CHAPTER 14 D·sease reve t1o• n control

regard to the prospect of achjeving 90% coverage Immunization with these antigens by the year 2000. Tetanus toxoid coverage of pregnant women continued 14.1 Progress in national immunization pro­ to be the least satisfactory: in developing coun­ grammes accelerated in 1990-1991, so that, for tries only 39% of pregnant women were re­ the first time, more than 80% of children in the ported to have received two or more doses. first year of life were covered by a third dose of combined djphtheria, pertussis and tetanus vac­ 14.2 At current coverage levels, it can be esti­ cine (OPT) (see Figure 14.1) and poliomyelitis mated on the basis of the vaccine efficacy rates vaccine. In developing countries, coverage and the disease attack and mortality rates that reached 85% for a thUd dose of poliomyelitis during the biennium immunization programmes vaccine, 83% for a trurd dose of DPT vaccine, increased from 2.2 mjllion to 3.2 million the 90% for BCG vaccine used against tuberculosis, number of lives saved per year from measles, and 79% for measles vaccine (the corresponding neonatal tetanus and pertussis. Figure 14.3 shows figures for january 1988 were 52%,51%,53% the progress during the period 1980-1990. In ad­ and 38%, respectively). Substantial progress was djtion, tbe number of cases of poliomyelitis pre­ made .in all WHO (see Figure 14.2), de­ vented rose from 360 000 to some 442 000 cases spite many special social and economjc prob­ per year. The urgent need to maintain and fur­ lems. These accomplishments justify optimism in ther increase immunization coverage levels is

Figure 14.1 Expanded Programme on Immunization: immunization coverage 1980 to 1990

100~------. .., ""c 0 BCG ~ Q) 80 >- OPT, lhird dose =::::: Q) Poliomyelitis, third dose -=.!: 60 c: Measles ~ ::E .:s Tetanus toxoid, second 0 Q) 40 or booster dose in E"" pregnant women Q) > 8 Q) c 20 'E"" Q) ::::: .....Q)

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 (data before 1984 ore estimated)

83 THE WORK OF WHO 199(}-1991

Rgure 14.2 Immunization coverage of children in the first year of age, by WHO , Augustl991

100~------,

80-

enCD :ii 60- 8 "'en c0 ~ 40 - .f?.

20-

Africa Americas Eastern Europe South·Eost Western Global Mel!iterraneon Asia Pacific

• BCG D OPT, third dose D Poliomyelitis, third dose D Measles• D Tetanus**

• up to 2 yeors of oge •• tetanus toxoid (in pregnant women)

Figure 14.3 Progress in terms of prevented and expected deaths from diseases covered by the Expanded Programme on Immunization (developing countries), 1980-1990

5

2

0 -1""- - 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

~ Expected deaths without immunization • Prevented deaths with immunization

Source: WHO estimates

84 DISEASE PREVENTION AND CONTROL

Figure 14.4 Number of deaths due to measles, neonatal tetanus and pertussis and number of poliomyelitis cases occurring and prevented by immunization in developing countries, 1990

3000 0 occurring 2500 - death$ 0 prevented

., 2000 - -c: 5: ::> 0 ~ 1500 - ·=~ -=E =::> 1000 - deaths .. [QSeS 500 -

0 Measles Neonatal Pertuss~ Pot!omyelilis let onus

underlined by the continuing occurrence each IH The development of management struc­ year of some 1.7 million deaths from measles, tures for immunization activities has provided an neonatal tetanus and pertussis and over 100 000 opportunity for including other vaccines in addi­ cases of poliomyelitis that could be prevented tion to the five standard ones. Some countries through immunization (see Figure 14.4). have added yellow fever vaccine, hepatitis B vac­ cine (to a limited extent, because of its cost) and 14.3 During the biennium, substantial progress Japanese encephalitis vaccine. was also made in improving supplies and logistics for immunization activities in primary 14.6 Despite these achievements, the continued care. In particular, single-use syringes were de­ success of immunization programmes is by no veloped and put on the international market, means assured. Social and economic problems more than 500 000 sterilizers of a design suitable are likely to constrain the growth of health serv­ for use in health centres were delivered, solar ices in developing countries, and the application refrigeration became a usable technology for of existing immunization management methods storing vaccines and pharmaceuticals, and work and technology is far from complete. Outbreaks began on improving the management of fleets of of poliomyelitis still occurred during the vehicles, especially motor-cycles. biennium, especially in the South-East Asia and Western Pacific Regions, and neonatal tetanus 14.4 Within WHO, collaboration was directed and measles were once again major killers of towards neonatal tetanus prevention, vitamin A chjldren. If immunization programmes do not supplementation, preparing training manuals continue to receive high priority, the gains and providing training in logistics. There was could be jeopardjzed. also an impressive degree of cooperation in sup­ port of immunization programmes at global and 14.7 To maintain the standard of global immu­ regional levels between WHO and a wide range nization is already a challenge; if it is to be of organizations, including UNICEF, the World improved so as to further reduce disease inci­ Bank, UNDP, Rotary International, bilateral dence, four activities must be pursued, which development agencies and nongovernmental may be briefly summarized as follows: (1) taking organizations. Such cooperation has been one advantage of the 500 million contacts per year of the principal reasons for the successes so far that mothers and children have with immu­ achieved in immunization programmes. nization services to ensure that tbey also receive

85 ------THE WORK OF WHO 199D-1991 other vital advice on maintaining and improv­ ing their health; {2) devising new ways to help Disease vector control countries sustain their achievements, by de­ veloping bener-managed, and therefore more ef­ 14.9 Development and evaluation of new pesti­ ficient programmes; (3) improving and imple­ cides has continued under the WHO Pesticide menting strategies within the conte."n of primary Evaluation Scheme, in cooperation with the pes­ ticide industry and WHO collaborating centres. At a meeting in Geneva in 1990 between WHO and representatives of the pesticide industry, the procedures followed by the Organization in ap­ proving pesticides were discussed and it was agreed that the two parties would cooperate more closely in future.

14.10 A field trial of lambda-cyhalotrin against malaria vectors in the United Republic of was successfully concluded, and trus insecticide has been added to the List of those that can be used for public health purposes. Field trials of reldan and carbosulfan against malaria vectors have been initiated in .

14.11 Monitoring of insecticide resistance in dis­ ease vectors continued, with WHO providing test kits and technical guidance. In its fifteenth report, 1 the WHO Expert on Vector Biology and Control, which met in Geneva from 5 to 12 March 1991, discussed the present state of vector resistance throughout the world, critically The schedule for protection of infants against poliomyelirts requires o reviewed standard and newly proposed bio­ first dose os soon os possible after birth, then three more doses at chemical methods for early detection of resist­ least one month aport. ance and made recommendations for resistance management.

14. 12 Pyrethroid-treatcd bed-nets have been health care to achieve the global eradication of shown to reduce the incidence of malarial infec­ poliomyelitis, the elimination of neonatal tetanus tion and cljnicaJ illness. About six million people and the reduction of measles; and (4) continuing to provide fi nancial support to many countries, especiaUy to meet recurrent costs and the cost of new or improved vaccines that may be intro­ duced.

14.8 The success of immunization services and of the related primary health care activities will have long-term effects on health far beyond the sphere of immunization. Benefits will accrue in the form of better primary health care manage­ ment, including supervision, training, financial administration and equipment maintenance, not Nets impregnated with insecticide protect sleepers from mosquito bites, to mention the promotion of public health as a ond ore already reducing the spread of molorio in many oreos of the cost-effective development activity with wide world. social ramifications. Also, parents may begin to accept that they do not need to have a large number of children to ensure the survival of the 1 Vector resistance to pesticides, to be published in lhe WHO Technical family. Report Series.

86 DISEASEPREVENTION AND CONTROL are now protected with these nets, mainly in opened up to economic exploitation, in which rural areas of and Viet Nam, and field health services tend to be rudimentary or nonex­ trials are being conducted in Africa and other istent. Tropical Africa is believed to account for parts of the world. 80% of the clinical cases and 90% of all the parasite carriers in the world, but reporting is 14.13 The increased incidence and wide dissemi­ fragmentary and irregular. of classic dengue in the Americas, associ­ ated with the circulation of multiple serotypes of dengue virus, resulted in more cases of dengue hemorrhagic fever and dengue shock syndrome. Ensuring the sustainabiliry of measures against dengue vectors remained a problem both in South-East Asia and in the Americas. As most countries in the Americas have been reinvaded by Aedes aegypti and have serious funding prob­ lems, particular attemion has been given to mo­ bilizing communities for vector control ac­ tivities. Community participation, especially in the emptying of water containers, has played a considerable role in Aedes control in Panama, In addition to the suffering associated with the onset of disease, bouts and pilot projects are being carried out in of molorio prevent children like this girl in Gombio frorn going to Honduras and Venezuela. Trials of ultra-low­ school. ond interrupt their . volume application of insecticides for mosquiro control were conducted by the Venezuelan Min­ istry of Health and Social Welfare with the col­ laboration of PAHO/WHO, USAID, and the 14.16 Adequate treatment is being hindered in Centers for Disease Control in Atlanta, GA, African rural areas by the rapid development of USA. In Central America dengue control activi­ resistance to chloroquine in Plasmodium ties in the frontier areas were intensified. falcipamm, which has also been reported from most countries where that malaria para­ 14.14 Other WHO activities during 1990-1991 site is transmitted. Resistance to suliadoxine/ included the proviSion of guidance on pyrimethamine is continuing to be reported from disinsection of airct'aft, the drafting of a new South-East Asia, South America and some foci in manual on vector control in airports and sea­ Africa, mefloquine is no longer effective in up to ports, evaluation of pesticide application equip­ 50% of cases in , and in Thailand and ment through collaborating centres, preparation Viet Nam resistance to quinine is increasing. of a comprehensive practical manual of vector There have been reports of chloroquine resist­ control methods for field workers and participa­ ance in Plasmodium vivax in and tion in teaching at international workshops on Papua New Gujnea. various aspects of vector control. 14.17 WHO, in collaboration with the drug manufacturers, is continuing to monitor the effi­ cacy and side effects of ancimalaria drugs. A Malaria monitoring system that has been developed is being made available to malaria control pro­ 14.15 Malaria remains one of the world's grammes i_n endemic countries. major health problems, causing fatalities, chronic ill-health and decreased productivity in many 14.18 In its support for collaborative studies on parts of Africa, South America, southern Asia how best to assist malaria control programmes and the Western Pacific. Over 40% of the in planning and funding control projects, WHO world's are still exposed to varying has emphasized the need to evaluate the suscepti­ degrees of malaria risk. Excluding Africa, 5.2 bility of P. falciparum to operationally used million cases were reported to WHO for 1989 drugs and to determine the efficacy and safety (returns completed in 1991), 39% of them from of alternative therapeutic regimens as a basis for and 11% from , where the disease is developing national policies on antimalarial particularly rife in Amazonian areas recently drugs.

87 THE WORK OF WHO 199D-1991

14.19 The WHO Collaborating Centre on the basis for providing better guidance on surveil­ Epidemiology and Control of Malaria, in Rome, lance, preparedness and control methods. has carried out epidemiological studies on malaria vectors and transmission in , 14.25 Efforts to expand and improve interna­ , and with a tional basic training activities and the training of view to the development of vector control activi­ trainers continued in cooperation with UNDP ties in those countries. and a number of Member States. Altogether, 175 participants were trained at nine inter­ 14.20 National malaria control programmes in national courses for health personnel at different Burundi, China, , , India, levels on malaria and its control. , Myanmar, , , , , and have been re­ 14.26 WHO again cooperated with countries in viewed, with emphasis on the need to integrate strengthening their capacity for training staff for diagnosis and treatment in the general health planning, implementing and evaluating malaria services. control programmes. The Government of Bel­ gium cooperated in the launching of a course in 14.21 In collaboration with the Overseas Devel­ French in Burundi in 1991, while the already opment Administration of the , established courses in Burkina Faso and Thailand WHO is supporting the drawing-up of a malaria continued, with the support of the Governments control programme in . Particular at­ of and respectively. tention will be paid in the programme to the management of severe and complicated malaria, 14.27 Considerable progress has been made in determination of the at greatest preparing and improving training materials and risk, improvement of epidemiological reporting visual aids for training various categories of systems and the production of information health personnel and for health education of the material on malaria for use at all levels of health public. WHO also continued to prepare training care. material and operational guidelines on such sub­ jects as microscopy, the treatment of severe or 14.22 In all control programmes the integration complicated malaria, and programme planning. of malaria activities in the general health services is the basis for the strategy advocated. A paper has been drafted on malaria control strategy for review by the forthcoming interregional meet­ Other parasitic diseases ings and submission to the Ministerial Confer­ ence in 1992. The first interregional meeting in 14.28 The Organization's work on parasitic Africa on malaria control took place in diseases provides several examples of how pro­ Brazzaville in October 1991. grammes to combat specific diseases can be in­ strumental in strengthening the local primary 14.23 An epidemic control team was established health care services. Successful tropical disease at headquarters in 1991 and has already re­ control has encouraged local communities to build sponded to requests from Burundi, and on experience and has led to the adoption of inte­ to evaluate the situation and cooperate grated approaches to health care in accordance with ministries of health in drawing up national with local priorities and constraints. For several of control programmes. It has also led two missions these diseases frameworks for analysis of cost­ to northern Pakistan and southern Afghanistan effectiveness have been developed and have either to assess the malaria situation there, particularly been issued or are available on request. in relation to the possible repatriation of refu­ gees. A plan of action has been formulated 14.29 The results of studies on the impact of calling for the development of a policy on the parasitic diseases on health in urban and peri­ use of antimalarial drugs, the training of health urban areas, updated in the context of the current workers, the strengthening of epidemiological socioeconomic trends, population migrations surveillance and operational research. and subsequent environmental disturbances, were issued in 1990.1 14.24 A data base on past malaria epidemics is being established with a view to analysing the 1 Molt, K. E. et al. Parasitic diseases and urban development. Bulletin of the operational constraints that were observed as a World Health Organization, 68(6): 691-698 (1990).

88 DISEASE PREVENTION AND CONTROL

schools and national control programmes.1 A Schistosomiasis video-tape, "Kichocho, a story of schisto­ somiasis", on a successful control programme (Distribution: 74 countries; exposed: 600 million; based on primary health care that was conducted prevalence: 200 million) in the island of Pemba, United Republic of Tan­ zania, with financial assistance from the Govern­ 14.30 The disease is endemic in 74 Member ment of Italy and the German Pharma Health States following the change of status of Fund, has been produced by WHO for use in (formerly Democratic Yemen and Republic of conjunction with the manual. Yemen) during the period, and confirmation by the WHO Expert Committee on the Control of 14.34 Applications of microcomputer technol­ Schistosomiasis (November 1991) of its eradica­ ogy to programme management have been devel­ tion in . Changes in the epidemio­ oped under a grant to WHO from the Edna logical pattern underline the close interrelation McConnell Clark Foundation, USA. A data of the environmental and economic factors and base on the epidemiology and control of control of the disease (see Figure 14.5). Control schistosomiasis and an interactive training pro­ of schistosomiasis is carried out through the gramme are in the final stages of preparation. primary health care system, which has to be strengthened accordingly. WHO has colla­ borated with the Ministries of Health of , Egypt, Madagascar, and African trypanosomiasis (sleeping the United Republic of Tanzania in develop­ sickness) ing control approaches adapted to national resources and needs. The successes previously (Distribution: 36 countries in Africa south of the reported in reducing the prevalence and inten­ Sahara; exposed: 50 million; prevalence: 25 000) sity of schistosomiasis by chemotherapy have led to further collaboration by WHO 14.35 The prevalence of sleeping sickness has with UNESCO and UNICEF in assisting the increased in several countries, particularly in Government of Egypt to prepare a national plan central Africa. In general, national health auth­ of action. orities are conscious of the risk, but shortage of trained staff and funds or political instability 14.31 As experience in endemic Member States have led to a breakdown in surveillance and con­ has shown the high cost of praziquantel to be the trol and retarded the deployment in the field of main limiting factor in the implementation of the efficient new operational tools developed control measures, WHO has been requested by through research in recent years. the countries concerned to negotiate a lower price for this drug, and discussions are now 14.36 In southern Uganda a serious outbreak of underway. Trypanosoma brucei rhodesiense infection is be­ ing combated through a combination of medical surveillance and treatment with an extensive vec­ 14.32 At training courses conducted in Bo­ tor control programme supported by the French tswana, China and Indonesia emphasis was laid Government and the Commission of the Euro­ on the importance of integrating control with pean Communities. This project has demon­ primary health care and involving the commu­ strated the feasibility of large-scale trapping in­ nity at all stages. A regional seminar on volving community participation as a means of schistosomiasis epidemiology and control for reducing disease transmission. French-speaking African countries was held with the collaboration of the Organization for 14.37 A trypanosomiasis control programme Coordination and Cooperation in the Control of has been designed for the countries of central Major Endemic Diseases in Niger. Participants Africa where T. b. gambiense occurs. It provides emphasized feasible and essential measures for a framework for the sustained efforts required to the use of the results of research to guide national control the disease in all active foci. control programmes.

14.33 Health education efforts will be made 1 Health education in the control of schistosomiasis, Genm, World Health easier by the publication of a manual for use in Organization, 1990.

89 Figure 14.5 Schistosomiasis control and related changes in the situation in selected countries and areas

Ghana Egypt CI'Mna Since the construction of the WHO/UNICEF!Ministry of Health prOject Intestinal schistosomiasis Schistosomiasis is now Akosombo Dam (Volta Lake), io the Nile Datta showed a sustained has now spread to the north reappearing in areas previously intestinal schistosomiasis has been reduction of schistosomiasis for up to 5 due to war and refugee under control, especially in increasing in the Volta Delta. years after a single treatment. migration. Hubel and Hunan Provinces.

India Urioaty schistosomiasfs was fitst reported near Hyderabad in 1989.

Lao Peopkt•s Democratic Republic Schistosoma mekong/ prevalence ~ has been reduced by 70% after ~ treatment in Khong District. Other measures are now needed. =~ ..0 Cl 8enegal C)~

.An epidEl!nlc of 'CI Intestinal lndonHia - schlstosomiasis Prevalence in Lake Undu region, ! (1987~1990} has Central Sulawesi, continues to 'CI decrease and is less than 2%. ~ ~ ooourring 1n now Richard Toll since WH091779 the construction of 1he Dlama Dam. I'

4b Urbtm schistosomiasis Is now \ present in and around major Pamba, Zanzibar, cities In Norti'MHI8t Brazil and Unfted Republic of Africa. Tanzania The des1gnat1ons employed and the Botswana Prevalence of urinary presentation of material on th1s map do not schistosomiasis () tmply the expresston of any opmton Prevalence of intestioaJ schisto­ whatsoever on the part of the World Health somiasis has been reduced from reduced from 55% to o1~ Organizat1on concernmg the legal status of 29% to 16% among school about 10% in school any country, terntory, c1ty or area or of 1ts authont1es, or concern1ng the delimitation of chlta«~ in Ngamlland. children. 1ts frontiers or boundanes Source: World Health Orgamzation, 1991 DISEASE PREVENTION AND CONTROL

14.38 The provision by the French pharmaceuti­ compares favourably with the 60% efficacy of cal company Rhone-Poulenc, through WHO, of traditional insecticide spraying (see Figure 14.6). pentamidine free of charge to treat the early The cost per treated house for 24 months was stages of T.b. gambiense infection is a much ap­ $29.00 for the paints, as against $66.34 for preciated gesture bringing considerable relief to deltamethrin. the countries affected. 14.42 By resolution XVI the XXIII Pan Amer­ ican Sanitary Conference in September 1990 re­ quested the Regional Director, in consultation American trypanosomiasis (Chagas with the Member States, to establish mechanisms disease) for determining the feasibility of eliminating Chagas disease in the Region. At its 107th Meet­ (Distribution: Central and South America; ex­ ing, in June 1991, the Executive Committee of posed: 100 million; prevalence: 16-18 million) the PAHO Directing Council, in its resolution VI, urged Member States to foster cooperation 14.39 A multicentre study was launched by with a view to preventing, controlling and main­ PAHO/WHO in , , , taining surveillance of Chagas disease transmit­ Honduras, Paraguay and Uruguay on commu­ ted by blood transfusion, which accounts for a nity-based use of fumigant canisters, insecticidal large percentage of cases. paints and simple detector traps against the triatomine bugs that carry Chagas disease. A common protocol is being used in this research to ensure better comparability of the results. Leishmaniasis

14.40 Following four years' use of fumigant (Distribution: 80 countries; exposed: 350 million; canisters in Argentina and Brazil the prevalence: 12 million) seropositivity rate in infants fell from 5.5% to zero. The cost of this measure was $4.7 per 14.43 A novel approach for leishmaniasis control house per year, or one fifth the cost of systematic based on the recommendations of the Expert insecticide spraying. Committee that met in 1989 1 has been established. The wide range of leishmaniases has been nar­ 14.41 In a field project in central Brazil, locally rowed down to 11 nosogeographical entities and a manufactured insecticidal paints proved highly control approach established for each variant. effective, keeping over 85% of the treated dwell­ ings free of triatomines for 24 months, which 14.44 Technical and management support in de­ termining control needs was given to Afghani­ stan, China, Costa Rica, India, Nepal, Paraguay, Figure 14.6 Efficacy of insecticidal paints in the Saudi Arabia and . A framework for prevention of Chagas disease in a field project in assessing costs and the cost-effectiveness of Posse (Goais), Brazil, 1990 leishmaniasis control was distributed to the national services concerned.

S' 14.45 A direct agglutination test was tried out in ..,.coc:::> 80 and Nepal and shown to be simple, "'S relatively cheap and reliable in large-scale screen­ ,g 60 ing for visceral leishmaniasis. lG lS Deltamethrin ..=c (2 applications) 40 14.46 A seminar on approaches to leishmaniasis e control, attended by health workers from 10 ~ Paints ... (l application only) ~ countries in the Eastern Mediterranean Region .5 20 - iii (Cairo, October 1990) drew up protocols for ~ HCH 0 (2 applications) ~ the establishment of national leishmaniasis 0 control programmes. lstyear 2nd year Years after application 1 WHO Technical Report Series, No. 793, 1990, section 10.

91 THE WORK OF WHO 199D-1991

Decade and through national eradication pro­ Lymphatic filariasis grammes, annual incidence has dropped consider­ ably and is now estimated at less than three mil­ (Distribution: global, except for Europe; ex­ lion. India and Pakistan are on the verge of posed: 905 million) eradicating the disease and most of the endemic 14.47 In India (with an estimated 40 million countries in Africa have set a national goal of people infected), and Thailand, interrupting local transmission by the end of 1995. filariasis control by the drug diethylcarbamazine combined with antilarval measures remained one 14.51 WHO has contributed to the move to­ of the basic elements of primary health care. In wards eradication by organizing an informal con­ the South Pacific Islands mass administration of sultation on the criteria for the certification of diethylcarbamazine drastically reduced filariasis dracunculiasis elimination (Geneva, February but sporadic transmission persisted. Vector con­ 1990), the Third Regional Conference on Dracun­ trol using impregnated mosquito nets was intro­ culiasis in Africa (Yamoussoukro, March 1990) duced in , and . Clinical trials and the Dracunculiasis Eradication Programme on the effect of ivermectin on the prevalence and Managers' Meeting (Brazzaville, March 1991). transmission of lymphatic filariasis have started in eight countries in Asia, Africa and Latin 14.52 Increased support for the eradication of America. dracunculiasis was reflected in the adoption of recommendations on this subject at major meet­ ings and the offer of grants by international agen­ Onchocerciasis cies and corporations. In Africa, even as active case detection revealed the full extent of (Distribution: Africa and Latin America; ex­ dracunculiasis in endemic countries for the first posed: 85.5 million; prevalence: 17.5 million, of time, implementation of eradication measures in whom some 340 000 have become blind) countries with the largest number of cases began to reduce the overall total dramatically. A reduc­ 14.48 Ivermectin gave further proof of being a tion of more than one third of cases was achieved highly effective microfilaricide for morbidity in and in 1990.1 control, alleviation of the debilitating symptoms, and prevention of ocular manifestations. Its im­ 14.53 In May 1991 the Forty-fourth World pact on disease transmission has been limited, Health Assembly adopted a resolution except in . The manufacturer con­ WHA44.5 declaring its commitment to the goal tinued to make the drug available to oncho­ of eradicating dracunculiasis by the end of 1995. cerciasis patients free of charge, a much appreci­ If that goal is achieved, dracunculiasis will be­ ated gesture. In Africa distribution programmes come the second disease to have been eradicated are being set up in Benin, , Chad, throughout the world. Nigeria, and Zaire. (For intestinal parasitic infections, see para­ 14.49 In the Onchocerciasis Control Pro­ graphs 14.163-14.167.) gramme in West Africa, where vector control operations have ceased in much of the original area, community-wide ivermectin treatment in hyperendemic zones continued, involving more Tropical disease research than 500 000 treatments. 14.54 In 1990 the Forty-third World Health As­ sembly adopted resolution WHA43.18 marking Dracunculiasis (-worm disease) the achievements of the UNDP/World Bank/ WHO Special Programme for Research and Training in Tropical Diseases "in the develop­ (Distribution: sub-Saharan Africa, India, Paki­ ment and testing of a number of important new stan; exposed: 140 million; annual incidence: disease control tools, many of which are already under 3 million) in operational use, as well as the innovative and 14.50 Following the considerable progress achieved in many countries during the Interna­ tional Drinking Water Supply and Sanitation 1 Weekly Epidemiological Record, 66: 225-230 (1991)

92 DISEASE PREVENTION AND CONTROL pioneering approaches taken in strengthening re­ against onchocerciasis; it was found to reduce search capability in developing countries", and eye lesions in Africa, and to have potential for requesting the Director-General to ensure con­ blocking transmission in Guatemala. The drug tinuation of the Programme's "global leader­ also proved effective against lymphatic filariasis, ship role in tropical disease research". and studies were begun to compare its efficacy with that of diethylcarbamazine. Two new com­ pounds, CGI-18041 and UMF 078, showed promise in experimental animals for the develop­ Research and development ment of a macrofilaricide (a drug that will kill the adult female worm). A "cocktail" of four well­ 14.55 A product development unit was set up defined recombinant antigens of Onchocerca was within the Special Programme to examine re­ shown to provide a sensitive diagnostic test for search products of high priority for disease con­ the parasite. trol and to collaborate with industry in order to turn them into practical tools for field use. 14.59 African trypanosomiasis. The Programme supported studies leading to registration of the 14.56 Malaria. The Programme continued its drug eflornithine by the Food and work on the development of new drugs against Drug Administration in November 1990 for use malaria, and on making the best use of available against Trypanosoma brucei gambiense sleeping drugs, measures to combat drug resistance, im­ sickness. Eflornithine is being combined with proved treatment for severe and complicated other drugs in the search for formulations effec­ cases, vaccine development, diagnosis and vector tive against the rhodesiense form of the parasite. control. Clinical trials began of arteether and A test that detects antibodies (the procyclic ag­ artemether, derivatives of the Chinese herbal ex­ glutination trypanosomiasis test) was developed tract qinghaosu (artemisinin). Development of for the diagnosis of the disease. Evaluation of diagnostic kits based on DNA probes and antigen-ELISA for the detection of current in­ monoclonal antibodies continued. Self-diagnosis fection began. was found to be surprisingly reliable in identifying individual malaria cases in certain communities. 14.60 Chagas disease. A large multi-country Production and global distribution of in vitro kits study was launched in six Latin American coun­ for testing the sensitivity of parasites to tries on the use of fumigant cans, insecticidal chloroquine, amodiaquine, quinine, mefloquine paints and simple vector detection traps against and sulfadoxine/pyrimethamine combinations the triatomine vectors of Chagas disease (see also began in the . A study in West Africa under Other parasitic diseases, paragraphs 14.39- has suggested that home-made bednets, impreg­ 14.42). In other research supported by the Pro­ nated with a biodegradable insecticide against gramme, sodium ascorbate was shown to reduce mosquitos, can dramatically reduce child mortal­ the amount of crystal violet needed to clear ity. blood-bank blood of infection; and parasite anti­ gens produced by recombinant DNA techniques 14.57 Schistosomiasis. The Programme is seek­ were selected for use in test kits to detect infected ing the most effective means to supply and ad­ blood. Clinical tests were begun of allopurinol, minister the drug praziquantel and is developing commonly used against gout, for its effects preventive techniques, such as the use of against chronic Chagas disease. vaccmes. Studies in East Africa showed that questionnaires completed by head teachers can 14.61 Leishmaniasis. Immunotherapy using be used for cheaply and accurately determining recombinant gamma-interferon in conjunction how severely a community is affected by urinary with chemotherapy was shown to be effective schistosomiasis. Acute toxicity studies con­ against cases of visceral leishmaniasis resistant to firmed that praziquantel can be combined with chemotherapy alone, and compounds that act the wide-spectrum antihelminthic benzimi­ against the "tubulin" skeleton of the parasites dazoles, thus opening up the possibility of being were shown in vitro to be active against able to deal with several helminthic infections by leishmaniae. Studies began of a whole killed means of a single treatment. Leishmania vaccine against cutaneous leish­ maniasis in the Islamic Republic of Iran. The 14.58 Filariasis. Ivermectin was shown conclu­ trials of the direct agglutination test for large­ sively to be an effective microfilaricide for use scale screening of visceral leishmaniasis con-

93 THE WORK OF WHO 199D-1991 tinued. The polymerase chain reaction was used consolidated the new funding mechanisms, new to identify Leishmania parasites in lesions for structures and new initiatives established during diagnostic purposes. the preceding biennium.

14.62 Leprosy. Ofloxacin was shown to be 14.66 Efforts to build up social science resources highly effective against Mycobacterium leprae, in developing countries were intensified. In 1991 and to be well tolerated in combination with eligibility for programme-based grants was re­ standard multidrug therapy. The prospects of stricted to institutions located in developing reducing the length of treatment to one month are countries and committed to field research on the being assessed. The polymerase chain reaction Programme's target diseases that involves the was used successfully to detect low numbers (10- social sciences. These grants also provided for 100) of M. leprae in biological specimens, with a the establishment of posts for social scientists, view to speeding up diagnosis of infections. research fellowships in the social sciences and North-South links designed to improve social science research skills. Efforts were also made to Research on biological control of vectors strengthen research in developing countries on the application of new disease control tools. In the award of research grants, greater preference 14.63 Bacillus sphaericus was developed as an was given to scientists or institutions in the least ecologically safe larvicide against mosquito vec­ developed countries. tors of lymphatic filariasis in polluted waters in urban areas. The toxin-producing genes of B. thuringiensis H-14 and B. sphaericus were cloned in blue-green algae in a search for a Diarrhoeal diseases method of maintaining the toxins in bodies of water where vectors breed. Work continued on 14.67 Efforts aimed at the control of diarrhoeal bacterial formulations that float, spread and re­ diseases were intensified at all levels in 1990, lease toxins in a controlled manner, with a view when a new target was set of halving diarrhoeal particularly to controlling malaria vectors. mortality by the year 2000. The state of activities in relation to 1995 targets is presented in Figure 14.7. Continued priority was given to Social and economic research training in programme management, supervisory skills and correct management of diarrhoea cases in health facilities and in the home. By the end of 14.64 A socioeconomic study in Venezuela dur­ 1990, a total of 67 programme managers' ing the biennium demonstrated that people were courses had been held and 26.8% of health staff prepared to borrow, and repay, money to recon­ had been trained in supervisory skills. The pro­ struct their houses to make them resistant to the portion of curative health staff trained in correct triato mine vectors of Chagas disease. In Thailand, diarrhoea management was estimated to be village volunteers already experienced in the ap­ 14.3% at the end of 1990. New training materials plication of traditional medicine were found to be developed during the biennium included a pack­ the most effective in malaria control. In Nigeria, age for a four-day management course; a self­ work was begun to find the best and most cost­ instructional coursebook; elements of a package effective methods of delivering ivermectin with a to improve the teaching of diarrhoeal disease view to bringing onchocerciasis under control in control in medical schools, which were used dur­ the largest remaining focus of the disease in Africa. ing four workshops for paediatric teaching staff Research began on the development of cheap, in Nigeria and VietNam; and materials for the rapid techniques to determine high-risk areas for basic training of nurses and paramedical workers. each of the Programme's target diseases. 14.68 The exchange of information on the correct management and prevention of diarrhoea in the home was another important area of activity. Strengthening research capability Progress was made, in collaboration with UNICEF, in the planning and implementation of 14.65 In order to strengthen the research capaci­ communication activities in Sudan, United Re­ ties of developing countries, the Programme public of Tanzania and VietNam, particular at-

94 DISEASE PREVENTION AND CONTROL

Figure 14.7 Progress in reo

1995 Category of target target Progress ORS access role(%) G 63 ORT use rote(%) EJ 36 (me management role (%) G Superv~ory skilk training coverage (%) G dinicol monogemenltroining coverage (%) G

Percentage of target

• No lorgel set lor 199S. Progress shown in relorion lo 19891orgel. •• Based on survey resu~s !~om 17countries ond globol role of use of orof rebydrolion lheropy (ORT).

tention being given to careful timing of interven­ guidelines for the planning and assessment of tions to coincide with other programme activities. national activities in this area were produced. Seven more countries are known to have taken 14.69 It was agreed with UNICEF that the avail­ action to reduce the availability of inappropriate ability to all developing countries of an adequate drugs, and two manufacturers withdrew ineffec­ supply of oral rehydration salts (OR$) rather tive or unsafe drugs from the market in develop­ than support for limited production should be the ing countries. main objective. The production figure in develop­ ing countries increased slightly, passing the 1987 14.71 Among the available interventions for the level of 350 million packets, and 64 countries are prevention of diarrhoea, promotion of breast­ currently producing the salts. feeding is being given special emphasis. Visits were made to Bolivia, Brazil, Islamic Republic of 14.70 A review of commonly used Iran, , Philippines and Viet Nam to assist antidiarrhoeal drugs was published in 1990 with in assessing the situation and planning activities. the aim of promoting a more rational use of drugs in diarrhoea management.• A drug use ad­ 14.72 In 1991 cholera spread to Latin America dendum2 to the household survey manuaP and fo r the first time in this century, and extensive epidemics recurred in Africa. More deaths due 1 The rational use of drugs in the management of acute diarrhoea in to cholera were reported during 1991 than in children. Geneva, World Health Organization, I990. the previous five years combined. To coor­ 1 Document COO/SER/91.2. dinate WHO's activities in response to these 3 Document CDD/SER/86.2 Rev. 1, 1989. epidemics, a Global Task Force on Cholera

95 THEWORKOFWHO 199()-1991

Control was created in April 1991, including one trol measures (e.g. travel and trade restrictions; staff member from UNICEF; this has strength­ vaccination). ened global control efforts and collaboration with national programmes to improve

14.74 The global use rate for oral rehydration therapy by the beginning of 1990 was 36%, an increase of 4% compared with 1988. The case management rate (the proportion of diarrhoea episodes treated with appropriate oral rehydration therapy, including increased amounts of fluid and continued feeding) IS estimated to have been 19% (Figure 14.7).

14.75 In 1990 the scientif-ic working groups which had guided research activities since 1986 were replaced by a core of experts to advise on Open community well neor limo. Open wells such as this ore easily priority issues in each study area. Support was contomined and thus may become a source of serious infection os in given in 1990 to 18 new projects in 13 countries the cholero epidemic affecting Peru. and 25 established projects in 12 countries. and the Eastern Mediterranean to draw up na­ 14.76 A review of 13 controlled trials indicated tional cholera comrol plans and coordinate tech­ that a solution of ORS containing 50-80 g/1 of nical and financial resources; and six rice powder in place of glucose reduces the stool intercountry courses were beld to train trainers output of adults and children with cholera by in case management. Increased efforts were made 27% to 34% during the first 24 hours of treat­ to stimulate the local production of oral ment compared with standard WHO ORS solu­ rehydration salts in order to meet the additional tion. However, the stool output of infants and demands, and emergency supplies for treating children with acute diarrhoea not due to cholera cholera, including donat.ions from pharmaceuti­ is reduced by only 17% in the same period. A cal companies, were provided to Bangladesh, clinical trial of an ORS solution containing Benin, Cameroon, Chad, Liberia, , Niger, 50 mmol/1 glucose and 50 mmol/1 L-alanine Nigeria, Peru, Togo, and the displaced Kurdish with reduced total osmolarity showed that it populations in Islamic Republic of Iran and Tur­ had no appreciable advantage over standard key. In the Eastern Mediterranean Region coun­ ORS solution. tries at greatest risk were provided with emer­ gency stocks of medical and laboratory supplies. 14.n [n the area of epidemiology and disease Revised guidelines for cholera concroJI were pre­ prevention, ethnographic studies were con­ pared and widely diw·ibuted in English, French, ducted in poor peri-urban communities to deter­ Porntguese and Spanish, either separately or in a mine suitable methods of promoting breast-feed­ cholera information kit together with informa­ ing. The importance of poor hygienic practices as tion on case management and inappropriate con- a risk factor for severe diarrhoea was highlighted

1 Ootument WHO/COD/SER/80.4. , Rev. 2, 1991 (to be published ). I Ootumenf (00/ SER/90.1.

96 DISEASE PREVENTION AND CONTROL by the results of a study in the Philippines, and the roles of malnutrition and cell-mediated Acute respiratory infections immunodeficiency as risk factors for persistent diarrhoea were confirmed. In a multicentre 14.82 There is growing concern about the fact study, acute watery episodes were found to be that acute respiratory infections, mainly pneumo­ the most frequent clinical pattern for diarrhoeal nia, are now the first cause of childhood mortality deaths in Senegal (58%), whereas in Brazil per­ in developing countries, accounting for about sistent episodes contributed to 62% of deaths, 800 000 deaths in neonates and a total of 4.3 mil­ followed by acute watery diarrhoea (28%) and lion deaths in children under five. Correct case dysentery (10%). management with an appropriate antibiotic is the key to preventing most pneumonia deaths. Immu­ 14.78 Operational research is under way con­ nization against diphtheria, measles and pertussis is cerned with finding patterns and determinants of recommended as a specific preventive measure. correct use of oral rehydration therapy; evaluat­ Other preventive measures are being analysed with ing a treatment algorithm for the management of a view to selecting effective ways of dealing on a persistent diarrhoea; and developing methods of large scale with the main risk factors for pneumonia. analysing the breast-feeding situation and deter­ mining the critical elements and impact of inter­ 14.83 The World Summit for Children, held in ventions. September 1990, recognized the feasibility of con­ trolling childhood mortality from pneumonia and 14.79 The mam findings in WHO-supported established the goal of a one-third reduction in trials of rhesus and rhesus-human rotavirus deaths due to acute respiratory infections in chil­ vaccines are that single-serotype vaccines and dren under five by the year 2000. The Forty-fourth tetravalent vaccine provide substantially more World Health Assembly, in resolution WHA44.7, protection in developed than in developing urged Member States to" initiate or intensify activi­ countries; that the protection conferred by ties for the control of acute respiratory infections as single-serotype vaccines is not serotype­ an essential part of primary health care and as one of specific and is sustained for at least three years; the high-priority programmes for reducing mortal­ and tetravalent vaccine is no more protective ity in infancy and early childhood". The Regional than single-serotype vaccine. Whereas trials of Committee for Africa considered the status of the WC-3 vaccine carried out in infants in three problem and the regional control programme at its countries showed widely varying protection, forty-first session, in September 1991. ranging from nil to 76%, against rotavirus diar­ rhoea (caused mostly by serotype 1), a study of 14.84 WHO, UNICEF and UNDP sponsored WI79-9 (a derivative of WC-3 that produces the an international consultation for the control of VP7 antigen of serotype 1) showed 100% pro­ acute respiratory infections (Washington, D.C., tection against disease caused by rotavirus of December 1991) to draw the attention of policy­ serotype 1 or 3. makers to the problem. Intercountry meetings of programme managers evaluated the situation of 14.80 In the completed trials of live oral such programmes in South-East Asia Qakarta, Ty21a typhoid vaccine carried out in Chile and October 1990) and the Eastern Mediterranean Indonesia the most effective formulation was (Tunis, June 1991). found to be one in which lyophilized bacteria were reconstituted in a buffer solution before 14.85 A major target for the Organization is to being swallowed. The efficacy of the vaccine have programmes for the control of acute respi­ ranged from 53% to 77%, was greater in adults ratory infections operating by 1995 in all coun­ than in children, and was greater in Chile than in tries with an infant mortality rate of over 40 per Indonesia, which has a ten-fold higher attack 1000 live births per year. Among the 88 countries rate. falling in this category, 44 (50%) had control programmes in operation in at least one major 14.81 As the currently available cholera vaccine administrative division by the end of 1991. is not recommended for public health use, efforts to find an effective vaccine continued. Arrange­ 14.86 Revised technical guidelines on case man­ ments are being made to conduct trials of two agement1 and two review papers, one on the candidate oral vaccines in two or three Latin American countries in 1992-1993. 1 Document WHO/ARI/90.5.

97 THE WORK OF WHO 199D-1991 management of pneumonia in children1 and the 14.90 A multicentre study was organized in other on the use of antibiotics/ were issued. Two Ethiopia, Gambia, and devices developed in cooperation with UNICEF Philippines to obtain information on the clinical and industry-an electronic respiratory rate timer signs and etiological agents of pneumonia, sepsis and an oxygen concentrator suitable for use in and meningitis in infants under three months old. developing countries -were made available. Studies in Gambia and Malawi showed that sulfamethoxazole and trimethoprim in combina­ 14.87 Intercountry and national training courses tion are clinically effective against Plasmodium for programme managers, using material devel­ falciparum in children. A meeting of experts on oped during the previous biennium,3 were at­ overlap in the clinical presentation and treatment tended by 1316 participants. A set of materials of malaria and pneumonia (Geneva, April1991) for training supervisors in case management4 was recommended that a five-day treatment course also used at 430 national courses attended by with this combination alone can be administered more than 13 000 participants. Materials for the to children with signs of pneumonia and fever in training of staff at first-level facilities, and of areas where P. falciparum is endemic. Support community health workers, in outpatient care was provided for the surveillance of invasive H. were developed and field-tested in two countries. influenzae type b disease in theWestern Division A regional training centre for French-speaking of Gambia, in preparation for a vaccine efficacy countries on acute respiratory infections was es­ trial in 1992. tablished in Tunis in collaboration with the Arab Council for Childhood and Development. Posi­ tive changes in clinical practices, such as reduc­ tion in the use of antibiotics for mild infections Tuberculosis and of cough and cold medicines, and less fre­ quent referral of children with such infections to 14.91 With an estimated eight million new cases hospitals, have been reported in a number of and nearly three million deaths yearly, tubercu­ countries as an immediate result of training ac­ losis constitutes a world health problem of stag­ tivities undertaken in national programmes. gering proportions (see Table 14.1).

14.88 A protocol for specific ethnographic stud­ Table 14.1 Global tuberculosis situation: ies was developed and tested in 14 countries. The estimated cases and deaths, 1990 information collected on beliefs and practices related to pneumonia and other respiratory con­ Prevalence New Deaths ditions in children was used to adapt generic of Infection cases educational messages to local cultural conditions. 18 social scientists from 10 countries were Reg1on (thousands) trained in the use of the protocol at three work­ Africa 171 000 1 398 656 shops held in , Thailand and United Amencas1 117 000 564 220 States of America. South-East As1a 426 000 2 480 932 Eastern 14.89 The preparation of the manual on meth­ Mediterranean 52 000 594 163 ods for the surveillance of bacterial drug resist­ Western Pac1f1c 2 574 000 2 557 894 ance was completed and the draft was reviewed lndustnal1zed by a group of experts (Geneva, December 1990). countries3 382 000 409 42 In the light of two field studies, it affirmed that surveillance can be based on the investigation Total 1 722 000 8 002 2 907 of strains of Streptococcus pneumoniae and Haemophilus influenzae isolated from the naso­ ' Exclud1ng and the Un1ted States of Amenca pharynx of children with signs of pneumonia. 2 Excluding , Japan and New Zealand 3 Australia, Canada, Japan, New Zealand, United States of Amenca and all European countnes 1 Document WHO/ARI/91.20. 1 Document WHO/ARI/90.1 0. 3 ARI Programme Management: A training course, Geneva, World Health Organization, 1990. The decline in incidence observed in industrial­ 4 Supervisory skills: Management of the Young Child with an Acute Respira­ ized countries for many decades appears to have tory Infection. Revised edition. Geneva, World Health Organization, 1991. stopped. The downward trend in the United

98 DISEASE PREVENTION AND CONTROL

States of America has been reversed, mainly be­ ization. This strategy was further discussed by cause of the interaction of tuberculosis and hu­ the Forty-fourth World Health Assembly and man immunodeficiency virus (HIV) infection, approved by it in resolution WHA44.8. but the reasons for the change in some European countries and in Japan are not yet known. Large 14.95 The target is to achieve by the year 2000 increases in numbers of cases are being observed an 85% cure rate among sputum-positive cases in the countries of tropical Africa and the Carib­ under treatment and a 70% case detection rate. bean, where HIV infection is highly prevalent. Priority is given to improving the cure rate Over three million people are infected with both through well-managed programmes of short­ the tubercle bacillus and HIV, 2.4 million in sub­ course chemotherapy. Case-finding activities Saharan Africa alone. Many national tuberculosis will be expanded only when an acceptable cure programmes now have to deal with case loads rate has been achieved. At the district level, na­ that have doubled over the last few years. In­ tional programmes will operate wherever poss­ creases in reported cases of tuberculosis have also ible through the primary health care system, been noted in some countries, such as Lebanon, supervision, training, monitoring and leader­ Philippines and VietNam, before any reports of ship being provided by a specialized central an HIV epidemic. unit. This approach should strengthen the local health infrastructure and, in some cases, help 14.92 In many countries in the developing develop the curative component of primary world national tuberculosis programmes are not health care. functioning satisfactorily; it is estimated that less than half the existing tuberculosis cases are being 14.96 Although the control strategy calls for the detected and less than half those detected are application of the technology already available, being cured. However, a number of countries attention will be given to new approaches in have shown that national programmes can service delivery and programme management achieve, under a variety of conditions, at least an and to research on new diagnostic, treatment and 80% cure rate when short-course chemotherapy preventive methods. While it is for Member is backed by effective programme management. States to take the initiative in developing their Furthermore, evaluation of the programmes has national programmes, WHO will build up a shown that with good management tuberculosis global coalition with other international organ­ control is one of the most cost-effective health izations and bilateral agencies, nongovern­ measures. mental organizations and the medical and scien­ tific community to assist them in their efforts. 14.93 The main objectives of the WHO tuber­ culosis programme for the biennium were to 14.97 As for the regions, the Regional Commit­ draw up a new coordinated global tuberculosis tees for South-East Asia and the Eastern Medi­ control strategy, develop tools for implementing terranean have adopted resolutions on tubercu­ it, provide national programmes with direct sup­ losis control; subregional and regional work­ port, single out high-priority research areas and shops in and Venezuela, respectively, implement field studies on AIDS-related tuber­ trained staff from 30 countries in methods for culosis. introducing the new strategies.

Strategy development Technical guidance

14.94 The recommendations of a number of 14.98 Following a workshop held in Geneva in technical meetings and workshops convened to July 1990, guidelines were prepared on tubercu­ develop new control strategies were reviewed by losis treatment for adults and children. Another the Coordination, Advisory and Review Group workshop drew up recommendations on case in May 1991. It endorsed the proposed targets, definitions and case reporting systems for use in approach and activities and called for the estab­ national programmes. lishment, under WHO leadership, of a global tuberculosis programme to implement a compre­ 14.99 Countries were given advice on how to hensive strategy providing for control activities, improve their programmes, together with sup­ basic and applied research and resource mobil- port in the form of supplies, equipment, and

99 THE WORK OF WHO 199o-1991

WHO fellowships. The number of countries global elimination of leprosy as a public health using short-course chemotherapy has in­ problem, defined as a reduction of global preva­ creased during the biennium, and almost all the lence to below one case per 10 000 population. countries of the Americas and the Western This has become a practical possibility as a result Pacific now apply the method. of the adoption of multidrug therapy, the in­ creased priority accorded to leprosy by several of WHO's Member States and the substantial support given by nongovernmental organiza­ Training and research tions, in particular the Japan Shipbuilding Indus­ try Foundation, the International Federation of 14.100 The first draft of a training manual was Anti-leprosy Associations, and the International prepared in 1990, then reviewed by education Leprosy Association. specialists and tested in the field. Training courses were held in India, Japan, and the United 14.104 The number of registered cases in the Republic of Tanzania for 90 English-speaking world decreased by some 30%, from 5.4 million participants and in for 50 French­ to 3.7 million, between 1986 and 1990, and cov­ speakers. Participants in the course in the erage with multidrug therapy continued to in­ United Republic of Tanzania were given an crease, rising from 45% in 1989 to 56% in 1990. opportunity to study for themselves that coun­ Successful application of multidrug therapy also try's very successful national programme, helped to foster awareness of the problem within which has served as a model for the development communities and to increase self-reporting of of WHO's new control strategy. Regional and cases. national training courses were held in Argentina, Brazil, Chile and Mexico. International bacteri­ 14.1 OS A working group on leprosy has been set ology training courses were held in Argentina up which is expected to meet annually from 1991 and Canada. onwards to review the strategies for eliminating leprosy as a public health problem. With guid­ 14.101 Joint research projects were undertaken ance from this group, the global and regional with the Global Programme on AIDS in order to leprosy programmes have started preparing elucidate the epidemiological impact of HIV on strategies which will in turn be used as a basis for tuberculosis, to evaluate the efficacy of tubercu­ the development of strategies by each country. losis treatment in HIV-infected persons, and to study the efficacy and acceptability of preventive 14.106 Many leprosy cases remain undetected, chemotherapy in persons with tuberculosis/HIV the proportion varying from country to country. coinfection. Nevertheless, the significant reduction in regis­ tered leprosy cases over the past five years sug­ 14.102 Several workshops were held to review gests that the prevalence of the disease has fallen. current technology and determine the research Estimates are currently being updated. The activities necessary to develop new tools for im­ number of new cases detected over 12 months in proved diagnosis, treatment and prevention. 1989-1990 indicates a global case-detection rate Under the WHO/UNDP programme for vac­ of 1.09 per 10 000 population. cine development a collaborative study of the role of the polymerase chain reaction in the diag­ 14.107 Efforts have been made to strengthen the nosis of sputum-smear-negative tuberculosis was management of national leprosy control pro­ initiated. In September 1991 a WHO scientific grammes by organizing courses and workshops working group met in Geneva to assist in the and to promote health systems research in order development of a specific research plan for the to find feasible, cost-effective solutions to opera­ tuberculosis programme. tional problems that might impede the carrying­ out of multidrug therapy. Courses on control programme management were held in New Delhi, Alexandria and Lagos, with about 60 par­ Leprosy ticipants in all. Consultant services have been provided to support governments in the prepara­ 14.103 In resolution WHA44.9 the Forty-fourth tion of plans of action, in training and in the World Health Assembly declared WHO's evaluation of leprosy programmes in various commitment to achieving by the year 2000 the countries.

100 Figure 14.8 Prevalence of registered leprosy cases in the world as ot31 October 1990

bo 'V~

"'

~ 5:: ~ ....;;g ;Sj Q :a: 0 " 0 ::::! I •4'. ~ 0 ·. <) @ ~ (]) ~ ~ ID B 0 :a: ID ~c.~~···.:::~·.; 0 Q ;;;: Prevalence rate ~ ~=ooo-,w 1·· . ~ 0 per 1000 (Number of ... . countries/areas) 0 CJ < 0.1 (109) 01 0 ,_.,.. \d ~:.:)j:::.\:J 0.1 - 0.9 (65)

IIIIIIIIIIl 1 - 1.9 ( 19)

2-2.9 (06) D ~ ~3(03) dlJ ~ 0 ~ No data (02) ~

The designations employed and the presentat1on of matenal on th1s map do not 1mply the express•on of any opin1on whatsoever on the part of the World Health Orgamzat1on concernmg the legal status of any country, terntory, city or area or of 1ts authontles, or concermng the dehm•tat1on of 1ts frontiers or boundanes THE WORK OF WHO 199D-1991

Table 14.2 Distribution of registrered leprosy cases, by WHO region, 1990

WHO region Registered Prevalence Percentage New cases Case detection cases per 10 000* of total detected per 10 000*

Afnca ...... 482 669 9.20 12.91 37 335 0 71 Americas ...... 301 704 4 20 8 08 30 543 0 42 South-East Asia ...... 2 693 104 20 50 72.06 488 285 3 72 Europe ...... 7 246 010 0.19 87 0 00 Eastern Mediterranean ... 99 913 2.60 2 67 6 008 0.15 Western Pacific ...... 152 739 1.00 4 09 14 103 0.09

World ...... 3 737 375 7 10 100.00 576 361 1 09

' Based on the 1990 m1d-year populat1on data from Un1ted Nat1ons World population prospects 1988 New York, Un1ted Nat1ons, 1989

14.108 Table 14.2 shows the distribution of regis­ cination campaigns, led to a marked reduction in tered leprosy cases by WHO region in 1990, the number of human cases, saving hundreds of Table 14.3 shows coverage with multidrug lives (see Figure 14.9 showing the correlation therapy, and Figure 14.8 the prevalence of lep­ between dog vaccination and lower numbers of rosy in the world. human rabies cases in Sri Lanka). The final evalu­ ation indicated, however, that although rabies was 14.109 More information on recent develop­ brought under control in the three countries in­ ments in research is given under "Tropical dis­ volved, the national or local projects did not reach ease research" (see paragraph 14.62). the target of elimination. The main reasons for this were weaknesses in intersectoral collaboration, leading to inadequate resource mobilization; high dog population turnover requiring annual instead Zoonoses of biennial dog vaccination campaigns; the need for special efforts to obtain access to 70% of the 14.110 Prevention of animal and human rabies is dog population; and an inadequate supply of ef­ one of the priorities in the zoonoses programme. fective veterinary rabies vaccines. In the Region of Activities have been concentrated on research the Americas the programme for the elimination promotion and coordination and on management of urban rabies, also based on mass dog vaccina­ of interregional and intercountry field projects for tion, has contributed to reducing the number of canine and wildlife rabies control. The joint human deaths from rabies in the Latin American WHO/AGFUND project for prevention and countries, especially in the major urban centres. In control of human and canine rabies in Ecuador, Sri these areas 95 deaths were reported in 1989, as Lanka and , consisting mainly of dog vac- against 169 in 1980.

Table 14.3 Multidrug therapy coverage, by WHO region, October 1990

Registered Coverage Completed WHO reg1on cases (%) multldrug therapy

Africa ...... 482 669 18.37 102 552 Americas ...... 301 704 23 75 23 114 South-East As1a ...... 2 693 104 66 15 1 020 453 Europe ...... 7 246 49 72 238 Eastern Mediterranean ...... 99 913 38.87 17 177 Western Pacific ...... 152 739 63.40 41 287

World ...... 3 737 375 55 68 1 204 821

Source World Health Stat1st1cs Quarterly, 44 ( 1991 )

102 DISEASE PREVENTION AND CONTROL

Figure 14.9 Effect of dog vaccination in reducing the number of deaths from human rabies in the AGFUND project area in Sri lanka

1975 f==1 1976 1977 1978 1979 1980 1981 1982 ===:J 1983 1984 1985 1986 1987 "$2 1988 o; 0 1989 ~ 1990 I I I I 150 100 50 0 0 100 200 300 Human deaths Dog vaccinations {in thousands)

14.111 Oral rabies vaccination of dogs could be­ canine-rabies vaccine production unit with an come a powerful tool for elimination of canine annual output of 500 000 doses. This informa­ rabies if used as a complementary method in the tion will be especially useful when a feasibility numerous countries where dog rabies has or study is being carried out for the establishment could be brought under control by means of of such units at national or regional level. parenteral vaccination. The technique would also be of major interest in those countries where 14.113 The occurrence in in 1988 of a accessibility of dogs to parenteral vaccination is rabies outbreak caused by an Arctic strain of low or requires extensive efforts. WHO-coordi­ virus stimulated WHO-coordinated research on nated research during the two years under review the control of Arctic rabies, including studies on was therefore focused on the assessment of can­ oral vaccination techniques under Arctic or sub­ didate vaccines and the selection of appropriate Arctic conditions. baits for oral vaccination of dogs. Research on bait delivery systems was carried out in Mexico 14.114 WHO continued its active promotion of and Tunisia, and field trials were initiated in 1991 cross-border collaboration for oral vaccination in . Guidelines for testing oral vaccines, of foxes in Europe and intensified surveillance bait composition and bait delivery for dog rabies for evaluating the efficacy of the oral vaccination control were prepared during a WHO consulta­ technique in Europe (see Figure 14.10). The tion in Geneva in July 1990.1 Organization also strengthened its collaboration with the scientists involved in bait delivery pro­ 14.112 WHO continued to promote transfer of grammes for control of rabies in various wild technology for rabies vaccine production by pro­ animal species in the Americas, and cooperated viding production units with technical advice, with the countries in the South-East Asia Region consultants and reagents. It also prepared in­ in launching programmes for rabies prevention structions for designing, equipping and staffing a and control. Activities to combat the disease continued in the Eastern Mediterranean Region, where urban rabies is still prevalent, and notably in the Persian Gulf countries, where the im­ 1 Document WHO/RAB.RES/91.37. portance of fox rabies is increasing.

103 THE WORK OF WHO 199D-1991

Figure 14.10 Area in Europe for coverage by oral vaccination of foxes, 1991

Poland

France

B Rabies vaccination campaign, 1991

Spain 0 50 lOOkm ~

14.115 Eight years of WHO-coordinated col­ provided encouraging results on the efficacy of laborative studies led to the development of three large-scale distribution of baits containing panels of monoclonal antibodies for rabies diag­ praziquantel for tapeworm treatment of foxes in nosis and research. Selected monoclonal anti­ nature. An ELISA technique has been tested for bodies constituting the core of these identifica­ screening human populations at risk and also for tion panels are now available through WHO. determining prognosis after surgery and during chemotherapy. Genetically engineered candi­ 14.116 In the eighth report of the WHO Expert date vaccines against Echinococcus granulosus Committee on Rabies (Geneva, September have been used in experiments in target species. 1991)1 important recommendations were made The WHO guidelines for echinococcosis/ on human post-exposure treatment, rabies vac­ hydatidosis control in man and animals are being cine potency testing and international transfer of updated. animals. The 1973 edition of the WHO mono­ graph on laboratory techniques in rabies2 was 14.118 Results of studies on oral brucellosis updated and the new fourth edition should be­ brought evidence of a protective effect of the come available by 1993. Brucella suis strain 2 vaccine, although further trials are needed to determine whether and to 14.117 Collaborative studies on alveolar what extent this vaccine strain will be able to echinococcosis initiated by WHO four years ago eliminate the pathogenic strains of B. melitensis under field conditions. Countries in the South­ East Asia and Eastern Mediterranean Regions 1 Report to be published in the WHO Technical Report Series. were provided with technical expertise for the 1 Kaplan, M. & Koprowski, H. eds. Laboratory techniques in rabies (3rd drawing-up and implementation of brucellosis editron). Geneva, World Health Organization, 1973. control programmes.

104 DISEASE PREVENTION AND CONTROL

14.119 In view of the increasing significance of sexually transmitted diseases. A standardized zoonoses caused by enteric bacteria and the com­ system for reporting on the status of national plexity of their epidemiology, new approaches programmes on sexually transmitted diseases have been developed for veterinary education in was developed and field-tested in Africa and the basic epidemiology, as well as animal production Americas. Emphasis was placed on the inclusion and product hygiene. First results indicate that of measures to control sexually transmitted dis­ more effective salmonellosis control is feasible at eases in primary health care, on coordination all steps along the food chain, particularly in feed with national AIDS programmes, and on joint provision, farming and slaughter processes. This activities with programmes for mother and child requires the establishment of procedures for health care, family planning, the strengthening of quality assurance by food-chain partners, par­ health laboratory infrastructure and the provi­ ticularly by the sub-sector for production sup­ sion of essential drugs. port (feed, pharmaceuticals, vaccines), hus­ bandry, slaughter and harvesting. Complemen­ 14.122 Rational management of patients remains tary research on diagnosis, microbiologically a cornerstone of programmes on sexually trans­ controlled production of animals, vaccine devel­ mitted diseases, as it achieves the twin aims of opment and slaughter technology is being organ­ reducing morbidity, particularly from complica­ ized by ten research teams. tions of infections, and preventing transmission of infections, including HIV. 14.120 Technical cooperation between WHO/ PAHO and countries in the Americas for the 14.123 The report of a WHO Study Group on prevention and eradication of foot-and-mouth Management of Sexually Transmitted Diseases disease continued with a view to facilitating the Patients2 gives practical guidance on diagnosis organization of animal health services and the and treatment, particularly as part of primary increased production of protein foods of animal health care, on counselling and health education ongm. of patients, on partner notification and treat­ ment, on additional testing and on reporting of (For more information on food safety, see the cases. relevant section in Chapter 9, paragraphs 9.30- 9.39.) 14.124 Bacterial sexually transmitted diseases, in particular gonorrhoea and chancroid, whose pathogens are often resistant to commonly used antibiotics such as penicillin and tetracyclines, Sexually transmitted diseases are having to be treated with more expensive antibiotics, such as cephalosporins and 14.121 National programmes on the prevention quinolones. A global network to monitor the and control of sexually transmitted diseases were sensitivity of gonococci to antimicrobials came further developed or strengthened in many into operation during the biennium. countries of all WHO regions, with particular emphasis on linking or integrating strategies to 14.125 Guidance was given on how to set up a control sexually transmitted diseases and human sexually transmitted diseases clinic as the nucleus immunodeficiency virus (HIV) infection. The for a national centre of excellence for training framework for this coordination was laid down and research in the many aspects of prevention in a WHO consensus statement.' It is now clear and control.J that curbing the AIDS pandemic will call for an urgent intensification of efforts to control sexu­ 14.126 In the absence of effective vaccmes, ally transmitted diseases, and the World Bank, changes in sexual behaviour must remain the es­ the Commission of the European Communities, sential strategy for primary prevention of most and USAID and other major bilateral donors are sexually transmitted infections, in particular now committing considerable resources for this those of viral origin. At a meeting convened by purpose. Within WHO, administrative arrange­ PAHO/WHO (Kingston, December 1990) ments have been made to coordinate activities for scientists from 44 countries reviewed their the prevention and control of AIDS and other

1 WHO Technical Report Series No. 810, 1991. 1 Document WHO/GPA/INF /90.2. 3 Document WHO/VDT/90.453.

lOS THE WORK OF WHO 199D-1991 experiences of behavioural interventions for the 14.132 Endemic treponematoses persisted, with control of sexually transmitted diseases. new outbreaks in West and Central Africa, the Caribbean and South-East Asia. National pro­ 14.127 As infection by sexually transmitted dis­ grammes received WHO support in Mali and eases is often asymptomatic, active case-finding Papua New Guinea, but additional resources will must be undertaken in high-risk groups and in be necessary if these crippling diseases are to be specially vulnerable subjects such as pregnant eliminated. women. Guidelines for the prevention of ad­ verse effects of maternal syphilis on the outcome of pregnancy, based on experience of the Zambian programme, were issued.' AIDS 14.128 The WHO "laboratory-bench" manual on sexually transmitted diseases2 has proved to 14.133 The AIDS epidemic, which appeared at be a valuable tool in training and in the develop­ first to be a problem more or less confined to ment of efficient laboratory services, which are homosexual men and injecting drug users in in­ an essential support for case-finding, the man­ dustrialized countries, has now evolved into a agement of patients and surveillance. The global pandemic affecting millions of men, women, and proficiency testing system for syphilis serology children in all . Heterosexual trans­ was extended to 42 national reference labora­ mission of human immunodeficiency virus tories and it is hoped to expand it further. (HIV) is growing in importance throughout the world and is the predominant mode of spread in 14.129 A practical guide on a system for the sur­ sub-Saharan Africa, Asia and parts of Latin veillance of sexually transmitted diseases is in America. Women are therefore increasingly af­ preparation for use in training in collaboration fected, and by the year 2000 there will be as many with the African Union against Venereal Dis­ infections in women as in men (see Figure 14.11). eases and Treponematoses. Methods for rapid As more women acquire the infection, more chil­ assessment of the prevalence of sexually trans­ dren are born with it. mitted diseases were studied in Senegal and Uganda in collaboration with the World Bank. 14.134 HIV infection resulting from contami­ nated blood transfusion has been virtually elimi­ 14.130 Twenty priority topics for research to im­ nated in the industrialized countries and is de­ prove interventions have been singled out to clining elsewhere as a result of the WHO Global guide WHO and international donor agencies. Blood Safety Initiative. However, HIV trans­ Current knowledge of the relation between mission through needle-sharing by injecting human papillomavirus and cervical cancer was drug users is on the rise in many places. reviewed at a meeting (, November 1991) organized by IARC. 14.135 While a cumulative world total of 203 599 AIDS cases had been reported by 152 countries 14.131 In the industrialized world hepatitis B or areas as at 1 January 1990, by 31 December virus infection is mainly sexually transmitted, 1991 the total had doubled to over 400 000 cases but in the developing world, where only 20%- reported by 163 countries or areas. However, 30% of infections are believed to be acquired taking into consideration under-diagnosis, sexually, it is predominantly transmitted in the under-reporting and delays in reporting, WHO perinatal period and in childhood. This is the estimates that by the end of 1991 more than a only sexually transmitted disease for which an million AIDS cases and some 8-10 million HIV effective vaccine is available. A consensus state­ infections had occurred in adults, plus over ment on how to control it as a sexually transmit­ 500 000 paediatric AIDS cases due to perinatal ted disease was drawn up at a WHO meeting in transmission (more than 90% of them in sub­ Geneva in November 1990.3 Saharan Africa) and about a million cases of chil­ dren born with HIV infection. Cumulative to­ tals of 30-40 million HIV infections and 12-18 million AIDS cases in adults and children are 1 Document WHO/VDT/91.455. expected by the year 2000. During this decade 2 Document WHO/VDT/89.443. and the next, AIDS may increase child death 3 Document WHO/MIM/VDT/91.457. rates in some countries by as much as 50%,

106 DISEASEP REVENTION AND CONTROL

Figure 14.11 Estimated or projected annual global adult incidence of HIV infection, by sex, 1980-2000

1.2 female - D D male r--- . ~ 0.8 - ·e - :§. 0.6 - e ...c: r- 7§ 0.4 - -= - 0.2 -

0 -~ 1980 1985 1990 1995 2000 Year

eliminating the gains in chjld survival achieved fected persons and a danger to public health; and over the past two decades. Over and above the to fight complacency and denial so that countries direct health care costs, the pandemic will thus everywhere confront the AIDS pandemic in a have an overwhelming socioeconomic impact. spirit of realism and solidarity.

14.136 Six priorities have been identified for 14.137 There has been an unprecedented re­ WHO's work in AIDS prevention and control sponse to the pandemjc from the governments of in the early 1990s. They are: to strengthen the world. By the end of 1991, all Member States national AIDS programmes, especially their had a national AIDS programme, and of the managerial and technical capabilities; to plan for 169 countries or areas collaborating with WHO the social and economic consequences of AIDS 131 had formulated short-term and 125 medium­ which threaten individuals, families, communi­ term plans for thetr AIDS programme (Table ties and the economic stability of many develop­ 14.4). Resource mobilization efforts to guaran­ ing ; to develop more effective mterven­ tee the sustainability of these programmes had tions for halting the spread of HN and caring for resulted in pledges of approximately $440 mil­ infected persons; to accelerate biomedical re­ lion, indudmg funds channelled through the search aimed at producing safe, practical, effec­ WHO Trust Fund for the Global Programme on tive, affordable and universally available vacctnes AJDS and those from multibilateral and bilateral and drugs; to support and to op­ sources. In.itiaUy, owtng to the rapid growth of pose discrimination and stigmatization as irra­ the pandemic, national programmes "'vere unable tional and unethical attitudes towards H IV-in- to make effective use of all the funds available.

Table 14.4 Status of collaboration with notional AIDS programmes by activity, December 1991 (cumulative numbers)

1987 1988 1989 1990 1991 December December December December December

Initial technical visits 111 152 159 169 169 Short-term plans 75 11 8 123 130 131 Medium-term plans 26 51 95 113 125 Programme reviews 1 10 34 62

107 THE WORK OF WHO 199()-1 991

Then, as both they and WH 0 gained more expe­ the past three years through social and behav­ rience in AfDS prevention and care, their mana­ ioural surveys which have been initiated or com­ gerial capability improved, resulting in better pleted in many Member States, including devel­ utilization of funds and more effect.ive pro­ oping countries where such research has hitheno gramme implementation. Managerial changes been rare. The most relevant results of these have also been made foUowing the formal re­ surveys are being analysed and summarized for views of national AIDS programmes undertaken publication and dissemination. In addition, an by countries with WHO support. In all, since evaluation of the quality of the data is under way the first review in December 1988, 62 have been to determine the reliability and valjdiry of an­ carried out by 53 countries: 39 reviews in Africa, swers to sensitive questions on sexual behaviour 19 in the Americas (most of them in the Carib­ and practices. National communications staff bean), three in South-East Asia and one in the have also been trained in the design of campaigns Eastern Mediterranean. An analysis of the first of information, education and communication. 14 programme reviews was reassuring about cer­ tain managerial aspects. The central unit of the 14.139 Campaigns to promote the use of con­ programme, usually located w ithin the ministry doms under national AIDS programmes, par­ of health, was widely recognized as providing ticularly in the African Region, have received leadership, direction and coordination; and core special attention and suppon; 80% of the staffing for the national programme was in place. 114 million condoms shipped during 1990-1991 These were considered remarkable achievements were delivered to Africa. During the biennium for such new programmes. However, the analy­ five informal interagency meetings were con­ sis also showed a need for general broader vened to mobilize resources and coordinate ac­ strengthening of the management of pro­ tion for ensuring global condom supplies to meet grammes and for high-level political commit­ the needs of national AIDS programmes. ment. UNICEF, UNFPA, the World Bank, the United States Agency for lntcrnationaJ Development, 14.138 The paramount need for information, and the International Planned Parenthood Fed­ education and communication was uniformly eration were joined at the fifth meeting by the recognized in all national medium-term plans Overseas Development Administration of the but, as would be expected in the early stages of a United Kingdom and the Commission of the pandemic, there were a number of constraints. European Communities, and other bilateral do­ Two crucial problems were the absence of base­ nor agencies have expressed interest in partici­ line informati~1n oo local knowledge, attitudes pating .in future meetings. An overall strategy and practices regarding AIDS and lack of trained based on guidelines for condom procurement staff. These problems have been tackled during and logistics management, and including a train­ ing curriculum for national programme man­ agers, has been developed and is being imple­ mented. Nine condom quality assurance labora­ tories have been established in the African Re­ gion with WHO assistance, enabling local pro­ grammes to monitor the rate of condom deterio­ ration while products are in the distribution pipeline.

14.140 WHO continued to cooperate in develop­ ing a safe blood supply and rationalizing the use of blood in developing countries, since up to 10% of all HIV infections in many countries are caused by transfusion of blood or blood pro­ ducts. Specific guidelines and recommendations have been developed for ensuring safery at source (through recruitment of voluntary blood donors), excluding infected blood, improving Learning from young people about the causes of their concern regarding laboratory and manufacturing practices and AIDS in order to ensure that control programmes ore meaningful fo r quality control, and educating prescribers of them. blood to reduce unnecessary transfusions. Since

108 DISEASE PREVENTION AND CONTROL

1986 all developing countries have been screen­ centre cohort study involving 26 centres and ing blood for HIV, but many of them are still a 907 patients.1 long way from screening the whole of the blood supply. Great strides have also been made in 14.144 In recognition of the socioeconomic con­ rationalizing blood transfusion practices (see sequences of the pandemic, WHO has promoted also Chapter 13, paragraphs 13.6 and 13.7). multisectoral action with other agencies in the system. To cite but a few exam­ 14.141 Nowhere should AIDS prevention and ples, the Organization has collaborated with control rest wholly on the shoulders of govern­ UNDP in mobilizing external resources for na­ ment. Nongovernmental organizations, includ­ tional AIDS programmes and in other areas un­ ing community groups in the private, voluntary der the WHOIUNDP Alliance to combat AIDS; sector, have a unique role to play, e.g. in efforts with the World Bank in studies on the likely to change sexual behaviour and in the provision effectiveness and cost of interventions to prevent of health and social services to ease the burden HIV transmission and provide care for HIV­ on infected persons and their families. The infected persons and AIDS sufferers; with involvement of nongovernmental organizations UNFPA to incorporate information on HIVI in AIDS prevention and control was promoted AIDS into training materials for maternal and through the "partnership programme", an child health and family planning workers, and in experimental seed-funding mechanism for programme or project development in several innovative, replicable AIDS projects at com­ developing countries; with UNICEF to pro­ munity level. During the biennium $2.4 million mote an effective community response to the was allocated to such projects, building collabo­ needs of children born to parents with HIVI rative relations between WHO, nongovern­ AIDS; and with UNESCO in a pilot project on mental organizations and national AIDS AIDS education in schools in seven developing programmes. countries in Africa, Latin America and the Pacific. 14.142 WHO has promoted the development of candidate vaccines for preventing HIV infection, 14.145 In spite of continued efforts to counteract inhibiting the development of AIDS in persons discrimination against and stigmatization of per­ already infected, or preventing perinatal trans­ sons with HIV infection and AIDS, in response mission. It has supported the strengthening of to World Health Assembly resolution facilities in field sites for AIDS vaccine efficacy WHA41.24 (May 1988), some countries have trials in developing countries to ensure that they been slow to tackle this issue. Certain govern­ are not excluded from participation in vaccine ments have been reluctant to take the necessary development and the resultant benefits. In June steps because AIDS is associated with strong so­ 1991 a meeting of senior officials from 18 phar­ cial taboos. WHO has, however, consistently maceutical companies involved in AIDS vaccine advised governments that non-discrimination is and drug development was convened by WHO not only a human right but a requirement for and UNDP, in collaboration with the Interna­ ensuring that infected persons are not driven tional Federation of Pharmaceutical Manufac­ underground, where they are inaccessible to in­ turers' Associations, to discuss collaborative formation and education or as credible bearers of activities related to the development, testing and AIDS prevention messages for their peers. In global availability of new products. May 1990 the Director-General sent a note verbale to all Member States suggesting that they 14.143 A manual giving model prescribing infor­ should review their national policies and laws mation for drugs used in HIV infection was pre­ with a view to repealing any that may give rise to pared, together with protocols to help countries discrimination against HIV-infected people and make rational choices on drug use and correctly people with AIDS. Attempts to keep HIV -in­ estimate drug requirements. WHO's aim is to fected travellers out of a country, and to detect ensure the availability of drugs for HIVI AIDS and confine infected nationals, are dangerous be­ to the population at an affordable price, and cause they can never be a hundred per cent effec­ to strengthen the capacity of developing coun­ tive, but may delude the general public into be­ tries to participate in their development. To lieving that precautions are no longer necessary facilitate research in this field, a WHO clinical staging system for HIV infection and AIDS was developed and validated through a multi- 1 See Weekly Epidemio/ogtcal Record, 65; 221-224 (1990).

109 THE WORK OF WHO 199D-1991 in such a "risk-free" environment. In recogni­ ers per year. WHO has been working with tion of the need to formulate a clear policy on health ministries in planning the introduction of laws regarding short-term entry a systematic glo­ the new hepatitis B vaccine into infant immuni­ bal study was undertaken in 1991. WHO policy zation programmes. More than 30 countries is being further developed in the light of the have instituted routine use of the vaccine to im­ study, using a consensus-building approach munize infants, and 20 others are seeking re­ which includes consultation with representatives sources to enable them to follow suit. Recom­ from governments and nongovernmental organi­ mendations to include the vaccine in routine im­ zations and experts in the fields of human rights, munization of all children were issued by the public health and ethics. Global Advisory Group of the Expanded Pro­ gramme on Immunization. Guidelines for con­ 14.146 WHO coordinated the worldwide ob­ trol of hepatitis B as an occupational hazard and servance of World AIDS Day on 1 December for as a sexually transmitted disease are to be issued. the third and fourth years. This has become an Control projects are in progress in Brazil, annual event in most countries and provides an Cameroon, Gabon, , and Peru. opportunity to enhance awareness of AIDS, A major conference on hepatitis B immunization stimulate discussion, give recognition to the ef­ in the developing world was held in Cameroon in forts already being made to fight the pandemic, October 1991. and encourage new action. The theme "Women and AIDS" was chosen for 1990 with the aim of 14.149 Arthropod-borne viruses and viral encouraging individuals and national AIDS pro­ haemorrhagic fevers. The causal agents of den­ grammes to give greater consideration to the spe­ gue fever are the most widespread arthropod­ cial needs and status of women. In 1991, the borne viruses, being endemic in about a third of theme was "AIDS: Sharing the challenge", WHO Member States. Unfortunately, the dis­ which underlined the need for individuals, ease has recently been spreading to new regions, groups, communities, nongovernmental organi­ and it has become a major new health threat in zations, agencies of the United Nations system, many areas of the developing world. In the last and nations to join in providing a multisectoral two years there have been major epidemics in response to the AIDS pandemic. While WHO Peru and Venezuela and limited outbreaks in will continue to provide global leadership, the Brazil. This increased incidence, combined with spreading threat clearly requires a multisectoral the circulation of many different serotypes, has response, with input and support, both financial led to the reappearance of the clinically most and technical, from all partners. severe dengue haemorrhagic fever- dengue shock syndrome - and in Venezuela 3108 cases out of the total of 12 220 were in this category. WHO cooperated in strengthening national capability Control and surveillance of for aerial insecticiding, laboratory diagnosis and viral and bacterial diseases case management.

14.147 Recommendations were again made each 14.150 Viruses causing haemorrhagic fever with year as to the influenza virus strains to be used renal syndrome have now been shown to be for producing vaccines for the coming influenza present in many parts of the world. WHO is season. In cooperation with the Expanded Pro­ continuing efforts to develop simple methods of gramme on Immunization, studies on environ­ rapid diagnosis. mental surveillance of polioviruses were organ­ ized and a bank of wild poliovirus strains was 14.151 A long-term collaborative project be­ established. tween the Argentine and United States govern­ ments and PAHOIWHO has led to the success­ 14.148 Viral hepatitis. Hepatitis B can now be ful development of a live attenuated vaccine prevented with a safe and effective vaccine - the against Junin virus, the cause of Argentine first vaccine against a potential cause of cancer. haemorrhagic fever. Extensive field trials have Approximately 300 million persons in the world established the vaccine as safe and highly effica­ are chronically infected carriers of the hepatitis B cious. Preliminary animal testing indicates that it virus, at high risk of serious illness and death might also confer protection against Bolivian from cirrhosis of the liver and primary liver can­ haemorrhagic fever, which is caused by a closely cer, diseases that kill more than one million carri- related virus.

110 DISEASE PREVENTION AND CONTROL

Figure 14.12 Yellow fever: number of cases notified to WHO, 1980-1990

4500 4000 3500

~ 3000 ...::: 2500 C> ~ 2000 ::> z 1500 1000 500 0 1980 1981

14.152 Yell ow fever is re-emerging as a major sequelae in the form of rheumatic fever and rheu­ health threat in Africa. Routine immunization, matic heart disease remain a serious problem in originally used for its control, was abandoned in developing countries. A resurgence of severe 1960 in favour of emergency measures taken streptococcal infection reported in North after the start of an outbreak. Since then, a series America, Scandinavia and other industrialized of epidemics of varying severity have occurred, areas gives reason for concern, since studies have as shown in Figure 14.12. A new and disturbing so far failed to elucidate the cause of this increase. epidemiological trend has been seen in some re­ To strengthen laboratory diagnosis in pro­ cent outbreaks; the majority of cases occurred in grammes for control of streptococcal infections children less than 14 years of age. Recently, the and their sequelae WHO promotes training, the Global Advisory Group for the Expanded Pro­ provision of reference reagents and the transfer gramme on Immunization reviewed the situation of new diagnostic technology to developing and recommended that countries in the endemic countries. A WHO Streptococcal/Rheumatic area should incorporate yellow fever vaccine in Fever Newsletter is published twice a year. Sur­ their routine immunization programmes. veillance of Neisseria meningitidis strains circu­ lating in a number of geographical areas is con­ 14.153 Following the epizootic of Rift Valley tinuing. fever in the Senegal River basin, WHO contin­ ued to work with F AO to improve diagnosis and 14.156 Legionellosis. In cooperation with the surveillance. A new live attenuated vaccine for WHO Collaborating Centre in Stockholm, a animals has been developed and arrangements project has been launched to establish a surveil­ are being made to test it for possible use through­ lance system for Legionella infection in travel­ out Africa. lers, using data available through an international network in Europe. WHO also supported 14.154 Lassa fever remains endemic in many projects aimed at the development of rapid and parts of Africa. A number of nosocomial out­ sensitive methods for detection of Legionella in breaks also occurred. WHO is continuing to clinical specimens and environmental samples promote studies to formulate strategies for con­ and production of a panel of markers for typing trol of this highly lethal disease. An antiviral virulent strains. Information exchange was drug has been shown to be effective, but is cur­ promoted through two consultations on rently very expensive. legionellosis (Moscow, May 1990; Elsinore, , May 1991), and a workshop on 14.155 Streptococcal diseases and cerebrospinal Legionella infections in travellers (, meningitis. Streptococcal infections and their May 1991).

111 THE WORK OF WHO 199D-1991

14.157 Plague. There was no decrease in the inci­ UNIDO/UNEP/WHO/FAO Working Group dence of plague during the biennium and several on Biosafety. countries reported human cases for the first time. WHO provided support to Member States in instituting the surveillance of plague in enzootic foci using WHO reagents for sera-epidemiologi­ cal studies. An updated plague manual is in Preparedness for epidemics preparation. 14.161 In Africa epidemics of cerebrospinal men­ ingitis and yellow fever continue to take a toll in human lives and disabilities but their effects can Resistance to antimicrobial and hospital be mitigated by applying the available control infections measures. A meningococcal vaccine was made available, for instance, to countries in the Eastern 14.158 A computer programme (WHONET) Mediterranean Region at risk of epidemics. A was developed and is being progressively Pan-African epidemic preparedness project was introduced for surveillance of resistance to initiated in September 1991 with support from antimicrobials in the Americas and the Western Canada and the United States of America. It has Pacific. National workshops on hospital­ five components: early warning systems, devel­ acquired infections were conducted in opment of a plan of action and guidelines, Bangladesh, India, Myanmar, Nepal and Sri strengthening of laboratory facilities, training of Lanka. programme managers and the establishment of a stock of basic drugs, vaccines and equipment for a quick response to emergencies. Activities have so far included assessment of the epidemic pre­ Rapid diagnosis of infectious diseases paredness of four African countries, the draw­ ing-up of national plans of action for two of them and support for Uganda in investigating a 14.159 Under the project for global surveillance meningitis outbreak. of rickettsial diseases, data were obtained on the geographical distribution of spotted fevers and other infections of the typhus group in ten coun­ tries. The project for global surveillance of respi­ ratory viruses using the WHO monoclonal anti­ Smallpox eradication surveillance bodies kit is under way and information is now available on the etiological role of influenza and 14.162 The Ad Hoc Committee on parainfluenza viruses, respiratory syncytial virus Orthopoxvirus Infections met in December 1990 and adenoviruses in respiratory diseases of chil­ to review the post-smallpox-eradication pro­ dren in 16 countries. A panel of reference gramme1. It recommended that the remaining reagents for diagnosis of human herpes viruses stock of viable variola viruses should be de­ has been developed. With the financial support stroyed before the end of December 1993. In the of UNDP, five institutes (in Bangladesh, meantime, the two WHO collaborating centres Cameroon, Myanmar, Nigeria and Sri Lanka) on smallpox and other poxvirus infections in were involved in the local production of simple Moscow and Atlanta (GA, USA) will determine diagnostic reagents. the complete nucleotide sequence of the genome of at least one variola virus strain. All Member States have been informed that routine smallpox Safety measures in microbiology vaccination is no longer recommended in any population group and that vaccination of mili­ tary personnel should be discontinued in all 14.160 Work proceeded on the preparation of a countries. new edition of the WHO Laboratory Biosafety Manual and a training programme was organ­ ized. A voluntary code of conduct for the release of organisms into the environment has been de­ veloped as part of the activities of an informal 1 See document CDS/SME/91.1.

112 DISEASE PREVENTION AND CONTROL

tacts with the health services required to obtain Other communicable disease immunization against a wide range of diseases. prevention and control activities 14.169 In 1991 the World Health Assembly, in resolution WHA44.4, endorsed new objectives and targets for the programme. Priority will be given to the improvement of existing vaccines to Intestinal parasitic infections simplify their use and increase their efficacy under the special conditions found in the developing 14.163 It is estimated that 1000 million people are countries. Specific goals in this respect will be: to infected with Ascaris, 900 million with replace vaccines requiring multiple doses, such as hookworm and 500 million with Trichuris, mak­ tetanus toxoid, diphtheria/pertussis/tetanus and ing soil-transmitted helminth infections among hepatitis B, by single-dose preparations so as to the commonest in the world. Entamoeba eliminate the problem of drop-outs; to replace histolytica infection is second only to malaria as a injectable vaccines by preparations that can be cause of death from parasitic disease. given orally and so obviate the problems of ex­ pense, special training and sterilization associated 14.164 Morbidity and mortality due to intestinal with the use of injection equipment; to improve parasites can be controlled in rural and urban heat stability of all vaccines, particularly oral po­ areas by using single-dose drugs. The targeting liomyelitis vaccine, so that the need for a "cold of chemotherapy on school and pre-school chil­ chain" will no longer impede vaccine delivery; to dren was recommended by an informal consulta­ develop vaccines, e.g., against measles, that can be tion in July 1990 and this is now being done given soon after birth so that protection may begin in the and the United Republic of when the child is not yet at risk of exposure and is Tanzania (Zanzibar). still in contact with health services; to increase vaccine efficacy and ensure long-lasting protec­ 14.165 A training seminar on the integrated con­ tive effects, notably in the case of BCG and trol of intestinal parasites and schistosomiasis pertussis vaccine. was held in Kenya in August 1991. 14.170 Work will also be intensified on the devel­ 14.166 An information consultation was organ­ opment of new vaccines against major bacterial ized in cooperation with PAHO to advise the and viral diseases for which no efficient immu­ Organization on the implementation of a strat­ nizing agent currently exists, particularly chol­ egy for control of intestinal protozoal infections. era, Shigella infection, typhoid fever, menin­ gococcal meningitis, rotavirus infection, respira­ 14.167 Guidelines for control of cysticercosis tory syncytial virus infection, hepatitis A, C and were prepared in 1990 and presented to seven of E and dengue. the most severely affected countries (Bolivia, Brazil, Colombia, Ecuador, Guatemala, Hon­ 14.171 New management structures have been duras and Mexico). established to accelerate vaccine development. For each vaccine specific task forces have been created to carry out, on a continuous basis, all the activities needed to reach the final stage of devel­ opment, including appropriate trials. These task Research and development in the field of forces will also collaborate with vaccine manu­ vaccines facturers in both the private and the public sec­ tors. 14.168 In 1990 UNDP became a partner in the programme for vaccine development. Further 14.172 Progress has been made towards the impetus was given to the programme by the development of single-dose or reduced-dose launching of the Children's Vaccine Initiative vaccines. Two approaches have been used in by WHO, UNICEF, UNDP, the World Bank attempting to replace vaccines requiring multiple and the Rockefeller Foundation in September injections by one-dose preparations. The first is 1990. The first project under the initiative will be microencapsulation: a one-dose controlled­ to develop single-dose vaccines containing sev­ release vaccine is being developed by enclosing eral antigens, thus limiting the number of con- tetanus toxoid in injectable microspheres, which

113 THE WORK OF WHO 199D-1991

are biodegradable and after injection release the tists associated with the programme as well as by enclosed antigen in such a way as to mimic re­ private or public institutions, using different peated injections. Studies have progressed molecular biological methods. These are being quickly and four projects have produced candi­ tested for safety and protective efficacy in early date vaccines. The first comparative animal tests animal trials. Vaccines against respiratory started in 1991. The new vaccine will be com­ syncytial virus, the main cause of respiratory vi­ posed of three types of microspheres: the first ral infection in infants, have been developed us­ releasing the antigen within two weeks after in­ ing either purified proteins or engineered viral jection, the second after one to three months and vectors (vaccinia or adenovirus). They are now the third after nine to 12 months. The same being assessed for safety. A centre is being estab­ technology is now being applied to other lished to evaluate the safety and protective activ­ vaccines which at present require several injec­ ity of new candidate vaccines in chimpanzees tions (hepatitis B, diphtheria/pertussis/tetanus). before they are tested on human beings. Animal trials on live attenuated and inactivated candidate 14.173 The use of live-vaccine carriers is the sec­ vaccines produced by industry against ond approach to developing a one-dose or re­ hepatitis A have now been completed and human duced-dose vaccine: unrelated live viral or bacte­ trials have begun. New conjugate vaccines to rial vaccines are employed as carriers to deliver a protect infants against meningitis caused by second vaccine more efficiently; genes which group A and C meningococci have been designed code for the protective components of a vaccine for use in the Expanded Programme on Immuni­ are inserted into the genome of a currently avail­ zation and have reached the stage of human able viral or bacterial vaccine (e.g., vaccinia or trials. Candidate vaccines against cholera, BCG). typhoid and meningitis caused by Group B meningococci have also been developed. 14.174 Work on most oral vaccines is in an early stage of development. The main goal is to replace 14.177 Training in vaccinology, immunology and vaccines that at present need to be inoculated by biotechnology. In 1990-1991, 86 scientists from orally administered preparations that will induce developing countries were trained with WHO either systemic or mucosal immunity. Both the support in areas of immunology and microencapsulation and the live-vaccine carrier biotechnology related to the evaluation of vac­ approaches will be used. cine immunogenicity and efficacy.

14.175 Research on the genetic stability, immunogenicity and heat-stability of poliomy­ elitis vaccine is now well advanced. New candi­ Prevention of blindness and date vaccines produced by recombination of deafness type 1 attenuated strain with type 3 are being evaluated in animal model systems and early hu­ 14.178 Some 80 Member States, the majority of man trials. Another important development has them developing countries, now benefit from been the production of transgenic mice that ex­ WHO support in implementing national blind­ press the human poliovirus receptor gene and ness prevention programmes based on a primary might be used instead of chimpanzees for the health care approach. In many countries, how­ initial screening of poliomyelitis vaccines for ever, further expansion of the programmes will neurovirulence. Significant progress has been depend on a reversal of the downward trend in made in the molecular analysis of the bacteria extrabudgetary resources observed over the last causing tuberculosis. Studies are now under way two years. Fortunately, nongovernmental or­ to develop candidate vaccines, and the knowl­ ganizations collaborating with the WHO pro­ edge gained has already been applied to improv­ gramme have been able to increase their support. ing diagnosis of tuberculosis using the polymerase chain reaction. 14.179 As cataract is the cause of more than 50% of all blindness in most countries, it is becoming 14.176 Substantial progress has been made in de­ a major challenge in the fight against blindness. veloping vaccines against dengue, hepatitis A and A manual on cataract management' was prepared respiratory syncytial viruses. The initial phases of study have now been completed and a number of 1 Management of cataract in primary health core services. Geneva, World candidate vaccines have been produced by scien- Health Organizatron, 1990.

114 DISEASE PREVENTION AND CONTROL and a pamphlet produced giving guidelines for undertake activities in such areas as low vision the provision of surgical services on a large scale. services. Close collaboration with nongovern­ A consultation on the use of intraocular lenses in mental organizations included the issue of guide­ cataract surgery in developing countries was held lines on local small-scale production of eye in December 1990. The report1 notes that there drops,S and staff support at global level by Lions is a backlog of 13.5 million unoperated cases at Clubs International. present, with a further 1000 cases per million population occurring each year. Given the mag­ 14.183 Human resources development is of par­ nitude of the problem and of the resources ticular importance in Africa, where there is a needed, the introduction of intraocular lens im­ severe scarcity of trained personnel for eye plant surgery in developing countries will thus care. Funds provided by the Consultative have to be a gradual process. Group of Nongovernmental Organizations were used to convene a training workshop for 14.180 Childhood blindness is a particular French-speaking African countries on blind­ tragedy addressed by the WHO programme to­ ness prevention (Lome, 1990). In particular, it gether with collaborating nongovernmental or­ defined the minimum requirement for cataract ganizations. A global meeting on the prevention surgeons as one per 250 000 population.6 Cov­ of childhood blindness was convened with the erage in many developing countries is still well support of the Christoffel-Blindenmission (Ger­ below this level, whereas in highly developed many) and Sight Savers (United Kingdom) (Lon­ countries there is often one ophthalmologist don, May-June 1990)2 which stressed the impor per 20 000 or 30 000 population. A training tance of intervention at an early age. workshop on low-cost spectacles production was set up at the collaborating centre in Bamako, and an assessment of blindness under­ * There are 1.5 million blind children in taken in Benin.7 Research on a macular disease the world. amongst adolescents was carried out in the * Each year, half a million children go United Republic of Tanzania. blind. 14.184 In the Americas, work continued, with * 70% of childhood blindness is due to AGFUND support, on the development of pri­ vitamin A deficiency. mary eye care in nine countries. Contributions * More than 90% of all childhood from the Organizaci6n Nacional de Ciegos de blindness is preventable. Espana (Spain) and Sight Savers (United King­ dom) made it possible to appoint a full-time 14.181 The use of ivermectin against oncho­ regional adviser as from March 1991. cerciasis has become a matter of great interest not only to WHO, but also to nongovernmental 14.185 In Europe work continued on formulating organizations working in the field of blindness strategies for glaucoma control in Malta and for prevention. The Consultative Group of Non­ national programme development in Turkey. governmental Organizations therefore provided the support for a meeting to be held on strategies 14.186 In the Eastern Mediterranean the status of for ivermectin distribution through primary trachoma has been evaluated in , Oman, health care systems (Geneva, April1991), which Saudi Arabi, Sudan and Tunisia, and national drew up a work plan3 for distribution of the drug blindness prevention programmes have been to 2.7 million people over the next two years. strengthened.

14.182 The WHO programme advisory group on 14.187 In South-East Asia and the Western Pa­ the prevention of blindness, at its ninth meeting cific, a four-week course was held for national (Banjul, March 1991),4 agreed that WHO should managers from 12 countries in the two Regions (Nakhon Ratchasima, Thailand, February 1990).

1 Bulletin of the World Health Organization, 69, 657-666 (1991). 2 Prevention of childhood blindness (WHO publication in preparation). 5 Document WHO/PBl/90.20. 3 Document WHO/PBl/91.24. 6 See document AFR/BLIND/3. 4 See document WHO/PBl/91.22. 7 See Weekly Epidemiological Record, 66: 337-340 (1991 ).

115 THE WORK OF WHO 199D-1991

Model facilities for the local production of eye drops and the manufacture of low-cost Primary prevention spectacles are being set up in Nepal and Sri Lanka in collaboration with Christoffel­ 14.192 Countries in all regions have received sup­ Blindenmission () and with funding port in cancer prevention, which is a key compo­ from UNDP. nent in national cancer control programmes. A national programme provides an ideal entry­ 14.188 The development of a simplified trachoma point for anti-tobacco activities, which the coun­ assessment scheme and the evaluation of low-cost try would probably not undertake on its own. vanadium steel sutures in cataract surgery were About 30% of cancer worldwide is associated completed with support from the Edna with tobacco use, either smoking or chewing. McConnell Clark Foundation and the National Anti-tobacco measures in countries have taken Eye Institute (Bethesda, MD, USA), a WHO the form of education, especially of schoolchil­ collaborating centre. dren; legislation and taxation; and the establish­ ment of national multidisciplinary ministerial 14.189 The prevention of deafness and hearing for the purpose. impairment has been hampered by a lack of pro­ gramme resources. It has, however, been possible 14.193 At least a third of all cancers are related to to provide consultant services for assessment of diet. In 1990 the recommendations of a Study hearing loss and its causes in Indonesia, Myanmar, Group on Diet, Nutrition and Prevention of Nepal and Thailand with funds from the Interna­ Chronic Diseases' were accepted by the Execu­ tional Federation of Oto-Rhino-Laryngological tive Board as guidelines for a disease prevention Societies. Programme planning was discussed by strategy based on national dietary goals, appro­ an informal working group (Geneva, June 1991) priate for the reduction of cancers and of other and at a regional workshop on the subject (New chronic diseases in industrialized countries and Delhi, September 1991). for the prevention of further increases in those diseases in developing countries.

14.194 WHO is supporting research projects in China on primary prevention of hepatocellular Cancer carcinoma by vaccinating newborns against hepatitis B. Transfer of technology for produc­ 14.190 The global programme on cancer has two ing third-generation vaccines will allow coun­ main components. The first, concerned prima­ tries to vaccinate most newborns at risk. rily with cancer control (primary prevention, early detection and treatment, palliative care), is the responsibility of headquarters and the regions. Its basic concepts are that one-third of Early detection all cancers are preventable, that one-third are curable if detected and treated at an early 14.195 Activities for early detection and treat­ stage,and that cancer is also a problem in devel­ ment are concerned mainly with cancer of the oping countries. The second component, con­ breast, cervix and mouth and are generally car­ cerned with research on epidemiology, etiology, ried out within primary health care systems. In­ prevention and the mechanisms of carcino­ tervention studies at country level have been genesis, is the responsibility of the International launched in the Americas, South-East Asia and Agency for Research on Cancer (see para­ the Eastern Mediterranean. Trials to assess the graphs 14.200-14.219). value of breast self-examination in reducing mor­ tality from breast cancer were continuing in the 14.191 An independent study has been made of USSR. Cervical cancer is the most common can­ WHO's cancer control programme, which was cer among women in developing countries. As it reoriented in 1980; following its favourable can be cured if it is found in time, special efforts conclusions, a proposed expansion of the pro­ are being made to design methods for early de: gramme activities to cope with the expected in­ tection and treatment suitable for use in develop- crease in cancer in both developed and develop­ ing countries during the 1990s has been carried out. 1 WHO Technical Report Series, No. 797, 1990.

116 DISEASE PREVENTION AND CONTROL ing countries, where national screening pro­ grammes with effective coverage are few and far National cancer control programmes between and most cases are already at an incur­ able stage when they are detected. Guidelines 14.199 National cancer control programmes offer have been produced.' The approach proposed the most rational framework for applying exist­ for cervical cancer can serve as a model for other ing knowledge. Even when resources are lim­ cancers in which screening can reduce mortality ited, programmes can have an impact if the right substantially. priorities and strategies are established. Princi­ ples and guidelines for such programmes have been drawn up at headquarters and in the Euro­ pean Region. Support in setting up national pro­ Training grammes was given to Chile, , India (Karnataka and Kerala), Indonesia, Pakistan, 14.196 Programme activities have been limited to Philippines, and Spain (Catalonia), areas where WHO can play an important role in and establishment of such programmes was training and technology transfer. In Africa, a under way in Cameroon, Canada, United Arab national and regional training course in radio­ Emirates and Zimbabwe. At a workshop therapy and oncology was started in Zimbabwe (Geneva, November 1991) representatives from in 1990. In South-East Asia seven radiotherapy the first 11 countries that established pro­ specialists have graduated from the national grammes analysed the last 10 years' experience training course in Sri Lanka launched in 1985, and agreed on updated indicators for monitoring and another seven are still under training. A and evaluation. To support country initiatives, a manual on basic radiotherapy is being prepared manual on ways to establish national cancer con­ in collaboration with IAEA. trol programmes has been produced, together with a set of fact sheets, covering primary pre­ vention, early diagnosis, therapy and palliative care. Palliative care

14.197 An international network of experts and institutes active in palliative care has been estab­ International Agency for 3 lished in recognition of the fact that most cancer Research on Cancer patients are incurable by the time of diagnosis and that this will be the case for many years to 14.200 IARC carries out epidemiological and come. The cancer pain relief guidelines produced laboratory research on the etiology and preven­ earlier are being used to great benefit in several tion of cancer to provide a basis for primary countries. Policies for cancer pain relief and pal­ prevention programmes. It also develops liative care are given in the report of the WHO methods for use in cancer research and promotes Expert Committee on Cancer Pain Relief and such research in all regions through collaborative Active Supportive Care.2 They will be followed activities, training and publication programmes. by updated guidelines on the subject, including management of the ten most common symp­ toms. Descriptive epidemiology 14.198 The quality of life and comfort before death could be considerably improved through 14.201 Preparation of the sixth volume of Cancer the application of current knowledge of pallia­ incidence in five continents, covering the years tive care, which must be regarded in both devel­ 1983-1987, is well advanced. It will contain data oped and developing countries as an integral part from 170 cancer registries throughout the world. of cancer care. Data from the previous volumes have been used for analysing time trends in cancer incidence and

1 Cervical cancer screening programmes: Managerial guidelines, Geneva, 3 For a more detailed description of IARC's activities in the biennium, see World Health Organization (in press). International Agency for Research on Cancer. Biennial report, 1990·1991. 1 WHO Technical Report Series, No. 804, 1990. lyon, 1991.

117 THE WORK OF WHO 199D-1991 the results will be published. Studies of migrant any previously reported in smokeless tobacco. populations such as those moving to Israel, Aus­ This could be a factor in the relatively high inci­ tralia and South America and from and dence of oral cancer in Sudan. Italy continue to show the effects of changing environment and life-style on cancer incidence. Support has been provided for the establishment or improvement of national and regional cancer Genetics and cancer registries, especially in developing countries. 14.208 Mapping of human genes is continuing in a search for genes related to X-linked lymphoproliferative syndrome, medullary thy­ Etiological studies roid cancer and familial breast cancer. Mapping of genes in families known to have suffered un­ 14.202 The role of nutritional factors in cancer is usually large numbers of cases of breast cancer the subject of epidemiological studies and bio­ suggests that a gene on chromosome 17 is impli­ chemical research aimed at elucidating the com­ cated in a high proportion of cases. plex interactions of dietary components. Meth­ odological studies have improved reliability in 14.209 The enzymatic make-up of lung cancer estimating and recording individual diets. Pro­ patients is being examined to establish whether spective cohort studies on diet, nutrition and differential inherited ability to metabolize to­ cancer have been launched in several European bacco smoke constituents can affect individual countries. They have shown a protective effect susceptibility to the disease. of fresh vegetables and vitamins, which will be assessed in a trial in Venezuela. 14.210 Linking epidemiological data with infor­ mation on genetic disease suggests that at least 14.203 Research under the SEARCH programme 4% of childhood cancers are due to inherited for collaborative case-control studies at a mutations. Experiments on mice show that mu­ number of centres is beginning to produce data tations caused by chemicals can lead to tumours on the causes of brain tumours in children and in their offspring. adults, and of breast and colorectal cancer.

14.204 Cervical cancer has epidemiological char­ acteristics typical of a sexually transmitted dis­ Mechanisms of carcinogenesis ease. In research coordinated by IARC in Spain and Colombia, three different molecular biologi­ 14.211 Mutations in the p53 tumour suppressor cal techniques have shown a tenfold greater risk gene have been detected in samples of human of cervical cancer when human papillomavirus is oesophageal squamous cell carcinoma and present. hepatocellular carcinoma. Certain mutations ap­ pear to be specific to the type of tumour. 14.205 To assess the effects of low levels of ioniz­ ing radiation on cancer incidence existing data on 14.212 The importance of intercellular connec­ workers in the nuclear industry in three coun­ tions and signalling in controlling the prolifera­ tries are being analysed prior to a new study of tive behaviour of cells has been established by such workers in 12 further countries. In addi­ examining dye transfer between cells and the ex­ tion, a study of childhood leukaemia and pression of genes that code for the proteins form­ lymphoma in populations exposed to fall-out ing intercellular junctions. The use of assays of from the Chernobyl accident is in progress. gap-junctional intercellular communication in detecting tumour-promoting agents is being 14.206 Research continued on occupational examined. causes of cancer, including dioxin exposure in the manufacture of certain herbicides, and 14.213 Sensitive techniques have been developed on occupational cancer risk in developing coun­ for detecting the presence of alkylation adducts tries. in human DNA in order to measure exposure to certain classes of carcinogen. Aflatoxin adducts 14.207 Sudanese snuff has been found to contain with albumin can also be measured to assess re­ levels of nitrosamines several times higher than cent exposure to aflatoxins.

118 DISEASE PREVENTION AND CONTROL

14.219 A total of 26 fellowships were awarded Cancer prevention research during the biennium to young scientists from 14 countries. Twelve training courses were 14.214 In the hepatitis intervention study in held, attended by a total of 645 participants. A Gambia, recruitment of subjects has been com­ number of these courses, including three in pleted prior to measurement of the incidence of French or Spanish, provided basic or more ad­ liver cancer among them through the cancer vanced instruction in epidemiology and registry set up as part of the project. Hepatitis B biostatistics; others dealt with such topics as the vaccine is now routinely administered to all new­ safe handling of toxic agents, molecular biology, born infants in Gambia. A high level of protec­ and the scientific basis of carcinogenicity testing. tion against infection has been demonstrated among the vaccinated children.

14.215 An intervention trial is being carried out Cardiovascular diseases in Venezuela to examine the effectiveness of ad­ ministration of vitamins C and E and carotene in 14.220 The steering committee of the cardio­ preventing precancerous lesions of the stomach. vascular diseases programme met in Geneva in February 1990 to review programme activities 14.216 Screening programmes for cervical, and strategies for the next five years. It under­ stomach, lung and breast cancer are being studied lined the importance of the WHO MONICA to measure their effectiveness in reducing inci­ project (see paragraphs 14.223-14.226 below), dence of or mortality from these cancers. and recommended that its methodology and or­ ganization be used as the basis for the urgent development of health information technology in developing countries to promote cardiovascu­ Information and training lar diseases prevention and control programmes.

14.217 New volumes in the IARC Scientific Pub­ 14.221 WHO and the International Society and lications series include the findings of a wide­ Federation of Cardiology (ISFC) continued their ranging study of cancer incidence and etiology joint activities under the intensified programme and the possibilities for preventive measures, 1 a for rheumatic fever and rheumatic heart disease review of methods and results in evaluating prevention, including the development of eradi­ primary prevention measures/ and a textbook on cation strategies. Initial steps will include a cancer registration.3 worldwide assessment of the extent of these con­ ditions. 14.218 A total of 53 volumes have now appeared in the IARC Monograph series. The latest have 14.222 Together with UNESCO and ISFC, dealt with coffee, tea and mate, and some related WHO is producing health education material to substances; chlorinated drinking-water and train physicians and other health personnel in the some halogenated compounds, as well as cobalt primary and secondary prevention of rheumatic and its compounds; and some widely used pesti­ fever and rheumatic heart disease, and also of cides. In no case was conclusive evidence found Chagas disease (see paragraphs 14.39-14.42), for carcinogenicity to humans of the agents which affects about 18 million socio­ evaluated, although hot mate drinking and occu­ economically disadvantaged people in South pational exposures to some insecticides were America, of whom up to 30% will develop heart evaluated as probably carcinogenic. disease.

14.223 A major segment of the World Health Sta­ tistics Annual, 1989 was devoted to a description 1 Tomatis, L. et al., eds. Cancer: causes, occurrence and control. lyon, International Agency for Research on Cancer, 1990 (IARC Scientific Pub­ of the WHO project for multinational monitor­ lications, No. 100). ing of trends and determinants of cardiovascular 1 Hakama, M. et al., eds. Evaluating effectiveness of primary prevention of diseases (MONICA) and its first results.4 A cancer. lyon, International Agency for Research on Cancer, 1990 (IARC Scientific Publications, No. 103). 3 Jensen, 0. M. et al., eds. Cancer registration: principles and methods. lyon, International Agency for Research on Cancer, 1991 (IARC Scientific 4 World Health Statistics Annual, 1989. Geneva, World Health Organization, Publications, No. 95). 1990, pp. 27-149.

119 THE WORK OF WHO 199 ~ 199 1 workshop was held in Helsinki in April1991 to its progression under various sociocultural con­ prepare the hypertension data for publication. ditions. Following a pilot study, 18 countries are now collecting specimens and sending them to 14.224 Analysis of data from the second popula­ centres in and Switzerland. Material tion risk factor survey for the MONICA project from almost two thousand cases has been col­ is now under way, and the first trend analyses­ lected to date. Analysis of the first two years' after five years of data collection-are expected to data is under way and will be reviewed early in be published in 1992. The third and final survey 1992. is now in preparation. Training and quality con­ trol procedures were developed in the light of 14.229 A hypertension patient education pro­ experience of the first two surveys, and it was gramme was launched in collaboration with the decided that the information to be collected World Hypertension League. At a meeting in should include several new items, including data Geneva in May 1991, a protocol for a pilar study on use of oral contraceptives and medicaments. on this subject was discussed and approved, and various audiovisual techniques were tested 14.225 The biennial meeting of MONICA prin­ among the participants. Work commenced on cipal investigators to review progress and take the study in the autumn, and the results of this decisions on such questions as policy and publi­ phase will be evaluated in mid-1992. cations was held in Lugano, Switzerland in April 1990, with the support of the Swiss Government 1U30 A WHO/ISFC task force on pulmonary and the Canton of Ticino. embolism began work on standardizing nomen­ clature and diagnostic techniques. 14.226 At a working group in Geneva in October 1990, the possibilities were discussed for devel­ 14.231 WHO continued to support ISFCs an­ opment of a global cardiovascular monitoring nual ten-day teaching seminars on cardiovascular and prevention network, including the establish­ epidemiology and prevention, held in Germany ment of focal points of interest in the developing in 1990 and in Sweden in 1991. world and links with existing MONICA and other resource centres. This will help provide information and develop skills that can be used in assessing local problems and in drawing up, im­ plementing and evaluating prevention pro­ grammes.

14.227 In June 1990 a meeting was held in St John's, Canada, bringing together investiga­ tors of the cardiovascular diseases and alimen­ tary comparison project (CARDIAC), a multi­ centre cooperative study set up in 1985 to assess the relation between food intake and the car­ diovascular system; the study is coordinated by the WHO Collaborating Centre for Research on Primary Prevention of Cardiovascular Dis­ eases in Izumo, Japan. The meeting discussed results of the project, which were subsequently published.1

14.228 The main objective of the WHO/ISFC study on pathobiological determinants of atherosclerosis in is to explore structural changes in the arteries of children and young people that may determine the development of atherosclerosis particularly in its early stages, and

1 Journal of Cordiovosculor Pharmacology, 16, Supplement 8 (1990). Blood pressure is checked among possers·by ino pork in Modrid.

120 DISEASE PREVENTION AND CONTROL

14.232 A global teleconference, "Heart health tion (IDF) on 27 June 1991. WHO also coop­ around the world", was organized in in erated with IDF in launching a major European 1990 to promote awareness among professionals regional control programme, and planning a of the worldwide problem of cardiovascular dis­ similar initiative in the Eastern Mediterranean eases and their rapid emergence in developing Region. countries. It linked participants in 25 countries, who discussed aspects of prevention, the role of 14.236 In line with resolution WHA42.36 on pre­ physicians and nongovernmental organizations, vention and control of diabetes, adopted in 1989, action being taken by governments and its effec­ guidelines for the development of national pro­ tiveness, and legislation, particularly in develop­ grammes on diabetes were issued3 and are being ing countries where cardiovascular and other used to implement activities in a number of chronic diseases have become a problem. Member States.

14.233 A WHO Expert Committee on Rehabili­ 14.237 Chronic rheumatic diseases are a leading tation after Cardiovascular Diseases, with Special cause of disability and exact a huge social and Emphasis on Developing Countries, met in economic toll - for instance, in health care ex­ Geneva in October 1991,1 One of its tasks was to penditure and lost wages. During the biennium consider future trends in patient education, the WHO supported the further development of a role of primary care physicians and ways of pre­ community-oriented programme for the control paring them for this task. Government policies of rheumatic diseases in developing countries. relating to health and patient education were re­ The first results of a study conducted under the viewed and recommendations made. Attention programme have shown a high prevalence of was paid to the exercise testing and rehabilitation rheumatic complaints and disability in Indone­ training of adolescents and young adults, and sia, where there is a surprising similarity with the also to special problems of the old in this respect. levels of urban and rural prevalence in Australia. An assessment was made of advanced rehabilita­ The rate of osteoarthritis was 5.1% in the popu­ tion techniques and their relevance to developing lation as a whole aged over 15 years, and reached countries' requirements. 27.3% in older groups.

14.234 Work continued on the production of 14.238 The development and appropriate evalua­ health education material for children and young tion of predictors for the identification of pa­ people, with emphasis on developing countries. tients at risk of osteoarthritis were the main topic of an international workshop on articular carti­ lage and osteoarthritis (Wiesbaden, Germany, May 1991), cosponsored by WHO. Support was Other noncommunicable disease also given for the fourth interscience world con­ prevention and control ference on inflammation (Geneva, April 1991), activities during which various aspects of the problem were reviewed, with emphasis on rheumatic and 14.235 Diabetes mellitus is a growing public pulmonary chronic diseases. health problem in both developed and develop­ ing countries, causing severe and costly compli­ 14.239 Data were published on the epidemiology cations, including blindness and heart and kid­ of hip fracture in Europe,4 representing the first ney disease. Knowledge of its worldwide dis­ findings from the Mediterranean study on tribution has accumulated rapidly. At global osteoporosis; they showed that hip fracture due level, its prevalence is now known to be high­ to osteoporosis occurred 3.3 times more fre­ est (over 10% of adult populations) in some quently among women than among men, and developing countries and among minorities and that it was strongly associated with a low level of disadvantaged groups in developed countries.2 physical activity during youth and adult life. At To promote advocacy in this field, the first the fourth meeting of the joint WHO/Inter­ World Diabetes Day was cosponsored by national League against Rheumatism task force WHO and the International Diabetes Federa- (Geneva, July 1991), representatives of the

1 Report to be published in the WHO Technical Report Series. 3 Document WHO/DBO/DM/91.1. 2 Bulletin of the World Health Organization, 69(6): 643-648 (1991). 4 Revista Clinica Espanola, 188, Supplement 1, 12-14, 1991.

121 THE WORK OF WHO 199o-1991

League and the pharmaceutical industry exam­ 14.242 The fact that almost no thalassaemic in­ ined current approaches to the pharmacotherapy fants are now being born in Cyprus and the of rheumatic diseases. Italian region of Sardinia bears witness to the efficacy of national haemoglobinopathy control 14.240 Work continued on the WHO integrated programmes based on WHO approaches and programme for community health in recommendations. Future collaboration to im­ noncommunicable diseases (INTERHEALTH), prove the diagnosis and treatment of which now has 16 demonstration projects in all haemoglobinopathies was discussed at a meeting WHO regions, including nine in developing with the International Thalassaemia Federation countries. Guidelines1 were distributed to all the (New York, March 1990). projects in 1990. Ways of strengthening project coordination were discussed at a meeting of the 14.243 In response to countries' growing inter­ INTERHEALTH steering committee (Geneva, est in hereditary diseases, educational materials October 1990). A model for forecasting chronic on different forms of thalassaemia4 and guide­ disease risk factors2 was demonstrated at the lines on the formulation of national programmes 1990 meeting of INTERHEALTH programme to control phenylketonuria/ congenital hypo­ directors (Helsinki, January); and a tele­ thyroidism6 and sickle cell disease7 have been conference on the prevention of life-style dis­ produced. An international panel discussion on eases was organized on the occasion of the 1991 education in medical genetics was held during meeting (Alma-Ata, March). At a special session the annual meeting of the Japan Society of Hu­ during the fourteenth world conference on man Genetics (Tokyo, August 1990). health education (Helsinki, June 1991), a report was presented on INTERHEALTH and the 14.244 WHO supported a training course on European programme of countrywide integrated physiotherapy in the treatment of cystic fibrosis, noncommunicable disease intervention attended by 25 trainees from different countries (CINDI). Ways of devising effective methods (Prague, May 1990), as well as individual training for the monitoring and evaluation of chronic dis­ in the use of DNA probes. ease development within INTERHEALTH were discussed at a conference on demographic 14 245 Proposals were made for the designation trends, aging and noncommunicable disease of new WHO collaborating centres in Milan problems (Moscow, October 1991). The first (Italy) for management of haemophilia and in results of the INTERHEALTH baseline survey New Delhi for training in genetics. were published.3 They show a surprisingly high prevalence of smoking among men in the United 14 246 In 1991 the United States National Republic of Tanzania (48.2%) as compared with Neurofibromatosis Foundation presented its Finland (North Karelia) and the United States of first International Public Service Award to the America (Florida and Texas). Special features on WHO hereditary diseases programme in recog­ INTERHEALTH and diabetes were published nition of the Organization's contribution to in the May-June 1991 issue of World Health. activities for the prevention and control of neurofibromatosis. 14.241 Hereditary diseases. Following discus­ sions at several WHO meetings in fields of medi­ cal genetics relating to haemophilia, mental dis­ orders, cystic fibrosis, cardiovascular diseases, Technology development, neurofibromatosis and congenital malforma­ assessment and transfer tions, networks have been established of experts and institutes interested in collaborating with 14.247 In 1990 the Organization established a WHO and Member States in the further imple­ distinct programme area concerned with tech­ mentation of control programmes. nology development, assessment and transfer

4 1 Guidelines for protocols for loco/ demonstration projects Geneva, World Documents WHO/HOP /EMT/90 1 and 90.2. Health Organllotion, 1990 5 Document WHO/HOP /PKU/Gl/90.4. 2 lnternatJOna/Journal of Epidemiology, 19 (4): 1019-1 03 6 6 Document WHO/HPD/CON.HYPO/Gl/90.4. 3 World Health StatiStics Quarterly, 44(2) 48-54. 7 Document WHO/HDP/SCD/Gl/91.2.

122 DISEASE PREVENTION AND CONTROL with a view to formulating general policies, ap­ prepare guidelines to support countries in the proaches and methodology in this field and pro­ development of national programmes on health moting better coordination with other organiza­ care technology. tions working in the same area. Later, in June 1991, the responsible regional officers met in 14.249 The terms of reference of the WHO Col­ Geneva for an informal exchange of views and laborating Centre for Information Transfer for experience with representatives of technical pro­ Medical Devices (Emergency Care Research In­ grammes. They identified principal activities to stitute, Plymouth Meeting, PA, USA) were ex­ be undertaken over the next few years, including panded with a view to giving countries access to orientation of health policy-makers, setting of the information on health technology that they priorities, technology assessment, quality assur­ require, in a form appropriate to their needs. ance, training and institutional development. 14.250 The potential contribution of health tech­ 14.248 Further meetings will now be held involv­ nology to the control of diseases of public health ing WHO regional staff and national focal points importance was promoted through WHO for health technology, to formulate specific plans cosponsorship of a first international conference of action, commence training activities, initiate on health technology in the field of diabetes case studies and, in the light of this experience, (Kyoto, Japan, April1991).

123

CHAPTER 15 Health information support

ized information centres, improving the use of Health literature services locally available information facilities. WHO cosponsored the Sixth International Congress of 15.1 In order to furnish the elements of local Medical Librarianship (New Delhi, September documentation centres, information kits com­ 1990). posed of basic WHO documentation, electronic files, tools and guides were delivered to the of­ 15.5 A network of 14 documentation centres fices of all WHO representatives in the African was established in the European Region, an ap­ Region and most in the Western Pacific Region, proach discussed at a meeting on "WHO docu­ an arrangement that may be extended to other mentation and health for all" (Berlin, November regions. WHO made agreements with organiza­ 1990). Special efforts were devoted to providing tions in the United Nations system and with support for documentation services in the coun­ international development agencies to cooperate tries of central and eastern Europe. in identifying information resources in Member States and to coordinate the introduction of in­ 15.6 The Eastern Mediterranean Region an­ formation technology and the training of infor­ nounced a strategy for the national development mation professionals. A newsletter, Liaison, was of health literature and information services, launched to disseminate information about suc­ with emphasis on training in the use of CD­ cessful initiatives and new developments in these ROM and on-line data bases (see also Chap­ areas. ter 21, paragraph 21.18).

15.2 In the African Region, where a library and 15.7 In the Western Pacific Region attention documentation centre had been set up in the was paid to developing national capabilities and subregional office in Harare, African librarians, resources. Collaborative centres were designated documentalists and health information assistants in China and VietNam, and a plan was initiated were trained in the use of new technology during to improve health documentation in small coun­ the Third Congress of the Association for Health tries in the South Pacific. Information and Libraries in Africa (Harare, July 1991), in which WHO participated.

15.3 By the end of 1991, WHOLIS (the com­ WHO publications puterized WHO Library Information System) was in the process of being included in the 15.8 Some 140 works were published during LILACS (Literatura latinoamericana en Ciencias the biennium. There were four issues in the de la Salud), CD-ROM, which is produced and WHO AIDS Series, covering prevention, first distributed by BIREME (the Regional Library of aid in the workplace, counselling, and biosafety Medicine in Sao Paulo, Brazil), and which also in laboratories. Other publications included the includes the PAHO/WHO bibliographic data last of three volumes dealing with anaesthesia base. and surgery at the district hospital, two manuals on basic laboratory techniques in parasitology 15.4 The WHO South-East Asia Health and bacteriology, and the first - a two-part Literature, Library and Information Services manual on basic malaria microscopy - in a (BELLIS) network expanded to include special- planned series of training modules dealing with

125 THE WORK OF WHO 199D-1991 malaria control. Emphasis was again placed on Spanish (there is also an Arabic edition and, pub­ design, and colour printing was used to good lished outside WHO, Farsi and German ver­ effect. Twenty-seven reportS of WHO expert sions).' committees and similar advisory groups were published in the WHO Technical Report Series, 1S.1 0 Some 25 books, many of them containing providing authoritative guidance on a wide range the proceedings of meetings or highly technical of public health and medical subjects aud specialized studies, were published on WHO's behalf by outside publishers. Low­ cost reproductions of WHO publications multi­ plied in India, where commercial publishers pro­ duced some 85 reprints, and further agreements were concluded for the reproduction of WHO material in electronic media. Translations of WHO books outside the Orgauization again in­ creased in numbers and in languages of transla­ tion: 174 we.re received during the bieuuium, which saw the preparation of more than 350 agreements for the publication of translations into 43 non-official languages by academic and commercial publishers, professional associations, specialized institutions, and minimies in all regions. The joint WHO/UNICEF statement ou breast-feeding appeared in some 25 Languages.

15.11 In the regions, PAHO focused on dis­ seminating health-related informacion of par­ ticular interest in the Americas through scientific publications and periodicals. The latest edition of Health conditions in the Americas was published in two volumes in 1990. Thirteen new titles in the Anew departure in the WHO publications programme: this kit comprises o European Series were published by the Regional monuol with instructions ond gomes designed to stimulate interest in Office for Europe in English, as well as five disease prevention in the community. French and four German translations of texts in the EURO Reports and Studies Series. Fourteen works origina6ng in the Regional Office ap­ 15.9 The Bulletin of the World Health Organi­ peared under the imprint of outside publishers in zation, in addition to the six bilingual (English/ seven countries. Translations of regional publi­ French) issues each year, had two supplements - cations undertaken outside the Regional Office on infant feeding and malaria vaccine develop­ proliferated, in languages used within and out­ ment. The quarterly journal WHO Drug Infor­ side the Region. matiotz provided up-to-date information on me­ dicinal products, reported on major drug regula­ tory action throughout the world, gave prescrib­ ing information on selected essential drugs con­ Technical terminology tained in WHO's Model List, and conveyed International Nonproprietary Names (INN). 15.12 The WHO Terminology Informacion The quarterly World Health Forum, published in System (WHOTERM) was redesigned as a cor­ the six official languages (and outside WHO in porate information management system, and de­ Italian), had as themes for its "Round Tables" velopment began of a large mulrilingual data during 1990-1991: women and tobacco; health promotion in the media; primary health care; safe motherhood; health effects of global warm­ 1 The themes of issues in 1990 were: Our planet- ou1 health, Think globally ing; meat and health; and care of the dying. -oct locally (World Health Day issue); Least developed cauntlies; Women World Health, WHO's health promotion and and health; Tiopical diseases; Sauth·East Asia Region; and Women and AIDS, and in 199 1: Emergency preparedness (World Health Day issue); information magazine, appeared six times a year Urbanization; lnterHealth/Diabetes; Nutrition; Molorio; ond European in English, French, Portuguese, Russian. and Region.

126 HEALTH INFORMATION SUPPORT base to cover areas of interest to WHO and to biennium, 860 libraries receiving WHO publica­ permit on-line retrieval of WHO terminological tions free of charge or on a subscription basis had information. Integration of terminology ma­ indicated their willingness to make their collec­ terial collected informally by translators and tions accessible to the public without restriction. editors was promoted, and support was enlisted During 1990-1991, 12 new WHO depository from other international organizations to libraries were officially designated, bringing the develop an international bibliography for total to 154. mono- and multilingual dictionaries of public health and medicine. 15.14 An annotated catalogue covering publica­ tions issued during 1986-1990 was made avail­ able in English and French editions, followed by a 1991 supplement. Numerous subject cata­ Distribution and sales logues were prepared, devoted to particular topics. Displays of WHO publications were ar­ 15.13 WHO books and periodicals to a value of ranged for over 200 specialized meetings and approximately $14 million were distributed free congresses. Sales maintained the upward mo­ of charge during the biennium. The accessibility mentum achieved in the previous biennium. In of WHO publications in developing countries 1990-1991 the sales level reached $7 000 000, an was improved by strengthening and extending increase of 20% over 1988-1989. New strategies the networks of health-related establishments were introduced to enhance sales in developing and libraries receiving comprehensive or selec­ countries and improve the performance of sales tive groups of publications. By the end of the agents in developed countries.

127

~---~~------~~ ---

CHAPTER 16 Support services

countries from 14 to 11 and that of over-repre­ Personnel sented countries increased from 21 to 23. The number of adequately represented countries-the 16.1 On 30 November 1991, the total number ultimate criterion for evaluating geographical of staff (excluding PAHO) was 4693, compared representation- increased from 93 to 102. The with 4596 on 30 November 1990 and 4453 on number of staff in excess of the upper limits of 30 November 1989 - an increase of some 5.4% desirable ranges fell by more than 11%. during the biennium November 1989 to Novem­ ber 1991. The number of professional staff rose from 1465 in November 1989 to 1568 in Novem­ ber 1991, and that of general services staff from Office accommodation 2988 to 3125 in the same period. 16.4 Following the completion of negotiations with the Host Government the Regional Office 16.2 While the proportion of women in estab­ for the Eastern Mediterranean has finalized plans lished offices1 was still below the target of 30% for an extension to its premises. It is expected to set by the World Health Assembly, steady complete the building in 1993. progress was made. The proportion of profes­ sional and higher-graded posts in established of­ 16.5 For several years the Regional Office for fices filled by women increased from 22.3% in the Western Pacific has been suffering from a October 1988 to 23.2% in October 1990 (mid­ shortage of space resulting from expanding biennium). During the same period, the number extrabudgetary activities. This Office is now of posts in established offices at grades P.S and proceeding with an extension to its premises that above filled by women increased from 9.2% to will provide office accommodation for 30 to 11.2%. The percentage of women employed as 35 persons as well as improved facilities for the associate professional officers has been main­ library, audiovisual services and meetings. The tained at 40%. The percentage of women em­ extension should be completed in 1992. ployed as consultants in all locations rose from 20.6% in 1988 to 23.3% in 1990; at headquar­ 16.6 The Host Government for the Regional ters, 28.1% of all consultants and 38% of short­ Office for Europe has agreed in principle to pur­ term professionals (excluding conference staff) chase two villas contiguous to the present loca­ employed between October 1988 and October tion of the Office for use by WHO as office 1990 were women. There was a small increase in accommodation. the proportion of women members of WHO's 54 expert advisory panels. 16.7 The extension to the headquarters building in Geneva has been completed and occupied. After 16.3 The 40% target for appointment of na­ almost 25 years of service the headquarters tele­ tionals from unrepresented and under-repre­ phone exchange and system have been replaced. sented countries was again met. The number of unrepresented countries decreased from 36 to 27 by mid-biennium, that of under-represented Budget and finance

1 Established offices include heodquorters, regional offices, offices of the 16.8 The budget proposals for 1992-1993, WHO representatives end IARC, but not projects. covering the second period of the Eighth Gen-

129 THE WORK OF WHO 199D-1991 eral Programme of Work, were prepared and ages under the main categories of the Eighth submitted to the Programme Committee of the General Programme of Work, were as follows: Executive Board for review of the global and interregional component in accordance with % resolution EB79.R9. The entire budget was subsequently reviewed by the Executive Board Direction, coordination and at its eighty-seventh session in January 1991 management 11.96 and was approved by the Forty-fourth World Health systems infrastructure 30.97 Health Assembly in May 1991. To meet the Health science and technology 30.75 wishes of the Board that for the foreseeable fu­ Programme support (including health ture the budget proposals should continue to information support) 26.32 be based on a policy of "zero budget growth in real terms", the effective working budget 100.0 level for 1992-1993 was established at $ 734 936 000. This approved budget provided Owing to budgetary difficulties, with actual cost for cost increases for inflation of 10.05% over increases by far exceeding what was provided in the two-year period and for exchange rate fluc­ the regular budget for 1990-1991 and going be­ tuations of 2.62%. Taking into account a small yond cost absorption capacity, various economy real net decrease of 0.25%, there was a 12.42% measures had to be applied. Financial data for all increase over the 1990-1991 effective working sources of funds as well as financial statements at budget. 31 December 1991, with supporting schedules and tables, are presented in the Director-Gener­ 16.9 In 1991 an interim financial report cover­ al's financial report for the biennium to the ing the first year of the biennium 1990-1991 was Forty-fifth World Health Assembly. reviewed by the Committee appointed by the Executive Board to Consider Certain Financial 16.12 Further enhancements were made to the Matters prior to the Forty-fourth World Health computer-based Administration and Finance In­ Assembly, and was subsequently accepted by formation (AFI) system which is established on a that Health Assembly. large common central data base and provides in­ formation support for budget preparation, 16.10 Due to the significant adverse exchange budget control, expenditure and general ledger rate fluctuations which occurred during the first accounting, payments, treasury operations, sup­ year of the biennium in respect of the Swiss plies, personnel, payroll and the master mailing franc, the Danish krone and the CFA franc, it list. Staff of the Divisions of Personnel and became evident that if the rates persisted for the Budget and Finance have access through on-line remainder of the biennium, the level of the ex­ terminals. The system also allows technical pro­ change rate facility which had been approved by grammes to query their allotments, earmark their the World Health Assembly, namely $ 31 mil­ funds, link obligations to the programme's ac­ lion, would be insufficient to protect programme tivities and transfer data to "local" microcom­ budget implementation. Accordingly, a puters for further analysis. $ 12 million increase in the facility, to $ 43 mil­ lion, was exceptionally sought and this was ap­ 16.13 Two new components were implemented: proved by the Forty-fourth World Health As­ a new central payroll system for all fixed-term sembly. By the close of the biennium it had been staff and a microcomputer-based system to sup­ necessary for the Organization actually to utilize port the budget preparation process were intro­ only $32 361 900 of the expanded facility, result­ duced in all regional offices. A new component ing from an improved exchange rate relationship to assist in the shipping of supplies to their desti­ from early 1991. nations is being progressively introduced. A sys­ tem was developed for the Transport Manage­ 16.11 In 1990-1991, obligations totalling ment unit of the Onchocerciasis Control Pro­ $686 089 017 were incurred under the regular gramme in West Africa in Ouagadougou. It is budget and $707 271 817 under funds from other used for control, ordering and distribution of sources. As at 31 December 1991 arrears of con­ spare parts for vehicles in use by the Programme. tributions in respect of 1990 and 1991 amounted to $65 310 715. The obligations in respect of the 16.14 The administration and finance informa­ regular budget for 1990-1991, shown as percent- tion system was also installed in the Regional

130 SUPPORT SERVICES

Office for South-East Asia. All the regional of­ WHO projects, on behalf of Member States - fices now operate the system. under the reimbursable procurement programme -and for the Expanded Programme on Immuni­ zation. The procurement value during the biennium 1990-1991 was $79 953 984. In addi­ Equipment and supplies for tion, the Procurement Department provided Member States source and price information to Member States on a wide range of commodities. 16.15 The total value of supplies and equipment purchased by WHO (including PAHO) during 16.20 In the South-East Asia Region the Supply the 1990-1991 biennium reached $248 675 974. Services catered to the Member States' requests Compared with 1988-1989 this is an increase of for medical supplies and equipment, literature, 13% in monetary terms. data processing equipment, kits for the AIDS control programme as well as conventional items 16.16 In 1990-1991 the Global Programme on such as drugs and pharmaceuticals, chemicals, AIDS continued to be the largest user, in dollar and laboratory supplies and equipment. Supplies terms, of the WHO procurement supply serv­ were sent urgently to help combat epidemics and ices, followed very closely by the Onchocerciasis health problems arising out of natural calamities, Control Programme. On behalf of the Division such as those in Bangladesh and Maldives. Local of Emergency Relief Operations, the Supply unit sources of supply were used whenever supplies at headquarters initiated a large number of ship­ of acceptable standards of quality and competi­ ments of emergency supplies, mainly pharma­ tive prices were offered. ceuticals and hospital equipment, to various countries in connection with the Gulf crisis and 16.21 In the European Region substantial sup­ to Bangladesh, Ethiopia, Liberia and Sudan. plies and equipment were provided to various country projects funded by UNDP, UNFPA 16.17 Member States continued to avail them­ and UNEP. In answer to requests from some of selves of the possibility of requesting advice on the countries of Central and Eastern Europe procurement from WHO and the purchase of various supplies and equipment were provided, medical supplies and equipment on their behalf, funded by voluntary donations. either under the WHO Revolving Fund or against reimbursement in convertible and non­ 16.22 In the Eastern Mediterranean Region the convertible currencies, for the promotion of Supply unit was actively involved in providing their health programmes. medical supplies and equipment to cope with natural disasters and other emergencies. The 16.18 In the African Region the Supply unit transfer to the regions of responsibility for much dealt with many urgent requests for supplies as a of the Global Programme on AIDS has widened result of outbreaks of meningitis, cholera and the scope of traditional supply activities. yellow fever, and national emergencies following civil unrest in some countries. An increased del­ 16.23 In the Western Pacific Region supplies and egation to buy locally resulted in more procure­ equipment for projects financed from ment within the Region and shorter lead-times extrabudgetary funds accounted for 50% of the for delivery. procurement act1v1t1es. In rapid response to emergencies in the Philippines, drugs and other 16.19 In the Region of the Americas the Pro­ supplies were provided. Local purchase for curement Department purchased supplies, projects, and reimbursable procurement on be­ equipment and services in support of PAHO/ half of Member States, showed an increase ..

131 Regional offices and the areas they serve

#

~,MANILA ~ ~

~~~"'• 4. \

AREA SERVED. AS AT 31 DECEMBER 1991, BY: ;;- ~

Regional Office - Regional Office for nTnl Regional Office for ~ for Africa Soulh·East Asia WlJJ the Easlcrn Med:terranean ~ Rcg1onal Office for (' ,·:· Y;' :! Regronal Office ~ Reg1onal Office for @ Regional Office ~ lhe Americas/PASS ·' ,,.... tor Europe ~ lhe Western Pacific ~ CHAPTER 17 African Region

17.1 Although social, political and economic prove coordination of WH0 support to Member upheavals continued to affect activities in the countries. Region, consolidation of the implementation of the "African health development scenario" con­ 17.5 The Regional Committee has defined ob­ tinued at all levels in the countries, with due jectives for national AIDS programmes in con­ regard for national specificities and resolutions sideration of the severity of the AIDS epidemic of the WHO governing bodies. in Africa, population target groups, and the so­ cial, political and demographic complexities of 17.2 The economic crisis and the restnct1ve African societies. In the absence of effective measures adopted to overcome it have resulted in drugs and of vaccines action must be oriented reduced spending on health both by households towards the adoption of behavioural patterns and by governments in some countries. In gen­ likely to prevent HIV infection due to sexual eral, however, government health expenditure intercourse, which is the main manner of trans­ has fallen in real terms, while direct household mission, and to check the spread of the pan­ spending on health appears to have been main­ demic. Social mobilization measures of an un­ tained or even increased. Although reliable data precedented nature have been implemented in are scarce, a growing share of the total health many countries. resources in many African countries appears to be provided from nongovernmental sources. 17.6 Net reductions in the budgets of countries made it necessary to devise new ways of financ­ 17.3 The Region is experiencing the fastest ing health systems and programmes. In coopera­ population growth in the world and a general tion with partners in both the public and the deterioration in some health indicators and sys­ private sectors, such as professional associations tems. New and more virulent forms of the major and religious groups, strenuous efforts were endemic diseases are gaining ground, and the made to stimulate community participation. problems are compounded by the AIDS scourge Links with UNICEF, UNFPA and non­ and scarcity of resources of all kinds. governmental organizations were strengthened within the context of the Bamako Initiative, with 17.4 The pandemic of human immuno­ the aim of generating self-renewing resources for deficiency virus (HIV) infection and AIDS re­ the procurement and management of essential mained the greatest concern of the African drugs at community level. A special health fund Region during the biennium. Decentralization for Africa was also launched in July 1990 during of AIDS control activities commenced following the OAU Council of Ministers conference. This the adoption of resolution AFR/RC39/R7 by has helped to popularize the concept of commu­ the Regional Committee in Niamey in 1989, nity participation, so vital to any health under­ with responsibility devolving to countries and taking in the Region. the Regional Office, and by 31 December 1990 several country programmes had been thus 17.7 The second evaluation of health-for-all "regionalized" (Benin, Botswana, Burundi, strategies was carried out in all Member States by Cameroon, Central African Republic, Congo, teams composed of national and WHO staff. Ethiopia, Gambia, , Rwanda, Zaire, The report of this evaluation shows noteworthy and Zimbabwe), in accordance with pro­ progress in the organization and reorientation of cedures and a timetable adopted in order to im- health systems based on primary health care,

133 THE WORK OF WHO 199o-1991 although some indicators call for greater atten­ this disease has been aggravated by associated tion by countries. HIV infection.

17.8 Programmes for health protection and 17.10 Immunization coverage against all the tar­ promotion were implemented in all Member get diseases of the Expanded Programme on Im­ States, particularly in the field of mother and munization increased. Current efforts in the child health including family planning. In that countries are directed to improved planning, area, 19 countries received direct WHO financial monitoring and evaluation, especially at the support and 11 undertook projects financed by community level. UNFPA and executed by WHO. The nutrition programme was very active, particularly in 17.11 The independence of Namibia was a ma­ preparations for the "International decade on jor political achievement during the period under food and nutrition in the African Region", in review, and the Regional Office spared no effort accordance with resolution AFR/RC39/R4. Of in supporting this young country in promoting two interregional workshops supported by the health of its people. UNFPA in the period on the theme of leadership and participation of women in mother and child 17.12 Action in the strengthening of the mana­ health, including family planning, one was held gerial process, training and development of tech­ at the Regional Office (October 1990) (see also nology was pursued at all levels for support of Chapter 9, paragraphs 9.4 and 9.11). national health systems. The Regional Office cooperated with two Member States in setting up 17.9 Epidemics of communicable diseases, par­ their schools of medicine and maintained its sup­ ticularly malaria, plague, cholera, meningococcal port of existing schools. meningitis and yellow fever, continued to destabilize national health systems. Disease con­ 17.13 Continued emphasis was placed on hu­ trol continued to receive high priority, and man resources development through further studies were started to develop new integrated training, national courses, and specialized pro­ control programmes, which should limit the im­ grammes. A complete review of the fellowships pact of these diseases in areas where they are programme was undertaken, priority being given endemic. Particular attention was paid to train­ to the provision of fellowships for regional pro­ ing and the development of national programmes grammes for improved training of personnel for malaria control. A meeting to prepare for the working at intermediate and district level. By Ministerial Conference on Malaria (1992) was resolution AFR/RC41/R9 the Regional Com­ held in Brazzaville in October 1991. Encourag­ mittee also approved the introduction of study ing progress has been made in the dracunculiasis grants among measures designed to increase the eradication programme. High priority has also number of trainees, strengthen national health been given, through support to management, systems and enhance participation by countries training and research at district level, to the con­ in health development without necessarily in­ trol of tuberculosis; the situation with regard to creasing the fellowships budget.

134 REGION OF THE AMERICAS

CHAPTER 18 Region of the Americas

18.1 Most countries in the Region of the prevalence of chronic diseases - particularly car­ Americas have entered the 1990s in conditions of diovascular diseases, cancer and diabetes - and serious economic and social deterioration. The the consequences of demographic change, espe­ pervasive economic crisis of the past decade has cially urbanization, which are altering life-styles sharply eroded the average standard of living of and may lead to deterioration of the environ­ the population in Latin America and the Carib­ ment. There has also been an increase in disabil­ bean, adding to the number of previously unmet ity and morbidity due to accidents, mental disor­ social needs. Real decline in per capita produc­ ders, and addiction to drugs and alcohol. The tion in the Region, as well as higher levels of epidemic curve of AIDS has also risen sharply in inflation, deteriorating terms of trade and grow­ Latin America and the Caribbean, demonstrating ing underemployment are manifestations of the a prevalence similar to that in North America crisis in the national economies. These factors, five years ago. combined with lower levels of domestic saving and investment, have reduced the availability of 18.4 The difficult conditions facing countries goods and services. of the Region in the last decade of the century are creating an enormous challenge for the Organi­ 18.2 The crisis is particularly acute in the so­ zation. In response to this challenge, the XXIII cial sector, where a marked decrease in public Pan American Sanitary Conference approved the spending is exacerbating the deficiencies in ba­ document "Strategic orientations and program sic infrastructure and services. In most coun­ priorities for the Pan American Health Organi­ tries, new investment is extremely limited, and zation during the quadrennium 1991-1994 ", resources for the operation of services have which provides general guidelines for the Or­ been reduced or cut off entirely. In particular, ganization's policy during that period. The this has affected basic sanitation and the re­ policy is based on the understanding that, since placement, maintenance, and conservation of health is a fundamental part of development, equipment. Moreover, it has proven imposs­ health initiatives must play a promotional and ible for many countries to maintain current political role in development efforts. Accord­ levels of expenditure, which has impaired the ingly, the Organization has consistently endeav­ operation of essential programmes that address oured to guarantee involvement of the various prevailing problems and restricted administra­ social factors in discussions of health-related tive development and training of personnel. problems so that health sector policies stem from The rapid spread of cholera since the epidemic a concerted multisectoral approach. began in early 1991 is a reflection of the de­ terioration of the sanitary infrastructure in the 18.5 In order to strengthen and develop local Region. health systems the Organization has carried out a number of activities which have been recognized 18.3 Most countries in the Region still have as a valid response to the need to prepare health high rates of mortality and morbidity from com­ services to deal with the ever-increasing restric­ municable diseases - mainly gastrointestinal dis­ tions placed on the sector. Efforts have focused eases including cholera, respiratory diseases and on reorganizing the sector through local health vaccine-preventable diseases - and those associ­ system development so that external financing, ated with malnutrition. The epidemiological resources and actions are channelled toward situation has been exacerbated by the increased high-risk population groups. As a result, there is

135 THE WORK OF WHO 199Q-1991 now better coverage, less fragmentation of mission, and reduction of the impact of the epi­ sectoral actions, and greater equity in the distri­ demic on individuals and social groups, with spe­ bution and accessibility of health services. cial emphasis on prevention of drug addiction, sex education for children and adolescents, 18.6 Within the framework of local health sys­ strengthening of laboratories, and quality con­ tem development, immunization programmes in trol of blood and blood products. the Americas have increased their coverage, attain­ ing for the first time in history a level of over 70% 18.9 Environmental health activities having in­ for all the vaccines concerned. In 1990, 30 000 creased during the International Drinking Water deaths from measles, pertussis and neonatal teta­ Supply and Sanitation Decade (1981-1990), Sep­ nus were prevented, as were 5000 cases of polio­ tember 1990 marked the adoption of a regional myelitis. During the same year only 14 occur­ declaration on "Health and the environment", rences of wild poliovirus were detected among which outlined strategies for achieving universal more than 2000 specimens, representing a reduc­ coverage by the year 2000. The Organization has tion of 40% compared with 1989. All the indica­ also supported the development of national water tors show considerable progress toward the eradi­ supply programmes in coordination with the cation of poliomyelitis in the western hemisphere. Inter-American Development Bank, UNICEF, UNDP and bilateral cooperation agencies. In 18.7 When the first cases of the disease were 1990, 259 courses and seminars were offered on detected in Peru, PAHO/WHO formed a chol­ water supply and sanitation in 18 countries of the era study group to coordinate the international Region, representing a marked increase in training response, identify human and financial resources, atthe nationallevel. PAHO/WHO has promoted and provide essential information to Member certification programmes for non-professional States and other concerned agencies. The Or­ personnel in the area of environmental sanitation ganization has sought to strengthen national ca­ in some countries and has provided support for pacity for the rapid mobilization of resources, the creation and consolidation of regional net­ intercountry and intersectoral cooperation, and works of institutions to facilitate efforts in various emergency logistics and communications under areas, including the treatment and recycling of the emergency phase of the strategy for cholera refuse, toxicology, environmental epidemiology, prevention and control in the Region. Together and the assessment of environmental impact. In with USAID and UNICEF, PAHO/WHO co­ addition, the Organization has collaborated in operated with all Member States in the Region to strengthening the Pan American Network of develop an effective programme for the control Information and Documentation in Sanitary of diarrhoeal diseases. Efforts in this respect Engineering and Environmental Sciences. have included the development and distribution of a training module on cholera which describes 18.10 Throughout the biennium efforts at the epidemiological and clinical characteristics of subregional level were intensified. In the light of the disease as well as laboratory and control pro­ the important role played by the Central Amer­ cedures. This has helped to standardize measures ican health initiative known as "Health, a bridge to combat cholera, thus making it possible to for peace", the XXIII Pan American Sanitary mount a more efficient and effective campaign Conference resolved to support the second stage against the disease. of the initiative approved in by the minis­ ters of health of the subregion under the title 18.8 AIDS continues to be a major concern. "Health and peace for development and democ­ Top priority has been given to directing technical racy in Central America". The Organization's collaboration with the Member States in the cooperation has been aimed mainly at the devel­ Region towards the development, execution, opment of national and subregional capacity to financing and evaluation of programmes for mobilize resources for national and subregional AIDS prevention and control. During 1990 a projects in four priority areas: health infrastruc­ total of 80 consultant-months were devoted to ture, health promotion and disease control, support of national and subregional pro­ health care for special groups, and protection of grammes. The national programmes are based the environment. on four principal strategies: prevention of sexual transmission of human immunodeficiency virus 18.11 In the Andean subregion support was given (HIV), prevention of transmission by blood and for important advances in health sector coordina­ blood products, prevention of perinatal trans- tion. Since May 1990 there have been periodic

136 REGION OF THE AMERICAS subregional meetings of the directors of social 18.13 The principal task confronting the health security institutions. In 1991, for the first time in sector is that of modernizing itself. This will the subregion, comprehensive coordination entail development of the capacity to make ef­ agreements were signed between ministries of fective use of epidemiology in order to set pri­ health and social security institutions. With the orities and provide effective coverage for the continuing support of the Andean "Cooperation population groups at greatest risk. Above all, it in health" initiative, arrangements were made to will be necessary to enhance the efficiency and mobilize considerable resources for the social effectiveness of the sector by improving mana­ emergency plan for combating cholera. gerial capacity in services and by introducing qualitative and quantitative changes in the pat­ 18.12 Ifthe Organization is to meet the challenges terns of health services production. These of the decade, health must be assigned greater measures should help to reduce disparities in the importance in the formulation and implementa­ health status of different social groups and tion of social policies and must be seen as a funda­ guarantee all citizens access to services that meet mental component in country development. their basic health needs.

137

CHAPTER 19 South·East Asia Region

19.1 The health situation of the Region is 19.5 In countries it is being recognized that characterized by slow decline in crude mortality governments can no longer take the sole respon­ rates and rates of infant and child mortality. sibility for meeting the health needs of the The infant mortality rate is a comprehensive in­ people. Alternative means are being sought to dicator not only of the standard of living and support services, including the development of level of health education but also of the effec­ technology suited to the local situation. A tiveness of the health care system. In the period scheme for providing grants to strengthen re­ under consideration, only in one country was search institutions in health systems research has infant mortality higher than 100 per 1000 live been implemented, and Member States are show­ births; in two countries it was lower than 20 per ing increased commitment to activities in this 1000, and in another three it was less than 50 per field. 1000. In some countries there was a direct cor­ relation with the educational and economic 19.6 Although some inadequacies exist in the levels of the mothers. current health system structure, particularly for the support of primary health care, greater atten­ 19.2 The available evidence shows that, in tion has been paid by all countries to strengthen­ spite of constraints on the Member States in the ing the district health system, for it is at this level Region in financing health care, a higher level of that national policies and strategies are translated human development has been achieved through into action, and support is provided for an emphasis on equity, efficiency, quality of care, "people-centred" development. Identification social development and people's participation, of problems, setting of objectives and targets, even in low-income countries development of detailed plans of action for local application of appropriate technology, use of 19.3 Respiratory diseases, diseases of the diges­ monitoring and evaluation - all the activities re­ tive system, malnutrition and nutritional defi­ quired to strengthen the district health system ciency disorders, vector-borne diseases, tetanus, are implemented through the "learning-by-do­ diphtheria, tuberculosis and leprosy were the ing" process. It has been possible to adapt the major causes of death and illness. Cardiovascular process to other settings, and even expand it for diseases and neoplasms have more recently be­ the large-scale health care system. Many success­ come major public health problems, particularly ful examples of health development are coming in those countries which have achieved higher out of these "health districts", which put into levels of life expectancy, such as the Democratic practice what is known as "decentralized man­ People's Republic of , Indonesia, Mon­ agement". golia, Sri Lanka and Thailand, and this trend is expected to continue. 19.7 Classical nutrition disorders such as kwashiorkor, acute beriberi and overt vitamin A 19.4 Such previously unknown diseases as den­ deficiency are diminishing. However, malnutri­ gue haemorrhagic fever, Japanese encephalitis tion is still rife, especially among the poor sec­ and El Tor cholera have appeared over the past tions of the population, but also in affluent com­ two or three decades in some countries. More munities where a certain degree of malnutrition recently, AIDS has emerged, and some diseases related to life-style exists. Nutrition research has thought to have been virtually eradicated have been emphasized and a regional nutrition re­ reappeared. search-cum-action network has been established.

139 THE WORK OF WHO 199o-1991

WHO's support to nutrition activities at coun­ most eradicated, is now a cause of serious con­ try level placed emphasis on staff training, and it cern in several states of India, Bangladesh and cooperated with two countries in the Region in Nepal. the reorganization of nutrition training pro­ grammes for community and district health 19.11 Support was provided to countries for workers. measures to improve diarrhoeal disease control as part of a regional programme which is receiv­ 19.8 The essential drugs concept is well ac­ ing high priority, the primary objective being to cepted by the countries of the Region. Most have reduce mortality from the disease in children formulated a list of approximately 250 essential under five years of age and to prevent related drugs, and a short list of some 10 to 30 items for morbidity. Cholera is generally under-reported primary health care. The rational use of drugs and the epidemiological data may not be realistic. has been actively promoted in the Member States. Steps have been taken to reduce the total 19.12 Acute respiratory infections continued to number of pharmaceuticals marketed in most of be a major threat, accounting for 25% of all the countries, to de-register irrational drug com­ deaths in young children. WHO provided sup­ binations, and to eliminate pharmaceutical port in the formulation of detailed plans of op­ preparations of dubious efficacy and safety. Sup­ eration and issued technical guidelines for con­ port is being provided for development of hu­ trol. There are about 5.5 million cases of tuber­ man resources for various aspects of the essential culosis in 11 countries of the Region and about drugs programme. It is also extremely important 2.5 million new cases are reported every year. that the medical profession, in general, prescribe Some 900 000 deaths from tuberculosis occurred drugs in accordance with the essential drugs con­ in 1990 - one-third of the corresponding global cept and programmes. figure. Member countries in the Region received technical support and supplies, including drugs 19.9 With routine vaccine coverage at 80% or and X-ray equipment, financed from regular and higher in most countries, the target diseases of extrabudgetary sources. The new WHO strat­ the Expanded Programme on Immunization are egy for the 1990s was brought to their attention. on the decline. Poliomyelitis eradication efforts have been extended to identify areas of low cov­ 19.13 There has been a decline in the registered erage or recently reported cases, and to provide cases of leprosy, from 3.7 million in 1985 to supplementary coverage in such high-risk areas. 2.7 million in 1990, but the epidemiological ap­ The eradication programme for the 1990s proach needs to be intensified for effective con­ stresses strengthening of disease surveillance in trol. WHO gave technical and material support order to meet the target. To complement surveil­ to national control programmes committed to lance, a network of laboratories equipped to iso­ the rapid expansion of multi-drug therapy, late poliovirus was established in 1991. which has become universally accepted as the method of choice. This is particularly important 19.10 Although there is some decline in malaria in the light of resolution WHA44. 9, which set cases, Plasmodium falciparum infection has re­ the target of eliminating leprosy as a public mained at the same level during the past two health problem by the year 2000. 1 With contin­ decades. In order to facilitate the cost-effective ued political commitment, sustained efforts and implementation of malaria control programmes, new technology the countries of the Region WHO collaborated with countries in pro­ should be able to achieve this target. gramme planning, implementation, monitoring and evaluation, and related training and research, 19.14 WHO provided support for promotion of including field studies on drug resistance, insecti­ regional self-reliance in vaccines. Facilities for cide resistance in vectors, and biological and en­ production of bacterial and viral vaccines are be­ vironmental control methods. There was also ing strengthened in India, Indonesia, Myanmar cooperation at regional level in external assess­ and Thailand. WHO is also supporting research ment of malaria control programmes in four in development of a new polyvalent vaccine countries, and in preparations for the Ministerial against dengue haemorrhagic fever in Thailand, Conference to be held in 1992. Guinea-worm and cell vaccine for prevention of rabies disease (dracunculiasis)- a health problem in the greater part of India - should disappear within a few years. Visceral leishmaniasis, which was al- 1 See Chapter 14, paragraph 14.103.

140 SOUTH-EAST ASIA REGION m India. Plans for clinical trials for these from some countries but the exact extent of in­ vaccines are now at various stages of develop­ fection is not known. Large and small-scale out­ ment. At the same time the Organization has breaks of hepatitis E virus are becoming more made headway in developing expertise in quality common. WHO cooperated with Mongolia and control of bacterial and viral vaccine through the Myanmar in the development of plasma-derived establishment of a network of WHO collaborat­ hepatitis B vaccine. Demonstration programmes ing centres for quality control in India, Indonesia for the control of hepatitis B infection in Indone­ and Thailand, where facilities are available for sia, Mongolia, Myanmar and Thailand have pro­ testing of vaccines and training of nationals in gressed significantly. WHO also continued col­ quality-control procedures. laboration in the evaluation of a local diagnostic reagent for this virus in Democratic People's 19.15 In the 1990s AIDS is emerging as a major Republic of Korea, India, Myanmar, and concern in South-East Asia. WHO estimates Mongolia. that the annual incidence in Asia will exceed the annual number in Africa sometime during the 19.18 The incidence of cancers in the Region is mid- to late 1990s. The highest prevalence in the rising. In 1988 the incidence range in six coun­ Region has been in India, Myanmar and tries of the Region was estimated at between 56 Thailand, where cases are expected to exceed one and 167 in males and 52 and 158 in females per million. Countries such as , Democratic 100 000 population. Tobacco-related cancers per People's Republic of Korea, Maldives and 100 000 population range between 31 to 76 for Mongolia continue to report zero incidence, and males and 4 and 37 for females. WHO provided are considered to be in an advantageous position support to four countries in the formulation of for preventing the spread of human comprehensive national cancer control pro­ immunodeficiency virus (HIV) infection grammes; allocations for cancer control activi­ through the effective implementation of global ties at country level increased. control strategies. 19.19 In view of the evolving situation with re­ 19.16 The HIV/AIDS situation in the three gard to demography, epidemiology and disease countries mentioned above is a serious warning patterns, the priorities, trends and actions to for the future. The rate of increase of HIV infec­ meet these changes will have to be studied care­ tion, as noted in Thailand and India between fully and modified as necessary. It is clear that in 1987 and 1990, is similar to that observed in the the next few decades the population will con­ earlier stages of such infection in sub-Saharan tinue to grow, with more old people suffering Africa. Factors that continue to impede preven­ from chronic disorders and perhaps a larger tion and control efforts include ignorance of the number of them disabled. Rapid urbanization nature of the disease, denial of the relevance of and industrialization will result in the growth of AIDS to the individual or to society, and com­ shanty towns and suburban areas, with many placency in the face of the pandemic's magni­ underprivileged and underserved people below tude. WHO cooperated with Member countries the poverty line. in measures for the prevention of the spread of HIV infection through the formulation of short­ 19.20 The major constraints to achieving health­ and medium-term plans of action with the main for-all goals in the countries of the Region have focus on health education, promotion of condom been: use and safe use of blood and blood products. All countries except Maldives have formulated - economic recession and instability in the medium-term programmes. In Nepal and 1980s, and the legacy of indebtedness that has Thailand, such programmes are being imple­ carried over into the 1990s; mented with both national and external re­ -lack of a suitable political climate for sources, while in other countries external re­ health development; sources have yet to be mobilized. -rapid urbanization, high fertility and low status of women; 19.17 Hepatitis A remains a problem in many -problems of leadership and management countries. More information is now available on in ministries of health, with insufficient the situation of hepatitis B; some 10-12 million reorientation of health system infrastructure people in the Region are infected by the virus. and inadequate development of planning and The hepatitis delta virus has also been reported managerial capabilities at the district level;

141 THE WORK OF WHO 199o-1991

- inefficient development and use of re­ 19.21 A number of issues need to be tackled sources, including human resources; in the spirit of equity and social justice. -inadequate information support for deci­ While the approach to most problems appears sion-making; to be similar in the Member States of the - a low level of literacy, including a low level Region, some issues require country-specific of health education; solutions. However, certain patterns of devel­ - misconceptions or lack of proper under­ opment can be anticipated on the basis of ex­ standing of primary health care at different perience of the past ten years. The aim levels, and insufficient funding of health de­ should be to build on positive trends and to velopment activities. attenuate adverse ones.

142 CHAPTER 20 European Region

20.1 During the biennium the European Re­ works for long-term collaboration with key gion continued to experience rapid political, partners in stimulating movements for health technological and cultural change with major for all. consequences for WHO's regional pro­ gramme. On the political scene, Europe was 20.5 A review of progress towards the health­ transformed more swiftly than would have been for-all targets was carried out during the thought possible two years earlier, two major biennium, and an evaluation report submitted to events being the unification of the Federal the forty-first session of the Regional Committee Republic of Germany and the German Demo­ in 1991; it will form the regional contribution to cratic Republic to form a single Member of the Eighth Report on the World Health Situa­ WHO, and the independence of republics that tion. Extensive consultations took place with were previously part of the Soviet Union. Member States, advisory bodies and experts in order to update the regional health-for-all policy 20.2 The Regional Office for Europe has man­ and targets, and the resulting proposals were en­ aged to respond quickly to new and emerging dorsed by the Regional Committee in 1991. A priorities in Member States. On the advice of the new edition of the 1985 book, Targets for health Regional Committee for Europe in 1990 and a for all, will be published in 1992. subsequent advisory group of the Committee, a special programme of intensified cooperation in 20.6 During the biennium three more countries health with countries of eastern and central Eu­ finalized health-for-all policy documents; and, rope (EUROHEALTH) was set up to respond most notably, the United Kingdom produced to the new priorities. More than $ 1 million of The health of the nation, a stimulating and inter­ the regular budget were allocated to the pro­ esting blueprint for a health-for-all policy. At gramme in 1990-1991, and about $10 million the same time there was growing interest in for­ have been raised in funds and in kind for these mulating health-for-all policies at subnational operations. In addition, a series of missions was and local levels - for example, at county level in undertaken to assess the health needs of the Denmark, at province level in Spain, and at can­ countries in cooperation with headquarters, tonallevel in Switzerland. other international organizations and potential donors. 20.7 During the last two years the Regional Office has been involved in a thorough review of 20.3 Effective emergency relief operations health-for-all policy development in Finland, at were undertaken to respond to health and ref­ the invitation of the Government. The report of ugee problems resulting from the armed conflict this review has already been the subject of con­ in the Persian Gulf, and internal conflict in the siderable debate in the country and can serve as a Soviet Union and Yugoslavia. model for similar reviews in other countries.

20.4 The European regional programme con­ 20.8 Promotion of the European regional ac­ tinued to concentrate on the three main strat­ tion plan on tobacco and extensive collection of egies of formulating and updating the health­ country statistics continued, as well as the foster­ for-all policy, developing methods and ap­ ing of international collaboration and the proaches that countries can use to improve the strengthening of networks of national counter­ health of their populations, and creating net- parts to the WHO programme staff.

143 THE WORK OF WHO 199D-1991

20.9 Major conferences in the area of health the quality of health care. Good progress has promotion have spread understanding and been made in practical projects for this purpose knowledge to many new partners who had not relating to diabetes and hospital infections. In been traditional collaborators of WHO. These 1990 WHO and the International Diabetes Fed­ included a conference on investment in health eration took steps jointly to implement an action (Bonn, December 1990), organized in coopera­ plan on diabetes care and research in Europe, in tion with local governments and other partners; accordance with the 1989 St Vincent Declara­ a conference on life-styles and health (St tion, and so improve the health of more than Petersburg, December 1991 ), which assessed the 13 million diabetics in Europe. Since one theme needs in countries of eastern and central Europe; of the current health services debate is to see the and a European conference on food and nutrition hospital in a wider context, the concept of the policy (Budapest, November 1990), which "health promoting hospital" has been developed stressed that agricultural and industrial sectors in cooperation with a WHO collaborating centre must gain a better understanding of their import­ in Vienna with a view to setting up a new hos­ ance for public health. The Regional Office also pitals network in conjunction with other inter­ participated actively in the Third International governmental organizations. Conference on Health Promotion (Sundsvall, Sweden, June 1991), which looked at the poss­ 20.14 A conference, "From abortion to contra­ ibilities in sectors other than the health sector for ception: public health approaches to reducing stimulating healthy life-styles. unwanted pregnancy through improved family planning services", held under the joint sponsor­ 20.10 The European Healthy Cities network, ship of WHO, UNFPA and the International established in 1986, continued to progress and Planned Parenthood Federation (Tbilisi, Geor­ has since become a truly international movement gia, October 1990), focused attention on high involving more than 400 cities in Europe, North abortion rates due to inadequate family planning America and Australia. programmes, and outlined steps to help Euro­ pean countries deal with this problem. Efforts to 20.11 The impact of the European Conference strengthen maternal and child health care in re­ on Environment and Health (Frankfurt-am­ spect of family planning, reduction of the risk to Main, Germany, December 1989) has been con­ women of HIVI AIDS, and improvement of vac­ siderable, particularly in influencing the environ­ cination programmes in countries of eastern and mental health policies of Member States. In 1990 central Europe have already yielded appreciable a European Centre for Environment and Health, results. comprising three units located in Rome, Bilthoven (Netherlands) and the Regional Of­ 20.15 The network for countrywide integrated fice, was established with financing from the noncommunicable disease intervention (CINDI) Governments of Italy and the Netherlands. has been further expanded and now includes With over 20 new posts and substantial pro­ 14 countries. Demonstration projects contin­ gramme resources, the Centre will increase ued and consultations on policy development WHO's capability to cooperate with Member were started. States in an area of major public and political concern in the years ahead. 20.16 In accordance with recommendations of the first European Conference on Nursing 20.12 The Regional Office is giving more em­ (Vienna, 1988), model programmes and educa­ phasis to health services organization, manage­ tional packages were developed to support the ment and financing and has set up a project concept of a primary health care nurse with a (EUROCARE) to deal with these issues in an family health orientation. WHO collaborated integrated way at both central and local levels, with the Association of Schools of Public Health from the standpoint of health care reform. A in the European Region to develop a European major focus for this activity has been the co­ Master of Public Health degree; regional coop­ operation with countries of eastern and central eration also continued with medical and pharma­ Europe (EUROHEALTH, see paragraph 20.2). cists' associations.

20.13 Particular attention has been paid to new 20.17 Many new publications were issued dur­ mechanisms, systems and indicators that can be ing the biennium in addition to a large number of used to measure and stimulate improvements in technical documents; 14 WHO documentation

144 EUROPEAN REGION centres were set up in Member States to help and called on governments to ensure that the maintain a bibliographic data base, to reproduce principles and objectives of the policy are borne and distribute WHO publications and docu­ in mind in the preparation and implementation ments, and to have them translated into local of national health policies and legislation. languages (see also Chapter 15, paragraphs 15.5 and 15.11). 20.19 In consultation with the Director-General and the Regional Director for Africa technical 20.18 Technical cooperation with the European cooperation was established with a number of Community was strengthened in several fields. African Member States, including Mauritius, in Relations with the Council of Europe took on a selected fields of health development. In order to new dimension with a landmark decision by the stimulate the exchange of experience and infor­ Parliamentary Assembly in April1991, whereby mation, a joint plan of cooperation was drawn up it embraced the European health-for-all policy withPAHO.

145

CHAPTER 21 Eastern Mediterranean Region

21.1 Despite the Gulf War and other causes of lated recommendations of the regional Advisory instability in the Region during the biennium Committee on Health Research, which met in WHO strove to meet a number of emergencies. Abu Dhabi in March 1990 and in the Regional The measures included the visit to Jordan by the Office in April 1991. The deliberations of a Regional Adviser, External Coordination to pro­ consultation on the development of the regional vide support for the WHO representative's of­ programme of research promotion and develop­ fice and to assess the situation of evacuees; the ment with emphasis on health systems research visit of a joint WHO/UNICEF team to in (Teheran, December 1990) were also relevant. February and again in May-June 1991 to assess The regional Health Services Journal continues the cholera and malaria situation; the visit of a to be the medium for dissemination of informa­ WHO regional team to in March 1991 to tion on health systems research. assess the epidemiological, immunization and es­ sential drugs situation; and a joint mission of 21.5 WHO cooperated with eight Member representatives of WHO and other international States in reviews of their health legislation and organizations to Somalia in June-July 1991 to regulations and in measures to prepare new or estimate health and nutritional needs. improved legislation.

21.2 WHO continued to assist Member States 21.6 An encouraging sign in the development in the Region in developing health systems based of human resources for health was the increasing on primary health care and in implementing na­ number of countries that established units to tional health-for-all strategies. Health systems undertake related planning, but there was less management also received attention in many progress in human resources management. countries. More emphasis was given to support Studies are needed on measures to improve the for national community-based integrated pri­ quality and conditions of employment of health mary health care and to promotion of self-reli­ workers. Undergraduate and postgraduate train­ ance. Support was also given to governments in ing received WHO support in several countries, strengthening their national health planning particularly for the review of curricula and meth­ mechanisms with emphasis on health systems de­ ods of teaching and the introduction of modern velopment and financing and on cost-sharing concepts of learning and evaluation. Commu­ schemes. Health information systems still have nity-oriented medical education continued to be to be much improved in most countries, and given high priority, and educational develop­ planning and management and the evaluation of ment centres are now firmly established and are national health-for-all strategies have to be ren­ contributing to making curricula more relevant. dered more effective. The Regional Advisory Panel on Nursing was reactivated and met at the Regional Office in 21.3 The fifth round of joint WHO/govern­ September 1990 to consider factors affecting the ment programme review missions was carried recruitment and retention of nurses in the out in all Member States with the exception of Region with a view to strengthening this aspect Somalia. of human resources development.

21.4 Eight Member States carried out health 21.7 The second session of the leadership devel­ systems research in cooperation with the Or­ opment programme commenced in August 1991, ganization. Such research is guided by the re- with 12 participants from 10 Member States. The

147 THE WORK OF WHO 199CH991 aim is to train leaders in health development who lent in the Region. A technical paper on iodine­ will also play a major role in efforts to achieve deficiency disorders was presented at the thirty­ health for all in their respective countries. seventh session of the Regional Committee (Da­ mascus, October 1990). A Regional Advisory 21.8 There is rapidly growing interest in the Panel on Oral Health was established. While reorientation of health teaching/learning materi­ smoking is being banned in some public places als, especially for primary health care workers at and in government offices, as well as on some the district level. Resolution EM/RC37/R4 of airlines, smoking advertisements in many coun­ the Regional Committee earmarked 5% of coun­ tries are still much in evidence. try allocations to further the use of national lan­ guages in health and medical education. Prob­ 21.11 Maternal and child health in terms of re­ lems persist, however, in how to make the teach­ duced maternal and infant mortality and morbid­ ing/learning materials more relevant to national ity rates in the Region improved, but large differ­ health-for-all strategies. ences remain between poor and wealthy coun-

Offset machines and equipment were provided ond technicians pre pored for their operation and maintenance in Afghanistan with WHO's cooperation.

21.9 Focal points for information and educa­ tries. The importance of birth-spacing and of tion for health were established and were the reducing unwanted pregnancies is increasingly subject of technical cooperation with some being recognized in national programmes; inte­ Member States. Material relating to three annual gration of maternal and child health in primary events (World Health Day, World No-Tobacco health care remains vital for the success of family Day and World AIDS Day) was provided, and, planning. WHO technical support was also among other things, a workshop on "AIDS and directed towards country and intercountry ac­ the media" was organized in Morocco to mark tivities for workers' health. A consultation was AIDS Day (December 1990); WHO also partici­ held on the health of the elderly, which devel­ pated in an AIDS workshop in Cairo (December oped guidelines for formulating national pro­ 1991 ). grammes.

21.10 In general health protection and promo­ 21.12 Member States have commenced the tion, the nutrition programme focused on prob­ elaboration of comprehensive national mental lems of under- and overnutrition that are preva- health policies and programmes characterized by

148 EASTERN MEDITERRANEAN REGION a multisectoral approach and emphasizing deliv­ tions relating to immunization in general and ery of mental health services at the primary poliomyelitis eradication and elimination of health care level. neonatal tetanus in particular. Emphasis is now being placed on maintaining high immunization 21.13 In environmental health, progress in water coverage and on disease reduction through im­ supply and sanitation during the International proved surveillance, energetic measures for the Drinking Water Supply and Sanitation Decade investigation of cases and outbreaks, and imme­ (1981-1990) was evaluated: water supply cover­ diate containment. The introduction of new age increased to 98% in urban and 49% in rural vaccines, particularly that against hepatitis B, in areas; sanitation coverage rose to 82% in urban the Expanded Programme is very encouraging; and 20% in rural areas. Under a regional strategy 17 Member States in the Region have already for water supply and sanitation beyond 1990 the introduced the new vaccine or are in the final same momentum will be maintained in tackling stages of doing so. problems such as water scarcity, rapid popula­ tion increase, lack of human resources, and fi­ 21.16 Regional initiatives in integrated vector nancing. The Centre for Environmental Health control and efforts to ensure the safe use of pesti­ Activities in Amman continues to cooperate in cides gained momentum. Measures to consoli­ providing support to Member States. The Re­ date achievements in the control of diarrhoeal gion is experiencing an unprecedented increase in diseases were maintained, with emphasis on re­ urban population growth, resulting in pollution, ducing morbidity. Acute respiratory infections congestion, inadequate housing and other diffi­ are receiving high priority. The devolution of culties. To respond to these a regional Healthy responsibility for the AIDS programme to coun­ Cities programme was initiated. An intercountry tries under the supervision of the Regional Of­ Healthy Cities conference was held in Cairo in fice in 1990 also led to much activity. A regional November 1990, and country projects are being AIDS information exchange centre was estab­ formulated; the concept of "healthy villages" is lished in the Regional Office which has distrib­ also being promoted. While some progress was uted widely documentation on AIDS prevention made in developing pollution control pro­ and control. This, along with a resolution of the grammes, they have not kept pace with industrial Regional Committee calling for multisectoral ap­ and urban growth. The first priority is to pro­ proaches for AIDS prevention and control, has vide personnel appropriately trained in environ­ paved the way for WHO to involve, for example, mental health through fellowships and national nongovernmental organizations, the media, and training activities. nursing and dental schools in the fight against this intractable disease. 21.14 As regards diagnostic and rehabilitative technology, WHO has supported the develop­ 21.17 Although communicable diseases remain ment of a network of health laboratories, espe­ the predominant problem in the Region, blind­ cially at the periphery. Quality assurance pro­ ness and deafness and noncommunicable dis­ grammes, establishment of national programmes eases such as cancer, cardiovascular diseases, for blood donation on a voluntary, non­ diabetes, haemoglobinopathies and hereditary remunerated basis, and adoption of appropriate disorders are coming to the forefront in many legislation governing blood transfusion have countries. been encouraged. Community-based rehabilita­ tion continues to be the best approach to ensure 21.18 The regional programme for health and accessibility to rehabilitation services and inte­ biomedical information has both substantive and gration of the disabled in communities. support components. Besides the documentary support to all other programmes and a consider­ 21.15 Civil disturbances adversely affected able volume of translation, on the substantive achievements in some programmes. Natural and side national programmes have been established man-made disasters led to mass movements of with increased allocations from countries over populations, rendering them vulnerable to dis­ the years: some 19 countries now have national ease. Despite these constraints, there were some focal-point libraries, 17 have focal points for major advances: the Expanded Programme on health and biomedical information, and 15 have Immunization continued to progress in the related country budgets. Major activities at Region and achieved to a large extent the overall country level relate to the promotion of national objectives stipulated in Health Assembly resolu- languages and the policy of arabization of medi-

149 THE WORK OF WHO 199D-1991 cal education. Library support at country level during a substantial portion of the reporting pe­ focused on the selection and acquisition of riod in dealing with the effects of the Gulf crisis books, subscriptions to journals, training of li­ on travel, shipping and the assignment of staff brary personnel, and advice on new technology, and consultants to Member States. including computer technology. 21.20 In May 1990 the former Yemen Arab 21.19 Apart from its routine activities, the gen­ Republic and People's Democratic Republic of eral support programme was fully mobilized Yemen united to form the Republic of Yemen.

ISO CHAPTER 22 Western Pacific Region

erable vanatwns between countries, however, Regional health·for·all and between different areas within the same evaluation countries. Accordingly, the emphasis is now on providing immunization services where coverage 22.1 The second health-for-all evaluation, de­ is low or nonexistent. scribing the regional health situation in 1991, was discussed at the forty-second session of the 22.4 National control programmes against Regional Committee (Saitama, Japan, September acute respiratory infections are now operational 1991 ). It shows that most countries in the in 15 countries and areas. In the space of two Region have made good progress in terms of the years this has made WHO's standard case man­ health-for-all indicators. For example, 29 of the agement available to 20% of the child population 35 countries and areas in the Region indicated in developing countries of the Region, mainly by that at least 80% of the population have access to means of well organized large-scale training pro­ health care, which includes the availability of at grammes for health workers in first-level health least 20 essential drugs. Twenty countries and facilities. areas indicated that in 1991 at least 90% of their newborn had a birth weight of 2500 grams or 22.5 Diarrhoeal disease control has made more. Infant mortality continued to decline, steady progress, and oral rehydration therapy is although there are still five countries with 50 or now available to over 70% of the children in more deaths per 1000 live births. Standards of some of the developing countries in the Region. living, measured in terms of gross national Very active training is proceeding both in the product and literacy rates, continued to rise in field and in the various training institutions for most countries and areas. health workers.

22.2 In general, Member States expressed the view that such results were very encouraging, but at the same time problems of equity and Diseases still resistant to quality of care are still in urgent need of atten­ control tion. Also, with the rapid rise of diseases related to life-style, and pressing environmental health 22.6 On other fronts there are major public issues, the Region faces new challenges in its health problems which continue to resist efforts pursuit of health for all. to control them. Perhaps the most outstanding of these is malaria, of which about 800 000 cases were recorded in the Region in 1990. This repre­ sents a 35% rise in incidence since 1984 in coun­ Progress in disease control tries other than China, where incidence declined from almost one million cases to less than 22.3 By the end of 1990 over 90% of the chil­ 100 000 during the same period. Several factors dren in the Region had been immunized against have contributed to the improvement in China, the six target diseases of the Expanded Pro­ including strong support for control pro­ gramme on Immunization. This is 10% higher grammes, low population mobility and the rela­ than the threshold set for 1990 by the World tive instability of the disease in that country. Health Assembly in 1978. There are still consid- Most of the national malaria programmes in the

lSI THE WORK OF WHO 199D-1991

Region are facing a shortage of human and finan­ cial resources and an acute need for approaches Newer health challenges better suited to prevailing conditions. It is hoped 22.10 By 1 September 1991, 3569 cases of that the Ministerial Conference on Malaria in AIDS had been reported in the Region. 1992 will help to meet these needs. Though this represents less than 1% of the global total, the number is increasing steadily, 22.7 Tuberculosis also continued to be a major and the conditions associated with rapid trans­ health problem in the Region. Although the mission appear to exist in some parts of the situation improved gradually in most countries, Region. Nearly all countries and areas in the it remained stationary or deteriorated in some. Region have formulated national prevention In 1990, 1.4 million new cases were recorded, and and control plans under the Global Pro­ the incidence rate is 100 or more per 100 000 in gramme on AIDS. These plans are now 11 countries and areas of the Region. Short­ mainly concerned with improving surveillance, course chemotherapy is now used throughout training health care workers, securing labora­ the Region, and efforts to prevent extra­ tory diagnostic capability, testing blood donors pulmonary forms of the disease by extending the and educating the general public, particularly coverage of BCG vaccination continue. Here groups at high risk. In most countries health too, however, new approaches to prevention and education is by far the largest component of control are needed if significant progress is to be the medium-term plans, but cultural barriers, made. as well as shortages of personnel, are still com­ mon problems.

22.11 The nsmg prevalence of non­ Eradication of selected diseases communicable diseases has made health educa­ tion and health promotion essential in several 22.8 At its forty-second session, in 1991, the other programme areas as well, requiring new Regional Committee reaffirmed its commitment courses of training for health workers, increased to the eradication of poliomyelitis in the Region sharing of information, and more activities to by 1995. The disease is still endemic in six coun­ make the public aware of how these diseases can tries, but a plan of action to eradicate it within the be avoided. There has been strong support for next four years has been endorsed by Member the Region's action plan on "tobacco or States and is being carried out. Vaccine shortages health", but in the developing countries numbers still have to be overcome, however, and the sur­ of smokers are still increasing. veillance systems need further reinforcement. Provided sufficient resources are mobilized 22.12 Environmental health is claiming more nationally and internationally, these needs will be and more attention in the Region. Recurring met and the goal achieved. themes in recent Regional Committee discus­ sions include the use of remote islands as dump 22.9 The possibility of eliminating leprosy as a sites for hazardous wastes, anarchic urban devel­ public health problem in the Region (i.e., reduc­ opment, indiscriminate logging, the squandering ing prevalence to below one case per 10 000 of marine resources and the proliferation of population) by the year 2000 was also discussed chemical fertilizers. "Healthy urban environ­ at the forty-second session of the Regional Com­ ment" was selected as the topic of the technical mittee. There were 152 000 registered cases of discussions to be held in conjunction with the leprosy in the Region by the end of 1990, and forty-third session of the Regional Committee. 70.2% of them were on multidrug therapy. It Member States have also endorsed the develop­ was agreed that the first step towards elimination ment of an initiative for a healthy urban environ­ would be to bring all known cases under ment in the Region. multidrug therapy by 1995. The Committee ex­ pressed optimism about the prospects for elimi­ 22.13 On the basis of past experience it can be nation, although it recognized that serious diffi­ expected that the needs and challenges of the culties would have to be overcome, such as case­ Region will be met successfully, but this will finding, especially in remote areas, case manage­ require a high degree of determination on the ment, and the maintenance of an adequate drug part of WHO, and very strong support from the supply. Member States.

152 Annexes

153

Annex I

Members and Associate Members of the World Health Organization

The membership of the World Health Organization reached 170 Member States during the biennium, with one Associate Member. They are listed below with the date on which each became a party to the Constitution or the date of admission to associate membership.

Afghanistan 19 April 1948 Cyprus':- 16 January 1961 26 May 1947 Czechoslovakia'f 1 March 1948 Algeria'f 8 November 1962 Democratic People's Republic 15 May 1976 of Korea 19 May 1973 Antigua and Barbuda* 12 March 1984 Denmark'f 19 April 1948 Argentina'f 22 October 1948 Djibouti 10 March 1978 Australia'f 2 February 1948 'f 13 August 1981 '-· 30 June 1947 Dominican Republic 21 June 1948 Bahamas'f 1 April1974 Ecuador'f 1 March 1949 Bahrain 2 November 1971 Egypt'f 16 December 1947 Bangladesh 19 May 1972 22June 1948 'f 25 April 1967 Equatorial Guinea 5 May 1980 Belarus 7 April1948 Ethiopia 11 April1947 '-· 25 June 1948 Fiji'f 1 January 1972 Belize 23 August 1990 Finland'f 7 October 1947 Benin 20 September 1960 France 16June1948 Bhutan 8 March 1982 Gabon'f 21 November 1960 Bolivia 23 December 1949 Gambia'' 26 April 1971 Botswana'f 26 February 1975 Germany'f 29 May 1951 Brazil'-· 2June 1948 Ghana'f 8 April1957 Darussalam 25 March 1985 ':- 12 March 1948 Bulgaria* 9 June 1948 Grenada 4 December 1974 Burkina Faso'f 4 October 1960 Guatemala':- 26 August 1949 Burundi 22 October 1962 Guinea'f 19 May 1959 Cambodia 17 May 1950 Guinea-Bissau 29 July 1974 Cameroon 6 May 1960 'f 27 September 1966 Canada 29 August 1946 Haiti* 12 August 1947 Cape Verde 5 January 1976 Honduras 8 April1949 Central African Republic'-· 20 September 1960 Hungary'f 17 June 1948 Chad 1 January 1961 Iceland 17 June 1948 Chile'f 15 October 1948 India'f 12 January 1948 China* 22 July 1946 Indonesia'-· 23 May 1950 Colombia 14 May 1959 Iran (Islamic Republic of)'f 23 November 1946 9 December 1975 Iraq* 23 September 194 7 Congo 26 October 1960 Ireland* 20 October 1947 9 May 1984 Israel 21 June 1949 Costa Rica 17 March 1949 Italy'-· 11 April1947 Cote d'Ivoire 28 October 1960 'f 21 March 1963 Cuba* 9 May 1950 Japan'f 16 May 1951

>f Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII.

ISS THE WORK OF WHO 199Q-1991

Jordan'-· 7 April1947 Saint Lucia'f 11 November 1980 Kenya'' 27 January 1964 Saint Vincent and Kiribati 26 July 1984 the Grenadines 2 September 1983 Kuwait* 9 May 1960 Samoa 16 May 1962 Lao People's Democratic San Marino 12 May 1980 Republic'f 17 May 1950 Sao Tome and Principe 23 March 1976 4 December 1991 Saudi Arabia 26 May 1947 Lebanon 19 January 1949 Senegal* 31 October 1960 Lesotho'f 7 July 1967 Seychelles'f 11 September 1979 Liberia 14 March 1947 Sierra Leone'-· 20 October 1961 Libyan Arab Jamahiriya* 16 May 1952 Singapore'f 25 February 1966 Lithuania 25 November 1991 4 April1983 'f 3 June 1949 Somalia 26 January 1961 Madagascar* 16 January 1961 7 August 1947 Malawi* 9 April1965 Spain* 28 May 1951 '' 24 April1958 Sri Lanka 7 July 1948 Maldives'-· 5 November 1965 Sudan 14 May 1956 Mali* 17 October 1960 25 March 1976 Malta* 1 February 1965 Swaziland 16 April1973 Marshall Islands 5 June 1991 Sweden'f 28 August 1947 Mauritania 7 March 1961 Switzerland 26 March 1947 Mauritius'' 9 December 1968 Syrian Arab Republic 18 December 1946 Mexico 7 April 1948 Thailand'f 26 September 1947 Micronesia (Federated States of) 14 August 1991 Togo* 13 May 1960 Monaco 8 July 1948 Tonga'f 14 August 1975 Mongolia'f 18 April1962 '' 3 January 1963 Morocco'' 14 May 1956 Tunisia'f 14 May 1956 Mozambique 11 September 1975 Turkey 2 January 1948 Myanmar 1 July 1948 Uganda'f 7 March 1963 Namibia 23 April1990 Ukraine 3 April1948 Nepal* 2 September 1953 Union of Soviet Socialist Netherlands* 25 April1947 Republics'f 24 March 1948 New Zealand >f 10 December 1946 30 March 1972 '' 24 April1950 United Kingdom of Niger* 5 October 1960 Great Britain and Nigeria* 25 November 1960 Northern Ireland'-· 22 July 1946 * 18 August 1947 United Republic ofTanzania'f 15 March 1962 Oman 28 May 1971 United States of America 21 June 1948 Pakistan'f 23 June 1948 Uruguay'' 22 April1949 Panama 20 February 1951 7 March 1983 Papua New Guinea 29 April1976 Venezuela 7 July 1948 Paraguay 4 January 1949 VietNam 17 May 1950 Peru 11 November 1949 Yemen 20 November 1953 Philippines'' 9 July 1948 Yugoslavia'f 19 November 1947 Poland'f 6 May 1948 Zaire'f 24 February 1961 13 February 1948 Zambia'f 2 February 1965 Qatar 11 May 1972 Zimbabwe'f 16 May 1980 Republic of Korea'f 17 August 1949 Romania* 8 June 1948 Associate Member Rwanda* 7 November 1962 and Nevis 3 December 1984 Tokelau 8 May 1991

'-· Member States that have acceded to the Convention on the Privileges and Immunities of the Specialized Agencies and its Annex VII.

156 ANNEXES

Annex 2

Regional Distribution of Members and Associate Members of the World Health Organization

African Region

Algeria Cote d'Ivoire Malawi Sierra Leone Angola Equatorial Guinea Mali South Africa Benin Ethiopia Mauritania Swaziland Botswana Gabon Mauritius Burkina Faso Gambia Mozambique Togo Burundi Ghana Namibia Uganda Cameroon Guinea Niger United Republic Cape Verde Guinea-Bissau Nigeria of Tanzania Central African Republic Kenya Rwanda Zaire Chad Lesotho Sao Tome and Principe Comoros Liberia Senegal Zambia Congo Madagascar Seychelles Zimbabwe

Region of the Americas

Antigua and Barbuda Colombia Guyana Saint Kitts and Nevis Argentina Costa Rica Haiti Saint Lucia Bahamas Cuba Honduras Saint Vincent Barbados Dominica Jamaica and the Grenadines Belize Dominican Republic Mexico Suriname Bolivia Ecuador Nicaragua Trinidad and Tobago Brazil El Salvador Panama United States of America Canada Grenada Paraguay Uruguay Chile Guatemala Peru Venezuela

South-East Asia Region

Bangladesh India Myanmar Sri Lanka Bhutan Indonesia Nepal Thailand Democratic People's Maldives Republic of Korea Mongolia

157 THE WORK OF WHO 199o-1991

European Region

Albania Greece Monaco Turkey Austria Hungary Netherlands Ukraine Belarus Iceland Norway Union of Soviet Belgium Ireland Poland Socialist Bulgaria Israel Portugal Republics Czechoslovakia Italy Romania United Kingdom of Denmark Latvia San Marino Great Britain and Finland Lithuania Spain Northern Ireland France Luxembourg Sweden Germany Malta Switzerland Yugoslavia

Eastern Mediterranean Region

Afghanistan Iraq Morocco Sudan Bahrain Jordan Oman Syrian Arab Republic Cyprus Kuwait Pakistan Djibouti Tunisia Lebanon Qatar Egypt United Arab Emirates Iran Libyan Arab Saudi Arabia (Islamic Republic of) Jamahiriya Somalia Yemen

Western Padfic Region

Australia Kiribati New Zealand Tonga Brunei Darussalam Lao People's Papua New Guinea Vanuatu Cambodia Democratic Republic Philippines VietNam China Malaysia Republic of Korea Cook Islands Marshall Islands Samoa Fiji Micronesia (Federated Singapore Associate Member Japan States of) Solomon Islands Tokelau

158 ANNEXES

Annex 3

Organizational and related meetings

1. Meetings in 1990

Executive Board, Committee on Drug Policies Geneva, 13 January Executive Board: eighty-fifth session Geneva, 15-24 January Executive Board: Standing Committee on Nongovernmental Organizations Geneva, 16 January World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Geneva, 23-30 April Executive Board: Committee to Consider Certain Financial Matters prior to the Forty-third World Health Assembly Geneva, 7 May Forty-third World Health Assembly Geneva, 7-17 May Executive Board, eighty-sixth session Geneva, 21 May Executive Board: Programme Committee Geneva, 27-31 August Regional Committee for Africa, fortieth session Brazzaville, 5-12 September Regional Committee for the Western Pacific, forty-first session Manila, 10-14 September Regional Committee for Europe, fortieth session Copenhagen, 10-15 September Regional Committee for South-East Asia, forty-third session New Delhi, 18-24 September Regional Committee for the Americas, forty-second session/ Washington, D.C., XXIII Pan American Sanitary Conference 24-28 September Regional Committee for the Eastern Mediterranean, thirty-seventh session Damascus, 8-12 October

2. Meetings in 1991

Executive Board, eighty-seventh session Geneva, 14-25 January Executive Board: Standing Committee on Nongovernmental Organizations Geneva, 15 January World Health Assembly: Special Committee of Experts to study the health conditions of the inhabitants of the occupied territories in the Middle East Geneva, 22-26 April Executive Board: Committee to Consider Certain Financial Matters prior to the Forty-fourth World Health Assembly Geneva, 6 May Forty-fourth World Health Assembly Geneva, 6-16 May Executive Board, eighty-eighth session Geneva, 20-21 May Executive Board: Programme Committee Geneva, 1-4 July Regional Committee for Africa, forty-first session Bujumbura, 4-10 September Regional Committee for Europe, forty-first session Lisbon, 10-14 September Regional Committee for the Western Pacific, forty-second session Saitama Qapan), 10-16 September Regional Committee for the Americas, forty-third session/XXXV meeting Washington, D.C., of the Directing Council of P AHO 23-27 September Regional Committee for South-East Asia, forty-fourth session Kurumba Village Resort (Maldives), 22-28 September Regional Committee for the Eastern Mediterranean, thirty-eighth session Tunis, 6-9 October

159 THEWORKOFWHO 199lH991

Annex 4

Intergovernmental Organizations that have entered into Formal · Agreements with WHO approved by the World Health Assembly, and Nongovernmental Organizations in Official Relations with WHO at 31 December 1991

1. Intergovernmental organizations

African Development Bank Islamic Development Bank International Committee of Military Medicine League of Arab States and Pharmacy Organization of African Unity International Office of Epizootics

2. Nongovernmental organizations

African Medical and Research Foundation International Association for Child and Adolescent International Psychiatry and Allied Professions Aga Khan Foundation International Association of Hydatid Disease Christian Medical Commission International Association of Lions Clubs Christoffel-Blindenmission International Association of Logopedics and Collegium lnternationale Neuro- Phoniatrics Psychopharmacologicum International Association for Maternal and Commonwealth Association for Mental Neonatal Health1 Handicap and Developmental Disabilities International Association of Medical Laboratory Commonwealth Medical Association Technologists Commonwealth Pharmaceutical Association International Association for the Study of the Liver Council of Directors of Institutes ofTropical International Association for the Study of Pain Medicine in Europe International Association for Suicide Prevention Council for International Organizations of Medical International Association on Water Pollution Sciences Research and Control Helen Keller International, Incorporated International Astronautical Federation Industry Council for Development International Brain Research Organization Inter-American Association of Sanitary International Catholic Committee of Nurses and Environmental Engineering and Medico-social Assistants International Academy of Legal Medicine International Centre of Social Gerontology and Social Medicine International Clearinghouse for Birth Defects International Academy of Pathology Monitoring Systems International Agency for the Prevention International College of Surgeons of Blindness International Commission on Occupational Health International Air Transport Association International Commission for the Prevention of International Association for Accident Alcoholism and Drug Dependency and Traffic Medicine International Commission on Radiation Units International Association of Agricultural Medicine and Measurements and Rural Health International Commission on Radiological International Association of Cancer Registries Protection

1 In August 1990 the International Association changed its name to Mother and Child International.

160 ANNEXES

International Committee of the Red Cross International Group of National Associations of International Confederation of Midwives Manufacturers of Agrochemical Products International Council on Alcohol and Addictions International Hospital Federation International Council on Jewish Social and International League against Epilepsy Welfare Services International League against Rheumatism International Council for Laboratory Animal International Leprosy Association Science International Life Sciences Institute International Council of Nurses International Medical Society of Paraplegia International Council of Scientific Unions International Organization of Consumers Unions International Council on Social Welfare International Organization for Standardization International Council of Societies of Pathology International Organization against Trachoma International Council for Standardization in International Pediatric Association Haematology International Pharmaceutical Federation International Council of Women International Physicians for the Prevention of International Cystic Fibrosis (Mucoviscidosis) Nuclear War Association International Planned Parenthood Federation International Dental Federation International Radiation Protection Association International Diabetes Federation International Society for Biomedical Research on International Electrotechnical Commission Alcoholism International Epidemiological Association International Society of Biometeorology International Ergonomics Association International Society of Blood Transfusion International Eye Foundation International Society for Burn Injuries International Federation on Ageing International Society of Chemotherapy International Federation of Business and International Society and Federation of Cardiology Professional Women International Society of Haematology International Federation of Chemical, Energy International Society for Human and Animal and General Workers' Unions Mycology International Federation of Clinical Chemistry International Society of Nurses in Cancer Care International Federation for Family Life International Society of Orthopaedic Surgery and Promotion Traumatology International Federation of Fertility Societies International Society of Radiographers and International Federation of Gynecology and Radiological Technicians Obstetrics International Society of Radiology International Federation of Health Records International Society for the Study of Behavioural Organizations Development International Federation of Hospital Engineering International Sociological Association International Federation for Housing and Planning International Solid Wastes and Public Cleansing International Federation of Hydrotherapy and Association Climatotherapy International Special Dietary Foods Industries International Federation for Information Processing International Union of Architects International Federation for Medical and Biological International Union of Biological Sciences Engineering International Union against Cancer International Federation of Medical Student International Union of Family Organizations Associations International Union for Conservation of Nature International Federation of Multiple Sclerosis and Natural Resources Societies International Union for Health Education International Federation of Ophthalmological International Union of Immunological Societies Societies International Union of Local Authorities International Federation of Oto-Rhino­ International Union of Microbiological Societies Laryngological Societies International Union of Nutritional Sciences International Federation of Pharmaceutical International Union of Pharmacology Manufacturers Associations International Union of Pure and Applied Chemistry International Federation of Physical Medicine International Union of School and University Health and Rehabilitation and Medicine International Federation for Preventive and International Union against Tuberculosis and Lung Social Medicine Disease International Federation of Red Cross and International Union against the Venereal Diseases Red Crescent Societies and the Treponematoses International Federation of Sports Medicine International Water Supply Association International Federation of Surgical Colleges Inter-Parliamentary Union

161 THE WORK OF WHO 199o-1991

Joint Commission on International Aspects of World Federation of Hemophilia Mental Retardation World Federation for Medical Education Medical Women's International Association World Federation for Mental Health Medicus Mundi lnternationalis (International World Federation of Neurology Organization for Cooperation in Health Care) World Federation of Neurosurgical Societies National Council for International Health1 World Federation of Nuclear Medicine Network of Community-Oriented Educational and Biology Institutions for Health Sciences World Federation of Occupational Therapists OXFAM World Federation of Parasitologists Population Council World Federation of Proprietary Medicine Rehabilitation International Manufacturers Rotary International World Federation of Public Health Associations 2 Royal Commonwealth Society for the Blind World Federation of Societies of Anaesthesiologists Save the Children Fund (United Kingdom)2 World Federation of United Nations Associations World Assembly of Youth World Hypertension League World Association of Girl Guides and Girl Scouts World Organization of National Colleges, World Association of Major Metropolises Academies and Academic Associations of General World Association for Psychosocial Rehabilitation Practitioners/Family Physicians World Association of Societies of (Anatomic and Clinical) Pathology World Organization of the Scout Movement World Blind Union World Psychiatric Association World Confederation for Physical Therapy World Rehabilitation Fund World Federation of Associations of Clinical World Veterans Federation Toxicology Centers and Poison Control Centers World Veterinary Association World Federation pf the Deaf World Vision International

1 United States of America. 2 United Kingdom of Great Britain and Northern Ireland

162 Annex 5

Structure of the World Health Organization at 31 December 1991 Structure of the Secretariat of the World Health Organization

Director-General (DG) Adv1ser on Pol1cy Cooperation Adv1ser on Health and Development Pol1c1es Deputy Director-General (DOG)' Plann1ng, Coord1nat1on and Cooperation (PCO)' Programme Development and Mon1torrng (PDM) International Agency Headquarters Regional Offices for Research on Cancer

DIVISIOn of Diarrhoeal and Acute Programme DIRECTOR Resprratory D1sease Control (CDR) Coord1nat1on, DIVISion of Communicable D1seases Promot1on and (CDS) I nformat1on DIVISion of Cont10l of T10p1cal D1seases Secretanat (CTD) Programme WHO Intercountry Health Expanded Programme on lmmun1zat1on Management Development Teams (EPI) WHO Representatives Spec1al Programme for Research and OnchocerciaSIS Control Tra1n1ng 1n Trop1cal D1seases (TOR) Support Programme 1n Programme West Afnca

DIVISIOn of Emergency Rel1ef DIVISion of Drug Management and Operations (ERO) Pol1c1es (DMP) Global Programme on AIDS DIVISion of Fam1ly Health (FHE) PAHO/WHO Representa­ (GPA) Spec1al Programme of Research, tives Off1ce of Aud1t and Adm1n1strat1ve Development and Research T1a1n1ng Ass1stant D1rector Programme Coord1nat1on 1n Human Reproduction (HRP) Management (AAM) Deputy Drrector Off1ces Off1ce of Information (IN F) DIVISion of Noncommunicable D1seases Canbbean and Health Technology (NHT) Off1ce of Legal Counsel (LEG) Health Systems Infrastructure Programme Off1ce of Research Promot1on and Programme on Substance Abuse (PSA) Coord1nat1on Development (RPD) Health Programmes WH091809 Development Health and B1omed1callnformat1on Programme (HBI) DIVISIOn of Development of Human Programme Resources for Health (HRH) Management DIVISion of Epidemiological Surveillance and Health S1tuat1on and Trend WHO Representatives Assessment (HST) DIVISion of St1engthen1ng of Health Support Serv1ces (SHS) Programme

Programme D1v1S1on of Envrronmental Health (EHE) Management DIVISIOn of Health Educat1on (HED) DIVISion of Health Protection and WHO Representative Promotion ( HPP) Support DIVISIOn of Mental Health (MNH) P1ogramme

Programme DIVISIOn of Budget and F1nance (BFI) Management DIVISIOn of Conference and General Serv1ces (CGS) WHO Representatives DIVISIOn of Personnel (PER) Drrector of Health, UNRWA Adv1ser on InformatiCS (AOI) Support Information Technology Off1ce (ITO) Programme

Programme Management 1 !ncludes tre representat1ve of tre D1rector-General of WHO to tre WHO Representatives Unrted Natrons system and other rntergovernmental bod res at New York WHO Country L1a1son Off1cers Includes the WHO Offrce for the Organrzatron of Afrrcan Unrty and the Support Economrc Commrssron for Afrrca, Ad drs Ababa Programme 3 Reg ronal Offrce for the Amerrcas/Pan Amerrcan Sanrtary Bureau Structure of the Secretariat at Headquarters

' -t~ttl. ;QC"l~l'l~i ,, ....-.•Jiiiiliiiill.,~l llt11 Director-General (DG) Advtser on Pol1cy Cooperation Advtser on Health and Development Pollctes Deputy Director-General (DOG) Plannmg, Coordination and Cooperation (PCO) Off1ce of External Coord1nat1on (ECO) Off1ce of Governing Bod1es and Protocol (GBP) Off1ce of International Cooperation (I CO) Programme Development and Monitoring (PDM)

I I I I I Divisron of Emergency Relief Operations (ERO) I Global Programme on AIDS (GPA) IOffice of Audit and Adminrstrative J IOffice of Information I I Office of the Legal I lOffice of Research Promotion and Emergency Preparedness and Response (EPR) Sexually Transm1tted D1seases (VDT) Management (AAM) (INF) Counsel (LEG) Development (RPD) Rel1ef Programme (REL) Planning and Pol1cy Coordination (PPC) Off1ce of Cooperation w1th National Programmes (CNP) Off1ce of Intervention Development and Support (IDS) Off1ce of Research (RES) Ombudsman (OMB) I Adm1n1strat1ve Support Serv1ces (ADS) ------l

ASSISTANT DIRECTOR-GENERAL ASSISTANT DIRECTOR-GENERAL ASSISTANT DIRECTOR-GENERAL ASSISTANT DIRECTOR-GENERAL ASSISTANT DIRECTOR-GENERAL

Drvrsion of Diarrhoeal and Acute Respiratory Division of Drug Management and Policies Health and Biomedical Information Programme Division of Environmental Health (EHE) Division of Budget and Finance (BFI) Drsease Control (CDR) (DMP) (HBI) Commun1ty Water Supply and Adm1ntstrat1on and Fmance Information 1- Support (AFI) Control of Acute Resp11atory Infections (ARI) 1- B1olog1cals (BLG) D1stnbut1on and Sales (DSA) San1tat1on (CWS) ~ Diarrhoeal D1seases Control (COD) Traditional Med1c1ne (TRM) Health Leg1slat1on (HLE) - Promotion of Chem1cal Safety (PCS) Budget (BUD) Action Programme on Essential Drugs (DAP) I"' Off1ce of L1brary and Health Literature Prevention of Enwonmental Pollution (PEP) Finance (FIN) Divisron of Communicable Drseases (CDS) Pharmaceuticals (PHA) Serv1ces (HLT) M1crob1ology and Immunology Support Off1ce of Publ1cat1ons (PUB) ~ Division of Health Education (HED) DIVISIOn of Conference and General Serv1ces (MIM) Divrsion of Family Health (FHE) Off1ce of Language Serv1ces (TRA) AudiOVISual and Programme Support (APS) Servrces (CGS) 1- Tuberculosis (TUB) Adolescent Health (ADH) World Health Journals (WHJ) Health Education and Health Promot1on (HEP) Bu1ld1ng and Off1ce Serv1ces (BOS) Vetennary Public Health (VPH) Women, Health and Development (WHO) - Communtcat1ons, Records and Conference Maternal and Child Health and Fam1ly Plann1ng Division of Development of Human Resources Division of Health Protection and Promotion Serv1ces (CRC) Division of Control of Tropical Diseases (CTD) 1- (MCH) for Health (HRH) (HPP) Supply Serv1ces (SUP) F1lanas1s Control (FIL) Child Health and Development (CHD) Educational Development of Human Resources Health of the Elderly (HEE) Leprosy Control (LEP) Fam1ly Plann1ng and Populat1on (FPP) for Health (EDH) Prevention of Deafness and Hearmg Division of Personnel (PER) Malana Control (MAL) Maternal Health and Safe Motherhood (MSM) Health Learmng Matenals Programme (HLM) lmpa11ment (PDH) Contract Adm1n1strat1on (ADM) Operational Research (OPR) ... Human Resources Pol1cy Analyses (HPA) Rehab1l1tat1on (RHB) Employment Pol1cy and Adm1n1strat1on (EPA) - Sch1stosom1aS1S Control (SCH) Special Programme of Research, Develop- Human Resources Management (HRM) ln;ury Prevention (IPR) - L1a1son and Staff Relations (LSR) Tra1n1ng (TOT) ment and Research Training m Human Nurs1ng (NUR) - Occupational Health (OCH) Manpower Resources Adm1n1strat1on (MRA) Trypanosom1as1s and Le1shman1ases Reproduction (HRP) Plann1ng of Human Resources for Health (PHR) Oral Health (ORH) Jo1nt Medical Serv1ce (JMS) Control (TRY) Programme Management (HRAJ Research Tra1n1ng Grants and Fellowships (RTG) Prevention of Blindness (PBL) Research and Development (HRD) Staff Development Programme (SOP) Tobacco or Health (TOH) Adv1ser on InformatiCS (AOI) ..., Expanded Programme on Immunization (EPI) Resources for Research (HRR) Food and Nutnt1on Programme (FNP) - I Stat1st1cs and Data Processing (HRS) Division of Epidemiologtcal Surveillance and Food A1d Programmes (FAP) ..., Information Technology Off1ce (ITO) Health Srtuatron and Trend Assessment (HST) Food Safety (FOS) Spec tal Programme for Research and Training WH091807 in Tropical Diseases (TOR) Division of Noncommunicable Diseases and Ep1dem1olog1cal and Stat1st1cal Nutnt1on (NUT) Research Capab1l1ty Strengthemng (TDC) Health Technology (NHT) Methodology (ESM) Ep1dem1ology and F1eld Research (TOE) Cl1n1cal Technology (CLI) 1- Global Health S1tuat1on Assessment ~ Divisron of Mental Health (MNH) - Commun1cat1ons (TDI) Cancer and Pall1at1ve Care (CPL) and Pro;ecllons (GSP) Programme Management (TOM) Cardiovascular D1seases (CVD) Mon1t0t1ng. Evaluatton and ProJeCtion Soc1al and Economic Research (TDS) - Diabetes and other Noncommunrcable Methodology (MEPi D1seases (DBO) Strengthening of Ep1demlolog1cal and Stat1st1cal Health Laboratory Technology and Blood Serv1ces (SES) Safety (LBS) Rad1at1on Med1c1ne (RAD) Drvision of Strengthenrng of Health Services (SHS) 1.. ~ Programme on Substance Abuse (PSA) D1stnct Health Systems 1DHS I Health Systems Research and Development (HSR) National Health Systems and Pol1c1es (NHP)

Index

References are by paragraph. Main references are in bold type.

Abortion, 9.6, 10.5, 10.9, 10.35, 20.14 emergency preparedness, 2.38 Abuse Trends Linkage Alerting System (WHO), epidemic preparedness, 14.161 11.14 essential drugs, 13.25, 17.6 ACC, see Administrative Committee on Co-ordina­ food safety and tourism, regional conference (Tunis, tion 1991), 9.37 Accident prevention, 9.51-9.59 food and nutrition, international decade, 17.8 priorities for the health sector, 9.57 health economics, 5.4, 17.6 road safety, 9.59 health expenditure, 17.2 safe communities, 9.54-9.56 health-for-all strategies, evaluation, 17.7 see also Injury control health systems research, 4.40, 4.44 Accidents, nuclear, 2.8, 11.30, 12.34, 14.205 immunization, 17.10 ACHR, see Advisory Committee on Health Research information training, 15.2 Action Programme on Essential Drugs, 13.12, 13.24- malaria, 14.12, 17.9 13.26 management training, 5.9 Administration and finance information system maternal and child health, 10.2, 17.8 (AFI), 16.12, 16.13 medical education, 6.16, 6.22, 6.24, 17.12 regional, 16.14 occupational health, 10.54 Administrative Committee on Co-ordination (ACC), Pan African Centre for Emergency Preparedness 2.27 and Response, 2.38 Intersecretariat Group for Water Resources, 12.10 public health, 6.19 Adolescent health, 10.26-10.31 rehabilitation, 13.33 AIDS, 10.3 research, 9.10 arteriosclerosis, 14.228 supplies, 16.18 mental health, 11.6 tobacco control, 9.67 sexual behaviour, 10.29 urban development, 12.19 Advisory Committee on Health Research, global water supply, 12.10 (ACHR), 8.1, 8.2, 8.9 women, 9.11, 17.8 subcommittee on health and the economy, 5.6, 8.2, see also Member countries, Annex 2 8.7 African trypanosomiasis (sleeping sickness), 14.35- subcommittee on research capacity strengthening, 14.38 8.2, 8.6 national control programmes, 14.36, 14.37 task force on health development research, 8.2, 8.3 research and development, 14.59 task force on monitoring of emerging areas in sci­ African Union against Venereal Diseases and ence and technology, 8.2, 8.4 Treponematoses, 14.129 task force on investigation of evolving problems of Aga Khan Foundation, 5.7 critical significance to health, 8.2, 8.5 AGFUND, see Arab Gulf Programme for United Na­ Advisory committees on health research, regional, tions Development Organizations 8.12 Aging, 10.59-10.61 Eastern Mediterranean, 21.4 research, 10.61 South-East Asia, 6.14 see also Elderly Afghanistan, 2.49, 9.71, 11.17, 13.37, 14.23, 14.44 AIDS (acquired immunodeficiency syndrome), African Development Bank, 2.31 14.133-14.146 African Region, 17.1-17.13 children, 9.8, 10.3, 14.101, 14.133, 14.135 AIDS/HIV infection, 14.139, 17.3, 17.5, 17.9 conferences, 7.9, 7.15 blindness prevention, 14.183 discrimination against sufferers, 14.136, 14.145 cholera, 2.46 Global Programme, 2.12, 14.101 dracunculiasis, 14.52 trust fund, 14.13 7

167 THE WORK OF WHO 199o-1991

AIDS (continued) see also Member countries, Annex 2; Pan American legal and ethical aspects, 4.50 Health Organization partnership programme, 14.141 Anaemia, nutritional, 9.7, 9.27, 10.11 prevalence, 14.135 Andean region, 18.11 prevention and control, 14.136 Andrew Mellon Foundation, 10.25 blood products, safety and screemng, 13.7, Antibiotics and antimicrobials, 14.82, 14.86, 14.87 14.134, 14.140 resistance, 14.89, 14.124, 14.158 condoms, use, 9.8, 14.139 Application of the International Classification of Dis­ national programmes, 14.121, 14.137, 17.5, 18.8 eases to Dentistry and Stomatology, 9.44 traditional medicine, 13.22 Arab Council for Childhood and Development, 14.87 vaccine, 14.142 Arab Gulf Programme for United Nations Develop- relation to tuberculosis, 14.91, 14.93, 14.101 ment Organizations (AGFUND), 14.110, 14.184 research, 14.138, 14.143 Argentina, 6.19, 12.31, 14.39, 14.40, 14.100, 14.151 treatment, 14.143 Argentine haemorrhagic fever, 14.151 women, 9.8, 10.3, 14.133, 14.146 , 9.48 World AIDS Day (1990), 14.146 Arthritis, see Osteoarthritis see also Human immunodeficiency virus (HIV) in­ Asian Conference on Food Safety, First (Kuala fection Lumpur, 1990), 9.34 Albania, 10.5 Asian conference on occupational health, thirteenth Alcohol abuse, 11.11, 11.12, 11.16,11.21-11.23 (Bangkok, 1991), 10.49 interregional meeting (Tokyo, 1991 ), 11.16 Associate Members of WHO, 2.1, Annexes 1 and 2 Algeria, 5.4 Association for Health Information and Libraries in Alliance to combat AIDS (WHO/UNDP), 14.144 Africa (Third Congress), Harare, 1991, 15.2 American Geriatrics Society, 10.59, 10.62 Association of Schools of Public Health in the Euro- American trypanosomiasis (Chagas disease), 14.39- pean Region, 6.20, 20.16 14.42, 14.222 Audiovisual materials, 7.5, 7.11, 7.20, 14.229 research and development, 14.60, 14.64 Australia, 4.16, 9.72, 10.25, 20.10 transmission by blood transfusion, 14.42 Austria, 11.23 vector control, 14.40-14.41, 14.60, 14.64 Auxiliary health personnel, see Community health Americas, Region of the, 4.14, 18.1-18.13 workers and under the various categories of AIDS, 18.3, 18.8 health personnel blindness prevention, 14.184 Chagas disease, 14.39 cholera, 2.46, 4.18, 18.2, 18.7 dengue, 14.13 Bacterial diseases, 14.155-14.157 diarrhoeal diseases, 18.7 see also under names of individual diseases drug and alcohol abuse, 11.13, 11.17, 11.21 Bamako Initiative, 17.6 elderly, health of, 10.61 Bangladesh, 2.37, 2.41, 3.6, 4.16, 5.13, 5.18, 10.8, 14.45, environmental health, 18.9 14.158, 14.159 essential drugs, 13.25 Basic Radiological System (WHO-BRS), 13.9, 13.11 food safety, 9.38 Basic Safety Standards for Radiation Protection, foot-and-mouth disease, 14.120 13.11 health expenditure, 18.2 The battle for health -a global challenge, 7.11 health-for-all activities, 3.6 Behavioural science, training, 11.7 health legislation, 4.51 Behaviour, problems related to malnutrition, 9.27 health systems research, 4.41 see also Psychosocial factors and health human resources, 6.4, 6.5, 6.7 Belarus, 2.1 immunization, 18.6 Belgian R.T. International Holding, 4.29 maternal and child health, 10.3 Belgium, 14.26 medical education, 6.18, 6.22 Belize, 2.1 mental health, 11.2 Benin, 10.8, 14.19, 14.48, 14.183 mortality and morbidity, 18.3 Bhutan, 3.6, 4.27, 7.15 mosquito control, 14.13 Bioethics in human reproduction research in the Mus­ occupational health, 10.54 lim world, conference (Cairo, 1991), 10.42 rabies, 14.110, 14.114 Bioethics: issues and perspectives, 4.49 rehabilitation, 13.34 Biologicals, production and control, 13.18-13.20 sexually transmitted diseases, 14.126 reference materials, 13.18 tobacco control, 9.68 training, 13.20 tuberculosis, 14.99 Biomedical research, see Research vaccine, 14.151 Biosafety, 14.160 women, 9.12 Biotechnology, 9.31, 12.23

168 INDEX

BIREME (Regional Library of Medicine, Sao Paulo, Carnegie Foundation, 10.25, 11.9 Brazil), 15.3 Cataract, 14.179, 14.183 Birth control, see Fertility regulation Centers for Disease Control (Atlanta, GA, USA), Blindness prevention, 14.178-14.188 14.13 cataract, 14.179, 14.183 Central African Republic, 4.28 childhood, 14.180 Central and eastern Europe, 2.17, 5.5, 6.6, 6.20, 9.70, ivermectin, 14.181 11.26, 13.36, 15.5,20.9 national programmes, 14.178, 14.185, 14.186 Centre for Environmental Health Activities (Eastern through primary health care, 14.178, 14.181 Mediterranean Region), 21.13 training, 14.183 Cerebrospinal meningitis, 14.161 see also Eye care Certification Scheme on the Quality of Pharmaceuti- Blood and blood products, screening and safety, 13.6- cal Products, 13.14 13.8, 14.42, 14.134, 14.140 Cervical cancer, 14.130, 14.195, 14.204 transfusions, 13.6, 13.7, 14.42, 14.134, 14.140 Chad, 4.27, 14.48 Bolivia, 4.28, 11.17, 12.31, 14.39, 14.151 Chagas disease, see American trypanosomiasis Botswana, 6.10, 9.66, 14.30, 14.32 Chancroid, 14.124 Brazil, 6.19, 10.29, 10.58, 11.2, 11.17, 11.25, 11.29, Chemicals, 12.21-12.26 14.40, 14.41, 14.100, 14.148 agrochemicals, 12.30 Breast-feeding, 9.22, 10.17, 10.25, 14.77, 14.78 in food (pesticide/veterinary drug residues), 12.23 Bridge, 4.38 international programme on safety (IPCS), 12.21- Brucellosis, 14.118 12.26 Brunei Darussalam, 11.25 poisons control and treatment, 12.25 Budget, see Programme budget (WHO) risk evaluation, 12.22, 12.24 Bulgaria, 9.45, 10.5 training, 12.26 Bulletin of the World Health Organization, 15.9 see also Drugs Burkina Faso, 9.45, 14.19, 14.26 Chernobyl accident, international programme on the Burma, see Myanmar health effects of, 2.8, 11.30, 12.34, 14.205 Burundi, 14.20, 14.23, 14.26 psychosocial aspects of, 11.8 Byelorussian SSR, see Belarus Child abuse, 10.15 Child day care, 11.9 Child health, 10.1-10.7, 10.13-10.21 acute respiratory infections, 14.82-14.90 Cambodia, 2.42, 2.47, 14.21 AIDS/HIV infection, 9.8, 10.3, 14.101, 14.133, Cameroon, 4.43, 5.10, 6.3, 7.15, 10.8, 14.48, 14.148, 14.135 14.159, 14.199 blindness prevention, 14.180 Canada, 10.57, 14.161,14.199 cancer, 14.203, 14.205 Canadian International Development Agency, 9.25 cardiovascular diseases, 14.228 Cancer, 14.190-14.219 diarrhoeal diseases, 14.76 carcinogenesis, 14.211-14.213 mental health, 11.6, 11.9 control and primary prevention, 14.191-14.195, vaccine, 7.5 14.199 see also Adolescent health; Immunization; Infant dietary aspects, 14.193, 14.202 and young child feeding; Maternal and child etiology, 14.202-14.207 health genetic aspects, 14.208 Children's Vaccine Initiative, 7.5 information, 14.217, 14.218 Children, World Summit for, 2.32, 7.5, 9.24, 10.13, national programmes, 14.199 12.4, 14.83 oral contraceptives, relationship with, 10.33 Chile, 10.57, 10.58, 11.2, 14.39, 14.100, 14.199 pain relief and palliative care, 14.197-14.198 China, 2.37, 2.41, 4.17, 4.46, 5.9, 6.4, 9.72, 10.14, 10.52, registries, 14.217 10.58, 10.61, 11.2, 11.6, 11.7, 11.17, 11.24, 12.33, research, 14.200-14.219 13.1, 13.29, 14.12, 14.20, 14.32, 14.44 SEARCH programme, 14.203 Cholera, emergency response, 14.72 tobacco-related, 14.192, 14.207 epidemic, 2.46, 4.18, training, 14.196, 14.219 Global Task Force on Cholera Control, 2.46, 4.18, Cancer incidence in five continents, 14.201 14.72 Cardiovascular diseases, 14.220-14.234 information, 14.72 CARDIAC (cardiovascular diseases/alimentary national control plans, 14.72 monitoring), 14.227 vaccine, 14.176 hormonal contraceptives, 10.34, 14.224 Christoffel-Blindenmission (Germany), 14.180, MONICA (WHO monitoring), 14.220, 14.223- 14.187 14.226 Chronic diseases, dietary preferences as a factor in, training, 14.222 9.20

169 THE WORK OF WHO 199D-1991

CIDA, see Canadian International Development see also Data bases; Information systems Agency Conference on Food Standards, Chemicals in Food CIOMS, see Council for International Organizations and Food Trade, FAO/WHO and GATT of Medical Sciences (Rome, 1991 ), 9.30, 12.23 Classification of diseases, 4.19, 4.20, 9.58 Congo, 9.66 impairments, disability and handicaps, 4.21 Constitutional and legal matters, 2.1-2.8 neurological disorders, 11.3, 11.31 amendments to the WHO Constitution, 2.2, 2.3, 2.4 Clean air at work, conference (Luxembourg, 1991), authentic texts, 2.4 10.47 Consultation on Strategies for Implementing Com­ Climate change, 12.30 prehensive Health Education/Promotion Pro­ Clinical technology, 13.1-13.5 grammes (WHO/UNESCO/UNICEF), 7.15 Codex Alimentarius Commission, FAO/WHO, 9.30 Consultative Committee on Administrative Ques­ Collaborating centres, 8.13 tions, United Nations (CCAQ), 2.27 accident and injury prevention, 9.53, 9.54, 9.58 Consultative Committee on Primary Health Care adolescent health, 10.30 Development, 5.2 applied human ecology, 12.19 Consultative Committee on Substantive Questions, blindness prevention, 14.183, 14.188 United Nations (CCSQ), 2.27, 2.28 cardiovascular diseases, 14.227 Consultative Group of Nongovernmental Organiza­ development of human resources for health for all, tions, 14.183 6.20 Consultative Group on Primary Health Care Devel- disasters and emergencies, 2.37 opment, 4.36 genetics, 14.245 Continuing education, 6.18 haemophilia, 14.245 Contraceptive safety, 10.33-10.35 health aspects of housing, 12.19 Contraceptives, 10.33-10.38 health literature services, 15.7 condoms, 9.8, 14.139, 19.16 health planning, 12.19 implants, 10.34 Healthy Cities, 12.19 injectables, 10.36, 10.38 hospitals, 20.13 intra-uterine, 10.36 information transfer for medical devices, 5.10, male pill, 10.36 14.249 morning-after pill, 10.36 legionellosis, 14.156 oral, 10.33 malaria, 14.19 sterilization, 10.36 management of physical resources, 5. 9 vaccines, 10.36 mental health, 11.30 see also Fertility regulation nursing development, 6.10 Contributions of Member States to WHO, 1.7 occupational health, 10.52 Convention on the Privileges and Immunities of the pesticides, 14.9 Specialized Agencies (1947), 2.5 radiation emergencies, 12.35 Coordination and collaboration, intersectoral, 5.23- school health education and promotion, 7.15 5.27 smallpox and other poxvirus infections, 14.162 within the United Nations system, 2.25-2.30, 2.32 urban and regional planning, 12.19 see also under the names ofindividual organizations urban development, 12.19 Costa Rica, 14.44 vaccines, 19.14 Council for International Organizations of Medical Colombia, 6.19, 14.20 Sciences (CIOMS), 4.52, 8.10 Commission of the European Communities, see Eu­ Conference on development of guidelines for epide- ropean Communities miological research and practice (1990), 8.10 Commission on Health and Environment (WHO), Council for Science and Technology (WHO), 8.8 12.1, 12.2, 12.13 Cuba, 6.19, 14.199 Committee on Programme Coordination (CPC) Cyprus, 3.6, 6.24, 9.66, 9.71, 11.2 (United Nations), 2.27 Cystic fibrosis (mucoviscidosis), 14.244 Communicable diseases, see under the names of Cysticercosis, 14.167 individual diseases Czechoslovakia, 5.4, 10.5 Communicable eye diseases, see Blindness prevention Community health workers, 5.16, 7.17 Community participation in health development, 4.28, 4.33, 5.11, 5.16-5.17, 7.12, 7.17, 17.6 training, 2.37 Danish International Development Agency Computer technology for health information, 2.19- (DANIDA), 6.17, 9.34, 10.16, 11.25 2.24 Data bases: microcomputers applications in health services bibliographic (PAHO/WHO), 15.3 management, 2.23 development indicators, 9.20

170 INDEX

Data bases (continued) Dracunculiasis (guinea-worm disease), 14.50-14.53 foodborne diseases, 9.39 see also International Drinking Water Supply and health-for-all monitoring, 4.1 Sanitation Decade malaria, 14.24 Drug information, WHO, 13.17, 15.9 maternal health, 10.11 Drugs, 13.13, 13.17 mental health, 11.26 abuse, 11.11-11.15,11.17-11.24 oral health, 9.40 AIDS among drug users, 11.22, 11.23, 14.133, schistosomiasis, 14.34 14.134 statistical information, 4.3 designer drugs, 11.20 WH0,2.21 national control programmes, 11.17, 11.24 women's health, 9.6 certification, 13.14 Data processing, see Computer technology for health essential drugs, 13.12 information; Information systems action programme, 13.12, 13.24-13.26 Data Sheets on Pesticides, 12.23 dosage, 13.15 Deafness, 14.189 information and training materials, 13.25 Declaration of Caracas (1990), 11.27 model list, 13.12 Declaration on Health as a Foundation for Develop­ national programmes, 13.12, 13.25 ment (1990), 4.32 nonproprietary names, 15.9 Declaration, (1990), 2.26 policies and management, 13.12 Declaration on the Protection, Promotion and Sup­ quality control, 13,13, 13.14, 13.15 port of Breastfeeding, Innocenti (1990) 9.22, registration, 13.13 10.17, 15.10 regulatory aspects, 13.16, 13.17 Declaration, St Vincent (1989), 20.13 supplies, 2.44, 16.16, 16.20, 16.23 Delagrange International, 11.29 see also Contraceptives Dengue and dengue haemorrhagic fever, 14.149 vaccine, 14.176 vector control, 14.13 Denmark, 6.24, 9.54 Dental health, see Oral health Eastern Mediterranean Region, 21.1-21.20 Developing Countries, WHO Working Group on AIDS, 21.16 Health Promotion in, 7.13 blindness prevention, 14.186 Development indicators, 8.8, 9.20 brucellosis, 14.118 Diabetes, 14.235 diarrhoeal diseases, 21.16 health technology, 14.250 environmental health, 21.13 national programmes, 14.236 epidemiological training, 4.14 Diagnostic technology, 13.6-13.9 health economics, 5.4 Diarrhoeal diseases, 14.67-14.81 health-for-all activities, 3.6 case management, 14.74 health systems research, 4.40 children, 14.76 Healthy Cities, 21.13 control programme targets (WHO), 14.67 human resources, 6.5 drugs, 14.70 immunization, 21.15 information, 14.68 information services, 15.6, 21.18 national programmes, 14.73 maternal and child health, 10.6, 21.11 prevention, 14.71, 14.77 management training, 5.9 rehydration therapy, 14.69, 14.72, 14.74, 14.76, 14.78 mental health, 11.2, 21.12 research, 14.76-14.81 Nursing, Regional Advisory Panel on, 21.6 training, 14.67 Oral Health, Regional Advisory Panel on, 21.10 vaccines, 14.79-14.81 rabies, 14.114 see also Cholera rehabilitation, 13.37, 21.14 Dioxin, 14.206 respiratory infections, 14.84 Director-General's guidance, 1.4, 1.5 supplies, 16.22 Disaster relief, see Emergency relief operations teaching/learning materials, 6.24 Disease vector control, see Vector control tobacco control, 9.71 Djibouti, 2.43, 4.26, 4.29 urban waste management, 12.15 Documentation System for Basic Legislation in the women, 9.15 Health Sector for Latin America and the Carib­ see also Member countries, Annex 2 bean (LEYES), 4.51 Eating habits, healthy, 9.17 Documents (WHO), see Health literature services ECA, see Economic Commission for Africa Dominican Republic, 9.36, 11.2 Echinococcosis, 14.117 Dracunculiasis Eradication Programme Managers' Economic Commission for Africa, United Nations, Meeting (Brazzaville, 1991), 14.51 (ECA), 2.31

171 THE WORK OF WHO 199D-1991

Economic development and health, international preparedness, 14.161 forum, 3.10 Epidemiology and epidemiological surveillance, 4.11- Economic and Social Commission for Asia and the 4.18 Pacific, United Nations (ESCAP), 12.16 Bridge, 4.38 Economic and Social Council, United Nations, 2.40 research, 8.10 Ecuador, 5.19, 9.45, 11.25, 14.20, 14.110 Epilepsy, 11.31 Edna McConnell Clark Foundation, 14.34, 14.188 Equipment and supplies for Member States, 16.15- Education, see Health education; Medical education 16.23 Egypt, 11.6, 11.25, 13.37, 14.30, 14.46 ESCAP, see Economic and Social Commission for Elderly, health of the, 10.56-10.62, 14.233, 19.19 Asia and the Pacific surgery for, 13.5 Essential Drugs Monitor, 13.25 see also Aging Essential drugs, see Drugs, essential Emergency Care Research Institute (Plymouth Meet­ Essential health research, 8.1 ing, PA, USA), 5.10,14.249 Ethics, see Medical ethics Emergency relief operations, 2.34-2.49 Ethiopia, 2.43, 2.47, 5.3, 5.13, 11.25, 14.23 communicable diseases, epidemics, 2.43, 2.46 European Centre for Environment and Health, 20.11 disaster preparedness and response, 2.34, 2.35 European Communities (Commission), 2.31, 4.29, evacuees/returnees, 2.44 9.19, 9.59, 10.43, 10.47, 12.21, 14.36, 14.121, food aid, 9.17 14.139 International Decade for Natural Disaster Reduc- Dental Liaison Committee of the, 9.44 tion, 2.35 European Conference on Environment and Health Pan African Centre, 2.38 (Frankfurt-am-Main, 1989), 20.11 supplies, 14.72, 16.16, 16.18, 16.20, 16.22, 16.23 European Conference on Food and Nutrition Policy see also Natural disasters, psychosocial relief; Refu­ (Budapest, 1990), 9.19, 20.9 gees European Conference on Nursing (Vienna, 1988), Ending hidden hunger: a policy conference on micro­ 20.16 nutrient malnutrition, 9.25 European Industrial Hygiene Conference (Milan, Entre Nous, 10.5 1990), 10.45 Environment, 8.10 European Region, 20.1-20.19 epidemiology network, 12.31 blindness prevention, 14.185 European Conference on Environment and Health cancer control, 14.199 (Frankfurt-am-Main, 1989), 20.11 CINDI, 20.15 health and, 2.10, 12.17 conferences, 9.19, 20.9, 20.11, 20.14, 20.16 training, 12.31 documentation centres, 15.5, 20.17 United Nations Conference on Environment and emergency relief, 20.3 Development (UNCED), 2.32, 7.14, 12.2, epidemiological studies, 4.10 12.30 EUROCARE, 20.12 Environmental health, 12.1-12.35 EUROHEALTH, 2.17, 20.2, 20.12 agrochemicals, 12.30 family planning, 10.5 chemical safety, 12.21-12.26 female condom testing, 9.8 climate changes, 12.30 food safety, 9.39 national capabilities for health protection, 12.27 health-for-all activities, 3.4, 4.15, 20.5-20.7, 20.18 pollution hazards, 12.27-12.35, 22.12 Healthy Cities, 20.10 pollution monitoring, 12.28 human reproduction research, 10.43 regional centres, 20.11, 21.13 human resources, 6.5 sanitation, 12.3-12.11 management training, 5.9 urban health, 12.12-12.20 medical education, 6.20 water supply, 12.3-12.11 mental health, 11.6, 11.26, 11.29 see also Chemicals; Sanitation; Water supply occupational health, 10.45, 10.47, 10.51, 10.54 Environmental Health Criteria, 12.22 programme budgeting, 2.16, Environmental monitoring: rabies, 14.114 air quality monitoring (UNEP/WHO expert meet­ rehabilitation, 13.36 ing), 12.28 substance abuse, 11.23 freshwater quality monitoring (UNEP/WHO con­ supplies, 16.21 sultation), 12.28 technical cooperation, 20.18, 20.19 Global System, UNEP/WHO/UNESCO/WMO tobacco control, 9.70 (GEMS), 9.32, 12.28 women, 9.14 radiation monitoring (WHO/UNEP), 12.35 see also Member countries, Annex 2 Environmental technology, global network, 12.33 Executive Board, 1.4, 1.5, 2.28, 6.9, 6.23, 16.8, 16.9 Epidemics, epizootics and major outbreaks of disease, membership, 2.2 2.43, 2.46 Programme Committee, 1.4, 1.5, 16.8

172 INDEX

Executive Board (continued) food contamination, 9.32 resolutions, 16.8 health education, 7.21 sessions, Annex 3 health legislation, 4.47 Expanded Programme on Immunization, see lmmuni­ Joint Expert Committee on Food Additives, 12.23 zation nutrition, food safety and hygiene, 2.32, 9.30-9.32, Expert advisory panels (WHO), 8.14 12.23 Expert committees (WHO): PEEM, 12.8 on Cancer Pain Relief and Active Supportive Care, Food contamination and hazards, 12.23 14.197 joint monitoring programme UNEP/FAO/WHO, on the Control of Schistosomiasis, 14.30 9.32 on Drug Dependence, 11.18 pesticides and veterinary drug residues, 12.23 on Environmental Health in Urban Development, Food safety, 9.17, 9.30-9.39 12.13 acceptable intake levels (of contaminants), 12.23 on Health Promotion in the Workplace: Alcohol biotechnology, food products derived from, 9.31, and Drug Abuse, 10.51 12.23 on leishmaniasis, 14.43 human resources development, 9.34 on oral health, 9.42 infrastructure development, 9.34 on Rabies, 14.116 tests, 9.33 on Rehabilitation after Cardiovascular Diseases tourism, African regional conference (Tunis, 1991), with Special Emphasis on Developing Coun­ 9.37 tries, 14.23 3 see also Infant and young child feeding; Nutrition on Vector Biology and Control, 12.23, 14.11 Food Standards, Chemicals in Food and Food Trade (FAO/WHO and GATT), 9.30, 12.23 Foodborne diseases and food poisoning, 9.17, 9.38 Foot-and-mouth disease, 14.120 Facts about WHO, 7.11 Foundation for Health Services Research, 4.38 Family Health International, 10.34 France, 4.29, 5.7, 5.9, 6.6, 6.20, 9.54, 14.26, 14.36 Family planning, 10.5, 10.22-10.24, 17.8, 20.14, 21.11 French Technical Cooperation, 5.7 see also Contraceptives; Fertility regulation; Functional literacy, 5.8 Human reproduction research FAO, see Food and Agriculture Organization of the United Nations Federated States of Micronesia, 2.1 Gabon, 14.148 Federation for International Cooperation of Health Gambia, 9.8, 12.31, 14.90 Services and Systems Research Centres, 4.44 General Agreement on Tariffs and Trade (GATT), Feldshers, 6.22 9.30, 9.62 Fellowships, 6.23, 14.99, 17.13, 21.13 General Programme of Work of WHO, Eighth, 2.9, Fertility regulation, 10.35, 10.36-10.39 2.10, 2.11, 9.24, 16.8, 16.11 meeting, 9. 9 Ninth, 1.5, 2.11, 4.7 natural methods, 10.39 Genetics, 14.243 research, 10.37 Geriatrics and gerontology, see Elderly, health of the transfer of technology, 10.38 German Pharma Health Fund, 14.33 Fiji, 5.9, 6.18, 6.21, 13.29, 14.47 Germany, 2.1, 9.44, 10.52, 11.29, 13.11 Filariasis: Gesellschaft fur Technische Zusammenarbeit (GTZ), chemotherapy and chemoprophylaxis, 14.58 (Agency for Technical Cooperation, Germany), lymphatic filariasis, 14.47 9.34, 9.36 primary health care approach, 14.47 Ghana, 3.1 0, 4.27, 4.40, 4.43, 5.3, 5.12, 5.14, 5.19, 5.27, research and development, 14.58 14.52 see also Onchocerciasis Global Blood Safety Initiative (WHO), 14.134 Films and videos (WHO), 5.21, 7.5, 7.20 Golden Triangle, 11.17 Finland, 3.4, 4.29, 7.14, 8.9, 9.66, 10.48 Gonorrhoea, 10.40, 14.124 Fondation Ipsen, 11.30 Good Practices in the Manufacture and Quality Con­ Fondation Marcel Merieux, 6.6 trol of Pharmaceutical Products, 13.14 Food additives, 12.23 Governing bodies, see Executive Board; Regional Food aid, 9.17, 9.28-9.29 committees; World Health Assembly Food and Agriculture Organization of the United GTZ, see Gesellschaft fur Technische Zusammen­ Nations (FAO), joint activities: arbeit biotechnology, 9.31 Guatemala, 4.28, 6.19, 14.48 chemical safety, 12.21, 12.23 Guiding Principles on Human Organ Transplanta­ conferences, 9.18, 9.19, 9.25, 9.30, 12.23 tion, 4.52 environmental management, 12.8 Guinea, 4.26, 4.27, 4.29, 9.11, 10.8

173 THE WORK OF WHO 199o-1991

Guinea-Bissau, 4.27, 4.29, 5.3, 5.12 Health manpower, see Human resources development Guinea-worm disease, see Dracunculiasis for health Gulf crisis, 2.44, 20.3, 21.19 Health and Safety Guides, 12.22 Health Services journal (Eastern Mediterranean Re­ gion), 21.4 Health situation and trend assessment, 4.1-4.10 HABITAT, see United Nations Centre for Human Health systems/services: Settlements based on primary health care, 5.1-5.27, 17.7, 21.2 Haemorrhagic fevers, viral, 14.149-14.154 capabilities, strengthening, 5.11 see also Dengue and dengue haemorrhagic fever community participation in, 5.16-5.17 Headquarters accommodation, 16.7 costs and financing, 4.30, 5.2, 5.4-5.8, 21.2 telecommunications, 2.22, 16.7 development, 4.1-4.4 5 Health, a bridge for peace (Central American health district and peripheral levels, 5.11-5.15, 18.5, 19.6 initiative), 18.10 learning materials, 5.21 Health care delivery, costs and financing, 5.5 management, 5.12, 5.13 quality, 4.15, 5.11, 11.28 expenditure, 5.2, see also Health systems/services; Primary health information, 5.10 care interregional meeting (Mexico, 1991 ), 5.5 Health centres, 5.20 management, training, 2.23, 5.9, 5.13 Health charter for workers, 7.19 microcomputer applications in management, 2.23 Health conditions in the Americas, 15.11 national level, 4.22-4.31 Health development, national, 4.22-4.31 physical resources management, 5.9 Health economics, 5.4-5.10 public/private "mix", interregional meeting on, 5.5 training, 5.7 organization in a changing environment, meeting · Health education, 6.17, 7.12-7.23, 9.16, 9.35, 9.36, on, 5.2 9.72, 10.7, 12.7, 19.20, 21.9, 22.11 training, 5.9, 5.13 communicable diseases, 7.21, 14.27, 14.33, 14.138, user fees, 5.4 14.144, 14.222, 22.10 see also Health care delivery; Primary health care community-based, 7.17 Health systems research, 4.33-4.45, 19.5, 21.4 noncommunicable diseases, 14.222, 14.233, 14.234, cooperation, 4.44 22.11 directory, 4.44 work-site, 7.17 information and awareness, 4.37 workshops, 7.21 infrastructure strengthening, 4.44 World Conference, 7.14, 14.240 research needs, 4.45 Health Equipment Management, newsletter, 5.10 training, 4.41-4.43 Health expenditure, see Health care delivery; Health Healthy Cities, 9.70, 12.16, 20.10, 21.13 systems/services see also Urban health; Urbanization and urban de­ Health for all by the year 2000, economic develop- velopment ment and, 3.8-3.10 Hearing impairment, see Deafness human resources, policy analysis and planning, 6.1 BELLIS (WHO South-East Asia Health Literature, leadership development, 3.5-3.6, 6.10 Library and Information Services), 15.4 monitoring and evaluation, 2.12, 3.1-3.3 Helminth infections, 14.163 common framework, 3.2 Hepatitis, viral, 14.131, 14.148, 19.17 reports, 3.1, 3.3 vaccine, 14.176, 21.15 nursing/midwifery personnel, role in, 6.9 Hereditary diseases, 14.241-14.246,21.17 strategies, global, 1.1, 2.26, 3.1-3.8 training, 14.243, 14.244 national and regional, 3.4, 4.32 Herpes viruses, diagnosis, 14.159 see also Primary Health Care HIV infection, see Human immunoaeficiency virus Health indicators, 4.6 (HIV) infection Health informatics, see Computer technology for Honduras, 14.13, 14.39 health information Hong Kong, 10.58, 11.17, 11.24, 12.33 Health information support, see Information support Hospitals, 5.4, 5.11, 5.17, 14.158 Health legislation, 4.46-4.52, 6.9, 6.11, 9.67, 9.72, equipment, 5.8, 16.16 12.33, 14.145, 14.232, 21.5, 21.14 Human Exposure Assessment Location (HEAL) ethics, 4.49, 4.50 Project, 12.29 human resources, 6.11 Human immunodeficiency virus (HIV) infection: information and awareness, 4.46 blood donors, prevalence in, 13.7 Health literature services, 15.1-15.7 discrimination against HIV-infected persons, information systems, 15.3 14.136, 14.145 Health management, see Health care delivery; Health mental and neurological problems, 11.29 systems/services; Primary health care oral manifestations of, 9.44

174 INDEX

HIV infection (continued) Industry Council for Development (lCD), 9.36 prevalence, 14.135 Infant and young child feeding, 9.22 prevention, 14.121, 14.122 Infertility, 10.40 priorities, 14.136 Influenza, vaccine, 14.147 traditional medicine, 13.22 Informatics and telematics for health, 2.24 transmission, 14.140 Informatics, see Computer technology for health in- treatment, 14.143 formation see also AIDS Information of the public, see Public information Human organs, purchase, sale, transplantation, Information support, 15.1-15.14, 19.20, 20.17, 21.18 4.52 distribution and sales, 15.13, 15.14 Human reproduction research, 10.32-10.43 literature services, 15.1-15.7 ethics, 10.42 publications, 15.8-15.11 national self-reliance, 10.41 terminology, 15.12 Special Programme, 9.9, 10.32, 10.34, 10.36, 10.40, Information systems, 2.21, 4.13 10.41, 10.43 Administration and Finance Information (AFI) sys­ Human resources development for health, tem, 16.12-16.14 6.1-6.25 health legislation, 4.51 data base, 6.15 see also Computer technology for health informa­ financial aspects, 6.3 tion; Data bases information support, 6.12-6.15 Infrastructure development, see Health systems/ leadership, 6.10 semces legislation, 6.11 Injury control, 9.52, 9.53 policy analysis and planning, 6.1, 6.2-6.11 priorities for the health sector, 9.57 research training grants, 6.23 surveillance, 9.58 skills workshops, 6.24 Innocenti Declaration on the Protection, Promotion training, 6.1, 7.17 and Support of Breastfeeding (1990), 9.22, 10.17, training materials, 6.5 15.10 see also Community health workers; Fellowships; Intensified cooperation with countries in greatest Health systems/services, management, train­ need, 5.19 ing; Medical education; Public health schools; Intensified health development action, 2.10 Teacher training; Teaching/learning materials; Interagency Steering Committee for Water Supply and under the various categories of health per­ and Sanitation, 12.10 sonnel Inter-American Commission on Drug Abuse Con­ Hungary, 9.19, 10.58 trol, 11.17 Hypertension, 14.229 Intergovernmental organizations, Annex 4 Hypothyroidism, 14.243 see also Coordination and collaboration, with the United Nations system, and under the names of individual organizations International Agency for Research on Cancer (!ARC), 14.130, 14.200-14.219 IAEA, see International Atomic Energy Agency publications, 14.217, 14.218 IARC, see International Agency for Research on Can­ International Association for Adolescent Health, cer Congress (Montreux, 1991), 10.28 Iceland, 10.58 International Atomic Energy Agency (IAEA), 4.47, IFAD, see International Fund for Agricultural Devel­ 13.9, 13.10, 14.196 opment International Chemical Safety Cards, 12.22 ILO, see International Labour Organization International Children's Centre, 10.28 Immunization, 14.1-14.8 International Classification of Diseases, 4.19-4.21, coverage, 7.5, 14.1, 14.2, 18.6, 19.9, 22.3 9.58, 11.3, 11.31 Expanded Programme, 13.20, 14.147, 14.148, International Classification of Impairments, Disabili­ 14.152 ties and Handicaps, 4.21 in primary health care, 14.8 International Clinical Epidemiology Network, 4.38 national programmes, 14.1 International Code of Marketing of Breast-milk Sub­ training, 14.4 stitutes, 9.23, 10.25 see also Vaccines International Commission on Radiological Educa­ India, 2.37, 3.6, 4.16, 6.7, 6.17, 7.18, 9.13, 9.44, 10.14, tion, 13.9 11.17, 12.31, 13.29, 14.20, 14.44, 14.47, 14.158, International Confederation of Midwives, 10.25 14.199 International Confederation of Free Trade Unions, Indonesia, 2.37, 3.4, 4.43, 4.45, 5.21, 6.11, 6.17, 9.13, 7.19 10.8, 10.38, 12.31, 14.32, 14.199 International Conference on AIDS, Seventh, Industrial health hazards, see Occupational health (Florence, 1991 ), 7.15

17S THE WORK OF WHO 199o-1991

International Conference of Drug Regulatory International League against Rheumatism, 14.239 Authorities (Sixth) (Ottawa, 1991), 13.17 International Leprosy Association, 14.103 International conference of experts on science and International Life Sciences Institute, 9.34 technology for development (Rabat, 1991), 8.8 International meeting on health research for develop- International Conference on Health Promotion ment (Kuopio, 1991), 8.9 (Third): Supportive Environments for Health International Nonproprietary Names (INN), 15.9 (Sundsvall, 1991), 7.14, 12.17, 20.9 International oral health year, 9.43 International conference on health technology in the International Organization for Migration, 13.9 field of diabetes (Kyoto, 1991), 14.250 International Pediatric Association, 9.22, 10.25 International conference on micronutrient malnutri­ International Pharmacopoeia, The, 13.15 tion (Montreal, Canada, 1991), 9.25 International Planned Parenthood Federation, 10.5, International Conference on Nutrition (planned for 10.25, 14.139, 20.14 December 1992), 2.32, 9.18 International primary health care conference (Aruja, International Conference on Radiology in Africa 1990), 5.16 (Kenya, 1991 ), 13.9 International Prpgramme on Chemical Safety (IPCS), International Conference on Safe Communities WHO/UNEP/ILO, 10.43, 12.21-12.26 (First), 9.56 International programme on the health effects of the (Second) (planned for 1992), 9.56 Chernobyl accident, 2.8 International Congress of Medical Librarianship International Public Service Award, 14.246 (Sixth, 1990 ), 15.4 International Society and Federation of Cardiology International Congress on Traditional Chinese Medi­ (ISFC), 14.221, 14.222, 14.228, 14.230, 14.231 cine (Beijing, 1991), 13.21 International Society of Radiology, 13.9 International Congress of the World Association of International Society of Surgery, 8.11 the Major Metropolises (METROPOLIS), International symposium on future trends in the (Third, 1990), 5.19 changing working life (Helsinki, 1991 ), 10.48 International Council for the Control of Iodine Defi- International Thalassaemia Federation, 14.242 ciency Disorders, 9.25 International Union of Architects, 5.10 International Council of Scientific Unions, 8.10, 12.21 International Union against Cancer, 9.70 International Dental Federation, 9.43 International Union for Health Education, 7.14 International Development Research Centre (Cana- International Union of Pure and Applied Chemistry, da), 4.41 12.21 International Diabetes Federation, 14.235, 20.13 International Union of Toxicology, 12.21 International Digest of Health Legislation, 4.47, 4.48 International Women's Health Coalition, 9.9 International Drinking Water Supply and Sanitation International Year of Disabled Persons (1981), 13.28 Decade (1981-1990), 12.3, 12.4, 12.11, 14.50, 18.9, International Youth Foundation, 10.31 21.13 Interregional consultation on quality assurance m International Epidemiological Association, 4.11 primary health care (1990), 4.45 International Federation of Anti-Leprosy Associa­ Interregional meeting on city health (1989), 5.19 tions, 14.103 Interregional meeting on health learning materials de­ International Federation of Gynecology and Obstet­ velopment (Livingstone, Zambia, 1990), 6.24 rics, 10.25 Interregional meeting on malaria control (Brazzaville, XIII World Congress (Singapore, 1991 ), 10.25 1991), 14.22 International Federation of Oto-Rhino-Laryngologi­ Interregional meeting on the "public/private mix" in cal Societies, 14.189 national health systems (1991 ), 5.5 International Federation of Pharmaceutical Manufac­ Interregional workshop on nursing informatics turers' Associations, 14.142 (Washington, D.C., 1991), 6.13 International Federation of Surgical Colleges, Thirty­ Intersectoral action, 5.23-5.27, fourth Congress (Stockholm, 1991 ), 13.5 Intersectoral coordination, see Coordination and col­ International Film and TV Festival of New York, laboration, intersectoral 5.21 Investment in health, conference on (Bonn, 1990), International forum on "Health: a conditionality for 20.9 economic development - Breaking the cycle of Iodine deficiency, 9.24, 9.25, 9.26 poverty and inequity", 3.10, 5.27, 9.2 IPCS, see International Programme on Chemical International Fund for Agricultural Development, Safety 4.29 Iran, Islamic Republic of, 2.41, 3.6, 5.4, 13.37 International Group of National Associations of Irrigation, see Water supply Manufacturers of Agrochemical Products, 12.21 Italian Society of Gerontology and Geriatrics, International Institute on Aging, 10.61 10.62 International Institute for Environmental Technology Italy, 4.29, 5.19, 6.24, 9.22, 10.25, 10.52, 11.25, 14.26, and Management (Stockholm), 12.20 14.33 International Labour Organisation (ILO), 4.47 lvermectin, 14.47-14.49, 14.181

176 INDEX

Jamaica, 5.16, 6.5 Malaria, 14.15-14.27 Japan, 4.29, 6.3, 9.44, 9.72, 10.52, 10.58, 12.34, 13.23 bed-nets, 14.12, 14.56 Japan Shipbuilding Industry Foundation, 4.29, 14.103 chemotherapy and chemoprophylaxis, 14.16, 14.17, Japan Society of Human Genetics, 14.243 14.18, 14.23, 14.90 Joint Committee on Health Policy, UNICEF/WHO, data base, 14.24 2.32, 10.28 epidemics, 2.43, 14.23, 14.24 Joint Expert Committee on Food Additives, FAO/ epidemiology, 14.19, 14.23 WHO, 12.23 interregional meeting (1991), 14.22 Jordan, 3.6, 14.148 Ministerial Conference (1992), 2.32, 14.22, 17.9, 19.10, 22.6 national control programmes, 14.17, 14.18, 14.20- 14.23 Kenya, 4.40, 5.4, 5.10, 7.17, 9.66, 11.29, 12.31 research and development, 14.56, 14.64 Kellogg Foundation, 6.13 training, 14.23, 14.25-14.27, Kiribati, 6.21, 11.24 vector control, 14.10, 14.12, 14.13,14.19 Kuwait, 12.29 Malawi, 4.27, 9.66 Malaysia, 11.25, 12.33 Mali, 5.7, 14.132 Laboratory technology, 13.6-13.8, 21.14 Malnutrition, 9.17 Lao People's Democratic Republic, 4.26, 4.28, 5.3, anthropometric indices, 9.21 5.4, 5.12, 5.14, 11.25, 13.1 behavioural problems in relation to, 9.27 Lassa fever, 14.154 children, 9.21 Latin American Network on Epidemiological Surveil- micronutrient deficiencies, 9.24, 9.25 lance of Foodborne Diseases, 9.38 Malta, 10.57 Latvia, 2.1, 9.44 Management, see Health care delivery; Health sys­ Lebanon, 2.44, 13.37 tems/services, management Legionellosis (Legionnaires' disease), 14.156 Manifesto for Safe Communities, 9.51, 9.56 Legislative action to combat the world smoking Manpower, see Human resources development for epidemic, 9.65 health Leishmaniases, 14.43-14.46 Manual on radiation protection in hospitals and gener­ control, 14.43, 14.44, 14.46 al practice, 13.11 research and development, 14.61 Marshall Islands, 2.1, 11.24 screening, 14.45 Maternal and child health, 10.1-10.25 Leprosy, 14.103-14.109 data bases, 10.11 case detection, 14.106 human resources development, 9.5 multidrug therapy, 14.103, 14.104, 14.107, 14.108 information and awareness, 10.11 national programmes, 14.107 national programmes, support, 10.8 prevalence, 14.104, 14.106, 14.108 participation of women, 9.4 research and development, 14.62 safe motherhood, 10.10, 10.25 training, 4.42, 14.107 task force, 9.5 Lesotho, 4.43 Maternal mortality, 10.2, 10.3, 10.6, 10.8, 10.10 LEYES (Documentation System for Basic Legislation Mauritius, 14.30 in the Health Sector for Latin America and the McConnell Clark, Edna, Foundation, 14.34, 14.188 Caribbean), 4.51 Measles, 14.2, 14.6, 14.7, 18.6 Liaison, 15.1 vaccination and vaccine, 13.9, 14.1, 14.82, Library Information System (WHO LIS), 15.3 14.169 Libraries, see Health literature services; Medical Meat hygiene, 15.9 libraries Medical care, see Health care delivery Life-styles and health, conference on (St Petersburg, Medical education, 6.16-6.24, 11.7 1991), 20.9 continuing education, 6.18 LILACS (Literatura latinoamericana en Ciencias de la learning materials, 6.24 Salud), 15.3 problem-solving approach, 6.17 Lions Clubs International, 14.182 social relevance, 4.39, 6.16 Lithuania, 2.1 Medical ethics, 4.52, 8.10, 10.5, 14.145 Logistic support, see Support services (WHO) Medical libraries, 5.21, 15.2, 15.3, 15.4, 21.18 Lymphatic filariasis, 14.47, 14.58 Medical schools, research in, 4.39, 17.12 see also Medical education Mellon, Andrew, Foundation, 10.25 Membership of WHO, 2.1, Annexes 1 and 2 Macao, 11.24 suspension of rights and privileges, 2.3 Madagascar, 14.19, 14.30 Meningococcal vaccines, 14.17 6

177 THE WORK OF WHO 199o-1991

Mental disorders, 11.25-11.30 Nutrition, 2.10, 2.26, 9.18-9.27, 18.8, 21.1, 21.10 Mental health, 11.1-11.31 children, 9.21 behavioural factors, 11.4, 11.7, 11.10,11.12 international conferences, 2.32, 9.18, 9.25 classification of neurological disorders, 11.3, 11.~1 Nutritional deficiencies, see Malnutrition economic aspects, 11.25 national programmes, 11.1-11.3 primary health care, 11.25 psychosocial factors, 11.4-11.10 publications, 11.25 OAU, see Organization of African Unity services, 11.25, 11.27, 11.28 Occupational health, 7.19, 10.44-10.55 training, 11.25 conferences, 10.45, 10.47, 10.48, 10.49, 10.52, 10.54 see also Alcohol abuse; Drugs, abuse ergonomics, 10.46 METROPOLIS, see World Association of the Major exposure to chemicals, 12.22, 12.26, 14.206, 14.218 Metropolises in nuclear industry, 14.205 Mexico, 4.40, 4.43, 6.3, 6.19, 10.38, 12.31, 14.100 Occupied Arab territories, 2.7, 2.48 Micronesia, Federated States of, 2.1, 6.21 OECD, see Organisation for Economic Co-operation Micronutrient deficiencies, 9.24, 9.25 and Development Ministerial Conference on Malaria (1992), 2.32, 14.22, Office for OAU and ECA (WHO), 2.31 17.9, 19.10, 22.6 Oman, 11.2 Model List of Essential Drugs, 13.12, 15.9 On being in charge, 6.8 Model Prescribing Information, 13.12 Onchocerciasis, 14.48-14.49 Mongolia, 4.29, 9.66, 14.148 Control Programme in West Africa, 14.49, 16.13 Montserrat, 14.30 ivermectin treatment, 14.48, 14.49, 14.181 Morocco, 6.24, 8.8 research and development, 14.58, 14.64 Mozambique, 4.28, 4.29, 4.40, 4.43, 10.8, 14.20 Oncology, see Cancer, research Myanmar, 3.6, 6.7, 6.17, 11.17, 13.1, 14.20, 14.158, Open Eye (Netherlands), 11.6 14.159 Oral health, 9.40-9.50 data collecting methodology, 9.44 equipment, 9.49 essential medicaments, 9.49 Namibia, 2.1, 2.6, 5.3, 5.4, 7.15, 9.66, 14.23, 17.11 expert committees, 9.42 Natural disasters, psychosocial relief, 11.8 personnel, 9.42 see also Emergency relief operations preventive agents, 9.45 Nepal, 3.6, 4.26, 4.27, 6.17, 9.13, 11.17, 13.1, 14.20, training, 9.50 14.44, 14.45, 14.158, 14.187 of refugees, 9.4 7 Netherlands, 4.44, 6.24, 9.23, 9.47, 10.52, 11.23, 20.11 research, 9.45 Network of Community-Oriented Educational Insti- services, future, 9.42 tutions for Health, 4.39 Oral health care facilities, infection control in, 9.50 Neurological disorders, 11.25, 11.29, 11.31 Oral health surveys: basic methods, 9.44 New Zealand, 9.44, 9.72 Oral rehydration salts (ORS), see Rehydration Newborn, care of, see Perinatal care Organ transplantation, 4.52 Niger, 9.45 Organizaci6n Nacional de Ciegos de Espana, 14.184 Nigeria, 4.40, 4.42, 5.13, 5.16, 9.45, 10.57, 11.25, 14.48, Organization for Coordination and Cooperation in 14.52, 14.67, 14.159 the Control of Major Endemic Diseases, 14.32 Noncommunicable diseases: Organisation for Economic Co-operation and Devel- integrated programme (INTERHEALTH), 14.240 opment (OECD), 4.29, 9.59, 12.21 country-wide intervention programme (CINDI), Organization of African Unity (OAU), 2.31, 17.6 14.240, 20.15 Organizational and related meetings, Annex 3 see also individual diseases: Organizational structure of WHO, see Structure of Nongovernmental organizations in official relations WHO, and Annex 5 with WHO, 2.33, Annex 4 Orthopoxvirus Infections, Ad Hoc Committee on, Norwegian Agency for International Development 14.162 (NORAD), 10.25, 12.33 Osteoarthritis, 14.238 Nosocomial (hospital) infections, 20.13 Osteoporosis, 10.58, 14.239 Nuclear medicine, 13.9 Nurses, shortage of, 6.9, 6.14 Nursing: education, 6.18, 11.7 informatics, 6.13 Pacific Basin Medical Officers Training Program, 6.21 leadership, 6.10 Paediatrics, see Child health role in health-for-all strategy, 6. 9 P AHO, see Pan American Health Organization

118 INDEX

Pakistan, 5.19, 7.18, 9.36, 9.71, 10.14, 11.6, 11.17, conference (1990), 5.16 13.37, 14.10, 14.23, 14.199 management systems, development of, 5.13 Palestine, 2.7 newsletter, 5.22 Palestinian people, technical cooperation for health, occupational health, 10.53 2.48 quality assurance, 4.45 Pan African Centre for Emergency Preparedness and teaching/learning materials, 11.15 Response, 2.38 see also Health for all by the year 2000; Health Pan American Health Organization (PAHO), 2.13 systems/services Directing Council, 14.42 Pro Gastronomia Foundation, 9.36 programme budgeting, 2.13, 2.14 Programme budgeting, 1.4, 1.5, 2.11 publications, 4.38, 4.49, 15.11 Programme budgets (WHO), see also Americas, Region of the for 1990-1991,1.7, 16.8-16.11 Pan American Network of Information and Docu­ for 1992-1993, 1.6, 1.7, 16.8 mentation in Sanitary Engineering and Environ­ for 1994-1995, 1.4, 1.5, 2.11 mental Sciences, 18.9 Programme Committee of the Executive Board, 1.4, Pan American Sanitary Bureau, see Regional Office 1.5, 16.8 for the Americas Programme of WHO, development, 2.9-2.18 Pan American Sanitary Conference (XXIII), 10.54, priorities, 1.5, 1.6, 2.10 14.42, 18.4, 18.10 support costs, reimbursement of, 2.30 Panama, 14.13 see also General Programme of Work of WHO Panel of Experts on Environmental Management for Protozoal infections, 14.166 Vector Control, WHO/FAO/UNEP/World Psychosocial factors and health, 11.4-11.10 Bank (PEEM), 12.8, 12.9 Public health administrators, training, 6.15, 6.19 Papua New Guinea, 6.21, 11.24,14.132 Public health services, see Health systems/services Paraguay, 14.20, 14.39, 14.44 Public Health Summit (Omiya, Japan, 1991), 3.8 Parasitic diseases, 14.28, 14.29 Public information, 7.1-7.11 intestinal, 14.163-14.167 see also Health education training, 14.165 Publications (WHO), 15.8-15.11 see also Tropical diseases; Vector control, and un- regional, 4.38, 6.18, 15.11, 20.5, 20.17 der the names of individual parasitic diseases Public Services International, 7.19 Parasuicide, 11.10 Puebla Group, 4.44 Paris Declaration (1990), 2.26 PEEM, see Panel of Experts on Environmental Man- agement for Vector Control Perinatal care (care of the newborn), 10.18-10.21 Peru, 12.31, 14.20, 14.148 Qinghaosu (artemisinin), 14.56 Pesticide Evaluation Scheme (WHO), 14.9 Pesticides, 12.23, 12.24, 12.33, 14.9, 14.14, 14.218 Pharmaceutical Newsletter (WHO), 13.17 Pharmaceuticals, see Drugs Phenylketonuria, 14.243 Rabies, 14.110-14.116 Philippines, 2.37, 2.41, 4.17, 9.72 10.8, 11.2, 11.25, vaccination, 19.14 12.33, 14.199 Radiation medicine and radiological services/systems, Physicians, training, see Medical education 13.9-13.11 Plague, 14.157, 17.9 dosimetry, 13.10 Planning, see General Programme of Work of nuclear medicine, 13.9 WHO radiation protection, 13.11 Pneumonia, 14.82, 14.83, 14.86, 14.88-14.90 radiodiagnosis, 13.9 Poisoning, see Chemicals; Food contamination and radiotherapy, 13.10 hazards; Foodborne diseases and food poisoning Recommended Classification of Pesticides by Hazard Poland, 9.44, 12.31 and Guidelines for Classification (WHO), 12.23 Poliomyelitis, 13.2, 14.2, 14.6, 14.147, 14.175, 18.6 Refugees and displaced persons, 2.44, 9.17, 9. 47, 11.8, eradication 14.7, 19.9, 21.15, 22.8 14.23 vaccination and vaccine, 14.1, 14.169, 14.175 Regional Committee for Africa, 14.83, 17.4, 17.5, Poliovirus, wild, 14.147, 18.6 17.13 Pollution, see Environmental pollution and hazards Regional Committee for the Americas, see Pan Amer­ Population Council, 10.34 ican Sanitary Conference Portugal, 5.9, 10.45 Regional Committee for the Eastern Mediterranean, Press, 7.3, 7.5 14.97, 21.8, 21.10, 21.16 Primary health care, 4.24, 5.1-5.27 Regional Committee for Europe, 2.16, 9.14. 20.5 Development, Consultative Committee on, 5.2 Regional Committee for South-East Asia, 14.97

179 THE WORK OF WHO 199D-1991

Regional Committee for the Western Pacific, 2.18, Safe Motherhood, 10.11 22.1, 22.8, 22.9, 22.12 Safe Motherhood Initiative (WHO/UNDP/ Regional committees, 1.4, 2.28 UNFPA), 10.4, 10.6, 10.25 meetings, Annex 3 Saitama Declaration, 3.8 Regional Conference on Dracunculiasis m Africa St Vincent Declaration, 20.13 (Third) (Yamoussoukro, 1990), 14.51 Salmonellosis, 14.119 Regional Congress on Radiological and Nuclear Samoa, 9.72, 14.47 Safety (Buenos Aires, 1991), 13.11 Sanitation, 12.3-12.11, 18.2, 21.13 Regional Office for Africa, information systems, coordination and cooperation, 12.10 4.13 environmental management, 12.8 Regional Office for the Americas, 18.7 indicators, 12.9 Regional Office for the Eastern Mediterranean, ac­ information exchange, 12.9 commodation, 16.4 information system, 12.9 publications, 4.38 monitoring, 12.9 Regional Office for Europe, 6.20 national institutional development, 12.5 accommodation, 16.6 operation and maintenance, 12.6 publications, 6.18, 15.11, 20.17 see also Environmental health; International Drink­ Regional Office for South-East Asia, information sys­ ing Water Supply and Sanitation Decade; Water tems, 16.14 supply publications, 5.26 SAREC, see Swedish Agency for Research Coopera- Regional Office for the Western Pacific, accommoda­ tion with Developing Countries tion, 16.5 Saudi Arabia, 9.71, 13.37, 14.44 Regional offices, telecommunications, 2.22 Save the Children Fund, 5.12 Rehabilitation, 11.25, 13.27-13.38, 14.233 Schistosomiasis, 14.30-14.34 community services, 13.28, 13.33, 13.35, 13.37, chemotherapy, 14.31 13.38, 21.14 control, 14.30-14.33, 14.165 national programmes, 13.28, 13.37, 13.38 data base, 14.34 primary health care approach, 13.28 epidemiology, 14.30, 14.32 training, 13.30-13.32 health education, 14.33 Rehydration (oral rehydration salts), 14.69, 14.72, microcomputer applications m programme man­ 14.74, 14.76, 14.78 agement, 14.34 Reproductive health, see Human reproduction re­ research and development, 14.57 search training, 14.32, 14.165 Republic of Korea, 9.72, 12.33 Schizophrenia, 11.25, 11.29 Research, 8.1-8.14 Science and Technology, Council for (WHO), 8.8 ethical aspects, 4.49, 8.10, 10.42, 11.30 international conference of experts (Rabat, 1991 ), meeting, 8. 9 8.8 priorities, 8.3 Scientific groups (WHO): training grants and awards, 6.23 on clinical diagnostic imaging, 13.9 see also Health systems research, and under individ­ on the Treatment of Psychiatric Disorders, 11.25 ual subjects of research Scout Movement, World Organization of the, 7.18, Respiratory diseases, acute, 14.82-14.90, 18.3, 19.12 10.29 case management, 14.82, 14.86, 14.87 Seminar for Europe, Middle East, and Africa on Radi- meetings, 14.84, 14.90 ation Dosimetry (Leuven, 1991), 13.10 national programmes, 14.85 Seminar on plants and health (Kobe, 1991), 13.23 prevention, 14.82 Senegal, 10.8, 14.19 surveillance, 14.89, 14.159 Sexual behaviour, 10.29, 10.35 research, 14.88, 14.89, 14.90 Sexually transmitted diseases, 14.121-14.146 training, 14.87, 14.88 primary health care approach, 14.121, 14.123 Respiratory syncytial VIruses, 14.159, 14.170, reporting, 14.121 14.176 training and research, 14.125, 14.129, 14.130 Rheumatic diseases, chronic, 14.237-14.239 see also AIDS, and under the names of individual Rheumatic fever, 14.155 diseases Rheumatic heart disease, 14.155 Seychelles, 14.164 Rickettsial diseases, 14.159 Sickle cell disease, 14.2 4 3 Rift Valley fever, 14.153 SIDA, see Swedish International Development Au- Rockefeller Foundation, 4.38, 5.20, 10.25, 10.41, thority 14.168 Sierra Leone, 7.17, 14.48 Romania, 13.9 Sight Savers (United Kingdom), 14.180, 14.184 Rotary International, 14.4 SIMAVI (Netherlands), 13.9 Rwanda, 14.20 Singapore, 9.72, 12.33, 14.199

180 INDEX

Sleeping sickness, see African Trypanosomiasis Staff of WHO, 16.1-16.3 Smallpox, 14.162 training, 6.25 Smoking, see Tobacco control Statistics, 4.1-4.10 Socioeconomic development and health, see Health classifications, 4.19-4.21, 9.58, 11.3, 11.31 for all by the year 2000, economic development information system, 4.3 and publications, 5.20, 14.223 Somalia, 2.43 see also Data bases South-East-Asian Ergonomics Society, third confer­ Sterility, 10.11, 10.40 ence (Bangkok, 1991), 10.49 Streptococcal infections, 14.155 South-East Asia Region, 19.1-19.21 Structure of WHO, 2.34, 6.25, 14.247, Annex 5 acute respiratory infections, 14.84, 19.12 Study groups (WHO): AIDS/HIV infection, 19.15, 19.16 on Aging and Working Capacity (Helsinki, 1991), behavioural problems, 9.27 10.60 blindness prevention, 14.187 on Diet, Nutrition and Prevention of Chronic Dis­ brucellosis, 14.118 eases, 14.193 cancer, 19.18 on Management of Sexually Transmitted Diseases Consultative Committee for Programme Develop- Patients, 14.123 ment and Management, 2.15 Substance abuse, 11.11-11.24 dengue, 14.13 Sudan, 2.37, 2.43, 4.26, 14.44, 14.68 development policies and health, 5.26 Suicide, 11.1 0 diarrhoeal disease control, 19.11 Sundsvall Statement on Supportive Environments for district health system, 19.6 Health, 7.14 essential drugs, 19.8 Support services (WHO), 16.1-16.23 health economics, 5.4 Swaziland, 4.43 health-for-all activities, 3.4, 3.6 Sweden, 5.9, 6.24, 7.14, 9.23, 9.45, 9.54, 10.52,11.23 health systems research, 19.5 Swedish Agency for Research Cooperation with De- hepatitis, 19.17 veloping Countries (SAREC), 10.25, 12.31 human resources, 6.7 Swedish International Development Authority immunization, 19.9 (SIDA), 9.23, 10.17, 10.25, 12.31, 13.31 information services, 15.4 Switzerland, 9.36, 10.25, 14.225, 20.6 leprosy, 19.13 Syphilis, 14.127, 14.128 malaria, 19.10 Syrian Arab Republic, 9.45 maternal and child health, 10.4 medical education, 6.24, 17.12 mental health, 11.2, 11.9 nursing education, 6.18 Tanzania, see United Republic of Tanzania nursing research, 6.14 Targets for health for all (European Region), 20.5 nutrition research, 19.7 Teaching/learning materials, 5.21, 6.5, 6.20, 6.24, 21.6, occupational health, 10.49, 10.54 21.8 programme budgeting, 2.15 Technical cooperation among developing countries rabies, 14.114 (TCDC), 4.32 rehabilitation, 13.29, 13.35 with Member States, 2.25 research, 8.12 Technical discussions at Health Assembly, 1.9, 4.36, substance abuse, 11.22 5.19, 8.1, 8.9, 12.14 supplies, 16.20 Technology development, assessment and transfer, teacher training, 6.17 14.247-14.250 tobacco control, 9.69 Tetanus, 14.2, 14.4, 14.6, 14.7, 19.3, 21.15 urban waste management, 12.15 vaccination and vaccine,10.18, 14.1, 14.169, 14.172, vaccines, 19.14 18.6 women, 9.13 Thailand, 3.6, 4.42, 5.16, 6.12, 6.14, 6.17, 6.18, 7.14, see also Member countries, Annex 2 9.45, 9.54, 9.62, 9.66, 10.14, 10.29, 10.38, 11.29, Spain, 10.57, 14.199 14.26, 14.47 Spanish Agency for International Cooperation, 9.34 Thalassaemia, 14.242, 14.243 Special Programme for Research, Development and Tobacco Alert, 9.65 Research Training in Human Reproduction, see Tobacco control, 9.60-9.72, 20.8, 22.11 Human reproduction research, special programme conference, 9.61 Special Programme for Research and Training in information support, 9.65 Tropical Diseases see Tropical diseases, research in school health curricula, 9.66 and training, special programme national programmes, 9.66 Sri Lanka, 3.6, 4.40, 4.43, 7.15, 11.17, 13.1, 14.47, protection from involuntary exposure, 9.60 14.110, 14.158, 14.159, 14.187, 14.196 production, alternative crops, 9.63

181 THE WORK OF WHO 199D-1991

Tobacco control (continued) Overseas Development Administration, 5.7, 5.12, trade barriers, 9.62, 9.63 14.21, 14.139 world no-tobacco days, 7.8, 9.64 United Nations, General Assembly resolutions, 2.28, Tokelau, 2.1 2.29 Tonga, 9.72, 11.24, 14.47 see also Coordination and collaboration, intersecto­ Tourism, food safety, African regional conference ral; and under names of other organizations (Tunis, 1991), 9.37 within the United Nations system Toxicology, see Chemicals; Drugs, control; Food safe­ United Nations Centre for Human Settlements ty; Foodborne diseases and food poisoning; Pesti­ (HABITAT), 12.8, 12.20 cides United Nations Centre for Science and Technology Traditional birth attendants, 10.12 for Development, 8.8 Traditional healers, 5.16, 13.21 United Nations Children's Fund (UNICEF), joint Traditional medicine, 13.21-13.23, 14.64 activities: Training, see Human resources development for AIDS, 14.139, 14.144 health, and under subjects African Region, 17.6 Treponematoses, 14.132 Americas, 18.7, 18.9 Tropical diseases, research, 11.31, 14.54-14.66 breast-feeding, 9.22, 10.17, 15.10 Special Programme (UNDP/World Bank/WHO), cholera, 14.72 9.10, 14.54, 14.55 diarrhoeal diseases, 14.68, 14.69, 14.72 see also Vector control, and under names ofindivid­ emergency relief, 2.41, 2.45 ual diseases epidemiology, 4.17 Trust Fund for the Global Programme on AIDS health economics, 5.7 (WHO), 14.137 health education, 7.15, 7.21 Trypanosomiasis, see African trypanosomiasis immunization, 7.5, 14.4 (sleeping sickness); American trypanosomiasis indicators, 4.6 (Chagas disease) infant and young child feeding, 9.22 Tuberculosis, 14.91-14.102, 19.3, 19.12 Joint Committee on Health Policy, 2.32, 10.28 case detection, 14.92 maternal and child health and family planning, deaths, 14.91 10.25 global control strategy, 14.93, 14.94-14.96 national health development, 4.29 interaction with HIV/AIDS, 14.91, 14.93,14.101 nutrition, 9.25, 9.26 national programmes, 14.91, 14.92, 14.96 respiratory infections, 14.84, 14.86 prevalence, 14.91 sanitation, 12.9 research, 14.93, 14.101, 14.102 schistosomiasis, 14.30 technical guidance, 14.98-14.99 Special Programme on Capacity Building for Child training, 14.97, 14.100 Survival and Development, 4.42 vaccine development, 14.102, 14.175 vaccine development, 14.168 Tunisia, 10.6, 11.2, 14.87, 14.110 water supply, 12.9, 18.9 Typhoid, vaccine, 14.170, 14.176 United Nations Commission on Human Rights, 11.27 United Nations Commission on Narcotic Drugs, 11.18 United Nations Committee on Programme Coordi­ Uganda, 9.8, 9.11, 10.8, 14.20, 14.36 nation, 2.27 UNCED, see United Nations Conference on Envi­ United Nations Conference on Environment and ronment and Development Development (UNCED), 2.32, 7.14, 12.2, 12.30 UNDP, see United Nations Development Programme United Nations Consolidated List of Products whose UNDRO, see United Nations Disaster Relief Coordi­ Consumption and/or Sale have been Banned, nator Withdrawn, Severely Restricted or Not Ap­ UNEP, see United Nations Environment Programme proved by Governments, 13.17 UNESCO, see United Nations Educational, Scientific United Nations Convention on the Rights of the and Cultural Organization Child, 4.48, 10.13 UNFPA, see United Nations Population Fund United Nations Coordinator for Humanitarian and UNHCR, see United Nations High Commissioner Economic Assistance Programmes relating to for Refugees Afghanistan, Office of the, 2.49 UNICEF, see United Nations Children's Fund United Nations Decade of Disabled Persons, 13.28 Union of Pure and Applied Chemistry, 12.21 United Nations Development Decade, International Union of Soviet Socialist Republics, 6.5, 6.22, 9.45, Development Strategy: 9.48, 10.52, 12.34, 13.9 Fourth (1991-2000), 2.26 United Arab Emirates, 13.37, 14.199 Third (1981-1990), 2.26 United Kingdom of Great Britain and Northern Ire­ Programme of Action for the Least Developed land, 4.48, 5.7, 5.21, 5.22, 12.15 Countries, 2.26

182 INDEX

United Nations Development Decade Urban Management Programme (United Nations (continued) Centre for Human Settlements/World Bank/ Substantial New Programme of Action for the Least UNDP), 12.20 Developed Countries, 2.26 Uruguay, 11.2, 14.39 United Nations Development Programme (UNDP), USAID, see United States Agency for International joint activities, 2.30 Development AIDS, 14.142, 14.144 blindness prevention, 14.187 chemical safety, 12.21 diagnostic reagents, 4.159 Vaccination, see Immunization, and under individual elderly, health of, 10.61 diseases environment, 12.33 Vaccines: epidemiology, 4.16 Children's Vaccine Initiative, 7.5, 14.168 health learning materials, 6.24 cold chains, thermostable vaccines, 13.20, 14.3, human reproduction research, 10.32 14.169 immunization, 14.4 research and development, 14.61, 14.102, 14.168- malaria, 14.25 14.177, 19.14 malnutrition, conference on, 9.25 training, 14.177 management development, 4.29 see also under individual diseases medical education, 6.22 Vanuatu, 11.24 respiratory infections, 14.84 Vector control, 14.9-14.14 urban management, 12.20 bed-nets, 14.12 vaccine development, 14.102, 14.168 environmental control, Panel of Experts, (PEEM), water supply, 12.10, 18.9 12.8, 12.9 see also Human reproduction research, special pro­ insecticides, 4.10, 14.11, 14.13 gramme; Tropical diseases, special programme pesticides, 14.9, 14.14 (UNDP/World Bank/WHO) research, 14.63 United Nations Disaster Relief Coordinator, Office Venereal diseases, see Sexually transmitted diseases of the (UNDRO), 2.40 Venezuela, 14.13 United Nations Educational, Scientific and Cultural VietNam, 4.26, 4.46, 9.16, 11.25, 12.31, 14.12, 14.20, Organization (UNESCO), 7.21, 14.30, 14.144 14.67, 14.68 United Nations Environment Programme (UNEP), Violence, women and, 9.12 12.8, 12.18, 12.30, 12.35 Viral diseases, 14.147-14.154 see also International Programme on Chemical Safe­ see also under names of individual diseases and vi­ ty (WHO/UNEP/ILO) ruses United Nations General Assembly, 12.4 Vitamin A deficiency, 9.24, 9.25, 9.26-9.27 United Nations High Commissioner for Refugees, Voluntary Fund for Health Promotion, 9.45, 10.32 Office of the (UNHCR), 2.41, 2.42, 2.45 United Nations International Drug Control Pro­ gramme, 4.47 United Nations Population Fund (UNFPA), 2.30, Washington Inter-Organizational Board on Interna­ 4.17, 4.29, 4.47, 9.4, 10.5, 10.28, 10.32, 14.139, tional Cooperation, 11.21 14.144, 17.6, 17.8, 20.14 Wastes disposal and management, see Environmental United Nations Research Institute for Social Develop­ pollution and hazards; Sanitation ment, 8.8 Water supply, 12.3-12.11,21.13 United Republic of Tanzania, 4.43, 5.7, 5.14, 5.18, cost recovery, 12.5 6.10, 9.11, 10.8, 11.25, 14.10, 14.30, 14.33, 14.68, global strategy, 12.11 14.100, 14.164 human resources development, 12.7, 18.9 United States Agency for International Development indicators, 12.9 (USAID), 9.25, 9.26, 10.17, 10.25, 14.13, 14.121, information exchange, 12.9 14.139, 14.151, 18.7 information system, 12.9 United States of America, 5.9, 9.26, 9.44, 9.45,10.43, monitoring programme, 12.9 10.57, 14.161 national institutional development, 12.5 United States National Neurofibromatosis operation and maintenance, 12.6 Foundation, International Public Service Award, technology development, 12.9 14.246 see also International Drinking Water Supply and Universities, 6.19, 7.23 Sanitation Decade; Sanitation Urban health, 5.11, 5.18-5.20, 12.12-12.20 Water Supply and Sanitation Collaborative Council, see also Healthy Cities 12.10 Urbanization and urban development, 5.20, 12.13- Western Pacific Region, 22.1-22.13 12.20, 18.3, 21.13, 22.12 acute respiratory infections, 22.4

183 THE WORK OF WHO 199o-1991

Western Pacific Region (continued) (Second) (planned for 1993), 9.53, 9.55, 9.56 AIDS, 22.10 World Conference on Education for All - Meeting blindness prevention, 14.187 Basic Learning Needs, 7.14, 9.2 diarrhoeal diseases, 22.5 World Conference on Health Education (Fourteenth), environment, 22.12 7.14, 14.240 health-for-all evaluation, 22.1, 22.2 World Conference on Smoking and Health (Seventh), human resources, 6.5 9.61 immunization, 22.3 World Diabetes Day (27 June), 7.8, 14.235 information services, 15.7 World directory of schools of public health and post­ leprosy, 22.9 graduate training programmes in public health, malaria, 22.6 6.15 maternal and child health, 10.7 World Federation for Education and Research in Pub- medical education, 6.18, 6.21 lic Health, 6.15 mental health, 11.2, 11.25 World Food Programme (WFP), 9.28 occupational health, 10.54 World Health, 14.240, 15.9 programme budgeting, 2.18 World Health Assembly, 1.3, 1.6, 1.7, 2.7, 2.8, 9.24, rehabilitation, 13.29, 13.38 9.60, 12.11, 16.8-16.11 substance abuse, 11.24 meetings, Annex 3 supplies, 16.23 method of work, 1.8, 1.9 tobacco control, 9.72, 22.11 resolutions, 4.52, 6.9, 8.1, 8.2, 8.9, 9.1, 9.4, 9.60, tuberculosis, 14.99, 22.7 12.14, 13.21, 14.53, 14.83, 14.94, 14.103, 14.145, urban health, 12.13 14.169, 14.236 women, 9.16 Technical Discussions, 1.9, 4.36, 5.19, 8.1, 8.9, 12.14 see also Member countries, Annex 2 World Health Days, 2.36, 7.8, 9.56, 21.9 WFP, see World Food Programme World health situation, eighth report, 4.7, 20.5 WHO Drug Information, 13.17, 15.9 World Health Statistics Annual, 14.223 WHOLIS (WHO Library Information System), 15.3 World Health Statistics Quarterly, 5.20 WHOSIS (WHO statistical information system), 4.3 World Hypertension League, 14.229 WHOTERM (WHO Terminology Information Sys- World Psychiatric Association, 11.19 tem), 15.12 World Summit for Children (1990), 2.32, 9.24, 10.13, Women, health and development, 9.1-9.16 12.4, 14.83 AIDS, 9.8, 10.3, 14.133, 14.146 World Tourism Organization, 9.37 leadership, 6.10, 9.2, 9.4 World No-Tobacco Day (31 May), 7.8, 9.64 literacy and education, 5.8, 9.2 World Organization of the Scout Movement, 7.18, nutritional anaemia, 9.7 10.29 research training, 9.5 staff of WHO, 16.2 status, 9.2 see also Family planning; Maternal and child health; Yellow fever, 14.152, 14.161, 16.8, 17.9 Maternal mortality vaccine, 14.5 Workers' health, year of (Americas, 1992), 10.54 Yemen, 2.1, 3.6, 4.26, 13.37 see also Occupational health Youth organizations, involvement in health develop­ Working Group on Health Promotion in Developing ment, 7.18 Countries (WHO), 7.13 Yugoslavia, 2.45, 5.7, 20.3 World AIDS Day (1 December), 7.8, 14.146,21.9 World Assembly of Youth, 7.18, 10.29 World Association of the Major Metropolises (ME­ TROPOLIS), 5.19 World Bank, 2.31, 5.7, 5.12, 5.25, 9.25, 9.59, 10.5, Zaire, 11.29, 14.48 10.32, 12.8, 12.10, 12.20, 14.4, 14.121, 14.129, Zambia, 4.29, 4.43, 5.18, 5.19, 7.18, 9.11, 10.16,14.127 14.139, 14.168 Zimbabwe, 2.5, 4.43, 5.9, 5.10, 5.13, 5.21, 6.10, 9.8, see also Tropical diseases, special programme 9.66, 10.16, 14.196, 14.199 (UNDP/World Bank/WHO) Zoonoses, 14.110-14.120 World Conference on Accident and Injury Prevention national programmes, 14.110 (First), 9.51 research, 14.111, 14.113,14.117-14.119

184 IIIII~ IIIII IIIII 111111111111111111111111111111111 00082271