Least developed countries [full issue]

-RLD HEALTH ORGANIZATION.JUNE 1982 „ .■ '14 1, . • .4:24 Z!si<bv. ` , • , - 4 4 -4, hi irt , a„, • • r ;gr. '. 11144.4.‘ • a,. . , • 1 * 4 1 1%.1 . Rji ir rp 441"; -a,. Jr.' LEAST DEVELOPED COUNTRIES The Paris Conference and after The UN Conference on the 31 Least Developed Countries held in Paris last September was "a qualified success," ceclares Thomas G. Weiss. Writing in his private capacity, rather than as an economic affairs officer with UNCTAD, Vir Weiss shows how the Substantial New Programme of Action drawn up in Paris high- lights the critical importance of improving health conditions in those countries by Thomas G. Weiss Cover: .. i What prospects for "development" with " hand-held wooden ploughs? (Photo WHO/ L. -4. ' J. Mohr) IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Vied ma 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 Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents The Paris Conference and after by Thomas G. Weiss 2 Nepal: a suitable case for development by Nedd Willard 6 Can statistics lie? by Gamini Seneviratne 8 Rwanda: too many people, too little land by Jeremy Hamand 12 Haiti and Samoa 16/17 Vicious circle by Paul Harrison 18 Africa: the Sahel zone by Pape Marcel Sene 23 Laos: progress will be slow by Ravi Ramdoyal 28 News Page 30 This issue of World Health reflects the growing consensus that, whatever else occurs during the Third United Na- tions Development Decade, much more significant efforts must be made on behalf of the poorest. The UN system has expanded its activi- ties to improve the particularly precarious situation and develop- ment prospects of the 31 least developed countries (LDcs). These efforts took a decisive turn by convening the UN Conference on the Least Developed Countries, held in Paris from 1 to 14 September 1981, in which 130 countries participated. This unique attempt to mobilise resources in favour of the poorest and weakest nations on the face of the earth resulted in the adoption of the Substantial New Programme of Action (sNPA). The Programme is intended to bring about nothing less than the transformation, over the next ten years, of all those countries' economies with their common af- flictions of extreme poverty, mini- mal industrialisation and limited supply of skilled manpower. It fell to UNCTAD (the United Nations Conference on Trade and Develop- ment), as the lead agency in this undertaking, to organize regional review meetings which, over the preceding year, gave the least de- veloped countries an opportunity to present their development needs for the coming decade to a group of trade and aid partners selected by them. UNCTAD, which plays a major role in the efforts to establish a new international economic order, was also the nucleus around which other members of the uN family formed. From the outset the undertaking was seen as a collective effort encompassing all relevant parts of the UN system, each contributing in its field to an unprecedented Digging for water is a community effort for these Sudanese villagers- -who are among the globe's most desperately poor people. (Photo WHO/E. Schwab) The following countries have been designated as LDCs: In Africa: Benin, Botswana, Burundi, Cape Verde, Central African Republic, Chad, Comoros, Ethiopia, Gambia, Guinea, Guinea-Bissau, Lesotho, Malawi, Mali, Niger, Rwanda, Somalia, Sudan, Uganda, United Republic of Tanzania and Upper Volta. In Asia: Afghanistan, Bang- ladesh, Bhutan, Democratic Yemen, Laos, Maldives, Nepal and Yemen. In Latin America: Haiti. In Oceania: Samoa. concentration of expertise and experience. With a perspective of the past nine months, was the decade of preparations that led to the neg- otiation of the Substantial New Programme of Action for the Least Developed Countries worth the effort? The reply depends on the po- sition of the observer—a compro- mise text meaning that the glass may be either half-full or half-empty. Based on calculations made by the least developed countries them- selves, external assistance needs to double in real terms by 1985 if the Paris Programme of Action is to succeed. However, donor countries refused to commit themselves to this target, and instead agreed on an approach which, depending on their economic growth, could bring a 25 to 75 per cent increase in assistance flows in the next five years. In other words, least developed countries can only hope to receive less than the minimum they have calculated would be required for noticeable improvements in their development prospects. Nonetheless, participants gener- ally agreed that the Conference had been a qualified success, a rarity these days in the stalemate of international cooperation. A wide- ranging package of special meas- ures, designed to improve the unacceptable position of least de- veloped countries on the extreme periphery of the world economy, The least developed countries in the 1980s Yemen Sudan Chad Niger Mali Bangladesh Laos Haiti Cape Verde Gambia Guinea Bissau Guinea Upper Volta Benin Rwanda Burundi Tanzania entral African Republic Democratic Yemen Somalia Ethiopia Uganda Comoros Malawi Botswana Lesotho Samoa ° 0 The Paris Conference and after Left : The distribution of the Least Developed Countries shows a great concentration in Africa, a smaller group in Asia, and one each in the Caribbean and the Pacific. Map by courtesy of UNCTAD. Right : Both mother and child are suffering from scabies, a skin infection which is common in rural areas of Bangladesh. (Photo WHO/P. Harrison) was adopted without dissent. Am- ong the most important results of the SNPA was the commitment by most donor countries to devote 0.15 per cent of their gross national product as overseas development assistance to least developed coun- tries during the 1980s, and by others to double their assistance to these countries. Another crucial decision was the establishment of follow-up arrangements at the national and international levels to ensure that commitments made in Paris would not be forgotten, as has been the case for many other UN conferences. The Conference focussed the attention of the international com- munity on the plight of some 280 million of the globe's most des- perately poor people. The truly cooperative atmosphere—labelled the "esprit de Paris" by the President, Mr Jean-Pierre Cot, France's Minister for Cooperation and Development—led to a Pro- gramme of Action that is far more concrete and specific than those emerging from previous UN con- ferences. The fact that unanimous, and even enthusiastic, agreement was reached on a comprehensive set of policy measures for a group of poor countries must be looked upon as a solid achievement, particularly in light of the unpropitious interna- tional economic climate. But what are the Least Developed Countries? And what implications does the SNPA have for the health care of people living in them? The present list of the 31 LDCS contains 21 nations in Africa, 8 in Asia, one in the Pacific and one in the Caribbean. As a group, their population is approximately 13 per cent of the population of all de- veloping countries. There is much that is obvious about poverty. Photos of famished people with distended stomachs and spindly legs and arms have sat- urated the media to the extent that we have all become blasé and inured to them. The destructive impact on the human spirit of absolute poverty, characterised by malnutri- tion, ignorance and disease, shows in the loneliness and despair on the faces of those so afflicted. There is no need for sophisticated criteria and measurements, nor of in-depth analyses, to recognise hard-core poverty. Criteria for I.DCs However, consensus on the iden- tification and diagnosis of relative poverty among nations becomes more difficult. The original selec- tion of criteria for the least developed countries reflected weighty discussion among experts about the utility of various types of economic and social indicators. A lengthy technical debate surround- ed their categorisation, yet these countries are poor in every way. Their income per head (per capita gross domestic product of less than US $ 100 in 1968) indicates unac- ceptably low levels of development and widespread poverty; their rela- tively small share of manufacturing in GDP (less than 10 per cent) indicates a lack of structural trans- formations usually thought to be the basis for a modern economy; and their low adult literacy (less than 20 per cent for the age group 15-and- older) indicates the relatively poorly developed potential of human resources. 4 One could generalise further by stating that, with few exceptions, the least developed countries have small populations, are geographic- ally disadvantaged (15 are land- locked and 5 are small or remote islands, while others suffer from severe climatic or topographical disadvantages), and in the past were not focal points of colonial interest. In the post-independence period, they have suffered more from rela- tive neglect than from exploitation. These countries have limited inter- nal markets with no leverage over the suppliers of goods and services, have extreme difficulties in securing access to markets, and have not inherited either an adequate infra- structure or a base for export growth. Their economic prospects remain extremely bleak, since their economies have stagnated and even declined during the 1970s. That the rich get richer and the poor get poorer is a well-known truism. Incredibly, the gaps between the least developed countries and other developing countries—themselves hardly well off have also con- tinued to widen. In Africa there is a saying that "human rights begin with break- fast". Hitherto, the focus of the UN criteria for the least developed countries has been primarily eco- nomic. As minimum levels of nutrition, health, education, and employment at a wage permitting a dignified life may be regarded as among the most fundamental human rights, the abysmal social conditions for the vast majority of the population of these countries must not be overlooked. They suffer particularly from malnutrition and the lack of safe drinking water, as well as from extremely limited health services and educational systems. Their crude birth and death rates are among the highest in the world. Since most citizens of LDCS depend on agriculture, predo- minantly at the subsistence level, they have only very limited access to modern, monetised economic activ- ity, and to the health care services that are reasonably accessible in urban areas. In fact, the very nature of "least development" poses acute problems for delivering basic health services. Firstly, these countries are mainly located in some of the most unheal- thy parts of the planet: in Sub- Saharan Africa (particularly the Sudano-Sahelian region and tropi- cal central Africa) and in the core of Asia (particularly its swamp and desert areas). The location of most people in vast rural areas, typically in scattered communities that are poorly served by transport and communications, means that access to basic health care is necessarily expensive. Such expenditures are difficult to justify for poor govern- ments, which tend to react more quickly to demands made from politically volatile urban popula- tions. Further, the link between eco- nomic growth and continued im- provements in health services should not be ignored. The low cost of programmes of disease eradica- tion in the 1960s, which improved health and life expectancy, meant that advances were possible without much real per capita income growth. It will be difficult to im- prove living standards further without significant economic growth. Acceptable levels of basic human welfare in least developed countries thus remain a distant goal. "Development," for many people, has meant that the prospects for life are not so much "nasty, brutish and short" as "nasty, brutish and long." The importance of the SNPA for health resides in the general charac- ter of the programme as well as its specific content. It reflects the recog- nition by the international com- munity that "least development" is a characteristic of some nations. And it calls for the evolution of a partnership, and the creation of a framework, for a more equitable division of resources built on a commitment to changes in local priorities and policies and a greater acceptance of responsibility for poor development, including that of health services, by the least developed countries themselves. In terms of its specific content, the SNPA highlights the critical impor- tance of improving health con- ditions in the LDCS. The efforts of these countries—in the form of their policies, strategies and plans—and those of the international commun- ity are to take place within the context of the "Global Strategy for Health for all by the year 2000." Improving health and basic nutri- tion, promoting family planning and enhancing other living con- ditions are seen as interrelated goals, important not only for their own sake but also as major contri- buting factors to economic growth. As in all international gatherings, the proof of the Paris pudding will lie in the eating—that is, the imple- mentation of the Substantial New Programme of Action. The task of those concerned with basic health care is to pursue the opportunities of this Conference assiduously, so that poor health and poor social services no longer act as serious impediments to social and eco- nomic development in the least developed countries. ■ 5 Nepal: a suitable case for development by Nedd Willard • -,‘ .• etkpr :4" A tr: • / • S4 . ee . - . VI ' „ A small country-100 miles wide and 500 miles long—spread like a table- cloth from the Himalayas to the plains of the Ganges, Nepal is land- locked between two great neighbours, China and India. In many ways Nepal is the archetype of a least developed country trying to struggle its way up to better health and a wider horizon for its people. Many of the other least developed countries are landlocked, and this has had important consequences for the flow of goods and of ideas for those countries. A country of some 13 million people, Nepal is deceptive in appearance. The terraced hills, the majestic Himalayas, the peaceful villages don't reveal to the admir- ing visitor that an overwhelming majority of its people struggle against ill health every day, and that many succumb. A recent study of a typical village showed that 43 per cent of the population were ill at least once every two weeks. The people are friendly, with easy smiles; yet the rate of infant mortality is one of the highest in the world. Directly related to this is the status of women, who bear more children than their health can support in order to make up the gaps caused by death from disease and malnutrition. The fertility rate is about 6.5 children per woman, so, in spite of the horrendous death rate, Nepal's population continues to grow. It may double in less than 30 years, and this will produce a major crisis in a country that is small and restricted; those spectacular mountains which impress the tourist represent so much unproductive land, where no crops can be grown, no life supported. The pressure on the remaining land, on the scarce resources of water and firewood, will increase. Already erosion is visible everywhere in the lower hills, and this means less water retained, less land to cultivate, a steady increase in poverty for a country which is one of the poorest in the world. Like other least developed countries, Nepal is overwhelmingly agricultural. About 93 per cent of its population are primarily engaged in working the land. The isolation of communities and the absence of a system of education that reaches most of the population have maintained people in ignorance, since today only 20 per cent can read and write. A figure like that seems too bare and banal. It needs to be translated into an inability to tap the knowledge that is locked away in books, the difficulties of organizing projects when so few people can under- stand and transmit instructions, which have to be written down to make sure they are standard, clear and properly carried out. Therefore every project for health development in Nepal must work with a slender base of literate people. Just as everything is tied up together in real life, so the problems faced in Nepal are all inter-related. Poverty, the low status of women, the absence of hygiene all contri- bute in turn to the appalling status of health, the illiteracy, the lack of capital, the swelling population and the dwindling physical resources. And they will all have to be tackled together as part of a general drive for development. Everything has to be done at the same time. It represents an overwhelming task. Cow-dung dries on the wall behind a poorly dressed Nepalese child. Facing page: A farmer gets an impromptu eye examination from a health worker engaged in Nepal's blindness prevention programme. ( Photos WHO IN. Willard) King Birendra Bir Bikram of Nepal delivered a key-note address to the Least Developed Countries Conference in Paris last September. His Majesty said: "A poor man in a least developed country and his number runs into millions—suffers from poor nutrition. He is vulnerable to diseases. His average life span is short. He lives in huts where squalor perpetually surrounds him. He is illiterate both in letter and skills. He does not get his meals regularly but when he does he is haunted with the fear of where his next meal will come from. He is clad in rags, if at all. He walks without a pair of shoes. Lack of hygiene, minimal food or contagious diseases have inflicted some scars on his body. He lives mostly in villages—remote and inaccessible to the rest of the world or in slums or shanty towns. The water he drinks is neither safe nor clean. He is either unemployed or underemployed. But when he is employed he is overworked and underpaid. "He suffers from apathy and ignominy. From birth to death he remains a destitute. Usually he dies an infant but if he does survive, dearth and want haunt him to his end. Flood, famine, drought and other natural disasters continually plague him. If he is a villager, he may be landless, if he is a town-dweller he rarely has a roof over his head. When the price goes up, the quality and quantity of his food goes down, because his income can no longer buy him the food he needs. His wife, if she is pregnant, can only have a worse fate. "He cannot buy books for his children, nor pay fees for the school, let alone the tool-box he would love to buy for them to make their ends meet. When he falls ill, he cannot pay fees to a doctor, nor can he buy the medicine for himself let alone getting better amenities of life in these crises. He can neither read nor afford to buy a newspaper. A radio-transistor is a luxury to him Many of his kin never see a bicycle. Starvation and death stare him at his face as in medieval times. Indeed, for him, times have not changed since the Dark Ages. And as though these afflictions were not enough, it is he—and this is the greatest irony of all—who gives birth to the largest number of children, thus spreading and multiplying misery to a dark universe of destitution. When death comes to him finally, he seems to be the happier than those he has left behind him. "I speak of a destitute at such length not merely because this occasion places on me the special obligation to speak for him, but even more, because his story is perpetrated on a scale and dimension that indeed is tragic in view of what man can do for man and yet is not done... "Let us resolve to work together, to work with the people and governments of the less-developed world, to help the poor man out of his poverty." ■ 7 Can statistics lie? by Gamini Seneviratne (The perniciousness of the statistical approach is that it implies, for instance, that salvation lies in obtaining for the LDCs such wealthy-country features as doctors, hospitals or drugs which will ostensibly ensure health and long life» Statistics seem to say it all. People in the Least Developed Countries are a lot less healthy than those in any other economic category of the world's nations. Here are some of those statistics: Life expectancy among the 280-odd million inhabitants of the 31 LDCS is 45 years; this compares with 60 years for the 3,000 million living in the other 89 developing countries, and 72 years for the 1,100 million in the 37 developed countries. Of every 1,000 babies born in the LDCS, as many as 200 die in infancy; the figures are 94 and 19 in the other two country-categories. Safe water supply reaches 31 per cent of the people in the LDCS; against 41 and 100 per cent in the other two. Adult literacy rates are 28 per cent; and 55 and 98 per cent respectively. The Gross National Product per capita is US $ 170 ; against $ 520 and $ 6,230. Public expenditure on health each year, per capita, is $ 1.7, $ 6.5 and $ 244 respectively. In the LDCS, there is, statistically, one doctor for every 17,000 of the population; against one for 2,700 and one for 520 in the others. The list is long. And since it is so clearly intended to reveal both the Life expectancy in the 31 Least De- veloped Countries is only 45 years, compared with 60 years in the rest of the Third World, and 72 years in the developed countries. (Photo WHO/A. S. Kochar) plight of the LDCS and the urgent need for help to be forthcoming, it seems cruel to recall the words sometimes attributed to former British Prime Minister Benjamin Disraeli on the subject of untruths. "There are three kinds of lies," he is supposed to have said over 100 years ago: "lies, damned lies and statistics." The figures are indubitably accurate. But as bases for programmes to meet the health needs of LDC populations, they are largely irrelevant, sometimes to the point of being false. Broad global statistics of this sort do not, admittedly, pretend to be accurate in particular areas. But, while many countries and communities within them can, as it were, live with the generalisations, they are dangerous for the great majority of people in the LDCS. The truth is that for them (and this applies to sizeable numbers in the "other developing countries" as well), there are no statistics. The truth is that those doctors and those adult literates and those health services on which the per capita $1.7 is spent, are all con- centrated in just a few areas of each country. Remove these from the equation and there is practically no health service, nor even health surveillance. Life expectancy plummets, infant mortality becomes a matter of guesswork, and literally millions of men and women will grow up, survive to so-called adulthood and die, without ever having seen a doctor. Statements of such severity usually require statistical support. The irony is that statistics do not reach that far into the hinterland of poverty. It has to be accepted on empirical evidence that people, particularly infants, are born and die without ever getting in touch with a registry office; that huge num- bers spend their lifetime without the sight of any health facility, not because they are healthy but—on the contrary—despite being chronically sick much of the time. Clearly there is no easy or short-term solution to the syndrome of under- development, of which health is one important indicator. The pernicious- ness of the statistical approach is that it has so many non-solutions built in and masquerading as answers. The most serious of these is the implica- tion that salvation lies in obtaining for the LDCS those features of richer countries—doctors, hospitals and staffs, field services, equipment and a rich pharmacopoeia of drugs— which ostensibly ensure health and long life. To do this is to mistake the health industry for health. Even when the distinction is made, as WHO seems to have done with its emphasis on Primary Health Care, the cost of "conventional" medical services is high. The World Bank's 1981 Develop- ment Report notes: "Primary health care systems can use commercial energy and foreign exchange quite intensively. Referring patients to se- condary and tertiary levels requires transport. So does the supervision of peripheral health workers and the delivery of drugs. Refrigerators for vaccines and small generators for rural hospitals require power. "The secondary and tertiary levels of health care—essential to support the primary level service—require sophis- ticated medical equipment, energy for operating theatres, food preparation 9 Left: Armed with his fishing spear, a Bhutan peasant sets out for the nearest trout stream. Right: If this baby aboard a houseboat in Bangladesh manages to survive into adulthood, what will be the quality of his life? ( Photos L. Sirman and WHO/Z. Sestak) and refrigeration of blood banks and other supplies." Foreign exchange is, needless to say, crucial. It is the single most important factor in all development planning, and this is why so many programmes which require a high percentage of it scarcely ever get moving. The World Bank report says, by way of example, that "perhaps 40 per cent of Malawi's recurrent health budget requires for- eign exchange." And later: "Drugs are typically a large share of health bud- gets... In most developing countries, these must be imported." In its 41-page contribution to the September 1981 UN Conference on the Least Developed Countries, wHo out- lines the estimated funding require- ments for primary health care in the 1980s and 1990s. The cost for the two decades is put at US $ 163,740 million. "This projection," says the document, "uses a number of parameters and assumptions which are of necessity based chiefly on informed sup- position." Having done the projection, it makes another assumption, thus: "If it may be assumed as a working hypothesis that the LDCS are able to provide 80 per cent of the resources needed..." But is this a valid assumption? Can it be a working hypothesis? How much of that 80 per cent ($ 131,000 million) will be needed in convertible foreign cur- rency? What share will it be of total LDC foreign exchange earnings? How is it to be earned? The document does make a succinct case for greater priority for health in national budgets: "It is unrealistic to plan the development of a country without taking into account the health of those who implement that develop- 10 ment." It also stresses that the prerequisites for Primary Health Care—"community involvement, a multi-sectoral approach, and appro- priate technology"—imply "a major transfer of responsibility for safeguard- ing health to the community itself." PHC will certainly make more realis- tic use of investment on health. It will also reduce the percentage share of foreign exchange in the total expen- diture. But any significant rise in the total will mean more foreign exchange. What are the implications for health of earning more foreign exchange? WHO's document put before the LDC Conference states, on the subject of nutrition: "Malnutrition is, and is likely to be for some time, the most important factor influencing the qual- ity of human life in the LDCS. It is one of the major contributing factors to the very high rates of infant and young child mortality. Whereas in the de- veloped countries the average per capita daily calorie supply is about 3,400 calories—a figure far in excess of standard requirements—and in other developing countries is 2,400 calories, in the LDCS it is 2,000 calories, resulting not only in a reduction in energy and motivation, with attendant lowered performance at school and work, but in a greatly reduced resistance to disease." The next paragraph of the document begins: "Yet these people are among the world's least served in terms of health services." It would have been no less true to say : "Yet these are the people most diverted from growing food to cultivating cash crops to meet their countries' foreign exchange needs; and becoming increasingly de- pendent on strange foods which come in as food aid." Too little is known (statistically) of the correlation be- tween government "development" programmes and the growth of malnu- trition. What does the export-crop drive—a common characteristic of most LDCS—do for rural health, or for that matter for urban health? What is the relationship between growing crops to be sold far away and food aid from far away? What is the health impact of the epiphenomenon of eating strange foods? Answers to this kind of questions may not necessarily call for (still less lead to) any major shift in development policy. But they have an important bearing on any visionary drive to improve health in the LDCS. There can be no argument against much greater investment in health in the LDCS. On the other hand, there is real danger in any 11)c-development effort which tends to move inexorably towards the grand design for tomor- row, thus losing sight both of today's needs and of the purpose of the exercise itself. It has happened before. It will happen again. Consider, by way of illustration and at the risk of seeming to digress, the current International Drinking Water Supply and Sanitation Decade 1981-90. The subject is not a million miles from the subject of health. After long gestation in the ozone layer of international diplomacy, this was duly born during the UN General Assembly in November 1980. Like who's goal of Health for all by the year 2000, its targets are desperately urgent and it looks great on paper. Will it work? Here are some selections from a long and not despondent answer, delivered at a recent conference in Bombay, by Mr Cornelis van der Veen who is, among other things, Managing Direc- tor of the Amsterdam Water Supply. Having examined recent studies by the World Bank and by WHO, van der Veen concluded that some $ 50,000 million would be needed annually. The total now being spent by the World Bank, by other international agencies, by governments, by everyone, was $ 7,000 to $ 8,000 million. With commendable restraint, van der Veen commented: "So one can assume there is a wide gap to be bridged." Manpower does not exist. "To satisfy the conditions of the Decade, millions and millions of skilled people will be needed." This will take time, therefore "on the job training should be promoted as much as possible." There is no money. "Nevertheless there must be opportunities to attract more private money... If governments could hand out satisfactory conditions for water supply in large urban areas, it must be possible." Cornelis van der Veen, while sug- gesting some ideas on how the Decade can be made to work, does not, nor can he possibly, make it even look like working as designed. His view that "to be frank the Decade runs a danger of being a bureaucratic action if the public at large do not become involved" is generously uncritical of a design which has a number of holes in it. The holes are the reality. Time, money, manpow- er, motivation, the inability to adjust and respond to specific needs in par- ticular situations; these are common problems for a great many countries. The valid statistics of the health situation in LDCS reveal that millions of people are today living in constant sickness and dying young. Doctors, nurses, hospitals, medical equipment —everything will help if only they can be deployed. But suppose it is unreal to expect that they can be mustered for generations yet to come? The danger of being captivated by grand designs and of presenting them as sweeping solutions for current problems is that they could pre-empt small everyday solutions which, given a fair chance, might have good prospects for success. ■ 11 Rwanda: too many people, too little land A republic in the heart of Africa, Rwanda found until recently that its farm production was increasing even faster than its population. Today there is practically no more land available by Jeremy Hamand Compared to many of the Least Developed Countries, Rwanda is relatively lucky. Set in the heartland of Africa, it has an altitude which tempers the extremes of the equatorial climate and the soil permits a wide variety of crops to be grown, ranging from some of the best coffee in the world to maize, soya and wheat. The rains are reliable (the last famine was in 1943-44) and the country has technic- ally been almost self-sufficient in food, if only that food could be evenly distributed. Which is just as well, since the nearest port is 750 miles (1200 km) away and internal communications are hampered by a largely unsurfaced, though extensive, road network and by mainly hilly or mountainous terrain. There is no shortage of people—some 400 of them for every square kilometre of cultivated land. This is an advantage from the health administration point of view. But in other respects the high population density poses a big headache for the government, particularly since the 1978 census (the country's first complete one) revealed that the population has been growing at the rate of 3.6 per cent per year. This is one of the highest growth rates among the 31 Least Developed Countries. It is also a full percentage point higher than the 2.6 per cent that the government had assumed for the period of its Second Five-Year Plan (1977-81). This rapid population growth has important consequences for Rwanda's public health; the shortage of land is likely to increase the incidence of malnutrition, and the government's efforts to improve health care are being overtaken by the increased numbers. The growth rate figure for the Third Plan (1982-86), to be published shortly, is to be set at 3.7 per cent per year, although some experts believe that this too will be exceeded and that Rwanda will overtake even Kenya's current all- time record of 4.1 per cent per year. The authorities are extremely con- cerned by the implications of this growth rate. In an address to the newly elected National Development Council (Parliament) in January of this year, President Juvenal Habyarimana stress- ed that the country "faces a serious situation because of the very rapid growth of her population within a territory which is already fully settled. There is a major gap between agricul- tural production and population increase." The government fears that peasants will be increasingly forced off the land and will flock to the capital, Kigali, in search of non-agricultural employ- ment—of which there is already a shortage. Kigali has grown in 20 years from a small town of 7,000 to a sprawling city of over 150,000 in- habitants, and is increasing in size at around nine per cent a year. Certainly the farmers are under pressure. Most families own only a small piece of land (0.36 hectare), and even though the soil may be potentially good, agronomists speak of soil ex- haustion through overcropping and missed fallow periods. The result in some areas of the country is malnutri- tion, especially among the children, and increased susceptibility to weaken- ing by infection and parasites. A study made in 1976 of 3,000 children aged under five throughout the country 12 A woman in Rwanda heads for the market with her tiny harvest of ripe maize. And the baby goes too. (Photo J. Hamand revealed a high prevalence of protein- calorie malnutrition, particularly in the period after weaning; 11 per cent of the 12- to 23-month age group were seriously under weight. Altogether, about one-third of all the children suffered from stunted growth—an in- dication of widespread chronic malnutrition—and the proportion in- creased with age, so that 50 per cent of five-year-olds were affected. Until recently, agricultural production was increasing even faster than the popula- tion, because of the creation of new arable land from forests and savan- nahs. Today there is practically no more land available. Child malnutrition would certainly be much worse than it is, were it not for the existence of a network of 130 nutrition centres. The first centres were created by missionaries in the 1950s and 1960s. In 1972 the government took over the supervision of existing centres and expanded the network with help from FAO and the UN Development Programme, setting up a national training centre for nutrition instructors at Ruhengeri. The impact of these centres on child health is considerable; their personnel deal with more than 100,000 children, representing about 12 per cent of families with small children. The main nutritional problem is a shortage of animal protein. The staple protein source is beans, but the centres encourage people to keep rabbits, chickens and pigs as a source of extra meat—and extra cash. Disposable in- come is in short supply in this poor country, increasingly so as land be- comes scarcer. Few people have shoes and, as a result most children suffer from hookworm; there is often no money for school-books. Partly be- cause of the shortage of money and goods for the bride-price, and partly because plots are getting too small to divide, people tend to get married later; the average age has risen to 24 for a man and 21 for a woman. This in turn has created another national problem—that of unmarried mothers. And theirs are not the only unwanted pregnancies. The Ruhengeri Nutrition Centre makes no bones about pointing out the health dangers of too closely spaced pregnancies. But in fact few Rwandan women have much choice. Many of the country's health centres and some of the hospitals are run by Roman Catholic missions, most of whom offer either no family planning advice, or only the Billings ovulation detection method. Since this method relies on periodic abstinence from intercourse, and therefore on high motivation of the couple and the full co-operation of the husband, it is unlikely to be very effective in Rwan- dan society. A Catholic Rwandan doctor admitted that the failure rate is as high as 40 per cent. This same doctor, a senior gynae- cologist at the country's largest Catholic hospital at Kabgayi, told me that he had problems reconciling his duties as a doctor with the position of the Church. He was prescribing contraception—mainly intra-uterine devices (iups)—to several different categories of women: when he felt the mother's life would be threatened by pregnancy; to women who had many 13 children and did not want any more; to younger women who were becoming pregnant every year; and in the case of medical conditions such as a ruptured uterus, for which he preferred to use the injectable Depo-Provera. Many husbands, as well as wives, asked for family planning advice, he said. Like other Rwandan doctors I spoke to, he found that the Pill raised problems for many illiterate wo- men—and in any case, many of the women he was treating were over 35 and so unsuitable for this method. He found the IUD was the most acceptable method; the women came regularly for their check-ups and there were few cases of infection—partly because there is little sexually transmitted disease in rural Rwanda. This hospital has a large training college for nurses, and the same doctor was responsible for the gynaecological and obstetrical courses there. He ass- ured me that contraception was fully explained. In 1981 the government set up the Office National de la Population (oN AP()) to carry out research, training and co-ordination of family planning activities. The International Planned Parenthood Federation (IPPF) supplies contraceptives, and the Pathfinder Fund and the World Bank are now helping with training and motivational projects. The Director of ONAPO, Madame Gaudence Habimana Nyirasafari, be- lieves that popular demand for family planning will override any opposition from the Church authorities. ONAPO also aims to introduce sex education in primary schools, which take children up to 15 years of age. Certainly a better popular understanding of human re- production could reduce a lot of suffering. Dr Etienne Mbarutso, senior gynaecologist at the National Univer- sity Hospital in Butare, told me that infertility was fairly common and created some of the worst human problems he saw. But not infrequently this arose from the widespread practice of ritual sexual intercourse between At the Ruhengeri nutrition centre, a girl clutches her younger sister who clearly suffers from kwashiorkor—severe pro- tein deficiency. ( Photo J. Hamand e) spouses eight days after the birth of a child, on the occasion of its naming ceremony. This act is popularly be- lieved to ensure the child's fertility, but ironically the result for the mother is often endometritis—which sometimes causes sterility. The ruling Party in Rwanda has a grass-roots organization which could be mobilised to tremendous effect. The density of population is such that nationwide "coverage" is much simpler to achieve than in many African countries—and there is only one lan- guage that is universally understood, Kinyarwanda. There are strong com- munity traditions, with every able- bodied person participating once a week in umuganda, voluntary work for the community, including building roads, health centres and so on. Apart from the network of nutrition centres, there is a remarkably good coverage of health centres and dispen- saries for such a poor country. Few people need to walk more than 6 miles (10 km) to reach a health establishment of some kind. In fact, many of these facilities are run by missions. For instance, of the 105 health centres in 1980, which between them had 2,100 beds, 53 were private sector establishments—a medical "subsidy" of tremendous value to the country. And 65 per cent of the medical training is also carried out by the missions—both Protestant and Catholic. The mission health centres have certain built-in advantages, which means that they suffer less from the chronic problems of "underdevelop- ment". One government dispensary I visited at Rubona, near Butare, could only function for two weeks each month because of a shortage of drugs; one medical assistant and two nurses, with nine beds for in-patients, catered for four communes within a radius of five miles, with a total population of 30,000. The mission health centres tend to be better staffed, better equipped and better supplied, and the Catholic nutrition centres often have food to Instruction in sensible feeding for young mothers at a Catholic mission near Butare. ( Photo J. Hamand C)) give away supplied by the United States Catholic Relief Services. Just how valuable this entire health network is can be seen from the early results of the measles immunization campaign being carried out at present with WHO and bilateral assistance. Throughout the country, the reported cases of measles, one of the biggest baby-killers in Rwanda, fell from between 1,500 and 2,000 per week in 1980 to under 1,000 per week by the end of 1981. In Ruhengeri prefecture, where the campaign began in October 1980, reported cases fell from 9,421 in 1980 to 2,180 for the whole of 1981. This measles campaign alone is likely to have a significant effect on the infant mortality rate, and therefore must be seen as a positive sign of progress in a generally dismal picture. ■ 15 Haiti Alone among the countries of the Americas, Haiti (which shares half of the island of Hispaniola with the Dominican Republic) is listed among the 31 Least Developed Countries. In common with the others on the list, its inhabitants have an annual income averaging little over US $100, adult literacy is very low, and manufacturing re- presents only about 10 per cent of the gross domestic product. (Photos L. Sirman C)) Samoa Many thousands of islands dot the vast area of the Pacific Ocean. Among these, Samoa comprises two main islands, both of them moun- tainous, and several smaller ones. The roughness of the terrain and its isolation have helped to put this kingdom among the Least De- veloped Countries. The idyllic beach scene in our first picture cannot conceal the fact that the shack at the end of the jetty is a latrine. (Photos L. Sirman ©) Vicious circle Trapped inside a vicious circle from which, with their own unaided efforts, escape is extremely difficult, the LCDs are actually falling further behind the other developing countries by Paul Harrison Aorema in Upper Volta is no more than a broad scatter of walled compounds, each one containing an extended family of three or four generations. Though it is only 10 miles from the district capital of Ouahigouya, no road leads to it, only a narrow footpath, so gullied that even a landrover has problems negotiating it. In the most overcrowded, most poverty stricken region of one of the world's poorest countries, it is a good place to get the feel of what life is like in the Least Developed Countries. The head of one family, Mou- mouni Ouedraogo, a lanky, wrink- led 60-year-old, told me about his problems. When he was a child, he remembered, only 12 people lived in his father's compound. Now there are 39: five brothers and their nine wives and 25 children—though five of the young men were away, like many of their compatriots in their twenties, in the neighbouring Ivory Coast. The land has not expanded with the population. To restore its fertil- ity, it should be left fallow for at least 12 years after a couple of years of use; now the fallow periods have been cut to five or six years, and the soil is suffering. Moumouni showed me his fields: those closer to his home were dusty, hardened, dark red, without a trace of humus. Further out, on the fallow land, much of the vegetation had died out completely. He complained about the climate: "It rains less now than it used to, but the rain seems to be getting harder and harder. It takes all the soil away." The human results were all too visible. The younger children stood around watching, with bulging bell- ies and dry, powdery faces. Two of them had eyes closed up with pus. None of them went to school. The health of adults was not much better: Moumouni told me that two of his brothers had had meningitis. Diarrhoea was a universal afflic- tion. And in the rainy season came frequent attacks of malaria and fevers from guinea worm caught from using contaminated water; these confined people to their sleep- ing mats at a time when they should be working in the fields. What about health care? Mou- mouni told me that the doctor came around about once a year to ino- culate the children, but never treated adults for their ailments. "The doctor is only for children, not for adults," he told me, and he meant it. Last year's Paris conference on the world's Least Developed Coun- tries highlighted their plight and launched a programme of action to alleviate it. Action is desperately needed. For not only are the LDCS extremely poor their average per capita income in 1978 was only US $ 183, against a developing country average of $ 661. But they are, for the most part, falling further behind. If the trends of the past two decades continue, their inhabitants will be only $ 10 a year better off by the year 2000, compared with an average increase for other develop- ing countries of $ 242. They are caught in a trap of slow growth, of which poor health is both a conse- quence and a cause. The LDCS suffer more than their share of natural, and of man-made disasters. The largest group straddle the Sahel, where recurrent drought threatens. Others are located in earthquake zones or in the paths of tropical cyclones. Often as a direct result of their poverty, many are torn by civil or international strife —sometimes with neighbours that are also LDCS. A high proportion of the world's refugees originate from, or are accommodated in, LDCS. Just take one example, Bang- ladesh. A destructive war of independence in 1971 was followed by drought in 1972-73. Floods came in 1974 and 1977, drought again in 1978-79, each time slashing food production drastically. No sooner Above: With a despairing gesture, Moumouni Ouedraogo shows how his fields in Upper Volta have been devastated by alternating droughts and floods. Below : Oxen power in Bangladesh. Cereal yields in the Least Developed Countries amount to less than three- fifths of the world average. (Photos WHO/P. Harrison) 18 71 , had people recovered from one disaster than another struck. In most LDCS, agriculture has performed very poorly. Per capita food production, which stayed level in developing countries as a whole between 1961 and 1979, fell at an average of one per cent a year in LDCS. Yields are low—less than three-fifths of the world average for cereals. Irrigation is non-existent in most LDCS, and the use of fertilizer is minimal. And yet agriculture is the key- stone of their economic fortunes. It employs four-fifths of their labour force. Almost 70 per cent of their exports are agricultural products, whose volatile and unpredictable prices wreak havoc with national economies and government bud- gets. In many cases, prices of these products have not kept pace with the cost of imported manufactured goods or of oil. As a result, the exports of these countries pay for only 53 per cent of their imports—against an average of 80 per cent for developing countries as a whole. The LDCS cannot attract commercial credit to cover the deficits—so they are heavily dependent on outside aid to finance essential imports. They do attract a greater share of aid now than they did a decade ago, but it is still sadly inadequate. In 1980 it amounted to only $ 11.70 per head from member countries of the Organization for Economic Cooperation and Development (oEcD),while middle income coun- tries, with average incomes six times higher, received no less than $ 15.50 per head. Some LDCS, such as Afghanistan, Bhutan, Burundi, Chad, Ethiopia, Guinea, Nepal and Sudan, got very little in the way of aid. Sadly, internal political con- ditions, or the lack of skilled people to identify or administer projects, made it difficult for some of them to absorb the aid they so desperately needed—just as illness, which in- creases the need for food, often reduces the ability to absorb it. Health facilities are thin on the ground, and each doctor must serve an average of 17,000 people. Imm- unization in childhood could have prevented this African youth from being crippled by polio. (Photo WHO/P. Harrison) The lack of a local agricultural surplus, or of sufficient aid to compensate for that lack, has meant that industry has grown slowly. In 1979, manufacturing accounted for only 8.3 per cent of the gross domestic product in the LDCS, less than half the developing country average. There are other handicaps too which hold back industrialisa- tion. Home markets are small in purchasing power and often in size. Transport is appalling. Whereas the United Kingdom, for example, has nearly 100 miles of road for every 38 square miles (100 square km), Afghanistan, Ethiopia and Nepal have only 1.8 miles, while Burundi, Mali and Niger have 0.6 miles or less. Travel takes days, rather than hours, especially in the rainy season. To visit one village in Bangladesh, only 50 miles from the capital, I had to go by road, then car ferry, then road again, and finally take a long trip in a tiny boat with a single back oar and a tattered sail made out of old sacks. It took a total of six hours. _VOW"- So in rural areas the shops are few and very far between, and markets sell only the barest essentials such as food, matches, kerosene. Access to export markets, too, is harder than ever for the 15 LDCS which are landlocked and the four that are islands. The underdevelopment of indu- stry and agriculture leads to, and is compounded by, the underdevelop- ment of people, and underlies the appalling state of health and health services in LDCS. Nutrition is inadequate in quan- tity. In 1977, the average daily calorie supply in LDCS was only 2,000 which is 14 per cent less than the recommended minimum and 400 calories below the average for developing countries. And the qual- ity is deficient too : look in the lunchbowl of a labourer in Bang- ladesh and you will see nothing but plain boiled white rice, and not much of that either. Cereals take priority in the diets of the poor : they cannot spare the cash or the land for vegetables to provide essential vita- mins and minerals. The consequence is lowered resis- tance to disease, malnourished pregnant and nursing mothers, and children born and reared with physical and mental capacities be- low their potential. Some 30 per cent of LDC babies are of low birth 20 weight, against an average of 17 per cent for all developing countries. Health facilities are extremely thin on the ground; indeed modern health care is quite simply non- existent for the majority. Even in life and death cases, there is little alternative but to sweat and hope. And so the usual health indica- tors for LDCS make depressing reading. Sixteen children in every 100 die before their first birthday. Life expectancy is a mere 45 years-15 years less than the de- veloping country average. Diarr- hoeal diseases are major sources of morbidity and mortality. Malaria is present in all but two of the 31 LDCS. Widespread poverty means that taxes cannot be high, so govern- ment budgets have to be modest. And far too much of what is spent goes on arms and armies—almost always more than on health, and in some cases up to 14 times as much. Spending on health is low, averag- ing a mere $ 1.70 per person, against an average of $ 6.50 for other developing countries and $ 244 for developed countries. Provision for education is scanty—again, poor transport and widely scattered populations create problems beyond those of finance. Only 57 per cent of 6- to 11-year- olds attend school, and a mere 12 per cent of 11- to 16-year-olds—well below half the average for develop- ing countries. This means that the supply of qualified manpower at all levels of government and private enterprise is very limited. The situa- tion is aggravated, in many coun- tries, by the massive emigration of the more adaptable and educated to countries that can offer better job prospects or higher salaries. The low average level of literacy-28 per cent, as against 55 per cent for other developing countries—also reduces the potential supply of community- based workers for self-help projects in health, water and sanitation, and nutrition. All in all, the least developed countries find themselves trapped inside a vicious circle from which, with their own unaided resources, escape is extremely difficult. Agri- culture produces little surplus to invest in improving agriculture, in developing industry, or in expand- ing government services such as health or education. Human beings, as a result, remain badly nourished, ill-educated and in poor health. This keeps their productivity low which—completing the circle helps to prevent agriculture from producing a surplus. The task, then is to break through the vicious circle at as many points as possible. Increased aid and tech- nical assistance can help to supply, from outside, the financial resources and skilled manpower needed to get the development process off the ground. The Paris Conference deci- sions may help towards this: most donors agreed to increase their aid to LDCS to 0.15 per cent of GNP (the current average is 0.06 per cent) or to double it. Unfortunately, no binding time scale was set for this to be achieved, and only time will tell whether this target will have any more real meaning than the in- definitely adjourned 1971 target for overall aid of 0.7 per cent of GNP. Health and nutrition are also important links in the chain at which the circle can be broken more important perhaps than was suggested by the token three para- graphs allotted to them in the Substantial New Programme of Action (sNPA) adopted in Paris. It is now well known that illness can depress work productivity: studies have found that production among Indonesian agricultural labourers was 15 to 25 per cent lower where hookworm-induced anaemia was present, and that schistosomiasis in Tanzanian sugarcane workers low- ered productivity by three to five per cent. Thus, improvements in health could help to effect dramatic in- creases in workers' productivity, which would serve to raise the surplus available for investment. The cost need not be prohibitive. The cost of achieving health for all in the LDCS by the year 2000, according to wHo calculations, would be about $ 6,000 million a year over the 1980s and $ 10,000 million a year in the 1990s one- fifth of that in the form of external aid. But much more effective use could be made of the present limited budgets, by redistributing spending away from over-centralised, high- technology facilities and into pri- mary health care using more ap- propriate technology, and preven- tive work such as water supply and family planning. In our concern for the Least Developed Countries, it is impor- tant to remember that their problems differ only in degree, not in kind, from those of many other low-income countries which may fall only marginally outside the arbitrary cut-off point. If the special category of LDCS is to be given priority in the allocation of aid, then there is a pressing need to review the criteria and the selection of coun- tries regularly. Eleven years after the first listing, some countries— notably Botswana and Samoa —have pulled far ahead, on most in- dicators, of several countries which are not on the list—such as Demo- cratic Kampuchea or even India. There is also a strong case for some special programme of action for the low-income countries which do not benefit from the title of less developed. Despite their level of need, this group has seen its share of aid drop from 43 per cent in 1974 to 34 per cent in 1980, though it made up 50 per cent of the population of aid recipients. The ground was lost, not to the LDCS, but to the middle- income countries (18 per cent of the population) whose share of aid rose from 33 per cent in 1974 to 42 per cent in 1980. Let us hope that the 1981 conference on LDCS will mark a first step towards a more general goal of improving the distribution of aid according to need, as well as increasing its total volume. ■ 21

Africa: the Sahel zone by Pape Marcel Serie As we approach the third millenium, must the historical image of Africa still be that of a continent adrift, a poverty-stricken outlying suburb condemned to lag behind other "civilised" continents in a perpetual state of underdevelopment? Recalling the former glories of African civilisations is poor comfort, and can do nothing to relieve the pain, despair and frustration felt by the inhabitants of the Sahel, for instance. In the present economic situation, there seems to be no hope left of changing the course of history and giving such people–the "dam- ned of the earth" as Frantz Fanon called them—full status in world civilisation. The outlook for Africa, com- pounded of the long-term conse- quences of the slave trade, colonisa- tion, and the results of bad management, is largely negative as the present century ends. One expert after another reports the same diagnosis : the African continent is sick and, unless there is energetic intervention, it faces disaster. What this amounts to is that the African, already one of the poorest of men, will become even poorer. Even now, as the figures and statistics show, there is little to envy in his situation. He has the lowest annual income in the world, no more than US $ 390, his expect- ation of life is about 47 years, drinking water is rare, education is practically inaccessible, and there is only one doctor for about 6,150 people. The many ills that afflict his country include a too rapid popula- tion growth, political instability, the wrong kind of institutions, poor Stilt houses in Benin are picturesque—but sanitation pro- blems are almost insuperable. Facing page: The man is a victim of river blindness in West Africa. Must his little nephew be doomed to the same fate? (Photos WHO/P.Pittet and WHO I P. Harrison) agricultural output, rudimentary industry, a deficit in the balance of payments, and underdeveloped human and natural resources. Because most African countries have to import a great deal of oil, they have been hardest hit by the worldwide galloping inflation and recession since the oil crisis of 1973. In some of them, allocations for the purchase of hydrocarbons have increased tenfold over a few years even while their purchasing power has dwindled wretchedly owing to worsening terms of exchange. On the most favourable view, the growth rate over the next ten years will, as a result, be zero or even negative. Further figures could be given, but the whole list of negative terms would not suffice to describe a situation that defies description : a scene of want, of insufficiency and of vulnerability, in brief the situa- tion of underdevelopment that is the tragic and daily reality of millions. Among the least developed coun- tries, two-thirds of which are in Africa, some ten lie along the edge of the immense desert waste of the Sahara. One cannot border on a desert and escape scot-free. For centuries, but especially since 1973, these Sahel countries have been living through a vicious drought spiral that is making desertification their main enemy. The advance of the desert is made more inevitable by devastating bush 23 fires, uncontrolled felling, and overgrazing. The vulnerability of economies based on extensive agriculture and two or three basic exports has been revealed by the mass deaths of cattle and the extensive degradation of ecosystems; all this has resulted in a chronic food shortage, if not a state of famine, for what are essentially rural populations (80 to 90 per cent of the total inhabitants). An economy under which poor prices are paid to producers, and where management training is ex- pensive and ineffective, has created a poor peasantry whose grievances focus upon lack of fodder, dispen- saries and schools, if not simply on the need for emergency food relief. The soil is no longer capable of feeding those who work it, and the countryside is being increasingly abandoned by the most vigorous, who leave to seek their fortunes in the urban centres of their own or neighbouring countries, or in the Western world. 24 Sudan is making efforts to develop the fertile plain of the Gezira through irrigation. But it is in the irrigation canals that the water snails live which transmit schistosomiasis. Left: An exhausted mother, living in a drought-stricken region of Ethiopia, tries to breastfeed two babies at once. ( Photos WHO/ E. Schwab and WHO !UNICEF' B. Campbell) Understandably, a pattern has arisen which is now practically traditional: an exodus from the countryside, over-rapid urbanisa- tion, the development of shanty towns, and unemployment. This leads in turn to a rising incidence of violent crime and of more subtle vices (misappropriation of public funds, extortion, corruption of all kinds), and to the emergence of the old demons of tribalism, religious intolerance, lack of respect for traditional moral values. The housewife is increasingly occupied in buying the necessities of life, paying more and more for less and less, since basic foodstuffs (rice, wheat and maize) are often impor- ted. The urban wage-earner has to support not only the family that he has with him, but also his relatives who have remained in the village. Here we have the paradoxical situation of a countryside living off the urban centres. The same situa- tion is reflected in the relationship between agriculture and industry. Through its significant inroads into scarce capital resources, the indu- strial sector becomes a burden on agriculture, itself continuously on the decline. This economic vicious circle is most strongly felt in the countries of the Sahel zone which are victims of drought due mainly to poor rainfall. Although there has been more rain than usual this year, the downward spiral continues. It was for this reason that the govern- ment leaders who form the Inter- State Committee for the Control of Drought in the Sahel (clLss), at their meeting last January at Praia in the Cape Verde Islands (which had only two days of rain in a year), reaffir- med their determination to achieve the aims of CILSS, namely self- sufficiency in food supply and control of desertification. These countries include the Cape Verde, Chad, Gambia, Mali, Niger and Upper Volta, and also Maurita- nia and Senegal, although the last two are not on the uN list of Least Developed Countries. The group could later include possible new members such as Guinea, Guinea- Bissau and Nigeria. Faced with underdevelopment in general and increasing desertifica- tion in particular, a variety of safeguards have been adopted by the respective governments, includ- ing the establishment of village woods, national movements of sol- idarity with the people of the countryside, reafforestation and so forth. A regional grain policy has also been furthered by measures 25 embodied in national food plans. Thus, particular stress has been laid on ensuring the food supply through crop growing in Gambia, Mali and Niger. As regards water supply for village use and for cattle rearing, the CILSS states have ob- tained finance for national water projects. A rural water supply improvement programme has been launched with $ 102 million provided by the Islamic Committee for Solidarity with the Sahel. As for desert control, it is worth noting that, despite international aid, reafforestation is carried out on only about 20,000 hectares annually, whereas more than 300,000 hectares are affected. Some programmes have been jointly established with the UN Sudano-Sahelian Office (uNso) and the Sahel Club for the control of desertification in the ciLss member countries. There are also joint activi- ties with the West African Economic Community (wAEc) on a regional solar energy centre, a regional project for improving peasant eco- nomies run jointly with the Food and Agriculture Organization (FAO), and other projects on transport and fish- ing. All of them form part of the "first generation" programme of CILSS. Only 60 per cent of this programme, the total cost of which was $ 4,000 million, had been carried out just be- fore its scheduled completion. However, the most ambitious CILSS project, estimated to cost $ 100 million, is the building up of emergency food stocks. Its financ- ing is not yet assured because of reservations expressed by interna- tional financial backers, who cited the adverse effects that the existence of such stocks might have on local production. For the countries of the Sahel the question is one of survival. This is especially so as regards emergency food aid, on which the interna- tional community shows similar reservations. For example, firm undertakings received from the Africa: the Sahel zone Left: Soapy lather turns this little boy in Upper Volta into a bizarre piece of sculpture. The construction of small dams and wells has brought much-needed water supplies to many communities. Right: Carrying water home for the fami- ly. A great many African states, particularly in the Sahel zone, have an urgent need to improve rural water supplies. Far right: Health, which cannot be separated from development, is another ac- tion priority. A nurse from the rural health centre makes her house-calls in a Botswana village. ( Photos WHO/FAO/W. Wiese, WHO/M. de Vreede and WHO/J. Mohr) international community for the 1979/80 campaign covered only 255,000 of the 830,000 urgently required tons of grain. The grain deficit in the cuss states has now risen to a little over one million tons, so that the aid agreed covers scarcely a quarter of the stated need. The Sahel will have about 50 mil- lion inhabitants by the year 2000, and if grain imports continue at the present low rate they are likely to be well below the need during the last decade. Many economic challenges must therefore be taken up. The UN has produced a regional food plan for Africa, now adopted by the Organization of African Unity (oAu), which lays emphasis on three key points : priority to be given to small-scale producers; overhaul of the incentive system (higher prices for the producer, freer and more competitive marketing arrange- ments, involvement of growers in decisions that concern them); and 26 the launching of quick-return operations in irrigation agriculture. The food plan, which provides for a growth rate of 3.9 per cent in the period 1980-85 and 4.8 per cent between 1985 and 1990, calls for an investment of the order of $ 125 million. Some 48 per cent will be devoted to food crops, 30 per cent to cattle raising, and 25 per cent to back-up services such as stocking and transport. Health, which cannot be separated from development, is another action priority. Health care must be available for as many people as possible if these West African countries are to preserve all their strength for development. Here again there is a need for regional and international coopera- tion to achieve the aims set by WHO for the year 2000. At the medical level, there is much to be done to combat the many bacterial, viral and parasitic diseases which flourish in this region. Those who attended the 10th Dakar Medical Meeting last January suggested a cheap and potentially effective strategy: prevention should stem from close cooperation between "planners, engineers, epidemiologists and economists". The fact is, it would be imposs- ible to list all the sectors in which the governments of the Sahel should be active in order to raise their countries from poverty. What is needed, no more and no less, is to make the most judicious and effective use of brain power and muscle power, capital, executives and technicians, as well as internal and external resources. According to the World Bank experts, external resources are destined to play a key role in supporting efforts by African coun- tries to accelerate their economic growth, and should be doubled in real terms. The international com- munity should make a basic commitment to increase aid and provide assistance in a manner better adapted to African needs than in the past, so as to support the reform programmes drawn up by African governments. The experts add that if aid were to increase from $ 4,900 to $ 9,100 mil- lion, and if internal policy were poin- ted in the right direction, the average growth rate per inhabitant in Africa could be around 2.5 per cent each year for the rest of the decade. They conclude that what Africa needs is a new social contract, implying recognition by the international community that the struggle against poverty in that continent is a common struggle involving responsibilities for both partners. All told, the rescue of the poor countries is a challenge to the whole of humanity. Africa, which undoubtedly got off to a bad start, but in a direction not of its own choosing, needs to be given a new start. ■ 27 Laos: progress will be slow A land shut in on itself, landlocked Laos has suffered from a protracted war which has put a brake on its economic growth. Overcoming this will need international sup- port, cooperation and goodwill for many years to come by Ravi Ramdoyal The Lao People's Democratic Republic has suffered through history from its geo- graphical position, which makes it an easy prey for foreign intervention. A landlocked part of South-East Asia, the country is faced with the pro- blem of ensuring an outlet to the sea. It is a land shut in on itself, with all the undesirable economic and social consequences which that entails. Any foreign products which it requires will be bought at a high cost in time and in scarce foreign exchange, yet without foreign ex- change the country cannot obtain what it needs for its economic and social development. The local man- ufacture of many items that are important for its growth remains limited because its dependence on supplies from abroad has always A course in sensible nutrition forms part of the training for nurses in Laos. Intensive training of health personnel is receiving high priority in that country. (Photo WHO/J. Mohr) 28 retarded technical development. Trade is restricted, since the coun- try's resources have been exploited in consideration not of its needs but of the international market. This slows or even halts investment and hampers all development pro- grammes. At present the national economy is advancing too sluggish- ly in relation to its capacity and to domestic demand. Warfare The historic past of Laos, en- riched by contributions from var- ious cultures, gives it a sense of identity and a capacity for develop- ment much greater than many other countries enjoy. But one serious adverse factor has been the protrac- ted war in which the country has been embroiled by its geographical position. This has put a brake on its economic growth. Warfare and insecurity have meant a redirection of attention to other objectives that completely absorb the individual, until a stage is reached where permanent apathy sets in, since every effort to achieve a normal life entails an expenditure of energy and imagination that is greater than in normal, peacetime conditions. The health services, especially in rural areas, reflect this situation, as indeed do all the other essential services. Defective communication networks and general logistic shortcomings have contributed to the weakness of the health sector. Past efforts have not given the results that were hoped for, though in some parts of the country a modicum of progress has been achieved. For many years the country has been receiving wHo assistance tail- ored to its needs, but the insecurity created by the war has precluded penetration into the most remote and underprivileged areas, even though some urban-fringe districts have been developed. Whatever progress was achieved was again put in jeopardy after the war; many qualified staff emigrated, leaving a vacuum that the country is now trying to fill as quickly as possible by giving priority to intensive training of the missing categories of personnel. At present the low rate of gradua- tion from secondary schools limits the recruitment of people to be trained for the many vacant posts in the health services. Since the need for qualified staff is urgent, this handicap will take a long time to overcome. Progress will be slow, for the training time for such personnel is long. Meanwhile, everything must be done to ensure that the personnel already serving are not discouraged by the uphill struggle. WHO has the technical capacity to help Laos to speed up its health development process. But first it must quickly overcome the most important hurdle by introducing little by little into the existing services a more efficient system of management, and by awakening among the staff the confidence and the decision-making ability that are lacking at all levels today. Thus supervision, which is still very ineffectual, will assume a more important role in helping both the rural health personnel and the population to find solutions to their day-to-day problems. Serious diseases At present WHO is helping the country to tackle the priority pro- blems that have been identified, for instance, the commonest and most serious diseases. Among these scourges, malaria has been brought under control in two provinces out of thirteen. Much remains to be done, however, and this will require large resources in order to cover the whole territory. A drinking-water supply project is being financed by UNICEF and UNDP, so that the rural population can have safe water and hence proper personal hygiene and a balanced, healthy environment. An immunization campaign against the common diseases of childhood has started, under WHO's super- vision, and is proceeding systemat- ically. Again, many areas remain to be covered. Present efforts in this sphere are being directed mainly towards training personnel in the control of poliomyelitis, diphtheria, tetanus, whooping cough and measles. Other diseases are also under surveillance, and Laos is receiving technical assistance as and when required. Spreading the message Health education is another pro- blem area for the health services. WHO assistance is directed par- ticularly towards developing this facility and towards training health educators to spread the message across the country. Help is also being given in the training of supervisors and health staff for the control of diarrhoeal diseases. In the rural areas, wHo is mainly concerned with a project for build- ing up primary health care so that improved health services can pene- trate into the remotest regions. UNDP is to finance several health projects that will be supervised by WHO. These are fairly ambitious projects designed to equip the health services with an infrastruc- ture and with the essential capabil- ity for meeting the country's needs. To this end, very substantial assis- tance is being given to the Faculty of Medicine in Vientiane so that it can recruit professors abroad to help the local teaching staff in the difficult task of medical education. For many years to come, the Lao People's Democratic Republic will need international support and cooperation in overcoming its difficulties and bringing its ser- vices up to an acceptable level, so that its people can enjoy the improved quality of life to which they all aspire. ■ 29 ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• •• • ••• • •• ••• ••• ••• ••• • •• ••• ••• ••• •• • ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• •• • ••• ••• ••• ••• ••• •• • ••• ••• Soo 000::: M oo. •.... • ••• ••• ••• ••• ••• ••• ••• ••• ••• •• • ••• Neediest, Needy, Affluent 31* Least developed countries 89 Other developing countries 37 Developed countries Population: millions 283 3,001 1,131 Infant mortality rate: per 1000 I iveborn 160 94 19 Life expectancy: years 45 60 72 Birth weight: 2500 gr. or more 70% 83% 93% Safe water supply 31% 41% 100% Adult literacy rate 28% 55% 98% GNP per capita $ 170 $ 520 $ 6,230 Per capita public expen- diture on health $ 1.7 $ 6.5 $ 244 Public expenditure on health as % of GNP 1.0% 1.2% 3.9% Population per doctor 17,000 2,700 520 Population per nurse 6,500 1,500 220 Population per health worker—all types 2,400 500 130 * In Africa: Benin, Botswana, Burundi, Cape Verde, Central African Republic, Chad, Comoros, Ethiopia, Gambia, Guinea, Guinea-Bissau, Lesotho, Malawi, Mali, Niger, Rwanda, Somalia, Sudan, Uganda, United Republic of Tanzania and Upper Volta. In Asia and Pacific: Afghanistan, Bangladesh, Bhutan, Democratic Yemen, Laos, Maldives, Nepal, Samoa and Yemen. In the Americas: Haiti. Figures are weighted averages, based upon estimates for 1980 or for the latest year for which data are available. The Least Developed Countries, What Makes Them the Neediest The 31 countries are deficient in all categories of health person- nel. Their infant mortality rate is the highest in the world, and their life expectancy lowest, as is their adult literacy rate. They spend less than $ 2 per capita yearly from public funds on health. Not only do they lack resources, both financial and material, to better the health of their citizens, but also their eco- nomies are burdened by runaway inflation. Added to the harshness of those and the other socio- economic factors shown in the table below, are the cruelness of their climate and geography. The terrain of most is inhospitable; half of the countries are land- locked; and five are islands. Many are situated in the world's "disas- ter belt", subject to a high risk of floods, earthquakes, and other natural disasters. Twenty-one countries in Africa, nine in Asia and the Pacific, and one in the Americas have such characteristics. Some 200 million of their total 280 mil- lion population are reckoned as in dire straits, without access to safe water or to health care. They are the victims of a combination of economic, geographic, political and administrative forces over which they have no control. The United Nations designated them the "least developed coun- tries". French President Francois Mitterrand called them the "most destitute of the destitute". A UN Conference, held in Paris last September, singled them out—over all other developing nations—for aid. And WHO, in a warning that health is often neglected in plan- ning for development, made a plea for support of their health programmes through a larger allocation to them of the develop- ment dollar. According to WHO estimates, the LDCs are able to come up with 80 per cent of the almost $164,000 million required to provide needy populations with primary health care. Therefore the funding sought from donor coun- tries is $ 32,750 million to meet health goals of the next two decades. Foremost among the goals are the following: Infant Mortality: A decrease to less than 50 deaths per 1,000 live births. The figure now is 160. Life Expectancy: An in- crease to at least 60 years from 45 now. Birth Weight: An increase to 90 per cent in the numbers of babies weighing 2,500 gr. (5 lb. 8 oz.) at birth. The figure is now 70 per cent. Adult Literacy: An increase to over 70 per cent, from 28 per cent now. Public Spending: An in- crease to 5 per cent of gross national product from the 1 per cent now. Age Discrimination Becomes an Issue In Year of Aging There is universal revulsion against discrimination in what- ever its form—religious, racial, or sexual. The same feeling of opprobrium, however, is not extended generally to prac- tices directed against the senior citizen. Yet it is older workers—more specifically, those who are 55 or older—who are most discrimi- nated against in questions of employment, the International Labour Organisation says in a report. They are too often the victims of prejudice based on one criteria—their age. Once out of a job, either because of retirement or retrenchment, they are the least likely to be hired. And while younger workers lose their job more frequently than older workers, the older stay jobless longer. After a year of job- hunting, 90 per cent of unem- ployed youth found work, one Dutch study showed. During the same time, only about half of the jobless over the age of 55 did. So far, however, there has been little public outcry against age discrimination even in the de- veloped world. On the whole, there is scant concern, partly because of high unemployment —at the highest level since the 1930s—and partly because of the acceptance by older workers of their fate. Many retirees just decide to give up looking for work. During the seventies there were 307 million people over the age of 60, UN statistics show. By the end of the century the num- bers are expected to rise to 580 million, and by the year 2025 to a billion. "This is a unique demographic fact that must be fixed in the minds of government decision- makers", says Mr William Ker- rigan, Secretary-General of the UN World Assembly on Aging. This Assembly opens next month in Vienna. Among factors that are re- making the face of human po- pulations are those of fewer births and—thanks largely to public health measures—of longer life. Now markedly evident in the industrialized world, those trends are projected for the Third World as well. The force of these numbers is compelling a re-assessment of age-old attitudes about aging. Studies discredit the stereotypes of older workers as being less productive, less adaptable, more accident-prone and more in- clined to absenteeism, ILO says. Particularly questioned today are retirement policies that were established, along with pension schemes, almost a century ago and based on the lower standards of health prevailing then. It is not retirement itself that is challenged—freely chosen it is to be desired for people everywhere UN officials hold—but the mandatory aspect of it only. "Retirement policies should be based on the ability and wish of the older person to work—not upon their chronological age", they say. They admit, however, that re- conciling the interests of the young with those of the aging is no easy task. On the one hand, some countries advocate the lowering of retirement age to provide jobs for the young. UN officials warn this may turn out to be a "short-term, partial solution of one social problem through the creating of another"—the in- crease in the numbers of the unproductive old. On the other hand, US President Ronald Reagan has proposed outlawing mandatory retirement based on age. "When it comes to retirement, the criterion should be fitness for work, not year of birth", he says. Unless the skills of the over- sixty generation can be har- nessed, then the work force will greatly shrink. Not only will production drop, but also social security schemes will be hard pressed to stay solvent. In Aus- tria, for instance, there are already just two workers for every pensioner. The need, therefore, is for a re- examination of the basis of retire- ment, as well as for training programmes geared to older per- I n the next issue The image of the nurse has evol- ved considerably since the profession first became respect- able for young unmarried women over a century ago. Today the nursing arts are not confined to women; both male and female nurses are taking part in, and helping to create, new patterns of health care delivery. The July issue of World Health looks at the new role of nursing in the closing decades of this century. 30 Authors of the Month Mr Thomas G. WEISS is the Economics Officer in uNcTAD's Special Programme for the Least Developed Countries. Mr Nedd WILLARD is an In- formation Officer with WHO's Division of Public Information in Geneva. Mr Gamini SENEVIRATNE is a freelance journalist based in Vienna. Mr Jeremy HAMAND is the Deputy Editor of People, the journal of the International Planned Parenthood Federa- tion. Mr Paul HARRISON is a freelance journalist and photographer specialising in stories on eco- nomic development in the Third World. Mr Pape Marcel SENE is a journalist working with the Dakar newspaper Le Soleil in Senegal. Dr Ravi RAMDOYAL is the WHO Programme Coordinator in Vientiane, Lao People's Demo- cratic Republic. WORLD HEALTH for readers everywhere 1982 Subscription Rates US$ Sw. fr. One year 15. 25.— Two years 27.— 45.— Three years 36.— 60.— ORDER FORM Please enter my subscription to "World Health" as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque/international postal order in the amount of • Name Street • City: Country: World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies, please contact your usual bookseller. sons, and for a counselling service to place the jobless in jobs. The aging should not be con- sidered as a burden on society, but should continue to play a productive role in it, the United Nations says. To deny them that opportunity "can amount to dis- crimination of the worst kind". Incentives Offered By Japan for Hiring of Older Workers As its work force ages, Japan is bracing for a decline in its gross national product, in combination with a rise in health and pension costs. According to Professor Naohi- ro Ogawa, an economist at Nihon University, Tokyo, to cushion the impact of these trends on its economy, it is the country's pol- icy to step up plant automation, particularly through the use of robots and to encourage older workers to stay on the job for as long as they are mentally and physically able to. Photo WHO/E. Schwab Older people: needing what people need. That commitment has turned Japan into a pioneer of pro- grammes aimed at training and re-training older workers. In addition the government has taken measures such as these: Beginning in 1966, it urged the creation of jobs suited to the capabilities of older workers. Be- ginning in 1976, it held that older workers must comprise at least 6 per cent of a company's full-time staff, and paid bonuses to firms which employ workers from age 55 to 64. Such incentives are particularly needed, inasmuch as pensions in Japan range from 60 to 80 per cent of salary — certainly within, but by and large exceeding, the 65 per cent minimum recommen- ded by the International Labour Organisation. Newsbriefs Aging. At ceremonies in London on 7 April, World Health Day, to launch this year's WHO theme of "Add Life to Years", messages were received from the host country's Prime Minister Margaret Thatcher, and, as well, from US President Ronald Reagan. Excerpts: From 10 Downing Street: "... the aging of population is a world- wide phenomenon. lam sure that our experience here can be of benefit to others, just as we can learn from them. - — From the White House, in a reference to the World Assembly on Aging, opening in Vienna: "That occasion will be the impetus for many nations to launch policies and programmes recognizing the older generation as an essential national resource..." The event was held under the sponsorship of Age Concern, a British group, and WHO, particularly its Regional Office for Europe, to draw public attention to what the United Nations calls the "age of aging". (For related stories, see adjoining columns.) Calendar. Of more than usual noteworthiness are these two international meetings: "The Emerging Global Village," sponsored by the Society for International Development, the largest non-governmental organiza- tion of its kind, as part of its 25th anniversary observance. Among topics to be discussed from 12-22 July at the Baltimore Convention Center, in the United States, are these: "The Lessons of Development Experience," "Primary Health Care," and "South-South Cooperation." The society's Kathy Morrell, SID, 1834 Jefferson Place, NW Washington, D.C. 20036, has more information. "Operation Firewood for the Sahel," sponsored by the Conseil International d'Education Mesologique, and others, including FAO and UNESCO. Among topics to be discussed at the seminar from 13- 18 September in Dakar, Senegal: the lack of firewood for basic human needs, such as cooking and just warmth. Professor Michel Maldague, C/EM, C. P. 39, Sillery, Quebec, G IT 2P7 has more information. Drugs & Dosages. With another tourist season beginning, WHO is once again asking travel agencies to warn of the risk of malaria. Several deaths are reported yearly among travellers who—either through ignorance or through under-estimating the danger, specially when their stay in malarious areas is short—did not take drugs. "For protection against malaria attacks, 4-aminoquinolines, such as chloroquine and amodiquine remain the drugs of choice," according to a recent issue of WHO's Weekly Epidemiological Record, except in certain Latin American and Asian countries, where chloroquine- resistant malaria is reported. The drug regimen should begin at the latest on the day of arrival, and continue for four to six weeks after departure. Just what should be prescribed depends on the physician. A table of suggested drugs and dosages, as well as a list of other protective measures, are set out in the publication. People. Appointed as Director of WHO's Division of Communi- cable Diseases, Dr Fakhry Assad (Egypt), a staff member since 1960. He is now responsible for these units: bacterial and venereal infections, epidemiological surveillance, leprosy, smallpox eradica- tion, tuberculosis and respiratory infections, veterinary public health, virus diseases, diarrhoeal diseases control, prevention of blindness, and safety measures in microbiology. Stopping Samples. Hospitals in Saskatchewan, Canada, have been asked by the province's Health Minister, Herman Rolfes, to stop giving away infant formula packs—which are provided free by manufacturers—to women who have just given birth. "If a hospital gives away samples, this may directly affect a mother's decision to stop breast-feeding. This is not best for the baby," he is quoted by Canadian Press as saying. And, he adds, "in these inflationary times, it doesn't help a family's budget." The move is supported by Saskatchewan's Registered Nurses' Association, and is in line with WHO's international code on the marketing of breast-milk substitutes. Free samples as gifts, not only to mothers and pregnant women, but also to their families, are proscribed under Article 5. Nomad herdsmen in Ethiopia—one of the 31 nations that are recognise0y ,the international community as `lefist developed". (Photo WHO)