Action at local level John Martin A mother walks a long, long way to the nearest health centre, carrying her sick baby for treatment. There are no drugs. Yet, in the same country, at the large teaching hospital, people are given expensive antibiotics to treat their sore throats when health workers know that such treatment has no effect. The same mother, perhaps, asks for family planning advice. Not possible. She has come on the wrong day. Yet, in another country, health centres and clinics are organized to provide all their services every day. A nurse is worried and depressed. Her salary is late as usual and she has school fees to pay. What's more, she does not feel confident to treat some of the difficult cases which are brought to her. She has never had the chance to attend refresher training since the day she graduated, and she has not seen her supervisor for more than a year. A school teacher is concerned that her pupils should know how to be healthy. In addition to knowing about healthy food and good hygiene, she wants the children to resist cigarette Now more than ever, primary health care is seen as the way to health for all the world. A nursing mother in Chad, and child care in India. smoking and drug taking which have become common amongst older age groups. She wants a health educator to guide her. She wants books both for her fellow-teachers and the children. There are none available. WHO's initiative on Strengthening District Health Systems Ten years after all countries of the world agreed that Primary Health Care (PHC) is the only way to achieve health for all the people of the world, problems such as these are still commonplace. To be sure, economic crises have deprived many countries of the money which might otherwise have been used to buy more medicines, equipment and even hospitals. But the root cause of problems like those above is not lack of money. Rather it is a lack of know-how and skills in planning, organizing and man- aging PHC. These skills may seem very mundane, particularly when contrasted with the drama and glamour associ- ated with the search for new vaccines and drugs, or with the development of high technology medical equipment. Yet it is a fact. The greatest obstacle to achieving Health for all is poor plan- ning, organization and management, particularly at the local level where the action is supposed to be. In response to the evidence which has been emerging from country after country, WHO has launched an initiat- --,,-..._'!"''l!l"'r"'~ .c 01 c: ijj o,; ~ Cover: The striking logo designed by Moses Gichuiri Kahugu for Kenya's Distri ct Level Health Servi ces. IX ISSN 0043-8502 '----~~===-' World Health is the official il lustrated magazine of the World Heal th Organ izat ion. Editor: John Bland Deputy Editor: Christ iane Vi edma This Month's Theme Editor: Sylv ia M oore Art Editor: Peter Davies News Page Editor: Philippe St root World Health appears ten times a year in English. French. Portuguese. Russian and Spanish. and four times a year in Arabic and Farsi . The German edition is obtainable from German Green Cross. Schuhmarkt 4. 3550 Marburg. FRG. Articles and photographs not copyrighted may be reproduced provided credit IS given to the World Health Organization . Signed art1cles do not necessarily reflect WHO 's views. World Health. WHO. Av. Appia, 1211 Geneva 27. Sw1tzerland. Contents Action at local level by John Martin ......... .. .. . . . . 3-4 A health care paradox by Kausar S. Khan. Kamal Islam and John H. Bryant .. ... . .. .. . . . 5-7 Light at the end of the tunnel by Gunnar Bolstad ... . .. ..... . . 8-10 Money for health by Sidney Ndeki .. . .. . . ... . . .. 11-13 "Health first" in Bolivia by Ramon Gra na dos. An gel Valencia and Juan Sotelo ... .. . 14-15 Reach out for health . : .. .. . 16-17 Health across barriers by Sylvia Moore . . .... .. ... .. . 18-19 District approach to primary health care .. .. . . ... . . .... ... . 20 Ethiopia's success story by Gebre Selassie Okubagzhi . . . 21-22 Allied health professionals by Edmund McTernan and Lee J . Holder .. . . . . . . . ..... .. . . .. . . . 23-24 A world fit to live in by Monroe T. M organ .. . ... ... 25-27 The birth of WHO Interview w ith Szeming Sze . . . . 28-29 News Page .. ... . ..... . . ... . 30-31 3 Action at local level An old man in China gets the message - just two tablets at a time. A wise mother cleans the latrine in Mozambique. ive called "Strengthening district health systems." Its overall objective is to find better ways of putting primary health care into effect. The basic idea stems from the fact that better health is not just a matter of going to the doctor for treatment when one is sick. For one thing millions of people have no doctor to go to, even if they wanted to! But the point is that treating the sick is not enough. To be healthy, people themselves need to know how to adopt more healthy lifestyles and how to make changes in their home and community environments which are both effective and feasible, especially for the very poor. But more than that, they need support to obtain better nutrition, better sanitation, better education, and better housing, as well as better health care. It is immediately obvious that better health is not the responsibility of the 4 Photos in this issue not marked WHO or C for copyright are entries in WHO's 40th anniversary International Photo Competition ities, and particularly their leaders who are members of health and develop- r~'lt ment committees, as well as traditional //. ~ midwives and community health r I E workers. The final group comprises ~ those people such as the school / ~ teacher, community development ...: worker, and so on, who staff these -~ sectors which already contribute to rJ5 social and economic well-being. To be health sector alone. Ordinary people have a key role to play, and so do those personnel who staff all the other sectors which contribute to social and economic development. Some may work for government, whilst others work for private and non-governmen- tal organizations. The challenge is to influence the way in which they work, and to coordinate their efforts so as to increase the benefit to people's health. One group comprises the personnel who staff the clinics, health centres and local hospital. Another group comprises people in their commun- practical and effective the coordination of all these group's activities must be carried out on a local basis. That is why the term "District" has been chosen - to indicate a local area which is manageable in size. Many countries already use the word district whilst others use indigenous names such as Au.raja, in Ethiopia, and Kabupaten, in Indonesia. Just as the names vary, so must the ways in which primary health care is implemented. Each country is unique and must find its own solutions to the obstacles which currently obstruct the road to Health for all. Nevertheless, the sharing of experiences is an extremely valuable way to stimulate good ideas as well as to avoid the repetition of mistakes. With this in mind, we hope that the articles that follow in this issue of World Health may prove both interesting and instructive. • WORLD HEALTH, May 1989 A health care paradox Kausar S. Khan, Kamallslam, and John H. Bryant A lma-Ata's challenge to view health as a human rights issue has not been adequately met by most Third World countries. Barring a few examples, health services continue to be either substandard, inaccessible, unaffordable and under-utilised, or to suffer from varying combinations of these factors . While governments of many coun- tries, Pakistan for example, have spent millions on building physical infrastruc- tures at district levels, the over-all health status, especially of the urban and rural poor, remains deplorable . It is now more than evident that con- structing a hierarchy of health centres, and even staffing them with doctors and paramedics, does not resolve the deeper issue of developing a health system that can achieve the goal of equity in health: universal coverage and care according to need. This challenge is faced not only by governments but also by the non- governmental sector concerned with the health of the people. There is a pressing need to develop primary health care (PHC) systems which are technically sound and predicated on these principles of universal coverage and care according to need, but which at the same time involve communities so as to ensure that their own percep- tions of their needs are fully recognised and that they are fully involved in the effort to address those needs. The health services of Pakistan are well planned and the health leadership has continuously pressed for effective implementation . But scarcity of resources and shortages of manpower (particularly as regards key roles of management, and as regards women as health care providers) have pre- sented massive obstacles to making effective services accessible to large numbers of people living in deprived areas. Recent favourable shifts in the politi- cal landscape of Pakistan have given rise to a new resolve to extend services to these populations, and fresh national health strategies are being drawn up. Of particular importance to health system development are: the design of PHC systems so as to achieve equity; the role of communi- ties in ensuring progress towards that goal; and the contribution that a non-governmental organization - the Aga Khan University - can make to the nation's effort to improve its health services. Like many Third World countries, Pakistan finds itself caught in a para- doxical situation. There is a hierarchi- cal infrastructure of health services, on the one hand, and a large under- served population of urban and rural poor on the other. Services are largely facilities-based and curative-oriented, though some vertical programmes, such as those for immunizations and diarrhoea treatment, do operate spor- adically. For the most part, the people who receive care are those who seek care - though whether the care they receive is the care they need is another question. It should be no surprise that these approaches have not brought about significant changes in morbidity and mortality patterns, especially for the urban and rural poor. A variety of organizations and agencies both inside Pakistan's health 'services are well planned despite staH shortages. A woman doctor checks these small child- ren for telltale signs of leprosy. WHO/ Zafar and outside of government have been working toward improvements in these systems. The Department of Community Health Sciences ( CHS) of the Aga Khan University has been attempting to address these problems through micro-level experiments in the katchi abadis (squatter settlements) of Kara- chi. Over 40 per cent of Karachi's eight million population live in these areas. During the past five years, CHS has developed a series of prototypes · of a PHC system in five different katchi abadis. Each prototype serves approxi- mately 10,000 of population and aims to provide affordable care appropriate to need. The key elements of the system are: simple and sound PHC technology, and community involve- ment. CHS believes that the paradox mentioned above cannot be resolved without close partnership between technical expertise and those in need. Under the CHS-Ied approach, literate or semi-literate women are selected with the help of the com- munity and given brief training in the 6 University and community have interac- ted positively in health services develop- ment in Pakistan. community as Community Health Workers (CHWs) . Each CHW is assigned 150 families who are visited at least once a month. The CHW monitors the nutritional status of all children under five by checking their weight for age, and also notes the immunization status of all children. She provides nutritional education to the mothers, propagates the use of oral rehydration salts, identifies the children and women at risk, arranges for immunizations, and makes referrals to the community-based PHC clinic. A simple record-keeping system enables information to flow from the home to the PHC centre, thence to the hub of the PHC network (currently the university) , and back to the field- based PHC centres. In addition, lady health visitors (LHVs, middle-level personnel) super- vise the CHWs and assist them in handling difficult problems and summarising information on malnu- trition, immunizations, births and deaths. Meanwhile community health nurses and community health doctors supervise the CHWs and LHVs, pro- vide clinical and managerial backup, analyse the data on the entire com- munity and prepare appropriate inter- ventions. House-to-house surveillance These prototypes, once in place, showed that house-to-house surveill- ance by CHWs ensures that care according to need can be extended to the entire population of a poor com- munity; and that a community-based PHC system is relatively easy to set up and to manage on a small scale. We also found that the system had a favourable impact on immunizations and the nutritional status of children under five (the impact on mortality rates is still under study), and that the system is affordable: the current cost is US$ 2.50 per person per annum (exclusive of costs of referral care), though a still lower cost is possible. While urban in location and not part of a formal district, this network of PHC modules - providing care for 50,000 people and organized around a uniform management system - represents the urban variant of a district-level, integrated PHC system. The CHWs are socially close to the community, and represent a special resource for reaching women in the community. Although this approach to community-based PHC was a distinct advance compared with the more usual health services, some drawbacks became apparent. The overall mor- bidity and mortality rates did not dramatically improve; severely malnou- rished children often died despite close monitoring, even when they were sent to hospital, and diarrhoea coupled with malnutrition remained the major killers of children. The CHWs and the PHC teams felt frustrated with the limited effects of their work in the face of the deep poverty and depressed living conditions of the communities. The farther one looked, the deeper the roots of the problems appeared to penetrate. The roles of communities now appeared in a new light. Their involvement in identifying problems, finding solutions and planning and implementing actions was an impera- tive. The CHS-Ied model, though technically sound, was weak in the extent that it involved the community. Consequently, the model was re- examined, and new strategies were explored. W ORLD HEALTH , May 1989 A closer assessment of the social dynamics of the urban poor and the implications for the role of CHS prompted two significant changes. Firstly, a new criterion for field site selection was developed that led to the selection of a community that had an active local organization committed to improving the quality of life. Secondly, CHS was to reverse its approach, so that the local organization would retain the leadership in identifying problems, setting priorities, getting programmes under-way and sharing costs, while CHS would act as a facilitator for the local organization in making its de- cisions and seeking outside assistance and resources. The need for stronger social expert- ise at the field level was also recog- nised , and the PHC team was rearranged to include a social organizer who would make the com- munity organization more aware of its enlarged role, and would mobilise the community at large to reflect over and analyse its own social realities and plan action for change. The community-led model is cur- rently being developed and monitored in a traditional fishing community on a small island in the Karachi harbour. It Tracking down possible cases of tuber- culosis_ Community health doctors and nurses provide clinical and managerial backup for the community health workers and lady health visitors. A health care paradox is based on a new kind of partnership, in which health personnel and social organizers work jointly with a com- munity body. A community-oriented physician and nurse together with the social organizer act as a team to ensure that a technically sound system and the community come together. It is too early to know which of the problems of community health and development will be resolved through this approach and which will remain unresolved, but CHS believes this is a fresh and positive step forward. So the micro-level experiments in the katchi abadis have established two types of PHC models: CHS-Ied and community-led systems. Although technically sound and appropriate to the needs of small communities of 10,000 people, can such small islands of success have an impact on the health services and health needs of the country? This underlying concern gives rise to two critical questions: how does a university like the Aga Khan University influence the design and function of the vast system and staff of the governmental health services? And can one go up-scale to real world applications with the model? An open process The new changed environment of Pakistan, with recent elections which installed a politically popular government, includes an open process for formulating national health strat- egies. The university has been invited to participate in that process by presenting its ideas, showing its experi- ence and joining in the give and take of policy-making. This will call for a dialogue between policy-makers and those people and institutions who are in a position to do practical health systems research. Pakistan bristles with social , economic and political problems that torment many developing countries. Desire for change is too frequently dampened by the poor carrying out of strategies. Such overall failures to boost the quality of life engender a tacit despair that gnaws at the will to change. Energies are then dissipated into platitutes and cynicism, and it becomes difficult to keep alive the flame of hope. However, five years of intensive field experience by the Aga Khan University have given a ne\v dimension to the role of a university and to the role of communities in health services development. That ----- experience has shown that community .Z! involvement need not remain only ~ rhetoric, and that the usefulness of ~ micro-level experiences for national =:: policy need not remain in doubt. • 7 Light at the end of the tunnel Gunnar Bolstad A rthur J. has come home at last. After almost 30 years in institutional care, the 55-year-old mentally handicapped man has returned to his home village in a small municipality north of the Arctic Circle. Now he is working in the local grocery store. He lives in his own small flat and manages his own money. Arthur enjoys life in his own village and does not look back upon the many years of institutional life with any nostalgia. Arthur's return to his home village is the consequence of comprehensive reforms for the mentally handicapped whose aim is to make local munici- palities fully responsible for mentally handicapped persons in their home environment. This "reform" in the health care system for the mentally handicapped is an important link in a far-reaching process within the Norwegian health service. Nothing less than a small revolution is in progress. Time will show whether it will be a successful revolution. There is light at the end of the tunnel, but it may yet turn out to be a longer tunnel than expected. This is not the first quiet revolution in the history of Norway. With the end of the 1940-45 war, a new chapter in national development opened. A new philosophy of social development, combined with economic optimism both nationally and generally in Scandinavia, led to rapid improve- ments in living standards in Norway. Massive resources were channelled into developing a public health service, and priority was given to building up central institutions and hospitals. The hospitals absorbed the vast majority of health personnel. Primary health care was starved of resources. The system had its weaknesses. Decisions were taken above the heads of local communities. No unified plan for the delivery of primary health services existed. In 1975, in a parlia- mentary paper on hospital develop- ment in a decentralised health care system, the idea was launched that primary health services were to form the basis of all health services. The idea won universal support. Thus the pri- mary health service team was to remain responsible for the patient even if she or he had to be "loaned" to higher levels of care for specialised treatment. An important task of the higher levels of the health service is to provide support and advice to the primary level. A process of legal revision was embarked upon, and the Act on Municipal Health Services was ready for adoption in 1982. It entered into W ORLD HEA LTH , May 1989 Norway is putting increasing emphasis on rehabilitation for disabled persons and on assisting their families, in the context of the nation's strategy for Health for all. Facing page: Care for the elderly is a special concern today throughout Europe. force two years later. The purpose of the act was to ensure the development of comprehensive primary health services, operated as one continuous system of care. It would bring about a more equitable distribution of resources between municipalities and regions. Under the new system, state grants would be given according to need rather than in the form of reimbursements to existing services. The act also ensured a more efficient use of resources and laid the foun- dation for better cooperation between W ORLD HEALTH, May 1989 health and social services at the local level, and between ambulatory care and institutional care. Subsequently the municipalities have taken over responsibility for run- ning nursing homes which were pre- viously regarded as institutions in the hospital system and were run by the countries. The emphasis in these homes will increasingly be on rehabili- tation and on assistance to families faced with the burden of looking after disabled persons . The care and support of mentally handicapped per- sons will in future be the sole responsi- bility of the municipalities. This far-reaching process of decen- tralisation is in keeping with the grow- ing emphasis on district health systems within the strategy for Health for all. It is the primary health service which can reach people where they live and work, in municipalities and in the local communities . The Directorate of Health, in its book "Health for all in Norway?" states: "Primary health services must be easily accessible and acceptable to all, and be planned and operated with the full participation of the local community. Other levels of health services must have as their aim to provide support to, and increase the effectiveness of, local health services." It has long been the expressed aim of Norwegian health policy to strengthen the ability of the primary health service to ·take care of the patient, and thus to ease the load on hospitals and specialists at the second- ary and tertiary levels. Today, more than ten years after the first public statement of this principle, we have to accept the fact that the pressure on specialised health services has not eased noticeably. It is hoped that the legal reforms and reorganization of the last few years will provide the neces- sary basis for realising our aim. 9 light at the end of the tunnel In many European countries, pri- mayy care has for years been defined only as the contact with a physician whom people see initially in case of illness_ In Norway, public health nurses have for years had a prominent place in primary health care and, since the 1970s, home nursing services have developed rapidly. Together with cura- tive physician and physiotherapist services, nursing services now consti- tute the major elements of the primayy level, while the role of midwives, dentists and pharmacists on the pri- mayy care level is currently less clearly defined. Conditions have become more favourable for the development of a comprehensive plan for health promotion and health services in each municipality. In order for primary health services to transmute into pri- mayy health care, the health sector needs cooperation with other sectors. We must succeed in creating a con- tinuous chain of services through all sectors and all levels of service, if we are to provide adequate housing for persons with disabilities or chronic diseases. In the meantime the target remains: "By 1990, the services provided by all sectors relating to health should be coordinated at the community level in a primayy health care system." Legis- lation exists to support this. 10 There have been conflicts. But the dividing line in this debate runs across party political boundaries. The Direc- torate of Health, which has the profes- sional responsibility for the health services, has on several occasions voiced its scepticism about the decen- tralisation process. Responsibility for Norwegian health services is at risk of fragmentation, says the outspoken Director-General of Health, T orbjorn Mork. He is worried by some of the things he sees. And Patricia Melsom, a board member of the Norwegian organization for the disabled, considers that health care for members of her organization has deteriorated. Central authorities have no way of intervening in the case of unreasonable decisions at the local level, she says. Regional inequities The main concern of both Mork and Melsom is with the risk of regional inequities. If one local authority gives higher priority to a swimming pool or a new office block than to a nursing home, it is free to use its money any way it wants. There is a real risk that domicile may decide what kind of health services one can expect. Some foresee the development of a nation on the move: the young will prefer municipalities which have given priority to education and housing, while the "We must succeed in creating a conti- nuous chain of services through all sectors if we are to provide adequate housing for persons with disabilities." elderly will pack their belongings and move to districts with renowned nurs- ing homes and cultural facilities. While the rest of Europe is exper- iencing reasonable economic growth, Norway has been suffering from an economic hangover since 1984-86. Local municipalities have had to take tough decisions in the course of budget processes. To all appearances the worst sufferers have been groups which were not so well-off before. The press has had juicy stories to tell of residents in nursing homes who - because of staff shortages - were put to bed at four o'clock on week-day afternoons, or who might not be able to get up at all on Sundays, or of disabled persons who have lost well- established services because the muni- cipality could not afford the necessary personnel. The period of prosperity which we hope Norway is now embarking upon will show whether the municipalities can indeed shoulder their responsi- bilities in keeping with the stated goals and in accordance with the Health for all strategy. • WOR LD HEALTH, May 1989 Money for health Sidney Ndeki K n a dusty township located in a wild expanse of northern Tanzania, Or E. Nashara has enormous financial and man-agement problems of a special kind: how to run a 90-bed government hospital, a health centre and 15 dispensaries serving about 100,000 people with a budget of only about US$ 30,000 a year. This district hospi- tal mostly serves Masai herdsmen. With that amount of money, he has to buy medicine, provide meals to in-patients, run and service two anti- quated vehicles and pay utility bills; all this for a full 12 months. He has medical, health and other auxiliary staff totalling more than 100 who must draw their salaries every month. And that same budget must also be used to support immunization programmes, nutrition, maternal and child services, the control of common preventable diseases and the running of health education programmes. In previous years, when the money ran out within eight or nine months despite frugal spending, a subsidy was provided by the central government until the next budgetary allocations - provided a satisfactory explanation could be given for the shortfall. Of late, new austerity measures administered as part of the national economic recovery programme require that the funds should last the budgeted period. Yet the hospital has to provide services daily and patients cannot be charged even a token fee because the official policy of the government is to provide free medical services to all the people. Fuel or firewood Or Nashara's biggest problem revol- ves around setting priorities and decid- ing how to use the meagre monetary resources at his disposal to make sure that the hospital remains in operation and that patients within Kiteto township and neighbouring villages receive the medical and health services they expect from the government. "At times I find myself in a dilemma," he says. "When the budget is in the red, should I ask for extra funds to purchase fuel for vehicles or firewood for cooking meals for in- patients?" He has really no choice between the two. Both are important and essential. The vehicles are needed to collect drugs and other supplies, usually from a regional hospital store in Arusha some 300 kilometres away. Sometimes he needs a vehicle to fetch water for hospital use from a spring two kilo- metres away. But firewood is also essential for cooking and sterilisation purposes when the aging electric generator is not functioning. Or Nashara's problems are over- whelming not least because, when he trained as a doctor at the University of Oar es Salaam, economics and health management were given the least consideration in the curriculum, while basic sciences and curative skills were emphasised. He had come to realise that chromosomal aberrations , bio- chemical balances and examination of a patient, all of which greatly out: weighed cost-benefit analyses and techniques for mobilising resources, are not always helpful in solving some of the health problems he was now encountering. Like many other di?trict medical officers in developing countries, he is in a frustrating situation. Thousands of people queue daily in dire need of his services but he is unable to provide them as he would like to, because material and human resources are limited or lacking altogether. The result is a poor service about which public complaints are abundant. A fond father feels the prick of the needle more than his son at an open-air immunization session in Tanzania. Providing a village community with safe water "on tap" is an obvious example of aHordable technology that will benefit health. Facing page: Primary health care is gaining acceptance as a strategy for bringing basic services to all people in Tanzania. The challenging situation facing the district medical officers is how to carry out and improve health services in their districts with the limited resources available. Experiences of many such officers show that there is very little data-gathering before budgets are drawn up or health service activities are started. There is no adequate information to permit a comparison of alternatives, so that cost-effectiveness analyses are sometimes unrealistic. Careful planning in all aspects of health care delivery could result in many savings, but this is possible only when those involved in planning health care delivery are fully aware of the economic factors involved in run- ning hospitals and other health services. A recent study on the use of health resources at a district hospital in Nzega, western Tanzania, indicates that elaborate planning substantially reduces recurrent costs of a wide range of services including vaccination, meals, transport and methods of training village health workers. It was also found that costs of vaccination could be reduced to one-third if more efficient use can be made of vaccines by ensuring that the "cold chain" is maintained. The cold chain is the system that keeps vaccines chilled all the way from the factory to the arm or the backside of the patient. Food wasted Many district hospitals in Tanzania provide free meals for in-patients. Or Nashara himself spends about one-fifth of his budget on such meals. "The type of food that we give to the patients is not the best but its costs are very high," he points out. Despite the expenses, much of the food that is cooked for patients ends up being thrown away. The tendency is to cook for all those admitted in the hospital without consulting them indi- vidually as to whether they would eat the often monotonous mealie meal (maize meal or ground maize) with © beans. % In most African communities, rela- ~ tives visit patients admitted in hospital ~ bringing food of their own choice. In g such a situation not many of the &: patients eat the prepared hospital WORLD HEALTH, May 1989 food. The Nzega district study shows a possible 50 per cent reduction of food costs when menus are properly planned. Affordable technology The costs incurred in running a district hospital are often high because the technology used in providing health services is neither sustainable nor effective. An affordable technology could be helpful to district health managers especially in the areas of support services and energy use. To cook for the 50 or so patients admitted each month to the Kiteto district hospital requires seven truck- loads of firewood, each weighing seven tons. This does not only mean defores- tation and destruction of the environ- ment, but is also an expensive and inefficient use of resources. Cooking is done on an open fire where three stones serve as a stove. Money could be saved by using an improved energy-saving stove, which also burns firewood. Such stoves are produced at an appropriate tech- nology centre in Arusha (CAMAR- TEC) and are sold to institutions which use firewood for cooking purposes. The stores reduce fuel wood con- sumption by more than 50 per cent compared to the three-stone fireplace. WORLD HEALTH, May 1989 Where energy problems prevail, health services are inevitably adversely affected. For example, refrigerators for preserving vaccines use kerosene but practice shows that the unreliability of fuel supplies may result in spoiled vaccines. The use of kerosene for refrigerators, lighting and sterilising purposes is too expensive for most district hospitals. Alternative sources of energy are available but capital invest- ments are forbidding. A biogas plant could be more efficiently and effectively used at a district hospital than wood-burning systems. Biogas is produced when bacteria break down organic material under airless conditions. It is a simple tech- nology and when carefully used in rural hospitals where human and live- stock dung is easily available, it would come cheaper than using kerosene, firewood or charcoal, with their added labour and transportation costs. Although capital costs are relatively higher - about US 1,000 dollars for material, labour and accessories - biogas is cheaper in the long run. Other technological innovations which could be used to reduce running costs in health care delivery include: - use of solar energy for refrigeration, lighting and heating; - water "harvesting" during the rainy season for hospitals and dispens- Money for health aries in areas where water is scarce; underground storage of water has been found to be relatively cheap; - use of ventilated improved pit (VIP) latrines in areas where water supply is unreliable and where resources are inadequate for installing and maintaining flush water toilets; - avoiding recently introduced brand- name drugs and relying instead on cheap generic products. Dr Nashara's five-year experience at the district hospital underscores the importance of preventive rather than curative measures. He has seen a steady drain of the resources needed to treat patients suffering from prevent- able diseases. "If the environment is kept clean, swamps are sprayed and water is treated, the incidence of diarrhoea can be kept low," he says confidently, since experience has shown him that diseases prevalent in the area have a devastating impact on the community and on available resources. Primary health care is gaining acceptance as a strategy for bringing basic health services to all the people. Such programmes can have a signifi- cant impact on health by focusing on a carefully selected number of health problems that are preventable by means of simple, and relatively low- cost, interventions. • 13 "Health first" in Bolivia Ramon Granados, Angel Valencia and Juan Sotelo JF or many years, the focus of Bolivia's health services was on hospitalisation and treatment, with little or no part being played at the local level. But, starting in 1982, an integrated programme of health care by local authorities began to take shape, with the emphasis on basic health services, the use of modern technology, and grassroots involve- ment in health care and hygiene. These are now the principal methods used to effect radical changes in this sector and to make them more efficient and widely available. The new methods stress involving social institu- tions in health care, and seeking the cooperation of the various segments of Bolivian society. In short, "Health for all" means that all are responsible. Since 1986, the main emphasis has been on restructuring the prevailing regional systems and giving them more decision-making powers. By 1987, the expansion of public health services in Bolivia meant that health facilities were available to most of the population. @ But the development of local health § systems on a district and regional level ~ has led to a more efficient adminis- . tration and better use of human and ~ financial resources. The end result is ~ that health care has become more ~ accessible to all classes of society. The transformation of the nation's health systems began with experiments in selected areas in order to gain experience in these new techniques, make the necessary adjustments and use them on a national scale. Two experiments show that they are indeed capable of providing effective health care for all. The Caranavi district Caranavi lies in the Department of La Paz, some 175 kilometres from the capital and much nearer sea level. Its climate is tropical and what roads there are leave many remote villages very hard to reach. The district has a population of 92,000, grouped into 780 communes over an area of 14,000 square kilo- metres. Its economy is largely farming and - on the social and economic level - it is a depressed area. The principal health problems are infectious parasitic and nutritional ailments, acute diar- 14 rhoea and respiratory diseases as well as tuberculosis, leishmaniasis, parasit- oses, malnutrition and goitre. The Caranavi experiment, launched in October 1986, focused on the integration of health facilities, so the involvement of the district community groups, agrarian trade unions and leading figures in the community was enlisted. The trade unions took an active part in improving health facilities and eventually, acting through agents elected by the community, were able to operate as people's health centres. The health centres are supported by the clinics and their medical staff. They developed their activities in four main areas - public education, supplies of medication and other items required for treatment, obtaining statistical data on community health, and logging background information on patients. Salt fortified with added iodine is a preventive measure against the iodine- deficiency disease goitre. The personnel of the health centres are selected by the social organizations in the different communities. As a result of the gradual transfer of tech- nology and the acquisition of skills and experience, the experiment has been a considerable success. Public health committees have cooperated with the health clinics in all sectors of com- munity life, and assist the medical staff in planning and evaluating health campaigns. Much effort has gone into training the staff at these clinics. The training programme initiated under the new system first concentrated on control measures for tuberculosis, a widely prevalent disease in the Caranavi district. It provided an excellent starting point for the clinic staff and a model for public education, information, background on patients and, generally speaking, a model for other health programmes. Where tuberculosis is concerned, the improved methods in diagnosis and treatment have paid off handsomely. This experience has been extended to other prevention and control pro- grammes such as those for acute diarrhoea, respiratory infections, para- sitoses, goitre and anaemia of preg- nancy. These methods can now be further applied this year to such prob- lems as mental disorders and psycho- motor disturbances. The successful collaboration with local health services means that early diagnosis and treatment can be encouraged in other areas: for example, women's com- mittees have now been set up not only to improve nutritional and educational standards but also to foster irrigation projects. Two years on, the Caranavi exper- iment has demonstrated the value and vast potential of grassroots involve- ment in the health sector, its effectiveness in raising health stan- dards in deprived areas, and the success of health programmes when the whole community is involved. It has shown the results that can be obtained through district health centres involving community participa- tion, and how effective the actions of the community can be when its own social organizations and institutions play an active role. The Caranavi district is now cooperating with non- governmental agencies to obtain medical supplies and even communi- cation systems. The experiment has also revealed certain weaknesses, among them a lack of qualifications in the health clinic staff. But conversely, the professionals have played a major role in motivating personnel to acquire the necessary skills and experience. The Sorata district Sorata is also situated in the Depart- ment of La Paz, and lies 153 kilo- metres from the capital with which it is linked by road - except in the rainy season. Within an area of 300 square kilometres it has a population of 22,800 people spread over 171 communes. This is a mountainous WOR LD HEALTH, May 1989 region with valleys and plains ranging from 1200 to 2600 metres above sea level. The climate is temperate and access is usually difficult. The most prevalent diseases are diarrhoea, acute respiratory infections, parasitoses, scabies, tuberculosis, malaria and endemic goitre. Accidents are also frequent although no statistics on the mortality rate are available. The "health first" campaign exper- iment was launched in March 1987 with the aim of expanding it at a later date. Stress was laid on regional cooperation, teamwork, community involvement and the training of human resources. The ultimate aim was to focus public attention on methods of prevention via publicity campaigns, and to reduce the mortality rate among high-risk groups. Much emphasis was placed on teamwork and eo-responsibility by the community services through improved standards of medical treatment and hygiene. Previously attitudes towards health needs had been somewhat passive, but now positive steps were taken to identify the sick and those at risk A district health programme was drawn up which called for closer cooperation between doctors and nursing personnel. Staff training at the health centres was a key ingredient of the programme, since much of its W OR LD HEALTH . May 1989 success in the remote countryside depended on qualified personnel. Also basic to the efficacy of the programme were regular visits to the local com- munities by doctors and nurses. The medical team conducted a population census and did a preliminary survey of health conditions in the various communes, thus gaining a clearer picture of the epidemiological situation and the risk potential. Data on births and deaths The experiment has involved a pro- found restructuring of the medical services and personnel which support the existing district services. A number of people's health centres have been set up so as to make medical attention accessible to all . Now the Sorata district has a capability for the exchange of information on patients between the local clinics and the central hospital. As a result, data are now available on births, deaths and the incidence of disease. Moreover, health care can now be provided in remote areas which were hitherto far outside the scope of normal medical services. Today, the newly-established medical teams are actively engaged in raising hygiene standards, in collaboration with the district clinics. The Sorata experiment has also led to stricter control of endemic diseases in the region, increased health care of The whole community takes an interest in Bolivia's campaign against goitre. Extending medical care through grass- roots participation has enormous potential for the improved health of the nation. women and children, better immuniz- ation programmes and a closer watch on fluoride levels. The programmes are tailored to local realities, and the clinics and people's health centres have even mobilised the churches and educational authorities as valuable collaborators in the joint effort. Not all the problems have been solved. There is still inadequate coordi- nation between the new methods and the old systems. But both the Caranavi experiment and, to a lesser extent, that in Sorata are highly encouraging. The lessons learned reveal that "health comes first" is a sound strategy that can be applied at all levels, including district ones. In the Bolivian context, the exten- sion of medical care through grass- roots participation has enormous potential for the improved health of the nation. The two experiments show that simple basic methods using trained personnel can be incorporated into more complex health systems, thus raising health standards at all levels of society. • 15 Who will till this rice-paddy in the Philippines if the farmer falls sick? Good health is everybody's business. 'The right way and the right time to brush your teeth." A simple message for two children in Indonesia. Beachoutf The greatest obstacle to achieving Health for all, the goal agreed by all of WHO's 166 member states, is poor planning, organi- zation and management, particularly at the local level where the most intensive action is supposed to be. This is why WHO launched the initiative which it calls "Strengthening district health systems." Better health does not just mean going to the doctor for treatment when one is sick. For one thing, millions of people - particularly in the Third World - have no doctor to go to, even if they wanted to. Instead, people need to know how to adopt more healthy lifestyles, and how to make changes in their home and community environments which are effective, feasible and affordable. And they need support to obtain better nutrition, better sanitation, better education and better housing - all this in addition to better health care. So the people who staff health centres, clinics and local hospitals need to recruit positive support from people at all levels in the locality -- and by "district" WHO indicates merely a local area which is manageable in size. And they must encourage coordination between government bodies and private and non-governmental institutions. Primary health care at the district level offers the best possible opportunity for even the remotest of rural communi- ties to reach out for health. A safe, clean water supply, like this pump in Nepal, is a benefit which most communities can afford. or health ... The proble• CDVER.AC-E DF Aspect of the proble11 tackled Notification of food poisoning cases Low percentage of i-.Jnised children IAAUWilATlO~ Low level of ~~&laria detection •~·••••••·,.N 0' MAlAiliA Maternal deaths due to postpartUII hae1110rrhage ft.l!..v......r•v•lS Malaysia's Action Research programme drew up a series of simplified learning cards, of which this is an example, to help in training health managers at the district level to solve the problems they would face. WORLD HEALTH. May 1989 ·! Q) z ~ A busy immunization session in the open air attracted a good response from the young mothers of this Burmese community. A well-kept- and well-advertised- ventilated latrine helps to ensure good health in a Tanzanian village, while (below) a maternal and child health aide keeps a check on the healthy growth of youngsters. Health across barriers C ommunity self-help action in isolation can-not be sustained without support from outside the community. This is especially so in developing countries and in the poorest areas of developed countries. Consequently, the responsi- ~ bility for disease prevention and health ..c promotion rests not only with govern- U: ments and the international corn- ~ munity but with the individual. The complexities of local and re- gional administration make it difficult for small communities to gain access to civil servants. Especially so for those communities living in a world apart - physically, socially, and economically - from the capital city, and therefore unable to share in the main stream of modern life. At the same time, their own traditionally sustaining resources are rapidly on the wane. In order to put primary health care into effective practice, the district system can help close this gap by bringing health care within reach of the most isolated areas. District level administration recurs in modified forms in all national structures, and can therefore be a crucial link between governments and communities. The district system has the potential of tying government resources , national goals and policies to the specific needs and aspirations of the local communities. By creating two- way linkages, it has a crucial role to play in advocacy and in policy implementation. Not only can the district network link local communities to the national system; it can also link different activi- ties at all levels of the community, such as agriculture, nutrition, education, employment, human settlements and environmental care. Since other sectors than those directly related to health are involved, improvements in health call for an integrated approach to development. So the district net- work can simultaneously tackle such unhealthy factors as lack of clean water, bad sanitation, inadequate housing, lack of basic education, and inadequate incomes. It can promote improvements in agricultural tech- niques , nutrition , literacy and numeracy , s kills train ing and employment. And it can encourage 18 Sylvia Moore It has often been said that health is indivisible. For young and old (above, in Chandigarh, India) and for the Russian worker getting first aid in a Volgograd clinic, health services are a basic human right. l..eonid T oprover health programmes for different sectors of the communities such as children, youth, women and the elderly. Strengthening health systems through the district approach was expressly encouraged by a resolution of the 39th World Health Assembly in Geneva in 1986. And WHO's first interegional meeting on this subject, held in Harare, Zimbabwe, in August 1987, drew up a number of concrete recommendations which stressed com- munity involvement, intersectoral action, district leadership and mobil- isation of resources. The following year, a: meeting held at Riga in the Soviet Union to reaffirm the 1978 Declaration of Alma-Ata called for accelerated action to W ORLD HEALTH. May 1989 "Strengthen district health systems based on primary health care, as a key action point for focusing national poli- cies, resources and local concerns on the most pressing health needs and on under-served people." The Riga meeting was held at the mid-point in time between the historic Alma-Ata Conference in 1978 and the year 2000. The meeting was held by WHO to review progress and problems experienced in pursuing the goal of Health for all. It was held at Riga, USSR from 22 to 25 March 1988, and brought together experts from all WHO regions as well as representatives of UNICEF, UNDP and non-governmental organizations. The participants found that the Health for all concepts have made strong positive contributions to the health and well-being of people in all countries. At the same time, they noted that problems remained and ~ that increased action was needed to ~ ensure that primary health care ~ reached everybody. c:o A working woman in Bangladesh has no need for a baby-sitter. [Further information on these meet- ings can be obtained from the Division of Strengthening Health Services at WHO Headquarters, Geneva. Docu- ments include: report of the Inter- regional Meeting on Strengthening District Health Systems based on Pri- mary Health Care (Harare, Zimbabwe, 3-7 August 1987); the World of Health Radio Information Programmes of November and December 1987, entitled "Health across barriers through the district approach" (Part I and II respectively); post-conference information comprising transcriptions of recorded interviews, audio-cassettes of the conference, video documentary of the main events of the conference; report "Aima-Ata reaffirmed at Riga 1988".] • W ORLD HEALT H, M ay 1989 Youngsters enjoy a nourishing meal in India. Nutrition is one of the eight supporting pillars of primary health care. Recommendations of the Harare Conference: Ensure Sustainability Adopt National Policies Decentralise Redefine the Role and Functioning of Develop a District Planning Process Strengthen Community Involvement Promote Intersectoral Action Develop District Leadership Mobilize all Possible Resources Hospitals Use Health Systems Research Ensure Equity between Districts Encourage the Mobilization of International, Multilateral And Bilateral Resources Recommendations of the Riga Meeting: I. Maintaining Health for all as a permanent goal of all nations up to and beyond the year 2000. Intensifying social and political action for the future Agenda 2000. 11. · Renewing and strengthening strategies for Health for All. Ill. Intensifying social and political action for health. IV. Developing and mobilising leadership for Health for All. V. Empowering people. VI. Making intersectoral collaboration for Health for All. Accelerating Action for Health for All - Agenda 2000. VII. Strengthening district health systems based on primary health care. VIII. Planning, preparing and supporting health personnel for Health for All. IX. Ensuring the development and rational use of science and appropriate technology. X. Overcoming problems that continue to resist solution. Special priority initiative in support of the least developed countries by WHO and the international community. 19 District approach to p health care Recent films available from Media Unit, WHO 1211 Geneva 27, Switzerland Reach out for health This video documentary illustrates the Kenyan approach to implementing the district focus strategy for primary health care in the district of Embu, Kenya. The Kenyan government is introducing the district primary health care approach in all Kenya's 41 districts, a process begun in Embu in February 1986. Then the aim was to expand this strategy to all of Kenya's 41 districts by June 1988. The Kenyan government had decided to decentra- lise the health system by strengthening the district services. The decentra- lisation act initiated the district focus. This was followed by the WHO/ Ministry of Health collaboration in three districts, Embu, Baringo and South Nyanza (February, May and November 1986 respectively). The video documentary "Reach Out for Health" serves as: - forum media showing early achieve- ments, limitations and problems in Embu as an aid to the application of this approach in other districts; - development of communication to strengthen national capacity for informing the Kenyan public of this approach to better health; - the base for exchange of informa- tion and for international dialogue in order to refine strategies at national, regional and international levels; - a means of strengthening national capacity for development broadcast- 20 Village women in Kenya's Embu District making bricks. A stiU from the video "Reach out for health." Photo WHO/S. Moore ing by providing technical and pro- duction assistance. In 1983 the Voice of Kenya recog- nised the importance of development broadcasting and introduced this approach through the district forum media. to ensure urban-rural communi- cation. Producers were posted in each district to gather information on the district situation - information of signi- ficance to the local communities. The VOK/ WHO production "Reach Out for Health" is the first time that VOK had the opportunity of filming a complete documentary of this kind for develop- ment broadcasting. VOK has broadcast the film nation- ally and throughout Africa via the Union of Radio and Television Stations of Africa's Programme Exchange Centre at Nairobi (URTNA). Several NGOs working for better health among the least served commu- nities in developing countries are using the film in community development and community training programmes. Distribution: World Health Organization, Media Service, 1211 Geneva 27, Switzerland, and Voice of Kenya, P.O. Box 30456, Nairobi, Kenya. • REACH OUT FOR HEALTH Subject: the district approach to primary health care Date: Filmed on location in Kenya, and Geneva 1 987 Production: Produced by the Voice of Kenya and WHO in cooperation with the Ministry of Health, Kenya Length: 37 minutes Languages: English, Arabic (French version in production) WHO/ S. Surin "WATER FOR THAILAND" Subject: Primary health care Date: 1982 Production: WH 0 Description: Colour 16 mm, optical sound Length: 28 minutes Languages: English In the film we see something of the daily work undertaken by the Village Health Communicators but the main emphasis is on the provision of clean water, one of the most important elements of primary health care. BERNARDIN AND HIS VILLAGE Subject: Primary health care Date: 1982 Production: Puhl Film Products S.A. Description: Colour 16 mm, optical sound Length: 42 minutes Languages: English, French This film illustrates animators from the National Health Service who are sent out to each village to make the villagers more sensitive to their health problems and to encourage them to take the organization of "primary health care" into their own hands. WORLD HEALTH , May 1989 Ethiopia's success story Gebre Selassie Okubagzhi 0 ne of the most serious obstacles to develop-ment of primary health care (PHC) in Ethiopia has been the absence of a decision-making mechanism at Awraja (District) level. This gap in the organizational structure is unique to the health sector. The existence of a strong district health system not only helps to forge a partnership between government and communities, but also serves to harmonise the policies of central at.jthority with local initiatives and resources. Although there is universal agreement on the need to set up Awraja health management, opinions vary on who should be trained and who should train them. Disenchanted by the existing situation of the training institutions, the Ministry of Health started a new training programme for district health managers at its own Training and Demonstration Centre. This action was supported by WHO, UNICEF and other bodies, and a curri- culum was prepared by an expert committee under the chairmanship of the Minister himself. One two-year training programme would take Awraja health managers to master's level in public health, a second lasting 10 weeks would be an accelerated course for such managers, and a third would train members of the Awraja health team. This training scheme is essentially based on the "learning-by-doing" approach, with extensive practical experience in rural and urban settings. The trainees are assigned to one of their future districts during their residency programme. They are thus encouraged to develop problem-solving approaches through community participation and intersectoral collaboration. They also design and carry out a research project on a primary health care (PHC) topic, which helps them to learn scientific methods of investigation in community diagnosis. They see something of the .organization of health services, the strategies used and the type of interac- tion involved with government and community organizations in delivering health services. Trainees conduct a small survey designed not only to familiarise them with the nature of district health W ORLD HEALTH, May 1989 services and the problems encountered, but also to help them develop the right methods and skills for analysing the prevailing health situation and drawing up an action plan. Serious attempts are made by the trainees to develop a dialogue with government and community leaders in the process of identifying problems and recommending solutions. Objective reaHties The second phase is devoted exclusively to covering the basic theor- etical courses provided by any gradu- ate programme in community health, but its contents reflect the objective realities of the country. The residency phase is the last part of the training programme. During this period the trainee is assigned to an Awraja where he or she works after graduation as an Awraja health man- ager. During this period the trainees are supervised once a month by at least one senior faculty member, who provides guidance and support in the field. The candidates present their health profile and action plan to the health committee of the district for approval, and finally report their findings to their colleagues and faculty members. The discussion that ensues enriches the health profile and action Panos/M. Edwards © plan and clarifies problem areas. The Awraja health team is com- posed of programme coordinators, heads of hospitals and health centres, and prominent non-governmental leaders. The team decides on all technical and managerial aspects of the Awraja health services. The health manager has a secretarial role and in this role ensures that local initiatives are consistent with national health policies. Invoking Ministry of Health experts in teaching has not only alleviated the shortage of instructors but also helped the trainees to receive up-to-date information on various policies, direc- tives and activities of the Ministry. Once the objectives and methods of the training process were clearly stated, a number of institutions were approached to support the pro- gramme. The McGill-Ethiopia Com- munity Health Project agreement was signed between the Ministry of Health and McGill University in Canada. Through CIDA (Canadian aid agency) funds , the project provides the A vital supply of firewood for a remote district community in Ethiopia. Health managers are now specially trained for work in such districts. 21 22 Ensuring safe water supplies is an incessant problem. Mountain streams are at risk from pollution and run dry during a drought. A training poster for Ethiopia 's Awraja health managers spells out the "pyramid" of available hospitals and health stations. essential permanent academic staff and other resources. WHO and UNICEF provided funds for the training pro- gramme and for the Avraja by provid- ing transport and seed money, and CIDA again collaborated in funding ten of the first batch of research projects. Accelerated course Because of the government plan to establish an increasing number of Awrajas, the need for trained Awraja health managers (AHM) became urgent. So the accelerated 1 0-week course was started to assist district health managers to improve the plan- ning, organization and carrying out of PHC programmes, and to develop the skills, leadership and attitudes necess- ary for working with the community, other sectors and the health team. After the course, managers return to their districts for a period of two to six months during which they draw up a health profile and plan of action for health activities. Back in the training institution, they present these and discuss them during a one-week workshop. So far two batches of the accelerated group - 45 trainees - have completed their course and are working as acting AHMs in different districts of the country. Their perform- ance is rated above average by the faculty members who visited them in their Awrajas and by those who work with them . The programme is expected to continue by providing two sessions per year. The Ethiopian training experience has entailed .an unprecedented involvement of the Ministry of Health in the operation of teaching insti- tutions. This may appear strange but has been very instrumental in creating the right kind of orientation towards the actual job of being a health manager. In the absence of well- trained staff for teaching institutions, the use of various experts from the Ministry of Health has proved a very useful and effective way of using the available local resources. The assignment of residents to Awrajas before graduation has many advantages. The residents are exposed to the realities of the district and are able to seek solutions through interac- tion with their colleagues, instructors and Ministry of Health officials. All this helps to prepare them to provide effective leadership in managing health services. International agencies, NGOs and other bodies are more likely to support a programme if they are convinced it will genuinely improve the health status of communities. The support channelled to this programme from the different sources is a prime indication of its usefulness. • W ORLD HEALTH , M ay 1989 AJlied health professionals The contribution of the "non-physician health care provider" is not yet fully recog- nised. A major conference in Denmark last June tried to set the record straight Edmund McTernan and Lee J. Holder § ince the provision of at least minimal primary care services has been a basic objective of the Health for all movement, most efforts have focused on developing a primary care system, str.uctured around com- munity health workers with physician back-up. This basic approach is appro- priate in less developed nations, where much of the population have lacked even the most rudimentary health services. In such settings, recent achievements have been impressive. However, "Health for all by the year 2000" is also conceived as a goal for the more developed nations, as a means towards the constant improve- ment of all mankind's health status. Furthermore, social justice requires that we continue to work for access to more sophisticated health care services in those areas where even the pro- vision of the indigenous, minimally- trained health worker has been a recent step forward. Most physicians, even those who are practising in primitive and isolated settings, received all or part of their professional training in modern and complex medical centres, such as are now found in most of the major cities of the world. They were typically trained to work in a team, depending upon and interrelating with a wide spectrum of other health care profes- sionals. In addition to nurses, the radiology or x-ray technicians and medical laboratory technologists are probably the most common members of the health care team alongside the physicians. Others include rehabili- tation specialists (physiotherapists, occupational therapists, speech thera- pists and so on), public health workers (such as health educators and sanita- rians) and several other categories of health service providers. Some coun- WO RLD HEALTH, May 1989 tries have mid-level providers such as physician assistants and nurse prac- titioners. While it is certainly true that these non-physician health care providers are often in short supply in developing nations, their gross numbers as part- ners on the care team are legion in a global context. And since they can typically be educated and trained for service in a much shorter time than the physician, their roles can be adapted to meet new needs and they can be more easily deployed in the service system than physicians. Medical chauvinism Many observers feel that a form of medical chauvinism has prevented the optimal use, appreciation, and deployment of the non-physician health worker, to the detriment of total health care. Whatever the reason, the literature and programmes of iAter- national public health have certainly largely ignored the existence and value of the non-physician health care pro- vider in recent times. In the April 1987 issue of World Health, for instance, devoted entirely to the shortage and maldistribution of health personnel, only one article referred to any of the allied health fields, and that reference was limited to just a few fields! To begin the process of assessing the current and potential contributions of the non-physician health profes- sional in world health care, and to focus added attention on this huge and complex group of professionals, a first World Congress on Allied Health was held last June at Elsinore (near Copenhagen), Denmark. The term "allied health professionals" was applied during this conference because it had been planned and funded through the efforts of the Washington- based American Society of Allied Health Professionals. (Major funding support was provided by the W. K. Kellogg Foundation.) But since it was recognised that this term is not in common, worldwide use, future Con- gresses might well use some other designation. The Congress was structured in such a way as to relate the human resources represented by the many millions of "allied health" workers to the concept and goals of Health for all by the year 2000. It was; in a way, an effort to sensitise these professionals themselves to the Declaration of Alma- Ata and its goals, and to alert world health planners and programmers to the often overlooked contributions which can be made by this immense human resource. Maternity visit in an Indian village by a public health worker. Is the contribution of such workers being consistently undervalued? Allied health professionals Prince Henrik of Denmark extended his patronage to the Congress, and the keynote address was given by Or J. E. Asvall, WHO's Regional Director for Europe. The 231 participants from 21 countries included representatives of more than 100 educational or training institutions, 17 professional associ- ations and 16 governmental agencies. Speakers addressed the concept of the allied health professional, the need for research by and for non-physician health providers, and aspects of edu- cation and training. A select panel fielded questions on a number of regional problems afflicting different regions of the world. More than 120 papers dealt with non-physician health care challenges, programmes and achievements in virtually every corner of the world. There were also a large number of excellent poster presen- tations. The Congress identified differences and similarities of problems in developing and industrialised nations. In developing countries, the greatest problems were infectious diseases, environmental factors such as basic sanitation and safe water supply, nu- trition, infant and maternal mortality, sexually transmitted diseases, acci- dents, and health service infrastructure - particularly the need to make services accessible to rural com- munities. 24 In the industrialised world, the accent was on diseases associated with lifestyles - tobacco, alcohol and substance abuse, AIDS and sexually transmitted diseases, and accidents. Certain health problems are specific to special population groups, such as the very poor, teen-aged girls and the effects of unwanted pregnancy, and the elderly. A major priority Common to both emerging and industrialised nations were environ- mental concerns, sexually transmitted disease issues (especially AIDS), and the fact that both health facilities and health personnel are unevenly distrib- uted. The need to allocate greater resources to primary care was gen- erally accepted as a major priority issue. The underlying question was whether the human resources grouped under the team "allied health profes- sions" could participate in a significant way in responding to these health care challenges, and add significant impact to needed solutions. The answer was strongly in the affirmative, but many speakers underlined the need for greater attention to be paid to developing and using allied health A dental assistant in South-East Asia checks children's teeth for signs of decay. resources. This first World Congress on Allied Health concluded that: - there is inadequate data on supply and demand of allied health person- nel. Data currently available focus upon physicians, dentists, pharmacists, nurses and midwives, to the exclusion of other disciplines. - there is a general lack of manpower planning, and insufficient continuity between and among the planning, education and training, and use and management of human resources. - there is a need for better recruit- ment, training and retention of allied health personnel, who deserve better recognition , continuing education opportunities, improved remuneration, and better opportunities for career mobility if they are to stay in effective contribution to the total health. - This first World Congress on Allied Health - and it will almost certainly be followed by a second - has made its contribution to the goal of Health for all by encouraging millions of non- physician health workers around the world to serve that goal. It has also helped the world's health planners and administrators to gain a better under- standing of, and appreciation for, this great resource. The result, it is to be hoped, will be a new and greater role for non-physician care providers in the health for all movement. • ~ I ....,; ~--~~~~~~~~~~--~~~----~~~----~--~ ~ W ORLD HEALT H, M ay 1989 A world fit to live in hat determines the health of the some five billion people in the world? What determines the health of people in developed and in less developed countries of the world? The pressure of rising health care costs increases the need to document and analyse the determinants of health and to delineate the role of environmental health in the health care system. There are surely four basic determinants of health: heredity or biological factors. medical care, lifestyle, and environment. Heredity or biological factors Human biology is largely con- trolled by one's genetics. One may be healthy in every other aspect but may have inherited from one's fore- bears such problems as haemophi- lia, diabetes. mental retardation. :g eye defects and lack of resistance ~ to disease. Research findings now 0 indicate that even whether or not ~ you may become addicted to alco- - hol or another drug may depend on your mothyr and father. Medical care Two princip9l aspects of medical care affect all of us. One is tech- nology. For several decades technological advances in the health field have been responsible for adding productive years to thousands of I ives. Examples include such devices as sophisti- cated equipment for kidney patients. artificial organs, m on i- taring instruments for the foetus in the mother's uterus, and electro- cardiogram devices worn by patients to detect the onset of a heart attack. These amazing , costly instruments have captured the fancy of society and in the industrialised world account for a large portion of the cost of health care. The second trend in health care is the increased interest in medic-al self-help on the part of the public. This emphasises self-examination of the skin. breasts. mouth. eyes. nails, to name a few. WORLD HEALTH, May 1989 Monroe T. Morgan Growing up amid urban squalor in a fast-growing European city. Proper disposal of solid and haz- ardous waste is one way of improving the environment. Lifestyle Lifestyle is a significant determi- nant of health. For example. lack of sleep and rest reduce our resistance to infectious or chronic degenera- tive diseases. Many Americans indulge in high-fat high-sugar, high-salt low-fibre diets; millions throughout the world are suffering from vitamin deficiency diseases. While there is over-consumption of protein in some countries, many in other lands are victims of kwashiorkor. Everywhere. people tend not to incorporate sufficient exercise into their lives. The heart like all muscles, will atrophy if not used. When this is coupled with high-fat high-cholesterol diets, it is easy to see · why heart disease is the number one killer in many parts of the world . Other diseases associa- ted with lifestyle are among the leading killers. Yet lifestyle could be the easiest of all the determinants to control so as to enhance one's health. Environment Taking the world as a whole, the environment more strongly affects the health of the public than any of · the other factors. Environmental health practice encompasses, as the name suggests, complex rela- tionships between the environment in which people live and the health which they enjoy. Human involve- ment has been selective, hence man has adapted to the environ- ment in which he finds himself by producing biological defences against disease- in which term we include deviation from the normal physiological states of the host. As the direct result of this evolution, man has also acquired intelligence. expertise. and the knowledge to make significant changes in his environment and thus create con- 25 A world fit to live in George McBean ditions which will lessen the likeli - hood of degrading health. This is accomplished mainly by controlling the causative agents of disease while they are in the environment. before they get to man and poss- ibly overcome the body's defence to the point where it requires therapeutic medicine. Some important aspects of environmental health management - the first line of defence against disease - include: - Water quality management - ensuring that potable water is available by carrying out appro- priate treatment of water supplies. - Proper human waste disposal - requiring that human wastes are adequately disposed of in pit latrines. septic tank systems and sewage treatment plants. it is esti- mated that five million children die each year from diarrhoea! diseases; that is 20 deaths every minute of every year. These diseases are the result of drinking water infected with disease-causing micro- organisms. The water is infected 26 because it has somehow received human wastes. either directly or indirectly. - Solid and hazardous waste man- agement - properly disposing of solid and hazardous waste. - Rodent control - removing potentia l habitats and sources of food for rats and other vermin. - Insect control - biological or other methods of insect control. Each year pests and disease con - sume or destroy about 45 per cent of the world's food supply. This leads to annua l crop losses worth about US$ 20 billion . WHO esti - mates that around the world each year more than 500,000 farm workers, pesticide plant employees. and children become seriously ill. and about 5,000 to 20.000 people die, from exposure to toxic insecticides. - Milk sanitation - ensuring that all milk for human consumption is produced under sanitary conditions and is pasteurised Salmonellosis outbreaks are still occurring today because of unpasteurised or Living conditions for this Napalese family have been improved by installing a smokeless stove, marketed through the Agricultural Development Bank. Smoke-filled kitchens and (facing page) gross industrial pollution put lungs at risk all over the world. improperly pasteurised milk. - Food quality management - maintaining surveillance over the food from the farm to the consumer so as to prevent contamination. Occupational health practice - making sure that a healthy and safe work environment is available. - Interstate and international travel sanitation - preventing the spread of communicable diseases between states and nations. - Air pollution control - controlling the emissions of harmful pollutants to the atmosphere. - Water pollution control - reduc- ing the effects of industrial and other wastes on water supplies and WORLD HEALTH, May 1989 WORLD HEALTH, May 1989 A world lit to live in recreational areas by the pre- treatment of industrial and dom- estic effluents. - Environmental safety and acci- dent prevention - designing into the environment those things that will compensate for people's inadequacies. such as pedestrian ramps. - Noise control -controlling noise in industrial settings and in the community to prevent noise from degrading the public's health. - Housing hygiene - ensuring that housing contains conditions necessary for the physiological, psychological, and physical well- being of humans. (Overcrowding has been found to have a corre- lation with deaths from all causes, infant deaths, suicide, tuberculosis, venereal disease, mental hospi- talisation. illegitimate births. juvenile delinquency and imprisonment.) - Radiation control - supervising radioactive sources such as nuclear fission plants and nuclear waste. - Recreational sanitation - moni- toring the environment to prevent unsafe conditions at swimming pools, parks and other recreational areas. - Institutional environmental man- agement - controlling the environ- ment to prevent the spread of infections among hospital patients. - Land use management - zoning so as to restrict the use of land for uncontrolled urban expansion, and so on. - Product safety and consumer protection - ensuring that drugs, toys and appliances are safe for use by humans. - Environmental planning - apply- ing environmental design in order to minimise human stress and accidents. Better funding for WHO What the world needs is more environmental health programmes, more and better prepared environ- mental health professionals and a better educated public. If the gen- eral public of the developed nations knew the role that the environment plays in determining the health of everyone - in rich and poor countries alike - they would guarantee better funding for WHO and other health agencies. If they knew the vital role that is played by environmental health practice, they fu would want to do more to en- 3 courage it and to support other ~ ways of improving the quality of _,_ ____ ~...._..,.,.,......,.__.~-~-..,,....~-.,...____, ~ life for all . • 27 The birth of WHO In an interview originally published in our sister periodical World Health Forum, Or Szeming Sze, who was a member of the Chinese delegation to the conference convened to draft the Charter of the United Nations in 1945, takes a look back to the days when WHO began. WHO: Or Sze, you are one of the "founding fathers" of the World Health Organization. Can you tell us something about what hap- pened during the United Nations Conference on International Organizations held in San Franci- sco in 1945, where the idea was born? Or Sze: Well, it came about quite accidentally. The San Francisco Conference was being held so that 50 countries could pledge them- selves to establish the United Nations, and nobody had any thought at the start of the Confer- ence of forming a health organi- zation. However. there were two medical men there besides myself: Or Karl Evang of Norway and Or Geraldo de Paula Souza of Brazil. As far as I know, there were no doctors in the French, Russian, United Kingdom, or United States delegations. So one day the three of us had what you might call a "medical lunch" together. WHO: What date was that? Or Sze: I am not sure exactly, but it must have been about 2 May 1945. Karl Evang, of course, was the most active of the three of us. He said. "Why don't we start a new health organization?" I was a little scep- tical because we had been asked to go to San Francisco to draw up the Charter for the United Nations, and I knew that there had been no thought beforehand of setting up a health organization. But Evang was so enthusiastic, as was his nature. that all three of us became keen to start something. Now, as you know, China was one of the four sponsors of the S!ln , Francisco Conference, along with UK, USA and USSR; so Or Evang and Or Souza thought the Chinese delegation should take the lead in making the proposal. Fortunately it was rather easy for me to help things along because I was there as the private secretary of the head of our delegation - not in any medical capacity, but because I could write his speeches in English. I merely 28 spoke to my boss and he said "Yes, go ahead" - just like that. So the first hurdle was easily surmounted; if I had not been working for him it would have taken weeks to have gone through all the different com- mittees and procedures that just our delegation alone would have required. Almost before I realised what was happening, I was landed with the job of presenting a propo- sal to the San Francisco Confer- ence that we should set up a single health organization. WHO: Why do you say a "single health organization"? Or Sze: Let us cast our minds back to 1945. At that time there were a number of pre-existing health organizations: the Office Interna- tional d'Hygiene Publique (OIHP), which had been set up by the International Sanitary Conventions and had been operating since 1907; the League of Nations Health Organization created after the First World War; and the Health Division of the United Nations Relief and Rehabilitation Admin - istration (UNRRA), which was dealing with health activities in the aftermath of the Second World War. In addition. there were regio- nal bodies like the Pan American Sanitary Bureau and the Egyptian Sanitary, Maritime and Quarantine The Interim Commission which met in 1946 served as midwife to the as yet unborn World Health Organization. Its chairman decided where its future headquarters would be. Board. So it became a matter of trying to tidy up the situation and of pulling all these disparate organizations into a single entity. That was our first aim. However, so as not to get tied up in practical politics we had to agree among ourselves how to present the proposal. lt was Or Souza who proposed that the word "health" be inserted into the United Nations Charter. We thought that if we got the word "health" in once, there would be an obligation to set up a health organization. I was all for playing · safe and getting a special confer- ence started, with the purpose of setting up the health organization. However, I saw no harm in letting the Brazilian delegation try to have the word inserted into the Charter. Rather to my surprise he succeeded. That's why you find "health" in the United Nations Charter, but it still did not give us the conference we wanted. A restriction had been announced on draft resolutions because there were too many of them. I was giving up hope of getting anything started when Fate took a hand: one evening at a dinner party I found myself sitting next to the Secretary-General of the Conference. Mr Alger Hiss. I asked him what we could do to provoke the attention of the Con- ference now that we could no longer present a resolution for its adoption. He immediately said, " Oh, it's very simple: don't present it as a resolution. call it a decla- ration." WHO: Did it work? Or Sze: Yes, very well. We pre- sented a recommendation for a general conference to be convened to establish an international health organization, as a joint declaration by the governments of Brazil and China, that is. the delegations of Or Souza and myself. We had to leave out Norway because Or Evang had been recalled following the liberation of Norway on 8 May 1945, and he had very important work to do at home as Director- General of Public Health. Our declaration was approved unani - mously by the Conference: that was the very beginning of the World Health Organization. Our proposal to convene a con- ference to set up a health organi - zation was approved by the Economic and Social Council in February 1946. Subsequently the International Health Conference was held in New York on 19 to 22 July 1946. WHO : That was when details were worked out about what the organi- zation should be called. how it should function. and so on? Dr Sze : Not entirely: much groundwork was done beforehand. Once things began to move. they went quickly. Before the confer- ence. a committee of experts called the Technical Preparatory Com- mittee was set up. and had its first meeting in Paris on 18 March. During the course of 22 such meetings we drew up the draft Constitution of WHO. which was signed at the New York Conference on 22 July 1946. WHO: How did the headquarters end up in Geneva? Dr Sze: That's another story. An Interim Commission had to be founded and it was understood that the place chosen for the Com- mission's meetings would probably be the headquarters of the future World Health Organization. We had a number of votes on the question - should it be held in Europe or in USA? USA won by a fairly large majority. However. it was left fairly flexible. and the choice of the exact location was left to the Chairman of the Interim Commission. Or Andrija Stampar of Yugoslavia. Most people thought that. in view of the vote. it would naturally be in the USA; however. as you said. we ended up in Geneva. and this was really Or Stampar's decision. Cer- tainly. it has been a very happy choice as far as I am concerned. WHO: Individual personalities were very much a determining factor in getting WHO started? Dr Sze: Well. I always said that my part in the foundation of WHO was 90 per cent diplomatic and only 1 0 per cent medical. lt was politics all the time. WHO: How did you arrive at a consensus on the definition of health? Dr Sze: A lot of people did not think that we should even define health in the Constitution of WHO. I only got into it because I found myself on the committee working on the preamble. I think there were WORLD HEALTH, May 1989 three of us - Or Brock Chisholm from Canada (who became the first Director-General of WHO). Or Gre- gorio Bermann from Argentina. and myself: it was a pleasant little group at which we had some interesting academic discussions. Chisholm. being a psychiatrist. wanted to mention mental health. and I thought we should put in some- thing that emphasised the impor- tance of the preventive side of health . That's how we came up with the wording in the Consti- tution that defines health as "a state of complete physical. mental and social well-being. and not merely the absence of disease or infirmity." WHO: What about the emblem of WHO? Dr Sze: We had a discussion on emblems and flags in the days of the Interim Commission . I remem- had to work out a compromise. We were able to come up with a formula that satisfied all concerned and left the door open for the integration of the Pan American Sanitary Bureau into WHO: this happened later. when Or Fred Soper took over from Or Cumming as PASB director. WHO Can you tell us something more about the people who were the instigators of WHO? What sort of a man was Karl Evang? Dr Sze: Oh. he was a delightful person. A little rigid. perhaps. because he had been very strictly brought up by his clergyman father. He always wore black. and I thought he was rather a severe man. but we played a lot of tennis together and became great friends. He was one of the outstanding personalities in those early days of WHO. He was a brilliant speaker in English and he had excellent ideas. He was always frank and honest and never held anything back. But it was his rigidity on certain ques- tions. particularly his advocacy of contraception. that lost him the support of the Latin-American countries. If he had had this support. he would have been a strong candidate for the Director- . Generalship of WHO. ~ WHO: What about the man who ~ actually became WHO's first _D_r_B_r_o_c_k_C_h-,-.s-h-o-lm-,- 0 -f _C_a_n_a-da_,_t_h_e D i rector- G en er a I . D r B rock first Director-General of the Chisholm? World Health Organization. Dr Sze: He was a very shy man. but with a good sense of humour. He ber one or two people thought that operated very quietly. He had sens- the proposed yellow flag with the ible ideas. and always expressed WHO logo on it was too much like them very quietly. but somehow the international shipping flag for they always came out on top in the quarantine. and they opposed it for end. it must be because he was a this reason. But it was nevertheless psychiatrist! adopted as a temporary emblem. WHO: We have been talking about WHO: The flag was yellow? some far-sighted young and not- Or Sze: Yes. Later. of course. it was so-young men some forty years changed to light blue. so as to have ago. Has their dream come true? a family resemblance to the United Dr Sze: In my opinion WHO has Nations flag. expanded and grown way beyond WHO: I understand that regional my dreams. I never imagined that arrangements provoked heated you could manipulate such a tre- debate. mendous budget as there is nowa- Dr Sze: Yes. that was one of the days and carry out so many few controversial questions we had programmes. WHO has grown to deal with in the Interim Commis- immeasurably beyond what I had sion. We had to take account of the hoped. strong regional health organization WHO: And now you have become that already existed in the Amer- interested in the history of WHO. do icas. The director of the Pan Amer- you think we can learn from it for ican Sanitary Bureau. Or Hugh S. the future? Cumming. wanted to be indepen- Dr Sze: Of course we can all learn dent of any single health organi- from history. We learn from the zation. Well. we all concentrated mistakes we made if not from the our efforts on him. I somehow successes: · learning the reasons found myself in the middle again. why certain things happened often because China was more or less saves us from making the same neutral in this discussion . . so we mistakes again. • 29 ...... .. .... ... ... .. ...... .... ..... . .......... . ....... .. .... ... ... .. ....... . ........................ . ....... .. .... ... ... .. ....... . ........................ . ••• ••• •• ••• ••• •• ••• • •••••••••••••••••• ... ... .. .... ... ... .. ...... .... . ... ... ... . ..... . ::: ::: :s :::: ::: ::: :: ·:::::: :::: • :::.:::::::::: ::::::: ... ... .. ... ... .. ... .. . .............. . ... ... .. .... .......... ....... .. . ................... . ... ... .. .... .......... ....... .. . .................. . ... ... .. .... .......... ...... .. . ................ . Healthy eating in Europe What do Europeans eat? How do their food habits affect their health? What dietary changes wou ld be likely to protect and improve their health? There is no simple or definitive answer to any of these questions. Nevertheless. much more can be learned about this subject in future thanks to a WHO Regional Office for Europe publication entitled "Healthy nutrition - pre- venting nutrition-related diseases in Europe." Draf- ted by medical nutritionists. this work describes in detai l the evo lution of diseases and of nutrition in Europe over time. as well as the increas- ingly evident ties which con- nect them. What is now known is that throughout Europe almost half the premature deaths of men and women aged under 65 are due to diseases in which diet plays a major role. Coronary heart disease. infarctus. cancer of all sorts. diseases of the mouth. anae - mia. goitre. cirrhosis of the liver. diabetes. gal lstones. obesity. hypertension and bone diseases in elderly per- sons - the list of such ai l- Food habits of Europe Photo WHO/J Germam ments is a long one. and they place a heavy burden on the medica l services. Yet all can be considered as avoidable even if it is not yet clear exactly how dietary excesses or deficiencies provoke them. A thoroug h analysis of these 30 nutritional factors has never- theless enabled the authors to define a series of common objectives to be achieved with respect to nutrition for al l people living in Europe. The publication specifies lower and upper limits which shou ld not be exceeded; these have been deduced from recommendations for - mulated by various national committees; they can be con - sidered as the basis of an idea l diet for preventing non - communicab le diseases. lt stresses particularly the per- centages of total energy which shou ld come re- spective ly from carbo- hydrates. proteins and fats. The consumption of fibres. sa lt. cho lesterol. and even fluor in water are also the subjects of precise recom- mendations A ll the evidence suggests that certain objectives w ill not be easy to attain. for instance keeping down to 20-30 per cent the propor- tion of total energy drawn from fatty foods For this reason . less ambitious inter- mediate objectives have been set: in the case of fatty foods. initial efforts wi ll be made to reduce their proportion to 35 per cent for the popu lation as a who le and to 30 per cent among. groups with a high cardiovascular risk These intermediate objec- tives seem particularly appro - priate for people living in North and East Europe. The Mediterranean countries already have a diet which is healthier and closer to the objectives fixed by WHO, alth ough certain negative trends continue to cause concern Th e purpose of "Healthy nutrition" is to encourage governments to trust in the dietary and cu ltu - ral traditions of their own countries whi le at the same time drawing up recom- mendations which wil l lead to improvements in the nutri- tiona l status of their people A coherent food policy which emphasises preven- tion necessarily involves close col laboration between the ministries of hea lth. agri- cu lture. food education. industry and economics. so as to ensure that the health benefits do not have harmful repercussions on local food production. Moreover. edu- cation of the public assumes cap ital importance. Appro- priate information. notably through the media. can help to modify the habits of the consumer. Emphasising especia lly the important role that news- papers and the radio have to play in educating people about nutrition or other health-related factors. the authors observe that doctors and other hea lth profes - siona ls often avoid contacts with press. radio and te levi- sion for fear that their intentions might be carica- tured or distorted. Conse- quently they leave to less Mortality in developed countries Statistics compiled by WHO now make it possible to obtain a comprehensive view of the health situation in developed countries - that is. the European countries as a whole (including the USSR). Australia. Canada. Israel. Japan. New Zealand and the qualified people the task of present ing their point of view. and this may on ly result in confusing the public Those in charge of public health in Europe are invited to use this new publication to help Europe to take a decisive step towards a more bal- anced nutritional diet. a con- dition essent ial if the goa ls of Hea lth for all are to be achieved "Healthy Nutrition" (European Ser ies. No 24 ISBN 9289011157) may be purchased from major booksellers. otherwise from Distribution and Sa les Unit. WHO. 1211 Geneva27. Switzerland. price Sw.Fr.20 • United States The popu- lations of these 33 countries amount to one thousand mil- li on inhabitants. which repre- sents about a quarter of the world population Some 11 million deaths occur every year in the developed countries. 3 4 mil- Above. Heart disease kills 3. 3 mil- lion people in the industrialised world every year Photo WHO/E Mandelmann WOR LD HEALTH, May 1989 lion of them before the age of 65. The overall expectations of li fe at birth for these coun- tr ies is 73.7 yea rs. but there are w ide va riations between countries. In Japan. for instance. life expectancy at birth is 79.1 yea rs. whi le for Eastern Europe it is around 70 to 71 years There is also a clear difference between the sexes. because women have a life expectancy of 77.2 years on average compared · with only 70 1 for men . In f our count ries ( France. Japan. Sweden and Switzer- land) life expectancy for women actua lly exceeds the 80-year li mit. headed by Japan with 82.1. lt is also in Japan that men live longest. w here their life expectancy reaches 75.9 - one year more than in Ice land and two years more than in Greece. Sweden and Switzerland. Out of the 11 milli on annua l deaths 1n 14 developed countries. there are some 3.3 mil lion deaths from heart disease. 1 .9 from cancer. 1. 5 from strokes. 0 9 from resp iratory diseases and 750.000 vio lent deaths. among which 170.000 resu lt from road accidents and at least 130.000 from suicide. As regards the ri sk of dying according to the cause. it can be sa id that one newborn baby out of three w ill die of heart disease (31.6 per cent). one out of six of cancer (16.2 per cent) and one in seven from stroke (144 per cent). The.risks of succumbing to a resp iratory ailment or a vio- lent death are about the same - some five per cent One of the factors on wh ich public health has the possibi li ty of maki ng an impact is obv io usly th e "premature" deaths. whether these resu lt from road acci- dents or su icides or from unhea lthy lifestyle behaviour - in particu lar from smoking. Extrapolating the results of studies ca rri ed out in the USA a tota l of 1.5 million deaths per annum are caused by smoking th roughout the developed countries as a w hole - a little over one- third among women and almost half-a-mi ll ion among people aged under 65. a finding which invalidates the theory that smoki ng is mainly a cause of morta lity among the elderly. Detai led results of this study were published in issue No. 14 (1989) of W HO's Weekly Epidemiological Record . • W ORLD HEALTH , May 1989 Nevvsbriefs Or Marc Danzon has been appointed Director of the French Committee for Hea!Jh Education (CFES) A medical doctor. he also holds a diploma in psychiatry and is a specialist in public health. From 7 985 until 7 988 Or Danzon was in charge of public information at WHO's Regional Office for Europe in Copenhagen. The 7th International Congress on Environment. Geo- cancerology and Preventive Medicine has been convened in Brussels in M ay Sponsored by WHO. UNESCO and the Commission of the European Communities. the congress was called to deal with the various types of environmental pollution as well as the geographical distribution of cancers and the means of preventing them The fight against smoking and alcoholism also figured prominently in the agenda. In his message on the occasion of World Health Day, 7 April. devoted this year to communication for health. Or U Ko Ko. Director of WHO 's Regional Office for South-East Asia. declared that the slogan "Let's talk health" should contribute to the establishment of a dialogue between those who provide health care and those who use it He added that it should also help to spread the light of knowledge and thereby to dispel the darkness of ignorance. superstition and disease. The Zimbabwe Broadcasting Corporation this year won the Radio Red Cross first pnze for a broadcast promoting primary health care in Africa. Awarded for the fifth time since its creation ten years ago. the prize is organtzed jointly by the League of Red Cross and Red Crescent Societies. WHO. UNICEF and the Union of National Radio and Television Orgamzations of Africa (URTNA) The second and third pnzes went respectively to Chad National Broadcasting and Rural Radio of Mauritania. A special pnze offered by the Norwegian Red Cross for programmes dealing with women ·s activities was awarded to the Gambian Red Cross and Gambian Radio. Countries all over the world made plans to mark 37 May as the World's 2nd No- Tobacco Day WHO chose as slogan for the Day "The female smoker. at added risk". and invited health educators and media communicators to focus world attention on those risks. Both developing and developed countries notified WHO of their intention to mark the Day with a variety of activities. "A lcoholic drinks are carcinogenous for humans ... This is the striking conclusion of a 400-page report on alcohol consumption published by the International Agency for Research on Cancer (/ARC) in Lyon. France. Prepared by 7 9 international experts. the report concludes that the consump- tion of alcoholic drinks has a clear cause-and-effect rela- tionship with cancers of the mouth. pharynx. larynx. oesophagus and liver. The risks increase as the quantity of alcohol rises. and smokers are particularly threatened since the harmful effects of tobacco are added to those of alcohol • In the next issue Epidemio logy is the study of the d istr ibut ion and of the causes of ill - health in popu lat ion s What may seem a dry-as -dust co llection of figures can provide medical science with cruc ia l clues to the prevention of disease. Some of the ways in wh ich epidemiology is serv ing public hea lth are exam ined in the June issue of World Health. Authors of the month Or John f)AARTIN is Responsible Officer for District Health Systems. at WHO headquarters in Geneva. Mr Kausar S. KHAN is the Coordi - nator for the Social Sector and for Women's Development in the Depart- ment of Community Health Sciences. Aga Khan University, Karachi. Pakis- tan: Dr Kamal ISLAM works in the same department: Or John H . BRYANT is Professor and Chairman in the same Department. He also served as a member of the Executive· Board of WHO. Mr Gunnar BOLSTAD is a journalist on health and environmental issues and Editor of the information bureau LIV in Oslo. Norway. Or Sidney Saul NDEKI is Principal of the Centre for Educational Develop- ment in Health in Arusha. Tanzania (the WHO collaborating centre) Or Raman GRANADOS is a health consultant with the PAHO/WHO rep - resentative's office in Bolivia: Or Angel VALENCIA is Director-General for the Health Department at the Bolivian Ministry of Social Services and Health. and Or Juan Manuel SOTELO is the PAHO/WHO Repre- sentative in Bolivia. Or Sylvia MOORE was until recently a Public Information Officer with WHO 's Department of Public Information and Public Relations. Or Gebre Selassie OKUBAGZHI is Associate Professor and Head of the Ras lmru Training Centre in Addis Ababa. Ethiopia Or Edmund J. -McTERNAN is Pro - fessor and Dean at the School of Allied Health Professions at Stony Brook. New York. USA. and Or Lee J . HOLDER is also with the School of Allied Health Professions at Stony Brook. Professor Monroe T. MORGAN is Professor of Environmental Health and Special Assistant to the President for International and Regional Devel - opment at East Tennessee State Uni - versity in Johnson City, Tennessee. USA. Dr Szeming SZE was a member of the Chinese Delegation to the Conference convened to draft the Charter of the United Nations in 1945. WORlD HEALTH for readers everywhere Since the start of 1989. two-year and three-year subscriptions are no longer being offered. Readers are invited to take out one-year subscriptions at the rates given below. USS 0 Sw.fr. 0 One year 20.- 25.- WHO also offers its "Health Hori- zons" combined subscriptions to both World Health (ten issues per year) and the quarterly World Health Forum The annual price will be: US$ 0 Sw.fr. 0 52.- 65.- 0RDER FORM Please enter my one-year subscription to World Health D Health Horizons D I enclose cheque/ international postal order in the amount of: Name: ............. ... ...•..... ·~· · .. Street: ...... ... ................... , ....... , ...... .. City: ....................... .... ......... .... ........ .. Country World Health. WHO. Avenue Appia. 1211 Geneva 27. Switzerland ~:: t. s- ~ ~ ::t 6t ~ ~ ~ ~ . . . 'S! :; (') ' ~~ ~g_ ~ e-m !;:' ~: :: ;- ~ C» {I) ~I :» 0 ~ ~ - ::l- g a, g ~{ I) g.Q o s· ~ ~ An e n tr y by T an g M in g to W H O 's In te rn at io na l P ho to C om pe tit io n Pr in te d in G re at B rit ai n by D av id G re en P ri nt er s Lt d. K el le ri ng . N or th am pt on sh ir e. En gl an d
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World Health: the magazine of the World Health Organization: May 1989 [full issue]: reach out of health
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