Summary reports on meetings 1982

Summary Reports on Meetings • 1982 WHO Regional Office for Europe SUMMARY REPORTS ON MEETINGS 1982 WORLD HEAL TH ORGANIZATION Regional Office for Europe COPENHAGEN 1983 ISBN 92 890 1008 8 © World Health Organization 1983 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen q), Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory , city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in these reports do not necessarily reflect the deci- sions or the stated policy of the World Health Organization. PRINTED IN DENMARK CORRIGENDUM This page: correct ISBN is 92 890 1014 2 This collection of summary reports is intended to provide health administrators and other health professionals with a con- venient guide to the proceedings and findings of meetings organized by the Regional Office for Europe in 1982 Separate editions in English, French, German and Russian are available. The Regional Office will be pleased to supply additional information on any of the activities described in the reports. CONTENTS ACCIDENTS AIR POLLUTION APPROPRIATE TECHNOLOGY FOR HEALTH BASIC SANITATION BIOTECHNOLOGY COMMUNI CABLE DISEASES FAMILY PLANNING HEALTH ECONOMICS HEALTH EDUCATION HEALTH OF THE ELDERLY HEALTH LEGISLATION HEALTH MANPOWER HEALTH PLANNING HEALTH STATISTICS HOSPITALS MALARIA NURSING NUTR ITION OCCU PATIONAL HEALTH ORAL HEALTH PHARMACEUTICALS PRIMARY HEALTH CARE PUBLIC INFORMATION TOXIC CHEMI CALS CONTROL WATER POLLUT ION WATER SUPPLY AND SANITATION page lJ 21 l.S 41 47 63 69 85 ':13 103 10':i 115 121 12 7 U3 137 14':i lSJ lb J 167 17 l 179 183 l d9 1~3 - 1 - . ACCIDENTS L Joint EURO/HQ Col!Ullittee on Statistical Indicators for Accidents St.-Etienne, 14-18 June 1982 - 3 - ICP/ADR 052(5) IRP/ADR 218-21 0218E 19 July 1982 ORIGINAL: ENGLISH Physicians, statisticians, sociologists, a health economist and representatives of the transport, home and industrial accidents and sports medicine fields, from dev~loped and developing countries, met to identify and review measures relevant to accident trauma and its sequelae, i ncluding factors connected with health and related interventions. The Committee focused its discussions on the following themes: (a) the accident trauma process, from the initial injury to a subsequent state of disability; (b) the health and related service intervention used in the course of the trauma process; (c) the circumstances surrounding the trauma event, including those factors implicated in precipitating the accident itself; and (d) the factors in the broad social enviromnent that may be significant in strategies to prevent accidents. On each theme attempts were made to identify basic indicators which could be used to monitor accident events, traumatic injury and subsequent disability. Conclusions With regard to the accident trauma process, it was concluded that the specific indicators developed, whether for policy, routine use, or for research purposes, should be simple yet versatile and adaptable, for all these levels and in all countries. Indicators of the circumstances surrounding the event and factors related to the victim were delineated. Basic factors include age, sex, type of accident, initial disposition and insurance coverage. The combined measure of SUM (Site, Underlying cause, Mechanism) is regarded as a useful composite indicator of circumstances. For the initial injury stage, the use of health services, the procedures employed, and the length of stay (for inpatients) were considered relevant indicators. Furthermore, measures of injury trauma and severity, such as the AIS-ISS (Abbreviated Injury Scale - Injury Severity Score ) and ICD (International Classification of Disease) code, were deemed essential for monitoring the victim's situation following the initial accident. It was recognized that other interventions, mainly by the social service sector, are also relevant and need to be identified, but specific indicators were not itemized. The subsequent state of disability of an injured victim is measured according to levels of functional capacity, particularly physical activity limitations, personal care and communication, mobility and psychological functioning. Indicators incorporating sets of items, such as the Activities of Daily Living Index, the Index of Functional Incapacity and the Psychological Dysfunctioning Rating Scale, were regarded as useful tools. The feasibility and practicality of other indices and scales for assessing a victim's subsequent state of disability were also reviewed but were not further specified. Some of the indicators delineated were not readily available on a routine basis from the L various sectors which could be expected to supply them. The Connnittee made note of the fact that further effort needs to be made to fill such gaps in the data gathering system. When ·considering accident prevention, the Col!Ullittee felt that basic indicators were essential to identify people's risk and exposure to accidents and to monitor policies, particularly at the - 4 - primary care level. Such indicators include environmental conditions in the home, on the road, at work, and in leisure settings. Also important are measures of product safety, of automobiles for instance, and the use of alcohol, drugs and other toxic agents. The Co11D11ittee recognized the multisectoral sources of indicators, and the problems of delineating specific indicators. The problem is similar in attempts to specify an aggregate measure of state of health (e.g. Index of Wellbeing) and of economic viability (e .g. unemployment rate, productivity loss). Measurement of the effects of different types of accidental injury should include their economic costs: both the direct costs of health and other services, and the indirect costs arising from residual impairments. It is, however, essential in the field of accident prevention to identify aggregate indicators, and further work must be undertaken to specify a basic set of these, since even the existing indicators are less effective when used independently. Following discussions about the specification of indicators for each theme, the Co11D11ittee made the following reco=endations. Recommendations l. Because of the increasing importance of accidents as a cause of mortality and morbidity, particularly in developing countries, the establishment of basic data collection systems should be encouraged. These can then be used by countries to develop prevention programmes which can be monitored and evaluated. 2. WHO should provide support and assistance in drafting the tenth revision of the ICD-E code, as well as chapter 17 of the ICD, on injury and poisoning. In addition, consideration should be given to the development of particular sub-modules of these codes fo r the purpose of identifying indicators related to impairment and lesion severity. 3. Efforts are being directed toward clarifying the applicability of the ICIDH (International Classification of Impairment, Disabilities and Handicaps) codes - particularly for impairments and disabilities . This activity relates to rev~sions which are currently under way on the ICD codes. To facilitate this, liaison should be established between representatives of this Committee and the ICD committee. Support should be provided to members of the Nordic Communities who are currently involved in: (a) demonstrating the practical a ppl ica tion of the SUM measures; and (b) developing severity scales, particularly aimed at ascer taining disability subsequent to accident trauma. Furthermore, support should be given to the efforts of other investigators and i nstitutions ho are i nvolved in assessing measures of accident injury, severity and subsequent disability, as ell as their practical application in health and related service intervention programmes. easures employed include AIS/ISS, fo r initial i n jur y and severity, functional incapacitat ion ( such s physical act ivi t y limitations, activities of daily living, and psychological dysfunction scales ) or dis abil ity, and use of health and social services (such as length of stay, medical procedures, ompensation insurance) for intervention purposes. Current and proposed studies (as indicated above) focus on the analysis of the accident injury rocess. A steering committee should be established to assist in the overall coordination of t hes e tudies and the dissemination of information arising from them. Where possible, the implementation f similar projects or studies should be stimulated in other locations such as in developing ountries where the capacity to carry out such activities exists. Given the wide spectrum of accident injuries and multisectoral agency involvement, efforts hould be directed toward coordinating and integrating information on indicators among the major ectors. This is also of concern to organizations such as CEC, ILO, OECD and particular government gencies whose interests cover the spectrum of road, home, sports and industry. Specific pilot "observatories" should be designated to monitor further the multiplicity of ctivities and areas of interest in accident injury and prevention, and to test the application of hese indicators in about five interested countries. L - 5 - 9. WHO should : (a) assemble available data on the costs of different types of health service intervention to prevent or treat accidental injuries, and initiate and support efforts to fill existing gaps in the availability of such data; and (b) collaborate with other international and national agencies to build an adequate data base on the overall economic costs of injuries caused by accidents of all types. Study Group on the Medicosocial Aspects of Accidents in the Aged Bordeaux, 2 9-30 June 1982 - 6 - IRP/ADR l06-20(S) 12711 8 July 1982 ORIGINAL: FRENCH A Study Group on the Medicosocial Aspects of Accidents i n the Aged met in Bordeaux on 29 and JO June 1982. The meeting was held in collaboration with the French Government and was a WHO initiative arranged as part of its contribution to the United Nations World Assembly on Aging, to be held in Vienna fro m 26 July to 6 August 1982. Some JO temporary advisers, drawn from backgrounds as different as public health, sociology and transport engineering, took part in the discussions, which were aimed at reviewing the state of knowledge on the subject, suggesting measures that could reasonably be applied in the short or medium term, and proposing research trends and the types of i nvestigation to be fos tere d. The Group began by stating the following : The elderly represent a section of t he population with an excessively high a ccident and inj ury risk factor as agains t other groups of the population. Their number is showing a rising trend, and the total number of elderly in the world will have more than quin tupled by about 2025, so that the incidence of accidents will probably show a similar trend, However, note should be taken of the almost total absence of i nterest in the subject, together with the paucity of research into accidents among the elderly, which calls fo r vigorous action to arouse political consciences, promote research and apply its results. Seven main topics were dealt with by the Group, whose conc l usions are surmnarized below . l. Epidemiology of traumatology among the elderlv General ly speaking , the epidemiological study of accidents and tr auma did receive the attention it deserved . The Group noted that there were numerous methodolog ical d i ff iculties ove r the acquisition of knowledge about the subject . The widely disparate sources of data hampered a general understanding of the history of a particular accident, a study of which should include i n logical order the phenomena occurring prior to the lesions responsible for it and a description of events following it, particularl y those which could produce permanent sequelae, An evaluation of present data sourc es would have to be made (i nsurance c cxnpanies, hospi tals, police), data collection s ys tems would have to be developed co meet clearly defined epidemiolo~ica l objectives, harmonize the definitions or indicators used, and above all improve analysis of statistical data by age groups while avoiding the use of clusters of age groups (65 years or more, for example) . Fo r their part, post-trauma handicaps should be defined in terms of functional disability, and not merely as disablement rates as is often the case, Of the different data available on t y pes of accident, figures for falls, particularly falls in the home or in hospitals or o ther institutions, turn out to be of chief importance in terms of their incidence, consequences for life or function, and their socioeconomic impact . Elderly pedestrians in traffic also form a high-risk population group. Ac cident-caused traumas among the elderly, in many cases the second most important cause of hospitalization in this age group, have a much more ominous prognosis for life and function than among the general population and this led the Group to suggest epidemiological and socioeconomic studies on standard types of trauma, such as fracture of the neck of the femur, still one of the most cormnon lesions among the elderly, or on syndromes of the drop-attack t ype. - 7 - 2. Poisoning and suicide Of the different types of involuntary poisoning, the Group singled out the effect of poorly measured doses of drugs, in particular in relation to falls in the home or traffic accidents . The Group noted that consumption of pharmaceutical d rugs increased with age and that its features included polypharmacy and self-medication. It was not a matter of doubting that such a state of affairs existed, but rather of seeing whether better use of drugs could not be made by the elderly, where account would be taken of such factors as alterations in pharmacodynamics attributable to aging, the need for prescriptions to be based on age-related doses, an understanding of the ways in which elderly persons were s ensitive to drugs, good information as to the faculty of comprehension among the old, and where polypharmacy could also be avoided. Another set of subjects that should be evaluated was the incidence of self-medication and the taking of drugs without medical prescription. The Group noted that suicide rates tended to increase with age . At the same time it c oncluded tha t this subject came under different methodologies than the study of accidents, but the Group did stress the fact that many cases of poisoning or accidents coming under other headings were probably due, to a not inconsiderable extent, to disguised suicide. 3. Economic aspects of accidents among the elderly This remained a largely unexplored field and also required work in selecting a method of study. It was particularly important for the overall approach to economic aspects not to be considered as the sum of the separate sectoral approaches; for example, to take costs of treatment and traumas in hospitals in isolation would be a very one-sided way of considering matters . On the other hand it would be useful to make a comparative study of different systems of care fo r the period following the acute phase of treatment, such as outpatient care, day hospitals or placement in a home . It would similarly be worth calculating the effect of treatment and minimal acute phase rehabilitation as often practised on subsequent costs during the chronic phase of disability . More generall y, it would also be interesting to contrast the cost of ergonomic adaptation of the homes of the elderly •,,1ith the cost of institutional treatment of traumas and th eir s equelae. 4 . The psychological predisposition process in aging and the role of desenerative conditions in accident proneness Although account should be taken of differentia l aging pr ocesses and the high degree of individual variati ons, physiological aging took the shape of involuti onal or ga ni c alterat ions that could be displayed in symptoms resulting in proneness to accidents. Les ions affecting the cen tral or peripheral nervous system were among the most important manifestations of involu tion, through the disorders of the equilibrium or deep sensibility they induced. Sensory disorders, in particular those related to sight or memory, and disorders of the vascular system such as or thostatic hypotension were all phenomena to be taken into account . Degenerative conditi ons such as arthritis of the knee or osteopor osis in a person sufferi ng from a fracture in the neck of the femur, might cause predisposition to fa lls or compl icate them when they occurred. In the elderly, major alterations to their perception of their surroundings also occurred, and this suggested that ergonomics-based solutions and a maximum investment should be made for the proper modification of the surroundings in which the y lived . 5. Physical and socioeconomic environment: factors , situations and risk groups Indus trial societies had evolved a world whose orga nizational elements and dynamics were r elatively compatible with the versatility of the young but were very poorly suited to the capacity of the old for adaptation. The adaptation of the envirorment to man (ergonomics) was by and large done to suit the industrial world, i . e . to the adult in good physical condition. The demographic i ncrease in the elderly population, the rapid growth of towns and cities, and the cultural chang es st emming therefrom, called for an extension of the ergonomic approach so that surroundings could be created which were less aggressive and better matched to the capacities of this population group, s omething that would also generally re duce the risks run by the population as a whole. - 8 - The Group therefore reviewed different types of environment ( temperature, sound, light, visibility, buildings in the habitat, traffic) in relation to accident risk, and risk groups (elderly workers, elderly pedestrians, groups of elderl y in areas being rapidly built up, elderly women) . The Group also attached importance co the risk factors caused for the elderly person by excessively fast technological and cultural change which failed to res pec t the period of adaptation needed for them to assimilate it . 6 . Priority in the treatment of trauma and in rehabilitation Aging had implications for the administration of first aid , medical or surgical treatment of trauma and for rehabilitation, which for a variety of factors was much more essential than among y oung adults . Medical rehabilitation activities should be initiated as soon as possible and most importantly must be planned for well before an accident victim was admitted to a care department . The Group also attached importance to two matters; on the one hand, non-discriminat or y admission procedures and ease of access by the elderly to rehabilitation, and on the other introduct ion of the concept of functional deficit to the evaluation of care a nd the calculation of compensation. 7. Information and educational priorities The Group made a comprehensive revi ew of the three following subject areas; types of information, persons capable of disseminating it, and methods and techniques fo r its dissemination. It was of particular concern to some professional groups, such as members of the health professions i n general ( the inclusion of traumatology in geriatrics programmes) or to architects, for town planning purposes or for ensuring safe surroundings . Accident prevention and safety should also be integrated with general c ourses in continuing education and education for health. Las e bu t not leas t, the Gr oup concluded that the most crucial concept was fo r elderl y people themselves to _be encouraged to participate in studies and programmes c oncerning them. 8. General conclusions The Study Group recommended a ser ies of research topics and activities to be undertaken under each of the headings referre d to above; t he y would be listed in deta il in the final report . At the same time , consensus was reached on the need to increase and imp r ove the s tate of knowledge of accidents among the elderly and their causes, an all too neglected sphere at present. The discussion also revealed chat there was nothing that might be termed " g eneral guidelines" to govern activities or research, notabl y over the lack of coordination among different professional groups, or among researchers f rom d ifferent fields ( transport, health, town and country planning, architecture, etc.). The Group therefore expressed satisfaction ove r the fact that WHO had included the question in its pro gramme of work fo r the following ye ars, and it was recommended that the Organization use its influence to arouse the governments of Member States to an awareness of the problem and thereby to facilitate and sustain the development of pilot projects or other suitable research. Study Group on Assessment of Country Surveys on Accidents in Childhood Ankara, 24-25 November 1982 - 9 - IRP/ADR 216 - 21($) 1272E 16 February 1983 ORIGINAL: ENGLISH A meeting of the Study Group on the Assessment of Country Surveys on Accidents in Childhood was held in the Turkish and International Children's Centre, Ankara, Turkey, on 24 and 25 November 1982. Representatives of 16 countries attended. The participants were mainly paediatricians, but the disciplines of public health, emergency medical services and behavioural sciences were also represented. The purposes of the meeting were: to review the general principles involved in preventing accidents in childhood; to secure reports from four countries (Benin , Brazil, Senegal and Turkey) which have carried out pilot studies jointly with WHO and the International Children's Centre of Paris; to discuss the methodological problems in data collection and analysis in these and other countries; to discuss how these pilot studies could be extended to other countries or used on specific problems appropriate to selected count ries; and to draw up guidelines on country surveys which coul d be used as a basis for accident prevention programmes . 1. Gene ral principles involved in preventin~ accidents in childhood The general principles were reviewed, and six stages were identified . These a re: the assessment of the size and nature of the problem; the identification of possible preventive facto rs; the delineation of possible interventions which would lead to a reduction in accidents; the planning and initiation of action at national or local level; the allocation of responsibilit y fo r action; and the evaluation of the action taken . 2. Country reports Reports from Benin, Brazil, Senegal and Turkey were presented. They can be summarized in two areas: facts on accidents and injuries that are common to most countries , whether developing or developed; and facts that show differences between or within countries . 2. 1 Common factors Childhood accidents in all countries show a rela tionship with the child's age and development : younger children have their accidents in and about the home (e . g . poisoning, burns and scalds), whereas older children have accidents outside the home (e.g. road accidents, accidents in vigorous sport or play and accidents at work, including agricultural occupations , in adolescence) . All c ountries show a predominance of boys over girls in the number of accidents . There appears to be a universal increase in the numbers of accidents among children in the families in the lower socioeconomic groups, including unemployed families. Increasing urbanization is everywhere associ a ted with an increase in the number of road traffic accidents reported. - 10 - The availability and degree of sophistication of emergency medical services and first-aid services affects the outcome in relationship to mortality and morbidity. In all countries accidents are becoming an increasingly important cause of mortality and morbidity as other diseases and nutritional problems are brought under control . 2.2 Variable fac tors The proportion of children injured who already have a pre-existing handicap appears high 1n some countries. Figures quoted include one of 10% in Brazil. The types and c auses of home accidents to young children vary considerably. Poisonous substances vary depending upon their availability: kerosene is common as well as petrol, but poisoning from drugs varies considerably. Burns and sc a lds depend upon the method of heating and the siting of the cooking stove . Finally, choking due to the use of particular feeding techniques was mentioned as an important cause of death in one country (Benin). Accidents away from home vary with a country or region's geography. Drowning accidents are common where open water is a feature, and falls from coconut trees, insect bites, piranha fish bites, animal bites and cuts from machetas used in cutting sugar cane were geographically related. Even young children help in minor agricultural tasks, but concern was also expressed about accidents to children of 10 years and older who are employed in small workshops or factories . The interrelationship of urbanization to road traffic accidents has already be en commented on, but stray animals were also mentioned as a factor, together with the fact that few roads had pavements for pedestrians in some countries. Diseases resulting from accidents, particularly tetanus and rabies, are more common than in some developed countries. 3. Methodological problems encountered in country surveys The following points were made. Mortality figures are not available for all deaths in some countries: national mortality figures in Brazil co ver only about 70% of dea ths. There are difficul ties in defining the population and age structure bases used in studies. These are vital f or the calculation of rates which are necessary f or comparisons between areas and between t imes in the same area . There are d ifficulties in getting control groups. It is vir t ually impossible to get national figures of the morbidity from different types of accident. Local studies are essential for s howing up differences between urban and rural areas, but seasonal differences can be considerable and a year's data is generally needed. Prospective studies are more valuable than retrospective ones, and in some countries the high illiteracy rate precludes the use of patient questionnaires. The value of data collected at hospitals or health centres will depend upon the use made of them by the community . There are clear advantages in collecting data from nonmedical as well as medical sources. A survey in Turkey had used school teachers very successfully. The relative nonavailabilit y of health services in some c ountries or areas made it ve r y difficult to assess the severit y and the long-term outcome . Finally, data on risk and exposure are almost nonexistent . Further development of pilot studies The pilot studies have shown that important and worthwhile data can be obtained. Suggestions 'for the future include: s. - 11 - continued emphasis on the importance of accurate and complete national mortality statistics; the carrying out of local prospective studies of the accidents occurring in an area of known population and age structure, using a control group as far as possible and with data collected by nonhealth personnel as well as by health workers; further, more detailed local studies should be carried out on specific types of accident, e.g. poisoning, burns and scalds, and r oad traffic accidents, with a view to defini ng more clearly the different roles played by the child and adult involved, the agent and the environmental circumstances; and further studies to evaluate the role o f traditional healers, where appropriate. Development of guidelines and their use in prevention The Study Group drew up provisional " guidelines" on data collection. A possible " check-list" of questions which mi ght be asked and data that mi ght be collected is included and is under further c onsideration at pre s ent. - 13 - AIR POLLUTION L Working Group on Assessment and Monitoring o f Exposure to Indoor Air Pollutants Nordlingen 1 Federal Republic of Germany 9-12 June 1982 - 15 - ICP/RCE 304(2)(S) 0098I 6 July 1982 ORIGINAL; ENGLISH The Working Group was convened to review recent work on exposure to indoor air pollutants and on the assessment of adverse health effects. It consisted of 13 temporary advisers and a participant from the Connnission of the European Connnunities. The Working Group assessed the adequacy of current knowledge about the nature and strength of the sources of indoor air pollution and their distribution. It considered the status of available measuring equipment and the adequacy of current knowledge about population exposure. The Group also reviewed the adverse health effects that have been reported in conjunction with indoor air pollutants and the current level of knowledge about the exposure-response relationships for each of the pollutant categories of i nterest. The meeting then reviewed ways that, in future studies, would be most effective for assessing the overall impact on public health of indoor air pollution, as well as effective strategies for bringing about improvement. The Working Group discussed assessment and monitoring of exposure in r elation to their estimates of the adverse health effects to be expected. Nine speci f ic areas were s tudied in small groups and reviewed by the complete Working Group. Discussion (1 ) The state of knowledge on population exposure to a number of pollutants was considered. The pollutants were tobacco smoke (passive smoking), nitrogen dioxide ( NOz), carbon monoxide (CO), r adon and daughters, formaldehyde, sulfur dioxide (SOz), carbon dioxide (COz), ozone (03 ) , as bestos, non-asbestos mineral fibres, organic substances and allergens. For each of the pollutants the subgroup estimated the fraction of the population exposed to low and to excessive concentrations. It also rated the adequacy of knowledge about sources, their characteristics and di stribution, the adequacy of available measuring equipment and of actual monitoring data. (2 ) The health effects associated with each of the pollutants were considered, as were the adequacy of knowledge about the exposure-response relationships and about the population expo sed. ( J) Based on current though inadequate levels of knowledge , an attempt was made to identify the concentration l evel below which exposures would not be of substantial public health concern, as well as the concentration level above which serious public health concern would exist. This as sessment was made for most, but not all, of the pollutants. (4) Existing criteria, guidelines and standards for air pollutants were examined. (5 ) It was proposed that the Working Group constitute i tself as an International Steering Connnittee on Indoor Air Quality. The scope and method of operation of such a connnittee were developed. (6 ) Methods and priorities for further research on assessing exposure were considered. (7 ) An evaluation was made of the rapid increase in a number of countries of the "sick" building syndrome in which occupants of large non-industrial buildings complain of a set of symptoms, the underlying cause of which is usually difficult to establish. (8 ) Consideration was given to the factors that would have to be taken into account if criteria, gu idelines and standards for outdoor air, or for the occupational environment, were to be applied to the non-occupational indoor environment. (9) Ways of assessing the health effects of indoor air pollutants were considered and priorities f or future work on the assessment of exposure-response relationships and on the impact of indoor a i r pollution on health were identified. - 16 - Conclusions The Working Group reached a number of widely shared conclusions about the problem of estimating and measuring exposure to indoor air pollutants and the nature and magnitude of the resulting adverse health impacts. (1) An abundance of case histories shows that a variety of air pollutants at high concentrations cause serious adverse health effects, particularly of an acute nature. Much less certainty exists about the delayed adverse health effects of chronic exposure co indoor pollutants at concentrations moderately above background levels. (2) Although a considerable amount of indoor air quality monitoring has been carried out, the level of knowledge about population exposure is still inadequate . Estimates of population exposure will therefore have to be made from an appropriate description of the characteristics of the building stock and a description of the internal sources, including man. The combined distribution of these factors will be required for such an assessment. (3) Reports of "sick" buildings are i ncreasing. In many cases it is difficult or impossible to associate the indoor pollutants with the reported health effects . The reported health effects are usually the sort which are also found in other similar populations . (4) The pollutants found in indoor air are also encountered in outdoor air, or in work places. For many of them, various authorities responsible for public health or occupational health have formulated and promulgated health criteria documents , concentration guidelines and even ambient air quality standards. The Working Grou p considered the applicability of such criteria, guidelines and standards to the indoor environment and concluded that it was limited. In adopting values for guidelines and standards, a great number of factors are taken into account such as the fluctuation of concentration over time, the mixture of pollutants involved, transformations in the atmosphere, etc. These factors vary widely according to the setting and guidelines ; criteria and standards for the occupational environment, the outdoor environment and the indoor environment (e.g. for S02) may be quite different . (5) There was ge neral agreement that, in principle, the required equipment for measuring indoor air quality is available, although the cost is often high . The ability to analyse and characterize complex mixtures of organic chemicals is still limited and cheap screening methods are not yet available. ( 6) Epidemiological studies of the adverse health effects of pollutants in the outdoor air are probably of very limited use in assessing the health impact of indoor pollution exposure, since most were carried out without taking into account how the indoor environment would modify the exposure. It is quite likely that new studies which do take the indoor environment into account will find significant health effects at concentrations that gave inconclusive results in earlier studies. (7) The Working Group found that the level of knowledge about exposure of the population and about the exposure-effect relationship was inadequate even to estimate the total impact on public health of indoor exposure to any one of the pollutants considered: tobacco smoke, N02 , radon and daughters, formaldehyde, so 2 , co2 , o3 , asbestos, mineral fibres, organics and allergen. The most serious inadequacies were in the knowledge of the distribution of sources of pollution, of the exposure-response relationship and of the population exposed. Data from monitoring of exposure were also inadequate. Emission characteristics of the sources, the measuring equipment and the type of adverse health effects to be expected were more adequately known. Recommendations The Working Group made the following recommendations. (1) A critical review paper on adverse health effects of formalde hyde should be prepared. It could conclude with reco111111endations about future research needs. (2) Building materials and furnishings with high rates of emission of toxic substances should be identified, as a first step in the process of classification of these materials according to their adverse health effects. ( 3) An assessment should be made of S02 and 03 concentrations in multiple compartments in indoor environments, to provide data on total exposure and to make new risk assessments of these pollutants . - 17 - (4) Adverse health effects of NOz, CO and other pollutants due to passive tobacco smoking and improper indoor combustion should be studied together. (5 ) Organic substances are ubiquitous in indoor air, but very little is known about the form of exposure involved. Priority should be given to identifying and quantifying these chemicals in the indoor environment. (6) The exposure to radon and daughters is largely determined by the level of radon emission by s oil, groundwater and building materials. Priority should be given to the study of the relative contribution of these three sources in various geographical areas. (7) Consumers should be encouraged to use appropriate technical means for the effective control of combustion products indoors. Unvented combustion indoors should be discouraged or prohibited. Education of the public is an effective way of bringing about improved indoor air quality. (8 ) It is recommended that a working group be convened to review the indoor air quality aspects of bu ilding and housing codes and, if appropriate, draft recormnendations for indoor air quality sect ions in such codes. (9) In some countries, registries exist which contain specific information about buildings such as construction materials, heating methods, room sizes, etc. Although these registries have been created for other purposes they could also serve studies of the effect of building characteristics on the health of the occupants. ( 10) For surveys, the development of passive monitors using 24-hour time integration (the ac cumulation over 24 hours) is recommended for nearly all contaminants. Surveys also require the development of proper questionnaires to obtain ancillary information. For surve ys measuring indoor air quality, a simple and inexpensive device for measuring ventilation rates is needed and its development is urgently recommended. (1 1) Field studies of exposure to indoor air pollutants and the adverse health effects associated with them should be carried out, whenever possible, on representative sample populations. Joint IIASA/WHO Workshop on Ambient Air Pollution - Health Effects and Management Schloss Laxenburg, Austria, 27 -30 July 1982 Introduction - 18 - ICP/RCE 301(8)(S) 05551 27 Oc tober 1982 ORIGINAL: ENGLISH Much information concerning ambient air pollution and i ts effects on mankind and the environment has been accumulated, and certain control and abatement strategies have been developed. There is still, however, a lack of understanding of various chemical processes occurring in the atmosphere and the impact of air pollution on human health and the environment. In certain cases the prediction of the resulting pollution costs to the national economy, and of the hazards posed to the wellbeing of the population, is still at an early stage. The range of disciplines i nvolved in the resolution of air pollution issues is very broad, and communication barriers need to be overcome. Specialist output, valuable as it may seem to workers in the same field, may not contribute to an overall management strategy. It was therefore appropriate that the WHO Regional Office for Europe and IIASA should organize a workshop attended by meteorologists, modellers, chemists , environmental engineers, plant physiologists, foresters, epidemiologists, economists and environmental managers. The presence of such a broad range of specialis ts created some initial communication problems but proved to be a wise strategy. The number of persons present totalled 54; they came from 19 countries and were drawn from academic, industrial, governmental and international organizations. One objective of the Workshop was to assist Member States in reducing ambient air pollution so as to benefit human health and wellbeing and to improve t he state of the environment. A second objective was to examine the effectiveness of mana gement techniques in the control and abatement of air pollution, both locally in cities and in the context of long-range transfrontier transport of pollutants. Finally, the participants were to reach conclusions and make recommendat i ons that would assist and strengthen national and municipal authorities in their efforts to combat air pollution. Over 20 papers were prepared i n advance of the meeting to provide the participants with background info rmation on the var ious topics discussed. The Workshop operated i n round-table plenaries, with small sub-groups being established as appropriate. The papers will be published in a special issue of the international journal, Atmospheric environment. The discussions were organized around fi ve themes: atmospheric pollution processes and associated models; effects of air pollution on the biosphere; effects of air pollution on health; effects of air pollution episode s; and, air pollution control and abatement. However, the inter-linkages among these topics were cont i nually stressed. Discussion Atmospheric pollution processes and associated models The background papers and the discussion in this session emphasized the complexities of atmospheric modelling and the i nevitable uncertainty introduced by the stochastic nature of atmosphere turbulence and errors in the meteorological and emission data used by models. These and other factors can be quantified to a degree in models but the usefulness of such models, which necessaril y yield a wide range of possible results, was felt to depend on the way in which other disciplines sought to use them. In particular, the scientists dealing with effects should specify their needs, including space and time resolut ions for atmos pheric data, and the accuracy and precision required. The level of effort necessary to achieve improved performance by the atmospheric scientists should be judged in the context of the precision with which health, ecological and economic factors can be specified. Thus an overall systems analys is approach is required. - 19 - Air pollution and the biosphere Discussions on this topic were subdivided into direct effects ( leaf and· needle damage, decreased crop yield, etc.) and indirect effects due to acidic deposition. With respect to direct effects, the main focus of the papers and discussion was on the difficulties involved in estimating dose-response relationships. Particular emphasis was given to the threshold levels of pollution at which ecological damage commences. The deliberations during the recent Stockholm Conferen ce on the Acidification of the Environment were referred to and the costs of achieving target reductions in pollution considered. There was no attempt to present a wholly rigorous estimate of such cos ts, but reservations were expressed by some participants about the willingness of national economies to bear further r ises in energy cost s to reduce environmental damage. However, the meeting noted that by the end of 1982 the convention on long-range transboundary air pollution would have the minimum of 24 signatory nations needed for it to be put i nto fo rce. The practical difficulties of measuring dose-response relationships were considered in some de tail. Major complications are the effects of various combinations of pollutants and atmospheric conditions , and the difficulty of conducting reliable fumigation experiments. Finally, the need to deal with photo-oxidant and ocher new types of pollutant in subsequent dose-response research was stressed. A large number of recommendations were made, including the following. l. Studies should be initiated on the irreversibility or reversibility of dama ge f rom the acidification of ecosystems, including the rate at which recovery would occur i n the latter case . 2. The assessment of long-term and sometimes rather subtle changes in ecosystems due to acidic deposition requires a multi-media systems approach. The Workshop attempted co identify the major outputs required from atmospheric scientists but the need for more detailed analyses was recognized; these should include linkages with other sectors dealing with air pollution effects . Air pollution and health The Workshop received several backgrou nd papers on the limits of health effect research. Health effect studies contain all the complexities of biosphere studies. In addition people move about, spending much of their time indoors, ye t relatively little is known about i ndoor air quality. People smoke and face industrial exposures, but ethical problems prevent direct investigations of dose-response relationships by fumigation. The use of statistical meth ods as an alternative co s tudies of individuals co estimate dose-response curves was extensively discussed. To a great extent, air quality is suf ficiently good in many pares of Europe and North America to remove the more extreme effects of pollution on health. Thus, research that examines individuals must now have impractically large samples if low-level effects are to be detected. Howeve r, high levels still occur in some urban and highl y industr ialized areas in Europe and in other parts of the world, and in some indoor environments, while other pollutants ( such as ozone and nitrogen oxides) have become impo rtant with respect to as thma and emphysema. Thus, there is still scope fo r research on i ndividuals. The Workshop made several recommendations with respect to health effects, including the following. l. Current efforts to estimate human exposure using personal pollution monitors and other methods are welcomed and should be fu rther encouraged. There is an associated need to quantify population lifestyle and activity patterns and to relate human exposures to ambient pollution levels as obtained f rom urban outdoor monitoring networks. 2. In parts of the world where high ambient pollution levels are prevalent health effect studies should be carried out, using the best modern techniques. Ai r pollution episode cycle s The meeting received background papers on the health effects and causes of annual episodes of acute air pollution. A number of difficulties in establishing the prec ise health impact of an e pisode were considered i n some detail, particularly the need to control for past exposure to pollution. The discussion also focused on individual episodes, their causes, and potential health effects . Subsequent discussion ge nerat ed a number of proposals for further research on episode causes and effects: - 20 - (1) detailed studies of the sequence of events leading to air pollution episodes are required to develop effective management schemes in episode-prone areas; (2) health effect studies should be carried out in urban areas that are prone to air pollution episodes cycles; (3) abatement strategies should consider episode control (fuel switching, elimination of open burning of waste, etc.), emission controls and land-use planning; in the last case, rather specialized mesoscale air pollution models would need to be developed. Air pollution control and abatement Air pollution management strategies were discussed throughout the Workshop in the context of each of the other topics. It was emphasized that air management programmes continually had to respond to new issues and challenges; for example, the problem of "acid rain" only came to prominence in the late 1960's. The strategies to be emphas i zed for air quality management must therefore be adaptable and should be multidisciplinary. The following aspects were considered essential: - appropriate administrative structures cost-effective monitoring of emissions and ambient concentrations - ability to describe and predict atmospheric processes - better information on dose-response curves for humans and for important components of the biosphere - better information on control technologies in the context of local environmental and economic conditions capability to generate and evaluate alternative abatement strategies - power and resources to implement chosen strategies. - 21 - APPROPRIATE TECHNOLOGY FOR HEAL TH Workshop on the Organization of a Health Technology Assessment Network in the European Region Budapest, 8-10 June 1982 1. Introduction - 23 - ICP/ATH 010(3)(5) 1129E 24 January 1983 ORIGINAL: ENGLISH The meeting was attended by temporary advisers from the European Region, representatives of the European Medical Research Council, the International Federation of Medical and Bio-Medical Engineering, the European Federation of Organizations for Medical Physics, the International Council of Nurses, and observers appointed by the Hungarian Government. The objectives of the meeting were to: discuss tentatively the objectives and task distribution of a future European health technology assessment network; review existing methods and advances in this field and identify focal points fo r internat ional collaboration; study the system of technology development, assessment and utilization in Hungary. 2. Discussion The workshop was intended as a follo.,...up to two earlier consultations held at the WHO Regional Orfice for Europe in Copenhagen where i t was established that there was a basic need for a network as a means of international co llaboration between institutions al re ady involved, or those potentially in t e rest ed, in health technology assessment. Participants f rom eight national institutions, varying from government agencies to research centres (all potential members of a fu ture network), and representatives from international professional orga nizations took part in the discussions. These discussions demonstrated the c omplexity of this problem area as well as the great interest in collaborat ing internationall y in this field. The in tri nsic mul tidisciplinary character of technology assessment will make it necessary to define carefully, within the frame of the fu ture network, several areas of activity , and to form severa l sub-networks and working parties. Alternating with the discussions on the future network, a study was made of the sys tem of medical technology development, assessment and utilization in the Hungarian People's Republic. The sys tem of technology utilization works at three diffe rent levels: district, regional and national. It assigns tasks of increasing complexity to higher levels , and specifies the quality and quantity of technological means to be used at each level. By visiting clin i cs at all three levels it was possible to ge t an impression of the trade-off betwee n a care-oriented and a technology-oriented system. 3 . Results The main results of this Workshop were: (1) the provision of summaries of current experience in assessment work; and (2) the collection of available information on methods of assessment. It was decided to focus future activities on: (a) investigations into possible, generally acceptable systems fo r the classification and terminology of devices which can be used in a data bank; (b) the promotion of education in the development of assessment programmes and decision-making processes, and in the proper util ization of technology by health care workers; (c) the implementation of case studies and the development of the necessary protocols; and - 24 - (d) the stimulation of an exchange of information on, and further development of assessment methods. 4 . Recommendations It was proposed to form three working parties from the potential members of the network, to elaborate further the basic elements where international collaboration under the aegis of the WHO Regional Office for Europe could be considered fruitful. (a) One working party should concentrate on the setting up of a classifiction and/or information system for medical devices, and the procedures related to their use. (b) A second working party should focus on policy research , and work out a possible general philosophy and method for health technology assessment in Europe. (c) A third working party should prepare a report on the importance of education systems to health care workers who teach how to make optimal use of modern medical technology. There was a consensus that these activities would also give WHO a basis fo r assembling existing information on technology assessment, that is at present scattered in various research areas. A very pragmatic, tangible and necessary beginning to the activity of the network should be the international organization of access to existing data on the broad evaluation of medical technology. It was proposed to appoint a coordination point for collection and redistribution of selected information. The setting up of a directory of persons and institutes involved in evaluation and assessment programmes was also recommended. - 25 - BASIC SANITATION Worki ng Group on Housing Indoor Climate Impact on the Health of the Elderly Graz, 20-24 September 1982 Introduction - 27 - ICP/BSM 002(3)(5) 0435I 30 November 1982 ORIGINAL: ENGLISH The health aspects of the indoor air climate of human habitations, especially the effects on the elderly, were reviewed by a WHO Working Group consisting of 19 public health scientists and adminis t rators representing various disciplines from 10 Member States in Europe and from Canada and the United States. The primary purpose was to discuss what is known about the interrelationship between the adverse indoor climatic conditions of housing and the physical health and wellbeing of the elderly. Of particular relevance are the thermal environment of human habitat ion, as measured by ambient indoor air temperatures, and humidity, and their effects on human physiology, and the incidence of acute respiratory diseases of elderly occupants. Another important purpose was to ensure better coordination between the European institutions collaborating on the European Study of Public Health Aspects of Housing through the development of recommended protocols for research and through regular in-depth discussions of the findings of each institution's study findings. The Working Group found that before discussing the effects of the indoor housing climate on the health of the elderly, it was necessary to review present knowledge of the interrelationships between various parameters that describe the indoor climate of human habitation and health indices of all occupants, not just the elderly. It was found that, in general, there is a dearth of valid, scientific data concerning those parameters that define the indoor climate of human habitations and the effects on the health of occupants. Most of the present standards that define minimum or maximum conditions of indoor thermal climate tend to be based upon human comfort. The Working Group noted that it was necessary to obtain data urgently concerning the effects of the indoor climate on the health of occ upants, since there is, and has been for several yea rs, a tendency in Europe and elsewhere , to reduce indoor ambient air temperatures and the ra tes of infiltration and ventilation, during the coole r seasons of the year, as a means of conserving thermal energy . Acknowledgement was given to the findings, recommendations and conclusions of two previous working groups, namely the Working Group on Health Aspects Related to Indoor Air Quality which was convened in Bilthoven i n April 1979,a and the Working Group on Assessment and Monitoring of Exposure to Indoor Air Pollutants which met in Nordlingen in June 1982 ( ICP / RCE 304(2)(5) ) . While the indoor climate of human habitations i ncludes the quality of indoor air, the Working Group decided to confine its discussions, findi ngs, recommendations and conclusions primarily to the hygrothermal characteristics of housing and their impact on the health of occupants, especially high-risk subpopulations, such as the elderly. The Working Group drew attention to the discussions and conclusions of the International Conference on Primary Health Care,b convened in Alma-Ata in 1978 by both WHO and UNICEF, in which it was declared that the provision of decent and healthful housing was a basic element of pr imary health care, a nd that housing that is adapted to local climatic and environmental conditions ma y a Health aspects related to indoor air quality: report on a WHO Working Group. Copenhagen, WHO Regional Office for Europe, 1979 (EURO Reports and Studies, No. 21). b Alma-Ata 1978 : pr imary health care. Report of the International Conference on Primary Health Care. Geneva, World Health Organizat ion, 1978. - 28 - have a positive effect on health. It was noted also that the strategies for achieving health for all by the year 2000 will have to acknowledge the necessity of providing thermal envirornnents in human habitations that are healthful to all occupants, especially the elderly, the handicapped, and young children, if the goal is to be met. The Working Group congratulated the Institute of Hygiene and Epidemiology in Prague, and the National Institute of Hygiene in Budapest for the progress that they have already achieved in implementing the European Study on Public Health Aspects of Housing, in accordance with the protocol designed by a WHO Planning Consultation convened in December 1979 (ICP/BSM 002(4)). Conclusions 1. Concurrence was given to the declarations of the part1c1pants of the International Conference on Primary Health Care which met in Alma-Ata, in 1978, that housing was one of the important elements in a prograirane of primary health care and that, when adapted to local climatic and environmental conditions, safe, sanitary, and decent housing has a positive effect on the health of occupants, especially if they are old. 2. The govermnents of Member States should place increased emphasis on the provision of healthful, sanitary, safe and decent housing in developing policies, and in implementing prograiranes, of primary health care and of those activities that are aimed at the attainment of the goal of health for all by the year 2000, taking into special consideration the needs of the elder ly . 3. The phrase healthful and decent housing means a human habitation that is structurally sound and relatively free from accidental injury hazards, provides sufficient space for all normal household activities of all members of the family, has readily and easily available an adequate supply of potable and palatable water, has a sanitary means of collection, storage and disposal of all liquid and solid waste, is provided with appropriate installed facilities for personal and household hygiene and cleanliness, is sufficiently weatherproof and watertight, provides proper protection from the elements, especially for those persons who may be particularly susceptible, for physical and/or physiological reasons, to these potentially adverse environmental conditions, provides a hygrothermal indoor envirornnent which is healthful and comfortable, is free from excessive noise from both interior and exterior sources of the structure, has natural and artificial means of illumination that are safe and adequate in quality and quantity for the fulfilment of all normal household activities and functions, is free from toxic and/or noxious odours, chemicals and other air contaminants or pollutants, has adequate but not excessive ventilation for the maintenance of the quality of air with appropriate and desirable chemical, microbial and thermal characteristics, provides sufficient but not excessive solar radiation, provides adequate protection from insects and rodents which may be reservoirs and / or vectors o f disease agents, and is served by the necessary and / or desirable health, welfare, social, educational, cultural and protective coiranunity services and facilities. 4. Available data regarding the impact of the indoor climate on the health of the occupants, especially selected high-risk groups, first of all the elderly, and then the handicapped, and young children, are insufficient for the iiranediate development of indoor hygrothermal parameters of environmental health criteria of human habitations or other similar minimum health criteria, guidelines and standards . It was concluded, however, that upon completion of the initial phases o f the European Study on Public Health Aspects of Housing, the development of such parameters for enviromnental health criteria of dwellings should be possible. 5. Present standards for the hygrothermal environment in housing which are in use in many Member States, tend to be based largely on the human comfort of healthy adults and do not relate necessarily to the minimum conditions which should be attained and maintained for the health and wellbeing of sub-populations which may be high-risk, such as the elderly, the handicapped, and young children. Some of these current standards may, however, be considered to be a reflection of good practices of construction, maintenance and operation, and tend to establish conditions which, when complied with, may often be healthful and comfortable for most occupants. 6. Two of the critical effects of substandard hygrothermal enviromnents on elderly occupants are hypothermia and hyperthermia, and in most cases a significant increase or decrease in the deep body temperature of an occupant of a dwelling is a good indication of an unhealthy condition in that individual. 7 . A urine temperature test is a valid and objective method of measuring hypothermia in elderly persons, particularly first thing in the morning, but the use of this test is limited since it cannot usually be repeated for several hours. - 29 - 8. In dwellings in which the dry bulb globe temperature (or ambient air temperature) is between 18° C and 24° C, there is minimal risk to the health of sedentary persons, such as the elderly, who are appropriately clothed, provided there is no significant radiant heat loss from the body (this presupposes that the mean radiant temperature of the room, i.e. the area-weighted surface temperature, is no more than 2° C different from the ambient air temperature) and provided there is negligible air movement, i.e. 0.2 m/s. (The Working Group noted that while many dwellings could provide thermal conditions within the stated range of values of dry bulb globe temperature, many of them, particularly in cooler climates, do not have sufficient thermal insulation to ensure an insignificant radiant heat loss from the body and are not sufficiently airtight to provide negligible air movement). 9. There is no single instrument that provides a valid measurement of the hygrothermal environment of dwellings, but the dry bulb globe temperature is probably the best measuring device of the hygrothermal environment of dwellings under cold conditions, while the wet bulb globe temperature is an acceptable single index for measuring heat stressing conditions. Statistical evidence shows, however, that 10% of deaths among elderly persons in Europe occur as a result of acute respiratory infections such as pneumonia and influenza. 10. There is very little valid data on the association between respiratory diseases and the hygrothermal, chemical and microbial parameters of the indoor environment of human habitations . Reccmmendations 1. "Healthful dwellings for all by the year 2000" should be included among WHO goals for Europe. 2. The WHO Regional Office for Europe should continue its collaboration with the Comnittee on Housing, Building and Planning of the United Nations Economic Commission for Europe ( ECE), and provide public health input to the ECE Model for Building Regulations, especially to Chapter 9 of the Model, "Hygrothermal requirements". 3. The proposed protocols drafted by the Working Group should be used by the participants in the European Study of Public Health Aspects of Housing as far as possible and practicable, and additional governments and institutions should be encouraged to join those presently participating in the European Study to make the output of this research more comprehensive. Letters should be exchanged between interested governments or institutions and the WHO Regio~al Office, thereby confirming the conmitment of these governments or institutions to this research effort, and denoting their involvement as participants. 4 . The WHO Regional Office for Europe should organize a coordination meeting during 19 84 of all the research agencies and institutions that are participants in the European Study on Public Health Aspects of Housing. 5. European governments should give high priority to policies and programmes aimed at the rehabilitation of sub-standard dwellings presently occupied by persons who may be considered as high-risk, the elderly and the handicapped, and such programmes should be made ke¥ components of the policies and progranunes of those governments to promote the health and wellbeing of aged and d isabled persons. 6. Special studies should be organized and carried out by participants of the European Study on fublic Health Aspects of Housing and by others, on the adverse effects on the health of occupants, especially the elderly, of the changes and/or modifications to dwellings that have been made as energy conservation measures, e.g. reduced indoor ambient air temperatures, increased use of various insulating materials, reduced ventilation rates, etc. 7. As health criteria are promulgated using the research findings of the European Study on Public Health Aspects of Housing and of other studies, housing policies and programmes of Member States should be established and/or revised, as appropriate, and as recommended in resolution WHAJS.28. 8. Available data concerning the characteristics of the occupational envirorment should be reviewed and examined carefully to determine their applicability in the housing and residential enviroment and, as appropriate, they should be used as guides in future research on the health effects of the indoor environment of human habitations . 9. Research should be initiated and implemented to determine whether or not there is a causal relationship between various parameters of the hygrothermal environment of human habitations and respiratory disease; such research should also consider the chemical and microbial characteristics of the indoor environment. This research should give priority to people over 60 years of age. - 30 - 10. Studies should be planned and conducted to detennine the degree of causality or association, if any, between such agents as household dust, other particulate matter and their component parts , and respiratory diseases, especially the illnesses suffered by those elderly people and young children who frequently spend much time indoors. Similar investigations should be undertaken into the ion composition of the air (both small and large air ions) in the indoor climate of housing. 11. Current research into the electromagnetic propert ies of human habitations and their effects upon humans should be continued and expanded, and additional research studies should be planned and initiated by those organizations and agencies with the nece s sary resources to conduct them. 12. Studies should be undertaken on the role and effectiveness of various preventive measures against respiratory illnesses in high-risk persons, such as the elderly. They should include il1111lunization of the elderly and yo ung children against some of the upper respiratory tract diseases caused by infection. 13. Building research i nstitutions and other similiar organizations should study ways of efficiently and economically recovering energy from human habitations without reducing the rate o f ventilation, or the rate of changing air within occupied spaces. Working Group on Rural Water Supply Stevenage, 1-5 November 1982 - 31 - ICP/BSM 003(2)(S) 07771 15 March 1983 ORIGINAL: ENGLISH The meeting was hosted by the Water Research Centre, Stevenage and was attended by 21 experts from 12 countries in the European Region, including representatives from various WHO collaborating centres and the WHO International Reference Centre for Community Water Supply and Sanitation in The Hague. The scope and purpose of the Working Group was co consider the current technology applied co small water supply systems in European countries, with particular reference co isolated rural co=unities. As well as present approaches and new technology, other related aspects such as surveillance, maintenance and the provision of chemicals were discussed. The reco=endations of the meeting will serve as guidelines to assist Member States of the European Region in selecting appro priate technology to cater for different types of water source under different social, cultural, topographic and climatic conditions. Review of rural water supplies As background to the meeting the Water Research Centre in Stevenage performed a study of the r ural water supply in six European countries, representative of a wide range of climatic, geological and sociopolicical systems. Participants from the 12 countries represented in the Working Group presented papers on the situations in their respective countries. Altogether chis gave a detailed insight into rural water supplies in 13 of the European Region's 33 Member States, which was generally representative of the Region as a whole. Review of appropriate water treatment technology As further background, a review was prepared for the meeting of the water treatment technologies appropriate to water supplies for rural communities. In general terms, the processes were divided into: slow sand filtration disinfection the removal of suspended solids the adjustment of pH the control of iron the control of taste and odour the removal of organic colour softening sludge treatment and disposal . Each process was analysed in terms of its capabilities and limitations, its cost and availability, and its operation, maintenance and surveillance. Discussion To facilitate detailed consideration of the various aspects of supplying water to rural, remote and isolated communities, and individual dwellings, three subgroups were formed to consider: appropriate organizational structures for the provision of rural water supplies, including administration, management, surveillance, operation, maintenance and training; the water treatment and disinfection technology appropriate for use with rural water supplies; and the technology of rural water supplies other than treatment and disinfection, including source selection, source protection and distribution. - 32 - Conclusions l. All countries in the European Region are faced co a greater or lesser extent with the problem of providing water services to rural areas. 2. All countries recognize that safe and adequate water supplies to all sections of the population is one of the key elements in primary health care. In the less well developed areas of the Region, and these are now largely the rural areas, primary health care is still the major concern. In the more developed areas, concern is growing over secondary aspects of health care such as the chronic effects on health of chemical contaminants in water. 3. The provision of a safe and adequate water supply to unsatisfactorily served rural populations is one of the main tasks to be undertaken in the European Region if the goals of the Internationa l Drinking Water Supply and Sanitation Decade are to be attained. As such this is one of the Region's top priorities in terms of the Decade. 4. It was not fe l t necessary for the purposes of the Working Group to define too strictly a rura l community, as conditions vary widely throughout the European Region both economical l y, culturally and socially. A pure categorization on the basis of population size would be- arbi Crary, and misleading. This is a question that would have to be resolved, however, if an exercise was contemplated on information collection, monitoring and international comparison. 5. Two basic problems were i dentified: (a) first time provision of water , and ( b) the upgrading of existing rural systems to comply with modern standards of quantity and quality. The first problem is related to the less developed parts of the Region, while the second is the concern of more developed areas where the first stage has largely been achieved but standards and public aspirations have risen. 6. Rural supplies present problems of remoteness and scale that may make it impracticable simply to scale down systems used for larger supplies, e.g. because of difficult access to works, lack of electricity supplies, infrequent operational visits, and remoteness from specialist technical and quality control attention. 7. It was agreed that the choice of system or of equipment for a new or improved system depends not only on the technical problems but also on the availabi l ity of adequately trained operators a nd reliable supplies of any necessary chemicals. In many cases these non-technical factors may be of overrid i ng importance for the provision of a reliable supply of water of adequate quantity and quality . 8 . Methods of financing the construct i on of new systems were reported to vary widely among t he countries of the Region. Various degrees of financial, technical and organizational support are given by central and regional governments. The Group did not consider this to be within its remit for discussion, but recognized its importance for the success of rural water supply programmes. 9. Because of the difficult i es associated with operating treatment and d isinfection equipment facilities, and with assuring their continuity o f operat i on , high priority should be given to protecting the water source a nd preventing contamination, particular ly of a bacteriologica l nature . 10. It was considered that the first priority in water treatment is reliable disinfection. Although there are many disinfection systems available there is no one method that is best in all situations. Further development of equipment is required for greater simplicity and reliability of operation, and at the same time controls should be applied during operation to match the raw water quality. 11. In all countries of the Region the authorities responsible for health also have responsibi l ity for monitoring the hygienic quality of water supplies. This is primarily a safeguard of health, however, and must be supported by sampling and testing at the operational level. Neither monitoring system is a substitute for the other. 12 . The provision of an effective quality surveillance service for rural water supplies presents many pract i cal problems. The cost i s high because of the distances that have to be travelled to collect samples, and thus sampling is done on l y at relatively infrequent intervals and is often insuf f icient. The range of ana ly sis is also limited by cost and is largely confined to microbiological testing, whi l e chemical testing is very infrequent. 13. There i s growing concern a bout the general increase in the concentrati on of nitrates in t he sources of rural water supplies in the Region, which results f rom the increased use o f nitr - 33 - fertilizers in agriculture. In the past, the concern was principally with methaemoglobinaemia (blue baby syndrome), but there is now additional concern about the connection between nitrate consumption and the formation of carcinogenic nitrosamines in the gut. 14 . It is felt that the nitrate problem arises in part from the indiscriminate or excessive use of nitrogenous fertilizers, and there is scope for further research into methods of optimizing the applications of these materials in agriculture with a view to reducing the seepage of nitrate into groundwater and surface water. 15. Responsibility for the operation of water supply systems and the hygienic quality of water in rural areas varies considerably throughout the Region, and the system adopted must be compatible with the sociopolitical conditions, cultural environment and level of development. Under all conditions, however, the community plays an important role and its degree of involvement and commitment is a key factor in assuring a satisfactory service. 16. When small communities have responsibility for operating their own water supply system, experience has shown that support from a district authority to provide technical back-up and to assis t in case of breakdown is important. 17 . One of the major problems, particularly in the less developed parts of the Region, is the shortage of suitable operating staff. Training schemes for staff are not well developed and there may be a lack of coordination between the local body responsible for water provision and the national or regional authorities who have the ability to provide training facilities. Methods for training part-time community-based operating personnel must also be considered. 18. In the less developed areas of the Region in particular, there appears to be a lack of appreciation of the benefits of a wholesome water supply. It can be difficult to recruit local operational personnel because the job is considered unsocial. Communities are often suspicious of chemicals used fo r disinfection and prefer untreated yet less wholesome well water. Disinfection devices used in wells, say in cartridge form, are likewise viewed with suspicion. Active consideration should be given to health education programmes both in schools and elsewhere. 19. Within the European Region, there is a wide variety of methods for charging the consumer for water in rural areas. These range from systems where the service is free, particularly in countries with relatively poor rural populations where water is seen as a social service and an element of health strategy, to the situation where the consumer is required to pay the full costs. 20 . There are several problems related to rural water supplies that occur only within relatively limited geographical areas; the presence of iron, arsenic, heavy metals and methane in raw water. These problems are very specific and involve special technical solutions. To be fully effective any solutions developed must take due account of the limitations on technology set by rural supply systems. RecollDllendations for action at national level Organization and management l . Responsibility for the operation of a water supply should lie with the community being served by the system. 2. Assistance from a higher-level, preferably regional organization should be available for technical and logistic aspects. 3. Responsibility for water quality surveillance should lie with the public health authority. 4 . Simple water quality surveillance is an essential part of plant operation but should be supplemented by personnel from a central laboratory. 5. Training must be provided for personnel. It should be appropriate to the tasks to be performed and avoid overtraining. 6 . Well documented records should be kept and used for operational and planning purposes. 7. Consumers should bear at least part of the cost of operating their water supply. 8. Individual supplies should be monitored and assistance given where necessary. - 34 - Technology other than treatment and disinfection 9. In designing a water supply system for small communities, preference should be given when practical to using the best quality sources so that treatment requirements are minimized. This must be developed within the context of regional plans, however, while of course taking due account of cost, geography, available technical expertise and sociocultural factors. 10. Several alternative schemes should be studied, and the plan must take account of existing supplies and consideration must be given to present and future agricultural and industrial development. 11. Before developing a new source the possibility should be investigated of connecting into an existing or planned water supply system serving the region or a nearby large town. 12. Before developing a single small supply, consideration should be given to the possibility of developing a larger system to serve several communities, thus facilitating operation and quality control. 13. The best quality water should always be reserved for potable supplies. 14. Even though the authority responsible for water supply may not be the same as that responsible for national or regional water resource planning, the primary concern must always be for potable supplies. matter of principle, all water supply resources should be protected against all pollution. This is particularly important where a source is being or is likely to be exploited rural supply purposes, since treatment of polluted raw water presents additional difficulties in rural areas. 15. As a 16. Two kinds of source protection should be considered: (a) legislation, control and planning to limit long-term degradation in quality, together with the ability to enforce legislation; and (b) the physical protection of individual systems. 17. Expert advice must always be sought when establishing t he zones of protection needed for groundwater sources, in view of the problems encountered in rural areas. for 18. Because surface sources are especially vulnerable to pollution, sur face water intakes should , wherever possible, be located upstream of known sources of pollution and protected from damage and pollution. 19. The possibility of modifying agricultural practices should be examined, in an effort to reduce the release of nitrogen compounds from fertilizers into water resources. 20. Direct participation by the community in the planning and construction of its water supply system should be encouraged. This normally fosters community spirit and helps to promote continuing successful operation. 21. Public awareness of the benefits of a safe water supply and of the risks associated with a polluted supply is an essential element in avoiding pollution from indiscriminate human activities; public ·education programmes should be undertaken in schools and elsewhere. 22. The new WHO guidelines for drinking water quality should be used as the basis of standards of service to rural communities. 23. Since systems requiring pumps inevitably require operation and maintenance, gravity-fed supplies are preferred for rural areas even though the initial capital cost may be somewhat higher. Gravity systems should be designed so that sufficient head is provided to minimize the power required by the treatment process. 24. Any well used for supplies to individual dwellings should be capped and direct access to the well-head should be avoided . 25. Intermittent water supplies are not advisable . It is not unusual, however, for rural water suppl i es to be intermittent and there may be no practical a l ternative, so consideration should be given to safe systems of domestic storage to avoid contamination and wastage. - 35 - 26 . Distribution and plumbing systems must also be designed to prevent the contamination of water and thus avoid wastage, 27 . Systems should include adequate _storage capacity and reduction in pumping capacity to provide flexibility of operation and to ca ter for sudden demands such as fire-fighting. 28, Even in rural areas, all European countries should be striving towards the connection of water supplies to any individual dwellings still unconnected, 29 . Every effort should be made to reduce leakage and other wastage, particularly in rural situations where pumping and treatment are necessary, to avoid unnecessary costs and to reduce the risk of contamination. 30, When new water supplies are being planned for rural areas, due consideration should be given to the increased consumption that will result from the wastewater disposal facilities provided. If this is not done there is a potential danger to water resources. Water treatment for rural supplies 31, Treatment methods that are simple in concept and easy to operate, and that minimize power and chemical requirements, should be adopted wherever possible. 32. Further research is required to develop suitable treatment systems for the removal of auunonia, nitrate, colour, tastes and odours. 33. It is advisable to provide a reliable method of disinfection as an assurance of microbiological quality and safety. 34. Further effort should be devoted to the development of simple, reliable systems for disinfection that are appropriate for use in rural areas. Recouunendations for action at international level l, Given the present rural water supply situation in the European Region, further working groups should be convened to deal in greater depth with the high priority aspects. Working groups on groundwater protection and on the effects of agriculture on water resource quality are particularly highly recommended. 2. A more substantial survey of rural water supplies in the Region should be promoted. 3. The performance and operational success of water treatment processes used in some pares of Europe and elsewhere in the world should be evaluated with a view co the more widespread application of those chat are most successful. 4. Information on treatment technology for rural water supplies should be collected and disseminated through WHO's reference and collaborating centres. The emphasis should be on disinfection . 5. All sources of documentary information for dissemination should be compatible, so that the utility of all information is maximized. 6 . Further development work should be promoted on disinfectant dosing systems appropriate for use with ·rural water supplies, 7. Simple guidelines should be published for the operation and maintenance of rural water supplies. 8. The setting-up of training schemes for operating personnel should be encouraged. 9. Further consideration should be given to appropriate technologies, advice and guidelines for the supply and treatment of water to individual properties, Seininar on Reservoir Eutrophication Control in Warm Climates Rabat, 13-17 December 1982 Introduction - 36 - MOR/RCE 001(2)(S ) 11401 25 January 1983 ORIGINAL: FRENCH This Seminar, bringing together 67 individuals (medical officers, sanitary engineers, hydraulic engineers, chemists, biologists and administrators) from 10 different countries, gave particular attention to countries with a Mediterranean or subtropical climate where water has to be stored by constructing dams and reservoirs. Eutrophication and the secondary pollution of lakes and reservoirs affected by the phenomenon jeopardizes the quality of drinking water from them and makes it more complex and costly to treat the water they yield. Most scientific and technical studies on eutrophication processes in natural and artificial lakes have been conducted in cold climates such as Canada, Sweden or Switzerland. The results of studies in such environments are difficult to extrapolate to warm climates because of the effect of temperature on the amount of dissolved oxygen, on the stratification of water layers and on the intensity of biological processes. The study of eutrophication in the artificial lake on the Bou Regreg River in Morocco was the first such investigation to be undertaken in a Mediterranean country . The reservoir has a capacity of 500 000 million cubic metres and the water is used exclusively for providing drinking water to supply the Rabat-Casablanca coastal belt. The study, which received support from the United Nations Development Programme (UNDP) and the World Health Organization (WHO), was made by Moroccan specialists from the National Office for Drinking Water (ONEP), and the Directorate of Hydraulic Engineering, assisted by experts from the Swedish National Institute for Water and Air Pollution and the Danish Institute for Water Quality. The purpose of the Seminar was to disseminate the results of the study at national and international level and draw general conclusions from them for better detection and prevention of eutrophication in warm climates. The main documents distributed to participants were the final report of the project "Reservoir Water Quality Protection in Morocco", the report of the Working Group on Reservoir Eutrophication Control in Warm Climates held in Copenhagen from 2 to 4 June 1982 and a study by Dr R.A. Vollenweider on the particular aspects of eutrophication that apply in warm climates. Discussion Discussion centred on the following subjects: special aspects of the eutrophication process applying in warm climates; the combined effects of primary pollution and eutrophication on the quality of water from downstream reservoirs in river basins; the public health impact of reservoir eutrophication; results of the study on eutrophication processes in the artificial lake formed by the dam on the Bou Regreg River; eutrophication of reservoirs in Mediterranean climates: special aspects and methods of forecasting and prevention; the alterations required to the Bou Regreg Water Treatment Plant to equip it to deal with the degradation in raw water quality occurring at the end of the dry season; restoration of water quality in lakes by ecological methods; restoration of water quality in lakes by artificial aeration of deeper levels; - 37 - the algae-bacteria re lationship and its effects on the eutrophication process; restoration of water quality in lakes by means of hydraulic engineering techniques; restoration of water quality in lakes by controlling and limiting inputs of fertilizer ingredients; and feasibility of various solutions that may be planned for the restoration and maintenance of water quality in the reservoir formed by the dam on the Bou Regreg River. An effort was made to identify the conditions in which Vollenweider's diagram, designed for temperate climates ( lakes of the "dimictic" t ype according to Uhlman), might be adapted to Medi terranean climates (lakes of the "monomictic" type). An evaluation was made of the applicability of the mathematical models developed for the Bou Regreg to other reservoirs of similar type. Finally, there was an exchange of experience on the control of eutrophication in countries along the shores of the western Mediterranean. Conclusions l. Surface waters can only be put to use in semi-arid climates of the Mediterranean type by building dams to form reservoirs. When the water in reservoirs is used for providing drinking wate r, the lake must be protected on the one hand against primary pollution, from wastewater being allowed to run into it or into the watercourses feeding it, and on the other against secondary pollution resulting from the eutrophication process. 2 . Although it remains an open question as to whether there are directly harmful effects on health as a result of eutrophication, the indirect effects of the phenomenon are known, and the new criteria for safe drinking water proposed by WHO take account of the fact. J. The aim of the Drinking Water Suppl y and Sanitation Decade is not only to increase the proportion of the population supplied with drinking water but also to make it more drinkable and improve its health quality . To do so it is essential, among ocher things, co protect the quality of water in reservoirs and also Co draw up and ensure adherence to potability standards in line with the new criteria for safe drinking water proposed by WHO . 4 . The experience gained by the Moroccan National Office for Drinking Water in control of eutrophicacion in warm climates is a contribution that should be of interest to the international sc ientific community . The final scientifi c report on the case of Bou Regreg should be translated and distributed internationally. 5 . The attention of the international scientific community should also be drawn to the following facts . {a) In-depth s tudies must be conducted on lake systems (lakes and storage reservoirs) in warm climates in order to understand their behaviour, so as to establish what the re gular links are between external factors (climate , hyd rological regime, catchment area, etc.) and resultant biological activit y . In practice it is impossible to make a direc t application of the models developed for temperate lakes, though they have proved very useful for the development of lake resources (Vollenweider's excellent model, for example ) . (b) Nutrients are more effectively utilized in lakes in warm climates than in temperate climate lakes and their self-regulating capacity is generally speaking g reater. ( c ) Eutrophication, frequentl y the result of a breakdown in balance giving rise to a lack of trophic effectiveness in the ecosystem of a lake, is in principle less of a threat in lakes in warm climates. However, if equilibrium is upset, the consequences may be more serious than in temperate lakes, partly because of the speed at which nutrients are converted . (d) There is a fundamental difference between a natural lake with its own mature ecosystem and an artificial lake, particularly in the case of a storage reservoir that has recently been changed from a lotic to a lentic system ( from a river to a lake). {e) The solutions that may be projected for coping with eutrophication in lakes and reservoirs in warm climates are not necessarily the same as chose that have proved effective in temperate lakes. - 38 - (f) The knowledge gained and the mathematical models developed during the ONEP/WHO/UNDP project in Morocco on the performance of the ecosystem in the Sidi Mohamed Ben Abdellah Reservoir and the factors governing it may prove useful for future studies on other reservoirs in warm semi-arid climates. (g) The methods recommended for improving water quality in the Sidi Mohamed Ben Abdellah Reservoir could easily be applied co other reservoirs of this type in the region. (h ) It is of overriding importance to study and evaluate the secondary consequences, some of them negative ones, that may result fro m measures devised to combat eutrophication. It i s therefore preferable to make it a priority to select measures that do not bring in elements totall y alien to the system it is desired to protect. Recommendations The following recommendations apply to lakes in warm climates in general. 1. The authorities responsible for the management of water resources must be concerned with the quality aspects of management, in particular the control of water pollution, including the control of eutrophication in natural and artificial lakes. 2. When drinking water is drawn from raw water coming from a lake subject to eutrophication, treatment plants must be made as dependable as possible (for activated carbon adsorption of organic micropollutants, for example), 3. WHO is recommended, as part of its responsibilities under the International Drinking Water Supply and Sanitation Decade, in its turn to call upon governments of Member States to attend to the risk of eutrophication in every reservoir construction project where the raw water is to be used fo r producing drinking water. 4. UNDP is recommended to promote technical cooperation between the Moroccan Na tional Office for Drinking Water (ONE P) and similar agencies in other developing countries in the protection of water quality in reservoirs. 5. WHO, UNDP and the Swedish Institute for Research into Water and Air Pollution are recormnended to continue their cooperation with ONEP in the field of water pollution control and to carry on with the international dissemination of scientific or technological results from joint projects by them that might be of interest to ocher countries with comparable characteristics. 6 . The Government of Morocco is recorranended to continue implementing the recommendations made at the Rabat Round Table (June 1981 ) and the Copenhagen Working Group (June 1982) f or dealing with the specific problems of the Sidi Mohamed Ben Abdellah Reservoir on the Bou Regreg River. 7. In addition, in the light of the study that they made of this reservoir, participants at the Seminar recommend: (a) inviting the various ministerial departments concerned to work together to apply solutions that may be projected for improving water quality in the reservoir; ( b ) planning an increase in the height of the dam, as to do so would be compatible with the capacity of the Sidi Mohamed Ben Abdellah Reservoir and the quality of raw water to be treated at the Bou Regreg Treatment Plant; and (c) paying particular attention to the socioeconomic activities established in the catchment area. 8. The building of new dams to create reservoirs should be studied as part of an integrated development project for the catchment area and should include a serious study of environmental safety. 9. Given the key role of climatic factors in the eutrophication of water, it is essential for the microclimate of reservoirs to be included in any eutrophication control studies and it is therefore recommended that the latter include meteorological studies. 10. Integrated water quality management in river basins and reservoirs built along them presupposes coordinat i on between the various technical and administrative departments concerned, and the d rafting and enactment of suitable legislation . The gove rnment s concerned are recommended to take account of this fact together with sociological factors . - 39 - 11 . When studying the environmental impact of the construction of artificial lakes it would be useful, and it is therefore recommended, to make use of the methodology developed by the I nternational Commission on Large Dams. - 41 - BIOTECHNOLOGY - 43 - Working Group on Health Implications of Biotechnology Dublin, 9-12 November 1982 Introduction ICP/RCE 602(1)(5) 08181 6 January 1983 ORIGINAL: ENGLISH The Working Group was hosted by the Irish National Board for Science and Technology. The Group met to consider the current state of biotechnology, to assess its likely impact on health, and to formulate conclusions and recommendations to ensure its continuing safe development with regard to man and his environment. The Group consisted of 32 temporary advisers from public health authorities, universities, research institutes and industry from 12 countries. The Group began with a general review of biotechnology and then selected the following topics for special consideration: the definition of biotechnology, recombinant DNA techniques, waste disposal, the assessment of immediate potential health hazards, the assessment of possible long-term hazards, the defi~ition of areas requiring further research and the possible requirements for public-health-related studies. These topics were discussed in subgroups which prepared short reports that, together with their conclusions, were reviewed in plenary session. Discussion The Working Group considered a background document on the impact on health of biotechnology and made comments and suggestions for amendments. There was some feeling that the background document might be too pessimistic in tone and that care should be taken not to raise unjustifiable public fears. The importance of education at all levels of biotechnology was emphasized. It was pointed out that the multifactorial nature of pathogenicity means that the probability of pathogens being generated during biotechnological developments is exceedingly low. However, there is still a need for methods to determine whether newly isolated strains of microorganism are pathogenic. As far as the assessment o.f risk is concerned, experiments are very difficult to set up, and full use must be made of existing information from all the work in biotechnology that has been carried out. The first of the subgroups considered the definition of biotechnology. As many definitions have been formulated, it was thought necessary to find one which was most acceptable and appropriate to the Working Group. The Group accepted the definition used in the background document with the addition of qualifying sentences indicating the disciplines involved and the wide areas of application. The application of recombinant DNA techniques to genetic therapy in plants, animals or human beings was not considered to be within the remit of the Group. The second subgroup considered recombinant DNA techniques and their application to microorganisms. Considerable experimentation over the last seven years has so far elicited no observable novel hazards. Providing accepted guidelines on safety precautions are observed, all the present evidence suggests that microorganisms containing recombinant -DNA inserts can be used safely. This is not to say that microorganisms containing recombinant DNA molecules are free of hazard. The evidence suggests, however, that the level of hazard may be assessed by examining the intrinsic and known hazardous properties of the components used in the recombinant DNA process. The third subgroup considered the problems of waste disposal. A major problem may be the large volume of water that can be involved in biotechnological processes and the presence in it of organic solvents and other materials used to extract materials. In principle, microorganisms should be destroyed at source, but for microorganisms which cannot survive in the wild, this may not be necessary. - 44 - Subgroup four considered the immediate short-term hazards of biotechnology and formulated suggestions to aid those involved in the asses sment of risk . It was cons i dered i mportant that each process should be considered on a case by case basis. Where existing national guide l ines , practice and laws are established, these should be followed. Attention should be paid to the appropriate monitoring and surveillance of human health and the environment . Care should be taken to avoid the microbial and chemical contamination of biotechnological processes. Subgroup five considered possible indirect and long-term hazards. In general, these were thought to be minimal, but again they should be considered on a case by case basis. Due care should be taken to evaluate fully the properties of microorganisms and plants with recombinant DNA inserts before they are deliberately released into the natural environment. Organisms produced for use in the natural environment must be carefully evaluated under conf i ned conditions before being applied. The possible socioeconomic effects of biotechnology should also be evaluated at an early stage . The beneficial effects on health of biotechnology and future developments were assessed by subgroup six. In health care, the manufacture of new vaccines is to be expected, and the large-scale production of human hormones and proteins by microorganisms is already foreshadowed by the production of human insulin by Escherichia coli K 12 with the appropriate DNA insert. The improved health care of farm animals by similar developments will lead to greater food production. Food production will also be facilitated by the increased production of essential nutrients and the production of new foods, such as single-cell proteins. Environmental protection will be enhanced by the availability of organisms to break down intransigent compounds such as oils and chlorophenols in waste. It is expected that biological pesticides will replace many of the chemical pesticides currently used and reduce the environmental hazard from this source. Finally, subgroup seven considered the impact of biotechnology on human and environmental health in its widest sense. The importance of the collaboration between scientists, biotechnology entrepreneurs and public health authorities was emphasized. To ensure the continued safe operation of biotechnological processes , vigilance must be maintained for the nonbeneficial effects, but opportunities for enhancing human health and environmental quality should be expeditiously exploited. Conclusions and reconunendations 1. Biotechnology has generally been defined as the applica tion of biological organisms, systems and processes to the manufacturing and service industries. This implies the integration of b i ochemistry, bio l ogy , microbiology , chemica l engineering and process engineer i ng in a way that opt imizes the exploit at i on o f their potential . Applic at io ns to health care, energy , agriculture, the treatment of waste and to the environment are implicit in this definition . . It should be recognized that biotechnology is not new but represents a developing and expanding techno l ogy with roots established many years ago. 2. The conjectural risks of the application of r ecombinant DNA and other techniques to biotechnology c an be assessed and managed with current risk assessment strategies and control methods. It i s recommended that a careful assessment of potential occupat i onal, environmental and public health impacts be a fundamental and integral part of present and future industrial applications of biotechnology. Good education and training of workers are essential to minimize risks. 3. Given the inevitability of very considerable waste from biotechnological processes, waste treatment should be considered as an integral part of these processes. The efficient treatment of waste in biotechnology requires the use of adequate disposa l processes that minimize risk. It is recommended that pathogenic organi sms should be contained at an appropriate level. Waste contaminated with viable microorganisms containing recombinant DNA molecules should not normally be released to the environment. The release of microorganisms may be considered only when it is assured that they will not be a hazard to the environment. The reuse and i n-plant conve r sion of wa ste is cons idered pre fe r a b le to discharge. - 45 - 4. Biotechnology in general is regarded as a safe industry. It is recommended that the implementation of new biotechnological techniques and processes should be monitored for long-term effects to ensure that future developments take place in an equally safe manner. It is assumed that many countries have or will develop guidelines adequate for future developments. Special attention should be paid to the industrial use of organisms pathogenic to man, higher animals and plants, and to the appropriate containment of such organisms. Special attention should also be paid, however, to any deliberate introduction into nature of genetically altered microorganisms or higher organisms that are able to survive or multiply in the environment. 5. Biotechnology contributes in several ways to the improvement of human health, and the extent of this contribution is expected to increase significantly in the near future. To support this development further, it is recorranended that the free exchange of information in this area between all parts of society, as well as between nations, should be strongly encouraged. It is reconunended that \o/11O consider how this may be implemented. 6. The realization of future progress in the application of biotechnology to the protection and improvement of human health and the environment will benefit through expanded collaboration and communication between public health authorities and those concerned in the development and implementation of biotechnology. 7. Public health priorities, to which biotechnology can make specific contributions, such as providing better food and improved preventive medicine, should be established. 8. The evaluation of the socioeconomic effects of biotechnology should be undertaken, taking into account conditions prevailing in different parts of the world. 9. A general responsibility rests with all those concerned with biotechnology to inform the public of its impact on health and the enviroranent. It is recommended that pamphlets and other educational materials should be developed and distributed to those involved in the education of the public regarding biotechnology . 10. It is recommended that \o/11O should maintain a watching brief on the prevailing state of the art, review new development and formulate, as appropriate, recommendations which could be of benefit co Che health and environmental authorities of Member States. - 47 - COMMUNICABLE DISEASES Regional Meeting of Officers responsible for Infectious Diseases in Europe - 49 - ICP/ESD 006(S) 6164K Copenhagen, 27-30 April 1982 26 May 1982 ORIGINAL: ENGLISH SUMMARY REPORT Conclusions The first meeting of officers responsible for infectious diseases in Europe took place at the WHO Regional Office for Europe in Copenhagen from 27 to 30 April 1982, with the aim of formulating a policy for infectious diseases control in Europe. Despite the considerable decrease of mortality attributable to infectious diseases and the substantial decrease or apparent disappearance of some these infections in the Region, infectious diseases in general still remain an important cause of morbidity and have a major socioeconomic impact on all countries of the Region. In recent decades, there have been important changes in the pattern of infectious diseases in the Region, characterized by, for instance, the increase of foodborne infections and intoxications, associated with changes in food production and distribution, as well as in eating patterns. Changes are also occurring in the nature and incidence of nosocomial infections, with the appearance of "new" and newly recognized diseases, changes in lifestyle and the emergence of severe i nfections in immune-compromised subjects caused by opportunistic microorganisms; Imported diseases tend to be of less importance for public health than for the affected i ndividual, but some of them, for example the African viral haemorrhagic fevers, not only pose a t hreat to individuals, but also to health service personnel and may, in addition, cause considerable anxiety. The Meetin~ stressed, therefore, the need for health administrators to strengthen the surveillance and control of infectious diseases. Surveillance of infectious diseases is essential for the monitoring and changing patterns of infection, so that earl y preventive action can be taken i nternational exchange of surveillance i nf ormation in the European Re gion is countries about problems that may require prompt national action. measurement o f when appropriate. needed, t o i nform An all Surveillance of long-term trends would also be valuable in the Region, to identify areas r equiring research and special attention. Although differences in di~ease definitions, and in the methods and completeness o f in f ormation collection systems, will make d irec t comparison di ffi cult, comparisons of trends are both possible and worthwhile. The comparative cost-effectiveness of prophylactic and therapeutic measures is especially i mportant for those diseases which involve large numbers o f individuals, are not usually too s evere, are without sequelae and for which there is more than one method of treatment or prevention. Cost cannot play a decisive role in the selection of treatment for diseases like ly to become chronic or to ·have disabling sequelae; in these situations, one may be obliged to consider using t he available means of combating the disease, irrespective of cost, and to foster efforts to provide economical alternatives. Immunization, prevention and control of infections form a basic c omponent of the WHO strategy of health for all through primary health care. In order that this be eff ective a more intensive effort by the infectious disease sector is required. Information on inf ectious disease incidence and mortality , and on vaccination coverage, may be used as numerical indicators for assessing the development and effectiveness of primary health care activities, in the field of inf ectious diseases control. - so - There is little coordinated prevention policy among the countries of the Region owing to wide differences in the legislative and infection control measures used, and to the fact that no attemp t has been made so far to assess the importance of the various control measures. Training in infectious disease epidemiology may be inadequate at undergraduate and postgraduate levels, since few countries have courses available. WHO has only recently been able to fund the first international postgraduate refresher course in the Region. Surveillance of smaller risk groups for infrequent infectious diseases could be carried out in close collaboration with a few devoted clinicians or a few hospital/laboratory centres not using the routine surveillance system. The same ad hoc system could also be used to monitor new diseases. Recommendations l. Infectious diseases are of major public health importance i n the Region. Therefore, higher priority should be given to the coordination of activities relating to infectious diseases' surveillance, control, training and research. This requires allocation of adequate resources. 2 . Countries should be assisted in the establishment of national centres fo r the surveillance and control of infectious diseases, and cooperation and exchange of staff between these centres should be encouraged. 3. Health administrations of the Region should: (a) include the WHO Regional Office for Europe (EURO) in the exchange of information, for immediate action, relating to infectious diseases episodes with international implications; such episodes are hard to assess and the decision to report therefore must be left to the responsible national authority; ( b) provide EURO with copies of routine periodical reports produced for national use; (c) provide EURO with information on the incidence of, and control measures for, infectious diseases of special national, regional or global interest, such as the target diseases of the Expanded Programme on Immunization, rabies, other infectious diseases against which immunization is used (including untoward reactions and vaccine-associated problems), and foodborne infections and intoxications; (d) transmit to EURO information considered important nationally in the field of infectious diseases and which would be of interest to other countries; this would include official publications relating, fo r example, to changes in i mmunization policy, and data relating to changes in diseas e patterns, to the emergence of resistance to pesticides or drugs and so fo rth. 4. Periodic reports should be compiled on topics of common interest national reports on surveillance and control of infectious diseases. distributed to the Member States. based on the analysis of These reports should be 5. Information on new events of international interest in the field of infectious diseases should be dissemina ted co Member States. 6. Research and training in aspects of infectious diseases that are important in the Region should .be s~imulated and supported. A trainins scheme should be devised for infectious disease epidemiologists in Europe, based partly in national surveillance units, to sponsor postgraduate teaching and refresher courses. 7. Research and training programmes should be promoted in rapid and specific diagnostic methods as should the production, testing and dissemination of standardized reference agents. 8. The International Classification of Diseases fails to document the importance and the frequency of infectious diseases. Mechanisms should therefore be worked out which would help co give a more real istic picture of infectious diseases in terms of morbidity and mortality. 9. EURO should continue to maintain and circulate a list of officers responsible for the national surveillance and control of infectious diseases. This list should be kept up to date and should contain the officers' names, addresses, telex and telephone numbers and cable addresses. - 51 - 10. A summary of the infectious diseases situation in the Region should be prepared, based on the reports submitted by the participants and on the papers presented at this Meeting. In particular, this summary should include information on surveillance methods used in the individual countries. 11 . The Meeting endorsed the relevant recommendations made by the WHO Working Group on the Economic Aspects of Communicable Diseases (Trier, 19-21 September 1981) which highlighted the overall importance and cost of infections. 12. A working group should be convened to elaborate a programme on infectious diseases based on these recommendations. This would include internationally agreed policies in this field, the definition of areas of research on the variation of pathogenicity of selected bacteria or viruses in relation to the ecology and the fluctuation in incidence of certain infectious diseases, and such aspects as the frequency and orientation of future meetings of officers responsible for infectious diseases in Europe. Working Group on Prenatal and Perinatal Infections Graz, 24-26 May 1982 Introduction - 52 - ICP/BVM 016(SJ 0013G 23 August 1982 ORIGINAL: ENGLISH The meeting, which brought together an embryologist, epidemiologists and microbiologists, was convened to discuss current knowledge and remaining problems relating to the etiology, laboratory diagnosis, epidemiology and, where appropriate, prevention and treatment of prenatal and perinatal infections, with a view to submitting recommendations to national health authorities. The findings of the Group are expected to be of value not only in making more rational use of existing expertise and health resources for prevention of the infections, but also in identifying future avenues of research. Although the infections are often assumed co be a relatively small problem numerically, the numbers of children damaged by them may well have been significantly underestimated. Many maternal infections, such as those induced by cytomegalovirus and Toxoplasma gondii, are subclinical or induce relatively minor nonspecific symptoms and are therefore unrecognized and not investigated. Infants at risk may be apparently healthy at birth but prolonged follow-up studies have shown that they may subsequently be found to have developmental anomalies of varying severity, including mental retardation. However, it may be difficult or even impossible to co nfirm diagnosis of the infections by laboratory tests during assessments in later infancy or childhood. The Group therefore emphasized the importance of carrying out additional prospective enquiries since they may lead co a better appraisal of the incidence and long-term effects of the infections. Many of the laboratory techniques described during the meeting, such as the recently developed enzyme i111111unoassays to detect serological responses co infections, particularly specific IgM responses, have considerable potential in providing enhanced sensitivity and reliability in the diagnosis of maternal infections and the monitoring of infants in high-risk categories. Nevertheless, it is essential chat clinicians, epidemiologists and laboratory workers are made aware of the possible pitfalls in the use of these techniques. In particular, commercial kits are now available that may provide erroneous diagnoses in the hands of inexperienced workers. Whatever the frequency of the infections, there can be no doubt that infants who are damaged as a result of them pose a considerable economic and social problem, since life-long care is often required. A multidisciplinary approach to problems relating to the etiology, prevention and management of the infections is therefore needed. Conclusions and recommendations 1. The control of prenatal and perinatal infections should be promoted through a number of activities. It is recommended chat the health organizations of each country take appropriate measures such as the institution of surveillance, case- finding , serological surveys, vaccination regimens and evaluation programmes. 2. Long-term follow-up of children with evidence of the infections is strongly reco111111ended. It should be carried out from birth up to school entry and even longer, if possible. 3. Infections due to group B streptococci (Streptococcus agalactiae) and to Listeria monocytogenes may be acquired during intrauterine life or during or shortly after delivery. A fatal outcome is common, but can be prevented through appropriate and rapid diagnostic procedures which should be carried out at the slightest clinical suspicion of infection, so that the requisite chemotherapy can be instituted without delay. - 53 - 4. In numerical terms, primary cytomegaloviral infection is a more common cause of congenitally acquired disease than primary rubella and results in severe handicap inducing mental subnormalicy and sensorineural deafness. Attenuated vaccines employed in recently described trials are unlikely to be licensed for general prophylaxis of susceptible healthy women on account of potential onc ogenicity. There is a need for the development of alternative substances, such as sub-unit vaccine. Continuous epidemiological surveillance of cytomegaloviral infection in different populations is also needed. 5 . All possible seeps should be taken co eradicate congenitally acquired rubella through a vaccination programme appropriate co the health organization of each country. 6. Women may inadvertently receive rubella vaccine shortly before or after conception. In chis event, the Group does not recollllllend routine termination of pregnancy but considers that the final decision muse rest with the vaccinated woman and those caring for her during the pregnancy. A large number of rubella-susceptible and pregnant women have been given attenuated rubella vaccine and have chosen co go to term. Although no rubella-induced defects have been reported in the newborn, the number of pregnant women given one of the now commonly used vaccines ( RA2713 vaccine strain) is still coo small to completely exclude the possibility of adverse effects. Each ~ouncry should therefore carry out follow-up studies on women inadvertently vaccinated in pregnancy. 7. The apparent increasing incidence of genital herpes which may induce perinatal infections associated with a high risk of perinatal morbidity and mortality is a cause of concern. Recognizing chat vaginal delivery is not always advisable, it is recommended chat women with a history of genital herpes and/or suspicious symptoms be tested for virus shedding a ·few days prior to term. If the virus is present, delivery by caesarian section should be considered. 8. As the laboratory diagnosis of toxoplasmosis is very often unsatisfactory, evidence of infection is frequently found too lace for therapy to be effective. It is recommended that appropriate steps be taken to ensure a high standard of technical performance in laboratories that are adequately equipped. As prenatal toxoplasmosis often becomes overt in early or lace childhood, long-term follow-up studies including careful clinical and parasitological tests should be carried out. If during screening in the early stages of pregnancy, a patient is found co be seronegacive, repeated serological examination for coxoplasma antibodies (monthly to bimonthly) are recommended in order to detect seroconversion. 9. Although the number of cases of congenital syphilis has declined markedly in Europe, there is little evidence of a decreasing incidence of sexually acquired disease. It is therefore strongly recommended chat routine screening for syphilis be continued. 10. Rapid and appropriate laboratory procedures should be encouraged co implement prophylactic measures, document infections in pregnancy and the newborn, and where appropriate, initiate treatment . Specific IgM antibody determination is the best method for identifying pre- and perinatal infections. Particular care should be taken co exclude nonspecific reactions. However, results should be interpreted in conjunction with ocher serological findings as well as clinical data before advising whether or not a pregnancy should be terminated. It is recotmnended that any such decision be based on the highest quality of clinical and laboratory diagnosis and be consistent with national legislation . The Group views with considerable apprehension the possible widespread use of commercially available kits by inexperienced personnel. 11. While the Group endorses the commitment co a multisectoral approach co the after-care and long-term rehabilitation of children with congenital defects, the extremely high cost of maintaining such services is an important consideration underlining the need for adequate preventive measures. 12 . The Group recommends further epidemiological monitoring of congenital defects among newborn i nfants in order co clarify existing knowledge and detect new associations with infections in pregnancy. Such studies should preferably be prospective but if chis is not possible, well designed retrospective analyses provide a satisfactory alternative. Because the numbers of infants with various defects induced by infectious agents may be small, collaborative studies should be encouraged. - 54 - Working Group on New Molecular Biology Tools in Epidemiology, Diagnosis and Control of Viral Infections Berne, 30 August - 1 September 1982 Introduction ICP/BVM 002(5) 0101G 11 January 1983 ORIGINAL; ENGLISH Historically, the characterization of medically important viruses fo r diagnostic and epidemiological purposes has relied heavily on serological and biological tests. The past decade has seen the development of many molecular biological techniques applicable to the detailed characterization of viral nucleic acids and proteins. In addition, new methods for the antigenic characterization of viruses are now available . The Working Group of 16 epidemiologists, virologists, clinicians and public health administrators met to assess the importance of these new tools in the epidemiology, diagnosis and control of viral infections; to define their applicability to the epidemiological surveillance, diagnosis and cont rol of specific viral diseases; to evaluate the need for laboratories able to perform the defined techniques, a nd to identify existing laboratories or delineate policies for establishing them; and to discuss international collaboration and the exchange of information. Conclusions and rec ommendations 1. The use of established molecular biological methods appropriate to studies of the epidemiology, diagnosis and control of viral infections is strongly encouraged. Collaborat ion between research laboratories involved in molecular virology and those concerned with epidemiological studies will enhance developments in this field and should be fos tered by WHO. 2. Analysis by ge l electrophoresis and other appropriate methods of the nucleic acid components of non-cultivable or poor ly cultivable viruses with fragmented RNA genomes, is a simple, practic a l and inexpensive method. It is recommended for the diagnosis, epidemiological study and partial characterization of rotaviruses. 3. Oligonucleotide fingerprinting is a suitable method fo r th e dif ferentiation of viruses with closely re la t ed RNA genomes. It is a powerful tool for the diffe rentiati on of ~i ld and vaccine-derived poliovirus strains, for the study of influenza subt ype variants and characterization of c ertain flaviviruses (e.g. dengue). The technique is demand ing in the use of radioisotope s and requires considerable technical expertise . 4 . Restriction endonuclease analysis of virus DNA provides a valuable method fo r appropriately equipped laboratories. It has been of value in the study of the transmission of congenital infections f rom mother to child by t he herpes simplex virus and the cytomegalovirus, and in the characterization of human papillomaviruses. 5. Techniques based on molecular hybridization are highly discriminating for closely related viruses and may enable the analysis of a large number of isolates. It has been shown to be of value for the epidemiological study and characterization of influenza, papilloma, hepatitis Band retroviruses. Like o ligonucleotide mapping these methods require the use of radioisotopes and are technically demanding. 6. Nucleotide sequencing provides the definitive analys is of the genomes of both DNA and RNA viruses together with information on the gene products . The methods are complex, however, and are available in only a few specialized laborator ies. Recombinant DNA technology is being increasing ly used fo r the c loning and sequencing of viral genomes. 7 . The identification and cloning of specific viral DNA sequences and their controlled expression in eukaryotic or prokaryoti c host ce l ls are potent tools for the preparation of diagnostic reagents through the production of specific nucleic acid probe sequences f or use as specific viral - 55 - antigens. This is also of great potential importance for the development and production of novel or improved vaccines, as it is for the detailed characterization of bacterial plasmids that are of epidemiological and medical importance (such as antibiotic resistance f actors for bacteria) and those used as gene vectors in experimental work. 8. Cell fusion (hybridoma) technology and the production of monoclonal antibodies against defined viral antigens is a potentially important tool for the diagnosis of viral infection for epidemiological s tudies and in the purification of viral proteins for the development of new vaccines. Monoclonal antibodies are particularly valuable for use in studies on the antigenic, structure and variation in viruses and the mechanisms of immunity to vi rus infection. 9. Recombinant ONA and monoclonal antibody techniques have great potential and should be vigorously exploited in attempts to improve the diagnosis and control of virus disease. These approaches are of particular value for viruses which cannot be readily cultivated and for highly pathogenic viruses requiring special handling facilities. 10. The new diagnostic reagents should be developed in parallel with quality control techniques. WHO should assume a role in developing guidelines for the quality control and standardization of reagents. 11. Future developments in the application of molecular methods to the diagnosis, epidemiology and control of viral disease will benefit from a multidisciplinary approach involving il!D1lunological, microbiological, molecular biological and ge netic approaches. WHO has a role in encouraging and coordinating collaboration between appropriate laboratories. 12. Internacional dissemination is strongly encouraged for these new biotechnological app roaches co the study of viruses (or reagents based on their use) for the epidemiology and control of viral disease. WHO should play a major coordinating role in this respect. 13. Research work on the targeting of drugs should be encouraged. Specific monoclonal antibodies directed against critical viral antigens and linked to potent biological reagents has important potential applications in the control of viral infec tion. 14 . Although the specific considerations and recormnendations encompassed in this report dea l with the field of virology, it is emphasized that most of the considerations have a general relevance to the diagnosis and control o f other infectious diseases including chose caused by Ch lamydia spp ., Rickettsia spp ., bacteria and parasites. Working Group on Schistosomiasis in Countries of the Region Rabat, 18-21 October 1982 Introduction - 56 - ICP/MPD 006(5) 0102G 12 January 1983 ORIGINAL: FRENCH The meeting was organized in conjunction with the Moroccan Ministry of Public Health . It brought together specialists from Morocco, Portugal and Turkey, as well as staff of WHO headquarters and the Regional Office in order to: review recent progress in the development of schistosomiasis control methods; suggest possible control strategies for countries in the Region where the disease occurs and constitutes a hazard; specify the research and studies necessary to identify potential transmission areas; determine the measures that should be taken in order to limit the spread of the disease; study the possibilities for regional and interregional collaboration in research, training and control. Discussion The group reviewed the present situation of schistosomiasis and the different control methods that are available. The aim of the control strategy is to reduce or wholly eliminate morbidity from the disease. The long-term goal in the Mediterranean basin s hould be to interrupt transmission. The group discussed the epidemiology of S. haematobium and its intermediate hosts, and the different factors influencing the distribution of the disease. Chemotherapy, using the new schistosomicides that are effective against S. haematobium, such as metriphonate and praziquancel, is one component of control. The most suitable diagnostic technique currently available is that of quantitative filtration of urine using paper, polycarbonate or nylon filters . For greater effectiveness, mollusciciding should be carried out in addition to chemotherapy whenever necessary. For all these measures, a sound system of data collection, treatment analysis and interpretation must be established. In the case of water resources development schemes i n countries of the Region (d ams, marunade lakes, irrigation systems), direct control measures muse be undertaken whenever any transmission of the disease occurs, or systematic surveillance whenever the conditions would allow transmission ( prevalence of human infection and presence of the intermediate hose). The control and surveillance measures should include health education, development of water supplies, destruction of breeding places, etc . Ac present transmission of human schistosomiasis does not occur in Portugal, but the presence of the intermediate host has been confirmed in the north and the south of the country. There is a known focus of S. haematobium transmission in the south-east of Turkey, near the fro nt ier with Syria. It is located in the middle of an extensive water resources development area, where there is a very great risk of transmission starting. Morocco has a well organized, operational national schistosomiasis cont rol programme. Recommendations for countries in the Region where transmission occurs 1. In countries where schistosomiasis control has not yet been started, a control programme should be set up at national level comprising a series of coordinated, multisectoral activities developed as part of the existing health services and in accordance with the principles of primary health care. - 57 - 2. In all water resources development schemes (dams, irrigation systems, etc.) it is important especially during the preliminary studies, to take into account: the danger of introduction of the disease, in areas that are at risk; the danger of an increase and/or spread of the disease, in areas where transmission already occurs. 3. Quantitative diagnostic methods should be developed and standardized. This applies especially to the urine filtration technique, which allows the collection of more comparable and reliable epidemiological data and enables a more accurate assessment of both the geographical distribution of the disease and of the impact of the control measures on the severity of infection. 4. Training for supervisory and operational staff of the programme should be organized in countries where control measures are undertaken, on the lines of the course recently conducted by the Moroccan Ministry of Public Health and WHO in Marakesh. The programme in Morocco, particularly in view of the experience gained in the technical and operational aspects of control, provides a suitable framework for the training of staff from other countries. S. WHO should stimulate and support applied research projects, as part of the schistosomiasis control efforts in the Region, and encourage regional and interregional exchanges. 6. A working group on schistosomiasis control should be convened at least every three years in order to assess the progress of the control programmes in the Region. Meeting on the Problems of Communicable Diseases associated with the Use of the Trans-Saharan Highway Tamanrasset, 8-11 November 1982 Introduction - 58 - ALG/ESD 003(5) 0174G 28 February 1983 ORIGINAL: FRENCH The Meeting was attended by representatives of Algeria, Tunisia and Niger, three of the countries concerned by the new Highway; the participants expressed regret at the absence of representatives of the other countries involved. It was noted that while there had been large-scale, rapid economic and general development in southern Algeria since 1978, the health services had not kept up. A number of achievements, such as the completion of a polyclinic and the opening of a 240-bed hospital at Tamanrasset, should, of course, be mentioned; the wilaya now has a coverage of one physician P.er 500 population compared with one per 3000 in the rest of the country. The opening of a paramedical school at Tamanrasset should also be noted. The existing capacity is still not fully used and the facilities are in any case not keeping pace with the growth of the population (which in Tamanrasset rose from 15 000 in 1979 to over 40 000 in 1982) . The local health workers are grossly inadequate in numbers, qualifications and skills. Training of university-level technical staff should be instituted as soon as possible. In the present situation of shortages of staff and equipment, the inability of the laboratories to carry out reliable diagnosis is sorely felt everywhere; it is still impossible to arrange for a parasitological examination of faeces, a blood examination, a cytobacteriological examination of the CSF, a serological examination (except for Bordet-Wassermann and the Kline or Kolmer test) or a blood grouping. While no epidemics have been reported in southern Algeria in recent years, isolated cases of tropical diseases have been diagnosed in Tamanrasset, despite the only rudimentary facilities available. There is a real and continuing risk of infections, which can be expected co grow as the Highway comes into service. The participants attempted to evaluate the risk, while stressing the need to bear in mind that infectious agents or their vectors may be carried not only south-to-north, but also north-co-south (as in the case of measles). They might also be transported "horizontally" along the feeder road s of the Highway and the nomadic tracks it crosses. The diseases that must be kept in mind in particular, either because they may be conveyed along the Highway or because of the gravity of their breaking out or even becoming established in previously unaffected areas, include malaria, schistosomiasis, diarrhoeal diseases (including cholera), cerebrospinal meningitis, measles, viral hepatitis, yellow fever, Rift Valley fever, Marburg, Lassa or Ebola virus infections, sexually-transmitted diseases and plague. On the question of zoonoses and animal health, all the participants expressed regret that the existing or planned veterinary laboratories are to be separate from those responsible for human health. This division is extremely unsatisfactory from the standpoint both of economizing on resources and of epidemiological reporting and research. The participants then made a country-by-country review of the health situation and discussed possible strategies. For the Algerian sector of the Highway, three broad approaches should be envisaged, i.e. labora to ry surveillance, entomological control and epidemiological surveillance, each of them compr i sing short-term (implementation in 1983), medium-term (following the scheduled completion of the hospital at Tamanrasset in 1984) and long-term (five to ten years) objectives. - 59 - (a) Laboratory surveillance In the short term, the laboratories for the polyclinic at Tamanrasset and the hospital at Ain Salah should be made operational. In the medium term, the laboratory for the hospital at Tamanrasset should be installed in the seven rooms set aside for the purpose. In the long term, a wila*i laboratory should be established; however, a final decision on its siting has yet to be taken. though Tamanrasset was considered initially, this may not be the best choice as the town lies too far south, below the feeder roads of the Highway; Ain Salah would seem preferable in terms of its geographical situation and water resources. The laboratory will be of the standard wilaya type, for which there is a carefully formulated plan ensuring effective organization of the work. Apart from a link-up with the hospitals, which will ensure mutual support in providing services and in carrying out clinical analyses, the laboratory will need to be readily accessible to road users. It must also have a separate room with multipurpose basic equipment for use by consultants should their services be required to deal with a particular epidemiological problem. It must also be borne in mind that some of the activities may eventually have to be expanded to meet the needs, e.g. in virology and entomology. Staff quarters should be attached to the laboratory. (b) Entomological surveillance The entire catchment area of the Highway must, of course, be covered by the surveillance system. In the short term, it will be necessary for this purpose to select as soon as possible at least six trainee technicians from the Sahara region who can be given rapid instruction, enabling them to carry out minimum surveillance measures. In the medium term, it will be necessary to provide resources (premises, equipment and staff) to support the work of the two physicians now being trained in entomology. Each physician will require a team consisting of one senior technician, four technical assistants and two laboratory aides, and each of the teams will need two cross-country vehicles. In the long term, the questions of es tablishing a reference centre, formulating a glob al policy and setting up special services (e .g. a vehicle disinsection station ) will have to be considered in the light of the surveillance results obtained in the short and medium term. (c) Epidemiological surveillance The main problems are P. falciparum malaria, cholera, schistosomiasis, cerebrospinal meningitis, haemorrhagic fever, measles, sexually-transmitted diseases and the emergence of plasmids carrying determinants of resistance. The surveillance will focus on correct diagnos is of all imported cases . Thus, for it to be effective, it will be necessary to ensure that the curative services are readily accessible and, to set up mobile preventive teams, suitably equipped for rapid diagnosis . The first priority should be to ensure reliable laboratory diagnosis. In the short term, the need will be for rapid and reliable microbiological and parasitological examinations. Once the laboratory for the polyclinic at Tamanrasset has been equipped, all that will be necessary for this purpose during the transition stage will be to recruit a medical biologist who would start up the service and provide steady, realistic support to improve the skills of the staff. The surveillance would be strengthened and reoriented 1n the event of a threat of an epidemic within the country or in a neighbouring country . Integration of the various surveillance, prevention and treatment measures will be the key fea ture of the system; because high-quality laboratory examinations will thus be ensured, it will be easier for clinicians to identify diseases in their patients, and these diagnoses will in turn furnish reliable epidemiological data. - 60 - In the short and medium term, the countries concerned by the Highway will have to exchange and upgrade their information, particularly in respect of areas along the route. Ideally, all the epidemiological information should be processed by a single central unit that would maintain close links with the preventive services in each of the countries. It would be very helpful if the latter were to convene meetings from time to time in order to arrange programmes of national or international research on specific topics. Sero-epidemiological surveillance, especially for Rift Valley fever, malaria, schistosomiasis and the major anthropo-zoonoses, should be developed gradually by agreement among the countries. For the control of anthropo-zoonoses, it will be particularly important to maintain close cooperation with veterinarians, since they will be working under the ministries of agriculture. In the medium term, consideration must be given to the possibility of setting up border health posts and the practical arrangements involved. Recommendations l . In view of the urgent needs for the operation of existing or planned laboratory services, priority should be given to basic, postbasic and refresher training of specialists, whatever thei r level. Such training will be feasible if both national and international resources are used. 2. A multidisciplinary study should be made of all the health problems posed by the Highway and the development of the Sahara, with the participation of ministries of the interior, agriculture, water engineering and education of the countries concerned. 3. It is considered regrettable that animal health measures are carried out as a separate activity rather than forming part of the surveillance system. For obvious epidemiological and economic reasons, i t would be much better not to draw an administrative, artificial distinction between forms of diseases that are common to both man and animals. If this unsatisfactory division must be maintained, the adverse consequences should at least be offset by ensuring continuous exchanges of information. This process should be centralized at the national and the wilaya level, and a liais on committee would, therefore, have to be established for the purpose. 4 . The responsib ili ties and tasks of the different ministries and agencies involved 1n the Highway should be clearly defined a nd coordinated. 5. As numerous facilities are expected to be buil t along the Highway in the near future (service stations, motels, bus inesses, etc.), it will be necessary to lay down strict architectural and sanitary norms that comply with the public health code and take int o account the local, ecological, climatic and epidemiological conditions. 6. In view of the need bo th to protect the environment and to promote envi ronmenta l health, regulations applicable specifically to the Highway should be int roduced without delay. Points requiring immediate a ttention include water pollution control and measures to prevent larva breeding places forming in refu se ( abandoned vehicles, tyres, bo tt les , tin cans, etc.). 7. Studies should be made of essential aspects of water supply (distribution, management, storage) in the areas concerned by the Highway. 8. The hopes placed in different types of vaccination should not be allowed Co justify any relaxation in the s urveillance of diseases that are already endemic. 9. Laboratories responsible for surveillance of the Highway should pay particular attention to monitoring for the presence or emergence of resistance in pathogens or their vectors. 10. Because practical steps as well as immediate and wider reaching epidemiological measures may have to be taken following the diagnosis of a case of a particular disease, the national reference laboratory should establish a system for permanent quality control of laboratory techniques and reagents. 11. As haemorrhagic fever poses a special hazard, the hospital at Tamanrasset should include an infectious diseases unit and at leas t one ward for isolating and caking specimens from "high-r isk" patients, with air-lock, protective clothing, d isposable equipment and apparatus for sterilization by boiling and disinfect ion of excreta and materials after use. - 61 - 12. Priority topics for research to obtain better knowledge of the risks associated with the Highway should include detection and study of the distribution of Rife Valley fever antibodies and investigation of the possibility that Anopheles labrachiae may not be able to serve as a vector of P. falciparum strains from tropical countries - which would necessitate setting up an Algeria-Niger and/or Algeria-Mali research team. The research should not be carried out in an area where there might be a risk of importing pathogens. - 63 - FAMILY PLANNING Working Group on Family Planning and Sex Education of Young People Copenha gen, 1-5 November 1982 1. Introduction - 65 - ICP / MCH 024 (S) 0713F 7 December 1982 ORIGINAL: ENGLISH The meeting was attended by 11 temporary advisers, including one from the United Nations Educational , Scientific and Cultural Organization (Unesco) and one from the International Planned Parenthood Federation ( IPPF). Disciplines represented included educatio n , psychology, paediatrics, demography, obs tetrics and gynaecology, family planning and psychosexual medicine. The meeting was a follow-up of the study on family planning and sex education of young people conducted by t he fami ly planning unit i n 1981 . The draft report of the study, wh ich contains descriptions and discussions of strategies employed i n different countries for the provision of family planning and sex education for young people, served as a background document for the Working Group. 2. Discussion The meeting discussed the obstacles found in several countries to sex education and the provision of family planning services for young people . The development of sex education programmes was studied, with th e emphasis on the development of curricula, the training of staff and the implementation of programmes . The development of family planning services for young people was also considered, and particular attention was given to the roles and training of staff a nd the provision of services acceptable to the target group . 3 . Recommendations Education Guidelines for educational programmes ( 1) There should be fu rther research in to the adolescents' own perception of their needs in sex ed ucation and be tter dissemination of research findings, through clearing-houses or other mechanisms, to raise the level of pu blic and official awareness. (2 ) Guidelines fo r sex education programmes and for sex educators should be laid down in written fo rm by individual programme designers according to local conditions, to prov ide a framework that will sa feguard the dignity and integrity of both student and teacher . (3) Sex ed ucat ion should be age- specific and begin early in life, before school age is reached, where parents play a cr~cial role. Channels should be developed to give parents the appropriate knowledge and skill to enable them to info rm and educate their children. ( 4) As the emphasis in sex education is frequent ly focused on reproductive practice and its consequences, and directed at girls, more emphas is should be given to the roles and responsibilities of both sexes . ( 5) Sex education should be an in tegra l part of education in every school system, implemented before puberty and enforced by legislation. Content of educational programmes ( 6) Owing to varying cultural and socioeconomic conditions in different countries , the content of sex education programmes should be tailored to meet individual requirements, but should contain bAsi~ i n formatio n on human anatomv. reoroductive ohvsiolo~v. famil y plannin~ and emotional aspects. - 66 - (7) As there is little written audiovisual material aimed specifically at adolescents, an increased variety of educational material should be produced aimed at this target group. (8) The ways in which sexuality and sexual relations are portrayed in the popular media and in advertisements should be considered in all sex educa t ion programmes, stressing the importance of equality between the sexes and the emotional aspects of sexual relationships. Educational staff and their training (9) Ministries of education should ensure that tra1n1ng in sex education is included in the basic content of all teacher and health professional training programmes. ( 10 ) Teachers who are actually working with sex education programmes should be given additional training. ( 11) Institutions providing sex education tra1n1ng should offer cont inuous updating courses and inservice training, and sex educators should be willing and encouraged to attend these courses . Services Guidelines for the provision of family planning services for young people (12) In order to make famil y planning accessible to young people, legal obstacles shou ld be removed . It is the du t y of concerned organizations, individual pro fessionals and groups to work t owards this end. Organization and setting up of family planning services for young people (13) Governments should recognize the need for the establishment of family planning services offered to young people and should ensure that appropriate funding is made available . ( 14 ) All young people's services should provide pregnancy testing. ( 15) Support pilot adolescent services should be sec up and supported at l ocal l eve l s to provide a . model for the national level. (1 6 ) Centres which do not offer comprehensive services shou l d have estab l ished channels for referring c lients co the re l evant services. ( 17 ) For overall coverage, it i s necessary co depend on ado l escent serv i ces i nt egra ted int o a comprehensive fami l y planning networ k, but it is recognized that separate services will a l wa ys b e essentia l as a supplement. ( 18 ) The provision of services should be adaptable to changing needs . ( 19 ) Services f o r young people should be provided by multidisciplinary teams. Service staff and their training ( 20) Staff working with young people either within integrated family planning services or in separate young people's services should have some special training in understanding adolescent sexuality and behaviour. ( 21 ) During training, personnel should be made aware of their own cultural values and sexuality , so that t hey may be more sensitive to the differences in others. ( 22 ) Inservice training, including continued support and refresher courses, should be provided for all categories of staff . ( 23 ) Training in the provision of famil y planning to young people should encompass not onl y medi cal bu t also psychological, social and emotional factors. ( 24) Midwives and suitable nurses should be trained for the delivery of all kinds of contraceptive services. Where legal barriers prevent such a ro l e, these obstacles should b e removed . - 67 - General Many factors in the provision of sex educa tion and services are overlapping and complementary . Hence: (25) there should be coordination at national and local levels be tween departments of health and educa tion and other concerned bodies in the provision of sex education and family planning services; and ( 26) there should be greater collaboration on the interna tional level between relevant intergovernmental and nongovernmental organiza tions engaged in similar activities and research o n sex education and services fo r young people. The meeting felt that it would be advisable to follow up this Working Group report with several studies in the field, in different countries, and to hold a meeting to review the situation in three to four years' time. - 69 - HEAL TH ECONOMICS Planning Meeting for the Study on t he Cost-Effectiveness of Alternative Strategies for Health Care of the Elderly London, 11-13 May 1982 - 71 - The Planning Meeting brought together experts from six countries. ICP/SPM 035(l)(S) lll4E 7 February 1983 ORIGINAL: ENGLISH They agreed that the Study should focus on the balance between institutional and community-based care in different European countries, as there is a feeling that the present balance of care may be inappropriate because of the growing number of very old people and the mobility of younger families, changing expectations regarding the roles of women and the nature of family life, rising costs of institutional forms of care and a growing awareness among governments, professionals and the public, that older people wish to continue to live independent lives in their own homes for as long as possible. The participants recommended that the national study reports be outlined as follows, and cover t he various points raised. 1 . Introduction 2. Who are the elderly? What are their preferences? Health care policies What are the policies for the health (and related) care of elderly people? What are the goals of different professional groups ? What is regarded as good practice ? 3 . Balance of care What is the balance of care of the elderly ? Are there incentives for maintaining the present balance? What are the criteria for assessment for receipt of services or admission to care ? Who might be deemed to be inappropriately placed and why? Are there any shifts occurring in the balance of care? Are any notable alternative strategies being introduced, locall y or nationall y? 4 . Cost-effectiveness issues What are the policy issues in relation to the cost-effectiveness of shifting the balance of care? What are the costs and effects of shi f ting that balance? How can· shifts be effected ? What i nformation is available on the costs and benefits of alternative mod es of provision t hat have run i n parallel on a long-term basis ? s. Information 'needs and availability What items of information would facilitate decision-making regarding alternative modes o f care or the shifting of the balance of care? What information is available / needed on costs and ef fectiveness? What factors are considered to be most important in assessing net gain or loss from t he introduction of an alternative strategy? How has the available information on costs or ef fectiveness been produced? What is the essential literature on the studies carried out in your country? 6 . Methodological validity How valid do you judge the available information to be ? Do the data have policy implic a tions or are they merely descriptive? Are the data general enough to be applied to other places i n your own country or elsewhere? Was the study biased, e.g. because of a possible "Hawthorne" e ff ect? - 72 - 7. Conclusions What conclusions do you draw regarding policy, the worth of changing the balance of care, further information needs , and the potential for further research? Finally, it was reconnnended that the report on the Planning Meeting should serve as the guidelines for the Study. Any interested institutes should contact directly the international study coordinator, Mr Jonathan Barker, Age Concern Research Unit, 60 Pitcairn Road, Mitcham, Surrey CR4 3LL, United Kingdom. Study Group on the Development of Health Economics Training Florence, 30 June - 3 July 1982 Conclusions - 73 - ICP/SPM 030(2)(S) 0335E 6 August 1982 ORIGINAL: ENGLISH The Study Group endorsed the view that the growing complexity and cost of health care require that health professionals be trained and educated in health economics . Countries with different approaches to the organization and financing of health services share the need to make greater use of the contributions of health economics. While some countries have made a start in developing education and training programmes in health economics for health providers and managers, there is considerable scope for improvement. Programmes tend to be of a very limited nature and be concentrated in a few localities. Consequently, serious gaps exist. The limited impact of health economics ca n partly be explained by the lack of economic thinking on the part of health care providers, especially doctors and nurses, as well as of health care managers and health policy-makers. The overriding concern of providers is with individual patients, and this has meant that they have failed to appreciate how their individual decisions cumulate to affect the health cf others. Likewise, managers often fail to see the link between their decisions - which affect particular groups of patients or institutes - and the growth and development of the health care system as a whole. The various links between the health sector and the economy as a whole have been imperfectly understood by policy-makers, health care providers and managers. A further factor inhibiting the contribution of health economics has been that health workers have misunderstood the role ·cf health economics. Thus economists are often mistakenly thought to be accountants, work-study experts, or business administrators. At the same time health economics is mistakenly seen as being helpful only during periods of financial stringency rather than on a continuing basis. It is not surprising that health economics is often viewed as simply an approach t o cut costs: while the contribution of health economics should be made at the beginning of the dec ision-making proces s , along with the medical and social input, it tends to occur a t the end and in an isolated fashion. On the other hand , it must be recognized that economists have not always appreciated the distinct perspective of health professionals which is oriented to individual patients or individual institutions. The approach to education and training programmes There is a great variety of health professionals, including, fo r example, those groups who wo rk directly with patients and those who do not. Moreover, they work at different administrative and institutional levels and function in different environments. Professional training programmes are conducted at undergraduate and postgraduate levels as well as on a continuing education basis, and may be cf various lengths. For these reasons the content of educational and training prograzmnes cannot and should not be uniform. Nevertheless, the Study Group felt that there were certain concepts so essential to an understanding and appreciation of health economics that they should form a cozmnon core in all such programmes, albeit studied to various depths. The core concepts selected were as follows: the economic role played by health workers and their institution within the health sector; and the economic relationships of the health and health-related sectors to the larger economy; the recognition of the scarcity arising from limited health resources and opportunities; the consequent need to compete fo r resources, seek alternative approaches and make choices; and the consideration cf opportunity costs as a consequence of the choices made; - 74 - the economic approach to selecting opportunities: the cost-benefit (or cost-effectiveness) approach and general concepts of costs and benefits related to health. In addition, the Group identified a number of other topics, the in-depth coverage of which would be expected to be of value to particular groups of health professionals: the need for health care, the supply of health care, and the demand for health care; finance and payment systems, both for the health sector as a whole and at the level of the individual institution or provider; existing and desired incentives to encourage the economical behaviour of health consumers and professionals; the outcome and benefit of health action: concepts and measurement; the resource consumption and the cost of health action: concepts (including average and marginal costs, and social and private costs) and measurement; the relationship of inputs to outputs (production functions) in health and health service action; the economic evaluation of health action: both the conceptual basis and the techniques; the economic determinants and consequences of ill health; the interrelationships between health and national economic development; the efficiency and equity aspects of health planning and resource allocation: the conceptual basis and relevant analytical tools. The existing situation: an assessment In addition to the widespread lack of education and training programmes, there is often a lack of enthusiasm among health professionals for the courses that do exist. In undergraduate medical training there is both a lack of interest in the subject as well as severely limited time available to devote to it. Traditional approaches to teaching have not been successful and more innovative approaches, such as the strengthening of the social science input in general, need to be developed and tested. In postgraduate training and continuing education the methods of teaching will also need to be improved. Various approaches were seen as being appropriate, depending on the circumstances. These included lectures, seminars, workshops, films, and correspondence courses. The emphasis, however, should be placed on case study work and different forms of interactive teaching. A major obstacle to progress in this area was the general scarcity of case study material. Many members of the Study Group also felt that an explicit orientation towards problem solving would be highly desirable in many instances, particularly when training time was short. Illustrations of "actions" that would provide a useful focus included: responding to external economic influences on the health sector and health policy; strengthening the role of the consumer and patient; mobilizing health care resources; setting health care priorities; choosing among alternative strategies of care; introducing incentives for efficiency, for instance, at the clinical level; reducing inequalities in health and health care; and influencing other sectors of the economy to take health-promoting action. The content of the teaching material would need to be closely tailored to the expressed concerns of the various target groups, in order to ensure their interest. Future material should also take into account the changing role and behaviour of physicians, nurses and administrators which will be required for implementing the European regional strategy for attaining health for all by the year 2000. It was also argued that health economics was best taught in conjunction with allied subjects, especially the social sciences, management, and epidemiology, where the number of hours devoted to health economics training was relatively limited. Attention needs also to be directed at the teachers themselves, i.e. the health economists, who, in many countries today, are in short supply. It would not, however, be sufficient simply to produce more health economists whose experience is limited to academic work. Experience has shown - 75 - the value of practical health service work for teachers of health economics. The desirability of heal th economics teachers being simultaneously engaged in research was agreed, however, as their research output would be particularly useful for teaching purposes. Reconnnendations l. Each country should develop health economics education and training programmes appropriate to its own national situation taking into account the suggested concepts, in order to meet the varying needs of its health care providers and managers. 2 . Where the desired programmes do not exist, a helpful starting point for reaching target audiences will be when policies on cost containment, quality assurance or health organization are debated or implemented. 3. Health order to be necessitate care providers and managers should have access to appropriate economic information in able to apply the skills acquired through their health economics training. This may the strengthening of existing health information services. 4 . More health economists are needed and these should be sufficiently broadly trained so that they can function effectively in complex health service environments and teach both the broader is sues relating to health and the economy as well as the narrower, more technical subjects. 5 . In teaching and in the development of teaching materials, emphasis should be placed on il lustrating the principles of equity and cost-effectiveness within the European regional strategy fo r attaining health for all by the year 2000. 6. The preparation of training material in health economics should be promoted by the appropriate centres and organizations for the core and the additional subjects outlined above and the national use of, and experimentation with, these materials should be encouraged. 7. In developing the above teaching material special emphasis should be placed on case studies wh ich illustrate how health care providers and managers can participate more fully in the implementation of the strategies for attaining health for all by the year 2000. Such studies could be channelled through a clearing house, and new materials could be developed and critically as sessed in workshops, working groups, and seminars. 8 . A committee of health economists should be organized to assess the state of the art of health economics, to advise on developments, and to promote the professional identity of health economists as agents of national health development. 9. Internacional training workshops should be organized periodically on health economics fo r le ading health care providers, managers, and policy-makers. 10. Member States should be encouraged to give special consideration to health economics when proposing candidates for WHO fellowships. International Training Workshop on Health Economics Copenhagen, 9-17 September 1982 - 76 - ICP/SPM 030(1)(S) 1127E 8 March 1983 ORIGINAL: ENGLISH The Workshop, which was moderated by Mr G. Mooney of the University of Aberdeen and Mr M. Drummond of the University of Birmingham, was intended to demonstrate the usefulness and feasibility of training and educating health professionals in health economics. It was part of an effort to promote such education and training in interested Member States which also includes a study on the development of training in health economics that seeks to develop suitable learning material, content and method for national adaptation. The 18 participants in the Workshop included senior physicians, senior nurses and senior health administrators from 10 countries of the European Region, as well as programme managers from the Regional Office. Few of the participants had any previous formal knowledge of health economics. They were selected on the basis of their potential to stimulate the use of health economics within the European Region and/or promote education and training in health economics in their respective countries or programmes. Economic concepts The core concepts that formed a basis for the Workshop programme were: the economic role played by health workers and their institutions within the health sector, and the economic relationships of the health and health-related sectors to the rest of the economy; recognition of the scarcity of limited health resources and opportunities; the consequent need to compete for resources, seek alternative approaches and make choices; and the consideration of opportunity costs as a consequence of the choices made ; the economic approach to selecting opportunities , the cost-benefit (or cost-ef f ectiveness ) approach , and general c oncept s o f costs and benefits r e lated to health. In addition, the Workshop f amiliarized the participants with the following concepts: the need and demand for health care, and the supply of health care; finance and payment systems, both in the health sector as a whole and at the level of the individual institution or provider; existing and desired incentives that encourage economical behaviour in health consumers and professionals; the outcome and benefit of health action and their measurement; the resource consumption and cost of health action (including average and marginal costs , and social and pr i vate costs) and their measurement; the relationship of inputs to outputs ( production functions) in health and health service action; the economic evaluation of health action and the techniques involved; efficiency and equity in hea l th planning and resource a llocation and the relevant analytical tools. - 77 - Learning modules The Workshop lasted eight days and each day was devoted to one of the following learning modules.a Economics and health policy: economics is relevant to health policy; its role is different from preconceived notions. The patient as decision-maker: policy-makers must recognize the importance of patients' wishes and demands. Mobilizing health care resources: there is more to financing health care than money. Setting health care priorities: knowledge of morbidity and mortality is not enough wh en it comes to priority-setting. Alternative strategies of care: economic appraisal makes for better policy changes both within the health care sector and in other sectors that can affect health . Incentives for efficiency: we cannot assume efficiency ; it needs to be encouraged. Reducing inequalities in health and health care: equity is an important objective in health policy; reducing inequality comes at a price. The way ahead: within each country there is the opportunity to make better use of health economics and economists, and to promote training in economics among health service personnel. Learning process Each day, and therefore each learning module, consisted of: an introductory lecture on approaches and techniques ; the clarification of concepts; case illustrations (participants being encouraged to provide additional illustra tions ) ; dis cussions in small groups, supplemented by exercises on related topics; the presentation of group reports and their discussion in plenary ; conclusions on the application of the approaches and techniques of hea l th economics to policy-making, planning and management. The first working day also contained a n assessment of the part i cipants' existing knowl edge and skills, while the f i nal working day involved an evaluation of the Wo r kshop , and an ass·essment of the participants' increased knowled ge. Workshop evaluation First, the informal working arrangements made the Workshop an enjoyable experience for participants and moderators alike. Second, the initial and final assessments of participant s' knowledge showed that they all gained in their level of appreciation of the role of economic s in health care and of some of the key concepts of economics. Third, participants' own evaluat i ons of the proceedings indicated that the Workshop had met its irmnediate objective of giving them an appreciation of the approaches and techniques of health economics in health policy-making, p lanning and management. Finally and most importantly, many national partic i pants formulated proposals for using the approach of health economics in their own managerial or policy-making roles and f or disseminating knowledge about health economics in their respective countries. It was, in addition, felt that the learning materials developed were a first illustration of the principles of equity and cost-effectiveness within the European regional strategy f or attaining health f or all by the year 2000. a These l earning modules, Teaching the es sentia l s of health economics, are available d irect from the authors, M.F. Drurmnond and G.H. Mooney , t or £2. ) U i ncluding postage. - 78 - Recommendations In the light of the experience of the Workshop the following actions are recommended for the promotion of training in health economics in Europe. l. Countries should consider holding national training workshops on health economics, possibly with assistance from WHO regarding the programme, the learning material and the train ing of teachers. 2. Countries where the current understanding of and interest in health economics is either low or unlikely to lead to policy action should consider mounting demonstration research projects in selected fields, such as eye health care and nursing. J. WHO should hold a similar training workshop in the French language. 4. Continued support should be given to those who attended the Workshop. - 79 - Consultation on Poverty and Health Aberdeen, 23-26 November 1982 ICP/SPM OSO(S) 1240E 10 March 1983 ORIGINAL: ENGLISH The Consultation was organized by the Medical Sociology Unit of the Medical Research Council, United Kingdom, on behalf of the WHO Regional Office for Europe . The participants, an interdisciplinary group of experts from all parts of the Region, were asked to review the existing state of knowledge regarding the relationship between poverty, unemployment and health and to draw appropriate conclusions about policy, research and training. Another task for the meeting was to advise the Regional Office on the content of its proposed programme on unemployment, poverty and health, over the period 1984-89 . Conclusions Despite cont inued progress in social security systems there still exists a high degree of social inequity throughout Europe. Inequalities in education, housing, standards of living and physical and menta l development exist among the countries of the Region and among geographical areas and population groups within countries. These inequities are suffered by a number of socially disadvantaged groups who, for various reasons, do not fully participate in society and therefore become socially, physically and/or economically vulnerable. On a European scale such groups include: migrant workers, unskilled workers, the unemployed and underemployed, low-income families , ethnic minorities, one-parent families, families with many children, the isolated elderly, the physically and mentally handicapped, and the institutionalized. People in such groups have fewer means of self expression and social contact, their initiative may be stunt ed from years of deprivation, and they are often excessively exposed to physical and socia l risks. Their lifestyles often reflect little knowledge of, identification with, and capacity for achieving health goals. This, in turn, results in higher rates of disease, impairment , disability, handicap and premature mortality than in the average population. At the same time they tend to be less articulate about their problems and rights, and this increases their vulnerabilit y . There is a vicious circle created by the socioeconomic symptoms of inequality and discrimination on the one hand and higher rates of illness on the other. Individuals from socially disadvantaged groups are less likely to attain health, while the ill are less likely to fulfil their socioeconomic roles and may therefore become impoverished . To illustrate the situation of vulnerability, the participants focused on three specific groups : the elderly, migrant workers and the unemployed. Although the rate of increase in the proportion of the elderly in the populations of European countries is beginning to slow down, this elderly population is itself becoming older, a trend likely to continue throughout this century. The inadequacy of social services and income supplements to cope with this problem may lead to an increased risk of their impoverishment in the more developed countries of the Region, while the breakdown of traditional family networks and the lack of social security provision produces the same effect in the developing countries of Europe. Most of the richer countries of Europe employ migrant labour from the poorer regions. Although migrant workers often settle in the host countries, they are not really viewed as an integral part of the resident population. Few statistics are kept on these groups and social services are inadequate to their needs. There is a tendency for migrants to be healthier than the average population in the home country. After arrival in the host country, however, their health status tends to dete riorate owing to various social factors, such as bad housing and employment in the poorer sections of the economy. This often necessitates a return to their country of origin where they no longer qualify for full health and social security benefits. - 80 - Unemployment is growing at an alarming rate in a number of Member States, severely hitting the weakest groups; the young entering the labour market and trying to lay a foundation for adult life; laid-off elderly workers; middle-aged women trying to re-enter the labour market after years as child-rearing housew i ves. The psychological, economic and social consequences of unemployment lead to health problems that are not limited to acute effects, such as depression, but constitute an increasingly broad spectrum of disorders such as alcoholism , drug abuse and other chronic health and social conditions. In other countries, heavy reliance on unskilled work or underemployment appears to produce similar problems. The bleak overall aspect of the European economies carries with it a real danger that social and health inequities will remain at their present level or even increase . The health sector must take upon itself the responsibility of providing convincing information on the true extent of the consequences to health, in order to create motivation for better policies and to stimu l ate other sectors to change their programmes accordingl y . Recommendations (a) Education and training 1. The undergraduate and postgraduate training of physicians and nurses should convey an understanding of socially vulnerable groups and of their health problems, and should be based on a social concept of health and illness. 2. Young scientists and researchers from fields such as epidemiology and health administration should be encouraged co obtain a scientific understanding of social structures and processes, and to l earn to apply social and behavioural sciences in the health field. 3. There should be scope for the education and training of physicians togethe r with social workers and other health professionals. (b) Research 1. Basic research into the life ftXperiences and li f estyles of socially vulnerable groups should be promoted. 2. As long as routine information systems are unable to do so, applied research should be geared to identifying the health needs of socially vulnerable groups and suitable strategies for meeting chose needs. 3. One particular area requiring promotion is c omparative inte rnational research, with special reference to the health of mi grant workers and their f amil i es. 4. Special emphasis should be placed on the promotion of studies in the developing countries of the Region. 5. Given the existence o f many small-scale studies on the health of socially vulnera ble groups in every country and o f relevant data embedded in s ome general studies, stress should be put on secondary ana lysis and the synthesis of research. (c) Information 1. There i s an urgent ne ed to improve the output of r outine information on social equity and social vulnerabilit y . A wider range of social indicators ought to be collected in routine statistics. 2. To supplement and interpret routine data on income and occupation and other census and administrative data, there is a need to promote ad hoc studies on individual or small segments o f the population. (d) Policy 1 . Social equit y - in terms of income, knowled ge, opportunity, power and participat i on - should be accepted as a basic criterion f or all health and social policy. 2. National and international efforts on behalf of migrant populations should be intensi f ied . 3. Social policy and health polic y shou l d join hands in alleviating social vulnerabilit y and its consequences fo r heal t h, while avoiding the medicalization of socioeconomic problems. - 81 - 4. Within the health services, a number of adjustments should be made to cater for the special needs and demands of socially vulnerable groups. These would include active outreach services, information retrieval by social group, special counselling, collaboration with social services and other sectors, the removal.of financial barriers to utilization, as well as a general reorientation towards primary health care. (e) Prograunne of the WHO Regional Office l. The proposed programme on unemployment, poverty and health should be expanded to become a programme on social equity and health. 2. It is recommended that this programme should attempt to help reduce the health gap among the countries in the Region, determine the extent of ill health within socially vulnerable groups i n different socioeconomic contexts, adapt the strategy of health for all by the year 2000 to the special needs and situations of the socially vulnerable groups, and make the public and other sectors aware of the burden on health of social inequity and of the existence of promising s trategies for change. 3. A standing advisory panel on the programme would be required, to help avoid duplicating t he work of international organizations, to build up knowledge systematically and to disseminate re sults. Workshop on Health Policy in Relation "to Unemployment in the Community _Leeds, 13-15 December 1982 Introduction - 82 - ICP/RPD 8O4(3)(S ) 11O9E 27 January 1983 ORIGINAL: ENGL I SH The third meeting within the Study on the Influence of Economic Development on Health was he ld in conjunction with the Nuffield Centre for Health Services Studies. The participants from eight countries reviewed evidence of a link between unemployment and ill health, received reports of a number of research projects in progress, and discussed their implications for health and health-related policy. Review of existing research Research on the experience of unemployed individuals (i.e. at the micro level) has consistently shown that unemployment of more than a few weeks' duration causes physiological stress, which leads to raised blood pressure and an increase in the risk of heart disease. In addition, there is not only a worsened affective state among the unemployed, with corresponding changes in body chemistry, but also a greater tendency to psychiatric symptoms as shown by an increase in admissions to psychiatric hospitals at times of high unemployment and by a higher than average proportion of suicides and para-suicides . It seems likely that this is caused by the financial strain and the breakdown in close relationships that occur in periods of sustained unemployment. Research on the nationa l and cross-sect i onal levels (i . e . at the macro and i ntermediate levels ) provides additional evidence that the unemployed su ffer excess morbidity and mortality. On the other hand, it also points to the likelihood that the he a lth of the employed suffers too, owing to additional work stresses, worsening work conditions and fear of unemployment. Moreover, those outside the labour f orce, such as infants and the elderly, are likely to be affected by the impact of unemployment on the family and the rundown of social services and social support networks. It has been s hown that help-seeking behaviour in general, not just the use of health services , increases in recessions and with economic instability . A large body of research shows, there f ore, chat high levels of unemployment and economic instability cause a significant increase in the levels of mental ill health and also have adverse effects on the physical health not only of the unemployed but also of their f amilies and the community in general. Further epidemiological, c ross-s ectional, longitudinal and co=unicy-level s tud ies are ~equired to elucidate the ways in which economic change has these observed effects, especiall y a s ~egards the relative roles of income loss, poverty and the psychological impact of being unemployed. Emphasis should be given to those social and demographic groups that are most vulnerable to disruptive effects, by linking socioeconomic, demographic and health-related information. Policy implications of research findings Economic policy. Economic decisions can be made socially more relevant by taking full account ,f social costs, such as the erosion of working capacity and the costs to the health and social 3ervices that unemployment and economic instability entail. It must at the same time be stressed :hat not all types of employment are preferable to unemployment: work has its own hazards and 1ocial costs, particularly when health and safety conditions and environmental standards are :elaxed in the name o f promoting employment. - 83 - Employment policy. In so far as there are limits to the possible scope of employment creation, there are advantages in sharing out of the existing employment opportunities rather than concentrating additional work hours and stress on those already employed. In addition, socially useful work can be devised to use temporarily spare capacity. The employment of workers below their skill levels and other forms of underemployment are nae viable solutions. Social policy. Health damage caused by unemployment can be limited by reducing poverty among the unemployed and other groups suffering from economic instability, and by ensuring that public decisions do not break networks of social support. There is the dual - sometimes conflicting - need to encourage, especially in children, the dependence of self-esteem on having a job, and to diminish the scope for self-blame among the unemployed. Agencies responsible for counselling the unemployed in a number of countries need additional capacity in times of recession because of the increased demands on them to attend to cash payments. Health service policy. Health services can be planned to meet the additional health needs resulting from recession. Better identification and quantification of the burdens on health services caused by disruptive economic events can help improve the relevance and cost-effectiveness of these services. The activities of nongovernmental agencies, such as self-help groups, labour unions and churches, can play a constructive role both in health and social policy. Recommenda tions 1. Governments should take account of the above-mentioned policy implications of unemployment and economic instability in general. 2 . Governments should promote or sponsor research on the causal links between economic instability and health, and obtain information on the health of their socially most vulnerable groups. 3. WHO, through the Institute for Medical Informatics and Health Services Research in Munich, s hould continue to act as a clearing-house for literature, both unpublished and untranslated works as well as ongoing research. 4 . WHO, in collaboration with one of the centres participating in the Study, should convene a f ourth workshop with the focus on the health of those social groups that are especially vulne rab le t o economic recession and instability. - 85 - HEAL TH EDUCATION Meeti ng on Lifestyles and Living Conditions and their Impact on Health Hohr-Grenzhausen, 18-21 October 1982 Background - 87 - ICP /HED 019(2)(S) 1466F 10 May 1983 ORIGINAL: ENGLISH The WHO Regional Office for Europe recognizes and encourages a strategic shift away from the tradi tional view chat health is most heavily influenced by professional interventions. Research i nto health risks, particularly as it applies to the prevention or postponement of chronic diseases, originally implicated individual behaviour as the causal factor in ill health. More recently, structural aspects of society (pove rty, unemployment, racism, etc.) and environmental haza rds (pollution, unsafe workplaces, etc.) have been recognized as being powerful determinants of chronic disease as well as being the underlying conditions associated with the adoption of many des tructive personal behaviour patterns. What has emerged is a multifactorial picture of the cause of ill health fixed in a social context. Clearly, then, the primary emphasis of the public health approach must somehow be shifted co the public aspect of public health. This, by and large, will mean that public health establishments muse enter unfamiliar conceptual and technical domains, even crossing over into other social jurisdictions, such as agriculture, law, industrial relations, religion and economic development. It is now recognized chat a social model of health development demands the broad participation of society in deciding on priorities and programmes chat are in the puolic interest. Indeed, fo r effective change co occur, the lay public, historically defined by health professionals as co nsumers , must now be seen instead as the resources of health and health care . Public awareness of the individual's own potential is seen in the increased interest in lifestyle (nutrition, exercise, etc.) and in social activism in health ( the women's movement and self-help) . There is little precedent fo r heal th promotion policies chat build on a social model of heal th and rely on the broad participation of the public in defining needs, establishing priorities, undertaking programmes and evaluating results. Both political and technical questions arise when th e power of decision-making and action is shared among a number of professional sectors and between professionals and lay people . To be able to recommend health promotion policies, targets and procedures to Member States, the WHO Regional Office for Europe muse have the advice and cr iticism of social scientists, epidemiologists, public health planners, health educators and communications specialists, as well as representatives of the public. A series of consultations is being held for this purpose. The Hohr-Grenzhausen Meeting The Meeting in Hohr-Grenzhausen involved 24 experts from the European Region, Canada and the United States. It was immediately recognized that the cultural, economic and social diversity of the European Region should inform health promotion policy and be a stimulus for innovation. The f acilitation of the interaction and exchange of values, views and technology was seen as an essential role for the Regional Office, using its network and organizational resources. The policy, programme and research implications of the emphasis on lifestyle in health promotion were brought out by the group, and there follows a summary of the central issues they considered. l. The term "lifestyle" is often glibly used without being defined . It is a term that often refers to individual behaviour associated (or presumed to be associated ) with certain health outcomes, but the term can also be used to mean styles of life or group values, a collection of behaviour patterns that may influence health. Healthy lifesty les, chose that affect health po sitively, are not fully understood, and their definition is subject co variation depending on the ep idemiological data available as well as on cultural variations in what constitutes good health . Policies based on considerations of lifestyle muse be explicit about what is meant by the term "healthy lifestyle", its epidemiological basis and its cultural relevance. - 88 - 2. Health promotion programmes that focus on changing individual lifestyles may end up blaming the victim if they ignore the structural context of health behaviour, namely the socioeconomic, polit ical and environmental factors in the causation or reinforcement of behaviour. It is also possible that the over-zealous pursuit of a change in lifestyle, at either the individual or the community level, may create its own health problem, namely "healism". A "healist" society is one where deviance from the imperative of good health is not tolerated, often on patriotic grounds. The group emphasized that a central objective in health promotion is to increase the quality and diversity of options to achieve lifestyles (and life circumstances) that are conducive to health, given that there is no agreed single lifestyle conducive to health. A strategic function of the lifestyle concept should be its support of cultural and social dive rs ity in health promotion . 3. The economic crisis in several countries of the Region presents opportunities for reassessing the productivity of the professional health resources. How much do they (or c an they ) contribute to health promotion or disease prevention, and what is their contribution to health care relative to the total social resources used for such care? This sort of appraisal can reveal the basis for redefining the role of health professionals and reallocating fiscal and technical resources. On the other hand, vigilance should be exercised to ensur~ that health promotion policies are not used to excuse reductions in appropriate and essential health services and equity of access to them. 4. Achievement of an appropriate and effective health promotion policy will require heightened polit ical awareness among health educators and a sense of where the decision-making power lies and how to work within the political process. Strategies should be adopted that develop new political constituencies among community health interest groups. In this sense, the health educator is a facilitator of community action, nurturing public involvement, creating a network of community resources and advocating the community's interest in health promotion. In this last r egard, an important contribution is the creation and maintenance of community access to data that are vital fo r informed decision-making and action by the community. 5. The participation of the individual at the community and national level is an essential ingredient in health promotion programmes, given the powerful social character of health and the political character of promotion. The social character of health requires that people define health in terms most relevant to them, and the political character of promotion requires that people determine the process that is most compatible with their values and preferences . This horizontal strategy of health development is more likely than any other to achieve broad social change, stimulate innova tion, alter the balance of government health policies and reduce negative consequences such as "healism", inequities in access to health-promoting benefits and victim blaming. 6. Achieving an informed and effective level of public involvement in health promotion depends heavily on continuous, accessible, creditable and attractive information . Mass communication med i a have a central role in this regard, particularly in serving to demystify health information and demedicalize the concept of health care. Innovative approaches under way in several countries of the Region need to be given wider dissemination through the organized efforts of WHO and regional nongovernmental agencies . The media can be even more effective if they are brought full y into the planning process of health promotion programmes and not left as an afterthought. The cultural impact of the media in the reinforcing of old or facilitating of new norms of health behaviour should not be ignored. The media can be a powerful ally or deterren t to the goals of health promotion. 7. Research on health behaviour and the social dimension of health requires a review or an inventory of what is available in the Region. In addition to studies on the direct relationship of behaviour to health, a review should include a secondary analysis of data derived from related work in epidemiology and the social/behavioural sciences . An inventory can reveal areas of insufficient data, problems of definition in both independent and dependent variables, variations in theoretical formulations, and latent hypotheses that are worth testing. This could be a first step toward developing a consistent, integrated and comprehensive research strategy or "mapping" that could guide a coordinated research effort in the Region. The Regional Office could play a key role in this process as a clearing-house for research in progress and by facilitating comparative research among Member States. Index variables related to lifestyle and health could be incorporated into existing national surveys as an effective and relatively inexpensive way of monitoring attitudes, values and behaviour associated with health. The epidemiological study of social behaviour affecting state of health and lay initiatives in health care (such as self-care and self-help) needs to be encouraged. The aim is to achieve an understanding of the way that lay resources in health and health care constitute a system of behaviour patterns. With such a perspective, it should be possible to assess the complementary role of professional health resources in supporting the social base of health promotion. - 89 - Clinical research, particularly those studies focusing on secondary prevention in the care of chronic disease (such as hypertension or diabetes), offers an opportunity for collaboration among behavioural, social and clinical scientists . The WHO Regional Office for Europe can be helpful in this regard by sponsoring symposia on the process of socioclinical research, a process that often i nvolves linking diverse theoretical frameworks and procedures. In recognition of the social, indeed public, nature of lifestyle and health promotion, the consulting group emphasized the importance of lay participation in research, particularly in generating hypotheses, selecting acceptable (non-invasive) methods of observation, and interpreting findings (identifying biases). Lay advice regarding the effective dissemination of results should also be sought. This is not meant to imply a downgrading of professional expertise, but to specify i ts technical role in the context of a social phenomenon. The integrity of the lifesty le concept in its mediating function, and in its focus on lay competence in health and health decision-making , must be maintained. The professionalization of the concept or practice of li f estyle would be clearly counterproductive as far as the public interest is concerned. The group was mindful that, as wit~ all aspects of health development, the overriding health issue of our time is the threat of nuclear disaster. The primary goal of health promotion must always be the promotion of peace. - 90 - European Meeting on Legislative Measures ICP/HED 020(3)(5) 1311F in Relation to the Development of Lifestyles Conducive to Health 2 March 1983 Dresden, 15-16 December 1982 ORIGINAL; GERMAN l. Introduction The Meeting was held in connection with the inauguration as a WHO Collaborating Centre for Health Education of the Institute of Health Education, Dresden, German Democratic Republic. It was attended by participants from 13 European countries, consisting of medical and legal professionals and senior health education specialists. 2. Scope and purpose The purpose of the Meeting was to prepare a study by the Regional Office on legislative measures for the development of lifestyles conducive to health. In so doing, the fundamental consideration is to achieve tangible progress in promoting lifestyles conducive to health as part of Wl:O's strategy to attain health for all by the year 2000 and hence to enhance the quality and effectiveness of health education . The study will identify more closely the part that legislative measures can play in this process. At the same time, it is intended to be instrumental in drawing up recommendations for further improving legislation and its impact on the development of lifestyles conducive to health. The study will be carried out under project ICP/HED 010 (Legislative initiatives in preventive health education), taking into account the outcome of the meeting of the Advisory Committee on Health Legislation, Dresden, 24- 26 June 1981. Par'ticipants were requested to state their position on the following questions from the viewpoint of their respective countries . l. What is the function of the law in promoting health-conscious lifestyles and how is the law to be integrated with the system of measures taken by society as a whole fo r the development of lifestyles conducive to health? 2. What scient ific preparations and initiatives (or community demands) exist in the European countries for laying down the necessary legislative groundwork ? 3. Which existing laws have an impact on the delineation of lifestyles conducive to health ? 4 . wbat are the supporting or inhibiting effects of those laws, the main barriers to their implementation and the deficiencies of the regulations themselves? The following were the positions that emerged from the information reports and discussions. (a) Laws play an important and indeed indispensable role in delineating lifestyles conducive to health. (b) It is essential to determine the general structure and content of such legislation in European countrie s focusing on: the level and status of the law concerned (p rovis ions of a constitution, general or specific laws for health protection, federal laws and regional or state laws, laws of national applicability or local bye-laws, etc.; the mode of action of the law (direct regulations mandatory or prohibitive in character; economic tools with legal force, such as taxation and tax legislation; indirect regulations to involve social groups, especially in health education; - 91 - the establishment of health protection regulations in all fields of legislation and at all levels of applicability (special regulations for health protection and family, labour and environmental legislation with specific relevance to health); the legal traditions of the country conc erned have always to be taken into account. (c) The enforceability of a codified law must be assessed, with particular reference to: the obligations of government bodies to sa tisfy the rights of citizens; the activities of social groups and community participation in such activities; in particular, the behaviour of citizens in response to their health needs; financial and other material resources and numbers of those employed in this sector, and other factors. (d) Longer term studies are required to determine the effectiveness and eniorceability of laws in promoting health behaviour, and the problems arising in practice must be emphasized . (e) It should be noted that legislation is but one of the social components influencing health behaviour. Consequently, any research into laws, their enforceability or practical effectiveness will be inadequate, unless due regard is paid to the necessary links between law and other factors influencing lifestyles conducive to health and - more generally - to the social background and foundations of legal applicability and law enforc ement . (f) With a view to providing a solution to selected specific problems (e.g. the control of smoking or alcohol abuse) in part through laws, an analysis should be made of the overall pattern and the interaction between different laws and other tools, and of their effectiveness and s hape. (g) The study should also be concerned with scientific research undertaken, where it has a bearing on this topic, and should provide insights into planned and pending legislation and new trends in the geographic applicability of laws . 4 . Recommendations 4 .1 In future programme activities of the Regional Office on aspects of the development of liiestyles conducive to health, due regard should be given co legal regulations. This is an important prerequisite to enhancing the effectiveness oi health education activities . Hence the planned study on the same subject as the Meeting will, in the opinion of the participants, assume considerable significance in the context of global and regional strategies for health fo r all by the year 2000. 4 .2 The information reports presented at the Meeting and the position adopted by the participants sho uld be evaluated thoroughly and incorporated in the study. It shoula be established whether the final report might be published in connection with the keynote papers read at the Meeting. 4.3 The participants concluded that the importance of the subject under discussion justified in-depth studies based on the results of the Meeting and their incorporation in a single study. Major working phases should be: a comprehensive evaluation of the outcome of the meeting; the carrying out of a survey in all European countries; consultations on specific countries and topics (in-depth studies ) in selected European countries; the drawing-up of a draft study and its discussion at a WHO working group in Dresden , late November 1983; completion of the study by the end of February 1984. 4 . 4 The participants recommended use of the following outline for the questionnaire and the study: the concept of health education and lifestyles in the context of the goal of health for all by the year 2000; - 92 - basic social and ethical problems of health legislation in relation to lifestyles conducive to health; basic principles and approaches to health legislation in general in selected European countries; legislation principles of health education in selected European countries; specific examples of legal regulations in relation to primary prevention; role of health education in relation to laws; participation in health legislation and health education; specific case studies/evaluation of effect; discussion of results of study in relation to the state of knowledge and research; relation to health for all by the year 2000 targets of the Regional Office for Europe: prospects and trends; recommendations of the working group based on the study . - 93 - HEAL TH OF THE ELD ERL V Workshop on Teaching Gerontology and Geriatric Medicine Edinburgh, 5-7 April 1982 l. Introduction - 95 - ICP/ADR 045(2)(5) 0096k 29 April 1982 ORIGINAL; ENGLISH The Workshop, organized jointly by the Department of Geriatric Medicine, University of Ed inburgh and the Regional Office, brought together 19 experts from 15 countries in the fields of gerontology and geriatric medicine. The purposes of the Workshop were: (a) to discuss methods of teaching gerontology and geriatric medicine in the European Region; (b) to formulate recommendations for action; and (c) to discuss the Information Centre on Educational Opportunities and Courses in Gerontology and Health Care of the Elderly, which is in its initial stages at the Andrija ~tampar School of Public Health, University of Zagreb, Yugoslavia. The discussions were conducted in three sessions. (1) The undergraduate curriculum - the basic science component. (2) The undergraduate curriculum - the clinical component. (3) Postgraduate and continuing education. 2 . Conclusions Growing old must be seen as a normal part of human development. Health professionals, if they are to meet the needs of their populations, must be familiar with aging and care of the elderly. The great majority of old people receive their medical care from doctors who are not geriatricians, and the bulk of this responsibility falls in the area of prima~y health care. A clinically competent, broadly based approach is required with full recognition of the effect of psychosocial factors on the wellbeing of the elderly. Practitioners must be willing to adapt to a multidisciplinary way of working. Well trained physicians who are confident and competent in care of the elderly will derive 1110re professional satisfaction from their work than those who lack such training. 3. Recommendations 3.1 The undergraduate medical curriculum 3.1 .1 Basic science component Basic science teaching in medicine should include substantial instruction on normal aging if it is to reflect the changing needs of society. Sociology and psychology of aging should be incorporated into the behavioural science course. In schools where no individual can be identified who has special expertise in gerontology, basic science teaching in this field may be stimulated and coordinated by the clinicians responsible fo r teaching geriatric medicine. - 96 - The basic science curriculum should reflect new knowledge on aging, the effects of aging on function, iaunune competence, pharmacokinetics and pharmacodynamics, cognitive function and personality. 3.1.2 The clinical component Sound clinical teaching in geriatric medicine should be provided, when the student has already acquired wider medical knowledge and clinical skills. An identifiable block of curricular time should be allocated specifically to teaching geriatric medicine. Teaching methods should exploit to the full the wide range of teaching opportunities available, including the patient's home, the day hospital, assessment and rehabilitation wards, continuing care units and nursing homes. The clinical course should place emphasis on prevention, the value of early detection of stress in patients and their supporters, and the benefits of appropriate intervention, as reflected in an expanded set of objectives based on those defined in 1981 by an earlier WHO Consultation. The organization and teaching should be in the hands of identified clinical teachers who are themselves trained in the health care of the elderly. Proper evaluation of teaching is proposed. This may be achieved by examination or by assessment of students by teachers. 3.2 Postgraduate medical education Geriatric medicine should be included in training prograaunes in internal medicine and psychiatry. All doctors involved in primary hea l th care should rece i ve instruction in a g ing and care of the elderly . Doctor s intending to specialize in geriatric medicine should undergo postgraduate training on a level comparable to that f or other specialties. Close training links with psychiatry are indicated. Disciplines such as rehabilitation medicine and orthopaedic surgery should be involved in teaching rehabilitation and locomotor and mobility prob l ems among the elderly. Guidance i n and opportunities for research in the field of gerontology, geriatric medicine or health care delivery should be avai l able. The acquisition of management skil ls should be reflected in training pro grammes, 3.3 Continuing education in geriatric medicine Continuing education in geriatric medicine should be comparable with that 1n other specialties in each country. Continuing education should be given high priority unti l undergraduate training in aging and geriatric medicine has reached an adequate level. 3.4 Resource centres Resource centres should be given urgent priority , either by identifying existing centres or by establishing new ones. Emphasis should be on the training of geriatricians and primary health care workers. Methods of teaching should be developed and evaluated in these centres. International and other agencies should be approached with a view to f unding these centres. - 97 - 3. 5 Training of teachers of gerontology and geriatric medicine A large and rapid increase is needed in the number of teachers. WHO could help in identifying resource centres to meet this need. Regional centres should be established and their experience shared with others through existing clearing houses, such as that at the Andrija ~tampar School of Public Hea l th in Zagreb. WHO should convene an early workshop on the training of teachers. Working Group on the Organization of Services to Prevent Disability among the Elderly Sokobanja, Yugoslavia, 12-15 October 1982 Introduction - 98 - ICP/ADR 025(S) 0813E 10 November 1982 ORIGINAL: ENGLISH The Working Group was composed of gerontologists, geriatr1c1ans, psychiatrists, general physicians, sociologists, technical engineers, nurses, physiotherapists and occupational therapists. The meeting was convened as a follow-up to a working grou p which met in Cologne at the end of 1981.a The high prevalence of disabling conditions in old age, such as multiple disability, locomotor problems, mental deterioration and sensory disabilities, are a challenge to the health services, particularly the disability prevention services. Disability prevention in the elderly is very comprehensive and requires Joint action by the health and social services, in both lay and professional sectors, and at various levels . The Group recognized the key role of primary health care in preventing disability in the elderly, and identified some of the main gaps in services currently provided. Services at secondary and tertiary levels play an important part in the prevention of further escalation of disability in old age. Presentations and discussion of national experiences in successful and less successful areas helped participants to identify gaps and to make recommendations for action. Psychosocial factors play an important role , not only in the etiology of disabilities in old age, but also as an accompanying factor to most of the disabilities. Special attention was pa i d therefore to the existing systems within services for coping with stress situations in old age. The nature of existing services and available manpower was reviewed with the aim of rectifyin g gaps seen f rom both professional and lay points of view and of formulating recommendations fo r: action in the context of f ollow-up to International Year of Disabled Persons ( 1981) and to the United Nations World Assembly on Aging; and interdisciplinary studies in priority areas of prevention and rehabilitation f or the elderly, including preventing the consequences of disease: impairment, disability and handicap. In discussion, the group emphasized the importance of making the general public aware of their own responsibility throughout life to maintain health and to prevent disability in themselves and in members of their families. Participants considered that the current negative expectation of the majority of the medical and lay public that elderly people will inevitably become increasingly unfit, is often a self-ful fil ling prophecy. It militates against the elderly seeking early advice on problems that may be remediable, and this acts as an important barrier to the prevention of disabilities in old age. a Preventing d i sability in the elderly: Report on a Working Group (EURO Reports and Studies 65) . Copenhagen, Regional Office for Europe, 1982. - 99 - Conclusions and recommendations I. Screening of elderly persons 1. The most important indicator of functioning in elderly people is performance in activities of daily living (AOL). The lack of such information on an individual often results in further deterioration in functioning and also gives rise to misunderstandings between and among professionals and the lay public. WHO should invite a group of experts to review the special t esting methods on mental, physical and social functioning currently being used for research purposes, and to recommend those they cons i der to be most suitable for practical application. At the same time the development of new simple methods should be actively encouraged. In collaboration with its Member States WHO should develop and adopt guidelines for assess i ng the performance of AOL, which will enable relevant personnel to obtain information on activities and aids likely to enhance the quality of life of individuals. Such assessments could, with appropriate refinements, fulfil the role of screening. 2 . At the present time a variety of screening methods are being used at secondary and tertiary levels to detect conditions such as hyper- and hypotension, lipidaemia, coagulation, gl ycosuria, low hearing/ vision, and disordered gait. A group of experts should be appointed to r eview, and subsequently advise on, the selective use of appropriate, specific and sensitive methods. The group should also critically examine the known efficacy of these methods. II. Early detection and intervention 3. Many of the problems of old age could be ameliorated, if not prevented, by interventions at an early stage of their development. These include conditions that affect mobility and communication, aphasia, dysphagia, osteoporosis, osteoarthrosis, depression, acute confusional states, dementia, vascular diseases, sensory impairments, and urinary incontinence. Some deficiency diseases could also be prevented by well-balanced diets and adequate physical activity. Study is required of the factors of personality, cognitive functioning, social environnent and motivation, which may influence the elderly person's response to programmes of health education, prevention and rehabilitation. Attention should also be given to techniques of communication and reinforcement mechanisms which influence that response. III. Technical aids and resource centres 4. In relation to self-care, further s tudy should be made of the behavioural patterns of those individuals with disabilities, particularly i n relation to the proper use of aids and prostheses. 5. Consideration should be given by Member Stat es co the establi s hment or further devel opment of national technical resource centres to include responsibility for undertaking research in engineering technology in relation to t echnical aids, the physical environment and means o f access in order to i ncrease the independence of e lderly people. 6. The possibility of developing a Regi onal technical resource centre should be explored, the function of which would include dissemination of technical informat i on, education in the use, applicat i on and maintenance of aids, promot i on of research, and evaluat i on of additional t echnical resources. Meanwhile WHO should gather i nformation on existing nat ional centres which could serve as catalysts for the development of integrated services for disabled elderly persons. To enable cost-benefit examinations to be carried out, WHO should also support the development of demonstration projects to test the usefulness and effectiveness of such models in different country settings. IV. Organization of services 7. In order to further develop services for preventing disability among elderly persons, research is required in the following areas: innovations in providing services and the use of technology, wi th special reference to systems analysis, operational research, and consequence analysis (including cost-effectiveness); ways of developing communication and links among primary health care, institutions and other major elements in the service system ( including self-help groups ) , particularly to allow competent and non-stress f ul transference of elderly pat i ents between levels of care; and organizational development in relation to the elderly person's access to all needed services and facilities. - 100 - The Regional Office programme should include the identification of innovative and other usefu l models in service provision; dissemination of information on these; promotion of their evaluation; and assistance in adapting them to meet similar needs of other countries. v. Manpower development at primary level 8. Member States should promote the organization model of the primary health care team, working in the local community and designed to identify the needs of the elderly, to screen those individuals at risk of developing disability, and to follow-up on recognized disabilities. WHO should collect and review other relevant primary care activities being undertaken in different settings and disseminate such information to the responsible authorities. 9. WHO and its Member States should promote the appropriate educational programmes to enable primary care workersa to function more effectively as key contact persons for elderly individuals. VI. Studies on morbidity, multiple pathology and effects of the environment 10. Studies on the health of elderly people have had little impact as yet on the planning and development of services to prevent disability in old age. In reviews of existing epidemiological data great care must be taken to avoid misinterpretation. Any new research undertakings, especially longitudinal studies, should state clearly the hypotheses to be tested and the possible application in practical ter,ns of the research findings. Nationally based comparable cohort studies of age prevalence of disabilities in Member States should be actively encouraged. 11. It is recognized that old age is characterized by morbidity resulting in multiple impairments. The development of disabilities as consequences of multiple impairments differs in individuals. In order to improve the quality of life of the elderly, it is necessary to correlate the existence of medical pathology with the ability to function. This requires not only standardized recording of morbidity but also of factors relating to the psychological, socioeconomic and cultural background of patients which may help to explain differences in functioning. Deeper insight into mutual interactions among such factors is also needed. The concept of multiple impairments and the assessment of daily living activities are useful in focusing on the global aspect of the problems of elderly people and attention should be given to general psychosocial factors and the i ndividual's general abilities which affect his response to any treatment or rehabilitation. It is essential that strategies for intervention should also be based on identifying the discrete elements of physical and psychiatric pathology with reference to their remediability and prognoses. Consideration should also be given to the extent to which aids or adaptation of the environment may simplify or reduce the task of rehabilitation. It is probable that intercountry va riations will be greatest in the la tter. 12. The positive and negative effects of diffe rent environmental situations on the life pa tterns of elderly people should be studied with a view to deve loping or improving those in which the elderly are able to live full and productive lives. To enable the elderly individual to continue to live i n contact with society in the locality he knows, a prime consideration should be the provision of suitable housing and means of access to persons and facilities i n his neighbourhood. WHO should stimulate further research into this important subject by forging or strengthening links with, and between, ' the agencies in Member States responsible for environmental studies. 13. There is a need to improve the accuracy of mortality statistics of the elderly as a source of information on multiple morbidity. To this end, WHO should promote improvement of the accuracy of death certificates and, for the older age groups, detailed analysis by age and sex of underlying and contributing causes of death. In addition, consideration should be given to modifying the International Classification of Diseases to include simultaneous failure of multiple organ systems as an increasingly common cause of death in the very old. VII. Intercountry communication and cooperation 14. Progress reports on specific fields of activities relating to the prevention of disabilities in old age at primary, secondary and tertiary levels of care are of great value to all Member States. Through its task force on health ca re of the elderly, the Regional Office should promote the presentation and discussion of such reports by convening follow-up meetings on various aspects of the prevention of disability. a "Primary care worker" in this context may be defined as the first contact person within the health care system. - 101 - 15. Since terminology is of vital importance for mutual understanding, more precise definitions are needed for terms such as "prevent ion", "activities of daily living", "dependency" and "functioning". The Regional Office should revise the glossary of terms in health carea to include terms that are either missing or require further refinement. The definition of "rehabilitatio~• should also be incorporated into a revised edition of the publication. a Hogarth, J. Glossar of health care terminolo . Copenhagen, WHO Regional Office for Europe, 1978 (Public Health in Europe, No. 4 . - 103 - HEAL TH LEGISLATION International Course on Health Le islation teer1ng omm1ttee Brussels, 8-10 December 1982 Introduction - 105 - ICP / HLE OOS ( S) 2280L 27 January 1983 ORIGINAL : FRENCH The meeting was convened by the Regional Office, with the support of the Belgian Government, i n order to prepare a first international course on health legislation . It brought together a broad multidisciplinary group of 13 experts from 11 countries, including senior staff of ministries of health and universities and physicians and jurists specializing in such fields as health legislation, health law, medical law, social medicine and forensic medicine . The preparation of the course forms part of the implementation of WHO's health legislation programme for the European Region. The situation analysis carried out by the Regional Office to set objectives for this programme had already pointed to the shortage of trained staff in this f ield as a major problem . Then in June 1981, the Advisory Committee on Health Legislation, which met in Dresden in order to review the programme, recommended that the Regional Office should organize such a course. Thus, within this context, it was decided to convene the present meeting with the following terms of reference: ( 1) to formulate objectives for the course; (2) to consider criteria for the selection of participants; (3) to prepare a curriculum; (4 ) to discuss teaching methods; (5 ) to consider criteria for the selection o f lecturers; ( 6) to discuss practical arrangements with regard to documents, date and place, and publicity . The Committee discussed these points and d rew up conclusions and recommendations . Discussion l. Objectives After identifying the gaps in the present teaching of health legislation, the Committee addressed the question of what the ultimate purpose of the course should be . It recalled that health legislation is both the expression of a stated health policy and an instrument whereby governments seek to strengthen their health activities. It stressed that, although the course would be of considerable scienti f ic value in fostering exchanges of information, searching theoretical studies and comparisons of health institutions and systems in terms of le g islation, its main purpose should be practical, namel y to show what role legislation can play in tailoring the existing health structures to WHO's regional strategy for attaining health for all by the year 2000. This point was made quite clear l y in the statement of the scope and purpose of the meeting (document ICP/HLE 005 / 2) , namely that the aim of the course should be to provide basic or further training for public health administrators in this field so that, on the one hand, they can appl y this knowledge in order to make better use of health legislation as a tool for the implementation o f health policy and, on the other , the y can then take the necessary steps to strengthen the teaching o f health legislation in their countries. - 106 - 2. Participants The Committee noted that an international course on health legislation ~ould be addressed to very different categories of participant: administrators who are required to deal wi th health matters, physicians and other health professionals, jurists , administrators and specialist staff of social services. After examining the different possibilities, the Committee took the view that the essential aim of the course should be to promote health legislation that could serve as a tool for formulating and strengthening health policy . The c ourse should, therefore, be open to persons wh o are directl y responsible for elaborating such leg islation and have a role to play in the development and application o f health po licy . The partic ipants should make up a multidisciplinary group in terms of the strate gy for health for all by the ye a r 2000 and, at the same time, be high - level administrators who participate in decision-making . After considering the possibility of holding several courses, the Committee recommended that the Regional Office should, in the first instance, organize a single course and that this should be limited to participants from the 33 Member States o f the Region. To f acilitate dialogue, exchange of ideas, thinking on the subject and teamwork, the Committee felt that the number of participants should preferably be l i mited to a maximum of 30. 3. Curriculum The Committee gave much thought to the question of the c ourse curriculum. It took note of the recommendations of the Advisory Committee on Health Legislation, which had drawn up a list of components of health legislation. It also examined three draft curricula that had been circulated in the form of working documents. The Committee expressed clear preference for one of the draft curricula, while making certain additions and giving more emphasis to some of its features. It recommended that the curriculum should be subdivided into broad sections, as follows. An introduction, describing WHO's policy and its health legislation programme and describing the role that legislation should play in attaining the goal of health for all by the year 2000 . A first part dealing with basic concepts of law, since many of the participants might not have any legal education other than that acquired in the course of their administrative work . A second part devoted to health le gi s lation and its fi ve c omponents: consumers ( individual and group measures), providers, institutions, re gulat ory authorities and systems o f financing. The Committee felt that the emphasis in the teaching relating to each of the five components should be as follows. With reference to consumers, it s hould be on prot ection of the environment and legislation influencing lifesty les, in the case of group measures, and on the rights o f patients and of vulnerable groups s uch as the handicapped, the mentall y il l and the a ged, in the case of individual measures. In matters relating to providers, it should be on legislation governing professional practice , ethics and research ( both medical and social ethics ) and leg islation on the question of responsibility. With regard to institutions, it should be on legislation governing primary health care and preventive measures. As far as the regulatory authorities are concerned, it should be on legislation dealing with centralization and decentralization. Finally , in the matter of s ystems o f f inancing, it shou ld be on methods for comparing the different systems and assessing the e f fectiveness of the relevant legislation . A third pare devoted to case studies. - 107 - It was felt that the curriculum should not be regarded merely as a list of topics to be studied each year, but rather as a broad framework in which to draw up the specific programme for the year in question. Although the curriculum might contain some of the same items each year, others could be introduced for a particular session in the light of international developments and the priorities identified by the United Nations and WHO or in the light of the overall trends in WHO's programmes. 4. Teaching methods The level of the part1c1pants, who would be persons already active in professional life, as well as the multidisciplinary nature of the group, were seen as the deciding factors in the choice of teaching methods. The Committee recommended that the case study and group discussion methods be used routinely and the lecture method for certain topics. It felt that no single method could be regarded as suitable for the entire course; for instance, in the introductory section, more reliance would probably have to be placed on lectures, while subsequently giving greater emphasis to group discussions, case studies and possibly the drafting of a paper as a team effort. 5. Lecturers The Committee fel t that, apart from lecturers as such, it would be desirable to appoint a course director and three discussion leaders who should be present throughout the course. The number of lecturers need not be very great (seven or eight, for instance). They should be selec ted in the light of the particular items in the curriculum and be drawn from the higher levels of administration, universities, etc.; each could be made responsible for a broad topic and would be present for the time allotted to it within the course. The Committee felt it would be useful to call a meeting of organizers and lecturers at some stage before the start of the course. 6. Practical arrangements Documents The Cormnittee recommended that the participants be provided with working documents. would comprise, on the one hand, documents sent out in advance f or study before the start course and, on the other, a collec tion of materials at the site of the course which might compendiums of treaties and laws, documents of an international nature, treatises, etc. Place They of the include A member of the Cormnittee proposed that the course be held at the University of Leuven ( Belgium). This suggestion was approved unanimously, and it was noted that the university could easily make available lecture rooms as well as f acilities for board and lodging; the participants would also be able to use the university library. Date and duration of the first course The Cormnittee felt that the first session of the cours·e should be held in 1984 and suggested that it take place during the university vacation, preferably during the month of July. It should be of two weeks' duration. Working languages The Committee discussed the question of working languages at some length. Eventually, it decided to recormnend that only one language be used for each of the sessions. It proposed that the first (1984) be conducted in English and the second (1985) in French. Candidates should be required to give evidence of an adequate command of the language concerned. Promotion of the first course The Committee stressed the importance of the Regional Office sending information about the course to Member States, which should then c ollllllunicate it to those concerned. This information should be issued sufficiently in advance and include details of the curriculum, the working language and the requirements for admission. - 108 - Conclusions l. The main purpose of the course should bet~ show what role legislation can play in implementing the regional strategy for health for all by the year 2000. 2. The participants should constitute a multidisciplinary group of about 30 high-level administrators responsible for developing and applying health policy. 3. The curriculum should be subdivided into broad sections under the following headings: introduction, basic concepts of law, components of health legislation, case studies. 4, The teaching methods should vary, depending on the part of the curriculum conc erned, and considerable reliance should be placed on group discussions and case studies. 5. A course director and three discussion leaders should be appointed as well as seven to eight lecturers suitable for the particular items in the curriculum. 6. Working documents should be issued in advance and a collection of materials on other topics should be made available to participants at the site of the course. 7. The proposal of the University of Leuven as site of the course should be given favourable consideration. 8. The first session of the course should be of two weeks' duration and be held during the university vacation (July 1984). 9. Working languages should be English for the first session (1984) and French for the second (1985). 10. The Regional Office should send advance information on the course to Member States. - 109 - HEAL TH MANPOWER Fourth Meeting of National Fellowships Officers of the Eur-0pean Region - 111 - ICP/PTR 004(4)(S) 0146J Thun (Switzerland), 26-29 October 1982 1 December 1982 ORIGINAL: ENGLISH Introduction Twenty-five Member States were represented at the Fourth Officers of the European Region. A representative of each of British Council and the Council of Europe also participated. the WHO Regional Office, were to: Meeting of National Fellowships the other WOO Regions, as well as The aims of the Meeting, convened (a) review WHO fellowships activities and their contribution to the development of health personnel in the quantity and of the quality needed to provide effective health care; the by (b) discuss new approaches and procedures for the fellowships programme in terms of general policies and priorities established by the World Health Assembly in accordance with the national strategies fo r the attainment of health for all by the year 2000 through primary health care; (c) intensify the cooperation between WHO and the Member States in order to facilitate appropriate and geographically adequate placements of trainees and to improve the use of training resources within and between the Regions in accordance with training needs; (d) Further improve the daily operation of the fellowships progrannne by strengthening the mutually beneficial interaction between fellowships officers and WHO staff; Cone lusions The participants concluded that the WHO fellowships programme should make a viable contribution to health for all by the year 2000 as an integral part of health manpower development. The objectives of each fellowship have to be well defined and a system of fellowship evaluation established to ensure that its impact has the desired effect especially on primary health care. The main thrust should be directed cowards the promotion of lifestyles conducive to health; the reduction of preventable disease; and the provision of acceptable health services accessible to everyone. To achieve this, alternative appro aches to the use of fellowships may have to be considered: for example, the setting up of seminars and workshops at regional or country level or the organization of study groups to gain knowledge of existing relevant facilities . More collaboration will be necessary between sending countries, WOO and receiving countries in the planning of fellowships programmes, to eliminate recurring administrative problems. In particular, sending countries should recognize the need to ensure that all fellows have sufficient competence in the language of instruction. Fellows should also be given more information about the difficulties they may encounter during their stay in the host country . As regards the questionnaire on report forms which was tabled at the Meeting, the participants agreed to await the outcome .of the study of these forms, to be undertaken shortly by the Regional Office for Europe, before completing a special document based on this study which will . eventually be sent to governme nts. Recommendations Examination of the WHO fellowships programme as a way of strengthening national health manoower resources in the light of the global strategies for health for all by the year 2000 Cons idering that the successful outcome of a WHO fellowship is largely dependent on the knowledge of educational institutions in the host country built up over the years by the national - 112 - fellowships officer and h is ability to explain to these institu t ions the special way in which they will contribute to the sending country's hea lth manpower development, the Meeting recomme'l'h:!ed: • ( 1) that the national fellowships officer, designated by the host country, should, by establishing liaison with committees concerned with the post-basic education of hea lth personnel , use hi s influence to ensure the smooth implementation of WHO requests for training, or alternatively to advise WHO when modification of the requests could provide more a ppropr iate results; (2) that the national fellowships officer of the host country should receive stm1111ary info rmation about the country health plan of the sending country with an outline description of how the fellowship requested will contr ibu te to the health manpower development within that plan , if available. Administration and mana gement of the WHO fellowships programme in the European Region Taking in t o account that i nsufficient time to arrange a fellowship programme, improper lv completed WHO fellowship applica t ion forms and inaccura te accompanying doc umentary ev inence cause inconvenience and embarrassment to the host count ries and ma y even result in an unsatisfactory outcome, the Meeting recommended: (3) that where necessary national fellowships officers of sending countries should be prepared to give guidance to WHO fellows as to the complet i on of the fellow ship application fo rm (WH052 ); (4) that nat ional fellowships officers of the sending country should be prepared to take responsibility for establishing the validity of any evidence presented wit h the fellowship application fo rms, part ic u larly evidence of competence in the language that will be used for instruction at the host i nst ituti on ; (5) that if, on scru t inizing the fellows h ip appl ica t i on fo rm , i t is considered that the training needs of the fellow ca n be more readily fulfilled within the send ing Region, national and regional fellowships officers should be prepared to question the value of acquiesc i ng to the req uest _for extra-regiona 1 training; (6) that the health administration of the coun try of origin in collabora t ion with the WHO Regional Office should take responsibility for deciding whether exceptionally to ask a host countrv to receive a WHO f el low, wh en le ss tha n three months can be given to the programme preparation, or to recommend postponemen t of the fellowship for an appropriate period. Taki ng into consideration that request s for extensions of fellows hips at short not ice are, as a general rule, the resul t of circ umstances that might have been avoided at the planning stage of the training programme and that nevertheless such reques ts do a r ise from time to time (fo r examp le, where a fellow.unexpectedly fails an examination ) the Mee ting recommended: (7) that when ever possible short not ic e requests for extensions shou ld be avoided, bu t wher e this is unavoidable a nd to prevent unnecessary financial hardship to the fellow; the WHO Regional Office for Europe should be mandated co award an ex tens io n of up to one month to allow for the necessary administrative processes. Considering the many problems that can arise where a WHO Fellow proceeds on a fellowsh ip study programme accompanied by one or more dependants, for whom inadequate fina nc ial provision ma y have been ma de , and acc ept i ng that a WHO fellow should be free to arrange for his dependant s to travel with h im, the Meeting recommended: ( 8 ) that WHO should consider the problems of accompanying families as a fundamental policy matter requiring urg ent consideration and action; (9) that , to assist WHO to reach a satisfactory decision on the problem of accompanying dependants, national fellowships officers should notify the WHO Regional Office for Europe in writing of all such problems as they arise, so that a corps of fa ctual evidence can be accumulated. Because the WHO Reg ional Office for Europe cannot arrange stipend and o ther expense payments to o r on behalf of a WHO fellow, until notificati on has been received that t he fellow has arrived i n the host country , the Meeting therefore recommended: (10) that the WHO Regional Office of the sending Regi on should ensu r e chat all WHO fellows are in possession of a "noti fi cat io n of arrival " ca rd; - 113 - (11) that national fellowships officers in host countries should notify the WHO Regional Office for Europe immediately of the date (and time) of arrival of a fellow in the host country. Review of the cooperation among Member States and the WHO Regional Office for Europe in promotion and evaluation of the fellowships progranrne Since the monitoring and evaluation of fellowships is a shared responsibility of the sending country, WHO headquarters and Regional Offices, host countries, host institutions and fellows, the Meeting recommended: (12) that the Fourth Meeting of National Fel'lowships Officers of the European Region should congratulate those Member States which have adopted advanced and comprehensive evaluation procedures for their former WHO fellowship progra11111es, and should invite those countries which do not have any evaluation procedures to adopt at least a very simple one; (13) that the evaluation of the impact of a fellowship should be the responsibility of the sending country; (14) that host countries in the WHO European Region should contribute to the overall evaluation of the fellowship by monitoring the WHO fellows' training programme in the host institution, reporting on progress, and recording any deficiencies in the fellows' ability to meet the demands of the programme or in the host institutions' provision of training to meet the fellows ' needs; ( 15) that evaluation should cover all aspects of a fellowship including selection procedures, completion of application forms, arrangements for training, termination of studies reports, utilization reports and the final impact of the fellowship on the health manpower development plans of the sending country within the framework of its health needs; (16) that to facilitate the overall evaluation and progress of the fellowship, other Regional Offices of WHO should be invited to consider the possible applicability and adoption of a confidential report form similar to that already used by the WHO Office for the Eastern Mediterranean Region. Fifth Meeting of National Fellowships Officers of the European Region (17) The Meeting was c onsidered useful in that it allowed national fellowships officers the opportunity to meet and compare experiences . The suggestion was made that in future the working groups should consist of no more than 10 members . Re gret was voiced that a few countries were unable to se nd a representative to the Meeting, but it was hoped that all 33 Member States would be represented at the next fellowships officers meeting, which was likely to occur sometime in March 1984. - 115 - HEAL TH PLANNING - 117 - First European Seminar for Leading Public Health Administrators on Health for All by the Year 2000 Antalya, Turkey, 1-5 November 1982 Introduction ICP/GPD 008(5) 0707F 8 December 1982 ORIGINAL: ENGLISH This meeting, the first in a proposed annual series, was attended by 25 participants f rom 15 countries. Participants included a representative of UNDP. The Seminar was intended to give particular emphasis to health-related problems of more developed countries. Another aim was to e ncourage closer coordination among the Member States of the European Region of WHO in the development of national health policies, based on the regional strategy for health for all. The seminar focused on likely future developments in the political, social, economic and c ultural environment of Europe; on possible trends in health research; on how to deal with developments i n health technology; on intersectoral collaboration in health development; on the r ole and place of lay care; and finally on national health policy development, t~king Turkey as a case study. Discuss ion The f uture is not what it used to be The world of health and health care is undergoing r apid and dramatic change, as a result of the worldwide, interdependent and accelerating disturbances in political, cul tural, social and economic affairs. Western society appears to be rushing into a new industrial revolution and the so-called " Third Wave" or "knowledge society" is creating a worldwide challenge. Europe's vulnerable dep endence on natura l resources from other continents is compounded by the economic challenge presented by countries in Asia . There seems to be hesitation in deciding whether to choose a "greening" of Europe or to emulate the economic ally successful synergy arrived a t by some Asian government s, universities and industrial communities. As a result, the social contex t and prospects of a number oi crucial issues must be redef ined, among them employment and unemployment; education and overeducation; and the prevailing social contract between society and the individual . Among factors with an impact on he alth are indications that the life expectancy of adults is increasing and that the aging o f the population may be accelerating. Traditional family structures a nd geographical distribution of populations are shifting. Major breakthroughs are appearing on the scientific horizon which, it is said, will surpass those discoveries made earlier in the fields of chemistry, biochemistry a nd physics. The new areas of discovery are i n micro-electronics, microbiology, immunology, genetics, bioengineering, receptor-physiology and new materials. At the same time, profound changes in values are taking place in the population in matters as fundamental to life and society as procreation, pairing, mating, coping, work, relationships, dependence, beliefs and death . These are bound to a ffect prevailing modes of care and cure, yet there has been a simultaneous overproduction of traditional health resources (manpower, hospital facilities and drugs), forcing most nations to reduce resource levels. Health technology and health policy Regarding new technology and its relationships with health policy, the source of fu nding f or research into the efficacy and effectiveness of new technologies varies from one country to another both in Europe and North America, but continued significant funding from public sources seems important. The problems faced by small countries in funding certain types of reserach, particularly large controlled clinical trials, could partly be overcome if WHO were enabled to ace in a facilitating capacity on a European scale. There are some indications of a trend towards the commercialization of research, which may present inherent dangers. For example, if research is dominated by private enterprise, who does the de velopment work on matters that are important but not commercially valuable and therefore unattractive to private enterprises. Despite the dangers, ic is - 118 - nevertheless true that the research, community and business must learn better to coexist, and to work together. National authorities should maintain a strong interest in and some form of control over the development of technology, particularly by overall supervision of research. It would be more helpful, however, if the classical type of supervision was replaced by active stimulation and guidance in health technology research and development by national medical and social research councils. Motivation is of critical importance in steering researchers into the most fruitful area s of research and development. Bicxnedical research is more attractive to researchers because its findings may be of universal relevance, whereas the relevance of health services research is sometimes seen as being limited to the system within which it is carried out. As one possible incentive to health services research, participants at the meeting mentioned the institution of a prize in this field by WHO. Control of health technology also requires suitable response by the medical profession; in particular, the individual relationship between patient and doctor and the consequent requirement for clinical autonomy is a delicate issue. The creation of any new structures and procedures for technology assessment will therefore need to be supported by an appropriate promotional and educational campaign aimed particularly at the medical profession; it remains to be seen to what extent political pressures will have to be mobilized to create new mechanisms fo r technology assessment and evaluation. In many countries better methods may also have to be found to ensu re that health systems are more effective in the way they apply useful findings in technology research , appraisal and evaluation in the day-to-day provision of health care. A key issue is the need to arrive at a better understanding of the interrelationships and interactions among technology, medical manpower, education, deployment and utilization. In this context, due attention must also be given to the wider problem of controlling costs in the field and accurate forecasting of the £inane ial consequences of emerging technology. Though the benefits of technology assessment and research are being passed from one country to another, there is growing concern and resentment that all countries do not share equally the burden of research and assessment. Conversely, every effort should be made for countries not to duplicate each others' research; WlD could play a more active role in helping avoid duplic ation of effort. Streng th th rough i ntersec tor a 1 collaboration Intersectoral cooperation is a key element of the concept of health for all, but changes in the environment make it a n increasingly complex matter. It is important to recognize that such collaboration must be in an everchanging system and that a realistic balance should be struck between a naive harmony model and a cynical antagonism mode l. A number of changes are occurring in intersectoral coo peration: shifts in the prevailing intersectoral mix, with traditional clusters such as health and environment now cha nging their alignments; changes in public/private re sponsibilities; changes in the administrative/political balance; erosion of the national state through the trend towards subnational and supranational entities, etc. The relative importance of traditional powers (legislative-executive-judicial) and non-traditional powers (interest-groups and bureaucracies) is also changing. This means that there is a need to realign intersectoral collaboration. In the first place a change in outlook is overdue: instead of a resources-dominated outlook the health care system should adopt a result-oriented posture and should use this perspective to negotiate collaboration with other agencies more effectively. In the second place, costing procedures should try to place the overhead social costs of health and health care in the hands of the agency responsible, for example by making the polluter pay. Coordinating machinery can also be improved by making wider use of professionals with academic qualifications in more than one discipline, by the use of integrated committees, by coordinated planning structures and by ensuring that in the course of their careers key officials circulate among the various cooperating agencies in a given system. A greater and more focused use could also be made of national or international charismatic figures to inspire and promote intersectoral collaboration in heath. Towards a new alliance with lay care The role and place of lay initiatives in health promotion, cure and care are of growing importance. A great many problems are solved by lay elements in society: spouses, relatives, neighbours, friends, colleagues, fellow-sufferers, etc. Shifts are taking place in the scope of problems that such lay care address and in the machinery that is used and preferred. hnong other things, this results from changes in the family structure, in the living and working environment , in social networks, etc. New knowledge, new skills, new technologies in the health field are now accessible to the lay person. This requires a realignment in the interface between the formal (professional) and the informal (lay) care sectors . There is an urgent need to come to grips with this realignment and to bestow on it the necessary legal and social authorization, approval, incentives and disincentives. In so doing it is essential to keep in mind, on the one hand, t he - 119 - scarcity of financial and natural resources, and on the other, the abundance of health manpower and othe r health resources. The new alliance between lay care cure and professional care cure needs serious and well focused research. In this regard, an active posture on the part of both national heal th administrations and WHO would be desirable. The increased awareness among the general public, in particular among pressure groups, might be utilized to promote policies under the regional strategies for health for all, but it is essential not to overlook the fact that well-organized lobbies may distort priorities. National health policy development - Turkey: a case in point In Turkey a new form of health services organization was introduced in the nineteen-sixties, through the gradual establishment of a state health centre infrastructure. Main health problems include malaria, tuberculosis, other communicable diseases, child health and family planning etc. The chief constraints in health care development are: the difficulties in organizing primary health care; the distribution, quantity and quality of manpower; the low degree of decentralization and integration of health services administration and, finally, the lack of success in many areas in arousing community interest and participation in health care development. Finance is a major cons traint, with only 2. 7% of the national budget being devoted to health. The activities of specialty boards in postgraduate medical education are now being standardized, as is medical education generally. The numbers of entries to medical schools have now become strictly controlled, and a compulsory year of specialized training in family medicine after graduation has been added. All postsecondary education is now being reorganized and directly related to the country's manpower needs through the new Council of Higher Education. One result of standarized curricula, combined with the other measures, is that medical schools in the smaller cities are now able to develop better. Much attention has also been given to building up the education of sufficient numbers of other health professionals. The United Nations system, has been assisting with health development in Turkey. During the past three decades assistance in the health sector has undergone a shift in form, from an early emphasis on equipment and supplies to the present stress on technical cooperation and the building up of management responsibilities. In UNDP's third country progra111De 1983-84, the health projects which will be supported are: an occupational safety and health centre; development of the environmental secretariat; assistance to the biomedical engineering institute; water-supply and sani tation schemes ; primary health care. WHO cooperation is of importance in this effort; in money terms, Turkey is the country in the European Region receiving most support for individual country projects. Machinery has been established for the regular joint review of programmes by Turkey and the WHO Regional Office for Europe. Initial emphasis in WHO support was on c ommunicable di sease control, sanitation, water-supply, food safety and maternal and child health. In the fu ture a major component will be primary health care (i n three different pilot areas), a project conducted i n conjunction with the Government, UNDP an UNFPA . A second major component will be the development of water-supply and sanitation. Future programmes also include other environmental health activities, such as prospective studies on the implications of irrigation schemes for malaria control. Collaborat ive efforts in malaria control and family planning will co ntinue; other fields of cooperation may include road traffic accidents, drugs and vaccine production . Conclusions In health policy development in the various countr ies of Europe, though there seems to be gene ral acceptance of the WHO regional health for all strategy, there appear to be a variety of starting points for formulating the corresponding national strategies. In progressing towards such national strategies, several underlying principles, concepts and issues are to be faced. Inequality in health is unacceptable: How can national health policies and programmed deal more effectively with issues of social justice and health? Health and socioeconomic development : the encouragement of intersectoral cooperation and the matching of health development to general socioeconomic development is of paramount importance. Governmental responsibility and social control: the degree of centralization and decentralization and the interaction between public and private sectors are fundamental issues which must be faced openly in order to develop effective health care systems. Public involvement and participation: what are the best practical mechanisms for accomplishing this in the complex societies of today 's Europe ? - 120 - Promotion and prevention: these are central to any health strategies, but much more energetic intersectoral action is called for. Cost and financing: how the public and private systems should relate to each other (for example, should patients pay? are there mechanisms for controlling remuneration of health workers?), and must be carefully planned in order to ensure a health care system which can guarantee both equity in provision of care and economic use of available resources. Coordination and cooperation for the formulation of strategies are necessary not ony within countries but among countries in the Region on a subregional or other basis. The expected adoption of clear targets, within the main areas of the regional strategy, by the Regional Committee in September 1983, will give a better direction for future natonal health development in Member States. Three large European conferences dealing with future action in Europe with regard to health for all strategies are scheduled to take place shortly after the next Regional Committee: (a) a conference in 1983 on primary health care in industrialized countries; (b) a conference in 1983 on issues related to intersectoral collaboration in environmental health; (c) a conference in 1984 on management and planning of health care. There will be major difficulties in pushing matters forward because of vested int erests and fear of change. Managerial processes for national health development can help to effect change, and a series of detailed documents has been produced by WHO to help in this respect. WOO is also cooperating with some countries in developing so-called "scenario techniques" for health planning purposes. - 121 - HEAL TH STATISTICS - 123 - Third Joint ECE / WHO Meeting on Health Stat i stics Geneva, 15-18 February 1982 Introduction ICP/HST 010(5) 0014k 3 May 1982 ORIGINAL; ENGLISH The Third Joint ECE / WHO Meeting on Health Statistics was held in Geneva from 15 to 18 February 1982 . On the basis of working documents presented by invited experts and the secretariats of ECE and WHO, the Meeting studied the following points: (a) classification of impairments, disabilities and handicaps for use in household surveys; (b) linking of population-based and institution-based data; (c) social indicators in the field of health; and (d) problems relating to health accounts. Cohclusions and recommendations Classification of impairments, disabilities and handicaps for use in household surveys The Meeting agreed that there is a recognized need for an international classification of impairments, disabilities and handicaps for use in household surveys, in order to allow for i nternational comparisons; that the concepts included in the International Classi f ication of Impairments, Disabilit i es, and Handicaps (ICIDH) proposed by WHO are considered rational and acceptable to all participants; and that the definitions of impairment, disability and handicap as s tated in the ICIDH are considered adequate. The Meeting also concluded that further work is needed to adapt ICIDH to di ff erent t ypes of survey; to clari fy and simpli fy the concepts i n order to make it more operat i onal and acceptable f or use by non-specialized interviewers; to improve its capability for dealing with mental and sensory disorders; and to include the measurement of environmental conditions. Instruments should be developed for measuring individual performance and environmental conditions. An exchange of i nformation on this subject would be a useful f irst s tep towards the improvement of the classification. Parallel to that effort , a survey should be organized to obtain information on the i ntended purposes for which an international classification of impairments, disabilities and handicaps would be used by countries. It was recommended that WHO and ECE set up a small group of speciali s ts from the med i cal and social sectors to participate in the further work conducted on the classification, and to make proposals f or adapting it to household surveys . Linking of population-based and institution-based data The Meeting reviewed national experiences and discussed problems related to the quality and confidentiality of health information. Suggestions were made that such problems could be minimized by closer liaison between the users of administrative registers and the officials who work on such r egisters, and by establishing systems providing external researchers with anonymous data . The Meeting was informed that the programme of work of the Conference of European Statisticians makes provision for further work i n this field, but not specifically for health statistics. It was recommended that the exchange of national experience should continue in future joint meetings. - 124 - Social indicators in the field of health Commenting on a list of indicators related to the WHO European regional strategy for health for all by the year 2000, proposed by the secretariat, the Meeting considered that: (a) the list includes several detailed items which are characteristics to be used in the formulation of indicators, rather than indicators themselves; (b) the list is too long for use as a basis for collecting information from countries, and further work is required to determine and delineate the purpose of the list, what the list is intended to measure, and the expected frequency of reporting from countries; (c) the list should point to the need for disaggregation of indicators in order to show variations within countries and among populat i on groups; (d) systematic use should be made of accumulated experience, and international organizations should coordinate their activities in this field; and (e) efforts should be made to deve·lop and use more "complex" indicators, in which several of the proposed characteristics could be combined. The Meeting also provided detailed comments on the proposed indicators, and these were noted by the WHO secretari at for its subsequent work on refining the list. It was recommended that the Meeting review progress achieved in this field at its next session. Problems relating to health accounts Having reviewed national experiences, the Meeting agreed on the need for a statistical system for measuring various dimensions of the economic aspects of health activities in the form of a "system of health accounts". This system should complement both the basic body of the systems of national accounts and balances and f it into the system of health statistics, and should also be part of a more comprehensive system of "social accounting". The system of health accounts should therefore be linked with other systems and its concepts, definitions and classifications harmonized with those used in these other frameworks. It was pointed out that the health accounts and related statistical data should, under ideal circumstances, show the direct and indirect impact that any health activity has on economic development and on the improvement of the population's health conditions. Toe Meeting recogni zed, however, that the f irst objective should be to formulate a more modest programme in which basic information on economic aspects of health activities could be incorporated in a comprehensive way so as to achieve greater international comparabilit y . Toe Meeting agreed that, i n the present round of revision of SNA, considerable at t ention shou ld be given to the requirements of health accounts and other subsystems of social accounting- While it was generally accepted that the basic system of national accounts cannot be expected to provide specific and detailed information for the various special areas of social activity , it was considered advi sable to extend and i mprove the relations between the SNA and social statistics. As work on health accounts is going on in several international organizations it would be useful to collect information on national practices f ollowed in the field of health accounts, particularly as regards concepts and definitions. This work should be reviewed at a further joint meeting. Other recommendations In addition to the recommendations included in the above sections the Meeting recommended that comparative studies be conducted on: (a) national experiences in ca l culating indicators of the performance of health services ( i.e. relating outcomes and outputs of health services to their inputs); and (b) national experiences in setting up and utilizing national and subnational information systems for the planning, management and evaluation of health services, with particular emphasis on primary health care, as well as f or evaluating changes in the state of health of the population. Toe latter study should serve as a basis for f ormulating guidelines on the adaptat i on of related systems f or health statistics. r - 125 - Meeting on the Study on Trends in the Demographic Structure in the European Region: Health and Social Implications Berne , 22-26 March 1982 l, Introduction ICP/MCH 025(J)(S) UNFPA/RMI/79/POS 0016k 26 April 1982 ORIGINAL: ENGLISH The Meeting formed part of a study initiated in 1980 by the WHO Regional Office for Europe, with the support of the United Nations Fund for Population Activities. The objective of the Meeting was to study the health and social implications of the demographic structure and trends i n the European Region for the period 1960-2000, and to make reco11DDendations on developing health, social and related services according to the population needs arising from demographic trends. Working papers were presented on trends in demographic structure with regard to mortality, fertili t y and family formation, and on the effect of trends on young people, adults and the elder ly. Fourteen country reports were available, of which a synopsis was presented. 2. Conclusions and reco11DDendations General conclusions and recommendations about population policy, health and social policy, research, general morbidity and mortality were formulated, as well as conclu sions and recommendations specifically oriented towards the major age groups. The main recommendations are summarized below. 2.1 General Whereas in the past people and policy-makers were often concerned mainly with quantitative population growth or growth control, the orientation of policy ought to move towards a greater conce rn with the qualitative aspects of human life, including behaviour and living conditions. Policy-makers should seek to respond to changes in the demographic structure and population needs, rather than to the demands and self-interes t of health care and social establishments. Population scientists and health and social researchers should form multidiscipl i nary teams and mutually broaden their scope, in order to achieve interdisciplinary and policy-oriented research on the relationship between demographic behaviour, demographic structures, and health and social care . More attention should be given to research on the effects of socioeconomic status and other socially and biologically differentiating factors on morbidity and mortality. There is also a need for more information about the services required by specific age groups, particularly the elderly . Efforts should be made co use available health and demographic data more adequately , to improve their quality, to unify their codification, and to interrelate data from different sources. 2.2 The young population (0-1 9 years) The relative reduction expected in this age group in most countries should not justify minimizing its problems, and efforts should be sustained to improve the health and social welfare of young people. Children are perceived more and more as a valuable and precious resource in society. Impairments and disability must be reduced through improved antenatal, obstetric and paediatric services, and through better means of preventing accidents and their consequences. The education and information of children and adolescents in matters of health, sexuality and psychosocial development are to be considered as f undamental elements of policy for this age group. This has to be complemented by adequate and parallel information for parents and educators. - 126 - Additional child care resources will be needed as a result of the trend towards increasing female employment, and increasing family disruption. Special attention will need to be paid to the integration of migrant children into their new society. 2.3 The adult population (20-59 years) The size of the adult population will not change too much in the next two decades, but the age structure of this group will alter, with a higher proportion of older adults. This population will have to bear a greater economic burden in their support to the elderly. The trend towards smaller family and household size, coupled with increasing divorce rates, will lead to more people living in isolation and consequently special problems fo r the provision of health and social services. A grea ter flexibility will be needed for such services and for housing to cope with the needs of various household t ypes and their geographical distribution. Information should be given to parents and young adults so that they can exercise their right to choose the number and spacing of their chi l dren. There is a need for increased flexibility in working conditions to permit couples greater freedom in deciding on their respective economic participat ion and the timing of activity during the working life, allowing for a more equitable sharing of household and parental responsibilities. Efforts should be made to reduce the consequences of unemployment, and alternative contributions to the social life should be recognized. Marked variations in mortality and morbidity exist among population groups. The needs of these groups must be recognized and appropriate health promotion measures developed to reduce their risk. Social targets should be formulated in terms of reduc i ng mortality and morbidity due to detrimental lifestyles and harmful environmental influences. When planning for health and social services, attention should be given to the change in nature, volume and distribution of needs due to external and i nternal migration. 2 . 4 The elderly population (60 years and over) The European societies need to prepare themselves to face and handle the challenges presented by the aging of their populations, and specially the rapid increase in the number of the very old. One of the central issues is how to provide meaningful social r oles for the elderly , who constitute a potential resource which could be used for important tasks i n societ y . Mo re flexible retirement policies should be developed, and promotive and preventive measures i mplemented during the working life, to reduce the differences between occupational groups and give equal possibilities fo r a satisfactory retirement age. Isolation is becoming more and more f requent among the elderly, with adverse effects on the older person and the delivery of services when these are needed . Imaginative social policies must be developed to prevent or break down the social isolation of the elderly. Many people are placed in ins titut ions, although the care they need could equal ly well be given in their own homes. This argues for the strengthening of primary health care for the benefit of older persons. Education and training programmes for medical and social personnel should provide for adequate knowledge, proper skills and right attitudes concerning problems of old age . The elderly themselves should benefit from educational programmes promoting their possibilities for continuous self-development. The general public requires correct information aimed at influencing the attitudes towards old people in a positive direction. - 127 - HOSPITALS Workshop on Hospital Infections Brussels, 30 November - 2 December 1982 Introduction - 129 - ICP/ATH 016(S) 1445E 21 March 1983 ORIGINAL; ENGLISH Temporary advisers from 10 countries in the WHO European Region and from the United States met to discuss the results obtained in recent surveys on infection in hospital patients, the methods employed in these or planned surveys and the emergence of antibiotic-resistant pathogens. In recent years, hospital-acquired infections have become an increasingly important problem. The main reason is the evolution of medical technology: methods of investigation and treatment are becoming more sophisticated and the use of broad spectrum antibiotics has been accompanied by a change in the microbial flora in hospitals. It is therefore necessary to study the incidence and/or prevalence of these infections if there is to be any prospect of avoiding them. Several studies of hospital infections have been carried out, a nd several more are continuing in various countries. Most of these studies use different definitions and methods. This multidisciplinary Workshop considered past and present studies and the methods they used, and reached agreement on gu idelines fo r recording hospital infections, It also discussed the standardization of systems for surveillance that would be applicable in various settings . Recording hospital infections National or international prograrrmes for the surveillance the detection of new patterns of antimicrobial resistance have United States for several years by a number of investigators. investigators were chosen fo r consideration by the Workshop. of infections in hospitals been carried out in Europe Four of these groups of and for and the l . The European Working Party on the Control of Hospital Infection is a self-supporting group of microbiologists and hospital epidemiologists who met f or the first time in Copenhagen in 1980 and decided to carry out some collaborative investigations, Two multicentre studies have been completed . 2 . The WHO Global Programme on Hospital Infection Co ntrol includes a prevalence study o i infections in hospitals in as many count ries as possible, including developing coun tries . A protocol for this study has been prepared. 3 , The Center for Disease Control (CDC) in Atlanta has been conducting a national nosocomial infections study since 1970 . 4 . The Select Committee of Experts on the Prevention of Infections in Hospitals, under the auspices of the Council of Europe, is developing and testing a model for recording infections and implementing control measures . In addition, an example of a surveillance prograrrme at the national level in Finland was discussed, as was the specific problem of infections in cardiovascular surgery in France. Ten years' Finnish experience in the field indicated that surveillance could successfully be performed at ward level. Clinical services requiring surveillance were identified (e . g . surgical, obstetric and paediatric wards and intensive care units ) and ward personnel recorded the incidence of infection in each . Up to 10 sites of infection were specified, such as the urinary tract or wounds, Some pertinent data on the infection, the site and t he procedures performed (e . g . the classification of operations) were also rec orded, Laboratory data were incorporated and simple computer programs were developed t o handle the compiled data . - 130 - Conclusions and recommendat ions l. Although in general it appeared that the definitions, criteria and terms used for surveillance by different investigators did not differ greatly and followed, to a certain extent, the outlines for surveillance of hospital infections issued by CDC in 1972, distinct differences were nevertheless noted, making the direct comparison of results difficult. Agreement was reached on the basic scientific definitions, c riteria and terminology to be used in hospital infection studies, and these will be outlined in the final report. 2. It was recognized that there were variations in the professional background of the members of different groups carrying out surveillance. Because of the nature of this work, cooperation between clinicians, nurses and o ther hospital staff on the one hand and microbiologists on the other seemed essential. By forming a committee of hygiene or an infection ~ontrol committee, they c ould work together on policy planning and the development of s trategies for recording and preventing hospital infections. Laboratory-based surveillance systems may nevertheless operate efficiently at the local level even without formal multidisciplinary involvement. 3. The purpose of continuous surveillance should be to alert clinicians to outbreaks of infection and enable them to detect the clustering of unusual pathogens or the emergence of multiresistant or unusual pathogens. 4 . Continuous surveillance may be based on routine laboratory data or on clinical data obtained at the bedside or both. Using laboratory data for purposes of surveillance allows for the immediate detection of unusual pathogens or the emergence of multiresistant strains, but it is often impossible to discriminate between infection and colonization by this method. Systems for surveillance based on bedside observations are time-consuming and tend to be less comprehensive and more inaccurate, but may offer clinica l data that are not easily obtained at the laboratory bench. On balance, laboratory-based surveillance should be encouraged because it represents a practical, easily operated and inexpensive method for surveillance that was thought to be adequate in many c ire urns tanc es. S. For rough overall estimates, o n the other hand, point prevalence studies based on bedside observations of infections, consumption of antibiotics, etc., are a cheap and easily operated tool. This type of surveillance would appear to be of interest to health authorities and to be useful for identifying areas for further scrutiny. It has also proved of promotional and educational value in the training of different groups of hospital employee. Gentamicin-resistant staphylococci Since 1977, seve r al countries have r eported gentamic in resistance in Staphyl occus aure us . The mechanisms o r the conditions necessary to generate this type of resistance a r e not fully understood. Minor differences between methodology (e . g . breakpoints of minimum inhibitory concentration va lues ) for determining ge ntamicin resist ance in staphylococc i or in other bacteria that may exist were not thought to account for the very different rates reported. Nevertheless, the use of aminoglycoside antibiotics outside hospitals differs between coun tries and may be restricted in vari ous ways. The topical use of these antibiotics also varies considerably, and in some countrie s preparations fo r topical use on the skin have been withdrawn f r om the mar ke t altogether. It was reported that in countries where the use of amino glycosides is restricted, the rate of multiresistant strains varies from zero to 17., whereas in countries where aminoglycosides are used outside hospitals, the rate varies between 27. and 307. and serious hospital epidemics occur. This aspect requires further investigation. Concl usions and recommendations Wide variations in the occurrence of gentamicin-resistant (or multiresistant) S. aureus and Serratia and Pseudomonas spp. were reported among hospitals and among countries. Without basic quantitative information on the use of antibiotics in the various hospi tals and countries, it was impossible to validate the hypothesis that there is a positive correlation between an indiscriminate use of aminoglycosides, especially for topical treatment, and the occurrence of gentamicin-resistant strains. This makes a strong case for the inclusion of information on antibiotic consumption in relevant surveillance data. - 131 - Occupational infections in hospital employees Occupational diseases such as infections in hospital employees were regarded as hospital infections. Trade unions have claimed that hospitals are unhealthy workplaces, but this statement does not seem to be substantiated by available data as regards infections. Although it was recognized that the potential clearly exists for some viral and bacterial diseases to spread, further studies appear co be essential. Hepatitis B infection is a g r eat problem, and 10-15 years ago it represented a substantial occupational hazard to hospital employees in some areas of hospitals, such as laboratories and d ialysis units. In many developed countries, the incidence of this infection decreased rapidly during the 1970s, and the problem it presents these countries in absolute terms is rather small. Co nclusions and recommendations Protective measures, primarily immunization but also isolation and other barrier precautions, are effective when adhered to . The hospita l workplace is extremely he terogeneous with re spect to the exposure of s taff to infection, which makes overall rates of occupational infections meaningless. Only high-risk areas should be identified for the evaluation of protective measures. The cost of hospital infections Although many estimates o f the costs of hospital-acquired infections suggest that they are a significant extra burden, hospitals are operated against very different economic backgrounds, so that no method of estimation can be regarded as a universally applicable model. For example, the prolongation of s tay, usually regarded as a common consequence of infection, seems an insufficient measure of the costs of infection for several reasons, one being that the length of stay d i ffers considerably among countries, even in patients not acquiring infec tions, another be ing the known ef fect of hospital infection on other items s uch as the level of care, the use of a ntibiotics, post-hospital care, and the social costs of disease. A small proportion (about 10%) of hospital patients seems to consume as many e conomic resources as are required for the care of the other 90% . It was noted that the most costly group of patients includes ma ny with hospital-acquired infect i ons . Conclusions a nd recommendations Despite available techniques using direct es timate "case control" comparison or indirect standardizat ion of the control group, very few studies exist. At fi rst sight, there seems to be l ittle interest in es tima ting costs , as hospital authorities seem unable to use such information. Nevertheless, economic studies of infection control must be e nc ouraged : omitting useless infection control procedures seems to be of great value for promoting the rational prevention of infections, and studies should be unde rta ken to show the exten t to which this can directly reduce costs; infection control officers and experts on economic model s should cooperate on the question of how, whether and to wha t extent the preve nt ion of infections in hospitals can be expressed in terms of reduced costs (cost- benefit and cost-effectiveness studies) . - 133 - MALARIA Coordination Meeting on Malaria and other Imported Communicable Diseases in Mediterranean Countries Mahon, Minorca (Spain), 1-4 June 1982 1. Introduction - 135 - ICP/MPD 002(S) 0004G 30 June 1982 ORIGINAL; ENGLISH Although malaria has been eradicated from many countries and transmission brought to a low leve l in others, there are still countries in the Mediterranean area with a hi gh level of transmission . The increasing importation of malaria into non-endemic countries as well as the occasional importation of cases of severe viral diseases are consequences of the unprecedented increase in population movements due to tourism, labour migration and trade. Besides this, severe autochthonous arboviral infections are present in some European countries, and there is serological evidence of the circulation of viruses in several others as well as evidence of frequent cases of cutaneous and visceral leishmaniases in most Mediterranean countries. A meeting was, therefore, convened as part of WHO's global efforts relating to malaria control , biological control of vectors and research and training in tropical diseases, and follows on from those held in Izmir in 1978, Erice in 1979, Sofia in 1980 and Cagliari in 1980. Delegates from the following 11 Mediterranean countries took part in the meeting: Bulgaria, France, Greece, Italy, Morocco, Portugal, Spain, Syrian Arab Republic, Tunisia, Turkey and Yugoslavia. They included staff of ministries of health, officials responsible for the control of malaria and other communicable diseases, and experts from university teaching bodies in the fields of tropical parasitology, virology, research and manpower training. 2. Recommendations On the basis of reports submitted by each participating country and a comprehensive discussion, the group made the following recommendations . 2.1 Malaria ( 1) The compulsory notification of malaria cases should be introduced in all participating countries . (2) In countries where malaria transmission still continues, existing antimalarial activities should gradually be integrated with primary health care and thereby receive multisectoral and mul tidisciplinary support. It is recommended that, in these countries, people exper ienced in malaria control should have an important role in the development of primary health care in order to ens ure that information systems are adequate and decisions are made at the appropriate levels. (3) Countries in which malaria is non-endemic, but in which transmission could be re-established, should have an adequate vigilance system for malaria operated by a small group of trained, competent people who, inter alia, should check positive slides, perform epidemiological and entomological investigations and provide treatment, as well as maintain among the population an awareness and understanding of the potential malaria risk. (4) It is recommended that border meetings be encouraged, particularly if no other coordination meeti ngs are held. - 136 - 2.2 Viral haemorrhagic fevers (1) Further studies need to define more precisely the public health importance of this problem, especially in terms of the transmissibility, severity and lethality of these diseases in endemic and non-endemic areas. (2) An information system for special pathogens should be set up, by which all countries in the Region would be iJIDDediately notified of any new cases or outbreaks of these pathogens. (3) Countries should establish con t ingency plans in case of importation, specifying in particular the measures required for transport, rapid diagnosis, isolation, management of cases, disinfection, surveillance of contacts and training of a nucleus of personnel. Countries may wish to explore the options for regional cooperation and the use of existing facilities instead of or before deciding to construct maximum containment laboratories. (4) A clear guide should be prepared with indications of how to proceed in the event of a suspected case. This guide should be continuously updated through information sheets. (5) The occurrence and distribution of these diseases should be monitored and the importance of other vectorborne viral diseases should be assessed. 2.3 Leishmaniases (1) Obligatory notification of all human leishmaniases cases, both visceral and cutaneous, should be introduced. (2) Epidemiological invest igation of Leishmania reservoirs, and isolation of the parasites from their reservoirs, and from man, to identify their etiological strains should be carried out. (3) Research should also be carried out on phlebotomid flies considered as vectors of leishmaniases in differen t foci . (4) A national centre should be established in each participating country to analyse all data related to the above aspects of leishmaniases. 2.4 General Before planning another coordination meeting, WHO should carefully consider the value of such meetings by determining the degree of implementation of reconnnendations of the present meeting. - 137 - N_URSING Workshop for the Preparation of Coders Co penhagen, 25-28 January 1982 Introduc tion - 139 - ICP/MPM 026(4)(S) 9452B l March 1982 ORIGINAL: ENGLISH The Workshop, convened by the WHO Regional Office fo r Europe and held at the Danish Institute for Health and Nursing Research, was attended by 26 programme managers and contact persons from selected Type 1 participating centres in 13 countries of the Region. Also present were the Acting Regional Officer for Nursing and a WHO Short-Term Consultant from the Nursing unit. The scope of the Workshop was to provide an opportunity for developing skills in those persons who will be involved in coding of data to be collected in the multinational research project which is being conducted as part of the Medium-Term Programme in Nursing/Midwifery in Europe. More specifically, the purposes of the Workshop were to·:- (a) provide information on coding of data to be collected in the research project; (b) develop skills in data coding (practical exercises); (c) develop skills in data review so as to ensure the best quality of coded data; and (d) plan for the organization of the data coding process at the national level. Background A Workshop on the Nursing Process was organized at the Regional Office immediately prior to this Workshop. Twenty-one participants attended both workshops. This situation influenced considerably discussions throughout the second workshop. Activities Having gained experience during the first workshop in the utilization and application of the nursing process, the participants followed through with coding of data from nursing care plans, in part through theory and in part through practical exercises. Three independent coding exercises on the first three days provided material and background for all subs'equent presentations and discussions. In fact, the coding exercises became the focal point in discussions and demanded most atten tion. The handouts giving instructions for coders served as a guide for the participants in coding data from selected nursing care plans. The overall results were presented to the whole group as overhead transparencies and printouts to facilitate discussion. In addition, individual results were distributed to each participant as confidentially numbered printouts . The above results included data from the standard coding sheet showing categories selected in relation to needs, objectives and interventions as well as outcomes. Inter-rater reliability was de termined on the basis of these results. Discussions The actual steps in completing the coding sheets were mastered quite readily by the majority of the participants and rated by 15 out of 25 as a good or excellent learning experience. Similarly, 15 out of 25 rated their attainment on the second objective - to develop skills in data coding - as good to excellent, while 10 rated it as fair to bad. Certain factors seriously affec ted the degree of attainment of this objective. The main problem for some participants was their limited command of the English language, which enabled them to code only a small number of needs . This in turn limited the scope for determining inter-rater reliability. J - 140 - The second major factor affecting coding related to the quality of data on the nursing care plans. Concern was expressed over the poor quality of data provided for the coding exercises. The nursing care plans originated from the third pre-test. The nurses who had collected the data had not been exposed at the time to skills in documentation of clinical data. There seemed to be limited agreement that documentation skills of prospective data collectors could be expected to improve as a result of the teaching of the nursing process following the workshops. Much discussion focused therefore on how to code/deal with poor data. One suggestion was to establish criteria for the rejection of data that could not be coded. A further constraint to coding appeared to be related to the categories of needs, objectives and interventions as listed in the instructions for coders. Apart from the discussions about categories it was considered necessary to clarify certain points in the instructions, and suggestions made by participants cou ld contribute to this. The fact that the participants felt they were not sufficiently familiar with the contents of the instructions obviously added to their difficulties. Limitations on time affected not only the quantity and quality of the data coded during the exercises, but equally the extent to which discussions of results presented by the statisticians could take place. Because of the limited number of needs coded by some participants the results of the inter-rater reliability tests pertained to a few needs only. For this reason only trends can be deduced. The overall inter-rater reliability for needs identified was about 70% on each of the first, second and third coding exercises. This figure was affected by the discussions after each coding exercise and the subsequent changes. For the same reason it was difficult to establish inter-rater reliability, although needs were reintroduced at second and third exercises. The participants practised in small groups how to establish inter-rater reliability using their own coding sheets. This exercise was favourably rated at the end of the workshop. Other aspects of the coding process included data entering, cleansing of data and data validation, and registration of data in countries. Much discussion took place, but few problems were identified. Concluding remarks Throughout the Workshop many questions and problems were raised. Some were dealt with during the discussions, while others were deferred for later solution or decision. Because of the deliberations during the Workshop much information is already available for use in the decision-making process. This is an important outcome, in addition to the coding skills developed. The concern over the poor quality of the data on the nursing care . plans, which demanded much attention, is a matter for the progrannne managers and contact persons to deal with in the teaching of the nursing process. Since the coding process is an integral pare of the overall research project, frequent references were made during the discussions to the project itself and to the roles and relationships of people involved in the project. - 141 - Working Group on the Clinical Practice of Nursing: Identification, Development and Evaluation Ulm, 2-5 November 1982 Purposes of the meeting ICP/SPM 047(5) 0132J 22 November 1982 ORIGINAL: ENGLISH The Working Group was attended by 20 temporary advisers (18 nurses, a physician and an economist) and two staff members of the Regional Office . The purposes of the meeting were to: (1) review the acceptability of current principles governing the expectations of students from the learning experience during clinical practice; (2) examine the development and current status of the nursing process and nursing research as basic decision-making tools for clinical practice; (3) review the effects of the current enabling and constra.n,ng factors within the European Region on the relative use of the above tools and/or methods; (4) examine the existing data available on approaches that could improve the cost-effectiveness of clinical teaching; (5) formulate recommendations and strategies relating to short- and long-term planning for the medium-term programme in nursing/ midwifery in Europe with regard to: next-step act,v.ties that will communicate Working Group recommendations to relevant persons, institutions and bodies; methods that could be used to ensure and enhance the incorporation into curricula of the contempora r y approaches examined and the reorientation towards primary health care. Majo r issues examined The varying expectations governing the experience of students during clinical practice were co nsidered. Nursing administrators and facultya in a clinical situation face the question of who is paying for and who is responsible for nursing education and nursing care. Co nsideration was g iven co the interrelationship of teacher and learner, in particular the need fo r the learning theories used by the teacher to complement the methods of learning adopted by the student. A teacher having a n eclectic ability to use several ap propr ia te theor ies was most likely to be successful. Teaching that uses role-modelling as a basis assumes that the role model (the qualified cl inical practitioner) is engaged in learning throughout his / her practice years. This active st ance helps provide an ideal model. The need fo r standards Standards must be set on the basis that the programme is of a professional as well as of an educational nature. A professional educational programme, if it is to remain viable must have a curriculum that reflects society's needs. On the other hand it was deemed to be quite appropriate, and educationally and professionally sound, to expect the nursing programme co be of the same intellectual quality as any other discipline in the same setting, and the hours and conditions for s tudent nurses to be the same as for students in other disciplines . a The term '1 facult y 1' is used in this report to indicate university, college or school of nursing . - 142 - The wider context within which nursing education takes place, and the pressure brought to be a r by society, the economy, government, legal systems and other agencies, was discussed, As a result of these pressures, nurses must develop an economic awarene s s and evolve not only decision-making tools but evaluative techniques for assessing the outcome of nursing care and nursing education. Without evaluative tools the cost-effectiveness of clinical teaching and practice is unmeasurable, The nursing process could be regarded as a very useful framework for teaching/learning, for practice, for evaluation and for research, The development and evaluation of the process itself was considered to be vital in attempting to make use of techniques of cost-effectiveness and cost-benefit analysis. The content of the students' clinical practice must include consideration of reality as well as the ideal, and practical placements must therefore be chosen appropriately. Practice within a profession demands personal accountability; this must be taught, as must the ability to work and to lead (when and where appropriate), within a multidiscipl i nary framework. The legal framework of nursing should also be taught. The role of facult y The faculty to which the nurse is attached has a prime role in ensuring that the student's educational requirements are met. Whilst recognizing the educational input given by the clinical practitioner as a role model, it was agreed that it was the responsibility of the faculty member t o teach the student. It was particularly considered essentia l that the faculty be responsible for setting selection criteria and be involved in the selection of the students. Whatever level of responsibility is expected of the student during clinical practice, the teacher is also responsible, as is the qualified nurse practitioner to whom supervision is delegated. The patient or client was regarded as having a l egal right to a form of care that is safe and in accord with legitimate expectations, and the patient/client should be made aware of, and agree to, students giving care. The responsibility of the faculty is to ensure as far a s possible that practical experience is st i mula ting and educational . Further, it should meet the l e arner's needs and expectations, and protect the student from any harm ful consequences of the e xperience. Additionally , there should be adequate monitoring of both the process and outcome of education. The degree of facult y supervision of the student should relate to the level of competence of the student at any g iven time, and to the risk to the patient, There should be a n adequ a t e number o f other staff of the hi ghe s t quality available to provide an ideal learn i ng environment. Approaches used The participants attempted to set a framework for discussion by the use of working papers, previous relevant WHO working group reports, simulated role-play, sub-group consideration of important topics and by c alling u pon t he unique expertise o f participants such as the economise. Conclusions and recommendati ons 1 . It is recognized that, by virtue of the fact that nurs i ng is a practice discipline, the student will be involved in g iving service during the course of his/her education: the content o f clinical practice should be directed by the student's pro gressive educational needs rather than th e needs of the nursing service. 2, The education of the student should therefore be financed in the same manner as that of other students in the same country, 3. Nursing as a practical discipline requires education in health care settings as well as in institutions of hi gher learning. Practice in the clinical setting should, however: complement t he theoretical content of the student's education, which should be based upon a holistic view of man; include consideration of clinical practice both as it exists and as it could exist ideally in the fu ture; and avoi d or overcome any conflict between what is taught in the academic setting and what is undertaken and observed i n practice. - 143 - 4. The term "profession", amongst other thi.ngs, i.mpli.es a body of knowledge, whi.ch must be included i.n the student's education, along wi.th the necessary practical ski.lls. Thi.s should ensure that he or she i.s knowledgeable of, and able to per f orm i.n practice, that essential part of h i.s / her role that i.s uni.que to nursing and whi.ch ensures i.ndependence i.n the practice of nursi.ng. 5. Practice wi.thi.n a profession, particularly i.n health care, involves the need for the development of communi.cati.on ski.lls; relati.onshi.ps wi.th others; the abi.li.ty to enter i.nto the frames of reference of members of other di.sci.pli.nes; the adoption of leadership roles and of practice wi.thi.n an ethi.cal framework. These matters should not be learned i.n a haphazard fashi.on but should be included as important elements i.n the education programme and fostered duri.ng the practical experience undertaken by the student. 6. To teach and learn the complex subject of nursing requires an analytical, problem--solvi.ng approach. The framework provided by what i.s currently termed "the nursi.ng process" i.s re ga rded as a useful one for teachi.ng/learni.ng, practice, evaluation and research. The approach provided by the process should be used to relate the vari.ous aspects of nursi.ng e.g. i.ts beliefs and values, kno wledge and sk i.lls, i.n an orderly way and to provi.de a sound basi.s for development. , 7. The student has a ri. ght to expect assistance from both the faculty and the staff wi.thi.n the servi.ce. Whatever thei.r relative role i.n the s tudent's education, the student must have: a ri.ght to be exposed to si.tuati.ons whi.ch wi.11 provi.de hi.m/her wi.th essential knowledge, ski.lls and attitudes; the faci.li.ty of usi.ng sound role models i.n practice; and an expli.ci.t wri.tten contractual agreement defi.ni.ng these ri.ghts. 8. The cri.teri.a for the selection of students must relate directly to the overall objec tives of the programme. Si.mi.larly, the total length of the programme and the components wi.thin i.t must bear a re lati.onshi.p to the objectives. It must be remembered that the ti.me allocated must enable the teach i.ng /learni.ng of a complex and detailed body of knowledge. Thi.s i.s essential i.f the newly-quali. fi.ed practi.ti.oner is to be expected to perform safely and competent ly i n variable, complex si.tuati.ons. Based upon the objectives of the programme, the abi.li.ty of the student co meet the demands of the course, the teaching resources and the a vai.labi.li.ty of suitable practical expe rience, i.t should be for the nursi.ng faculty to set the criteria for se lection, and essential that they be involved i.n the selection process. 9. The student should be taugh t the impli.cati.ons of professional accountabi.li.ty . The student mus t be clear that he/she wi.11 be held responsible fo r acti.ons taken by hi.m/her to the level of competence which can be legitimately expected of hi.m/her . Neve rtheless, shared responsi.bi.li.ty shou ld not be reduced. The faculty member i.s also responsible fo r the student's actions both when directly supervi.si.ng and as a result of the way his/her teaching affects the student's practice. The last point is particularly relevant where the faculty member has delega ted supervision to someone else, such as the head nurse. The responsi.bi.li.ty also fl ows to the head nurse and any othe r quali.fi.ed nursi.ng staff i.n practice i.n so fa r as supervi.si.on of the student has been expli.ci. tly delegated to and accep ted by them. The degree and level of responsibility and accou ntabi.li.t y must be defined i.n written, contractual terms as i. t relates to: the student the faculty and faculty members others, e.g. nursing practi.ti.oners 10. The pati.ent/cli.ent has a legal ri.ght to a form of care that i.s safe and i.n accord wi.th legi.ti.mate expectations give n the context wi.thi.n whi.ch the care i.s gi.ven. Thus, the patient should be informed i.n writing that students are engaged i.n practice, and give informed consent to trea tment and/or care give n by students. 11. The content of the curriculum shou ld i nclude consi.derati.on of the lega l aspects of nursing practice. This knowledge should be imparted to the student prior to placement for practical experience. 12. It should be the responsi.bi.li.ty of the facul t y to ensure that the student's experience i.s, as far as possible, stimulating, and educationally meets the learner's needs, and to protect hi.m/her fro m the harmful consequences of hi.s/her experience. In this context, i.t was recognized that the philosophy of the faculty should, i.n respect of clinical practice, closely follow that of the service agency . In a si. tuati.on involving the concept of "health care for all", students would at ti.mes , i.n gai.ni.ng practical experience, be placed in si.tua ti.ons of risk. If comprehensive experience i.s to be gai.ned , not all risk i.s avoidable or indeed easily recognizable . The i.ni.ti.al - 144 - contract with the student must make the posttton clear as to the known and potential risks involved. The student should have a choice of clinical experiences if faced with a high-risk experience or with one that conflicts with genuine ethical or religious beliefs. 13. The faculty should be responsible for the selection of the clinical areas for student placement according to agreed criteria. 14. The faculty should be responsible fo r the provision of adequate supervision either directly, or by means of mutually-agreed delegation to other qualified staff. 15. There should be adequate monitoring both of the process and the outcome of education which should include: examination/assessment procedures which are well defined; faculty evaluation of its own performance; student evaluation of the programme; evaluation/assessment of the newly-qualified nurse by employers; and clinical staff assessment of the impact upon the service of giving practical experience to students . 16. There should be explicit contractual arrangements between the faculty, students and service agencies. The latter should be able to define the criteria for the acceptance of students' to give care within their controlled area. These cri teria will need to take into consideration: the number of students involved; their current level of competence; and the degree of supervision available. 17. The amount of supervision by faculty staff should be determined by: the student's level of competence; the learning needs of the student; the level of risk to the student and to the patient / client. 18. The number and quality of supervisory staff should be adequate to provide the desired experience and the ideal learning environment . - 145 - Working Groue on the Develoement of ICP/SPM 048(5) Standards of Nursing Practicea 1203E 3 February Sundvollen 1 Norwa:i:: 1 6-9 December 1982 ORIGINAL: Introduction The Working Group was attended by 23 temporary advisers from 15 count ries, the Regional Officer for Nursing, and the Senior Scientist for Nursing from WHO headquarters . 1983 ENGLISH The initiative for the meeting arose out of one of the conclusions reached by a WHO Symposium on Nursing Servicesb that: Research should be conducted to establish standards of care in nursing and to describe the attributes (knowledge, skills, attitudes) which ensure competency to practise the discipline. The same report states that the establishment at the national level of standards of nursing care determined by the profession should be emphasi_zed within the WHO medium-term programme for nursing/midwifery in Europe. The purpose of the meeting was to: (1) establish broad philosophical statements about nursing and definitions of nursing practice; (2) review issues related to existing national s tandards; (3) establish the key elements of general standards of nursing; (4) create a series of guidelines which can be used in creating standards for nursing practice in Member States of the European Region; and (5) make a series of guidelines which can be used in creating s t anda rds for possible review and adoption by the nursing education sector. General discussion What is quality care? This question led to an examination of a quality assurance modelc with an eight-point cycle . One of these points was the choice of criteria and the establishment of s tandards. Further examination showed chat a statement of a standard could be seen i n three pa res: structures, process and outc ome. It was agreed chat outcome was the most difficult to identify, but also the most important, and should be exp ressed in cenns of patient /cl ient out come . It was accepted that all standard-setting was subject to constraints and it was noted that any s tandard should be reasonable, understandable, useful, measureable, observable and achievable in the s etting in which it is developed and used. A standard has three possible levels: maximum, optimum and minimum. Minimum was equated with safety, and the nurses' responsibilit y to draw the dividing line between acceptable and unacceptable care was emphasized . a In this report, the tenn "nursing" is used in its generic sense and includes midwifery . b Nursing services: report on a WHO Symposium. Copenhagen, WHO Regional Office for Europe, 1980 (EURO Reports and Studies No. 22). C Quality assurance model. British Columbia, Registered Nurses Association of British Co lumbia, 1977 - 146 - Standards of nursing care in Europe Most of the work on developing standards of nursing to dace has been carried out in the United States, Canada and New Zealand. Work in Europe is still at a very early stage, although some is b~ing done in Finland and the United Kingdom. The professional accountability of the nurse is a key factor. In order to be answerable for work and decisions about work, the nurse needs the authority to act and must have the necessary skills and knowledge. While the nurse is accountable for her own specific independent function, other areas of her work are interdependent with other members of the health team, and her areas of accountability to others must be identified. The development of standards In discussing how to develop standards, the Group became convinced that it would not be possible to set standards applicable to the whole of Europe. It agreed that guidelines for the development of standards were important, and within these a country could set nursing standards in its own national setting. In order to progress further, the Group agreed on the following working definitions within the context of the title of the Working Group. Standard - An agreed level of care required for a particular purpose. Guidelines - A collection of statements providing a framework within which a country may develop standards of nursing practice. Nursing practicea (or the practice of nursing or midwifery) - Representing oneself as a regisceredb nurse or midwife while carrying out the practice of (selected) functions. These functions are carried out directly or indirectly with other health workers. They have as objectives five points: (1) promotion of health; (2) prevention of illness; (3) alleviation of suffering; (4) restoration of health; and (5) maximum development of health potential. Each country needs a nursing philosophy as a bas is for the setting of standards. This must be seen within the philosophy of health care which in its turn has to be seen within the totality of human philosophy. The individual nurse always stands between the ideal of proposed values and norms, and the reality of nursing practice. If the gap between the two is too great, the chances of maintaining high levels of commitment are reduced and the likelihood of attrition in the profession is increased. Conclusions The Working Group agreed on six main areas it considered central to the preparation of guidelines for the development of standards of nursing practice. l. The need for standards Standards of nursing practice are required within the culture and social, economic and political development of a country. They should be developed in this context . Nurses and midwives are an important pare of the health ~earn and their standards of practice have an effect on total health care delivery. Individual nurses have a right to be able to relate to the general standards of their profession which establish a desired level of performance. a Qualic7 assurance model . British Columbia, Registered Nurses Association of British Columbia, 191 b Registered is equated with licensed, diplome or other national titles. - 147 - The acceptance and successful application of standards ensures the quality of care to the individual and can serve as ethical guidelines to nurses and the public in determining the characteristics or attributes of a professional person. 2. The responsibility for developing standards of nursing practice The prime responsibility for developing standards rests with the profession. Recognizing the interdependency of their work with others providing health care, however, nurses and midwives will take into account contributions from other professionals and disciplines, patient advocate groups and government agencies. They will also work within the constraints of the national setting . 3 . Standards should be applicable in any field of nursing/midwifery practice Standards of nursing practice should be of two k inds. The first should be applicable in all fields of activity where nursing or midwifery care is given. The second should govern care in a specific field within the general outline of the first group. 4 . Standards and the function and responsibility of the nurse or midwife The function of the nurse or midwife should be reflected in the standards, setting the parameters within which he/she provides care in line with training, qualification and experience. Standards should state the different independent, interdependent and dependent functions of the nurse or midwife, the categories of nursing personnel that should carry out the fu nctions, and fix the responsibility for the tasks . 5 . The relation of standards of nursing practice to the provision of health ca re by other members of the health team Nursing standards affect the range and quality of care given by others, and the converse is t rue. This must be taken into consideration in setting standards. 6 . The management of change The development and implementation of nursing standards implies the need for change both wi thin and outside the profession, and will require consultation with many groups, education at all levels of the health team, and a change in attitude by both the consumer and the health team. The way fo rward can be twofold. (a) WHO could collaborate with countries in promoting the development of guidelines for nursing standards, and in publishing and disseminating valid information and an exchange of experiences between countries . ( b ) Standards could be created and action piloted in selected areas of the Region. Re commendations 1. Any guidelines proposed should include the six areas delineated in the conclusions above . 2. The Working Group wishes to stress the importance it attaches to the development and di ssemination of guidelines for the development of standards of nursing practice among and between countries of the European Region, and recommends that work on this issue be pursued as a matter of urgency. - 149 - NUTRITION Strategies for Legal Implementation of the International Code of Breastmilk Substitutes Copenhagen, 10-12 November 1982 - 151 - ICP/NUT 010(5) 0804F 13 January 1983 ORIGINAL: ENGLISH This meeting was held for the purpose of informing participants from Member States of the European Region about the International Code of Marketing of Breastmilk Substitutes, with the aim of developing national level strategies for its legal implementation. The participants came from the following countries : Austria, Denmark , Finland, France, Greece, Hungary, Malta, Netherlands, Sweden, Switzerland and Turkey . UNICEF and the EEC also sent representatives. Temporary advisers included experts who spoke on various topics including: the nutritional/medical aspects of breastfeeding, the marketing of breastmilk substitutes, the role of intergovernmental organizations, and the role of nongovernmental organizations, in the implementa t ion of the Code. In addition, each participant gave a n account of the present initiatives being taken in his or her home country to implement the Code. Some participants also discussed the constraints on the implementation of the Code in their country, including constitutional limitations and in some cases the fact that nongovernmental organizations, consumer groups and womens' organizations have not yet become involved . It was generally agreed that implementation of the Code can be achieved by different means and that strategies will vary according to the specific conditions in each country. Legislation might be needed to implement some sections of the Code such as labelling, while voluntary agreements might be useful to implement other sections. After lengthy discussions and a sharing of viewpoints, the following opinions were expressed by participants . These ideas should not be read as indicating that a consensus was reached. It should also be noted that participants were present in their personal capacity and not as official representat ives of their governments. The meeting on strategies for legal implementation of the Code of Marketing of Breastmilk Substitutes, recognizes the importance of developing national strategies fo r the legal implementation of the Code with the view to protecting the health of mothers, infants and children; is aware that when considering national strategies for the legal implementation of the Code, due consideration should be given to the fact that national needs will vary according to specific national situations (economic, social, cultural, as well as legal); emphasizes the fac t that the International Cod e should be viewed in its entirety when national measures are developed to implement it (e . g . legislation, regulation and/or o t her suitable measures), and that different strategies may be chosen in accordance with article 11 of the Code to meet the specific situation in each country. - 153 - OCCUPATIONAL HEAL TH Worki ng Group on Women and Occupational Health Risks Budapest, 16-18 February 1982 Introduction - 155 - ICP/WKH 012(5) 9645B 15 March 1982 ORIGINAL : ENGLISH The meeting was convened by the WHO Regional Office for Europe together with the Governme nt of Hungary. It was attended by 16 temporary advisers from 13 countries of the European Region and representatives of the Conunission of the European Communities and the International Labour Office. The objectives of the meeting were to (a) discuss the health aspects of working women, with emphasis on problems arising from their exposure to chemical, physical, biological, psychosocial and ergonomic hazards; (b) consider occupational health and ergonomic surveillance and services to be provided to working women; and (c) identify research needs, Discussion Interest in protecting the health of women at work is increasing. Several sociopolitical, economic, physiological and biological issues in this regard have been raised in recent years. The present situation in the countries of the European Region was reviewed in the presentation of country statements, and attitudes to health protection of the working woman, social implica tions and existing legislation were noted. All countries considered the s ubj ect against a background of equal rights legisla t ion . In all countries the percentage of women in the total workforce had inc reased over the past 30 years, but there was variation in the percentage of female iabour among countries. It was realized that the subject was very broad and the following were selected as the principal topics for discussion. A fundamental aspect of discussion was whether, in the light of current knowled ge, women should be considered an occupationally vulnerable group . The morbidity and mortality experiences of women at work were considered and an attempt made to identify problem areas and gaps in existing knowledge . Specific consideration was given to pre gnant and lactating women and women of reproductive age/capacity. Reproductive hazards, with particular reference to spontaneous abortions and malfonnacions, were considered . Occupational epidemiology on spontaneous abortions and malfonnations is a relatively new field and many selection mechanisms and risk factors may have to be established before definitive causa l conclusions can be drawn. The difficulties of extrapolation from animals to man in this field was noted, and transplacental carcinogenesis was discussed . The difficulty of defining "a woman of reproductive age/capacity" was noted and a range of potential effects was discussed. There was a need for a general policy on the ability of women to work and the interaction of occupational health and social policy. Of general concern and interest to the Group were psychosocial factors and their relationship to the health of women at work . It was appreciated that psychological health has a multifactorial etiology, chat successful intervention strategies may be difficult to devise, and that they may not be practicable in many circumstances. Nevertheless, psychosocial problems might be widespread among women at work and constitute a significant risk factor . Moreover, if successful intervention strategies were devised and adopted they might have •a general effect on, for example, family morbidity. It was considered, however, that sound epidemiological data needed co be collected before any specific reconunendations could be made. - 156 - - Ergonomic aspects were considered by the Group to be an important topic worthy of careful evaluation. Two areas were discussed: first, the general implications of the lack of ergonomic intervention in the workplace and associated deficiencies and second, the particular consideration that needs to be given to pregnant women. These two aspects were discussed from the point of view of the anthropometric differences between males and females, and physical working capacity and muscle strength. Physical hazards including noise, vibration, and ionizing radiation were discussed, as were other topics such as night and shift work. Conclusions and recommendations 1. Historically, much of the legislation relating to women has been promulgated on social and moral grounds. Many biases and assumptions are revealed in discussions of the special requirements and provisions for the protection of women's health. In many studies the problems of selection into and out of the occupation has been ignored. Further, the additional effect of limited job opportunities for women in the past compounds this problem and existing studies may be of questionable value. 2. Pregnant women require a specific measure of protection against teratogenic and embryotoxic agents; caution should also be exercised when women of reproductive age and capacity are exposed to these agents. The occupational health services should ensure that undue exposure of pregnant and lactating women to any toxic agent is prevented. 3. There is some evidence to suggest an association between laboratory work with anaesthetic gases by pregnant women and spontaneous abortion. There is also evidence to suggest that the same risk may exist with regard to lead, copper smelting, solder fumes, sterilizing agents and materials in plastics. 4. There is evidence associating laboratory work by pregnant women and malformations in their offspring, and some suggestion of a similar risk from anaesthetic gases and copper smelting. 5. Animal data may be used as an aid suitable for epidemiological research. with possible human exposure. in setting control l imits and in identify ing problem areas The dosages used in animal experiments should be comparable 6. Owing to physiological differences, genotoxic effects may more often be transmitted to the fetus by the female rather than the male. 7. Women with fertility problems or suffering spontaneous abortion should be relocated if exposure to toxic substances is suspected of being the cause. 8. The basic philosophy of ergonomics, which is to adapt occupations to the capacities and limitations of specific populations, is the primary consideration. Compared with men, female workers may be at higher risk of health impairment or injury because of physically demanding jobs or inadequately designed machines, tools and personal protective equipment. However, when age, build, stage of acclimatization and training have been taken into account, this does not appear t o have an overwhelming influence on the ability of an individual to perform sustained physical work. 9. It was concluded that there was no significant difference in noise-induced hearing loss between males and females. There is some evidence that unacclimatized women have a lower heat tolerance than their male counterparts, but caution is needed in the interpretation of such evidence and further research in this field is indicated. 10. Vibration effects (both local and whole-body vibration) were discussed extensively. It was concluded that methodological problems concerned with the measurement of levels and with differential biological effects in females (when compared with males) need to be overcome before valid recommendations can be made. 11. The ergonomic aspects need special consideration for the pregnant woman. The work should be adjusted to her capacity and consideration given to work methods. 12. Exposure to ionizing radiation in pregnancy should be avoided. This is also advisable during lactation if there is likelihood of contaminants being excreted in the milk during breastfeeding. - 157 - 13. Much research has been done on the negative effects of shiftwork. There seems to be no evidence that women are more susceptible to shiftwork than men, if given equal opportunities for relaxation. There are, however, indications that the state of health of women performing shift- work is not optimal. This can probably be attributed to the total load being too high, especially i n those with family duties besides their occupational ones. 14. The following broad research areas were identified: Reproductive hazards. Systematic compilation and analysis of existing data should be carried out and further experimental studies made on embryotoxicity arxl teratogenicity. WHO should examine how this work should best be pursued . Heat tolerance . Experimental studies should be conducted on sex differences in the response t o light and moderate workloads under hot conditions. Psychosocial stress . Differences in the response of males and females to soc i a l and psychological demands at work should be explored. Special consideration should be given to methodological issues in such research and also to the potential extra burden placed on some working women because of domestic obligations. Ergonomics. Research in this area should examine the following: (a) the prolonged fixed posture required by some tasks; (b) problems with inappropriately designed equipment; and (c) evaluation of ergonomic interventions particularly directed to the health of women at work . Preparatory Group for EURO Manual: Ep1dem1ology of Occupac1onal Health Paris, 2-4 June 1982 - 158 - ICP/WKH OO1(4)(S ) OO97E 23 June 1982 ORIGINAL: ENGLISH Experts on the epidemiology of occupational health and representatives of the International Labour Office, International Epidemiology Association and the Permanent Commission and International Association on Occupational Health met for a critical review of chapter manuscripts contributed by participancs. Epidemiological methods are widely used to assess risks, including the effects of long-term exposure to low-level occupacional hazards. These methods need to be described in a manual on occupational health epidemiology for use by occupational health personnel. The manual should also be of value to scientific institutions in evaluating criteria for Che working envirornnenc. The WHO Regional Office for Europe, in collaboration with the Office of Occupational Health at WHO headquarters, therefore convened this meeting to review material prepared for che manual and to review the terminology being used, defining it if necessary. In 1979, the Regional Office arranged a consultation at which a structure for the manual was outlined, and writing tasks subsequently assigned to experts. Of the 16 chapters and subchapters envisaged, all buc two have now been completed and were distributed to the participants. The dra ft chapters and further chap cer plans were introduced by the authors and discussed by the Group. The authors agreed co provide final manuscript for peer review before 15 August 1982 to selected reviewers, who would forward the material with cormnents to the Regional Office for editing before 15 September 1982. With regard to terminology, recommendations of WHO and of the International Epidemiological Association are co be followed. The Group confirmed Cha e che manual would consisc of the following chapters: introduce ion; nature and class ification of occupational hazards; assessment of occupational stress; work, health and disease; evaluation of long-cerm effects; sources of daca; screening in assessment of health risks; methods of epidemiology: descriptive epidemiology; c ross-sectional studies; cohort studies; case-control s tudies and a noce on proportional mortality evaluation; study of combined effeccs; statistical methods; validity aspects of epidemiological studies; interventive epidemiology ; accident epidemiology; uses of epidemiology in occupational health; reappraisal of an epidemiological study; and glossary of terms. The Group concluded that the material presented covered the field of epidemiology in methods of occupational health and was suited for the manual, with some revision. When published, the manual should be publicized and made available worldwide. The Group welcomed the opportunity presented by the publication of this book by WHO to promote training and research in the important application of epidemiology to occupational health . They felt that this would become a direct contribution to the health of workers and was thus of vital importance. - 159 - Finally, the Group took the opportunity to express its sincere regret at the deleter i ous effect upon the progress of epidemiology - and the consequent danger to workers' health - wh i ch r esults from the growing and dangerous shortage of good data. Consultation on Health Surveillanc e of Workers Exposed co Chemicals Varna, 26 -28 October 1982 Introduction - 160 - ICP/WKH 013(S) 0974E 2 December l9R2 ORIGINAL: ENGLISH Eleven specialists met, with three observers and one representative from another organization, to discuss the health surveillance of workers exposed to chemicals. The health surveillance of workers exposed to chemicals is an important function of the occupational health services. The assessment of the health risk of occupational hazards is used co protect the health of exposed workers and co establish Che adequacy of control procedures in the working environment. The health surveillance of workers exposed to chemicals is organized in various ways throughout tne European Region. Nowhere does it cover the whole of the exposed working population and 1t is fre~uencly inadequate ror the level of risk that exis ts in the workplace. The registration of exposure and tne recording of health status and exposure level are not coordinated and require general guidelines. Bearing in mind the above , the meeting was convened with the following purposes: (a) to review existing nealth surveillance of workers exposed to chemicals in the ~ember States; . ( b) to define the role and place of health surveillance within the occupational health information system; and (c) to develop guideline s on the health surveillance of workers exposed to toxic chemicals, paying particular attention to those who are exposed to carcinogenic and genotoxic agents. Two sub-groups were convened, one to consider the role of health surveillance and the other co consider the place of biologic al monitoring for ca rcinogens and mutagens within the system of healtn surveillance. Discussion The existing health surveillance of workers exposed to chemicals in nine Member States was reviewed. These countries were Bulga ria, Czechoslovakia, Denmark, Finland, Italy, Poland, the USSR, the United Kingdom and Yugosla via. Health surveillance wa s discussed wicn reference to its role within the occupational health information syscem and with reference to special groups of worKers, particular health hazards, and methodology. It was not possible to develop precise guidelines for exposure to individual chemical substa nces on this occasion, nor to discuss the action required to deal with acute emergencies arising from untoward exposure. The following summarizes the substance of the discussion. The place of health s urveillance within the occupational nealth information system was described by reference to a Polish computerized data-base consisting of five systems: the ~re valence of occupational disease , sickness abse ntee ism, toxicolog ical information, health care, and occupational exposure. It was noted that the collection of information, particularly about exposure, might prove difficult, and it wa, accepted that the requirements should be kept as simple as possible. The basic information needed was personal details of the worker, his or her nealth stacus or oiological measurement at a 6 iven point in time, and details of exposure to noxiou s agents. Wnere possible, tne information should be related to social and ge neral environmental experience and linked to other medical records pertaining co the individual. - 161 - The health surveillance of specific occupational groups exposed to chemicals was considered in relation to three vulnerable groups: working women, young persons and the elderly. In respect of women it was recognized that, by reason of their sex and reproductive function, certain special precaut ions were necessary to limit their exposure to some chemicals. For young persons, too, specific precautionary measures might be needed, while fo r the elderly, no specific measures were envisaged. The special requirements of women in early pregnancy were noted, as were the possible effects of chemicals on the male reproductive system . Methods of health surveillance, including biological monitoring of workers exposed to carcinogenic and genotoxic chemicals were discussed under six headings: measurements of chemical compounds or their metabolites; the testing of body fluids for mutagenicity; the determination of the alkylation of macromolecules; the analysis of cytogenetic alterations; the determination of the products of tumour development and growth; and the measurement of the altered immunological sta te. These methods are all at stages of rapid scientific development, though some are already applicable t o the routine health surveillance of exposed workers. In some cases the technical complexity of the methods or the need for multiple indices of effect within a monitoring programme, and in others the presence of compounding factors such as smoking, have so far made difficult an accurate interpretation of text results when applied to working populations. Some of these methods will find an active role in routine health surveillance in the near future . Studies already begun or planned will help to clarify the role of these methods, but, in the meantime, unanimous emphasis has been placed on the desirability of keeping accurate records for long periods of time, because of the latency period after exposure before clinical cases may be expected to appear. Certain chemicals are already known to be human carcinogens, and special care is needed in controlling exposure to them so that risks to workers are minimized. Further research was recommended to identify the precise place of some of the tests in occupational health surveillance. The role of the occupational health surveillance of workers exposed during manufacture, fo rmulation and use to the many chemicals used as pesticides, exemplified some of the problems of app lying practical protective measures to a large group of workers exposed to diverse chemicals in various physical forms and quantities. Before being permitted for use as pesticides, many chemicals are screened for their adverse effects on humans and the environment. Their wide use in agriculture and horticulture demands that special recognition be given to their potential hazard; that accurate records of exposure should be kept; that pre-employment and routine health surveillance should be car ried out on workers exposed co certain chemicals, such as organophosphorus and organochlorine compounds; and that further studies should be made of the possible long-term effects of exposure. The occupational health surveillance of workers exposed to radioactive chemicals has been recommended by the Internacional Commission on Radiological Protection ( I CRP), and widel y adopted i n many countries . The ICRP recommendations should be followed and regarded as the minimum essential for this purpose. The advantages and disadvantages of periodic medical exa~inations were consi dered . In some countri es these could conveniently be allied to programmes designed to improve the general health of the population. The merits of screening procedures were propounded and their possible advantages over periodic clinical examinations were deba t ed . It was recognized that screening tests had a useful role to play within the health surveillance system, provided they were valid procedures which offered the possibility of detecting biological changes at an early, reversible stage. Examples of screening tests noted were the estimation of cholinesterases in workers exposed to organophosphorus compounds, and the measurement of 6 -amino-laevulinic acid in lead workers. Information is still required on the optimum frequency of periodic surveillance. In some cases it may be necessary to use multiple screening indices. In general, screening tests should be cost-effective, and applicable to large groups within which they may detect individuals who require further investigation or examination, or to whom special precautionary measures may need to be applied . The contribution of non-occupational factors to changes in workers' health was discussed at leng th. It was recognized that possible social and general environmental conditions, as well as personal habits, were of importance, and might influence the health effects of exposure to chemicals at work in many ways. The example of cigarette smoking plus exposure to asbestos, which causes a higher incidence of lung cancer than either factor alone or even i n combination, was quoted. Though knowledge of the interaction between work exposure and non-occupational factors was poorly developed at present, particular reference was made to ambient climate for outdoor workers, dietary factors, alcohol consumption , drug usage and personal characteristics. Quantitative evaluations of the interact ion between various types of exposure are feasible in suitably planned - 162 - studies, and surveillance programmes should, whenever possible, be designed to take existing information into account. Concern was expressed about the possible effects of smokers' habits on non-smokers in the workplace. Much further information was needed to clarify these issues. Conclusions and recommendations l . Systems for the health surveillance of workers exposed to chemicals vary greatly from country to country. Some systems are comprehensive and emphasize general health as well as specific occupational health conditions. The methods by which these systems are implemented also vary greatly. 2. It is desirable to establish greater uniformit y in the methods of health s urveillance of workers exposed to chemicals. This uniformity should, howe ver, be based on an accurate knowledge of the hazards and their relationship to health effects. In particular, the desired fre quency of health surveillance is not yet established on any scientific basis. 3. Health surveillance includes biological monitoring; an area of rapid scientific development. At present the application of valid biological screening procedures is limited, bu t it is likely chat laborat or y tests for workers exposed to many chemicals, including carcinogens and genot oxic compounds, will become available for routine practical use in the near future. Such tests should be validated when used in surveillance and their results be open to accurate interpretation . They should offer the prospect of practicable remedial actions. 4 . Exposure to chemicals at work does not occur in isolation. Workers are also exposed to a variety of influences in the general environment and diet, and variations in personal habits such as smoking, alcohol consumption and drug-taking . Other individual or social factors may affect the consequences of exposure at work. These non-occupational fac tors should be taken into account within the system of occ upational health surveillance. 5. The information produced by health surveillance procedures lacks integration with other health indices. Health s urveillance provides an essential component of the total occupational health information system, but its results should be linked to measurements of environmental exposure, and to o ther health and vital records pertaining to the individual worker. Likewise, consideration should be given to allowing health authorities to have access to information about jobs, work areas and exposure to chemicals, as well as to information from health surveillance programmes. To achieve this would be difficult within some health care systems as they are or ganized at present, bu t it is recommended that efforts be made to es tablish linkage systems. 6 . Certain groups of workers may, by reason of age o r sex , or specific physiological states , be at special risk from expos ure to certain chemicals . Special systems of surveillance or the application of specia l standards within the surveillance system should be conside red for these workers. 7. Health surveillance procedures should be applied only with the consent and cooperation of workers, and they, their representatives, employers, and government bodies muse be fully informed and especially given access to the results of the surveillance, though personal details and results should remain co nfiden tial to individuals. 8. Procedures for the health surveillance of workers exposed to chemicals should be designed according to the nature of the hazard and, in general, be s pecifically directed towards detecting c hanges in health at a stage when these cha nges are still reversible. This is rational only when remedial action can be implemented to correct the de tected changes. 9. Within the surveillance procedures there should be scope for assimilating workers' complaints about their health, so that previously unsuspected effects may be brought to light. 10. Much fu rther work is required to rationalize the health surveillance of workers exposed to chemicals, including the determination of optimum procedures and frequencies. The question of cost-efficiency and cos t-ef fectiveness must be borne in mind, so that health surveillance is not divorced from wider economic issues. 11. Finally, the development of specific systems of health surveillance will depend on an accurate assessment of the hazards to which worke rs are exposed, and the development of appropriate t echniques fo r the de tection of the earliest signs of biological effect. Surveillance procedures should be i nitiated at the s tart of employment, with periodic re-examinations while expos ure continues. In some cases it may be necessary to continue surveillance after a worker has ceased being exposed, or has left the employment, or retired. - 163 - ORAL HEAL TH - 165 - Workshop on a Review of Current Recol!Dllendations for the Organization and Administration of Col!Dllunity Oral Health Services in Northern and Western Europe Oslo, 24-28 May 1982 Introduction ICP/ORH 008(l)(S) 0006H 15 June 1982 ORIGINAL: ENGLISH The Workshop brought together participants from 11 countries in western and northern Europe, a representative of the International Dental Federation, five observers, six temporary advisers and three WHO staff members from headquarters and the Regional Office. In the light of three main factors - increasing knowledge concerning prevention, increasing expecta tions for dental health from the population and governments' concern over costs - the Workshop addressed itself to considering what the new role of the dental profession might be and how it might be encouraged. Discussion The interim results of the WHO/USPHS International Collaborative Study of Dental Manpower Systems were first considered and problems causing concern to the individual countries represented at the Workshop identified. The Workshop then considered how dental professions might reasonably be expected to respond to these problems up to the year 2000 . Five major problem areas were identified: the implications of the changing dental needs of populations; the overemphasis on the restorative approach to oral health; the overemphasis on demand rather than need; current economic constraints; dental manpower. In a number of papers and in the ensuing discussions, five broad developments were identified i n the evolution of den tal health services in northern and western Europe: prevention of oral diseases; primary health care; planning for oral health; dental education and manpower planning; health services research. The need for oral disease prevention to become an integral component of health education as a whole was particularly emphasized. In view of the labour-intensive nature of individual and small group counselling in preventive dentistry and the need to orientate the training and motiva tion of those involved, the extensive use of auxiliary personnel was recognized as important. The narrow concept that primary health care is only the first contact between an individual demand ing care and the oral health care system was rejected in favour of the broader WHO view which emb races actions throughout the health, social and economic sectors in society. The planning of oral health services was seen as part of the management cycle which includes implementation and evaluation. The stages in planning were outlined, and the categories of information needed by planners were identified . In particular, planning was not seen to be an abstrac t exercise but one in which those receiving and those providing care must be actively involved. Indeed, the acceptability of a service to everyone, but especially to the consumers, was recognized as perhaps the most important single factor in planning. - 166 - It was felt that the isolation of various groups within dentistry was a major contributor to many of the problems that exist, particularly in dental education. It was causing a re l uctance to change existing systems, for instance, and personnel were consequently being trained for roles which might not exist in the future. The need was recognized for dentists to be very broadly educated as generalists, capable of accepting a responsibility for the whole health care of individuals and of changing as the communities' needs change. To achieve this, appropriate auxiliary personnel in adequate numbers are needed, and the educational systems, including continu ing education, ough t to be effectively integrated. The urgent need to direct interest and funds towards further applied research was emphasized and seen as a fundamental responsibility of all health care systems. The Workshop made a number of recommendat i ons aimed at sustaining and developing the reduction in incidence o f dental diseases, and suggested that workshops might be organized to examine certa i n important areas in greater depth and that a research data base and information transfer systems might be established. - 167 - PHARMACEUTICALS Eleventh European Symposium on Clinical Pharmacological Evaluation in Drug Control: Drugs in General Practice Sch langenbad, 19-22 October 1982 I ntroduction - 169 - ICP/PHB 009(ll)(S) 0664F 26 November 1982 ORIGINAL: ENGLISH Like previous symposia in the series, the Eleventh Symposium was made possible by the fi nancial support of the Federal Ministry for Youth, Family Affairs and Health, in the Federal Republic of Germany. It took as its theme "drugs in general practice" and brought together general practitioners, clinical pharmacologists and drug-regulating officials. Participants and observers attended from countries representing many different systems of health care, ranging from those with no ge neral prac titioners, to those where highly complex systems of general practice existed. In spite of thes e differences, agreement was reached on the importance of five broad areas: the education of general practitioners; drug evaluation and prescribing in general practice; drug information in general practice; the auditing of prescribing in general practice; general practitioner/patient cotmDunication in general practice. Co nclusions and reconnuendations The education of general practitioners General practice is a medical specialty which requires specific training 1n how to cope with the different range of problems and patient expecta tions as compared with those encountered in hospital patients. The teaching of prescribing in general practice should be an integral part of this special training or else be taught on its own if no such training exists. The aim should be to improve the selection and use of the medications prescribed. The foundati on for such training should be laid in the undergraduate curriculum. Pharmacology should be taught to undergraduates as part of their basic medical training. The teaching of pharmacology and therapeutics should be integrated with clinical teaching at all stages. Training in therapeutics should continue after qualification, in the early postgraduate (vocational training ) period and form part of a doctor's continuing education throughout his career. The teaching s hould be carried out at all stages by teams, which should include experienced general practitioners, clinical pharmacologists and possibly other specialists as well. There are frequent changes in the range of drugs available and in prescribing practice. It is therefore vital to ensure that continuing education is available to all general practitioners, to keep them ' informed of these changes. The educational materials used should be appropriate to general practice, well presented and use modern cotmDunication techniques. Drug evalua tion and prescribing in general practice A more critical and cos t-conscious approach should be adopted. General practitioner associations should encourage their members to collaborate on improving their prescribing practice. If a general practitioner limits the number of medicines he prescribes and familiarizes himself with them, then he will be able to prescribe them more appropriatel y and to provide better information to his patients. - 170 - It must be remembered that prescribing is only one form of therapy. It must there fo re never be undertaken lightly or without proper indications. Medication used in general practice should be studied under those conditions. There is therefore a need for ethically acceptable clinical trials to be carried out by general practitioners and clinical pharmacologists, cooperating in a general practice setting. Drug regulatory agencies should meet the needs of the general practitioner by involving them in their work. Drug information and general practitioners The general practitioner needs to receive a range of drug information with ou t being overwhelmed with conflicting information. This problem should be studied by all bodies providing drug information or engaged in drug regulation. Clinical pharmacological services should provide information and advice on prescribing problems to the general practitioners in their area. The general practitioner has a right to reliable, comprehensive and up-to-date data on marketed drugs and their problems. These data should be provided at national and international levels. Drug regulating agencies should inform general practitioners both of their decisions and of the reasons underlying them, and seek to recruit their help in the study of known and unknown adverse effects. A general practitioner should receive drug utilization data from impartial sources in such a form that it enables him to compare his prescribing practice with that of others. Auditing and prescribing in general practice There is a need for various types of auditing in general practice, including exte rnal auditing, which may be performed by fu nding agencies, and internal or self-auditing, carried out by general practitioners, whether working singly or in groups. The overall aim should be to identify inappropriate prescribing . Auditing techniques ough t to be part of the training fo r ge neral practice. General practitioner / patient communica tion on prescribing The importance of general practitioner/ patient communication is increasingly recognized in all fields. It is vital that the ge neral practitioner, when prescribing, has adequate data to provide information both for himself and the patient. Patient package inserts must be attuned to the patients' needs and the gene ral practitioner must be aware of their contents. The media are becoming increasingly important in providing prescribing i nformation. This information should not be sensationalized or one-sided. Offic ial bodies must provide journalists with reliable i nformation and ensure that misleading reports are promptly corrected. Patients should be encouraged to share in the responsibili ty for their treatment. This can be done if they are told what is the intended effect of the particular medicines prescribed, o r why no prescription was supplied on a particular occasion. - 171 - PRIMARY HEAL TH CARE - 173 - Working Group on Primary Health Care in Urban Areas ICP/PHC 022(9)(5) 27 January 1983 ll59E Zagre b, 14-17 June 1982 ORIGINAL: ENGLISH Introduction The Working Group was a link in a chain of activities in tend ed to promote the development of primary health care (PHC) in Europe. The Group consisted of 20 temporary advisers from ll countries, The Group's main objectives were to: (l) identify the most characteristic features of urban settlements in Europe and sunnnarize their main problems; (2) review the existing community health services in a number of European cities that reflect different health care systems within the Region, paying special attention to the primary health care concept; (3) analyse major obstacles and opportunities for the improvement of primary health care in urban environments; (4) elaborate a detailed set of primary health care principles for the development of PHC in urban areas; and (5) propose basic strategies for the improvement of health care in urban areas . The Group related its discussion to the definition of PHC contained in the Alma- Ata declaration of 1978. Characteristics of urban se ttlements in Europe The followi ng general characteristics that influence health and health care were identified . l . Demographic: dec lining number conurbations and an increasing proportion of elderly, particularly very elderly, people; of inhabitants of inner cities and increasing mobility within and between countries . a 2 . Epidemiological: an overall decline in infectious diseases, but with persistent pockets remaining; increases in conditions associated with an urban lifestyle and stress, in intractable chronic and degenerative disease and in diseases associated with old age and mental illness; continuing problems of physical and mental handicaps. J . Social and cultural: a decline in the ex tended f amil y and pressure on life-l ong marriage and the nuclear family; social isolation, seg re ga tion, and a loss of " community"; s i gni fica nt urban poverty, poor housing, deprivation and a positive correlation between health status and social clas s; continuing problems of minority groups, intolerance of deviance, the stress of competition, and periodic violence and social unrest; a greater questioning of medical authority , the i ncreasing appeal of "alternative" medicine, and a desire for greater autonomy and self-determination in health care . 4. Economic : the prospect of continuing unemployment associated with a changing industrial structure; rapidly changing technology and economic recession; increased participation by women in the labour market, earlier retirement and shorter working hours; problems of environmental pollu tion; a conflict between economic and social policy, and the effects of policies of economic growth upon health; limitations on public spending further constraining the res ources available for the health sector . 5. Political : a slow responsiveness t o change and a lack of creativity in poli cy-making; inadequate mechanisms for connnunity participation. - 174 - Characteristics of European health services in urban areas The considerable achievements of European health ca re were recognized. It was felt, however, that the more fundamental principles of good health care, particularly PHC, had generally become obscured and overshadowed by the dominance of curative, secondary, high technology and institutional care. There is a dominant orientation towards cure and treatment, and a failure to take prevention and health promotion seriously. Increasing investment in health care, particularly manpower, is accompanied by diminishing returns in health sta tus. Other shortcomings in the European health services include: - inaccessibility; a lack of continuity of care; a fail ure co respect peronal autonomy and to acknowledge the importance of the social context of ill-health; an inequitable distribution of resources both geographically and among the parts of the health-care system; a distortion caused by funding arrangements and competition between public and priva te health care; poor communications within and between primary and secondary care; disconnected and distorted information systems; a lack of comprehensiveness; a duplication of facilities; emerging problems of acceptability to clients; and a lack of strategic vision. Principles for the future development of primary health care in urban areas in Europe The Working Group concluded that primary health care in the countries of Europe f alls shore of the criteria established by the Alma-Ata declaration. European countries vary but, in each country, the main obstacle to PHC development is the present organization of health care. The Working Group therefore proposed the following principles fo r further consideration by each c ount ry in the light of its own particular circumstances. 1. Health promotion: emphasis must be placed upon the broad concept of primary health care as defined in the Alma-Ata declaration. 2. Participation: there should be maximum participation by the community at large. 3. Autonomy: PHC should aim to promote individual autonomy and to decrease dependence upon professional care . 4. s. 6 . 7. Continuity: PHC should provide continuity of ca re. Comprehensiveness: PHC should be comprehensive or provide access to comprehensive care. Accessibili t y : PHC should be readily accessible. Acceptability: PHC should be individually and socially acceptable. 8. Minimal financ ial dis tortion: PHC should respond to heal th needs and should not be distorted by the mechanisms used to finance it. 9 . Vertical integration: PHC should be fully integrated with the secondary and tertiary pares of the health care sys tem. 10. Lateral (o r functional) integration: there should be full intersectoral coll aboration at all levels to identify and solve health problems. 11. Professional teamwork: the basic unit of PHC organization in the local setting should be th e multidisciplinary PHC team. 12. Positive pl anning: the planning of PHC must be a positive, continuing, innovative and participatory process. 13. Hospital commitment: hospital-based services should be fully orientated in support of PHC. 14. Appropriate information: better information systems should be developed to enable more comprenensive and accurate epidemiological surveys, and community and individual diagnosis. 15. Review of effectiveness: health professionals and authorities should initiate and sustain systematic reviews of the ou tcome of PHC so that their performance can be assessed by themselves and the communities they serve. - 175 - 16 . Continuous learning: PHC should be a continuing process of mutual learning. Strategies for change There is no single or simple way in which the development of PHC in Europe will be promoted or accelerated. Successful achievement depends upon a creative blend of related strategies. These must include the following: 1. Education. Each member of the PHC team needs an education that is more closely orientated towards PHC, including education on how to work with other disciplines. Imaginative education for health is also required. 2. Research. PHC needs its own research base. The medical/scientific model needs to be complemented by social and action-research approaches. The coordination of existing PHC research is perhaps more important than new research, but research must not be allowed to become an excuse for inaction. 3. Information. Health care information systems that emphasize the demographic and epidemiological context and the needs of PHC must be developed. 4 . Devolution of decision-making. Many European health systems are professionally dominated, over-cen tralized and inflexible. Participation by a wider community is an important key to PHC development. 5. Professional development. Professional chauvinism can impede useful innovation. There is a need to review and develop the role and functions of members of PHC teams. 6 . Financial investment. PHC is believed to be cost-effective. It will require financial investment if its claims are to be proved. 7. Political commitment. The resources of international agencies, national, regional and local governments, the professions, voluntary associations, client groups and health authorities need to be mobilized to overcome the inertia of current health service practice and organization. Conclusions 1 . There was enthusiastic support within the Working Group for the concepts of PHC embodied in the Alma-Ata declaration. The declaration was believed to have as much relevance to the i ndustrialized and predominantly urban countries of Europe as to the less developed and predominantly rural nations of the world. 2 . The nations of Europe should continue to be encouraged to examine and understand the importance and relevance of PHC in urban industrialized societies. A greater effort must be made by each country to relate the provision of health care more closely to identified and anticipated health needs. 3 . WHO should continue to explore and develop PHC within Europe. Emphasis should be placed upon the establishment and reinforcement of networks of people within and among the European countries who are commit ted to the ideals of PHC and wish to see them translated into practical action. Working Group on the Principles of the Development of Model Health Care Programmes Turku, Finland, 3-6 May 1982 Introduction - 176 - ICP/SPM 042(5) 0140E 1 July 1982 ORIGINAL: ENGLISH The Working Group was the first major activity under the aegis of the WHO Regional Office for Europe's new programme on model health care and quality assurance of health services. Seventeen temporary advisers participated in the meeting. They represented experience in the development of model health care programmes, the administration of health care institutions, national health planning, economics and health services research. Model health care programmes are written guidelines that make recommendations on combinations of preventive, diagnostic, therapeutic, nursing, monitoring and rehabilitative procedures for the care of patients with certain given diseases or health problems. In a number of countries, associations of health authorities have developed and issued such guidelines. In other cases, while no explicit recommendations exist, there may nevertheless be dominant sets of health care procedures. One reason for the growing interest in such guidelines is the increasing complexity and interdisciplinary nature of medical care: the selection, ordering, scheduling and coordination of the most appropriate and beneficial combination of procedures often exceed the skills of single health care providers, be they a physician, a nurse or a social worker. Their work will, therefore, be facilitated by a programme which indicates their possible role in the process of care. At the same time, the changing pattern of morbidity has made the use of such guidelines feasible: the treatment of chronic diseases does not usually require immediate decisions; health care providers have time to consult recommended standard patterns of care and apply pre-established decision-making rules. An earlier WHO Workshop on the Cost-Effectiveness of Recommending Standard Patterns of Long-Term Care raised the question: "Is it worthwhile (in terms of cost-effectiveness) to recommend standard patterns of care?" Using the deliberations of this workshop as its point of departure, this Working Group focused on the question: "How should model health care programmes be developed and how can they be implemented?", bearing in mind that such programmes are a way of finding the most appropriate combination of health services for each patient. The principles identified during this first phase were then applied to a particular health problem, lower back pain, for which a number of collaborat i ng centres have agreed to develop a care programme. Topics Definition of, and motivation for, a model health care programme: this included arguments on cost, quality and integration. The fundamental motivation for them was the opportunity of improving the quality of care and of integrating the different components of care. There was agreement that cost was not sufficient motivation~- Presentation of national experiences: reports were given from Finland, Sweden and the USSR. Finland and Sweden seem to have the longest experience in developing model health care programmes both at national and local levels. Several programmes have been tested in the last few years with promising results. In these countries, they are used particularly for low back pain, hypertension , diabetes, breast cancer, stroke and hip fractures. Identification of areas amenable to the use of model health care programmes and criteria for their selection: there was agreement that a disease problem should have both economic and social importance or have been seriously neglected. It was also agreed that interest in such programmes must be shown by the professionals concerned. - 177 - Requirements for the successful development of model health care programmes: it was agreed that a model programme for lower back pain should consist of the following parts. 1. Background knowledge What is the problem? Is it an important problem and, if so, why? Is quality of care insufficient? Can quality be improved? Can costs be changed? What length of planning period is needed to develop a programme? May extra resources be needed? 2. Aims/objectives Can treatment be improved given the existing resources or should more attention be paid to preven tion and self-care? 3. Strategies Which strategies should be used to improve prevention, self-care or treatment. 4. Preventive measures Description of existing options: how, where and when? 5. Diagnostic measures Classification problems, diagnostic methods and procedures at different levels. The pros and cons of different procedures . 6. Therapeutic measures How, where and when? 7. Organization 8. Organizational aspects of prevention, diagnosis and treatment. Social aspects Description of social, socioeconomic and psychological factors relating to work, leisure time, insurance, family. Encouragement of professionals to think of non-clinical solutions. 9. Education and research, and other supporting measures Explanation of the need for more research into cost-effectiveness of alternative care, and fo r be tter knowledge about the etiology and nature of lower back pain. Model health care programmes should stimulate research and consumer education. 10 . Evaluation An attempt should be made to show the effect of the programme in terms of its objectives. 11 . Target groups and areas for model health care progral!Ulles Th~ introduction and running of a programme for lower back pain should involve all relevant grou ps as well as areas such as schools and schoolteachers, occupational medicine, consumers and providers. The development of a programme for lower back pain would be based on the general recommendat ions contained in the final report on this Working Group and would take place in the following stages: the writing of a national model health care programme for use at national or local level in different countries, following the recommendations; the implementation of th i s programme as appropriate to the particular problems of the participating countries; the recording of the experiences gained and evaluation of the results achieved. - 178 - Recommendations The Working Group recommended the development of a pilot model health care programme for lower back pain in various countries with different health care systems. This programme should pay special attention to the management of lower back pain in primary health care. - 179 - PUBLIC INFORMATION Sfiposium of Journalists and Experts; " a Life to Years" Lyons, 30 March - 2 April 1982 - 181 - ICP/INF 002(5 ) 0043L 23 June 1982 ORIGINAL; ENGLISH The Symposium was convened to stimulate public awareness of the role of the elderly in the community. It provided the opportunity for the 24 participants - journalists ( including several who specialize in reporting on health subjects), members of the medical profession (some of them public health officials) and a sociologist - to discuss the practical applications to the elderly o f the concept "Health f or all by the year 2000". The Symposium adopted as its standpoint the safeguarding o f an economicall y and socially satisfactory life for the elderly. Participants discussed the problems of aging in a broad geographical and historical perspective. They differentiated between age groups among the elderl y , rev iewed the health hazards the elderly face, and considered their social handicaps, including i solation and poverty . Practical measures to improve the situation of the elderly were considered, taking into acc ount such issues as sel f -care, personal care, family involvement, and community approaches as we ll as classical medical care. The journalists discussed the sort of information they receive about the elderly, what might be done to improve it, and how the mass media could work in favour of the elderly. The Symposium c onsidered a number of questions. Do journalists obtain all the news the y require? Do the y have proper access t o the health services in t heir i nvestigations and to the elderly themse l ves ? Are the health services aware of the role the media c ould pla y in bringing news to the elderl y a nd in c ommunicating the viewpoints of elderl y people to the policy-makers and to the general public ? Are t he elderly aware of the opportunities the media provide to promote their interests ? Topics discussed With more people living longer there is a much large r a udience now than 25 years ago d irectl y in terested in in formation a bout t he social, political and medica l problems that come with a g ing, about solutions to those problems, and in sources of help and information that could enable people t o cope with them. More emphasis should be placed on preparation for o ld a ge t h rough a better understanding of ways of maintaining mental and physical health. Activities open to the elderly should also be explored. It was a case o f ma k ing better known what was being done , not on ly for the e l derly but als o by them, and of ensuring that the facilities available to them, to th e ir famil i es and to medicosocial workers were surveyed and their existence publicized. To the extent that this was the task of journalists, it was important that they should have hard facts to work on. In-depth studies, real-life stories, visits and seminars on speci f ic themes provided them with a basis for reporting. On the other hand, plans of action, resolutions, r ec ommendations, theories, statements of principle or wishful thinking were of interest to no one but administrators. Journalists could help to eliminate the existing confusion between aging and d isease in the minds of both the public and the medical profession. Conclus ions l . WHO should give priority in its public i nf ormation programme to the rapid and timel y d issemination of factual information, bearing in mind the need for advance notification o f meetings a nd publications, and the desirability o f developing a feature of service. In the distr i bution process , WHO should take account of the interests of individual journalists, and when dealing with t hem collectively, do so by specialization a s well as by medium, country and re g ion. - 182 - 2. The initiative taken by WHO in organizing the present Symposium was welcomed. More such meetings should be organized on selected topics so that appropriate representatives of the media could meet and discuss them with scientists and experts. 3. Care of the elderly should be seen, studied and publicized in a global perspective rather than from the purely medical or social points of view. When dealing with topics concerning the elderly, the media should avoid the use of stereotyped images which cannot be supported by the results of current research and experience. 4. As a focal point for nongovernment organizations active in health care of the elderly, WHO should help the media to give greater coverage to their activities. S. The media should encourage among the public the concept of primary health care, including home care of the elderly as an alternative to institutional care, unless medically indicated. The home care of the elderly has economic, social and human implications that merit greater consideration. 6. There should be wider dissemination of information on the range of facilities open to the elderly that can ease their daily lives and relieve their problems. These information services should be directed not only at the elderly themselves but also at all those concerned with their care, both professionally and otherwise. 7. Social programmes should incorporate more preventive action to avoid situations that create particularly acute problems for the elderly. 8. The increasing proportion of the elderly in society affects the distribution of national resources, but even more important are the social implications of such change, and these deserve more attention. - 183 - TOXIC CHEMICALS CONTROL Workshop on Allergic Responses and Hype rsensitivities induced by Chemicals Frankfurt am Main, 12-15 October 1982 Introductio n - 185 - ICP/RCE 903(18)(5) 06031 16 November 1982 ORIGINAL: ENGLISH There is growing evidence that the exposure of workers and the ge neral population to chemicals may be responsible for a range of health problems such as allergies, hypersensitivities and int olerances, resulting in such conditions as contact dermatoses and occupational asthma. Recognizing the growing importance of the problem, the WID Regional Office for Eu rope and the Commission of the European Communities invited 34 experts from 21 countries to Frankfurt to discuss these issues. The participants included chemists, biochemists, pharmacologists, and publ ic health practitioners, as well as physicians involved in clinical and i n occupational medicine. Rep resentatives of the trade unions and industry also participated . The Workshop discussed the mechanisms of action of major allergenic chemicals, and human factors that could influence allergic responses and related conditions. It examined a vailabl e meth ods for the cli nical surveillance of exposed population groups, as well as problems of monitoring and epidemiological studies. It also considered the major problem areas in terms of chemicals, sources and routes of exposure. The meeting concluded that there is a significant health problem associated with allergy and int olerance of man-made chemicals, both in terms of the severity of the clinical conditions and the ser ious interference with quality of life, and in terms of the number of people exposed. Man-made chemicals and / or their metabolites are important in the formation of allergens. The mai n problems arise from ignorance of the precise structures responsible for allergenicity and the relevant immunopathological mechanisms. The meeting developed the following recommendations on resea r ch priorities, dissemination of information a nd preventive measures. 1. Research The following research topics urgently need priority consideration by international orga nizations, governments and scienti fic institutions. (a) Assessment of the allergenic potential of chemica ls in terms of induction of immune response and allergic reactions. (b) Investigation of the relationship of molecular and physicochemical characteristics to the induction of hypersensitivity and to the elicitation of allergic reactions. (c) Investi ga tion of dose-response relationships for the induction of hypersensitivity and elicitation of allergic reactions, and investigation of possible dose-effect relati onshi ps. (d) The role of respiratory tract hyper-reactivity in terms of predisposition to respiratory allergy, the and influence of specific and non-specific factors. (e) The role of atopy in the development of sensitization to chemical compounds, and dis tinction between allergenic and non-allergenic effects. - 186 - (f) A systematic integrated approach to immunological studies for antibodies in all the different irnmunoglobulin classes, including in v i tro cellular tests, and their correlation with skin and other tests and clinical manifestations. (g) Comparison of existing animal test methods for predicting contact skin allergy and developing more precise scoring systems. (h) Development of predictive tests for respiratory tract allergenicity (antibody- and / or cell-mediated). (i) Development of test methods for predicting chemically induced antibody-mediated skin reactions. (j) Epidemiological studies related to specific exposures and particular situations, starting with occupational exposure and extending, when possible, to the community. The object would be to assess the effects of different exposure circumstances and the frequency of allergic disease. 2. Dissemination of information The following actions are proposed for improving the availability and use of knowledge in thi s field. (a) Establishment of a mechanism for better transmission of information within and between occupational and general health services, from health services to the public and at internat i onal level, to cover skin, respiratory tract and other organ systems. (b) Education of the medical profession, industrial management, trade unions and workers concerning types of allergy, control methods and the common allergenic materials and substances should be intensified. Educational programmes for the general population are also advisable. (c) Criteria for labelling and the labelling systems for allergens based on experimental, epidemiological and c l i nical in fo rmation should be made internationally compatible. Data sheets should contain all relevant information in this respect. (d) Lists o f proven and suspected chemical allergens are desirable. Where necessary, criteria and mechanisms for the establishment of such lists should be developed. ( e ) The establi s hment of international f ocal point (s) to serve as expert centre ( s ) for collection and dissemination of information and training. J. Preventive measures In the handling of any chemicals, adequate attent i on should be paid to potential allergenic e f fects and the following specific actions are proposed. ( a ) Te s t i ng f or allergenicity s hould be inc l uded in the safety as s essment of any new chemicals. ( b ) Exposure to sens1t1z1ng chemicals should be reduced as much as possible in the workplace. This can be achieved by a variety of approaches, such as: improvements in all aspec ts of technology ; the use of lower concentrations of the chemical or its substitution by a suitab le safer alternative; and protective procedures, gloves, clothing, respiratory masks, personal hygiene, etc. (c) Guidelines for the safer handling of known allergens should be developed and made wide ly available. (d) The institution of appropriate health examination procedures to assess sensitization potential prior t o exposure , the maintenance of occupational surveillance, and the provision of adequate information on the nature of any relevant exposures should be promoted. Similar measur e s should be adopted as appropriate for the community at large. (e) Harmonization of terminolo gy, test methods and t heir evaluation should be further promoted. Workshop on Rehabilitation following Chemical Accidents Rome, 8-12 November 1982 - 187 - ICP/RCE 903(20)(S) ISS/Dir. 324 06541 25 November 1982 ORIGINAL: ENGLISH Because of the large volume and number of chemicals chat are being extracted, manufactured, transported, marketed, stored, used or disposed of as waste, there is a significant potential for accidents invo lving toxic and hazardous chemicals. Consequently there is a real need to develop more rational and effective approaches to tackle the consequences of these accidents in order to minimize envirorunental damage and hazards co human health. Recognizing this need the WHO Regional Office for Europe, within the framework of the International Programme on Chemical Safety, has in the past produced guidelines for contingency planning for, and response to, emergencies and accidents involving the release or misuse of potentia lly toxic and hazardous chemicals. The WHO Regional Office for Europe, organized the present workshop on behalf of the International Programme on Chemical Safety, jointly with the Istituto Superiore di Sanita, Rome, and with the participation of the Commission of European Communities. The aim of the Workshop was to develop a draft guideline document on the rehabilitation after chemical accidents of people, water resources, land, biota, facilities and buildings, with an outline of management plans, including the health system. This document is intended to provide guidance at all levels of government on the management of the recovery process in an effective and rational manner. The guidelines cover rehabilitation after accidents in the production, transportation, storage or use of chemicals or 1n the disposal of their waste. The rehabilitation of people and areas after chemical accidents is a complex problem with public health, scientific, technical, administrative, information and socioeconomic aspects. The Workshop was attended by 44 experts from a broad range of disciplines, including planners, physicians, engineers, sociologists, ecologists, toxicologists, communicators and public administrators from 16 European and 5 non-European countries. Extensive preparatory material for the document was presented co the Workshop and reviewed in detail . Coo:lusions 1. The rehabilitation of areas and people affected by major accidents involving the release of potentially toxic and hazardous chemicals requires a comprehensive approach involving the coordinated efforts of many government agencies at various levels as well as of scientific, health and other institutions. 2. The effects of chemical accidents may be insidious, and provision for public information systems and arrangements for public participation in decision-making are essential. 3. An adequate interinstitutional and international flow of information is essential. The availability of an internationally developed guideline document on rehabilitation will fill part of this need. 4. The meeting concluded that many costly rehabilitation efforts could have been avoided, had preventive measures been in operation. - 188 - Recommendations l. The WHO Regional Office for Europe/International Programme on Chemical Safety, in collaboration with other international organizations and with national institutions, should finalize the document on rehabilitation after chemical accidents, which deals with information requirements, rehabilitation action, monitoring, feedback and adjustment, information systems and international cooperation. This document should be followed up by a series of specific technical guideline documents on various aspects of the rehabilitation action. 2. The specific technical guideline documents should deal with: (a) procedures for the diagnosis and treatment of people; (b) a legislative and regulatory framework for rehabilitation; (c) the cleaning and decontamination of buildings and facilities; (d) the rehabilitation of soil and biota; (e) the rehabilitation of water resources; (f) the safety and protection of rehabilitation personnel; (g) a search for and rehabilitation of abandoned chemical dumps and other contaminated sites; and (h) the technology for disposal of redundant toxic chemicals. 3. Case studies on rehabilitation after past accidents should be collected, collated, stored and made available. 4. National governments and regional organizations should be encouraged to establish and maintain centres to deal with the major components of rehabilitation programmes. International assistance should be provided where necessary. 5. The study of past chemical accidents should be undertaken actively in an attempt to develop methods of preventing the most common and serious accidents. 6. An annotated inventory of data bases containing information on chemical accidents and/or rehabilitation methods should be developed and made available. 7. Governments should be encouraged to mount an active search for, and rehabilitation of, abandoned chemical dumps and other contaminated sites to prevent future chemical accidents and health threats. 8. A study should be made of the feasibility of rapidly extracting from, and transmitting to, existing data bases, information on past accidents and rehabilitation. This should be undertaken by WHO and the International Register of Potentially Toxic Chemicals (IRPTC/UNEP), in conjunction as appropriate with national institutions and/or industrial establishments. 9. Governments should be encouraged to develop and maintain data bases containing information necessary for the prevention of, and rehabilitation after, accidents resulting from the manufacture, transport, storage and consumption of individual chemicals or their mixtures, or from the disposal of waste. - 189 - WATER POLLUTION Consultation Meeting on Methods for Monitoring Se lected Pollutants in Sewage Effluents and Coastal Recreational Waters: WHO /UN EP Joint Project Rome, 24-26 November 1982 In troduction - 191 - ICP/RCE 211(2)(5) 08831 17 January 1983 ORIGINAL: ENGLISH The Meeting was convened jointly with the United Nations Environment Programme (UNEP), and was held at the Istituto Superiore di Sanita in Rome. It was attended by 28 temporary advisers from 10 Mediterranean and 5 non-Mediterranean countries, a representative of UNEP, and one staff member of the WHO Regional Office for Europe. During the pilot phase of the Mediterranean Pollution Monitoring and Research Programme (MED POL), the project on coastal water quality control, jointly coordinated by WHO and UNEP, was concerned with bacteriological and related parameters for the monitoring of coastal recreational wa ters, shellfish-growing waters and shellfish flesh. During the course of this project, the two main methods of bacteriological analysis used were the membrane filtration culture (MF) technique and the most probable number (MPN) technique. Draft reference methods for the determination of ( a) total coliforms, ( b) faecal coliforms and (c) faecal streptococci, all in seawater, by the MF technique, and of (d) faecal col iforms in bivalves by the MPN technique, as well as guidelines fo r monitoring the quality of coastal recreational and shellfish-growing water, were developed for eventual use by Mediterranean laboratories during the long-term phase of MED POL. During the summer of 1982, these reference methods were tested by a number of selected Mediterranean laboratories under local environmental conditions, and a joint intercalibration exercise was held at the Istituto Superiore di Sanita in Rome, on 22-23 November 1982. To allow fo r the eventual use of these methods in other regions, a small number of selected non-Mediterranean laboratories also participated in the local testing and jo int intercalibration exe rcise. During the same period, a number of other Medite rranean laboratories performed a study on sampling and anal ytica l methods for bacteriological and related parameters, covering pollution sources (sewa ge effluents), recreational waters and reference areas, including a comparative s tudy on the MF and MPN techniques. The purpose of the Meeting was to review the results of the study on sampling and analytical me thods, and the comparis on of the MF and MPN techniques; to review, and amend as appropriate, the draf t reference methods in the light of local testing a nd the joint intercalibration exercise; and to make appropriate recommendations vis-a-vis the long-term phase of MED POL and other similar regional activities. Discussion The Meeting reviewed the exercise on sampling and analytical methods both through the reports presented by individual participating laboratories and through a synthesis of the results prepared by the Istituto Superiore di Sanita. A number of problems affecting both individual da ta and their comparability were discussed in detail. They included sampling procedures, particularly in the examination of sand and sediment, the potential damage to organisms as a result of the specific me thods used, resuscitation techniques for stressed organisms, and time-lags between sampling and analysis. The MF and MPN methods were reviewed from the point of view of their correlation. The draft reference methods for the determination of bacteriological parameters in seawater we re reviewed, as a result of which a number of revisions were made. The joint intercalibration exercise carried out on 22-23 November 1982 was discussed, and essential points to be ob served during future exercises were noted. - 192 - Conclusions The Meeting recognized that there was a limit to the number of samples laboratories could cope with and agreed it was often acceptable to sacrifice duplication and take the maximum possible number of samples. The Meeting stressed the importance of recormnended methods being simple and explicit, and particularly the need for a standardization of procedures where the examination of sand and sediment was concerned. Standardization should cover not only the analytical techniques themselve s but also the processing of results. The Meeting agreed that the time-lag between sampling and analysis should be kept to a minimum (not more than eight hours altogether). The importance of improving the recovery of stressed organisms was underlined, and a number of resuscitation techniques were proposed. It was concluded that good correlation had been obtained between the MF and MPN techniques at the critical level (i.e . between 100 and 200 faecal coliforms per 100 ml). The choice of method should therefore be based on considerations such as the nature of the samples, the legal aspects and the cost. A final decision could only be taken following a costing exercise i n the various countries. In reviewing the first draft of the guidelines for monitoring coastal recreational and shellfish-growing waters, it was concluded that sand, sediments and especially the sediment water interface, were of particular importance . In addition various microorganisms, including pathogens , deserved more attention than that accorded to them to date. Recommendations The Meeting recol1llllended that: the research component of MED POL should include the development of methods in connection wit h pathogenic organisms, and s tudies on factors capable of affecting results i n the case of organisms currently being monitored; periodic intercalib ration exercises, on both a country and an intercountry basis, should be carried out, to ensure comparability and quality control; beach surveillance and control should be included together with microbiological monitoring; and more frequent meetings of investigators participating in the prograrmne should be held. - 193 - WATER SUPPL V AND SANITATION Working Group On Appropriate Technology for the Treatment of Waste Waters for Small Rural Communities Lyon, 7-11 June 1982 - 195 - ICP / BSM 003(3) ( 5) 08601 18 October 1982 ORIGINAL: ENGLISH The meeting was held on the premises of the International Agency for Research on Cancer. It was attended by 20 experts from 11 countries in the European Region. The purpose of the meeting was to review the latest developments in the collection and treatment of domestic wastewater in isolated dwellings and small rural communities and the approaches being adopted throughout the European Region to solve the problems related to them. By so doing, a review of the technology options appropriate to Europe and guidance for the selection of systems was to be prepared. Appropriate technology The systems in the countries were presented, with the emphasis on new approaches, and reference was made to both good and unsatisfactory experience. Some recent developments in less developed countries in other Regions of WHO were also presented, showing how the possibility of providing satisfactory sanitation at relatively low cost had improved. Some of these approaches could play a valuable role in rural areas of Europe. The main systems reviewed were: ( a) pit latrines (b) cesspools ( c) septic tanks (d) grass plot treatment ( e) subsoil infiltration (f) rapid sand infiltration (g) lagoons/facultative ponds (h) oxidation ditches ( i ) extended aeration (j) biological discs ( k) trickling filters Of these, following (c); solids removal own. items (a) to (c) are primary treatment; (d) to ( f) are secondary treatment, usually (g) to (i) are secondary treatment, usually following some form of sedimentation, or disintegration; and ( j) and (k) are usually complete treatment systems on their Of particular interest was the experience and practice in all countr i es with septic tanks as a method of primary treatment. Even this well-tried and universally-used system was under review. New rational design approaches being adopted in Scandinavia to the land disposal of septic tank effluents included subsoil infiltration and rapid sand filtration. Although properly designed lagoon treatment was highlighted as the most effective treatment system as far as pathogens were concerned, it was stressed that no form of treatment, whether a relatively simple pit latrine or a relatively sophisticated extended aeration package plant, could completely remove pathogens. This raised the whole question of effluent disinfection by chlorination, but although it may have application under special circumstances, for example, during a cholera epidemic, it i s generally difficult to justify for cost reasons. - 196 - In recent years there have been certain improvements to the basic pit latrine, perhaps the most important being the introduction of fly suppressing ventilation systems . The Working Group concluded that the pit latrine in remote areas was an appropriate system for Europe. A system that so far has not been widely applied in Europe is that of small-bore sewers, yet they offer an opportunity for considerable cost savings. They are particularly suitable where a small community opts for a water-borne sewerage system to replace an existing system of individual septic tanks. Another way of cutting costs is to reduce the size of sewer and treatment facilities. One method of doing this, which to date has also not received sufficient attention in Europe, is a reduction in water consumption. Ye t owing to water scarcity, efficient flushing sys tems have been desi gned that use on l y 3 litres of water which could cut wat e r needs by between a third and a fifth. Another approach to the reduction of sewage volume in rural areas is to keep faecal wastewater and sullage separate. Health considerations Excreta-related diseases can be controlled by; (a) the provision of a toilet, of whatever type, which all members of the household use; (b) the provision of an adequate water supply for personal and domestic hygiene; (c) the effective treatment of excreta or sewage prior to discharge or reuse; and (d) effective sanitary/health education s o that facilities are used properly. Under these conditions, the well-designed and properly-utilized pit latrine can give the same health benefits as conventional water-borne sewerage systems. All sanitation systems, however, have potential disadvantages for health, which have to be appreciated, and provided for. With careful design and proper operation and maintenance, however, the health hazards of a sanitation system can be minimized. Conclusions and reco!TDnendations A. Technical Gene ral l . The provision of an appropriate sanitation sys tem, properly operated and maintained, is an important safeguard fo r health in rural areas and isolated conununities. 2. The type of sanitation system that is appropriate depends primarily on the water supply system and the amount of water consumed. 3. independent and small waste systems of the land disposal type, such as the pit la tr ine, the septic tank and the different forms of land infiltration, are not second-best systems or cheap substitutes for water-borne sewage and convential waste treatment; under certain conditions they are the most appropriate and bes t solution. 4. Individual sanitation has an important role to play in attaining the goals of the International Drinking-Water Supply and Sanitation Decade. 5 . New systems, introduced in developing countries, seem to have an application in Europe, and such developments should be encouraged. Treatment processes 6. The septic tank will be one of the main primary treatment methods for waste disposal in rural areas in the foreseeable future. 7. Lagoons, in particular when shallow, appear to be the most efficient process for reducing microbes in the effluents from small co!TDnunities. - 197 - 8. Although lagoons can be used under almost any climatic conditions, allowance has to be made for poor operation in winter at northern latitudes, with only 4% B0D5 removal, followed by gross overloading because of accelerated biological activity in spring. 9. Lagoon treatment should be considered in all cases for the treatment of waste from small communities since it is a simple process to operate and it produces a high quality effluent. It may be rejected because of local conditions such as the lie of the land, the natural soils or land use, but the reasons should be compelling. 10. Taking into account recent technical developments of rapid sand filtration and i nfiltration, the use of these systems, with appropriate dimensions, should be considered as secondary treatment whenever possible. Their use depends on: the geological and soil characteristics of the site; the pr oximity of sources of drinking-water (in this case the depth of the groundwater has to be taken into account as does the distance between the waste disposal system and the point of dra.,...off for potable water). 11 . Small-bore sewers would play an important role in cost reduction in rural areas if connected to already existing septic tanks, rather than as part of a newly built conventional water-borne sewerage network which totally replaces the original septic tanks. 12. A system of septic tanks and small-bore sewers must be accompanied by the necessary organizational backup to ensure the regular and efficient emptying of the tanks. 13 . The degree of treatment required should at all times be determined on the basis of the effect of the discharge on the recipient and the quality of recipient water aimed at, be i t groundwater or s urface water . Waste volume reduction 14 . Rainwater infiltration into small community sewerage systems should be kept to a minimum, with th e goal of twice the dry-weather flow being set for the flow received at a treatment plant. 15. Sanitation systems in which the sullage and faecal water are separate should always be c onsidered. 16 . The reduction in the volume of water used for flushing faecal matter is an important means of f acilitating it s treatment and thus allowing reductions in cost. Design considerations 17. Standard model designs can play an important role in saving costs and ensuring that systems are built to a recogn ized technical standard. The y should, however, be well tested and proved before general introduction . 18. Sludge handling and removal should be a n important element in plant de sign, with sufficient disposal capacity being available to ensure good hygienic practice. Unfortunately, waste treatment i s often looked at as a question of liquids while the solids are ignored or at best only considered secondary . 19 . Attempts should be made to look for materials that are lighter and less expensive than concrete fo r the construction of small treatment facilities; there has been a tendenc y in the past t o build even the smallest conventional waste treatment plants of reinforced concrete. Disinfection 20. Disinfection by chemical means (chlorination) of waste effluents from small treatment units can only rarely be justified, for the following reasons: disinfection is never total; in particular viru se s and parasites are not eliminated completely; the process is costly and difficult to operate; chlorination produces by-products whose presence is environmentally undesirable; and chlor ination s hould be considered primarily as part of the potable water treatment process and not as a means of reducing t he number of pathogens in the environment . - 198 - Operation, maintenance and training 21 . The efficiency of small rural ccmmunity treatment plants is often dependent on operational factors. The choice of the type of treatment should be made after serious consideration of the operational conditions and possibilities . Historically, concepts of treatment planes have ne glected operational constraints. This situation can no longer be allowed co continue, and operational limitations must be taken into account at the design stage . 22. The operators of small treatment plants in rural areas onl y work, in gene ral, part time. It is therefore of primary importance that they have technical support for the operation. This may be obtained through the technical units at nearby larger plants , or through a technical assistance service covering a geographical area. It is important that the technical assistance service be used for organizing training courses for operators of small treatment plants. 23. Staff responsible for designing systems should be encouraged co gain operating experience early in their career. B . 1. General A WHO Collaborating Centre for rural sanitation should be established. 2 . Support should be given to studies on the effects of different sanitation systems on the dispersion of pathogens. 3. An exchange of information should be promoted between developed and developing countries, on technology for rural sanitation. 4 . Studies should continue on the sanitary aspects of the reuse of waste effluents from rural communities for agriculture. 5 . A working group on the training and upgrading of operators of small treatment planes should be organized. The training should be process- oriented. 6. Member States should be encouraged co develop the infrastructure and organizational systems necessary for the effective operation, control and evaluation of the performance of small treatment planes for wastewater in rural areas. Consultation Meeting on Evaluation of Methylmercury in Mediterranean Populations and Related Health Hazards Athens, 13-17 September 1982 In troduction - 199 - ICP/RCE 211(1)(5) 04691 11 October 1982 ORIGINAL: ENGLISH The Meeting was convened in collaboration with the United Nations Environment Programme (UNEP) Coordinating Unit for the Medi terranean Action Plan, and was held at the headquarters of the Unit. I t was attended by eight temporary advisers from five Mediterranean countries, a representative of the International Atomic Energy Agenc y, three representatives of UNEP and two staff members and one consultant from WHO headquarters and the Regional Office for Europe. Some of the population in the Mediterranean region may have an intake of methylmercury through s eafood in excess of tolerable levels. An integrated monitoring and epidemiological study is t herefore needed to fill the serious gaps in existing knowledge that make it impossible to undertake the proper evaluation of health hazards from mercury or protect the sectors of the population that may be at risk . The purpose of the Meeting was thus to discuss and finalize a monitoring and epidemiological programme, to be undertaken both within the framework of the long-term Mediterranean Pollution Monitoring and Research PrograUDDe (MED POL Phase II) and as part of the Regional Office programme on chemical safety. Discussion International act1v1t1es on health hazards from methylmercury in the Mediterranean region were r eviewed. The criteria on which the epidemiological programme should be based, including the s election of areas where intakes of mechylmercury are (or could be) relatively high, and the id entification of population groups that could be monitored, were comprehensively discussed . It was emphasized that the possible interference of other organometallic compounds with the results should be adequately covered, The imp'ortance of taking possible occupational and/or general exposure to mercury into account, besides the actual seafood intake, was also underlined. This could be catered for by a limi ted multi-exposure study which would provide complementary information co dietary s urveys. It was considered important to analyse tissues other than human hair, such as the placenta, for methylmercury and, in view of the antagonistic role of selenium, it was recognized that parallel determinations of selenium and methylmercury were necessary. One o f the main problems in connection with the current monitoring programme in the Mediterranean is the fact that seafood species are being analysed for total mercury rather than for methylmercury. While it was agreed that figures for total mercury in seafood could afford a reasonably accurate ba sis for the assessment of methylmercury intake, it was recognized that a specific determination of methylmercury would have to be made and more studies on the relationsh ip between total mercury and methylmercury levels in seafood species should be conducted, Conclusions The Meeting developed a project on the evaluation of methylmercury in Mediterranean populations and related health hazards, with the following specific objectives. The selection of populations in the Mediterranean with a relatively high intake of methylmercury. The identification of groups whose methylmercury intake exceeds the WHO Provisi onal Tolerable Weekly Intake (PTWI) . - 200 - An estimation for the above groups of (a) their size; (b) the pattern of individual consumption of seafood; (c) their exposure to other forms of mercury intake; and (d) the actual concentrations of methylmercury in the various species consumed. An assessment of methylmercury exposure in the critica l segments of the population. An investigation of methylmercury-associated abnormalities in high-risk population groups as compared to control groups. The project will essentially consist of parallel studies carried out in a number of Mediterranean countries, and will include the following act i vities: dietary surveys to assess seafood consumption patterns in selected areas; the sampling and analysis of edible seafood for total mercury and methy lmercury; sampling and analytical programmes on the determination of methylmercury in human hair and, whenever appropriate, in other tissues; appropriate epidemiological studies on selected population groups within the sample. The Meeting developed a detailed protocol for conducting a dietary survey in selected areas (which will constitute the initial stage of the project), agreed on the procedures for making the fullest possible use of existing programmes on seafood analysis (mainly the current MED POL monitoring programme), developed the criteria on which to base detailed protocols for (a) the sampling and analysis of human hair, and (b) epidemiological studies (which will now be finalized for implementation during 1983), and agreed on the phasing of the project. A preliminary identification of the participating institutions from Mediterranean countries was also made.