HI AITH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · OCTOBER 1987
The Americas Eighty-five Years of Dedication by Dr Jorge Osuna
riginally, international coop Pan American Health Organization among countries of the Americas eration in the health field was (PAHO), the political process was and specified the "functions and aimed at protecting the what gave birth to the technical duties " of the Pan American Sani populace from the risk of illnesses process. Policy first grew out of tary Bureau. These included collect brought in from other countries. humanitarian and economic con ing and analyzing data about trends Thus, in the United States during siderations targeting control of cer in illnesses prevalent in the region the nineteenth century, several tain infectious diseases that not and informing member govern episodes of cholera broke out, only produced high morbidity and ments about scientific advances and traceable mainly to European im mortality, but interfered with inter the results of experiences in health migrants, and yellow fever was in national commerce as well. This development. troduced through maritime contacts approach has been sustained by In 1947, the XII Pan American with Central and South America. PAHO throughout its long history. Sanitary Conference decided to The first efforts to arrive at interna firmly establish the identity of the tional quarantine agreements re Prepared at WHO 's regional Pan American Sanitary Bureau garding cholera were initiated in office in Washington, World through the creation of the Pan Europe during the 1851 meeting in Health this month looks at the American Sanitary Organization Paris of the First International Sani history of collaboration in pub consisting of four bodies : the Pan tary Conference. lic health in the Americas. American Sanitary Conference, the By 1901, the etiology and Directing Council, the Executive method of transmission of cholera, Committee, and the Pan American yellow fever, and plague had been Although cooperation in the fields Sanitary Bureau. In this way, the clarified sufficiently to permit the of science and technology has often Bureau became the headquarters testing of methods of control, as influenced policy decisions at the and secretariat of the regional or was discussed at the Second Inter national level, the Organization has ganization. In 1949, the Second national Conference of American always promoted health develop World Health Assembly ratified the States, held that year in Mexico. ment as part of economic progress agreement signed between the Di The conferees decided that the Ad and social welfare. During recent rector-General of the World Health visory Board of the International years, the Director of the Organiza Organization (wHo), Dr Brock Union of American Republics (to tion, Dr Carlyle Guerra de Macedo, Chisholm, and the Director of the day, the Organization of American has added a very important compo Pan American Health Organization States) should convene health nent which is the contribution of (PAHO), Dr Fred Lowe Soper, ac administrators from all over health towards establishing peace cording to which the Directing the hemisphere to formulate among peoples. Council and the Pan American "agreements and regulations " to The recommendation that the Sanitary Bureau would act, respec assure that "the requirements of International Sanitary Bureau be tively, as WHO 's Regional Commit quarantine be reduced to a located at the International Of tee and WHO 's Regional Office in the minimum" in relation to cholera, fice of the American Republics Western Hemisphere. yellow fever, bubonic plague, and (Panamerican Union) was approved Over time, concern for infectious "any other serious epidemic". This at the Fourth International Confer diseases gave way to a more gener group was also asked to "designate ence of American States, held in al focus on international health ac an executive committee of not less 1910 in San Jose, Costa Rica. tivities, and improving the health of than five members" to be called the The Fifth International Confer all the people became the main International Sanitary Bureau and ence of American States, meeting in goal. From there, it can be said that headquartered in Washington, DC. Santiago, Chile, in 1923, decided the Americas became a world van That is how the First General Inter that from henceforth the meetings guard in developing international national Sanitary' Convention of the should be called " Pan American" cooperation on health matters, American Republics came to be rather than "International", a achieving important progress in held in December 1902, at the Wil change which would apply also to many fields: protection of the envi lard Hotel in Washington, DC. This the International Sanitary Bureau. ronment, especially the physical en was the first in a series of meetings The Seventh Pan American Confer vironment; strengthening health which later came to be known as ence was held under this new name service systems at the national and Pan American Sanitary Confer in Havana, Cuba, in November local levels; improving the institu ences and which were held every 1924. The Pan American Sanitary tions involved in training health four years. Code signed at that meeting set personnel; and promoting col It should be pointed out that, international quarantine regula laborative research aimed at during the early beginnings of the tions for air and maritime travel broadening scientific horizons and
2 W oRLD HEALTH , October 1987 Cover: A Guatemalan woman from the Lake Atitlan region reminds us of the colorful diversity to be found i.n the 'American continent. PAHO/WHO Photo by Carlos Gaggero IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization.
Editor: John Bland
Deputy Editor : Christiane Viedma
Editor: Peter Davies
News Page Editor : ·Peter Ozorio
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. Scnuhmarkt 4, 3550 Marburg. FR·G. Articles and photographs not copyrighted may be reproduced provided credif is given to the Worlcl Health Organization. Signed articles do not necess· arily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland.
Contents Eighty-five Years of Dedication by Jorge Osuna ...... 2 Health as a Bridge for. Peace by Mark L.. Schneider ...... 5 The Need to Know by Jose R. Ferreira ...... , 7 Health Prpblems Old and New by A. Alleyne ...... 9 Water, Source of Life by Horst Otterstetter and Alberta Flores ...... 11 Children of Latin America and the Caribbean Eisa M. Moreno, Nestor Suarez and Giro de Ouadros . . . . . 14 Health for: All in the Americas ...... 16-17 Centers and advisory assistance to A young Colombian boy symbolizes Disaster Preparedness in the hope for the future of the people of governments. the Americas the Americas. In an editorial in the May 1972 by Claude de Vi lie de Goyet , . 20 Pan American Sanitary Bureau Bul PAHO/WHO Photo by Julio Vizcarra letin commemorating a half cen Health Services for All Jorge Osuna ...... 23 tury of publication, Dr Abraham stimulating information exchange. Horwitz, then Director of the Or The Challenges Ahead Furthermore, the countries have ganization, stated that "Health as by Carlyle Guerra de Macedo .. . . . 26 science and art has become diver been fostering technical coop era 30-31 tion through Specialized Regional sified over the last fifty years,
WoRLD HEALTH, October 1987 3 Eighty-five Years of Dedication extending its reach from molecular To meet the agreements and biology to social biology. We be mandates coming out of the World lieve the root of life as well as the Health Assembly of 1977, when the destiny of every human being is to goal of Health for All by the Year engage in work; we understand it 2000 was set, PAHO's Directing as the framework for happiness, as Council - in 1982 - approved a a stimulus and component of plan of action to implement corres economic development; we experi ponding Regional Strategies. More ence it as the goal of every indi recently, in October 1986, the XXII vidual and a means to social wel Pan American Sanitary Conference fare. " The breadth of his conceptu approved a document entitled "rs entral America" conveys an al framework and the dynamism of " Orientation and Program image of internal violence, in his remarks are characteristic of the Priorities for PAHO for the Period ternational conflict, and hu historic evolution of cooperation 1987-1990", which offers several man misery. Those images unfortu among the countries of the focal points for the reorganization nately are all too real ; but there Americas, as they searched to of national health systems: also is another reality in the field of gether for ways to improve the - development of a health ser health, one of international cooper health and well-being of their vice infrastructure, emphasizing ation, intrasectoral collaboration popula tions. primary care ; and intersectoral coordination. According to the basic premises - attention to priority health prob It is called "Health as a Bridge of the Punta del Este Charter, lems appearing in vulnerable for Peace". which was signed in 1961, " public human groups by establishing This subregional initiative was health programs are essential and specific programs to deal with launched three years ago by the complementary to economic ones." them; and seven nations of the Central Ameri Member governments approved the - information management to can Isthmus working together with Ten-Year Plan for the 1960s, in bring about the foregoing, mak the Pan American Health Organiza which they pledged to establish na ing optimum use of the resources tion, the regional arm of WHO in the tional health plans and recom of PAHO/WHO. Americas. PAHO/AMRO was asked mended to PAHO that it undertake The Director of the Pan Ameri by the governments of Belize, Cos the responsibility for advising coun can Health Organization, Dr Car ta Rica, El Salvador, Guatemala, tries on how to best prepare their lyle Guerra de Macedo, summarizes Honduras, Nicaragua and Panama plans and implement them. the significance of this resolution as to help coordinate this joint effort. The Ten-Year Health Plan for the follows: "At this turning point in Four examples will demonstrate Americas, formulated for the Third the history of the countries of the some of the consequences of that Special Meeting of Health Ministers Americas, marked as it is by pro decision: in Santiago, Chile in 1972, repre found economic and political crises, - Each of the past three years, a sents the culmination of a series of the role of international organiza temporary cease-fire has been de coordinated efforts undertaken by tions becomes even more crucial. clared in El Salvador between gov countries of the region to improve The Pan American Health Organi ernment and guerrillas to permit a their citizens' health. This plan is zation, through increasing involve three-day nationwide immuniza more detailed than the previous ment in consultation and participa tion campaign to be carried out one and includes concepts, mea tion with governments of member throughout the country. More than surable objectives, methods of countries and increasing awareness 200,000 children and mothers have achievement, and implementation of the challenges implied, has been been vaccinated each year as the programs. able to define the main criteria and church, private voluntary groups, At the IV Special Meeting of priorities underlying its policies of the press, PAHO/AMRO, UNICEF, Health Ministers of the Americas, technical cooperation to fit with the Rotary International, and several which took place at PAHO Head current developmental stage of the donor nations joined in these cam quarters in September, 1977, the countries and their needs, within a paigns which were led by the Minis 28 member governments of the Or framework for collective decision ter of Health. ganization reported on national making for the region. " - For more than three decades, the health service coverage, and of Despite economic recession, Ministers of Health in Central fered strategies for further expan along with structural readjustments, America and Panama had met each 1 sion and improvement based on a explosive population growth, and year to share common concerns document made available by PAHO extreme diversity-geographic, cul -but Belize had never been in entitled "Expansion of Health Ser tural, and epidemiologic-the prin cluded, nor had any other entities vices Coverage, Strategies for Prim ciples and methods espoused by from the health sector participated. ary Care and Community Participa PAHO still manage to address preva Through this subregional initiative, tion". The national strategies that lent health problems, offer modern Belize was included and the annual emerged in the reports indicate a techniques to reduce their impact, event also matured from a gather realignment in terms of internation concentrate resources on groups at ing of the ministers of health to al cooperation, and the reports greatest risk of illness and death, a meeting of the health sector, express unanimous agreement to and provide prevention and prim with the full participation of the share experiences and resources ary care as part of an organized directors of the Social Security within the region. system of health service delivery. • Institutions.
4 WoRLD HEALTH, October 1987 llth as a Bridge for Peace by Mark L. Schneider
- Although recent conflicts had met and decided that the initiative, area. A second round of review strained international dialogue, the whose formal name is "Priority refined the projects, established initiative spurred cooperation be? Health Needs in Central America priorities and developed the first tween all countries of the region, and Panama" would concentrate package of 123 national projects including formal agreement be on mothers . and on children aged and 29 subregional projects to be tween the Ministers of Health of under five, on refugees and dis presented to the international com Honduras and Nicaragua to conduct placed persons, and on the urban munity for support. joint border monitoring to prevent and rural poor. Endorsements in the Americas the spread of malaria and other Its seven priority areas of action came from the Presidents and For tropical diseases, mutual spraying would be strengthening health ser eign Ministers of the participating in malaria endemic areas by Nicara vices, developing human resources, countries, as well as from the Con gua and Costa Rica, and dozens of essential drugs, food and nutrition, tadora countries and the Contadora training and technical cooperation control of tropical diseases, water Support group. Formal approval exchanges among the countries and sanitation, and child survival. was certified by resolution of the themselves and also with their Directing Council of P AHO which is neighbors. the Regional Committee of WHO. - Last year, in the first joint pur In the global arena, the World chase from the revolving fund for Health Assembly heard the plan the procurement of essential drugs presented by a unified Central sponsored by the initiative, the American delegation, and adopted countries obtained some 17 drugs resolutions of support and exhorta more than 300 per cent cheaper tion to its members to translate that than each had purchased the same political commitment into material drugs separately the previous year. and technical support. The five-year initiative was a President Felipe Gonzalez of product of the spirit of Contadora, Spain responded immediately by the cooperative venture by other agreeing to host an international Latin American nations to try and pledging conference for the Plan in promote peace and development in November 1985. The conference that strife-torn subregion. Conta A refugee camp in Central America, was attended by thirty-two nations dora found the underlying causes where the "Health, a bridge for peace " from Europe, as well as Japan, the of the political and ideological initiative is promotingcooperation to United States, Canada, the Holy conflicts to be the conditions of improve health. See and a host of international and social and economic injustice, them PAHO/WHO Photo by Carlos Gaggero regional organizations. selves the bitter legacy of In the narrow sphere of mobiliz undefdevelopment. ing external resources, more than AMRO Regional Director Carlyle Objectives, strategies and ac US $100 million has been commit Guerra de Macedo, who is also tivities were defined in each area, ted by a dozen donors, including PAHO Director, said, "Health was and then two kinds of projects de Scandinavian and Western Euro the one area where everyone could veloped-subregional projects and pean countries, the US, the EEC, agree, the one goal which overrode complementary national projects. the Inter"American Development ideological . differences, the one The Ministers voted that the sub Bank and UNDP for 19 multi-year field where there wasan impressive regional projects were the highest subregional projects; another tradition of Central American coop priority because they carried the $255 million was approved by eration and the one sector where a, dominant theme, in addition to those and other European and common long-term ideal, Health for health development, of subregional North American donors for nation All by the Year 2000 already was . integration, promoting internation al projects. More than 90 projects shared''. al understanding and solidarity, and are underway with that external The subregion W oRLD HEALTH, October 1987 5 Health as a Bridge for Peace gional gathering of Contadora and Contadora Support Group coun tries which yielded new commit- . ments for the sharing of training, research, and collaboration with the countries of Central America and Panama. PAHO/AMRO has selected subreg ional initiatives like the five-year Central American endeavor as a flexible and powerful vehicle to convey the Organization's manage rial strategy for the optimum use of P AHO/WHO resources to the countries. It has concentrated on the coun tries as the key participant in the design of the Organization's techni cal cooperation and enhanced the role of the Ministries of Health in defining national health priorities, in setting national social objectives, in coordinating external resources, in promoting national awareness of health goals, and in mobilizing na tional resources to meet those goals. P AHO/ AMRO also has become a far more active and involved actor helping to mobilize national and external resources to respond to the subregional and national needs con tained in the overall Plan. Also, both the nations and PAHO/AMRO have garnered new knowledge in the design, promotion and exe cution of health development projects. The Central American initiative already has become the inspiration for the launching of a similar Carib bean subregional initiative, "Carib bean Cooperation for Health", and Andean and Southern Cone pro jects also are being planned for the countries comprising those subreg ions of the hemisphere. This imaginative venture has also cloned a similar endeavor in the areas of education and housing .. Under the aegis of the Organization of American States (the Western Hemisphere's regional political body), the Inter-American Devel opment Bank and PAHO/AMRO, a program for social investment in Central America and Panama has come into being. As was done with the subregional health initiative, national coordinators have been named, subregional meetings have been held, and both subregional and national development projects are under preparation. • 6 WoRLD HEALTH , October 1987 The Need to Know by Dr Jose R. Ferreira m proving the health of the World Health Organization The United States, through the population as a whole requires (wHo)-has pulled together all these National Library of Medicine, has ~ the delivery of services based on initiatives, supporting national in made a landmark contribution in mastery of already available know stitutions and projects in specific bringing together the largest collec ledge, whether scientific and tech fields and developing such multina tion of medical literature in the nical or political, social, and tional centers as the Institute of world and developing an efficient economic. This statement is neces Nutrition of Central America and reference system, the Index sarily broad because of the com Panama located in Guatemala, the Medicus. In addition, through the plexity represented by the multiple Caribbean Food and Nutrition Insti application of modern technology, efforts of research, dissemination, tute in Jamaica, the Pan American it has created MEDLARS, a corn~ and transmission of knowledge, a Foot and Mouth Disease Center in puterized system for analyzing and process which, in the health con Rio de Janeiro, the Pan American retrieving the entire biomedical text, has been called "information Zoonosis Center in Buenos Aires, bibliography. management". the Pan American Center for Sani PAHO, with the support of that tary Engineering and Environmen library and national libraries, has tal Sciences (CEPIS) in Lima, been able to establish a Regional Outcomes and Research the Latin American Center of Library of Medicine (BIREME), de The information management Perinatology in Montevideo, and signed to serve all of Latin America, process requires countries to take the Caribbean Epidemiological and located in Siio Paulo. This lib charge, first of all, of diagnosing Center in Port of Spain. rary, by incorporating the same their own situation and organizing The Organization's efforts have computerization system, was able to improve their information sys been concerned mainly with carry to develop a Latin American Index tems and their capacity for analysis ing out research, as well as lending Medicus and create an information in overall socio-economic terms, as support to particular projects and network with more than 400 par well as in relation to health care in training specialized personnel, in ticipating libraries. In addition, two particular. More specifically, there cluding strengthening the capacity specialized information systems is a need to strengthen capacity in to stimulate development of new have been created: the Pan Ameri the areas of analysis of national knowledge and to critically analyze can Network of Sanitary Engin policy and the financial sector and it, always with reference to the eering and Environmental Science to probe in depth the factors pro actual situation of the country in Information and Documentation, moting efficiency and efficacy in volved. A case in point is the cur headquartered at CEPIS in Peru, health interventions in order to bet rent effort to foster countries' which represents about 200 centers, ter serve the whole population. capacities to evaluate new tech and the Latin American Cancer Re Other priorities include biomedi nologies applicable to health care search Project (LACRIP), an inter cal research related to hygiene and and therapy which are sometimes national computer network con public health, as well as studies on of disputable value, contributing cerned with collecting and dis nutrition, infectious diseases, en unnecessarily to the high cost of seminating up-to-date information vironmental protection, and the health care. on cancer. problems of high risk groups, such So far these technologies, which as children, women of childbearing Data Collection permit on-line utilization of inter age, workers, and the elderly. Re national data banks, are accessible search in the area of child survival and Dissemination only through satellite telecommuni is another priority. These provisos notwithstanding, cations networks, such as is the case Efforts so far have come out of essential health information, with LACRIP, which usually in the universities and national re whether produced in more de volves considerable cost. The Or search institutes charged with fos veloped or developing countries, ganization is working on an alterna tering scientific development. The will be useful only to the extent that tive which will initially rely on the Pan American Health Organization there are adequate mechanisms for facilities of BIREME and CEPIS, (PAHO)-the regional office of the its documentation and dissemina eventually going to other general tion. With exponential growth in information sources. The new sys the order of 6 to 7 per cent per tem uses compact video disks This young Central American girl may year, the body of biomedical and hooked up to a personal computer be the ultimate beneficiary of joint health literature and data will dou to gather and manipulate large vol health action by the seven nations of ble every 10 or 15 years, providing the Central American isthmus. umes of information and dissemi an immense challenge in terms of nate it cost-effectively throughout PAHOIWHO Photo by Ca rl os Gaggero information management. the affiliated network. This system WoRLD HEALTH , October 1987 7 The Need to Know new educational centers, the revi sion and upgrading of professional courses of study, faculty training, and methods development, along with the collection, production, and distribution of educational material. Professional training is being reor ganized according to the goal of Health for All by the Year 2000, with an emphasis on the expansion of primary health care. Regarding this educational effort, it should be pointed out that the public health training approach has been adopted by 24 US and 13 Latin American schools of public health, in addition to 16 graduate programs in community and social medicine, as well as several short term core courses and specialized residencies in health administra tion. More recently, in Latin Ameri ca a series of ten Regional Programs of Animal Health Training have been established which combine the resources of public health training centers with those of health care training facilities, reinforcing their strategic planning component. Most of these programs, mindful of the commitment to Health for All, have stressed the need to reor ganize health delivery systems as well as leadership and advanced training in order to strengthen the decision-making process. Special emphasis has been placed on what has been called "the multidimen A network consisting of more than interpretations by incorporating a sional focus of epidemiology", 1,500 Latin American institutions helps dictionary of phrases which shows which covers not only traditional the countries carry out training pro the multiple meanings of each monitoring and control of infectious grams, such as this laboratory course in word. diseases, but also everything rela Trinidad and Tobago. tive to health analysis and evalua PAHO;WHO Photo by Julio Vizcarra Transmission and tion of health services to serve as a basis for health planning and also offers the advantage of large Training monitoring in all aspects of disease capacity, since each compact disk The creation of effective informa control, both acute and chronic, may contain the equivalent of one tion management mechanisms al infectious and degenerative. thousand books of 200 pages each. lows the possibility of further trans In this advanced formulation, it is This mechanism is designed to open mission of this knowledge and of important also to elaborate on in access tci sources of knowledge, not stepped-up staff training efforts. A terdisciplinary relationships in or only to the health library network, network has been formed consisting der to treat health within its but also at the level of health ser of more than 1,500 Latin American broader social context, considering vices and, eventually, to the profes institutions engaged in training pro the implications for other fields in sional caregiver. grams for 100,000 specialized per terms of responsibilities and out In order to facilitate the exchange sonnel each year in various health comes. Therefore, all aspects need of information between countries, fields. The Organization's efforts to be considered: educational, ad the language barrier must be over range from the promotion of human ministrative, legal, economic, and come. To deal with this situation, resource planning and surveys of political to assure future leaders the PAHO came up with another innova the health care job market to setting knowledge they need to enlarge the tive initiative to promote the devel standards of operation for the train dialogue in favor of health develop opment of a computerized English/ ing network as a whole and lending ment, reduction of dependency, Spanish translation system. The institutional and program support. and promotion of an attitude of process, now in full operation, The focus has been on promoting confidence and determination to overcame the dilemma of different the design and establishment of move ahead. • 8 W oRLD HEALTH , October 1987 Health Problems Old and New by George A. 0. Alleyne he developed countries of the and longer life expectancy have rates for women aged 15 to 19 world have passed through increased the proportion of both running as high as 86 per 1,000 in 11 three distinct stages of health adolescents and the elderly. These certain countries. In at least three problem evolution and resolution. trends, coupled with rapid urbani nations of the region, abortion is The first saw a concerted attack on zation, have further taxed the the leading cause of death for this infectious diseases, the ravages of capacities of existing health care group. Suicide and homicide also severe under-nutrition, and poor facilities. take a large toll among youth. sanitation. This was the golden age Within the burgeoning cities, 2. The urban poor-Like other of dramatic health breakthroughs three major problem groups parts of the world, Latin America is when progress could be seen, mea emerge. experiencing considerable popula- sured, and appreciated. Antibiotics, immunization, water purification, and improvements in diet con verged to produce a generation of healthy children, most of whom survived to adulthood. The next stage focussed on chronic, non-contagious conditions such as heart disease, cancer, and diabetes. A sophisticated, tech nologically-based health industry arose, more concerned with saving individual lives than with promot ing health. The third and latest phase has been marked by attention to life styles and environment. National health planners have become in creasingly aware of the health ef fects of social pathology, such as substance abuse and traffic accidents. Movement through all these phases may have taken developed countries a century to accomplish. Malnutrition remains a problem in tion growth, mostly in urban areas. However, an accelerating rate of many developing countries, while In several Latin American countries, change has now forced developing sophisticated, technologically-based over half the population now lives in nations to confront the problems of facilities form part of an industry more municipalities with more than all three stages simultaneously. concerned with saving lives than with 100,000 inhabitants, compared with Traditional scourges remain ram promoting health. only 15 per cent in Asia. This Latin pant, while instant worldwide com PAHO/WHO Photo by Julio Vizcarra American urbanization has a predo munications about new or exotic minantly youthful character. ailments create panic in areas 1. Youth-In 1985, the 15-to- While theoretically a concentra where health resources might be 25 age group comprised fully one tion of people in urban settlements better devoted to more basic needs. fifth of Latin America's population, should facilitate delivery of health the majority living in urban areas. care services, this is not always the In countries where as many as case. Inhabitants of large cities suf Demographic trends 85 per cent of this youthful group fer from high rates of malnutrition, Apart from infection patterns are city residents, accidents are violence, poor medical care for and environmental influences, their leading cause of death. While mothers and children, and illnesses economic difficulties and shifts in a it is normal for adolescents to ex associated with unsatisfactory wa population's age composition both periment, their involvement with ter and sanitation services-in short, have substantial impact on the type sex, alcohol, and drugs can have from all the health problems of and frequency of health problems serious health repercussions. Un social marginality. Cities are not encountered. In Latin America, par wanted pregnancy remains very just concentrations of people, but of ticularly, decreased infant mortality much a problem, with pregnancy health problems. W oRLD HEALTH, October 1987 9 Health Problems Old and New 3. The elderly-Whereas expo order to focus interventions where surge m hospitalizations and nential growth among adolescent they are likely to be most effective. deaths. and urban populations is mainly The situation does appear to be Flavivirus infection is another characteristic of Latin America and stabilizing somewhat, with 884,000 malady beginning to receive more the Caribbean, an increase in the cases of malaria being reported in attention as the result of the arrival number of senior citizens is occur 1985, compared with 830,000 in in the Americas of aedes albopictus. ring throughout the Americas. In 1983. However, Brazil and Guyana This mosquito, widely distributed the period from 1980 to the end of are still showing steady increases around Asia and the Pacific and this century, the number of persons and the outlook for eradication or once native to the forest, has be aged 60 to 69 in Latin America and even a reduction in overall inci come quite at home in the city, the Caribbean will rise from dence is bleak, in the light of di breeding not only in tree holes and 14 million to 23.5 million. In 1900, minished national and international leaf axils, but in bottles, vases, only 4.1 per cent of United States' resources being allocated to the abandoned tires, and other man residents were over 65, whereas problem. made containers. Remarkably har by 1980 the figure had risen to What is more, too little attention dy, it can even survive in hiberna 11.3 per cent. has been paid to indirect influences tion. This creature has been associ This rapid "greying" of the on patterns of disease transmission, ated with many dengue epidemics population affects patterns of dis whether the introduction of new in the Far East and can transmit all ease as well as of health care deliv systems of mining and agriculture four forms of the virus. ery. Since the elderly are more or stepped-up migration within and Yet, a far more serious threat is prone to chronic ailments, most between countries due to social and that aedes albopictus could also countries are gearing up for higher political upheavals. How people become a transmitter of yellow expenditures and a different mix of live, their income level, and where fever. The region would then face health services. The high cost of they travel all are factors affecting the prospect of widespread infesta caring for the aged in developed the spread of malaria. Although a tion with a hardy, adaptable species nations, due partly to expensive vaccine may be in sight, the best not only carrying dengue viruses technology, has provoked alarm in near-term strategy is one based on between forest and city, but also developing countries. While these sound epidemiological methods, in introducing yellow fever into urban cost concerns are understandable, cluding the incorporation of now settlements. Mosquito control pro the social aspects of changing na separate malaria-control efforts grams need to be stepped up quick tional age profiles also need to be into general health services. The ly to definitively eradicate this pest considered. To get a better handle difficult question is how to do this before it spreads further and be on all aspects of the situation, the when general health services are comes even harder to control. Pan American Health Organization already overextended in areas is promoting collaborative research where the disease is most rampant. on the needs of the elderly in ten Drug resistance presents another AIDS nations of the region. However, all dilemma in malaria control. A By far the most important new countries in the region will have to number of strains are now resistant health problem confronting the make long-range policy decisions not only to the usual chloroquine, Americas is the far-flung occur about what services to provide, and but also to dehydrofolate reductase rence of acquired immunodeficien how best to care for those elderly inhibitors and even to potentating cy syndrome (AIDS) . In the United institutionalized for medical or so compounds of these with sul States, the patient population has cial reasons. The countries of the fanamides or sulphones. There been mostly homosexual and bisex Americas also have to address a fore, the search for new drugs or ual men, along with intravenous phenomenon occurring with in drug combinations has very high drug abusers. Certain Caribbean creasing frequency, that of elderly priority. countries have a disproportionately people burdened with the care of Dengue fever, another tenacious high incidence of cases. their very old parents. insect-borne disease, has increased One of the most alarming devel steadily over the past 20 years opments has been an increase of the Vector-borne -with no end in sight. In the great disease among heterosexuals in pandemic of 1977-80, approxi some countries, notably Brazil, ag diseases mately 700,000 people were af gravating the likelihood of a much A health problem dating back to flicted in the Caribbean, South and more rapid rate of transmission. Biblical times is that of insect-trans Central America, Mexico, and AIDS not only adds immeasurably mitted-or vector-borne-diseases. Texas. Cuba alone recorded to human suffering, but takes up Of these, malaria in particular has 340,000 cases in 1981, 24,000 of considerable medical resources in been a persistent plague which these developing the complications terms of patient care, public educa shows no signs of abating. Coun of dengue hemorrhagic fever (DHF) tion, and research. If current projec tries in the hemisphere accept that with 158 deaths. And in a more tions materialize and a commitment wiping out malaria in the foresee recent epidemic, Brazil reported is made to care for those afflicted able future is not feasible, and have 200,000 cases. A frightening spec until they die, AIDS will place opted instead for a strategy of con ter for the future is the combination another enormous strain on the tainment based on epidemiological of a high frequency of DHF with already overburdened and under approaches which examine people dengue shock syndrome, as has oc funded health systems of the in their environment over time in curred in Asia, with a consequent region. • 10 W oRLD HEALTH, Octo ber 1987 Water, Source of Life by Harst Otterstetter and Alberta Flares he International Drinking Wa Yet progress has been uneven be made. Making the best use of ter Supply and Sanitation De and, overall, less than anticipated, resources involves identifying areas 11 cade (1981-1990) represents a especially regarding sanitation. If of greatest need, cost reduction, worldwide thrust to extend drink the same rate of growth continues optimization of capacity, mobiliz ing water and sanitation services to for the rest of the Decade, member ing community participation, and the largest possible number of peo governments will not be able to matching technology to socio ple. This effort targets the popula reach their goals ; to do so would economic conditions. Likewise, wa tion most in need of these services, require providing drinking water ter and sewer agencies must be those living in urban slums and to some 58 million additional inspired to greater efficiency and rural areas. urban dwellers-most of them in effectiveness-for instance, control For the Americas, the Decade is low income areas-and sewerage to ling water leakage to allow exten the third in a series of major politi 61 million by 1990; in short, a sion of coverage to more people. cal accords designed to improve doubling of the efforts made during These are principles which have water and sanitary services in coun the first five years. Similar expan been acknowledged since the begin tries of the region. Following two sion would be required in rural ning of the Decade, but their im previous agreements-the Punta del areas. plementation has been slow and Este Charter, signed in Uruguay in sporadic. Continued population 1961, and the Special Meeting of growth and migration into cities Health Ministers of the Americas, will exert even more pressures to held in Santiago, Chile in 1972-the find appropriate solutions to chang nations of Latin America and the ing and growing needs. Caribbean made considerable pro Of particular concern are the gress toward expanding the scope 40 per cent of urban dwellers who of coverage and increasing national live in slums and who totally lack capacity on these fronts. These drinking water and sanitation ser achievements raised hopes for even vices, or must rely on rudimentary faster progress during the 1980s. facilities dangerous to health. These However, just before the period under-served urban areas are pre was about to get underway, severe cisely where recently arrived mig economic crises began undermining rants are adding disproportionately the ability of nations to fully realize to population pressures. In an effort their plans for the Decade. to address the serious health prob Member countries of the Pan lems of slum dwellers, the Pan American Health Organization American Health Organization, in have made important strides 1984, held a Regional Symposium nonetheless. During the first five on Potable Water Supply and Sani years of the Decade (1981-85), the tary Waste Disposal in Santiago, urban population with access to a A large proportion of urban dwellers Chile. This conference, part of the who live in slums Jack drinking water. water supply went from 186 million observance of the Decade, looked (83 per cent) in 1980 to 226 million PAHOIWHO Photo by Julio Vizcarra at institutional, economic, technical (86 per cent) in 1985, while those and social barriers to the provision covered by sewer and household An analysis of 1981-85 expendi of water and sanitary services to sanitary services rose from 132 mil tures provides clues to this relative urban shantytowns. The search for lion (59 per cent) to 156 million ly slow rate of advancement during solutions has highlighted the im (60 per cent). Similar progress was the period. To begin with, expendi portance of being willing to experi made in rural areas, where water tures came to an estimated ment with innovative practices. availability jumped from 40 per US $5,000-$7,300 million, or cent (49 million persons) to 45 per between 20 and 25 per cent of the Water and Sanitation, cent (55 million) and sanitary ser total anticipated. This means that vices reached the 15 per cent level. an additional $22,500 million (at Vital to Health In urban areas, these gains encom 1980 prices) would have to be spent Water and sanitation are basic passed a large factor of population to reach the goals set. Quite obvi human necessities, as well as funda growth, especially among low in ously, given current economic pres mental requirements of modern come persons living around the sures, these resources are very un life, especially in crowded living fringes-in keeping with the goals of likely to become fully available and conditions where residents may be the Decade. therefore adjustments will have to unaware of health ramifications. W oRLD HEALTH, October 1987 11 Water, Source of Life Nevertheless, for the guardians of projects is that of the "New Town" to bring water to these dwellings is the public interest, the main of Huaycan in Lima, Peru. a series of step-by-step improve rationale for such services is, and Lima is no exception to the popu ments based on simple, immediate always has been, public health. lation explosion sweeping the low ly available technology in keeping Water of sufficient quantity and income areas of Latin American with the socio-economic level of the quality for human consumption is a cities. Because of this, the Peruvian community. There are four stages recognized component of preven Government, in conjunction with of development planned for this tive health services, as well as of the Pan American Center of Sani- particular community in coopera- human well-being and life itself. The health impact of water and sewer services is further enhanced when these are combined with other programs, such as oral rehy dration and immunization. A number of nations of the Americas are taking a comprehen sive approach to health, bringing together water and sewer services, immunization, oral rehydration, education about sanitation and nut rition, and other measures to obtain the long-term, effective results that are the raison d'etre of all health services. Since health is a basic human right, access to health ser vices is also a right. The countries of the hemisphere are strengthening all primary health services to meet WHO's worldwide goal of "Health for all by the year 2000 " . Primary health services must therefore be tary Engineering and Environmen tion with the Water and Sewer viewed broadly as encompassing all tal Sciences (CEPIS)-part of the Department of Lima (SEDAPAL). processes and measures affecting environmental health program of In the first stage, water is distri health and quality of life. the Pan American Sanitary buted by tank trucks and stored in Community participation is also Bureau-identified a settlement metal drums or bottles next to or essential to the achievement of 17 kilometers outside of Lima as a inside each house. In the second health and includes water and good prospect for experimenting stage, the trucks, instead of making waste disposal, along with trash with cost-effective alternatives for deliveries door-to-door, deposit the removal, clean housing, and sani water supply, sewage disposal, and water in a storage tank constructed tary food handling. Community solid waste management in such for each communal living unit and participation, in the broadest sense areas. connected to a public faucet. The of the community simultaneously as third stage consists of individual agent and beneficiary of health ac water hook-ups, and the fourth tivities, requires the formulation Huaycan's Experience stage will see the installation of of health projects that are-from Unlike many unauthorized squat minimal sanitary services within their inception-culturally accept ters' settlements, this one has been each unit. able and financially feasible. Com recognized by the City of Lima, The first stage is being im munity participation necessarily en which has been encouraging devel plemented now, while some CLUs compasses the low income sector opment of innovative ways to meet have gone on to the second stage of which constitutes such a large seg the housing needs of the 19,620 building their own storage tanks. At ment of the urban populace. A families living there, specifically the same time, to free the communi previous tendency to ignore slum through creation of 327 communal ty from dependence on water deliv settlements is giving way to an · living units (CLUs) on some 400 ery trucks, SEDAPAL has con acceptance of their existence as a hectares (960 acres) designed for an tracted with a local firm to drill a socio-economic fact which must be eventual population of 110,000. well to be connected with storage addressed. Every CLU will accommodate 60 tanks and has engaged another firm Water services in urban slum families and will occupy a lot 90 to develop a complete drinking wa areas are usually quite costly to the meters square. Some 4,800 families ter project. user, while leaving much to be have already moved into completed · To improve water quality during desired in terms of supply and qual CLUs (now at two-thirds occupan the first phase of the plan, it was ity. A number of projects in the cy), most of them unemployed or considered advisable to chlorinate region have been designed to ad underemployed, which has allowed the water first in the tank trucks, dress these problems, taking local them to contribute considerable then again in the individual house contingencies into account. Among manuallabor to their own housing. hold drums. Since community par several successful demonstration The strategy proposed by CEPIS ticipation was recognized as essen- 12 W o RL D HEALTH, O ctobe r 1987 extent to which each stage of im provement in basic sanitation has been reflected in a reduction in the incidence of disease. Outlook for the Year 2000 No reversal of the trend toward increasing urbanization in the Americas appears in sight; the cities remain magnets for rural families. By the year 2000, 80 per cent of the population will live in cities, a large proportion in urban slums and in low income areas around the periphery. This situation cannot help but further aggravate the pre carious conditions of health, water, sanitation, and garbage removal services in such areas. Pollution of air, water, soil, and the whole envi ronment will create even greater challenges in the future to the creation of economically viable, healthy communities. Giving priori ty to low income areas is urgently needed to prevent or reduce these negative effects. Most importantly, the effort to mobilize the community on its Their achievements to date in In some Latin American slums water is own behalf involves citizen trucked in, left, while many cities, clude the following : education-especially among the above, have sophisticated water ser - Reduction in the incidence of young-to insure that proper health vices. diarrhea and other illnesses concepts become firmly grounded Left photo by Julio Vizca rra. above photo by Carlos caused by contaminated drinking and that people understand their Gaggero water and by the inadequate dis own essential contribution to the posal of sewage and solid waste. solution of environmental health - Active participation by the peo problems. This effort also needs to tial to reduce costs, CEPIS staff ple in the chlorination and re be tied in with institutional changes came up with the idea of giving chlorination of water, as well as which encourage active community householders small bags of pre in the construction of latrines and involvement. measured calcium hypochlorite to small sanitary landfills. Equally essential is the search for add to the truck tanks and to their new urban planning criteria which - Preparation of educational mate individual water drums, similar to can shape city development and the little bags of rehydrating salts rials for purposes of local instruc stimulate the necessary correlates tion and training of community for diarrhea with which they were of economic growth, and work to already familiar. Also, in collabora health advocates, who will be solve the problem of the uncontrol able to pass along basic informa tion with the Health Ministry, a led growth of urban slums. very simple calor-coded calibrator tion on sanitation to residents. The health sector has an indis was developed which housewives - Formation of school-based youth pensable role to play in this whole were taught to use to detect re brigades to transmit sanitation process. Agencies charged with re sidual chlorine before adding new education and stimulate support sponsibility for health and sanita bags of chemicals to their water and participation by local lead tion must be able to anticipate the supply. ers, family heads, and students in impact of urban development and The team brought together by the basic sanitation programs of guide it toward health improve CEPIS to develop the basic sanita the community. ment. Standards need to be e~tab tion program consists of an en Community participation has lished to govern daily life and to gineer from the Health Ministry and been a key element in the success bring the vision of "Health for all one from SEDAP AL, a physician achieved so far; however, this par by the year 2000" to full fruition, specializing in disease control, a ticipation has never been automa especially among low income citi social welfare aide, _students of sani tic. Instead, it has had to be nur zens. As the year 2000 draws near, tary engineering and social sci tured through patient teaching and health must go beyond mere plan ences, and eight sanitary technol motivation. The program continues ning and strategizing to become a ogists working directly with the in operation and is in the process of palpable reality for the people of community. developing an evaluation of the the Americas and of the world. • W oRLD HEALTH, October 1987 13 Children of Latin America and the Caribbean by Dr Eisa M. Moreno, Dr Nestor Suarez Ojeda and Dr Ciro de Ouadros ithin the Western Hemi sphere live more than 200 Wmillion children and adoles cents afflicted with a variety of health problems. Significantly, these problems are always related to some aspect of underdevelop ment deriving from one or more of the following: - unequal distribution of income; - accelerated population growth, especially in the poorest areas ; - large-scale voluntary and in voluntary migration from rural areas to the cities. The interaction of these factors has led to a result appalling beyond any doubt: the deaths of more than a million children under five occur annually in the region; deaths which, in many instances are due to perfectly preventable illnesses-a cost in lives which could be sub stantially reduced through tested strategies and technological appli cations. The experience of the last few decades with the development of high efficiency and low cost tech nology clearly demonstrates that health care's ability to reduce child hood deaths has grown accordingly. The efficacy of health interventions in this area has held up across differences in social strata and levels of development. Through optimum application of health ser vices, several countries of the re gion have been able to reduce in fant mortality to less than 20 per thousand over the past ten years, a dramatic decrease, especially given the lack of a significant rise in per capita income during the period. Mortality Rates for Young Children Childhood deaths in Latin Ameri ca and the Caribbean have plunged 14 W oRLD HEALTH, October 1987 over the last decade, but are still geographic areas where mortality is structure of morbidity/mortality excessive in comparison to more higher than that. seems to be a trend in most coun advanced countries. Children's Children of illiterate mothers tries and should be taken into mortality rates vary considerably face a risk of death five times that account in any reorganization of among countries. In 1984, for ex of children whose mothers have services. ample, infant mortality ranged from completed at least five years of 15 per thousand live births in Cuba formal education. to 117 per thousand in Haiti. In most countries of Latin Ameri Strategies for Change Among one- to four-year-olds, ca and the Caribbean, the main According to current estimates, Bolivia registered a mortality rate causes of deaths of young children some 60 million children lack access of 23 per thousand compared with are birth problems, diarrhea, acute to basic health services and, if this only one per thousand in Costa respiratory infection, and infectious situation continues unchecked, Rica, Cuba, Panama, and Trinidad diseases subject to vaccination. these numbers could reach 100 mil and Tobago, equivalent to the rate Malnutrition underlies many pre lion by the year 2000. This prospect · in the United States. These differ ventable deaths, although it is rare indicates the need for a fundamen ences occur not only between coun ly recorded on death certificates. tal change in health care delivery tries, but also between different Typically, countries with high rates and in the orientation of providers. areas and localities of the same of infant mortality, such as Clear policy direction is needed to country. Guatemala and Honduras, show pull together efforts within and be diarrhea as the principle cause, tween disciplines and to promote while those with low rates, such as the active participation of families The Risk Factors Chile and Cuba, have birth defects and communities in the improve If all the countries of the region in first place. This change in the ment of their own welfare. could achieve, as some already Expanding coverage no longer have, infant mortality rates of 20 means the classical solution of set per thousand, then more than It is estimated that 60 million children ting up more physical plants to 500,000 children under one year of lack access to basic health services. But await the arrival of patients. age could be saved annually. Al primary health care reaches out to Rather, the only acceptable avenue though most countries have these young Peruvian children, left, now is to recognize the communi reached infant mortality rates be and this Costa Rican volunteer, below, ty's key role and the impact of in a community improvement project. low 50, more than 60 per cent of popular mobilization as the last Latin American children live in PAHOIWHO Photos by Julio Vizcarra stage of a decentralization process empowering decision making and problem solving at the primary care level. That is why, in the Americas, primary health care has become an action strategy and the leaven for change throughout the health sys tem as a whole. The growing, developing young child always belongs to a given family and a given nation. Improv ing health conditions for the chil dren of the Americas depends on a process of identifying priority prob lems and searching for solutions through the combined efforts of individuals, families, and neighbor hood organizations. Innovative Approaches All countries in the region recog nize that improving the quality of life for the children of the Americas requires mobilization of a wide range of resources. The health sector lacks sufficient funds and staff to do the job alone. Meeting the challenge of Health for All by the Year 2000 requires talents and resources from many sources, in cluding international agencies, non governmental organizations, and Continued on page 18 W oRLo HEALTH . October 1987 15 Children of Latin America and the Caribbean national institutions outside the International Rotary Club has the Italian Government, and USAID health field. raised its contribution to the world have promised additional financial As important as resource mobili wide Expanded Program of Im support amounting to $39,582,100 zation is, it is not enough by itself. munization to $23 million so far, for a five-year period; on the other, A more comprehensive form of assigning a large portion to the PAHO, UNICEF, and the Institute of mobilization is now gaining Americas. UNICEF is continuing its Nutrition of Central America and momentum; this is social mobiliza support, which is now in the order Panama have improved collabora tion, which involves calling on all of $12 million. tion by augmenting technical coop sectors of society to work toward In order to coordinate this whole eration capacity and strengthening common goals. For instance, in effort, the Pan American Health the exchange of experts and tech stead of being passive consumers of Organization (PAHO) has formed an nologies among countries of the health services on behalf of their Interagency Coordinating Commit region. children, parents are being encour tee representing each of the above With the participation of all the aged to actively seek care, to par mentioned agencies, along with governments and agencies included ticipate in carrying it out, and to PAHO itself and the Task force for in the Health Plari, a Technical pass along the word to their neigh Child Survival, a group which Coordination Committee was hors. In addition, modest instruc meets periodically to review pro formed to supervise health ac tional materials are being produced grams and coordinate the effective tivities in the region and assure the for the general public to enable use of resources. complementarity of national pro educational, charitable, and religi Another application of these grams. A total of 39 projects have ous enterprises to disseminate in strategies and approaches can be been developed, 38 of them nation formation about major childhood found in the Child Survival Pro al and one subregional. Each coun illnesses and preventive measures gram within the Health Plan for try has also formulated its own (vaccination, oral rehydration, Central America and Panama, Child Survival Integrated Plan, prompt treatment of acute respirat " Bridge for Peace " . The plan was which not only covers additionally ory infections, influences on growth originally conceived as a consensus funded activities, but encompasses and development). The mass media project, intented to promote dia all national-level measures of ma are lending their support, with logue among heads of state and ternal and child health, such as magazines and newspapers making among countries diametrically op personnel training, technical man health-related announcements and posed ideologically to the point of agement, critical inputs, informa recruiting volunteers from all social military confrontation. In a region tion systems development, and strata. In this way, many talents and convulsed by armed struggles, health services evaluation. resources are brought together. political violence, and forced migra The most important activity so tion, the theme of health care far has been immunization. Four A Hemisphere priorities still had sufficient pulling countries-Guatemala, Honduras, power to bring together top health Nicaragua, and El Salvador-spon freed from Polio authorities from seven countries of sored two to three campaigns of These new approaches have spe the Central American isthmus, who one or two days each, Belize held cial meaning in relation to a goal together designed national and sub three five-week campaigns, and adopted by all the governments of regional programs aimed at improv Panama and Costa Rica zeroed in the hemisphere in May of 1985 : to ing health and living conditions for on local areas of least coverage, eradicate the natural transmission their 25 million inhabitants. In this while promoting immunization of the polio virus by 1990 in the overall plan, measures for child sur among the population as a whole. whole hemisphere. Between 1969 vival and maternal and child health All the countries have achieved and 1977, the average number of held special prominence. It was rec significant progress in terms of vac polio cases in the Americas reached ognized that children are highly cination coverage, especially Be ~ 4,000 per year. Since 1980, this vulnerable due to their social and lize, Guatemala, and El Salvador. figure has fallen to 1,000. The physical dependence, especially in Nevertheless, 33 cases of polio number of countries recording any an area undergoing such economic were reported in Guatemala, 15 in cases at all fell from 19 in 1975 to and political upheavals as Central El Salvador, and 4 in Honduras. 13 in 1986. Encouraged by this America. The health situation of As for oral rehydration therapy, progress, but aware that greater children in the region has been all the countries make oral rehydra efforts would be needed to reduce identified as a most pressing prob tion salts available. About 7.3 mil the incidence to zero, the coun lem, not just because of the mag lion envelopes of salts were distri tries of the region agreed on the nitude represented by more than a buted through health services. In El common goal of eradicating polio million children under five who die Salvador, this program was ex completely. annually, but because so many of tended through 1986. The main At the international level, a these deaths could have been pre problem in Guatemala has proved number of organizations have vented by available technology. to be an insufficient supply of salts. joined in the battle. The United This initiative was very successful Two countries produce their own States Agency for International De in mobilizing international re salts, Costa Rica and Honduras, and velopment (usAm) has committed sources and promoting the com two more will begin production in US $20 million to the effort, the bined efforts of technical coopera 1987. All children's hospitals and Inter-American Development Bank tion entities. On the one hand, the university pediatric departments has pledged $5 .5 million, and the European Economic Community, use oral rehydration units in train- 18 W oRLD HEALTH, October 1987 Innovative approaches are needed to bring health services to children such as these residents of a refugee camp in Central America. PAHO/WHO Photo by Carlos Gaggero ing medical, nursing, and graduate pediatric students. The control of acute respiratory infections was another effort initi ated by PAHO/WHO between 1984 and 1985 in nearly all the countries. During 1986, progress was achieved in rev1Slng and dis seminating technical standards, the training of medical and auxiliary personnel, and the production of educational materials. Five coun tries have established programs for control of acute respiratory infec tions in one or two health regions. Lack of antibiotics has been the major obstacle to carrying out this program. In the area of breast-feeding, all the countries have national commit tees working in conjunction with other institutions outside the health arena. All have completed surveys on breast-feeding over the last two or three years, either nationally or in particular geographic areas. This will serve as the basis for a follow up evaluation of trends in infant nursing in each country. All the countries have mothers' milk banks available for ill and low birth weight newborn babies. The area of growth and develop ment presents difficulties in terms of the ability of existing statistical systems to monitor what is being provided. All countries use height and weight growth curves to evalu ate nutritional status. In two coun tries, Costa Rica and El Salvador, the health identity card given to the mother shows the growth curve. While it would be premature to judge the impact of these interven tions, they do seem to represent an increased effort to control and pro tect children's health. The theme has also been adopted by the mass media, with the result that families are beginning to express greater concern for the optimal growth and development of their children. Without any doubt, the Health Priorities Plan for Central America and Panama, as well as the Bridge for Peace, represent a significant policy commitment to the survival and improvement of the quality of life for all of Central America's children. • W oRLD HEALTH, October 1987 19 Disaster Preparedness in the Americas by Dr Claude de Ville de Goyet eventeen years ago, a power ful earthquake killed 66,000 people in Peru. In 1972, just two days before Christmas, 10,000 Nicaraguans lost their lives under similar circumstances. Then in Feb ruary, 1976, another devastating temblor left 23,000 dead in Guatemala. The Guatemalan quake, no less than the others, brought a realiza tion that natural disasters posed a continuous threat to the region. This led member governments of the Pan American Health Organiza tion (PAHO)-which serves as WHO's regional office for the Americas-to ask the Director to establish a spe cial unit at the Washington, DC, headquarters. Called the Emergen Rescuers search for survivors among cy Preparedness and Disaster Relief the rubble of a Mexico City hospital, Coordination Program, this unit above, while patients being evacuated, was charged with a variety of re below, point up the need for adequate sponsibilities, including preparing hospital emergency preparedness. guidelines, formulating plans of ac PAHO/WHO Photos by Julio Vizcarra tion, training emergency personnel, and establishing effective coordina gram. This is accomplished by as tion among non-governmental and suring the existence and vitality of a international agencies. national emergency preparedness Today, more than ten years later, program in the health sector of each the Americas' vulnerability to member country. To meet differing natural disasters is as great as ever. needs and priorities among coun ments develop preparedness sur The last two years alone attest to tries, the PAHO program offers a veys of key hospitals, increase per. this. Major earthquakes have occur variety of approaches : technical as sonnel training, and factor local red in Chile, Ecuador, Mexico, and sistance in formulating national dis earthquake and hurricane prob El Salvador. Colombia's snow-cap aster plans, support for multidisci abilities into the early planning and ped Nevado del Ruiz volcano plinary workshops at national and design phases of hospital construc erupted violently, killing more than local levels, promotion of close tion. Wherever possible, educa 23,000 and almost completely cooperation between the ministry tional materials and training pro burying the city of Armero under of health and other organizations, grams are formulated to be passed volcanic mudflows and tumultuous and training and fellowships for along, thus multiplying their im streams of debris and ash. Although health leaders. Special emphasis is pact. The availability of publica less widely publicized, slow-onset placed on sharing examples of suc tions and audiovisual programs disasters such as floods .periodically cessful programs from around the covering all types of disaster and hit many parts of South America world. issue promotes a common philoso and the Caribbean. Within the limits of human and phy and approach to disaster man material resources, national health agement in the region. services must be ready to respond Emergency Preparedness appropriately to mass casualties, Rapid and effective response to both at the scene of a disaster and in Relief Coordination post-disaster health problems is a hospitals where victims are cared The second prong of the PAHO major goal of PAHO's disaster pro- for. PAHO helps member govern- program is coordination of the re- 20 W oRLD HEALTH, October 1987 Volcanic mudflows left more than 23,000 persons dead in Armero, Co lombia, above, with rescue by air, right, the only way out for survivors. PAHOIWHO Photos by Julio Vizca rra lief that usually pours into an af fected country in the wake of a disaster. Thanks to modern com munications, word of global tragedies often reaches the interna tional community within minutes and, in just a matter of hours, relief is on its way. This generous out cines-all generally unneeded or Governments and private organi pouring can be of immense benefit actually counterproductive. zations should consult their own to a disaster-stricken country as - Developed countries increasingly country's disaster relief experts, the long as it meets real needs. But airlift emergency response teams ministry of health of the affected charity can quickly become a bur to disaster sites, but usually too country, or PAHO/WHO before send den when it is unsolicited and based late to save lives. They end up ing off any supplies or personnel. on false perceptions. vying with each other and local Common pitfalls to avoid are ex Although diverse strands contri personnel for visibility, meaning cess donations of food and clothing, bute to international aid problems, well but only adding to the unneeded blood and plasma, vac some common patterns are evident confusion. cines to combat imaginary ep the world over. How can the requirements of a idemics, and field hospitals and - Competition among donor coun disaster-stricken country be better medical teams which often arrive in tries eager to be "first" in re matched with international con time for good public relations but sponding to an emergency may tributions? Correct information is too late for emergency relief. mean that inappropriate assist obviously a key to proper emergen Individuals who want to assist ance arrives before needs have cy management and precious time should consult their national health even been identified. spent gathering and disseminating authorities, the Red Cross, or the - Disaster publicity fanned by the facts is not wasted. Unfortu P AHO/WHO office in their own coun media overemphasis often results nately, political expediency and try. They should not travel to the in the wholesale dispatching of public pressure may lead donors to location of a disaster until they mobile hospitals, medical person jump the gun before a situation can have made sure they will be useful nel, and drugs, blood, and vac- be properly assessed. and welcome. Finally, they should WoRLD HEALTH, October 1987 21 than one dose and several weeks to become fully operative. Emergency mass vaccinations are wasteful of money and manpower, benefiting the politicians who advocate them while lulling the populace into a false sense of security. The affected population and local authorities are too shocked and helpless to take responsibility for their own survival. Disaster sur vivors are not necessarily depen dent or immobilized. Many find new strength during an emergency, as evidenced by the thousands of volunteers who spontaneously un ited to sift through the rubble in search of victims after the 1985 Mexico City earthquake. And most Latin American countries have sophisticated and farflung health services, plus a good supply of physicians. Natural disasters create severe food shortages. This is not so, yet the belief is so common that it has led to many post-disaster food gluts. Earthquakes, for instance, usually have little immediate im pact on food supply. Food relief decisions always should be made with care, since food distribution relies on transport and personnel perhaps better deployed elsewhere. Everything is needed and needed now! Again, the haste-makes-waste mentality spawned by many catas trophes may produce assistance that harms more than it helps, thereby aggravating disorder and contributing to a secondary disas ter. Foreign medical personnel ar Unsolicited pharmaceuticals such as What are some of the persistent riving too late for emergency help those in a Mexican warehouse must be myths behind well-meaning but must still be met, housed, oriented, sorted, classified and labeled, diverting misguided disaster efforts? and provided with interpreters. health personnel from more pressing An accumulation of dead bodies Similarly, unsolicited pharmaceuti tasks. PAHO/WHO Photo by Julio Vizcarra will lead to catastrophic outbreaks cals take up needed space and must of exotic communicable diseases. be sorted, classified, and labeled, Indeed, it has been common for thus diverting health personnel consider giving cash-the most flex self-appointed experts to predict from more pressing tasks. Yet, there ible and versatile form of assistan more deaths from these secondary are many instances of genuine ce-through a reputable agency. A epidemics than from the original assistance whose common de good rule of thumb for the donor is : calamity. This is simply not the nominator is response to needs offer the same type of help you case. Human bodies, especially clearly identified by national health would like your own community to when buried under a landslide or authorities. receive in the event of a disaster. earthquake debris, pose no particu When it comes to disaster lar threat of disease. The problem is -whether natural or man-made-all Dispelling one of fear, not of actual danger. nations are at risk. Many national Mass vaccination is required after health systems have recognized Common Myths a disaster. Improvised vaccination that emergency preparedness must Inappropriate disaster responses campaigns are inadvisable for a be an ongoing process of testing, are based on misconceptions widely number of reasons. Many vaccines, critiquing, and updating. Mean held by the public, as well as some such as that for typhoid, are not while, PAHO's disaster unit stands people in the scientific community, very effective in last-minute appli by, supporting measures to prepare and perpetuated by the media. cation because they require more for tomorrow's disasters today. • 22 W oRLD HEALTH, October 1987 Health Services for All by Dr Jorge Osuna he evolution of systems to al health services and the rest to PAHO/WHO for the 1973-77 period, provide health services to the benefits for illness, retirement, and approved by the XVIII Pan Ameri 11 countries of the region has death. can Sanitary Conference. This sys reflected the processes of economic Meanwhile, health ministers cre tem differentiates problems directly and social development experi ated ever more complex organiza related to health from those of enced by national societies from the tions to both regulate and carry quality, quantity, and organization time of the 15th century discovery out massive campaigns against of resources and of methods and to the present day. During the epidemics rampant in local areas procedures to improve health. The European conquest, the first hospi and programs to deal with collec former are grouped under the title tals sprang up to meet the military tive health problems, while also of personal health services and en needs of the conquerors; later, as providing-in varying degrees compass maternal and child health, colonies, almost all the countries set -public medical care. The rapid nutrition, treatment of infectious up public aid hospitals to care for acceptance of a broad concept of and chronic diseases, and anything indigents. During this period, in health as a fundamental human regarding the environment. The lat tandem with the establishment of right and a basic function of the ter fall under the rubric of infra services, came the founding of reg state was reflected in the name structure development and include ulatory bodies and of medical train change made by many ministries human, technical, and auxiliary re ing centers allied from the begin which went from being "Public sources; the processes of adminis ning with the universities that blos Health Ministries" to merely tration, planning, evaluation, and somed in the colonial capitals. "Health Ministries". information; legislation and regula About the end of the nineteenth tion; basic and applied research; century, along with independence and financing. and national governments, national The World Health Assembly of health departments began appear 1977 determined that all member ing, frequently as part of ministries governments should have as their of the interior. These departments, primary goal to achieve by the year which were designated differently 2000, a level of health that would in different countries, were con allow their citizens to enjoy an cerned above all with protecting economically and socially produc foreign commerce by controlling tive life. The goal is now known as "quarantinable illnesses" through "Health for All by the Year 2000" health campaigns quarried out (HFA/2000). primarily in the main seaports. Na The 1978 declaration of Alma tional health departments rose to Ata identified primary health care the ministerial level in most Latin as the avenue for achieving these American countries during the objectives within a framework of 1930s and 1940s, with the early general development and in a spirit exceptions of Cuba, 1907, and of social justice. In 1980, the gov Chile, 1924. ernments of the region agreed, This period also saw the emer through the XXVII PAHO Advisory gence of mandatory social security Human resources: A nurse cares for a Board, on the strategies and re programs, which now play such a sick child. gional objectives of HFA/2000. crucial role in the region. In succes PAHO/WHO Photo by Julio Vizcarra Since then, important efforts have sion, such programs were adopted taken place to restructure health by Chile in 1925, Brazil in 1934, In 1972, at the Ill Special Meet systems and activities to meet the Ecuador in 1935, Peru in 1936, ing of Health Ministers of the proposed goals and objectives. Venezuela in 1940, Costa Rica and Americas, held in Santiago, Chile, The concept of primary health Panama in 1941, Mexico in 1942, the countries of the region collec care as an integral health strategy Paraguay in 1943, Argentina in tively adopted the Ten Year Health that encompasses and affects the 1944, Colombia and Guatemala in Plan for the Americas, in which an whole population and the health 1946, the Dominican Republic in "operative nomenclature" was system at all levels is expressed in 1947, and Bolivia and El Salvador proposed, along with the setting of the following statement from a in 1949. Since their establishment, priorities, budget allocations, and document on regional strategies : social security programs have de the performance of specific ac " Once it is accepted that the goal is voted approximately 50 per cent of tivities. These were contained in the reduction of inequalities among their resources to financing person- General Programme of Work for countries and among human W oRLD HEALTH. October 1987 23 Health Services for All groups, this strategy should be con I have said was formulated in San cent private. When the current sidered valid and applicable to the tiago, Chile in 1972. In general, number of beds per thousand in population as a whole and not re member countries made important habitants is compared with the stricted to backward or marginal strides in expanding basic health 1970-72 period, a reduction has groups, although satisfying the services · and organizing them ac occurred overall, attributable for basic needs of the latter is still one cording to the size and concentra the most part to population growth of the primary objectives. It is not tion of population groups. Informa with which hospital physical plants possible to conceive of basic health tion available at the beginning of have been unable to keep up, given care as a program limited in any the decade gave rise to assumptions the costs involved. In North Ameri way to meeting only the minimum that people living in settlements of ca and some Caribbean countries, a needs of those who live in extreme more than 2,000 inhabitants had general upgrading of living stan poverty." relatively satisfactory coverage. dards and shifts in health service In the process of reforming health Consequently, the main efforts delivery, mostly to outpatient care, systems to meet the goals of HF AI were directed toward improving have reduced the need for hospital 2000, countries are facing the need beds. to make substantive changes to sol Within the general context of ve two problems common to exist health service systems develop ing health systems in the region. ment, all the countries emphasize First, the systems are already inade strengthening diagnostic support quate to meet the growing demands services, such as laboratory and of a large proportion of the popula radiology. The enormous tech tion and, second, such systems tend nological expansion in these fields to be inefficient in their use of the over the last few years has meant very limited resources available. considerable cost increases for med In terms of lack of resources, it ical care, which has further cut into has been estimated that nearly one the chances of extending the be third of the population of Latin nefits of complete care to the popu America and the Caribbean enjoy lation as a whole. no regular access to health services. Satisfying the needs of marginal groups There is an increasing trend in the That means about 130 million peo is vital. region towards establishing nation ple in the region are still without PAHOIWHO Photo by Julio Vizcarra al laboratory networks based on health coverage. To this uncovered high-quality, simplified technology population would have to be added the organization of health service to support various health activities projections from now until the end systems and increasing the number in the war against infectious dis of the century totalling another 160 of units devoted to primary care in eases. These national laboratory to 170 million persons. Thus, over health locations and centers, systems have proved most success the next 13 years, Health for All primarily in rural areas where they ful where they have been tied in presents a serious challenge to would be tied together by a referral with an already existing central achieve what countries in the re system. Thus, the population gained laboratory which sets standards, gion have never been able to access to more complex facilities trains staff, provides supervision, achieve since the discovery of hospitals and specialized cen and maintains and repairs equip America. Other dimensions are ters-generally available only in the ment. In radiology, the main con added by the aging of the popula cities. cerns have been to bring basic diag tion, the population concentrated in This trend is reflected in the con nostic systems to rural and urban urban areas, and the growing adop siderable growth of outpatient slum areas, provide backup for tion of patterns of health service clinics, estimated at 64,000 in Latin diagnosic and therapeutic radiology consumption common to developed America and the Caribbean in referrals, develop human resources, countries and more favored classes, 1983. Even though there is no up reduce equipment costs through use which further increase health costs. to-date information on the geo of simple, good quality technology, Of the almost US $40,000 million graphic distribution of these and establish national systems for spent annually for health services in facilities or of their relation to protection against radiation. Latin America and the Caribbean, it population distribution, it is esti Another area of concern for all can be fairly estimated that 25 per mated that increasing availability of the countries is the availability of cent is wasteful in cost-benefit this type of facility has helped in medicines needed for the adequate terms. At the same time, the health crease coverage principally in terms treatment of health problems. In a system suffers from chronic man of the care of mothers and children dizzying upward spiral, total phar agerial deficiencies causing losses and of educational activities and maceutical expenditures in Latin whose true dimensions are un environmental health programs America and the Caribbean have known, but which certainly contri geared to families and to outlying risen to more than $5,100 million bute to overall inefficiency. rural communities. As for the avail annually. Yet there is still consider Expansion of health service ability of facilities for more compli able disparity between the avail coverage to unserved or under cated care, estimates are that, as of ability and cost of basic drugs and served populations was the princi 1983, there were 22,493 hospital the abundant supply of specialized pal goal of the Ten Year Health facilities in the region, of which drugs for the urban population of Plan for the Americas, which as 45 per cent were public and 55 per means with access to private care. 24 W oRLD HEALTH, O ctober 1987 There is limited access to basic Implementing efficacious me health professionals, and voluntary medications for all the people under thods of planning, administration, organizations. Besides contributing equitable conditions. and evaluation of health services to national health insurance, the Countries are also confronted opens up a third important avenue federal government plays a leader with the need to carry out policies for health improvement. All the ship role in public health, promot and programs to increase service countries have shown a renewed ing and financing research and the networks in geographic areas not interest in decentralization, since adoption of healthy lifestyles. Pro currently being served and, at the experience indicates that too much vincial governments are in charge same time, to upgrade their centralization and lack of local par of health service delivery, including methods of organization, financing, ticipation contributes to inadequate organization, administration, and and administration to make a service. The establishment and financing of public health activities. reasonable effort to reach the goals strengthening of local health sys Provinces sometimes delegate some of Health for All. Genuine oppor tems serving a given population in a of these functions to local and re tunities to expand service networks defined geographic area offer a gional governments or they may are seriously hampered by the se clear example for the re-design and provide direct service, usually on a vere economic conditions affecting reform of the health system at all regional basis. Professional groups -to a greater or lesser degree-all administrative and care levels. At have played an essential role in the the countries of the region. Conse the same time, the efficient opera design of the national health insur quently, efforts are aimed primarily tion of local health systems is essen ance system and in the implementa at improving the maintenance of tial for bringing resources together tion of standards. installations and of equipment and to improve utilization and assure An outstanding aspect of the making prudent investments to re wholehearted community participa Canadian system is National Health novate and modernize existing tion by creating empowering instru Insurance which·covers medical and facilities to meet pressing needs. ments and channels of expression, hospital services for all the people, Modest efforts are being made to including such activities as educa under shared financing between replace deteriorated facilities which tion, information, dissemination, federal and provincial govern have become totally inadequate. social organization, interdiscipli ments. Community participation The improvement of health sys nary coordination, and adoption of has been the rule ever since munici tems represents an extraordinarily new styles of decision making. pal health advisory bodies were complex task which cannot be put organized to control epidemics at off any longer because of the pro the end of the last century. Today gressive accumulation of "social Better Services community participation is express debt" and the poor utilization of In the United States, there has ed through various mechanisms ex available resources. Almost all the been extraordinary growth in the tending from the local level all the countries of the region are looking health sector through the expansion way to Parliament. The organiza into three main strategies. and improvement of hospital ser tion of the health system has shown First, there is the search for new vices, increasing availability of satisfactory results in terms not ways of inter-connecting health sec health insurance and pre-paid only of the care provided, but also tor institutions and of meshing the plans, greater access to care by new in its democratic and equitable form goals and operations of each institu population groups, and substantial of delivery. Among future needs of tion with overall policy and nation ly improved information systems. the system, some of the most im al objectives. This is where the idea Nevertheless, the problems of rising portant are strengthening inter of health ministries comes in, taking costs and rational resource alloca disciplinary cooperation, increasing on the broad task of guiding, lead tion remain. Because social organi training on critical aspects of health ing, and mobilizing national and zation and economic development policy at the user and provider international resources and analyz in the United States favor private level, and targeting resources to ing progress toward the goals of sector activity, open competition areas of greatest need. HFA/2000. and decentralized government reg Within this broad context, the Second, all the countries have ulation, the new health service ap cooperation of PAHO/WHO with tried hard to offer better alterna proach of the country can be member governments is expressed tives for service financing to permit characterized as a strategy of de in joint activities designed to im better and fuller health coverage, centralized intervention. This re prove individual and collective including equitable access by all quires state and local participation understanding of the health field people to the level of care required in comprehensive health planning, and trends, promoting and facilitat by each case and elimination of revision of standards of hospital ing the exchange of experiences unnecessary procedures that raise care, development of measures to regarding the development of na costs and contribute nothing to sol prevent duplication of facilities, tional health policies, improving in ving real health problems. As part promotion of pre-paid systems as formation and techniques for basic of this strategy, the countries are an alternative to conventional pay health services, supporting training developing projects to improve ment practices, and creation of new and instruction, administering staff staff utilization and to rationalize planning entities at local, regional, resources, supplying information the use of health technology, espe and state levels. and data on the health technology cially where it can reduce costs The Canadian health system is a process, and strengthening analysis in terms of either service or product of a long tradition of co of economic/financial processes im equipment. operation between government, pacting on health development. • W oRLD HEALTH, October 1987 25 The Challenges Ahead by Dr Carlyle Guerra de Macedo dozen peasants file in proces · Americas, remind us of another ing the health needs of tens of sion along the side of a dirt challenge we face daily: how to millions of people now lacking road in a country in the avoid the tendency to intellec those services and, as if this were Americas. One of the men carries a tualize and distance ourselves from not complex enough, of the millions small, crude coffin on his shoulder. what can be a day-in and day-out of new people who will be added It holds the remains of one of more bitter fight for life, for health, and this century. The magnitude of this than 700,000 persons, mostly chil dren, who die annually from com pletely preventable causes. This sad, grim scene, which is repeated a thousand times a day, provides a searing commentary on poverty and is a tragedy that offers a pro found challenge. In still another country, health workers hold a sit-in at health cen ters and hospitals, seeking higher salaries and more fringe benefits. Here we get a glimpse of the conse quences of the. financial and economic crisis Latin America is currently undergoing and of the failures in health systems' operation and leadership. We are also re minded that the challenges we face sometimes have their roots in our own backyard. In a third country in the hemi sphere, health professionals spend their days rushing from one job to A health worker checking blood another. We see them in a mad race pressure, above, and a rural medical that doesn't let them ·carry out any team making its rounds by boat, below, of their multiple functions with the illustrate the consensus view that degree of professionalism their pa health is the fundamental right of every tients deserve and which their self human being. respect · demands. This rushing PAHO/WHO Photos by Julio Vizca rra around doesn't afford them the ele vated socio-economic status that some believed would be their di for justice in our continent. We vine right after graduation from must be clearly aware that if we do medical school. They find them not address the practical goal of selves in a constant struggle to changing and improving the bitter maintain a modicum of dignity in an realities that many of our people urban environment super-saturated live, then we are part of the prob with health professionals and with lem, not of the solution. specialties that neither the popula The Americas in general and the tion nor the institutions can even field of public health in particular afford. What can be done about this will face serious challenges in the poor use and unequal distribution remainder of this century and for of such valuable resources? Here is the years to come. These challenges another challenge which the health are both quantitative and qualita field must face in the years and tive in nature. challenge is evident when we con decades to come. The quantitative challenge in sider that historically, in Latin These familiar vignettes, well volves the extraordinary effort of America and the Caribbean, ·health known to all those involved in the making real the global and regional services have reached the point of everyday struggle for health in the strategies of Health for All, satisfy- providing · coverage for about 26 W oRLD HEALTH , October 1987 270 million persons. The 135 mil Health services must be prepared mary health care: equity, universal lion people who live in extreme to deal with a population in which cov~rage, participation, and effi poverty do not have regular access the proportion of elderly persons is ciency. Extreme poverty and the to health services, and it is esti increasing each year, and which is disparities in access to health ser mated that another 160 million per becoming increasingly urbanized, vices among different social groups sons will be added by the year both geographically and culturally. must be reduced. Health services 2000. In other words, we must The needs which the health services must be reoriented to allow each provide services that will cover 300 must fill will be more complex, and individual to live a socially and million persons in addition to the the demands greater. Dealing with economically productive life. The 270 million already covered. Sim this situation under optimum condi need for community participation ply stated, in the next 13 years we tions would already represent a in health goes beyond the use of must create, organize and set in notable effort; dealing with it under community members as workers in .motion health services that will current conditions, in which the health campaigns and programs, to double the coverage of what we external debt crisis demands that involve the community in decision have been able to reach today. countries devote 30 to 50 per cent making and control of activities. of their export earnings to pay only Efficiency demands that we halt the the interest on their debt, leads waste in health systems of Latin inexorably to the search for new America and the Caribbean, which approaches. is estimated at 10,000 million US We can only face these chal dollars. This waste involves the un lenges if we initiate a process of coordinated and duplicative ser profound change, which must be vices offered by different institu promoted in each of the countries tions, delays in decision making, of the Region of the Americas. The organizational deficiencies, the use health systems and their relation of inappropriate technologies, and with the social, economic, and polit the idleness of costly equipment ical environment in which they op rendered ineffective because of lack erate must change. This need is of maintenance. There is also ineffi obvious since, if current approaches ciency in the recruitment and man agement of personnel with obso lete, feudal attitudes which gener The caring hands of health workers, left ate underground resistance or open and below, demonstrate the unifying confrontation. The values and prin potential of health among all peoples. ciples outlined in the goal of Health PAHO/WHO Photos by Julio Vizcarra for All are just as pertinent, if not more so, than when they were ap proved a decade ago. In order for health services to be in accord with those values, there must be a revision in the way health is integrated into socio-economic development. Health can and must change its role and image as a "non-productive" sector, tolerated and given resources for pragmatic political reasons, for reasons of charity or philanthropy, or as a result of trade union pressures. We must be able to show the positive social, economic and political reper cussions that a tangible improve \ ment in health conditions can bring. t Societies, governments, and indi viduals cannot avoid the question of how to reshape the processes of . socio-economic development ac cording to new models. As the twentieth century lurches fitfully The qualitative challenge is a re and trends continue, they will toward a close, the models of devel flection ofthe changes now occur guarantee a disaster with incalcul opment which have been debated ring in Latin America and the able repercussions. It is indispens and put into practice over the last Caribbean in social and economic able that health services be or 150 years are beginning to show terms ; in terms of the ecology ; and ganized and administered in ac clear signs of weakness, fatigue, in terms of the patterns of morbidi cordance with the principles and and even obsolescence. Theoretical ty and mortality. values of Health for All and pri- orthodoxy, when applied to the W oRLD HEALTH, October 1987 27 The Challenges Ahead infinitely complex variables of hu to all political and social sectors of reiterate new concepts and values, man living, has propelled govern each country. This message is that and to revive others that have been ments, societies, and individuals to health is the concern of everyone forgotten. It requires understanding ward the ruin of pyrrhic victory. In for everyone; that health is not the of the interdisciplinary character of Latin America and the Caribbean, last car in the train, but the locomo health and of the political process even before the current economic tive which can lead us effectively and its repercussions for health. crisis, as for example during the on the track to development. Leadership goes beyond accepting a growth period of 1972-80, the num The challenge of redefining and mandate and begintiing to carry it bers of people living in extreme modernizing health systems cannot out. It is the indispensable basis for poverty still went from 95 to more be met without leaders who will the search for excellence. And with than 130 million. promote and cultivate the search out this continuing search for ex Yet, the high cost of the little for excellence. The efficacy and cellence the perspectives for the progress made so far, added to efficiency of socio-economic pol health sector, and particularly for stagnation and popular discontent, icies, particularly those pertaining the peoples of the Americas, are have led us toward experimenta to health, are determined in any dimmed. tion and away from orthodoxy. On country by the capabilities of those However, probably the most seri all sides, then, there is a gradually charged with the conception and ous crisis and greatest challenge of growing socio-economic flexibility execution of those policies. Leader the coming years and decades is and a thrust toward economic and ship has many facets. It includes the political planning performed "as if patient and persistent struggle to Primary health care must include not people really mattered." form coalitions within and among only community based services such Thus, this quantitative and qual institutions and sectors. It includes as the immunization visits in Peru, itative challenge we face requires the challenge of orchestrating per below, but also health education of mobilization of political will. It re sonal agendas and interests in the public, right, to deal with priority health problems among the most quires the search for opportunities search of a different vision and of vulnerable groups. and ways to deliver a clear, precise the common good. It encompasses message, in a spirit of collaboration, the need to express, define and PAHOIWHO Photos by Julio Vizcarra 28 W oRLD HEALTH, October 1987 all seek. The truces held in El Sal vador to allow vaccinations for wo men and children and the initiatives of the Pan American Health Or ganization PAHO/WHO in Central America entitled "Health, a Bridge for Peace" constitute a dynamic demonstration of the unifying po tential of the health field. Over the past few years, after some successes and a number of frustrations, PAHO moved to meet these challenges, expressed by the unmet needs of daily life in the countries of the region, and by the unacceptable social debt that brings about so much suffering and so many preventable deaths, and so much injustice and inequality. But despite these frustrations, we have achieved considerable progress. And the clearest demonstration of this is the strong support that the Organization has received from its member countries. The approval in 1986 by the Pan American Sanitary Conference-the highest policy or gan of PAHO/WHO in the Western Hemisphere-of program priorities for the 1987-1990 quadrennium has provided us the tools to con front these challenges in a systema tic and pragmatic way. This political decision established the quadren nial frame of reference for the Or ganization's cooperation in trans forming health systems, with its activities now underway in three related areas of priority: the devel that of solidarity. We might become tries. We see it in the short-sighted opment of the health infrastructure aware of different and better av mentality that erroneously divides with emphasis on primary health enues, be willing to change direc sectors according to .production or care; specific programs to deal with tion, achieve new heights of institu consumption of resources. We suf priority health problems among the tional and personal efficiency, and fer from it when localism and most vulnerable groups; and the produce the best national and inter institutional chauvinism impede process of information management national leadership; but if we fail to reaching agreement, even within needed to carry out these programs. act together, we will have made the health sector. And we promote By targeting these three areas, little headway beyond manipulat it when in our daily conduct, the member countries have given ing resources in a hit-or-miss fash perhaps because we suffer from the Organization a mandate to ion or on a case-by-case basis. fatigue and frustration, we are move effectively against the human The human . race unleashes ever guided by petty goals and personal catastrophe that would be rep more spectacular scientific and interests. resented by the prospect of having technological pyrotechnics, almost Rejection of humanistic values 300 million people lacking health on a daily basis. Meanwhile, hu and a lack of unity bring about services by the end of the century. manity's ethical evolution, of which world conflicts and impede human This is a regional approach, de solidarity forms a part, leaves much advancement. Nonetheless, the veloped on the basis of the particu to be desired. The lack of solidarity broad consensus ,that physical and lar socio-economic and health con takes many forms. We see it when mental health is beneficial and the ditions of the Western Hemisphere. international ·organizations are right of every human being But it is also an approach that fits criticized-sometimes for reasons together with the widely accepted perfectly within the universal prin that are justified, and other times fact that illness knows no border, ciples which the Member States of for ideological reasons-and attack race, or ideology-show that health the World Health Organization ac ed politically and economically. We can become, increasingly with each cepted when they approved in 1977 see it in a growing preference for passing year, the catalyst for the the universal call for Health for All bilateral cooperation among coun- solidarity among people which we by the Year 2000. • WoRLD HEALTH, October 1987 29 '' Pre-Emptive "AIDS: A Worldwide Effort Will Stop lt" Enforcement Ban'' Above: The theme of a Alone Is Not Sought Against worldwide hea lth education Enough to Fight and public information pro Smokeless gramme launched recently by Drug Abuse Tobacco WHO to increase awareness of how AID S is spread, and, just Measures aimed against traf By World Experts as importantly, how it is not. ficking and at law enforcement At right.· The symbol. are essential in the fight to curb A group of experts meeting Through them. the aim is not drug. abuse around the world. under the aegis of WHO has only to "communicate the severity of the AIDS threat," as but by themselves are not Dr Jonathan Mann, Director of WH O's programme on AID S, cal led for a "pre-emptive ban" enough. Because drug abuse is explained during an unveil ing ceremony, but also to make it on smokeless tobacco wher a health problem too, health plain that "only a global strategy can control it. " measures are needed also. ever this product has not been There is good reason for mounting such a concerted introduced to "prevent a new Drug abuse is both a symp attack against AIDS, the dreaded acquired immuno-defi tom and a cause of psycho public health epidemic from a ciency syndrome. According to figures received by the end social deterioration, according new form of tobacco use". of Aug ust. 144 countries reported cases and, in the six years to Dr Norman Sa rtoriu s, Direc As the basis for its recom since the disease was first identified in 1981, the total tor of WH O's Division of Mental mendation, the experts stated number of victims reached some 57,000. Tha t figure, while Health. high, is stil l estimated to be less than a half of all actual that smokeless tobacco is " it strikes at youth, a most "now being promoted cynical ly cases worldwide. The need for a global assault was endorsed by the leaders vulnerable section of the popu and aggressively around the lation, " who need help, not world despite its known harm of the world's seven major industrialised countries- Canada, the Federal Republic of Germany, France, Italy, Japan, the punishment. he said in ad ful health consequences". United Kingdom and the United States. At their meeting last dressing the recently con Thus, governments "should June in Venice, according to Dr Halfdan Mahler. WHO's cluded UN International Confer as a matter of urgency, pre Director-General, they sing led out WHO as the "best forum ence on Drug Ab use and Illi cit emptively ban the manufac for drawing together international efforts on a worl d wide Trafficking in Vienna. ture, importation and sale of level to combat AID S." The development of "de smokeless tobacco products In explaining the symbol, its U.S. designer, Milton Glaser, signer drugs," made in before they are introduced into said he sought an image with the "power to persist in the laboratories by tampering with the ma rket." memory." The result of this work- two red hearts that legally permitted compounds, Dr Gregory N. Conno ll y, Di converg e on a blue fright mask. • has also added to the "catas rector of Dental Health, Depart trophic health consequences of ment of Public Health, Boston, drug abuse." These synthetic formulations have an addictive who chaired the week-long ...... impact as much as a thousand meeting said, " lt is vital that ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• times more than natural, plant we do not repeat the mistakes ••• ••• ••••••• ••• ••• ••• ••••• • •••••••••••••••••••••••••••••••••• ••• ••• ••• ••••••• ...••• ...••• ...... ••• ...••• ...••• ...••• ....• .• .•••...... •••••••••••••••• . based substances. which have led to the massive ...... And AID S, "infesting and kill health problems caused by ...... ing not on ly those injecting cigarette smoking ." drugs but also spreading from The experts were from Aus WHO as a "new threat to samples of tee-shirts, and of them into a far wider popula tralia, Hong Ko ng, Ind ia, Ireland, society" - particula rl y to young " introductory" pouches pack tion," has raised the threat to Pakistan, Sweden, the United males who are. thus far, the aged in look-alike tea-bags. health to new heights. Kingdom and the U.SA. major targets in promotional Also recommended are a Th e use of forms of smoke and advertising campaigns. series of regularly rotated less tobacco-that is, tobacco Studies have shown "bey health warnings on smokeless not smoked but chewed, dip ond any reasonable doubt." ac tobacco products and adver ped, or just left in the mouth, cording to a WHO working tisements. even overnight between gum paper, "that its use has led to In Western nations. smoke and cheek- has already been leukoplakia, white patches on less tobacco is sold as : prohibited in Hong Kong, Ire gums, which in turn may de • Moist snuff, tobacco finely land, Israel and New Zea land. velop into cancer. and to gums cut and marketed loose. or in Although promoted as an al that recede from the crowns of pouches, which is avai lab le in ternative to cigarettes, smoke teeth thereby leaving roots ex different flavours. This form is less tobacco is described by posed. Its addiction is "similar preferred in the United States to that produced by cigarette and in Sweden. The UN Message: Say Yes to smoking and by other addictive • Chewing tobacco, which is Life; No to Drugs. drugs such as morphine or coarsely cut tobacco. cocaine". • Dry snuff, tobacco in a dry In another major recommen and finely powdered form, Prevention, treatment and dation, the experts urged coun which is sniffed or taken by rehabilitation are preferable to measures that might ali enate tries where smokeless tobacco mouth. already confused young drug is already in use to subject the In the United States alone, a users. In large part. a country's product to legislation that is as form of smokeless tobacco is anti-drug programme shou ld be strong as that for cigarettes. used by an estimated 12 mi lli on based on prevention. The primary aim. however. people, three mill ion of whom "No country can claim it is should be ending its use. are under age 21. dealing with the fearful threat Among measures ca ll ed for In India and Pakistan, it is of drug abuse unless the health are the prohibition of sa les to estimated that lea st 100 mill ion sector is intimately involved in adolescents, as well as a ban people use smokeless tobacco, demand-reduction." he said. To WHO PHOTO!Tibor Farkas on promotion in the mass often combined in the betel reduce the demand, there is Free samples : A need to pro media. Among promotional quid w ith li me and flavouring the need for countries to pro hibit them. techniques are offers Gf free agents. • mote healthy behaviour, to 30 W oRLD HEALTH , October 1987 make hea lth and well-being possible and enduring, and Authors drug abuse less likely. News brief Above all, there is need for of the Month an international all iance • Awards: Candidates are being sought for the second A!bert Dr Jorge OsUNA is Area Direc aga in st death, disease, socia l Dubois Quinquennial Prize for Tropical Pathology. The prize, of a tor of Health Systems Infra deterioration and misery which half million Belgian francs, is named for a scientist regarded as a structure at WHO's Regional Of drug abuse is bringing to the founder in tropical medicine, and who began his life's work at age fice fo r the Americas, PAHO. world." In all countries narcotic 24 in the Congo combating sleeping sickness and leprosy. Mr Mark L. SCHNEIDER is a and psychotropic drugs are be Candidates are asked to submit a summary, in Dutch, English Technical Officer in the Analysis ing misused and abused. The or French, at least ten pages long, of studies carried out and and Strategic Planning unit at number of cocai ne abuse rs published within the past five years. Deadline is 37 December WHO's Regional Office for the stands at 4.8 million, of opium 1987, with the award to be made in 1988. Americas, PAHO. abusers at 1.7 million, and of (For more details. write Academie Royale de Medecine de Belgique. Palais des Dr Jose R. FERREIRA is Program heroin abusers at 750,000, ac Academies. 1 rue Oucale. 1000 Bruxelles). Coordinator, Health Manpower cordin g to figures reported to - Next month, Or Fe del M undo, a pioneer in the development Development, at WHO's Regional the United Nations. • of family planning programmes in the Philippines, will receive the Office fo r the Americas, PAHO . triennial IAMANEH-Bourguiba Award in recognition of her life Dr George A. 0. ALLEYNE is time's devotion to maternal and child health. it will be presented Area Director, Health Programs on 7 November during the 3rd International Congress of Maternal Development, at WHO's Regional A Step Forward and Neonata! Health to be held in Lahore, Pakistan. Office for the Americas, PAHO. Given by the International Association for Maternal and Mr Horst 0TIERSTETIER is a In Protecting Neonatal Health, Geneva, and the Tunisian Association for the Sanitary Engineer in the En The Ozone Layer Health of the Mother and the Newborn, the award is named, in vironmental Health Program at part, after Tunisia's President Habib Bourguiba. UNFPA. UNICEF and PAHO, and Mr Alberto F'LORES is WHO are on the selection committee. Director of the Pan American By 1990, world production of - For "sustained contribution made to the cause of refugees Center for Sanitary Engineering chlorofluorocarbons wi ll be in their country, and throughout the world over the years," the and Environmental Sciences in frozen at 1986 levels. Over the Lima, Peru. people of Canada have been awarded the Nansen Medal by UN two following yea rs, production High Commissioner for Refugees, Jean-Pierre Hocke. Dr Eisa M. MORENO is Program wi ll be reduced by 20 pe r cent, The award is named for Norwegian scholar and explorer, Coordinator of the Maternal and and from two to four years later Fridtjof Nansen, who was the first commissioner, under the Child Health Program; Dr Nes cut by a possible 30 pe r cent. tor Suarez OJEDA and Dr Ciro League of Nations, for refugees. Th at is the gist of a draft de QuADROS are both Medical proposal that is likely to form • Calendar : Of more than usual noteworthiness, the Interna Officers in the same program. th e basis of a "meaningful in tional Conference of Ergonomics, Occupational Safety and Health, Dr Claude de V ILLE DE GO YET is ternational ag reement to pro and the Environment, to be held a year from now- from 24 to a Medical Officer in PAHO's tect the ozone layer " from the 28 October 7988- in Beijing, China. Emergency Preparedness and sun's destructive ultra-vio let Th e Chinese Society of Metals, and the Darling Downs Disaster Relief program. radiation, accordin g to Dr Mos Institute of Advanced Education, Australia, are joint sponsors of Dr Carlyle GUERRA DE MACEDO tafa K. Tolba, Executive Di rec the conference aimed at making workp!aces safer and healthier. is Director, Pan American tor of the UN Envi ronment Pro The event, they say, will be " the biggest of its kind yet staged in Health Organization, and Re gramme. China." gional Director fo r the Americas Evidence over th e past de (For details. write ICEOSHE Administrator. P 0 Box 44. Darling Heights. of the World Health Organi cade shows that use of CFCs, Toowoomba. Queensland 4350, Australia). zation. fo r instance, in aerosol cans, • Still Playing, but Only When Safe: Hollywood has responded, refrigerators and cleansing at least in part, to a call by the US. Department of Health and agents, thins the ozone and as Human Services for AIDS education programmes that stress a consequence raises the abstinence and "safe sex." The first AIDS-influence films, which WORLD HEALTH planet's temperature, as well reached movie houses last summer, show that while heroes still For readers everywhere as accelerating the so-ca lled play, they play it safe. "green-house" effect that In the latest James Bond film, "The Living Daylights," Secret 1987 Subscription Rates cou ld alter the earth's cli mate. Agent 007 practices monogamy. While in previous adventures he US$ Sw. fr. One health effect of ozone has been required to go to bed thrice with three different women, One year 14.- 25.- depletion is an increase in skin he frolics now thrice with the same woman. Two years 24.75 45.- cancer. And in a police thriller, "Dragnet," the hero, albeit reluctantly, Three years 33.- 60._: "There was no dissent at all passes up a liaison with a blond on discovering that his stock of about the fact that we are fac condoms has run out. ORDER FORM ing a rea l problem of the deple "We have to conform to what's going on in the world. We Please enter my subscription to tion of the ozone," the top UNEP have to be responsible, " the New York Times quotes the " World Health" as follows : official sa id during a 31-nation producers as saying. co nference held in Geneva One year 0 in May, " but because of • Turning to Nutritious Fast Foods. The message of a current Two years 0 economic factors, ind ustry advertising drive by McDonald's Restaurant is that the worldwide needs to have time to adjust to hamburger chain is cutting back on fat and salt, thus in effect Three years 0 change." striving fo r more nutritious content in the "fast food" it serves. I enclose cheque/international About a month later, in a it has lowered the sodium content of pork sausages and postal order in th e amount of: related development, U.S. and pickles. it is frying fish and chicken in pure vegetable shortening, Name: ______~------Soviet scientists agreed to ex instead of animal fat. thereby helping to lower cholesterol levels. Street: ______pand a pact between the two natio ns on research in the at City: ------~- mosphere, in particular the ex In the next issue Country:------ cha nge of inform ation. If their studies show that a WHO has long been in the forefront of efforts to find and World Health, WHO, Avenue Appia, 1211 Geneva 27. Switzerland "hole" in the ozone layer over develop new and better methods for fertility reg ulation. Some of th e exciting developments in the field of re search World Health is also distributed through Antartica is widening, UNEP is the network of international bookstores committed to ca ll ing an into human reproduction are discussed in the November and subscription agencies. For payment emergency conference later issue of World Health. in national currencies. please contact this yea r. • your usual bookseller. WoRLD HEALTH, October 1987 31 A young boy suffering from a rash is checked by a doctor in a rural hospital in Guatemala. PAHOIWHO Photo by Carlos Gaggero .., ,.,> c Q) t9