WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN
ANNUAL REPORT
of the
REGIONAL DIRECTOR
to the
TWENl'Y-FIRST SESSION OF THE REGIONA.L COMMITIEE
1 July 1970 - 30 June 1971
EM/RC2l/2
TABLE OF CONTENTS
INTRODUCTION • • • . • .. .. .. .. .. .. .. .. .. .. . .. .. ' .. .. .. .. .. . .. .. ..
THE REGIONAL COMMITl'EE FOR THE EASTERN MEDITERRANEAN TWENTIEl'H SESSION
. PART I ,.. GENERAL REVIEW
I ADVISORY AND TECh'NICAL SERVICES
1. EDUCATION fu'ID TRAINING
Medical Education. • • . • • . • • • • Training of Auxiliary Health Personnel Fellowships Programme ••••••••
2. MALARIA ERADICATION
Status of Malaria Eradication Activities and General Progress • • I nternational Assistance in 1970 Problems ... Training • . • Co-ordination Prognosis
3. COMMUNICABLE DISEASES
Virr.l Diseases (Smallpox Eradication) Bacterial Diseases (Cholera - Tuberculosis - leprosy) .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . Parasiti c Diseases (Schistosomiasis - Leishmaniasis -
EM/RC21/2 page i
3
13
17 19 21
24 25 27 29 30 30
44
Onchocerciasis) .. .. .. .. .. .. '. .. .. .. .. .. .. .. .. . 49
4. PUBLIC HEf.LTH SERVICES
Public Health Administration Community and Rural Heal th Health Labor atory Services Nursing. • • . • • . • • . Health Education •.•.• Maternal and Child Health Family Health ~ .. ~ .. .. .. Pharmacy and Medical Supplies Vital and Health Statistics
5. HEJ:.LTH PROTECTION AND PRorvtarION
Cancer Control . Radiation Health • . . . • . . •
. . . .. .
53 55 57 60 61 62 64 66 68
70 71
EM/RC21/2 page ii
II
5. H&~LTH PROTECTION J,ND PROivl0rI ON (Cont I d)
6.
7.
Nutri t i on • • . • . . . . . • • Nental Health . • • . . . . . . r·ledical Care and Re habilitation
ENVIRONI"iEN'l';,L HEf,LTH PJID COMHUHITY WATER SUPPLY
Vector Control
SPECIf>L FUND CO - ORDINi1.TING SERVI CES
PUBLIC INFORF!,,',.l'I ON • • • •
III ADro1INISTRATION hND Fl NiiliCE
General Personnel . • • . Budget and Fi nance 1-1edical Supplie s end Equipment
FOREl-IORD
hfghanistan Cypr us . Et.hi opi c::. Iran • Iraq • Israel Jorda.'1 Kuwait l.€benon Libya Pakistan
PART II - PROJECT LJST
PDRY (People's Derlocr ati c Republic of Yemen) Qa t ar Saudi Arabia Somal ia • . Sudan Syrian Ar ab Republi c Tuni sia . ' . ' • . . United Arab Republic Yeme n [,rab Republic
Inter-Countr y Projects
ANNEX - Agreements signed between 1 July 1970 and 30 June 1971
74 77 78 80
84
86
9J
94 95 96 97
100
101 n o 112 121 129 135 139 143 145 149 163 177 181 182 187 192 203 208 215 225
233
INTRODUCTION
INTRODUCTION
In introducing my last report I drew attention to the more liberal
concepts of social and economic progress and the essential role of
health in that progress which is increasingly receiving the attention
of the Regional Govermnents. These trends are serving to broaden
the base of health activities and to emphasize the importance of good
planning and management in the expansion and development of health
services.
* The rapid general and economic development which is taking
place in large areas of the Region is changing the 'picture in rural
areas tremendously. Education and health facilities, social and
agricultural extension services and potable water are being extended
to a large number of rural areas which have long , suffered from
deprivation and cultural isolation. Notwithstanding this commendable
development, the majority of the rural population in the Region still
suffers from serious problems and is exposed to health hazards which
are basically similar, being related in a large extent to environm.ental
conditions, defective sanitation' and lack of personal hygiene. With
the development of urban and rural life and economy, new problems
are arising and a change in the pattern of disease is becoming apparent.
Improved irrigation and land reclamation have led in several countries
to the extension of schistosomiasis and malaria and adaption syndromes
associated with sedentarization. Rapid industrialisation and urbanization
are causing new health problems such as air and water pollution and
entan a need for greater attention to occupational and mental health.
There is, therefore, a need for developing a plan and strategy that
relates health to development in the broadest possible ways, with the
EM/RC2l/Z page 4
main objectives of providing most of the people with optimum health
care using the often limited resources in ways that will yWld the
g reate st pos sible benefits.
* There can be no doubt that ' TiTHC 's assistance will be most
effective if it is given in the context of a well-thought-out national
health plan. It is encouraging t o see not only that an increasing
number of countries in the P.egion have already such health plans
integrated within their social economic d e velopment plan, but
especially that their quality is steadily improving as trained man
power and information become available.
I am c onvinced that one of the greatest contributions t o improve
ment in health services would b e brought about if all senior officers
of the Ministries and provincial health departments as well as
Directors cf health institutions were to appreciate fully the need to
devote time and expertise to improving and modernizing their
adxninistration. I therefore hope that the interest which C: overnments
have always shown in supporting candidates for fellowships to take
advanced courses in Public Health Administration and National Health
Planning wfil continue.
* The trend towards greate r emphasis on planning and coordination
of international development assistance at the country level, which I
mentioned in my report last year, has continued. The TJ nited Nations
Development P rogramme has b ee n developing procedures for country
prograxnn-iing with the collaboration (If all organs within the United
E!>tt/RC2l/2 page 5
Nations system. The methodo by which VTHO can best cooperate in
this process are being worked out, b earing in mind the Organization's
constitutional role in assisting c ountries in the development of their
health services al~d coordinating all assistance available to the health
programme from bilateral or interr.ationa l resources. Our participa
tion in the UNDP, UNFPA , IBRD a::ld WFP programmes is expanding
and it is anticipated that our association with the Economic Commis
sion.s of the Un!ted Nations, especially the ECA, ECAFE and UNESOB,
will also grow in the light of the n ew procedures f o r the country
programming within the UN far.'lily. Cur long-standing cooperation
with UNICEF, FAC, ILC, UNESC'J and IAEA ·w ill als o , of course,
continue, However, I need n ot elnph::!.s i ze that the extent t o which
health will obtain its fair share or a dditio;I?l resources available will
depend on the priorHy tile Cover:J.::11C::.:O c oncerned and especially the
health authorities wi!.l g ive to :he l-.e 2.1th c omponent of these joint
programmes.
.' . . ,'
As in the previous years, in'::i'eadr:g importance continues to be
given by WHO to the tra ining of the h ealth m a npower so lnuch needed for
the development o f the b as ic heaLth se rvices throughout the Region.
Governments are adopting a broad e r c onc ept in this direction and
training of paramedical and auxUial'Y personnel is expanding parallel
with that of the doctors. A ire 1311. app r oach t o the shortage of physicians
is being worked out; since b a nun1be r of our Regional countrIes there
is no possibility, f or a t l east a generation, of producing enough physicians
to carry out their traditional functions, these duties must be reallocated.
Many activities regarded as t i1e El ci1 e r e sponsibil ity of physicians can well
be performed by auxiliary w o rker s if they are suitably trained and
E M/RC2l/2 page 6
adequately supervised. The e stablishment of th e H ealth Manp ow e r
Development Institute s in Aden, Pe ople's Democratic Republic of
Yemen, and in Sa na' a, Yeme n, a r e steps in the dire ction of d e vel op
ing c omprehensive prog::-amm es f or the training of various catego ries
of health p e rs cmnel r equired t o m eet the growing demand fo r h e alth
services.
In the fi eld of medical educa tion, I w ould like t o refer briefly
to the Second Regional C onfe r e nce on this subje ct which was h eld in
Teh e ran in D e cembe r 1970 .
Various m a tte rs of impo rta nc e with r e gard to the training of
physicians w e r e discuss ed in d epth. The c onfe r e nc e r e viewed the
situation in the Reg i on, particul a rly pr e -medical education, c ommunity
centred training of m edical stude nts, the plac e of pre ventiv e m edicine
in the m edic"l curriculum, probl e m s c onne ct ed with the planning and
establishme nt of n ew m e dical sch ools, organiza tion of librarie s and
training of teache rs in scho c1s of m e dicine .
A gathe ring of this kind shculd be evalued by its contributi on t o
an appropriate c ommon unde rstanding of the ess e ntial pr oblems of
medical e ducation a m ong the m edica l educa t ors in the R egion. This
in turn help s c ommunica ti on b e twe en the scho ol s of different c ountrie s,
which the Regiona l C ffic e has e nd eavoured to pr om ot e in various ways,
one being through c ontinuation of the proj e ct f 0r th e exchang e of
profe ssors b etwee n m edica l s chools in the Region.
* Assistance c ontinued t o b e prcvide d t o C-ov e rnme nts in the R e gion
in nursing education t o pre p a re varicu a c a t eg orie s of nurses at pro
fessional and a uxiliary level s . The increa s ing opportunitie s f o r the
EJ-.1/RC21/2 page 7
education of wOmen are slowly raising the standard of the recruits
available. A general awareness of the need to revise the admission
requirements periodically if) being fostered to ensure that all well
educated girls are riot diverted to other professions. In fact, due to
increased acceptance of nursing as a profession, the number of avan
able trainees is showing a steady increase.
With the acute shortage of nurses in the Region, efforts are being
made to promote an awareness of the need for Governments to revise
the conditions of service for qualified staff. This in turn should
minimize the apparent increase in the search for employment in other
countries.
* In the field of malaria eradication the problem of vector resistance
to insecticides continues to receive all due attention from governments,
as well as WHO. Although DDT is still by far the most commonly used
insecticide in malaria campaigns, it is almost certain that there will
be a considerable increase in the use of newer insecticides in the years
to corne. The opportunity to plan community malaria measures on a
realistic basis, taking into consideration technical, administrative and
financial feasibility, has to be seized in time and I am glad to note that
there is an obvious desire to improve the administrative and operational
measures and also not to repeat the mistakes which in certain instances
have led to development of insecticide resistance through undUly pro
tracted spraying operations. It is, therefore, important that the utmost
effort be made to obtain rapid progress from the attack phase to the
consolidation phase wherein insecticides of any nature are not required.
In the interim there will have to be increased use of and research into
such supplementary measures as drug administration, larviciding,
E~,1/RC21/2 page 8
source reduction and biological control. There is also, as has been
pointed out in my previous reports to the Committee, an urgent need
for more widely developed rural health services which can ultimately
integrate the malaria programme and undertake vigilance against re
introduction of malaria.
It can be said that malaria as a public health menace and a bar
to social economic development still receives the best attention of
all concerned in its c ontrol or eradication. Although there are prob
lems, there is als o determination t o find a solution. This being s o ,
we will continue t o assist GovernmentG of the Region fully in the
conduct of their malaria eradication campaigns in order that the
remarkable protection already given to m o st of the people is maintained.
* During the period under review, EI T o r cholera again appeared
beyond its usual range and f or the first time reached north, east and
west Africa, a situation which gave conce rn t o the public health
workers of the invaded as well as of c ountrie s at risk. "'accination
was the first preventive measure the health authorities thought of -
although this is the least effective - and c onsequently the demand for
vaccine was great .
In countries where basic health services and environmental sani
tation were adequately run, and when personal hygiene was exercised,
morbidity and particularly m ortality rates were low and the disease
was easlly overcome.
Experience has shown that almost 100 per cent recovery could
be expected when patients were taken immediately to hospitals and
received proper treatment.
*
E M/RC21/2 page 9
As in previous y ears, the C- overnment of Saudi Arabia and WHO
gave considerable importance t o the Mecca Pilgrimage. Two WR C
missions c ompo sed of epid e miol ogists, bacte riologists, clinicians
and sanitary e nginee rs, we r e as s igned t o Saudi Arabia before and
during the · Pilgrimage. I am happy to r ep ort that the 1970 Pilgrimage
s eason was d eclared fre e fr om quarantinabl e diseases.
In the field of nutrition, the rcl e of s ound nutrition as an essential
f or better health a nd the need f or a planned and c oncerted approach
to bring about an improv e m e nt in the nutritional standards of the
people in diffe rent countries of the P.egion has been receiving increasing
attention. Although the magnitude of malnutrition in the various
c ountries of the R egion still n eeds t o be m ore precisely defined, it is
evident that vulne rabl e segments of p opulation in several c ountries
suffer from frank d e ficie ncy diseas e s such as protein cal o rie mal
nutrition, anaemias, vitamin A deficiency, ricketts and g oitre . It is,
of course, well known that many of the s e can b e effectively controlled
or prevented by appropriate programmes through the integration of
nutrition activitie s into the w ork of the ba s ic h ealth s e rvices .
A proble m c emmen t o many de vel oping c ountries is the nutritional
management of infants in the weaning p e riod. This has been in the fo re
front of our minds and e fforts t o produce prot e in-rich weaning foods,
with the assistance of F AG and UNICEF, a r e being pursued in many
countries of the Region (production of such mixture s is already unde'%'
way in E thiopia, I r a n, Tunisia and the United A rab R epublic).
*
EM/RCZl/Z page 10
Many countries of the Region are realizing the constraints which
are being placed on their economic development by a high population
growth and have adopted policies fo r its contre-I. VlHC, according to
its mandate, does net pr omote or endorse any particular population
policy but does, upon request , assi~t its l'f.embers in developing
family planning activities as part of their health services.
Priority is being given t o the training cf health personnel respons
ible for family planning and to integration of family planning into
general health services, particularly in the maternal and chUd health
services. The United Nations Fund for :Oopclation Activities has
made considerable funds available for assistance t o Iran, Iraq,
Pakistan, Tunisia and the United Arab Republic in training of
personnel, provision of advisory services and research.
* In the latter part of 1970, a devastating cyclone struck East
Pakistan, resulting in widespread floods and other damage to installa
tions, communications and dwellings. The resulting morbidity and
mortality figures assumed d~6aster proportions, and emergency relief
operations on a vast scale were undertaken, partly with assistance in
the form of men, materials and money from all quarters of the globe
as well as from the UN system of agencies and UNICEF. WHC took
part in relief operations, n ot only by making certain essential supplies
available at short notice t o a value d s ome VE: f/ 100 000, but also by
helping to coordinate other medical and health assistance offered by
friendly countries and non-g cwernmenta1 and voluntary organizations
and agencieo. I am sure !":n Members share my feeling of sympathy for
the sufferers . in this natural calamity, and join me in wishing them
a speedy return t o health and prosperity.
*
EM/RCZl/Z page 11
Twice this year events have occurred in our Region that have
interrupted WHC assistance to the c ountries concerned - in Jordan
and Pakistan. In Jordan, international staff, including WHC staff,
were temporarily withdrawn last fall as a result of disturbed condi
tions, and, for a while, delivery of project supplies and the recruit
ment of staff and consultants had to be halted. Happily, this position
could be reversed before l ong, and a 'NHC staff member was one of
the first to resume duties when normal conditions began to return.
Much the same action had to be taken some months later in East
Pakistan. At the time of writing, the situation has practically returned
to normal and it is planned that staff return to duty soon. The diverted
supplies are also being routed back t o the area.
In conclusion, I should like once again to extend my thanks and
gratitude to the ('!overnmento of the Region for their unfailing and very
much appreciated assistance in the planning and implementation of WHO
programmes in the Region.
* It is also a great pleasure for me to welcome the C:overnment
of Cman as a new Member of the ur orld Health Organization and the
Eastern Mediterranean Region. I aIn sure that our collaboration will
prove mutually beneficial. I look forward to close cooperation with
the Government and the Health Authorities in the Sultanate of DInan.
TWENTIETH SESSION OF THE WHO REGIONAL COMMITTEE
Country representat ives at Sub-Committee A o f the Twent ieth Session of the WHO Reg io nal Com mittee held in Broummana , Lebanon, from 21 to 24 September 1970.
SECOND REGIONAL CONFERENCE ON MEDICAL EDUCATION
Problems and prospects for medical education were reviewed by more than 100 medical faculty deans, health policy-makers and senior educators from 17 countries at the second regional Conference on Medical Educat ion, which met in Teheran from 12 to 19 December.
(Below) A ple nary session at the Labour Mi nistrys Conference Hal l. (Right) A group of partic i ~ants pict ured against snow.capped Elburz .
" .... y ,.,.~~
The place of psychia try in medical ed ucat ion was looked at af~es h by partici pants in a WHO sponsored sem inar convened in Alexan dria from B to 15 Jul y. They are photogra phed he re with H.E . Dr Abdou Sallam , Mini ste r of Public Hea lth (U AR), and H.E. Dr A.W. EI Borollossy, Minister of Scientific Research 11111R ,\ f"h ~,... Min ic:tPI" nf ~jah ~,. I= rill(,"-::Itinn
THE REGIONAL COMMITTEE FOR THE EASl'ERN MEDITERRAt'lEAN
T~JENTIETH SESSION
EM/RC2l/2 page 13
Sub-Committee A of the Twentieth Session of the WHO Regional Committee
for the Eastern Mediterranean met in Broummana, Beirut, Lebanon, from 21 to
24 September 1970. There was no meeting of Sub..committee B.
Sub-Committee A was attended by Representatives of eighteen Member
states and two associate members.
The United Nations, the United Nations Development Programme, the
United Nations Children's Fund , the United Nations Relief and Works Agency
for Palestine Refugees and the Food and Agriculture Organization of the
United Nations were also r epresented as well as fourteen international
non-governmental and inter-goverTh~ental organizations.
The proposed programme and budget estimates for the Region for 1972
were endorsed for transmission to the Director-General. These provided
for a working budget of about US $ 9 098 000, to which should be added
fUnds from the United Nations Development Programme and governmental
sources for Funds-in-Trust operations.
In the discussion on the Regional Director's Annual Report for the
period 1 July 1969 to YJ June 1970, the importance of integration of health
planning into socio-economic plans was emphasized. The need for evalua-
tion of programmes was stressed. The continuing problem of shortage of
technical manpower was recognized and it was hoped that the increasing
number of medical schools and better conditions of service for health
personnel in the Region would solve the problem of the "brain drain".
Eradication of malaria was still a priority, agricultural and irrigation
developments having aggravated the situation. Improvement of public
health laboratories, pharmaceutical services and radiation protection
measures and legislation, were all considered important. Special Fund
projects amounting to over two million dollars, for which HHO is the
EM/RC21/2 page 14
executing agency, comprising feasibility studies, training programmes,
health manpower institutes, environmental health programmes, notably
community water supplies and sewage schemes, are in operation or being
planned.
Other subjects considered included the fifth programme of work for a
specific period, long-term finrulcial indicators, recent advances in tubercu
losis control with reference to the control measures in the Eastern Mediter-
ranean Region, medical education and the need f or teacher training, and
cholera.
"The main zoonotic diseases in the Eastern Mediterranean Region" was
the subject of the technical discussions. "The integration of l<ICH and
family planning activities in the general health services" and "Occupation_
al health services in meeting the health needs of the people in developing
countries li were confirmed as the themes for technical discussions 1n 1971
and 1972, respectively.
Sub-Committee A confirmed its previous decision to hold its 1971 and
1972 sessions in Tunisia and Jordan, respectively, and accepted the invita
tion of the Government of Syria to meet in Damascus in 1973.
PAR T I
GENERAL REVIEI>1
I ADVISORY AND TECHNICAL SERVICES
1. EDUCATION AND TRAINING
MEDICAL EDUCATION
EM/RC21/2 page 17
A major obstacle t o the development of health is the dearth of trained
medical, nursing and auxiliary personnel. For this r eason, assistance to
institutions for medical education, both direct and indirect, continued to
be considered as a priority.
Thirteen l,ffiO professors were assigned to medical schools in Afghanistan,
Ethiopia, Iran, Pakistan, Syria and Tunisia, while five consultants were
sent to Ethiopia, Israel, Sudan and Syria.
Fellowships, as shown in a subsequent section in this chapter, formed
a significant part of WHO assistance to medical education. The contribu-
tion of teaching and scientific supplies and equipment, specialized books,
and scientific periodicals has been considerable.
Within the programme for the exchange of professors amongst medical
schools in the Region (EMRO 0121), eight professors from Iran, Sudan and
the United Arab Republic visited and participated in teaching and scientific
activities of medical schools in Iran, Iraq, Sudan, Tunisia and the United
Arab Republic.
The Seminar on the Place of Psychiatry in ~1edical Education, held in
Alexandria in July 1970, focussed on a review of the teaching of behavioural
sciences and psychi atry in medi cal schools of the Eastern Mediterranean
Region. It concluded with recommendations concerning the methods and con-
tent of teaching of psychiatry and its position in the medical curriculum;
training in clinical psychiatry; planning of the teaching field, and pre-
paration of teaching staff. The role of the general practitioner in mental
health, including its preventive aspects, was particularly stressed.
On 12 December 1970, the Second 1'/H0 Regional Conference on Medical
Education met in Teheran. During the following week, representatives of
EM/RC21/2 page 18
all medical schools in the Region and three nei~~bourinb countries, and
of 11inistries of Health, together with special WHO advisers invited from
different parts of the world, ~~d observers from international crganiza-
tions and certain countries, discussed sever al basic aspects of medical
education. During discussion of the main topic - the role of basic
sciences in medical undergr aduate education - particular attention was
given to the r ecruitment and training of basic-science t eachers, and to
the possible stages in the integration of the teaching. The importance
of the community as a field for student-training was another special item ,
involving discussion of the position that soci al and prcventive medicine
and paediatrics should be given in an undergraduate medical curriculum.
Planning the establishment of a new school of medicine was t he third main
topic, which gave the Conference ~" opportunity to discuss in general the
objectives and methods of medical education, as well as the minimum Tcquire-
ments any new medical school is expected to meet. The final topic was the
introduction and practical demonstration of What can usefully be achieved
in medical education by employing adequate audiovisual aids.
In preparation for the Conference, twenty-c ight papers were distributed
to all participants, some prepared in advance by WHO staff 3..Yld t emporE,ry
advisers, others contributed by r epresentatives of vE,rious countries. A
number of relevant :ljflO publications were likewise distributed. The proceed-
ings of t he Conference , including the report of the meeting, introductory
papers and the recommendations, have been pr8par 8d for pub 11 cC'. ti on .
Immediately after the closure of the Conference, the first General
Assembly of the Assoc ic:ti on of ["ledicc:.l Schools in t he f'.1iddle East was con-
vened and r eviewed the Association's programme of work. At the srune time
the Officers of the Associo.tion, including the President, Vice-presidents
and the Secretary-Gener~l, were elect ed.
A mission in which the Division of Education end Training, HQ., and the
Centre for Educational Deve lopment, University of Illinois, were represented,
visited the Faculty of Medicine, Po.hlo.vi University in Shiraz and strongly
MEDICAL EDUCATION
A well·attend ed cour~e in a M id d Ie· Ea s t medical facu lty.
MEDICAL EDUCATION Undergraduate medical educa t ion in the Eastern Mediterra nean Reg ion Is illustrated here in some of its many facets and features.
I.. Bedsid e training : students wan t to learn by doing. S:me newly-establ is hed medical scheols, inclu ding the Baghdad Facu lty of Medicine , are already providing direct health care to the nearby communit ies
2. Laboratory work : at the Medical Faculty of Tunis, a test- tube sess ion to foster the hab it of sCielltific enqUiry.
; ,,- 4 -
3. Practice in dissection: the bcginning of medical wisdom in an anatomy laborato ry of the Teheran Medica l Facu lt y.
4. Preclinical education: the first-year students at the Medical Sciences Institu t e of Addis Ababa's Univcrsity probe the m)steries of the human body during a dissection course.
5. Active learning: the material in the textbooks does not look ir re levant t o this student from ,he Khartoum Medical School tryi ng to translate th eory into practice .
6. Inducement to rural practice: C airo UniverSity ass igns its students t o med ical care in the countryside w l. ere they get fIrst hand knowle dge of rural health problems.
NURSING (AFGHANISTAN)
Helping hands reach out from the hospita ls in to the vil:ages of Afghanistan with the graduation of 65 nurses annually from Kabul's tnree sc hools of nursing and 50-odd auxiliar ies from provincial schools now com plet ing their training programme,
(Left l Auxiliary nurse -Il1 'dw:fe 01 h ,r rounds , (Above ) Adv ising an exp~:nn:
at the rural health su b-centre, (R ig ht) nurse-mi dwife giving h ~alth talk at
L-. .......... j ~.,1
vil lage mo:'ler Studen t
Z.i;hgah
NURSING EDUCATION (IRAQ)
Nurses graduate from the University of Baghdad College of Nursing and Midwifery after four years ' training with a Bachelor of Science in Nurs ing. The aim is to prepare them for leading posts in nurs ing services admin ist rat ion and in nursing education. Thirteen graduates received the ir B.Se. at tbe end of the 1970 academic year, while thi rty new st udents were admitted to the College, bringing t he total stud en t body to ninety-one.
(Left ) Firs t·year students karn to app ly dressings. (Top right) Practi cal training in midwifery for tlmd-year stu dent s under the WHO nurse educa tor. : Right) Car ing for a newborn at t he Karkh Maternity Hospital.
--------
(
NURSING (Y EMEN) Taiz Health Cen t re , opened in 1966, saw its fi rst six ass is tant nurses graduate in 1969, and a further twen ty in 1970, with eighteen students in t he pre-nurs ing school at t hat ti me .
Simp le, yet vi tal, activ iti es at t he Taiz MCH clin ic: (clock wise)d is tri buting soap to you ng mothers , checking the haemo globi n leve ls of preg nant women an d re(ording weight gain of infa nts. (Below) A t heoretical cl ass for assi stant nurses.
Ef.1,IRC2lj2 page 19
recommended this School to be considered as the site ~or the first regional
centre for teacher tra i ning. Action was initiated for the establishment
of this regional centro f ollow5.ng t he mission's r e commendations.
The Region~l Offi ce was r epr esented at the Sixth Annual Conference of
the Association of Nedical Schools in Africa, convened in C:!.iro from 26
to 30 April 1971. The theme of t he Conference was "Definition of Tasks
of Health Personnel in Africa!;. A total of nineteen medical schools were
represented at t he Conference, including the ten Medical Schools from the
African cOQ~tries of the East ern Mediterranean Region.
A f.1eeting of Directors or Representntives of Schools of Public Health
in the geogrnphica l 2.reas covered by the African, Eastern f.1edi terranean,
South East Asia and VIestern Po..cific Regions of '!1HO was held in New Delhi in
March 1971. The six Schools of Public Health of this Region participated
in t he Meeting, which was attended by the Regional Director, as well as in
the General Assembly of the Association which followed.
TRAINING OF AU'AILIARY HEALTH PERSONNEL
The training of auxiliary health personnel continued to be a very import
ant activity of the Regional Office, in response to the increasing need for
this type of training and to r equests from ~>ny countries of the Region.
The importance of trajnlng of auxiliary health personnel in order to
carry out disease eradication and control programmes e ffectively and to
provide staff for the expru1ding health services to meet t he health needs
of the entire popul ati on in many of the countries of the Region cannot be
over-emphasized.
Numerous WHO-assisted projects for the training -of auxiliary health
personnel are in operation and nearly all of them are expending their acti-
vities. Different categories of auxiliary health personnel are trained
and the number of trainees hr.s increQ.sed consider ably over the years.
The tremendous expansion that happened in this type of important train
ing is not only indicated by the increase in the number of candidates who
EIVI/RC21/2 page 20
completed their tr2.ining, but is manifested by the continuous precess of
improvements introduced in the qU2.lity of training by the r evision of the
curricula of the different courses and by the upgrading of the basic edu
cational standard required for admission to many of these courses.
The role and the nature of the responsibilities entrusted to the
auxiliary health personnel has and will always de termine the type of
training required for each needed category of personnel. Recognizing
this fact, types of training are being modified constantly or specific
courses structured with the main objective to make available auxiliary
health personnel qualified t o carry out their role effectively in the
delivery of health services to the population.
Although the training of auxiliary health personnel activities and
projects in the Region are making re 2.sonable and appreciated progre ss,
there is still r oom for further development. The gap between the rate
of expansion and development of the health services in many countries of
the Region and the r2.te of provision of qualified trained staff needs a
great effort to bridge it. Taking into consideration the different as-
pects of life in many of the countries of the Region, e.g. the cultural,
socio-economic factors, educ2.tional possibilities, it become s evident that
one of the important means of bridging this gap is by planned expansion,
development and improvement in the training ef auxilie.ry health personnel.
Careful preparati on of te2.chers, availability and selection of suitable
candidates, provision of f acili ties for theoretical and practical field
training, periodical revision of curricula of courses are nll important
aspects of training thnt can always be improved.
The training of national or counterpart tutors in all i,mO-assisted
projects receives due consideration and was given high priority and it
is gratifying to note that quite a number of ne,tional counterparts and
prospective candidates planned to work as tutors in many of the training
projects have either already been trained, or are actually on \-JHO fellow
ships receiving further training.
FEUDWSHIPS PROGRAMIVlE
EM/RC2l/2 page 21
The WHO fellowships programme continued to be one of the most
important activit ies of th8 Region. All the countries of the Region
attach consider~ble impo~tance to t he program~e as a means of educationg
and training national health personnel to meet the growing needs of the
health services.
The fellowships progr~~c continues to play a substantial and
effective role in the develo~~ent and promotion of health services.
Requests for WHO assistance from all the countries of the Region have
shown a progressivel y increasing trend and the response to these demands
continues to be in line with the expressed requests, needs and plans of
the countries.
The programme has multiplied fourfo l d in the past fifteen years; the
total number of f ellowships awarded during the year 1970 being 514, involv
ing a cost of US $ 1 452 178, which accounted for 16.56 per cent of the
total expenditure on t he overall activities of t he Region.
Taking the percentage of the total number of f ellowships awarded in
1969/1970 as an index , the order of priority of various training fields was
as follOWS, for the Reeion as D. whole: (1) public health administration,
(2) medical educati on, (3) laboratory techniques and statistics, (4) com
municable diseases , (5) nursing, (6) sanitation, (7) undergraduate studies.
As compared to the corr e oponding figures in the period 1964/1968, the 1969/
1970 figures denote an i ncreasing interest in the fields of medical educa
tion, sanitation, laboratory techniques and statistics, and nursing.
Fellowships awarded fo~ undergraduate studies and training in communicable
diseases had lO~ler indices in the later than in the earlier period, while
those in the field of public health administration just maintained their
top position. The combined fields of public health administration and
medical education accounted for over fifty per cent of all fellowships in
the period 1969/1970.
EM/RC21/2 page 22
For detailed analysis of the fi~lds of study of all the fel lowships
awarded from 1949 up to last year, reference is to be made to Figure 3.
Trend in Fellowships award"d by subject, 1949 - 1970.
During the year 1970, 103 fellows sponsored by ~ffiO are pursuing
undergraduate studies. Out of these , eighty-two fe llows are studying
undergraduate medicine, thirteen nurSing, three pharmacy, two sanitary
engineering, two dentistry and one veterinary medicine. Nine of these
fellows are from Cyprus, e ight from Ethiopia, one from Israel, six from
Libya, three from Saudi Arabia, twenty-five from Somalia , two f rom ?unisia ,
eighteen from PDRY and thirty from Yemen . Thirteen fellows have complet-
ed their studies and graduated during the year 1970.
Only seventeen fellowships were awarded during 1969 and sixteen
during 1970 for undergraduate studies, representing 3 per cent of the
total as stated .
The t otal number of host countries wher e placement was arranged for
our fellows during 1970 was fifty-four in V[,rious continents; but at tne
same time training facilities present within the Region at post-graduate,
undergraduate and auxiliary levels are being increas ingly utilized.
Nore effective utilization of the "!KO fellowships progrrunme by
advanced planning, giving due consi deration to t he needs <'.nd priorities of
the diffe r ent components of health aspects together with the ess enti Q.l
need to co-ordinate the fellowships programme with the development of the
health services, continues to be given increasing i mportance . It is
gratifying to note the.t due consideration and attention ar e being given
to the selection of suitable candidates and the proper utilization of
fellows on their return home.
While quantitative evaluation and some qualitative evaluation of the
WHO f el lowships programme is continuously being made, more comprehensive
evaluation of the programme 115 being planned and is expected to be made
during the next two years.
NUMBER OF FELLOWSHIPS AWARDED BY WHO EMRO
191.9 -1970
(Extensions of undergraduate hltowships no t includ.d)
FIGURE 1
Co u n_t_r y _ __ -+-'_94_9_-. 19531954 _ 1958 1959:-'963 1964 _1969 1969 11970~_9 ___ ~ ~ I ~vera9· number per year i i TO tal
~~~oniston (5 ) 0 , (9) ~_~(14) (2~~~37 ( Ii ill 66:3) 93 I ~._h_ro_in _ _ l=ct -+_ . __ 2_~ __ ~ __ , _~_ , 1Z .. _ ,
Cyprus ! 1 _ I 10 1 3 I 16 i 12 152 . I
Ethiopia B 1 5 7 13 16 11. 195
1---: _;_:_: _ __ + 11 _ _ ,_:_---1If--~-~ ~: - : ; :: :: i : : :
Israel 8 e 11 1 2 13 17 220
Jordon 2 5 16 26 22 25 293 ~-----4-----~--4---_.~----_+---+_--_+---_1
Kuwait 2 c 7 5 5 50 l-------1----+.---.-+----4-----~---~-+_----~
7 12 I 13 12 i 9 11 238 r-~---1-----+---r_--4---~r--+_-_+----~
Lib Y a 2 6 7 12 33 33 204
Po kiston 10 8 29 33 54 38 490
l--P~D~R~V __ r_-~-~4_-~--_+-~1-~-~9-+_-~2~3_+~2~4_+---9~7~_;
~-a-o-t-o-r-.--+---~.-4_-~.--_4-~.-4_-~4-~--3~r_~3~~-~2~S~_1
r-~S_. ~A~r~o~b_io __ +I ___ ~2 _ _ _r--3~--r-~1 •. ~2~--+---'~O~--1~~6~-~5~~---'-4~9--1 5 omalio _ 4 17 1 Ii 15 17 217
l--~S~u~d_o:~n ____ _4--~3-_r-':~2~~~-2~5~_4-~33~_4--I.~'_+~3~4c_1~-4~3~9 __ ~
Syria 7 12 13 27 34 45 376 f----'-------+------ --.~-----~---4_---+_ ------
Tuni sio ( 3) (ZO) 13 0 19 1 7 18 21 (56) 2 55
U A R 1 3 25 22 46 60 60
Vemen 15 24 39 25 275
Tot a l ,90 148 259 386 518· 514 f 5449 H
Nat y.t a m"mber of til. Region
o Figures between brackets represent fellowships oworded before joining EMR. They are not included in the totol
b For 1969 only, tile yeor Bahrain joined WHO
c Four-year averoge . Joined WHO in 1960
d Three-yeor overoge. Joined EMR in 1956
e Includes 2 fellowsh ips oworded to F T A I
f Includes one fellowship awarded to a Palestinian retugee
N
IU cr ~ ~ u.
FELLOWSHIPS AWARDED BY LENGTH OF STUDY
191.9 _ 1970
UNDERGRADUATE (ACADEMIC) STUDIES UNDER ONE YEAR ONE YEAR AND OVER
-c .. u .. ..
Q.
8
7
6
S"
4
3
2
0 CD ... CD· 11'1 '" 10
'" lZ! '" ~ ~
'" '" ~ ~ In 10
'" '" lZ! ~ ~
60
50
.. c
LO .. u .. ..
Q.
30
20
10
0
~ '" .. CD
II> $!!
'" ... ... ... '" ... '" ...
'" III
'" 10
'" '" .. ... '" I! II> $!! <II ...
0 ... '" ... '" '" $!I
... c .. " .. ..
Q.
40
35
30
25
20
15
10
5
oj~ CD .., CD 0 11'1 10 ID ... '" '" '" en ~ ... .. ... en ~ ~ '" ~ 10 ID
$!! '" '" '" ~ .. ~
FIGURE 3
TREND IN FELLOWSHIPS AWARDED BY SUBJECT 191.9 _ 1970
% 25
20
15
10
5
MEDICAL
EDUCATION
'"'''' In'" I I
'" .... .. .,., ~~
,.,,,,0 U) CD t" ..
, I I "' .. ", V'I\OCD
"''''''' ~~ ~
PUBLIC HEALTH
ADMINISTRATION
% 30 S(
~
'" ' I) ~
~ Yl(
25 X ~ ~}r >< 1":<
t$ 1«, ;,x I<' 20. ~ . IX D< f\'
15~ t9 [xOd() () x
X f~ l'Q [6 Oi I 9 ~~ ~ ~ <
10~ ~ (.>< ,Yo
'j ~< k:
): r;.. :>,. 9- >to ~.
'.(' ,
~ (', ~ x ~
0 ,., co "'CDC) "' II> "'lOt--
I I I I I
"' ... "''''''' ... '" ",10", "'0\ "''''''' r ~ ~ ~ ~
NURSING
8
,
4
COMMUNICABLE DISEAses
( including malaria) 0/a
30
25
20.
15.
10
<
f:!~~~~ I I I I I
0'1 ..... 0'1 ...., 0'\ ""tnUl4D~ O\O'IC1IC7t O'\ - ~ -.,...-
""COtw)coc lnLn4Dc.oc---
I I I I f 0'1"'0"""0'1 -4't.n\ll'D(O 010"01;0\", .... .- ---
SANITATION
% 12 -
10 .
II -
i -
2 :.
o
~ , ~ >.
~ ~ R'
t2 ~ VJ
~ ~ ~2>
>
~
~~ . X k) t-< ki [X
..,"'C) <0 .,,, ...
I I I '" .... 0\ ",,,,ID 0\0\0\ ~ ~r
LABORA TORY AND
::1 10
9
6
4
STATISTICS
t"')mI'l'tCZlO U'I&nIC'-Dt'
I I I f I m ... cn ...... cn ...,.V'llIlfIQ\oO C1\O\C7'IO\O\ -----
UNDERGRADUATE
EDUCATION
M CI)f")O)O 1I"IU"IlIIDtOt'-
I I f ' I
"''''''''''''0'1 ""Y"IW")tC'" 0\0\0\0\0\ - - --.-
~
W a: ::l I!)
i&:
... c • " ~ ..
<l.
FELLOWSHIPS AWARDED BY TYPE OF STUDY
191.9 -1970
UNOERGRADUATE STUOIES POST-GRADUATE STUDIES OTHER ARRANGEMENTS
9 90
8 ~ ~ ~ 7
25 60
fi ~ ~
~~ ~~;C ,
l0 :>¢'
eX: k' x: 0-
- '0 k" ;s:~~ , ~f).
5
4
3
2
50 20 ... ...
c c .. • 40 u u ~ ~ .. 15 ..
D- <l.
30
10 20
o II "><,,,{><X
» ~r(v: iN'>
UY'; )(')(').
5 10
o 0 0 CD PI m 0 It'I II> ... ... '" '" 0'\ '" .- ... ..- c-
CD ,., II> 0 CD ... CD
'" '" ... ... . In .., .. '" 0'\ '" Q\ (/\ (/\ '" .- c- .- .- .- .- .-
'" '" ~ '" ~ U'I '" II> 0'\ '"
.,. '" .- .- .- .... m (/\
~ '" .... '" ... ... In ... '" '" It'I ...
'" '" '" ~ 01 01 01 .- .- r- .- .- .-
0 ... 01 0-
'" to
'" r-
El'l/RC21/2 page 23
The National Fellowship Officers' l'leeting referred to in my last
report was convened at the Regional Office from 1 to 3 July 1970. Par
ticipants from fifteen countries of the Region attended the Meeting.
Fruitful discussions covering all aspects of fellowships took place and
the exchange of experiences on the technical and other non-technical
fields of the WHO fellowships programme proved to be very valuable in
co-ordinating efforts and promoting closer working relationships . The
recommendations of the Meeting are being followed up by the Regional
Office.
EMjRC2l/2 page 24
2 . IVJAIARIA ERADICATION
SI'ATUS OF MAIARIA ERADICATION ACTIVITIES A.liD GENERAL PROGRESS
The estimated population of the countries in the Eastern Mediter
ranean Region of l'iRO totalled 289.4 million as of 30 June 1971, of whom
245 million were living in malarious areas.
The high priority given to control and eradication of malaria as a
serious threat to the health and live lihood of their peoples by the
governments of the Region is evident from the fact t hat 94.5 per cent of
the 245 million living in malarious arcas are being prote cted by various
anti-malaria measures; 72 per cent by on-going malaria eradicati on pro
grammes, and 22.5 per cent by various control measures.
Table 1
Funds Allocr,t ed by Governments to Malaria Eradication Programmes of the Region for Fiscal Year 1970 or 1970/1971 US $
Country Fiscal Year
Afghe.nistan 1970
Ethi opia 1970
Iran 1970/71
Iraq 1970
J ordan 1970
Libya 1970
Pakistan (E) 1970/71
Pakistan (Vi) 1970/71
Syria 1970
Tunisia 1970
Actually spent
262 500
3 816 000
392 000
56 000
546 512
Estimated from Pla11s of Action
11 492 000
2 442 000
11 260 436
10 100 786
1 081 000
% of Health Budget
15·7
10·9
5.2
2.5
5·5
EMjRC21/2 page 25
Nine of the countries in the Region are conducting malaria eradication
programmes. Table 1 shows the annual country budget for the year 1970,
or Fiscal Year 1970/1971, either actually spent or estimated as being
required.
In the afore-mentioned countries, approximately 176 million people
were afforded protection from malaria, at an average cost to government of
23.5 cents ~ capita.
In addition to the malaria eradication programmes, which, although
they have been somewhat slowed down by various problems, are continuing to
perform a useful public service, there has been an extension of anti
malaria operations in those countries of the Region which have not as yet
begun malaria eradication. During the last two to three years there has
been an increasing realization that protection against malaria should be
as widespread as possible, and not confined to those fortunate countries
where a malaria eradication programme is in all ways feasible. This
philosophy has been translated into action, so that only about 13.5 million
of the 289 million total population of the Region are not being protected
against malaria by some means or other.
One of the objectives of the reviews of malaria programmes undertaken
by Afghanistan, Ethiopia, Iraq, Pakistan and Sud= was to determine whether
eradication was feasible, and, if not, to provide the incentive to insti-
tute control of ma laria as a function of the health services, The first
four of these countries have decided to carryon with eradication, in part
or all of the country, Sudan deciding to centralize all anti-malaria
measures under the ,Health Ministry. The ultimate objective, however,
still remains the eradication of malaria.
International Assistance in 1970
Under its Regular Budget, WHO provided various types of assistance to
malaria eradication and control programmes in fourteen countries of the
Region, at a total expenditure of US $ 1 259 498. This amount covered
EMjRC2l/2 page 26
the services of eighteen malariologists, six entomologists, sanitary
engineers (thirty man/months), six technical officers, sanitarians (186
man/months), besides short-term consultants, supplies and equipment,
fellowships and sundry local expenses.
WHO has also provided through the Technical Assistance Component of
the UNDP advisers ru1d supplies ~~d equipment to the value of US $ 52 800,
including a malariologist for Syria and an entomologist for Tunisia.
UNICEF has continued to provide assist&~ce to eradication programmes
in Afghanistan, Iran and Iraq. Their contribution during 1970 was
US $ 1 168 000.
US AID continued to assist eradication programmes in Ethiopia and
Pakistan on a loan basis, but governments' difficulty in raising the
necessary counterpart funds continues to cause delays in disbursement.
Under the Malaria Eradic~tion Special Account US $ 212 900 were
requested, but due to delayed payments into this Fund by Member States no
allocations were received.
The overall cost borne by governments, IlliO ,=d UNICEF for the nine
me.laria eradication programmes in 1970 was US :~ 4:;, 527 000, which repre-
sents a rise of US $ 7 627 000 (17.5 per cent) over 1969. The respective
governments provided US $ 41 449000 (95.3 per cent), HHO provided
US $ 910 000(2 per cent) and UNICEF US $ 1 168 000 (2.7 per cent).
In recent years there has been an increasing trend, followed by some
governments, to prefer W'rlO assistance in the form of supplies end equip-
ment, fellowships or local costs, rather than advisers. In those coun-
tries where national malaria workers ar e experienced, this is of course
encouraging and mutually advantr.geous to both government and HHO. There
are instances, however, where countries, although still in need 'of advisory
assistance in organization, planning and training of personnel, have been
led by the rising cost of health programmes in general, the addition of
EM/RC21/2 page 27
new health projects, and the loss of financial assistance from other
agencies to look to ~IHO to pay for some of the fe.cili ties they may require.
In these particular instances it is felt that VIHO advisory assistance has
to be maintained at an optimum level, below which ~~O will be prevented
from assisting malaria programmes in the best and most economical manner.
This is particularly true in countries where serious technical and ad
ministrative problems have not yet been overcome, and where the mere
addition of money or commodities will do little to solve them.
Problems
The year 1970 has seen a wide variation of achievement in efforts to
control or eradicate malaria. Cyprus, Israel and Lebanon (except for a
small outbreak on the border with Syria) have reportedly remained free
from malaria except for the expected importation. Ir~~ and Tunisia have
managed to maintain satisfactory progress towards eradication of the
disease. Syria and Jordan, despite the year's disturbances and the
resistance of An.sacharovi to DDT, have managed to retain the endemicity
of malaria at an encouragingly low level. Libya is also satisfactorily
controlling the disease. In Iraq, despite an early set-back due to
flooding of the Shatt-el-Arab river, Malathion has produced encouraging
results. There is, however, evidence of the spread northwards of DDT/DLD
resistent An. stephens! , which may necessitate the extension of Malathion
spraying. On the credit side are the improved administrative conditions
in the north of the country. All northern liwas received DDT-spraying,
the benefits of which should be seen during next year.
Both Afghanistan and Pakistan have been the victims of a considerable
degree of recrudescence of malaria.
There have been successively more widespread outbreaks of malaria in
the north of Afghenistan, where the vector An.hyrcanus, recently incrimi
nated, is resistant to DDT, and An.pulcherrimus exhibits a strong tendency
EMjRC21/2 page 28
to avoid DDT-sprayed surfaces. In the East on the border with West
Pakistan there has been an outbreak of malaria, described as "of epidemic
proportions" • Although operational deficiency cannot be ruled out as a
possible cause in both instances,t.he resistance to DDT of An.hyrcanus,
An.stephensi, An.culicifacies, and An.superpictus in the presence of
infected nomadic populations has played a major role.
In West Pakistan the year's far-reaching internal events, such as
provincialization and the general election, have in some degree negated
efforts to contain the extension of malaria by the malaria service.
Added to which it is becoming clear that DDT-resistance in An.culicifacies
and An.stephensi is widening its distribution.
In Ethiopia, eradication is to continue in Area A, and spraying
protection is to be extended to development project areas throughout the
country. The problems are of all types, financial, operational and
technical. Progress has been slow.
In addition to Iraq and Sudan all three above-mentioned countries
have conducted reviews of their malaria eradication programmes. There
has been in each case a long period of re-planning and re-appraisal of
expected targets and achievement. This period of reorientation has also
slowed down progress, but it is expected that efforts will be intensified
once plans for reorganization and strengthening of the respective malaria
services have been finalized.
Of the nine countries which are currently operating malaria eradica
tion programmes, six have malaria vectors which are resistant to DDT.
There are also DDT-resistant malaria vectors inhabiting countries where
control measures are being applied, notably Saudi Arabia, Sudan and the
United Arab Republic.
The reviews of malaria eradication programmes brought to light many
administrative and operational problems. As has been mentioned, costs
EMjRC21/2 page 29
have increased tremendously . There is still a shortage of trained and
experienced personnel, bot h for malaria eradication and for health
services in gener al. The deve l opment of rural he~lth services is under-
standebly slow and by its nature does not keep pace with phased eradica
tion. , Concise evaluation of the eff ect of anti-malaria measures has in
s ome instance s been severel y handicapped by the interruption of active
case detection during the control of ~ Tor cholera epidemics, when
malaria eradication transport and personne l have been diverted from their
proper tasks.
Urban malaria r emains to be t ackled as a source of re-introduction
into already cleared areas, as does the periodic migration of nomads,
vacationers and transitory workers.
Training
Four malaria er adication training centres (METC) are being assisted
by WHO in the Regi on . Three of t hese centres are in the countries with
malaria er adication pr ogrammes (Ethiopia, East and West Pakistan), and
one in a country with a pre- er adication programme (Sudan).
A total of 577 students were trained at t hese centres during 1970.
In t he r~c, Nazar et h (Ethiopia), owing to the r eview of the mal aria
programme and its future policy towards training, a very limited teaching
programme was conducted during 1970 . Five courses were conducted and/or
completed with 135 trainees, of whom 132 grndu~tcd successfully. Those
courses were for microscopists, secto~ t echnicians (surveillance and
operations), r efr esher courses for oper ations personnel, and one course
for smallpox eradicati on.
Twelve courses were conducted at the METe, Lahore (West Pakistan)
during 1970, with a total of 387 trainees.
following types:
These courses were of the
EM/RC21/2 page 30
Senior courses for professional st~ff
Junior courses for sub-professional staff
Microscopists courses
Refresher/promotion courses for in-service sector in-charges
Heal th education courses.·
Refresher courses in entomology for in-service assistant-
entomologists.
During 1970, three courses were he ld at the METC, Sennar, (Sudan),
(22nd, 23rd, 24th), for sanitary overseers (operation2.1), labore.tory
assistants (microscopists), and technical personnel, with the participa
tion of fifty-five trainees out of whom fifty-four succeeded in the final
examinations.
Fifteeno fellowships were granted by WHO during 1970 for training in
the field of malaria.
Co-ordination
Meetings of importance which t ook place during the period under review
were as f ollows:
Co-ordination Board , Indin/pakistan - 24 October 1970, at Ganda Singh Wala.
Fourteenth and Fifteenth I'leetings of the Inter-country Malaria Eradication Board between Iraq, Jordan, Lebanon, Syria and Turkey in Dara'a on 11 July 1970 and in Baghdad, 8 to 10 December 1970.
Spec i al Meeting between Jordan/Lebanon/Syria in Beirut, 2 to 3 June 1971.
PrOgnOSis
It is to be noted that the m2.1aria eradication and control programmes
of this Region have afforded a protection to millions of human beings
which far exceeds any other health projects which governments have as yet
undertaken. Although it is satisfying to see an increased interest in
Er-1;RC2l/2 page 31
rure l health devel opment, smallpox eradication, f amily planning, etc.,
malaria should still r emain an importent concern of health workers. It
is a dynamic disease with a pot entia l f or explosive recrudescence.
The main factors affecting future prospects are insecticide resist
ance in malaria vect ors, revi c~ls of ma l aria eradication programmes and the
controversy over the use of DDT. The f irst two of these are, in princi-
ple, in the hands of health workers and will be dealt with in the best
interests of the protected popUlations. The attitude of the conserva-
tionists to DDT, however, is e more serious matter .
Following a consider able out cry against DDT as an environmental
pollutant by conservationists, the Government of the USA, where the major
ity of DDT is manufactured , decided t o submit its use t o strict control;
a decision which was f ollowed by the closing down of four of the five
US DDT factori es and a consider able rise in the cost of this boon to the
health of the devel oping nat ions.
The Director-Gener nl of 1'1HO was quick t o point out to the Executive 1 Board that any restriction on the use of DDT f or health protection would
be catastrophic, and that there was every proof that the DDT used in
malaria eradication programmes was of no signi f i cant danger to either the
operators or the peopl e, millions of whom rely upon it for their protec -
tion. The most import~t evidence t hat the DDT used in malaria er adica -
tion is virtually harmless is t he f act that I;tho only cases of injury have
been massive accidento.l or suicidal ingesture" , despite the use of its
peek of 60 000 tons annually . The danger of DDT used i n malaria er adica -
tion to wild life is also minimnl because it is only used as a r e sidual
spray indoors.
This controversy over t he use of DDT is ye t anothe r r eason for ~.n0
o.nd governments t o press on towards consolidati on, but in the meantime
~B471v1P/14 - Reviel" of Pr oposed Programme o.nd Budget Estimates, The Place of DDT in Operations against Malaria o.nd other vect or-borne diseases.
EM,lRC2l/2 page 32
it is to be hoped that the Director-General's warning will not fall upon
deaf ears.
As demonstrated by the reviews l"hich have already been made, govern
ments and vmo are still manifestly determined to press forward the attack
on malaria, despite the setbacks and handicaps which have been previously
described . As l ong as t his interest and high priority is maintained the
prognosis of anti-malaria campaigns cannot help but be good.
STATUS OF MALARIA ERADICATION IN THE EASTERN MEDITERRANEAN REGION
o
-, .. ;,
~il . '"~' ~
" :;;~; .
Malaria ".ver existed, eradication claimed, or eradication programme in maintenance phose
•
Eradication programme in consolidation or attack phas.
END 1970
.::
[22£--=-1
~
East Pakistan
Pre-eradicotion or control programme
Malaria present, but no specific anti-molaria programme
.." G'i c:: '" m III
'" ILl IX ::l l!)
u.
~
c- Ol u Q; ll.
100
90
eo
10
60
50
40
30
20
10
0
DISTRIBUTION OF POPULATION WITHIN AREAS OF THE REGION
ACCORDING TO EXPOSURE TO MALARIA
1961 - 1970
1963 1965 1966 1967 1968 1969
UlllI In non-malarious areas and where eradication claimed
~ In malarious areas where eradication not claimed. but population protected
~ In malarious areas where population not protected
1970
Type of
Programme
Malaria Eradication Claimed or Originally Free
Eradication
Pre- eradication
Countries not under- taking specific Malaria Programmes
G RAN D
Table 2
STATUS AND DEVELOPMENT OF MALARIA PROGRAMMES IN THE EASTERN MEDITERRANEAN REGION - 1970
(POPULATION IN THOUSAND)
EM/RC2l/2 page 33
Total Population Population Eradication Programmes Countries Popu- at Malaria Protect - Year Year end-
lation Risk ed V Attaclt ing con- Type Began sol1dation
Cyprus 636 6}6 6}6 PTAI !I 81 81 81 Gaza 356 356 356 Israel 2 935 2 935 2 935 Kuwait 628 - - Lebanon 2 7~5 926 926
TOTAL 7 381 4 934 ~ 93~
Afghanistan 17 O~O 8 629 8 629 1957 1980 Country-wide Ethiopia 25 553 12 778 8 612 1966 §I By stages Iran 29 089 24 552 2~ 552 1957 1976 By stages Iraq 9 161 5 738 5 738 1957 1976 Country-wide Jordan 2 265 1 200 1 200 Y 1958 §I Country-wide Libya 1 97!f 93 93 1959 1974 country-wide Pakistan 115 }77 115 377 115 377 1961 1976 By stages Syria 6 115 ~ 374 ~ 37~ 19:i6 1975 Country-wide Tunisia 5 19~ 5 19~ 5 19~ 1968 1975 Country -wi de UAR ?:.I 33 730 33 730 33 730 In Preparation
TOTAL 245 500 211 6C5 207 1l.99
Saudi Arabia 7 37~ 2 640 993 !I Frenoh Territories of the Somalia 2 842 2 81l.2 2 842 Atars and the Issas Sudan 15 830 15 830 12 130 ?:.I United Arab Republic
TOTAL 26 0~6 21 312 15 965 V People's Demooratic Republic of Yemen
Bahrain 217 217 217 Y 647 in Maintenance in
SuIt. of Oman 565 565 Jordan - Qatar 116 116 11 21 Including both eradication
PDRY V 1 261 1 261 283 §/ and control methods
Trucial Oman 135 135 - §/ Population of Aden
Yemen 5 000 2 000 V Representing 94.5 per cent - of population at risk
TOTAL 7 294 4- 29~ 511 V §I Uncertain at present
TOT A L 286 221 2 ~2 205 228 909 _._&~~_=_-=~~C=:--=======I#===_=a .e:==:...~==-= b=e:;::;I==-aa==_ b:.:a_--=c-= __ ===_==_ -
EM,flW2l/2
page 34
). COMMUNICABIE DISEASES
Apart from the WHO-assisted projects, the Regional Office has
extended its activities towards problems of regional interest in the
field of communicable diseases.
VIRAL DISEASES
SMALLPOX ERADICATION
General Considerations
The smallpox eradication programme has made considera.ble progress
since its inception four years ago. The progre.mme of mass vaccination
has continued and developed; the new policy for eradication of smallpox
through an intensified reporting-surveillance-containment system has been
implemented; more contingents of skilled manpower, advisers and others,
have come to complete the teams to give better supervision and fulfil
ment; supplies and equipment have been provided over and above the
budgetted allocations and additional funds have been made available to
those countries where operations are s t ill in their initial stage and
need to be fortified.
The enlightened approach to t he problem, by recognition of surveil
lance-containment as the key to eradication, is yielding satisfactory
results. There are increasing hopes that in Afghanistan and East
Pakistan, the goal of eradication may be reached in the near future.
Epidemiology
The 7451 cases of sma llpox recorded for this Region in 1970 reveal
an increase when compared t o the figure of 5 886 cases reported in 1969;
however, they represent only about half of the incidence in 1968 of
12 000 cases.
The increase during this period is due to t he establishment, improve
ment and development of the reporting-surveillance system, particularly
EMjRC21/2 page 35
in Afghanistan, Ethiopia and part of West Pakistan. The surveillance
teams were able to detect a much grenter number of cases than were offi-
cially reported. Furthermore, some local outbreaks, due to the periodical
fluctuations of smallpox, may also account for a part of the increase in
incidence.
Afghanistan accounts for 1 044 cases in 1970 against only 254 reported
in 1969. Doubtless this can be attributed to the aggressive programme of
reporting-surveillance under the aegis of an active and alert team, both
national and international. However, it is gratifying to note that the
seasonal exacerbation usually witnessed in temperate climates of the
northern hemisphere during the cold season was not apparent this year.
With some more concerted efforts, ~ steady decline in incidence should
show in the near future.
The conceptual basis of the newly-initiated programme of eradication
in Ethiopia through active reporting-surveillance, led to the discovery of
fifty-seven hidden foci of infection, and brought the incidence figure for
1970 to 722 against only 179 cases reported in 1969, end 3663 cases for
the first quarter of 1971.
In spite of the reorganization of the project in West Pakistan due to
the formation of four administratively independent provinces, and in spite
to the fact that operations had almost stopped in three of the four pro
vinces, the number of cases has sli~htly decreased from 3 501 in 1969 to
3 136 in 1970.
The most striking decrease has been witnessed in East Pe~istan, with
2 041 cases for 1969, 1 473 cases for 1970 and the last six months yield-
ing tlnil" reports. This 1s in spite of the intensification of the
reporting-surveillance network. Five outbreaks reported during these six
months proved on investigation that chickenpox, not smallpox, was the res
posible agent.
EMjRC21/2 page )6
However, Pakistan still has the highest i ncidence of this Region,
and accounts for 60 per cent of all cases for 1970.
The l at ent epidemi c in the Sudan (1 046 cases) is also part l y r cs-
ponsible for the i ncrease in the number of cases this year. Unfortunate l y
the outbr eaks occur mostly i n the three souther n provinces wb..ich ar e inac-
cessible t o proper containment measures due to security measures.
The Trucia l State of Dubai also r eported an outbreak of twenty- one
cases, which were traced back to an i ntroduced case in a family of
Paki stani immigrants. The outbreak was contnined with a mi nimum lapse
of time and terminated in January 1971, due to the a l ertness of the
Government and the effective containment action undertaken .
IreJ1 r eported an 'Jutbr eak of ni ne cnses, resulting from an importation
in a fruni l y from Afghanistan en route t o the annual pilgrimage of IViashad .
The following Table shows tr..e nUinber of cases reported in this Regi on
for the year 1970, and for the first quarter of 1971, as compnr ed with the
previous years: Table 3
Country N u m b e r o f c r. s e s
1957 1968 1969 1970 1971*
Afghzmistan 202 739 254 1 044 128
Ethiopia 466 426 179 722 3663
Pakistan Enst 6 377 9 229 2 041 1 473 ... Pnkistzm West 4 818 1 836 3 501 3 136 456
Sud2J1 10 106 130 1 046 48
Yemen 3 - 29 - - Trucial Oman 10 2 - - - Trucia l Dubai - - - 18 3
Kmlait 41 - - - - Saudi Arabia - - - 12 - Ir2J1 - - - - 9
* up to end of March 1971 ••• data not availabl e
2600
2400
2200
2000
11\ 1S00 II III Q 1600 u ... II
1"00 ... ... 0 "-..
1200 .. -0
... 1000 II ..Q
E " 800 z
600
400
200
0 . . 0 N o J ~
1967
·§MALLPOX IN ENDEMIC COUNTRIES OF THE REGION
INCIDENCE 8 Y MONTH
1968 - 1970
M A M SONDJFMAMJJASONDJ FMAM
1968 1969 --+ f0iXss:J Area repruents the range bdween the highest ond lowest incidence reported durin!! 1960 -1966
JJASOND
1970 ----~ ."
~ c :n fT1 ...,
SMALLPOX IN THE EASTERN MEDITERRANEAN REGION
m W ~ ~ ~
INCIDENCE RATES (PER 100 000 POPULATION)
~ Mor. than 5/100 000
~ 0 .5 - 5/100 000
1970
~ /
East Pakistan
Smallpox Vaccination
EM/RC21/2 page 37
As an integrated part of smallpox eradication, vaccination activities
have been continuing satisfactorily throughout the countries of the Region.
In Afghanistan, the vaccination programme has progressed in the
Kunduz and Kabul zones and extended to the Kandahar zone, reaching diffi
cult areas, mountainous and with poor communication facilities. The
activities were quite satisfactory. The highest possible coverage was
achieved; some 500 vaccinators engaged in the programme have performed
during 1970 more than 3.6 million vaccinations, which means 2 million more
than during the previous year.
In Ethiopia, the vaccination programme depends mostly on the activi-
ties of the surveillance/containment teams. During FJ70, around 200 000
vaccinations were performed in relation to outbreak containment measures,
through surveillance teams. Vaccine and vaccination tools have been
provided to the existing health units and machinery, for performing routine
vaccinations.
In East Pakistan, 1 500 vaccinators were engaged in mass vaccination,
and around 4.5 million vaccinations were performed, despite several inter
ruptions due to natural calamities, which reduced the average output es
pecially in the last quarter of 1970.
In vlest Pakistan, although the country underwent decentralization
into four new provinces, mass vaccination activities have continued accord-
ing to the schedule envisaged in the plan of operation. In the Punjab
province, about 600 vaccinators have achieved coverage of above 15 million
population. The other provinces are being prepared for such actiyities
in the near future.
In Saudi Arabia, vaccination activities have been concentrated mostly
on pilgrimage areas. Thirty-six vaccinators are engaged in the programme
and, during 1970, some 300 000 vaccinations have been performed. All
EM/RC21/2 page 38
manpower and r esources of t he proj ect were diverted for ~ f ew months to
anti-cholera nctivities.
In Somalia, the vaccination activities are progressing according to
the schedule envisaged in the plan of operation. Some thirty-two vacci-
nators are engaged in t he programme and have performed during 1970 about
750 000 vaccinations, despite the fact t hat smallpox manpower was diverted
for a f ew months in favour of the anti-cholera vaccination campaign in
the country.
In the People's Democratic Republic of Yemen, the smallpox eradication
programme is going on in Governorates I and II, combined with BeG vacci
nation, with the assistance of UNICEF.
In the Sudan, smallpox vaccination is combined with BeG vaccination,
and activities are continuing in the provinces of Kordofan, Darfur and
Blue Nine North and South, with a coverage of about 2 million population,
using some 400 vaccinators. Operations were interrupted and all forces
of t he programme , including budgetary resources,were diverted to the anti.
chol er a vaccination campai gn for mor e than three months, but were fin nlly
resumed in December 1970.
I n Yemen, vaccinat i on activities nre continuing ~ccording to t he
schedule in the plan of oper ati on. The Gover norates of Taiz and Hodeida
have been completed, and t he programme has moved to the Ibb Governornte ,
which is a mountainous area with poor communicati ons and l ack of facilities.
Some thirty-six vaccinators are engaged in the activities, and during 1970,
about one million population have been cover ed.
Surveillance and containment measures
Giant strides have been made in this Region on the surveillance and
containment front. It has been noticed that even a high coverage of
vaccination alone would not guarantee t otal interruption of transmission
but may only slow it down.
EM/RC21/2 page 39
In Af&~anistan, the sensitive and closely-knit reporting system
network has been markedly improved, and unrelenting efforts towards fully
active surveillance and containment have quickened the pace on the road
to progress and narrowed down the gap to total eradication. Eighty-three
outbreaks have been investigated and 758 cases have been discovered by
the surveillance teams.
Even in the very difficult geographical conditions, and in the worst
of bitter winter, energetic intrepid volunteer surveillance teams succeded,
on horseback and sometimes even striving on foot through knee-high snow,
in reaching three affected villages where thirty-two cases had occurrcd
and in carrying out the necessary containment action.
In Ethiopia, the whole programme is based from its inception on
surveillance and containment; special teams have been organized for the
four southern provinces, and are actively engaged in dealing with reported
cases, and ensuing containment activities. They have already dealt with
some 3 741 cases, 90 per cent of which have been dis~overed by them during
their investigations. A total of fifty-seven outbreaks were discovered,
thirty-two of which were contained and sixteen others investigated.
In East Pakistan, much headway has been made by active surveillance
activities, both at central and provincial levels. Every single reported .
case/outbreak was thoroughly investigated.
were discovered by the surveillance teams.
Eighty per cent of all cases
Thirty-four ~utbreaks in all
were investigated; eleven of which proved to be smallpox, while of the
remaining twenty-three, some turned out to be chickenpox, and some had no
foundation, being due to false reports.
In West Pakistan, the halt in the project has delayed progress of the
surveillance-containment activities. However, teams for each new province,
as well as independent teams for the large cities of Karachi, Lahore,
Rawalpindi, etc., have been established. The surveillance team for the
Punjab province has been active since the cnd of 1970, and its keen
EM/RC2l/2 page 40
awar eness has permitted the dete ction and containment of f airly l arge out-
breaks in Gujranwalla, Lahore and Rawalpindi, which unfortunately were not
r eported by the provincial authorit i es concerned , and thus gave rise t o a
l arge number of cases.
In Saudi Arabi a, no cases were r~ported beyond March 1970 . strong
surveillance continued t o oe exer cis ed , espec i a lly i n the pi l grimage
areas. A suspect case of sm0.llpox was di agnosed in Aden on boc.rd a ship,
t he "Kuala l umpur :i , en route t o Saudi Ar<'.bia from Mal aysi c., carrying pil-
grims to the Mecca Pi l grimage . Specimens were collected, anal yzed i n
record time, and happi ly c. negative l abor atory diagnosis could be communi
ce.ted to the S<'.udi Arc.bian Health Authorities .
In the Sudan, as i n 1969, about 90 per cent of the cases r eported
occurred in the t hree southern provinces , and subsequently gave rise t o
several outbreaks in the nor thern parts of thu country and i n t he areas
under operation . The southern provinces still remain practically inac -
cessible for surveillance and containment activities, due to security
reasons. However, the project has r ecentl y been gi ven a fresh i mpetus,
surveillance teuros have been established and, during 1970 and the first
part of 1971, several outbreaks have been dealt with successfully, 95 per
cent of the cases be i ng de t ect ed by the surveillance teems. The reportine;
system is now functioning fnirly well, end i s still i mproving .
In the People' s Democratic Republic of Yemen, Somalia and Yemen, no
cases of smallpox were r eported f or the period under r evi ew. Surveil-
lance teams have been established and ar e r eady t o deal wi th any emergency
t hat might arise. In Yemen , a suspected case was hospitalized, with a
f at al issue after three days . Speci mens collected immediat e l y on l abor a -
t ory anc-.lysis proved negative for smallpox .
Assessment
Assessment continued to be carried out as an integr~ted part of the
progrnmme in a ll pro jects of the Region . In some ,.r eas, the coverage vlUS
EM/RC21/2 page 41
excellent, due t o the co-operati on of the public, and r eached the level of
90 to 98 per cent. In other ~reas, due partly to the resistance of the
community to vaccination, be cause of social, cultural or religious condi
tions, the coverage was poor and r anged between 35 and 60 per cent.
Scar surveys wer e conducted in pr imarily vaccinated children under
four years old, and the to.lce -ro.t es determining the potency of the vaccine
were above 95 per cent, which shows that the vaccine was highly potent and
adequate f or usc in er adi cation progro.mmes.
Supply of Vaccine
The overall use of free ze-dried smo.llpox vaccine continues to be
encouraged. Afghanistan is r eceiving t he vaccine necessary for the
project by bilat er al agreement. East Pakistan is using vaccine produced
with WHO assistance at the Institute of Public Health, Dacca. Bahrain,
Ethiopia, It/est Pakistan , PDRY, Saudi Arabia , Somalia , Sudan, Trucial State
of Dubai and Yemen have been suppli ed with \<1HO~onated vaccine. Two
million doses of donated vaccine were a lso provided by WHO to Lebanon, on
the occasion of the mass vaccination programme carried out in that country
at the beginning of 1971.
Vaccine Production
Mueh attention has been devoted t o the quality of the vaccine produced
by national l abor at ories in t he Regi on in terms of potency and stability.
East Pakistan is now pr oducing enough smallpox freeze-dried vaccine of
good quality, in the Institute of Public Health , Dacca , to cover the needs
of the whole pr ovince . Substant ial supplies and equipment are routinely
provided to the Institute in or der t o ensure the continuation and quality
of their production. I n West Pakis t an, supplies and equipment were pro-
vided to the Murree Laboratory. However, it has recently been decided to
shift the smallpox freeze-dried vaccine production unit from the Murree
Laboratory t o t he National Hea l th Laboratories in Islamabad, at central
level, so that its production may be used f or the four provinces of West
EM/RC21/2 page 42
Pakistan. The shifting has not yet mat erialized, but is planned f or the
near future. The first batches of vaccine produced will be experimental,
until such time as good quality vaccine cen be produced in quantities
sufficient t o cover t he needs of the four provinces.
The national laboratories in Iran, Iraq, Jordan, Syria, Tunisia and
the United Arab Republi c were also assisted. Seed virus was provided to
s ome, and en offer of r egular f ree -of-charge testing of t heir production
in WHO reference laboratories was made to all laboratories, in order to
ensure good potency end stability of the vaccine produced.
Training
Training seems imperative, as personnel is frequentl y transferred to
other sections or provinces, and due to the need for up-to-date info~ation
on the latest development of smallpox eradi cati 0n methods .
In Ethiopia, a s pecial two -week training course was organized in
January 1971, in Nazareth, with t he participation of expert senior staff,
for surveillance officers, sanitarians and Peace Corps Volunteers engaged
in the programme . The a~n end methodology of smal lpox eradication,
through t he new approach by reporting-surveillance-contain~ent, were well
described and taught.
In East Pakistan, a training course for fifty-four sub-d1visional
medical officers was he l d in 1969, and subsequently ther e was no need for
additional training.
In West Pakistan, the reorganization of t he smal l pox eradication
programme has created a need f or fresh training. The already-trained
personnel l e ft the project t o engage i n other government activit ies, or
return to their own provinces. A training course in the new approach
through surveillance-containment was or ganized for surveillance medical
officers. In-service training in the province of Punjab f or newly-
appointed personne l was also carried out.
EM/RC21/2 page 43
In the Sudan, in-service training for surveillance officers is being
provided. A special course on surveillance for medical officers and
surveillance officers was also organized.
In Afghanistan, PDRY, Saudi Arabia, Somalia and Yemen, training
courses were held in 1969. In-service training for surveillance officers
is being given as an integrated part of the programmes, for up-to-date
information on the methods and results of surveillance-containment acti
vities.
Seminars and Meetings
The Inter-Regional Seminar on Surveillance and Assessment of Smallpox
Eradication Programmes was held in New Delhi, from 30 November to
5 December 1970. From this Region, Afghanistan and Pakistan were repre-
sented with four and ten participants respectively. The national officers
involved were all actively engaged in and responsible for operations,
assessment and surveillance activities in the WHO-assisted smallpox eradi
cation programmes cur'rently being carried out in these countries.
The Regional Advisers' Meeting was also held in New Delhi following
the Seminar, from 6 to 8 December 1970, and reviewed the problems of
global smallpox eradication, as well as policy and motivation for future
activities.
Publications
In East Pakistan, the monthly "Newsletter II issued by the project has
continued to be published and was distributed by the Regional Office to
other field projects, liHO Headquarters and other Regional Offices. It
fully described surveillance activities in East Pakistan, and the con
tainment measures undertaken by the project.
In Ethiopia, a monthly publication on "Surveillance f1 has been prepared
by the project, starting in January 1971. It described the activities of
EM/RC21/2 page 44
the project, gives epidemiological informat i on and other data.
likewise been distributed to other field pro j ects.
It has
Provision of Vaccination Tools, Teaching Media and Health Education Materials
All non-endemic countries of the Region have been supplied with
samples of bifurcated needles, boxes of slides on t he differential diag
nosis of smallpox and chickenpox, and health education materials such as
posters and pamphlets on smallpox.
Some of the countrie s were interested and have already requested
further supplies. Consequently Bahrain, Dubai , Iran, Iraq and Lebanon
received more needles , slides and pamphlets, all of whi ch were provided
free of charge.
BACI'ERIAL DISEASES
CHOIERA
The 1970 outbreak of cholera biotype ~ Tor has once again aroused
the anxiety of public health workers in this part of the world, after a
care-free interval of freedom f r om cholera f ollowing t he last outbreak in
1965/1966.
Sequence of events has shown that tb~s part of t he world was involved
in the seventh pandemic of cholera which began in 1961 in t he Celebes
Islands.
The 1970 outbreak was reported in several countries of this Region
which had not been invaded in 1965/1966 and, in addition, in areas of
north, ~Iest and east Africa which had been unfamiliar wi t '1 or free from
cholera f or decades. This might give rise t o t he potential danger of
the disease becoming endemic in this Region.
villO promptly responded t o requests f or assistance; experts and teams
of experts were sent t o nearly all t he countries of the Region whether
EM/RC21/2 page 45
invaded or at risk; cholera vaccine was provided to an amount of approxi
mately 30 000 000 millilitres (28 000 000 donated by the UAR and 2 000 000
by Iran); diagnostic sera, antigens, culture media were provided in ade
quate quantities, as well as rehydration fluid with giving sets; anti
biotics have been generously supplied.
Evidence has shown that in countries enjoying an adequate standard
of basic services, sanitation and health education, morbidity and parti
cularly mortality rates were low and the outbreak was rapidly quelled.
In order to augment and improve production of vaccine and rehydra
tion fluid and to improve laboratory diagnosis of cholera, a number of
countries where facilities existed, were advised of ~~O'S preparedness to
assist them in these fie lds.
Moreover, arrangements were made for a consultant bacteriologist to
visit a few countries of t he Region to diSCUSS, with the officials con
cerned, methods for improving cholera vaccine quantitatively and quali
tatively.
In October 1970, an Inter-Regional Seminar on the Organization of
Cholera Control Programmes (for senior administrators) was held in Manila,
which five participants from this Region attended.
A ~aining Course on Cholera Bacteriology was organized in Beirut in
February 1971 for laboratory technicians, with seventeen participants.
In order to assist the Government in drawing up preventive measures
for cholera, two WHO missions composed of epidemiologists, bacteriologists,
clinicians and sanitary engineers visited Saudi Arabia before and during
the Mecca Pilgrimage, which took place from 5 to 9 February. The WHO
mission was given all facilities and access to all the Holy Places. It
is worth mentioning that the arrangements made by the Saudi Arabian author
ities for the prevention of cholera are to be commended, and the Pilgrimage
was declared free from quarantinable diseases.
EM/RC2l/2 page 46
A new book (W'rlO Public Health Papers No. 40) "Principles and Practice
of Cholera Control " was distributed to all Member states of the Region, as
well as other publications on cholera.
TUBERCULOSIS
Recent advances in tuberculosis control with reference to the control
measures in the WHO Eastern Mediterranean Region were reviewed at the
Twentieth Session of the Regional Committee held in September 1970. The
ensuing Resolution reflects the views of Governments and the Organization
on the long-term strategy for tuberculosis control in the Region.
Great emphasis was given to the promotion of training . There was an
obvious trend to enlist the participation of other educational institu
tions, such as schools of nursing, health training institutes and similar,
with a view to incorporating subjects on tuberculosis in the curricula
for different categories of health personnel. In order to ensure field
orientation first attempts were made t o establish rural demonstration
areas, of which the r ural health centre in Balad, Somalia, represents a
very promising example, as well as t he Shew-aki rural health centre in
Afghanistan. A new approach, to decentralize training to the provinCial
level, is being attempted in Ethiopia by preparing provincial teaching
teams. To increase the pool of well-qualified tuberculosis control offi-
cers, WHO fellowships were awarded to a number of doctors to attend inter
national courses in Prague, Rome, Tokyo, Oslo and Copenhagen.
Basic health services are increasingly carrying out simple tubercu-
losis control procedures, integrated in their r outine work. Methods,
plans of action and target time schedules in tuberculosis projects faith
fully f ollow those planned for expansion of the former.
For the first time, the BeG component of the mass smallpox eradication
campaigns was evaluated in PDRY and Sudan. While the techniques observed
EM/RC2l/2 page 47
in the field were of satisfactory standard, operational and administrative
aspects deserve full attention if t he desired outputs and coverages are
to be achieved. There were good reasons to believe that the BeG compo-
nent would not jeopardize the overall field operations. Preservation of
the BCG vaccine against heat r emains a vulnerable point. The relevant
technical instructions of 1969 were distributed once again to all concer
ned. Countries t hat are approaching the maintenance phase would soon
have to make the necessary preparations for absorbtion of personnel at
present engaged in mobile teams. Independent simple assessment by ran-
dom sample scar surveys should be introduced as a regular feature.
Strategy of BCG vaccination on a permanent basis, under various epidemio
logical and operational situations, requires a lot of flexibility to peach
the susceptible population .
In several countries , a substantial number of assistant laboratory
technicians are trained in the teChniques of examination by direct micro
s copy as an integral part of the comprehensive curricula; the tendency
of creating specialized umi croscopists" has been abandoned for all practi-
cal purposes. Constant technical supervision would be indispensable to
minimize over- and under-reading.
The Regi onal Sub-Committee strongly discouraged f luoroscopy on the
grounds of its inaccuracy and radiation hazards; on t he other hand, when
resources permit, static mass miniature X-ray apparatuses are considered
as a useful diagnostic tool at intermediate levels. It has been recog-
nized that mass mobile case - f inding failed to achieve any epidemiological
impact and that diagnosis of a true case of tuberculosis in such a way
may cost as much as US $ 80 to 100.
In spite of the availability of effective and cheap anti-tuberculosis
drugs, chemotherapy of tuberculosis on a community-wide basis remains a
weak point. The overall management of ambulatory treatment lacks firm-
ness. Even t he simple appointment system f or drugs collection has not
EM/RC2l/2 page 48
yet been introduced everywhere, but efforts were made to rectify the
situation. It is be lieved that with the expansion ~~d subsequent con-
solidation of basic health services, chemotherapy would be brought within
the reach of rural patients. In this respect, stepping-up of health edu-
cation would be greatly instrumental. Data from a trial on side-effects
due to thioacetazone carried out in Libya are under analYSis, but the
preliminary information strongly indicates that this drug should be as
acceptable as any other. This is confirmed from a "test-run" treatment
in Somalia. Ethiopia is studying the practicability of a bi-weekly regi-
men on ambulatory basis.
The entire field of operational and technical assessment leaves much
to be desired. There is still a great deal of pragmatism. A relevant
document on assessment of case-finding and treatment was received from
Pakistan and the possibility of applying a similar methodology in other
countries is being explored.
Technical assistance was given to PDRY, Somalia, Sudan, Syria and
Yemen in the review of development of tuberculosis control programmes.
IEPROSY
The duration of t he disease , the disabilities incurred and the
attached stigma require planning of control programmes on a long-term
basis so as to reach the community, the majority of which is rural.
As r esources are norm~lly very constrained, priority in programmes
should be given to treatment, follow-up and surveillance of contacts.
Epidemiological aspects demand that at least 75 per cent of the
estimated lepromatous and borderline cases should be treated regularly.
In view of high relapse rates, it is now recommended that after attaining
the quiescence, regular treatment for at least ten years should be adminis
tered to lepromatous and borderline cases, which involves serious opera
tional difficulties.
EMjRC21/2 page 49
The controversy about the protective value of BeG vaccine against
leprosy is obviated by the fact that BeG vaccination is a standard prac
tice in all countries of the Region.
Scarcity of skilled personnel requires incorporation of teaching on
leprosy control in all relevant curricula. Field demonstration areas
are indispensable for demonstration of integrated leprosy projects in
rural areas.
Promotion of health education should be considered amongst the major
tools for improving community participation.
Leprosy control was given a high priority in the Fourth Five-Year
Plan of Pakistan and it was planned to expand the project allover East
Pakistan.
The WHO Chief Leprologist visited Sudan and Ethiopia. This was
followed by a r eview made by a WHO leprologist in preparation for n WHO
assisted leprosy control project.
A WHO leprologist further reviewed the problem of leprosy in Yemen
and discussed the feasibility of implementing an integrated scheme.
PARASITIC DISEASES
SCHISl'OSrnIASIS
With the increased number of neWly-constructed irrigation schemes
and agrarian reform projects, which are operating in most cou!ltries of
the Region, breeding places for snail hosts of the parasite are being
created. At present, the problem of schistosomiasis is receiving great
attention from public health workers. It has also attracted the atten-
tion of field scientists, apart from the medical personnel, such as bio
logists, biochemists, immunologists, hydrologists, sanitary engineers,
etc. However, in spite of such varied efforts, the progress of schisto-
miasis control is slow. Recent information bas been accumulated in
EM/RC2l/2 page 50
connexion with epidemiological changes which occurred in the transmission
of schistosomiasis as a result of th~ creation of new l akes (Nigeria).
A new Special Fund project on the Epidemiology and Methodology of Schis
tosomiasis Control in Man-[vJade Lakes (Ghana and UAR) will be implemented
shortly.
During 1970, an improved method of mollusciciding was introduced in
the project UAR 0049, by applying molluscicide frequently in the trans-
mission season from Apri l to November. Five rotations of molluscicidings
were carried out during 1970 us ing a total of six tons of Bayluscide. In
comparison to the level in Harch-April, the populati on of Bulinus truncatus
was reduced by 99 per cent in June, 95 per cent in July, 99 per cent in
August, 98 per cent in September-October and 100 per cent in October-
November. The population of Biomphalaria alexandrina was reduced by
88 per cent in June, 74 per cent in July, )2 per cent in September
October and 54 per cent in October-November, but increased by 11 per cent
in August in the mollusc i ci ded ar ea . These encouraging r esults conf irmed
the efficacy of the five r otations application compared with the two r ound
applications the result of which was f ound, by evaluation operation, un-
satisfactory. The first-year evaluation on the prevalence of schistoso-
miasis in children is expected to be made in April 1971, at which date
mollusciciding will start.
In order to find an economic and effi cient way of controllingschis~
tosomiasis in the Nile Delta area, therapy programmes will be introduced
in t he project. Selection of areas was started in July 1970 . Towards
the end of the year, the Sidi-Ghazi section was chosen f or human therapy
and mollusciciding and the Awad section for human therapy alone. Trials
of drugs (Astiban) have been carried out in two villages in the Sidi-Ghazi
area in February-April 1971. \I.!hen baseline data are completely collect-
ed, mor e villages will be used for treatment programmes.
D-l/RC21/2 page 51
During the visit of t he ccnsult~~t epidemiologist, the work done in
the past and present Viere reviewed in great detail and many valuable
recommendations for t he future of the project have developed.
IEISHMANIASIS
Leishmaniasis is receiving considerable attention from a number of
countries in the Region. Cases of visceral leishmaniasis are increas-
ingly reported in Iraq where seventy-eight cases of Kala-Azar, all under
five years of age, were admitted to the Children's Welfare Hospital in
Baghdad between 1963 and 1967. A Unit has been created in the Endemic
Diseases Institute in Baghdad to undertake epidemiological studies.
Publications on l eishmaniasis were sent to the unit upon their request.
An official request has been received fr om t he Government of Iraq for a
long-term project to be implemented in 1972. A consultant entomologist
will be visiting the country for a phlebotomus study. In Syria, cuta-
neous leishmaniasis (Aleppo boil) has been known for a l ong time and was
described even before the discovery of Leishmania tropica by Wright
(1~3) . At the request of the Government, a consllltant entomologist
visited Aleppo and undertook an entomological study in villages in the
vicinity. In a small village about 70 km south-west of Aleppo, sixty-
three out of 154 persons (41.4 per cent) examined were found to be either
suffering from the disease or marked by its scar. The sand-fly specimens
found in the area were P.papatasi, P.sergenti, P.major and P.dentata.
ONCHOCERCIASIS
Vlhile at the moment no WHO staff are assigned to specific projects
for the control of onchocerciasis, this problem has received nevertheless
attention in the reports of various conSUltants, for example the epidemio
logist assigned to the Lake Nasser Development Centre in the United Arab
Republic, and the Regional Office has r emained at the disposition of
Governments to assist, if r equested, in the formulation or review of
EMjRC2l/2 page 52
programmes. One such request has been received from the Sudan, where at
present onchocerciasis control is being supervised by national staff, with
assistance from WHO by means of f e llowships, supplies and equipment. A
WHO consultant entomologist will make a follow-up study of the programme
l~r~lm·
At present, t he onchocerciasis programme is being carried out satis-
f actorily . A r esident team for fly (Simulium darnnosum ) catching and dis-
secting has been stationed at Abu Hamman, and four sub-units stationed ct
Shi rri Island, Merowe, Debba and Argo are continuing with their fly catch-
ing for assessment of density and infection rate. The team is also doi ng
a survey on Simulium breeding in the canals of the Gezira Scheme .
4. PUBLIC HEALTH SERVICES
PUBLIC HEALTH AI1'<lINISTRATION
EM,IRC21/2 page 53
Public health administration, providing as it does the framework and
co-ordinating mechanism for all other health activities, has rightly con
tinuously preoccupied Governments i n the Region.
Some Ministries of Health have been reorganized during the year,
others have undergone minor modification in a universal trend to provide
the drive and organized expertise required to plan, promote and operate
the rapidly expanding services . Ther e is a near-universal recognition of
the importance of s ound l ong-term health plans based on adequate data, and
designed to contribute effecti vely t o overall national socio-economic
development objectives.
Although some s ixteen countries of the Region now have such health
plans, few ministries are yet effectively gear ed to their tasks. structure
alone cannot assure that tasks will be adequately performed. Good per-
formance depends upon well-defined macro- and micro-objectives, a clear
allocation of responsibilities and a continuous review of progress.
An adequate machinery for the collection, analysis, study and re
trieval of data is the essent i al base for the objective definition of
problems, t he establishment of priorities and evaluation of progress. All
countries of t he Regi on are making efforts to improve their health intel
ligence, but much work is still necessary before a satisfactory level is
attained. Reporting systems vary in their efficiency and pertinence and
need attention.
A high level of health expertise, combined with knowledge and
experience in the application of modern management approaches and techni
ques, is essential if scarce resources are to be deployed to best advantage.
EM/RC2l/2 pae;e 54
The more senior the post occupied by a health prof essional, the greater
becomes the administrative component of his wor k . Yet there are s o f ar
few professional health workers who have had f or mal training in managerial
appr oaches, methods and techniques. There is inadequate recognition of
the fact that a good s ci entist may not make a good aQ~inistrator, or t hat
a person with a talent for administrati on r equires training i f his natural
gifts are to be fu lly developed .
It is encouraging t hat more attenti on is being given t o these matt ers
in institutes of public health, and t hat us~ is beginning t o be made of