(wpRlRC44/SRl8)
SUMMARY RECORD OF THE EIGHTH MEETING WHO Conference Hall, Manila Thursday, 16 September 1993 at 2.30 p.m. CHAIRMAN: Mr S. Naivalu (Fiji)
CONTENTS
1.
WHO Response to Global Change: Report of the Executive Board Working Group (continued) ...................................................................
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WHO RESPONSE TO GLOBAL CHANGE: REPORT OF THE EXECUTIVE BOARD WORKING GROUP: Item 21 of the Agenda (Documents WPRJRC44/18 and Add. 1) (continued from the seventh meeting, section 3) Dr SCHUSTER (Samoa) endorsed the opinions expressed by other representatives. He
asked for clarification on the timing of the Regional Committee's report to the Executive Board: must the report be prepared at the present session, or could it be finalized at the forty-fifth session? The REGIONAL DIRECTOR replied that if the matter was delegated to a sub-committee with instructions to report back to
the Regional Committee in 1994, the report would not reach
the Executive Board until January 1995. Alternatively, the sub-committee could be delegated full authority to submit the report on behalf of the Regional Committee. The five other regional committees were likely to submit their views to the Programme Committee of the Executive Board in November, and he felt it was important that the Region should not lag behind in presenting its own views. He suggested that the Regional Committee should endeavour to reach a consensus on a number of major issues at its present session. Its standpoint on those issues could be submitted as a preliminary measure to the Programme Committee of the Executive Board in November. A sub-committee could also be set up to look into the regional implications of the proposed Executive Board actions more thoroughly and report to the Regional Committee in 1994. The whole, detailed reaction of the Regional Committee could then be given to the Executive Board in January 1995. Dr TAPA (Tonga) said he felt the recommendations contained in section 6. of document WPRJRC44/18 could be transmitted to the Executive Board as the preliminary views of the Regional Committee, but not necessarily as its final standpoint. He believed that the Sub-Committee on Programmes and Technical Cooperation should be mandated to conduct a detailed analysis and make recommendations so that the Committee could then decide on its definitive standpoint in 1994 and forward its decisions in 1995. Mr WAENA (Solomon Islands) endorsed the views of the representative of Tonga. Mr LOVELACE (New Zealand), Professor NGUYEN TRONG NHAN (Viet Nam), Dr RASMY (Lao People's Democratic Republic), Mr DURAND-DROUHIN (France) and Dr TAPA (Tonga) expressed support for the Regional Director's suggestion.
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Ms BLACKWOOD (United States of America) urged the Regional Committee to support the option of a search committee, put forware in section 4.2.2.4 of the report of the Executive Board Working Group, as a method for obtaining nominations for the posts of Director-General and regional director. Now would be a good time to introduce such a policy as it could not imply criticism of anyone currently in office. Dr DOl (Japan) asked for clarification of the purpose of this proposal. He could see no defect in the present system. He seconded the proposal of the representative of Tonga. Mr LOVELACE (New Zealand) noted that section 4.2.1.1 was strongly supported by his country. Concerning item 4.2.2, he would echo the comments of the representatives of the He emphasized that the requirement to maintain a United States of America and Australia. the initial response. Mr DURAND-DROUHIN (France) said it was important that the Regional Committee's report to the Executive Board should contain its carefully considered views on the, method of work of the regional committees and on coordination with the United Nations and other agencies. Mr LOVELACE (New Zealand) supported the comments made by the representative of France. Dr TAPA (Tonga) pointed out that, in accordance with Article 49 of the Constitution of WHO, the Regional Committee had adopted its own Rules of Procedure, which set out the arrangements for nomination of the Regional Director. The proposed change in the nomination process would oblige the Committee to amend its Rules of Procedure. The REGIONAL DIRECTOR summarized the areas in which consensus was apparently being reached, namely, the decentralization of authority to the regional office, the method of work to be considered by the sub-committee; the strengthening of the office of the WHO representative; and the coordination of health resources, He noted that the only area where the representatives were not in accord was on the issue of the nomination and terms of office of the Director-General and regional directors. Mr HENRY (Cook Islands) agreed with the comments of the representatives of Japan and Tonga on the nomination process, and insisted that the Region should maintain its own procedures which had worked well.
strong and effective regional committee and regional office should be an essential component of
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Dr LI Shichuo (China) expressed agreement with the Regional Director's suggestion. The issue of nominations for the posts of Director-General and regional directors required careful study. He was in full agreement with the summary of the points of consensus made by the Regional Director. Dr ADAMS (Australia) agreed with the previous remark of the representative of China. He explained, as an example, that a search committee could look for about 12 candidates and submit its views and recommendations to the Regional Committee. It was essential that the most important health posts in the world should be filled by the right people. Mr LOVELACE (New Zealand) pointed out that the idea of a search committee had been put forward in the Working Group report as only one of several options to be considered, not as a specific proposal. Mr WAENA (Solomon Islands) urged representatives to reach consensus on the issues and suggested that the Committee defer discussion on more difficult or substantial issues. He agreed with the representative of Japan on the nomination issue. Dr TAPA (Tonga) said that if the Committee was unable to reach consensus on a particular issue, it should state that to the Executive Board. Mr BUNE (Fiji) wondered whether the Executive Board would be prepared to wait until the Regional Committee reached a consensus before taking a decision. Dr TAPA (Tonga) suggested that, since the Executive Board had asked for the views of regional committees, the Regional Committee for the Western Pacific should report on those aspects of the Working Group's recommendations on which it reached consensus and should also report the diverse views expressed on other points that required further study. It was so agreed.
The REGIONAL DIRECTOR, taking the comments in the order in which they had been made, summarized the various views presented as follows: All representatives accepted the need for reform and approved the spirit in which the Working Group had made its report. However, the manner and means of implementation of recommendations for action required thorough review, which the Regional Committee entrusted to its Sub-Committee on Programmes and Technical Cooperation for final decision by the Regional Committee itself.
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The Regional Committee had expressed consensus on the need for clarification of the respective roles and responsibilities at different levels of the Organization, at headquarters, regional office and WHO Representative offices. In addition, it was generally agreed that proper delegation of authority to the regional and country level was an important consideration for the future. The WHO Representatives' offices in particular should be strengthened. In order for WHO to properly exercise leadership in international health, its structure should be strengthened by reorganization, better staffing with more highly qualified personnel recruited from a larger pool of international experts, and greater utilization of institutions and centres of excellence, such as the WHO collaborating centres. Support had been expressed for the concept of "zero-based budgeting", but with more efficient use of the resources available to WHO. The role and method of work of the Regional Committee was one of the subjects to be referred to the Sub-Committee. Concerning the method of selection of the Director-General and regional directors, the Regional Committee, after long and serious debate, had not reached any clear consensus. It had therefore referred the matter to the Sub-Committee which would in turn report to the Regional Committee. The Committee would then submit its findings to the Executive Board in 1995. The recommendation of the Working Group on prior review of resolutions proposed to the Executive Board and Health Assembly had been found acceptable. Drawing attention to the table in Annex 4 to document WPRlRC44/18, he proposed that a further column be added in which the Regional Committee's preliminary views would be incorporated to form part of the report to the session of the Programme Committee of the Executive Board in November 1993. In reply to Dr TAPA (Tonga) be confirmed that the revised table containing these preliminary views and the summary record of the debate would be forwarded to headquarters for submission to the governing bodies. They would also be sent to the representatives for their information, together with the Report of the Regional Committee. It was so agreed. The Chairman asked the Rapporteurs to prepare an appropriate resolution.
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(WPRIRC44/SRl8, continued)
SUMMARY RECORD OF THE EIGHTH MEETING (continued) WHO Conference Hall. Manila Thursday. 16 SqJtember 1993 at 4.10 p.m. .
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CHAIRMAN: Mr S. Naivalu (Fiji)
CONTENTS
1. 2.
Health promotion ."."".".""" .. """ .. """""""." ....... "",,",,.,, ..... ,,........ Tim~ and place ~fthe forty-fifth and forty-sixth sessions ~f the . RegIOnal Comnuttee .. " " " .................................. :. . . . . .. . .. .... .. .. .. . . . . . . . .. . . . . .
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3. 4.
Cholera and diarrhoeal diseases Development of health research
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1.
HEALTH PROMOTION: Item 18 of the Agenda (Document WPRJRC44/15) Introducing document WPRJRC44/15, the REGIONAL DIRECTOR said that, since
health promotion had been recognized in 1989 as a priority area, there had been extensive collaboration in the Region in the preparation of the programme outline. involvement by the Member States had been diverse. Though the concepts and strategies were wide-ranging, the outlined programme had a truly regional approach. The health promotion programme recognized that people needed to take responsibility for health throughout their lives and make full use of their physical, mental and social capacities. Health and well-being would be primarily achieved by the people themselves. the community and in public policy. To enable individuals to realize improved health status. there must be a supportive environment, both in The development of health-supportive policies which reduced risks in the physical. economic and social environment required coordinated action by many sectors. The programme recognized that health problems transcended national frontiers. that health promotion aimed at equity. and that health was a fundamental factor in development. The resulting strategies for future action had been formulated at several working groups and meetings of experts. The meetings had culminated in the WHO Working Group on Health Promotion Planning in Singapore in March 1993. which had been kindly arranged and chaired by the Permanent Secretary of Health Dr Kwa Soon Bee. The Working Group had reviewed the programme outline and stressed the balance between individual, community and government action as the main strategic component. By the end of the century the Region would have changed considerably. Its population would have increased in number and average age. The peoples would be concentrated in larger cities, striving to maintain some degree of freshness in their environments. The dominant diseases would be strongly influenced by lifestyles. Those were one of the targets of WHO's health promotion plans. The disabilities and difficulties of an aging population could be prevented or at least reduced by simple interventions. People would be encouraged to develop, as early as possible. healthy behaviour patterns and healthy lifestyles. That included breast-feeding infants, regular exercise, appropriate dietary patterns, not smoking, reducing salt intake and so on. Reflecting the knowledge that a wide, multisectoral approach to health and well-being was necessary,
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Ways had to be found to be more effective in convincing people to change their habits and their ways of life, and the context or environment in which they could do it must be provided. The key role that individual behaviour change played in the prevention of HIV transmission was already known. The major transmission routes of sexual contact or injecting drug use were obvious targets for educational activities within the health promotion sphere. That was just one example of the areas in which the active support of governments and communities was absolutely essential to enable individuals to lead healthier lives. The Committee should therefore consider the document very carefully, and consider what steps might be taken to foster the growth and development of that most essential programme and policy area. WHO had outlined its proposal for action. health and better lives. Dr DOl (Japan), described a new aspect of health promotion and public health action in Japan. The cultural aspect was important, he said, and described the emerging "health culture". Culturally adapted projects were increasingly found in his country, for example, involving communities in the design of premises for healthy living and other community action for health. Related projects launched by the Ministry of Health and Welfare were for "comfortable social life", healthy life promotion and the design of social environments for children, the handicapped and the elderly, as well as promotion of voluntary work, day care services for the mentally disabled living at home, and waste reduction and recycling. The emphasis on health and culture was expected to encourage community action and gain the support of government, local authorities, and the private sector. It was proposed that health authorities should contribute to city planning. An international symposium on the subject was to be held in Kochi City, Japan, in November 1993 and the results would be reported to the Regional Committee in 1994. Dr LI Shichuo (China) said that health promotion was an important component of the health service, and one of the Region's six priorities. The targets for 1995 were noted and had China's full support; the programme would be stressed in WHO's Ninth General Programme of Work. Health promotion was an applied science, not limited to dissemination of information since it fostered a sense of health. Much could be achieved at little cost, but it must be directed He was convinced that it could prepare
successfully for joint efforts to enable every country, community and person to achieve· better
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at influencing the entire life span and involve all sectors.
China placed great emphasis on
people's involvement in measures for their own health, and had encouraged "cooperative mother" groups, for example. Much remained to be done to accommodate the great variations in conditions of its population in different regions. He urged WHO to develop models for health promotion in countries and to mobilize the necessary resources. Dr CHEN Ai Ju (Singapore), commending the Secretariat's initiative in strengthening health promotion, said that, since the 1960s when her country's effons in that domain were related mainly to communicable disease prevention and environmental health, the concept had evolved so that healthy lifestyles were now promoted in a bid to prevent noncommunicable diseases and change the traditional pattern based on the patient/doctor model. Over the last ten years the Ministry of Health had conducted campaigns on proper nutrition and exercise, and non-smoking, as well as stress management. The health education programme and health policy had political support. In 1992 a ten-year "healthy lifestyles" project had been launched with annual themes for a month-long campaign. It relied on multisectoral suppon and community panicipation, with
government voluntary organizations and professional bodies providing skills, training and a supportive environment. In 1993 the emphasis was on physical activity. There was also a "trim and fit" scheme for schools, a workplace health promotion programme, and numerous other initiatives for the elderly, housewives and the general population, concentrating on healthy living rather than disease. Monality and morbidity
statistics and special surveys were used to monitor the programme and evaluate results. Political commitment was a key feature. Dr DURHAM (New Zealand) congratulated the Regional Director on the repon. Her
country's programme was based on the concepts of individual responsibility for health and collective responsibility for health policy and a supportive environment for healthy choices. Those concepts should permeate health action and related programmes focusing on the whole life cycle. New Zealand's approach, based on a public opinion survey, favoured specific goals in the promotion of a social and physical environment to protect public health. The activities listed in section 6 of the document should include a balance of aspects that relied on individual and collective responsibility. and it was recommended that some specifically regional environmental
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approaches be incorporated to complement the "healthy cities" and "healthy schools" approaches. Dr REODICA (Philippines) also commended the report, which reflected the Region's philosophy and action. The Philippines also applied the life-cycle concept of community and individual action for health, and had much experience with campaigns to mobilize the population for such causes as immunization and nutrition. It was recognized that, while "points of service" for health still offered the main
opportunity for health messages, much could now be done with well-directed involvement of the media. Mr TEBANIA (Kiribati) said that, since his country had become a Member of WHO the Government had designated 9 May as National Health Day with the objective of promoting, strengthening and sustaining the primary health care activities that were implemented throughout the islands with WHO support. The 1993 National Health Day had included a keynote address by the President, reiterating the Government's commitment to primary health care strategies and health-for-all goals through equity, intersectoral cooperation, community commitment and national self-reliance. The President had also expressed his appreciation of all the support provided by WHO. With the aim of increasing public awareness and encouraging the outer islands to compete with each other, awards for the cleanest and healthiest island, the most active in supporting primary health care, the most successful health district, the cleanest ward in the Tungaru Central Hospital and the most active health worker had been presented during the celebrations. The main island, South Tarawa, provided a large number of sporting facilities which were well used, indicating the healthy lifestyle activities being pursued there. The April 1992 issue of the Regional Office magazine "Health and Development" had reported Kiribati health promotion activities under the heading "A Leap for Health - Kiribati Ministry of Health Promotes Fitness at the Workplace". With continued support from WHO, Kiribati would spare no effort to make each of the 33 islands in Kiribati "a healthy island". Dr CLARO (Portugal) said that, as in other countries or areas in the Region, mortality and morbidity, particularly from communicable diseases, had declined in Macao and iife-expectancy was increasing as a result of the improvement in socioeconomic status and well-being. The infant mortality rate had dropped to 7.5 per 1000 live births. However, lifestyle-related diseases were increasing and cardiovascular disease had become the principal
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cause of death. To meet the new challenges the Government had started a number of health promotion activities through health education, environmental measures, community and organization development, nutrition and regulatory activities, aimed at changing individual behaviour, community, society, the environment and the health systems. Health education was a core component of health promotion and various educational activities had been organized for specific population groups. control. Environmental measures had been taken, as outlined earlier during discussion of item 16 of the agenda. Community and organization involvement was important for the success of health promotion and Macao had implemented several measures in that regard. Current increases in the availability of a wide variety of food and reduction in physical exercise could lead to poor nutrition because of inadequate or incorrect food choices and poor physical fitness. Nutrition education was promoted by health professionals in health centres, schools and neighbourhoods. Health promotion activities were relatively new in Macao and it was hoped that collaboration with WHO and other Member States would be strengthened, particularly in the areas of training and information exchange. Dr MONT AVILLE (France) said that health promotion was an important matter involving a balance between behavioural patterns and responsibilities at the individual and collective level, which in some areas could be difficult to achieve. The report referred to a number of activities such as nutrition, AIDS, lifestyle-related diseases and the Healthy Cities concept, which France supported. While interventions aimed at adults were needed, it was perhaps more cost-effective to focus on children and adolescents in an educational setting. Health research was needed in the area of health promotion to determine the best ways of achieving sustainable and effective lifestyle changes. useful in that regard. Dr LIN (United States of America) welcomed the report, commended the WHO collaborating centres might be A community-based diabetes control programme had been developed which included education regarding diabetes and its
activities undertaken by the Secretariat and endorsed the actions proposed. Health protection required the exercise of individual and shared responsibilities. The achievement of an appropriate agenda depended heavily on changes in individual attitudes and behaviour.
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However, it also required national and local approaches through legislation, regulations and social sanctions to achieve healthier places in which to live, and effective disease prevention. Finally, it required the health sector to take the initiative in securing intersectoral commitment and the support of other components of government in championing health promotion and healthier lifestyles. It was time for the health sector to convince other sectors of the long-term benefits of health promotion to their own sectors. Expenditures on childhood vaccines would result in the eventual eradication of the respective diseases and their disabling legacies, thus reducing subsequent expenditure on treatment and rehabilitation. The health sector could not succeed alone; intersectoral education and cooperation were essential. For example, at its forty-ninth session, the Economic and Social Commission for Asia and the Pacific (ESCAP) had adopted a resolution sponsored by the United States of America on health promotion and protection. Although the session had focused on economic and social development, Member States had supported the concept of health promotion in relation to the eradication of poliomyelitis, education on and prevention of HIV infection and AIDS, and reduction of unhealthy activities such as the use of tobacco, alcohol and illicit drugs. They had understood their individual responsibilities to themselves, their families and their communities and had recognized the future economic gains to their respective countries in releasing resources previously required for treatment and rehabilitation. The resolution invited WHO to present a paper on the eradication of preventable diseases at the 1994 ESCAP Ministerial Conference in preparation for the World Summit for Social Development. The United States of America was fully committed to the health promotion programme in the Region. Dr ABU BAKAR (Malaysia) commended the report and supported the action plan proposed. Malaysia had launched a healthy lifestyles campaign in 1991, concentrating on The enthusiasm healthy diet and food safety, which had been well received by the public.
generated was most encouraging. The campaign was part of the Government's approach to improving the quality of the family and promoting a caring society. Malaysia was currently considering how to set targets related to behaviour change and requested WHO's collaboration. Mr CAPELLE (Republic of the Marshall Islands) said that the Republic of the Marshall Islands strongly supported regional efforts in the area of health promotion. While the process of development brought obvious benefits, the resulting changes in patterns of choices and lifestyles could have a negative impact on health that was only just being
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recognized by the people. The consequences were especially critical for the young, who made up the major part of the population. His country recognized the urgency of addressing that issue.
It was important to target health promotion activities at that age group so as to influence young people in their formative years before lifestyle patterns became established. The Ministry of Health and Environment was implementing an innovative health promotion strategy involving young people who were selected to join health education touring groups promoting healthier lifestyles throughout the country. He expressed appreciation of the resources made available by WHO. Mr HENRY (Cook Islands) commended the report. Cook Islands had implemented a
number of health promotion initiatives with the support of WHO aimed at various population groups. The activities for mothers and babies were centred on the clinics in the public health service which had been running since 1945, and methodologies were updated every few years. Youth programmes were implemented in youth clubs, sports clubs and colleges, mainly through volunteers. With the support of commercial sponsorship, programmes aimed at adults to reduce smoking, improve diet and encourage family planning were publicized by television, which was now reaching the outer islands. Access to the elderly was through hospitals or home visits. The Ministry was making every effort to encourage the involvement and participation of the community. Centralization of the administration of health promotion was under way and support was being given to relevant nongovernmental organizations with office accommodation and equipment. hygiene. It was hoped that health promotion would lead to disease reduction in due course. In the meantime, there were a number of obstacles to effective treatment, one of which was the difficulty in procuring essential drugs. During the previous session of the South Pacific Forum, the Prime Ministers of the smallest states had discussed the need to collaborate so as to achieve cost benefits through bulk purchasing. Any support in that regard would be greatly appreciated. Dr Haji HUSSAIN (Brunei Darussalam) commended the Regional Director on his report. In addition to ensuring equity of health for all in the country, the national health policy drawn up by his Ministry of Health called for the intensification of programmes to support and Hospitals and clinics were inspected regularly to ensure a high standard of
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promote a cleaner environment and the adoption of healthy lifestyles. activities had been actively pursued in recent years.
Health promotion
Health promotion in Brunei Darussalam relied heavily on the primary health care concept and collaboration with other ministries and nongov~rnmental organizations to support programme activities. Other ministries and nongovernmental agencies also conducted health promotion programmes from time to time, often in coru;ultation with the Ministry of Health. Brunei Darussalam was a Malay Muslim State and health promotion strategies called for respect for the natural, social and cultural structure of the targeted population. For example, programmes with sexual overtones had to be tailored to suit local expectations. Health promotion had been undertaken on the areas of AIDS, nutrition, cardiovascular diseases, road safety, home and industrial accidents, occupational health, tobacco and health, etc. Brunei Darussalam was also planning collaborative activities and joint projects with other Member States in the Region in a number of areas. Mrs HOMASI (Tuvalu) said that health promotion in Tuvalu was very similar to that in Cook Islands. Nongovernmental organizations participated in health promotion pr,ogrammes as well as in programmes on health education, family planning, and awareness-raising. how to brush their teeth. Health promotion needed to be strengthened in the area of health materials. Tuvalu produced few materials aside from radio programmes, which were the principal means of communicating messages to the outer islands. She endorsed the comments of the representative of Cook Islands on economies in the procurement of essential drugs. Mr WAENA (Solomon Islands) said that his country was reviewing such activities as logging, which had caused permanent environmental damage. He hoped that, when the SubCommittee visited Solomon Islands, it would take note of what was happening, and cooperate with the Government in drawing up appropriate policies that might alleviate environmental damage. Moreover, the type of investor that came to Solomon Islands, apparently to help the economy, were those who invested in such areas as tobacco products, health hazard to local communities. which represented a The national bank had banned smoking on its premises. In primary schools children were taught
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The REGIONAL DIRECTOR, referring to bulk purchasing of drugs in the G5 countries in the South Pacific, explained that a project based in Apia had been cooperating with small
Member States in the Pacific in pharmaceutical management. including procurement of essential drugs. That project had even prepared information for the smaller countries on where the He assured the G5 cheapest good quality medicine could be obtained. Unfortunately, when the incumbent left last year. the post had had to be frozen because of financial difficulties. "helping hands" if needed. The CHAIRMAN, noting that there were no further comments, requested the Rapporteurs to draw up an appropriate resolution. countries that he would respond to any requests for support and was prepared to provide
2.
TIME AND PLACE OF THE FORTY-FIFTH AND FORTY-SIXTH SESSIONS OF THE REGIONAL COMMITTEE: Item 24 of the Agenda The REGIONAL DIRECTOR invited the representative of Malaysia to inform the
Committee about the situation regarding the invitation of his Government to hold the forty-fifth session of the Committee in Malaysia. Dr ABU BAKAR (Malaysia) informed the Committee that last year his country had offered to host its meeting in 1994. Preparations were already under way and he expected to sign shortly the memorandum of understanding as stipulated in resolution WPRlRC43.R13. He looked forward to welcoming all representatives at the meeting next year. The REGIONAL DIRECTOR thanked the representative of Malaysia and suggested that the dates of the Committee's forty-fifth session should be from 19 to 23 September 1994, provided those dates were suitable to the Government of Malaysia. Efforts were made to coordinate the dates of all six regional committees. firstly, to enable the Director-General to attend at least part of all of them, and secondly, to allow enough time for the discussions of all the regional committees to be reflected in the documentation for the Executive Board meeting in January. The forty-sixth session. in 1995, would be held at the WHO regional headquarters in Manila. The Chairman asked the Rapporteurs to draw up an appropriate resolution.
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3.
CHOLERA AND DIARRHOEAL DISEASES: Item 17 of the Agenda (Documents WPRlRC44/14 and INF.DOC.lI) The REGIONAL DIRECTOR said that document WPRlRC44/14 provided a summary of
the regional cholera and diarrhoeal diseases control activities. Diarrhoeal diseases, including cholera, represented a major cause of morbidity and mortality in most developing countries. Globally, an estimated 1000 million episodes and 3.3 million deaths due to diarrhoea occurred annually among children under five years of age. Appropriate treatment, in particular the use of oral rehydration therapy averted an estimated 1 million diarrhoea deaths each year. The WHO diarrhoeal diseases control programme, which had been initiated in 1978, had as its specific objectives the reduction of diarrhoea-associated mortality, morbidity and malnutrition among infants and young children in developing countries. Twenty-two countries in the Region in which diarrhoea was a public health problem had now developed national control programmes in collaboration with WHO. Cholera was already endemic in many countries. In 1992, a total of 7249 cholera cases and 247 deaths had been reported by eleven countries in the Region. That was about four times the number of reported cases in 1991 and about twice as many as in 1990. An ominous new development was the identification of a new serogroup of Vibrio cholerae, namely V. cholerae 0139.
The new serogroup had first been reported on the Indian subcontinent in The first cases of cholera due to
March 1993 and had spread further to Asian countries.
V. cholerae 0139 in the Region had been reported in China in May 1993.
The illness caused by the new organism was both clinically and epidemiologically indistinguishable from that caused by V. cholerae 01. Populations living in areas where cholera regularly occurred appeared to lack immunity to the new serogroup, which might explain the present large, unexpected outbreaks. The cholera caused by the new strain was likely to spread. Current WHO guidelines for cholera control, which remained valid for that new cholera, should be applied vigorously. The situation clearly indicated the need for Member States to be constantly alert and able to respond to cholera outbreaks with adequate control measures. A strong national programme for the control of diarrhoeal diseases was the most important way to improve the state of preparedness of countries affected or threatened by outbreaks of cholera. When health workers
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were trained in the case management of acute diarrhoeal diseases and supplies were available. countries were able to respond most effectively to possible cholera outbreaks. An informed public was much more likely to understand and support rational and effective control measures. avoidable loss of life. WHO had widely disseminated current information on cholera. Proper rational preparation and education helped to prevent major outbreaks, and minimize When an outbreak did occur, making the proper response was very A proper response included important to the continued smooth functioning of the country.
prompt reporting of cholera cases, organization of surveillance, and implementation of control measures. Timely reporting of cholera cases was of the greatest importance in order to promote international collaboration in the control of cholera. Inadequate preparation could result in an escalation of domestic problems as international tourism and exports of seafood and agricultural products suffered, and there was domestic fear and sometimes panic. There were strong links between health and larger development issues. To effectively prevent and control diarrhoea and cholera, sustained improvements in water and sanitation facilities, housing, personal and domestic hygiene and other environmental conditions were required. Those issues must be addressed by the Member States if the long-term objectives of the programme were to be achieved and sustained.
In the future, high priority should be given to further strengthening the national diarrhoeal diseases control programmes, especially if the goals of reducing childhood morbidity by 25% and mortality by 50% by the year 2000, as endorsed at the World Summit for Children in 1990, were to be achieved. That would have the additional benefit of providing cholera control, as that was best achieved by having the strongest possible national diarrhoeal diseases control programmes. A principal task for the future would be continuing to provide advice to health officials on the implementation of control activities. To gain public awareness and cooperation, health education on prevention and treatment of cholera would be encouraged. Countries were strongly encouraged to report suspected or confirmed cases of cholera promptly to WHO as required by the International Health Regulations. Although no country had objected to the requirement. compliance with the regulations had been less than optimal. There were still problems with reporting of inaccuracy, delays and incomplete data. Improved surveillance would be made a high priority, and support would be given to Member States for prompt reporting of cholera.
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Dr RASMY (Lao People's Democratic Republic) infonned the Committee that in May 1993 there had been an outbreak of diarrhoea in 18 villages in southern Lao. A total of 452 cases were recorded, with 31 deaths. Microbiological tests confinned the serogroup to be Vibrio cholerae 01. A cholera outbreak had occurred in a neighbouring province, with 801
cases and 98 deaths - a fatality rate of 12.2 %. The strain involved had not yet been confinned. The Ministry of Health and local authorities had taken a number of measures to control the epidemic. WHO had recently infonned the Ministry of Health that a new strain - 0139 - had emerged, and had sent guidelines which were very useful in the effons to control the spread of the disease. He requested WHO's cooperation in the translation of those guidelines into the Lao language, which would be extremely helpful for health workers in the field, and in the supply of oral rehydration salts and appropriate drugs. Dr WANG Zhao (China) reponed that China had revised its national programme on diarrhoea control, and that for 15 provinces, autonomous regions and municipalities had fonnulated their programmes. The target was a 20% reduction in diarrhoea incidence. Effons were geared towards strengthening public education, reducing abuse of antibiotics and promoting the use of oral rehydration salts. An outbreak of diarrhoea clinically resembling cholera had occurred in southern China in May, with 167 recorded cases and four deaths. The epidemic was caused by the serogroup Vibrio cholera 0139. The pathogen was sensitive to tetracycline, chloramphenicol, doxycycline
and neomycin, but resistant to trimethoprim-sulfamethoxazole. Comprehensive measures had been taken to protect water supplies and to sterilize drinking water. Research was being carried out and epidemic surveillance had been strengthened throughout the country to prevent the spread of the epidemic. No new cases had been reponed since September. Dr HONG SUN HUOT (Cambodia) said that cholera epidemics were rather frequent in Cambodia; at least eight major outbreaks had been declared by the Ministry of Health since 1980. More than 2100 cases had been reponed from all areas during the last three years. The mortality rates was 12 % on average. The pathogen had been confinned as Vibrio cholerae serotype Ogawa. The Ministry of Health was taking public health measures for the prompt control of the outbreaks. The National Centre for Hygiene and Epidemiology was providing technical support to affected provinces, investigating outbreaks, training local staff in case management and implementation of preventive measures, and promoting health education at community level. Collaboration with nongovernmental organizations in the field was particularly effective. Mass educational health campaigns using all available media had been
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conducted during the last outbreaks. The Ministry of Health had recently developed a national cholera warning system in order to improve surveillance and the effectiveness of interventions. Dr ABU BAKAR (Malaysia) reported that Malaysia was still experiencing
sporadic outbreaks of cholera and other diarrhoeal diseases in certain areas. A national plan of action had been implemented to counter changing disease trends. Research findings and disease management had been incorporated into the health personnel training. Health messages targeted at specific people in high-risk areas and workplaces had been modified in order to promote changes in behaviour and practices. measures. High priority had been given to encouraging notifying stations to report cholera cases promptly, to improve surveillance, and to take urgent control Health authorities were particularly vigilant for imported strains, especially the non-O 1 strain of Vibrio cholerae from the Indian sub-continent. Unfortunately, 20 cases has just been reported. The sources appeared to have been a non-licensed food handler in contact with the sub-continent. With the number of people arriving from abroad he thought that it would not be possible to prevent that kind of contact. Dr PRETRICK (Federated States of Micronesia) said that diarrhoeal diseases were the second most commonly reported illness among all age groups in the Federated States of Micronesia. In 1992, 6% of the population was reported as having suffered a diarrhoeal illness, although that figure was understated. Although outbreaks of cholera had occurred in the country in 1982 and 1990, and some level of endemic cholera existed in Chuuk State, no further cases had been reported. All health care workers had been trained in the use of oral rehydration salts. His Government was taking the necessary steps to establish a diarrhoeal diseases programme and to
ensure further training of primary health workers and community members in
the early recognition and appropriate treatment of those diseases. Dr NGO VAN HOP (Viet Nam) commended the report on cholera. The national control programme for diarrhoeal diseases and cholera had been established in 1982 with projects in four provinces, and currently covered approximately 90% of the target population. It was being implemented in 8407 communes (83%) involving about 8.5 million children under five years old with a coverage rate of 90%. Although the programme had reached 90% of the target popUlation, compared with 84% in 1990, the quality of implementation varied from province to province and was far from optimal in mountainous areas. In 1992, four million sachets of oral rehydration salts had been distributed to the provinces. Most of the cholera cases had occurred in the southern provinces. Although the new strain Vibrio cholerae 0139 had not so far occurred, the collaboration of WHO would be required in such an event.
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Dr TINIELU (Tokelau) wished to emphasize that the regional disease. surveillanclt programme for notification and early dissemination of information to Member States was' a very important first line of defence in the Region. particularly in his area. Dr REODICA (Philippines) commended the document and fully agreed with the major points highlighted concerning cholera control through the diarrhoeal diseases centrol programme; the use of oral rehydration therapy; the ineffectiveness of available vaccines; the marginal effectiveness of antimicrobial chemotherapy; and the importance of surveillance and reporting in targeting and evaluating interventions. In 1988. a national epidemic sentinel surveillance system had been established. with eight sentinel sites for the monitoring of 14 diseases of epidemic potential. including cholera. 1991. that system had recorded 533 cholera cases compared with 996 in 1990. In The 46%
decrease could be attributed to the ban on the consumption of mussels during. the rainy season because of the red tide alert. The geographical distribution of cholera in 1992 showed that two provinces had recorded the highest number of cases; affecting,mostly children under ten years of age. Case fatality rates for 1990 and 1991 had been low. signifying that C3$es had been promptly and adequately managed. At the San Lazaro Hospital sentinel site. tttere had been no deaths among admitted cases in 1992. Strengthening of the national diarrhoeal diseases control programme had been the cornerstone of the improvement of the cholera situation, A national cholera task force had been created at the peripheral level for effective implement;ttion of the WHO guidelines. She suggested that cholera be used as an issue to fuel.PQlitical sUpPort for the diarrhoeal diseases control programme. building safer water· and sewerage systems and improving sanitation. and that there should be more focused epidemiological studies on transmission and appropriate control measures. Regarding section 6 of the document, future action could include specific preventi,ve measures Member States might take. such as the improvement of food and water vendor sanitation. and water and sewage systems. The Government would appreciate receiving a regular update . 0(10 the incidence of the 0139 cholera serotype.;
Dr MONTAVILLE (France) expressed his delegation's appreciation of the report which drew the attention of the Committee to the magnitude of the epidemic in the Region. The control of diarrhoeal diseases was an important issue that involved prevention through the upgrading of water and sanitation services. Through the .European Community. Fr/lIlce had provided experts to a number of Latin American countries and similarly coItaporated with
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Member States in Polynesia and the South Pacific. For example, an intercountry meeting in the South Pacific had been held in Vanuatu. The REGIONAL DIRECTOR assured Member States that updated information on cholera outbreaks including the new serotype 0139 would be provided as part of the regional surveillance system. He fully supported a request from the Lao People's Democratic Republic to have the WHO guidelines on cholera control translated into the vernacular and requested further details. The Chairman asked the Rapporteurs to prepare an appropriate resolution.
4.
DEVELOPMENT OF HEALTH RESEARCH: Item 14 of the Agenda (Document WPRlRC44/10) The REGIONAL DIRECTOR said that document WPRlRC441l0 provided information
on the main activities performed by the regional research promotion and development programme. The programme had two closely related purposes: firstly to obtain results that could solve problems related to achieving health for all and secondly, to strengthen national research capacities. In that context, efforts had been made to promote national research coordination so as to direct research towards solving priority problems. Although the development of national research coordination mechanisms differed considerably between countries, there had been increasing interest in that effort. In 1990 the Regional Office had commissioned a study to provide information on the outcome of WHO research support mechanisms throughout the 1980s. The findings had indicated that research grants definitely benefited the individual researchers. However, it was less clear to what extent the studies had resulted in improvement in the health programmes of the country as a whole. WHO had continued to provide grants for research and for research training promoting research activities within WHO's six regional priority areas. For the future, and in order to use limited funds most wisely, there should be a more direct focus on studies on priority areas which could immediately and directly be utilized to eliminate or reduce the health problems of the people. The document presented the observations and recommendations made by the Western Pacific AdviSOry Committee on Health Research and the directors of health research councils or
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analogous bodies at their meeting in August 1992. He hoped that the Conunittee would endorse them and comment further on the report. In view of the long-term nature of the effects of health research, he hoped that discussion of the future directions and priorities of WHO's research programme would also be of interest to the Committee, so as to provide guidance for its work in the next bienniwn. Mr Jeong-In SUH (Republic of Korea) expressed appreciation of WHO's activities in health research promotion and development. There was a need to establish a regional information network. In his country, a research project on the development of district health management information systems had been launched to provide a model for such information systems using a computerized information system of various district health institutions and computer-based communication channels. The project was being carried out by two interrelated working groups: a health services group responsible for the analysis of information associated with the execution and management of various service programmes of health centres and subcentres and a computer programme group developing computerized information systems on the basis of the results of the health services group's analyses. The system was being tested in several project sites using computers provided to ten health centres as an initial step in developing satisfactory systems for health centres and sub-centres. Mr AGUIGUI (United States of America) thanked the Regional Director for his overview of activities in the Region on health research and congratulated him on the publication of the WHO manual Health research methodology: a guide/or training in research methods l , which would help broaden the Region's knowledge of the fundamentals of research design and methodology. Noting the initiative taken by WHO collaborating centres in Australia in 1991 to discuss the contributions of collaborating centres to research and to the transfer of technology to the developing countries of the Region, he said that the importance of the transfer of new technology derived from research could not be overemphasized. As an example, the outcome of a study being conducted in the Federated States of Micronesia to analyse ground water quality at varying distances and directions from pour-flush latrines would help similar developing countries with increasing populations environmental health care needs. in infrastructure planning and assessment of
lWHO Regional Publications· Western Pacific Education in Action Series No.5, 1992, Manila.
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The implementation of the general and topical recommendations found in Annex 3 of the working document would serve to strengthen the processes for decision-making and acceptance of research proposals at a time when there was great interest, but limited fiscal and personnel resources for the programme. He noted in particular the recommendation to develop a strategic health plan for health research in the Region for the next five years, to be accompanied by the determination of specific targets. He sought the Regional Director's comments on whether the Regional Office saw the establishment of focal centres as a prerequisite to receiving WHO support for research and research training grants. If, as a matter of consistency and national accountability for health research activities, the focal centres had served their respective countries in providing local coordination and oversight of health research priorities and WHO-supported health research, then Member States with focal centres should not only have a designated point of contact for the Regional Office, but also a recognized single advocate for the Member States on those matters. He also sought clarification of the criteria by which operational research awards were made, when a clearly indicated outcome of the research was a marketable product such as a vaccine, diagnostic reagent or medical device. He also queried the levels of awards made for that category of operational research during the reporting period. The momentum gained on behalf of the Region's health research programme was notable and not to be taken lightly. The additional development of the proposed strategic framework within which future research directions could be aligned, and support prioritized, would certainly add to
the stature gained thus far.
Dr MONT AVILLE (France) stressed that priority should be given to malaria. Coordination of research studies should be done on two levels - regional and global levels, together with other organizations such as the South Pacific Commission. Referring to the report published recently by the World Bank, he said two elements should be emphasized. Firstly, the Bank had provided mechanisms for coordination of research in the health field along the same lines as those for agriculture and environment. Secondly, the report had revealed that the World Bank had been following a strategy completely opposed to that of WHO. The Bank had suggested that WHO should stop subsidizing local production of vaccines based on the criteria of quality control standards, indicating that doing immunization campaigns with poor quality vaccines meant a substantial loss in time, efficiency and money. France, together with the Regional Office, wished to uphold quality control of vaccines specifically for BCG in Viet Nam and suggested that the issue of safety and efficacy of vaccines could be presented for discussion.
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Referring to health research in the Region, he said there should be more information on research and training progranunes. Expertise along those lines was available at the Pasteur Institute in New Caledonia and at the Malarde Institute in French Polynesia. Dr DOl (Japan) stressed the importance of communication among collaborating centres scattered throughout the Region. Through a new device called computer networking, using work stations, all collaborating centres working in the same field would be able to exchange information, expertise and ideas. stations in the world. millions of dollars. WHO headquarters had already established a networking system through Internet, a commercial system, and therefore could access almost all work To establish the networking system did not require investments of All that would be required were telephone lines and MODEM with
practically no installation costs. Noting that management of information would be facilitated by the use of technology, he said Japan would support the establishment of inter-collaborating centre networking in the Region. Dr Haji HUSSAIN (Brunei Darussalam) commending the Regional Director on the report, said his country recognized the importance of health research, especially operational or applied research. Development of health research in Brunei Darussalam was still in its infancy, mainly owing to lack of trained manpower in that field. However, efforts had been continually made to enhance national capabilities to carry out health research. A workshop on principles of research design and methods had been held recently in collaboration with WHO to acquaint medical staff and auxiliary health workers with the principles of health research. He was glad to report that many of the recommendations of the workshop had been implemented. A research project on the prevalence of congenital hyperthyroidism in Brunei Darussalam had been started in 1990. Up to 1992, among 17 552 newborn babies that had been screened, six cases of congenital hyperthyroidism had been detected, an incidence rate of 1 in 2925 live births. Screening for congenital hypothyroidism had been routinely done for all newborns in the country. A collaborative study on the status of community nutrition had been planned with the Institute for Medical Research in Kuala Lumpur, Malaysia. The medical and health libraries had been updated to provide information support facilities for research. Brunei Darussalam would welcome the establishment of an effective regional information network with WHO collaboration to enhance national research capabilities in health.
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Mr WAENA (Solomon Islands) said that his Government considered health research essential in order to make their programmt' strategies effective, affordable and sustainable within the country's available resources. Research findings from other countries, while being equally important, would need to be carefully evaluated with respect to their applicability and adaptability to the existing local situation. Having that in mind, his Government had therefore encouraged applied or operational field research as part of its health policy since 1988. To support that policy, the Medical Training and Research Institute had been established in Honiara in that same year. His Government believed that research, if it were to serve its purpose, had to be directly related to the priority needs of the country. Malaria being one of them, research activities had been focused on the use of impregnated bednets. As a result, that effective and affordable method of controlling the disease had gained wide acceptance among the country's population. Given the current momentum of activities, and with the required support, it was projected that impregnated bednets would be used throughout the country by 1994. Experience proved that research findings based on local conditions were vital in allowing decision makers the choice of the most effective and efficient alternatives. He therefore requested WHO, subject to funding availability, to provide support to the activities of the Medical Training and Research Institute. His request was made in the spirit of the recommendation made by the Western Pacific Advisory Committee on Health Research. Referring to the research activities being carried out in the Region, the REGIONAL DIRECTOR agreed that a significant amount of work was being done; however, funding limitations remained a constraint. With regard to the question raised by the representative of the United States, "focal centres" seemed to be an ambiguous tenn. If what was meant was national health research councils or analogous bodies or regional reference centres where research activities were being undertaken, WHO did not nonnally provide support, but only used their research findings. It had been WHO's policy to encourage operational research rather than basic research. Support for the latter should ideally come from WHO headquarters, which had better access to resources. Research on vaccine development was one example. Although a few activities had been undertaken in that area within the Region, the funds provided averaged only US$20 000-US$30 000, which was quite low for that type of undertaking. The main criteria used in the Region in evaluating research proposals for funding was whether the findings would contribute to the immediate solution of health problems. The two types of research grants were (I) those submitted by individuals; and (2) studies specified by the Regional Office and commissioned to individuals or institutions. Both types underwent
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critical review by the Regional Research Development Committee. comprising Programme Directors and headed by the Director. Programme Management. He agreed that research training was an important pan of health research. However. in view of funding constraints. the duration of training should be limited to a few months and placements made in research institutions within the Region where possible. With regard to the issue raised by the representative of Japan. the greatest number of collaborating centres in the Region was in Australia (40). China (64) and Japan (49). The existing linkages and networking activities among those institutions would continue to be promoted. The heads of those centres had met to discuss ways in which they could be more useful in their role as WHO collaborating centres. He said that networking development using the modem technology available was very promising provided that funds were available. He hoped that in the future. the research findings of collaborating centres would be published in an official WHO document and disseminated as information for countries within and outside the Region. However. he expressed some concern that the results of research He studies performed by most centres were so far too varied in quality for publication. results. The CHAIRMAN requested the Rapponeurs to prepare a suitable draft resolution.
therefore urged Member States to encourage the collaborating centres to produce high quality
The meeting rose at 6.15 p.m.