(WPR/RC29/SR/6)
SUMMARY RECORD OF THE SIXTH MEETING WHO Conference Hall, Manila Wednesday, 23 August 1978 at 2.30 p.m. CHAIRMAN: Dr S. Foliaki (Tonga) CONTENTS
1.
Sub-Committee on Technical Cooperation among Developing Countries: Report of the Sub-Committee (continued) ••.••••.•.•..••••.•.••.•.•••.• Host Agreement between the Government of the Government of the Republic of the Philippines and the World Health Organization ••••••.••.•.•••••••.•••••• WHO's role in the development and coordination of biomedical research: greater involvement of the Regions in research ••••.•..•.•.••.•.••••....•..•..•• Special Programme for Research and Training in Tropical Diseases: Joint Coordinating Board: selection of government representatives ••.•••••••...•.•.••• Regional coordinating group on the mental health progr8llJlIle ••••••••••••••••••.••••••.•••••.•.••••••••••••••••
185
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3.
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4.
189 190
5. 6.
Status of the antimalaria programme ••.••••.•..•.•..•.••.••• Workers' health programme
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7.
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For the List of Representatives at the twenty-ninth session,
!!! pages 39-46 of the present volume •
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1.
SUB-COMMITTEE ON TECHNICAL COOPERATION AMONG DEVELOPING COUNTRIES: REPORT OF THE SUB-COMMITTEE: Item 13.2 of the Agenda (Document WPR/RC29/l0) (continued from the fifth meeting, section 4)
Dr FISCHER (United States of America) congratulated the Sub-Committee on its practical approach and on its recommendations, which performed an important service by translating technical cooperation among developing countries (TCne) into practical terms. In particular, he agreed with the recommendation that governments be encouraged to create national focal points to stimulate TCDC, and stressed that the responsible officer in each country should have a sufficiently high government position to bring about intersectoral cooperation. The recommendations on pharmaceutical and drug policies management were in accordance with WHO's drugs programme; however, he would have welcomed a reference to the importance of developing national infrastructures for the storage and distribution of drugs. Dr HU CHING-LI (China) expressed agreement in principle with the Sub-Committee's report. It was important to become self-reliant but to avoid separatism. Medical knowledge should be shared, for it was an asset to which all mankind was entitled. His country's health ministry had approached the problem by sponsoring training courses and study missions in collaboration with WHO, UNDP and other agencies, and planned to develop such activities further. Voluntary agencies in China were considering the organization of international conferences, inviting experts from· other countries. Turning to health manpower development, he said China was constantly looking for ways of raising the quality and quantity of health workers, and would be glad to cooperate in that area with other countries of the Region. It was to be hoped that WHO, as the world's main coordinating body in the health field, would be able to do even more to promote TCDC. Dr CHEW (Singapore) expressed approval of the report and stressed his country's support for TCDC. As a small country, Singapore was obliged to buy many drugs from abroad, and experience had shown that costs could be brought down by making joint purchases with other countries. His government attached great importance to quality control; the setting-up of joint laboratory services would also be helpful to small countries. Dr NOORDIN (Malaysia) endorsed the Sub-Committee's report and recommendations, and asked that Malaysian programmeslwith a TCDC component be added to the tables in Annexes 3 and 4 • Dr TRAVERS (Australia) congratulated the Sub-Committee on its report. He expressed particular appreciation of Annex 4, and suggested that it be regularly updated and if possible expanded. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the eighth meeting, section 8.2.) 1
See pages 88, 90 and 95.
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(For consideration of the Sub-Committee's report on its third meeting held in Manila on 24 August 1978, see the eighth meeting, section 7.) 2. HOST AGREEMENT BETWEEN THE GOVERNMENT OF THE REPUBLIC OF THE PHILIPPINES AND THE WORLD HEALTH ORGANIZATION: Item 19 of the Agenda (Document WPR/RC29/l6)
The REGIONAL DIRECTOR, introducing document WPR/RC29/16, stressed his appreciation for the excellent and cordial relations the Regional Office had enjoyed with the host Government since 1951, and hoped that the present difference of opinion would be speedily and amicably resolved. WHO would be willing to comply with the wishes of the Government of the Republic of the Philippines concerning the reinterpretation of the Host Agreement, but he felt strongly that WHO should be informed in advance of any such changes and asked to give its agreement. Counsellor GARRIDO (Philippines) pointed out that the Regional Director had submitted proposals for the revision of Section 22(g) of the Host Agreement, and those proposals had been accepted by the Government of the Philippines. The only problem remaining would appear to be whether or not vehicles imported by WHO staff members before 31 December 1976 should be liable to tax and duty. Exemption of such vehicles was not acceptable to his Government. His Government's position was that non-exempted persons buying vehicles imported under Section 22(g) of the Host Agreement must pay tax and duty on them, irrespective of the date of importation. The REGIONAL DIRECTOR said that if WHO had been informed of the intentions of the Host ~Qyernment before the changes were put into effect he would have agreed willingly. In order to reach an amicable settlement, it would be helpful to arrange a further meeting with the Ministry of Foreign Affairs. In reply to a question from Dr FISCHER (United States of America), Counsellor GARRIDO (Philippines) said his Government had declined to accept the cut-off date of 31 December 1976 as it would mean refunding tax and duty already paid by non-exempted buyers. He proposed that the Committee note document WPR/RC29/16 and the comments made during the discussion. Dr FAAIUASO (Samoa) endorsed the Regional Director's suggestion that it should be left to him to arrange further meetings with the Philippine authorities. It was very important to reestablish good relations, and he hoped the Regional Director would be able to report progress to the Regional Committee at its next session. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.4.)
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'3.
WHO'S ROLE IN THE DEVELOPMENT AND COORDINATION OF BIOMEDICAL RESEARCH: GREATER INVOLVEMENT OF THE REGIONS IN RESEARCH: Item 14 of the Agenda (Document WPR/RC29/ll, Add. 1 and Corr.1)
The REGIONAL DIRECTOR presented a report on the progress made in implementing the reconunendations of the 1977 session of the Western Pacific Advisory Committee on Medical Research (WPACMR) endorsed by the Regional Committee at the twenty-eighth session. It was presented in such a way as to show how voluntary and regular budget funds had been utilized. The preliminary work of estabUshing the WPACMR and its task forces having been completed and their recODlllendations endorsed by the Regional Committee, the put year had seen a considerable expansion in reaearch activities. It was not by chance that this had coincidedwitb tl'le' app&tntment of a medical officer responsible solely for the reaearch programme. Several working groups had been held to plan research progra1llDles in individual fielda, the lateat of which va1l tha't on health servicel research held from 14-18 Aupat 1978. 1 January 1978 law the decentralization of responst1tility for administerinl research grant. and relearch traininl Irants and quite a number, in a variety of fields, had been awarded by the Regional Office over the past eight months. In April 1978 the WPACMll had held its third session in Kuala Lumpur, where the regional centre for relearch and training in tropical diseases was being established. llec011lDendations of particular interest had been on the programmes of research in pneumonia and respiratory infections and in diarrhoeal diseases, to mention only two. The utmost was thus being done to respond to the Health Assembly's request to the Director-General, made in resolution WHA31.3S, for greater involvement of the Executive BOard, the Regional Committees and the Advisory Committees on Medical Research in the formulation of research po licy • The Regional Director referred to the new plan for the management of the WHO global research prograame which would soon be put into effect for a trial period of two years. Its basis lay in the maximum involvement of Member States, their institutions and their personnel, in the work of WHO so that the Organization could serve the best interests of cooperation amonl those Member States. A regional strategy, based on the general plan, was being worked out and the WPACMR would cooperate in monitoring and evaluating the plan. Dr NICHOLSON (United Kingdom) noted the efforts made to promote an interdisciplinary multicountry programme of research in diarrhoeal diseases, and the reconunendation for continuing collaboration in research between the Western Pacific and South-East Asian Regions. He asked whether, in the field of diarrhoeal diseases research, there had been any collaboration with the Cholera Research Laboratory in Dacca, Bangladesh.
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Dr MACFADYEN (Medical Officer, Research Promotion and Development), explaining the mechanism for collaboration with South-East Asia, iaid that the document used at the Working Group on Enteric Infections had emanated from that Region. There had not been any specific cooperation with the Cholera Research Laboratory in Dacca, but a regional programme on diarrhoeal diseases was being formulated, the key to which was to establish links between institutions. The expertise in setting up effective programmes in diarrhoeal diseases was largely concentrated in the South-East Asia and Western Pacific Regions. Dr TRAVERS (Australia) strongly supported the recommendation that a meeting of directors of national medical research councils should be convened, since it would be a practical step towards achieving maximum coordination 0·£ research activities in that area. Dr FISCHER (United States of America) asked why Cali, Colombia, had been selected as the place where Philippine research workers were to study standardized instruments ·in mental health research. Dr IGNACIO (Vice-President, World Federation for Mental Health for the Western Pacific Region) referred to the study on strategies for expanding mental health care in general health care deliverY, which the Department of Psychiatry, University of the Philippines. was undertaking in collaboration with WHO, and of which she was the chief investigator. One of the requirements of the study was that the chief investigator should be trained in the screening version of a particular mental state examination, which was used in the collaborative study. Cali had been chosen because it provided training at the recently established Collaborating Centre for Training and Research in Mental Health, and also to permit her to compare the work done there with similar work in Manila, as well as to test her training in mental health instruments. Dr NOORDIN (Malaysia) expressed satisfaction at the increasing involvement of the Region in biomedical and health services research. The official agreement for the creation of the Regional Centre for Research and Training in Tropical Diseases and Nutrition, at Kuala Lumpur, had been signed by the Government of Malaysia and the WHO Programme Coordinator on behalf of WHO on 8 August 1978. The Regional Director was to be commended on his success in obtaining funds from the Japan Shipbuilding Industry Foundation for research and development programmes. He fully supported the recommendations made at the third session of the WPACMR, held in Kuala Lumpur, especially that providing for further financial resources for research on filariasis. Dr CHARPIN (France) asked if the recommendation, mentioned on page 5 of document WPR/RC29/ll, to organize a symposium on parasite immunology and a training course in research management was a mere wish expressed by the WPACMR or if the relevant programming had already been done.
lsee document SEA/RES/6 (SEA/DD/4), Report of the Research Study Group Meeting on Diarrhoeal Diseases of Children, New Delhi, 12-16 September 1977, 9 March 1978.
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In reply to Dr Charpin, Dr MACFADYEN (Medical Officer, Research Promotion and Development) said that a regional symposium on parasite immunology had indeed been planned. Preliminary discussions had been held with the Government of Australia, which would it was hoped act as host to the meeting. It was for the present Regional Committee to endorse the recommendation. Planning had not started for a research management course, although enquiries had been made regarding a suitable place for training. An alternative might be to use an existing course, perhaps in North America, and to make research fellowships to attend the course available to Member States of the Region. The REGIONAL DIRECTOR expressed his appreciation of the valuable work done by the WPACMR. The Advisory Committee had made many recommendations, all requiring funds. While every effort was being made to obtain funds from private foundations, it was to be hoped that Member States of the Region would contribute to the Voluntary Fund for Health Promotion so that the useful recommendations of the WPACMR might be carried out. There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.5.) 4. SPECIAL PROGRAMME FOR RESEARCH AND TRAINING IN TROPICAL DISEASES: JOINT COORDINATING BOARD: SELECTION OF GOVERNMENT REPRESENTATIVES: Item 15 of the Agenda (Documents WPR/RC29/12 and Add. 1)
The REGIONAL DIRECTOR said that the Memorandum of Understanding on the Administrative and Technical Structures of the Special Programme for Research and Training in Tropical Diseases provided for the establishment of a Joint Coordinating Board (JCB) consisting in 30 members. Among the members would be twelve government representatives, selected by those who contributed to the resources of the Special Programme, and twelve government representatives selected by the six Regional Committees; two by each Committee. All the selected members would attend the first meeting of the JCB to be held on 15 and 16 November 1978. The contributors to the resources of the Special Programme had already selected their twelve government representatives, for different durations of tenure in order to provide for some continuity in membership when the time came for reappointment, but all commencing on 1 January 1978. Member States from the Western Pacific Region selected by the contributors were Australia, the United Kingdom, and the United States of America. The Regional Committee now had to select, from among those directly affected by the diseases dealt with by the Special Programme, the two Member States it wished to be members of the JCB. The Regional Director proposed that one member should be appointed for a duration of two years and the other for a duration of three years, both from 1 January 1978. Reappointment or selection of a replacement would then be for three years and continuity would thus be ensured. -,'
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The Committee now had to propose which two Member States should be selected. Once that selection had been made, he suggested that the Chairman draw lots to decide which of the members should serve for three years and which for two years. It was so agreed. Dr TRAVERS (Australia) proposed that Malaysia and the Philippines should be selected, and Dr NOORDIN (Malaysia) seconded the proposal. Decision: Malaysia and the Philippines were appointed as members of the Joint Coordinating Board, the former for three years and the latter for two years. The CHAIRMAN requested the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.6.)
5.
REGIONAL COORDINATING GROUP ON THE MENTAL HEALTH PROGRAMME: Item 16 of the Agenda (Document WPR/RC29/13)
The REGIONAL DIRECTOR reminded the Committee that, at the twentyeighth session, when discussing the reiolution adopted by the World Health Assembly on mental retardation, a suggestion had been made that a regional coordinating group for the mental health programme might be established. This would be linked to the global coordinating group and the regional coordinating groups already in existence. It would monitor and evaluate the implementation of the medium-term programme for mental health adopted by the Thirty-first World Health Assembly in resolution WHA3l.21. The most important concern of the mental health programme was that the programme should be socially relevant. Document WPR/RC29/l3 described the functions of regional coordinating groups and the various types of national coordinating mechanisms in operation. It also gave the proposed terms of reference and composition of a coordinating group for the mental health programme in the Western Pacific Region, should it ~e considered feasible to establish such a group. The Regional Director proposed to the Committee that, if it considered the establishment of a coordinating committee to be feasible, it might wish to authorize him to select its members and convene its meetings. Dr FISCHER (United States of America) supported the creation of a coordinating group with the terms of reference indicated in the document. The Regional Director was to be commended on having adopted a much broader approach to the problem, not merely oriented towards research, but taking public health and social aspects into consideration. The shift in emphasis would be appreciated and supported by the agencies concerned with that field. 1
See resolution WHA28.S7, WHO Handbook of Resolutions and Decisions, Volume II (2nd edition), 1977, page 46.
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, Dr HU CHING-LI (China) stressed the importance of community participation in mental health work. In China, in addition to psychiatrists, barefoot doctors and other basic health workers were being trained in mental health care. Retired workers, relatives, and neighbours were being involved in the care of milder cases. "Day centre~' had been set up to supervise treatment and provide physiotherapy and psychological assistance to patients during the day time. As a result, it was possible to deal with many problems that could not have been solved by psychiatrists alone, and the relapse rate among patients had dropped from 70.3% to 10.6%. China supported the establishment of the proposed regional coordinating group on ml'nta 1 health. There being no further comments, the CHAIRMAN asked the RapporteurR to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.7.) 6. STATUS OF THE ANTIMALARIA PROGRAMME: (Document WPR/RC29/14) Item 17 of the Agenda
The REGIONAL DIRECTOR referred to the discussion at the twenty-eighth session of the Regional Committee on the topic of the 1978 Technical Presentation. At that time it had been decided that the status of the antimalaria programme in the Region should be placed on the agenda of the twenty-ninth session. A stage had been reached at which there was no marked progress in the control of malaria. In some places the situation had, unfortunately, even deteriorated. A much more flexible approach was needed than had hitherto been applied, to enable a quick change to alternative control measures should conventional methods prove unsuccessful. Research activities were being intensified in coordination with the Special Programme on Research and Training in Tropical Diseases. The development of the primary health care concept was opening the way for inclusion of a number of measures for the control of malaria in remote rural areas where the disease remained a considerable problem. The training of adequate manpower had ,always been a problem and remained so. The problems had been recognized by the World Health Assembly which, in resolution WHA31.45 adopted last May, had urged Member States to reorient their antimalaria programmes as an integral part of their national health programmes, following guidelines submitted by the Director-General. Dr DIZON (Philippines) stated that in the Philippines the disease was still endemic, the level of endemicity varying from one area to another. The urban areas were largely free of the disease. Incidence had decreased over the years but extensive population movements and other factors still posed problems. The control programme was supported by the rural health units and every effort was being made to encourage community participation in control measures. Biological and other types of control measure were being tried out in addition
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to spraying. A fourth vector had been identified and was being intensively studied. Malaria control personnel were given pre-service and in-service training and paramedical workers were also given instruction in malaria control. Mapping of drug-resistant malaria was being carried out. Dr HU CHING-LI (China) said that the report was a very comprehensive one. The Representatives of China agreed with the measures proposed. The results of some of their preliminary researches might be of interest to other Member States. DDT-spraying against A. balabacensis had been unsatisfactory and malathion and ultra-lowvolume spraying had had no more effect than DDT; but studies of the insects' 24-hour behavioural cycle had shown that clearing bushes for a radius of 300-500 metres round dwellings and the building of houses which let in more sunlight had positive results. A herb from the Chinese traditional pharmacopoeia - Chin Hao Su (Artemisia apiacea) - had proved a useful adjunct in the treatment of malaria caused by drug-resistant strains but the relapse rate was still too high. Most of China was hypo endemic in regard to malaria, the level varying considerably, but determined community efforts in one model county had shown the way towards more complete control. Dr PRAM NGOC QUE (Socialist Republic of Viet Nam) agreed with the report. Substantial progress had been made in the control of malaria in the Socialist Republic of Viet Nam with assistance from friendly countries but the problem was still a major one. The Socialist Republic of Viet Nam had a long-term budget for control operations. Meetings like those held in Kuala Lumpur and Manila in 1977 had been very valuable and should be continued. Dr TARUTIA (Papua New Guinea) said that in his country malaria was still considered a major public health problem. He agreed with the Regional Director that inadequate finance, manpower and transport were the main obstacles. For Papua New Guinea, DDT-spraying was still the only financially feasible control method. Some problems could be solved by incorporating malaria control in primary health care activities. In part of the Northern Province a study was being conducted on DDT house-spraying alone or in combination with anti larval measures. The control measures would be carried out by members of the community after suitable training and with the support of the malaria service.
Dr FISCHER (United States of Amedca) agreed that the report was a good summary of present and future prospects but did not think that too much reliance should be placed on international and bilateral assistance. As stated, one of the prerequisites for controlling malaria on a larger scale was a political decision on the part of governments to provide the necessary long-term support for the programme. The population must be drawn into the malaria control activities, as must the rural health services. That depended on the health departments. Perhaps the best way of cooperating in malaria control was helping to train staff for the intermediate and higher levels of the malaria control service and determining optimum drug regimens to deal with P. falciparum and vivax parasites.
II
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As regards imported malari,), on tite> basis of research carried out in the United States it seemed highly doubtful whether control measures at international ports and airports, including the disinsection of aircraft on international flights, would have any substantial effect. Dr NOORDIN (Malaysia) said the picture in regard to malaria in the Region was a sombre one. He agreed with the previous speaker that too much reliance should not be put on outside assistance, since assistance bodies were prone to sudden changes of policy. A political commitment to control was the prime requiSite and there must be no tendency to reduce that commitment once progress had been achieved. Fortunately Malaysia had a good sYRtem of rural health servi.ces to support malaria control activities. The main problems were extensive population movements, the opening up of new land and chloroquineresistance. Border meetings with Thailand and Indonesia had been held with encouragement from WHO. Certain popular but erroneous beliefs regarding the side effects of chloroquine (and later of Fansidar) had been an obstacle to progress.
Dr NICHOLSON (United Kingdom) thought the report was excellent. Some eradication campaigns had failed in the end because of the lack of an adequate primary health care structure during the maintenance phase. Perhaps in the New Hebrides an attack on the vector moving from south to north might have the best effect, since the insect in that area was at the limit of its range. Dr VAN DIJK (Regional Adviser in Malaria) confirmed that vectors at the edges of their normal range were more amenable to control measures, as had been demonstrated on the northern and southern boundaries of the Anopheles gambiae range in Africa.
In the absence of further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.8.) 7. WORKERS' HEALTH PROGRAMME: Item 18 of the Agenda (Document WPR/RC29/l5 and Corr.l)
The REGIONAL DIRECTOR said that a review of the workers' health programme in the Western Pacific Region had been placed on the Agenda of the Regional Committee at the specific request of the World Health Assembly, which wished to promote active i,plementation of regional programmes of work in occupational health. There was no doubt that, despite some progress since the Committee had adopted resolutions WPR/RC22.R3 and WPR/RC23.R4 in 1971 and 1972, national capabilities for planning and developing occupational health services needed to be strengthened. Workers in small industry and in agriculture, and migrant workers, were under-serviced and presented the greatest problem.
lSee resolution WHA29.57, WHO Handbook of Resolutions and Decisions, Volume II (2nd edition), 1977, pages 50-51.
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The Regional Director said that a number of strategies and approaches were proposed in document WPR/RC29/lS to help strengthen national capabilities and develop knowledge and practice in controlling workers' health problems. Improvement of monitoring and development of an epidemiological approach were essential and needed to be studied further. Dr NOORDIN (Malaysia) said that experience had shown that good relationships between the Ministry of Health and the Ministry of Labour were of great importance for occupational health activities. A problem Malaysia was facing was that trained occupational health experts were leaving the public service for the private sector. Dr ANGARA (Philippines) pointed out that, in addition to workrelated diseases, there were also "work-related situations". As more and more women joined the labour force, there were repercussions on the health of infants and older children left without adequate care. Health education in the factories was needed. Dr CHIN WEN-TAO (China) said that unified leadership on occupational health matters was essential, since the problems involved, in addition to the Ministry of Health, the Ministries of Industry, Trade, Transport and Communications. In China the Party and Government provided such leadership and care for the health of workers, soldiers and peasants was a prlncipie enshrined in the Constitution. To ensure such care, regulations and criteria had to be established to guarantee healthy working conditions in the factories and mines, which were also served by hospitals or clinics, depending on their size. Laws had been passed to protect labour and part-time health auxiliaries - workers in the factories themselves - investigated conditions on the spot. The Ministry of Health had its own Office of Industrial Hygiene and there was also an Institute for Research on Industrial Hygiene.
Much depended on prevention - sports, physical training, pollution control and so on. The chemical industry was posing new problems and a great deal remained to be done in general. International and bilateral cooperation in occupational health should be intensified. , Dr CHRISTMAS (New Zeaiand) drew attention to the diploma in industrial health awarded by the University of Otago's School of Public Health. Dr WAINETTI (Papua New Guinea) stated that occupational health had only recently become a component of his country's health services. A health worker from papua New Guinea was currently receiving training in occupational health in Singapore under a fellowship scheme.
There being no further comments, the CHAIRMAN asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of draft resolution, see the seventh meeting, section 2.9.)
The meeting rose at 5.05 p.m.