YEAR IN 2006REVIEW Acronyms 2006 Year in review – WHO/DGO/2007 Contents ● ● ● ● ● ● ● ● ● NIS Joint United Programme of the United Nations on AIDS UNAIDS TTR SARS International Medical Products Anti-Counterfeiting Taskforce SAGE Human immunodeficiency virus/Acquired immune deficiency syndrome RED IMPACT WHO-recommended treatment strategy for detection and cure of TB HIV/AIDS Global Alliance for Vaccines and Immunization GAVI ALLIANCE FCTC DOTS S M Y DDT N O R C A Publications Timeline 2006 – A year of unexpected change at WHO World Health Report 2006 Diminishing the risks Care for vulnerable groups Safeguarding health security Investing in health to reduce poverty S T N Foreword: A message E from the Director-General T N O C © J. Spaull/Unaids Lung Foundation – p. 25: © IRIN – p. 27:p. ©16: J. © Rae/TheAMRO/PAHO Global Fund– p. – 19:p. © 28:JP ©Zellweger/World G. Walker/WorldP. Lung Lung KoopmansFoundation Foundation – C. McNab– p.–– J. p. 21:Perugia 37© (red– WorldP. ribbon): Lung PhotosWiggers Foundationother – P.than specified – Williams)p. below 23: are © copyrightG. Walker/World WHO (K. Asiedu – O. Asselin – C. Black – P. Formenty © –World S. Health Organization, Hollyman 2007. – M. Kokic International Facility for funding the purchase of drugs and diagnostics for United Nations Children’s Fund WHO UNITAID UNICEF the management of HIV/AIDS, tuberculosis and malaria Treat, Train and Retain Severe Acute Respiratory Syndrome WHO multi-country study on global ageing and adult health Reaching Every District Framework Convention on Tobacco Control Dichloro-diphenyl trichloroethane used for malaria vector control World Health Organization All rights reserved. 38 36 34 32 24 16 10 2 1 F o r e w o r d A message from the Director-General

The year saw some important achievements and some setbacks, some new growth standards for infants and young chil- steady progress and some surprises requiring dren that make breastfed babies the biological emergency action. The work of many people norm. We also saw the power of statistics to raise helped to propel the momentum to reach the the profile of a problem, such as that of violence health-related goals set out in the Millennium against children. Declaration. These goals aim to reduce childhood and maternal mortality and lower the number of Some achievements were strategic. In a welcome deaths caused by the major infectious diseases: trend, programmes for reaching children in every HIV/AIDS, tuberculosis, and malaria. district added life-saving and health-promoting interventions, thus increasing operational effi- With support from our many partners, record ciency with a value-added bonus for health. levels of childhood immunization were achieved. The year also saw the launch of synergistic In contrast, the number of deaths during preg- strategies, whereby neglected tropical diseases nancy and childbirth remained stubbornly and with similar operational demands are now being tragically high. tackled in an integrated way.

For malaria, the year began with the launch of Above all, when we look back over the year, we an aggressive new programme designed to get see the huge diversity of challenges – from the better results quickly. Monitoring of the global dramatic rise of chronic diseases to the looming tuberculosis epidemic registered steady progress threat of an influenza pandemic, from persistent but also encountered a setback: the emergence malnutrition in Africa to an epidemic of child- of a form of this disease that is extensively hood obesity in Europe. resistant to drugs and causes extremely high mortality. The extent of this disturbing develop- The World Health Report 2006 drew attention The Year in Review 2006 The Year ment is not yet fully known. to a critical shortage of health workers that is jeopardizing the delivery of essential care in For HIV/AIDS, a milestone was reached in sub- 57 countries. This problem combines with the Saharan Africa, where the number of people weakness of delivery systems, especially in receiving antiretroviral therapy surpassed one reaching the poor, to define one of the greatest million for the first time. This figure represents obstacles to progress in public health. a ten-fold increase since December 2003. My predecessor, Dr Jong-wook Lee, who died Many initiatives have powerful interventions, suddenly in May, would have been pleased by good financial support, and strong political com- this result. It is one of many that can be attributed mitment. But the impact on health outcomes is to the “3 by 5” initiative he launched with such diminished by the inability of services, supported personal passion. by sufficient staff, to deliver these interventions to those in greatest need. Some of our work during the year required very rapid action: emergency responses to outbreaks, If we want improved health to work as a poverty- humanitarian crises, and the dumping of toxic reduction strategy, we must do a better job of chemical wastes. Others represented the culmi- reaching the poor. We have much to be proud nation of years of meticulous research, like the of, and much left to do. Investing in health to reduce poverty ● In recent years, health has gained unprecedented prominence In recent years, prominence unprecedented has health gained poverty and spend household incomes incomes household spend and poverty of out way their work to populations allows health poverty.Better in people of numbers large anchors health poor and health, poor to Povertycontributes as a key driver of socioeconomic progress. losis, and malaria. and losis, HIV/AIDS, especially diseases, tubercu infectious from death to vulnerability increased and mortality maternal and childhood high as expressed is poverty countries, all in reality: the with align Goals Health-related relationship. way poverty at their roots, recognize this two- of causes interacting the attack to aim The Millennium Development Goals, which illness. other than something on h t l a e h o t n o i t n e t t a d e t n e d e c e r p n U - and vaccines. and substantial funds for purchasing medicines cial facilities for securing predictable and form with the creation of two new finan concrete a on took goals development meet to determination International people. of billion at least one potential human the improve to way a as attention due received impairments, life-long cause which diseases, tropical neglected the of control Better Goals. Development Millennium time-bound the achieve to momentum the in pated in numerous activities, which also partici poverty-reduction strategy a was reflected as health in interest increased The - - page 3

Reducing childhood mortality: a “best buy” gets better

Each year, more than 10 million children die the responsibility for doing so firmly in the hands before their fifth birthday. Nearly 4 million of of district service providers and managers, thus these deaths occur during the neonatal period. fostering local ownership. Of all these deaths, an estimated 6.5 million could be prevented using proven, cost-effective In most parts of the developing world, immu- interventions. As just one example, neonatal nization services are best at reaching remote, tetanus, which has been virtually eliminated in underserved populations, thus achieving the wealthy countries for more than a century, still kind of targeted access that lies at the heart of kills around 130 000 babies a year in impover- poverty-reduction strategies. In impoverished ished areas of the world. populations, these services frequently provide the first – if not the only – contact with the health Immunization has long been recognized as one system for mothers and babies. During the year, of public health’s most successful and cost-effec- a study conducted by WHO determined that the tive interventions. In terms of reducing childhood provision of a range of interventions promoting deaths, the expansion of routine immunization childhood survival could be promptly expanded services brought the greatest gains throughout using the RED approach as a strategy for inte- the year. Support from the Global Alliance for grated delivery. As part of a growing trend, the Vaccines and Immunization (GAVI Alliance), great effort needed to reach these populations which provides funds for health and immuniza- was used as an opportunity to deliver multiple tion in the world’s poorest countries, was instru- life-saving and health-promoting interventions mental. WHO data for 2006 show that, with the in addition to vaccines, thus making one of help of the GAVI Alliance, rates of immunization the “best buys” in public health an even better coverage reached record high levels. investment for health.

During the year, sub-Saharan Africa, which has Immunization campaigns delivered vitamin lagged behind the rest of the world in immu- A supplements to boost the immune system, nization coverage, began to catch up. In late deworming tablets to improve child growth August, African countries, building on a 15% and school performance, bednets to protect increase in immunization coverage since 2000, against malaria, and tetanus vaccine to protect launched an ambitious region-wide strategy pregnant women. In Nigeria, a country with one for doing more immediately. The new four-year of the lowest rates of childhood immunization, plan for Africa draws on proven strategies such an estimated 29 million children were reached as the Reaching Every District (RED) approach. with measles and polio vaccines, vitamin A Developed as part of the drive to eradicate polio, supplements, and bednets in one of the largest where universal coverage is essential, this opera- health events of the year. tional approach has proved its ability in bringing services to hard-to-reach populations. It places page 4 ● Maternal mortality:stubborn–andtragicstatistics a woman is 100 times more likely to die from die to likely more times 100 is woman a countries,these greatestin burden;the bears occur, deaths maternal all of half than more maternalof deaths. Sub-Saharan Africa, where 99% for account countries Developing birth. child and pregnancy of complications from die women 000 510 estimated year,an years. Each 20 past the for unchanged virtually remained has mortality Maternal successful. lesswere mortality maternalreduceto Efforts more impressive in that it targeted the country’s the all is life.achievement in The later cancer liver to linked firmly is that infection severe a one third of all newborn babies in China against for protection represents figure This 2002. in an initiative that had begun, with GAVI support, more than 11 million children against hepatitis B, health officials announced the immunization of Anotherlandmark wasreached Chinain when emergency obstetric services. Any great advance estimated to arise from complications requiring For example, up to 70% of all maternal deaths are lenge is great and much more needs to be done. immunization, HIV/AIDS, and malaria. The chal services with existing services, such as those for an integrated manner, the provision of maternal servicedelivery and–proposes ways tolink, in poor – deaths these of many of causes root carefor everybirth. Thestrategy addresses the new strategic approach aimed at ensuring skilled In response to the lack of progress, WHO issued a the industrialized world. in woman a than pregnancy complicationsof - - ambitious targets. As China’s Minister of Health successledtotheestablishment evenof more Africa, in As decisive. was leadership Chinese the fromcommitment political butguidance, provinces. WHO and UNICEF provided technical remotecentralmostwesternpoorestandand health districts. They use a modular approach to among service providers and managers within competence managerial instil needs health integrated programmes for addressing priority Like the RED approach for immunization, these the heart of poverty-reduction strategies. areas – a move towards universal access that is at bring high-quality essential care to underserved todelivery. is service overridingobjective The to approaches innovative through settings resource-limited in well function to designed treatment with prevention. And each has been integrates Each morbidity. and mortality on impact greatest the have that interventions health priority the integrates Each elements. significant ways. The initiatives share important theyear, these programmes moved forward in During adolescents. and adults of and dren inanintegrated way, the chief illnesses ofchil joined existing WHO programmes for managing, This approach to the management of pregnancy gency services for many more women. willdepend improvedon access tosuchemer authorities. this virus at birth is the next goal for the health announced in July, protection of all babies from - - page 5

simplified but standardized high-quality care, confirmed value in terms of cost–effectiveness, using standard lists of quality-assured drugs. the quality of services, good outreach, and the They have mechanisms for shifting tasks from superior quality of care provided by trained staff. doctors to nurses and then to patients, who One evaluation took these conclusions a step assume personal responsibility for home care further: these approaches can serve as a generic and compliance. During the year, results were platform for strengthening the delivery of a issued of external evaluations of the approach, range of essential services, providing the very including a multi-country study. Findings backbone of a primary health care approach.

HIV/AIDS: a milestone achievement in Africa

As in past years, an updated report on the HIV/ The momentum to expand access to treat- AIDS situation was issued in December. These ment, unleashed by the WHO “3 by 5” initiative, statistics show that an estimated 39.5 million continued to grow. The provision of treatment people are living with HIV/AIDS, around 95% significantly accelerated the demand for of whom reside in the developing world. Of the counselling and testing, thus strengthening 4.3 million new infections in 2006, 2.8 million preventive approaches. The results of an external (65%) occurred in sub-Saharan Africa, which evaluation, issued in June, confirmed the value continues to be the most severely affected part of WHO’s public health approach for expanding of the world. In some countries in this region, access to treatment. The integrated manage- the disease has brought life expectancy at birth ment of adolescent and adult illness, with its down to only 47 years. Disturbing trends were emphasis on simplified, standardized tools, high- also observed in some parts of eastern Europe quality care, and patient responsibility, has been and central Asia, where infection rates have risen used as the platform for service delivery and by more than 50% since 2004. performed well. As the evaluation noted, this approach has shown that antiretroviral therapy In countries with generalized epidemics, declines can be provided in even the most resource- in HIV prevalence among young people between constrained settings. The approach worked well 2000 and 2005 were attributed to effective in integrating HIV services into existing primary prevention programmes with a positive impact care services. One additional conclusion was on sexual behaviour. In other countries, even applicable to many WHO activities: the most limited investments showed high returns when successful development programmes are those focused on target groups, such as sex workers that devolve power and responsibility to local and injecting drug users, considered to be at communities and district managers. increased risk of exposure to the virus. page 6 ● Tuberculosis: asetbackinthemidstofsteadyprogress two important indicators: the percentage of cases Controlareeffortspayingoff, measuredas by and may now be declining. world the of parts some in stabilized have to global annual incidence of the disease appears trend: after more than a decade of increase, the encouraging an herald figures deaths. These around1.6with 2005,millionoccurred losis in tubercu of cases 8.8 million some estimates, availablelatesttuberculosis.According the to of control the for set targets global meeting in progress considerable announced WHO regiontreatmentDecembersincethe in 2003. to access in increase tenfold a representing therapy surpassed one million for the first time, antiretroviralreceivingHIV people of number the whereAfrica, sub-Saharan in reachedwas milestone a therapy, to access Concerning fuels the tuberculosis epidemic. owing largely to the impact of HIV/AIDS, which incidence of tuberculosis remains extremely high, to 84%. In sub-Saharan Africa, however, the grown,annual the rate of successful treatment has risen hasdetectedcasesnewly of number thethat doubled over the past five years. At the same time percentage of cases being detected has almost againstestimatedthe 2001,rateinthe30%of rate has risen from 11% to 59%. When measured are being cured. Since 1995, the case detection beingdetected and the rates at which patients - preventive services. and care treatment, of provision widespread further the to obstacle key the as identified weresystems health in weaknesses health, of areasmanyotherin echoedobservation an In scope of control activities. and scale the in expansion significant to lead strategy,the whichbuildspastsuccess,on will of Implementationovercoming each. of ways incorporatescontrolbetterandconstraints to control. Thestrategy takes itsimpetus from six launched in March a new strategy for accelerated set by the Stop TB Partnership. As a result, WHO Millennium Development Goals and the targets the in tuberculosistarget2015 theachieve to WHO control strategy standard – would not the alone be sufficient – DOTS that indicated situation the of monitoring year, the During 19% in Latvia. andKorea, of Republic the in 15% USA, the in 4% resistantis extensivelydrugare that cases yet known, the proportion of multidrug-resistant Although the global scale of the problem is not Reported mortality was extremely high at 98%. resistant disease in association with HIV infection. Africa,Southextensivelyreportedthe casesof disease. During the year, 20 countries, including outcomes than multidrug-resistant forms of the tuberculosis with significantly worse treatment drug-resistant extensively of emergence the an important setback occurred during the year: In the midst of generally encouraging progress, page 7

Malaria: WHO launches an aggressive new programme

Unfortunately, similar progress was not seen in curing malaria. The rationale is straightforward: the case of malaria. This disease continues to when two drugs with different modes of action cause an estimated 350 million to 500 million are administered simultaneously they attack clinical episodes of illness each year, with at least different targets in the parasite. Should a muta- 1 million deaths. Around 60% of these cases and tion make the parasite resistant to one of the more than 80% of the deaths occur in sub-Saharan drugs, it will be killed by the second drug. Africa, which is home to the most lethal species of the parasite. For malaria, the two-way link with Shortly after its establishment, the new programme poverty is particularly strong. A study conducted took strong action aimed at preserving the efficacy in one endemic country found that malaria of this last class of effective drugs. In mid-January, consumes around 25% of household income. WHO not only recommended the exclusive use of Poverty, in turn, reduces access to preventive combined therapies but took the further step of interventions and life-saving services. asking manufacturers to remove monotherapies from the market. During the year, 19 pharmaceu- No country met the targets for Africa set for 2005. tical companies agreed to comply. Negotiations Political commitment lagged, financial support are continuing with others. was less than expected, and WHO was criticized for a lack of strong technical leadership. This lack The use of long-lasting insecticide-treated of progress led WHO to establish an aggressive mosquito nets remains a key tool for preven- new Global Malaria Programme in early January. tion, but coverage must be scaled up signifi- Control options are currently limited: a single class cantly if internationally-agreed targets are to of widely effective drugs for treatment, bednets be met. The recent development of nets treated to prevent mosquito bites, and insecticides to with long-lasting insecticides has dramatically kill or repel mosquitoes. The new programme improved their usefulness. Unlike their pred- aims to use each of these tools to its best stra- ecessors, which need to be re-treated every six tegic advantage while promoting research and months, these long-lasting nets remain effective development for better interventions. for up to five years. The great effort needed to distribute these nets to hard-to-reach popula- As with tuberculosis, the rapid development of tions thus has a payback lasting years instead of resistance to mainstay drugs is a major impedi- months. During the year, WHO began a system- ment to malaria control, especially as the speed atic exploration of strategies for distributing of drug failure greatly outpaces that at which bednets as part of routine programmes for new drugs are developed. Resistance has now childhood immunizations. developed for all classes of antimalarial drug save one: artemisinin and its derivatives. When In September, the malaria programme took used correctly in combination with other antima- another important step when it recommended larial drugs, artemisinin is nearly 95% effective in a return to the use of DDT for targeted spraying page 8 ● Neglected tropicaldiseases:astreamlinedoperationalapproach for combating four of these diseases: river blind In October, WHO launched an integrated strategy agricultural companions. and householdconstant are vectors insect and wheresanitation poor,is housing substandard,is These diseases flourish under conditions of poverty, erished people throughout the developing world. to maim, debilitate, blind, disfigure, and kill impov nolonger seen in affluent societies, that continue The neglected tropical diseases are ancient diseases, WHO has approved as safe for spraying in house that insecticides 12 the infections.Of malarial ofnumberreduce thequickly insecticides can its reassessment. Indoor residual spraying with scientific and programmatic evidence to support cides for malaria control. WHO cited compelling of phasing out the use of DDT and other insecti areas,indoorreversing30-yearthusoftrend a firststep combiningin treatment regimens for critical a provides approach streamlined new devised. Thebeen have systems delivery tive case-finding and diagnosis. Low-cost and innova costly for need the obviating thus risk, at ties be administered pre-emptively to all communi The drugs are so effective and safe that they can prices. reduced substantially at or charge of drugsthat are supplied by industry, either free zations. All four diseases can be prevented using with the support of more than 25 partner organi heart of the new strategy, which was launched helminthiasis. Preventive chemotherapy is at the filariasis),schistosomiasis, and soil-transmitted ness (onchocerciasis), elephantiasis (lymphatic ------heldin Washington,DCexpressed full support December, when a White House malaria summit by WHO. Thisposition endorsedwasfurther in ronment when properly used as recommended causes no harm to humans, wildlife, or the envi effective.most the chemical holds,DDTisThe niasis, Chagas disease, and Buruli ulcer. Buruli disease, and niasis, Chagas support for the control of this disease, leishma financial direct and for sickness cines sleeping sanofi-aventis, announced the donation of medi October when the pharmaceutical manufacturer, in came support occur. Further disease the of cases where settings impoverished remote, in implement to difficult and cumbersome are tests Existing infection. of course the in early that is invariably fatal if not detected and treated diagnostic tests for sleeping sickness, a disease of work to the developstart and evaluate new Bill and Melinda Gates Foundation, announced the from grant a with Diagnostics, for Innovative Foundation the and WHO February, In treatments. better and tools diagnostic new ambitious control targets cannot be set without needed; urgently are interventions ulcer, new ness), leishmaniasis, Chagas disease, and Buruli human African trypanosomiasis (sleeping sick For other neglected tropical diseases, including and that benefit from shared delivery systems. interventions with similar operational demands diseases that, although medically diverse, have for indoor residual spraying. for the WHO strategy, including the use of DDT - - - - page 9

Two new financing facilities: substantial – and additional – funds for health

Momentum to reach internationally agreed antee fair distribution of this wealth. UNITAID has development goals spurred the creation of two been designed to operate as a mechanism for innovative funding mechanisms for securing moving wealth from affluent sectors to improve predictable and substantial long-term funding. In the health of poor populations. Much of the new February, the new International Finance Facility funding is secured from direct national taxes for Immunization, established as part of the GAVI on airline tickets, with higher taxes on business Alliance, became operational. Recognizing that class and first class tickets. traditional increases in donor aid budgets will not be enough to meet international development UNITAID contributes to greater market efficiency goals, this new multinational fund adapted a by creating a steady demand for drugs. It also proven financing model from capital markets. creates economies of scale thanks to long-term It uses pledges of future aid, made by six pooled purchases, and it uses its purchasing European countries in legally-binding commit- power as leverage to negotiate lower prices. Over ments, to leverage money from international time, UNITAID is expected to reduce drug prices, capital markets. Money is leveraged, via the promote the diversification of generic products, sale of bonds to investors, for immediate use and stimulate the entry of new manufacturers in supporting immunization programmes. into the market. Initial priorities for use of these funds include the introduction of new vaccines into routine immunization programmes and the strength- ening of health systems.

September saw the launch, at United Nations headquarters in New York, of UNITAID, an inter- national facility that funds the purchasing of drugs and diagnostics for the management of HIV/AIDS, tuberculosis, and malaria. The initia- tive was started by the Presidents of Brazil and France, and was subsequently joined by Chile, Norway and the United Kingdom as founding members.

UNITAID is an innovative mechanism for addressing health needs under the unique conditions of the 21st century. Globalization creates great wealth but has no rules that guar- ●

Health security during crises The routine functioning of health services can be severely Safeguarding health security disrupted by conflicts and natural disas- WHO has robust mechanisms in place for ters, epidemics of infectious diseases, or global outbreak alert and response, and an outbreak caused by a new pathogen. these mechanisms were fully operational Few health systems have adequate surge throughout the year. capacity in terms of staff, hospital beds, and supplies for responding to large-scale In conflicts and natural disasters, the emergencies. In the developing world, disruption of routine health services may the demands of coping with an explosive be compounded by a breakdown in water- outbreak can push a fragile health system supply and sanitation infrastructures or to the brink of collapse. interruption of supplies of medicines and equipment. Moreover, the risk of epidemics Under the highly mobile and closely inter- increases dramatically when people are dependent conditions of the 21st century, crowded together in temporary shelters. vulnerability to outbreaks and their Most natural disasters and long-term consequences is universal. Shared vulner- conflicts require assistance from the inter- ability implies shared responsibility and national community, with WHO assuming creates a need for collective defences. leadership for the health sector. Outbreaks and epidemics

During the year, WHO teams verified 197 disease continued for a third year. That threat, which is outbreaks, 43% of which originated in sub- linked to human and avian infection with the Saharan Africa. The diseases most frequently highly pathogenic H5N1 virus, evolved in some implicated included cholera and others with ominous ways. In birds, the year began with the an acute watery diarrhoeal syndrome, acute most explosive and extensive spread of an avian respiratory diseases, epidemic meningitis, and influenza virus on record. Some 36 countries in the viral haemorrhagic fevers. Media reports Africa, Asia, and Europe reported their first cases were the most significant source of early alerts, of infection in domestic or wild birds, or both. accounting for 52% of initial reports; this figure Evidence mounted that migratory waterfowl reflects the efficiency of the electronic intelli- are responsible for at least some of this spread, gence-gathering system used by WHO. The time thus greatly complicating control efforts. between receipt of a report and verification of So-called “relay” transmission was documented, an event averaged two days. Important events whereby the virus spreads from domestic to wild were verified in less than 24 hours. birds and back again.

The tendency of epidemic-prone diseases At a consultation convened by WHO in Sep- to flare up under the right conditions was tember, international experts summarized dramatically illustrated by cholera. Outbreaks the situation succinctly: the seriousness of occurred in numerous African countries, espe- the present situation, including the risk that a cially when weak water-supply and sanitation pandemic virus might emerge, is not likely to infrastructures were aggravated by unusual diminish in the near future. patterns of rainfall. The most dramatic outbreak occurred in Angola in the middle of In the course of the year, researchers deter- the year, causing 47 000 cases and more than mined that the H5N1 virus has now evolved into 1900 deaths. In Kenya, flooding was linked to a several genetically distinct groups. Viruses from large outbreak of Rift Valley fever that began in all groups are currently circulating in different December, marking the first outbreak of cases geographical areas. This divergence greatly of this disease in humans in six years. complicates vaccine development. Initial trials showed that experimental vaccines protective for Of greatest international concern was the one virus group did not confer good protection looming threat of an influenza pandemic, which against viruses in other groups. page 12 ● Sudan: continuity of services inDarfur Sudan: continuityofservices domestic birds. of disease a primarily still is and humans to sporadic cases in humans, but is poorly adapted causing is virus influenza novel a III: phase at remained 2004, January in place in put alert, Throughout the year, the WHO level of pandemic member. family infected an with contact close in relatives to transmission were short, and most were limited but did not do so. of human-to-human Chains workers, care health unprotected infect to or population general the into spread to nities opportu many had virus the instances, such human-to-human transmission occurred. In all of instances Some 69%. of rate case-fatality a representing countries, 9 from reported were fatalities, 80 including humans, in cases 116 virus lost none of its virulence. During the year, the rare, remained humans in cases Although an estimated 3.5 million people. on aid workers and the forced displacement of precarious by military conflict, including attacks progress despite an operational situation made significantmake to managed Sudan in offices sub- and office countrythe WHOat care. Staff health essential of provision the ensuring by lives more claiming from crisis humanitarian Activities aimed at preventing an already severe fromresponsesustained WHO. andmassive a region, Darfur thecontinuedlarlyin requireto the deteriorating situation in Sudan, and particu Concerning support during humanitarian crises, - - That Resolution was both an expression of deep pandemic.a ofthreat the and influenzaavian to relevant Regulations Health International revised the in provisions with compliance voluntary immediate for calling Resolution a adopted Assembly Health World the May, In diseases, including cholera, meningitis, and and meningitis, cholera, including diseases, The prevention of outbreaks of epidemic-prone nets were distributed to prevent malaria. long-lastinginsecticide-treatedmosquitoand were sustained, water supplies were protected, supplies. Childhood immunization programmes continued to purchase essential medicines and delivery, WHO service supporting of terms In were supported by quality control programmes. were upgraded, and primary health care clinics laboratories health public rehabilitated,were In terms of basic health infrastructure, hospitals nity to become an international threat. outbreak at its source, before it has the opportu proactive risk management that aims to stop an strategyaborders, ofto seaports andairports, at measures control passive on focus a from intoforce Junein 2007,have moved theworld revisedRegulations,theeffect, come which In Regulations will enhance strengthened global health security.greatly and revised the that international concern and a sign of confidence - page 13

hepatitis, remained an urgent need and a high priority for WHO. An efficient early warning system, extending routine surveillance to more than two million people, functioned well to guard against potentially explosive outbreaks in camps where hundreds of thousands of people live under crowded conditions. The year saw major outbreaks of cholera but good care, supported by medical supplies procured by WHO, kept the fatality rate low.

In collaboration with the Sudanese Ministry of Health, morbidity and mortality bulletins were issued weekly. To ensure a rapid response to epidemics, essential supplies have been pre- positioned in strategically important areas. Every Lebanon: vaccines, drugs, and safe water suspected case of an epidemic-prone disease is now immediately notified and thoroughly In Lebanon, the conflict that began in July investigated. damaged health infrastructures and disrupted services in the southern part of the country, Although renewed fighting over the summer requiring international assistance. As many threatened to shut down international assist- as 900 000 people initially fled their homes. ance, WHO continued working to keep an already An estimated 25% of health facilities were unable tragic situation from causing preventable deaths to function properly because of physical damage, from disease. lack of staff, or lack of fuel to run generators in the absence of power supplies.

Teams conducted rapid assessments to identify priority needs. WHO provided drugs to ensure that patients under treatment for chronic diseases received uninterrupted care. Vaccination campaigns were conducted to protect people from diseases, such as measles and meningitis, that can flare up when routine services are disrupted. Together with other United Nations agencies, WHO also addressed the urgent need for safe water supplies. Emergency humanitarian operations continued until the end of October. page 14 ● a threattodiseaseeradicationefforts Conflict andinstability: continued to cause international concern. these areas into previously polio-free countries Nigeria, and Pakistan. Importation of cases from voir zones in four countries: Afghanistan, India, reserofnumber small a toback pushedbeen setbacks – during the year. The disease has now eradicate polio saw further progress – and some tives made progress despite civil unrest. Efforts to In other instances, global disease control initia until peace is achieved in Sudan. tion of guinea-worm disease will not be possible Most experts agree that the successful eradica a disease that is now close to global eradication. largest number of cases of guinea-worm disease, world’stheaccounted forSudanexample, for 2006, During goals. health international of can also have significance for the achievement country given a within instability and Conflict is now the target of immunization campaigns. now targetimmunization is of the disease of young very children, and this group a polio made has gap immunity population the of closing the example, for India, In areas. lenges and capacities in each of the remaining chal match to tailored been have Strategies missed. not are cases that ensure to place in are systems surveillance sensitive Highly immunization. targeted for available now are vaccines monovalent Improved eradicated. been has poliovirus wild of strains three the Other developments were encouraging. Oneof

- - - - together together with polio vaccine has proved attrac nets mosquito of distribution the Nigeria, In areas to allow access for vaccinators. periods of tranquility in security-compromised negotiate to motion in set also were Efforts posts at border crossing points were increased. polio eradication. During the year, immunization countries agreed to strengthen collaboration on of transmission, the health ministries in the two mentsarefluid. Toaddress theseshared zones security concerns are high and population move lems are concentrated in the border area, where In Afghanistan and Pakistan, the remaining prob cooperation. their increasing thus populations, local for tive - - -

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Care on the

Care for vulnerable groups international agenda

A policy of equity calls for attention to the health needs of populations made vulnerable because of miserable yet may not show up in statis- social and economic factors beyond their tical tables. The problem is compounded control. The health-related Millennium by the fact that these groups usually live Development Goals address health condi- in remote rural areas or shantytowns tions, strongly associated with poverty, and have little political voice – whether that are expressed as high levels of because of young or old age, gender, morbidity and mortality. ethnicity, or education. The fact that their health problems are poorly documented Populations whose health is compromised further contributes to the low profile by economic or social factors face many they receive on national and international other problems that make their lives health agendas. page 17

Obstetric fistula: a devastating but neglected complication of pregnancy

During the year, the continuing drive to ensure around 90% of affected women to return to that all women have access to a skilled attendant active and fulfilling lives, including the birth of during childbirth addressed a common but further children. The manual adopts a program- long-neglected problem: obstetric fistula. matic approach, arguing strongly for the inclu- Obstetric fistula is a preventable and treatable sion of prevention and management of the complication of childbirth that is rarely seen in condition as part of national programmes for affluent societies. Elsewhere, mainly in parts of the integrated management of pregnancy and sub-Saharan Africa and Asia, at least two million childbirth. The rationale is straightforward: women currently live with this devastating condi- the factors that lead to obstetric fistula are the tion. This estimate is considered conservative: same as those that cause maternal morbidity reliable statistics are difficult to compile as the and mortality and many neonatal deaths. As with condition is largely “hidden”. Strongly associated other complications of childbirth, improving with poverty, obstetric fistula occurs most often access to emergency obstetric care is the most in poor, young, and often illiterate women and important preventive measure. girls living in remote areas. In September, Liya Kebede, a fashion model who Obstetric fistula is also hidden for another acts as the WHO Goodwill Ambassador for reason. The condition occurs when obstructed Maternal, Newborn and Child Health, returned labour results in an abnormal opening between to her native Ethiopia to launch the obstetric the woman’s vagina and bladder or rectum, fistula manual. The event brought together causing a continuous leakage of urine or faeces. medical experts and heads of state to raise The pain and shame that follow loss of control awareness about the problem and motivate over bodily functions, the poor hygiene, and the action. In opening the event, Ms Kebede foul smell are compounded by stigmatization addressed the urgent need to prevent the condi- and a heightened risk of recurring infection. tion through better access to services. She also Those most frequently affected are usually girls spoke about the equally urgent need for social who become pregnant when their pelvises are reintegration and rehabilitation of the roughly not fully developed, increasing their suscepti- two million women already affected. bility to obstructed labour.

During the year, WHO issued the first compre- hensive manual for the prevention and manage- ment of obstetric fistula, including advice on clinical management and procedures for surgical repair. As noted in the manual, a single simple operation can usually end the problem, allowing page 18 ● Female genitalmutilation:moreevidenceofharm due attention A globalfirst:violenceagainstchildrenreceives services for childhood victims of violence. grammes,provideconsiderstoneedand the improvementsto legislation, policies, and pro- It makes recommendations for prevention through schools, the workplace, and the community. five settings: the home and family, institutions, in children against violence of picture global Secretary-General Nations and provides United the first the in-depth by commissioned was Rights. basediswhichreportThe studythe on United Nations High Commissioner on Human from technical WHO,support UNICEF, the and childrenagainst In November,first the one to violence.disturbing: particularly is thatthreat attention increased saw year The health. to threats multiple from protected be to needs that group another are Children or early neonatal death. in hospital, resuscitation of the infant, or stillbirth section, postpartum bleeding, an extended stay caesarean by complicated be to likely more haveundergone theprocedure significantlyis Thestudy found that childbirth inwomen who conducted.conclusionsIts were unequivocal. morethan 28 000women, was the largest ever on obstetric outcome. The study, which included mentingthe effect offemale genital mutilation collaborative study in six African countries docu childbirth. In June, WHO published the results of a Traditional cultural practices can also jeopardize was launched in Geneva with Geneva in launched was World report on violenceonWorld report

- recommendations issued by WHO. abandonment of the practice, in line with the firm reproductive outcomes should contribute to the data, such as these, about its harmful effects on remainspressinga human rights issue. Reliable As the authors conclude, female genital mutilationimmediate and long-term effects of the procedure.perinatal outcomes to an existing list of harmful The study conclusively adds adverse obstetric and post-traumatic stress disorders. attempts,panicdisorders,of10% of 27% and anddrugabusedependence, or suicideof8% 6% of cases of depression, 6% of cases of alcohol of child sexual abuse accounts for approximately other forms of sexual violence. The lifetime impact 73 million boys face forced sexual intercourse and dren under 18 years of age, 150 million girls and children in high-income countries. Among chil areover twice aslikely todiefrom homicide as Childrenlow-inandmiddle-income countries children. Some findings are particularly striking. consequences of various types of violence against Thestudyalso documents themagnitude and - page 19

Access to sexual and reproductive health services: a disturbing decline

Strategies aimed at reducing maternal morbidity According to these statistics, more than and mortality include access to sexual and repro- 100 million curable sexually transmitted infec- ductive health care. Statistics released during tions occur each year. Around 40% of the esti- the year show poor access to these services. The mated 4.3 million new HIV infections in 2006 consequences for young people are particularly were in young people between the ages of 15 severe. In sexually active adolescents, problems and 24 years. In the developing world, unsafe include early pregnancy, unsafe abortion, sexu- sex is the second most important risk factor for ally transmitted infections (including HIV), and illness and death. sexual coercion and violence.

Pesticide ingestion: a leading cause of suicide

Self-directed violence is another major public poisoning patients admitted to European hospi- health challenge. WHO estimates that nearly tals, fewer than 5 die, whereas for every 1000 900 000 suicides occur every year worldwide. In admitted to rural hospitals in Asia, 100–200 die. April, reports drew attention to the link between suicides and pesticides – a significant yet largely In response to the problem, three WHO depart- hidden problem, particularly in rural areas of the ments – for mental health and substance abuse, developing world. Asian countries are the most injuries and violence prevention, and the promo- severely affected. In surveys conducted over a tion of chemical safety – worked together to 10-year period, pesticide ingestion was respon- issue a plan of action, released in September, for sible for 60–90% of suicides in China, Malaysia, preventing both intentional and unintentional Sri Lanka, and Trinidad and Tobago. WHO also deaths from pesticide poisoning. received reports of a growing number of suicides due to pesticide ingestion in Central and South American countries. These new estimates clearly make pesticide ingestion the most common method of suicide worldwide.

The estimates also open possibilities for signifi- cant new approaches to suicide prevention on a large scale. Controlling access to pesticides is one approach to prevention. Better treatment is another. For example, for every 1000 self- page 20 ● Active agingforolderpeople ways that make life easier and more rewarding to provide services and adapt infrastructures in ages municipal authorities and urban planners making cities “age-friendly”. The initiative encour promising of these initiatives is a new project for and independent as they age. One of the most ties aimed at helping populations remain active During the year, WHO continued a range of activi poor health and diminished well-being. traditionally vulnerable group at greater risk of a leave life, later in isolation with combined resources,fewer to access and hardship long developingworld,lifethe in peopleolder for Moreover,needs. their meet to fail or people excludemayolder support social and services developing countries, where systems for health concernedmosttrendsof inimpact aboutthe is WHO world, the of parts all affects ageing developingtheworld. Althoughdemographic reachyears.60ofagethese,the Of live80% in worldwide people million one month, Every surgery and hip replacement, that help main helpreplacement, thathip and surgery cataract as procedures,such cost-effective to income-generating activity, and increase access activities,create opportunities for voluntary or introduceencouragedtorecreationalalso are give people more time to cross the street. Cities that lights traffic to walking, encourage that housing and public transport, to well-lit streets The resulting changes range from age-friendly they feel is missing in their day-to-day lives. dents: what they want, what they need, and what designed following consultation with older resi for the elderly. Projects within individual cities are - - - - - some of the burden on health and social support mobility and preserve self-reliance, thus reducing prolong help actively”,authorities municipal to people older enabling“age activity.By tain monitor the effects of interventions. to and factors, risk related the and morbidity of patterns document to base evidence an as populations adult older for data comparable generatereliable,tolaunched valid,beenand has June, in site field first the at began which countries, including China and India. The study, middle-income and low- six on is focus The socioeconomic consequences of these changes. in health and well-being and to investigate the patterns and dynamics of age-related changes and survey tools, is being undertaken to examine study, which uses a standardized methodology SAGEso-called study. Thisrigorously designed the –health adultand ageing global on study the inauguration of a large WHO multi-country and middle-income countries. The year also saw countries but remain poorly understood in low- ageing have been well-documented in affluent population of implications and dynamics The New Delhi – were participating in the initiative. 30 cities – from London and Tokyo to Nairobi and peopleisolated. year,theofend By morethan older leaves and support social of networks zation,disruptsoftenwhichtraditional family responds to the trend towards growing urbani also world.It throughoutpeoplethe older of approach for responding to the growing policy a number as potential great has initiative The systems and resources. - page 21

Health problems in sub-Saharan Africa: vulnerable on multiple fronts

For reasons of history, geography, climate, The present weakness of health systems was and ecology, countries in sub-Saharan Africa identified as the single greatest challenge bear the greatest burden of disease and poor facing health development in these countries. health, including chronic undernutrition. Increased investment in health will have little Drought combines with poor soil conditions impact in the absence of basic infrastructures to jeopardize food security. The region has more and evidence to guide policy decisions, priority- than its share of conflict and natural disasters. setting, and choice of interventions. Parallel These countries are the most severely affected systems for addressing the various infectious by HIV/AIDS, tuberculosis, and malaria, by the diseases are yet another burden on countries, neglected tropical diseases, and by high rates of again pointing to the need for integrated maternal, infant, and childhood mortality. service delivery.

In the case of malaria, the region is home to However, while the report acknowledges the deadliest form of the parasite and of the existing challenges, it highlights progress in mosquito species that transmits the disease the region. For example, of the 42 malaria- most efficiently. Africa has the so-called “menin- endemic countries in the region, 33 have moved gitis belt”, where deadly epidemics flare up in a towards better treatment policies by adopting recurring pattern. Africa is also home to the still- artemisinin-based combination therapy, the unidentified reservoirs of the Ebola and Marburg most effective antimalarial medicines available haemorrhagic fever viruses, and is vulnerable to today. River blindness has been eliminated as a explosive urban outbreaks of yellow fever. public health problem, and guinea worm control efforts have resulted in a 97% reduction in cases In November, WHO issued the first African since 1986. Leprosy is close to elimination, and regional health report as both an inventory of measles deaths have declined by more than health problems and a guide to actions needed 75% since 1999. for an adequate response. Among its many conclusions, the report notes that infectious diseases continue to impose the greatest burden on health and economies, and that health systems are almost universally weak. Many of Africa’s diseases are strongly linked to poverty, and will persist as long as poverty remains. The shortage of skilled health staff is critical: neither antiretroviral drugs for AIDS nor the DOTS strategy for tuberculosis can be delivered on an adequate scale. page 22 ● while makingclinicalresearchmoreefficient Standardized registrationofclinicaltrials:protectingparticipants industry, and the editors of medical and scientific groups,doctors, scientists, thepharmaceutical 2004, initially by collecting in the views ofproblems patients’ these addressing began WHO such results may not be made public. unfavourableresultsof andtrials, thedisclose example, some companies may be reluctant to by common scientific and ethical principles. For coordinated and their operation is not governed not are they butworld, the aroundexist trials to the public. Hundreds of registries for clinical and content of results that should be disclosed timing the and trials, such of registration the participants (especially in developing countries), been raised, however, about the recruitment of have Questions care. clinical improvementof continuing the to essential are volunteers, healthy or patients on tested are drugs, new as such interventions, which in trials, Clinical Clinical Trials Registry Platform. the dataset, which is known as the International mental scientific and ethical principles underpin of clinical trials throughout the world. Two funda dataset that should be used for the registration ment,byallparties,standardized a on 20-item agreeinternational May: in announcedwere journals.broadconsultationthis results Theof - - all interventional trials, including early-phase including trials, interventional all of registration the for calls Platform the First, overall efficiency of clinical research. increasingthetrials,thus new ofplanning the recorded,guide also outcomesunfavourable reduce duplication of research efforts and, with beingasusednot “guinea-pigs”,willpolicy the earning public confidence that trial subjects are from surroundingApart trials.clinicalparency trans full ofendorsement WHO’sof an policy as welcomed been has Platform Registry The participant is recruited. first the before – registration of time the at items 20 all on data registration of disclosure public full for calls it important, equally and teers that may not be further pursued. Second, uncontrolled trials in patients or healthy volun

- -

● Diminishing the risks

Protecting populations from harm International standards and norms issued by WHO support a range of public health functions that accompanied by dangerously high levels protect the health of populations on a of pollution and counterfeit drugs often daily basis. WHO programmes continu- flood the market. ously update safety standards for industrial chemicals, pollutants in air A population-wide approach to health and water, additives and contaminants protection also includes measures aimed in food, and the quality and efficacy of at preventing chronic diseases, many of medicinal products. which are linked to lifestyle factors, the marketing and labelling of consumer These standards guide national protective products, and – above all – the sale measures, including legislation, aimed at of tobacco products. In this regard, the population-wide protection. They also WHO Framework Convention on Tobacco facilitate international trade. Unfortu- Control provides an outstanding example nately, health legislation and regulatory of collaborative legislation, whereby controls are weak in large parts of the countries agree on a common legal frame- developing world, where rapid indus- work for protecting all populations from trialization and urbanization may be a lethal product. page 25

The hazards of toxic waste

The year’s highest-profile incident involving many urgent questions about international industrial chemicals occurred in Côte d’Ivoire. trade in toxic waste and the need to protect During the night of 19 August, a tanker unloaded developing countries from being used as around 500 tonnes of liquid chemical waste, dumping grounds. The incident also illustrates which was then dumped at open-air garbage the extreme consequences of improper disposal sites across the commercial city of Abidjan. of toxic waste: dozens of hospital admissions, No health or environmental precautions were more than 85 000 medical consultations, and taken. Within days, residents began complaining the mass resignation of the Prime Minister’s of respiratory symptoms, nosebleeds, rashes, cabinet. The country’s already fragile health nausea, diarrhoea, and headaches linked to toxic system was paralysed. fumes emanating from the waste.

A WHO team assisted with the emergency response, which included supplies for the immediate care of patients, measures to prevent further exposure, and arrangements to accel- erate removal of the waste. The incident raised

Urban air pollution: greater threat, stricter protection

During the year, WHO revised its guidelines By reducing values for acceptable levels of for urban air quality, concentrating on the four common air pollutants, WHO aims to give most common air pollutants: particulate matter, governments a tool and a reliable yardstick ozone, nitrogen dioxide, and sulfur dioxide. The for protecting the health of urban residents. guidelines, which specify levels considered safe According to WHO assessments, an estimated for human health, were revised in line with two million premature deaths can be attrib- mounting data linking air pollution to a number uted each year to the effects of urban outdoor of adverse effects on health. A critical review and indoor air pollution. More than half of this of this evidence led to a dramatic lowering of disease burden is borne by populations in the recommended levels for particulate matter, developing world. ozone, and sulfur dioxide compared with earlier WHO guidelines. page 26 ● Chronic diseases: on the rise – at a very highcost Chronic diseases:ontherise–atavery Unsafe drinking-waterandsanitation:anacuteprobleminurbanareas significant impediment to development that development to impediment significant a are asthma, and diabetes, cancer, stroke, disease, heart including diseases, Chronic missing of danger in is world the that warned report WHO/UNICEF joint a September, In a hugediseaseburden. diseases are also transmitted by water, causing parasitic of number large world.A developing the in children young and infants in largely deaths, million 1.8 around with yearly, illness of episodes billion 4.5 estimated an causes from the consumption of contaminated water, Diarrhoea, the most common symptom arising cholera. epidemic and fever typhoid to A titis transmitted by viruses and bacteria – from hepa diseases of number large a to linked are tion sanita inadequate and drinking-water Unsafe economic growth by 1–5% per year. backhold toshown diabeteshavebeen alone growth, for example, heart disease, stroke, and high. In countries experiencing rapid economic consequencesnationalforeconomiesalso are the costs to households can be catastrophic. The to cope with the demands of chronic care, and is usually lower, health systems are ill-equipped middle-income countries, where the age of onset andlow-greatest nowin isburden world,the the of part every in felt are diseases these of consequences the overlooked. While often is - - a dramatic increase in the pace of work and the tationtargetthe by requirewill Meeting 2015. Goals for access to safe drinking-water and sani the target set by the Millennium Development and management of these diseases. these of management and prevention the both to approach integrated for service delivery. WHO therefore promotes an of these diseases creates a set of shared demands risk for several diseases. Similarly, long-term care addresses one of these factors thus reduces the sive alcohol consumption. An intervention that diet, inadequate exercise, smoking, and exces share a limited number of risk factors: improper diseases chronic major the Fortunately, tion. these by preven to priority high caused gives WHO diseases, expense recurring and suffering long-term the Given person’slife. a of decades for often disability, cause diseases in 2005. Apart from this high death toll, chronic of the estimated 58million deaths that occurred Chronic diseases were responsible for 35million lack basic sanitation. billion 2.6 and drinking-water safe to access lack dwellers city billion 1.1 than more worldwide, that, indicate report the in out set Statistics slums. in live 72% these, of cities; in for example, around 37% of the population live of basic sanitary services. In sub-Saharan Africa, tion growth has greatly outpaced the provision particularly acute in urban areas, where popula become has investment.problem of The level - - - - page 27

In November, a high-level ministerial confer- licensed. The new vaccine prevents infections ence was held in Istanbul, Turkey to search for that are responsible for some 70% of all cervical ways to combat the epidemic of obesity now cancers. Cancer of the cervix is the second most seen throughout Europe as well as most other common cancer in women; almost 90% of the parts of the world. As evidence of the concern, estimated 500 000 new cases in 2005 occurred the meeting was attended by ministers, deputy in the developing world. ministers and secretaries of state representing 48 countries. New data helped generate this WHO data show that well-organized screening concern. Over the past two decades, the preva- and early treatment programmes are effective in lence of obesity in Europe has risen almost three- preventing the most common form of cervical fold. Half the population of Europe and one in cancer, but they are costly and difficult to five children are overweight. Moreover, WHO implement in low-resource settings. While the estimates that the costs of treating problems new vaccine has great potential to save lives, associated with obesity amount to around 6% its impact will depend on affordable prices for of total spending in the health sector. the developing world and adequate systems for delivery. The Istanbul meeting adopted a European charter on counteracting obesity. Noting the broad social, economic, and environmental causes of the epidemic, the charter calls for a population-based preventive approach, paying major attention to collaboration with the food industry and regulatory measures to reduce the promotion of energy-dense foods and bever- ages, especially towards children. The need to encourage more exercise was also considered. To support high-level political action, the WHO Regional Office for Europe issued new guides on practical strategies for increasing physical activity, especially in urban settings, and ways of addressing the underlying factors that influence eating habits and physical activity in adolescents.

Efforts to reduce the burden of cancer, particu- larly in the developing world, received a boost in December when a new vaccine conferring protection against human papillomavirus was page 28 ● Risks fromtobacco:deadlyinanyformordisguise The WHO FrameworkThe WHOConvention on Tobacco on packaging. labels warning and regulation strict through countries and governments to counter this trend disguise”. or with form any working in is WHO No Tobaccowas 2006 in Day “Tobacco:deadly World of slogan the trend, this of awareness packaging. attractivemore flavours or To raise fruity by masked or names healthy-sounding tobacco products are being camouflaged under to linked dangers the trend, disturbing a In low- and middle-income countries. smokers in the world, 900 million, or 84%, live in million deaths each year. Of the total number of fivenearly – deathsadult ten in one aboutfor death in the world, being currently responsible Tobacco use remains the second major cause of death. and disease,disability, of toll its afford least can that ravagingcountriesincreasingly is thatTobaccoepidemicglobal a is addiction of cross-border advertising and illicit trade. trade. illicit and advertising cross-border of areas the in initially protocols, legally-binding developing begin will that groups working create and budget, a on secretariat agree WHO, within permanent a establish to met Parties the Conference of first February, the In treaties in the history of the United Nations. early 2005, is one of the most widely embraced in force into entered which Convention, The Convention. the to Parties Contracting as countries 125 than more by supported now isdisease, tobacco-relatedreduceand deaths to designed treaty international an Control, regulating tobacco products. regulating of ways effective find and places smoke-free establish countries help to developed being addition, In non-legally-binding guidelines are where most smokers live. to fighting tobacco use in developing countries, ofprivate and public donor resources devoted totalthe doubles contributionthanThis more developingworld.the on emphasis particular withInitiative, Smoking new WorldwideStop a support to million 125 US$ of contribution New Yorkof Foundation’sCity,hisannounced mayorBloomberg,the Michael when support In August, global tobacco control received strong page 29

Counterfeit medicines

One of the major reasons for gaps in health African countries found that 50–90% of antima- outcomes is a lack of access to essential larial drugs failed quality control tests. medicines of assured quality. WHO has long- standing programmes, including its model In response to this growing problem, WHO lists of essential medicines, for addressing the formally launched the International Medical situation. In recent years, however, the problem Products Anti-Counterfeiting Taskforce (IMPACT) has been compounded by a rise in supplies of in November. This new initiative, developed counterfeit and substandard medicines – in some during meetings earlier in the year, aims to put cases, flooding the market with useless or even a stop to the illegal trade in counterfeit drugs, toxic products. vaccines, and other medical products. IMPACT is taking action through a coordinated network, According to WHO, the drugs most commonly within and between countries, that engages counterfeited include antibiotics, antimalarials, international organizations, law enforcement hormones, and steroids. Increasingly, anticancer agencies, pharmaceutical manufacturers, and antiviral drugs, including those used to treat nongovernmental organizations, and drug and HIV/AIDS, are also being faked. regulatory authorities.

WHO estimates that, in developing countries, The approach is two-pronged: to encourage the some 10–30% of medicines on sale, often in public, distributors, pharmacists and hospital open-air markets, are counterfeit. Countries staff to report suspicious products to the authori- with economies in transition have an estimated ties, and to help governments make better use proportion of counterfeit medicines above 20% of their police forces and customs authorities. of market value. Medicines purchased over IMPACT is also encouraging manufacturers the Internet from sites that conceal their true to make their products more difficult to fake. physical address are counterfeit in over 50% Another strategy being pursued is to package of cases. medicines with a unique identifier that can be tracked using widely available technology, Counterfeit drugs are found throughout the thus allowing authenticity checks at any point world, but sub-Saharan Africa is particularly throughout the distribution chain. affected by the problem. In this part of the world, an ideal market for fake and substandard drugs is created by weak health systems, a lack of labora- tory capacity for testing drug authenticity and quality, and thriving open markets where medi- cines are sold without prescription. For example, a recent study conducted by WHO in selected page 30 ● A new–anduniversal“goldstandard”formeasuringchildhoodgrowth and weight by age, and weight for a given height, heightlength, asmeasurements, Simplesuch norm.detectingdeviationsthe andfromdren youngchilinfantsgrowthandplotting the of fortoolsimple a as 1970s early thesince used widely been have charts and curves Growth in malnourished children to childhood obesity. to problems ranging from stunting and wasting health purposes. They are also far more sensitive family,foruse ofclinical, research, public and their accuracy, universal relevance, and versatility dramaticallyfromthose thepasttermsofin of tion and care are met. The new standards differ a similar way provided essential needs for nutri have a similar growth potential, and will grow in tested and proven: all infants and young children assumptionan thatnowbeenhasthoroughly problems.thenewstandardsofAttheheart is infantsyoungandchildren detectingandany revisedstandards formeasuring thegrowth of significantly and new issued WHO April, In recognized as inappropriate, if not misleading. was norm the as infants bottle-fed of use the grew,breastfeeding of advantages immense country.affluentMoreover, the evidenceof as single a in grew children young and infants werebased onobservations ofhow bottle-fed years these all over used References defined. been had how “normal” growth about arose these references became apparent as questions recentgrowth.normalyears, In weaknesses in are a useful way for parents and doctors to assess - - begun in 1997, that included children from from children included that 1997, in begun a rigorously-designed long-term investigation, problems.these duringdevelopedwere They of all to respond standards growth new The increasing epidemic of childhood obesity. – that are particularly useful for monitoring the growthindicators beyond– height and weight model. The standards also include innovative new normativebreastfedthethegrowth infantas breastfeeding the biological “norm” and establish departure from the past, the new standards make orfor largea geographical area. anotherIn key eitherforindividualan child, community,fora a reliable signal of a problem in feeding or care, the world. Deviations from the standards are thus thehealthy growth childrenof ofeverypart in establishsingleuniversala “goldstandard” for that curves growth new of set a is result The breastfeeding, and did not smoke. as such followedpractices,health-promoting mothers their addition, In infection. and diets well-known constraints to growth, including poor wereenvironmentraisedanin thatminimized geneticgrowthfullpotential.their of ment All achieve favourthe to likelyconditions under living children healthy selecting by standard deliberatelywas designedproducetoideal an study backgrounds. The ethnic and cultures, locations, geographical different of range a -

World Health Report 2006 ● The world health report 2006: working together for health health for together working 2006: report health world The is impairing the provision of essential essential of provision the impairing is – 36 of which are in sub-Saharan Africa – shortage of health workers in 57 countries According to the latest statistics, a serious abroad. jobs up take to training their in invested that countries the leaving often and ones, wealthier for areas poorer leaving are workers health trend: growing a by caused crisis health a to attention drew f o e g a t r o h s l a c i t i r c A

solutions tosolutions the crisis. by urgently identifying and implementing is to pursue the report’s recommendations Workforce May.in Alliance, It’s purpose Health Global the partnership, new a In response to the report, WHO launched urgent action. taking for agenda 12-point a out sets life-saving interventions. The report also s r e k r o w h t l a e h

page 33

Health services jeopardized by this trend include to the shifting of routine tasks to less-skilled childhood immunization, care during pregnancy workers, to reduced incentives for early retire- and childbirth, and access to treatment for HIV/ ment and changes in training and career incen- AIDS, tuberculosis and malaria. Sub-Saharan tives to encourage service in rural areas. Africa faces the greatest crisis: this part of the world accounts for 11% of the global population In August, WHO announced a new plan to tackle and 24% of the global burden of disease, but has the shortage of workers for HIV/AIDS prevention only 3% of the world’s health workforce. and treatment. This shortage is especially critical in sub-Saharan Africa, where rates of illness and Factors contributing to the shortage of health mortality are highest, depleting and demoral- workers include growth of the global population izing the workforce and making health work an as training of health workers stagnates, the rise in undesirable career choice for young people. The chronic diseases, and the ageing of populations, new plan, known as “Treat, Train, Retain” (TTR), which increases the need for long-term care. draws on a growing body of evidence of what Globalization of the labour market facilitates works best to improve the performance of the migration, which is often step-wise: from rural health workforce. areas to cities and then abroad. The “treat” component ensures that health Health systems in a number of industrialized workers themselves have priority access to countries depend heavily on doctors and nurses prevention, treatment, and care services, who have been trained abroad. English-speaking including testing and counselling services, countries draw the greatest share of their health protection from transmission in the workplace, workers from abroad. In Canada, New Zealand, and access to antiretroviral drugs for themselves the United Kingdom, and the United States of and their families. The “train” component gives America, a quarter or more of all physicians have national authorities a set of strategies to expand been recruited from other countries. the numbers of new health workers and maxi- mize the efficiency of the existing workforce. The In the 57 most severely affected countries, “retain” component embraces a set of interven- more than 4 million additional doctors, nurses, tions to help ensure that countries can keep the midwives, and other health workers are urgently workers they train. Interventions range from needed to maintain essential services. Evidence improving the quality of the working environ- cited shows a clear relationship between an ment, to guarantees of job security, to the provi- increase in the ratio of health care workers in sion of financial and other incentives. a population and increases in infant, child, and maternal survival.

Recommended steps in the report range from more direct investment in training and support, ●

Tribute to Dr LEE Jong-wook

Dr LEE Jong-wook, Director-General of the World Health Organization since 2003 and the driving force in WHO’s effort Dr Lee will be remembered for initiating the to expand AIDS treatment to the developing ambitious “3 by 5” campaign to bring treatment world, died in Geneva on Monday 22 May at the to at least half of the world’s 6.5 million people age of 61. His death followed surgery to remove living with AIDS by the end of 2005. Although a subdural haematoma. the effort fell short of its goal, it marked the first serious international effort to bring expensive Dr Lee served the Organization for 23 years. anti-AIDS drugs to the countries of Africa. A few Before taking the reins as Director-General in days before his death, Dr Lee told his staff that 2003, in the aftermath of the SARS epidemic “there can be no ‘comfort level’ in the fight against and amid the initial signs of the avian influenza HIV.” A key outcome of the 3 by 5 programme was, crisis, he played a key role in eliminating polio he said, “the commitment to universal access by from the Western Pacific Region and organizing the end of 2010”. the battle against tuberculosis. Shortly after taking up office, he was faced with containing His death was announced at the official opening avian influenza. He ensured that outbreaks were of the World Health Assembly by Dr Elena Salgado, controlled and that affected poultry flocks were Minister of Health of Spain. She described Dr Lee slaughtered. He arranged for WHO to stockpile as “an exceptional person and an exceptional three million treatment courses of Tamiflu Director-General”. The Health Assembly then donated by Roche, and warned that in the event observed a two-minute silence. Delegates to of a pandemic it was unlikely there would be the Health Assembly signed books of condolence, 2006 – A year of unexpected change at WHO enough vaccine, drugs, health care workers, and adding to hundreds of tributes and messages hospital capacity to cope. At the same time, he received from people around the world. Dr Lee reassured the world that no one had caught the was the first national of the Republic of Korea to disease after eating properly cooked poultry. head a United Nations agency. “LEE Jong-wook was a man of “While Dr Lee’s death is a “I would above all like to “My father loved his work and “Dr Lee worked tirelessly to conviction and passion. He was tragic loss for the global health convey my admiration for his colleagues and those whom improve the health of millions a strong voice for the right of community, the world will Dr Lee’s tireless efforts in the he hoped to help 100%, while of people, from combating every man, woman and child to benefit from his vision and service of mankind and for his also loving his family 100%. tuberculosis and HIV/AIDS health prevention and care, and inspiration. His commitment outstanding contribution to the This was the only way he could to his aggressive efforts to advocated on behalf of the very to a healthier, more equitable ideals of the United Nations.” have accomplished all he did in eradicate polio.” poorest people. He tackled the world will be his enduring his career, devoted to helping most difficult problems head legacy.” Jacques Chirac, President others, while supporting my George W. Bush, President of on, while upholding the highest of the French Republic mother’s work in Peru and being the United States of America principles. He will be very Bill and Melinda Gates, an incredible and loving father, gravely missed, but history will the Gates Foundation husband, brother, and uncle. mark LEE Jong-wook’s many Even as a doctor he gave 100% contributions to public health.” to his patients and through his work in WHO. He had a lot to Kofi Annan, Secretary-General give and he did give it all.” of the United Nations Tadhiro Lee, son of LEE Jong-wook

Warm reception for Dr Margaret Chan

On 9 November, at a one-day special session of Kong Department of Health in 1978 and was the World Health Assembly, Dr Margaret Chan appointed Director of Health in 1994. As Director, was confirmed as the next Director-General of she was known for her decisive management WHO. Dr Chan told the Health Assembly that she of avian influenza in 1997 and for her work to would focus on six key areas for health: develop- halt the outbreak of SARS in 2003. Prior to her ment and security, capacity and evidence, and appointment as WHO Director-General, she was partnerships and performance. “All regions, all Assistant Director-General for Communicable countries, all people are equally important. This Diseases and Representative of the Director- is a health organization for the whole world. General for Pandemic Influenza. Our work must touch on the lives of everyone, everywhere,” she said. “But we must focus our Acting Director-General Anders Nordström attention on the people in greatest need.” welcomed Dr Chan and confirmed his support together with that of all Member States. “You In her acceptance speech, Dr Chan said: “what know that you have the commitment, energy and matters most to me is people. And two specific enthusiasm of all of us behind you,” he told her. groups of people in particular. I want us to be Dr Nordström remained Acting-Director General judged by the impact we have on the health of until Dr Chan took up her post on 4 January 2007. the people of Africa, and the health of women… In recognition of this responsibility, the Health Improvements in the health of the people of Assembly passed a Resolution commending Africa and the health of women are key indicators Dr Nordström for ensuring the continuation of of the performance of WHO.” WHO’s work on the global health agenda after Dr Lee’s sudden death. Dr Chan obtained her medical degree from the University of Western Ontario in Canada and also has a degree in public health from the National University of Singapore. She joined the Hong ● Timeline

March May

World No TB Day World Health Trends in TB control Assembly are positive: 22 May February 26 countries and April June areas reach target Dr Lee died, a shock World Cancer Day World Health Day World Blood Donor ahead of schedule on the first day of and launch of Day 3 February 24 March the World Health World Health Report Assembly: tributes 14 June 2006: Working January poured in from Together for Health around the world; Visit of UN Secretary Headquarters is a comprehensive Dr Anders Nordström General to WHO building 40 years study of the global was nominated Headquarters old health workforce to serve as Acting 21 June pointing to a Executive Board Director-General. opens severe shortage of health workers 22 May 23 January which impairs many countries’ ability to Visit of Prince improve health Charles to WHA 7 April 23 May

Africa Malaria Day World No Tobacco Day 25 April 31 May

Jorge Sampaio Former President of Portugal appointed as Special Envoy to STB July September November

G8 Meeting in WHO’s Goodwill The appointment St Petersburg Ambassador for of Dr Margaret Dr Anders Maternal, Newborn Chan as the next Nordström, acting August and Child health, October Director-General December Director-General, supermodel Liya was confirmed in led a senior WHO WHO assessment Kebede, travelled World Mental a special one-day World Aids Day team at the G8 visit to Lebanon to Ethiopia, where Health Day session of the World 4 December Summit where she saw first hand 10 October Health Assembly AIDS Conference surveillance for WHO’s efforts to 9 November infectious diseases, in Toronto – improve the well- World Sight Day Medicines, money including improving being of mothers 12 October Opening of new and motivated transparency by all and their newborn WHO UNAIDS health workers are countries in sharing babies building with UN key to universal information was Secretary General access to HIV/AIDS given top priority EMRO Regional Kofi Annan prevention, 4 July Committee treatment care 22 November and support 9 September Launch of African 16 August WHO welcomes Health Report Republic of which provides an SEARO Regional Montenegro as unprecedented Committee WHO’s 193rd overview of recent 22 August Member State achievements in the Region – Africa EURO Regional AFRO Regional is finding African Committee Committee approaches to 28 August 11 September solving its health problems WPRO RC 18 September

AMRO RC 25 September www.who.int • Publications • Useful links ● AVIAN INFLUENZA AIDS HEALTH AFRICAN WORLD HEALTH WORLD WER WATER VIOLENCE TUBERCULOSIS TRAVEL TOBACCO STATISTICS HEALTH SEXUAL FISTULA OBSTETRIC OBESITY MALARIA GROWTH CHILD CANCER BULLETIN

The The WHO Framework Convention on Tobacco Control (FCTC): Mobilizing the world for global public health, is First world report on violence against children produced by WHO, UNICEF, and the United Nations High High Nations by WHO,producedUNICEF,United children the against and violence on report world First The WHO Statistical Information System launched a new, user-friendly web-based profiles for all Member States The The Sexualand Reproductive health Laying– the foundation for morea just world through research and action. The WHO Child Growth Standards, developed using data collected in the WHO Multicentre Growth Reference

Global pandemic influenza action plan to increase vaccine supply – a plan to reduce the gap gap the reduce to plan a – supply vaccine increase to plan action influenza pandemic Global

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