Africa and the drug threat [full issue]

AFRICA AND THE DRUG THREAT WORLD HEALTH THE MAGAZINE OF THE WORD HEALTH ORGANIZATION DECEMBER 1981 Cover: The shadow of drug dependence hangs over Africa's youth. See article on page 10. (Photo - WHO/P. Pittet) IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and 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 Jaipur Limb by Jitendra Tuli 2 Mongolia: 60 years of public health by D. Nyam-Osor 6 Africa and the drug threat by Pape Marcel Sene 10 Nicaragua invests in health by Maggie Jones 14 An income of one's own by Diana Gibson 18 The high latitudes by Hannu Vuori 22 Who teaches the teachers? 25 The spirits in the water-pipe by Jose C. Abcede 26 News Page 30 The Jaipur Limb by Jitendra Tuli From all over India, people come to Jaipur to receive artificial limbs which will give them greater mobility and new hope. This is the Jaipur Centre's contribution to the International Year of Disablec Persons rom the main road, the building looks like many others in the area—low, squat and of grey stone. A couple of ancient neem trees, one inside and the other outside the compound, provide welcome shade and an irresistible opportunity for young boys to test their climbing skills. Even as we walked towards the building, a group of admiring youngsters was watching the progress of a climber as he deftly climbed from branch to branch. Soon the "performance" was over, and Chandra Singh jumped down from a height which made the audience gasp. A big smile lit up his face. "It was great fun", he said, brushing away some leaves. "I am sure I can race anyone to the top". Nobody took up his challenge, as he had proved himself more than once. It was only when Chandra Singh started walking away that we noticed his gait: he had an artificial leg. Inside the building, run by the Mahavir Viklang Sahayata Samiti, a community aid association attached to the Rehabilitation and Research Centre of the sms Medical College in Jaipur, India, there were more surprises, and they came in many shapes and with different names. In the shade of the other neem tree in the courtyard, some men were sitting, just as they would have done in their village. They were busy talking or eating their lunch. Some, who had already finished, were washing their plates, and yet others were resting in the rooms along the courtyard. It was a mixed group, with a sprinkling of the young. There were people from all over the country, including some who had travelled over 1200 kilometres, 750 miles, to get to Jaipur. And they were from diverse back- grounds. They included farmers, and workers, and the unemployed. What they all had in common, however, was their determination to overcome a handicap. Each of them had lost one leg, or both. Each was using a pair of crutches. Each wanted an artificial limb. There were those, like Rajan, who had come all the way from Andhra Pradesh, in South India, waiting to be fitted with a limb. Then there was young Romesh, a railway employee, who had lost a leg, well above the knee, in an accident. He had come to the Centre just a few days ago and was already walking around confidently—without any support. In another part of the building, Mr Ram Chander, or "Masterji", which means teacher, was busy explaining in fine detail to a young craftsman how to give proper shape to an aluminium piece that formed a part of an artificial leg under preparation. And in the "office", Dr Pramod Karan Sethi, the spirit behind the whole scheme Even climbing trees is possible for an amputee fitted with the "Jaipur limb". Facing page: No more crutches. This farmer's artificial leg gives him much greater mobility and newfound confidence. ( Photos WHO/R. R. Centre, Jaipur) and an untiring pioneer in helping to give a new lease on life to the handicapped, was assuring an elderly farmer that his leg would be replaced in a couple of days. "He first came to us four years ago for an artificial limb. After he was fitted he went away, very happy and confident. He suddenly turned up yesterday, with his artificial leg completely worn out. It had been literally bound up with bits of string and rope, and the foot piece was reduced to a mere scrap of wood. The rubber had been completely scraped off'. Dr Sethi ex- plained that now the farmer was anxious to get a new limb, as soon as possible, so that he could get back to his fields. This was the sowing season. Dr Sethi, who was awarded the Mag- asaysay Award for 1980 for his work in developing what is now known as the "Jaipur limb", explains that—contrary to what many people think—none of the injured coming to the Centre to be fitted with artificial limbs stays even one day longer than is required. Board and lodging are free, as are the artificial limbs. But on several occasions he has found that no sooner has the limb been fitted than the person concerned is off. And this is irrespective of whether such persons have a place to go back to or not, whether they are employed or not, or whether they are educated or not. At any given time, the Centre has more than 100 people waiting to be fitted with limbs, or trying them out, or having them altered. During 1980, the Centre was able to provide more than 2,000 persons with artificial limbs, making it the largest such institution in this part of the world. What adds so much to the unique character of the place is the atmosphere of hope and confidence that is generated there. Each one of the inmates knows that soon he will be walking out of the Centre, leaving his crutches forever behind him In the words of Dr S.C. Kasliwal, a long- time associate of Dr Sethi, there is a strong spirit of fellowship that binds all the inmates together. Young or old, they give a helping hand to one another to overcome a handicap which, more often than not, has been the result of an accident. Dr Sethi himself says that the most satisfying aspect of the Centre's activities, apart from the actual fitting of limbs, is the fact that there is a strong element of community involvement. The Viklang Samiti is run mainly through donations, while many of its members give freely and willingly of their time. The other significant element is the use of rural skills and talent 3 •et e.oit -11! • 4.1■1007kianow M. Above: Dr P. K. Sethi holds up a Jaipur limb for inspection by Mr Ram Chander, who teaches craftsmen at the community-based workshop. Facing page: With his "new leg", this rickshaw-driver can continue to earn his livelihood. ( Photos WHO/R. R. Centre, Jaipur) brought to bear by carpenters, blacksmiths and leather workers. The artificial limbs prepared in Jaipur have a special feature which concerns the foot piece. A conventional limb, based on a standard design of Western medicine, has a foot piece which requires to be covered by a shoe. This, apart from increasing the cost of the limb, introduces certain social and cultural difficulties. It has also been noticed that the Western-designed artificial legs do not permit the user to squat or sit cross- legged on the floor, as people generally do in this part of the world. "In order to overcome these problems, we designed the Jaipur limb, which has a foot piece that looks like a natural foot", explains Dr Sethi. "It does not need a shoe, though one can be worn if desired. The foot is waterproof and sturdy, and has a unique design which not only enables the user to squat and sit cross-legged on the floor, but also to walk on uneven terrain". This is especially useful, since most of the users are farmers, who spend a lot of time in the fields, in water and slush. Of course, it took a long time and patient research before the Jaipur limb actually became functional. What made it possible was the deep involvement of people like "Masterji" and other craftsmen to create a limb that would fully meet the require- ments. A story that we were told summed up this feeling of involvement most aptly. Once, just before Diwali—the annual Festival of Lights—more than 70 people were waiting at the Centre for limbs. The artisans worked late, and even over-night, to ensure that every single person was able to get his limb and return home to celebrate the festival. Nobody had asked them to do it, and as for any overtime payment—the matter was not even brought up. Today, as Dr Sethi points out, much to the astonishment of visiting medical ad- ministrators and other professionals, a below-the-knee amputee can be fitted with a trial limb within 45 minutes of the time that the measurement for his limb is taken. There have been instances when such persons have walked out of the Centre within a few hours of being admitted. The sheer joy and the sense of fulfilment that the craftsmen experience on seeing someone discard his crutches are beyond description. This is especially true in those cases where a limb has been fitted several years after an accident. As one of the craftsmen explained, 1981 may have been declared the International Year of Disabled Persons; but for him and his colleagues, that "Year" began when the Centre was established in 1975, and it will end only when all those who need artificial limbs are able to get them. Sounds like a dream? But dreams do come true, given the will and determination of the people. As Mother Teresa of Calcutta, winner of the 1979 Nobel Peace Prize, wrote to the Centre, "May God bless your beautiful work, giving new hope to the handicapped". It seems likely that the successful experiment in Jaipur will spread to other parts of India, and to the outside world, not only giving the handicapped new hope, but also affording them a chance to live in society, with dignity and equality. ■ 5 Mongolia: 60 years of public health by D. Nyam-osor rom its earliest days, the Mongolian People's Republic has paid great attention to health. Indeed, the creation and development of public health services providing everyone with readily available, free medical care has been one of the greatest achievements of social- ism on Mongolian soil. The brotherly assistance of the Soviet Union has been decisive in the creation and development of a modern health service system in our country. There is no branch of the health services and medicine in Mongolia that has not benefited from the creative skill, deep knowledge, rich ex- perience and organizing flair of Soviet doctors. We feel proud of the progress achieved by Mongolia in providing health care during the 60 years of our State's existence. Our population, which was 647,500 according to the 1918 census, stood at 1,685,400 in 1981; thus it has practically trebled since the People's State was esta- blished. A high birth rate, low general mortality and accelerated rates of natural population growth are features of the population pattern. In 1980 the birth rate was 37.9 per thousand of the population, the death rate 10.4, the increase 27.5. This pattern has persisted from the late 1950s down to the present. The population is increasingly a young one, so our policy has been to favour the development of paedia- tric services in the public health system provided by the State. The average life expectancy has more than doubled, and is now 65 years, as against 30 in 1925. Before the 1921 Revolution, infectious diseases—notably smallpox, plague, tuber- culosis and certain others—were the main causes of sickness and death. But natural smallpox had been completely eradicated by 1940, while plague, polio and diphtheria had vanished by the 1970s. Tetanus and whooping-cough have become isolated occurrences. Non-communicable diseases are now the largest factor in the pattern of disease. The first places are occupied by non-specific inflammatory diseases of the respiratory organs, diseases of the heart and circulat- ory system (ischaemic heart disease, hypertension), diseases of the digestive organs, disease of the nervous system, cancers and injuries. The main causes of death are diseases of the respiratory organs, diseases of the heart and circulat- ory system, cancers, injuries and gastro- intestinal diseases, in that order. This general pattern of diseases and the causes of death provides the basis for the planning and provision of treatment and preventive medicine. Because Mongolia is very largely an agricultural country, further improvement of rural health care is important. The fact that the population is scattered and un- evenly distributed has given rise to a multi- level approach to the organization of specialized medical care and the provision of first-aid, ambulance and emergency medical services. General medical and midwifery stations, without a doctor in attendance, providing primary health care to the rural popula- tion, are the first level. Such stations, which operate on farms or serve the teams of State farms and agricultural combines, provide services for 250 to 300 people over a radius of 30 to 45 kilometres. District medical stations are the second level. Each station, which has 10 to 15 beds and one or two doctors, has its own An ancient lion statue guards the temple gates in Ulan Bator. Facing page: A technician prepares a pharmaceutical drug at the Mongolian Institute of Traditional Medicine. ( Photos WHO/D. Henrioud) ambulance vehicles and serves an average of 2800 to 3500 people over a radius of 60 to 80 kilometres. Hospitals serving a number of districts form the third level, and this is the first at which the rural population can receive specialized medical treatment. These hospitals—each with between 25 and 40 beds—have doctors for all the basic requirements: a general ward doctor, a surgeon, a paediatrician, and a gynaecolo- gist. Specialized treatment for the population of a province is provided by a provincial general hospital with polyclinic attached. The average number of beds in these hospitals was increased from 150 to 250 in the years 1976 to 1980. The hospital has its own ambulance and first-aid station, a mobile outpatient clinic and a blood transfusion station. Hospital facilities have been consider- ably expanded during the last ten years. The number of beds was increased by 23 per cent during the fifth Five-Year Plan (1971-1975), and by a further 25 per cent during the sixth (1976-1980). There are now 107 beds for every 10,000 of the population, and 75 per cent of the hospital beds are earmarked for specialist treat- ment. Increasing specialization in the allocation of hospital beds is being inten- sively promoted in Ulan Bator and other towns. Special attention has been paid to health protection and the improvement of medical care for the workers and employees of industrial enterprises throughout the de- velopment of the public health service. Great importance has been accorded to the fight against cancer, especially in the last 20 or so years. The national detection, treatment and prevention centre, which has its own hospital, and the cancer surgeries and departments in the polyclinics of the district centres and the towns are very active in providing treatment and diag- nosis, organizing the screening of certain groups of the population, and detecting groups at risk. The national cancer preven- tion, detection and treatment centre has mobile teams which carry out screening for the early detection of cancer and pre- cancerous conditions. Methods for the diagnosis and treatment of malignant tumours are being developed and im- proved; successful use is being made of a combination of surgery, chemotherapy and radiotherapy. The new innovations are Immunological diagnosis and cryosurgery (destruction of tumours by surgical ap- plication of extreme cold). The services for skin diseases, sexually transmitted diseases and tuberculosis are the oldest forms of specialized care in our public health services. We now have a hospital for skin diseases and venereal diseases in Ulan Bator, district and urban detection, treatment and prevention cen- tres, a TB hospital, a clinic for thoracic and bone surgery, sanatoria, and centres providing traditional treatment mainly for tuberculosis with koumiss (fermented mare's milk). Psychiatric care has become a separate service. We now have a national psycho- neurological detection, treatment and 7 prevention centre, similar centres serving groupings of districts, and psychoneurolo- gical departments in the hospitals and polyclinic surgeries of each district. There is a central psychiatric hospital in Ulan Bator and a rehabilitation centre (combining treatment with work) for chronic psychia- tric patients. For the treatment of injuries, a separate 150-bed orthopaedic and traumatological hospital was set up in 1976 in Ulan Bator; it has a burns centre and a rehabilitation centre for the physically handicapped. New advances in medicine and technology in the treatment of injuries and the resulting disabilities are being introduced here. Very successful use is being made of a method for the surgical joining of fractured bones developed by the Soviet scientist G.A. Ilizarov. The first-aid and ambulance service has been further developed; special teams have been set up to provide emergency treatment for stroke and infarction patients. There are now more than 30 first-aid and ambulance stations operating in the coun- try. Besides helicopters, aircraft and specialized vehicles, we make wide use in difficult terrain of animals, especially horses and camels. The underlying prin- ciple of medical care is that the worker at the bench, the miner deep in the earth, the shepherd in the pastures, the peasant in his field, the driver on a long journey, the hunter in the forest, students in laborato- ries, that is—every citizen of our country, should have prompt access to essential medical care. The outpatient clinic and the polyclinic are the key elements of our national health service. It is their work that makes health care generally available, and they provide for the active detection of disease in its early stages. A new approach being adopted in this type of medical care is to set up separate polyclinics for transport workers, building workers, care of the aged, indus- trial and occupational diseases, and so on. There is an epidemiological station in each district centre and each large town. These centres have specialized public health and anti-epidemic departments and laboratories. The State Institute for Hy- giene, Epidemiology and Microbiology is Health workers pay close attention, not only to the day-to-day health of elderly persons, but also to their living conditions. Children's health too has high priority. Youngsters at play in a kindergarten where working parents may leave them for the day. ( Photos WHO/D. Henrioud) the organizational and methodological centre for the country's epidemiological service. In addition, a special network of establishments exists for the control of particularly dangerous infectious diseases. The epidemiological service carries out State preventive and regular health and hygiene inspections in all enterprises and elsewhere, and is active in nature conser- vancy and in devising measures for the eradication or sharp reduction of a number of infectious diseases. Mother and Child A network of mother and child care centres has been created throughout the Republic. The children's medical district is the initial link in the paediatric service. 8 There were 280 such districts in 1980, in each of which there were 900 to 1,000 children up to the age of 16 under the constant supervision of a qualified paedia- trician; this figure includes 100 to 120 children up to one year old. All pregnant women are on a medical register and see the doctor on average at least 12 times during their pregnancy. In all districts and settlements, there are special homes funded by State farms and agricul- tural combines, where women may spend the week before and after the expected date of delivery under the observation of a doctor or midwife. The position has now been reached where 99.3 per cent of births take place in nursing homes. The provision of higher and secondary education for medical workers has been one of the great achievements of our country's health services. The Mongolian State Medical Institute, formed in 1942 as the medical faculty of the Mongolian State University, has been independent since 1961. Its therapeutic, paediatric, phar- maceutical, stomatological, and sanitation and hygiene faculties have more than 2,000 students. The Institute has a faculty for special and postgraduate medical training, the training of clinicians and preparation for higher degrees. Middle-level medical staff are taught in four medical schools in the towns of Ulan Bator, Darkhan, Sain Shanda and Gobi Altai. There are now 13,000 middle-level medical workers in the public health services. There are 3.4 people with middle- level medical education for every one doctor. In 1929, only one Mongolian woman, who became the first Mongolian doctor, graduated from a medical institute in the Soviet Union. There are now some 4,000 doctors working in Mongolia, 70 per cent of whom are women. There is currently one doctor for every 460 people. Suffice it to mention that the first Mongolian doctor to submit a candidature thesis in the Soviet Union did so in 1952; nowadays some five per cent of all doctors hold the degree either of candidate or of doctor of medical sciences. All districts, agricultural combines, State farms and built-up areas now have a pharmacy providing medicines and drugs; for the country as a whole there is one pharmacy for every 3,000 to 3,500 in- habitants. Mobile pharmacies have been used during the last few years to supply rural workers, and specialized pharmacies have been set up for town dwellers. The Mongolian Ministry of Health collaborates with its counterparts in the USSR, Bulgaria, Cuba, Czechoslovakia, the German Democratic Republic, Hun- gary, Poland and Viet Nam. Mongolia has been a Member of WHO since 1962 and has cooperated successfully with wHo on 10 programmes dealing with various branches of health care and medical science. Our cooperation with WHO is constantly being extended and deepened. The Eighteenth Congress of the Mon- golian People's Revolutionary Party, which was held in May of this year, set public health workers new major assign- ments in protecting the health of our people. It is a matter of honour for the health authorities and establishments and for all workers in the health services to carry out these assignments. ■ 9 Africa and the drug threat by Pape Marcel Sene 10 V ost African countries in recent years have seen the menace of drug abuse spreading with frightening speed. All efforts to counteract drug dependence are probably doomed to fail if neighbouring countries do not apply the same strict controls ome ten years ago, the prevailing view both in Africa and in the outside world was that drug depen- dence posed no threat to African countries, even if some of them were producers of the raw materials used in manufacturing narcotics. This view has now been proved wrong. Africa is not only the producer of some sixty of the world's toxic or potentially toxic substances, but this continent also consumes them in large quantities. Most of the African countries in recent years have seen drug dependence growing with fright- ening speed, and frequently involving more than one drug (including the use of alcohol). Furthermore there has been a distinct increase in the number of African countries which have reported the existence of drug trafficking within their frontiers. There has also been a significant increase in the quantities of drugs seized. These have mainly concerned cannabis and, to a lesser degree, cocaine. By contrast with the "Western" coun- tries, it is true, there have been no reports of massive seizures of heroin or morphine in significant quantities, and up to three years ago there were no clandestine laboratories for the manufacture of psychotropic drugs. But Africa has not escaped scot-free from the present worldwide trend for ever greater efforts to be put into converting medical drugs to illicit purposes through thefts from pharmacies or dispensaries, or through the misuse of medical pres- criptions. Drug dependence has taken hold of different countries at different rates. The picture looks gloomy in Ghana, Morocco, Nigeria and Senegal, for instance, but less serious in Algeria, Madagascar, Rwanda, Togo and Zambia. But generally speaking the measures taken to combat drug abuse are inadequate, if not simply derisory. Yet this battle against the problem of drug dependence cannot be separated from other battles against under-development in Africa. By reducing addicts to the state of nervous wrecks, drugs are depriving this continent of valuable manpower which it must have if it is to make economic progress and usher in an era of social well-being. The authorities are at last becoming aware of the dangers of this scourge and are showing their determination to halt it by adopting a variety of weapons, according to each country's needs. Let us look at three examples taken from among French- speaking African countries. These are Morocco, where the battery of measures taken to fight against drug abuse is only matched by the country's large capacity for cannabis production; Senegal, where drug consumption is giving rise to intense concern despite the existence of legal and Two pictures that sum up Africa, ancient and modern. Facing page, an age-old method of irrigating parched land. Above, a worker in the copper industry. As traditional cultural values are eroded, what is the social price that Africa—and especially African youth—may have to pay? (Photos WHO/D. Deriaz and WHO/UN) statutory regulations against it; and Togo, a small country which sadly lacks effective means for the fight against this new-born monster. Squeezed between Ghana and Nigeria, two countries with a strong existing trade in narcotics, Togo acts as a kind of relay point for the international drug traffic, even though the consumption within Togo is quite slight. All the same, it is possible to find substances displayed for sale in Togolese market places which are legally prohibited, while the trade in amphetamines and antibiotics evades the control of the Togolese authorities. A police brigade specialising in the battle against narcotics has been formed, even though its personnel have not yet completed their training. A national commission for drug control has also been set up. As regards legal sanctions against drugs, only those who traffic in them face long terms of imprisonment or expulsion from the country. Youngsters who smoke Indian hemp (cannabis) are treated as sick people. Better endowed In terms of weapons for the fight against drug dependence, the Kingdom of Moroc- co is much better endowed. This country has a long tradition of cannabis growing, an activity which boomed during the colonial period. After independence, a vigorous policy against drugs was initiated. The most notable of the measures taken to check the spread of drug abuse was put into effect with the help of the United Nations. It consists of replacing the cultivation of cannabis with that of vines. Project Derro, as it is called, was the first of its kind and deserves close study. It enables the Moroccan state to buy directly from the producers their crops of Indian hemp, to destroy these harvests, and then to grant the growers the cash needed to convert them into planters of vines. All the same there are a number of stumbling-blocks. These relate first of all to the special position of Morocco, lying between two seas and at a pivotal point between Europe and America. This situa- tion makes Morocco a promised land for both international traffickers and tourists. Among the latter are a few individuals who offer exorbitant prices to Moroccan cannabis producers and make their transactions from the decks of small pleasure boats. Very early on, Morocco adopted a series of measures in an attempt to tackle the drug problem. These include several legislative and statutory acts controlling the importa- tion, trade, possession and use of toxic substances. For example, there is the Law 11 Africa and the drug threat Left: Some countries have sought to curb the spread of the drug habit by persuading farmers to grow tobacco or vines instead of cannabis. Unfortunately the financial yield from cannabis is very high, and two crops can be harvested each year; small wonder that small farmers like these tend to turn away from tobacco in preference for the quick profits of cannabis. Some critics add that tobacco may be as harmful a "weed" as cannabis. Right: Bewildered by the speeding traffic, a recent arrival from the countryside squats by the roadside in a North African city. The psychological isolation of the individual, stemming directly from the exodus from country to town, shares some blame for the increasing problem of drug dependence in the African continent. ( Photos WHO/FAO and J.-F. Chretien (G) of 24 May 1974, created after Morocco had ratified the Single Convention on Narcotic Drugs of 1961. This law lays down severe terms of imprisonment and heavy fines against both users and traffickers in Indian hemp. It also punishes any advertising of the use of drugs. In addition, since 1965 a National Narcotics Commission has been set up composed of representatives of various ministerial departments and specialised services. The objectives of this Commission are to put the international conventions and protocols into effect at the national level; to investigate all effective steps that can be taken against the traffic in drugs; to ensure that toxicogenic drugs are used only for strictly medical purposes; and, finally, to draw up programmes of public educa- tion about the dangers. Parallel with these measures, Morocco has taken other steps of a practical nature. These concern the training of personnel for the drug control services, the reinforcement of staff of these services, severe control checks at the frontier posts, surveillance of territorial waters, and the use of dogs to sniff out hidden drugs. This policy has already given good returns, but a great deal remains to be done. In Senegal, the coastal regions of the Niayes and the swampy areas of the Casamance, in the south of the country, lend themselves readily to the cultivation of "yamba" as cannabis is known here. The financial yield from this crop is very high, and two harvests can be gathered each year. One kilogram of Indian hemp costs be- tween 5,000 and 12,000 CFA francs (between US $18 and $43) compared with 70 CFA francs ($0.25) for one kilogram of groundnuts. The figures speak for them- selves. However, production of yamba is not the only problem to preoccupy the Senegalese authorities and health officials; closely linked with it is the large-scale consump- tion of drugs. Drug addiction and multiple drug dependence have already made in- roads into all social classes and all age groups. Apart from cannabis, increasing use is being made of "datura metel" or "koubediara", a plant with disturbing and harmful effects, and of many other psycho- tropic substances such as psycho- stimulants, anxiolytics, hypnotics, neuro- lytics and various depressant drugs. What is more, there is a growing tendency to make use of certain solvents such as benzine, essence of turpentine, and to indulge in such crude practices as drinking a mixture of beer and ordinary petrol, or inhaling the fumes from empty petrol cans. The authorities fear that this new form of craving for drugs will pose a still bigger headache in the future for Senegal. Already some people associate the abuse of drugs with the present spread of mental illness. As in Morocco, Senegal has adopted a series of legislative and statutory measures against drug abuse. It is a signatory to all the international conventions in this field, and participates in the work of the uN Commission on Narcotic Drugs. Since 1965, there has been a National Com- mission on Narcotics and last year this body played host to the first international symposium on the drug problem to be held in the countries of French-speaking Africa. The Narcotics Squad from Senegal's Division of Criminal Investigation often takes part in operations in the south of the country which lead to fields of cannabis being destroyed and a number of growers being arrested. Each month half a dozen smokers of this drug are arrested by police and gendarmes. Despite the increase in control measures, the authorities have to admit that the number of drug dependents is steadily increasing as each year passes. The causes underlying this phenomenon are perhaps to be found in the allegations of a Senegalese judge, who believes that the country's legislators have concentrated primarily on setting up institutions aimed at suppressing and discouraging the con- sumption of drugs, rather than creating infrastructures designed to reintegrate the addict into society. If we accept the fact that the addict should be regarded more as a sick person than as a delinquent, most measures are not orientated in this direc- tion. In prohibiting addicts from remaining in the regional capitals, for instance, the law has not resolved the problem. Because now it is the rural areas themselves that face the threat of drug abuse. As regards treating drug addicts, a new experiment is being tried in Senegal. The therapeutic approach used to consist of sending the patient to the psychiatric centre of Fann. It turned out that this just didn't work: the drug addict was not accepted there. After being rejected by his own family, he found himself spurned too by the rest of the community at the psychiatric village. The large numbers of addicts who ran away testified to the failure of this experiment. 12 Now a new approach is under way which attempts to combine curative therapy and prophylaxy. This includes such fundamen- tal steps as the creation and strengthening of treatment centres for drug dependents, the formation of centres for re-education and social reintegration, the promotion of in-depth, multidisciplinary studies into the whole question of drugs, and the running of seminars aimed at educating the general public, teachers, medical and paramedical personnel, employers, parents and so on. Heaven helps those who help themselves. Faced by the complexity of the drugs issue, African countries have recognised their inability to tackle this modern-day scourge on their own. So they have felt the need to cooperate together at all levels—whether bilateral, regional, continent-wide and so on—as the only possible solution. Concerting their efforts in this way will be vital in order to master a problem with so many diverse implications. It is this spirit of cooperation which last year brought to Dakar representatives from many coun- tries of Francophone Africa to consider the drug situation. The recommendations of those who took part in the symposium, which have recently been taken up again by a meeting of experts in Morocco, hinge essentially on the need for each country to set up national commissions to combat drug dependence; the maintenance of statistical data on drug addicts; the support of African countries for the international conventions on narcotics; recognition by African countries of the social and eco- nomic value of participating in the work of the UN Commission on Narcotic Drugs; and the introduction of education pro- grammes on drugs in school establish- ments. Too much stress cannot be placed on the importance of an epidemiological study—an essential part of this struggle, since it is not possible to tackle this social evil effectively unless one knows the scale of it. At present, most of the African countries could still not give exact figures about the number of drug addicts (including those who succeed in hiding the habit), the total area of cannabis under cultivation, what motivates the cannabis growers, the quan- tities of drugs that are transported and by what social class of people. Moreover they have still no means of selecting or control- ling the medicinal products which are on public sale. It is worth noting that only 15 African countries had ratified the 1961 Single Convention on Narcotic Drugs up to 1980, while only seven have signified assent to the 1971 Convention on Psychotropic Sub- stances. The fact is that all efforts undertaken by one country are doomed to fail if neighbouring countries do not apply the same measures against drug abuse. There remains plenty still to do to protect the health and well-being of African societies. The problem of drug dependence—a recent development for Africa but one which has already had a devastating impact—has to be seen both as a modern-day sickness and as the conse- quence of a rootless age. The situation may best be illustrated by the apocryphal story of an anxious father who takes his drug- addicted son to the psychiatrist and tells him: "My son is not ill, he is not suffering from one of our diseases. He is suffering from one of your diseases. Keep him and treat him!" We may well wonder whether Africa is not in the end about to pay for a certain policy of artificially boosted development, the repercussions of a certain form of tourism, the erosion of traditional social and cultural values, the breakdown of the cellular family, the psychological isolation of the individual stemming directly from the exodus from countryside to town and the unemployment which inevitably fol- lows. It is clear that all efforts undertaken with a view to treatment, rehabilitation of drug dependents and prevention must bear in mind all these social and cultural factors, as well as the needs of the populations of each country concerned. The assistance of the international com- munity is vital. That is why the uN Economic and Social Council, ECOSOC, in its Resolution 2065 of 1977, invited the Member States "to ensure that the various specialised bodies of the United Nations and the specialised agencies shall devote special attention to the African countries, particularly those south of the Sahara, and assign to them some measure of priority in their programmes designed to combat narcotic drug abuse." This international assistance is being made available through the activities of such bodies as WHO, UNESCO and ILO (the International Labour Organisation), as well as the uN Division of Narcotic Drugs, the UN Fund for Drug Abuse Control, the International Council on Alcohol Pro- blems and Drug Problems, and the International Narcotics Control Board. ■ 13 Nicaragua invests in health Two years after the revolution and civil war which brought it to power, the youthful govern- ment of Nicaragua has called for a much bigger health budget, and now gives high priority to primary health care and preventive programmes by Maggie Jones L oiling off the highway and up the rough track under the baking sun, with Nicaragua's great volcanic cones looming in the far distance, the bus stops at Ciudad Sandino. One of the squalid shanty town built under the Somoza regime a few miles away from the capital city of Managua, the town now boasts the name of the revolution's symbol- ic leader, Augusto Cesar Sandino. It also provides a fine example of the govern- ment's new plans in health and social welfare—plans which are already making an impact just two years after the revolu- tion which removed President Anastasio Somoza from power. A dreary assemblage of makeshift huts without roads or services, where people used to rent the land from the Somoza family at a high price, Ciudad Sandino was previously lacking in health facilities of any kind. Now it has its own clinic called "Bello Amanacer", or "Bright Dawn", with two doctors, three nurses, and a pharmacist to care for the local population. Vaccinating the local population, espe- cially the children, against diseases such as polio, seeing that the people understand the value of better nutrition, and providing maternal and child health care are among the priorities listed by the young German doctor in charge. Bello Amanacer clinic is one of 79 health centres scheduled to be set up by the government throughout this Central American country. Nothing like this existed before, because—up to the revolution—all medical care was con- centrated in a relatively small number of hospitals. Moreover 45 per cent of health resources used to be concentrated on Managua, where only 26 per cent of the country's total population live. After the great earthquake of 1972, which took more than 30,000 lives and left its own toll of disability and disease, little was done to repair the damaged hospitals; indeed it was alleged at the time that aid directed to this purpose went astray and into the hands of corrupt politicians. At any rate, medical care was costly and directed towards the few. Social security covered only 17 per cent of the economically active people in the country and only one per cent of agricultural workers. Living conditions too were poor, tending to nurture disease. Only nine per cent of the rural population had clean drinking water, and there was a severe deficit of proper housing, especially for the men and women who worked on the big cotton and coffee estates. With this background, the new govern- ment decided to make primary health care and preventive programmes its priority. Medical services, which in the past had focussed on emergency treatment, now took a new direction. These measures, calling for a greatly increased health budget, have been taken despite the acute economic problems now faced by Ni- caragua, a massive external debt inherited from the past regime, and the devastation caused by the civil war–which resulted in 50,000 deaths as well as destroying communications, transport services and hospitals. The figures for this new programme are impressive. The 1980 budget was 345 per cent up on the 1978 figure. The National Vaccination Campaign administered 1.2 million vaccines against polio, tetanus, diphtheria and other diseases in the first six months of the year alone—a 146 per cent increase over what was achieved in the whole of 1978. Medical attention, measured by the number of consultations, increased by 121 per cent in the same period compared with the whole of 1978. By June 1980, less than a year after the Sandinista victory, 110 Oral Rehydration Units were functioning, deal- ing with some 29,572 children critically ill from diarrhoeal diseases. For 1981—which was to have been proclaimed the "Year of Health" if exter- 14 Above: Advice to a mother on the best foodstuffs to buy for her child. A scene at the Bello Amanecer clinic—one of 79 such health centres to be set up throughout Nicaragua. Right: A new concept of health is helping to safeguard children like these, growing up on the outskirts of Managua. Today, it is the people themselves who will be expected to work towards their own health improve- ments, without the need for costly institutions and medical staff ( Photos M. Jones ©) nal pressures had not caused a revision of this aim to the "Year of Defence and Production"—the government planned greater spending with a view to creating what it calls "a new concept of health". While greater government expenditure is needed to provide the basic services and train new staff, it is the people themselves who will be expected to work towards their own health without the need for too many institutions, doctors, drugs, and other costly facilities. This will be achieved through health education, through im- .proving working conditions, by the construction of latrines and supply of clean water, by immunization, and by improving maternal and child health. 15

Above: A lecture on maternal and child health in a poor neighbourhood of the Nicaraguan capital. Vaccinating the local population, especially the children, and ensuring better nutrition are among the other top priorities. Facing page: Nurses at the Bello Amanecer Health clinic at Ciudad Sandino discuss their work with an overseas doctor loaned to the clinic through the Intergovernmental Com- mittee for Migration. ( Photos M. Jones C)) For the short term, health education and improving living conditions will be brought about by the Sandinista Defence Commit- tees (cDss), a political "club" which has been created in every urban district along lines pioneered in Cuba. Apart from their political function, the CDSS will improve the quality of life in the poor neighbourhoods by helping everyone to keep the barrio (district) clean, looking out for those who need assistance, and seeking solutions to the areas' most press- ing problems. An appointed member of the CDSS will be on the alert for signs of illness and malnourishment in any member of the community and will encourage appropriate treatment, as well as giving advice to everyone in the neighbourhood on basic health care and nutrition. Other health measures are being taken on the big state-appropriated coffee and cotton plantations and in the various agricultural industries to give health check- ups to all. For many people this will be the first check-up in their lives, and it will help to prevent such diseases as malaria and tuberculosis. While 70 per cent of Ni- caraguan industry and agriculture is still in private hands, this new initiative by the government has encouraged private busi- nesses to improve their services to their workers too. Maternal and child health care is clearly a priority in improving the nation's health, and medical attention for some 64,000 pregnant women was written into the 1981 budget. But family planning services have had a low profile, despite the need for child spacing and despite the fact that the average Nicaraguan mother has six or seven children. The population problem has little meaning for the two and a half million people of war-ravaged and earthquake-scarred Nicaragua. In the weeks following the revolution, a private organization, the Nicaragua Demographic Association (ADN) cam- paigned successfully against the pro- posed banning of the contraceptive pill. But publicity is still not permitted for family planning methods, nor are these offered to women unless they specifically ask for them—which would be an unlikely move by a woman of poor reading skills in this predominantly Roman Catholic country. Nonetheless, ADN is working alongside the government to provide family planning services in the government hospitals and clinics. The Association is also developing a project with the government health service to train empirical (traditional) midwives in better techniques of delivery and to make sure that they know when to refer their patients to a hospital. In a country where all resources are needed, other private organizations too are playing their part. Nicaragua's literacy campaign, which in the space of five months claimed to have brought illiteracy rates down from 50 per cent to 13 per cent of the population, has been highly praised. This Central Ameri- can Republic's progress in health care, while necessarily somewhat slower, can hardly be regarded as any less impressive. ■ 17 An income of one's own One makes ledgers and exercise- books, another raises chickens; one bakes loaves, another grows veget- ables; one makes rope from coconut husks; others are mistresses of the more traditional crafts; some are far- mers. What all these women have in common is a source of income for the first time, and the capacity to use this income for better health and living for themselves and those around them. by Diana Gibson l8 Othe Women's Bureau of Sri Lanka was set up in 1978 with the objective of making women equal partners in national development. What women needed most urgently, the Bureau's Director found, was training for better family living, and programmes for income- generation. "There's no point in telling us anything", the women had said, "unless you can enable us to get another meal for the children!" So the Bureau set about coordinating the existing governmental and non- governmental resources for programmes which will gradually be directed to women in six main areas: the tea, rubber and coconut estates; the rural areas; the Mahaweli river development scheme; the urban slums; the fisheries; and the indu- strial Free Trade Zone. Mrs Vinitha Jayasinghe, the Director of the Women's Bureau (funded by NORAD —the Norwegian Agency for International Development—for its first two years), first told me about the Bureau's family health/ income-generation projects at the UN World Conference on Women in Copen- hagen last year. And this was how, some months later, I found myself with Mrs Kalyani Wijewardane, Assistant Director, and Mrs Rohini Bamunavitharana, Dis- trict Development Officer, picking my way down a steep path to a neat house in Matara, the southernmost district of Sri Lanka—to the loud barking of an aggress- ive but efficient watchdog. We had come to Matara, a beautiful wooded area near the sea, to visit the Having an income of their own has made a significant difference to these Sri Lankans. 1 Residents of Henamulla, one of Colom- bo's slums, now help support whole families with the products of their coir workshop. 2 A coir team in Matara, in the south, at work under the palms in their garden. With their new income, they can practise better family health. 3 The home gardener already keeps her family in vegetables. Like other Matara trainees, she is a member of the Lanka Mahila Samiti, the country's oldest organization for rural women. 4 Samiti members study better family living, including health, agriculture and income-generation, at the Training Cen- tre and farm at Kaduwela. They pledge themselves to two years' voluntary service. (Photos WHO/D. Gibson) Bureau's first trainees under the rural women's programme, which is supported by SIDA, the Swedish International De- velopment Authority. The dog was in fact guarding from polecats the young chickens of apprentice poultry-farmer Miss N.K. Devika, who lives with her parents, study- ing for an external degree. Behind the house is a large poultry-shed which the family built entirely themselves, even making the bricks, with a bank loan arranged by the Bureau. At the time of our visit Miss Devika had about 100 four- month-old chicks that would begin to lay in five months more. As eggs are in big demand, she expected to be able to buy a new batch of chicks in a year's time and then to continue without further financial assistance. Before starting the poultry training, Miss Devika told us, she took part in the one- month family health education course that covers maternal and child care, nutrition and environmental sanitation. There she learned about a balanced diet, food preservation, the value of leaves, how to can pineapples and mangoes, and how to make a cordial from passion-fruit. She keeps house methodically and insists on cleanliness and good sanitation. Former schoolmates and neighbours ask her advice on these matters, and she encourages pregnant women to use the government health facilities. Nearby lives Miss P.H. Somalatha, who got her school diplomas but found no work and was glad, at the age of 24, to have the chance to relieve her father, a mason, of maintaining his wife and five daughters singlehanded. She also has 100 chicks; looking after them, she said, takes about three hours a day. She mentioned learning how to prevent water-related diseases, and knows several other women who would like to join the poultry-farming programme. A group of houses that crouch under the palms at the sea's edge house a number of trainees who have learnt a quite different trade—making coir-rope from coconut husks. The husks are soaked under large stones in "retting-pits" in the sea, then beaten to remove the hair, which is spun into string and finally twined into two- stranded rope on wooden machines. Mrs Kusuma de Silva Jayasinghe already knew the process but had to work some distance away, which meant neglecting her family. Now the Women's Bureau has provided her with a machine and she can earn her own income at home; she has two children and her husband is a watchman. Her child care has improved, she boils the water and she makes balanced meals, she reported. It takes three people to operate the coir machine, so Mrs de Silva Jayasinghe works with her mother and a neighbour, even though this means that some of the income has to go outside the family. Mrs Nandani Gunathilake operates her machine with her mother and father. She too told us that neighbours had shown an interest in what they learned in the family health course. These women's income from the coir makes a valuable difference to families that till now have lived on the very modest wage of masons and labourers, perhaps 200-300 rupees per month (100 rupees are US$4.80). Other activities taught in the Matara scheme are flower-growing and home gardening. The gardener we met was Mrs Sunita Sirisena, daughter of a teacher and an Ayurvedic doctor. She has a son of eight and wanted him to benefit from her new income. Now she grows chilies, brinjal, cabbage, beans, sweet potatoes and other vegetables from plants provided by the Bureau. After the Agricultural Extension Division had shown her the best methods, it took her only three months to get results: already the family have stopped buying any vegetables from the market, saving 10 rupees a day or 280 rupees per month, the equivalent of a labourer's wage. The outgoings are 40 rupees monthly for cow- 19 dung and manure packets for compost. Any surplus produce can be sold. The fourth member of our visiting party in Matara was Mrs Mabel Ponnambalam, the hospitable and energetic district or- ganiser of the Lanka Mahila Samiti (women's organizations), the oldest group in Sri Lanka for rural women, which works closely with the Women's Bureau. All 150 Matara women trained by the time of my visit were selected members of the local Samiti, and this collaboration illustrates how the Women's Bureau coordinates those resources for women which already exist in Sri Lanka. The Bureau itself, as part of the Ministry of Plan Implementation, was welcomed by the non-governmental organizations be- cause it could count on the cooperation of other government departments. For exam- ple, the coir-project training was done by the Department of Small Industries. For the poultry-farming, the initial bank-loan of 3,800 rupees per woman to build the chicken-house and pay for veterinary fees and medicines was arranged through the Agricultural Development Authority, with six months' grace before the first repay- ment. In general, the projects are designed to fit into the existing integrated rural development programmes. At the Lanka Mahila Samiti's own Training Centre—a group of buildings and a farm—at Kaduwela, a village just north of Colombo, the courses also concentrate heavily on health and income generation. The L.M.S. was founded in 1930 by a Canadian, Dr Mary Rutnam, who based it on the idea of the Women's Institutes she knew elsewhere and strove for the uplift- ment of the rural women. Today the Samiti receives a government grant as well as donations from abroad. Miss Chandrani Wijeyesekera, a member of the Central Board and Executive Committee, points out that the pioneers were far-sighted women who anticipated 50 years ago today's L.M.S. programme for better family living all aspects of health care, home management and nutrition, education, agriculture, and income- generation—"because otherwise people can't live a healthy life and better themselves". The current class of about 30 young women at Kaduwela took us on a tour, and posed with much laughter for photographs in the handicrafts room and on the farm. In the lecture-hall they told us why they had wanted to come on this five-and-a-half month course. One, from Anuradhapura district, wanted to teach handicrafts to other village women, and to help the community to develop. Her two Sri Lanka wants to make women equal partners in national development. 1 This Matara poultry-farmer, who also studies at home, will be independent of financial help within a year. 2 Lanka Mahila Samiti graduates of Kadu- wela will teach crafts to village women so that they can earn money from raw materials they have at hand. 3 Apprentices from low-income families in Colombo train at the Marketing Depart- ment Bakery, prior to taking over the jobs of older bakers, who will shortly retire. 4 Bookbinders trained at the government press now have their own workshop in Henamulla. Thanks to their salaries, their families eat better. (Photos WHO/D. Gibson) years' voluntary service, to which all of them are committed, will include colla- borating with health officials and pointing to gaps in health services. Another, whose home is a model village very active in health promotion, says there will be a great demand for lessons in hemp-work. A third student's neighbours are farmers, but she says they are not aware of the importance of home-gardening. A fourth talks of the water problems she will help to solve. Matron Millie Samaraweera, the teach- ers and local medical personnel instruct the students in communicable diseases, nutri- tion, environmental sanitation, maternal and child care and first aid; later the women will direct mothers to village clinics, and keep an eye open for health problems during home visits to as many as 250 houses. They look after the Centre's cooking and cleaning, balance the budget, plant and tend crops, see to chickens and the cow, weave, make pillow-lace, crochet, and make bags and baskets. Since they will ensure the future liaison between village and government officials, great emphasis is laid on building up their confidence as leaders and orators. Before leaving Kad- uwela, they make a pledge holding a lighted clay lamp in their hands. This, the sign of the Samiti, symbolises the woman passing on knowledge to others in the village. In the Kaduwela Production Unit, 20 young village women have found employ- ment making up the cloth woven by some of them into blouses and table sets. The creche—training ground for L.M.S. creche workers from all over the country—also provides a service to the village, much sought after by the rural women, who know their children are being well cared for while 20 they earn income. Older children too need not miss school to look after younger ones. From the Lanka Mahila Samiti Training Centre it is not a long journey back to Colombo, where the first Women's Bureau projects have begun for women of low- income families living in urban slums. These projects are being supported by UNICEF, and the Project Officer, Mrs Sumitra Weerasinghe, was my guide. For slum women, the most urgent need is income. Our first call was to the Marketing Department Bakery, where Miss Flory, aged 21, is the monitor of a group of 25 trainees in bakery work. Her father is dead; of the 11 children in her family, five are still at home with their mother, supported mainly by a brother who works on the railways. They live in two rooms and a kitchen, and share a bathroom with seven other houses. Miss Flory left school at 13 and has never had a job before—she would have liked to be a nurse. Selected for training from a Charity Commissioners' list, she now earns 300 rupees a month from the National Apprentice Board during the one-year training and then will get a salary of 500 rupees luckily some older women at the bakery will soon be retiring, leaving vacant jobs. It's easy to guess how much difference this salary will make at home. The next stop was Henamulla "camp", where life in the plank houses roofed with plaited palm-leaves is a struggle, despite the efforts of the many bodies which are trying to help. Miss Sithi Januba, aged 17, chose to learn coir techniques at the open-air workshop. There are ten in her family, supported by her father and one brother. She invited me in to their neat, modest home verandah, drawing-room (where they sleep) and kitchen. Right outside the back door is an unhealthy ditch; they have to share a dirty latrine with 100 other people. The piece-rate for coir-work here is not very much, but it does help when added to the combined family income, while the Women's Bureau is trying to find more outlets for their ropes and brooms. The women told me they would be glad to do any work, but most people here have little education and no job. Fathers or brothers usually support the family on a labourer's rate of 15 rupees a day. Some can't afford to eat rice twice daily; they may get an egg once a week, and vegetables occasionally. In certain houses four or five families live together. Five buckets of water which is used unboiled—have to be carried home each day for use in the house; washing of clothes and persons is done at the tap in the road. The women say, through Mrs Weerasinghe, that life was bad for them earlier. Now they are "just OK", and they think the future will be better for them. Next door, ten more women aged between 19 and 22 are working under the guidance of a retired bookbinder. Having done nine months' training at the govern- ment press, they now produce ledgers for offices and exercise-books for schools. They cut the paper, rule it, bind it and sew it—most of this by hand—and for this work receive 500 rupees monthly, again earning for the whole family. They were in a "bad situation" before, they say, but now they can make a living and maybe even start a savings account. Their families eat better. For each woman being trained now by the Women's Bureau and the Lanka Mahila Samiti in the projects described here, there are hundreds more all over the country who long to follow in her foot- steps. Mrs Vinitha Jayasinghe, Director of the Women's Bureau, hopes that with their knowledge and skills these women will become catalysts for a change to good family health in their families and in the community. The need for an income of their own is vital for women everywhere. Once acquired, this income is used for the increased well-being of the woman's family and community. An investment in women is an investment fully repaid. ■ 21 The high latitudes ie he Wild West has been won, but—luckily for adventurous mankind—our planet still holds one "last frontier", the circumpolar regions. Population pressures and dwind- ling natural resources will inevitably force mankind to try to extend his habitat to areas that have previously been considered unsuitable for permanent settlement or suitable only for small native populations. These regions will therefore become the focus of increasing attention. They will be exposed to migration, industrial exploita- tion and ecological changes. For the daredevil, this may provide a welcome chance to test his strength and stamina against extreme environmental conditions: but for the average migrant and for the native populations, the development is fraught with potential health and ecologi- cal problems. To anticipate and solve these problems, wuo's Regional Office for Eu- rope has decided to launch a special programme in circumpolar health. In this era of cost-consciousness, it could be argued that a special WHO programme in circumpolar health is a waste of resources, because of the small size of the populations concerned, the nature of the health prob- lems involved and the fact that most circumpolar areas belong to rich, industrial countries. Let us examine these points a little more closely. In relation to WHO's global activities, the population living in the true Arctic (about one million) is indeed negligible, and even the population living in the sub-Arctic is tiny (about 20 million). It is also true that these populations live primarily in countries such as Canada, the United States and the Soviet Union—that are willing and able to provide them with health services. The health budgets of arctic Alaska and Canada are among the highest in the world on a per capita basis. On the other hand, most countries, including the rich industrialized ones, tend to suffer from a maldistribution of health services, which often hits hardest those population groups that are ethnically different from the majority and that live in remote areas, where the distances are long and the settlements small. These are characteristic features of arctic and sub-arctic areas. However, it is not the size of the population that matters. Article 25 of the Universal Declaration of Human Rights, adopted by the United Nations General Assembly in 1948, specifically mentions a right to medical care and a right to a standard of living adequate to provide for each person's health and well-being. The preamble to the Constitution of wHo states that "the enjoyment of the highest attain- able standard of health is one of the fundamental rights of every human being without distinction of race, religion, politi- cal belief, economic or social condition," and that "governments have a responsibil- ity for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures". The most recent reaffirmation of this principle appears in the Declaration of Alma-Ata, adopted by the leading health authorities of more than 140 countries in 1978: "The existing gross inequality in the health status of the people, particularly between developed and developing coun- tries, as well as within countries, is politically, socially and economically unac- ceptable and is, therefore, of common concern to all countries." So it is clear that the provision of health services to people living in circumpolar areas should not be based on any considerations concerning the prospects of finding natural resources in these areas and of exploiting them economically, but on the principle of "right to health". The concept of vulnerable and high-risk groups, which also features in the Alma- Ata Declaration, can be evoked to justify WHO's involvement in circumpolar health. It is true that there are relatively few problems that are specific to the circum- polar areas, or exclusively limited to them. Consequently, it may be unwarranted to speak of a medical specialty called arctic or circumpolar medicine, even though, in the past, such problems as frostbite gained great attention as examples of the proper subjects of such a specialty. Even today there seems to be a "latitude bias", a tendency to think that the mere fact of residing in the extreme north or south is in itself a major health risk. But the example of many migrant communities engaged in mining, oil drilling and similar activities demonstrates that it is possible to reach and maintain a level of somatic health fully comparable to that of people living in less extreme areas. Nonetheless, the paucity of unique health problems does not mean that the circumpolar populations, particularly those who are native to these regions, do not qualify as vulnerable and high-risk groups, deserving high priority in health planning. Most health statistics covering circumpolar areas show a sombre picture: the average life expectancy is shorter, infant mortality is higher, and so on, than 22 A special programme in circumpolar health, launched by WHO's Regional Office for Europe, is planning new strategies—including a shift of emphasis from clinical to community medicine—to serve the needs of scattered communities who live and work in the frozen regions by Hannu Vuori stand was spelled out in a position paper entitled "the Approach to Circumpolar Health". The first proposal to establish a special EURO programme on arctic medicine was Above: Chimney smoke—token of interior warmth—drifts over a little settlement in the frozen north of Canada. Right: An active volcano provides the smoke above the lonely tents of an Antarctic research team. Below: Herdsmen in Central Siberia prefer reindeer to horses in the deep powder snow. ( Photos L. Sirman C)) ,41 in the south. Before dismissing the health problems of the circumpolar areas as trivial, we should also remember the fragility of the circumpolar nature and its vulnerability to harmful ecological in- fluences. There is a third, pragmatic reason for wrio to become involved. The biggest problems related to providing health ser- vices do not stem from any specific circumpolar pathology, but from long distances and scattered and small popula- tions. These are problems that are shared by many other areas, such as arid regions and archipelagos. Such areas cover roughly one-third of terra firma and provide a habitat for quite considerable populations. Consequently, solutions found to the problems of providing services in the extreme north and south can also be applied to the benefit of people living in many other parts of the world. International symposiums WHO showed considerable interest in circumpolar health as early as the 1960s, and arranged a conference on Medicine and Public Health in the Arctic and Antarctic in 1962. Because a majority of Member States did not consider this to be a high priority area, interest flagged for a while. Even so, the European Regional Office (EuRo) was represented at the Second and Third International Sym- posiums on Circumpolar Health (in Oulu, Finland, in 1971 and in Yellowknife, Canada, in 1974) and participated actively in preparations for the Fourth and Fifth Symposiums. At the Fourth Symposium in Novosibirsk, Soviet Union, in 1978, EURO'S 23 made in 1975. The suggestion was that this programme should cover the problems of nomadic populations in the Arctic, the extremely difficult conditions of work, the problems of mankind adapting to these conditions, and the development of com- prehensive health care systems to serve such populations. It was also suggested that EURO should collaborate actively with Canada and the United States in implementing this pro- gramme, although the Regional Office for the Americas accorded it a low priority. Gradually, because of the known interest of Canada, the United States and the USSR, and the possible interest of countries concerned with the Antarctic, the idea emerged that the programme should be made a global one, with EURO as focal point. In 1979, following a Working Group on the health problems of local and migrant populations in arctic regions, a special consultation was organized with American, Canadian, Russian and Scan- dinavian participants to define WHO's role in circumpolar health. As a result of the recommendations made at this consulta- tion, a full-scale Medium Term Programme in Circumpolar Health was drawn up in 1980, to become effective as a global programme from 1983, should the Director-General of WHO so decide. It is expected that Canada, Denmark, Finland, Iceland, Mongolia, Norway, Sweden, the Soviet Union and the United States, and possibly Argentina, Australia, Chile and New Zealand, will be interested in it. The Working Groups on environmental health problems in arctic areas and on comparative studies in circumpolar health, organized in connection with the 5th International Symposium on Circumpolar Health, are, in a way, first steps towards the implementation of this programme, although they are still being carried out under the auspices of other EURO programmes Basic premises The programme rests on certain assump- tions about the nature of the problems to be tackled and the obstacles to be overcome when implementing it. These assumptions, the correctness of which must be cor- roborated by concerned health authorities and scientific community and community representatives, are as follows: Target population: There are two main population groups: the natives and the settlers. Particularly with regard to psycho- social problems, the settlers can be divided into temporary migrants (workers coming to complete a defined task of relatively short duration), first generation settlers (persons who intend to stay permanently in the circumpolar areas but who have lived part of their lives in non-circumpolar areas, and who have their original domicile and possibly relatives in such areas), and second and further generation settlers (persons born in the circumpolar areas and intending to stay there). The relative importance of these populations varies from country to country depending on their size. Miner's homes in the extreme south of Argentina. Many migrant communities in the polar regions manage to enjoy as high a level of health as people living in far less extreme areas. (Photo WHO/ILO) Health problems: The natives and set- tlers have some problems in common and some different problems. Both groups are confronted with a new culture. Since the culture of the settlers is dominant, accul- turation problems are much more difficult for the natives, and probably constitute the main cause of their health problems. The settlers may also experience acculturation problems because they have been uprooted from their original culture. The natives may still carry the burden of some traditional diseases (for instance, contagious and parasitic diseases), but they are also confronted with health problems related to "modernization" and industrial- ization (occupational injuries and diseases, or "behavioural diseases" such as certain types of cancer and cardiovascular di- seases). Long adaptation has usually enabled them to endure the harsh climatic conditions, whereas the settlers often have both biological and psychological adapta- tion problems caused by the climate, darkness, lack of leisure activities, sexual deprivation, and so forth. Dynamic picture: The circumpolar re- gions are going to become the focus of increasing interest. Migration will inevi- tably create ecological problems and difficulties of acculturation. Similarly, settlers attempting to live in adverse conditions will experience both biological and psychological adaptation problems. With some countries actively encouraging migration, the number of people exposed to these problems is increasing rapidly. This may result in the population becoming more vulnerable than in the past. In earlier times, the circumpolar areas were inhabited by, in many respects, "abnormal" settlers. They were often individuals with great stamina, and fre- quently of peculiar character. With the influx of new settlers, the previously male- dominated population has become more "normal", including more women and children, which is resulting in a rapidly changing and more diversified health and disease panorama. With the increase in the size of settlements and in the sophistication of the technology used, the impact of the new culture and technology has reached previously unknown dimensions. As yet we do not have the necessary skills to predict their long-term impact. Problems of implementation:A major stumbling-block, from EURO'S point of view, to developing and implementing the programme in circumpolar health is the fact that only a few Member States have circumpolar areas. Support for this pro- gramme, for example in the Regional Committee, is not unanimous. The coun- tries concerned, however, consider this is a problem area of great and growing impor- tance. The suggested global character should make the programme more viable as the number of countries actively sup- porting it, and participating in it, increases. The global approach should also increase the possibilities for international coopera- tion, both in research and in the provision of services. The overall objectives of the new pro- gramme are: to reduce the prevalence and incidence of problems caused by deficient acculturation and adaptation, and by deteriorating environment; to increase the range, number and acceptability of avail- able services; to train more manpower (including health workers recruited from amongst the native populations) which is better equipped as far as motivation, knowledge and skills are concerned; to encourage lay-care and self-care; to en- courage research on circumpolar health and to develop research methodology. As in the case of all Yam programmes, it should be noted that these objectives are expected to be reached, not by the single- handed efforts of wHo, but through, and in collaboration with, the Organization's Member States. ■ 24 Who teaches the teachers? he skills and attitudes of primary health care workers do not come naturally. The same is true for medical doctors, nurses, sanitary engineers and all those who—alone or in a team—contribute towards better health for their community. Their role will not be confined to treating the serious and trivial diseases, or the major and minor accidents, that beset everyday life. They will also have the task of making the community health-conscious. They will need to convince the village elders, or the district administrator, that a smelly, mosquito-infested swamp lying between the houses must be drained, or that the pollution emitted by a factory must be controlled. They will have to persuade unwilling, even hostile, residents that the local river should not be used for drinking water; that it will be worth spending effort and a little cash to bring piped water from an unpolluted source several hundred yards away, or perhaps paying additional taxes so that the river becomes clean again. They must overcome the natural reluctance of mothers to seeing needles pushed into their babies' bottoms; they must show them that the brief discomfort of regular immunization will save those babies from later illness, perhaps from death. So these personnel, ranging from com- munity health workers to specialist doctors, must be taught their skills and motivated to think and act in the right direction. But the skills and attitudes of teachers of health sciences do not come naturally either. It is in order to assist these teachers in the training of competent and self-reliant health professionals, both for countries of the Third World and in the technologically advanced areas, that the World Health Organization has now pub- lished the fourth edition of its Educational Handbook for Health Personnel, prepared by Dr Jean-Jacques Guilbert, Chief, Ed- ucational Planning and Methodology, at WHO Headquarters in Geneva. This teach- ing guide is first and foremost aimed at teachers themselves, but also at health programme directors and at decision- makers at all levels. This new edition has been completely revised, but the broad principles followed by previous editions have been maintained. Essentially, the author advocates a syste- matic approach to educational develop- ment for both teachers and students. Dr Guilbert has, however, introduced a number of important changes in the light of his experience, and as a result of the many constructive suggestions made by people who have used the Handbook in practice or studied its principles at teaching work- shops held around the world. One important revision to the chapter on educational objectives puts special stress on the quasi-identity of these objectives and the tasks which health personnel will have to undertake in the exercise of their profession. Defining and delimiting their roles, functions, activities and professional tasks will in turn lead to better and more relevant planning of the process of drawing up educational goals. The most noteworthy innovation in the section which looks into tests and methods of evaluation is a set of suggested criteria which should make it possible to evaluate not only the students but also the quality of the goals and the way they are drawn up, and the training programme itself. Advice on how to organize a teacher- training workshop of short duration has been filled out in the light of past experience. This part of the guide, which describes one of the best means for making teachers more competent and more effec- tive, is directed particularly towards those who, after taking part in meetings of this kind, wish to organize similar activities for other colleagues in their school. All the problems examined here are specifically those which arise during the training of health personnel—whether they are doctors or nurses, dentists, medical assistants, sanitary engineers and so on. The structure of the Handbook has been revised so that it is even better adapted to the special educational needs of users at different levels. Apart from the texts in English and French published as wHo Offset Publica- tion No 35 (obtainable from Distribution and Sales, wHo, 1211 Geneva 27, Switzer- land, price 28 Swiss francs), editions in Spanish and Italian are also available. The Spanish edition should be ordered from: Instituto de Ciencias de la Educacion, Universidad de Valladolid, Palacio de Santa Cruz, Valladolid-2, Spain. The Italian edition should be ordered from: Editore Armando Armando, Via della Gensola, 60-61, 00153 Rome, Italy, Earlier editions of the Handbook have also been translated into Bulgarian, Czechoslovak, German, Hungarian, Indonesian, Polish, Portugese and Russian. Further transla- tions in Arabic and Serbo-Croat are planned. ■ 25 The spirits in the water-pipe by Jose C. Abcede ate in 1978, the people in the village of Dawage had a big celebration. Seven pigs were slaughtered for the feast. The occasion was the opening of the village water tap, built with funds from the local council. After the feast, the jawbones of the seven pigs were strung across the water tap, and a taboo sign was planted nearby. Almost three years after the feast the jawbones were still there, painted with bright red spots. The taboo had been effective; no one had dared to tamper with or mutilate the water tap. When we visited the place, the tap appeared to have been very much in use. Dawage is a village of about 1,000 people in the Kerowage district of Chimbu province, in the highlands of Papua New Guinea. But the water tap itself served fewer than 200 people living in a cluster of huts by the village mountainside. The provinces of Chimbu, Enga, South- ern Highlands and Western Highlands —with almost one million inhabitants— together embrace the rugged, mountainous central highlands of the country. In Janu- ary 1978, Papua New Guinea's Depart- ment of Health, with support from UNICEF and wHo, embarked on a project to provide water supply and sanitary toilets in these four provinces. The target, for the first three years, was the provision of 60 water supply systems and sanitary latrines for each province, or a total of 240 projects. In these mountainous provinces, the people depend only on rivers and streams Left: The jawbones of pigs from a ritual feast, reinforced by a secret "taboo" sign, have ensured that nobody tampers with the precious water tap in this Papua New Guinea village. Right: Digging the trench to lay a water- pipe was a joyous occasion for the whole community. (Photos WHO/J. Abcede) 26 Even before the International Drinking Water Supply and Sanitation Decade began, the highlands of Papua New Guinea were getting piped water and sanitary toilets. And despite some early doubts, villagers are now recognising that nothing but good can come out of a water tap 27 for their water needs. They have had no tradition of village wells or common water taps. It was therefore a matter of showing the villagers the benefit and convenience of communal taps or water pumps. And in a land of many taboos and deeply held beliefs, to start something new could spark off many complications. The first water systems were therefore put up in community school grounds. Village leaders and parents were then invited to see what the schoolchildren were enjoying. Next, the villagers were told that if they wanted this flowing water near their homes, they would have to ask for it—and pay for it. Health officials appear to have been pleasantly surprised by the response. Mr Michael Gandi, project coordinator in the highlands, told World Health that the "response was too much, we could not cope with the demand". About 50 to 70 requests have come in every month since the start of the project. In many instances, the village people expressed readiness to do their share, in the form of voluntary labour or cash payments. During the first two years, 104 water systems serving 42,000 people have been constructed, and some 350 toilets have been built. Dr Damien Wohlfahrt, Provincial Medi- cal Officer, Western Highlands, confirmed that there had been "a great deal of community interest in water supply and environmental health in general". How- ever, he made it quite clear that there have been difficulties in obtaining a pump that works properly. In the villages, the gravity-fed system works better, particularly if the villagers themselves have selected the source. But pump wells have not been working very efficiently—after six months at most, something goes wrong, somehow. And it is very hard to find a villager who is competent to look after the pump, let alone to do repair work. Mr Gandi conceded that such break- downs have naturally proved to be great disappointment to the villagers. But they have been no less a disappoint- ment to the project staff! To install, a gravity-fed water system might require long hours (sometimes days and weeks) of talk and negotiations with village leaders, and with the owners of the land on which the pipes will be laid. In one village served by gravity-fed system, the people refused to draw water from the tap. Eventually the project staff learned that they had laid the pipe on a trajectory that cut across the path to the women's menstrual hut. Since the women were stepping across the pipe during their 28 The spirits in the water-pipe ,p. Left: Clean, safe water flows vigorously from a tap in a remote part of Papua New Guinea's central highlands. Hitherto, people depended on rivers and streams for their water needs, and there was no tradition of village wells or community water taps. Right: Under the central highlands' project—begun well before the start of the International Drinking Water Supply and Sanitation Decade ( 1981-1990 )—the villagers often proved willing to contribute their own labour or even cash. Consequently they are even more appreciative of the convenience, clean- liness and healthiness that water taps and sanitary latrines bring to the village. (Photos WHO /J. Abcede) monthly period, the water in the pipes must of necessity be contaminated! On another occasion, in a different community, the new water system was discovered to be scaring the wits out of the villagers. Apparently the water pressure was particularly strong, and certain super- stitious individuals became convinced that noises heard in the night emanated from spirits in the pipe! But all the reports agreed in the end that the project staff have been able to avoid coming in conflict with any of the many and varied taboos, and that they have often successfully driven away the "evil spirits". Once the mechanical problems of frequent pumpbreakdowns have been laid to rest, the people living in the central highlands of Papua New Guinea will begin to appreciate more and more the convenience, cleanli- ness and healthiness that water taps and sanitary latrines confer. ■ k = i 0400 41410000 0 00 00• 000 1100 000 0 0 0 000 ... I 000 •00 *00 000 000 0 00 000 ••• 0 410 •OOOO• 000 000 100 0•• •0• ••• 000 00• 000 000 5S 000 000 00 0 015 000 000 000 000 000 •00 000 0 410 0 00 40 •00 ••• 000 000•00 0• •0• 41•• 000 • • • 00 000 000 000 000 •00 ••000 0 Cancer Widely Prevalent in 3rd World; Accounts for More than Half of Cases The diseases known commonly and collectively as cancer are associated almost invariably with the developed world to an ur- ban and industrial style of life. The truth however, is far from that. Rather, it is to the contrary. According to WHO estimates, there are 37 million cases of cancer throughout the world. And of that number, a recent report of an expert group says: "It is estimated that more than half of all cancer patients today are in the developing world." In all its forms, cancer afflicts some 8 million persons each year. More than half those stricken are in developing countries. Needed: Compaigns against the chewing of betel nut. Photo WHO/Eric Schwab Furthermore, of four common cancers, three—mouth, cervix and liver—"chiefly affect the developing world". Together with lung cancer, each claims a million victims yearly, or a total of four million. However, the experts see lung cancer as also becoming a major health problem for the developing countries in the next century "unless the current in- creases in the sale of manufac- tured cigarettes are slowed or reversed". Despite all of the foregoing, the report says: "Little attention has been given to the needs of the cancer patient in the developing world". And, indeed, almost all of the $2 billion yearly for cancer research is spent in developed countries. These and other facts have led WHO to call for a fresh impetus against the diseases that, irres- pective of country, are among the world's three main causes of death. For, while there is the knowledge to decrease both can- cer incidence and deaths, it is not being applied. In advocating international cancer control programmes, WHO asserts that: Up to a third of all cancers can be prevented. Foremost in this category is lung cancer. "About 80 to 90 per cent of all cases of lung cancer in the developed countries are caused by tobacco", the report says. Mouth cancer, a significant problem among populations on the Indian sub-continent, is also avoidable through education programmes to discourage chewing of betel nut, and to encourage oral hygiene. Cervical cancer too is avoidable, through genital hygiene. There is the likelihood that the U.N. Water Decade aimed at providing pure water to com- munities could also bring about a "reduced incidence of cervical carcinoma", the report notes. Cervical cancer, along with breast cancer, are the two most common cancers in women. Up to a third of all cancers could be cured through early detection and treatment. In fact, the earlier the diagnosis is made, the greater the likelihood of a cure. Studies have shown, for instance, that up to ten years go by before pre-malignant lesions in the neck of the womb become cancerous and spread to the uterus. The aim of education pro- grammes should be to create knowledge in populations of certain warning signs, and to persuade them to seek medical care promptly when these show Up. For instance, unusual bleeding or a vaginal discharge could be an indication of cervical cancer; a lump on, or thickening of, the breast, breast cancer; a sore that does not heal, skin cancer; and a change in bowel and bladder habits, colon-rectum cancer. Finally, the majority of ad- vanced or incurable cases can be spared pain through inexpensive drugs, administered by the pa- tient, or family members, or even a primary health worker. The greater tragedy, says Dr Jan Stjernsward, chief of WHO's cancer unit, is that, because of a lack of knowledge or of the drugs, "in many developing countries, nothing is offered at all". The Simple Soybean Fights Malnutrition The soybean—or simply soya—is playing a large role in Sri Lanka's campaign to improve nutrition among its 14 million inhabitants. And in the successes achieved thus far, health officials say, there is a lesson to be learnt by coun- tries elsewhere. According to Soyanews, a newsletter put out monthly in Tamil, Sinhala and English, a pound of soya flour contains 182 grams of protein, as com- pared to 90 for lean beef, to 80 for fish and to 56 for eggs. Soya more than adequately satisfies the daily protein re- quirements set by the country, which range from 19 grams for one-year-olds to 52 grams for adults, the newsletter says. Dr Carl Hittle, a consultant to FAO and U N DP from the University of Illinois, which is a pioneer in soya research, comments: "Soybeans con- tain about 40 per cent protein and 20 per cent oils high in calories and minerals and vita- mins. In this country soybeans are the perfect substitute for fish and meat." It is also less costly. The U.N. agencies are working with the government in a soybean development project that has led, so far, to a thirty-fold increase in the land put under cultivation to the soybean. In 1972, just 200 acres were devoted to it. In 1977, the acreage had in- creased to 6,000. Near Kandy, a highland city, and the base of soybean de- velopment, the government has established the Soy Foods Research Centre at Gan- noruwa. Mr Peyton Johnson, FAO information officer, who sam- pled a multitude of goodies while on mission to the island, says that just a taste of what the centre's demonstration kitchen has cooked up, "con- vinces the most sceptical visitor that soya can be made to taste like, look like, even smell like, almost any food". Relatively new to Sri Lanka, soya was first cultivated in China some 7000 years ago. It is, experts say, one of the most versatile crops ever. Best known probably of all soya products is soya sauce, now as common on supermarket shelves of the West as it is in stores of the East. But more importantly for health, the centre's inventive chef- researchers have produced a line of soya-based food that is changing eating habits throughout the land. To cite but a few examples: biscuits, bread, noodles and roti from soya flour; bean curd, soya milk for drinking— just as nutritious as cow's milk, and best of all, it contains no cholesterol" the newsletter reports—and soya milk for cooking; weaning foods and instant drinks; bean curd, curry (see box for recipe), soya cutlets, soya rice, soya oil, and soya meal. There is much more. Vegetable Curry (4 servings) Y. cup dry clean soybeans 1 cup grated fresh coconut 5 medium sized capsicums 1 medium sized onion 2 moderately big tomatoes 6 lady fingers 1 tsp. tumeric powder 1 tsp. curry powder 1 tsp. chili powder a few curry leaves salt to taste Over a slow fire, heat and stir the soybeans in a pan for about 20 minutes, without letting them turn black. Boil 1% cups of water. Drop the heated soybeans directly into the boiling water. Cook for 15 minutes. About '/, of the water should be absorbed. Discard the excess. Grind coconut and boiled soybeans into a very fine paste. Mix the paste with 2 cups of boiling water. This gives a moderately thin soya slurry. Add cleaned and diced vegetables and continue cooking for another 15 minutes. Serve the curry with rice. In addition, the centre car- ries out a training programme, to date graduating some 600 persons skilled in preparing nutritious protein-rich meals from locally grown soya and other ingredients. "What else can double the nutritional content of bread at almost no extra cost?" the newsletter asks rhetorically. "What else makes mal- nourished children healthy in a hurry? What else is totally acceptable to Hindus and Buddhists as a substitute for fish and meat? What else benefits all who eat it, from the babe in arms to the aged and infirm?" The simple, sumptious soya, of course. 30 Budget Cuts Imperil Health of Refugees The idea of self-help has never been without detractors among refugees in the 61 camps ad- ministered by the U.N. Relief and Works Agency for Palestine Re- fugees in the Near East. Critics claim that self-help projects give the camps a permanent character and compromise the refugees' right to return home or to be compensated for the loss of their lands. In some camps, according to Mr Syed Moini, the U.N. official responsible for environmental health services, it took years of persuasion before self-help was accepted. Now a budget squeeze is endangering projects. For its current fiscal year, the agency faces a deficit of $45 million that has already forced programme cut-backs. Par- ticularly hard-hit are self-help projects. Of the $445,000 bud- geted for self-help in environ- mental health, for example, only $124,000 has been approved for expenditure. Yet self-help projects make life more livable in dreary camps and help accomplish tasks UNRWA cannot by itself do. A project at camp Mieh- Mieh, which is perched on a hill near Sidon, in South Lebanon, is typical of the self-help that the agency encourages. There was no easy access to water for 2,000 residents. They bought it and carried it, uphill. UNRWA chan- ged that through the purchase of such material as pipes, cement and sand. The refugees pitched in with labour, built a water tower, and by cementing paths and roads, protected the pipes. As a result, water runs into every shelter. Last year alone, self-help pro- jects were carried out in 7 camps in the Gaza strip, 2 in Jordan, 10 in Lebanon, 4 in Syria, and 14 in the West Bank. "Largely through providing basic services, serious outbreaks of diseases among refugees have been avoided for 30 years of the agency's operation" says Dr S. Meilland, director of health and WHO representative to UNRWA. Thus, the shortage of funds threatens to break the pattern of self-help as well as to endanger health. Briefs Aging. Appointed as Secretary-General for the U.N. World Assembly on Aging, Mr William Kerrigan (U. S.), formerly General Secretary of the International Foundation on Aging, Washington D.C. In much the same way as an earlier U.N. conference raised consciousness world-wide to the needs of women, so too does the assembly aim at bringing about a change in attitudes towards aging. It is set from 26 July through 6 August in Vienna. In support of that view, and in recognition of estimates showing some 580 million over age 60 by the Year 2000, WHO selected "Add Life to Years" as its theme for 1982. Common Market Consensus. The ten nations of the Common Market have voted to support WHO's international code for the marketing of breast-milk substitutes, a key article of which calls for a ban on "advertising, or other form of promotion, to the general public of products". Meeting in the European Parliament at Strasbourg, the nations are Belgium, Denmark, the Federal Republic of Germany, France, Greece, Ireland, Italy, Luxembourg, Nether- lands, and the United Kingdom. Conflict of Interest. The American Medical Association has sold $1.4 million worth of tobacco shares, it recently announced, thus heeding arguments that many physicians make—namely, that it is an embarrassment to support the tobacco industry by investing in it while being in the forefront in the fight against smoking. Family Planning. In Pakistan, 75 per cent of women of child-bearing age are aware of family planning, but less than half-32 per cent—have access to the means to plan family size. That there is a gap between knowledge and opportunity is a finding of the World Fertility Survey, which is now nearing completion, its sponsor, the U.N. Fund for Population Activities, reports. Message Through the Media. Dr Halfdan Mahler, WHO Director-General, has appealed for the cooperation of representatives of the mass media to transmit "messages of health" to populations. "Invite them to get your message across" he urged health officials from 44 African nations in an address recently delivered in Accra, Ghana. It matters little if "this is dubbed as health propaganda", he says. "Propaganda is used in so many areas of doubtful benefit to mankind that I see no reasons why it should not be used for something as undoubtedly beneficial as health." Nobel Peace Prize. When the U.N. High Commission for Refugees was established in 1954, few saw its existence as extending beyond the immediate task at hand—the reset- tlement of European refugees made homeless by World War II. For that role, UNHCR was awarded, in 1954, its first Nobel Prize for Peace. Twenty-seven years later, as it received its second—a medal and cash award of $180,000—and with its work among Vietnamese refugees singled out, its responsibilities are no longer confined to a single continent. It now has charge of an estimated 10 million refugees, half of whom are in 25 countries of Africa. Today, as Mr Poul Hartling, the High Commissioner, says, "the refugee problem knows no geographical or political bounds". In the next issue On 24 March 1882, before a small circle of scientists at Berlin Uni- versity, Dr Robert Koch announced the discovery of the tuberculosis bacillus. The January 1982 issue of World Healthwill mark the Koch centenary, and sum up the status of tuberculosis in the world today. Authors of the month Mr Jitendra I'm is the Public Information Officer for WHO'S South-East Asia Region, based in New Delhi. Dr D. NYAM-OSOR is the Minister of Public Health of the Mon- golian People's Republic. Mr Pape Marcel SENE is a journal- ist employed with the Dakar newspaper Le Soleil in Senegal. Miss Maggie JONES is a freelance journalist specialising in articles on development and health. Ms Diana GIBSON is a Public Information Officer at WHO head- quarters in Geneva. Dr Hannu VUORI is Regional Officer for Primary Health Care with WHO'S Regional Office for Europe, in Copenhagen, and is responsible for EURO'S new Pro- gramme on Circumpolar Health. Mr Jose C. ABCEDE is Public Information Officer for wHo's Western Pacific Region, based in Manila. WORLD HEALTH for readers everywhere 1980 Subscription Rates US$ 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. ed in Sw itz er la n d Im pr im er ie s Re u ni es S .A . La u sa n ne Separating coir from coconut-husks ;n Sri Lanka. See "An income of their own", page 13. (Photo WHO/D. Gibso.-1,1