Blindness; Family planning; The Thar desert; Immunization; Smoking [full issue]

THE MAGAZINE OF THE WO D HEALTH ORGANIZATION • OCTOBER 1977 • USA $ 1 blindness family planning the Thar desert immunization smoking Cataracts can be removed and eyes saved in Asia for as little as US $5 (Photo WHO/T.S. Satyan) did foresight prevent blindness? by Sir John Wilson o you remember the 1976 World Health Day theme? It was "Foresight Prevents Blindness". It was an exceptional campaign, both in the extent of its world coverage and as an exercise in cooperation be- tween official and non-governmental or- ganizations. Yet it is a fair question to ask whether it achieved practical results ; whether it prevented blindness. The objectives were clearly defined. In terms of official action, the aim was to support resolutions passed at different World Health Assemblies directed against the major causes of blindness in the developing world and to encourage governments to give greater priority to blindness prevention. Beyond this, the non-governmental organizations—con- vinced that a technological opportunity existed to control blinding disease on an unprecedented scale—wished to use World Health Day publicity to generate international interest and resources for a decade of systematic action. Fortunately these aims were not con- troversial. Nobody objects to overcom- ing blindness. What we had to establish beyond any reasonable professional doubt was that a technology existed for 2 ON OCTOBER 1977 USA s1 blindness family planning the Thar desert immunization smoking World Health appears in Arabic, English, French, German, Italian, Per- sian, Portuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. Co,ver: A preventable disease—river blindness—cost this man his sight. ( Photo If/ HO/P .A. Pittet ) Contents Did foresight prevent blindness? by Sir John Wilson 2 Breakthrough in Papua New Guinea by J. C. Abcede . 8 India's creeping sands by T. N. Ninan ....... 12 Protecting Zambia's children by R. Mann . .... 18 decisive action at an acceptable level of cost-effectiveness. Nothing concentrates the minds of ex- perts so surely as the prospect that their agreement, or lack of it, will be publi- cized internationally. One of the most significant achievements in the whole year's effort happened just before World Health Day (7 April 1976) at a WHO Inter-Regional Meeting on the Preven- tion of Blindness held in Baghdad. It was an impressive gathering of international experts and, with a unanimity which could probably not have been achieved in any other setting, they approved a policy statement which gave credibility to all the subsequent publicity. The following is a quotation from a press release issued from the Baghdad Meeting : "Adequate technology now exists to control four giant scourges which together cause most of the blindness in the developing world. These are tra- choma, river blindness, cataract and blinding malnutrition... "In terms of cost-effectiveness, the control of blindness presents a unique opportunity ... "This situation could be transformed by a modest adjustment in resources, priorities and attitudes ..." Publicity material—films, information kits, posters, press releases, broadcast and television features—had been care- fully prepared during the previous year. As the national and regional campaigns went into operation, it was evident that an exceptional international coverage was being achieved. Most of the world's major news- papers, as well as radio and television channels, carried news stories and many had extended features. Twenty-one coun- tries issued special postage stamps. The range of civic and scientific events was No room for complacency by A. R. Hinman ..... 22 The smokers' world by A. Hayward-Costa . 26 Young World Health 30

did foresight prevent blindness? extraordinary, from officially sponsored scientific conferences throughout the So- viet Union to a charming event in a West Indian island where a "Stop that Blind- ness" calypso was performed. The World Health Day slogan appeared in innumer- able languages and sometimes in bizarre variations; a poster outside one jungle health centre read "Blindness Prevents Foresight". A notable feature of the year's effort was the extent of non-governmental ac- tivity or, as one report expressed it, of "consumer participation". The World Council for the Welfare of the Blind and International Federation of the Blind had alerted their constituent organiza- tions in more than 70 countries. Every- where the blind themselves came forward as the most convincing advocates of ac- tion to restore or save sight. The International Agency for the Pre- vention of Blindness (IAPB) had been formed in January 1975. It is the major non-governmental partner in this field and used the opportunity presented by World Health Day publicity to create a network of national organizations. By the end of 1976, National Commissions or Committees for the Prevention of Blindness had come into existence in 45 countries and, from a small specialist group, the Agency developed in a single year into a central executive organization with an impressive international repre- sentation. From the outset the National Committees were designed not simply as ad-hoc organizations for the World Health Day campaign but as permanent centres for national action. Most national welfare systems owe much to the stimulus of voluntary organ- izations and, in many countries, societies for the blind were the pioneers. This history has its parallel in international action with non-governmental organiza- tions assuming the classic role of ad- vocate, opinion-former, catalyst, even "ventriloquist" in the sense that they can often amplify a call for official action which would otherwise go unheeded. The practical purpose behind much of the publicity was to generate funds. In terms of unit costs, blindness can often be prevented or cured for an astonishing- 4 An age-old scene of poverty and dependence. The two blind men subsist on alms donated by passers-by; the boy now sleeping in the noon- day heat serves as their "eyes". (Photo WHO) ly low expenditure. Five US dollars is the cost of a cataract operation in an Asian eye camp, one dollar the cost of a course of treatment in a mass trachoma cam- paign. Simplifying the total programme costs into understandable units formed part of the preparation for the year's campaign and made possible the launching of fund raising efforts in a number of countries. Usually funds have been raised for national purposes, but in 11 countries so far, fund raising included international objectives. One non-governmental or- ganization, the Royal Commonwealth Society for the Blind in the United King- dom, used the opportunity of the year's campaign to expand its medical projects. It recently announced that last year its medical teams in 15 countries treated the eyes of 842,000 people and performed 113,714 operations for the restoration of sight. Voluntary organizations have their es- sential role but, eventually, only govern- mental and inter-governmental funds can finance the decisive action required to reduce blindness throughout the deve- loping world. The obvious channel for such inter-governmental finance is the WHO Voluntary Fund for Health Promo- tion. During the year governments were invited to contribute to this Fund money earmarked specifically for the prevention of blindness. It is hoped that, using this procedure, governments will provide the resources needed to sustain momentum. Hitherto WHO has been active in com- batting those eye diseases which have been identified as international priorities, such as trachoma, onchocerciasis (in par- ticular through the Onchocerciasis Con- trol Programme in the Volta River Basin) and xerophthalmia. Successive resolutions of the World Health Assembly have laid increasing emphasis on these causes of blindness, as well as on cataract—the control of which in the developing world presents an op- portunity not merely to prevent blind- ness but actually to restore sight to millions. At the January 1977 meeting of WHO's Executive Board they were endorsed as components in a new techni- cal cooperation programme—the Pro- gramme for the Prevention of Blindness. This Programme was given the go-ahead by the 1977 World Health Assembly. In terms of immediate action to pre- vent blindness, perhaps the most impres- sive activity was at regional level. In New Delhi in March 1976, representatives of South-East Asian governments met, in pursuance of a resolution of the WHO Regional Committee, to devise strategies for the prevention of blindness. This meeting was notable for the unanimity with which the delegations recognized not simply that blindness constituted a priority health problem but also that the technology and resources could be mobi- lized to achieve effective control. It was recognized also that blindness would be prevented not primarily through special- ist clinical activity in urban hospitals but by inter-disciplinary cooperation. It required the grafting of ophthalmic tech- niques on to the basic structure of com- munity health services and a continuous effort at motivation. A recent report from the Regional Director shows the impressive results of this initiative in South-East Asia. The Indian National Plan for the Prevention of Blindness has been formulated with unprecedented targets. These include an- other 500,000 cataract operations annu- ally, protection of all vulnerable children against blinding malnutrition and the establishment of eye care services as part of the national health structure. Coordinated national action is also being taken in Bangladesh, Burma, In- donesia, Sri Lanka and Thailand. The greatest importance attaches to these regional and national initiatives in an area which contains massive blind popu- lations. An outstanding blind man, Sheikh Abdallah Al-Ghanim, made a powerful plea for the prevention of blindness at the Alexandria meeting in 1975 of WHO's Regional Committee for the Eastern Mediterranean. It is estimated that there are seven and a half million\ blind people in that Region, mostly victims of com- municable and preventable eye diseases. The Regional Office collaborated vigo- rously in World Health Day publicity and a number of governments have com- mitted themselves to systematic action. On the initiative of the Saudi Arabian Government, a regional plan for the prevention of blindness, with particular emphasis on the control of communi- cable diseases, has been brought to the attention of 22 Middle East govern- ments. This plan, towards which provi- sional financial commitments have al- ready been made by the Gulf States, assumes an eventual expenditure of 10 million dollars a year through a coor- dinated programme directed from a regional centre in Riyadh. 5 In Africa, international interest is focused on the effort now being made to control onchocerciasis, the river blind- ness which darkens the lives of whole communities. Seven West African governments are collaborating with the Food and Agriculture Organization, the UN Development Programme, the World Bank and WHO in a systematic control programme. By the end of 1976, trans- mission of the disease had been consi- derably reduced in the treated areas, and insecticide spraying to kill the blackfly which transmits the disease will shortly be extended to all three zones which will eventually embrace the whole of the Vol- ta River Basin. Of the four "giant scourges", blinding malnutrition (xerophthalmia) is proba- bly the most difficult because it involves complex interventions in the whole development process. During a World Health Day meeting held at WHO's Gene- va headquarters on 7 April 1976, atten- tion was drawn to the fact that some dried skimmed milk used for aid pur- poses is still not fortified with vitamin A, with potentially harmful consequences in some relief programmes. Essential docu- mentation was circulated on this subject and IAPB alerted its National Commit- tees. In Rome in November 1976, the Committee on Food Aid Policies and Programmes unanimously endorsed a WHO recommendation calling for the en- richment of dried skimmed milk with vitamin A. Other measures against xerophthalmia are the fortification of sugar in Central America, the distribution of millions of vitamin capsules in Bangladesh, India and Indonesia, and the beginning of spe- cific programmes of nutritional rehabili- tation. Nevertheless, the number of chil- dren going blind from this cause conti- nues to give alarm to public health and educational authorities. UNICEF, the United Nations Children's Fund, has drawn world attention to this problem, which is likely to be featured during the 1979 International Year of the Child. Ophthalmology is traditionally a spe- cialized, research-led, clinically oriented profession. This has been its strength in the advanced countries but has inhibited its flexibility in dealing with the massive problems of needless blindness in less well organized situations. Of the four giant eye diseases against which inter- national action is now concentrated, cataract can be treated only by surgery; in onchocerciasis control, the main ap- proach is control of the blackfly—the insect vector; xerophthalmia largely concerns nutritionists and biochemists; and trachoma can be controlled only through fundamental hygiene measures in rural communities. Common to all these complaints is the need for health education. Yet, in all these programmes, the oph- thalmologist has a leading role if he is prepared to function within an inter- disciplinary setting. One of the most impressive developments of the last few years has been the way in which the ophthalmic profession has expanded its boundaries, by accepting the inter-disci- 6 did foresight prevent blindness? Left : Once the funds are available, prevention or cure of blindness can be astonishingly cheap. One US dollar, for example, will cover a course of treatment in a mass campaign against trachoma. (Photo WHO) Right : by the end of this century, there are 20 million blind people in the world instead of the minimum prediction of 32 million, that fortunate. harvest will owe something to the climate-changing effect of World Health Day 1976 and its aftermath." ( Photo WHO/T.S. Satyan) plinary base of organizations such as IAPB and by recognizing the value of ophthalmic auxiliaries. In May 1978, the XXIII International Congress of Oph- thalmology meets in Kyoto, Japan; its agenda includes a plenary session on the prevention of blindness and there is an inter-disciplinary element in many of the clinical sessions. The main emphasis of publicity for World Health Day 1976 was on blind- ness in the developing world. However, as the campaign diversified at the national level, attention was rightly given also to blindness in the industrialized countries. Eye injuries at work are a considerable cause of industrial loss, and the efforts of such organizations as the American National Society for the Pre- vention of Blindness (whose literature was widely distributed in connection with World Health Day) have shown that effective publicity can change work- ing attitudes. In the developing countries improve- ment in eye care services is primarily a f . question of delivery of existing techno- logy; in the advanced countries research continues to be a primary necessity. Can such research break through into new possibilities of relieving glaucoma? Can it delay the onset of cataract or prevent diabetic retinopathy ? Is there an answer to retinitis pigmentosa? Can research unravel the complicated factors in hered- itary blindness? The chances of successful advance against these intractable problems have been considered sufficiently promising to justify allocating increased funds to oph- thalmic research in some countries. In the United States, the National Eye In- stitute this year has a record budget in excess of $ 60 million. We are now thinking in terms of a decade of systematic action. In the deve- loping world the aim is to break the link between blindness and population growth. In the industrialized countries, it is to break the link between blindness and ageing. The most encouraging devel- opment in this field is that these aims are now generally considered to be practical and that goverments are devoting to their attainment higher priority and larger resources. This would probably not have happened so quickly but for the concentrated publicity of World Health Day and the international campaigns which followed it. It is possible to be disenchanted about "World Days" and to question the rele- vance of publicity in international health programmes. As an Indian farmer was reported to have said during a recent agricultural campaign—"Publicity will not grow my field of rice". Perhaps not, but publicity might change the climate so that those who have for years been planting seeds in arid ground may for the first time have a chance of harvest. If, by the end of this century, there are 20 million blind people in the world instead of the minimum prediction of 32 million, that fortunate harvest will owe something to the cli- mate-changing effect of World Health Day 1976 and its aftermath. ■ 7 breakthrough in Papua New Guinea FAMILY PLANNING ACTIVITIES BEGAN AT THE MOTHERS' REQUEST by Jose C. Abcede lin Papua New Guinea, sex is not discussed openly between men and women. It may be talked about among men or between women. We hope to propagate discussions among men, who represent the bottleneck in family planning." That was how Dr Jeffrey 0. Tuvi, First Assistant Secretary for Health of Papua New Guinea, summed up the problem when I called on him in Port Moresby. Dr Tuvi was referring to people living in rural areas, who com- prise about 90 per cent of the country's total population. And how are they propagating discus- sions of family planning in the rural areas? In 1975 the Department of Health started training Aid Post Orderlies (APOs) in family planning. Through these health workers the Government expects to motivate the villagers and bring services to them. This was viewed as a potential breakthrough for family planning in the country. Some questions came up. What are APOs? Why should their training in this aspect be considered a breakthrough? What has been done so far in the family planning programme? And, in the first place, why undertake family planning in Papua New Guinea? To deal with the last question first, perhaps the answer it deserves is that family planning is not really a novelty in Papua New Guinea. Confronted with limited arable land and resources, people in the olden days used to resort to all sorts of taboos to limit childbirth. One such highly effective measure was the taboo on sexual relations while a mother was breast-feeding, for periods up to three or four years. It was quite common for husbands and wives to live separately and people then were very conscious of the need to space their children. But Papua New Guinea's Minister for Environment and Conservation, Mr Stephen Tago, commented recently : "Many things have combined to cause a collapse of our traditions and taboos that caused long periods of abstinence between husbands and wives. Hunting has been curtailed, clan fighting almost eliminated. With the emergence of alter- native lifestyles, people live more and more as small nuclear families, and taboos demanding abstention from cer- tain foods, sexual activity, and so on have been abandoned as irrelevant." Dr Nell M. Muirden, medical officer- in-charge of family planning, explained it like this : "During the first half of this century, throughout most of Papua New Guinea, a high birth rate together with a high infant mortality resulted in the pop- ulation remaining at a fairly constant level. In some areas the high mortality was combined with low fertility and a decline in population occurred. Maternal and child health services and malaria control programmes which have expand- ed during the last 25 years have resulted in an increase in fertility and survival of most of the babies. This has caused individual families to be burdened with large numbers of children, and the coun- try as a whole is faced with the problem of a rapidly expanding population." To quote Mr Tago again : "Our popu- lation is projected to double in about 25 years. Many families have ten or fifteen children. We must look at our present resources, particularly our arable land ; we must look at the investment in schools, health services, transport and housing, and ask whether we can meet the demands of such a growth in such a short time. If we can't, then we are condemning our descendants to a more troubled life than we, ourselves, have had to bear. "We have only to consider the prob- lems in the Chimbu province where land shortage has led to constant land dis- putes, clan fighting and the desire to resettle into other areas such as the Karamui. Such movements of people and constant disputes produce many social problems for our people." In the context of the mother's health, family planning assumes greater signifi- cance. Dr G. C. Bird, head of the depart- ment of obstetrics and gynaecology at Port Moresby General Hospital, said that 33 per cent of mothers who die in childbirth are "high parity", meaning women who have had more than five children. The WHO Representative in Port Moresby, Dr Y. H. Paik, explained that in Papua New Guinea, a woman bears many responsibilities. These include child-bearing, breast-feeding, bringing up many children, farming, cooking and so forth. These pressures may contribute, in combination with adverse living con- ditions, to the so-called maternal deple- tion, which affects the health of mothers, and to the large numbers of babies with low birth weight. These, in turn, bring An Aid Post Orderly (APO) demonstrates a contraceptive device before an attentive au- dience of both sexes. A vital link in the family planning programme, the APO can ensure that his advice reaches both husband and wife. (Photo WHO/J. Abcede) 8 et, . r • #' breakthrough in Papua New Guinea Left: Visiting day at an aid post in the West- ern Highlands of Papua New Guinea. The aid post is a C01111711111ity institution, to whose upkeep the villagers themselves, or their local councils, contribute. Right: Each aid post may serve from 500 to 3,000 people, providing not only family plan- ning advice but also out-patient treatment and health education. Here a lecture on sensible foods for pregnant and nursing mothers is in progress. ( Photos WHO/J. Abcede) about high infant mortality and growth retardation. "In other words, there is a vicious circle within the family life, and the health of mothers and the health of children are interlinked", he added. Family planning services at the Port Moresby General Hospital are directed heavily towards this high risk group of mothers. If the risk of childbirth is removed from what are called the "high parity" mothers through family planning methods, maternal mortality can be ex- pected to decrease by at least one-third. Nevertheless, family planning came about fundamentally because the women of Papua New Guinea asked for it. In her review of the programme, Dr Muirden said : "One doctor was approached by women from villages around Port Moresby. A councillor asked another physician to help women in the Kainantu area. I myself first became involved in family planning activities because at Samarai, Wabag and Mount Hagen, women came asking for them." Acting on these requests, the MCH unit started family planning services in 1965. However, these activities were lim- ited to Port Moresby and a few towns. Four years later—in 1969—nurses re- ceived training on how to insert Lippes loops (inter-uterine devices) and pre- scribe oral contraceptives. In 1972, the training programme was stepped up. A nationwide expansion of the family planning programme was approved by the Papua New Guinea Government in 1973, together with a decision to request international assistance. This paved the way for the collaboration of the United Nations Fund for Population Activities (uNFPA) and WHO in the programme. Since 1974, UNFPA has been providing funds for training courses, teaching aids, equipment, contraceptive supplies, fel- lowships and consultants, with WHO as the executive agency. Because it was a programme based on maternal and child health (MCH), fam- ily planning in Papua New Guinea worked through and mainly with wom- en. This was the way it worked for almost ten years. In 1974, family plan- ning workers realized that the approach was terribly one-sided. The women want- ed family planning methods but the men opposed them because they had no con- tact with the MCH health workers ; the latter in turn had no opportunities to talk to the husbands of the women who came for MCH services. "They (the men) did not learn of the benefits of family planning and conse- quently were opposed to it", Dr Muirden explained. That same year, 1974, training courses and workshops began for Health Exten- sion Officers, health educators, aid post orderlies and aid post orderly supervi- sors—all male health workers. A seminar was also held for officials of various government departments and organiza- tions whose work gave them the oppor- tunity to educate the community on fam- ily planning. In terms of new "acceptors"—women starting to use family planning methods—there has been a steady in- crease in numbers over the past five years. In fact the 1974-1975 figure dou- bled that of 1972-1973. The number of acceptors increased parallel with the training programme for auxiliary health workers. In 1975-1976, more than 10,000 new acceptors were recorded, in com- parison with the 7,268 registered in 1974- 1975. All the same, for a country with just over half a million fertile women, these figures are rather disappointing. Dr A. Saloheimo, WHO Medical Officer assigned to the Papua New Guinea fami- ly planning programme, said that "to have more effect, the number of accep- tors should be increased a few times more". The problem is how to get more acceptors. Dr Saloheimo points to moti- vation as a key factor. Obviously, the target should be the rural population. 10 And this leads to the questions we raised at the beginning. Who are the APOs and why should their training in family planning be considered a break- through for the national programme? APOs are the frontline workers in Papua New Guinea's health setup. Whether it is appropriate or not, they have been called "barefoot doctors" or at least Papua New Guinea's version of the popular health auxiliary so widely used in China. An APO works in an aid post, which is in fact a community institution. The villagers themselves, or their local coun- cils, contribute to the upkeep of an aid post as well as the APO's house. Actually an aid post is established only at the request of the local council. The council is then asked to sponsor a candidate for the two-year APO course. The local council pays the school fees of the student, who then returns to the village after he qualifies as an aid post orderly. In practice, an aid post serves from 500 to 3,000 people, providing out- patient treatment, health education and advice on environmental improvement. The APO also carries out some disease control activities and community health nursing in cooperation with the health centre. Dr A. da Silva Rosa, Provincial Health Officer for the Western High- lands, said the APO is vitally needed by the family planning programme. Besides operating at the grassroots level, his ser- vice is integrated. "Unlike the sister (nurse), the APO can reach husband and wife", Dr da Silva Rosa explained. The Western Highlands province has 120 aid posts, and so far 19 APOs have undergone training in family planning. Most of these are the older ones in the service. Since 1975, family health, includ- ing family planning, has been included in the curriculum for APOs at the Mount Ambra Training School for APOs in the Western Highlands. During their in-service courses, these health workers learn by "round table" discussion and questions. They become convinced of the value of family plan- ning and return to influence attitudes in the villages. In addition to being motivators, they are being trained to distribute pills and condom samples, as well as to promote the sale of condoms in trade stores. Pill distribution is done with the use of a checklist and without any embarrassing examination. Dr Muirden explained it this way: "Community-based family planning ser- vices have been found an important ad- dition to clinic services in developing countries. This means that people from within the community distribute con- traceptives to their friends and neigh- bours. Housewives, schoolteachers, folk entertainers, traditional midwives and shopkeepers have been used in various countries. "The aid post orderlies and trade store operators were felt to be the most sui- table persons for community-based dis- tribution in Papua New Guinea as both already have channels for receiving and distributing supplies." Dr Francisco J. Dy, WHO's Regional Director for the Western Pacific, has already observed that, with the Govern- ment's training scheme for APOs, family planning services have now been brought to remote villages at the grassroots level. He saw this as a "breakthrough" for the programme, and his appraisal has drawn strong support from UNFPA. Papua New Guinea has 1,667 APOs all over the country, working in strategi- cally located villages, and 400 of them are already engaged in family planning activities. With funds from UNFPA, the Department of Health plans to train an additional 400 APOs in 1977 and 1978. Eventually these primary health workers will be demonstrating the value of family planning in rural areas throughout the country. ■ 11 ••••• ).•••••• - .4-it 51, .,. - .-. -`.. 21;,....:...,`...-r,. t .4.- ,-t, • .. •• '1.i... .'''. ' •,„ t '47 `-.. '...-- .--/ - a''',4p •_....ni ' : / -'," 4 -• sr. . ..,....,., . . .......„.-- 7::',........-, : k,..04:„.....H, t 41.,:t....-::z..1f::. s...;■. '' ''''' .. .2‘:-..71.... , t •••-‘7, - • ..1.1.• ....... ."-I. .."..roe'' 0 f, in_ . . • "'-'" . t'• -; y, .'""..." ak.t. 'S 1' . ,f-;•.' - ....-1'1'.. - • ; ''' .. ' '` . .:-.1-:* ...f2. • t..7....-. jL'::' ......=:-‘ 4itz%:::', . • ...... 0-....p....,.. . .......„ A. , .., ... ► , 2.'1' „e; 1:4404 .!.. '.... ...-4, P•-z - - "c4-11.1.:41,- ■ ... ,..tt • --,."1* a., _ - -I. :t..-vere.: ..,.- -4- • ..4 ....3'.i, - ,...‘4,..„:". .. - ..- '''-::;1,4-•"1111:LP,'..0,3.....r.."+,•• . s' : '4 ; ..= t.., • '''' • ..' - •■■••,;' --. ' ' • N ' 4. 44 ' .. • . -* . •-•'''...•!. I s- .—', - ,-17 '— •:... ,.:41.: . ... `• A . 40' -”. ".-4, s':',Z i: .;tr ? "C • .. ,..,.--,......• ... ist . 1 ....' .... -.1 •0° . , r 'I . . ' . -.,r. - 1° ."., ......' -- •c--1 *.-- 4,-- .,.. ,-.---',...; ..- A programme to combat the great Thar Desert of north-west India while not yet making the desert bloom is at least taking the first vital measures to check the advancing dunes il dairamsar is a little known vil-lage near the desert town of Bikaner in India's western state of Rajasthan. But it is here that Indian scientists have won one of their most significant battles against the Thar Desert. Two decades ago, a sanatorium in Udairamsar faced the onslaught of desert sand, and a spreading dune finally buried the entire ground floor of the building. The surrounding land was soon abandoned, and the building itself virtu- ally disappeared under the sand. At this stage, the scientists moved in to try to stabilize the dune and restrict its further march. They planted various species of grass and trees over some 360 acres of land. Slowly, vegetation took root. Today, though some rooms are still un- der sand, the building has been rescued, and a fountain juts out of the sand— something a visitor would not have seen as recently as three years ago. Shivbari, a suburb of Bikaner, was also saved from the moving dunes by scientists of the Central Arid Zone Research Institute (cAzRI), set up in 1959 in Jodhpur, another Rajasthani town lying in the heart of the desert. Encouraged by such successes, CAZRI scientists have now started a project which will enable the Rajasthani vil- lagers themselves to control the desert, by means of water harvesting techniques, soil conservation, afforestation, cultiva- tion of fruit plants, sheep development, and rodent control. The villagers, who in the past had little option but to resort to methods such as tree-worship, are now showing an eager- ness to collaborate in the work. But the battle has only just been joined. The Thar Desert ranges un- checked from across the Pakistan bor- der, stretching 370 miles from north-west to south-east, and with a maximum width of 220 miles. Its sand dunes, salt tracts and sandy flats cover parts of four Indian states—Rajasthan, Gujarat, Haryana and Punjab. Till recently, it was believed that the desert was moving east- ward towards New Delhi, India's capital city, and this sinister lateral spread was even estimated at the rate of a kilometre a year. However, the latest research find- ings contradict this popular belief: the Thar is not spreading. Unfortunately there is little cause for rejoicing, since the process of desertifica- tion is continuing and intensifying within the existing desert area. A hill near Barmer was known, 40 years ago, to be free of sand cover. Today, it is almost buried under sand. Huge sand dunes have been piling up in other arid dis- tricts, and smaller dunes have made their appearances around Jodhpur town. Vil- lagers confirm that there has been a deterioration in rainfall, and an increase in the frequency of drought. Perhaps the most important reason for the intensifying of desertification is the pressure of human population. The Thar is unique in the world for the simple fact that its population per square kilometre is as high as 61, compared with fewer than five in other major deserts. In fact, the population density there today is three times what it was at the turn of the century. This led to over-exploitation of land and vegetation, triggering off a series of processes in nature that are intensifying the desertification process. The demand for firewood has trebled, and trees are being cut indiscriminately—despite the tree-worship. There has been excessive grazing of cattle and, in an effort to feed themselves, the people have stopped leaving land fallow every other year. At the same time, the water is getting brack- ish and the soil saline. To study this process of desertification in the Thar, UNESCO and UNEP together selected Luni block (district), comprising 13 < A spreading dune finally buried the entire ground floor of the old sanitorium at Udairam- sar, a village in the Thar Desert. (Photo WHO/A.S. Kochar) India's creeping sands 106 villages, for a detailed investigation. A report was prepared for the recent United Nations conference on desertifi- cation at Nairobi. Conducted by CAZRI scientists with the help of a few special- ists from other countries, the study revealed that the shortfall of forage in the area has increased from 50 per cent in 1957 to 54 per cent today. Sand undula- tions have accentuated over 166 square kilometres (an increase of almost 33 per cent), and the thickness of the sand has also increased. Salinity in the Luni area has shot up by 50 per cent in 20 years. Because of increased exploitation of wa- ter, the discharge potential of wells has fallen considerably, while the quality of water has deteriorated. The vegetation composition of the ecosystem has changed for the worse because of over- grazing. If much of this is the result of the pressure of population, the desertifica- tion process in turn has drastically affect- ed the lives of the people. The situation was made worse by nearly a whole decade of drought in the 1960s. Cattle and livestock died by the thousands. In 1968-69 alone, it was estimated that in some regions some 60 per cent of the total cattle population died. The overall quality of the surviving breeds has deteriorated. Large numbers of villagers had to leave their homes, trudging long distances in search of water and fodder. Today, deserted and temporary villages are a fairly common sight. With the water table falling in places to a depth of 700 feet, and sweet water turning brackish, the search for water has become a major pre-occupation. Drinking water is sometimes not avail- able closer than 12 miles from the village, and it is now a full-time duty of the fam- ily to fetch the water. Left: Wells may have to be dug several hun- dredfeet deep to reach the water table. It then requires the strength of a camel, or of a pair of bullocks, to draw the water to the surface. Right: Where surface water is available, it usually falls to the lot of the women to fetch water for their families, carrying their heavy pitchers for miles at a stretch. (Photos WHO/A.S. Kochar) 6 Even if a number of human practices have aggravated this desertification, the villagers have at the same time been able to muster some basic techniques in desert cultivation. Thus, under the traditional method of water harvesting, bunds (em- bankments) are built to channel rain- water into selected valleys. The accumu- lated water is then used for irrigating the farms. In other cases, the water run-off has been minimized by building bunds against the slope. Though the over-all impact of all this has been limited, scien- tists have used these age-old techniques as a starting point in their search for ways to tame the desert. Now the prod- ucts of scientific research are becoming available. Detailed groundwater investigations have been started to locate freshwater pockets for irrigation and drinking wa- ter, and canal irrigation has begun to a limited extent in a few districts. A fair number of surface irrigation projects have already been completed, and work continues on others. More important than all these is the still unfinished Rajas- than canal. It has already proved a boon to the agricultural economy in Gangana- gar, and at the Gujarat end of the Rann of Kutch (bordering the Thar) some reclaimed patches of land are already verdant. However, the area affected is still less than a quarter of the total arid zone. Serious water problem The tapping of groundwater is largely dependent on cheap energy in the form of electricity. But for a variety of rea- sons, and because of the limited demand for power in the desert regions, the elec- trification programmes have concentrat- ed on non-arid zones. And though drink- ing water remains a major problem, there does not seem to be enough money to provide this essential service to all the desert folk. The result : 24,000 out of Rajasthan's 33,000 villages still have a serious water problem. Even if funds are a problem, at least the technical know-how exists. CAZRI scientists have experimented with a vari- ety of trees and located those with the most promise for planting in the arid areas. The morphology of sand dunes has also been studied and techniques evolved for stabilizing them by fixing barriers, building fencing, growing sui- table plants and grasses, and creating shelter-belts with the right kinds of trees. Other techniques include strip cropping, which reduces wind erosion by maintain- ing grass strips on farm land, stubble 16 India's creeping sands Left : Less harmful to local vegetation than the goat, the sheep is a hardy animal which can withstand the rigours of the desert and provide a steady source of income for the farmer. Right : Fetching water can have a social func- tion too; village women gossip as they wait their turn at the well. More than two-thirds of Rajasthan's 33,000 villages still have a serious water problem. (Photos WHO I A.S. Kochar) mulch farming (retaining one foot of stubble on the land at harvest time, thus stopping wind erosion), farming by using the water run-off, maintaining proper crop rotation, mixed cropping, and so on. Water farming techniques include trickle irrigation which, it has been es- tablished, makes the best use of every drop of available water and has already led to a tremendous increase in yield. A major area of research has been on rodent control. It is estimated that a desert gerbil unearths 17,000 kilo- grammes of soil per hectare, and this upturned soil is blown away by the wind, leading to further desertification. Studies have been conducted on bait preferences, seed consumption, dosage of toxic chem- icals and the best season for launching a rodent control programme—apparently summer. Dairy culture is also receiving atten- tion. The goat is known to be very harmful to vegetation because of its manner of grazing. A local saying refers to the goat leaving behind nothing but pebbles. Ideally, therefore, the emphasis should be on sheep development. But for a number of practical reasons, it is not possible to do away with goats. For one thing, they are hardier creatures, and face drought better. They also help to lead the herd of sheep, and are the only ones to bleat when the herd is attacked by a wild animal. More than anything else, the goat is the poor man's substitute for a cow; so that, even if the animal is harmful to vegetation, it is more or less a necessity for the people. In an effort to make use of all scientific research, the Government has launched a massive programme for the drought- prone areas, covering roughly half of Rajasthan and a number of districts in the other states. Aimed at restoring the derelict ecosystem and generating ade- quate means of livelihood for desert peo- ples, the programme provides a package of facilities for the optimum use of land, water, vegetation, and human and live- stock resources. Groundwater develop- ment, sand dune stabilization, restruc- turing of the cropping pattern, and other objectives are also being pursued. In live- stock farming, fodder development and "fodder bank" schemes for drought years are receiving priority. This is the most concerted effort made so far in India to improve the quality of the desert peoples' life and of their envi- ronment. While it may not result in making the entire Thar Desert bloom, life will certainly be less difficult for many of those who live there, while the first steps will have been taken to check the advance of the dunes. ■ 17 protecting Zambia's children by Roger Mann L ach day throughout tropical Zam-bia thousands of barefoot women with babies on their backs and fashionably dressed city ladies with elegantly plaited hair bring their children to immunization clinics in well- equipped urban hospitals, rural health centres, country school houses and even thatched huts in remote villages. With the goal of wiping out prevent- able communicable diseases in the coun- try by the early 1980s, Zambia's National Immunization Campaign is in its second year. According to one doctor, "We have already learned so much from our mistakes that I'm sure we will suc- ceed." Zambia was one of the first African nations to take up the WHO challenge to mount an expanded immunization pro- gramme. That challenge was under- scored this year by the chosen theme for World Health Day (7 April)—"Immu- nize and Protect your Child". In view of the many difficulties that Zambia is struggling to overcome, it is not surpris- ing that some other African nations are hesitating before making the attempt. Like almost every country in Black Africa, Zambia suffers from a poor transportation network, a scarcity of trained public health professionals and an overstrained national treasury. To compound the difficulties, the doctors and nurses, the good roads, the hospi- tals, and the lion's share of the health services budget are disproportionately centered in the urban areas. Often in rural areas, where 65 per cent of Zambia's 5 million people live, it is almost impossible to reach remote out- posts. Sometimes there is no vehicle, sometimes there is no petrol, sometimes the roads are washed away and the com- munications network which routinely relies on bicycle messengers breaks down frequently. On the other hand, as one of the world's leading copper exporters, Zambia is wealthier than many of her sister Afri- can countries. Since independence in 1964, national budgets have emphasized expanded medical services and all health care is now absolutely free. In the late 1960s Zambia started an mcH (maternal and child health) programme with the support of UNICEF (the United Nations Children's Fund), so the expanded im- munization project has a solid founda- tion from which to build. Nevertheless, according to Dr Victor Chelemu, Director of the mcH pro- gramme, "Measles is still the greatest killer of Zambian children." He also cites polio, childhood tuberculosis and malnutrition as preventable diseases which are responsible for many thou- sands of deaths each year. In Mwamba Village in the remote Northern Province, near the border with Tanzania, a mobile health team from the District Headquarters in Mbala is work- ing like an assembly line. Their pick-up truck left Mbala at seven a.m. and by ten a.m. "Doctor" Evans Kalumba, seat- ed at an outdoor table, is interviewing the mothers waiting with their children. (In rural Zambia medical assistants like Mr Kalumba are called doctor.) When he sees a child who is obviously underweight, Kalumba gives the mother a full discourse on nutrition, but mostly he explains about immunization. Kalum- ba hands the mothers orange-coloured "children's clinic cards", which they will retain as a permanent history of all their children's immunizations. After check- ing to see if the youngsters already have smallpox and BCG (tuberculosis immun- ization) scars, Kalumba sends the moth- ers and children to the immunization table which has been set up by Ed- son Tunduma and Linnea Nyquist just outside the schoolhouse door. Tunduma, born in a small village near the home of Zambia's President Ken- neth Kaunda, has been vaccinating Zam- bian children for 15 years. He used to cycle from village to village vaccinating anyone who didn't already have a scar. Nyquist, a Public Health nurse from Sweden, has been organizing children's clinics in rural Zambia for three years. Swedish and Dutch nurses started mcx work in Zambia and they continue to play a vital role. As the first mother and her two-year- old daughter timidly approach, Tundu- ma examines the orange card. This is the first experience that this child has ever had with modern preventive medicine. Tunduma squeezes three drops of polio vaccine on the little girl's tongue, then gives her a smallpox vaccination. Mean- while Nyquist is carefully injecting BCG vaccine into the child's left forearm. Before the infant even knows why she is crying, she has been turned face down on her mother's lap and is being injected with DPT (against diptheria, tetanus and whooping cough) and measles vaccine. "It's really a lot for a baby in one day, but what else can we do?" says Nyquist. On a good day the team can immunize four to five hundred children by working in this way. As part of the campaign, pregnant mothers are given tetanus shots as well. "You see," says Kalumba, "most chil- dren around here are delivered by village midwives. They don't know the first thing about hygiene and use anything that's handy to cut the umbilical cord ... a kitchen knife or even a broken beer bottle. The risks of neonatal tetanus are great." Kalumba explains that he has run special courses for village midwives. "But when they return to the villages they think they should be paid more than before, so mothers prefer untrained ones who are only too glad to earn a dollar or ... 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"le I< • it 14 44. • 11 * * ut se***Is or ° .1.6 Ill * * * 0 it * "" 11 * • 0 0 $ 4. 0 • 04.1 No While111 111 *I * - 0 * 111 -11* 4.4.0 protecting Zambia's children Left: A megaphone lends volume to the medi- cal assistant's voice as he explains to villagers the value of Zambia's national immunization campaign. Right: The orange-coloured clinic cards are retained by the mothers as a permanent history of all their children's immunizations. (Photos WHO/R. Mann) two." The best solution all round would be for women to give birth at rural health centres, but the old people often discour- age this or people just live too far away. After one year of the expanded im- munization project, Zambians are hesi- tant to boast. "We don't want this splashed around," says Dr Chelemu, "because we haven't been all that suc- cessful yet. We are still learning how to carry out a national campaign." Zambian health workers agree that the most important elements for running a national campaign must be planning and coordination. "We didn't even have all the vaccines in the country when the campaign began," one provincial doctor admits. "But nobody had the guts to say, `wait a minute, it's too soon.' The ball was already rolling." Throughout the first year, BCG sup- plies remained a problem and almost every other vaccine was out of stock at some time either nationally or regionally, even though most of the vaccines are donated by WHO and UNICEF. "It's very difficult to pinpoint the blame for the vaccine shortage," explains Dr Chelemu. "Our ordering system is cumbersome, but we are trying to streamline it." "At least we have our cold chain working to ensure that the vaccines are constantly kept refrigerated against trop- ical heat," says Kalumba, who operates from Mbala, 620 miles from the capital city, Lusaka. "Zambia Airways has been very helpful. That's part of what we mean by a national campaign." "But," he adds, "in Mbala we didn't even reach half of our target during the first year. We began the campaign with DPT vaccine only and had to return to some villages with polio vaccine and then make a third trip with the rest." "It was a shameful waste of manpow- er, petrol and vehicle time," Kalumba says. "But we were told to begin. Trans- port, though, has been the biggest prob- lem ... a catastrophe, but we'll succeed in the end." The campaign's organizers agreed that each province should be thoroughly surveyed before the actual immunization clinics go into operation. "If we know how many children we have to immunize in each province before we actually begin, we can avoid wastage and keep track of where we stand," explains Dr Chelemu. According to a doctor in the Northern Province, vaccine wastage "is enormous, reaching 50 to 100 per cent with BCG. If we had succeeded in making a survey we could have avoided most of the wastage because we'd know exactly how many doses we need in every project area." But in the Northern Province, which is larger than Holland and Belgium combined, the people are so spread out that nobody has yet succeeded in surveying the area completely. Only the more compact Luapula Pro- vince successfully carried out a survey. Miss Bodil Fredlund, Luapula's Provin- cial Public Health Nurse, comments : "We used medical assistants, health as- sistants, nurses, councillors, teachers, secondary school pupils and even some older primary school kids to help us go from house to house. We now know exactly how many children live in every house in Luapula Province. I just don't see how a campaign like this can be carried out without a proper survey." As a result of the successful survey, the campaign in Luapula has reached more children with less wastage of vaccine, petrol and manpower than anywhere else in the country. 20 From the beginning, the campaign was not fully supported by some health workers. "The most difficult ones are the doctors," said Ibraim Longa, the North- ern Province's Principal Medical Assis- tant. "Doctors are more tilted to curative than preventive care, but once the cam- paign moved into full swing some of them have come around," he added. One doctor who is in charge of a struggling but modern hospital in a remote area explained : "The campaign is too costly. The people are being spoon- fed when a whole team and a landrover goes out to the same village—maybe five hours away—so many times each year. Bicycles should be given to medical assis- tants stationed at rural health centres, and they could give the second and third doses by themselves." A nurse from the same hospital said, "Do you expect us to be enthusiastic when we see our limited staff and our only landrover disappear into the bush? We have so many problems right here in the hospital. The campaign's a good idea, but for us it is just another head- ache." Though Zambia is one of Africa's leaders in per capita expenditure on health, the emphasis hitherto has been on the curative rather than the preven- tive. The Government now runs 920 rural health centres, three times as many as before independence, yet fully 70 per cent of all hospital deaths occur among children under 15 years of age. Now there is a conscious effort to shift to preventive services, but the country finds itself without trained nationals in the public health professions. Much of the mai work is organized by Swedish and Dutch public health nurses, but they will be leaving in 1979. An official from the Swedish International Development Authority (RDA) commented : "We start- ed the mcH programme ten years ago on the understanding that Zambian coun- terparts would fill in as soon as possible, but the Zambians have become depen- dent on us and that's not our idea of development." "We just have to use the staff that's available," says Dr Chelemu who is now beginning in-service public health courses for two-year trained nurses and medical assistants. They will replace the European nurses and will be called Dis- trict Public Health Coordinators. One continuing problem is that many Zambians don't like to serve in rural areas. Most rural health centres are un- derstaffed, while 60 per cent of Zambia's doctors work in the three largest city hospitals. To solve this problem, pay inducements may be offered to the Dis- trict Public Health Coordinators. "But first of all we are looking for commit- ment and devotion," says Dr Chelemu emphatically. Besides immunizing children, Zam- bia's current campaign is creating a national health consciousness in the rural areas. Local health committees have been formed to motivate people. "We're building up an organization that is reaching into the villages and educat- ing villagers to care," says Dr Bobby Hultberg, who heads the campaign in the Northern Province. "I am certain that the campaign will succeed," he adds. "But in the process, we have to change attitudes. People now see health in the context of dishing out medicine. Education is more important. Health for everyone in Zambia can only be achieved by the people themselves, and in the process of this campaign we hope they are learning how to do it." ■ 21

no room for complacency by Alan R. Hinman L n April this year, the Secretary of the US Department of Health, Educa-tion and Welfare, Mr Joseph A. Califano, announced a major national Immunization Initiative which had two goals : to assure adequate immunization of 90 per cent of the nation's children by October 1979 ; to establish a continuing mechanism that would thereafter ensure the immun- ization of nearly 100 per cent of the three million children born into the population each year. Announcement of the Initiative coin- cided with World Health Day—which had as its slogan "Immunize and protect your child"—and heralded the US com- mitment to WHO's Expanded Programme on Immunization (EPI). Besides offering support for the worldwide emphasis on immunizations as a primary tool of pre- vention, Mr Califano's announcement reflected a growing concern about the inadequacy of immunization levels cur- rently in existence in the United States. The introduction and wide use of safe and effective vaccines in the US has invariably been accompanied by a marked reduction in the reported inci- dence of the disease concerned. Polio- myelitis has been virtually eliminated. Fewer than 10 paralytic cases per year have been reported in the last four years, compared with 15,000 or more cases annually prior to the development and use of polio vaccines—first of the inacti- vated (Salk) and then of the live oral (Sabin) vaccine. The reported incidence of measles is now only 10 per cent of levels reported prior to the introduction of live measles vaccines in the mid 1960s. Similar reductions have been seen with diphtheria, pertussis (whooping cough) and tetanus. Rubella (German measles) <Smallpox vaccination certificates are no lon- ger demanded from visitors arriving in the United States. (Photo WHO/ P. Almasy) immunization—universal vaccination of all babies about one year old—has resulted in a marked decline in the reported incidence of both rubella and congenital rubella syndrome. Although there has not been a major commitment of Federal resources for programmes of mumps immunizations, the introduction of mumps vaccine (primarily through private physicians) has also been ac- companied by a decline in incidence. Smallpox was eliminated in the USA in the late 1940s and smallpox vaccina- tion is no longer routinely carried out. Because the incidence of tuberculosis is so low—fewer than one per cent of chil- dren age 15 are tuberculin-positive—the BCG vaccine is rarely used. In spite of the achievements noted above, it is apparent that there is no room for complacency and much remains to be done. An annual survey of immunization levels has shown that more than one-third of the country's children aged 1-4 have not received measles nor rubella vaccine nor a com- plete series of oral polio vaccine. Al- though more than 95 per cent had received at least one DPT injection, more than 25 per cent had not received a complete series. Immunization levels are lowest among the poor and among non- whites. Overall, there are approximately 20 million children in the United States under the age of 15 who still require one or more vaccinations to give them full protection. It was to correct these deficiencies that Mr Califano announced the new Initia- tive, which will involve expanded Feder- al support for immunization, intensified use of volunteers, public information and education activities, and greater co- operation between governmental agen- cies and with non-governmental agencies. Immunizations not delivered by pri- vate physicians are primarily given through local health departments, either as part of comprehensive child health care or in special immunization clinics. 23

no room for complacency Support for these activities comes from local, State and Federal sources, with the Federal Government providing about one-half of the total cost. This support may be general, as part of overall fund- ing for maternal and child health ser- vices, or it may be specifically targeted for immunizations. Federal funds specif- ically targeted for immunizations are dis- tributed to State and local health depart- ments through the Center for Disease Control in Atlanta, Georgia. This Federal support provides only a relatively small portion of total govern- ment funding for immunizations but it has been shown to have a decisive role in the provision of immunization services. In 1969, Federal categorical support for immunization switched from support for measles and polio vaccination to support only of rubella vaccination. The result of this change was that, although millions of children were immunized against rubella, measles immunization fell off dramatically and the incidence of measles increased. In recent years, sup- port has been available for a range of immunizations, but the level of support has declined until the current year. Over a two-year period, the level of Federal categorical support will now quadruple, to approximately $ 20 million. These funds will support a variety of activities. About one-half will be used to purchase vaccines. The remainder will mainly be used to employ individuals who will conduct surveillance and out- break control, assess immunity levels of individuals and groups, provide commu- nity and (where necessary) door-to-door education and motivation, and actually administer immunizations. In order to achieve the objectives, there will obviously have to be a major effort to identify those in need. Since more than one-half of those in need are of school age, schools will serve as a major focus of activity. Immunization histories will have to be obtained and reviewed for each child. Immunizations will then have to be provided to those needing them, often in the school itself. This task will be made easier by the fact that 47 of the 50 States currently require at least some immunizations prior to first entry to school. Unfortunately, the exis- Some 20 million US children under the age of 15 still need one or more immunizations to give them full disease protection. (Photo WHO/M. Jacot) tence of these laws does not solve the problem—many are of recent passage and refer only to those entering kinder- garten or first grade, and many cover only one or two immunizations. Addi- tionally, there has been uneven enforce- ment of these laws. Consequently, identi- fication and immunization of inade- quately protected schoolchildren will require substantial effort and a substan- tial number of people to do the work. In this area, volunteers will be particularly important. For children who are not yet of school age, the problem is more complicated. Most of these children are not in orga- nized settings such as schools, there are few official requirements for their im- munization, and they are at greatest risk of severe effects from the vaccine-pre- ventable diseases. Identification of these children may require review of all medi- cal records in health-care institutions to find those who received some care but did not complete an immunization series. Since more than 95 per cent of children have received at least one DTP (diph- theria, tetanus and pertussis) shot, such a review, though difficult and time-con- suming, should identify most of those in need. Other techniques, including door- to-door assessment, may be necessary in some areas. This also will require many people and will be an area in which volunteers will play a major role. The health authorities will also have to step up the number and hours of clinics, holding them at the most appropriate time of the day or week (often in the evening or at weekends), and holding them in special locations, such as schools. Since the resources are not available to employ the numbers of personnel required, it is apparent that the assis- tance of volunteers will be an integral part of the programme. Volunteers will also be necessary for community and door-to-door educational activities. This type of assistance has in the past proved very successful in individual localities and States, but the involvement of volun- teers to this degree at the nationwide level is unprecedented in the United States. To ensure most effective use, a national coordinating committee for volunteers is being formed and similar committees will be set up in each State if they do not already exist. Promotional and educational materials including pamphlets, posters, newspaper and magazine advertise- ments, television and radio announce- ments and advertisements for use in sub- ways and buses are being prepared for national distribution. These will attempt to increase public awareness of the need for immunization. Materials designed specifically to motivate identified groups in particular need will primarily be devel- oped at the local level, to ensure the most appropriate approach. Radio stations and churches reaching these groups will receive special attention. To alert the health care community to the extent of the problem and the need for action, articles will appear in profes- sional journals and newsletters. Conven- tions of professional groups will be a particularly important target area, since about one-half of the country's children receive immunizations from private physicians. To help educate the parents of tomor- row about the need for preventive health measures, classroom materials will be developed as a resource for teachers throughout the USA. Many different governmental agencies are involved in the delivery of health services, and many more have pro- grammes of other types which reach those most likely to be in need of immun- izations. To ensure that maximum coop- eration is obtained and that available resources are used to their greatest ad- vantage, an office for the Immunization Initiative has been established under the direct supervision of the Assistant Secre- tary for Health, Dr Julius B. Richmond, and his deputy, Dr Joyce C. Lashof. In addition to the government agen- cies involved, numerous other organiza- tions are cooperating with the Initiative through the provision of services or the dissemination of promotional and edu- cational materials. These include busi- ness organizations, labour unions, pro- fessional societies, and religious, frater- nal and civic organizations. Activities of these groups are being coordinated by committees at the national and State level. Through a concentrated effort of the public and private sectors and through massive use of volunteers, the United States is thus undertaking to markedly improve immunization levels in children over the next two years. If all goes as planned, at least 90 per cent of the child population will by then be adequately immunized against measles, polio, rubel- la, diphtheria, pertussis, tetanus and mumps. ■ 25 the smokers' world THE ANSWER TO THE PROBLEV OF HOW TO DIV INISH THE EFFECTS OF TOBACCO ON AILING LUNGS AND CHESTS ALL OVER THE WORLD LIES IN THE SOCIAL CONSCIENCE OF THE AFFLUENT NATIONS by Arthur Hayward-Costa moking is only a serious problem to the person whose addiction to tobacco is so strong that he can- not stop the habit from crippling his health. It is a mild flirtation to the light smoker, with little risk of disease, and an annoying pollutant to the non- smoker bystander. Only to the unborn child can it be said to be an inescapable menace. Otherwise, and on the whole, the uses to which tobacco is put today can be classed, along with the myriad excesses of human nature in seeking self- gratification in material well-being, as socially unacceptable because, on the whole, they have been found to be inju- rious to health. But so is drinking, eat- ing, motoring, hang-gliding and promis- cuous sex. Or so say the defenders of freedom to supply and promote tobacco, and they are many indeed, all over the world. Having once myself been a senior ex- ecutive in an international tobacco com- pany, I have disciplined myself over the years to keep looking at the tobacco problem purely from the point of view of the individual smoker; a discipline that was instilled into me early in life by the necessities of commerce, since only at his own peril does an executive ignore the basic truth that all profits come from sales, and all sales come from satisfied customers. In the case of tobacco, a satisfied customer is not necessarily a healthy one, but that has never stopped any tobacco company from selling its product vigorously, and most certainly drunkenness, and the promotion thereof, is seldom the aim of the distillers of wines and spirits. Business is business, and the health of the customer is not the concern of the manufacturer. It only becomes his concern when consumer protection measures threaten the profits of his firm. It is at this point that heavy lobbying comes into its own in the corri- dors of power; the pressure groups orga- nize themselves to cope with the oppos- ing side, and this inevitably leads to a war of statistics between rival factions, at the expense of the consumer himself who loses touch with the 'pros' and 'cons'. He might well take to heavier drinking, "This is how you burn up your health" . says the slogan on this Soviet anti-smoking poster. Right : For the mother-to-be, heavy smoking carries particularly serious risks for both her and her baby. ( Photo Norwegian National Council on Smoking and Health) smoking, eating or motoring to relieve the tensions both of the affliction and its proposed cure by social action. Social action, without an accurate social evaluation of the whole situation, is seldom anything more than steps along the tortuous path of social maturity, rather than the arrival at some desired superior destination through social activ- ity born of community sacrifice. Thus the man who, unknown to him- self, is smoking himself to death—and there are many of these around after the age of 35, and infinitely more after the age of 65—is ostentatiously protected from himself, yet little direct personal help is given to him to overcome his affliction by the community do-gooders and the professional medical men. Help comes in different forms : medi- cal, legislative and socially-corrective. In the United Kingdom, as in many other countries, the Government is usually concerned with the somewhat expensive underwriting of all three forms of activi- ty, but never concerned enough directly, it would seem, to substantially reduce the sale of tobacco products and thereby reduce the incidence of premature deaths from tobacco consumption. The medical profession, together with its associated health education services, in most countries with anti-smoking ac- tivity is content to see only moderate programmes of direct help to the addicts introduced. As a result, over the last ten years or so, we have seen various degrees of marketing controls, advertising bans, 26

and legislation to hinder, but not to prevent, the tobacco manufacturers from selling and promoting their wares, inju- rious to health though they have been found to be. Governments have failed to extract any serious commitments from the tobacco companies to uphold any kind of social responsibility programme designed to phase out the manufacture and sale of their products. These governments themselves, caught between both a substantial tax revenue earner and a health hazard of epidemic proportions built into an international trading asset, have maintained a some- what schizophrenic stance, whereby they are both 'for' and 'against' tobacco. The manufacturers all over the world, and their supporting growers, curers, shippers, wholesalers and promotional experts, have always maintained that smoking is an addiction reinforced by social customs and rituals. The condition of the product has to be such as to satisfy the most discerning customer in any par- ticular country. Unknown to many lay adherents of a brand, the same interna- tional pack often contains different blends of tobaccos to suit the particular local taste, and this means that many secrets are hidden in the same well- known international packets in popular circulation around the world. Not to mention the counterfeit packs that are "passed off- by pirate manufacturers at the expense of the leading companies. It has been erroneously assumed by the anti-smoking lobbyists that under- mining the promotional efforts of the manufacturers by slight touches of legis- lative control here and there would be sufficient to curb the incidence of addic- tion and disease. Over the past decade, much ground has been covered by such countries as the United States, the United Kingdom, Norway, Sweden and Italy, and the overall pattern of progress is encouraging; but the pressure groups are still far from their declared aim of seriously affecting the sales and profits of tobacco companies. Considerable em- barrassment has been caused to many companies, as well as to some state monopolies selling tobacco, without dis- lodging the substantial hold that the manufacturers have on their markets. The latter have adapted their styles to suit their adversaries. Pushed out of tele- vision commercials, they increased their sport promotions in those sports that command peak television coverage, and by supplying much-needed cash to ailing sports they have also succeeded in get- ting national sporting organizations to publicly defend their subsidies from tobacco sales. Restricted in press cover- 28 the smokers' world Left: Pollution begins at home. The stubbed- out ends of cigarettes tell their own story in this cartoon, one of a series of health education slides made by Norway's National Council on Smoking and Health. Anti-smoking groups are still far from their declared aim of se- riously affecting the sales and profits of to- bacco companies. Right: Many youngsters start smoking as a furtive way of flouting parental or school authority. But it is a short step from fun to habit, and from habit to addiction—and the damage may be lasting. (Photo WHO/T. Farkas) age in main circulation newspapers, they switched to other printed media com- manding overall the same readership ex- posure but spread over a wider field of publications. Two major innovations in recent years have been the introduction of low tar cigarettes, and the cautious courting of "new smoking mixtures" or "supple- ments" as they are sometimes known. The former have been particularly popular, judging by sales in the United Kingdom and other parts of the world, where introduced with adequate market- ing supports. The latter, much to the embarrassment of many of the interna- tional manufacturers that originally went in for them, have proved "only a quali- fied success". These cellulose-based addi- tives to normal blends of tobacco, in proportions ranging from 15 per cent to 25 per cent, have been test-marketed in various countries, with notable failure in the Federal Republic of Germany, par- tial popularity in Switzerland, and a fair- ly indeterminate programme of tests and trials in other parts of the world. The answer to the real problem of how to diminish the effects of tobacco on ailing lungs and chests all over the globe lies in the social conscience of the af- fluent nations ; for smoking itself only attracts expressions of concern, from physician and economist alike, when it has already been recognized as a major health risk. Society must first agree on a concept of health that involves the whole person, in mind, body and any other spiritual dimension appropriate to the custom or the culture involved. This would inevita- bly lead to a health emphasis being brought to bear on the sum total of all human pollutants, whether physical, chemical, mental or even moral. And limits would then be strictly laid down according to local community considera- tions and not to international trading requirements. Social progress, in sick- ness or in health, depends on concerted legislative action to achieve the greatest happiness of the greatest number, at the lowest possible cost, backed by judicious public education campaigns to support the legislature in its more difficult tasks. What is needed is to translate passive, mildly palliative, official token concern into active, planned and fully financed "welfare programmes" of the kind that consider the whole person in relation to local community needs. The decision whether to smoke or not to smoke, though in the ultimate degree still an individual one, carries with it social re- sponsibilities that are reflected at the national, if not the international level. ■ 29 WORLD HEALTH milestones in medicine PARACELSUS Just 450 years ago, in 1527, a Swiss doctor called Paracelsus published an angry pamphlet overthrowing most of the long-held beliefs about diseases and their treatment. He publicly burned the books of Galen and Avicenna— whose medical notions had never been challenged for centuries—and declared : "It is because these doctrines prevail that so few physicians have a precise knowledge of illnesses and their causes." Nature, he said, was the prime healer. It amounted to a revolution in medi- cine! Indeed Paracelsus was usually portrayed wearing a great sword which he brandished while he thundered "My beard and my shoe-buckles know more than you and your old writers." Al- though the enemies he made forced him out of his job at the University of Basle, in Switzerland, he spent the rest of his years wandering all over Europe, healing the sick and seeking at every turn to increase his understanding of medicine. "The universities teach us nothing", he would say. "A good physician should be ready to learn from midwives, gip- sies, nomads, brigands and others who live outside the law. He should inquire among all classes of people, seeking out everything that might contribute to his knowledge. He should travel widely, undergo many adventures and learn, learn all the while." Paracelsus —or to give him his proper name Philip Aureolus Theophrastus Bombastus von Hohenheim—was still wrong about many things of course. Although he did not believe in horo- scopes and the astrology of his day, he did think that the stars influence disease and his far-reaching new ideas about treating diseases and wounds were mingled with magic and alchemy. But from our point of view four-and-a- half centuries later, we can see that he was a philosopher, physician, physicist, chemist, geologist and astronomer. He has been called the founder of chemo- therapy—the treatment of disease by chemical agents. He was the first doctor to describe an occupational disease- phthisis, a lung disease suffered by coalminers—and he added significantly to what was known about epilepsy, paralysis and speech disorders. His claim that mental illnesses were natural diseases and not due to "spirits" put him far ahead of his time. His great achievement was his insis- tence on practical experience, the ob- servation of nature and regular contact with the sick or injured, which he almost alone in his day recognized as the basis of scientific medicine. When he died in 1541, aged only 48, he left only a handful of coins and a few books. But in his will he committed his soul to God and all of his life's work "to the poor, the wretched and the needy". in the next issue The November issue of World Health will show the progress that is being made in integrating Traditional Med- icine into modern health care sys- tems A ERIC SCHWAB 1910-1977 Chosen from among two million entries, this appealing picture of a little African hospital patient featured in the Family of Man photographic exhibi- tion, first shown at New York's Museum of Modern Art and later circulated throughout the world. It was taken by Eric Schwab, who first undertook a WHO assignment as long ago as 1950 and whose work has frequently been featured in the pages of World Health. We record with regret his death last June, after a long illness. WORLD HEALTH for readers everywhere Authors of the month Sir JOHN WILSON is the President of the International Agency for the Prevention of Blindness, which has its headquarters at Haywards Heath, England. JosE AIICEDE is the Public Infor- mation Officer at WHO'S Western Pacific Regional Office in Manila. T.C. NINAN is a journalist with the Hindustan Times, New Delhi. ROGER MANN is a freelance jour- nalist and phOtographer working in Nairobi and specializing in health matters. Dr ALAN R. HINMAN directs the Immunization Division of the Bu- reau of State Services, Center for Disease Control, in Bethesda, Maryland, USA. ARTHUR HAYWARD-COSTA IS an English journalist whose special concern is the risk to health from tobacco-smoking. without words The slogan for World Health Day 1977—"Immunize and protect your child"—is also the title of a non-verbal animated cartoon made for WHO by Zagreb Film of Yugoslavia. A 16 mm colour film lasting five minutes, it was designed by Aleksandar Marks. Its main purpose is to motivate mothers in developing countries to bring their infants to the local health centre for a series of vaccinations against the prin- cipal diseases of childhood. The car- toon attempts to accomplish this objec- tive without the use of words, whether spoken or written. In this way it can be used without regard to linguistic or cultural boundaries. The message of this lively cartoon is simple: if you fail to immunize your child, it may not survive. Copies of the film are available on sale from the Film Officer, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland. ORDER FORM Please enter my subscription to "World Health" as follows: US$' Sw.f r. • One year 10.— 25 Two years 18. 45 . Three years 24.— 60 One year: Two years: Three years : I enclose cheque/postal order in the amount of Name : Street : _______ City: Country : "or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Smoking: is it worth the risk? (Photo WHO)