World Health: the magazine of the World Health Organization: January-February 1989 [full issue]: let's talk health

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · JANUARY-FEBRUARY 1989 World Hea lth Day cover specia ll y designed for thi s issue by Peter Davies. IX ISSN 0043-8502 World Health is the offic ial illustrated magazine of the World Health Organization Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English. French. Portuguese. Russian and Spanish. and four times a year in Arabic and Farsi . The German edition is obtainable from German Green Cross. Schuhmarkt 4. 3550 Marburg. FRG . Artic les and photographs not copyrighted may be reprod uced provided credit is given to the World Health Organiza tion. Signed articles do not necessarily refl ec t WHO's views World Health. WHO. Av . Appia. 1211 Geneva 27. Switzerland . Contents Let's talk health by Hiroshi Nakajima ... .. . . . .. . Folk-wisdom and pseudo- information by Andreas Fug lesa ng .... .. .. . Information is power by Eric R. Ram ............... . Cinemas on wheels 3 4 8 by Daniel J . Henrich ...... .... . 10 Let's communicate by Gloria Gordon ... .... ...... . 12 Talking to teenagers about sex by Anameli Monroy de Velasco 15 The health game .... .. . . ... . 16-17 Satellite medicine by Petar Jovanovic . . . . . . . . . . . . 18 The public as partners by Nedd Willard . . . . . . . . . . . . . . . 20 The tobacco tradition in India by Mira B. Aghee .. .. .. . . ........ 23 The media's role by Jack C S Ling . . . . . . . . . . . . 24 The art of healthy living by Karl Schmidt . . . . . . . . . . . . . . . 26 "Take care of yourself" by Babill Stray - Pedersen . . . . . . . 27 Save a Life by Peter Riding . . . . . . . . . . . . . . . 29 News Page . . . . . . . . . . . . . . . . . . 30 2 What is World Health Day? World Health Day lasts for a whole year! As we explain on the opposite page, 7 April marks WHO's "birthday". And each year the Organization chooses a "slogan" or message highlighting some international public health activity. Most of WHO's 166 member states mark the Day with special functions. news- paper features, TV and radio broadcasts. events and festivities -often involving top decision-makers and even heads of state. But the Day goes on. For the whole of 1989, WHO and its member countries will find ways to drive home the message "Let's talk Aealth" - perhaps through children's plays that will '' convince their parents about hygiene in the home, or a song explaining how malaria can be held at bay by draining a local swamp, or media campaigns aimed at reducing the toll of deaths and injuries on the roads. This issue of World Health invites all its readers around the globe to think about ways of informing, motivating. convincing others to Talk Health. ' WoRLD HEALTH, January- February 1989 Let's talk health On 7 April each year, WORLD HEALTH DAY commemorates the coming into force of WHO's Constitution, in 1948. This year, countries around the world will use World Health Day to stress the value of com- municating- by every means possible- the messages of good health by Or Hiroshi Nakajima Director-General of the World Health Organization n the eve of the 21st century, it becomes more and more clear that health goes hand in hand with economic and social development. We must talk about this . . . it must be said. Communication is a key element of today's world. Every man, woman and child should be in a position to choose a healthy way of life. To do this, they must be adequately informed on mat- ters that have an influence on health: the environment, water, food, good habits and bad ones. The World Health Organization works to promote and protect public health. We need to identify communi- cators who can talk and who can make others talk about health at every level of society. People with the knowledge, the WORLD HEALTH, Janua~y. February 1989 information and the experience must learn to share what they know with others. In order to survive, the world must adopt healthier ways of living. Each person should feel responsible for his or her own health . I have decided to devote World Health Day 1989 to the theme of communication for health and I should like to make a solemn appeal to all those responsible for informing, for educating or for creating social dia- logue - the cause of health needs you. Health is our most precious posses- sion, both individually and col- lectively. Doctors, journalists, teachers, decision-makers, parents and friends, let us assume our responsibilities. Let us communicate health rather than disease. Let's talk about it! Nothing is possible without health ... Let's talk health! 4 Folk·wisdom and pseudo· information Health for All, the slogan used by the primary health care movement, is considered a hope by many. lt is an enigma that some consider the slogan to be a threat by Andreas Fuglesang T he "western" educated medical doctor practising in the African village is, for all his good intentions and good results, an example of oppression by profes- sionalism. That the oppression is often unwitting does not make it less suspect as a human relationship. It is the example of the professional so preoccupied with his knowledge that he can see only the ignorance of others. Platitudes expounded in the name of professionalism include: child malnutrition is a disease caused by the ignorance and poverty of the mother; the mother's lack of clean- liness causes diarrhoea. Ignorance and poverty remain undefined, but the diagnosis is considered precise and mothers are prescribed a shot of health education or a dose of nutri- tion lessons. Primary health care and nutri- tional improvement are emerging as high priority issues in the process of social transformation in Third World countries. Those who work with people in rural villages or urban neighbourhoods recognise the potential of these issues for improv- ing the quality of life. Health and nutritional status are seemingly measurable concepts, but they have social and cross-cultural implications which require elaboration. In affluent societies, clinical and preventive medicine is focused on the comfort and well-being of the indi- vidual. Health has become distorted to the practising of a concept in which people are consumers of medical treatments. Almost exclusively, health is measured by the physical state of the human body. By and large, health is produced for consumers by the definitions offered by the medical establishment and by the vested interests of the phar- maceutical industry. In an African village, health is a more comprehensive concept. Cer- tainly it concerns a person's body, but equally it concerns a person's relationship to other people. This relationship extends to the family and the wider circle of the clan and the tribe as well as ancestors and spirits. Health is not an individual matter. It is a matter of a person's well-being in the context of the community. Community health is a concept in Boys attending a village clinic in Uganda. Many of the ailments treated here are likely to be debilitating rather than immediately dangerous to life. Photo World Council of Churches/P. Solbjerghoj W ORLD HEALTH , January-February 1989 medical terminology that requires assessment. It can be better under- stood by comparing the fundamental differences in the value systems and lifestyles of a western and an African community. In the modern urban community, people are oriented to individual performance and achieve- ment. They produce material goods and services and the process is one of high prod ucti vi ty. The reward accompanying achievement is an improvement in material living standards. In the rural setting, people have other values. They are certainly interested in good food and material comfort, but more as a communal concern. People's real desire is to produce good and lasting social rela- tions. What seems to an observer to be endless time idled away under a tree or in the bar is highly productive time from the viewpoint of this value system. The subsistence community is a social formation on the edge of fragility. People know it; they also know the weakness of human nature. Great effort is needed to keep the delicate balance between individual needs and community interests. Agreements must be made and alli- ances forged. Grudges must be aired and claims settled. One thing is certain: no-one survives without the survival of the community. The fundamental difference in value systems - one emphasising the material and the other the social - is illustrated by some of the differences and similarities to be found in the treatment of patients in modern and WORLD HEALTH, January-February 1989 traditional medicine. Only a small percentage of patients seeking treatment in western societies are actually suffering from a fatal or serious physical illness. Per- haps half of the patients have symp- toms which can be attributed to a psychiatric origin. In addition, there are those patients with relatively minor ailments whose symptoms are disproportionately aggravated by the patient's anxieties. The pattern is very similar to the traditional herbalist or diviner in an African village. Here, however, an added dimension is that people suffer from a variety of diseases, such as parasitic infections, fever and skin ailments, which are generally more debilitating than immediately dangerous to people's lives. In both situations, the illnesses and ailments of the majority of patients are such that they respond to a variety of treatments. We should be aware that in the field of both western and traditional medicine there are not enough conspicuous treatment failures to challenge the efficiency of or the belief in either system. Modern medicine makes a decisive difference to a relatively small number of lives. Surgical and obstetric emergencies, acute infec- tions and childhood diseases are the areas where modern medicine is infinitely superior. Traditional medi- cine seems incapable of dealing with the terrifying problem of infant mor- tality and epidemiological diseases. Ultimately, the concern of both healer and patient is the health and Radio studio in Zambia. "It is the fallacy of modernity that we believe we communicate better through machines. Human beings communicate through bonds of mutual confidence. , Photo World Council of Churches/ P. Williams sound functioning of the community; patient and community are insepar- able. It is worth noting that tradi- tional healers seem to have considerable success with certain manifestations of mental illness. Usually it is the diviner, with or without the help of a herbalist healer, who determines the diagnosis by invoking the spirits. Although the treatment may include the dispensing of herbal medicines, it often takes the form of the modern concept in psychology called group therapy. The ultimate yardstick of the efficacy of any health approach or programme should be the judgement of the community itself. Does it feel that the imbalance of disease and misfortune is rectified and social order restored? And the patient - does he feel that he has returned to healthy status as a community member? In an African village, the rules for · when and how a mother weans her child are detailed in the tribal code and have deep socio-economic impli- cations. Nutrition educators tend to think of early weaning as a hostile act towards the child and recom- mend prolonged lactation. This prin- ciple is not easily applied in rural 5 areas. The lactation period relates to the division of labour. Being respon- sible not only for the household chores, such as preparing food, carrying water and collecting fire- wood, but also for the weeding of the fields and the harvest, the woman tends to wean early in order to cope with the workload . In the urban setting, where the mother takes a full-time job, such considerations apply even more. Observers who insist that mothers breastfeed their babies in the fields have succumbed to pastoral romanticism. No mother wants to carry her child on her back when she has hard work to do. It is true that mothers can frequently be seen putting the child to the breast, but usually just to soothe it. The real breastfeeding takes place in the morning o r the evening when the mother is rested . Community disorders In fact , it should be recognised that diseases and malnutritio n are not states of illness in individuals 6 but community disorders which can be successfully trea ted only in that context. This is not a modern idea, but a fundamental principle of traditional medical services. It is interesting to note that several specific remedies now considered valuable in medical treatment, such as opium, quinine and digitalis, were not discovered by scientific research but by traditional prac- titioners of medicine. Traditional doctors command a body of useful knowledge and skills that can no longer be ignored. Indeed , there is reason to subject these practices to intensive research for the community's use in the development of a relevant and appropriate primary health care function. What the traditional doctor may lack in knowledge of the physical sciences, he compensates for in his practice as community psychiatrist - a field where his work is often salutary. This does not exclude the de- generation of knowledge and the oc- currence of formidable medical gangsters or small-time tricksters. Such people are found in all soci- eties. Sincerity and pride in a profes- sion can also be observed . And regret, when a patient fails to respond to a treatment or an adverse reaction occurs. In that respect , the traditional medical practitioner is in the same situation as the western doctor administering thalidomide to pregnant women who realises belatedly that he is not an omnipotent professional, but simply a person who does his best and sometimes fails. Luckily, WHO is now promoting traditional medicine. Social transformation in modern Africa will not take an appropriate direction unless the traditional Afri- can community is better under- stood. A social transformation, by definition , is something which can happen only to a social formation. If genuine change is desired , it will occur only through the social mechanisms for change which the community has established and to which it is accustomed. People are W ORLD HEALTH , January- February 1989 Folk wisdom and pseudo-information Left: The communal television set can be a medium for health messages - as here in Brazil - provided it is used wisely. Enthusiastic and perceptive community health workers can learn through self-experience the importance of new ideas and approaches. Right: Traditional doctors like this one at work in a small African community command a body of useful skills that can no longer be ignored. Indeed, their practices deserve intensive research aimed at developing for the com- munity's use a relevant and appropriate primary health care function. Photos World Council of Churches and WHO/H. Anenden. eager to change behaviour if they perceive the change as beneficial. The change is set in motion through the mechanism of community con- sensus. The consensus is sometimes overt, sometimes tacit. The way it is achieved may vary with the com- munity ' s socia l organization or structure. The community is a self- regulating social formation that processes information. It will decode, select or reject incoming information and compare it with information stored in its memory. Ultimately, the community will pro- duce new information accepted or regarded as normative for individ- ual behaviour and conducive to communal interest. Fostering trust It is the fallacy of modernity that we believe we communicate better through machines . Human beings communicate through bonds of mutual confidence. It is the prime task of the health communicator to facilitate a state of communal trust. W ORLD HEALTH , January- February 1989 Unfortunately, the staff of the public health services belong to the educated elite. Therefore, typical bourgeois values permeate the hier- archy from the top to the level of the field-worker. Reality is seen through the reports of the latter, who knows that his superiors only welcome "facts" which are consis- tent with their social values and views. Large amounts of pseudo- information are concentrated around the false fact that poverty and ill-health are caused by ignor- ance. This allows the establishment to launch masses of educational programmes, the purpose and result of which only distract attention from the need for a structural change in society and a redistri- bution of wealth. In the process, the livelihood of the health education establishment is sustained. Health and nutrition messages processed by the system have been devised and meted out according to the measure stick of the middle-class bureaucrat behind a desk. With their frequent characterisations of rural or village people's actions as mistakes, habits as bad and atti- tudes as wrong, they reflect a feudalistic lack of trust in the ability of common people to cope with their lives. There is little doubt tha t the pattern of working life in an organizational bureaucracy o f which health services are a pa rt tends to retard emerging moves towards change. A hope or a threat? Enthusiastic and perceptive com- munity health workers can be given training and made to realise through self-experience the importance of new ideas and approache s. However, the problem remains that sensitive field workers are quickly overwhelmed by the system and lapse into fulfilling the expectations upon return to their work milieu. "Health for all" , the slogan used by the primary health care movement, is considered a hope by many . It is an enigma that some consider the slogan a threat. • 7 Information is power To some degree contradicting the previous article, the author suggests that poverty and ignorance do predispose to ill-health by Eric R. Ram T here was a time when we used to think that more doctors and nurses would result in better health . Consequently more and more hospitals were built, and for a long time physicians dominated the medical-ca re systems and tried to build patterns of medical care around themselves . Now, however, there is a greater awareness throughout the world that the prob- lems of ill-health are strongly related to , and interdependent on, such factors as poverty, poor housing, poor environment, lack of safe drinking water, lack of food , malnu- trition, undernutrition, high fertility rates , illiteracy, unemployment and low-income, land tenure, inaccessibi- lity of social services and unwise lifestyles. Ignorance and Jack of correct information about health put people at a greater risk of contracting and spreading diseases. Health is not a commodity like rice, oil , computers or automobiles which can be ' 'delivered" to people. Rather, it is a social and spiritual phenomenon and greatly depends upon the interac- tions of people - their participation and involvement in all the matters that affect their health . Loss of self-worth and human dignity, and the abdication of personal responsi- bilities to the professionals, to the point where people look to the doctors, the nurses and the state to provide everything for them, includ- ing health, have proved to be a major cause of unhappiness in much of the world . People cannot be treated as objects; they must be active partners in the healing process. They have to take responsibility for their own health and they have to be em- powered to do so. That process of empowerment is something that the 8 people must do for themselves. We health professionals can only facili- tate the process by helping to increase the level of awareness, giving people confidence to take actions, creating opportunities to increase self-reliance, sharing health information and strengthening com- munity building skills. Giving health information to the people means sharing power with the people because information is power. Talking health in a Bolivian village. We should be aware of the potential of women as transmitters of health information. Photo World Council of Churches/P. Williams It fights ignorance, which lies at the base of many diseases. The challenge is to put across health messages in ways that can take into account different cultures and local practices. We need to translate the scientific knowledge in simple and understandable language for the mass of the people. Health information and health ser- vices go together, so all levels of health staff have to be involved. We trained traditional birth attendants (TBAs) to conduct home deliveries safely in the villages of Maharashtra, India, using "Dai's Delivery Kits" which cost all of 50 paise ( 5 US cents). As a result, maternal morta- lity came down to near zero within two years. But more important still, each TBA became an effective chan- nel of communication for health. Women in the villages listened to the TBAs and valued their health advice more than anyone else because they commanded respect in the com- munity. Each community health worker also became a carrier of health messages through his or her work in the community. Women themselves constitute another large resource of health communicators. In addition to con- sidering women as receivers of health care, we should also be aware of their potential as providers of health care and transmitters of health information. It is they who tend most of the people in the world - whether as workers in primary health care, in clinics, hospitals or more informally in families , as they care for children, the sick and the elderly. Yet the contribution that women make to community health is often ignored. When we look at women's traditional chores - cleaning, cooking food, feeding the family, washing dishes, disposing of trash, obtaining and storing water, doing laundry, bathing children - then we realise that women are also the basic teachers of hygiene, nutrition and sanitation. The way they live their daily lives and pass on the informa- tion has an important influence on the health of their children, families and communities. It is all the more vital therefore that the level of education and health knowledge of women should be raised, and that they should have more voice in decision-making at every level of health work. Similarly, each schoolchild should be taught not only the causes of illnesses and how they can . be prevented and controlled but also ways to promote health. They will form the future network of health communicators. My experience in Miraj, India, shows that helping small groups of people in the villages to form health committees to discuss health prob- lems, analyse the causes and develop strategies to tackle them is a good first step. The village health com- mittee serves as a nucleus; later it grows in confidence as more com- WORLD HEALTH , January- February 1989 mitted people are drawn in and begin to share their information and experiences. This way they are able to tackle bigger and more difficult problems themselves. Social change For most of the people in the world, the root cause of poor health is poverty, and the people's power- lessness to do anything about it. Primary health care (PHC) as described in the Declaration of Alma-Ata is a comprehensive process and, in its fullest sense, has a liberating and empowering potential. By helping people to gain control over some aspects of their lives, it can bring about collective action for social change. People work together to improve the total situation of their community, and deal with the underlying causes of poor health and poverty. This requires . organized action on the part of poor people themselves in developing their own strategies, selecting priorities, controlling inter- ventions and carrying them out. Running village communities and using PHC as a strategy to achieve the target of health requires a strong commitment to social justice, human values and respect for life, by communities and governments alike. Early in my career I thought that the best way to change people's attitudes towards better health prac- tices was to show films , distribute pamphlets and hang up wall posters. . It proved to be not quite so simple! Undoubtedly these methods help to increase knowledge to some extent, but how much has the average person's health changed because of that? Unless people are actually involved in making decisions which affect their health, they are not going to participate even by availing themselves of the best of health services provided for them. For instance, we learned in our district that 75 per cent of all water-pumps installed in the villages by the government and humanitarian organizations went out of order within six months, because the vil- lagers had no say in the matter and were in no way involved in their construction. Most illnesses (as much as 80 per cent) in the world, both in the developing and industrialised coun- tries , are preventable by either changing lifestyles or the environ- ment. Health education in general ought to bring about changes which result in better health, but our experience tells us that this is a rare WORLD HEALTH, January- February 1989 "' wm.tAtANti D DlEl ~~-~ phenomenon. The usual health edu- cation methods using a one-way mass media approach do not create the motivation necessary to bring about changes from unhealthy to healthful practices . If people in a given community are confronted by the health workers and their ignor- ance of health knowledge is exposed, they tend to become defen- sive and this in turn . becomes a barrier to learning. To overcome this barrier, one of the most effective ways to communicate the message is by telling a story about another person with similar problems; this allows people to identify with others and seek comparable solutions . In this way the information is not rejected but internalised, and becomes a powerful force within the people themselves for change. According to UNESCO nearly one thousand million adults are unable to read . The finest of publications will not reach these people~ but the traditional method of story-telling will. A story told very simply leaves the listener to fill in the details, evoking a level of imagination which promotes further participa- tion and involvement. Listening to stories helps people to discover truth for themselves, and people learn best what they discover for themselves. Health is an abstract idea that is much better understood in the context of persons and places. So there is a need to demystify medicine and technology. Medical knowledge needs to be put in simple and understandable language backed up by appropriate tech- nology . For example, to control Giving health information to the people means sharing power with the people. lt fights ignorance, which lies at the base of many diseases. Photo World Council of Churches/J. Taylor diarrhoea our TBAs promoted home-made oral rehydration salts added to rice, water and light tea , rather than commercially prepared ORS packets, and had excellent results . Similarly, there is nothing like setting personal examples for bringing about health communi- cation. It wasn' t until we set up water-seal latrines and smokeless ovens for the use of our community health workers that we were able to promote them in the Indian villages . People are responsible Making people aware of their rights and responsibilities helps them to determine their own health priorities and take part in solving their own health problems, a step so essential in the process of empowerment of the people. We have to employ all credible channels of com- munication , including the tradi- tional methods of story-telling and drama, in order to reach all people . Films, radio and television whenever available can be useful , but we have to recognise their limitations; they are useful in creat- ing awareness among people in their communities, but to bring about a real change in health practices people have to decide for themselves and take responsibility for their own health. • 9 Cinemas an wheels by Daniel J. Henrich M ost evenings in most v i 11 a g e s o f s u b-Saharan African can be pretty borin g. Certainly m ost people who live there are delighted when an opport unity for a n evening's entertainment comes their way. Films can be a way of bringing ed ucation in an entertaining way to millions of country-dwellers. When health communication stra- tegies are being developed, the visual media form an integral component in the "media mix" . A great deal of research is already available on the growth and use of television in the developing world. Television is a powerful medium, allowing the producer to comm uni- cate strong messages both directly and indirectly to la rge segments of the population. In Egypt, for in- stance, 85 per cent of the population own television sets and 98 per cent have access to them. 10 Kenyan villagers look forward to regular visits from the mobile cinema. Facing page: Entertainment and information attract a rapt audience in a Moroccan community. Photos Cinema Leo ;!_'l/D. Henrich and WHO/ UNESCO/ G. Bohm This is not the case is most of sub-Saharan Africa . In Kenya , tele- vision transmissions primarily reach big cities like Nairobi , Mombasa and Kisumu. To compound the problem, a considerable percentage of Nairo- bi's 2.5 million inhabitants do not have basic services like water, toilets and electricity. Thus, television can only reach the middle to upper classes of Kenya - leaving a majority of the country's 20 million popu- lation untouched. Handclasp International ( HC I) is a Cali fornia-based non-profit-making ed ucational and charitable organi- zation with field offices in Cairo, Bangalore and, most recently, Nai- robi . As funding becomes available, HCI will produce a series of health and development films targeted to lower class and primarily rural audi- ences. Preliminary research has shown that the most effective method of reaching this target audience is through cinema vans. These vans travel from village to village showing a broad variety of films. Most of them are supported by advertising of consumer products. In Kenya, there are three commercial groups which show " Wild West" films, a Ministry of Agriculture cinema project, and a cinema van programme run by a religious group. Pre-production research showed that for HCI our film format should be short, only 10 to 20 minutes, and preferably semi-dramatic; and that the films shown along with our films should not be violent ones. Additional research was commis- sioned through a local university research department and carried out on the audience of the religious cinema van group, Cinema Leo. It arrived at the same conclusions, and showed that their audience of over 250,000 per month most closely fitted our target audience, that is, an age-level under 29 years, la rgely tradesmen and farmers of the "emergent" class, and mostly rural. In the research phase, another non-governmental organization financed three health-related films. Each film has original Swahili music, lasts between seven and 15 minutes and has a relaxed, inductive ap- proach to communication. Titles include "Clean and strong teeth for good health", " Clean hands and face" and "A special drink for diar- rhoea". The films are widely accepted; indeed the tooth care film proves so popular that it has been shown at a number of weddings! Handclasp plans to produce 15- 20 health and nutrition films over the next two years. Each film has a budget of under US $14,000 includ- ing production, overheads and show- ing three times on Cinema Leo. The films will be produced in English and dubbed into Swahili for distribution in East Africa as well as in English- speaking West Africa. We are plan- ning other language versions, includ- ing French for such countries as Zaire and for Francophone West Africa. There will be a series of five 15- to 20-minute dramatic films on AIDS. Using Cinema Leo initially as the major distribution outlet, the films will have a "soap opera" format and will deal frankly with this growing WORLD HEALTH , January - February 1989 threat, approaching it from the standpoint of a monogamous rela- tionship. Each film has a budget of approximately $32,000. In communicating health among the poorest of the poor in sub- Saharan Africa, India or other parts of the world, it is important to research existing avenues of commu- nication . This is true for any commu- nication effort, but especially so where the target audience is not an upper class, urban population. In parts of Africa, the cinema van can provide a powerful medium for communicating health. Properly pro- duced, short, topical films on health, safety, agriculture topics, small busi- ness development, and attitudes to the handicapped are planned by HCI, and expected to have a strong impact on rural audiences. Entire villages often come out to view the films - providing an eager "captive" audience. The cinema van concept entails building up a circuit where a van goes to the same place on the same day each month, and thus creates a loyal audience which will attend month after month . Cinema Leo has four vans which show films in 104 towns and villages WO RLD HEALTH , January-February 1989 each month in Kenya, and two vans in Tanzania which reach another 40 to 50 villages. The reason for the circuit is accountability - both to the audience and to the advertisers. Other groups who have recognised the potential for health and develop- ment have put cinema vans into operation in Ghana, Tanzania and Uganda. Ready-made audience Handclasp continues to make a careful study of the use of cinema vans in health communication. The vans have a ready-made audience that crave visual entertainment and education. In many ways, the same aspects that attract people to televi- sion also attract them to the cinema vans. Another interesting finding in the Cinema Leo audience survey was that the respondents wanted African-produced films, with Afri- can actors, produced in Africa. This fact reinforces HCI 's long-running policy to produce films specifically for the audience. Our development communication projects in India and Egypt share this policy. Cinema vans may not be most appropriate for very isolated areas of Africa. Discussions are under way for a "Cinema Donkey" project that would carry a small generator, a 16mm projector, an amplifier and a screen to isolated valleys of Kenya where roads are not passable . For instance, in northwest Kenya the Kerio Valley has a population of around 150,000 and is not easily reachable by road . Scattered throughout the valley, however, are grain grinding mills and market areas where local farmers gather. The " Cinema Donkey" could travel to these locations showing films. Handclasp feels that its policy of having a permanent on-site produc- tion crew as well as writers and editors is an important key for making culturally relevant produc- tions. National crew members and eo-writers are used as much as possible, both as a training exercise and in order to make the produc- tions truly African . The group is also moving into television and is already producing a series of child- ren 's television programmes in Cairo aimed at communicating development concepts to young audiences. • 11 Let's communicate by Gloria Gordon T he theme of this year's World Health Day is "Let's talk about health ." But let's do more than talk. Let's communicate about health. Conversation without communication won't save lives, but effective communication will affect behaviour, thus helping establish a lifeline to good health. As we work with the vital health problems facing the global com- munity, whether they be within highly sophisticated "first world" countries or in obscure and isolated locations where even basic informa- tion on nutrition, hygiene or health is lacking, it takes team effort to save lives. In addition to deploying the medical and teaching skills of physi- cians, nurses, pharmacists, midwives, health advisers and practitioners, why not make communication part of the team? Communication skills will help you "tell it like it is" effectively, and thus add another link to the lifeline of health. The AIDS epidemic made health care professionals painfully aware of the need for open, candid, honest, no-holds-barred distribution of information. When health officials realised the enormousness of the AIDS situation and how rapidly the disease was spreading, along with misinformation and fear of the un- known, it became obvious their communication procedures needed to be rethought drastically. At this time the only real defence against the spread of AIDS is through beha- viour change. No drugs, operations or other medical answers exist for its cure - just communication on how the disease can be prevented. In a precedent-setting measure, Dr C. Everett Koop, Surgeon General of the United States, drafted a bro- chure to be sent to every household in the country. Words and illustra- tions describe exactly how AIDS is spread; for the first time, many people were exposed to the graphic and explicit information that just five years ago would have been unaccept- able to any general population. For the most part, this type of direct mail information, as well as television , radio , posters and billboards conveying such explicit illustrations and descriptions, can be presented - and generally accepted - in "first world" countries such as the US, the United Kingdom, Europe A mother waits for a consultation at a Jerusalem clinic; behind her- a graphic poster shows how she can help her child to grow. Photo World Council of Churches/ M. Murray WOR LD HEALTH, January-February 1989 Extreme examples of the haves and have-nots. Much of the battle for health consists of finding the golden mean. Photos WHO/ P. Almasy and most of Asia. But this would be unacceptable for dissemination in most "third world" countries where cultural and religious taboos about sex exist. But where there is a need, there also must be a way to fill it, and in this case, the need is to save lives. Dr Koop and hi s communication advisers are meeting the challenge head-on and with candour - by going back to communication basics. Which leads us to the challenge of communication - how can we communicate any and all vital health information to a ll people everywhere? Pharmaceutical companies, health care agencies, doctors, nurses and health workers as well as government agencies are beginning to see that talks, education programmes and reporting are not enough to awaken awareness of today's critical health demands. Another dimension needs to be added, and that is the develop- ment and putting into effect of the basic communication skills to effect behaviour change. For example, some speech writers use this edict to convey a message: 1) Tell them what you're going to tell WORLD HEALT H, January · February 1989 them, and why. 2) Tell them. 3) Tell them what you told them, and why. 4) Answer questions and, in your answers, tell them again. It sounds easy, but when cultural barriers have to be crossed, some fine tuning is in order so that you can direct your message to influence and persuade your receiver. messages must be interpreted within the cultural framework , the greater the cultural disparity between the communicators and their receivers, the less likely the communicator will be able to define and interpret. To communicate is also to per- suade. And a key to effective persua- sion may lie in discovering how a situation affects a family or com- munity in such a way that it becomes a part of them personally. Since Gestures, symbolic movements, may be unique to one ethnic group and have entirely diverse meanings in different cultures. So the challenge comes in how to define them and work with - or through - them to convey a message to the individual. Communication expert Roger Haywood of Haywood Associates, -Promote actions which are realistic and feasible within the constraints faced by the community. -Build on ideas. concepts and practices that people already have. -Repeat and reinforce information over time, using different methods. c - Use existing channels of communication such as songs. drama and storytelling. and be adaptable. -Entertain and attract the attention of the community. -Use clear. simple language with local expressions and empha- sise short-term benefits of action. -Provide opportunities for dialogue and discussion to allow learner participation and feedback on understanding and implementation. -Use demonstrations to show the benefits of adopting practices. (Reprinted with permission of Dr John Hubley, senior lecturer in health education at Leeds Polytechnic. U.K.) 13 Let's Communicate London, offers the follow guidelines in designing and crossing cultural communication boundaries. Firstly, look for similarities in cultures and ethical standards, but beware of stereotyping. Secondly, be sensitive to space, planning, status symbols, personal content, methods of agreement, attitudes, cultural details. Pace the degree of development. Explore ethical dimensions. "What is the receiver's view of reality? What are his or her needs? What factors affect his everyday existence? A message needs to square with hi s environmental and situational realities. It needs to relate to individuals' value systems and levels of understanding," adds David Pincus, communication professor at California State University , Fullerton. lndi Rana, in a recent article for the Clearing House on Development Communication, explains how researching and eventually distribu- ting a comic book became an effec- tive tool for offering information on immunization to rural schoolchil- dren, and to their parents, in India. "The idea was to use child-to-child and child-to-parent communication to carry the message that all children under 12 months of age should be immunized. Children between 8 and 12 years were to read the publica- tion, perhaps in class, perhaps as an extra-curricular give-away and take the message home to their parents." To test this theory, a survey was conducted to discover the target audience's pre-knowledge of immu- nization and determine how much information should be included. It also assessed their visual literacy to determine their level of sophisti- cation, and their interest in story types so as to select the most accept- able vehicle for the health messages. Results showed that, given the right kind of comic book, rural children, being naturally eager and curious, would adapt to this new and interesting form of reading and - it was hoped - would take the message home to their parents. In this case, the children became the agents of change, the communicators. Did the comic book meet the objectives? Rana says, "UNICEF in New Delhi is distributing 85,000 copies in Hindi. The comic book will eventually be translated into all of the Indian languages. WHO offices worldwide have received copies and have shown interest in adapting the book for their regions. Other health agencies in Sri Lanka, Nepal, the Maldives, Bhutan, Burma and 14 Indonesia are looking into adapting the publication. "With careful research and thoughtful presentation , comic books with health information built into their storylines could become a common sight in rural communities, helping to dispel the belief that this popular format is not suitable for social messages." The shrinking globe with its open- ing channels of awareness is also affecting the communication pro- grammes of large worldwide cor- porations and agencies. Most find that the grandiose communication programmes of the past just don't work any more. Going directly to - and through - the people is what works best. Johnson and Johnson, one of the world's largest distributors of phar- maceutical products, directs its 167 satellite companies in 53 countries to work through local management to disseminate information about its products and services. Bob Andrews, assistant director of corporate public relations, says: " It is far more effec- A ball-game helps to convey the message of immr,mization to children in a Beijing park. Photo WHO/Chinese Health Education Institute. Below: Cartoon from Jian Kang Bao, the popular Beijing health newspaper. tive to tailor individual communi- cation programmes to suit the communities served, using residents of the country to relay information. Our corporate guidelines may contri- bute to consistency, but it's those who actually live and work in an area who make a programme work." Merck, Pfizer and other com- panies also find that effective dis- tribution and proper use of pharmaceuticals in developing coun- tries are best carried out through indigenous groups rather than from "front office headquarters." Peter Keating, executive vice- president in charge of operations of Americares, an organization which works with pharmaceutical com- panies and other agencies to distri- bute medical information and supplies in areas of dire need, says: " We initiate discussions, make con- tacts. Our concern is getting information to people to help them- selves. We help retrain physicians and find physicians who are willing to donate their time. We use them to work in a community and train local medical staff. The end result is that, through training and communicat- ing , pride among participating residents develops. " Inconsistent laws Distributing life-saving medical help doesn't always work as smoothly as intended, though. Spokesmen for most of the pharmaceutical com- panies I talked with. agreed that it is a frustrating experience to have available the means to help, but not to be able to do so because not only communication but also consistent regulatory measures are lacking. " Each country has its own laws governing distribution. What requires a physician's prescription in one country can be picked up at a local market over the counter in another," says a pharmaceutical communication specialist. He adds, "There is no such thing as a safe drug. All can be dangerous if misused. We have strict guidelines requiring us to provide printed in- formation with each product - but if that information disappears in tran- sit, we lose control. It becomes a political problem. The result is that activists campaign against the dis- semination of pharmaceuticals in Third World countries because of inconsistent laws and misinform- ation about their distribution and use. Why should this be? If we can't reach all in need, why deprive those we can reach?" • WOR LD HEALTH, January- February 1989 Talking to teenagers about sex by Anameli Monroy de Velasco M exico's answer to the problems of adoles-cent sex is known as CORA. This is a net-work of "orientation centres" (Centros de Orientacion para Adolescentes) which for nearly a decade has been providing health services to young people, with special emphasis on sexual and reproductive health. A non-profit-making, private association, CORA in fact offers a whole range of educational, social, psychological and medical services to adolescents, their families and the professionals who work with them. Drug abuse is another special topic at these centres. Since adolescents may be found either in school, at work or on the streets, CORA - the first institution of its type in Latin America - has designed different strategies to reach them, wherever they are. Youth pro- moters, young students aged between 17 and 24, organize sporting, recrea- tional and cultural activities in order to encourage youngsters to attend the centre during their leisure time. The network provides contracep- tive methods and information about sexually transmitted diseases in schools, factories and communiti~s. And youth teams, based either in the centres or in nearby youth clubs, go out to talk to young people in the streets or at work. CORA has collaborated with Tele- visa, a commercial television station, in making a TV "soap opera" called "Caminemos - Let's Walk." The programme has a story line specially aimed at young people and their parents, and includes fairly frank discussions of sex education and family planning. Another very successful strategy has been the annual contest to find the best Adolescent Theatrical Play- wright. The contest has been run since 1980 in collaboration with the National Institute of Fine Arts WORLD HEALTH , January-February 1989 (INBA) and the office of the Mayor of Mexico City. Contestants must be between 12 and 22 years of age, and the objec- tives are: - to offer young people a forum for self-expression where they can reveal their health problems and concerns; - to prevent problems of vagrancy by channelling their energy in a positive direction; - to stimulate artistic expression; - to sensitise community leaders to the needs of young people. Slide-tape shows can be important edu- cational tools for adolescents. Photos WHO/E. Schwab Over the past eight years a total of 308 groups, averaging 20 members each, have participated, and about 30,000 people have seen the perform- ances. In an effort to reach still more young people, their parents and the professionals who work with them, five of the best dramatic works were chosen to be put on video-tape. They are: - Susana: A story of two teenagers who experience the consequences of an unplanned pregnancy. - Jovenes Desorientados (Disorien- ted Youth): Lack of communi- cation with his parents causes a youth to run away and become involved with drugs and delin- quent behaviour. - Dos Adolescentes (Two Adoles- cents): A friendship develops between two teens with different sexual histories. This video deals with rape, sexually transmitted diseases , gender roles, and communication within the family. - Poesia en Voz Muda (Poetry in a Mute Voice): The story highlights the factors that cause the break- up of relationships among young people, such as immaturity and lack of financial resources and support. - Requiem para el No Nacido (Requiem for the Unborn Child): Abortion as an alternative to unwanted pregnancy seen from the point of view of two couples from distinct social classes. (These videos are available for purchase, and may be obtained by contacting CORA, Apartado Postal 21-205, 04000 Mexico D.F.) Puppet theatre is a tool we have found to be very effective. We use it to promote our services, explain the work of the youth promoters, and motivate young people to learn about AIDS, contraceptives, un- wanted pregnancy during adoles- cence, drug abuse and other health topics. We combine puppet shows with games of chance such as bingo when we have tables available, although theatre is often used in the streets where bingo is not permitted. We regard comic books as very important educational tools for adolescents. So we have developed a series of three comics on sex edu- cation (including prevention of STDs and AIDS, contraceptives, and preg- nancy). These are targeted at adoles- cents from 12 to 15 years old, but we are planning another series of five comic books for older adolescents. All the comics will be on sale in ordinary shops. We also use more traditional books and pamphlets, and in addi- tion have had some of the books made into slide-tape shows for use with large groups. These materials too are put on sale. During its ten years of experience, the lesson that CORA has learned is that adolescents are very creative and discover for themselves how best to communicate with their peers. Con- sequently, instead of providing them with material developed by adults, the best approach is to allow them to create their own materials and to learn from the process. • 15 16 9~ The health game A throw of the dice shows the pathway to better health-or the pitfalls on the way KIZIBENHAVN 26 Concept G. Padey, ~ ill •-- VHO Geneva. Design G. Auberson NEW-DELHI WORLD HEALTH, January-February 1989 17 RULES of the health game 1 • Each player throws the dice once. The player with the highest number starts. If two have the same (highest) number, both players will throw the dice again and the one with the highest number of points begins. 2. You advance as many squares as the number indicated on your dice. 3. The player who is lucky enough to reach a square with the WHO logo can throw the dice again straight away and move on the number of squares indicated on the dice. 4. The winner is the first player to arrive at WHO. 5. For each square, here are the rules and the health messages attached: 1 . The logo is that of the World Health Organization which was established in 1948. Play again. " 2. Too much salt and sugar are bad for your health - go back to 0 for a health check-up. 3. Sport is good for your health! Keep it upl 4. You save a baby from dying from diarrhoea by giving a salt-sugar mixture. Bravol Advance to square 6. 5. AIDS- a worldwide effort will stop it. Before the game continues each player must state what he or she can do to stop the spread of AIDS. 6. Vitamin A can save children's eyesight. 7. Swimming is the perfect sport for all ages. Keep it up and advance three squares. 8. 9. right. WHO has 166 Member States. Play again. Education for family planning is a human 1 0. You ate too much fatty food. Wait one round to slim down. 11. For a healthy baby, pregnant should have regular health check-ups. women 12. Sports should begin early in life to establish a healthy life-style. 13. Smallpox was declared eradicated in 1980. Bravo! Advance five squares. 14. You drank too much alcoholl Go back four squares. 15. Polio is the next disease to be eradicated. Are you immunized? If yes, jump 4 squares. 16. WHO has six regional offices Alexandria, Brazzaville, Copenhagen, Manila, New Delhi and Washington. Play again. 17. Primary health care is the way to provide health care to everyone! 18. Helicopters spray insecticide against the blackfly which can cause river blindness (onchocer- ciasis), a deadly tropical disease. 19. Have you had a health check-up during the last two years? If not, stay in the same square during the next round while you have your check-up. 20. Sport is essential in any rehabilitation programme. Jump 4 squares. 21 . Smoking, drinking and a sedentary life-style - a sure way to destroy your health! Go back to square 19 for a check-up and health education. Remain in square 19 during two rounds. 22. Toilets can stop the spread of disease. But leave it as clean as you want to find it. 23. The ideal family has two children . 24. WHO was 40 years old in 1988. Play again. 25. Babies should have food in addition to breast-milk after 3 months. 26. You tried narcotics? A dangerous game indeed. Return to square 1 and start a new life! Are you stressed? Don't use drugs, try yoga. 27. 28. Breast-milk is best for baby. He or she will be a good dancer. Jump to square 30. 29. Water is life - but it must be clean! 30. Dancing is good exercise - have fun! 31. Bad luck, the dog was not vaccinated against rabies. You must leave the game! 32. The Director-General of WHO is Or Hiroshi Nakajima from Japan. Play again. 33. Add life to years - take a good walk to square 36. 34. Child labour is bad for a child's health - stay in square 34 during three rounds while the child is in hospital. 35. You were bitten by a mosquito and got malaria. Stay in square 35 during one round and study preventive measures against tropical diseases. 36. "Rough " food has lots of fibre, which is good for health. 37. Tetanus in the newborn kills many infants every year. Immunization of pregnant women against tetanus is essential. 38. A clean mouth and nice teeth make for a healthy smile! Play again! 39. WHO's budget is 300 million US dollars a year - less than it costs to run a university hospital. Play again. 40. Handle pesticides with care. Thank you! (They can be dangerous.) 41. Watch your blood pressure- and treat it if it is higher than 140/90. Heart diseases flourish in both rich and poor countries. Stay here during the next round for a check-up. 42. You did not take your antimalaria tablets although you were in a malarious area. Go to bed and shiver during two rounds! 43. Smoking is costly, filthy and dangerous. Shame on you! Stay in square 43 during one round. 44. Science makes important contributions to health. You get the Nobel Prize in medicine and WIN THE GAME! 45. Traditional medicines can be useful but consult someone who knows. 46. Protect food against flies. You didn't, got diarrhoea and have to take rehydration salts. Return to square 22 and sit out one round. 4 7. You drink and drive. Two weeks in jail- you lose two rounds. 48. You are lucky- WHO is there to help you win the health game. You go to visit WHO in Geneva or a Regional Office, to learn (even) more about health. More copies? If you would like to reproduce The Health Game in other languages or to have additional copies printed locally, in both cases for non- commercial distribution only, WHO can provide you with poster-sized copies of the board. Write to: The Editor, World Health, WHO, 1211 Geneva 27, Switzerland. satellite medicine Artificial satellites orbiting the earth far out in space already represent a mine of inform- ation about our planet. What contributions can they make to primary health care? by Petar Jovanovic T he efforts of WHO and Member States to attain "health for all" through the primary health care approach requires support from all available technologies. One of these in particular, space tech- nology, or - more precisely - satellite remote sensing (and sending), deserves to be included in those efforts. Let us look at the potential application of satellite remote sens- ing in primary health care. The full impact of this technology will be realised only with careful project planning and the cooperation of specialists from many disciplines. Many of the member countries of WHO already make use of remote sensing imagery in various health- related fields, including agriculture, forestry , public works, water devel- opment, geology, urban planning, communications, education, climato- logy, meteorology, assessment of natural resources, and monitoring of natural disasters. So far, medicine has not included this technology among its broad approaches to preventive health care. Although public health could adapt this tech- nology to its own independent needs, as a powerful tool to reduce morbi- dity and mortality from many diseases, it is still not numbered amo_ng the users of satellite remote sens1ng. Satellite sensory systems have the capacity to detect environmental parameters closely linked to pathogens or vectors of diseases. Of course the satellites, orbiting high above the earth's atmosphere , cannot observe these organisms nor the symptoms of diseases in humans. But they can determine those para- meters of the air, water, soil and An Ariane rocket carries a satellite into orbit from Kourou, in French Guyana. Photo International Telecommunications Union 18 vegetation which can be examined to determine the likely presence in the environment of the pathogenic agents. This information will be of value to epidemiologists and will have immediate potential for disease control. The list of parameters detectable from space includes: temperature of water, air and soil; humidity of the air; turbidity of water and its alkali- nity, acidity, velocity of flow; aquatic vegetation and catchment areas; quantity of vegetation; presence of minerals, plankton, chlorophyll and heavy metals. Among the sensory systems cap- able of measuring those parameters from space are: radar, laser beams, microwaves, x-rays, ultra-violet, infra-red and, of course, optically visible light. If we should need more specific sensors, researchers could develop new ones or adapt existing systems as needed for assessing public health problems. If we look at the eight essential elements of primary health care as defined in the Declaration of Alma- Ata (see August-September 1988 World Health , page 16), it is not hard to foresee the probable application of satellite technology to each of them. Education about prevailing health problems can deploy both remote sensing and remote sending of mes- sages and pictures. Combined with all other methods of education, it can transfer necessary knowledge to the populations concerned and help to train all those who take part in education and training activities. As regards food supply, remote sensing survey can be reliable in identifying good land and soil for proper food production, and in con- trolling industrially polluted air, water and soil - all of which reflect on the provision of proper nutrition. It can facilitate an easier food supply in remote areas and indicate the extent of problems in normal or in emergency situations. Safe water and basic sanitation depend on a well-run water supply. Satellite imagery can play an impor- tant role in locating water resources, monitoring the quality of surface water, and surveillance of water pollution. Areas that are most likely to be flooded or exposed to droughts can be identified, and this in turn can sound a warning about the risk of water-borne diseases, In the field of maternal and child health care - since mothers and children are most vulnerable to ende- mic infectious diseases and water and food problems - systematic remote sensing surveillance of environmental situations can predict, locate and help control health hazards. Radio and television communications can also popularise curative health measures linked to this category of the population. Many viral bacterial infections are environmentally linked to climate, as arthropod-borne, air-borne, water- related diseases. So the planning of immunization can be based on satel- lite surveillance. Sometimes epidem- ics start during migratory events, during · the mingling of populations in disaster situations, or near water supplies. In all these situations, satellite imagery can help to predict potential epidemics and to pfan effec- tive immunization programmes. Among the main locally endemic diseases are malaria, schistosomiasis, onchocerciasis (river blindness), and trypanosomiasis (sleeping sickness). The presence of the parasitic agents concerned can be deduced by detecting indicators of their presence or physical conditions likely to encourage their growth (or the growth of their vectors). The dis- tribution and differentiation of environmental parameters can then be compared with the distribution of morbidity and mortality in the human population in order to identify the link between pathogens and environment. This method of satellite surveillance, together with WORLD HEALTH , January-February 1989 studies of environmental changes of air, water, soil and vegetation, can locate potential places of growth of pathogens and vectors. Subsequent field action can help to cut out the links in the biological chain which encourage the survival of the pathogens and their vectors. Common diseases and injuries are usually dealt with by local health personnel. However, fast advice and guidance given to local health workers from larger health centres by more skilled personnel can be based on satellite radio and television communications; indeed medical emergencies have already been handled in this way in remote islands of the Pacific. Training in this kind of health care can be orally and visually provided by satellite to otherwise inaccessible areas. Provision of essential drugs is more a problem of production, but it is not totally separated from satellite tech- nology, which can play an important role in locating places where the needs are urgent. It can also identify the best soils and land for growing essential herbs for pharmaceutical production. On a broader canvas, satellite imagery can detect environmental degradation over large areas and at the same time identify specific details. Large areas can be seen in a small picture. Repetitive coverage over long periods allows us to follow and study seasonal and other changes that are relevant to epidem- iological surveillance and control measures. If combined with ground or sensor systems and field verifi- cation of data, the results can pro- vide a reliable data-base for public health planning. The communication of messages and television pictures can reach every spot on the earth, Solar panels fan out to catch power from the sun for an orbiting satellite. Below: Equipment in WHO's Geneva headquarters captures and relays an intercontinental teleconference on AIDS. Photos International Telecommunications Union and WHO however remote. Would the introduction of this technology in public health be unac- ceptably expensive? Even though resources and manpower are limited, public health workers in many coun- tries can use already existing photo- graphs commissioned for other government sectors or commercial enterprises. It is not difficult to learn to interpret them and understand them. They have only to read the existing data in a new way. Remote sensing facilities exist in many coun- tries, and public health authorities only need to seek access to these available resources. Public health is already in a position to open a new chapter in preventive medicine , "satellite epidemiology". When to these functions can be added the transmission of advice and guidance on curative care, it will be possible to speak of "satellite medicine." • 19 The public as partners by Nedd Willard S uccessful campaigns against breast cancer, tobacco and AIDS in California have relied more than health pro-grammes in the past upon dialogue between health profes- sionals, volunteer organizations and the public at large. To do this, original techniques had to be tailored and adapted to their audiences or, better still, had to involve the public as partners in health . Cancer is a large group of diseases characteri sed by uncontrolled growth and spread of abnormal cells; if the spread is not controlled it results in death. Fortunately, many cancers can be cured if detected and treated promptly. Increasingly common among American women, breast cancer is one form of cancer that has a high rate of cure if detected early. Up to 90 per cent of women whose cancer is detected early and treated promptly can save their lives. Given the gravity of the situation - one out of every ten women in the United States has breast cancer at some point in her life - the local branch of the American Cancer Society in the San Francisco Bay area took action. Its membe rs decided to alert women by using every appropriate form of media so that they would be examined for breast cancer and, if needed, could take immediate steps to do some- thing about it. The Smart Women programme was launched during the week of 18 April, 1987, and used the most popular regional television station as its point of focus . As the programme went on the air, backed up by the press and radio, nearly 16,000 phone calls were received at a central phone bank staffed by volunteers. No fewer than 13,257 women who called in were eligible and 9,100 low-radiation mammograms were completed dur- ing the Smart Women programme. Blood pressure check-ups for passers-by in a Madrid park. Photo WHO/T. Farkas 20 A programme this vast reqmr~s planning, and a regional orgam- zation was set up and divided into task forces . A medical task force dealt with such technical issues as the radiological facilities. A promotion and response task force planned the operations of the phone bank, briefing and organizing over 1 ,000 volunteers. Finally, an evaluation task force was chaired by a professor of public health at the University of California, Berkeley. Media coverage was extensive. Articles appeared in 29 newspapers with a circulation of over two mil- lion. Some publications ran articles on more than one day or devoted full pages to Smart Women. Many TV and radio stations ran public service announcements. Evaluation proved that the target population had been reached. Women heard about the programme, understood it and did something about the information they received. Also, as a result of Smart Women a legislator sponsored a bill to en- sure medical insurance for mammo- graphy in California; the bill became law on 1 January last year. Women who had been successfully treated played an important role on TV, over the phone or face-to-face. They spoke frankly , woman-to- woman. And not only the public was educated. Studies showed that 30 per cent of women at high risk - those whose mother or sister had had breast cancer - did not have a physician recommend a mammo- gram; yet 88 per cent of women over 35 said they would take one if their physician recommended it. These facts have been presented to the medical profession for action. Grim harvest Meantime the fight against smoking and use of tobacco is in the winning phase in the United States, but much remains to be done. The facts are still discouraging. Previous years of smoking sowed the seeds for a grim harvest of lung cancer. The incidence of this cancer in white males rose from 82.7 per 100,000 in 1982 to 84.2 in 1984. Incidence among white females and black males and females also rose. Tragi- cally, only 13 per cent of patients diagnosed with lung cancer, white and black, live five years or more after diagnosis. The message is "Don't smoke, and if you do, stop!" The good news is that overall smoking is on the decline in the US. From 1976 to 1985, the proportion of male smokers aged over 20 dropped from 42 per cent of the population to 33 per cent, and of women smokers from 32 to 28 per cent. In 1987 the US Government reported that only 26.5 per cent of Americans now smoke. Unfortu- nately the average smoker appears to be smoking more heavily and some young people continue to contract the habit. Hence the need for the Great American Smokeout. The Smokeout sponsored by the American Cancer Society is now 12 years old, and is a good-natured effort to encourage smokers to give up cigarettes for 24 hours. As some- one said, "the technique is to aim for the funny bone, not the jugular vein." To ensure success, the Society prepares a detailed Promotion Guide each year to give communi- ties a step-by-step approach to this campaign at the local level. The chairman of the Smokeout, actor Larry Hagman of the televi- sion series "Dallas", encourages schools, corporations, businesses, hospitals and others to get into the act. Some companies even stuff no-smoking messages in with their monthly bills or payroll cheques. There is no limit to imagination. One of the latest ideas is a T-shirt given to infants born on Smokeout Day, 17 November. The shirts pro- claim, 'Born Non-smoker'. In some places, hospitals compete with the honour of delivering the first baby on Smokeout Day and local busi- nesses contribute prizes to go with the T -shirts. Statistics show that only 16.7 per cent of physicians, 14.1 per cent of dentists and 23.4 per cent of nurses now smoke in the US. Physicians have a special role to play since 71 per cent of patients who smoke a pack a day or more said they would quit if their physician told them to do so; this was particularly true of young smokers. Volunteers staHed the phone-in desks during the Smart Women programme in San Francisco. Photos WHO/N. Willard Top: The poster said it all. Smart women paid $50 for a cancer screening that caught the problem in time. WORLD HEALTH, January-February 1989 The American Medical Associa- tion prepares a Physician Leader- ship kit that goes to local medical societies . It contains material on how to make hospitals and offices smoke-free, background facts to encourage health professionals to speak at schools about the dangers of tobacco , including the new menace of chewing tobacco . The AMA asks its members to lobby for more effective legislation . To drive the message home , cards are included to be sent by physicians to elected politicians informing them that one of their constituents has died from tobacco-related disease. But there are many citizens ' groups in the field . One dynamic organization has spearheaded the concept of everyone's right to clean air. They are the " Americans for Nonsmoker's Rights" in Berkeley. They have successfully lobbied for non-smoker 's rights legislation across the country, defended the involuntary smoker and supported the initiative of airlines that have initiated non-smoking flights. They also show young people how to see through tobacco advertisements . For example, young people often get the impression that most teens smoke even though this is not true. 22 In the US today, only 15 to 20 per cent of all teenagers smoke, yet when young people were questioned they guessed about 65 to 85 per cent of their peers were smokers. In fact, the best news is that the percentage of high school seniors aged 17 and 18 who smoke cigarettes every day decreased to 18.7 per cent in 1986. But the goal remains - a smoke-free generation by the year 2000. A dramatic example of talking about health that works is the campaign against the spread of AIDS in the San Francisco Bay area. Non-judgmental and frank, it used the language of those to whom it was addressed. This was done through explicit posters and bro- chures that shocked many people but had their effect on those who needed to receive the message . AIDS was found to be spread by the sharing of unsterile hypodermic needles . When it was found out that sterilising the needles with bleach could prevent the transmission of the virus, an information campaign was launched relying heavily on cartoon strips. Ethnic minorities had to be reached. They are being alerted by messages like this: "AIDS is striking people of colour. It is not limited to The good news is that, overall, smoking is on the decline in the United States. The bad news is that some people are smoking more heavily. And the Third World has special problems. Photo WHO/H. Anenden gay white men. In fact , one of five Americans with AIDS are Black, Latino, Asian, American Indian or other people of colour. Among women with AIDS, half are black and one in five are Latina." Broad- cast in various languages, these messages are backed up by com- munity action groups working directly with these members of the population. Although there are differences in the material produced, the lessons learned by all these programmes are the same. Whether to reduce breast cancer in women, to end smoking in the general population or to stop the spread of AIDS among drug users, the facts have to be put across and understood. Moreover, they need backing-up by real individuals talking face-to-face with others. These programmes show that dia- logue about health problems based on facts and carried out with imagination can bring results: better health for all. • WOR LD HEALTH , January-february 1989 The tobacco tradition in India by Mira B. Aghee W hen the Portuguese first introduced tobacco into India in the 17th century, it was credited with the qualities of calming and relaxing an individual and was also considered to be a sort of stimulant. Various cultures gradually discovered their own ways of using tobacco, and as time passed, tobacco habits became not only socially acceptable but a tradition, even playing a part in cultural rituals . The younger generation began to equate tobacco usage with adult behaviour. Over the years, tobacco usage in India has evolved in two distinct forms, namely chewing and smoking. Chewing is hardly a correct descrip- tion of the habit because in most cases tobacco is kept in the mouth and not chewed. The practice of pan chewing is at least 2000 years old and has the sanction of ancient Indian scriptures. Basically pan is a combin- ation of betel leaf, slaked lime (calcium hydroxide) and pieces of areca nuts, with sweetening added . Today, however, almost all the habi- tual chewers of pan chew it along with tobacco. Khaini can be described as the habit of chewing tobacco without the betel leaf, and M ishri is prepared from burnt powdered tobacco . It is primarily used as a way of cleaning teeth, mostly by women. The bidi is undoubtedly the most common and widespread smoking habit. This is a reed-like cigarette made by rolling a dried rectangular piece of temburni (Diospyros Mela- noxylon) between the fingers with a small amount of tobacco into a roughly conical shape and securing the roll with a thread . Unlike a cigarette, the bidi cannot be held between the fingers for a long time, and it has to be puffed continuously, otherwise it goes out. A chutta is a coarsely prepared cheroot, commonly smoked on the east coast of India. It is often smoked in reverse (with the burning end kept inside the mouth) especially WORLD HEALTH , January- February 1989 by women. The hookli is a clay pipe smoked by men in Gujarat. In other regions, men smoke another pipe called a chilum which is cone-shaped. In the hooka, the smoke is filtered through water kept in a bottle con- nected to a special receptacle con- taining a small amount of tobacco, seasoned with molasses and topped with pieces of burning charcoal. __ . No awareness or knowledge exists in rural India about the ill-effects of tobacco._. Photo WHO/M. Puhl Today the most fashionable form of smoking is the cigarette. More than 80 brands are available but since they are generally very expen- sive, they are confined mainly to urban upper income people in the cities. The bidi is the village cigarette. India ranks third in world tobacco production, and of the 250 million kilograms of tobacco per year allo- cated for local consumption, 78 per cent is smoked, 20 per cent is chewed and the remaining 2 per cent is taken as snuff or rubbed on the skin. No health warning Much is known about the smoking behaviour of children in the industrialised world, but in India hardly anything on this subject is documented. But as a matter of common observation, it can be said that, since more people live in villages, more children in villages smoke. And the villager knows nothing about the hazards connected with smoking. Cigarette advertisements with the statutory health warning are not found in the village, and a bundle of bidis does not have any warning on it. Yet there is a higher risk of lung cancer for bidi smokers and also a risk of oral and pharyngeal cancers. Among well-to-do city families , it is yet not acceptable to the Indian lifestyle that daughters and daughters-in-law should smoke, even though the men do. Away from home, in schools, colleges and other public places, young girls rarely smoke and few young boys do so although the number is on the increase. The real problem is located among the urban poor, where boys commonly start to smoke before the age of ten , and sometimes even as early as five to six years. These children smoke not so much because their friends do so , but because they constantly see their movie film heroes with a cigarette. In the villages of Kerala State, one survey found that the main reason given for starting smoking was tooth-related problems; tobacco is believed to have magical and medicinal value in curing toothache. In Gujarat , village boys start smoking from about the age of nine. They are often sent by their fathers to buy the bidis and, if they take away a few from the bundle, the fathers do not mind . . But certain myths have grown up about smoking - that it facilitates bowel movement in the morning, helps one to concentrate at work and wards off sleep at night when it is essential to work in the fields. A majority of young girls who smoke (backward or reverse chutta) reported that they had been advised to smoke by older women to appease "longings" during preg- nancy, as a cure for anaemia and asthma, or to get relief from tooth troubles. And a belief has even grown up in the Andhra Pradesh countryside that "one should not see a non-smoker's face in the morning" as this brings ill-luck! These observations are just ex- amples of what is known about the dynamics of tobacco consumption in the Indian countryside. What certainly needs to be brought to the attention of the policy-makers is that no awareness or knowledge exists in rural India about the ill- effects of tobacco . The responsibility for ensuring that youngsters "talk health" before they start the danger- ous smoking habit rests with health workers at every level. • 23 The media's role by Jack C. S. Ling "Lifestyles are no longer conditioned by climate and (traditional) culture. They are initiated as fast as communications speed information from one country to another." The speaker was Tan Sri Chong, Malaysia's Minister of Health . The time was May 1983; the place, the Palais des Nations in Geneva; and the occasion, the inaugural address of the President of the World Health Assembly. It was one of the more important and profound comments about the contemporary public health scene, although few of the assembled dele- gates and representatives caught the significance of this statement. Mr Tan was referring to those illnesses that have their principal roots in life patterns: cancer, heart diseases, alco- hol and drug abuse, stress, and the 24 many environmentally caused and psychosocial illnesses. In effect, he had defined a new type of communi- cable disease. In addition to bacteria or viral and vector-borne diseases, the world was witnessing an invasion of illnesses that are "communicable" by images and information. It may take a little longer for such infections to take hold, but they are no less "infectious." During the last two or three decades there have been profound changes in communication technolo- gies, systems of information dissemi- nation and the patterns of knowledge diffusion and learning. Transistor radio has bridged geogra- phical barriers and overcome illiteracy gaps. Television pictures are now available to most of the fast- expanding population in cities, including the urban poor. Ever larger numbers of country-dwellers are gaining access to the images of TV. Satellite communication has rendered terrestrial distances almost irrelevant, just as teenagers using the telephone have changed the concept of neighbourhood friends. These changes have of course helped a better flow of positive health information with its atten- dant, more equitable prospects for good health. But it has also brought about the possibility of bad images and influences, of which Mr Tan spoke. In fact one may well argue that it is time for WHO, as the international directing and coordi- nating authority on health, to recog- nise the new era of causation that modern communication has ushered in, perhaps the most important factor in the etiological web for a growing number of lifestyle-related illnesses. Indeed, WHO should face up to this insidious form of infection: the communication of harmful images and information. The world is witnessing an invasion of illnesses that are "communicable" by images and information. Photo WHO/ E. Schwab WORLD HEALTH, January- February 1989 How do the unhealthy pracices in our daily life come about? How does a trend for a given youth behaviour get started? How does the trend, or a health practice, get diffused from one country to another? What has been the role of the mass media? What should be the relationship between the health sector and the communi- cation (media) sector? What actions should the health promoters and health educators take? No comprehensive research work has been undertaken to trace the specific influence of the media in establishing a particular health behaviour. Perhaps this would be an impossible task, since many people believe that there are too many variables and determinants in health behaviour for any scientific measurement of any one determi- nant. Others argue that such studies are hardly necessary; whole industries would not be spending billions of dollars on advertisements aimed at changing buying habits in favour of a given product if those advertisements were not having the desired impact. Nevertheless, for some reason - perhaps out of defen- siveness - many health educators still downplay the role of media. Health promoters and educators need to be convinced that the mass media can operate in the public interest and should play a critical role in social affairs, including health issues . The health concerns of readers, listeners and viewers are very much the concerns of the print and broadcast journalists. The basis of the relationship between the health and media sectors should therefore be one of partnership, not one of user-helper. Health and media are not natur- ally inclined to work in unison. Historically, medical scientists trained in the methodical and meticulous search for knowledge have been somewhat sceptical of any effort at popularising their work. Some doctors even view the media with suspicion and ambivalence. Media people, on the other hand, need to have their source material in language understandable to the lay- man; they have no time to dwell on technical details, and often lose patience with lengthy scientific papers. Yet media and health in a close partnership have much to contribute to the public's welfare. Without the involvement of the media, the health sector cannot hope to inform the public on health issues or to help stimulate a community's involve- ment, which is .critical to the success of any health effort. Without the WORLD HEALTH, January- February 1989 technical input of the health sector, the media cannot fulfil their obliga- tions to serve the interest of the public - and these public interests certainly include health. The complexity of the media, with their obsession for meeting deadlines and their own technical constraints, is little appreciated or understood by health professionals. Those in health A mother caresses her sleeping child - but the cigarette is a threat to the health of both. Below: A trainee broad- caster in Guatemala learns how to put across positive messages that will encourage healthy lifestyles. Photos WHO/T. Urban and World Council of Churches/Salgado who most work in partnership with the media need to acquire a rudimen- tary knowledge of how media work - not in order to become media specialists but to be more empathetic in their dealings with the journalists and broadcasters. This in turn will call for a good hard look at the core curriculum of the training of health promoters and educators. Whether the health professionals can play their rightful role in battling successfully against lifestyle-related illness - including AIDS - and whether health education and pro- motion practitioners will enter the 21st century adequately prepared for the communication challenges, will depend on the actions that health authorities take now. • 25 Photo WHO/P. Almasy The art of healthy living by Karl Schmidt 0 nly a few decades ago, epidemics of smallpox or diphtheria, and - in tro-pical countries - malaria and microfilarial diseases, killed or disabled a large percentage of children and young people. Smallpox at least has been eliminated, and other diseases have been controlled to some degree. At the same time, better health care for pregnant and nursing mothers has started to have a real impact in reducing perinatal mortality and sickness. But with the increase in the numbers of people in late middle age 26 or old age, the diseases of degener- ation have steadily advanced. WHO has pointed out that more than half of the people who die of cancer are citizens of Third World countries, and that "heart attacks are developing in developing countries too." These diseases include cardio- vascular disease (heart attacks), cerebrovascular disorders (stroke), hypertension, diabetes , kidney diseases, arthritis and arthrosis, auto-immune diseases, cancers, pro- state disorders, dementias and tooth decay. What can the individual do to prevent or at least defer such problems? Research during the past two decades suggests that there are indeed ways of preventing most if not all of the diseases of degener- ation. Yet these possibilities have not been grasped by a majority of doctors, nor by the general public. Certainly the means already avail- able are still not widely practised. Let's begin by talking about health and learning about health. Every individual has to learn the art of healthy living. An enormous amount of medical science remains untapped and is not put into practice by the populace at large; if it were, perhaps it would help to empty hospitals of most of their long-stay in-patients and chronic out-patients. Weigh less, live longer? One of the most important measures concerns diet, and above all the avoidance of too many rich meals - rich, that is, in protein and fat. My own recommendation is for a "biogenic" diet, low in calories but highly nutritious and with an emphasis on raw vegetables and fruits. This kind of diet is essential for weight control, and studies among people of widely varying cultures suggest it may contribute to greater longevity. There are many other measures that can form part of a "natural" approach to better health . They include regular exercise, plenty of sleep including (if possible) a mid- day nap, non-smoking, drinking plenty of water- preferably natural spring water, avoiding excessive use of alcohol, and social communi- cation with people of all ages . The latter point is vital in order to avoid that generation gap which can be detrimental to both physical and mental health. To these, I would personally add the practice of yoga and meditation, a preference for herbal teas rather than coffee, and occasional fasting periods. Another key factor - if only we could - would be to choose our parents wisely! I also believe we have a lot to learn from the tradi- tional approaches to good health practiced in many cultures, such as the regular use of herbal medicines. Above all, it is important for everybody to recognise that health is not just a matter for doctors and hospitals and nurses; the responsi- bility for our own health rests with ourselves and our health practices. With a proper effort by each one of us, we can attain the goal of a disease-free middle- and old-age, still with a full capacity for creati- vity and enjoyment. • WORLD HEALTH, January· February 1989 "Take care of yourself" by Babill Stray-Pedersen A s in many other coun-tries, young people in Norway start their sexual life earlier than ever before. In the last 30 years, the age of the first inter- course has fallen by between two and three years. About half of the boys and one-third of the girls have had their first experience by the age of 16. With this rising prevalence of sexual activity among youngsters, it is likely that its undesirable conse- quences are increasing too. A quarter of all legal abortions in Norway are performed on teenagers, and the frequency of sexually transmitted diseases (STD) is increasing - not the well-known infections like syphilis and gonorrhea but newcomers such as chlamydia, genital herpes and genital warts. Unlike gonorrhea , chlamydia is difficult to detect since there are often no acute symptoms to alert the girls. But it may result in pelvic inflammatory disease and cause reproductive problems later in life. Genital herpes and warts may also be of special significance because of their suspected role in the genesis of cervical cancer. Our health policy among the youngsters should be aimed at prevention rather than treatment. In most countries of northern and western Europe, sexual education in the context of ethic and human values is well integrated in the school curriculum. Boys and girls are taught the facts about reproduction and are informed about the different family planning methods. Why then do we have so many unwanted pregnancies and cases of sexually transmitted diseases in these age groups? Six years ago, after a long period of involvement in medical research, I returned to clinical work, and what did I see? Our hospital was visited daily by teenagers- not promiscuous girls, but "good" girls, the girls of Norway's "Take care of yourselF' pro- gramme in schools tries to reach youngsters before they start their sexual life. Photo WHO/ P. Almasy WORLD HEALTH, January-February 1989 my neighbours and my friends - suffering from vaginal discharge, irregular bleedings, salpingitis, unwanted pregnancies and pelvic pain, all consequences of too early sexual intercourse or STD. I had to do something, and so together with the Norwegian Family Planning Association we started the "Take care of yourseir' programme in schools. This is aimed at 14 to 15-year-old boys and girls, and tries to reach the youngsters before they start their sexual life. Usually at the end of their regular class of reproductive biology, parents and pupils are invited to a late afternoon meeting at school. The first lecture is given by a sexologist, or a psychologist, talking about how youngsters react to the sexual pressures in society, the influence of the mass media and the emotional conflict often related to having a too early sexual relationship. I myself or another gynaecologist may then talk about the medical implications of an early sexual debut and having many sexual partners. Two aspects are put in focus: how to avoid unwanted pregnancies, and how to prevent STD and their complications. The questions which we try to answer are: - What kinds of contraception are the best during the adolescent period? - What happens when sexual part- ners are changed very frequently? - What signs or symptoms should 27 "Take care of yourself" lead sexually active youngsters to the physician or school nurse, and what happens there? The lecture concludes that those youngsters who start a sexual life should be old enough and respon- sible enough to take care of their own body. "Nobody else does, and this body is going to be with you for ever." Both lectures are illustrated with overhead projections or slides. The language is simple and we avoid difficult medical terms. Thereafter the audience divides into small groups for discussion on various aspects, including the most impor- tant topic: What kind of emotional involvement should be the basis for a sexual relationship? No children are allowed to be in the same group as their parents and no personal confes- sions are allowed. Finally, the different reflections of each group are collected and discussed in the auditorium. In the days to follow, the class again resumes discussing sex education, family life, human and ethical values and responsibilities. The response to the programme has been very encouraging. Youngsters and their parents have commented that it is much easier to discuss these matters at home now. Parents in particular say they have gained knowledge about the teenage period, but also about themselves and their own bodies. I myself have felt that it is a challenge to talk to young people. You have to make them listen , to get them to understand and to get them to care. Personally I think they do not listen if you point a moral finger. (And this may be why I have difficul- ties talking to my own children; they know my values and attitudes all too well!) So perhaps it is better for an unknown professional to talk to and educate young people about sexua- lity. In every aspect it is easier today - in this era of the AIDS epidemic - to discuss sexual be ha vi our; society has become more open-minded. After our programme had been running for a time, we did a ques- tionnaire study at four different schools in order to gain more information about our target group. Nearly 600 boys and girls aged between 14 and 16 years answered anonymously. Seven per cent of our 14-year-old girls, 20 per cent of our 15-year-olds and 30 per cent of our 16-year-olds had experienced sexual intercourse. Among the boys the figures were higher; 30 per cent of the 15-year-olds and 45 per cent of those at 16 had started. While 25 per cent of the sexually active teenagers 28 Society has become more open-minded about sex. These Japanese youngsters brought photos of babies to school to fonn part of a sex education lesson. Photo L Sirman <D answered that they had had three partners or more during the last year, only two-thirds of these had used contraception regularly. All the pupils were asked what they con- sidered to be of most importance in their life. Remarkably enough, the answers were equally distributed among the boys and girls regardless of whether they were sexually active or not. Good friends were most important, followed by a happy family life, thereafter the status of having a steady girl or boyfriend, and last on the list was sexual experience. Indeed 96 per cent of those having had sexual intercourse stated that this experience was of no great significance for them. The results of the study confirmed our belief that sexual activity in this age group is not of great importance to them and lends itself to being discouraged by imparting sound information. Earlier studies from different parts of the world have reported that sex education courses do not lead to sexual experimen- tation or promiscuity, but serve to increase young people's knowledge about human sexuality. Surveys in the United States found that students who received sex education were less likely to have sexual intercourse or, if they were sexually active, were more likely to use contraception than those who had not had such education. My own efforts are now directed towards encouraging the medical profession to start similar program- mes throughout the country as a supplement to the regular sex and family life education in schools. It is always better to prevent than to treat. Converting this from pious platitude into reality is the responsi- bility of the health care providers. • WOR LD HEALTH, January- February 1989 save a Life by Peter Riding I t cannot be every day that a television production team can claim to have helped save 24 lives, but that is what hap-pened when BBC Television in the United Kingdom became a part- ner in a nationwide campaign to teach emergency first aid. Called "Save a Life", the cam- paign set out to use television to teach viewers what to do if they found themselves the first on the scene in an emergency, be it a road accident, a heart attack, or a choking or drowning incident. In many life- threatening situations, the victim may only have a few minutes to live unless someone comes to his or her aid. As there is seldom time for trained medical assistance to reach the scene, there is obviously a real need for a significant proportion of the general public to be taught the elements of cardiopulmonary resus- citation (CPR). But how can this aim be achieved over a short period? The strategy of the Save a Life campaign, launched in September 1986, was to make use of public television both to teach CPR directly on the screen and also to recruit the public to attend specially organized two-hour training courses. This use of television in the UK was not something new. Since 1976 the Con- tinuing Education Department of BBC Television has been making health promotion programmes on topics such as smoking, alcohol, diet, exercise, road and home accidents, and mental health. To have any significant effect, such programmes need to reach a mass audience and so must be shown at or near peak viewing times and must be attractive to watch. We have found that a ten-minute length allows chan- nel controllers to "sandwich" health promotion programmes between popular, general interest ones with- out losing their viewers. And it is important to offer the public the opportunity to develop their interests or skills through associated written materials or even, as in the case of Save a Life, through training courses. Each of the Save a Life program- mes lasted ten minutes and six were made. They each contained drama WORLD HEALTH, January-February 1989 sequences to draw the viewer into the theme of the programme, docu- mentary sequences to tell real-life success stories, and teaching sequences to show viewers the key emergency CPR skills. Meanwhile BBC Television joined with a number of national medical and first aid organizations to form a coordi- nating committee. This committee took on the task of agreeing what should be taught, raising funds, pro- ducing posters and booklets, recruit- ing 120 voluntary local coordinators and, finally, establishing emergency aid classes in every part of the UK. After 18 months, a total of 155,000 people had been trained in Mouth-to-mouth resuscitation. Photo WHO/Save a Ufe emergency CPR via the two-hour classes. Surveys conducted by the BBC Broadcasting Research Depart- ment showed that, in two specific emergency situations (unconscious- ness and choking), there were signifi- cant increases in actual knowledge and that, as a direct result of the campaign, the number of people correctly aware that there are three to four minutes available for re- suscitation increased from 30 to 41 per cent. But what about actual lives saved? Two out of the 24 confirmed stories will serve as examples: - Two friends, M rs Maureen Hayden and Mrs Marianne Still, were on a bus in Essex when the driver suffered a heart attack. The women were able to resuscitate him with mouth-to-mouth breathing and chest compression until an ambulance arrived. They had learned the technique from the Save a Life TV programmes. - Steven Tonge from Yorkshire saved his father's life when he had a severe fall down some steps. Steven gave him mouth-to-mouth resusci- tation - a skill which he had just learnt on a Save a Life course. • 29 .. ... ....... ... ... ... ...... ..... ..... . .......... . .. .... ....... ... ... ... ....... . ......................... . .. .... ....... ... ... ... ....... . ......................... . •• ••• ••• ••• ••• ••• ••• • ••••••••••••••••••• •• ••• ••••••• ••• ••• ••• ••••• ••••• • ••• ••• ••• • •••••• :: ::: ::::::: ::: ::: ::: •:::: : ::::: . :::.:::::::::: ::::::: .. ... ... ... ... ... . . ... . .............. . •• ••• ••••••• ••••••••••• ••••• • ••• • •••••••••••••••••••• .. ... ....... ........... ..... . ... . .................. . .. ... ....... .......... ..... ... . ................ . Let's talk AIDS World AIDS Day December last year - conjured up a remarkable display of glo- bal so li darity as over 1 50 nations from Australia to Zam- bia. each in its fashion. put the spotlight on this deadly disease. Health ministers and heads of state made television or radio broadcasts explain ing how to prevent its spread. whi le mass meetings. marches. workshops and exhibitions drove home the messages of informati on and education. In al l. over 1.000 events took place. In the Federal Republi c of Germany. a Federal Minister went on TV to condemn dis- criminati on aga inst people w ith A IDS. In Montreal. Canada. a solemn ceremony commemo- rated those vict ims who have died from it In Nai robi. a special exhibition was moun- ted. and a full day's program- mes o f inf ormatio n and education messages were ai red in Sierra Leone and Zam bia. The island of Mauritius added mobile exhibit ions to rad io and TV broadcasts as well as an essay competition for school- ch ildren . Stockholm staged a gala benefit performance at the Opera House to help vict ims. and in Sao Pau lo. Brazil. five days of events included photo exhibits. a disp lay of art by artists w ith AIDS. and the in- augu ration of a specia l care centre. A two-day workshop on A IDS took place in Austra lia. an "anti-AIDS week" in Thailand and video screen ings and radio ta lks in Bhutan. The Soviet Union featured the Day prom i- nently in all the mass commu - nications med ia. My Ryoichi Sasakawa. 90- year-old chairman of the Japan Shipbuilding Industry Founda- Photo WHO/ E. Mandelmann Youngsters talk about AIDS. 30 tion. announced a special con- tribution of US $10 mil lion to WHO's Global Programme on AIDS (GPA) At the Geneva headquarters of WHO in Switzerland. World AIDS Day literally lasted 24 hours. A rad io "hotline" en- abled ca llers around the globe to interview WHO experts about the disease. w hil e a worldwide television satelli te network allowed v iewers in many countries to follow the Day's activities. Scientists. poli - ticians. re ligious leaders and young peopl e took part in scientific and ethical debates. Dr Jonathan Mann. Director of GPA. commented "World A IDS Day is a chance for us all to look to a new dawn in the g loba l struggle against th is disease. Th roug h individual action. and international soli- darity. we are confident that we w ill dominate AIDS and keep it - and the fears w hich surround it - from dominating us." In a keynote address at the opening ceremony. Dr Hiroshi Nakajima. Director-General of WHO. pledged that the Global Programme w ill continue to provide leadership equal to the c hall enges o f A I DS. He commented : " Every country knows the broad outli ne of a prevention and contro l pro- gramme. That is not enough. We must continue to lea rn . and to open up new channels of commu nicat ion about A IDS among different commu nities. cultures and creeds." • Ten Points on AIDS AIDS is a new worldwide problem 2. We know how the A IDS virus spreads 3. To know how the A IDS virus spreads is to know how to prevent infection 4 . The sexua l spread of the AI DS vi ru s can be prevented 5. Infection th rough blood can be stopped in a variety of ways 6. lt is important to know how the A I OS virus is not spread 7. There is no need to fear people w ho are infected wi th the A IDS virus 8. In the absence of a vaccine or cure for AIDS. information and education constitute the vital tool 9. A global mobil isation is under way to meet th is global threat 10. Together. we can stop AIDS Planning for a smoke-free Europe Queen Sofia of Spain is seen here receiving a WHO commemorative medal in- scribed "Tobacco or health: choose health." The award marked her efforts to focus worldwide attention on "the threat to health of tobacco-related diseases. and the need for tobacco-free societies." Queen Sofia had just declared open the First European Conference on Tobacco Policy, held in November in Madrid - a concerted effort by Euro- pean countries to combat the scourge of smoking. Participants from 30 coun- tries looked in depth into the health. education. in- formation. legislation and financial aspects of the problem. and called for effective policies to be put into effect as an emer- gency, lifesaving measure. About two arid a half million people die prema- turely every year through- out the world from tobacco-related diseases. At one death every 1 3 seconds. this makes to- bacco "the largest single preventable cause of ill- health in the world." says WHO. Another recipient of the special WHO award at the Madrid conference was Miss Victoria Brynner. photo- journalist who was corn- mended "for keeping alive the advice of her father. actor Yul Brynner. " A victim of lung cancer in 1 985. he made a tape- recording when he was near life's end in which he pleaded: "Whatever you do. please do not smoke." The conference drew up a Charter against Tobacco for Europe as part of a Five Year Action Plan endorsed by the member countries of WHO 's European Region. The Charter states: - Fresh air which is free from tobacco smoke is an essential component of the fundamental RIGHT to a healthy and unpolluted environment; - Every child and adoles- cent has the RIGHT to be protected from all tobacco promotion and to receive all necessary educational and other help to resist the temptation to start using tobacco in any form; - All citizens have the RIGHT to breathe air in the workplace which is unpol- luted by tobacco smoke; - Every smoker has the RIGHT to receive encou- ragement and help to overcome the habit; - Each citizen has the RIGHT to be informed of the unparalleled health risks of tobacco use. • WORLD HEALTH, January-February 1989 0 0 .S! c ::J River blindness After 13 years of field oper- ations. the Onchocerciasis Control Programme in West Africa can claim that about 100.000 people are still clear- sighted - and will remain so - who would otherwise have been stricken with "river blindness ." This parasitic disease is transmitted to humans by the bite of the blackfly. and the main spear- head of the programme has been to attack the larvae of the blackfly as they cling to rocks in the streams and rivers of West Africa . Recently. good progress has been made in testing and putting into use drugs which can safely be used to destroy the parasite (Onchocerca volvulus) in the human body. Today. the programme has controlled transmission of on- chocerciasis over an area of some 800.000 square kilo - metres. in which 18 million people live. Over four million children born since the pro - gramme started in 1975 are protected from the disease. Had the control programme not been in operation. about 200.000 of these would have suffered the debilitating ef- fects of the disease. About 40.000 would have been blind before reaching adult - h o od. and their life expectancy would have been reduced by 15 years In addi - tion. 1 8.000 kilometres of the riverside lands are now safe - guarded for agricultural and other development as well for human settlement Of the programme's 800 staff. 768 are Africans; and a total of 400 candidates from all over Africa. but mostly in the oncho-stricken countries. have been trained in su ch sciences as entomology. epi - demiology and hydrobiology. The programme is spon - sored by the UN Develop - ment Programme (UNDP). the Food and Agriculture Organization (FAO) . the World Bank and WHO; WHO is the executing agency. • WORLD HEALTH, January-february 1989 Nevvsbriefs Birthday honours. Two senior scientists who have long worked with WHO have been honoured in Berlin at a ceremony that linked the Organization's 40th anniversary with their own 75th Birthdays. Professor Mohammed Abdussalam (Pakistan) and Professor James H. Steele (USA) received honorary dtp!omas from Professor 0 Grossklaus, President of the Federal Health Office. during a symposium on "40 years of WHO .. Endotoxin research. Immunologists and physicians with a special interest in endotoxins - natural poisons which occur in bacterial cells and provoke severe fevers in humans - have formed an International Endotoxin Society. Or Alots Nowotny, Professor of Immunology at the University of Pennsylvania and President of the Society, invites interested scientists to write to him at Room 525. Levy Building, 4070 Locust Street. Philadelphia PA 19104. USA. Cancer pain relief. The WHO booklet with this title publtshed some two years ago has proved a best-seller in several languages. The Engltsh edition. for example. has more than doubled its original print-run. bringing the total tssued to 21.000. while the Japanese printing has soared from the original 3.000 to 14.000 In Italian the first print-run was 60.000 The booklet is also published in Arabic. Chinese. French. German. Portuguese. Russian. Spanish and Turktsh. while ha/f-a-dozen other language editions are being planned Medical school update Since the publication of the World Directory of Medical Schools the Government of India has informed us of a number of changes in the names and affiliations of medical schools The new names and addresses are listed below. Chingleput Medical College Bharathidasan University Ching/eput- 603007 Tamil Nadu and Pondicherry Regional Medical College Manipur University /mpha/- 795007 Manipur M.G.M . Medical College Devi Ahilva Vishwavidyalaya /ndore-452007 M adhya Pradesh Medical College Ra ni Durgavati Vishwavidya laya Jabalpur-482007 Madhya Pradesh M.L.B. Medical College Bundelkhand University J hansi-2 84 7 2 8 Uttar Pradesh Kottayam Medical College Ga ndhij i University Kotta yam-686008 Kerala Christian Medical College Panjab University. Chandigarh Ludhiana-7 4 7 00 7 Punjab Dyanand Medical College and Hospital Panjab University, Chandigarh Ludhiana-7 4 7 00 7 Punjab Government Medical College Punjabi University. Patiala Patiala-7 47007 Punjab lndira Gandhi Medical College Himachal Pradesh University Sim/a- 7 77007 Himachal Pradesh Thanjavur Medical College Bharath idasan University Thanjavur- 67 3007 Tamil Nadu and Pondicherry Kakatiya Medical College Kakat iya University Warrangal- 506002 Andhra Pradesh Mrs oria GORDON is Editor of Communication World magazine, a monthly publication of The Interna- tiona l Association of Business Communicators. San Francisco. USA. nameli MONROY DE VELA- Director-General of CORA. A.C .. Mexico City_ ' Or Petar JOVANOVIC is. a Yugoslav physician, and was the official repre- sentative . of tne International Astro- nautical Federation to the Technical Discussions held during last year's World Health Assembly_ _ Mr Nedd WILLARD, formerly an information officer with WHO. 1s now a freelance journalist based in C911for- nra,USA_' ' Or Mira B. AGHEE is a behavroural scientist with the Tata Memorial Insti- tute in Bombay. India. Mr Jack C. S. LING, director of rnformatron UNICEF and WHO. now time between teaching cations and health in States .and consultancy for UN organizations. :. Or Karl SCHMIDT is a, Mental Health Specialist and Consultant Psychiatrist at the Suri Seri Begawan Hospital. Brunei Darussalam. Or Babill STRAY-PEDERSEN is As- sistant Professor at the Department of Gynaecology and Obstetrics. Aker University Hospital. Oslo. Norway. Mr Peter RIDING Is an Executive Producer in the Contrnuing Education Department of BBC Television in London. He was , a member of the co -ordinating committee of the ."Save a Lrfe" campaign In the' U K. WORLD H6ALTH for readers everywhere 1989. Subscription Rates From the start of 1989. two-year and three,yEW subscriptions will no lpnger be offered . .Readers will be able to take out only., one•vear subscriptions at the rates given below. Oneyear ~g,! 0 u . ' WH~ ill conti 1989 s "He comb subs ns tO both World Health (ten issues per year) and the quarre~ly Wor!cj Health Forum - The annual price will be: US _$, 0 Sw.f_r. 52c~ 65,,..., ORDER:FORM Please enter my one· year subscription to World Health D Health_ Horizons I epclose cheque/ihternatiopal post@ I order in the amount of: i·''' ' . ,, Country: World Health, WHO, Avenue Appia. . 1211 Geneva 27.. Switzerland 6 JJ r 0 I w m )> en Ci I • - - . . . . ~ =< - - ~ 11 . . . . . L I (0 t~'~ \ () ) (0 ~ ) ' I . ,~ , ' Pr in te d in G re at B rit ai n by D av id G re en P rin te rs L td , K et te rin g, N or th am pt on sh ire , En gl an d