Citizens with disabilities [full issue]

~ l ~ Wp,:a· ~ RLD ~~i! -~ THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION In this issue Equal opportunities 3 Bengt Lindqvist Disability prevention and rehabilitation 4 Ann Goerdt Community-based rehabilitation 6 Tambo Comma Safeguards that prevent disabilities 8 Pierre Maurice Living with disability 10 Volker Krause What are the Abilympics? 11 Harry S.Y. Fang Morocco's friendly association 12 Nejla Essaafi Prostheses and orthoses in developing countries 13 Anders Eklund Landmines: dragon's teeth 14 Alessandro Loretti Mental health: choice and dignity 16 Judi Chamberlin Intellectual disability 18 Peter Mittler Mental health in China 20 Yanfang Chen Aging well! 21 Alexandre Kalache Cerebral palsy 22 Adriano Ferrari Childhood blindness 24 Clare Gilbert & Alien Foster Preventing nutritional blindness 26 Keith P. West Thailand's battle against nutritional blindness 27 Vallop Thaineua, Emorn Wosantwisut & George A. Attig The legacy of leprosy 28 Denis Daumerie Children's hearing endanrred 29 Andrew W. Smith, Juanita Hatcher & Ion Mac enzie International action against deafness 30 Yosh Pal Kapur World Health • 48th Year, No. 5 September-October 1995 IX ISSN 0043-8502 Correspondence should be addressed to the Editor, World Health Magazine, World Health Orgonizonon, (H.l21 1 Geneva 27, Switzerland, or direc~y to authors, whose addresses ore given at the end of each article. For subscripnons see order form on page 31. HEALTH World Health is the official illustrated magazine of the World Health Organization. lt appears six nmes a year in English, French, Russian and Spanish, ond four nmes a year in Arabic and Forsi. The Arabic edinon is available from WHO's Regional Office for the Eastern Mediterranean, P.O. Box 1 51 7, Alexandria 21 511, Egypt. The Farsi edinon is obtainable from the Public Health Committee, Iron University Press, 85 Pork Avenue, Teheran 15875·4748, Iron. The Russian edinon con be obtained from "Medit>ino" Publishing House, Petroverigski per., 6/8, I 01000 Moscow, Russian Federonon. Front cover: Len Sirman © Articles and photographs that ore not copyright may be reproduced provided credit is given to the World Health Orgonizonon. Signed articles do not necessarily reflect WHO's views. The designations employed and the presentonon of material published in World Health do not imply the expression of any opinion whatsoever on the port of the Orgonizonon concerning the legal status of any country, territory, city or area or of its outhorines, or concerning the delimitation of its frontiers or boundaries. World Health • 48th Yeor, No. 5, September-October 1995 Editorial Equal opportunities Mr Bengt Lindqvist, Special Rapporteur of the UN Commission for Social Development on Disability. The United Nations' Rules on Equalization of Opportunities for Persons with Disabilities should be used to the maximum by all organizations for the disabled. "I n all societies of the world there are still obstacles preventing persons with dis- abilities from exercising their rights and freedoms and making it difficult for them to participate fully in the activities of their societies. It is the responsibility of States to take appropriate action to remove such obstacles." These two sentences figure in the introductory chapter of the United Nations' new instrument in the disability field: Standard Rules on the Equalization of Opportunities for Persons with Disabilities . They contain a message of vital impor- tance because there is no country in the world- not even the most afflu- ent, democratic and welfare-oriented -that has reached a decent or reson- able level of participation for its citizens with disabilities. Many obstacles to participation still re- main, concerning such fundamental issues as human rights and freedom. The United Nations' decision to draw up this new instrument fol- lowed an international debate where the disability community requested stronger leadership from the UN in implementing the policies and guidelines set forth in the 1982 World Programme of Action concerning Disabled Persons . Although there were some successes during the UN Decade of Disabled Persons, 1983-92, far too little was sustainable. More guidance was needed concerning how things could and should be done and about the crucial issue of responsibility. The above quotation states clearly that it is the responsibility of States, i.e. governments, to take appropriate actions to remove the remaining obstacles. The 22 rules of the documel)t explain what govern- ments should do, what principles they should apply, and what mea- sures they should take in different fields in order to progress towards full participation in the disability field. It is not easy to summarize an already concentrated document, but in brief: • persons with disabilities are citizens like everybody else and therefore entitled to participate in the activities of their community; 3 • governments should create a legal base for measures in the disability field leading towards accessibility and participation, and should support and cooperate with organizations of disabled people; • governments should integrate disability measures, based on laws or regulations aimed at achieving general accessibility- particularly in education, where the needs of disabled children and youths should be catered for in the general school system; • governments should actively support opportunities for employment, and take concrete action to open up various sectors of society like family life, culture and recreation to disabled individuals. The degree to which the Standard Rules are implemented by govern- ments is now being monitored by a Special Rapporteur appointed by the UN Secretary General, and it is obvious that this new instrument has revitalized the disability issue in many countries. Through taking part in elaborating and adopting the Rules, governments are strongly committed to take appropriate mea- sures. This is an opportunity that all organized movements of disabled people must grasp and use to the maximum. • Mr Bengt Lindqvist is Special Rapporteur of the UN Commission for Social Development on Disability, Swedish Parliament, S-1 00 I 2 Stockholm, Sweden. 4 World Health • 48th Year, No. 5, September-october 1995 Disability prevention and rehabilitation Ann Goerdt Reduction of handicaps requires a great effort on the part of all sectors to promote changes in beliefs and attitudes which limit the activities of people with disabilities. Primary prevention Positive beliefs and attitudes can reduce enormously the social handicap of disabled people. The measures promoted for the prevention of diseases which cause disabilities include immunization, particularly against poliomyelitis, measles , rubella and tuberculosis; prenatal care to ensure the healthy development and delivery of babies; appropriate nutrition, especially iron, Although different countries are noting different patterns in the occurrence of disability, the number of chi ldren with disabilities appears to be on the increase. This may be because those children are surviving longer as a result of improved health care, or because the number of young people disabled through accidents or violence is increasing. The number of elderly people with disabilities may also be growing. The occurrence of disability calls attention to the need for disability prevention, including rehabilitation. WHO addresses this need by promot- ing a variety of prevention measures. The terms impairment, disability and handicap are used as a reference for the primary, secondary and tertiary prevention measures which are related to disability (see diagram). Primary prevention consists of the measures aimed at the prevention of diseases and injuries. Secondary prevention includes interventions which are used to treat diseases or injuries in order to prevent impair- ments. Tertiary prevention consists of a variety of measures aimed at eliminating or reducing impairments or disabilities. Since handicaps result from the interaction between people with disabi lities and their societies, a change in society is also needed in order to reduce or elimi- nate handicaps. Primary Secondary Tertiary prevention prevention prevention 1 m ... ,., 1 6 ............ or iniury .................... Impairment .............. Disability ............ Handicap Defin ition of terms from the International Classification of Impairments , Disabilities and Handicaps (WHO, 1980). The curren t revision of this classification is scheduled for 1999 and is now being coordinated by the WHO Division of Mental Health . • Impairment is an abnormality of psychological , physiological or anatom ica l structure or function. Impairments refer to organs . Example: Paralysed muscles of the legs . • Disability is the restricted ability to perform an activity. Disabilities refer to persons. Example: Person cannot walk. • Handicap is the restrict ion faced by a person with a disabili ty in fulfil ling normal roles due to social barriers. Handicaps refer to the interactions of people and their societies. Example: Person cannot get a job because employers do not want employees who cannot walk. World Health • 48th Year, No. 5, September-october 1995 s A paralysed child being assessed for possible medical treatment. Polio immunization is one of the most efficient measures in preventing disability iodine and vitamin A, for mothers and children; and sanitary measures to prevent eye diseases, such as infections and trachoma. Injuries may result from inten- tional or unintentional acts and injury prevention has several aspects. One is education regarding measures which can be taken to prevent acts that cause injuries. A second is protection, which uses environmental or technical devices such as seat belts, helmets and air bags to prevent injuries. A third aspect is the promo- tion of safety as part of general health promotion policies, and this is being developed under WHO leadership. Secondary prevention When diseases or injuries occur, medical interventions are needed in order to prevent impairments, such as permanently paralysed muscles, damaged eyes or ears, or brain dysfunction. These interventions include the multidrug treatment of leprosy; the medical treatment of infectious diseases affecting the eye, ear, spinal cord and brain; provision of appropriate nutrients against malnutrition; and medical and other treatment for mental disorders. Tertiary prevention When impairments occur, they can be treated in order to prevent or to reduce disabilities, such as difficulty in seeing, hearing or walking. Eyeglasses can greatly reduce, or even eliminate, difficulty in seeing; a hearing aid can reduce difficulty in hearing; and leg braces can reduce difficulty in walking. When disabilities occur, measures aimed specifically at the limited function which a disabled person experiences can also be taken to reduce or to limit the progression of the disability. These are the mea- sures commonly referred to as reha- bilitation. Because they focus on the activities which people can or cannot do, they require their active partici- pation. The rehabilitation process may require a person to learn how to dress or feed; a new system for communication; a new method for moving around, perhaps using a wheelchair; or new methods for organizing and carrying out daily activities. Addressing the functional limita- tions of disabled people may also reduce the handicaps confronting them in their interactions with society. For example, if a person with paralysed legs can learn to walk with braces and crutches, he or she will have a far greater chance of being accepted by other people at school or at work. However, only treating disabilities is not sufficient to reduce handicaps. Societal attitudes must also change so that people with disabilities have increased opportunities to participate in the same educational, work and social activities as other people in their communities. lntersectoral collaboratiofl The prevention of disabilities is often viewed as the responsibility of the health sector, but for tertiary preven- tion and even for primary and secondary prevention other sectors are needed. Thus, safety measures, sanitation and adequate food supply cannot be provided by the health sector alone. Special education and training for skills needed to produce an income are part of the rehabilita- tion process, and are provided by the education, social or labour sector. Reduction of handicaps requires a great effort on the part of all sectors to promote changes in beliefs and attitudes which limit the activities of people with disabilities. WHO promotes an integrated approach to preventing disabilities by including all promotive, preven- tive, curative and rehabilitative care in primary health care. Integrated health services can strengthen dis- ability prevention by keeping health care personnel at district and sub- district level well informed about all aspects of disability prevention, including rehabilitation. In addition, the health sector can actively partici- pate in intersectoral efforts to provide living conditions which reduce the risk of diseases and injuries, address the needs of people with impairments and disabilities through community- based rehabilitation, and ensure their full integration in society. • Or Ann Goerdt was formerly with WHO's Rehabilitation Unit and is now working as a Rehabilitation Consultant. Her address is 145 East 27th Street, New York , NY 1 00 16, USA 6 World Health • 48th Yeor, No. 5, September-October 1995 Community-based rehabilitation Tambo Camara The 1980s saw the introduction on a global scale of a new ap-proach to rehabilitation of the disabled- community-based rehabil- itation (CBR) - and at the same time the spread of organizations for the disabled. Both these concepts had as their end-product the promotion of equal rights for disabled people and their full integration into every aspect of human society. The World Organization for Disabled Persons aims at the opening up of society to all, with more egali- tarian participation, in both economic and political terms, in every facet of society. In this process, all associ- ated organizations concern them- selves with the ways in which this development can best encourage the disabled to participate while promot- ing recognition and respect for their human rights. This can only be guaranteed if disabled people, through their organizations, demand and obtain the means for a resolution of their problems. Generally speaking, disabled people tend to have been more or less excluded from the normal life of the community as a result of physical , social or psychological barriers erected, or at least accepted, by society. They were categorized as incapable because people paid more attention to their limitations than to their potential. In developing coun- tries, particularly in Africa, this tendency has changed little, since the need to prepare them for full partici- pation as human beings and citizens rarely figures in national develop- ment plans . They have little access to services or to decision-making that relates to their own future; they are usually poor, living at the bottom of the social scale and taking little or no part in community production and consumption. However, in the last 20 years they have realized that they Tambo Camara . need to develop their own potential to the maximum, to take control of decisions that affect them and -in organized groups -to fight for change and obtain recognition and respect for their human rights. As Rick Hansen, the instigator and main organizer of the conference Autonomy 92, phrased it: "Nobody can get ahead in life on their own, whatever their degree of autonomy or however they struggle to acquire it. We are social creatures and we have to work together in order to help each other." And indeed it is by running their organizations that disabled people have learnt to solve their problems through concerted action and cooperation with CBR programmes. The role of organizations for the disabled includes forming pressure groups to work on governments so that they adopt national policies and legislation favourable to the development of community- based rehabilitation. The disabled, their families and the community need to be made aware of the advantages of participating in rehabilitation and social integration. World Health • 48th Yem, No. 5, September-October 1995 After Alma-Ata Community-based rehabilitation (CBR) is an innovative approach that was launched by WHO in the after- math of the Alma-Ata Conference on Primary Health Care in 1978. The aim was to enable developing coun- tries to offer essential services to as many disabled persons as possible, where they live, at a low cost and at a convenient time. What is original about it, compared with institutional rehabilitation, is the principle of participatory development where the beneficiaries are no longer objects but subjects and therefore agents for change. Moreover, it is global, multisectoral and decentralized, a positive factor in the community, offering to the disabled the chance and the responsibility to guide or even activate their own rehabilitation and social integration. The strategy to bring this about combines the efforts of the disabled themselves, their families, the com- munity and the appropriate health, education, labour and social services while making the best use of local ' resources and experience. All this calls for a partnership that includes the state and the public and private sectors, which need to put all their ideas, resources and potential at the disposal of the others in order to aiTive at the common goal of a shared interest. However, despite the goodwill and good intentions of the organizations for the disabled, there are constraints of an economic, organizational or training nature which -particularly in developing countries- undercut the efficacy of what they bring to this partnership. From the standpoint of the dis- abled themselves, financial arrange- ments ought to involve the state, the sponsors and especially the national body that looks after their interests. A national CBR programme should involve a single national body which groups together all categories of the disabled, that is, a national federation of associations, rather than dealing only with specific associations. Such a programme can offer support by setting up, equipping and managing a permanent office which should be accessible and easy to find ; training leaders in the democratic running of associ- ations for the disabled and also in the concepts and strategies of CBR; training managers capable of staging, following through and evaluating a development project; helping the leaders to achieve financial autonomy 7 so that they can devote their expertise and their time to the organization and to CBR; and aiTanging study visits and ex- changes to promote the open- mindedness and understanding that are vital to mutual aid and solidarity. The disabled should participate in the planning and joint management of CBR at both Integrating disabled students in schools is o good start for community rehabilitation. the national and local levels in collaboration with their partners. They should also receive appropriate training to enable them to set up small workshops for making tech- nical aids to serve other disabled people. The role of organizations for the disabled will include forming pres- sure groups to work on governments so that they adopt national policies and legislation favourable to the development of CBR. The disabled, their families and the community need to be made aware of the advan- tages of joining and taking part in rehabilitation and social integration . The needs of different categories of disabled people must be examined and identified, and the organizations will have to find and recruit volun- tary helpers, at the same time look- ing both at home and abroad for financial support and innovatory techniques. • Mr Tamba Camara is General Consultant of the Pan African Confederation of Handicapped People and Deputy Vice- President of Rehabilitation International for Africa His address is Post Office Box 1754 Nouokchott, Mauritania . ' When they ioin forces, persons with disabilities can considerably improve their living conditions. 8 World Health • 48th Year, No. 5, September-october 1995 Safeguards that prevent disabilities Pierre Maurice 5 ome of the disabilities from which large numbers of people suffer, often for a lifetime, are the result of injuries, whether inten- tional- that is , resulting from acts of violence- or unintentional , like those caused by road accidents. Preventing such disabilities, to a large degree, involves preventing injuries, and this is the approach that has been employed since the 1980s by the public health sector of Quebec Province in Canada. Injuries cannot simply be dis- missed as "accidents", that is to say fortuitous and unforeseeable events that are beyond our control. Rather they reflect a break in the dynamic balance that ought to exist in every community between the individual , the environment and all the different vectors capable of transmitting energy. Maintaining that balance should allow us to reduce to a mini- mum the number and the severity of injuries. In order to do this , we need first of all to fully recognize the problems, their causes and the possible counter- measures. Databanks have been developed or created in Quebec which will enable us to detect key events that may give warning of potential dangers ahead. In turn, countermeasures are devised that will help us to reduce the probability of events occurring which may lead to injury, to limit any damage incurred when in spite of all precautions such events occur, and finally to minimize the consequences of such damage. As in other fields, the most effective interventions are not necessarily those that are aimed directly at the most obvious cause. For instance, even though injuries are Promoting rood safety in Kuwait. "Security is a prerequisite for maintaining and improving the health and well-being of the population. lt is the state or situation of being safeguarded from hazards of a material or moral kind, thus giving rise to a public perception of being protected from danger. " very often a direct result of human behaviour, we tend to put greater emphasis on measures that do not call for a change in that behaviour, preferring rather to change the environment or make technological improvements, which usually prove to be more effective, more universal, more impartial and longer lasting. Only then do we get to work on changing behaviour as a means of reinforcing the impact of the priority measures that have been taken. Most of the effective solutions require skills that lie outside the range of the health system. So it is essential for the health system to be integrated within a multisectoral network, where it can play the role of informant, serve as a link between different organisms which usually tend to ignore each other 's existence, and steer the priority measures towards the goals of health and security. Raising awareness in favour of such security measures entails appealing to different deci sion-making levels -local , national , regional- all of which can be induced to contribute to a synergetic effect through defining common objectives. Health promotion WHO has defined health promotion as the process of enabling people to increase control over, and to improve their health . The public health network of Quebec adheres strictly to this definition and also to the different strategies enshrined in the Ottawa Charter for Health Promotion, adopted by 35 countries in 1986, name) y, to promote personal initiatives that favour health, to encourage mutual aid, to create healthy environments, to encourage community participation by the public, to reorient health services towards prevention and to promote public policies that favour health. Actions aimed at reducing in- juries need to be inserted within this World Health • 48th Yeor, No. 5, September-October 1995 A peaceful social climate contributes greatly to achieving a high level of security. general framework of intervention, an essential part of our activities being the promotion of security with the goal of improving the state of health of the general population. Security was defined as follows by the Quebec Public Health Centre in August 1994 during a workshop of the Security in Everyday Living team. "Security is a prerequisite for maintaining and improving the health and well-being of the popula- tion . It is the state or situation of being safeguarded from hazards of a material or moral kind, thus giving rise to a public perception of being protected from danger. "The attainment of an optimal level of security for an individual or a community presupposes the pres- ence of four conditions, and of a guarantee that everything possible has been done to bring about or to maintain those conditions: • the satisfaction of primary needs; • a peaceful social climate; • control of biological , physical or chemical hazards ; • respect for and protection of the physical and moral integrity of every individual. 'These conditions can be guaranteed by taking action: - on the environment (physical, social, technological, political, economic, organizational and so forth); and - on human behaviour." Ethics and health 9 This definition goes well beyond the mere prevention of unintentional or deliberate injuries such as has been practised hitherto in Quebec. Certainly it calls for the intervention of other people than those who are normally involved in this field. A large number of psychosocial prob- lems are directly linked to the issues of security (violence, abuse, negli- gence, poverty and so on). The task of promoting secure environments has therefore to be shared by the public health sector and a great many other partners. All these considerations only represent a start, a basis fro m which all the measures aimed at preventing inj uries can be developed in differ- ent ways so as to favour a more positive and all -embracing approach, complying with modern trends of health promotion and closer to the preoccupations of the general populace. Armed with such measures, the challenge for the future wi ll be to define properly the field of expertise of our health insti- tutions, to help our partners to appre- ciate that expertise, and to ensure that we have the necessary control to carry out preventive actions that will be truly effective. • Or Pierre Maurice is the Coordinator for Security in Everyday Living and Head of the WHO Collaborating Centre on Community Safety Promotion, Ouebec Public Health Centre, 2400 rue d'Estimauville, Beauport, Quebec G 1 E 7G9, Canada . Disabilities, and issues of health or ill-health in general, increasingly face us with ethical questions about individual choice, health policy and the value systems of the societies we live in. With the range of medical technologies constantly widening, how do we balance individual with social needs? Who should decide, the individual, the family, the doctor, or the State? How do we provide for prevention or rehabilitation while at the some time ensuring maximum opportunity for full participation in economic and social tde? If the development of technology is inevitably driven by market forces, what happens to the principle of equity? If not, what are the other forces involved, and how do we use them? Con the value of a human being's life or health be measured? Should it be? Perceptions of health itself vary from culture to culture. How do we promote mutual respect and human, social and international sohdarity? Questions of this kind are arising more and more frequently and urgently, thanks mainly to our many successes in health and economic development, and the ever-growing influence of technology. They arise in administrative settings too, where individual decisions easily disappear in the anonymity of bureaucratic procedures. To help establish forums and modalities for tackhng these issues, the Director-General of WHO convened an informal consultation on "ethics and health at global level" in Geneva from 30 August to 1 September 1995. The participants, from both developing and industrialized countries, came from a variety of professional backgrounds, including medicine, public service, scientific research, university lecturing and local development work. They joined several WHO staff members for three days of lively discussion, establishing eight major themes to be further explored during the coming months. 10 World Health • 48th Yem, No. 5, September-October 1995 living with disability Volker Krause The writer, who has impairments of a// limbs, describes how a person with the same impairment may encounter handicap in one country but be independent, mobile, self-sufficient, integrated and free in another. Because of a congenital skeletal impairment of my limbs, I wear two lower leg prostheses and am limited in my handling abilities. Over the years I have been able to compensate for my upper limb impairments by using my elbows and occasionally my mouth. My level of functional mobility depends on the use of lower leg prostheses. However, the level of handicap encountered depends on the society in which one lives. The International Classification of Impairments, Disabilities and Handicaps (ICIDH) (see box on page 4) devised its codes as a tool for measuring the effectiveness of policies for people with disabilities; but they also serve to assess cross- national differences. Up to the age of 21 I lived in Germany. I left that country six years ago for the United States. Handicaps of several kinds were an everyday experience in Germany, and only after my arrival in the USA did those handicaps largely disap- pear. Ramps, elevators, accessible public transport and adapted public facilities are mostly absent in Germany but fairly widespread in the United States where, further- more, I was not barred from taking driving lessons and driving a car. I still remember my driving instructor in Mississippi saying, "Show me In spite of having two artificial legs, Vofker Krause was encouraged to drive in the USA that you can do it." I had never previously been allowed the chance of showing that I could do it. Experts in my native country, who did not have any disabilities, declared that I could on ly drive a car that was specifically equipped for my needs. Their ruling that special equipment would have to be in- stalled at a cost of US$18-20 000 put an end to my hopes of acquiring a driving licence there. In fact their report itself cost more than all the driving lessons I subsequently took in the United States. For almost six years now, I have been driving a regular car with automatic transmis- sion but no extra equipment. The rush-hour traffic in Chicago, Detroit and Washington D.C. has given me no problems. A matter of legislation These experiences suggest that eliminating handicaps in the areas of jobs, social integration and economic self-sufficiency is largely a matter of disability legislation, political culture and social attitudes towards people with difficulties. These vary widely from country to country. In the USA, fundamental pieces of legislation such as the Americans with Disabilities Act (ADA) provide disabled people with legal recourse against discrimina- tion , while public attitudes tend to emphasize accessibility and integra- tion rather than segregation and confinement in isolated rehabilita- tion centres. In most countries there is no legislation equivalent to the ADA, and indeed some institutions may even side with those who discrimi- nate against people with disabilities. In 1993, in the north German town of Flensburg, for example, a court supported the claim of a vacationing couple that their holiday had been spoilt by the presence of disabled people in their hotel. The political culture tends to emphasize segrega- tion rather than encouraging inde- pendence and integration into society. My experience shows that a person with an impairment may encounter handicap in one country but may be helped to be mobile and self-sufficient in another. • Mr Volker Krause is o doctoral candidate in political science. His address is Department of Political Science, University of Michigan , 560 I Haven Hall, Ann Arbor, M/ 48 I 09- 1045, USA World Health • 48th Year, No. 5, September-October 1995 11 What are the Abilympics? Harry S. Y. Fang The 4th International Abilympics, held this September in Perth, Australia, brought people from more than 80 countries together for a week of contests of occupational skills, living and leisure skills, and artistic performances. At the same time, a conference addressed issues of employment, equity and empower- ment, legislation and policy, recreation and leisure. The 1st International Abilympics - a showcase of the remark- able talents of people usual- ly described as disabled- was organized in Japan in 1981 during the United Nations International Year of Disabled Persons. The objective was to demon- strate that people with dis- abilities are talented in many different work ski lls and should be offered equal opportunities in the voca- tional area. So much enthu- siasm was created in Japan that the 2nd Abilympics (in Colombia, 1985) and the 3rd Abilympics (in Hong Kong, 1991) both saw increased participation and a greater number of work areas con- tested. The fourth in a series of contests of occupational skills, living and leisure skills and artistic performances demonstrates that people with disabilities are talented in many different fields. partiCipation. The emphasis is on cooperation, friendship and inter- dependence. By contrast with the well-known Paralympics- the international sports competition for people with disability, the Abilympics offer opportunities for more people to explore their own potential and resources in diverse and productive areas. The competitive aspects provide motivation and reward. It is not only the "strongest and quickest" who can take part but those with and without disabilities , of all ages and backgrounds, independent of movement abilities . Whether held at district, city, national or international level, the Abilympics festival pro- vides opportunities for people to learn the fun and value of cooperation and mutual respect. There are obvious advantages The Hong Kong event attracted almost 2000 par- ticipants, both disabled and able-bodied. In addition to 30 "occupational skills" contests, including typing, woodwork, computer pro- Painting orchids. This young girl has developed the potential offered by her feet to compensate for having no arms. in holding these competi- tions in combination with conferences on rehabilita- tion. Many people who would not normally attend such meetings enjoy the chance to share experi- ences and exchange ideas, while also demonstrating their skills and reminding more seasoned confer- ence-goers of the enor- mous resource that people with disability represent. In the long term, the aim gramming, accounting, drafting and engineering drawing, Hong Kong extended the original concept by creating categories of Leisure and Living Skills and Performing Arts. The Leisure and Living Skills category is about pursuing quality in life. It challenges participants to exercise their imagination and ere- ativity in events such as cookery, kite design and flying, flower arranging, and waste recycling. The Performing Arts section appeals to music, dance and drama enthusiasts. In these contests, participants com- pete in teams composed of people with and without disability, high- lighting the ideal of equality through of the International Abilympics is a better working and playing society for all. • Professor Harry S Y. Fang is Director of the WHO Collaborating Centre for Rehabilitation, Hong Kong Society for Rehabilitation, and President of the 4th Hong Kong Abilympics Organizing Committee. His address is 7 Sha Wan Drive, Pokfulam, Hong Kong. 12 Morocco's friendly • • assoc1at1on Nejla Essaafi In the words of Morocco 5 association for the disabled, I'Amicale marocaine des Handicapes: "The only handicapped people are those who have lost heart!" World Health • 48th Year, No. 5, September-october 1995 ' he association that looks after disabled people in Morocco is called "the Friends of the Handicapped" - 1' Amicale maro- caine des Handicapes (AMH) - and its inspiring approaches and activi- ties ensure that it lives up to the name. It was in fact set up on the initiative of disabled people and their friends - people who have seen for themselves the suffering and unceas- ing struggle of victims of an accident or of a congenital condition. And these "friends" have together built up a very dynamic association in which everybody works on a strictly unpaid basis. This young polio victim, able to go to school on his own, symbolizes the hope of full integration aimed at by the Amicale marocaine des Handicapes. Indeed, by contrast with the rather gloomy talk that you occasion- ally hear in some such institutions, what immediately strikes you is the mature and positive attitude. The association's objective is integration of disabled people, not only in the heart of the community but equally in professional life. Although AMH is only three years old, it has set in train programmes of help and sup- port to the disabled through the grant of study scholarships or by helping to set up cooperatives, thus encouraging a wide range of professions and trades. Among those who have benefited from this substantial aid are an electronic engineer, two com- puter software experts, two doctors, a chartered accountant, a hairdresser, a beautician, a secretary and a graduate in economic sciences (who also captains AMH 's wheelchair basket- ball team- for we are a sporting association too). A positive image The association's President as well as the two Vice-Presidents are them- selves in wheelchairs , and all three are active in the professional field and perfectly integrated in society. The image that they convey all round the country is an absolutely positive one, to the point where young dis- abled people try to identify with them. Furthermore, being integrated both socially and professionally means that they are themselves entirely aware of the realities around them, can raise the alarm when necessary and can propose concrete solutions. It is precisely thanks to their unceasing activities in creating public awareness about the AMH that the Moroccan government felt morally obliged to launch a new institution, the High Commission for the Handicapped, whose duty it will be to coordinate action on a national scale in this field. The association already has several major events to its credit: two international symposiums on what it is like to be disabled, a solidarity parade which toured 15 towns, a mobile unit providing prostheses which visited 19 towns, a concert by singer Carlos Santana, and two phone-ins aimed at rai sing funds to build Morocco's first Centre for Functional Rehabilitation, which is a vital step if disabled people are to be fully integrated in society. We have every confidence that the "friends" of the AMH will succeed in channelling all their energies into making the centre a reality. As the slogan of the AMH puts it: "The only handicapped people are those who have lost heart!" • Mrs Nejla Essaafi is Programme Director of Handicap International, Amicale marocaine des Handicapes, I 0 rue Velasquez et boule- vard Abdelmoumen, B.P.5369, Casablanca, Morocco. World Health • 48th Year, No. 5, September- October 1995 13 Prostheses and orthoses in developing countries Anders Eklund There is a pressing need for better manufacturing and supply systems to provide artificial limbs and support devices in developing countries. Services to provide artificial limbs (prostheses) and appli-ances to support or correct a deformed limb (orthoses) play an important role in the rehabilitation of people with physical disabilities. The provision of prostheses for amputees , calipers for people with paralysed limbs, and orthopaedic sandals for leprosy patients -to mention a few examples - can make a dramatic change in the life situation of the disabled person. Instead of being dependent on charity, or even isolated from society, the person may be able to work and lead a normal, independent life. However, just as in the case of rehabilitation services in general, prosthetic and orthotic services are rarely given the priority they deserve. Though general awareness about disabled people has increased in developing countries during recent years, the financial resources for this sector are still very limited and the reality today is that only a small percentage of people with disabilities get assistance. Those resources are unlikely to increase much in the fore- seeable future, but it is still possible to improve the situation for people with physical disabilities. A new way of thinking is necessary, and an approach that is adapted to the local conditions of the developing country rather than to working methods in the industrialized world. Imported components In developing countries, prosthetic and orthotic production is often based on imported components (such as ready-made feet and knee joints for prostheses). These are used in high-quality orthopaedic appliances but, because of the high costs, only a limited number of people will bene- fit. If a less sophisticated technology is used, many more patients can be fitted with appliances. Such tech- nologies, which sti ll provide comfort for the patient and look good, are all based on local production of the components. Even though some raw materials have to be imported the appliances will cost considerably less than those made with imported components. Moreover, most of the money which would otherwise have favoured foreign suppliers will remain in the country and benefit the national economy. In some countries, prosthetic and orthotic services have been linked to community-based rehabilitation programmes. This makes it possible to identify people with physical disabilities in remote areas and to refer them to orthopaedic work- shops. Since the workshops must not be located too far from the vi l- lage, there is a need for small, decen- tralized satellite workshops, not permanently staffed but visited regularly by technicians from the main workshops. Provided appro- priate technology is used, the run- ning costs will be reasonable and the distribution of services to those who need them will be ensured. • Mr Anders Eklund is Proiect Manager of the WHO Collaborating Centre for Orthopaedic Technology, Department of Biomechanics and Orthopaedic Technology, University College of Health Sciences, Box I 038, S-551 I 1- )0nkoping, Sweden. Locally made prostheses and appliances ore reasonable in price, enabling more disabled people to lead normal, independent lives. 14 World Health • 48th Year, No. 5, September-october 1995 Landmines: dragon's teeth Alessandro Loretti Sown like so many dragon 5 teeth, landmines kill and maim an average of 150 human beings every week. They perpetuate a climate of fear even after a ceasefire and prevent a return to norma/life. About 110 million landmines have been sown in at least 65 countries worldwide. Afghan- istan, Angola, Cambodia and Iraq are at the top of the list for the sad title of most severely landmine-infested countries. No region is spared: landmines have been laid in parts of South America and in the Pacific, in northern Europe and in the southern Atlantic. The most heavily mined continent is Africa, where estimates speak of at least 40 million landmines. After Angola, the most severely infested countries are Mozambique and Somalia. Several countries north of the Sahara also have minefields, left behind by the Second World War; in May 1990, four professional de- miners were killed by mines laid in 1942 during the battle of El-Alamein. Landmines are an aggressive and long-lasting pollutant; they cannot be "stopped" by a peace agreement, and nobody knows for how long they can stay active. The General Assembly of the United Nations has called for a global ban on the trade of landmines, and for a revision of the 1980 UN Convention on Inhumane Weapons. The governments of the major manu- facturing countries have agreed on setting moratoria on the exports of these devices . But new landmines continue to be manufactured, traded and laid on top of those already in the ground. They are increasingly used in "low-intensity" conflicts in the world 's poorest countries. In this context, the hazard of landmines becomes deeply entangled with considerations of humanitarian action, environment, development, international economy and solidarity, and the issue reveals facets that are as paradoxical as they are tragic. 11 Cost-effective" There is no "big money" in land- mines, which cost about US$ 5 each. The financial interest of their trade is relatively small , but their grim "cost-effectiveness" in military terms seems to keep alive manufacturing and trade. Such defence considera- Victims of landmines: their numbers are unfortunately on the increase throughout the world. tions shou ld be put in the proper perspective of the cost of mine- clearance: once laid in the ground, each mine costs about US$ 1000 to retrieve and inactivate. The UN experience in Afghanistan is that de- mining one square kilometre of land, irrespective of the number of mines that may be present, costs about one million dollars. In terms of individual and collec- tive suffering, the cost of landmines is much greater. Besides killing and disabling people (worldwide, 150 every week according to recent estimates), landmines preclude access to farming land, water and firewood, markets and services: they have a dramatic impact on the environment, the life of the commu- nities and the economy of a country. In low-intensity conflicts, land- mines are laid in fields , villages and towns, around shops and health units, even inside individual homes. Under these circumstances, as many as 90% of victims are civilians, mainly women and children. This adds to the tragedy: one woman killed or mutilated means greater risk of illness and malnutrition for her entire family; one disabled child represents a long-term burden on his or her family, the health services and society at large. Landmines can be an insurmoun- table obstacle to the delivery of humanitarian assistance in times of conflict, and to the building of peace. Even after a ceasefire, land- mines hinder the demobilization of soldiers, the resettlement of refu- gees, farming , the free circulation of people and goods, and communi- cations. They perpetuate a climate of fear, and affect the normalization of life and reconstruction. Areas known, or feared, to be mined can remain lost to human settlement and economic development, for ever, as "effectively" as if contaminated by a nuclear explosion. World Health • 48th Year, No. 5, September-October 1995 The delicate ;ob of defusing mines. Public health and medical aspects The explosion of a blast mine de- stroys the foot of the victim and part of one, or both, legs. Fragmentation mines can kill or mutilate over a radius of 40 metres. Angola already counts 70 000 or more amputees, Somalia 15 000, and Mozambique 1 0 000. Besides the workload repre- sented by wounded and disabled, and the wide-ranging socioeconomic damage mentioned above, landmines directly affect the health sector's general performance. They preclude access to dispensaries and hospitals; they jeopardize mobile vaccination teams, the delivery of drugs and so forth. Financial and human resources must be diverted to special care and long-term hospitalization, hindering all primary health care activities. In human and medical terms, each landmine accident poses daunt- ing challenges. For medical care to be effective, it must be given within the first six hours but, on average, victims take between six and 36 hours to reach a health unit. Most accidents occur in remote areas; and since landmines are seldom laid in isolation, rescuing a victim from a minefield is difficult and dangerous. In fact, it appears that as many as 55% of victims die before receiving any assistance. For those who reach a dispensary or a hospital on time, only the proper management of shock, injuries and infections can ensure their survival. All this re- quires technical capacities and re- sources that are hard to come by in rural health services. For instance, each victim needs a blood transfu- sion; but "safe" blood is a scarce commodity, and contaminated trans- fusions can transmit HIV, malaria, hepatitis B, and so on. Each casualty will remain in the hospital for one to two months, and will undergo three subsequent opera- tions. Healing takes about six months, at which point the victim needs a prosthesis. One artificial leg costs between US$ 12 and $120 while learning to use it takes about six weeks; an appliance can last three to five years but it needs mainten- ance; growing children need a new one every six months, and prosthetic workshops can be rare. Under- standably, most patients suffer from depression . Farming or finding employment, maintaining or building a "normal" family- everything is difficult for them. All this points to a vast range of needs: from community awareness to means for physical, psychological and social rehabilitation, by way of education for first aid, access to health services and resources for Is the warning sufficient protection2 IS adequate treatment. All this goes well beyond the cuJTent reality of communities and services in most poor countries, especially in times of conflict or post-conflict. Of course, "prevention is better than cure" . Landmines are causes of death and disability; primary prevention against their effects can only be ensured by a complete ban on their manufacture, trade and use, greater awareness of the affected communi- ties, and de-mining of infested areas . Given the above figures, effec- tive solutions at country and global levels can only come from inter- national solidarity, political as well as financial. The UN Department of Humanitarian Affairs is already active in this direction through a special trust fund for mine- clearance. As far as the health sector and WHO are concerned, all plans for mine-infested countries should specifically address the needs in terms of surgical, medical and nursing capacities, blood- banks, long-term hospitalization, rehabilitation, employment policies and specific provisions for the disabled. • Or Alessandro Loreffi is Senior Technical Adviser for Africa, WHO Pan-African Emergency Training Centre, P 0 Box 3050, UN ECA Building, Addis Ababa, Ethiopia. 16 World Health • 48th Year, No. 5, September-october 1995 Mental health: cl Judi Chc Among people who use or have used mental health services, a strong leadership is developing which promotes positive values of individual dignity and the need to respect peoples own choices. People who use mental health services have, historically, been unable to control their own categorization or treatment, which have been designed by mental health professionals and which have frequently been considered by recipients as intrusive and unhelpful. In the past 20 years, this situation has begun to change, as users of these services in many parts of the world have begun to define for them- selves their own needs, problems, and solutions. User-controlled organ- izations are seeking to influence the manner in which mental health services are delivered, as well as to challenge the devalued role which those who are defined as "mentally ill" have in society. These user groups (sometimes referred to as "survivor groups") are usually locally based (although increasingly networked together nationally and internationally), and place primary value on self-determination, choice and the attainment of basic legal rights. At the same time, the world of mental health treatment has been changing, with a gradual reduction in the length of stay in institutions and the development of various methods of community care and treatment. But unless these changes include involving service users in their design and implementation, "community care" has often in practice meant the transfer of old, institution-based ways of thinking to new locales, with the same hier- archies preserved that leave service users, once again, in powerless and controlled positions. Respect for human dignity "Rehabilitation", as one of the more recent developments in mental health care, has the potential to be either one more method of profes- sional definition and domination or, alternatively, to become a joint enterprise in which professionals and users combine to transform the social roles of service recipients. If the latter approach is to prevail , it is essential that user groups be brought into the process of designing, imple- menting and evaluating programmes and services to ensure that they permit users to enter the worlds of work and community living in ways that respect individual choice and human dignity. Without such an approach, which necessarily involves recognizing the ways in which power and powerlessness have historically shaped mental health service delivery, rehabilitation can only become just one more thing which is done to people without their meaningful consent or participation . User groups now exist in many countries of the developed and it is essential that users of mental health services ore involved in the process of designing and implementing the services they need. developing world. Independently of similar groups in other places, their analyses of traditional psychiatry are remarkably similar, stressing the in- adequacy of a "medical model" of indi vidual defects to explain their disadvantaged role in society. When these groups develop communi- cations with other, more established groups, they find powerful confmnation of the truth of their in- sights, which are derived from personal experience and seem to transcend differences in culture, language, and political and social organization. World Health • 48th Year, No. 5, September--{)ctober 1995 • IOICe and dignity mberlin Networks like the European Network of Users and Ex-Users in Mental Health (Amsterdam, Netherlands) and the World Federation of Psychiatric Users (Auckland, New Zealand) help newer groups to feel confidence in their ability to accurately perceive their position in society and the value of their proposals for change. It is therefore essential for re- habilitation professionals who truly believe in the ability of their clients to enter or re-enter society in valued roles to ensure that rehabilitation services themselves place service users in such roles. Only by consult- ing in meaningful ways with the people who use their services can rehabilitation hope to become a truly different form of mental health service. User groups continue to develop their own programmes for assisting their members to leave the role of "mental patient" behind and to become contributing members of society. Their programmes of politi- cal and social change, while not (usually) cast in the language of rehabilitation, are truly rehabilitative in nature. Nurtured within groups in which everyone has shared the experience of being discredited and devalued because of a diagnosis , a strong leader- ship is developing which promotes positive values of individual dignity and the need to respect people's own choices. Further, individuals within user groups are given opportuni- ties (often for the first time) to exercise choice, work with others and develop skills. practical knowledge of recovery and empowerment, are essential job requirements . Such people serve as valuable role models , encouraging other users to see the untapped potential within themselves. In addition to developing job opportu- nities within user-run programmes, users are increasingly entering the mental health workforce in new roles in which their psychiatric experience is valued. A new concept needed "Rehabilitation" itself is a term that strikes many user activists as ques- tionable. What is it that users need to be rehabilitated from? To many, it is the concept of "mental illness" and the practices that flow from it that are in need of rehabilitation, since an individual defect model, particularly one based on biochemi- cal or genetic factors , does not seem to take into account the potentials for growth and development that are so clearly demonstrated within user groups. Professionals who want to Many user groups have created new work opportu- nities for their members in which experience as a psychiatric patient, and Job opportunities contribute to revealing untapped potential. 17 assist service recipients to realize their potential and to transform their lives need to pay close attention to the developing theories and practices within the user movement, and to examine the ways in which their own practice needs to be transformed. By entering into a true partner- ship, in which users and providers can respect their differing forms of expertise and thereby learn from one another, the concept of rehabilitation can become an instrument for gen- uine transformation. If, on the other hand, rehabilitation is to remain a strictly professional field in which old ways of thinking prevail, it will become just one more element of mental health care from which users will develop ways of extricating themselves. • Msjudi Chamber/in is Pra;ect Director at the Center for Psychiatric Rehabilitation, Boston University, 930 Commonwealth Avenue, Boston, MA02215, USA 18 World Health • 48th Year, No. 5, September-October 1995 Intellectual disability Peter Mittler The needs of people with intellectual disabilities have often been overlooked in programmes designed to reach disabled people in general. They themselves are calling for their needs to be met. The term intellectual disability is increasingly accepted as appro-priate by the main international professional and scientific associa- tions. Mental retardation is still the official terminology of WHO, as well as of the United States; other countries use terms such as mental handicap, learning disability, intel- lectual impairment. Mental defi- ciency or mental subnormality are no longer in use and language which appears to encourage stereotypes and generalizations is discouraged, such as references to the "retarded" . According to the American Association on Mental Retardation (AAMR), "Mental retardation refers to substantial deficits in cer- tain aspects of personal competence. It is manifested as significantly sub- average abilities in cognitive func- tioning, accompanied by deficits in adaptive skills ". For an individual to be regarded as having an intel- lectual disability, both cognitive functions and ability to function in society must be impaired; neither is sufficient on its own. The AAMR definition also emphasizes the nature and intensity of the supports that an individual may need to function in society. In other words, the current approach to mental health is not limited to identifying deficits in the individual ; it underlines the impor- ment and the support that is needed to do so. People with a mild intellectual disability may be accepted in schools and in the local community, though the threshold of acceptance will vary with social and economic circumstances and also with local attitudes. Most people with more significant degrees of intellectual disability will require support from their families and from social service ·agencies . It is estimated that one in ten of all disabled people has a significant intellectual disability- over 50 million in the world at the present time or up to l % of the population. Mild forms will affect up to 3%. By 2025, three-quarters of them will live in developing countries, mainly as a result of much more rapid popu- lation growth and also because many children who would previously have died at an early age are now surviv- ing and needing services. Stimulating learning and development The families of infants identified at an early age as having an intellectual disability will need practical advice and personal support in stimulating the learning and development of their children. Home-visiting schemes have been used in many developing countries. The essence of this approach is that the parent and a home vi sitor jointly assess the developmental level of the child and on that basis plan a programme of teaching which the parent carries out at home. Inclusive education involves schooling for all children and ensur- Ideally, people with an in tellec- tual d isabil ity: • have the same bas ic rig hts, needs and responsibilities as a ll other ci tizens to be fully included in society and social institutions; • can contribu te to and enrich society; • can learn , provided they are properly taught and are g iven time to do so; • will be supported by persons and services wi thin the commu- nity; • should be able to make their own choices and decisions; • should be able to live wi th their families or in the commu- nity with appropria te support , and shou ld not be segrega ted or placed in insti tu tional setti ngs. tance of interaction with the environ- Plans can be developed to enable teaching to be carried out at home. World Health • 48th Year, No. 5, September October 1995 Efforts should be made to educate children with in tellectual disabilities in their neighbourhood schools. ing that the teaching and the activi- ties of the school are accessible to all children in the community. Surveys by UNESCO suggest that although most children with intellectual di s- abilities in developing countries are excluded from any form of school- ing, an increasing number of children are being successfully educated in their local schools. The United Nations ' goal of a Society for All by the year 2010 applies not only to education but also to health, housing, employment, recreation and leisure, public trans- port- in fact to all social amenities and institutions. In many countries, progress is being achieved through a new approach to community-based rehabilitation, one that involves much closer collaboration between health, education and vocational training. People with intellectual disabilities are now beginning to gain access to rehabilitation programmes from which they were previously excluded. In future, this approach will need to be much more closely integrated, with access to local edu- cational and work opportunities. Better community understanding The needs of people with intellectual disabilities have often been over- looked in programmes designed to reach disabled people in general. But we now have enough knowledge and skill to ensure that their needs are more fully met in the future. They People with intellectual disabilities are able to learn, provided they are properly taught and given sufficient time. 19 themselves are calling more clearly and with greater persistence for their needs to be met. Their representa- tives have addressed the UN General Assembly. Human rights organiza- tions such as Inclusion International (formerly the International League of Societies for Persons with Mental Handicap) are disseminating exam- ples of good practice and protesting at examples of discrimination and abuse. Family members throughout the world are insisting on better support and better community understanding. Many local and national voluntary organizations are insisting on the rights of all citizens with an intellectual dis- ability to contribute to society and to live in a more inclusive society. Here are some practical steps that can be taken by health workers at field level and also by those involved in policy and planning. • Offer to meet and work with local voluntary organizations and parents ' groups concerned with this problem. If these do not exist, offer to support parents and volunteers who may be prepared to start a small group. • Help to ensure that families are supported when a child is identi- fied as likely to have an intellec- tual disability. This can be done by ensuring that guidelines are available on initial communica- tion with parents (such as the WHO behavioural science learn- ing module entitled Introducing parents to their abnormal baby), or by providing accurate and reliable information to parents, in written or pictorial form, which includes guidance and sugges- tions on what the family can do to stimulate and support the child's development. • Work with other professionals - especially teachers , social work- ers and staff of day centres - to develop a joint, multidisciplinary approach, using WHO's guide- lines on community-based rehabilitation. • Professor Peter Mitt/er is with the School of Education, University of Manchester, Oxford Road, Manchester M I 3 9PL, England, and a former President of Inclusion International. 20 World Health • 48th Year, No. 5, September-october 1995 Mental health in China Yanfang Chen More than 95% of the mentally ill in China are cared for at home by their families. Employers and community organizations also share responsibility for the disabled. Since 1978, economic reforms and increased contact with the West have brought about funda- mental social, economic and cultural changes in China. Partly as a result of these changes, diseases related to psychosocial factors and mental disorders have become a major health and social concern. The numbers of persons with serious mental disorders have risen dramati- cally, from 5.4 cases per 1000 popu- lation in the 1970s to 11.1 cases per 1000 in the 1980s. Today there are at least 11 million Chinese adults with serious mental disorders. State-run inpatient services for the mentally ill have about 140 000 psychiatric beds in 800 psychiatric institutions, or 1.17 beds per 10 000 population. the mentally handicapped. Today there is increasing empha- sis on both hospital-based and com- munity-based rehabilitation for the mentally ill, and more training of general practitioners in basic psychi- atric diagnosis and treatment. The model for psychiatric community care in urban areas is largely based on work stations, neighbourhood care networks, home care and factory liaison work. In rural areas, the model is based on training non- psychiatric medical workers to pro- vide mental health services at the local level. Programmes involving psychological counselling, psycho- therapy and behaviour modification have been set up in many general hospitals, universities and schools. Under a Work Programme for Disabled Persons, the government provides income tax relief to enter- prises that employ more than 35% of workers who are disabled. Mental rehabilitation The rapid development of psychiatric rehabilitation services has made it essential for academic groups to sponsor activities in this area. The China Disabled Persons' Federation consequently set up the Rehabili- tation Research Association for the Mentally Disabled, and a number of other societies have been formed under the auspices of the Chinese Medical Association. These soci- eties have provided professional consultative help to the concerned ministries and have played a signifi- cant role in the evolution of rehabili- tation policy. All this has helped to create favourable conditions for the continued development of mental rehabilitation in the country. There have been international influences too. The United Nations designated 1983-92 as the UN Decade of Disabled Persons, estab- lished a programme of international activities to promote the cause of disabled persons, and appealed to all countries to participate actively. As part of that initiative, the government set up the Chinese Organizing Committee for the UN Decade. Over the past I 5 years, WHO has worked closely with China in the reorganization of the mental health services, providing consultancy services and conducting workshops. Today there are five WHO Collaborating Centres in China concerned with neurophychiatric and behavioural disorders . This active collaboration has given a major boost to mental health services, manpower training and research. • This means that more than 95% of the mentally ill are unable to be admitted to hospital, so most of them are taken care of by their families . The revised Constitution of 1982 and the Law on the Protection of Disabled Persons (1992) emphasized that families, work units and community organizations must share responsibility for caring for the disabled. The Education Law of 1986 made it obligatory to pro- vide special education for Barefoot doctors: all health workers should receive training in basic psychiatry Professor Yanfang Chen is Chairman of the Department of Psychiatry, Shandong Medical University, and Chief Psychiatrist, Shandong Province Centre of Mental Health, Wen Hua Dong Road, )inan 2500 14, China. World Health • 48th Year, No. 5, September-october 1995 21 Aging well! Alexandre Kalache While aging in itself cannot be prevented, the pace of decline for most functions can. Each individual can dramatically reduce the risk of disability in old age. That age increases the risk of chronic diseases and disabilities is indisputable. But they are not inevitable consequences of aging. Throughout the world the vast major- ity of older people live independent lives in their own homes. They may well have their problems -who does not?- but only a proportion (which undoubtedly increases with age) will lose their basic functions and become dependent on others. What then makes some old people disabled and others active and fit? Age in itself is only one of the factors . There are aging-related changes that will incapacitate some individuals, and these are commonly called "intrinsic" factors for which science- at least until now- has little to offer. Specific functions such as respiratory capacity do decline with age; one cannot expect the same levels at age 20 and at 70. However, this in itself will not make an old person disabled. Provided individ- uals can perform functions above the threshold of incapacity, everything is fine. That threshold has to be culturally defined in the light of what is ex- pected from individuals where and when they live. In an extreme exam- ple, if a person were expected to hunt and run for miles in order to survive, Throughout the world, the vast maiarity of older people live independent, disability· free lives in their own homes. at age 50 most people would be considered disabled. Fortunately nowadays, virtually no society expects such extremes. Observing performance How should we define disability in old age? More and more researchers are adopting criteria based on the performance of activities of daily living (ADL). The essential activi- ties required in a given cultural context for independent living are labelled "instrumental" ADL- such as shopping, getting on a bus, man- aging finances - while others are called "physical" ADL- such as walking, eating, dressing, bathing and going to the toilet. The mea- surement of disability is often based on information obtained through interviews, but researchers are increasingly adopting methods whereby they can observe perfor- mance. The individual can dramatically reduce the risk of disability. Con- sider again the example of respira- tory function. A person who has throughout been physically active will develop an "extra capacity" and will remain above the incapacity threshold for longer. Conversely, a heavy smoker will reach the thresh- old much earlier. Thus while aging in itself cannot be halted, the pace of decline for most functions can be slowed. "Extrinsic" factors (which have little to do with aging) are crucial here. These factors are related, for instance, to lifestyle (how we live our lives), to the envi- ronment (consider what heavy pollution can do to our lungs after many years!), or to the social context (if you live on the sixth floor in a building that does not have a lift). The message is both clear and positive: most people can age well and maintain good health into very old age. In order to do so, choices have to be made - the earlier, the better. And the greatest barrier to that is poverty. As with other age groups, poverty is health's worst enemy- and in old age it is the strongest determinant of whether one lives an independent, active life or suffers disability and destitution. • Or Alexandre Kalache is Chief of the Aging and Health Programme, World Health Organization, 121 I Geneva 27, Switzerland. 22 Cerebral palsy Adriono Ferrori A child with cerebral palsy learns to walk. E verywhere in the world, out of every 1000 live births, between two and three babies will suffer from cerebral palsy. Such babies used to be known as "spastics". Cerebral palsy is a complex motor disorder at the level of the central nervous system. It is caused by irreversible brain lesions occurring before, during or shortly after birth. This condition is therefore clearly influenced by the quality of perinatal care. After a period when there appeared to be a significant reduction in this disorder, the incidence now seems to be on the increase in both developing and industrialized coun- tries - a trend that may be related to World Health • 48th Year, No. 5, September- October 1995 "Paralysis" for a child with cerebral palsy is not just a problem of movement and perception, but above all "paralysis" of intention, interest and participation. Rehabilitation must be directed towards promoting a balanced interaction between the individual and his or her physical and social environment. maternal age, to falling birth-rates and, above all, to the survival of pre- term infants. The movement disorder is cer- tainly the primary and most evident sign of the paralysis, but it does not always represent the most important aspect and, above all, it alone cannot entirely account for the disability of the child affected by cerebral palsy. By movement we mean both the "repertoire of gestures" produced at the various sites of our locomotor system and the "patrimony of pos- tures", that is the reciprocal position- ing of the various segments of our body that allows us to stand sti ll , to sit, to crouch, and so forth. While posture represents a fixed configura- tion of our movement sites, by "gestures" we mean the transition from one posture to another by simultaneous or sequential changes at one or more segments. In cerebral palsy, there is a reduction in the motor repertoire of gestures and also a loss in the quality World Health • 48th Yeor, No. 5, September-October 1995 of movement because the motor patterns which are produced are not normal. Similarly, the range of postures which the child can adopt and maintain, as well as their stabil- ity, is altered: the child has difficulty in both moving and staying still. The poorer these ranges are, the more severe is the final paralysis and consequently the greater the disabil- ity. The term "adaptation" expresses the child's capacity to modify motor performance to meet the needs im- posed by both body and the environ- ment in order to carry out a deter- mined task. Posture and movement therefore represent continually changeable solutions to the condi- tions imposed by a developing and growing body, by a constantly re- newing environment and by tasks which throughout childhood become progressively more complex. Paralysis entails a lack of adapt- ability of gestures and postures: • in response to the environment, which must be suitably simplified and modified to help the child; • in relation to the child 's own needs and ability to cope with them, proportional to his or her mental capacity and drive to independence; • in relation to the body, which in time becomes conditioned and deformed. "Ability" expresses the child 's ca- pacity to choose and use from his or her remaining repertoire the best solution to the required task. In cerebral palsy, not all the conserved repertoire can be used; above all, the child is not always able to choose the best motor strategy to carry out a required task in a certain context. Cerebral palsy is primarily a problem of projecting, planning and controlling movement. However, the flaws of the nervous system fairly quickly cause deformity of the loco- motor system, as happens with a bad driver when, the more he drives his car, the more he damages it. In turn, the damage inflicted on the child's locomotor system will inevitably have a negative influence on the motor (movement) solutions avail- able to the nervous system, just as a damaged car will limit the driver's possibilities. Ideally, physiotherapy will be directed towards guiding the nervous system to construct adaptive func- tions. Physiotherapy must also confront the consequences of the central nervous system's errors on the motor apparatus. These sec- ondary dysfunctions may necessitate the use of suitable orthoses or ortho- paedic surgery, which may need to be carried out more than once as the child grows. A problem of perception The disability in cerebral palsy is also a problem of perception. Much perceptual information cannot be received or processed by the cerebral palsy child, or else it may be analysed in an excessive or distorted way. In certain children, depth and distance may be overestimated to the point of creating an overwhelming fear of falling; or they may be under- estimated to the point where the children cannot perceive how their balance is compromised, leading to continual loss of control of their postures. Phrases like ''I' m falling" and "Straighten up" soon become familiar to the cerebral palsy child and the family. Rehabilitation in cerebral palsy therefore cannot be limited to the motor aspect alone, but must also include promotion of 23 perceptual functions. In many coun- tries, determined efforts are being made to integrate children with cerebral palsy within the ordinary school system. In Italy, for instance, the scholastic and the social integra- tion of the patients is particularly developed, since special schools no longer exist and no differentiation is recognized in the compulsory school system. "Paralysis" for a child with cere- bral palsy is not just a problem of movement and perception, but above all "paralysis" of intention, interest and participation. Rehabilitation cannot be limited to education of movement and percep- tion but must be directed towards promoting a balanced interaction between the individual and his or her physical and social environment. In order to achieve this goal, two conditions are essential. On the one hand, the child must become aware of his or her own needs and desires and be determined to fulfil them. On the other hand, a sensitive and in- formed community needs to be capable of accepting and appreciat- ing the diversity of ways in which the child copes with the environment and seeks to express his or her own individuality. • Professor Adriono Ferrori is Professor of Rehabilitation Medicine at the Presidio regionale ad alto specialita per la riobilitozione delle disabilita infantili, Arcispedale S. Moria Nuovo, Aziendo Ospedaliero di Reggio Emilia, 42100 Reggio Emilia, Italy Movement training in a special school for children with disability 24 Childhood blindness Clare Gilbert & Alien Foster Aperson is declared blind when the corrected visual acuity in the better eye is less than 3/60. These persons cannot see the largest letter of an eye chart (about 9 cm in size) with either eye at a distance of three metres , using spectacles if worn. This definition applies equally to children, although in very young chi ldren other methods of measuring vision may be needed. There is limited information about the proportion of children in the world who are blind. Data from registers of the blind in European countries suggest that two to three children in every 10 000 are affected. In Latin American countries, it is estimated that between four and six children in 10 000 are blind, and in the poorer countries of Asia and Africa the figure is probably in the region of nine to eleven. Using these figures, we can assume that there are 1 500 000 blind children in the world. About 85% live in Asia and Africa, reflecting the higher preva- lence of blindness in those regions as Although blindness in children is relatively uncommon, it poses a heavy burden on the individual, the family and society. Health care workers must be made aware of the need for preventive measures and early identification of children with eye disease. of childhood are also associated with a high mortality rate, e.g. vitamin A deficiency, measles , meningitis and congenital rubella infection. Causes of blindness in children The causes of blindness in children can be classified in two ways. The first is descriptive depending on the part of the eye involved: scarring and opacity of the normally transparent cornea; opacity of the lens of the eye (cataract); atrophy of the optic nerve; well as the large population of children. There is no information on the incidence of blindness - the number of chil- dren in a popula- tion who become blind each year - but it is estimated to be in the order of 500 000 per year. Of these, up to 60% die within one year of be- coming blind, since many of the blinding diseases Teacher and student working with o broille typewriter. World Health • 48th Year, No. 5, September-October 1995 and diseases of the retina. The sec- ond depends on the time of onset of the condition that led to blindness: factors operating at conception (genetic disease); factors operating during pregnancy (e.g. rubella infec- tion, the toxic effects of drugs and alcohol); factors operating around the time of birth (birth injury, con- junctivitis due to sexually transmit- ted diseases , consequences of premature birth) ; and factors acting during childhood (e.g. vitamin A deficiency, measles infection, injury, meningitis) . The main causes of blindness in children, which vary widely between countries and even regions, are largely determined by the level of socioeconomic development and accessibility to preventive and cura- tive health care services. In industri- alized countries the main causes are diseases of the retina, optic nerve and higher visual pathways, due to gen- etic factors or extreme prematurity. Cataract accounts for some 1 0%, and there are very few cases of opacity of the cornea. In countries with low socioeco- nomic develop- ment most blindness is acquired during childhood, and is due to corneal scarring from vitamin A defi- ciency, measles infection, injury and the use of harmful tradi- tional eye prac- tices. Studies in schools for the World Health • 48th Year, No. 5, September-October 1995 25 blindness could have been prevented by measles immunization, preventing or treating vitamin A deficiency, and avoiding the use of harmful eye medicines. Other conditions that can be prevented through primary health care include conjunctivitis of the newborn and congenital rubella infection . This Nepalese boy has just had surgery for congenital cataract. In other countries, infor- mation is less readily available, but there is evi- dence that retinopathy of prematurity is becoming an important cause in some Latin American coun- tries and in urban areas of newly industrializing countries. As a country's socioe- conomic status changes, so the main causes of blindness in children will change. There is Although blindness in children is relatively uncommon, in terms of years of disability, it poses a heavy burden on the individual, the family and society. It is essential to improve awareness among health care work- ers at all levels about the need for preventive measures, and the impor- tance of early identification and referral of children with eye disease. Appropriate training, facilities, equipment and specialist skills are required to manage surgically curable conditions, and to provide low-vision services. • blind show that 30-70% of blindness is due to corneal scarring in African countries and 20-30% in Asian countries. Other causes include congenital abnormalities, cataract and glaucoma. In countries with intermediate levels of socioeconomic development, for instance in Latin America and the Eastern Mediterranean region, the pattern of blindness is mixed, with corneal scarring accounting for 1-20%, cataract for 5-39%, optic nerve disease 8-15% and diseases of the retina 10- 50%. Changing patterns The major causes of blindness in children appear to change over time. In European countries, conjunctivitis of the newborn baby (due to gono- coccal infection) was a common cause at the turn of the century. During the 1950s, retinopathy of prematurity (disease of the retina in low-birth-weight babies) accounted for around 50% of blindness. These conditions are now less important, as a result of antibiotic treatment of sexually transmitted diseases and improved management of low-birth- weight babies. therefore a need to monitor the causes of blindness in children so that appropriate preven- tive or therapeutic strategies can be introduced. Data obtained from examination of children in schools for the blind in Africa, Asia and Latin America suggest that 30-75% of the causes were either preventable, or amenable to sight-preserving or sight-restoring treatment. In Africa and Asia, between a quarter and a half of all Or Clare Gilbert and Mr Alien Foster work at the International Centre for Eye Health , Institute of Ophthalmology, Bath Street, London EC I V 9EL, England World Day for Disabled Persons As a result of a dec ision taken by the United Nations at the end of its Decade of Disabled Persons 1983-92, 3 December every year is marked as the World Day for Disabled Persons. In Europe, the body responsible for organizing it is the European Forum for Disabled Persons. Th e Worl d Day for 1995 is being arranged by three nongovernmental organizations- a ll members of the European Forum - on th e th eme of Full C itizenship. Preparatory sess ions in September dealt wi th four themes, each w ith its own workshop: self-determination for the disabled , integration, non-discrimination, and help for families . Thi s event offers a good opportu ni ty for raising public awareness about disabled persons, the problems they encounter in their daily life, and their demand for ful l citizenship. Member States w ill be invited to ensure good coverage of the event in the public media. Contributed by Paul Bouliner, President of the Conseil franr;:ais des personnes handicapees pour les questions europeennes, and Bruno Gaurier, Director of External Relations, Association des Paralyses de France, 17 Boulevard Auguste Blanqui, 75013 Paris, France. 26 World Health • 48th Yeor, No. 5, September-October 1995 Preventing nutritional blindness Keith P. West Xerophthalmia currently afflicts 2-3 million children each year in the developing world, of whom as many as 250 000 go need- lessly and permanently blind. The name means "drying of the eye" and the condition is caused by a chronic, severe lack of dietary vitamin A among children. Infection often increases the risk of this eye disease by draining existing stores of vitamin A from a chi ld 's body. An additional 250 million children suffer "subclini- cal" vitamin A deficiency, itself a condition that increases the risk of severe infection and death. In severe xerophthalmia, the normally clear and glistening cornea becomes very dry. It may develop ulcers and, if left untreated, will soften, become white and "melt away" leaving a scarred, distorted and usually blind eye. It strikes children who are typically very ill and malnourished. Measles is one catastrophic illness that can cause rapid corneal destruction. Although the number of children blinded by vitamin A deficiency each year is proportionately small (usually far less than 0.1 % even in high-risk areas), the risk of death is extremely high (often 25% or higher) . Keratomalacia ("softening of the cornea") may condemn a child to a lifetime of blinding disability, eco- nomic deprivation and social rejec- tion. Victims of this nutritional blindness include many of the blind beggars in Third World cities. Most poor, blinded children in developing countries never have the chance to be rehabilitated in schools for the blind. So each severely xerophthalmic child who survives will suffer over 50 years of visual disability; one thousand surviving, blinded preschool children in a country will contribute between 50 000 and 60 000 person-years of Lack of vitamin A in the diet has severe consequences for the eyes and can lead to blindness . disability to their society. The good news is that this needless human tragedy and economic burden on society can easily be averted by improving the intake of vitamin A by young children. High-risk families At the primary health care level, governments should ensure that there are enough vitamin A supplies to treat children with xerophthalmia and other conditions such as severe diarrhoea, fever, malnutrition and measles. The brothers and sisters of a child diagnosed with xerophthalmia are ten times more likely to have or to develop xerophthalmia than other children; children living nearby also run a twofold higher risk of having xerophthalmia compared to children from communities where no cases are observed. High-risk regions can usually be efficiently targeted within countries. Preventive action can include supplying vitamin A capsules, forti- fying processed foods with vitamin A and encouraging greater availabil- ity and consumption of local food sources of this vitamin (e.g. egg, The good news about blindness caused by vitamin A deficiency is that this human tragedy and economic burden on society can easily be averted by improving the intake of vitamin A by young children. liver, dairy products, dark green leafy vegetables and yellow fruits). If governments strengthened gardening and small an imal husbandry pro- grammes, this could yield big divi- dends by controlling this nutritional scourge. Together, these strategies make the prevention of vitamin A deficiency an achievable child health goal today and a wise government investment in terms of developing full human capacity in the 21st century. • Or Keith P. West is Associate Professor of International Health and Ophthalmology, Division of Human Nutrition, johns Hopkins School of Public Health, 615 North Wolfe Street, Baltimore, MD 2 I 205, USA. World Health • 48th Year, No. 5, September-October 1995 27 Thailand's battle against nutritional blindness Vallop Thaineua, Emorn Wasantwisut & George A. Attig The leading cause of preventable blindness among children today is vitamin A deficiency (VAD), a form of malnutrition that puts about 250 million children around the world at risk of nutritional blindness and disease. Nutrition is therefore an important factor in disability causa- tion and prevention . Vitamin A is essential for a child's normal vision, growth, cell differentiation, health and survival. It strengthens the body's immune response and helps the body to resist disease and infection. Children who do not eat enough foods that are rich in vitamin A - such as breast milk, liver, eggs, milk, orange and yellow fruits , and dark green leafy vegeta- bles - are at risk of this deficiency. VAD can cause night blindness, lower the resistance to infections and, in extreme cases, lead to incur- able nutritional blindness; even in its mildest form, it may seriously affect children 's health, development and survival. VAD is a major public health problem among Asian children and, A child being given a high-dose vitamin A capsule. although Thailand is not listed by WHO as a country with a clinical problem, it represents an unseen threat which can emerge at any time. This lesson was brought home when hospital reports from 1988-91 in Yala province, southern Thailand, re- vealed that 31 children aged 3 to 15 months had become permanently blind because of VAD; another two cases showed up in a 1992 survey. Not enough vitamin A Since then, Thailand's Ministry of Public Health has waged a battle against this form of preventable disability. It was found that these children were not eating enough vitamin A-rich foods , firstly because they were breast-fed for only one month. Their mothers went to work on rubber plantations, leaving their children with grandparents or others who fed them sweetened condensed milk, which is not suitable for infant feeding, because it looks simi lar to breast milk and is inexpensive. The children also suffered from diarrhoea and pneumonia which further depleted their vitamin A stores. Con- sequently, inad- equate breast- feeding, use of inappropriate breast-milk substitutes, and infection brought about VAD and blindness. High-dose capsules The Ministry used a coordinated approach, starting by giving high- dose vitamin A capsules to all chil- dren in high-risk areas. Traditional birth attendants are now being trained to give these supplements. Legislation to fortify common foods like condensed milk with vitamin A was enacted and enforced, while longer-term measures entailed pro- moting breast-feeding and encourag- ing the use of vitamin A-rich foods as part of supplementary feeding. Social development workers helped community members to increase the production and consumption of the right foods, whi le improved immu- nization coverage, public health measures to control infection, and income-generating projects have also contributed to the programme's success. No new cases of nutritional blindness (keratomalacia) have been reported to date. Thailand's battle against vitamin A deficiency and nutritional blind- ness has taught health professionals valuable lessons that can be impor- tant for other countries too. The magnitude of the problem is im- mense and more challenges lie ahead as developing nations attempt to eradicate this disease by the end of this decade. Provided there are concerted efforts from community to international levels, VAD can be turned into Victory Against Disability by the year 2000. • Or Vallop Thaineua is Consultant to the Office of the Permanent Secretary, Ministry of Public Health, Bangkok, Thailand; Or Emorn Wasantwisut is Assistant Professor and Mr George A Attig is Consultant to the Institute of Nutrition, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom 73 170, Thailand. 28 World Health • 48th Year, No. 5, September-October 1995 The legacy of leprosy Denis Daumerie The ostracism that leprosy patients face is likely to be overcome only slowly, os communities realize that former leprosy patients living among them hove been totally cured, cannot transmit the disease to others, and must be encouraged to overcome their residual impairments and to integrate themselves into the community. A leprosy patient making arrows in a hospital in Bhutan. communities realize that cured patients li ving among them cannot transmit the disease to interpret, while the prevalence of disability among leprosy patients varies widely from country to coun- try; different studies have shown figures as low as 9% and as high as 57%. No stati stics can convey the true disability that stems from social rejection. In 1992, WHO estimated that the number of individuals suffer- ing physical impairment because of leprosy ranged between 2 and 3 million. The present study concludes that, whi le the precise prevalence of such impairment is still not known, there are today between one and two million cases. l eprosy earned its sinister reputa-tion because of its potential to disable and disfigure human beings. The dread of the deformities it causes only served to burden the sufferers with a further handicap: that of social ostracism. Today we know that leprosy can be cured; WHO is spearheading the drive to eliminate the disease as a public health prob- lem by the year 2000. New cases will continue to be diagnosed but, since person-to-person transmi ss ion will be stopped, a few decades into the 21st century should see the final eradication of leprosy from our planet. The key to this long-hoped-for goal is multidrug therapy (MOT)- a "cocktail" of three drugs which effect a cure and prevent the leprosy bacil- lus from developing resistance. But MOT cannot "cure" impairments and disabilities already present in pa- tients when the disease is diagnosed. Such persons will continue to be disabled and will require nursing care and rehabilitation. However, the ostracism that leprosy patients face is likely to be overcome only slowly, as others, and need encouragement to overcome their residual impairments. The message that cured but dis- abled patients cannot infect others has to be accepted by patients, fami- lies and communities if they are to be reintegrated into the mainstream of society. Formal health education can help to bring about such changes; informal methods of education can be used too , such as group discus- sions involving disabled leprosy patients, their families and opinion leaders (schoolteachers, village elders). When understanding re- places fear and stigma about the phys- ical and social handicaps, a major step will have been taken towards generating supportive measures to rehabilitate the image of leprosy. WHO has recently published a brief study entitled "Leprosy disabil- ities: magnitude of the problem", which reviews the global situation and attempts to estimate the burden and the impact of control pro- grammes based on MOT (Weekly epidemiological record, 22 September 1995, No. 38). Available statistics are scanty and not easy to The application of MOT is ac- tively reducing the overall incidence of impairment because it shortens the duration of the disease and limits the incidence and seriousness of compli- cations. This reduction is due to the efficacy of the drugs, as well as leprosy workers' regular monthly contacts with patients and improved monitoring and treatment of reac- tions. As the application of MOT may have prevented the occurrence of 80-90% of disabilities, it is esti- mated that between one and two million persons have been spared impairment. • Or Den is Doumerie is Chief of the Monitoring and Evaluation of Elimination of Leprosy Unit, Action Programme for the Elimination of Leprosy, World Heolth Orgonizotion, 1211 Genevo 27, Switzerland. World Health • 48th Year, No. 5, September-october 1995 29 Children's hearing endangered Andrew W. Smith, Juanita Hatcher & Ion Mackenzie A common disease among children in developing countries puts their hearing at risk; parents and teachers fail to appreciate its seriousness. Chronic suppurative otitis media (CSOM) is the commonest cause of persistent mild-to- moderate hearing impairment among children and young people in devel- oping countries. Studies in India and Africa, and among Aboriginal, North American Indian and Inuit people, have shown that CSOM may affect between 1% and 11 % of children. In developed countries, the prevalence is much lower and is decreasing, probably because of the more fre- quent use of antibiotics. CSOM follows poorly treated acute otitis media, usually in children under the age of five years. It is related to freq uent upper respiratory tract infections and poor socioeco- nomic conditions, and continues for months or years, with persistent draining pus, destruction of the small bones of the middle ear and increas- ing hearing impairment. There are frequent recurrences and sometimes life-threatening complications such as meningitis and brain abscess. Hearing loss produced by CSOM during the first two years of life can have serious effects on a young child's speech and language develop- ment, and later can cause slower progress at school. A recent survey of primary-school children in an affluent district near Nairobi, Kenya, showed the prevalence of CSOM among school attenders to be 1.1 %; A doctor examines a young boy's eardrum. but 63 % of ears with CSOM had a hearing impairment compared with 3.4% of ears without CSOM. Ear toilet The main methods of managing CSOM are: ear toilet (regular dry mopping and/or syringing, some- times with antiseptics); topical or systemic antibiotics (usually given following ear toilet) ; and surgery to repair the eardrum if it does not heal spontaneously. All these methods are in use in developing countries, but the management of CSOM is controversial and the results are disappointing, probably because of the ineffectiveness of many anti- biotics against common bacteria. In addition, treatment programmes may not be carried out widely, especially in rural areas . Trained health staff and necessary equipment may not be available in many developing coun- tries. Because of the disease 's com- mon occurrence and its omission from health promotion and school health programmes, parents and teachers may not appreciate its seri- ousness and fail to obtain treatment for affected children. The few trials that have been made suggested that ear toilet im- proves the natural history of the disease but some failed to show any additional benefit from antibiotics. However, the numbers investigated were small, follow-up times were short and the effects on hearing impairment have not been ascer- tained. A community trial was recently carried out in Kenya to determine whether simple methods of treatment, which can be taught to older schoolchildren and can be applied on a wide scale in a primary health care or school health care programmes, are effective against the disease. The results of this trial wi ll become avai lable shortly. • Or Andrew W. Smith, Msjuanita Hatcher and Or Ion Mackenzie are with the Hearing Impairment Research Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 50A, England. 30 International action against deafness Yash Pal Kapur Primary ear care should be integrated into existing primary health systems in countries, and is particularly useful in the early treatment of otitis media and early detection of hearing loss. obstacle to optimal development and education; in adults, it prevents them reaching their full economic poten- tial, and in the elderly it leads to loneliness and isolation, and inter- feres with successful aging. There is a lack of understanding and public awareness about the consequences of hearing loss, the available preventive measures, and effective management. In develop- ing countries, upper respiratory infections frequently lead to middle ear infection (otitis media); this Testing hearing ability in an Egyptian school far disabled children. H earing is the sense upon which human communication de-pends, yet hearing impairment is one of the most common sensory impairments. Recent epidemiologi- cal data indicate that over 120 mil- lion persons worldwide have hearing loss significant enough to interfere with their communication. In chil- dren, it prevents acquisition of lan- guage and constitutes a serious causes conductive hearing loss which can be prevented. Sensorineural hearing loss is present worldwide, and may be due to congenital causes, meningitis and infectious diseases in children. Between 10% and 26% of cases of hearing loss in children are present at birth or during early childhood - a result of rubella viral infections, the use of inappropriate drugs during World Health • 48th Year, No. 5, September-october 1995 pregnancy, birth trauma or premature birth. Improved prenatal and perina- tal care can prevent these problems. More than 50% of cases of congeni- tal deafness are due to hereditary or genetic causes. The custom of con- sanguineous marriages appears to contribute to the increased preva- lence of hereditary hearing loss in certain parts of the world; the answer may lie in genetic evaluation and counselling for parents interested in planning their family. Viral infec- tious diseases in children such as chicken pox, mumps and measles, can cause hearing loss. Many cases of hearing loss can be prevented by childhood immunization against target diseases of the Expanded Programme on Immunization, as well as against mumps, rubella and (meningococcal) meningitis. Particularly in rapidly industrializing nations, noise in the workplace is a major cause of hearing loss. Over half can be prevented More than half of current hearing impairment could be totally pre- vented or its consequences signifi- cantly reduced by the application of appropriate preventive measures. This constitutes the major thrust of international activities in this field. A programme for the Prevention of Deafness and Hearing Impairment has been set up by WHO to promote the development of technology, education for protection of hearing, and the strengthening of services aimed at preventing deafness and hearing impairment. The four main areas identified for WHO collabora- tive action with Member States are development of epidemiological studies, promotion of research, planning and setting up of national World Health • 48th Year, No. 5, September-october 1995 programmes, and exchange of infor- mation. Two professional bodies, the International Federation of Otolaryngological Societies (IFOS) and the International Society of Audiology (ISA) are particularly active in developing international activities. An Otological Centre was opened in Bangkok, Thailand, and was designated as the Regional Centre for South-East Asia in 1986. IFOS came into official relationship with WHO in June 1987, and an International Agency for the Promotion of Ear Care (IAPEC), made up of otolaryngologists and audiologists , was established in 1987. In 1992, the major international nongovernmental organizations working in this field came together to form an umbrella organization -the International Agency for the Prevention of Hearing Impairment and Deafness - known as Hearing International. Its major mission is to promote the worldwide prevention of hearing impairment and deafness. It seeks to investigate and make known the causes and consequences of hearing impairment, to cooperate with the United Nations anp its agencies , particularly WHO's Prevention of Deafness and Hearing Impairment Programme, and to assist in mobilizing resources for pro- grammes. Primary ear care should be inte- grated into existing primary health systems in cpuntries, and is particu- larly useful in the early treatment of otitis media and early detection of hearing loss. Detection of hearing loss before the age of two years is the key to effective medical and surgical treatment and to successful education of children. The later the detection, the more difficult it is to provide successful rehabilitation . In January 1995 the WHO Executive Board urged Member States to prepare plans for prevention and control of major causes of avoid- 31 able deafness, including ototoxic deafness and exposure to harmful noise, and stressed the importance of childhood immunizations. This was supported by the World Health Assembly in May. A series of Regional Workshops on the subject have led to countries taking an in- creasing interest in the problem of hearing impairment and allocating resources for programmes. WHO Collaborating Centres have been designated in Bangkok (Thailand), Malmo (Sweden) and Liverpool (England), and more are planned. • Or Yash Pal Kopur is Professor Emeritus in the Department of Surgery and Audiology at Michigan Stole University, Oyer Building, Wilson Road, East Lansing, Michigan M/ 48824-1220, USA Photo Credits Front cover: Page 3: Page 4: Page 5: Page 6: Page 7: Page 8: Page 9: Page 10: Page 11 : Page 12: Page 13: Page 14: Page 15: Page 16: Page 17-18: Page 19: Page 20: Page 21: Page 22: Page 23-24 Page 25: Page 26: Page 27: Page 28: Page 29: Page 30: Page 31 : len Sirmon © J. Wohlbarj © Declic/ le Toquin © S~ll Pictures; J Schytte ©; WHO/ J. Abcede OMPH/ Afrique © S~ll Pictures/ J. Schytte ©; WHO / l. Toylor WHO/ P. Almosy WHO/ E. Mondelmonn E. R. Nieuwenhuijsen © l. Sirmon © WHO/ G. Toutoin B. Neelmon © WHO/ A. Eklund Hondicop lnternotionoi/J. Temple©; Hondicop lnterno~onol © Declic/J. Vorlop © Declic/ Filip © Declic/Tibol ©; Declic/ Filip © WHO/ N. Grotz WHO/ N. Consignodo WHO/ l. Taylor S~ll Pictures/J. Schytte © WHO/ C. Gilliert WHO/ A. Sommer WHO / S. Sinowot S@ Pictures/ M. Edwords © HIRG, Liverpool School of Tropical Medicine © S~ll Pictures/ J. Schytte © WHO/ Zofor Protecting the ears from excessive noise can prevent hearing impairment. Back cover: WHO/ l. Taylor In the next issue Many people in the world today - refugees, migrants, no mads and the homeless - have to live on the fring e of society. The N ovember- December 1995 issue of World Health wi ll look into their hea lth needs and ways to meet them. • Did you enjoy this issue? Why not take out a subscription to World Health and enjoy reading about the world 's major health issues six limes a year. 1995 subscription prices ore listed below. WHO also offers ifs popular 'Health Horizons" subscription , a combined subscription (at a reduced role) to World Health and the quarterly World Health Forum. 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