c c i d e n t o n w a r d s . 3.
C r i t i c a l p h a s e u p t o a p p r o x i m a t e l y 7 weeks marked d e t e r i o r a t i o n i n t h e g e n e r a l s t a t e o f t h e p a t i e n t ; s e v e r e prostratiuri; i n t e n s e headaches; hyperthermia, sweating; g a s l - . r n i n t ~ d n as l i g n s a n d symptoms: amnesia, nausea, abdominal p a i n s , p a r t i a l o r complete i n t e s t i n a l obstruction o r even perforation; s i g n s of haemorrhagea: e p i s t a x i s , g e n e r a l b l e e d i n g , h a e m a t e m e s i s , melaena, h a e m o p t y s i s a n d p u r p u r a .
-
-
-
-
-
4.
Recoverv phase. d exposure has not been s u f f i c i e n t l y h i g h t o cause t h e d e a t h of t h e victim.
-
(b) Internal a c c i d e n t a l exposure. T h i s is t h e u s u a l route o f r a d i o a c t i v e s u b s t a n c e s i n t o t h e body. The t y p e of r a d i o n u c l i d e c o n s t i t u t e s a v e r y important parameter. Distribution within t h e body is d i r e c t l y dependent on its p h y s i o l o g i c a l form. T r a n s l o c a t i o n a n d formation d e p e n d o n p h y s i c a l metabolic behaviour and time of r e t e n t i o n i n t h e o r g a n s o r t i s s u e involved. 11113. Late e f f e o t o of i o n i z i n g r a d i a t i o n
111.3.1. Genetic effects: Effects which become e v i d e n t i n t h e d e s c e n d a n t s of a n i n d i v i d u a l e x p o s e d a r e called g e n e t i c e f f e c t s . T h e s e r e s u l t f r o m a l t e r a t i o n s i n t h e reproductive c e l l s which c a n l e a d t o d e f e c t s i n the offspring. Such changes a r e c a l l e d g e n e t i c mutations. Genetic e f f e c t s m a y m a d e s t themselves a s grossly deformed chddren, o r as children who may h a v e l a t c n t o r obvious metabolic or biological changes that r e n d e r t h e m less h e a l t h y t h a n normal.
M/URC/~-E
page 38 Detectable radiation i n d u c e d g e n e t i c m u t a t i o n s can L
c a u l L if Lhe
individual's reproductive cells have been exposed to an a p p r e c i a b l e amount of radiation. Such changes do not produce any observable e f f e c t on t h e exposed i n d i v i d u a l , b u t may a p p e a r i n s u b s e q u e n t qenerations. They may n o t b e marufested i n t h e children of the exposed i n d i v i d a , b u t may l i e dormant f o r s e v e r a l g e n e r a t i o n s and may e v e n t u a l l y be elminated completely from t h e g e n e t i c pool. Chromosome aberration is another genetic effect that. can be s e e n i n many descendents of individuals exposed t o radiation. However, gene mutations are induced a t h i q h e r f r e q u e n c i e s t h a n chromosome a b e r r a t i o n s . Furthermore, chromosome aberration w i l l be elrninated after a few generations, whereas gene mutation may persist through many more generations, d f e c t i n g a l a r g e r number of individuals. Radiation is not t h e only a g e n t t h a t c a n c a u s e g e n e t i c m u t a t i o n s . Certain chemicals, high body temperatures a n d o t h e r a g e n t s can a l s o produce them. Therefore, when a child shows a genetic defect it should not be assumed t h a t it was directly due t o t h e i r r a d i a t i o n of a parent. I n f a c t , a b o u t two t o four per cent of all b a b i e s born i n t h e United S t a t e s e x h i b i t some s u c h a b n o m a h t y even when neither parent h a s had any r a d i a t i o n e x p o s u r e e x c e p t that from t h e natural background to which mankind h a s always been exposed. 111.3.2.
Somatic ( c a r c i n o g e n e t i c ) e f f e c t s on s p e c i f i c o r g a n s a n d t i s s u e s
While experiments with animals suggest t h a t r d i g n a n t transformitions may occur i n most mammalian t i s s u e s i f t h e y a r e exposed t o s u f f i c i e n t r a d i a t i o n doses, t h e number of people exposed t o s u b s t a n t i a l d o s e s i s s o small t h a t t h e relationship between dose and incidence of malignancy i n man c a n o n l y be studied f o r t h e most r a d i o - s e n s i t i v e t i s s u e . By f a r t h e l a r g e s t a n d most informative g r o u p s of i r r a d i a t e d s u b j e c t s c o n t i n u e t o be s u r v i v o r s of t h e a t o m i c bnmhings at Hiroshima
and N a g a s a k i . To t h i s m u s t be added several groups of patients treated by radiotherapy and followed up f o r s e v e r a l y e a r s , as w e l l as a few groups of workers, especially t h o s e i n underground uranium mines.
I n fact, t h e incidence of all major forms of leukemia, e x c e p t t h e c h r o n i c lymphatic f o m , has been observed t o have i n c r e a s e d i n t h e human population after irradiation of the w h o l e body or a major part of the haemopoietic bone marrow. An increased incidence of breast cancer i n Canadian women s u b j e c t e d t o multiple f l u o r o s c o p i c e x a m i n a t i o n o f t h e c h e s t h a s b e e n r e p o r t e d . Epidemiological s t u d i e s h a v e r e v e a l e d t h e t h y r o i d g l a n d t o b e h i g h l y susceptible t o r a d i a t i o n carcinogenesis. An i n c r e a s e d i n c i d e n c e of l u n g n excess of bone turnours, cancer has been observed i n atomic bcmb survivors. A Cancers bath benign and malignant has been observed i n radLum dial painters. of t h e pharynx, oesophagus, stomach, colon, rectum and pancreas havc been observed with increased frequency i n i r r a b t e d human and animal populations. The frequency of gastric cancer is increased by 50% i n p a t i e n t s t r e a t e d with X-ray f o r ankylosis spondylitis. A n increased i n c i d e n c e of carcinoma of t h e colon h a s been s e e n i n atomic bomb s u r v i v o r s . T h e i n c i d e n c e of o v a r y carcinoma is increasing i n p a t i e n t s who have undergone r a d i o t h e r a p y of t h e pelvis.
EM/WRC/6-E page 39
V.
MANAGEMENT OF RADIATION EXPOSURE ( E X T E R N A L )
For better therapeutic management of overexposed persons, t h e r e is a need to obtain, a t t h e r i g h t moment and without delay all a v a i l a b l e information i n t h r e e p r i n c i p a l methods, i.e.: Physical d u ~ i r u e t r y ; Clinical investigation; Biological investigation. IV.1,
Physical dosimetry
Physical dosimetry is indispensable f o r d i a g n o s t i c accuracy, t h e r a p e u t i c ~ n d l c a t i o n sa n d e s l d l l i s h m e n t of prognosis for patients suff pri n g f r o m i r r a d i a t i o n . Therefore, t h e f i r s t a i m is t o e s t a b l i s h t h e r a d i a t i o n c o n d i t i o n s i n t e r m s of r a d i a t i o n type, space time d i s t r i b u t i o n a n d d o s e s received.
-
Radiation t y p e is obviously an e s s e n t i a l f a c t o r , because it g o v e r n s t h e p e n e t r a t i o n i n t o t h e organism, e-g. photon r a d i a t i o n is o f t e n i n v o l v e d i n radiation burns, e i t h e r i n t h e f o r m of X - r a y s o r i n t h e f o r m of g a m m a r a h t i o n s from a radioactive source. T h e r e f o r e t h e form of e n e r g y must b e determined. Knowledge of t h e form of energy is v i t a l l y needed t o a s s e s s i t s e x a c t ps?net.ratinn. For whole-body i r r a d i a t i o n , t h e e x p o s u r e c o n d i t i o n primarily concerns t h e type and energy of t h e g a m m a photon r a d i a t i o n a n d i n some cases of s u p e r a d d e d n e u t r o n r a d i a t i o n . A s space/tme distribution of irradiation i n the e x p o s e d tissue is worth knowing, it is important to identify t h e respective geometrical p o s i t i o n s of t h e source and t h e exposed tissue, and i n most cases t h e distance between t h e sourcc and the skin. It. 5n important t o know whether a wide r a d i a t i o n f i e l d i s i n v o l v e d , a n a r r o w beam o r a n e x t r e m e l y thin beam.
It is a l s o e s s e n t i a l t o i d e n t i f y t h e c h r o n o l o g i c a l c o n d i t i o n s of t h e exposure. Here, however, it is often very C b f f i c u l t t o evaluate t h e exposure t h e , which is n e v e r t h e l e s s i n d i s p e n s i b l e for t h e c a l c u l a t i o n of a b s o r b e d doses. A s far as t i m e d i s t r i b u t i o n is concerned, e s p e c i a l l y i n t h e case of whole b o d y i r r a d i a t i o n , o n e must d i s t i n g u i s h b e t w e e n i n s t a n t a n e o u s i r r a d i a t i o n s a n d / o r prolonged i r r a d i a t i o n , which may last s e v e r a l d a y s o r several weeks. Doses r e c e i v e d estimate of t h e absorbed dose.
~tis extremely di£ficult f o r physical dosimetry a l o n e t o p r o v i d e a good Tn o b t a i n t h i s , it is n e c e s s a r y t o u s e t h e
data furnished by body damage, e:g. f o r p a r t i a l i r r a d i a t i o n erythema l i m i t , necrotic phenomema and haematologlcd and cytogenetic damage f o r whole body irradiation. IV.2.
Clinical investigation The clinical observation of a
patient-victim of over-exposure b e g i n s a t
t h e very moment of t h e accident.
The i n v e s t i g a t i o n of a n i r r a d i a t e d s u b j e c t
EHfURCI6-E page 40
is t h e same as any complete medical examination. I t i s o n l y as a matter of principle t h a t t h e following points a r e stressed: ( a ) repeated e x a m i n a t i o n s o f t h e skin;
(b) n e u r o l o g i c a l e x a m i n a t i o n ; (c) c a r d i o v a s c u l a r examination; (d) gastrointestinal investigation.
IV.3.
Biological i n v e s t i g a t i o n
1. i m m e d i a t e b l o o d sample;
2. u r i n e s a m p l e s ; 3. b i o c h e m i s t r y a n d e l e c t r o l y t e s ; 4. t h ~ r r n n m ~ t ra y n d t h e r m o g r a p h y of t h e n r g a n s .
Any changes i n t h e biology of t h e o r g a n s d u r i n g t h e a t t a c k p e r i o d a n d t r e a t m e n t must b e c o n t r o l l e d IV.4. Critical doses T h e sensitivity of t h e organs and tissues are d i f f e r e n t i n tcrmo of doac
and manifestation. The slun is v e r y s e n s i t i v e t o r a d i a t i o n a n d w i t h d o s e s o v e r 4Q0 r a d s The male gonads a r e a l s o highly s e n s i t i v e t o radiation. Temporary sterilities may o c c u r , b u t t h e y become d e f i n i t i v e i n men f o r d o s e s a b o v e 300 r a d ( 3 Gy). Doses higher t h a n 6 0 0 t o 7 0 0 rads (6 to 7 Gy) couac sterility i n women. Damage to t h e hepatorenal system causes metabolic d i s o r d e r s a s s o c i a t e d w i t h i m b a l a n c e o f water, m i n e r a l s , p r o t e i n s , l i q u i d s a n d c a r b o h y d r a t e s . (4Gy) marufestations such a s e r y t h e m a and d e p i l a t i o n c a n b e o b s e r v e d .
Acute whole-body i r r a d u t i o n can cause d e a t h a b o v e a n e x p o s u r e d o s e of 300 r e m s ( 3 Sv). V. T H E R A P E U T I C M A N A G E M E N T
Based on t h e data f u r n i s h e d b y p h y s i c a l d o s i m e t r y a n d d i a g n o s t i c s , w e s h a l l deal i n succession with t h e g e n e r a l t r e a t m e n t s t r a t e q y , medical treatment and surgical treatment. ( a ) A c u t e partLal irradiation. The g e n e r a l s t r a t e g y f o r t r e a t m e n t h a s t h r e e e s s e n t i a l c o n s i d e r a t i o n s . (1) p l a c i n g t h e i r r a d i a t e d z o n e s i n t h e b e s t c o n h t i o n s to avoid any complication: t h i s means i s o l a t i o n of t h e i r r a d i a t e d zone as completely as possible from t h e o u t s i d e world, t o guard a g a i n s t a n y r i s k of exogenous M e c t i o n . (2) Making a d i s t i n c t i o n between i r r a d i a t e d a n d normal tissue, between t h a t w h c h is recoverable, and t h a t which i s a b s o l u t e l y lost. Tlus distinction must be made as early as p o s s i b l e a n d r i g o r o u s l y , I t relies e s s e n t i a l l y on p h y s i c a l dosirnetry a n d o n l y i n c i d e n t a l l y o n c l i n i c a l observations. The aim is to eliminate t h e immediately curldenrr~ed t i s s u e z o n e as q u i c k l y as p o s s i b l e . ( 3 ) The t 1 , i r d c o n s i d e r a t i o n i s t o p r e v e n t a n y potential complication i n t h e case of i n f e c t i o n : h e r e a n t i - i n f e c t i o n medical t r e a t m e n t h a s q r e a t value.
W/WBC/6-E
page 41
The medical t r e a t m e n t of r a d i a t i o n b u r n s is e x t r e m e l y l i m i t e d . N o specific t r e a t m e n t e x i s t s a t present t o prevent the i n e v i t a b l e e v o l u t i v e
process r e s u l t i n g from a c u t e p a r t i a l i r r a d i a t i o n , p a l l i a t i v e t r e a t m e n t f o r p a i n r e l i e f and t r e a t m e n t o f i n f e c t i o n a n d e x a g g e r a t e d r e a c t i o n s a r e suggested. Surgical t r e a t m e n t remains t h e major i n d i c a t i o n f o r p a r t i a l r a d i a t i o n burns. This can be divided i n t o two categories: (11 c l e a n i n g of t h e n e c r o t i c zone and enabling the lesions to develop more rapidly and m o r e s a t i s f a c t o r i l y ; ( 2 ) eliminating by s u r g e r y t h e organism of t h e t i s s u e s m o r t i f i e d by
irradiation, to avoid any potential complication. b e performed.
T h i s means amputation must
I b ) I n c a s e of whole-body r a d i a t i o n t r e a t m e n t t h e f o l l o w i n g s h o u l d b e considered:
1. T h e g e n e r a l t r e a t m e n t s t r a t e g y , w h i c h c o n s i s t s o f t h e f o l l o w i n g :
- p l a c i n g t h e p a t i e n t i n t h e most f a v o u r a b l e c o n d i t i o n s ; - a v o i h n g complicabons w h c h a r e g e n e r a l l y t h e immediate c a u s e of death. The patient's conditions consist of his i s o l a t i o n f r o m t h e o u t s i d e world to avoid any i n f d o n or other complications, p l u s i n t e n s i v e metdlulic: drid
haematological reanimation.
2. M e d i c a l t r e a t m e n t Treatment of p o s s i b l e complications such as:
- metabolic disorders; - haematological disorders. The f i g h t a g a i n s t c o m p l i c a t i o n s r e q u i r e s c o n t i n u o u s r e s p i r a t o r y , c i r c u l a t o r y and neurological monitoring. T h e a d m i n i s t r a t i o n of anti-haemorrhagic medication is i n d i s p e n s a b l e . The complete i s o l a t i o n o f p a t i e n t s i n a sterile room s h o u l d normally g u a r a n t e e t h e p r e v e n t i o n of exogenous infections. ~ a e m t n l n gral i rpanimt-inn, and n l ~ d i ilary l t r a n s p l a n t ahmild be considered
-
rieur.uluyicd1 i i i u u r d e r - s ;
a s a n e s s e n t i a l p a r t of m e d i c a l t r e a t m e n t .
VI. PROGNOSIS I n t h e case of a c u t e p a r t i a l i r r a d i a t i o n , it i s d i f f i c u l t t o e s t a b l i s h t h e p r o g n o s i s of r a d i a t i o n burns. A s f a r a s l e s i m s t h e m s e l v e s a n d t h e i r progress a r e c n n n p r n d , it i s d i f f i r i ~ l t t o m a k e predictions.
Improvement i s
often temporary. The victim must be informed of p o s s i b l e r e c u r r e n c e d u r i n g t h e months o r years a f t e r exposure; ndinimwn amputation is o f t e n a d v i s a b l e t o avoid repeated r e c u r r e n c e . Concerning l a t e complications, s k i n c a n c e r o r conjunctival s a r c o m a c a n o c c u r .
RegardLng whole body ~ r r a h t l o n , t h e r e a r e two types of prognosis, v i t a l and stochastic prosnosis. With r e s p e c t t o v i t a l prognosis, it should be noted t h a t t h e possibility of survival i n the absence of t r e a t m e n t i s 50% f o r a dose of about 4 0 0 remn 14 Sv) decreasing to 10% f o r a dose of 5 5 0 r e m s (5.5 Sv). This a p p l i e s p a r t i c u l a r l y t o i n s t a n t a n e o u s i r r a d i a t i o n . These figures can be multiplied by 2 t o 3 t i m e s f o r i r r a d i a t i o n s prolonged o v e r several weeks. Irradmtion of over 300 rads ( 3 Gy) can a l s o be considered t o induce s t e r i l i t y i n men and more t h a n 700 r a d s ( 6 Gy) s t e r i l i t y i n women. Concerning s t o c h a s t i c prognosis, l a t e manifestations may be seen such a s c a n c e r and h e r e d i t a r y diseases. VII. M O N I T O R I N G O F ENVIRONMENTAL R A D I O A C T T V I T Y
,
VII.1.
Radionuclide material8
Radionuclides released from nuclear f a c i l i t i e s with gaseous and l i q u i d effluents can contribute to t h e r a d i a t i o n exposure of t h e general public i n v a r i o u ~w a y s . T h e discharge ha= t o b c l i m i t c d a c c o r d i n g t o radiation p r o t e c t i o n r e g u l a t i o n s , b u t t e c h n i c a l f a c i l i t i e s a s w e l l a s economic considerations must a l s o be t a k e n i n t o account. There i s a dose l i m i t f o r r a d i a t i o n exposure, which must n o t b e e x c e e d e d d u r i n g t h e r e l e a s e of radionuclides i n air borne and liquid e f f l u e n t s from nuclear f a c i l i t i e s . For example, during routine operations, t h e dose limits should not exceed more than 30 rem/year f o r t h e whole body o r of 9 0 rem p e r y e a r f o r t h e t h y r o i d g l a n d , e v e n i n t h e most u n f a v o u r a b l e body site.
rw_or&nq o f propo&ioml
The whole purpose of monitoring environmental r a d i o a c t i v i t y i s t h e level of. .env~ronmentalradioactivity, t h e c o n t r o l of r o u t i n e o p e r a t i o n a n d t h e p r o v i s i o n f o r a c c i d e n t a l r e l e a s e s of radionuclides. All programmes concerned with these t h r e e elements should be accompanied by q u a l i t y c o n t r o l measures.
Regarding f o o d s and d r i n k s t h e r e should b e a l i m i t of r a d i o a c t i v e contamination below which n e i t h e r i n t e r v e n t i o n nor c o n s t r a i n t would be j u s t i f i e d i n t e r m s of i n t e r n a t i o n a l t r a n s p o r t t r a d e . It is clear t h a t national a u t h o r i t i e s might wish t o e s t a b l i s h d i f f e r e n t levels witkrn t h e i r respective countries, t o t a k e i n t o account p a r t i c u l a r a g e o r " c r i t i c a l population" g r a u p s o r t h e pal-ticular s i t u a t i o n as a r e s u l t of nuclear accident o r with regard to proximity t o t h e a c c i d e n t site. Provision of such national autonomy i s already recognized by i n t e r n a t i o n a l a u t h o r i t i e s
. I
VII.2. Waste management of r a d i o a c t i v e m a t e r i a l s Radioactive materials are used e x t e n s i v e l y i n l a b e l l e d c h e m i c a l s i n hospitals, research laboratories, induttrial and a g r i c u l t u r a l premises and f o r environmental studies. eve lop merit i n t e c h n i q u e s f o r t h e p r o d u c t i o n af radionuclides has ensured that, whenever possible, s h o r t - l i v e d r a d i o n u c l i d e s pan b~ p r n d i ~ c e d a n d w h i c h a r e s i i i t . a h 1 ~f n r p a r t i ~ l ~ l a applications. r
.
Wastes, some of whch w i l l be radioactive, a r e produced a s a r e s u l t of t h e use of radioactive materials. Through good p r a c t i c e s i n t h e production and use of radionuclides t h e wastes produced can be nunmuzed. However, t h e r e should be a control mechanism t o enslire t h e s a f e t y of the p u b l i c and a s a f e
EM/WBC/6-E page 4 3
-
environment when such radionuclides a r e used. All countries should have some form of national policy and r e g u l a t o r y c o n t r o l over t h e u s e of r a d i o a c t i v e materials and t h e disposal of radioactive wast-es. National a u t h o r i t i e s should t a k e t h e decision a s t o whether o r not such u s e is j u s t i f i e d and c o n t r o l s h o d d reflet t h e cost of implementation and t h e benefits gained fr n m t h e use of r a d i o a c t i v e a n a l y t i c a l t e c h n i q u e s . Control is usually e x e r c i s e d by i s s u i n g a l i c e n c e o r c e r t i f i c a t e f o r p a r t i c u l a r premlses o r group o t premlses a n d s h o u l d b e r e l a t e d t o t h e o p e r a t i o n s c a r r i e d o u t and t h e wastes produced. BIBIOGRAPHY
1. 2.
Nuclear Aazidents and Epidemiology ( WHO/EURO publication) Environmental H e a l t h No. 25 Radiation pmt;ection f o r medical and a l l i e d h e a l t h personnel. National council on r a d i a t i o n p r o t e c t i o n and measurements. ( N C R P r e p o r t N 48). October 1 9 8 6
3.
Chernobyl: Health Hazards from radiocaesium E n v i r o n m e n t a l H e a l t h No. 2 4
( WHO
EURO p u b l i c a t i o n )
4. 5. 6. 7.
Ionizing radmhon: l e v e l s and e f f e c t s , United Nations Publication, N e w York 1972 Management of r a d i o a c t i v e wastes produced by u s e r s of r a d i o a c t i v e materhl ( I n t e r n a t i o n a l Atomic Energy Agency, S a f e t y series 70, 198 5 Expert consultation on recommended limits f o r radionucl i d e contamination of f o o d s ( F A O , 1987) ESN/MISC 1987,l Chtrnobyl 1-tactor accident. 1986. R e p o r t of t h e consultation, WIIO/ EURO,
May
EH/WRC/6-E page 44 '
TABLE 111. THE MAIN NUCLIDES THAT HAVE BEEN FOUND IN THE AIR AND DEPOSITED ON THE GROUND AFTER THE ACCIDENT r
NUCLIDE Zr-95
HALF-LIFE 65 days
Nb-95
35 2 .R
days
Mo-99
Tc-9% Ru-103 Te-132 1-132 L-131 '
0.38 40
-
3 -3 C. 1
8.05 0.88 76 7
1-133 Cs-13b
Cs-136 Cs -13 7
13 11 000 12.8 1.7 32.5 285
Ba-140
La-140 Ce-141 Ce-lhG Np-239 b
2 . 4
EW/WRC/L-E page 45 TABLE IV. EXAMPLES OF INTERIM INTERNATIONAL RADIONUCLIDE ACTION LEVELS FOR FOOD (IRALFIS.
Target Organ Radionuclide
Dose Dose Radionuclide Level Conversion Intake (mSv) Factor ( B q corresponding t o the ( Sv/Bq ) dns~)
Food Intake (kg1
I F&F (&_/kg)
Sr-90
1st year follnwing
bone s u r f ace (infant)
50
1.9x10-~
26,000 5,200
375
70 2 fl
10
1 . 9 x loh6
375
years 1-131 1st year fhyruid 50
2.9 r
17,000
40
400
(infant1 CS-134
1st year following years
whole
MY
(adult)
1
2.0 x
50,000
750
50
CS-137 1st year
whole
5
1.4 x l b 8 1.4 x
360,000
750
500
following years ?u-239 1 s t year ,
MY
(adult)
1
71,000
750
100
bone surface (infant)
50 10
1.7 1.7 x
3,000
375
10
following years
I
m/mc/6-a page 46
TABLE V .
GENETICALLY SICNIFICANT DOSE (GSD) TO POPULATION IN THE FEDERAL
REPUBLIC OF GERMANY IN THE YEAR 1983 IN mSv (mrem) 1. N a t u r a l r a d i a t i o n exposure 1.1 cosmic r a d i a t i o n 1.2 e x t e r n a l t e r r e s t r i a l , r a d i a t i o n , mean v a l u e when o u t d n n r ~
when i n d o o r s 1.3 i n c o r p o r a t e d n a t u r a l r a d i o a c t i v e substances T o t a l n a t u r a l r a d i a t i o n exposure
approx. 0,3 approx. 0,s a p p r o x . 0,4 approx. 0,s approx. 0,3 approx. 1 , l
(30
( 5 01 (40)
I 50 1
(301 ( 1 10)
A r t i f i c i a l r a d i a t i o n exposure 2.1 nuclear i n s t a l l a t i o n s c 0,01*) 2.2 the a p p l i c a t i o n o f r a d i o a c t i v e substances and i o n i z i n g r a d i a t i o n i n medicine approx. 0,5,) 2.2.1 x-ray diagnostics approx. 0,s 2.2.2 r a d i a t i o n therapy < 0,01 2.2.3 nuclear medicine < 0,Ol 2.3 the use o f r a d i o a c t i v e substances and i o n i z i n g r a d i a t i o n < 0,02 i n r e s e a r c h , t e c h n o l o g y and h o u s e h o l d ( w i t h o u t 2.4) 2.3.1 i n d u s t r i a l products < 0,Ol 2.3.2 t e c h n i c a l radiation sources < 0,01 2.3.3 stray radiation emitters <0,01 2.4 o c c u p a t i o n a l exposure ( c o n t r i b u t i o n t o t h e mean p o p u l a t i o n e x p o s u r e ) < 0,Ot 2.5 r a d l a t l o n a c c i d e n t s and i n c i d e n t s 0 2.6 fallout f r o m n u c l e a r t e s t s <0,01 2.6.1 e x t e r n a l exposure <0,01 2.6.2 i n t e r n a l exposure < 0,Ol T o t a l a r t i f i c i a l r a d i a t i o n exposure approx. 0,6
( 1)
(so) (50) ( 1) ( 1) ( 2) ( 1) ( 1) ,
(1) ( 1) ( 0)
( 1 ) (1) ( 1) (60) 1