Official Document No. 81 2 Ndexed

OFFICIAL DOCUMENT NO. 81 2 NDEXED

EXECUTIVE COMMITTEE OF THE PAN AMERICAN HEALTH ORGANIZATION

55th MEETING-7 October 1966

56th MEETING-26 April-3 May 1967

57th MEETING-28-29 September 1967

58th MEETING-12 October 1967 a~)

Official Document No. 81 June 1968 PAN AMERICAN HEALTH ORGANIZATION Pan American Sanitary Bureau, Regional Office of the WORLD HEALTH ORGANIZATION 525 Twenty-third Street, N.W. Washington, D. C. 20037, E.U.A. TABLE OF CONTENTS

Page

55th MEETING OF THE EXECUTIVE COMMITTEE

Précis Minutes of the Single Plenary Session ...... 3

Final Report ...... 7

56th MEETING OF THE EXECUTIVE COMMITTEE*

Précis Minutes of Plenary Sessions ...... 15

Annexes:

1. Agenda ...... 239 2. List of Participants ...... 241

57th MEETING OF THE EXECUTIVE COMMITTEE

Précis Minutes of Plenary Sessions ...... 247

Final Report ...... 299

58th MEETING OF THE EXECUTIVE COMMITTEE

Précis Minutes of the Single Plenary Session ...... 307

Final Report ...... 312

INDEX ...... 314

* The Final Report of the 56th Meeting of the Committee appears in Official Document PAHO 79. 55th MEETING OF THE EXECUTIVE COMMITTEE PRECIS MINUTES AND FINAL REPORT CONTENTS

Page

SINGLE PLENARY SESSION (Friday, 7 October 1966, at 3:20 p.m.)

Item 1: Opening of the Meetlng ...... 3

Item 2: Adoption of the Agenda ...... 3

Item 3: Taking of Office by the Representatives of Colombia and the United States of America ...... 3

Item 4: Election of Chairman and Vice-Chairman ...... 3

Item 5: Study of Resolutions of the Conference, of Interest to the Executive Committee ...... 4

Item 6: Date of the 56th iveeting of the Executive Committee. 6

FINAL REPORT ...... 7 SINGLE PLENARY SESSION OF THE 55th MEETING OF THE EXECUTIVE COMMITTEE Friday, 7 October 1966, at 3:20 p.m. Acting Chairman: DR. MANOEL JosÉ FERREIRA (Brazil) Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 1: OPENING OF THE MEETING

The ACTING CHAIRMAN opened the session and welcomed the members of the Committee and others attending the meeting.

ITEM 2: ADOPTION OF THE AGENDA

Dr. SUTTER (Assistant Director, PASB) outlined the agenda presented in Document AG/1. 1/

Decision: The agenda was unanimously approved.

ITEM 3: TAKING OF OFFICE BY THE REPRESENTATIVES OF COLOMBIA AND THE UNITED STATES OF AMERICA

The ACTING CHAIRMAN welcomed the Representatives of Colombia and the United States of America, the countries elected by the XVII Pan American Sanitary Conference on the termination of the periods of office of Brazil and Mexico. He also expressed his thanks for the excellent cooperation and assistance he had received in carrying out his duties as Chairman.

ITEM 4: ELECTION OF CHAIRMAN AND VICE-CHAIRMAN

The ACTING CHAIRMAN stated that the meeting would proceed with the election of the Chairman and the Vice-Chairman.

Dr. SUTTER (Assistant Director, PASB) read Article 18 of the Constitution and Rule 9 of the Committee's Rules of Procedure governing the election of officers.

Dr. ACOSTA-BORRERO (Colombia) proposed Dr. Alberto E. Calvo, the Repre- sentative of Panama, as Chairman.

2/ Mimeographed document.

-3- Page 4 Single session 55th Meeting

Dr. ANDRADE (Ecuador) seconded the proposal.

Dr. CALVO (Panama), seconded by Dr. ANDRADE (Ecuador), proposed Dr. Daniel Orellana, the Representative of Venezuela, as Vice-Chairman.

Decision: Dr. Alberto E. Calvo, Representative of Panama, and Dr. Daniel Orellana, Representative of Venezuela, were unanimously elected Chairman and Vice-Chairman, respectively.

Dr. Calvo (Panama) took the Chair.

The CHAIRMAN thanked the members :for having elected him Chairman of the Committee.

Dr. ORELLANA (Venezuela) likewise thanked the members for electing him Vice-Chairman of the Committee.

ITEM 5: STUDY OF RESOLUTIONS O0 THE CONFERENCE, OF INTEREST TO THE EXECUTIVE COMMITTEE

Dr. HORWITZ (Director, PASB) said that a review of the resolutions did not appear to indicate that there were any which called for decisions by the meeting but rather should be dealt with by the 56th Meeting, to be held in April 1967. Nevertheless he would like to refer briefly to two or three of them.

First, with reference to Resolution IX, 2/ on the provisional draft of the proposed program and budget of the Pan Anerican Health Organization for 1968, he stated that, as in previous years, the debate on the item would be taken carefully into consideration together with the resolutions adopted in plenary session and, naturally, with any developments taking olace between the date of the present meeting and the 56th Meeting which might in one way or another affect the structure of the program and budget. He gave an assurance that an effort would be made to place the fullest information before the members of the Executive Com- mittee at an early date so as to enable it to take whatever steps were deemed necessary.

Turning to the peculiar situation of the Pan American Health Organization with regard to funds for malaria eradication, he said that the fact that the generous voluntary contributions made for several years by the Government of the United States of America were being incorporated gradually into the regular budget for that activity meant that there would be an item of some $400,000 for 1968, and of course more for 1969--$600,000. On the basis of the rate of budgetary increase recorded regularly over the previous few years, if expenditures continued to rise at the same rate, the time might well come when the Organization could not carry out any, or virtually any, of its new projects, since the customary increase of 8 to 10 per cent was to be absorbed by the malaria program under its regular

2/ Official Document PAHO 74, 65. Page 5 55th Meeting Single session budget. That did not mean new projects, but merely covered the steady expansion of common costs arising from the mounting cost of living observed throughout the Hemisphere.

With that in mind, it was proposed to place before the Executive Commit- tee a plan for financing malaria eradication similar to the one worked out by the World Health Assembly, which in three years had absorbed the $6,000,000 needed by WHO's world-wide malaria eradication program. When the time came for the Executive Committee to examine the two proposals--that of special contributions to cover the malaria budget, and the proposal for a progressive system to be started in 1967, it was possible that it would decide on one or the other, or agree to submit both to the Directing Council for consideration. He felt that the Executive Committee should have all possible information at its disposal when it came to examine the Organization's financing.

The demand for projects had increased enormously and would continue to increase. He considered that the execution of about 480 projects, some of them of considerable scope, on a total income of $22,000,000, was a most praiseworthy performance. That fact, taken in conjunction with the meager sums devoted to international health in Latin America, deserved to be borne in mind by Govern- ments when deciding what they should contribute to the Organization.

Referring next to Resolution XV 3/ on the textbook program, he said that in compliance with the wish of the Conference, the proposal would be sent to the President of the Inter-American Development Bank, with the request that he obtain a definitive statement from its Board of Executive Directors at an oppor- tune moment. If the statement revealed the Bank's intention to make a loan and specified the terms on which it would be done, the Bureau would contact the members of the Executive Committee, or if circumstances warranted it, a special meeting would be convened.

With regard to the eradication of Aedes aegypti, he hoped that by the date of the 56th Meeting of the Executive Committee more concrete data would be available, as well as on smallpox eradication.

He pointed out that by the time of the 56th Meeting of the Committee the Meeting of the American Chiefs of State would have been held or would be taking place shortly thereafter, and the Committee would be informed of the measures taken in compliance with the resolution adopted.

With regard to the use of artificial satellites for certain aspects of the health projects, he said that the question would be closely studied, and it was proposed, in collaboration with the OAS, to compile documentation on the subject so that the Executive Committee could give proper guidance.

In conclusion, he expressed the hope that by the date of the next meeting, the Committee would have before it a proposal agreed jointly with the OAS, for placing the Pan American Foot-and-Mouth Disease Center on a sound financial footing. The idea was to obtain the necessary funds from ministries of agriculture,

3/ Ibid., pp. 71-72. Page 6 Single session 55th Meeting and in that connection, support of the Venezuelan Minister of Agriculture had been obtained.

ITEM 6: DATE OF THE 56TH MEETING OF THE EXECUTIVE COMMITTEE

Dr. HORWITZ (Director, PASB) recalled that it was customary to schedule the meetings of the Committee close to the date of the World Health Assembly, in order to facilitate the travel arrangements of some of the representatives. The World Health Assembly was due to start on Monday, 8 May 1967; he therefore suggested that the Executive Committee meet during the week beginning 24 April.

Dr. WEDDERBURN (Jamaica) said that if it were possible he would request that the dates proposed for the meeting of the Executive Committee, 24-29 April, be changed, since they conflicted with the dates of another meeting he had to attend.

Dr. ORELLANA (Venezuela) thought it might be possible to review the dates in due course.

Decision: It was unanimously agreed to authorize the Chairman of the Executive Committee to fix the time of the 56th Meeting of the Committee in agreement with the Director of the Bureau.

The session rose at 4:10 p.m. FINAL REPORT OF THE 55th MEETING OF THE EXECUTIVE COMMITIEE 1

Washington, D. C., 7 October 1966

The 55th Meeting of the Executive Committee of the Pan American Health Organization was held in the headquarters building, in Washington, D. C., on 7 October 1966, as convoked by the Director of the Pan American Sanitary Bureau. The following members of the Committee and observers were present at the single plenary session:

Members:

Dr. Roberto Acosta-Borrero COLOMBIA Dr. Leoncio Andrade C. ECUADOR Dr. Charles C. Wedderburn JAMAICA Dr. Alberto E. Calvo PANAMA Dr. Benjamin D. Blood UNITED STATES OF AMERICA Dr. Daniel Orellana VENEZUELA

Member and Secretary ex officio of the Committee:

Dr. Abraham Horwitz, Director PAN AMERICAN SANITARY BUREAU Observers:

Dr. Manoel José Ferreira BRAZIL Dr. Miguel Antonio Ortega Peguero DOMINICAN REPUBLIC

Organization of American States:

Mrs. Alzora H. Eldridge

NEW MEMBERS

Dr. Manoel José Ferreira (Brazil), as Acting Chairman of the Committee, opened the meeting and welcomed the Representatives of Colombia and the United States of America, the countries elected by the XVII Pan American Sanitary Con- ference to fill the vacancies that occurred on the termination of the periods of office of Brazil and Mexico.

OFFICERS

The Chairman and the Vice-Chairman of the Committee were elected pursuant to Article 18 of the Constitution and Rule 9 of the Rules of Procedure of the

_/ Document CE55/2 (24 October 1966).

-7- Page 8 Final Report 55th Meeting

Committee. At the proposal of the Representative of Colombia, seconded by the Representative of Ecuador, Dr. Alberto E. Calvo, the Representative of Panama, was unanimously elected Chairman of the Committee. At the proposal of the Repre- sentative of Panama, seconded by the Representative of Ecuador, Dr. Daniel Orellana, the Representative of Venezuela, was unanimously elected Vice-Chairman of the Committee.

AGENDA

The agenda contained in Document 1AG/1 2/ was approved.

RESOLUT]ON APPROVED

As the result of its deliberations the Executive Committee approved the following:

RESOLUTION I

THE EXECUTIVE COMMITTEE,

Bearing in mind the provisions of Rule 1 of the Rules of Procedure of the Committee,

RESOLVES:

To authorize the Chairman of the Executive Committee to fix the date of the 56th Meeting of the Committee in agreement with the Director of the Pan American Sanitary Bureau.

IN WITNESS WHEREOF, the Chairman of the Executive Committee and the Direc- tor of the Pan American Sanitary Bureau, Secretary ex officio, sign the present Final Report in the English and the Spanish languages, both texts being equally authentic.

DONE in Washington, D.C., United States of America, this seventh day of October, nineteen sixty-six. The Secretary shall deposit the original texts in the archives of the Pan American Sanitary Bureau and shall send copies thereof to the Governments of the Organization.

ALBERTO E. CALVO Chairman of the 55th Meeting of the Executive Committee Representative of Panama ABRAHAM HORWITZ Director of the Pan American Sanitary Bureau, Secretary ex officio of the Executive Committee

2/ Mimeographed document. 56th MEETING OF THE EXECUTIVE COMMITTEE PRECIS MINUTES INTRODUCTION

Under the Chairmanship of Dr. Alberto E. Calvo (Panama) and the Vice-Chairmanship of Dr. Daniel Orellana (Venezuela), the 56th Meeting of the Executive Committee of the Pan American Health Organization was held from 26 April--3 May 1967, in Washington, D.C., in the headquarters building of the Organization, in accordance with the convocation of the Director of the Pan American Sanitary Bureau.

The meeting was attended by the Representatives of the seven Governments members of the Executive Committee--Colombia, Ecuador, Guatemala, Jamaica, Panama, United States of America, and Venezuela-- and by Observers of Chile, France, and the Kingdom of the Netherlands, and Observers for the Organization of American States.

The Committee held twelve plenary sessions and one closing session, the précis minutes of which are contained in this volume. The agenda and the list of participants are included as annexes.

Official Document 79 (August 1967) contains the Final Report of the Meeting, with the text of all the resolutions adopted. CONTENTS

Page

FIRST PLENARY SESSION (Wednesday, 26 April 1967, at 10:15 a.m.)

Item 1: Opening of the Meeting ...... 15 Item 2: Adoption of the Agenda ...... 15 Item 3: Amendments to the Rules of Procedure of the Executive Committee ...... 16 Item 12: Request of the Government of Guyana for Admission in the Pan American Health Organization ...... 18 Item 20: Request of the Government of Barbados for Admission in the Pan American Health Organization ...... 19 Item 6: Financial Report of the Director and Report of the External Auditor for 1966 ...... 21

SECOND PLENARY SESSION (Wednesday, 26 April 1967, at 2:30 p.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 ...... 25

THIRD PLENARY SESSION (Thursday, 27 April 1967, at 9:00 a.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation) ...... 45

FOURTH PLENARY SESSION (Thursday, 27 April 1967, at 2:40 p.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation) ...... 61

FIFTH PLENARY SESSION (Friday, 28 April 1967, at 9:05 a.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation) ...... 79

SIXTH PLENARY SESSION (Friday, 28 April 1967, at 2:40 p.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation) ...... 98

SEVENTH PLENARY SESSION (Saturday, 29 April 1967, at 9:10 a.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation)...... 118

- 11 - Page 12 Contents 56th Meeting

Page

EIGHTH PLENARY SESSION (Monday, 1 May 1967, at 9:15 a.m.)

Item 3: Amendments to the Rules of Procedure of the Executive Committee (conclusion) ...... 144 Item 6: Financial Report of the Director and Report of the hExternal Auditor for 1966 (conclusion) ...... 145 Item 20: Request of the Government of Barbados for Admission in the Pan American Health Organization (conclusion) ...... 146 Item 14: Supply of Textbooks for Medical Students ...... 146 Item 16: Amendment to the Financial Rules of the Pan American Health Organization ...... 153 Item 19: Resignation of the External Auditor ...... 154 Item 13: Amendments to the Staff Rules of the Pan American Sanitary Bureau ...... 156 Item 8: Arrangements for the XVII Mleeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas ...... 157

NINTH PLENARY SESSION (Monday, 1 May 1967, at 2:40 p.m.)

Item 15: Status of Smallpox Eradication in the Americas ...... 159 Item 18: Appointment of the Deputy D)irector and of the Assistant Director of the Pan American Sanitary Bureau ...... 167 Item 9: Representation of the Executive Committee at the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO( for the Americas ...... 171 Item 5: Report on the Collection of Quota Contributions ...... 172 Item 10: Report on Buildings and Installations ...... 172 Item 7: Provisional Agenda for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas ...... 177

TENTH PLENARY SESSION (Tuesday, 2 May 1967, at 9:15 a.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (continuation) ...... 178 Item 11: Status of Aedes aegypti Eradication in the Americas ...... 190

ELEVENTH PLENARY SESSION (Tuesday, 2 May 1967, at 2:40 p.m.)

Item 17: Fellowship Program ...... 196 Item 21: Intensification of Health Programs--Decisions Taken at the Meeting of American Chiefs of State ...... 203 Item 5: Report on the Collection of Quota Contributions (conclusion) ...... 211 Item 7: Provisional Agenda for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas (conclusion) ...... 212 Page 13 56th Meeting Contents

Page

Item 10: Report on Buildings and Installations (conclusion) ...... 212 Item 11: Status of Aedes aegypti Eradication in the Americas (conclusion) ...... 213 Item 17: Fellowship Program (conclusion) ...... 215 Item 15: Status of Smallpox Eradication in the Americas (conclusion) ...... 217

TWELFTH PLENARY SESSION (Wednesday, 3 May 1967, at 8:40 a.m.)

Item 4: Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (conclusion) ...... 221 Draft Resolution on the Pan American Foot-and-Mouth Disease Center ...... 222 Item 14: Supply of Textbooks for Medical Students (conclusion)... 226 Item 21: Intensification of Health Programs--Decisions Taken at the Meeting of American Chiefs of State (conclusion).. 229 Item 22: Other Matters ...... 232

CLOSING SESSION (Wednesday, 3 May 1967, at 4:15 p.m.)

Presentation and signature of the Final Report ...... 237 Tribute to the memory of Dr. Tomás Pineda Martinez, Director General of Health of El Salvador ...... 237 Closure of the Meeting ...... 237

Annexes

1. Agenda of the Meeting ...... 239 2. List of Participants ...... 241

FIRST PLENARY SESSION Wednesday, 26 April 1967, at 10:15 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 1: OPENING OF THE MEETING

The CHAIRMAN declared the session open and welcomed the members of the Committee, observers, and other participants. He hoped that representatives were ready and eager to carry out the Executive Committee's task and to examine the items of the agenda with a view to submitting resolutions or recommendations to the XVII Meeting of the Directing Council; and he trusted that under the able guidance of the Director of the Bureau and his technical staff the Committee's work would be brought to a successful conclusion.

ITEM 2: ADOPTION OF THE AGENDA

Dr. SUTTER (Assistant Director, PASB) presented the provisional agenda, Document CE56/1, Rev. 3.

The CHAIRMAN said that once the agenda was approved, an indication would be given of the order in which the various items would be dealt with.

Decision: The provisional agenda contained in Document CE56/1, Rev. 3, was unanimously adopted. l/

The CHAIRMAN suggested that the items to be taken up first should be Amendments to the Rules of Procedure of the Executive Committee; 2/ Requests of the Governments of Guyana and Barbados for Admission in the Pan American Health Organization; 3/ Proposed Program and Budget of the Pan American Health Organization for 1968; 4/ and Financial Report of the Director and Report of the External Auditor for 1966; 2/ and that they should be dealt with in that order.

Dr. BLOOD (United States of America) suggested that as an alternative and in accordance with wishes he had heard expressed at previous meetings, Item 6 (Financial Report of the Director and Report of the External Auditor for 1966) should be considered before Item 4 (Proposed Program and Budget Estimates of the Pan American Health Organization for 1968).

1/ See p. 239. / Document CE56/7 (mimeographed). Z/ Documents CE56/4 and CE56/18 (mimeographed) k/ Official Document PAHO 67 and mimeographed Document CE56/5. 2/ Official Document PAHO 75.

- 15 - Page 16 First session 56th Meeting

The CHAIRMAN said that if there was no objection, the suggestion made by Dr. Blood would be regarded as accepted.

It was so agreed.

ITEM 3: AMENDMENTS TO THE RULES OF PROCEDURE OF THE EXECUTIVE COMMITTEE

Dr. PORTNER (Chief of Administration, PASB) presented Document CE56/76/ and said that with the passage of time the need for certain changes in the Rules of Procedure of the Executive Committee had become evident, particularly those concerned with the reconsideration and withdrawal of proposals and the patterns of voting.

Proposed Rule 19 was based on Rule 34 of the Directing Council, at whose meetings its usefulness had been apparent. It read as follows:

"A motion may be withdrawn by its proposer at any time before voting on it has commenced, provided that the motion has not been amended or, if amended, that the proposer of the amendment agrees to the withdrawal. A motion thus withdrawn may be reintroduced by any representative."

Proposed new Rule 20 was also an adaptation of a rule of the Directing Council:

"When a proposal has been adopted or rejected, it may not be reconsidered at the same meeting unless the Committee by an affirmative vote of at least four representatives so decides. Permission to speak on a motion to reconsider shall be accorded only to one speaker opposing the motion, after which it shall be immediately put to the vote."

Proposed Rule 25 was an adaptation of Rule 40 of the Directing Council and provided that:

"For the purpose of these Rules 'representatives present and voting' means representatives casting an affirmative or negative vote or, in an election, a vote for a person or a Government eligible in accordance with the Constitution or these Rules of Procedure. Representatives who abstain from voting or who cast blank ballots or invalid votes shall be regarded as not voting. In computing a majority any fraction shall be counted as a whole number."

Proposed Rule 26 had also been take:n from the Directing Council's rules, with a minor editorial change:

"Motions shall be considered adopted when they have received the affirmative votes of the majority of the representatives present and voting except when the Constitution or these Rules of

6/ Mimeographed document. Page 17 56th Meeting First session

Procedure otherwise provide. If the votes are equally divided, the motion shall be regarded as not adopted or the candidate as not elected."

Proposed Rule 27 was based on Rule 42 of the Directing Council and was as follows:

"The Executive Committee shall normally vote by show of hands, except that any representative may request a roll-call vote, which shall then be taken in alphabetical order of the Governments represented as expressed in the language of the country where the meeting is held. The Government to vote first shall be determined by lot."

Proposed Rule 28 was an adaptation of Rule 45 of the Directing Council and provided that:

"Elections shall normally be held by secret ballot. When the number of candidates for elective office does not exceed the number of offices to be filled, no ballot shall be required and such candidates shall be declared elected.

Where ballots are required, one teller shall be appointed by the Chairman from among the representatives present."

Proposed new Rule 29 provided that:

"When only one elective place is to be filled and no candidate obtains in the first ballot the majority required, a second ballot shall be taken which shall be restricted to the two candidates obtaining the largest number of votes. If in the second ballot the votes are equally divided the Chairman shall draw lots to decide between the candidates."

Proposed new Rule 30 stipulated that:

"When two or more elective places are to be filled at one time under the same corditions, those candidates obtaining in the first ballot the majority required shall be elected. If the number of candidates obtaining such majority is less than the number of elective places to be filled, ballots shall then be taken separately for each of the remaining places in accordance with Rule 29."

Dr. OPELLANA (Venezuela) requested an explanation of the roll-call voting procedure referred to in the proposed new Rule 27. It stated that the vote "shall then be taken in alphabetical order of the Governments..." and then went on to say that "The Covernment to vote first shall be determined by lot."

Dr. HORWITZ (Director, PASB) explained that the Executive Committee could choose whichever method of voting it deemed most suitable. The expression "alphabetical order" implied "starting with the country drawn by lot;" in other words the country called upon to cast the first vote was chosen by lot, and after Page 18 First session 56th Meeting that the alphabetical order was followed for all the other countries. He suggested that a clearer text might be drafted in the light of the Venezuelan Representative's observation.

Dr. PORTNER (Chief of Administratior., PASB) said that while the proposed rule as drafted might raise a question in the mind of the reader, the sense of the Director's suggestion could readily be achieved by a minor grammatical change. However, such a change would involve a departure from the language of Rule 42 of the Rules of Procedure of the Directing Council, on which the proposed rule was patterned.

Dr. ACOSTA-BORRERO (Colombia) suggested that following the words "alphabetical order of the Governments represented," some such phrase as "the Govern- ment called upon to vote first being decided previously by lot" might be added.

The CHAIRMAN thought that the Committee might approve Pules 19, 20, 25, 26, 28, 29, and 30, to which no objection had been raised, leaving Rule 27 in abeyance until a new draft had been produced with the help of Dr. Acosta-Borrero and Dr. Orellana and submitted for consideration by the Committee at a later session.

It was so agreed.

ITEM 12: REQUEST OF THE GOVERNMENT OF GUYANA FOR ADMISSION IN THE PAN AMERICAN HEALTH ORGANIZATION

Dr. HORWITZ (Director, PASB), introducing the item, pointed out that the background of the request by the Government of Guyana for admission was outlined in Document CE56/4; 2/ he then read the communication on the subject from Mr. P. A. Reid, Acting Prime Minister and Minister of External Affairs of Guyana, dated 20 September 1966. He further mentioned that on 27 September 1966 the Govern- ment of Guyana had deposited with the Secretary-General of the United Nations the instrument of acceptance of the Constitution of the World Health Organization and that, as a Member of WHO, Guyana had been represented at the XVII Pan American Sanitary Conference, XVIII Meeting of the Regional Committee of WHO for the Americas by a delegation led by the Minister of Health.

Dr. ORELLANA (Venezuela) expressed his personal satisfaction and that of the Government of Venezuela at the admission of new Members; at the same time he had some misgiving concerning the function of the Executive Committee in that respect, and he would therefore like to know whether the matter to be discussed was the admission of Guyana or the transmission of the request to the Directing Council.

Dr. HORWITZ (Director, PASB) explained that it was the second alternative, i.e., transmission of the request for a final decision by the Directing Council, which was the competent body, to decide on the admission of new Members in the period comprised between Conferences. He recalled that that had been decided at the XVI Pan American Sanitary Conference in its Resolution IV. 8/

Mimeographed document. 8_/ Official Document PAHO 48, 10. Page 19 56th Meeting First session

Dr. AGUILAR HERRERA (Guatemala) thought that, in that case, what the Com- mittee should do was to transmit the request to the XVII Meeting of the Directing Council with a recommendation that the new State be admitted to the Organization.

Dr. BLOOD (United States of America) joined in welccming the application of the Government of Guyana and felt it would be most appropriate for the Com- mittee not only to transmit the application to the Directing Council but also to recommend its approval.

The CHAIRMAN suggested that Dr. Blood might draft a text to that effect, not only transmitting the request to the Directing Council, but recommending that it give favorable consideration to the application of admission of Guyana in the Organization.

Dr. BLOOD (United States of America) then presented the following draft resolution:

THE EXECUTIVE COMMITTEE,

Having examined the application of the Government of Guyana formembership in the Pan American Health Organization, contained in a letter dated 20 September 1966 from Mr. P. A. Reid, Acting Prime Minister and Minister of External Affairs, to the Director of the Pan American Sanitary Bureau,

RESOLVES:

1. To take note of the application of the Government of Guyana for membership in the Pan American Health Organization, and to instruct the Director of the Pan American Sanitary Bureau to transmit it to the XVII Meeting of the Directing Council.

2. To recommend to the Council that it give favorable consideration to the application of the Government of Guyana for membership in the Pan American Health Organization.

Decision: The draft resolution was unanimously adopted.9/

ITEM 20: REQUEST OF THE GOVERNMENT OF BARBADOS FOR ADMISSION IN THE PAN AMERICAN HEALTH ORGANIZATION

Dr. HORWITZ (Director, PASB), introducing the item, said that the request of the Government of Barbados was to be found in Document CE56/18, l_/ and that the communication on the subject had been sent to the Organization by Mr. F. L. Cozier, Permanent Secretary of the Ministry of External Affairs of Barbados. As in the case of Guyana, the communication had been circulated to all the Govern- ments of the Organization, informing them that it would be considered by the Executive Committee. He added that on 25 April 1967 Barbados had joined the World Health Organization.

9/ Resolution I. Official Document PAHO 79, 30-31. 10/ Mimeographed document. Page 20 First session 56th Meeting

Dr. ACOSTA-BORRERO (Colombia) asked Dr. Horwitz what had been the general response of Governments to the request under consideration.

Dr. HORWITZ (Director, PASB) said that the application by the Government of Barbados had been received on 5 April and that no replies to the communication sent to the various countries by the Organization some 10 days earlier requesting their opinion had come in so far.

Dr. ACOSTA-BORRERO (Colombia) considered that the Committee should merely transmit the request to the Directing Council, without recommending acceptance, since the views of the majority of the countries were not yet known.

The CHAIRMAN said that the Committee represented all the Governments of the Organization, and it was therefore empowered to make recommendations. More- over, there would be discrimination between the two requests if in the one case it were recommended that the request be given favorable consideration and in the other case not. He asked Dr. Acosta-Borrero to reconsider his view, and he inquired of the Director whether there was any precedent in the matter.

Dr. HORWITZ (Director, PASB) said it was a matter for the Committee to settle since it involved a decision by the Governments in respect of another Government. The question as interpreted b;y the Representative of Colombia amounted to determining whether the Executive Committee should or should not express its own view in regard to the two requests submitted. In that connection he pointed out that, while the recommendations of the Committee expressed its view, they were not binding on the Governments of the Hemisphere. That, he thought, was the point to be borne in mind when the Committee expressed an opinion in resolution form.

Dr. ACOSTA-BORRERO (Colombia) agreed with the Director's interpretation. The members of the Committee represented either ministries of health or Govern- ments, but the question was whether it was wise, without having some idea of the reaction of all the Governments of the Organization, to make a recommendation, favorable or otherwise, regarding the admission of a particular country. He was sure that his own country had no objection whatsoever to the admission of Barbados, but he thought that the Directing Council should be left absolutely free to decide on the matter.

Dr. AGUILAR HERRERA (Guatemala) felt that the Committee was not making a decision but that, with the documents and information at hand, it could form an opinion so that the request could be transmitted to the Directing Council with or without a recommendation as to its acceptance. After all, a favorable recommendation by the Committee did not in any way mean that the Directing Council was obliged to accept it, since the Council would comprise representatives of the various countries, who would no doubt have specific instructions on how to vote. Hence, he thought the Committee might make a recommendation on the basis of the documentation available.

Dr. BLOOD (United States of America), agreeing with the Representative of Guatemala, said that the Committee would in some respects be shirking its duty if it failed, with the documentation and information at hand, to give some indication of its feeling in the matter. It was conceivable that the Directing Council might adopt a completely different position, but the Executive Committee Page 21 56th Meeting First session could not always expect to be right. At least it should consider the question in its own right and make a decision and recommendation for the guidance of the Directing Council. He would recommend that the text of the resolution be identical to that approved with respect to the application of the Government of Guyana.

Dr. PEREZ RUEDA (Ecuador) said that the Government of his country had no objection to the admission of Guyana and Barbados in the Organization, and he endorsed the proposal of the Representative of the United States of America that the admission of the two countries should be recommended.

Dr. ACOSTA-BORRERO (Colombia) said he would like to reiterate that the Government of his country had no objection to the proposal submitted; in making his remarks he had been prompted by a spirit of caution and the desire, to avoid a vexatious debate in the Directing Council. The proposal that a resolution should be submitted to the Committee before a final decision was adopted seemed to him a sound one.

It was so agreed.

The session was suspended at 11:00 a.m. and resumed at 11:20 a.m.

ITEM 6: FINANCIAL REPORT OF THE DIRECTOR AND REPORT OF THE EXTERNAL AUDITOR FOR 1966

Dr. PORTNER (Chief of Administration, PASB), introducing Official Document 75, stated that it contained both the Financial Report of the Director and the Report of the External Auditor for 1966. The document described the management of the funds entrusted to the Organization by the Governments, as well as financial trends in relation to policies adopted by the Organization.

He called attention first to the statement in the Introduction that the Organization continued to be in sound financial condition. The Working Capital Fund stood at the highest percentage level since the beginning of 1958 and reserves had been established to meet termination costs. The picture with respect to quota contributions had improved considerably so that payment of both current quotas and arrears was above the level of 1965. The External Auditor had stated that the financial situation of the Organization had not been so sound since 1951 as it was at the end of 1966.

With regard to the Financial Report of the Director in detail, he called attention to Table A which showed a comparison for the year 1966, for all funds, of the budgeted amounts, with the amounts available and the amounts obligated. Table B showed the long-term picture with respect to income and obligations for the PAHO regular budget, and demonstrated that the Organization had been able to maintain its long-standing policy of maintaining obligations within income. Table C showed the situation with respect to the Working Capital Fund and provided ample evidence of the wisdom of the Governing Bodies in adopting a policy of gradually increasing that Fund. As mentioned in the Introduction, a study covering the last five-year period showed that requirements for advances from the Fund to finance operations pending receipt of quotas rose to about 35 per Page 22 First session 56th Meeting

cent of the budget by the end of June. In July large quota payments were normally received, but it was prudent to maintain an extra margin of safety in case those quota payments were not received until August. Consequently, the target level of the fund should be 40 per cent of the budget.

Dr. Portner then mentioned the references made in the document to all of the funds administered by the Organization. He enumerated the exhibits and the schedules covering the appropriations, obligations, and balances, the statement of income and expenditure for the 1966 budget, assets and liabilities, the status of various funds, the status of quota contributions, exhibits of INCAP and the OAS Program of Technical Cooperation, and the Informational Annex containing a summary and distribution of expenditure.

With reference to the Report of the External Auditor, Dr. Portner referred to the budgetary expenditure for 1966 as compared with that for the preceding two years. Those for Part II (Headquarters) had remained stable at 30 per cent, whereas the principal increase (62 per cent) was in Part III. As for quota contributions, there had been an improvement in the percentage of current quota contributions as well as in those in arrears.

Dr. Portner concluded by referring to the Auditor's Report on the Emer- gency Procurement Revolving Fund, the Building Fund, the Special Malaria Fund, the Community Water Supply Fund, Provision for Termination and Repatriation Entitlements, the Organization of American States, the Institute of Nutrition of Central America and Panama, and the Pan American Zoonoses Center.

The CHAIRMAN expressed his satisfaction at the indication in the Report that the Organization was in a sound financial position.

Dr. BLOOD (United States of America) stated that his country's Delegation was pleased with the favorable report which had been presented. Of course the fact that there was a more than a 100 per cent quota collection year after year meant that the Organization must have been rather far behind in the past. It was making up lost ground and had been doing so, obviously, for the last three years. That was a healthy situation and was correcting a state of affairs that had been unsatisfactory in the past. He then requested further information on the Working Capital Fund. Had it been used in 1966 and, if so, for what purpose? He could not find that information in the Report. Schedule 8 (page 30) showed the status of trust funds or funds received from other than regular budgetary sources, but he would like a general indication of the specific purposes of those different funds and how they had been used, since the schedule only provided an indication of the source. It would be interesting to know how the expenditure was related to program elements.

Dr. PORTNER (Chief of Administration, PASB), referring to the Working Capital Fund, as indicated by the document on quota contributions, said that collections during the first half of the year were relatively slight, being approximately 4 to 6 per cent. The Working Capital Fund had been established through the need for a treasury backlog with which to finance the work of the Organization during the first six morths of the year until heavier contributions became available. The Fund made it possible to conduct the ordinary business of the PAHO regular prcgram during that period., If it should so happen that the usual heavy contribution in July did not come in, a little more than 40 per cent Page 23 56th Meeting First session

of the authorized budget would be needed to finance activities through July. In 1966 the Fund had been used to support part of the activity of the Pan American Foot-and-Mouth Disease Center. From the Program of Technical Cooperation of the OAS it had received a reduced portion of the total approved budget per month. That amount was below the sum required to maintain the Center at even a reduced level of activity by between $12,000 and $14,000 dollars a month. Those funds would eventually revert to the Working Capital Fund from the Program of Tech- nical Cooperation, or from other sources.

In response to the query on grants, from Schedule 8 it would be seen that about 45 to 50 grants had been made. He requested permission to make the information available for the record so that it could be given in detail for each entry and item.

Dr. BLCOD (United States of America) said he would be most interested in the information to be submitted. He then asked how the surplus funds for the construction of the headquarters building were to be disposed of.

Dr. PORTNER (Chief of Administration, PASB) said that, at the XVI Meeting of the Directing Council, action had been taken to make such funds available for programs should it be desired. U/

Dr. ORELLANA (Venezuela) was gratified to see from the Report that the Organization's financial situation was sound; at the same time he regretted that the Report had not been distributed further ahead of time since it was a document that needed thorough study. With regard to the balance in the Building Fund, he suggested that, although in principle it was earmarked for programs, it might be used also for carrying out improvements in the buildings and installations of the Zone Offices.

The CHAIRMAN asked whether the Financial Report had been available to the Executive Committee "not later than 15 April" as stipulated in the Financial Regulations of PAHO.

Dr. PORTNER (Chief of Administration, PASB) said that every effort was made to distribute it before 15 April, but since the review of the External Audi- tor for the closure of accounts almost always took place between mid-March and the end of that month, it was extremely difficult to print and distribute the documents before that date.

Dr. ORELLANA (Venezuela) urged the desirability of making arrangements to ensure that the Financial Report was available for examination sufficiently far ahead of the meeting of the Committee.

The CHAIRMAN recalled that for the past two years discussions had been going on about the possibility of holding the meeting of the Executive Committee after the World Health Assembly, which would solve the problem. Possibly the matter might be taken up again at a later stage.

Dr. AGUILAR HERRERA (Guatemala) congratulated the Director on the Finan- cial Report and on the way in which the budget had been administered. He shared

1,/ Resolution XXVII. Official Document PAHO 66, 79. Page 24 First session 56th Meeting

Dr. Orellana's concern in the sense that the document should be studied with due thoroughness.

Dr. ANDERSON (Jamaica) then presented a draft resolution on the item.

Dr. BLOOD (United States of America) asked that the draft resolution be circulated.

It was so agreed.

The session rose at 12:05 p.m. SECOND PLENARY SESSION Wednesday, 26 April 1967, at 2:30 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968

The CHAIRMAN called the session to order and asked the Director of the Bureau to introduce the proposed program and budget estimates of the Pan American Health Organization for 1968 (Official Document 67 and Document CE56/5 L/).

Dr. HORWITZ (Director, PASB) recalled first of all that the Executive Committee was expected to take a decision on the proposed program and budget estimates of the Organization for 1968 after scrutinizing the document as closely as possible. Nevertheless, what was done in Latin America with PAHO funds was in no way different in regard to principles, problems, and methods from what was done with the funds channelled directly or indirectly through the World Health Organization, since clearly the international function of WHO was fulfilled in accordance with the policy laid down by the Member Governments, whatever the origin of the funds. He would like to take the opportunity to explain the principles underlying both the program before the Executive Committee, and the budget, which was its arithmetical expression. He thought that by analyzing those principles it should be possible to explain to the Committee the series of projects outlined and their justification, and hence the necessity for including them in the Organization's activities.

The first of the principles in question was the basic role of health activities in economic and social development, as recognized on 14 April 1967 by 18 Presidents of countries of the Americas and the Prime Minister of Trinidad and Tobago. 2/ A statement thus made by the highest political authorities of the Member States gave the finest backing the Organization would wish for to a phenomenon which had loomed large during the recent past, and, it was to be hoped, would be important for many years to come. Specifically it was the tacit recognition that death, disease, and disability were serious obstacles to production and productivity; that the environment and its physical, chemical, biological, psychological, and cultural components--all of them historically inter- connected--were in turn closely bound up with the exploitation of natural resources; in short, that the growth of the economy and fairer distribution of income were contributory factors in individual and collective health.

The second principle was that individual and community health activities were an organic whole; and the same was true functionally. Hence prevention and cure were activities which should be carried out within the various services on

_/ Mimeographed document. 2/ "Declaration of the Presidents of America." OAS Official Records, OEA/Ser.C/IX.1 (Eng.), pp. 57-61, 1967.

- 25 - Page 26 Second session 56th Meeting an ecological basis, since they were eco:logical in origin and as such insepa- rable. No differentiation or singling out was feasible. That explained the Organization's keen interest in combating zoonoses and its greater and greater insistence on including campaigns against those diseases in its program, as the only way of gaining an understanding of the process and endeavoring to cope with it. The fact that if progress was being made in health activities in any direction over the past 20 or 30 years it was precisely in the differentiation of ecological systems and in the recognition of the various species causing disease in man or disease transmitted by man. He emphasized the importance of zoonoses, especially the quite direct importance of foot-and-mouth disease; it was impossible to understand the ecology of plague without penetration into the forest, since it was essential to acquire a thorough knowledge of the dynamics of the diseases carried by an occurring in the species found in the forest. It was impossible to understand jungle yellow fever or plague unless they were viewed as zoonoses. Preventive and curative activities should be undertaken within the relevant services with due regard to the peculiar nature of the problems, their dynamics, and the quality of the resources available.

The third principle was that the health problems of the Americas reflected the degree of development of the particular society. In most of the countries, indeed to some extent in all of them, the essential problems were infec- tious diseases, acute and chronic, envirornmental hazards, malnutrition (by defi- ciency rather than by excess), and inadequate income in relation to the existing possibilities.

The fourth principle was that there were many levels of development in the Americas and throughout the world; in that connection he recalled what the Director-General of WHO had said during a recent visit to Canada: that it was misleading to speak simply of developed and underdeveloped countries, because within the "process of development," as it was called, the differences in what was wrongly labelled the underdeveloped wcrld were so enormous that the approach too had to be flexible. Within one and the same country there were many different manifestations of development. Between the quality of medical care in the rural areas of the Americas today and what had begun to be called the "new medicine"--a veritable union of engineering, electronics, and atomic energy-- the distance might almost be measurable in light-years. Nevertheless, precisely because there were many different levels of development, every country needed to have some center geared to the new technology, and international collaboration was affected thereby.

The fifth principle was that the amount of tried and tested knowledge available was far in excess of what was normally applied. The human and material resources were below a reasonable minimum for any given activity. Consequently, there were too many deaths that could be prevented and too much disease that could be cured, above all in children under five years of age. In some social groups in the Americas, adults could still be regarded literally as "survivors."

His sixth point was that sufficient stability had not as yet been achieved in regard to the expansion of the economy, so that in most countries the economy was growing at a slower rate than the population, a fact which complicated the national approach to the solution of problems. Page 27 56th Meeting Second session

As a seventh principle, Dr. Horwitz pointed out that the instruments normally used--a combination of human and material resources--were education and training; streamlined organization and administration of services; planning in the context of development; and basic and operational research. That too had been recognized at the Meeting of Presidents of the American Republics.

His eighth principle was that health activities as a social function were still imposed from above, in other words by Governments. There had been a tend- ency to underestimate the intrinsic capacity of the average man and his genuine interest in his own well-being and, as Aristotle put it, in the well-being of his neighbors living in viable comm!nnities. That was true even in terms of economic significance, let alone spiritual value. In the last few years an encouraging awakening had been observed, and the steady growth of the trend was destroying the myth. The fact was that the rural inhabitants had intimated their desire and eagerness to collaborate and to contribute to the common good, which considerably enhanced the possibility of solving the rural problems as time went on.

Dr. Horwitz's ninth principle was that the Americas had concrete and measurable health objectives, their most characteristic expression being the Ten- Year Public Health Program of the Alliance for Progress, 3/ the principles and targets of which had been reaffirmed in the recent Declaration of the Presidents of America.

The tenth principle was that international cooperation supplemented and did not replace; it operated between nations and States and not above the heads of nations. Thus, what was known as the "Pan American Sanitary Bureau Plan" was the sum total of activities closely dependent on the action of the Govern- ments and the various communities.

Nevertheless, the fact that a Common Market had been set up in Latin America--a genuine economic and social community--made it essential to review the aims and objectives of PAHO and determine whether within that new framework it should not adopt another functional approach. The Governing Bodies of the Organization should ask themselves whether within a vigorous economic community calculated to be in the throes of development by 1985, action in the health field did not call for the performance of tasks which were inavoidable if certain aspects of economic interchange were to prove viable, efficient, and of real social effect.

If the answer were in the affirmative, the question would arise as to the function of PAHO within the institutional framework that should be formed or consolidated round the international body which the Chiefs of State had decided only recently to establish. It seemed to him that until such time as that were determined, it would continue to be the task of the Pan American Sanitary Bureau, as representing PAHO and WHO, to supplement the work of the Governments. It was with that in mind that the proposed program and budget estimates for 1968 had been prepared, and he invited the Executive Committee to examine them in the light of the principles he had announced. They were to be found embodied, if not in every project, at any rate in many of them; but

3/ OAS Official Records, OEA/Ser.H/XII.l (Eng.), pp. 30-32. Page 28 Secornd session 56th Meeting the spirit underlying the principles inspired the 545 projects comprising the program before the Committee.

He recalled that the Organization was first in the field among international organizations in program budgeting, a system which could not be static, but had to be constantly reviewed and as far as possible improved upon; for that reason, year after year efforts were made to polish it, as was the case in all Governments which prepared their national health plans or translated them into program budgets. The essential feature was a yearly re-adjustment which enabled every item of expenditure to be correlated more accurately with its purpose, namely a clearly-defined health function and not a mere budgetary head, as had been the case previously, and was still the case in certain systems.

Turning to Official Document 67, he drew attention to Table 6 (pp. 12 and 13), pointing out that, in the past, the Governing Bodies of PAHO had approved the categories of the program budget, which were seven in number: Protection of Health; Promotion of Health; Education and Training; Program Services (i.e., technical activities of benefit to all the work carried out by the Organization); Administrative Direction; Governing Bodies; and Increase to Assets. The corresponding funds were grouped under four main headings: Planning and Execution; Development of Professional Personnel; Research; and Indirect Program Costs. The table in question gave a comparative picture of the budgetary allocations for the years 1966, 1967, and 1968. An effort had been made recently to define rather more specifically which activities fell under each of the four main headings, and "Protection of Health" had been made to include the prevention of disease and control of environmental hazards.

The category "Promotion of Health" included the growth and normal development of children, and the physical and mental well-being and active production capacity of adults. "Education and Training" covered what was known as the development of human resources, and the projects had to do with systems related to the education and training of professional and auxiliary staff in the science and arts of health and in basic and operational research. Those fundamental activities were carried on through health services which were classified into general and specific services for program budgeting purposes.

As could be seen from pages 12 and 13 of Official Document 67, a balanced distribution of funds was proposed: 38.1 per cent of the total went to Protection of Health; 34.3 per cent to Promotion of Health; 10.1 per cent to Education and Training in connection with the improvement of educational institutions; 4.4 per cent to Program Services (i.e., all matters relating to scientific publications, public information, audiovisual educational media, the library, diffusion of scientific information, etc.); 10.4 per cent to Administrative Direction (though part of that item was technical in nature at the executive direction level). The allotments for Administrative Services as such remained within 5.4 and 5.5 per cent.

He stressed the effectiveness of the process of administrative rationalization begun a number of years earlier. The principles had been maintained, and a careful watch was kept on any increase in funds for administrative activities, an effort being made to ensure that they bore a close relation to increases on the technical side. 'he item General Expenses, representing 3.6 per cent of the total, would be explained by the Chief of Administration, Dr. Portner. Page 29 56th Meeting Second session

The justification for that item was the constant increase in the cost of living in Latin America, which affected the operation of the Organization quite directly. The allocation for Meetings of the Governing Bodies remained at more or less the same level as previously. With regard to Increase to Assets, the proposed item of $300,000 was intended to increase the Working Capital Fund.

Continuing his statement, Dr. Horwitz said that communicable diseases were still the item which accounted for the largest share of the Organization's funds, namely 29.5 per cent, and the proportion was even higher if account was taken. of what was being done in regard to communicable diseases under the other program categories: maternal and child health, laboratory services, statistics, etc. That brought the expenditure up beyond the 30 per cent level, possibly over 35 per cent, for what had been a traditional function of the former Pan American Sanitary Organization and remained so for the Pan American Health Organization and the World Health Organization. Within the category of Com- municable Diseases, malaria represented the largest item--15.4 per cent, or rather more than $3.5 million, a sum which it was proposed to spend on activities in each of the malarious countries and on some Zone or regional activities. He referred to his proposal to make a substantial drive to cope with the malaria problem in 1968; concrete data could be given if the Committee so desired, based on the plans drawn up for the various countries. He trusted that the countries which had had difficulty in supplementing their own resources would be able to use the credits which some of them had obtained from the Agency for International Development (AID), of the United States of America. He was glad to see that the current credit policy allowed for the grant of funds for malaria campaigns in six countries, which had already received the funds, while negotiations were well under way for credits to three other countries. The problem of malaria was not exclusively one of funds; the Organization was equally concerned with questions of a biological nature, and considerable research was already under way. There were also administrative and organizational difficulties. Experience was making it clear that weaknesses in that field were affecting the whole of an enterprise which had to adapt to the facts of life and had to be accurately timed and efficient. Much damage had already been done to the campaign throughout the Americas by the failure to synchronize operations, i.e., by the fact that countries had initiated their programs at very different times, which meant that countries which had succeeded in eradicating malaria had to continue to spend enormous sums until such time as their neighbors did the same.

Dr. Horwitz was of the opinion that with the experience acquired in solving some of the technical problems, the recommendations made by the PAHO Advisory Committee on Malaria Eradication in August 1965 4/ could be gradually realized, especially in countries where the problem of finding funds had been solved.

He went on to speak of smallpox eradication, a campaign for which the budget estimates under consideration were proposing a substantial increase of funds, over three times the previous amount. In 1966 the figure had been 1.1 per cent, whereas the level proposed was 3.4 per cent, though that was still inadequate for the plan as formulated; it should be pointed out, however, that Governments had not contributed the funds required, and there were also countries which had had no smallpox for a number of years but were not immunizing

4/ First Report of the PAHO Advisory Committee on Malaria Eradication, 1965 (mimeographed). Page 30 Second session 56th Meeting

as they should to prevent the encroachment of the disease. He considered that the execution of the program with the efficiency expected by the world generally, was essentially a matter for Governments, since there was no doubt that the countries of the Americas were in a better position to eradicate smallpox than other regions. The Organization was making a considerable effort to provide Governments with better and more abundant information on the disease; it would not be surprising if during 1967 and the years to come the number of cases recorded were to increase. The Brazilian authorities had made a valiant effort during the year under the guidance of the Bureau, to obtain regular information from all States with a view to gaining a more thorough knowledge of the problem. Similar efforts were called for in regard to the "immunized" countries, so that a true picture of the situation throughout the Hemisphere could be obtained, thus ensuring that the goal would be att~ained.

Action to combat chronic diseases, especially tuberculosis and leprosy, was continuing, the aim being to incorporate such activities into the work of the regular health services, and hence to make the best use of existing resources and services. Some progress had been made in that direction, and it was hoped that it would continue in 1968,

With regard to zoonoses, the United Nations Development Program had approved a grant of $1.5 million over five years to the Pan American Zoonoses Center. The funds were being received as of 1967. He hoped that the Center would gradually be transformed into a Pan American institution serving the interests of the various countries of the Region, especially in relation to the more important zoonoses--rabies, hydatidosis, bovine tuberculosis, anthrax, brucellosis, leptospirosis, and possibly others.

He considered that special attention should be paid to the problem of foot-and-mouth disease; ever since it had been set up, the Pan American Foot- and-Mouth Disease Center in Brazil had been very active thanks to the help given to it by the Program of Technical Cooperation of the Organization of American States and the generosity of the Brazilian Government, which had provided buildings, installations, and an annual grant. The Inter-American Economic and Social Council had agreed 2/' that the contribution of the Program of Technical Cooperation should cease as of mid 1968, and as a result the Organization had decided to help the Center financially so as to avoid the serious upset that would occur if during the next two years the Center were to operate at a low level. The International Bank for Reconstruction and Develop- ment (World Bank) and the Inter-American Development Bank had agreed to make loans for the foot-and-mouth disease campaign, to be used to cover local expenses in some instances. That meant tha.t for the very first time an opportunity had arisen for systematic organized action to gradually reduce the incidence of the disease and to provide mothers and. children in Latin America with the animal proteins they greatly needed, the hope being that economists and planners would be able to strike a sound balance between the biological needs of the various countries and the needs of their export markets.

The Center had had serious setbacks, and the Bureau was profoundly grateful to the OAS for having maintained its contributions over a period of 15 years,

5/ Resolution 34-M/66. OAS Official Records, OEA/Ser.H/XII.11 (Eng.), pp. 70-71. Page 31 56th Meeting Second session which indicated the economic and social importance it attached to the problem. In the face of new calls on its resources, the OAS had been obliged to allocate for other purposes the funds earmarked for the Pan American Foot-and-Mouth Di- sease Center. That being so, with the approval of the Secretary General of the OAS, the Bureau prevailed upon Mr. Edgardo Seoane, the Vice-President of Peru, and incidentally a distinguished agricultural engineer with 40 years of experience, to act as a special representative of the OAS and PAHO to discuss with most of the Governments of Latin America the importance of foot-and-mouth disease to the economy and to health, and the basic role that the Center had played in the Americas generally and in the individual countries. The object was to make it clear that the financing of the Center should be established on a sound footing by fixing a system of quotas based on the OAS scale of contributions. The target would be a budget of $1.2 million, which would begin to be collected in 1968.

He urged the Executive Committee to examine the item carefully, since the outstanding success of the Mission and the understanding shown by all the Govern- ments, not only of the importance of the problem but of all the arguments for maintaining the Center in the light of its past achievements and the proposed future plans for a systematic campaign against foot-and-mouth disease, made it essential that the institution should continue. He considered that the problem of foot-and-mouth disease was essentially biological in character, although it had its organizational and administrative aspects as well. There was no difference between immunization against smallpox and gradual systematic immunization against foot-and-mouth disease as far as rational organization of services was concerned. He proposed that the Center should remain under the administration of the Pan American Sanitary Bureau, by agreement with the Organization of American States and with its various institutions in respect of the relative competence of each. He thought the time had come for the Directing Council--if the Executive Committee deemed it advisable to make such a recommendation--to adopt a resolution to the effect that the Center should be an institution administered by the PASB, the contributions made by Governments as a sequel to the Mission undertaken by Mr. Seoane to be adrministered by the Organization. He thought that Dr. Blood, Representative of the United States of America to the Executive Committee, and the sponsor of the initial project for the Center when it formed part of the Bureau--a project which had been approved by the OAS--might add further details, since he had followed the progress of the institutions very closely.

Dr. Horwitz next referred to the problem of environmental sanitation, including Aedes aegypti eradication. He informed the Committee that from 3-5 April a Conference on the Eradication of Aedes aegypti in the Americas 6/ had been held in Washington, D.C., and the need had been stressed for disposing of the problem once and for all, the current year being the 20th anniversary of the original agreement adopted by the Governments at Buenos Aires. 2/ A Study Group had been set up to prepare a document outlining a new continent-wide plan for the eradication of the urban yellow fever vector. The document was in preparation and would be submitted shortly to Governments for consideration. He considered it urgent to give new impetus to the program so as to reach a final

/ A Report of the Conference was published in Spanish in the Boletín de la Oficina Sanitaria Panamericana, Vol. LXIII, No. 2, pp. 169-172, August 1967. 2/ PAHO Publication 247, 3. Page 32 Second session 56th Meeting solution once and for all. It was a question of finance; from the technical point of view certain recent achievements made it possible to view the campaign more optimistically than in the past.

On the subject of the environmental sanitation program, more specifically the water supply and sewage disposal projects, he said that an item was proposed representing 6.5 per cent of total funds; to that should be added the sums earmarked for sanitation under the heading of "Education and Training," namely 2.3 per cent, mostly intended for the same purpose. The total was almost 9 per cent, or a sum slightly over $2 mi].lion. At the recent meeting of Chiefs of State at Punta del Este it had been agreed that the urban and rural sanitation projects should be stepped up and that in agreement with the international lending agencies, national revolving fun¿Ls should be set up to ensure continuity for that type of project. The agreement placed an obligation on the Governments and on the Bureau, which for the past three years had been urging that the rural problem should be tackled by means of machinery which made foreign credit unnecessary and thus gradually ensuring the well-being of the entire population. The proposed system might be tried out in the various countries. In two countries it had been found that the original. machinery used for the programs had produced results. Naturally, if a Government considered it unlikely that all the funds needed to gradually provide its rural population with water supplies and basic sanitation would be forthcoming, it was perfectly at liberty not to set up such a national revolving fund; but it was to be feared that with the high cost, it would be difficult to achieve the goal in any other way. The important point was that what the sceptics had queried as the great unknown quantity, namely the attitude of the average man, had turned out to be the most hopeful sign. It was the public that was most eager and most concerned, and once the public was adequately motivated, the response could hardly be better.

The Bureau would continue its advisory services, as hitherto, namely in accordance with the peculiar problems of each country, at the national rather than the local level, and in the formulation of annual programs and the task of collaborating on technical problems, whatever their nature, rather than on minor local projects for which Governments had all the experience and capabilities they needed.

The estimate for general health services was 17.2 per cent of the total, including health services at the ministerial and general health administration level, nursing, laboratories, health education, statistics, and administrative methods. A study of the relevant projects revealed a tremendous variety. Some Governments were greatly interested in modernizing their health codes, others in setting up or improving their statistical departments, and many were interested--indeed the time would come when they would all be interested--in stream- lining the organization and administration of their services, in other words, in introducing sound administrative practices and applying technology to individual and collective health.

In the near future a regional consultant or laboratories would be available, in addition to those already existing in certain countries. That particular branch of health would thus be given a considerable impetus, since naturally the quality of the diagnosis of disease and the causes of death were affected by the shortcomings in laboratory examinations. Something like 17.1 per cent of total funds, or approximately the same amount as for general services, was Page 33 56th Meeting Second session set aside for specific programs. The bulk of the funds were for nutrition and medical care. It was not surprising to find that a recent analysis or evaluation of a large number of expanded nutrition programs carried out jointly by various Governments through ministries of health, agriculture, and education, and at the international level in conjunction with the Food and Agriculture Organization of the United Nations (FAO) and the United Nations Children's Fund (UNICEF), showed generally speaking that the number of children benefiting from the scheme was steadily increasing. In some countries the beneficiaries had doubled, but the results were far from proportionate to the magnitude of the problem. It was a task that should be pursued in the same way as the training of technicians, research into cultural characteristics, nutrition in the various countries, and so on. Rather more than half the total sum of $2,156,000 was earmarked for the Institute of Nutrition of Central America and Panama, an agency set up by the Central American Governments in the interests of the Americas and many other countries of the world as well.

Turning to the allotment of over $920,000 for medical care, he said that the Kellogg Foundation had just made a grant of $111,400 for the establishment of intensive medical care units in some of the larger university hospitals, with a counterpart contribution of $28,000 by the Bureau. He stressed the dynamic nature of the program, which was changing almost daily, since new activities were being evolved and put into practice constantly. Because of the grant, the initial contribution of $60,800 and $16,800 by Kellogg and PASB respectively should be added to the figures from 1968 onward. A few days earlier the Minister of Public Health of Uruguay had urged the establishment of a national hydatidosis control program; that had not been taken into account in the project under consideration, but the activity had been assigned to the Pan American Zoonoses Center. Similarly, in Mexico there had been some talk recently of extending the joint activities of the Ministry of Health and Welfare and the schools of medicine so that, under the auspices of the Organization, medical education might be brought more closely into line with the peculiar nature of the local problems. With that in mind, Document CE56/5 gave a comparative analysis showing the corresponding column for 1968 of Official Document 67 (July 1966) in relation to what had been learned until a month ago. The main point was that the projects were geared to the main priorities and appeared to be in line with the policy which the Governing Bodies had laid down and were still following; and on the whole they coincided in terms of investment with the essential priorities of the Bureau.

He next referred to advisory services to public health, medical and nursing institutions, and engineering schools. In regard to the last-named,valiant efforts had been made in the form of what might be described as a process of continuing education for sanitary engineers, and the same principle might well be applied to other branches of higher education. In dentistry and veterinary medicine progress was being made, though perhaps not so rapidly as might be desired, with the inclusion of preventive medicine under those headings. All veterinary medicine should be preventive in essence, especially that which sig- nificantly affected the health of human beings. In biostatistics great advances had been made, but the figures were still not quite as complete and accurate as the Governments would like them to be and needed them to be. Turning to "Program Services," "Administrative Direction," and the other categories into which the program budget was divided, he said he would be happy Page 34 Second session 56th Meeting to give data on the analysis of the structure of total spending, and he quoted Document CE56/5 (p. 2, second paragraph), which read as follows: "The budget tables present the planned sources of funds for the various projects and structural units of the Organization. The program as a whole remains essentially as it is displayed in Official Document 67. However, adjustments made as the result of consultations with Member Governments have produced some changes in the individual projects to be operated. Current plans for the Program as a whole are for a total of $23,487,512, an increase of $620,246 (2.7 per cent) over the Official Document 67 estimates of $22,867',266." But the bulk of the budget (the 78.4 per cent plus the 8.8 per cent, in other words, a total of 87 per cent) could be regarded as allocated for activities directly related to health. The 78.4 per cent referred to field programs and the 8.8 per cent to the Bureau's technical staff at Headquarters, making E. total of 87.2 per cent. Meetings of the Governing Bodies represented 1.4 per cent, the Working Capital Fund 1.3 per cent, and Executive Direction, Administration and General Services 10.4 per cent. Of the last-named figure only 5.5 per cent represented administrative costs in the ordinary sense, i.e., expenditure on fundamental activities, which were often all complementary in that they helped to place technology at the service of mankind. Thus almost 92 per cent if not more of the outlay was allocated for direct health services.

Another way of analyzing the structure of expenditure was shown in Tables 4 and 5 of Official Document 67 (pp. 10 and 11). Table 4, where it referred to the year 1968, showed that planning and execution accounted for 66.5 per cent of all funds, development of professional personnel 11.4 per cent, and research 8.5 per cent, though it should be noted in regard to research that the regular budget included only research connected with the Office of Research Coordination at Headquarters, most of the funds for other research coming from various institutions which contributed generously to that end, especially the National Institu- tes of Health of the United States Public Health Service, and a number of foundations. Table 5 gave a summary of estimated expenditures by object of expenditure. It would be seen that personnel costs represented almost 67 per cent, duty travel 5.1 per cent, fellowships 8.7 per cent, seminars 0.7 per cent, supplies and equipment (largely for malaria) 7.9 per cent, and sundry grants connected with research 10.7 per cent. Official Document 67, from page 15 onward, gave a description of each category of the program budget, each program and each function, followed by an outline of each project by country.

Following the description of each program came the amount of the funds budgeted, and the figures were supplemented in Annex 3 (p. 246, et seq.), which gave a list of projects by program and category. The Bureau was ready to place the relevant information before the Committee if it so desired, since it was in the Bureau's interest that the closest possible scrutiny should be made of the proposals.

The total number of posts proposed was 1,198, of which 628 were professional posts. In addition, 923 months of service from short-term consultants were proposed on the basis of past experience. An expert consultant was completing a study of a selected sample of projects carried out by short-term consultants. The purpose of the study was gradually to improve the system, since in view of the progress made by the countries of the Hemisphere, many functions had already crystallized and there were other new ones requiring highly specialized experience. For that reason, the number of short-term consultants tended Page 35 56th Meeting Second session to increase year by year, and it was desirable to see to it that the system could and did operate at the highest possible level of efficiency. He felt sure that by the date of the XVII Meeting of the Directing Council, or at any rate by the 1968 Meeting of the Executive Committee, a summary of the study could be submitted and would be of value to the Governments.

The Committee's main task was to examine the increase in the regular budget of the Pan American Health Organization. The increase was 11.8 per cent over 1967, but that included the annual item of $600,000 to enable the Bureau to ab- sorb the voluntary malaria contributions made by a large number of Governments, especially the United States of America. Moreover, at least 4.5 or 5 per cent of the increase represented the increase in the cost of living. A study was being made which was designed to show specifically that the item should actually be higher if the activities of the Organization were to expand as its responsibilities increased. The increase seemed to him insignificant, and in justification of that he referred the members of the Committee to Annex 7, listing the projects requested by Governments but not included in the program and budget estimates. The total cost of those projects, as could be seen on page 263, was $4,417,275.

He pointed out that the table in question had previously not included more than $2.5 million, which made it clear that requests by Governments had grown substantially, so that it was a more and more complex task to prepare the Organization's program and budget estimates. Nevertheless, a large proportion of the projects were among those already included in the program submitted by the Bureau, so that it would be possible to undertake something at least of what Governments wished on the strength of the budget proposed; and the Organization did not think it was excessive in the light of the needs.

In conclusion the question he would raise was what was to be expected from all that outlay. A reply could be given by examining each individual project, in the light of the targets of the Ten-Year Public Health Program of the Alliance for Progress, which the Directing Council had taken over as the Organ- ization's policy; but he would emphasize that the targets fixed could not be achieved unless Governments so resolved, since the task was theirs and in the interest of their peoples. The task of the Bureau was merely ancillary, though it was carried out with the utmost pleasure.

Dr. PORTNER (Chief of Administration, PASB), continuing the presentation of the program and budget estimates for 1968, invited attention to the Constitu- tion and the Financial Regulations, which called for the Director's budget proposals to be considered by the Executive Committee and submitted to the Direct- ing Council together with such recommendations as the Ebcecutive Committee deemed advisable.

Before embarking on a detailed examination of the program and budget in financial terms, it was appropriate to deal with its historical background. He described the budgetary process in PAHO/WHO to date, emphasizing that since the objective was to present a comprehernsive view of the program plan and estimates of the Organization, the presentation was made (1) by program, (2) by part of appropriation and, thereunder, by offices in Part II, and by Zone, country, and projects in Part III, and (3) by object of expenditure. In its efforts to give the Governing Bodies an insight into the program of PAHO/WHO, the Bureau had been well in advance of the United Nations Ad Hoc Committee of 14, which had Page 36 Second session 56th Meeting recently surveyed the budgetary processes of the agencies in the United Nations common system. The presentation of a provisional program budget two years in advance enabled the Governments to make an appraisal of it more than a year before the date of its adoption. There were many other areas in which PAHO/WHO had endeavored to be in the forefront in matters of the management of an international agency.

Thus PAHO/WHO had sought to make the program and budget a basic tool of effective administration. Major changes in the format of the "grey book" were planned and would be presented to the XVII Meeting of the Directing Council. It would then feature a definitive program budget, broken down through the project level, in addition to the current presentation by part of the appropriation; AMRO projects, which constituted a significant part of the Organization budget would be attributed to countries, which was not the current practice; and finally, efforts were being made to include data for four years instead of three.

As a further step in facilitating the study of the program of the Organi- zation as a whole, and in keeping with the expressed desires of the Executive Committee to have as complete information as possible, the document before the Committee, CE56/5, for the first time included estimates from all sources of funds. It was the outgrowth of the continuum of the preparation of the PAHO program and budget; that for 1968 had had its beginnings in 1965, when broad plans for the development of the program had been discussed with Governments. Those discussions had resulted in the provisional draft of the program and budget for 1968 which had been presented in 1966 to the XVII Pan American Sanitary Conference in Official Document 67.

After considering it, the Conference had approved Resolution IX S/ which, "recognizing that the provisional draft of the proposed program and budget contains well-conceived and much-needed public health projects; and taking into account the recommendations and comments made by various delegations during the discussion of the provisional draft," and had requested the Director, in preparing the proposed program and budget for 1968, to consult with Governments on the matter, giving due consideration to the recommendations and comments made by the several delegations.

The entire program had been reviewed by the Director and his representatives with the Governments, especially the nature and elements of projects they desired, bearing in mind health needs and plans of the country concerned. The views of the Governments had also been obtained on the intercountry projects for educational activities, specialized consultant services, and research projects of interest to several countries. Consequently, the proposed program and budget estimates for 1968 reflected the latest known desires and requirements of Govern- ments, taking into account the established priorities of the Organization.

The budget tables showed the planned sources of funds for the various projects and structural units of the Organization. The program as a whole remained essentially that presented in Official Document 67. However, adjustments made as a result of consultations with Governments had produced some changes in the

8_/ Official Document PAHO 74, 65. Page 37 56th Meeting Second session individual projects. The total cost of the program as a whole was estimated at $23,487,512, an increase of $620,246 (2.7 per cent) over that given in Official Document 67.

The total budget was heavily weighted in favor of field programs, 78.4 per cent of the budget being assigned directly to those activities. The technical staff of Headquarters accounted for 8.8 per cent; Meetings of the Govern- ing Bodies, 1.4 per cent; the increase to the Working Capital Fund, 1.3 per cent; and the remaining 10.4 per cent was for executive direction, administration, and the cost of general services.

Since the Executive Committee was to make a recommendation to the Direct- ing Council, the PAHO regular budget called for special study. The document therefore facilitated a comparison of it with the provisional draft budget presented in Official Document 67. Specifically, the budget tables showed, for PASB regular, the Official Document 67 budget together with the revised figures.

The level of the proposed regular budget of PAHO remained at $10,190,000, as was decided by the XVII Pan American Sanitary Conference in 1966. All adjustments had been made within that ceiling, even though the program review had indicated a desire on the part of Governments for additional projects beyond foreseeable resources of the Organization.

The portion of the program which was expected to be financed by the Special Malaria Fund and the Community Water Supply Fund of PAHO had been revised and costs further refined. The l.atest estimates were reflected in the budget tables.

The Special Malaria Fund, estimated at $1,886,092 in Official Document 67 had been revised and stood at $1,984,862, an increase of $98,770, or 5.2 per cent.

The Community Water Supply Fund of PAHO estimated at $188,311 in Official Document 67 had been increased by $4,622 (2.5 per cent) to $192,933.

The other funds attributable to PAHO were currently estimated at $2,770,016, as opposed to $2,325,057 in Official Document 67. That revision reflected the latest approvals of various grants and expected contributions to PAHO. The amounts available varied according to current plans and approvals, and would again be revised before the XVII Meeting of the Directing Council in order to provide it with the latest information. Although a Special Fund for Research had been approved 2/ at the XVII Pan American Sanitary Conference and pledges made, no projects were shown since plans were not yet far enough advanced, and no money had been received.

The WHO regular column reflected the projects which appeared in Official Document 67 and which would be considered by the Twentieth World Health Assembly in May 1967. After that meeting, some changes might be desired by Governments, and the plan was to present such changes to the Regional Committee for the Americas at its October meeting.

9/ Resolution XVI. Official Document PAHO 74, 72-74. Page 38 Second session 56th Meeting

The WHO "other" column showed the estimates of the costs of that portion of the malaria eradication campaign which it was hoped would be financed by the WHO Malaria Eradication Special Account. In addition, funds were expected to be made available from a WHO special account to cover certain staff members in the environmental sanitation program.

The column for the United Nations Development Program contained the latest approvals for projects from both eectors of that agency: the Technical Assistance Program and the Special Fund. The Technical Assistance portion was currently approved at $1,529,053, a decrease of $62,937 (or 4 per cent), from the estimate of $1,591,990 presented in Official Document 67. Similarly, the Special Fund projects totalled $577,933, a decrease of $24,143, or 4 per cent, and reflected changes in the plans of operations of the four Special Fund projects approved and in operation. Several more projects were under consideration by the Special Fund and, if approved in time, would be included in the document to be submitted to the Directing Council.

As for the PAHO regular budget proposal, the ceiling was still $10,190,000, as noted by the XVII Pan American Sanitary Conference. At its direction it had once again been reviewed with Governments in order to provide for the latest known projects desired by them within that ceiling.

Of the projects shown in Official Document 67 that had been revised, 57 per cent showed minor changes related to recostings, transfers between projects of revised requirements for such elements as fellowships and short-term consul- ants; 17 per cent reflected no change; 11. per cent were newly-planned for financing from PAHO/regular funds; 11 per cent had been merged with other projects; and 10 per cent had been either advanced or postponed.

In the program projects were grouped within major program categories. In essence, the objectives of the program generally were the same as those discussed at the XVII Conference, but the approach to the solution of problems differed somewhat insofar as part of the fellowship program was being converted into a study of the manpower and training needed to meet specific problems by country, continuing education of medical personnel, particularly those from rural areas, improvement of training centers, and reference libraries and bibliographical services, and follow-up of programs for training in the field of medical care and hospital administration.

In the new proposals the cost of the Meetings of the Governing Bodies was $233,494; the technical staff and the Headquarters in Washington, $2,789,509; field programs, 16,616,997; and increase to the Working Capital Fund, $300,000.

Dr. Portner then undertook to review the entire document part by part, section by section, office by office, and projects, noting the significant changes in dollar terms, post changes, and other important differences from Official Document 67.

In conclusion he invited the Committee to make such recommendations on the proposals as it saw fit after it had reviewed them to its satisfaction.

The session was suEpended at 4:35 p.m. and resumed at 4:50 p.m. Page 39 56th Meeting Second session

The CHAIRMAN considered the Director's presentation a masterly performance, especially his 10 principles, which undoubtedly would serve as a basis for discussion and for future projections in the Pan American health field.

Dr, ORELLANA (Venezuela) endorsed the tribute to the Director's presentation of the proposed program and budget estimates; he had listened with the utmost satisfaction and interest to the excellent statements and comments on the health program for the Americas and the guiding principles on which the Organization should base a health policy.

He had been greatly impressed by the presentation, and he would like to ask Dr. Horwitz to enlarge upon his statements on possible changes in the Organ- ization's policy consequent upon the recent Meeting of the Chiefs of State at Punta del Este, especially in regard to the Common Market. In view of the role which the Organization had played in the establishment of a continent-wide health policy since the meeting in Punta del Este in 1961, earlier than that, since Bogotá, and earlier still since Buenos Aires, it was evident that the Organization had to follow step by step and very closely the great Latin Ameri- can movement for integration.

With regard to the Common Market and the integration of activities, the Organization had a very important part to play, for example in regard to the production of foodstuffs and the manufacture of biological products and certain types of vital supplies.

Dr. HORWITZ (Director, PASB) said that the question might be discussed in greater detail in connection with the item proposed by the Government of Panama. l_/ Nevertheless, he was gratified to see that the effects he had confidently anticipated were in fact being produced. To put the matter in perhaps somewhat general terms, it might be said that a viable economic community was not feasible in any region without an institutional framework, and there was no escaping the fact that a series of institutions would have to be set up or brought to life within the Hemisphere if the Common Market were to become a reality. The "Continental Parliament" would have to be placed on a solid foundation; a court of justice would have to be set up to deal with problems, as well as courts to settle disputes arising over trade matters; political power would have to be strengthened still further through the Organization of American States; and greater stimulus would have to be given to the agency responsible for education, science, and culture.

It was quite natural that in the health field PASB should be the body to take over such responsibilities as the community, in other words the Governments, entrusted to it because of their particular nature. For that reason, the first question to be asked wass where the region ended and where the nation began in regard to health. There were activities that were strictly regional and others that were not. The former obviously included one which had always existed--disease, which did not respect frontiers. The coordination of activities to combat diseases would have to be strengthened by expanding relations between the Govern- ments of the Hemisphere, which was manifestly shrinking. But in addition, Dr. Orellana had pointed to another activity still. A series of frontier problems

1,/ Document CE56/19 (mimeographed). Page 40 Second session 56th Meeting would inevitably arise where it would have to be determined how the resources were to be used to benefit the inhabitants, whatever their situation, since it was the frontiers themselves that were disappearing. That was actually happen- ning, and a careful analysis had to be made of the relevant problems.

At the same time, a series of sanitation problems would arise which would likewise have to be given the most careful study: water pollution, affecting more than one country; contamination of the soil; air pollution. Those different problems could only be tackled within an institutional and continental framework, but fundamental differences were bound to arise in regard to the cost of products, since the social benefits would vary and that would mean protests, so that if services were to be organized, an organ would be called for to collaborate with Governments to that end. Problems had already arisen in the Common Market with regard to canned foods not subject to control, and even more acute- ly with regard to drugs, where, with the exception of Canada and the United States of America, control was negligible or non-existent in the Americas. Thus control activities had to be stepped up and collaboration had to be forthcoming in setting up national control laboratories to serve a group of countries. How- ever, above all, rules and regulations had to be drawn up to facilitate the movement of the products concerned.

It had been argued that there could be no economic Common Market without a Common Market in the intellectual sense, and the latter could not exist unless there was at least some similarity of standards in the teaching leading to the award of professional degrees and diplomas in subjects directly related to health. That would mean reviewing the university training systems, in terms of the Region rather than of single countries, since interchange as practiced today was bound to be intensified to an extraordinary degree. None of those matters could be solved by regimentation. Health problems should continue to be solved in the local environment and in accordance with the local way of life, since the culture factor was paramount. The establishment of an institutional framework in the health field, far from hampering that effort, should supplement it if a viable economic community was to arise. Thus one of the first steps to be taken might perhaps be to bring the Pan American Sanitary Code l_/ up to date so as to include the new fields not covered by it. The code was of 40 year's standing; it had only been brought up to date in respect of the International Sani- tary Regulations, l_/ but not in respect of health throughout the Americas. In all fields, operations would have to be reviewed in terms of the new dimension-- the Hemisphere rather than the nation. The time would come when Governments would hand over executive responsibilities to the Organization in view of their essentially continental character. For thIe time being some modification was called for in the existing norms outlined for the Governing Bodies of the Organ- ization by the Chiefs of State in the Declaration which would be adopted by all the Governments at the XVII Meeting of the Directing Council as part of the Organization's policy.

Dr. BLOOD (United States of America) asked whether, even at such a late stage, it might not be appropriate to consider the program and budget in the light of the Director's statements with reference to the Declaration of the Presidents of America and the adequacy of their projections as a starting point

J/' Official Document PAHO 80, 1-9. 12/ Published by the World Health Organization, 1966. Page 41 56th Meeting Second session for the fulfillment of the objectives set forth by the Chiefs of State. Perhaps his proposal was too ambitious, but the document before them had not been drawn up with that in mind. Nevertheless, although clearly there were points in it that were in full accord with the Declaration, it would be interesting to note those that needed to be added if the requirements of the Declaration were to be met. Such an effort might have to wait until later, and he might be mixing up two items on the agenda, but it would be interesting to assess how far the countries had come, in the light of what had happened in Uruguay in the previous few days.

Dr. HORWITZ (Director, PASB) thanked Dr. Blood for his comment;he thought the budget for 1968 should be approved as it stood, since if the Directing Council decided that the time was not ripe to begin a study of the Organization in terms of the new continental objectives, nothing could be done except to hope for the best. After all, it could not be said that the proposed program and budget as it stood was inappropriate, since it contained the basic elements for the future development of the Organization as an institution of the Common Market in regard to health matters.

Dr. BLOOD (United States of America) said that he would like consideration of his request to be postponed until Item 21 was discussed, but hoped that it would then be brought into focus because the countries needed to know well ahead of time how far they were from attaining what would be needed for the next year, and five years hence, in order to reach the goals established for them at Punta del Este.

The CHAIRMAN invited the Committee to turn to Document CE56/5. It referred exclusively to Official Document 67, which had already been considered at the XVII Pan American Sanitary Conference and he drew attention to the difference between the totals given in the two documents ($23,487,512 and $22,867,266, respectively), representing an increase of rather less than 3 per cent.

Dr. ORELLANA (Venezuela) was glad to see that the members of the Execu- tive Committee were in a better position to examine the budget than the previous year, when an unexpected increase due to the increase in salaries adopted by the United Nations and later affecting the Organization had had to be approved without proper discussion. That had meant increasing the contributions of Goverments when they had already been approved. During the past year the ceiling was approved by the Conference in the preliminary draft--$10,190,000--as the regular budget of the Organization. That was highly satisfactory; nevertheless, over and above the general total figure approved in the preliminary draft, namely $22,867,366, Document CE56/5 mentioned an additional sum of $620,246, or 2.7 per cent of the figure discussed by the Conference. Further on it was explained that the increase was the result of adjustments in the individual funds of the Organization, two in particular: the Special Malaria Fund which had been increased by $98,770, and the Community Water Supply Fund for which the increase was only $4,622. There had also been fairly large-scale increases in other funds attributable to PAHO. He would be glad to have a statement as to the real possibility of the other grants materializing, since the sum mentioned was $620,246. Dr. PORTNER (Chief of Administration, PASB) said that, as had been indicated earlier, the presentation of the program and budget was a developing Page 42 Second session 56th Meeting

process. At the XVII Pan American Sanitary Conference in 1966 it had been noted, both in the text of the document and orally, that to speak of 3.2 per cent gross increase for all funds was doubtless to understate the case. How- ever, as of June 1966 that had been the best information available. Under- statement was almost inevitable when it came to grants, but adjustments were made as time went on. Before the XVII Meeting of the Directing Council there might be further modification, but it wou:Ld be a minor one, and would basically relate to grants. Mention was made of that possibility on page 2 of Docu- ment CE56/5. It was most unusual for changes to be made in PAHO/regular between the meeting of the Executive Committee and that of the Directing Council. A ceiling was set on the provisional budget presented to the Conference of 1966 and had been maintained. When the original 1966-1967 presentation had been prepared, knowledge of an impending wage :increase was not available. An adjustment had subsequently been made, but for :L967 the $260,000, which had been a special item for 1966, had been absorbed, and would be in the future. The other adjustments in the Special Malaria Fund and the Community Water Supply Fund had been made to bring them up to date. Basically, those funds were financed from voluntary contributions; however, as regards certain grants there was almost inevitably little certainty in the early planning stages. The grants received were reflected in the document; thcse still under negotiation were not.

Dr. HORWITZ (Director, PASB) said that the question put by Dr. Orellana was a highly important one, and he invited the members of the Committee to refer to Annex 4 of Official Document 67 (pp. 254-255) which indicated the "Other Funds" which the Representative of Venezuela had mentioned. He drew attention to the level being reached by those extra-budgetary contributions in relation to the Organization's regular budget. The figure for 1968 was $4,399,460, not counting the modifications mentioned by Dr. Orellana. Account had to be taken of the items under the Community Water Supply Fund and the Special Malaria Fund, and the adjustment shown on page 2 of Document CE56/5. If the Committee so desired, a list could be produced of the funds representing the increase of some $400,000 making up the total of $620,246 referred to by Dr. Orellana in relation to the funds whose sources were shown in the table in Annex 4. For example, the Kellogg Foundation had two days earlier approved an item of $110,000--not included in the list--for intensive medical care programs in university hospitals. The process was going on all the time. Requests made in the past and not decided upon by the institutions concerned at a given moment were being granted. Dr. Portner had referred to that point when he spoke of the best information available. A breakdown of the $620,246 should be provided for the information of the Executive Committee.

The CHAIRMAN said it would be desirable to make the data available not only to the Executive Committee but to the Directing Council in September 1967. He asked whether the totals constituting the regular budget of the Bureau, the malaria, water supply, and other budgets, had all been reviewed, in other words whether they were final figures. Since the definitive budget of WHO to be approved by the Twentieth World Health Assembly was not yet known, he wondered whether there would be any substantial difference.

Dr. PORTNER (Chief of Administration, PASB) said that, whatever the deviation might be, it would not be significant. The figures were subject to review by the WHO Director-General, following certain action by the Assembly. Page 43 56th Meeting Second session

Adjustments might be needed but, if experience were any guide, the change would not, in the aggregate, be significant, and in any event would probably amount to less than 5 per cent either way.

The CHAIRMAN said that an examination would be made, part by part, of the budgetary items shown in Document CE56/5. In the first place, he called for discussion of Part I (Organizational Meetings). In the absence of observation or objection, he submitted for examination the allocations under Part II (Head- quarters), which showed an overall increase of $7,217 in relation to the figures in Official Document 67.

Dr. PORTNER (Chief of Administration, PASB) said that the change in Chapter 5 of Part II, Section 2, represented the reclassification of a professional post. The change in the Medical Care Branch, under Chapter 7, represented a recosting based on the assignment of a certain person to a particular post for the full period of the year.

Dr. BLOOD (United States of America) asked whether the increase for common services at Headquarters (Section 5), represented a readjustment in the local salary scale, or was attributable to part-time employment, and whether it involved an additional $14,000.

Dr. PORTNER (Chief of Administration, PASB) replied that it was accounted for by an increase in the cost of night cleaning and the like. The figure quoted by Dr. Blood was correct.

The CHAIRMAN said that Part III, Section 2 (pp. 9-10 of Document CE56/5) showed a reduction of $62,000.

Dr. BLOOD (United States of America), referring to the increased cost for some Zone Offices, for instance, Zone IV, in respect of which Dr. Portner had mentioned common service changes, asked whether it was largely a question of inflated costs of living in some areas and whether it was possible to general- ize in regard to increased costs.

Dr. PORTNER (Chief of Administration, PASB) said that the position varied from one Zone to another. At least one local wage change per annum was to be expected. At some stations there might be up to three. Common services and building maintenance also were factors. In the Zone IV Office, the need for additional rented space entailed increased costs.

Dr. ORELLANA (Venezuela) noted that in most of the Zone Offices there had been a slight increase, except in Zones III and VI. He wondered why they did not follow the same pattern of increase as the other Zones.

Dr. PORTNER (Chief of Administration, PASB) said that in the Zone Of- fices there was a basic balance in the ratio of professional to secretarial posts. In Zone I that had entailed the addition of a secretarial post. For Zone II the change was essentially due to an increase in common services and required a recosting. There had been no change in manpower. The basic cost of the adjustment for Zone III was a minor item. In Zone IV one clerical post had been added, and there were additional common services costs. In Zone V a mes- senger post had been added. In Zone VI two posts had been added, but there had Page 44 Second session 56th Meeting been a reduction in the cost of certain clerical posts, so that the total cost was lower by $1,000.

Dr. BLOOD (United States of America) said it was interesting to relate the final figures to the cost for the previous two years not shown in the document before them. Official Document 67 showed that, despite variations, all the Zone Offices had increased budgets for 1967; that the increase was constant for all, though in some it was much greater than in others. Zones I, II, and IV seemed to have the largest increases, almost all of the same order of magnitude, whereas in the other three Zones the increase had been less. It was very difficult to relate the figures to those for previous years if they were not shown in the same document. Perhaps Dr. Portner would be good enough to relate the figures to a general pattern.

Dr. PORTNER (Chief of Administration, PASB) said that a comparative analysis was possible by reference to pages 50-51 of the Financial Report of the Director (Official Document 75). There, not in estimates but in terms of actual expenditure, it could be seen that the expenditure for Zone I for 1966 was $144,000 as against an estimated $118,000 for 1968; for Zone II, $108,000 as against $123,000; for Zone III, $101,000 as against $113,000; for Zone IV, $121,000 as against $126,000, and together with the other changes to be noted for the other Zones resulted in a gross cost for 1966 of $756,000 as against an estimated $707,000 for 1968. Therefore, it was not a pattern of constantly as- cending expenditure but rather of a pattern of changes indicating an effort to provide all possible services while keeping the cost within reasonable bounds.

The session rose at 5:40 p.m. THIRD PLENARY SESSION Thursday, 27 April 1967, at 9:00 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN, opening the session, said that the Representative of the United States of America had expressed some doubt to the Chair in regard to the examination of the proposed program and budget estimates based on Document CE56/5 in conjunction with Official Document 67. He asked the United States Representative to explain his doubts.

Dr. BLOOD (United States of America) said that Resolution IX l/ of the XVII Pan American Sanitary Conference had requested the Director, in preparing the proposed program and budget for 1968 and in his consultations with Govern- ments on the matter, to give due consideration to recommendations and comments made by the several delegations. Accordingly, he would like to know whether what was to be examined in detail was in fact Official Document 67 with such changes as had been proposed subsequently.

Dr. HORWITZ (Director, PASB) said that that was correct. During the Conference the provisional draft of the proposed program and budget of the Or- ganization for 1968 had been presented as shown in Official Document 67. On the other hand, in accordance with instructions received, the Bureau had continued its consultations with Governments and had taken into account the views expressed by the delegates of the Governments at the Conference and the information received between the date of the Conference and the meeting of the Com- mittee. The outcome of all that was the new document that had been prepared, giving in one column the figures as shown in Official Document 67 and opposite them the figures as revised in accordance with the Conference's instructions. Since in the past the Executive Committee had had certain technical difficulties in collating the program financed from PAHO funds with the whole of the operations of the Organization funded from WHO and from other sources,' Docu- ment CE56/5 showed the total expenditure figures so as to simplify the task of analyzing the PAHO program and budget.

Dr. PORTNER (Chief of Administration, PASB) said that the Regional Com- mittee of WHO in its meeting in 1966 had approved 2/ the program and budget for the WHO-funded activity in the Americas and had recommended that, when preparing the 1968 WHO budget, the Director-General adhere to the ceiling and program it had indicated. In effect, definitive action on that part of the budget had already been taken. l/ Official Document PAHO 74, 65. 2/ Resolution VIII. Official Document PAHO 74, 64-65.

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The CHAIRMAN asked Dr. Blood whether he was satisfied with the replies given by Dr. Horwitz and Dr. Portner.

Dr. BLOOD (United States of America) expressed his thanks for the clarification in the sense that the Committee should focus its attention on Official Document 67 as modified, i.e., the total program and budget for 1968.

The CHAIRMAN said that the study of Document CE56/5 would continue.

Dr. AGUILAR HERRERA (Guatemala) pointed out that under Part III (Field and Other Programs) the over-all budget for all projects and especially for those referring to Zones II and III had been reduced. In fact the WHO funds likewise seemed to have been reduced. Since those were the programs on which the main field activities of the Organization were based, he asked whether the reduction was offset by other funds and whether it was occasioned by the termination of certain projects, lack of intereist on the part of Governments, or other factors.

Dr. PORTNER (Chief of Administration, PASB) said that if the total funds were taken into account, it would be seen that the figure of $18,396,112 for all funds in Part III represented an increase of some $350,000 over the figure of $18,046,616 shown in Official Document 67.

The CHAIRMAN reiterated that for some Zones there was a reduction in funds, whereas there was a considerable increase in others, as Dr. Portner had pointed out.

Dr. PORTNER (Chief of Administration, PASB) added that the services given to a particular country by AMRO projects (which constituted a considerable portion of the PAHO/WHO program), also had to be taken into account. Zone II showed an increase of the order of $94,000. In Zone III there was a decrease of $50,000, but it should be emphasized that activities under many regional AMRO projects were being undertaken in Zone III. As he stated in his presentation of the budget document, plans were being made for the program and budget and the financial reports to indicate AMRO projects by country. That would help clarify the exact investment by country and by Zone.

Dr. AGUILAR HERRERA (Guatemala) thought that even though the reduction in question might be offset by means of AMRO projects, the Zone II and Zone III projects should continue to be financed with funds from the regular budget.

Dr. HORWITZ (Director, PASB) said t'iat further on in Document CE56/5 the same figures were likewise shown for Zone II, by country and by project, and that the regular budget of WHO had not been changed. For example, there was no change in respect of Cuba. On the other hand, in the case of the Dominican Republic, there was a.reduction from $117,064 to $104,620 because the Aedes aegypti eradication program was not shown. Similarly, the funds allocated for water supplies were increased by $8,577, and those for public health services by $6,299. The reduction of $20,733 for Haiti was attributable to the fact that the nutrition program had been carried on by means of a grant. All those programs were the outcome of consultations with the Governments concerned, and it was conceivable that since July the situation in respect of funds had changed in certain countries. Page 47 56th Meeting Third session

Dr. AGUILAR HERRERA (Guatemala) thanked Dr. Horwitz for his explanation and expressed satisfaction with the new projects undertaken and the increases in the funds budgeted.

Dr. BLOOD (United States of America) asked why, since the dissemination of information was such a fundamental part of the Bureau's activity, there should be such a heavy commitment ($332,000) for editorial services in the PAHO regular budget and only $26,000 in the WHO regular budget. He wondered whether that was by design or by accident, and how that related to the WHO publication program in general.

Dr. PORTNER (Chief of Administration, PASB) said that WHO had had a long history of publication activities and followed a pattern directed at all Regions of the world. Though the Bureau utilized the products of that activity, a regional publications program was also needed; accordingly, the PAHO Publications Program was primarily designed to meet the particular needs of the Hemisphere. The traditional balance between the expenditures of the two bodies evident in common services and other activities was not maintained in the realm of publications. That was an outgrowth of the way practice had evolved over the years, so that the Publications Program in the Americas was almost solely a PAHO regular fund activity.

Dr. AGUILAR HERRERA (Guatemala) asked what was the situation in regard to project Barbados-4801 (Hospital Administration) and why the previous allocation based on PAHO regular budget funds of $6,800 had been withdrawn, and why only $11,450 from the United Nations Development Program (UNDP) was retained.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) explained that the project in question belonged to the so-called "OPEX" projects for which PASB acted as executive agency. By agreement with the Government of Barbados, a change had been made; henceforward the Organization would merely furnish advice to the director nominated by that Government, so that it would no longer be necessary to allocate funds for the permanent officer previously attached to the project.

Dr. ACOSTA-BORRERO (Colombia), referring to the problem of Aedes aegypti eradication in Zone II, which he understood was the problem area, asked whether in drawing up the programs account had been taken of the recorrmendations made by the meeting of the Study Group held recently in Washington, and what possibilities there were from the financial point of view of putting them into practice, if they had not already been implemented. He was under the impression that the Study Group had stressed the need for increasing funds for Aedes aegypti control.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that the recommendations of the Study Group, based on a study of the requirements for the Aedes aegypti eradication program, had already been submitted to the members of the Committee, but that they could not be taken into account in the document under consideration since they had been made only a short time before the present meeting. He pointed out that the reduction in funds for Zone II was small, except in the case of the Dominican Republic; the other programs were maintained at approximately the same level. The main change was that for supplies and equipment, which were provided under the AMRO-2300 project. Page 48 Third session 56th Meeting

Dr. ACOSTA-BORRERO (Colombia) said that the reason why he had requested information was that no special funds were allocated for the eradication of the vector in the French Antilles and Guiana a:nd that there was a reduction of funds in the project for Venezuela. He reiterated his concern and said that the financial recommendations of the Study Group on the Eradication of Aedes aegypti in the Americas should be put into practice.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that the program for the French Antilles and Guiana had been financed with UNDP funds, and as was shown in the document under consideration, an item of $14,450 had been allocated. With regard to the Venezuela project, in view of the stage of development it had reached, only one sanitary inspector had been assigned to it, but the Organization would be glad to place one or two more inspectors at the service of Venezuela if it required them.

Dr. ORELLANA (Venezuela) pointed out that over the past three years there had been a constant increase in the funds earmarked for the Aedes aegypti eradication program, as could be seen from the proposed budget figures: $304,878 in 1966; $344,509 in 1967; and $384,717 in 1968. Thus, even though there had been reductions in certain specific projects under the various countries, activity in general under the program was on the increase. It seemed highly probable that, before the 1968 budget was implemented, measures could be taker to put into practice the recommendations of the Study Group on Aedes aegypti eradication.

Dr. PORTNER (Chief of Administration, PASB) referred to AMRO intercountry project 2301 in Zone I and said that the proposed expenditure of $65,000 represented an increase of $10,000 from 1966 to 1968. The total funding for the activity should be considered.

Dr. WEDDERBURN (Jamaica) said that, although it had been agreed that for two years PAHO should meet the cost of a senior consultant post for the provision of advanced nursing education at the University of the West Indies, the amount was to be found now under the WHO regular fund heading. He hoped the Organiza- tion would continue to finance the project, which had been begun in 1966 and was to continue in 1967-1968 on an experimental basis. Those territories which ordinarily contributed to the University should finance the program, but they often found difficulty in providing funds for such purposes. The project should not be allowed to die, and if financial assistance could be found for another two years, it might be possible to work out an arrangement by which continued support could be provided from the territories concerned.

Dr. PORTNER (Chief of Administration, PASB) said that the matter would undoubtedly be considered by the Director in preparing the provisional budget for 1969.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said that the provisional budget prepared by the Bureau for 1969 included the item referred to by the Representative of Jamaica, and in fact funds were made available for fellowships; thus account had been taken of the program in future plans.

Dr. BLOOD (United States of America) asked for further information on the provision for a virus laboratory for the French Antilles and Guiana and on the sum of $3,400 provided for environmental sanitation in Jamaica. Page 49 56th Meeting Third session

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that the Govern- ment of the French Antilles and Guiana was greatly interested in setting up a virology section in the Pasteur Institute Laboratory, and to that end had asked the Organization for the services of a consultant and for fellowships and a small amount of equipment.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that the Government of Jamaica had shown considerable interest in updating its staff with regard to problems of background radiation. It had also asked the Organization for assistance in training staff in both X-ray safety precautions and in the broader public health aspects of background radiation, similar to what was being given to a number of other countries in the Zone. In time, also, similar assistance would be needed in connection with precautionary and corrective measures in the handling of isotopes.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said that there were two clearly defined projects: the first had to do with the protection of hospital personnel against radiation produced by X-rays, and by radium where it was used; the other was for the measurement of background radiation in the air, and it was hoped it would also include the measurement of radiation in milk. The nine cities in Central and South America where background radiation was being measured included six where radiation in milk was also measured. In view of Jamaica's interest in the project, the amount indicated in the document under consideration had been earmarked for the training of two Jamaican officials, plus $1,000 for equipment.

Dr. HORWITZ (Director, PASB) referred to the section of the proposed program and budget estimates concerning radiation and isotopes and describing the activities so far carried out by the Organization as proposed for 1968. It stated that "By 1961, approximately 160 million X-ray exposures were being performed annually for medical diagnostic purposes." That justified Jamaica's interest in the projects. He drew the Committee's attention to the fact that both in medicine and in veterinary medicine X-rays were taken without proper precautions safeguarding the staff concerned and the human beings exposed to the X-rays.

During his recent visit to Canada he had paid a visit, along with the Director-General of WHO, to the Radiation Protection Division of the Department of Health and Welfare, and the Chief of the Division, whom he had asked what subject should have priority in a developing country, had answered without hesitation that priority should be given to safeguards against X-rays in view of the frequency with which that form of radiation was used. Dr. Horwitz pointed out that the Organization had in Washington the services not only of a physician, but also of a radiation physicist, who had been in contact with Govern- ments, including the Jamaican Government, with a view to organizing a radiation protection unit in health ministries and providing advisory services, at least in the larger hospitals, in regard to the application of simple measures to protect personnel and patients against X-rays.

Dr. AGUILAR HERRERA (Guatemala) asked why the Surinam-3101 (Fellowships) project had been suppressed. It seemed to him that the project in question was the chief means of training personnel. Page 50 Third session 56th Meeting

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) explained that project Surinam-6200 (Medical Education) provided for consultant services and fellowships.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said it was true that the fellowships under project Surinam-3101 had been eliminated, so as to include them in project Surinam-3100; and while in the latter the actual increase in funds was only from $9,600 to $11,000, three short-term and one academic fellowship had been added. Thus there were two fellowships more than before, since it had been found that short-term fellowships were more effective.

Dr. PORTNER (Chief of Administration, PASB) pointed out that the total of all funds for Surinam for 1968 was $185,740, or $775 more than the figure shown in Official Document 67.

Dr. AGUILAR HERRERA (Guatemala) said he would like to know how it was proposed to carry out the Venezuela-3103 project (Medical and Dental Manpower Studies).

Dr. ORELLANA (Venezuela) said that essentially the project was intended for dentistry, but it was hoped to extend it to the field of medicine. With advice from PASB, steps had been taken to interest the Government in a comprehensive study of dentistry with a view to similarly comprehensive planning of oral health campaigns. After the plan had been worked out by the consultants, an investigation had been made into the resources available and a sample had been produced, with the collaboration of the Bureau. The project had been presented to the Government, and an assurance liad been given that funds would be allocated to it. Two high-level officials had been designated to take charge of the scheme, and since then the temporary assistance of consultants had been made available by the Organization. Still more important, there had been collaboration from the three Schools of Dentistry and the National College of Dentists. The program would be completed in a year and a half, and was hoped it would then be possible to assess the capacity of the dental services available in the country and the main requirements to be met to bring about the over-all development of that aspect of public health in Venezuela.

He thought that in the future it might likewise be possible to interest the Government in carrying out a similar comprehensive study of human resources in health and medical education. In that connection, the International Confer- ence on Health Manpower and Medical Education to be held in Venezuela in June 1967 should give a fillip to the study in cluestion and serve as a stimulus to the other countries.

The CHAIRMAN thought that the Secret;ariat might perhaps wish to give the members of the Committee further particulars concerning the Conference on Human Resources referred to by the Representative of Venezuela.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that because of the Bureau's interest in promoting studies on human resources throughout the Americas, three years previously a study group had been set up and had established general guidelines for such studies in connection with the teaching of medicine. The Government of Colombia had shown interest in giving the method a Page 51 56th Meeting Third session trial, and with the collaboration of the Milbank Memorial Fund and the Bureau it had drawn up a research program through the Ministry of Public Health and the Colombian Association of Medical Schools. The research had taken two years and comprised several phases.

He pointed out that a document was being prepared embodying the findings of that research project, which would serve as background material for the In- ternational Conference on Health Manpower and Medical Education. The Govern- ments of the Organization would be invited to participate in the Conference and to send two representatives, one a specialist in public health and the other a medical education expert. It was hoped that the conference would induce other Latin American countries to undertake similar studies.

Dr. AGUILAR HERERA (Guatemala) found the experimental work done in Venezuela and Colombia most interesting and was convinced that the Conference in question would be of great value to all the countries of the Americas, helping them with their own studies and with the implementation of national health plans.

Dr. BLOOD (United States of America) then sought a clarification of the activities proposed under the Venezuela-4300 project (Mental Health). He said that Official Document 67 contained first a reference to the need for research into the problem, then described it as a planning activity, and finally referred to the provision of a nurse, fellowships, and consultant months. He found it difficult to relate the three aspects.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) said that project Venezuela-4300 had been under way for the last four years and consisted of several phases: first came the planning of services, with the collaboration of an adviser from the Bureau, who had worked out a plan of action for assistance and prevention. In the second phase, following the visit by the consultant, the mental health authorities of the country had thought it advisable to give greater emphasis to assistance in psychiatric nursing in view of the shortage not only of nurses in that sphere but also of rehabilitation personnel and social workers. The Bureau had assigned a psychiatric nurse on a permanent basis to collaborate with national personnel in the same field in organizing a course in the subject. Subsequently, a second nurse had organized a further course with the participation not only of the authorities of the Ministry of Health and Social Welfare but also of the military hospital, which had the only psychiatric ward in the country and could serve as a model for future activities. The Bureau had also provided fellowships for training social psychiatry specialists and a social worker in the same field.

Dr. BLOOD (United States of America) asked whether the aim was to have a pilot or model project that could demonstrate what might be done on a broader scale.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) said that the project had two purposes: to advise the Ministry of Health in regard to the training of personnel in psychiatric nursing, and to organize a pilot ward to demonstrate modern psychiatric treatment techniques; and the ward was already in operation. The Venezuelan hospitals were rather of the custodial type, and in Page 52 Third session 56th Meeting view of the difficulties in introducing new techniques into an over-all national plan, it had been decided to make a start with one small unit in a hospital ward.

Dr. BLOOD (United States of America) asked for a progress report on Venezuela-6400 (Sanitary Engineering Education), which he thought was interesting not only because of its subject matter but its scope. He wondered whether it was on schedule or had encountered any special difficulties, and what its potential was for international application.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) replied that the project, which was conducted under the United Nations Development Program, provided an ideal example of the study of the more sophisticated problems now being encountered in Latin America as a result of increasing industrialization and economic expansion.

It was aimed at strengthening training, research, and education at the four universities in Venezuela, which had collaborated in developing sanitary engineering work as part of the civil engineering curriculum. Laboratory facilities had been expanded as a basis for research, which had gone beyond water supply to pollution and the complex synthetic organics that were bound to be of importance in the forthcoming expansion of the country's petro-chemical industry.

The influence of the project, for which WHO was the executive agency, went far beyond the borders of Venezuela. It provided advanced education and study opportunities for other nationals, and the results of the research undertaken would be a major benefit to other countries in the next 10 years. On his most recent visit he had met colleagues from Colombia where, in Bogotá, the major plastics industry that was emerging presented a threat of synthetic organic pollution. There was close agreement between the two countries on the assistance to be given each other, and the pattern of activity each would follow.

There were other research centers in Brazil and in Chile. Similar developments were under way in Mexico and Peru. Work was beginning in Trinidad and Argentina, and all those countries would provide a network of research centers which would collaborate in teaching, training, and research matters.

The Venezuelan project was very much on schedule, a result not always attained, and had been the recipient of favorable comment by the officials of the United Nations Development Program in New York.

Dr. ORELLANA (Venezuela) described the sanitary engineering education project in Venezuela as an example of a national program with international assistance; he thought it would become a permanent program in the country and probably provide services for other countries. It had been started with the assistance of PAHO,and four universities, one of them private, had taken part. As Dr. Hollis had said, the program had proceeded smoothly and was on schedule.

Dr. HORWITZ (Director, PASB) said that Dr. Orellana had partly answered the question asked by Dr. Blood at the second plenary sesion concerning the relationship between the document under discussion and the interpretation he had given to the decisions concerning health matters adopted by the Chiefs of State at Punta del Este. It seemed to him that unless countries sought ways and means of enabling Page 53 56th Meeting Third session graduate students to bring their knowledge and their technical skills up to date so as to keep abreast of the over-all development of the Region, the ideas expressed at Punta del Este could not be put into practice.

Dr. Horwitz cited environmental sanitation, his favorite discipline, which went beyond the limits of engineering proper, since it involved the social and biological components of the environment. There had not so far been a single institution in Latin America for the further training of graduates in sanitary engineering, despite the fact that the number of graduates had increased considerably, as could be seen from the list of members of the Inter-American As- sociation of Sanitary Engineering. Still more serious was the lack of research, and such indicators as were available were drawn from studies carried out in technologically advanced countries.

He therefore thought that Dr. Orellana had put his finger on the nature of the program in Venezuela in referring to it as an example of a national program with international assistance, and the Organization was naturally only too glad to participate in undertakings which were successful. The Venezuelan program implied a "center for advanced study" such as should exist and become known in the Americas to provide professional workers in the "common market" of Latin America with facilities for training in surroundings in keeping with the fea- tures of their own culture, it being understood that when such professional workers required still more advanced training they should move to centers of advanced study in the technologically more developed countries.

The session was suspended at 10:35 a.m. and resumed at 11:00 a.m.

Dr. AGUILAR HERRERA (Guatemala) asked for further information concerning project Venezuela-6200 (Medical Education) and the projects undertaken in other countries with the cooperation of the Bureau.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) explained that in Venezuela medical education was entering upon a very progressive stage, and the medical schools, which were closely connected with the Ministry of Health and Social Welfare, were giving a new look to the problem of training medical personnel. The Venezuelan Association of Medical Schools, previously under the direction of Dr. Orellana and at present directed by Dr. Carlos Luis Gonzaález, had begun a series of studies with a view to better planning of the functions of the Association in close conjunction with the Ministry. The Bureau had designated a Zone consultant, who was working closely with the Association, and thought was being given to the possibility of more effective collaboration between the Bureau and the Venezuelan Government. He added that there was considerable collaboration in the country between national and international action in medical education; and he referred to the various national seminars on the subject which had been held in the country.

Dr. ORELLANA (Venezuela), supplementing the information given by Dr. Villa- rreal, said that collaboration between the Venezuelan Ministry of Health and the universities, which were vitally important in the training of medical personnel, was being steadily developed. The Ministry had seconded part of its personnel to the medical schools so as to give extra impetus to the development of the departments of preventive and social medicine. Similar collaboration was to be found in Page 54 Third session 56th Meeting the School of Public Health. The project outlined in the budget document covered some parts of the program, and he hoped that as time went on it would be gradually expanded so as to include other activities such as programs of continuing medical education, laboratories for human relations in the teaching of medicine, and others.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that the programs of assistance to Governments for medical education involved collaboration in various fields, including the planning of medical education through studies of the human resources and the needs of the country. Efforts were being made to establish close relationships between the ministries of health and the medical schools, and that was succeeding in a number of countries; there was also participation by associations of medical schools, the object being to ensure that planning was national in scope. Another important field was the training of teaching personnel to teach not only preventive medicine, to which PAHO had always attached great importance, but also basic and preclinical sciences, and indeed clinical sciences, since the teaching of the last-named was intimately connected with the organization of health and hospital services. He also referred to the human relations laboratories; they were directed by an educator, and they had regularly been provided with advisory services by the Organization. The proposal was that the laboratories should continue to be a normal activity of the schools, their aim being the revision and improvement of teaching methods. Finally, he referred to the journal Educación Médica y Salud, published by the Organization, which was a vehicle for disseminating information on experiences in the medical education field. In all those instances, efforts were being made to obtain the cooperation of national associations of schools of medicine and the Pan American Federation of Associations of Medical Schools.

Dr. BLOOD (United States of America) said that although project Venezuela- 6100 (School of Public Health) was not financed from the PAHO regular budget, he would like to dwell upon it for a moment. Two consultants, a health educator and a nutrition educator, had been working in the project since 1966. He would like to know how the project was progressing, and what the future held for it.

Dr. DIAZ-COLLER (Chief, Professional Education Branch, PASB) considered that the School of Public Health project of the Central University of Venezuela could serve as a model for other Latin American countries, regardless of any assistance it received from the Organization. He emphasized the relationship between the School and the Ministry of HeaLth, which made it possible to establish an order of priority in the training of graduates based on the needs and the wishes of the Ministry itself. The arrangement was giving highly satisfactory results.

Dr. BLOOD (United States of America) asked whether there were any plans for changing the discipline represented by the consultants and why a health educator and nutritionist had been chosen.

Dr. DIAZ-COLLER (Chief, Professional Education Branch, PASB), replying to Dr. Blood's question, said that assistance had been requested for the two disciplines pending the training of national personnel to replace them, which as a rule meant after two or three years. Page 55 56th Meeting Third session

Dr. ORELLANA (Venezuela) explained that the aim was to encourage the gradual development of the School of Public Health. A start had been made with the social sciences, and within a short time there would probably be no further need for the services of the consultant, since personnel had already completed training abroad. The second discipline was nutrition, and others would follow as the need arose.

Dr. BLOOD (United States of America) asked how many public health schools there were in the Americas, whether there was a system of accreditation in existence or under development, when the School in Venezuela would reach the point when that kind of assistance would no longer be needed, and what the criteria for that would be.

Dr. DIAZ-COLLER (Chief, Professional Education Branch, PASB) said that there were 15 schools in Canada and the United States of America, including Hawaii, and 11 in Latin America, including the new school at Havana. With regard to accreditation of schools of public health, in the United States of America it was a matter for the American Public Health Association, ard even two Canadian schools (those of Montreal and Toronto) had accepted the Associations' accreditation. In Latin America a more difficult problem arose, since the schools were university departments and in many cases autonomous, and they might not be willing to accept accreditation by an outside institution; the schools attached to ministries of health might be in the same position. The World Health Organiza- tion was taking up the matter of mutual accreditation of schools with a view to evolving a system which could be applied the whole world over.

Dr. BLOOD (United States of America) asked for further information on AMRO-3301 (Laboratory Services, Caribbean), a project which he believed significant for the entire area. He had in mind especially the epidemic disease situation and its bearing, if any, on the project.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that, because of the shortage of laboratory staff in all sectors, Governments had asked for cooperation from the Bureau, which had signed an agreement with the Pathology Department of the School of Medicine of the University of the West Indies for the establishment of a training center for laboratory technicians. At the same time, PASB had provided the services of a consultant to study the situation not only of public health laboratories but also of hospital laboratories, and it had made a grant for the publication of a manual of laboratory techniques.

Dr. BLOOD (United States of America) asked whether the purpose of the project was to provide laboratory support for health operations rather than laboratory services, in the sense of research.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) replied that it was a laboratory for diagnostic purposes, not for research.

Dr. BLOOD (United States of America) said it would be interesting and instructive to learn what personnel the Organization currently had in Cuba, the Dominican Republic, and Haiti, particularly as regards Country Representatives, or persons acting in that capacity, whatever they might be called, as well as Page 56 Third session 56th Meeting the general structure of the organization of the Aedes aegypti program in the three countries.

Dr. PORTNER (Chief of Administration, PASB) replied that, basically, the pattern of organization was to have a physician-public health administrator serving in the capacity of Country Representative under a Zone Chief. That was the practice in the three countries mentioned, as it was elsewhere in the Hemisphere.

Dr. BLOOD (United States of America) asked whether the Country Represent- atives were promoting the development of Aedes aegypti eradication in preparation for the time when the particular country, if it did not already have an active program, would undertake one.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that only Cuba had PASB personnel assigned especially to Aedes aegypti eradication, namely a consultant and four sanitary inspectors. Mexico was already free of the mosquito, and Haiti and the Dominican Republic had had to interrupt their programs, mainly because Aedes aegypti had developed resistance to chlorinated insecticides but also because of the difficult economic situation in those countries. Consequently, further research would have to be made. The Government of Cuba had expressed its firm intention to increase its contribution and would ask PAHO for a further contribution by way of supplies and equipment.

Dr. BLOOD (United States of America) said he had been concerned that such a program had not been mounted in some of the countries, nor was there any indication of what the future prospects were. However, Dr. Bica had answered his question by indicating that the new study to be undertaken would perhaps lead the way.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that in his opinion there was no technical obstacle to the eradication of Aedes aegypti, since effective insecticides were available. The problems were of another type--administrative and financial.

Dr. AGUILAR HERRERA (Guatemala) asked whether the Training Center in Im- munology referred to under project Mexico-3301 was strictly national in character or whether it could be used by other countries.

Dr. MARTINS DA SILVA (Chief, Office of Research Coordination, PASB) said that in 1965 a survey by two consultants, of the potential for immunological research in Latin America had recommended the establishment of two international centers in the Region, one at the Department of Microbiology of the Paulista School of Medicine in Sao Paulo and the ot1her in Mexico City. The development had been part of a WHO world-wide effort to strengthen research and training in immunology. The first such center had been set up two or three years before in Ibadan, Nigeria; the first in the Western Hemisphere, that in Sao Paulo, was in its second year.

The proposal for the center in Mexico had not yet been implemented but it was expected that, subsequent to the visit in June of a consultant, who was the staff member of WHO responsible for its imnunological unit, the necessary Page 57 56th Meeting Third session agreements would be completed. Specifically, it was an international activity in the sense that trainees would also come from other countries as they did to the Sao Paulo Center. The funds requested represented PAHO's contribution to the joint effort with WHO, and provided, essentially, for visits of professors, fellowships for students, and complementary equipment.

Dr. ACOSTA-BORRERO (Colombia), referring to project Mexico-4600 (Indus- trial Hygiene) observed that the amount of funds for the project was diminishing. He thought that, in view of its importance, it should be given definite priority at the present stage of development of the Latin American countries, and hence a greater budgetary allocation. He hoped that as time went on more attention would be paid to that subject, since it was of vital importance for the labor force.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) welcomed the opportunity to comment on what he regarded as a productive and important segment of the population whose problems would become more complex with the growing industrialization of Latin America. The project in Mexico had had an interesting history. The Government of that country had some years earlier become deeply concerned about the industrial health of the labor force and had, on its own initiative, set up the basic elements for an industrial hygiene program. It had called on the Organization for assistance and the regional consultant in industrial hygiene had worked with it to organize a broad national program.

Support had also been provided through fellowships and training. The project had moved forward in an orderly and commendable fashion. The current reduction involved the elimination of a consultant. Reductions of projects at the working level were always unwelcome, but the demands on the Organization for all types of services, including those related to industrial hygiene, were very great, so that as competent national personnel were trained, the Organization's contribution was being reduced. The Mexican authorities had agreed that the proposed level of assistance was reasonable.

The regional consultant was beginning to consider the specific problems of specific industries. The structure had been set and a good staff provided. The machinery for tying in social security problems and compensation payments was also in good order. The assistance proposed in the form of short-term consultants, both from the Region and from outside, would meet the needs for 1968.

Dr. HORWITZ (Director, PASB) said that Official Document 67 (p. 250), under project 4600 (Occupational Health), showed clearly that the reduction was due to the fact that in 1967 the contribution of $400,000 from the United Nations Development Program for the establishment of the Institute of Occupa- tional Health and Air Pollution Research in Chile would come to an end. But that did not mean that the program itself would come to an end, since fortunately the Organization had the services of a man who was undoubtedly the foremost expert in the world in occupational medicine, Mr. John Bloomfield, who was living in Lima but continued to give advice to the Institute from time to time. He ponted out that under project AMRO-4600 (Industrial Hygiene) there was an increase from $21,595 in 1966 to $59,326 in 1968 --more than twice the amount; that should provide for collaboration in the form of short-term consultant services, fellowships, and the organization of seminars whenever any Government so requested. Page 58 Third session 56th Meeting

He was well aware of the growing interest of Governments not so much in industrial hygiene as in air pollution, which was of course a very serious outcome of industrialization. The Organization was interested in all aspects of adult medical problems, and as concrete proposals were received they would be put before the Committee with a view to an increase in the budget.

Dr. ACOSTA-BORRERO (Colombia) asked for clarification of the difference between the figures for project 4600 as given on page 12 of Official Document 67, where they showed a reduction, and those cn page 250 of the same document, where they showed an increase.

Dr. HORWITZ (Director, PASB) explained that on pages 12 and 13 what was shown was the functional budget, and the total funds for occupational health were as indicated on page 250 under that heading. They were of course expressed in terms of the total funds allocated by the Organization, i.e., by WHO and PAHO for the years 1966, 1967, and 1968; and there was an obvious reduction because the allocation was reduced from $163,306 to $85,125. As he had already pointed out, the reduction shown on page 250 was due to the fact that the contribution from the United Nations Development Program had come to an end, but in view of the increase in demand, the general funds earmarked for industrial hygiene were increased from $21,595 to $59,326.

Dr. ORELJLANA (Venezuela), referring to project Mexico-3500 (Biostatistics and Social Security), expressed his satisfaction at the collaboration of PAHO with the social security institutions; but he observed that the descriptions of project activities on page 61 of Official Document 67 were hardly in keeping with the small figure of $6,400 allocated.

Dr. PUFFER (Chief, Health Statistics Branch, PASB) said that the request of the Mexican Government for statistical assistance in social security matters had been the first received. It was impossible to say what rate of progress could be expected. The provision of consultant services in order to initiate the work was under discussion, but so far the project was a very modest one.

Dr. ORELLANA (Venezuela) said he would like an explanation other than one based on statistical arguments.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) thought that the project should be examined in conjunction with another one--project Mexico- 4801 (Medical Services in Rural Areas). The Mexican Social Security Institute, in accordance with a fairly recent decision, intended to extend social security medical services to the rural areas, whereas so far they had been confined to the urban zones of the country. That naturally involved a series of preliminary statistical studies prior to the planning of the services, and hence help had been requested in two directions--in respect of hospital and medical care service statistics, and also of medical care service administration.

The Institute in question was proposing to use about 1,000 rural health centers which had been set up by the Ministry of Health and Welfare but were not functioning at full capacity, partly for lack of personnel and partly for want of funds. The preliminary studies were fairly complex, and so far no advisory services had been provided for the organization of the rural services since the Mexican Social Security Institute was not yet ready to start the program. Page 59 56th Meeting Third session

Dr. HORWITZ (Director, PASB) added that the descriptions of the projects corresponded to what the Governments were proposing to do. The Government of President Díaz Ordaz had set up under the chairmanship of the Minister of Health and Welfare, a joint commission in which all the social security institutions participated. The commission was actively at work and was setting up a series of subcommittees to deal with specific matters such as coordination, administration of services, statistics, standardization of methods, and others. In his opinion, the work of the commission was in line with the tenor of the Report -/ on the Technical Discussions of the XVII Pan American Sanitary Conference. During his recent visit to Mexico he had been impressed by the regularity and seriousness of the work of both the commission and its subcommittees. In addition, a permanent relationship had been established between the Ministry of Health and the National University, and a senior faculty member was to take part in the work of the commission's subcommittee on education, which coordinated all resources available throughout the country for sick care. He thought the question raised by Dr. Orellana should be considered within the new framework of a large country of the size of Mexico, with the enormous economic power it pos- sessed in the social security institutions, and naturally in the light of the important role given by the President of the Republic to health and to the Ministry of Health and Welfare.

Dr. BLOOD (United States of America) said that, in view of the considerable operational problems encountered in malaria eradication in Mexico, such as insecticide resistance and the like, it would be interesting to receive a report on developments since the original report was written, as well as an estimate of the time required to complete eradication.

Dr. da SILVA (Chief, Malaria Eradication Branch, PASB) said that the Mexican program was going through a financial crisis. A plan had been prepared with international help to tackle the problem of the areas where the transmission of malaria was persisting because of biological factors, and further expenditure was needed. But no local funds had been forthcoming for extending the program, although recently the Director had been informed by the Minister of Health and Welfare of Mexico that the Government was seriously considering allocating the necessary funds in the 1968 budget.

Dr. BLOOD (United States of America) asked whether the delay had been in the regular operational program or in the studies designed to solve some of the research problems, under the grant, or had both been affected.

Dr. da SILVA (Chief, Malaria Eradication Branch, PASB) said that the Bureau was collaborating financially and otherwise in the study being made of methods of approach to Mexico's problems. The Organization had a project to study the effectiveness of BHC in three-monthly cycles in a zone where DDT had failed, although not entirely so, since the disease had been arrested. A study was also being carried out in another area with a view to cutting down costs. The systematic application of DDT had been stopped, and a monthly inspection was made, sector by sector, only those parts of walls being sprayed where the insecticide had not accumulated during previous operations. At the same time

3 Published in Spanish in Coordinación de los servicios médicos. Scientific Publication PAHO 154, 1967. Page 60 Third session 56th Meeting an active search was being made to detect cases of malaria, which were then investigated, and if necessary radical cure treatment was applied throughout the area in question. The final report received showed that during the first year of the scheme a million pesos had been saved on DDT.

Dr. HORWITZ (Director, PASB) said that the reduction had not affected the experimental studies referred to by Dr. da Silva, but the regular operations of the eradication program, since as Dr. da Silva had explained very clearly, there had been a considerable reduction in the Government's contribution.

Dr. AGUILAR HERRERA (Guatemala) asked whether the withdrawal of the funds allocated to certain specific Zone II projects such as AMRO-3102 (Planning); AMRO-3602 (Administrative Methods and Practices in Public Health); and AMRO-6202 (Medical Education), meant that those projects were cancelled or whether they would continue in some other form.

Dr. McKENZIE-POILOCK (Chief, Office of National Health Planning, PASB) said that planning activities had not decreased as a result of the reduction in expenditure, which involved short-term consultants. It was the policy for Coun- try Representatives to take the planning course, so that even though there might not be a planning consultant in the country the Representative did have some knowledge of health planning. Planning was basically a national activity and the Organization's contribution had been the infusion of a certain methodology. Accordingly, there had been no decrease in planning activity.

Dr. PORTNER (Chief of Administration, PASB) said that the explanation given also applied to projects on administrative methods. It was possible to realize program objectives by drawing on the time and services of officers at Headquarters or in the Zones. The funds t:hus saved could be allotted to other activities.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that the changes in the intercountry projects had been made on the basis of an interpretation of the position of the Zone Offices.

The session rose at 12:25 p.m. FOURTH PLENARY SESSION Thursday, 27 April 1967, at 2:40 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM ANiD BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN called the session to order and said that the Committee would continue its examination of Document CE56/5 containing the budgetary changes, and discuss the Zone III programs.

Dr. AGUILAR HERRERA (Guatemala) requested general information concerning the status of the water supply projects in Central America; he asked whether the variation in the figures for projects Honduras-2200 and Nicaragua-22 00 implied a reduction or a transfer of funds earmarked specifically for water supplies.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said the project covered each of the countries of Central America and Panama. The slight variation in the figures for Honduras and Nicaragua was the result of the general effort to improve water supply in small towns, villages, and rural areas. More specifically, the expenditure for short-term consultants was of the magnitude of $3,400 for each of the countries. In addition, each had received a modest loan from the Inter-American Development Bank.

In answer to Dr. Aguilar Herrera's question, he said that, in the case of Honduras, the reduction would be offset by the provision of Zone consultant services and, in the case of Nicaragua, a transfer between funds was involved.

Dr. BLOOD (United States of America) said that project British Honduras- 2200 (Water Supplies) represented a rather ambitious undertaking but he noted that no sanitary engineer adviser was provided, nor was there provision for training or fellowsbips. He would like to know whether engineering services were to be supplied from project British Honduras-3100 (Health Services).

Dr. HO0TIS (Chief, Environmental Sanitation Branch, PASB) said they were. As the Director had mentioned, the point was being reached where, because of the growing competence of nationals, Organization assistance could be reduced. Thus, an engineer assigned to project British Honduras-3100 could very often be used to render a broader service in the country on other sanitary engineering projects. Moreover, in Central America and Panama, all the countries were relatively close to one another. There was an engineer in the Zone Office in Guatemala, in addition to the Zone engineer devoting his time to water supply as a specialist. Ln many cases the funds set aside would be used to provide special consultant assistance where extra strength was needed.

- 61 - Page 62 Fourth session 56th Meeting

Dr. ORELLANA (Venezuela) asked Dr. Hollis to be good enough to supplement the information given in Official Document 67 on project British Honduras- 6400 (Sanitary Engineering Education).

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that that project was part of the program whereby consultants gave assistance to institutions training sanitary engineers and operational personnel. In some cases, the assistance was short-term, involving refresher courses for engineers and the training of sub-professional technical people, or was provided at the universities as part of the over-all training program.

Dr. BLOOD (United States of America) requested information on the status of the malaria eradication program in Zone III generally. It seemed appropriate to discuss the problem for the Isthmus as a whole rather than country by country.

Dr. da SILVA (Chief, Malaria Eradication Branch, PASB) said that following the financial crisis which had affected all the malaria programs in Central America, which was due to the fact that a considerable amount of funds had had to be used to cope with other serious problems, the Governments were negotiating loans covering the local costs of malaria campaigns. The negotiations were slow, requiring a great deal of time in some cases. The relevant plans had been drawn up in October and November 1964, in the hope that they could be put into operation rapidly; but because of the delay in obtaining the necessary funds it had been decided to revise the plans. In November 1966 the Bureau, working in conjunction with the National CommunicabLe Disease Center of the U.S. Public Health Service, had reviewed the malaria situation in each of the countries and in many areas which at the time had been in the consolidation phase, and some of them had had to be returned to the attack phase. That meant that funds requested on a three-year loan basis had subsequently had to be increased in amount, and the length of the amortization period extended. The Government of the United States of America was considering the matter favorably.

He thought that in some areas transmission of the disease would be halted by means of an intense DDT spraying campaign. A start was being made on experimental projects for mass drug treatment. One such project was being carried out in collaboration with the Gorgas Memorial Laboratory and the Government of Panama, experiments being under way in one area of the Sambú River with a mixture of primaquine and pyrimethamine in tablet form. At the outset there had been a 17 per cent malaria positivity rate in the area, and by the end of the first year the rate had been reduced to 0.8 per cent. The tablets were administered every two weeks to all the inhabitants of the areas affected, and the experiment was giving fairly satisfactory results.

The Bureau was also proposing, in conjunction with the Government of Guatemala, to experiment with an injectable drug--camolar. Tests made with the drug showed that Plasmodium falciparum was entirely susceptible to proguanil. The experiment seemed worth while, and would begin early in May 1967, when a small group of persons would be inoculated and the effects observed. It was hoped that injections every six months would be sufficient to keep the population free of malaria infection. Should the results prove favorable, the treatment would be extended to other areas of Central America. Experiments were also being made with a syrup which would make it possible for the drugs to be administered in liquid form. Page 63 56th Meeting Fourth session

Dr. BLOOD (United States of America), after thanking Dr. da Silva for his comments, asked whether any points of significance for the Committee had emerged from the recent WHO/UNICEF/AID Malaria Coordinating Meeting in Geneva. He wondered whether UNICEF, for instance, would be continuing its assistance, or if any variation had been noted from the pattern of collaboration that had existed over the years between the international agencies either in Zone III or the Americas as a whole.

Dr. da SILVA (Chief, Malaria Eradication Branch, PASB) said that two years previously the Executive Board of UNICEF had instructed its Executive Di- rector that that Organization could only continue to give assistance to malaria eradication programs which were adequately financed. The consequence had been that UNICEF had withheld the assistance it was giving in a number of countries. Currently more insecticides and more vehicles were needed to cater for the needs of the new programs, which met the required conditions, so that the prospects for obtaining UNICEF aid were fairly good.

Dr. HORWITZ (Director, PASB), supplementing the information given by Dr. da Silva, said that recently in Guatemala he had attended the meeting of UNICEF Field Office Chiefs, and had had the opportunity to discuss with the Regional Director of UNICEF and one of its Deputy Executive Directors, Mrs. Sinclair, his views on the nature of the programs being carried out jointly by the Governments, the Bureau, and UNICEF. After he had emphasized the importance of carrying on with the malaria campaign--the position having been reached in the Americas where it was more costly to go back than to go forward-- Mrs. Sinclair had made it perfectly clear that it was UNICEF's intention to continue to contribute to the execution of the malaria programs. He thought the reference was to the entire world, although at the meeting what had been discussed was the Region of the Americas.

The CHAIRMAN, speaking in his capacity as the Representative of a country belonging to the zone in question, said he was concerned at the fact that at all meetings held by the Ministers of Public Health of Central America and Panama misgivings were expressed not only about the problems of financing the programs but about the functioning of the machinery for making proper use of resources and for improving the efficiency of the administrative system governing campaigns for the eradication of diseases. A joint decision should be taken by the Govern- ments to see that due importance was given to such administrative procedures, eliminating as far as possible the political factors which interfered basically with the efficiency of the programs. He thought that should be the keynote for the discussion of such problems at the forthcoming Meeting of Ministers of Public Health to be held in August 1967, possibly in El Salvador.

He thought it might be advisable for the Bureau to assist the Governments in working out a system consisting of basic administrative regulations acceptable to them all, in arranging loans from the external market to assist the national efforts, and in obtaining international cooperation for the execution of eradication programs. As long ago as 1961, the Latin American Governments had undertaken to carry out administrative reforms in that direction, and he thought it would be useful to draft, in conjunction specifically with the malaria program, an administrative document differentiating the various methods of using those funds from those of other health programs. A considerable effort was called for if in the next three years the attack phase of the campaign was to be Page 64 Fourth session 56th Meeting brought to an end once and for all in the Americas. He again requested the Director of the Bureau to help in preparing a document for submission to the Meeting of the Higher Public Health Council of Central America and Panama, establishing regulations for the administrative systematization of specific programs such as malaria eradication. The document would constitute an undertaking by any country applying for a loan from foreign or international banking institutions.

Dr. HORWITZ (Director, PASB) said he would be happy to comply with Dr. Calvo's request. He agreed that the administrative problems were no less important than the biological and financial problems, and he recalled that some years previously, at the request l/ of the Higher Public Health Council of Central America and Panama, regulations had been drafted for the establishment of what was to be called the "Malaria Eradication Service of the Central American Isthmus." In the final instance it was to consist of a single administration, literally a co-administration of the Governments and the Organiza- tion; that had been the express wish of the Higher Council.

In fact, it had been proposed that in the clauses concerning personnel it should be agreed that certain appointments should be made jointly; that there should be common rules for the collection and auditing of funds; and that certain purchases should be made in common, since obviously it was more economical to purchase DDT or drugs for the six or seven programs than for a single one. Thus in the various branches of administration feasible measures for joint action were planned, and a number of administration experts within the Organiza- tion had actually produced what would have been a set of regulations on the subject. The service was to be called SEMICA.

Unfortunately, although he did not wish to cast any reflection, since his policy had always been to respect the decisions of Governments, at the subsequent meeting of the Higher Public Health Council, one of the ministers had argued that some of the regulations, in particular that concerning the appointment of officials encroached upon constitutional prerogatives, and a cleavage appeared which affected the basic principle of a true administration. Later on, in April 1965, a Conference of the Ministers of Health of Central America and Panama on malaria eradication had been held in Washington, D.C., but the question had not been discussed on that occasion.

If the item were to be brought up at the next meeting of the Higher Council, steps could be taken to include it in the agenda, and the Bureau could prepare a document enabling the Council to determine both the basic responsibilities of Governments in that field and to define the collaboration to be furnished by the Organization. There was currently one consultant on administrative methods exclusively concerned with malaria eradication in Central America, and arrangements were being made to appoint a second, as well as other Bureau technicians, so that PAHO would be in a position to collaborate with Governments as far as was required. He emphasized that the Bureau was not interested in making its collaboration mandatory for Governments, in other words the Bureau was not anxious to see joint administrations set up, even in the

_/ Resolution I. Report of the VIII Meeting of Ministers of Public Health of Central America and Panama, 1963 (issued in Spanish only). Page 65 56th Meeting Fourth session case of certain Governments such as that of Haiti which had expressly requested the Bureau to co-administer the entire program, that being its voluntary wish. But in order to ensure that malaria eradication proceeded in Central America according to plan, the Organization would be happy to cooperate in whatever form and to whatever extent the Higher Public Health Council and the individual ministers wished.

The CHAIRMAN said that the topic in question would undoubtedly be the main item for discussion at the Meeting of Ministers of Public Health of Central America and Panama in August. The fact that SEMICA had not materialized had indeed been due to the feeling on the part of some Governments that it involved interference in their internal affairs. He saw no reason why regulations as formulated in a document such as he had requested of the Bureau should not be applied by each country freely, i.e., in accordance with its own governmental system, preferably being treated as an administrative base of reference, though possibly the Organization might become part of the administration in association with the Governments.

He wondered whether Dr. Aguilar Herrera, the Representative of Guatemala, shared his concern, since it seemed to him that the problem was similar in all the countries of the area.

Dr. AGUILAR HERRERA (Guatemala) said that malaria was one of the country's most serious problems and was causing profound concern. The eradication program had been started many years ago with high hopes, but they had been frustrated by various circumstances. He thought it vital that a valiant effort be made to achieve the goal, and the countries of Central America were in a position to make such an effort. An attempt should be made to find the assistance needed to eradicate the disease.

The CHAIRMAN said that ,he would arrange for the Government of Panama to ask the Higher Public Health Council of Central America and Panama to place the question under discussion on its agenda as the principal item at its forthcoming meeting.

Dr. AGUILAR HERRERA (Guatemala) said that the other programs were also very important, and El Salvador and Guatemala were concerned with the fact that in the projects numbered 3100 (National Health Services) a reduction had been made. Admittedly it was fairly small, but it was nevertheless a reduction. Incidentally, Official Document 67 did not make it clear to what items the reduction applied. He would be glad to have some explanation on the subject.

Dr. PORTNER (Chief of Administration, PASB) said that the reduction in project El Salvador-3100 funds represented the elimination of three consultant- months. The gross total for all projects and activities in the country was $4,000 greater than that shown in Official Document 67.

The reduction in the Guatemala project was due not to the elimination of posts or activities but merely to a recosting involving a person in a particular post.

Dr. BLOOD (United States of America) said that project Guatemala-2101 (Rural Sanitation) had apparently been carried through 1966 only, and then Page 66 Fourth session 56th Meeting disappeared from the budget entirely. He asked whether the project had actually been terminated, or had it become part of some other activity. It was clearly a very important project and he doubted that it had actually been terminated.

Dr. HOILIS (Chief, Environmental Sanitation Branch, PASB) said that the activity described was being taken care of as part of project Guatemala-3100 (National Health Services), but had been left out of the budget because no specific request had been made to include it among those financed from Techni- cal Assistance funds. However, he would emphasize that the service, as such, had not been eliminated. Furthermore, the Zone Office staff in Guatemala had been strengthened, and increasing services were being provided out of that Office.

Dr. BLOOD (United States of America) noted that project Guatemala-3100 envisaged the provision of a sanitary engineer in 1968, and asked what was happening to the project in 1967.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that for the current year the service was being provided by Zone Office staff, but as soon as a suitable officer was recruited the 1968 item might be advanced and picked up a little later in the current year.

Dr. HORWITZ (Director, PASB), enlarging upon the information just given by Dr. Hollis, pointed out that the current year's budget included projects 2103 (Sanitary Engineering, Zone III) and 2203 (Water Supplies, Zone III).

He recalled that both Technical Assistance and United Nations Develop- ment Program (UNDP) funds had been cut by 4 per cent for 1968, and it might well be that the Government of Guatemala had not made its request in time, or had not put sufficient pressure on the National Council responsible for the series of projects on matters such as health which had to be financed by UNDP. That had been happening more and more over the past five years. He took the opportunity to ask the members of the Committee, as Representatives of their Governments, to bear those facts in mind. In the case of Guatemala, for some reason the Government had not included the sanitary engineer's post, which had then had to be financed for 1968, the services of the Zone engineer being used in 1967. He stressed the need for exerting adequate pressure, since demand was very great and all possible sources of funds had to be exploited. His opinion was that sanitation projects were well received by the authorities of UNDP, just as they had been previously by the Technical Assistance Board.

Dr. AGUILAR HERRERA (Guatemala) explained that the question had been considered by the Guatemalan Government, but the National Economic Planning Council, which was responsible for distributing the Technical Assistance funds allocated to the country, had felt that the public health services had been enjoying the funds for a number of years at the expense of other branches of the administration and had decided that they should be transferred to other ministries.

Dr. OFELLANA (Venezuela), referring to the difficulties encountered by public health services in taking advantage of the financing provided by UNDP, said that they were largely due to the machinery for programming and administration at the national level. As a rule there was a senior department, usually at presidential level, responsible for coordination and planning activities Page 67 56th Meeting Fourth session and handling requests for Technical Assistance from the United Nations. Unless efficient coordination was established between that department and the ministry of health, requests by the latter would probably be ignored. In Venezuela that had not been the case, although it had to be admitted that the formalities for obtaining assistance were more difficult in the case of the United Nations than WHO or PAHO.

The only task devolving upon the health services was to think out requests carefully, to formulate them lucidly as part of an over-all health plan or a plan for external assistance in the health field, and to exert pressure to ensure that the funds were not allocated to other programs.

Central coordination and planning offices tended to place emphasis on the economic aspect, but a well-thought out plan could usually count on a favorable reception.

The CHAIRMAN asked the Committee to turn to the projects for Honduras, Nicaragua, and Panama.

Dr. ORELLANA (Venezuela) pointed out that the total of $186,607 for the Honduras projects, the U.N. Development Program part represented $63,000, or one third of the entire sum. That was exceptional, and he thought that further information might be given.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said that project Honduras-3100 (National Health Services) was similar to the general health service projects found in most countries. In the case in point there was an historical explanation, since the project was one of the first to be undertaken by the Organization in that country. It involved the development of general health services at the national level, although most of the health services in the country were not covered as yet. Progress was being made with every year that passed, and it was hoped to cover the entire territory over a period of five years. The Honduras five-year plan aimed at organizing and consolidating the seven health districts into which the country had been divided, along with their health services, and various targets had been set. One was to cut hospitalization by 30 per cent by increasing outpatient services. The system was producing extraordinary results, and from the financial point of view it represented a considerable saving, since with the same funds as before, a much larger segment of the population was being cared for, without the need for an increase in the country's budgetary allocation. The project staff consisted of a physician, an engineer, and a nurse, i.e., the traditional basic team, which advised the Minister and the Director General of Public Health at the national level.

Dr. BLOOD (United States of America) said that, in connection with Nicaragua-3101 (PAHO Fellowships for Health Services), he would like information on the size of the fellowship program at the current stage of development of the international health field in the Americas, on the proportion of total resources devoted to training, which was so fundamental, the relative emphasis on short-term and long-term training, and so on. Nevertheless, it might be best to postpone a general discussion of fellowships until the Committee reached Item 17 of the agenda. Page 68 Fourth session 56th Meeting

The CHAIRMAN, speaking as Representative of Panama, said he would like to make a brief reference to the projects for his country. He asked the Direc- tor why they did not include the highly important matter of food and drug control, stressing the efforts made by Panama in that direction over the past few years. He spoke of the strides made by the Specialized Analysis Laboratory of the National University of Panama, which had been used as a regional reference laboratory; the development of human resources through the granting of fellowships; and the project for training technicians for food and drug inspection in the area. He found it strange that the allocation for those purposes had disappeared, or at any rate did not appear in the Panama figures. What was included in the interzonal projects was very little. Page 261 of Official Docu- ment 67 showed an item of $21,310 for 1963 in respect of one project, specifically for Zone III. He thought the project should be strengthened at the country level, especially as food and drug inspection was being done for the entire Central American area. At the very least, funds should be made available for a short-term consultant and perhaps two fellowships so that local personnel could continue to be trained to serve the area.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) pointed out that ever since it had begun to be used as a Central American regional laboratory for the analysis of drugs, chemical products, insecticides, etc., the Panama project had been receiving help from the Organization through the AMRO- 4703 project (Food and Drug Control, Zone III) and the regional project. He felt, however, that the stage of development reached by the laboratory might justify specific assistance in the form of a short-term consultant and fellowships for personnel training.

The CHAIRMAN asked the Director of the Bureau whether an allocation for that purpose could be included in the proposed budget for 1968, and in future budgets. Panama needed the services of a short-term consultant, and two fellowships for the training of local personnel to carry on the training projects for Central America and Panama, where considerable numbers of technical personnel from different countries in the area had received training.

Dr. HORWITZ (Director, PASB) said that if the Committee so decided, the Organization would have no objection to acceding to the request; but it would involve reallocating funds, e.g., obtaining them from project AMRO-4703 (Food and Drug Control, Zone III) or from the AMRO-4700 regional project (Food and Drug Control). In other words it would mean taking from those projects whatever sums were needed for the consultant services and the fellowships, and entering them as a special Panama project.

Dr. AGUILAR HERRERA (Guatemala) endorsed the request by the Representa- tive of Panama, stating that the program was one of great importance for the country and for the area, which had been taking advantage of the training services offered by the Panama laboratory, a highly efficient institution.

Dr. BLOOD (United States of America) said that, if he understood it correctly, it would mean that instead of being applicable to food and drug control generally funds from intercountry project AMRO-4703 would be devoted to the facilities in Panama, which should certainly enjoy a high priority in funding. He would welcome some account of the activities of that testing service; it appeared that intercountry collaboration in the area of quality control of Page 69 56th Meeting Fourth session pharmaceuticals had been very successful, and might indicate ways to deal with the problem in other countries of the Americas, if not throughout the world. He would welcome also an indication of what they might expect from it, as a six-country operation, in the future.

The CHAIRMAN invited Dr. Acha also to give information on the functioning of the Panama laboratory and the services it provided for the Central Amer- ican countries.

Dr. ACHA (Regional Adviser in Veterinary Public Health,. PASB) said that the Specialized Analysis Laboratory of Panama belonged to the National Univer- sity and acted as an official analytical laboratory for drug and food control. It had a professional staff of 24, more than 60 per cent of whom had been trained abroad in Europe, the United States of America, and Canada. Many of them had held fellowships from the Organization and other international agencies. The laboratory had received financial assistance from the Agency for Interna- tional Development (AID), of the United States of America, which had enabled it to equip quite efficiently all the basic units for drug control, basically the control of pharmaceutical products, and most foodstuffs. In 1963 the laboratory had been offered to the countries of Central America and Panama as a reference laboratory for the analysis of pharmaceutical products, alcohols, and insecticides. The offer had been accepted by the Higher Public Health Council for the region. So far it had trained two chemists from the Public Health Laboratory of Guatemala, two from El Salvador, one from Honduras, two from the Institute of Health of Nicaragua, and one from the Public Health Laboratory of Costa Rica. It had also been used for the organization of a small international course, held during the current year, on analysis using atomic elimination techniques, with the help of a commercial firm. Similarly, the Ministries of Health had been sending the laboratory their products for analysis. The administrative system of the laboratory was quite sound as far as the financing of its activities was concerned. It made a charge for analyses it performed, which helped to make the laboratory self-supporting. The fact that it was housed in the University ensured a high academic level among the personnel. Incidentally, with the help of the Organization, the analysis of foodstuffs was being developed more fully, especially in the Microbiology Section.

The CHAIRMAN pointed out that when the proposed program and budget estimates were discussed during a meeting of Bureau staff a few days earlier, he had made no mention, for reasons of tact, of the problems of Panama, since he himself had at the time been acting as Chairman of the Committee. But the time had come to refer to project Panama-6200 (Medical Education), the allocation for which had been reduced from $18,000 to $11,800; the Bureau was well aware of the great interest which Panama had in the project. Since the general trend had been upward in respect of all countries, it struck him as odd that for Panama the item should be reduced rather than increased. Panama was in direct contact with the University of Alabama, where a joint program was being conducted with a view to the strengthening of some of the university departments. A start had been made with the Department of Pathology, and it was hoped to do the same with others, in an endeavor to improve the teaching of medicine in Panama. He repeated his concern that the funds had been reduced and he would be glad to have an explanation of the matter. Page 70 Fourth session 56th Meeting

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said it was true that the item in question had been reduced by the equivalent of two consultant- months. On the other hand the Zone project (AMRO-6203) had been increased and, under that head, more funds were being allocated for advisory services to the Central American medical schools.

Dr. HORWITZ (Director, PASB) pointed out that there was an error in the document in Dr. Villarreal's hands; however, the explanation was a simple one-- it was a matter of priorities. Thus since a sum of $4,400,000 had had to be left out of the programs, a whole series of changes had been made, technicians from the same Zone or the same country being called upon to furnish advice in regard to functions for which there was no specific allotment. During his recent, brief, but hectic visit to Panama, he had been impressed by the collaboration begun between the Schools of Medicine of the University of Alabama and the Na- tional University of Panama, and, if it was to succeed, a contribution from the Bureau seemed essential. He had been informed by Dr. Calvo of the scope which the Government would like to give to that activity, and he said that if the Com- mittee thought it desirable, an adjustment in funds could be made to enable the item to be restored, in which case funds would be transferred from the AMRO projects, either the general projects or those for other Zores, as necessary.

The CHAIRMAN thanked Dr. Horwitz on behalf of the Government of Panama for his interest in supporting the request made, and asked the Committee likewise to give its support, in view of the activities indicated in the course of his remarks.

The session was susp)erded at 4:00 p.m. and resumed at 4:33 p.m.

The CHAIRMAN asked the Committee to turn to the intercountry projects for Zone III.

Dr. AGUILAR HERRERA (Guatemala) said that two of the intercountry projects for Zone III had struck him in particular, one of them being project AMRO-3211 (Senminar on Planning for Nursing). He requested Dr. Portner to emplain why the funds earmarked for the seminar had been withdrawn, since according to the description in the text, the seminar promised to be most interesting and very valuable for the planning of nursing services in the Central American countries. The other project was AMRO-6203 (Medical Education) to which the amount of $27,800 had been assigned, and then eliminated completely. In his view the question was closely connected with the request made by Dr. Calvo in his capacity as Representative of Panama, ore of the Zone III countries, to the effect that projects for medical education should not be underestimated; actually they had become more important than ever in the light of the agreements with schools of medicine in other countries to carry out more extensive projects. He thought that the suppression of funds in that case was most unfortunate, and he requested that if no compensation was possible the funds should be restored, since they were of the utmost importance for Zone III.

Dr. HORWITZ (Director, PASB), referring to project AMR0-6203, said that, as had been mentioned, the $27,800 indicated in Official Document 67 had been suppressed. It was merely a question of the best possible distribution of the budget items. The Organization tried as far as possible to reduce the funds for Page 71 56th Meeting Fourth session intercountry projects rather than those assigned to any of the Governments. Nevertheless, as a means of solving the problem in question, he referred to project AMRO-6200 (Medical Education), one of the interzone projects shown in Docu- ment CE56/5 (p. 51) with a total allotment of $47,237, and also project AMRO-6216 (Preventive Medicine Education), costing $54,887. There would have to be a pro- portional redistribution of the two projects so as to restore the funds to project AMRO-6203 for Zone III. What could not be specified was whether the sum restored would be as much as $27,800.

Dr. AGUILAR HERRERA (Guatemala) stressed the desirability of restoring the original sum, or if not, as large a sum as possible.

Dr. HORWITZ (Director, PASB) agreed that the more completely each of the functions in question could be programmed for the next forthcoming years, the easier it would be to draw up the program and budget estimates. He cited the case of diseases for which eradication conventions had been adopted at the world level. For the Bureau it was much easier to determine by common agreement with a Government what was the particular portion of the national program to be taken over by the Organization. If the needs of the medical schools in Central America and Panama were known, it would be much simpler to program not only for 1968, but also for the following years, and to ensure satisfactory redistribution. The case of collaboration between the National University of Panama and the Univer- sity of Alabama was different. If it was a decision arrived at by both universities--since it was a very long-term project--it would be highly essential to know what was expected of the Bureau, so that the proper steps could be taken. With regard to project AMRO-3211, the truth was that it had been decided not to proceed with it in spite of its admitted importance. Toward the end of 1966 the Bureau had held a meeting on all aspects of nursing at Headquarters in Washington, which had been attended by the Staff Nurse for Zone III. In the view of the Organization, and particularly in the case of Zone III, the fact that there was a regional consultant on planning, that a number of PAHO/WHO Coun- try Representatives had been trained in that subject, and especially the fact that there were many national technicians who also had received international training, suggested that the seminar was not of the utmost urgency, and in the light of other demands it had been decided to postpone it.

Dr. ORELLANA (Venezuela) referred to one of the intercountry projects of major importance to Zone III and in actual fact going beyond the scope of the Zone, namely project AMRO-4203 (Institute of Nutrition of Central America and Panama). For a proper analysis of the budget it would be well to turn to page 184 of Official Document 67, where detailed particulars were given of all the data available in regard to the budget. The total funds allocated for the In- stitute showed a downward trend from 1966 to 1968, from $1,736,000 to $1,544,000. In any dynamic, evolving organ such as that in question a reduction in the budget meant a backward step. As far as sources of revenue were concerned, it would be seen that the contribution of PAHO increased slightly from 1966 to 1968, by $11,580, from $404,448 to $416,028. At the end of that same section there was a general item entitle.d "Grant" which remained constant at $200,000. The second source of income was Government contributions, which in the past three years had maintained the same level--$375,000; and finally the third source of income consisted of contingent funds--contributions, grants and subsidies, which showed a drop of $204,042. Essentially, in reviewing the budget of an institution having Page 72 Fourth session 56th Meeting

such importance and such potentialities for the Americas, it was disquieting to observe a reduction in funds over the three years in question. There was no doubt that the act:ivities of the Center were bound to increase more and more, and that the courses offered by the Center would not be cancelled, nor would research be interrupted. In a word, the Institute was clearly going to develop steadily. Yet in the budget under consideration, the funds were being gradually reduced, especially the contingent funds under the heading of contributions and grants, where there was always some doubt whether or not they would be maintained so as to ensure a continuing program over the years.

Dr. HORWITZ (Director, PASB), replying to Dr. Orellana, referred to Official Document 75 (Financial Report of the Director and Report of the External Auditor) to indicate what had actually been spent in 1966. Pages 66 and 67, Item 38 (Institute of Nutrition of Central America and Panama) indicated that in 1966 the Institute had had $1,946,643 to spend, in other words $210,000 more than was shown in Official Document 67. The reason for that was that, as Dr. Orellana had pointed out, almost 60 per cent of current funds came from grants, many of them from the National Institutes of Health of the Public Health Service of the United States of America, and a number of foundations--Kellogg, Rockefeller, Williams Waterman, and others--and from other sources which were renewed in the course of the year; and all of them had come in their entirety by the time the document was published.

The $210,000 over and above the figures shown in the budget for 1966 suggested that the same would happen in 1968, although at that juncture nothing could be said for certain. In addition, the item of $200,000 shown on page 184 of Official Document 67 (in the first section of project AMRO-4203) as a grant under the regular budget, represented a special agreement of the XV Meeting of the Directing Council 2/ in 1964 in the face of the respectful but vehement appeal for the stabilization of the Institute's budget, which needed at least $600,000 to guarantee proper functioning. It was then agreed to make the grant of $200,000, the sum being fixed by the Council. Nevertheless, the Governments of Central America had not only contributed funds to help set up a working capital fund for the Institute; they had also increased their quota contributions to over $80,000 a year.

Such generosity should be stressed, since it was an institution which was currently rendering services to the whole world. The list of its fellows made it clear that they came from the Americas, including the United States of America, and from many other countries throughout the world. The effort made had been on a prodigious scale, and the outcome was an item amounting to $375,000. But it should be noted that the item "grants" which had been $562,000 during 1965, had risen to $957,378 in 1966. Thus in a short space of time it had been found possible not only to stabilize the financing of the Institute, which was a vital necessity, but at the same time to increase substantially the total amount of funds at its disposal. It was to be hoped that the same thing would happen in 1968 as in 1966, and that the item of $1,544,364 would again rise to $1,900,000, as in 1965. Everyone was proud of the Institute, which had been described by Dr. Rene Dubos during his recent visit as the only institution in the world which

2/ Resolution VII. Official Document PAHO)58, 62-63. Page 73 56th Meeting Fourth session was studying nutrition in an absolutely all-embracing manner, with the human being viewed in his relationship to the environment.

Dr. BLOOD (United States of America) said that the Director's comments on INCAP had answered certain questions that had been concerning him. However, though the Directing Council had voted a continuing grant of $200,000, it was his impression that it was to be used to extend the activities of INCAP into other countries of the Americas. He would like to know whether there were any special reasons why it continued to appear in the budget as a lump sum rather than as an indication of the various activities in which it was to be used. The money was doubtless used for the payment of personnel in various categories and budgeted for in advance, but he would like a clarification.

The CHAIRMAN thought it would be useful to read the resolution approved by the Directing Council in connection with the item of $200,000 contributed by the Organization to the INCAP budget.

Dr. HORWITZ (Director, PASB) agreed with Dr. Blood that in the future the grant of $200,000 should not be shown as an independent head but that it should be spread over all the items financed out of the regular budget of the Organiza- tion. That would be done in the next edition of the relevant Official Document. He went on to read the portion of Resolution VII of the XV Meeting of the Direct- ing Council relating to INCAP. The preamble stated: "Bearing in mind that it would be advisable for the Pan American Health Organization to increase its contribution to the Institute of Nutrition of Central America and Panama (INCAP) so as to ensure the normal development of the Institute, which is supplying services not only to the nations of the Americas but to those of other countries as well," and the operative part read as follows: "(Resolves) To thank the Govern- ments of Central America and of Panama for the moral and financial support that they have given to the Institute of Nutrition of Central America and Panama." "To thank the Government of Guatemala for the additional contribution it is making to INCAP by providing it with a new building, which will enable the In- stitute to have the necessary means and services at its disposal for the better fulfillment of its purposes," and finally "To authorize the Director... to increase the contribution... by $200,000 and to include this sum in the Proposed Program and Budget of PAHO for 1966."

The CHAIRMAN asked the Director whether, since the resolution was quite specific as to authorizing the Director to include the item in the budget for 1966, it was necessary for the Directing Council at its next meeting again to authorize the Director to include it in the budget for 1968.

Dr. HORWITZ (Director, PASB) replied that it was not.

Dr. PORTNER (Chief of Administration, PASB) said that, as the Director had indicated, specific authorization had indeed been given. It had subsequently been included in the budget document and was an element of the project in the document under review. Therefore, it was accounted for in the gross total funding. It had not been specifically referred to after the first occasion, and had been included in every budget since the authorization. Page 74 Fourth session 56th Meeting

Dr. BLOOD (United States of America) emphasized that the preamble of the resolution had included a reference to INCAP serving not only the countries of the Americas but to those of other countries as well. It would be interesting to assess the relative services the Center was performing for each group.

He had heard comments that the countries outside Zone III would certainly welcome assistance from INCAP in research, general orientation, and consultant services. He did not know whether the relative figures were available but that was' a matter for consideration since the contribution from the general funds of the Organization approached the figure of US$500,000. Basically, of course, the Center was supported by the six countries referred to, but the Organization's contribution was a sizable one.

Dr. HORWITZ (Director, PASB) thought that Dr. Blood's remarks were very pertinent, and asked him whether he would like the Bureau to prepare for the current meeting of the Executive Committee a sunmmary of the services rendered by INCAP to other countries not belonging to the region.

Dr. BLOOD (United States of America) said that, if time permitted, a resumé of how the grant was disposed of would be of interest. However, his thought was that it was a matter that did not demand urgent attention, but would be constantly coming up and should receive consideration from time to time at future meetings.

The CHAIRMAN drew attention to a neglected aspect of the AMRO projects for Zone III, namely the problem of mental health. At the last meeting of the Higher Public Health Council of Central America an Panama the Ministers had approved a resolution 3 concerning an assessment of the mental health situation in the Zone, on the grounds that there was great interest in the subject and that it was not represented in intercountry projects. He asked Dr. González to give some information on the point.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) said that the Bureau had been informed of the resolution adopted by the Meeting of Ministers of Public Health of Central America and Panama, and that, in representation of the PASB Mental Health Unit he had visited the various countries, submitting to all the technical units of the ministries of public health a provisional draft for research, referring specifically to the item adopted by the Meeting, the first stage of the research to be exclusively directed toward an assessment of the situation as far as needs and resources were concerned.

Obviously, since the Meeting of Ministers was entirely independent of the Bureau, all the latter could do was to contribute ideas and to hope that the initiative would come from the Governments for the establishment of an interzonal or country project. In that respect, only the Government of Honduras had made an official request, and as a result, about the middle of the current year, a PASB consultant from the University of St. Louis (Missouri) would spend three months in Honduras helping the national authorities to draw up a scheme which would serve as a basis for an epidemiological study over a longer term. In

3/ Resolution XV. Report of the XI Meeting of Ministers of Public Health of Central America and Panama, 1966 (issued in Spanish only). Page 75 56th Meeting Fourth session addition to the document already mentioned, the Bureau had made known through the Country Representatives what were the minimum conditions required before undertaking research if it was to have a reasonably sound basis and not amount merely to a catalog of persons hospitalized or of hospitals having mental patients.

So far no official reply had been received from any of the Governments except Honduras. At the same time, but independently of the investigation, a request had been received from the Government of Panama referring exclusively to advisory services in regard to the organization of mental health services at the national level. The request had been met, and steps were being taken to select a candidate having suitable academic qualifications and the practical experience needed to furnish the Government with sound advice. At the next Meeting of Ministers of Public Health of Central America and Panama all that was needed was to submit the information obtained in the light of the resources of Governments, and possibly to work out a more organic scheme taking into account not merely the suggestions made by the Bureau but also the practical experience gained by ministries having mental health units or sections, such as those of Panama and Honduras.

Incidentally, in respect of projects 3100 and basically of psychiatric nursing, the PASB mental health nursing units had discussed the possibility of providing in future, as and when funds were available, a psychiatric nurse for a short or long period, who might possibly render services to the various countries of the Zone.

The CHAIRMAN pointed out that under some of the interzonal projects, more specifically AMRO-4300 and AMRO-4311, there were allocations for mental health projects and group studies on the administration of psychiatric services; and he wondered whether there might be a possibility of assigning or re-assigning the resources to intercountry projects for Zone III.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) said that the funds allocated to project AMRO-4300 provided for a number of consultant-months, which could be used in Zone III, but everything was subject to concrete requests being made by Governments.

The CHAIRMAN said that in the resolution adopted by the Ministers of Public Health of Central America and Panama at their 1966 Meeting help had been requested of the Bureau, and a specific request had been made for advisory services for a study. Thus there had been a general indication of concern on the part of all the countries for a study of resources, and indeed for an assessment of the psychiatric problem in Zone III, i.e., the countries of Central America and Panama.

Dr. HORWITZ (Director, PASB) said that such an agreement had indeed been made at the Meeting of the Higher Public Health Council, and the PASB Regional Adviser had paid a visit to the countries and would be in a position to submit a report on the subject to the next meeting of that Council. A clear distinction had of course to be made between that study of mental health resources and a study of the problems of mental health in any particular region, which implied an intricate epidemiological survey and a considerable outlay on the part Page 76 Fourth session 56th Meeting

of each Government and of the Organization. The Bureau was in a position to prepare an initial report on existing resources before the next Meeting of the Higher Public Health Council of Central America and Panama, and there would be no difficulty in transferring a consultant from the AMRO-4300 project to Zone III during the current year or the following year, but as and when the different ministers made requests to that effect; otherwise the funds would be frozen and would benefit no one.

Dr. AGUILAR HERRERA (Guatemala) was entirely in favor of the transfer of consultants to Zone III to set up mental health projects. Incidentally, he noticed that there was a very important item missing from the budget, namely health education. He wondered whether the Bureau had considered the possibility of including in the budget in the future funds for promoting health education programs.

Dr. VALLEJO (Regional Adviser in Health Education, PASB) said that one of the most important concerns of the Bureau was to provide the countries of the entire Region of the Americas with assistance in that sphere. That had been arranged as far as the countries of Central America were concerned, and from 1967 onward provision had been made for a Zone consultant to be stationed in Guatemala, who would meet the needs for assistance to national health education services. The VI Congress on Health Education for the Central American Isthmus and Panama would be held shortly in Guatemala City, and the PASB Zone consultant was furnishing advice. It was proposed to intensify the training of health education specialists from the Central Arnerican countries, and a study was being made of the best ways and means of doing so, giving every possible help to enable the health services to participate fully in the educational aspects of health programs under way in Central America, such as the malaria eradication and rural water supply programs.

Dr. BLOOD (United States of America) said that AMRO-2303 (Aedes aegypti Eradication) had been in operation at least for the period covered by the documents, i.e., 1966, 1967, and 1968. It was obviously a reflection of a project drawn up several years earlier and included provision for one sanitarian for service in Zone III. Unfortunately, certain things had happened since then which made him wonder whether the provision made was adequate. He was referring specifically to the reintroduction of the vector to the area. He wondered what the Committee could do, if anything, to support additional activity in that area.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that the project had begun shortly after the Bureau received notice of the re-infestation of El Salvador. Every effort had been made, in the first instance, to verify the degree of re-infestation, and then to assess the state of the vigilance services in the other Central American countries. That was why it had been regarded as an AMRO project and not as a specifically Salvadorean project. Apart from the work done in that country, the project had served to improve and train personnel for the vigilance services in various countries where eradication had been achieved a long time ago. The personnel in some of the countries were not familiar with the methods of identifying Aedes aegypti. In the case of El Salvador, it had taken some time to discover the source of re-infestation. Obviously, if the Government of the country was in a position Page 77 56th Meeting Fourth session

to obtain the funds to expand its current Aedes aegypti eradication work, the Bureau would have to increase its assistance accordingly, but so far the funds at the disposal of the Government were insufficient and only served to cover the capital city of the country itself in a rather haphazard way. The sum needed to eradicate Aedes aegypti once again from El Salvador was $2,000,000 and until the Government was able to obtain that sum there would be very little point in increasing the international staff on the basis of the resources available to the country.

The CHAIRMAN invited discussion on the intercountry projects for Zone IV, beginning with Bolivia.

Dr. AGUILAR HERRERA (Guatemala) asked what was the status of the Bolivia- 0901 (Typhus) project and why the funds for it had been reduced.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that the Govern- ment of Bolivia was greatly concerned about the problem, and in 1966 it had asked for the services of a consultant, who had spent two months in the country. Unfortunately the information which the consultant had been able to gather was very inadequate, and he had had to suggest that in 1967 and 1968 a survey should be carried out to determine exactly what was the real extent of the problem and at the same time to carry out a test with CIBA vaccine, E strain, already tested in the higher plateaus of Peru and Bolivia. The Bureau was trying to obtain the services of a consultant who could travel to Bolivia and carry out the serological and epidemiological survey, and at the same time undertake a new test of the vaccine prepared with strain E. According to the information available, the vaccine had passed its tests, it was very satisfactory, and its effect lasted six to seven years. But problems had arisen in regard to its acceptance by the public, because of the immediate and late reactions produced by the live strain vaccines, not the E strain vaccine prepared by Dr. F. Pérez Gallardo.

There were plans to vaccinate the entire population, but at the moment no vaccine was available. The only source of production was the laboratory of Dr. Charles L. Wisseman, Jr. at the University of Maryland, where there was sufficient available for the test. The vaccine had been prepared at a time when there was not much concern over contaminating viruses and it was later proved that there was a virus in the vaccine which was very difficult to eliminate. Dr. Wisseman had a batch of vaccine free of contaminating agents and was anxious to experiment with it in Bolivia. The Bureau had sent Dr. Wisseman the report written by Dr. Montoya, and had asked him if he would be prepared to travel to Bolivia and carry out not only the survey but also a test of the acceptance of the vaccine. Dr. Wisseman's reply was expected shortly, and provided he was in agreement it would be possible to undertake the survey and prepare a detailed control plan because in the way it had been planned it was not known if in some cases the reaction was the result of an attenuated virus, which would complicate the application on a mass scale.

Dr. ACOSTA-BORRERO (Colombia) asked for information concerning project Bolivia-3100 (National Health Services) and Bolivia-3104 (Health Services--Cocha- bamba and Tarija). Page 78 Fourth session 56th Meeting

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said it might be added that there was another project, Bolivia-3101 (National Plan for Rural Develop- ment). It all formed part of the national health plan being produced by Bolivia. It was a project involving advisory services to the Bolivian Government at the national level. Bolivia had been making enormous efforts to develop its health services and had problems similar to those of many other countries, although much more acute than most. The Bolivian rural population lived at an extra- ordinarily high altitude and there were tremendous transport difficulties, so that programs of nation-wide scope could not always serve the local zones adequately. Project Bolivia-3100 was the sequel to the advisory services at the national level in the planning of health services and in training at the local level in La Paz. Project Bolivia-3101 was financed by the United Nations Develop- ment Program and went back to 1952. It had been started on the initiative of the International Labour Office as a joint undertaking by all the international organizations, with a view to integrating the indigenous communities into development schemes and into civilized life. On the health side the organizations participating were the ILO, UNESCO, FAO, in social matters the United Nations, and WHO had been involved from the very beginning. The project had begun in a very modest way, a small rural center being started near Lake Titicaca in the Pillapi area, and through the years it had been expanding until there were seven rural health centers, which provided integrated services. He went on to explain that project Bolivia-3104 was a new program, likewise financed by UNDP; the Bolivian Government was greatly interested in using any suitable zone as a pilot or demonstration area. The purpose of the project was actually to develop the health services of the Cochabamba and Tarija zone!, which was exceptionally suitable for carrying out a successful program owing to the peculiar conditions of the town of Cochabamba and its health services. Both the Cochabamba and Tarija project and the rural health centers referred to in the Bolivia-3101 project were part of the national health plan, so that its dispersal over three projects was merely the focussing of one and the same national health project on different zones.

Dr. ORELLANA (Venezuela), referring to project Bolivia-3600 (Administra- tive Methods and Practices in Public Health), described it as a very important project. That was evident from the great difficulties experienced in applying knowledge and in the use of knowledge by technicians. He wondered whether the activities being carried out in all the countries through their own projects and zonal projects were really producing results, and he inquired how the activities were being carried on and whether in actual fact the berefit hoped for from them was forthcoming. In his view, administrative training was essential if knowledge was to be applied satisfactorily and the public services efficiently administered. He suggested that the Director of the Bureau might give an opinion on that matter and pointed out the benefit to be obtained from the activity in question.

Dr. HORWITZ (Director, PASB) said that a 2 6 -page report on the subject had just been drawn up by the World Health Organization. It was impossible to make a summary of the document in the short time that was left and he thought it would be better if at the next session, assuming that the Committee considered it desirable, Dr. Portner gave a short resumé of its various aspects.

The session rose at 6:35 p.m. FIFTH PLENARY SESSION Friday, 28 April 1967, at 9:05 a.m. Chairman: DR. ALBERTO E. CALVO (Panama) Later: DR. DANIEL ORELLANA (Venezuela)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN opened the session and said that consideration of Document CE56/5 on the proposed program and budget of PAHO would continue with a statement by Dr. Portner, Chief of Administration, on the advisory services furnished by the Bureau in the field of administrative methods and procedures in public health.

Dr. PORTNER (Chief of Administration, PASB) said that it had been several years since a report l/ had been made to the Governing Bodies on the assistance given to ministries of health to improve administrative systems and processes and, in response to Dr. Aguilar Herrera's request, he would endeavor to give the background and current status of the work as well as a simple projection for the future.

The activity, unique in character among the specialized agencies of the United Nations and the OAS, was a tribute to the foresight of the Governing Bodies and especially of Dr. Horwitz, who had proposed it 10 years ago when he served as Representative of the Government of Chile to the X Meeting of the PAHO Directing Council. His resolution, 2/ which had received the unanimous support of the members, had recognized that the attainment of the health goals of the Hemisphere depended in considerable measure upon administrative support that would ensure delivery of service.

The work had proceeded on a number of fronts. Before 1960 the effort had been almost solely in the malaria eradication activity, involving as that program did, major logistical factors in which administrative elements were heavily engaged. Thereafter, the work had become more diversified. The range of assistance currently covered many administrative activities and the processes and procedures of a considerable number of technical programs in which technical and administrative officers united their efforts. Assistance had been given to Governments, on request, but the primary need had been to drive home the basic point that those employed in health work in the Hemisphere were engaged in major enterprises of a widely diversified character in which expenditures in the public sector, on national and related programs, amounted to billions of dollars annually.

2/ Official Document PAHO 41, 462-463. 1/ Resolution XXXV. Official Document PAHO 22, 28-29.

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A further element, almost never mentioned, was the annual expenditure in capital investment which totalled tens of millions of dollars--an investment which was permitted to erode over a relatively short period, with the result that buildings, equipment, and similar items soon lost their basic value and required replacement.

The management of a sizable staff was also involved. The employees of several of the ministries could be numbered in the tens of thousands. The direction of so many people was a major problem in organization and management. Moreover, the range of activity in some ministries covered almost all of man's endeavors, from cradle to grave, and was a task to challenge the most astute manager.

A further element was that of geography, with its resultant problems of transportation and communication. In many jurisdictions there were also political problems affecting the structure of Governments and the relative powers at national, regional, and local levels, including the matter of the hiring and firing of personnel.

Basically, the Organization served on call, but had proceeded on several courses designed to help ministries and the autonomous water supply and malaria eradication programs to provide the desired services.

First, on the broad, doctrinal and educational level, there had been initiated in 1960, in San Jose, Costa Rica, a series of seminars to assist those at the upper levels of the health ministries to understand what was involved in managing large health institutions in the public sector. Seven seminars had been held to date. In the current year there would be three more: one in Panama for the Central American nations and Panama; one in Santiago, Chile, for the countries of South America, and another in Paramaribo, Surinam, for the English- and Dutch-speaking countries of the Caribbean. Some ministers and vice-ministers had attended the seminars but, basically, the attendance had been that of directors-general of health and directors of administration. There had been a review of principles of management for health establishments in the light of the needs of the particular geographic area, and its cultural, political, and other patterns. As a point of reference, there had been a periodic review and updating of the progress made in the ministries toward better administration. The June meeting at Panama, for instance, would first review the progress made since the last meeting held in Antigua, Guatemala, in 1964, and the resulting report would be presented to the XII Meeting of Ministers of Public Health of Central America and Panama, to be held in San Salvador in August 1967. At each of the seminars there would be a study in depth of a major aspect of administration: in Panama, supply and procurement; in Surinam, capital plant; and in Santiago, program budgeting and accounting. The results would form the basis for the preparation of manuals for use by health ministries and other bodies interested in the subject.

Second, and very important, was the matter of consultant services, with which almost every country of the Hemisphere had so far been provided. The consultants had helped in the restructuring of ministries, establishment of field organization, definition of authority and responsibility, preparation of manuals, establishment of administrative divisions, personnel management service, program budgeting and accounting units, organization and methods, better Page 81 56th Meeting Fifth session supply and procurement, records management, improved transportation procedures, the preventive maintenance of capital equipment, and other units and services in the administrative area.

Dr. Portner recalled the fine service rendered by the late Dr. V. Valdi- vieso in Panama, in assisting officers at both the top level and levels immediately below to gain an appreciation of management principles, an activity which had had its counterpart in other countries. That was typical of the service at the country, zone, and regional levels.

Assistance had also been given in education and training. The Organiza- tion had provided 150 fellowships for courses, including those of the Central American Advanced School of Public Administration (ESAPAC) in San José. Other courses had been arranged through the Institute of Organization and Administra- tion (INSORA) in Chile and the Public Administration School in Paraguay. Similar work had also been done in the Caribbean area where a second regional course was to start in July. An effort was made to provide assistance in the area in which officers resided. But that accounted for a mere fraction of the total number trained. The major training effort was in the ministries, where, in the personnel, budget, finance, supply, transport, and other units, more than 4,000 persons had been trained to give more effective performance.

Training had been given to drivers working in general ministerial pools and in eradication campaigns; assistance had been provided in the establishment of repair shops and the training of budget personnel, supply and procurement officers, and warehousemen and storekeepers had been undertaken. Training had been carried out at the national, regional, and local levels.

A reference service for consultants on the latest knowledge in the field had been provided and certain members of the Headquarters administrative staff had also been used. The activity absorbed only 1 per cent of the Organization's budget. The dollar cost was minor, but the work being done transcended dollar measurement. In few other endeavors was such teamwork in PAHO/WHO found--with the administrative staff and those in planning and medical care administration, with malaria eradication officers, and with those concerned with water supply. During that week, Dr. Portner said, assistance had been arranged for the reorganization of the administration of a medical school.

Critical always in the technical field was the question of evaluation. It was already possible to measure actual accomplishment; to point to the establishment of new budgetary systems in six countries; of new personnel management systems in four countries; record-keeping systems in three others; in a dozen places assistance had been given to malaria eradication programs through improved transportation, budgeting, and accounting systems, and in at least 10 instances where nationals had taken over the work of specialists and carried forward new systems and techniques.

Quantification was important; one could point to the number of administrators trained at key divisional and sectional levels, and to the numerous persons working more effectively in all tasks, ranging from that of a sweeper to high-level administrators. Page 82 Fifth session 56th Meeting

In assessing the assistance given one could declare that, on balance, the Organization's contribution had been from satisfactory to more than satisfactory.

The size of the health ministries and other agencies served by PAHO was increasing, and the critical importance of effective management at the top level, with efficient administrative support, was3 already more apparent than it had been in 1957. The allotments made in succeeding budgets indicated PAHO's conviction that the work should go forward, first in basic areas of administration and later, as in the case of one Government recently, in the more sophisticated activities such as systems analysis and cost-benefit studies, as part of what was really an evolving process. It was clearly apparent that scientific management was a need both at the national level and in the international organizations such as PAHO.

Dr. ORELLANA (Venezuela) expressed satisfaction with the various activities carried out in the field of administrative methods and procedures since 1956, when Dr. Horwitz proposed that advisory services be extended in that field. He emphasized the enormous difficulties, :particularly political problems, inherent in the establishment of an effective administrative system and the importance of placing public administration on a sounder technical and scientific basis. That required the training of qualified administrators so that the improvement of those services would make it possible to ensure adequate use of resources and capital equipment.

Referring to the logistical aspect of administration, mentioned by Dr. Portner, he said that it was inconceivable for health activities such as malaria and Aedes aegypti eradication, housing programs, and others to be administered under rigid and outdated systems. Although pleased with the progress achieved in the various areas of the program, he felt that increased efforts should be made in the dissemination of information and that greater stress should be laid on the problem of hospital maintenance. In that connection, he cited a hospital maintenance and environmental sanitation course being organized in Venezuela, which he believed could be useful to other countries as well. Venezuela already had a specialized engineer in that field.

The CHAIRMAN emphasized the importance of sound administration in the field of health, or in the "health industry," as some would call it, a sector of such scope that in the United States of America, for example, it was the third largest industry, after construction and transportation. If that enormous activity was to progress, it had to be properly administered, but that again depended on the quality of national administration. That was why the improvement of administration was included among the objectives of the Charter of Punta del Este. He felt that PAHO, which had taken the initiative in various matters affecting the development of the Americas, should continue its efforts to cooperate with the countries to improve the administration of health services in general.

Dr. BLOOD (United States of America) said that Dr. Orellana had spoken for them all in thanking Dr. Portner for his informative remarks concerning so funda- mentally important an activity, the extent of which he personally had not hither- to fully appreciated.

It had been said that good administration had many enemies, but it was to be hoped that increasing evidence of the value of good administration would at least strengthen the hand of those who were its friends. Page 83 56th Meeting Fifth session

He was interested that the Organization's own evaluation process should be constantly evaluated so that it would be possible to go beyond mere feelings and impressions to the measurement of results, and thus make it possible to demonstrate how better administration improved the efficiency of health services.

Dr. PORTNER (Chief of Administration, PASB) said that the Organization not only preached good management but sought to practice it. No clearer evidence was available than the success to date of the rationalization and automatization efforts within PAHO. It sought to make PAHO a model of good administration and was keenly interested in assisting the Governments to that end.

An example of an attempt to evaluate the success of the assistance in that field, closely allied to the work in planning, was that given to the Govern- ment of Trinidad and Tobago in the reorganization of its Ministry of Health, the creation of an administrative structure, the systematization of the administrative processes, and the review of techniques used in the various departments.

In the last three weeks an evaluation had been made and it was already available for review. There had been a five-day meeting in Port of Spain of the Ministry's Chief Medical Officer, Permanent Secretary, Chief Administrative Of- ficer, section heads, the PAHO administrative team in Trinidad and Tobago, and the Deputy Chiefs of Personnel and Finance from Headquarters. Any evaluation made so soon after reorganization was difficult, but it was possible to review quantitatively such elements as the current status of work,for instance, in the field of accounting. There was already no backlog in the operation of the system by which accounts were required to be registered monthly and a formal report submitted at the end of the month. A system of personnel activity, of strength counts by location and division, of identification of personnel, of posts, and other innovations had already been established. He could cite the reduction in accounting backlog in terms of numbers of vouchers, checks, and other items brought up to date, give the number of personnel folders established and so on. Of course there still had not been any activity in the sophisticated cost-benefit analysis sense.

Dr. Portner then referred to activities in national health planning. The major thrust in the Hemisphere was in the area of planning, but the implementation of plans was not possible without the prior establishment of the procedures he had described. An effort was being made to produce a program budget, but such budgets would be little more than nonsense unless they were founded on expenditure data in accounts by program.

Evaluation was a most serious endeavor and the Organization emphasized that constantly to all its officers. Further, it was recognized that resources were scarce and a consciousness of the need of maximum utilization, even beyond that practiced in the private sector, was an imperative in the work in health. PAHO sought a profit of infinitely greater meaning. That was service to the peoples of the Hemisphere, the key to action for the Director and for his staff.

Dr. HORWITZ (Director, PASB) said that there was no activity that could not be evaluated if such activity had a purpose. The only problem lay in dis- tinguishing between activities carried out and results actually achieved. In the essential discipline known as administration, it was always an easy matter to prepare an account of activities, whatever field they referred to. To measure Page 84 Fifth session 56th Meeting

results was of course not simple, for it involved a broader purpose. The mere fact that funds were invested at a given time in accordance with established policy and that they were used with absolute honesty did not provide a sufficient basis for measuring the social effects of that investment, which had to be expressed in terms of benefits to people. And measuring those effects was generally the principal problem in evaluating public health action.

One of the major difficulties in attempting to justify health services to the political authorities and their advisers in the economic sectors was that it was only possible to show the social effects of life and death but not the qual- itative effects on life and death. Dr. Horwitz was convinced that all those efforts to improve health administration were essential and would become even more so because in public health, as in all other disciplines, advances were being made and technological complications were bound to arise. He cited the case of a country that attempted to prepare a program budget, established functional categories of expenditure, and gathered the necessary data, only to find that the accounting services continued to function as in the past because administration had not been brought into the process. The result was an unintelligible document, as expenditures were recorded by a method that had nothing to do with functional groupings. In another country an excellent tuberculosis project had been drawn up as part of the national health plan, but the purchasing department did not buy the necessary streptomycin and the failure was even more re- sounding because the objectives had been much more obvious. Dr. Horwitz also recalled that on a visit to an exhibit sponsored by the Canadian Public Health Association he was told that plastic syringes and needles, disposable after a single injection, had been found more economical than the conventional instruments. That conclusion had been reached after a careful analysis of costs resulting from losses, breakage, sterilization, etc.

Dr. Horwitz was extremely pleased to find the Executive Committee so interested in the matter, the importance of which had been seriously underestimated in health as in every other field of public activity. He felt that the recognition of its importance--a prerequisite to progress--by the Latin American health ministries was extremely significant. That awareness had come about in a very short time as an outgrowth of the ten-year health programs of the Hemis- phere, which had shown that in the absence of administration, planning turned out to be nothing more than a theoretical exercise. He was confident that once the Governments were fully convinced of the far-reaching effects of administration, progress would be more rapid and PAHO would be called upon to extend its services to increasingly complex areas of administration, since the Governments would attend to the normal and basic areas with their own resources. Much remained to be done in the Hemisphere with respect to internal auditing, technical, and administrative services. He said that only a very few departments in the hospitals had periodic audits of their technical services, and he doubted that any of all had administrative audits.

Dr. AGUILAR HERRERA (Guatemala), referring to a new project, Colombia- 6203 (Center for Teaching Pathology), asked how the Organization proposed to assist the Colombian Government.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) explained that, two years before, a consultant had been sent by the Bureau to visit the departments of pathology in Latin America because it was felt that additional instructors Page 85 56th Meeting Fifth session should be trained in that field, not only because it would raise the level of instruction but also because it would help to improve diagnosis and, thereby, improve the quality of national statistical data. The consultant had visited 45 departments of pathology in Latin America, and his report indicated that Colom- bia appeared to be one of the countries having the necessary resources for the establishment of a regional training center. The departments of pathology of Bogotá, Cali, and Medellín were prepared to collaborate with the Bureau in this work, and through the Colombian Association of Medical Schools an agreement was signed with them for the use of their services in the training of pathologists and professors of pathology for medical schools in Latin America.

Dr. AGUILAR HERRERA (Guatemala) requested detailed information as to how the Organization would cooperate with that pathology training center.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that although the departments of pathology were prepared to collaborate in the project, they required certain assistance, particularly in the form of equipment to be used by the persons sent there for training. The purpose was also to cooperate with those departments so that their staff could devote part of its time to training fellows sent to the center. The item proposed in the budget was for strengthening the staff and equipment of those departments.

Dr. BLOOD (United States of America) asked how the activity was related to medical education in general, and whether it had been decidea that the teaching of pathology should receive priority attention, or was it part of a plan to establish centers in the various disciplines of medicine for the teaching of anatomy, microbiology, parasitology, and others.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) explained that the project was part of a broader effort by the Bureau to establish centers for various disciplines. A number of years ago PASB had conducted a survey to determine the availability of teaching staff, especially in the basic sciences. The survey revealed a substantial shortage of such personnel not only in pathology but in other fields as well. In 1965, with the cooperation of the Rockefeller Foundation, a program was established in Rio de Janeiro for the training of microbiologists, who were sorely needed by medical schools, in the Institute of Microbiology of the University of Brazil. It was also intended to cooperate in the training of teaching staff for the physiological sciences, and for that purpose preliminary discussions had already been held with certain groups, notably the Latin American Association of the Physiological Sciences, with a view to participating jointly in that endeavor.

Dr. ORELLANA (Venezuela) asked why it was that in the project Colombia- 3102 and those for other countries the only explanation given was "Fellowships."

Dr. CHARNES (Chief, Fellowships Branch, PASB) explained that the budget of the Organization formerly included a general project, AMRO-35, under which all fellowships were grouped without regard to their purposes. It was later decided that it would be much more useful and logical for each fellowship to be assigned to a specific country and AMRO-35 was divided into individual projects for different countries. However, in order to provide flexibility in the actual award of fellowships the item for each country project continued to be expressed as a lump sum, with no allocation by purposes. Page 86 Fifth session 56th Meeting

Dr. ACOSTA-BORRERO (Colombia) asked why the item of the regular PAHO budget formerly allocated to fellowships in Colombia-3102 had been completely eliminated.

Dr. CHARNES (Chief, Fellowships Branch, PASB) explained that the elimination of that item from the regular PAHO budget was offset by the addition of two academic fellowships to be charged to WHO funds.

Dr. AGUILAR-HERRERA (Guatemala) pointed out that Colombia-4200 (Nutrition) formerly had $2,800 which, he understood, was to cover the cost of a fellowship and which did not seem to have been transferred to any other part of the budget.

Dr. CHARNES (Chief, Fellowships Branch, PASB) replied that the fellowship would be considered under AMR0-4200 (Nutrition, Advisory Services), which included an item for fellowships in all the countries.

Dr. HORWITZ (Director, PASB), noting that the problem would no doubt be raised by others, said that a portion of the funds would be used for advisory services. Sometimes a consultant was unable to report for work on the scheduled date of the fiscal year, and the allocated funds began to accumulate. After the program and budget were approved, a review was made every three months to see how the program was progressing and also because other proposals were received from Governments calling for different priorities.

By the third quarter of the fiscal year there was generally a certain amount of unused funds, which were often allocated to fellowships the Governments had proposed. As a result, the total expenditure for fellowships had been rising in the last seven or eight years and had sometimes exceeded the amount that had been foreseen when the budget for the year was approved. When it was a question of training a qualified candidate for a job considered essential by one of the Governments, funds were usually found for the purpose. And the use of fellowship funds to cover urgent requirements of projects requested by the Governments did not affect the fellowships, because, as experience had shown, other funds were generally available for fellowships after the second quarter of the fiscal year.

Dr. BLOOD (United States of America.), referring to the item Colombia-3301 (National Institute of Health--Carlos Finlay), said that the project was of long- standing importance. The Carlos Finlay Institute of Special Studies had served as an international vaccine production center for many years and in 1965 had, for instance, distributed to other countries some 385,000 doses of yellow fever vaccine, in addition to that required to meet national needs. He would like to know what the rate of activity had been in the past year and what was the current trend.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that it was one of the oldest projects of PASB, having been started in 1950 along with an identical program in the Oswaldo Cruz Institute of Brazil. When the Rockefeller Foundation withdrew its support, the Bureau subsidized the projects so that they could continue to serve the countries. Their principal functions continued to be the preparation of yellow fever vaccine for free distribution to the American countries; the conduct of epidemiological studies,. and the provision of diagnostic services. Page 87 56th Meeting Fifth session

The National Institute of Health of Colombia, which, together with the Oswaldo Cruz Institute, was the principal diagnostic center for jungle yellow fever, produced sufficient vaccine to supply Colombia's needs and those of other countries in the Americas and other parts of the world. All that involved a substantial investment of funds, for the vaccine was relatively expensive (25 to 30 cents a dose) and those institutions sometimes distributed as many as a million doses to the countries free of charge.

Dr. Bica added that the Bureau's cooperation with the National Institute of Health of Colombia was expanding because the Institute was being reorganized and the Government was also extremely interested in the production of vaccines against diphtheria and pertussis, as well as tetanus toxoid. The Institute requested the services of a short-term consultant, who was subsequently reappoint- ed on a long-term basis, until such time as it were able to continue to manufacture the necessary biological products without external assistance. It also received a grant for the production of yellow fever vaccine, and the services of a short-term consultant.

Dr. BLOOD (United States of America) noted that some increase was suggested for 1968 but he was unable to relate it to the figures for the previous years. He asked for clarification on expenditures for 1967.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that an item had been originally included in Official Document 67 to finance the services of a consultant for four months and of two short-term fellowships and provide a $25,000 grant. In the course of the review the consultant was made permanent, the two fellowships were maintained, and the grant was reduced to $20,000. Approximately $35,000 was spent on that program last year.

Dr. ORELLANA (Venezuela) pointed out that the purpose of the grant given the Institute of Health of Colombia to supply vaccine to Colombia and other countries as well appeared to indicate that the program was international in scope. Actually, almost half of the vaccine produced was supplied free of charge to other countries.

He then raised another point and noted that the yellow fever vaccine was put up in ampoules of 200 doses, which meant that in many cases part of the product was lost when used for purposes other than mass vaccination campaigns.

Dr. PORTNER (Chief of Administration, PASB) said that the entire matter of attribution of portions of AMRO projects to countries was under review. He hoped that by the next meeting of the Directing Council it would have been resolved.

Dr. HORWITZ (Director, PASB), referring to the Colombian program, said that the Government had decided to create a number of national institutos of health and to include that program, which was operating independently. Therefore, the laboratory for the production of yellow fever vaccine became a department of the national institutes of health and, in those circumstances, it was thought that for budgetary purposes the project should be included in the chapter for Colombia, just as the project of the Oswaldo Cruz Institute was included in the chapter for Brazil. Moreover, the Government later decided to modernize those institutes and even construct a new building to house them, which was nearing Page 88 Fifth session 56th Meeting

completion; and later became interested in expanding the advisory services to include the modernized institutes. For all those reasons, it had been decided to leave the project in the chapter for Colombia.

The Bureau was aware that the countries were essentially interested in knowing exactly what part of the Organization's funds was going to each country, and for what purpose. Therefore, a thorough study was being made of the Zone and interzone projects in order to establish a simple administrative system that would enable the Bureau to tell a Government at any time just what part of the total expenditures had been made in its behalf in a given year, without altering the basic arrangement approved by the Governing Bodies for the program and budget. He considered it very important that a Government be able to know, at any time, the total amount of benefits it was receiving as a result of the-cooperation extended to it by PAHO/WHO.

Dr. Horwitz then recalled that at the Task Force on Health at the Minis- terial Level, held in April 1963 in Washington, D.C., as a result of the Charter of Punta del Este, a proposal had been made 3/ to establish a common market for biological products in the Americas. PAHO appointed a consultant, who made a very careful study of the various institutions producing biological substances in the Americas. The study revealed substantial deficiencies in the processing of those substances, which affected their cost, as well as inadequate quality control. That finding indicated that it was no easy matter to establish a common market, as the economists conceived it, so long as there was no assurance that the products would meet the international standards of quality and the:ir cost would be reasonable.

Later, however, the Organization convened a group of experts, composed of outstanding persons then responsible for the production in the countries of the Hemisphere. The group studied the problem and issued a number of suggestions, the first of which was that a survey be made to determine the products then available in the Americas for trade.

The findings of the survey were generally unfavorable and led to the conclusion that the first thing to be done was to modernize those institutions. In line with that conclusion, PAHO had been cooperating with the Government of Peru during the past two or three years in the establishment of a new institute for fth manufacture of biological products for human and veterinary use. The Inter- American Development Bank had not only accepted the idea but had also made an advance of $40,000 for an economic feasibility study of the proposal, which would soon be submitted to the Bank.

Dr. Horwitz concluded by saying that the Government of Chile had recently requested the services of a highly qualified expert to make a study in depth of the Bacteriological Institute of that counatry. The Organization wished to cooperate in that field because it involved not only the preparation of biological products but also the microbiological diagnosis of communicable diseases, an area in which, for reasons perhaps best determined by a sociologist, Latin America had actually retrogressed while tremendous progress was being made in microbiology in the developed countries.

3/ Official Document PAHO 51, 40. Page 89 -56thMeeting Fifth session

Dr. BICA (Chief, Communicable Diseases Branch, PASB), referring to Dr. Orellana's remarks on the packaging of yellow fever vaccine, said that many suggestions had been received that it be prepared in smaller doses, but the reply had been that the larger doses were more economical.

The session was suspended at 10:35 a.m. and resumed at 11:10 a.m.

The CHAIRMAN invited the Vice-Chairman, Dr. Orellana, to take the Chair.

Dr. Orellana (Venezuela) then took the Chair.

Dr. ACOSTA-BORRERO (Colombia) expressed the opinion that the estimate of the Governments' contributions to the various projects did not take account of the steady increase in those contributions. He suggested that the estimates be revised before being submitted to the Directing Council in final form. He said that in the case of Colombia-0200 (Malaria Eradication) sizable increases had been made in the past two years which did not appear in the documnent under consideration. Although he did not think that the Bureau was to be blamed for it, he suggested that an urgent request be directed to the Governments so that they revise the figures for the national counterpart funds and adjust them to reality.

The CHAIRMAN agreed with Dr. Acosta-Borrero that a better procedure should be found for computing the national contributions, so that the figures would be as accurate as possible. He said that perhaps in the draft resolution on the program and budget something could be said concerning the need to bring those figures closer to reality.

Dr. PEREZ RUEDA (Ecuador), referring to project Ecuador-O100 (Communicable Disease Control) asked what kind of services would be performed by the medical officer for whom an allotment was shown and if the funds would be charged to the PAHO budget.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that the services of the medical officer in question, in addition to those of an epidemiologist soon to be hired, were being provided in response to a request of the Government of Ecuador for cooperation, through the United Nations Development Program, in organizing an immunization program for the control of communicable diseases. The program would be related to certain health problems in other areas.

Dr. PEREZ RUEDA (Ecuador) requested on behalf of the Government of his country that the budget for the control of communicable diseases be increased, particularly the items for the immunization program against diphtheria, pertussis, and tetanus and, to the extent possible, against poliomyelitis. He inquired if the funds could be increased in next year's budget, so that the National Health Service could carry out the immunization campaign, already started in all regions and zones of the country.

In regard to project Ecuador-3301 (National Institute of Health), he asked why the item for that project had been eliminated. He considered the project very important to the accomplishment of the Institute's plans, especially those Page go90 Fifth session 56th Meeting for the preparation of biological products and of materials for vaccines against various communicable diseases.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that the item for the National Institute of Health had been deleted because the Govern- ment of Ecuador had made little use of those funds in recent years and the unused amounts were being frozen.

Dr. PEREZ RUEDA (Ecuador) asked if those funds could be used for the projects the Government proposed to continue the following year, or if they had been definitely cancelled.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that Ecuador was using the services of the Bureau under two AMRO projects: a Zone project in which the Zone consultant was cooperating very actively with the Institute, and AMRO- 3304 (Laboratory Services), in which advisory services were being provided. In addition, the possibility of supplying biological reagents, already furnished to Ecuador, was being considered.

Dr. PEREZ RUEDA (Ecuador) was pleased to know that his country could continue to count on the Bureau's cooperation, which he considered very important in view of the fact that his country was developing a program to improve the services of the National Institute of Health. He asked if the explanation given also applied to project Ecuador-4200 (National Institute of Nutrition).

Dr. DROBNY (Chief, Health Promotion Branch, PASB) explained that an item of $2,800 entirely for fellowships, had formerly been included for that project. He pointed out that it was one of the oldest projects; the National Institute of Nutrition in Quito had been receiving advisory services from the Organization since 1950, and it was interested in continuing those services to the Institute, which was currently being assisted through the Zone consultant, as indicated further on under project AMRO-4204 (Nutrition, Advisory Services, Zone IV).

Dr. PEREZ RUEDA (Ecuador) then inquired if only one fellowship in the amount of $2,800 had been eliminated, and if so what kind of fellowship was involved.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) explained that one short- term fellowship had been eliminated but that if any candidate should be interested in receiving advanced training in a spe!cialized area the necessary funds would be taken from the general item for fellowships. He noted that Ecuador was entitled to 19 fellowships under projects Ecuador-3100 (National Health Services), 3101 (Fellowships), and 3102 (Rural Medical Services), which made it one of the most favored countries as far as the fellowship allocations in the 1968 budget were concerned.

Dr. PEREZ RUEDA (Ecuador) requestedc information concerning the item of $2,812 for project Ecuador-4204 (Endemic Goiter and Mental Retardation).

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) explained that the item in question was the remainder of a grant made available by the National Association for Retarded Children (USA) for the purpose of studying the results of a campaign in calling for the injection of iodized oil, and its effect on the Page 91 56th Meeting Fifth session incidence of cretinism in the population. Although the study had been completed, the amount of $2,812 was kept in the budget to pay for the services of a pediatrician already in Ecuador. That specialist was examining newborn children, performing development and neurological tests, and determining their iodine blood levels.

Dr. PEREZ RUEDA (Ecuador) said that he was aware of the project but had been surprised to note that no description of it was included in Official Docu- ment 67.

Referring to the Organization's advisory services in medical education, which his country was interested in improving, Dr. Pérez Rueda said that upon returning to Ecuador he would submit a report and arrange for studies to be made with a view to asking PAHO's cooperation in that field as well as in mental health. The Organization would then be asked for the information necessary in order to submit a request for those services.

Dr. HORWITZ (Director, PASB), referring to the question of the Represent- ative of Ecuador concerning the Bureau's cooperation in the field of communicable diseases, said that he had been privileged to attend the inauguration of a new, modernly equipped, vaccine production department in the Leopoldo Izquieta Pérez Institute, which would produce freeze-dried vaccines for general use in the treatment of the most common communicable diseases. He had been very pleased to be told by the Minister of Public Health that the Bureau had cooperated in the project from the earliest stage when the building was planned. In the opinion of Dr. Horwitz, the next logical step was to organize an immunization program based on the Institute's production capacity. To that end, he assured the Represent- ative of Ecuador that the Organization was prepared to cooperate by making available the services of the Zone epidemiologist and of the other epidemiologist mentioned by Dr. Bica, who would be assigned to the Zone in the next few months.

As for the problem of immunization, Dr. Horwitz observed that the countries of the Organization had not established the practice of programming useful levels of immunity far enough in advance to enable the national production laboratories or purchasing departmenta to procure the basic products essential to the projects. He considered that programming phase of basic importance and said that the Organization would be glad to assist in that matter.

Dr. WEDDERBURN (Jamaica) asked whether the item Ecuador-6300 (Nursing Education) was concerned with basic training, post-basic training, or both.

Miss CAMMAERT (Regional Adviser in Nursing Services, PASB) said that the Ecuador project was basically to assist the schools of nursing in Guayaquil and Quito. The Organization had for many years offered assistance directly to the School of Nursing in Guayaquil, but within the past two years the assistance had been transferred, principally, to the National School of Nursing in Quito, which had expressed the wish to become affiliated with the University. Under the same project assistance was being given in the development and expansion of auxiliary training programs in the country.

Dr. WEDDERBURN (Jamaica) said that, in view of the nursing education project being developed at the University of the West Indies, he would like to know Page 92 Fifth session 56th Meeting what was meant by the statement in Official Document 67 that the assistance of UNICEF was anticipated when the project was expanded to national scope.

Miss CAMMAERT (Regional Adviser in Nursing Services, PASB) replied that the request for UNICEF assistance was concerned first with the auxiliary training program per se, and second, with the provision of supplies and equipment for the improvement of clinical practice areas in relation to the school of nursing.

Dr. BLOOD (United States of America) said that he had not been able to follow completely the comments of Dr. González concerning the endemic goiter and mental retardation program in Ecuador. He realized that the funds for :L1968 represented the completion of a previous project but could not find any description of the project for 1966 or 1967.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) explained that the project had been omitted because no provision was made for it in the budget. The funds for the project came from a foundation grant and were not included because the budget was already in preparation when they were received.

Dr. BLOOD (United States of America) asked whether it was a project that was presently developing and whether it would be continuing through 1967.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) replied that although the project itself had been completed, the observation of its results was in progress and would, no doubt, continue for several years. It was not known if the foundation that made the grant would continue to cover future expenses. Dr. BLOOD (United States of America) said he assumed it was not going to be a new project for 1968 as the document would suggest, but really the continuation of a project already in active development.

Dr. PORTNER (Chief of Administration, PASB) said that the proposed program and budget estimates, to be presented to the next meeting of the Directing Council, would contain a narrative reference to the item as a 1968 project, with all the necessary information. Dr. BLOOD (United States of America) said it would be very interesting to know more about project Peru-6300 (Nursing Education), which seemed to offer interesting possibilities for an international approach in education though it was not presently so described. He understood there had been some programmed instruction under consideration and, at first glance, that seemed to have application in many areas. He would like to know more about w'hat the Organization had in mind in that regard. Miss CAMMAERT (Regional Adviser in Nursing Services, PASB) said that the nursing education program would give direct assistance to the University of San Marcos in Lima in the establishment of a school of nursing at that level, as had been requested by both the University and the Ministry of Public Health and Social Welfare. The assistance had hitherto been rendered by two advisers who had assisted the country in the initial phase of establishing the school. In Peru the approach had been quite different from that adopted in other countries. Twenty-five nurses had been sent to the University of San Marcos to get their basic degree and during the summer vacation months, PAHO had, through additional short-term advisory services, provided complementary courses to complete their preparation. The school had established its first basic course for students during the current year, and the instructors for the school had been selected from the graduates who had completed the two-year course. Page 93 56th Meeting Fifth session

In relation to programmed instruction, at the present time it seemed that it was more appropriate for the professional people in Latin America, because of their general basic education, and that it would be of great value in post-basic courses or the in-service training of professional nurses. Experience in its application for auxiliary personnel indicated that little was known about their capacity for learning, as well as their specific functions and duties which varied from one country to another. A great deal still had to be learned about auxiliary training and answers still had to be found to the questions that had arisen as a result of the work carried out in Mexico in that regard. In the light of the findings of a study on that subject, consideration would then be given to whether programmed instruction would be useful or not. There were too many unldnowns at the moment so that programmed instruction had been suspended and the available resources were being used to find some of the answers needed.

Dr. BLOOD (United States of America) asked whether such re-evaluation was planned for the future, or whether sufficient resources were available with which to pursue it.

Miss CAMMAERT (Regional Adviser in Nursing Services, PASB) replied that consideration was being given to undertaking a study of that type in Peru. The person who would assume that responsibility was or leave at the moment but on her return would initiate the study.

Dr. AGUILAR HERRERA (Guatemala), referring to project Peru-0900 (Plague Con- trol), asked if the deletion of the funds formerly supplied from the PAHO budget was due to the fact that the Governments of Peru and Ecuador considered that there was no longer any need for the Organization's assistance in that project. He would like to know whether the disease was on the verge of being eradicated, whether the Bureau would continue to provide advisory services through AMRO-0104 (Epidemiology), and what the current situation was. He considered the project important because it dealt with a disease which still existed in the Hemisphere--although it should not--and which ought to be eradicated along with the others.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) replied that the situation with regard to plague had not improved in the Americas and that the number of cases had risen since 1960, except for a small decline in 1963. The principal increase had been in Peru and Ecuador, and therefore the Bureau had established the post of Regional Adviser in Plague, funded by WHO and with duty station in Lima. The Bureau had also entered into agreements with both countries under the terms of which it had provided equipment and supplies and would make available the services of health inspectors.

The Bureau proposed to use funds of project AMRO-0900 (Plague Control) to contract for the services of an eminent plague specialist, Dr. Marcel Baltazard of the Pasteur Institute in Paris, to survey the possibilities of developing a research program in Peru. The problem, therefore, had received ample attention, and it was only to be hoped that the Governments would have the necessary funds to pay for most of the equipment required.

He added that eradicating plague from the Americas was not an easy task, since it was a selvatic disease. It was not very likely that eradication could be achieved with the existing knowledge of the problem. It still remained to be determined why the disease persisted in certain areas, which were the primary foci of infection--so that control activities could be concentrated there--and which were the species involved in the maintenance of the enzootic infection in Page 94 Fifth session 56th Meeting

the area. The Bureau hoped to prepare a preliminary report on all those aspects and, prior to that study, had already published the available information in a book entitled Plague in the Americas. 4_/

Dr. AGUILAR HERRERA (Guatemala) thanked Dr. Bica for the full, if disheartening, information on plague and expressed the hope that research would be carried on to acquire a better understanding of the epidemiology of the disease and of all the conditions responsible for its continued existence, so that the problem could eventually be solved.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that while his remarks were indeed disheartening as far as eradication was concerned, it was nonetheless possible to control plague and to completely protect urban areas and some of the rural areas.

Dr. ACOSTA-BORRERO (Colombia) asked whether adequate control could be maintained despite the difference between the amount proposed and that which was approved in the preliminary draft in Official Document 67.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) stated that the proposed sum of $6,800 had been included for use in hiring a short-term consultant whose services, however, were no longer needed because a regular staff consultant had been appointed. The post of regional consultant did not appear in the budget of PAHO because those services were financed by the WHO budget, but it would be shown in the next document.

Dr. BLOOD (United States of America) asked whether, in view of what had been said at an earlier session about the international ramifications of the sanitary engineering education project in Venezuela, there was any relationship between that work and what was proposed for Peru.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that the purpose of the project for Peru was to assist the National Engineering Universi- ty in strengthening its School of Sanitary Engineering, which offered an undergraduate degree in that subject, and in building in the School a research program at the graduate level, and graduate level instruction. That work was related somewhat to the emerging sanitary engineering center in Venezuela that Dr. Blood had referred to.

The Committee would recall that in the discussions during the 51st Meeting held in Mexico in 1964, it had been emphasized that more attention should be given to air and water pollution. The I)irector had been asked ,/ specifically to look into the matter and report to the Directing Council. In turn, the Director's report 6/ to the XVI Meeting of the Council in 1965 had prompted a resolution Z/ requesting him to develop ways and means of strengthening the assistance program in those fields, and in regard to the related problems that would come with growing industrialization.

"/ Scientific Publication PAHO 115, 1965. 2/ Official Document PAHO 60, 242. 6/ Official Document PAHO 69, 396-399. Z/ Resolution XXXV. Official Document PAHO 66, 85-86. Page 95 56th Meeting Fifth session

After much study and deliberation it had been decided to develop in Peru a research and information center in the School of Sanitary Engineering that would serve the Zone, indeed all of the Americas. While it had no connection with the Government of Peru, it had been considered quite important to collaborate closely with the University, so that there would be a basis for carrying on some of the research programs that were needed in the more sophisticated fields of air and water pollution, and the effects of urbanization.

Those decisions had been made subsequent to the drafting of the current budget, but the modest resources provided for the beginning of that operation were contained in the interzone items. He would say in all frankness that their hopes for the operation were quite high, and envisioned the orderly development of resources that could support Government programs, for dealing with the complex problems presented by air and water pollution.

Since 1960 efforts had been concentrated on water supply, a program that had gone exceptionally well. As the Director had mentioned, more than a billion dollars had been committed by Governments to the improvement of urban and rural water supplies, some 200 million being devoted to the latter activity. The concentration on the water supply field had been designed to assist the Governments in developing the organizational patterns and systems to which Dr. Portner had referred, those needed to carry out public works programs of great magnitude, yet tied inseparably to the health needs of the individual nations. That had necessitated developing also a Latin American network of training facilities, another venture which had been very successful, as well as the strengthening of the university education structure and the development of the research program. All that activity was related and provided a foundation, which would not have to be duplicated, for attacking air and water pollution. It was necessary to begin building a center which would support their Zone structure and respond to the Governments' requests for assistance.

Following the Executive Committee's comments at its 1964 meeting, assistance had been stepped up, by the use of short-term consultants, numbering as many as 100 a year, which in itself had involved a logistics problem, because the higher the level of consultant, the more difficult it had been to match people with time and need. Thus, much effort and substantial resources had been expended in obtaining outside consultants and trying to fit them into the pattern. What was currently proposed would tend to eliminate that, and the resources re- leased thereby could be put into the center by way of additional support.

Dr. BLOOD (United States of America) said he had understood Dr. Hollis to say that the proposed center would have no connection with the Government of Peru. Yet he wondered whether there would not have to be a considerable input by the host country for such a center.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said he had meant that the project would be administratively independent in that it would be a regional facility serving all of the countries of the area. There would indeed be very close collaboration with the Government of Peru insofar as laboratory, research, and training facilities were concerned, because there had to be a balance between great aspirations and the reality of potential resources. For example, in the beginning regional consultants who were already budgeted for would be Page 96 Fifth session 56th Meeting employed. There was already a consultant in occupational health and industrial hygiene, one on air pollution, one on housing and urban affairs, and by post adjustment there would be by year's end another on water pollution and ultimate- ly another on water supply. Thus they were thinking of five professional people aready provided for who would permit the center to begin modestly and try to help the countries to develop their own research and further their own training networks.

They looked forward to very close collaboration with their colleagues in the University in Peru in supporting that small staff. Also, Peru was working on a proposal for a United Nations Development Program project geared to further strengthen research, training, and educastion at the University.

Dr. BLOOD (United States of America) said that precisely what he had been looking for was assurance that the host country was supporting the endeavor and would provide the base for all of its operations.

The CHAIRMAN announced that the next item of business was the examination of the AMRO projects for Zone IV.

Dr. AGUILAR HERRERA (Guatemala) inquired whether project AMRO-3304 (Lab- oratory Services) involved providing assistance to the biological products laboratories Dr. Horwitz had mentioned, in order to improve the quality of those products, or whether it had another purpose.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that while it was not a new project it had never been included in the budget before because it had been financed with a grant from the Inter-American Development Bank. Since the grant had been discontinued, the project was included in the PAHO budget for the first time. The consultant for the project had been advising not only the diagnostic laboratories, but also and especially, the laboratories preparing biological products in Bolivia, Colombia, Ecuador, and Peru.

Dr. CALVO (Panama) found a certain similarity between projects AMRO-4804 (Medical Care Services) and AMRO-4814 (Courses on Hospital Planning) and requested information on the purpose of each.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) acknowledged the similarity between the two projects but pointed out that AMR0-4804 was a program of assistance in organizing permanent services, whereas AMRO-4814 referred to a course to train personnel in one specific area of medical care. The consultant for AMRO-4804 advised all the countries in the Zone in matters of medical care, and, at the request of the Governments, had made a number of studies and suggested plans for the regionalization of hospital and medical care services. He had also worked with the countries to bring about a certain degree of coordination at the local level between facilities providing medical care to specific population sectors, and had assisted them in planning, equipping, and staffing certain new hospitals.

The course in hospital planning was specially designed for architects and engineers, who had shown great interest in them. Two had been held thus far. That was the first, and extremely interesting, phase of a project jointly Page 97 56th Meeting Fifth session undertaken by the Government of Peru and the Organization. The project, in which two groups of the Bureau's staff--the environmental sanitation engineers and the administration group--were participating, should help to fill one of the needs mentioned during the session in the discussion of Dr. Portner's statement on administration, namely, the need to organize certain professions very directly involved in the administration of those services.

Dr. CALVO (Panama) inquired if the engineers and architects participating in AMRO-4814 had had training in health planning or if they were hired with no experience in that field. He felt that those professionals in the ministries of public works or public health were generally not conversant with other aspects of health services. Furthermore, because of the tremendous progress in science, administration, medical care planning, and the use of electronic computers, it was increasingly difficult to provide hospitals with the latest equipment and train the staff in its use.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) emphasized that the Lima course in hospital planning was modest in scope and certainly did not satisfy all the requirements indicated by Dr. Calvo. Although it would take considerable time for the Latin American countries to familiarize themselves with the use of computers or to reach the stage of total mechanization of their hospital equipment, a first step was being taken in that direction by drawing the architects into hospital planning and construction. While it was true that, as Dr. Calvo had said, many of them had no experience with health programs, the Organization was interested in initiating them into principles of programming and planning in that field and hoped that similar courses representing a definite contribution to health planning would be organized in the future on a regular basis.

The CHAIRMAN said that possibly the current designation of project AMRO- 4814 was not the most appropriate. Hospital planning was a very broad field, and perhaps a better title would be "Hospital Programming and Design."

The session rose at 12:25 p.m. SIXTH PLENARY SESSION Friday, 28 April 1967, at 2:40 p.m. Chairman: DR. ALBERTO E. CALVO (Panama) Later: DR. DANIEL ORELLANA (Venezuela)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN declared the session open and announced that the examination of Zone V projects would continue.

Dr. ORELLANA (Venezuela) asked for information on project Brazil-6221 (Library of Medicine).

Dr. MARTINS DA SILVA (Chief, Office of Research Coordination, PASB) said that the item represented the commitment of the Organization through a multilateral agreement signed recently with the Government of Brazil and to be signed with the National Library of Medicine of the Department of Health, Education, and Welfare of the United States of America to establish in Sao Paulo at the Paulista School of Medicine a Regional Library of Medicine for South America.

In 1965, in an effort to improve scientific communications in the Americas, the Organization, in close collaboration with the National Library of Medicine of the United States of America, sent two consultants to South America to assess the situation and propose solutions. They made several recommendations 1/ which were discussed at the Fourth Meeting of the PAHO Advisory Committee on Medical Re- search and also submitted to the XVI Meeting of the Directing Council in 1965; among them was one that the first Regional Library of Medicine should be established in the area of Sao Paulo, Brazil. For the past two years an attempt had been made to obtain the outside funds necessary to launch the project but only in the last two months, by scaling down the proposed budget for the first year, had the Organization been able to sign the agreement. Accordingly, the project was already under way.

Besides the Organization, it involved the participation of the Ministry of Education and Culture and the Ministry of Health of Brazil and the National Library of Medicine (USA). The initial contribution agreed upon was $50,000 or its equivalent in local currency, by the Government of Brazil; $50,000 by the U.S. National Library of Medicine, and $25,000 by PAHO. In addition, the contribution of up to 50,000 books by the National Library of Medicine and the U. S. Book Exchange would complete the collection of the host library, which was also offering space, facilities, and certain personnel.

_/ Mimeographed document RES 4/12 (9 June 1965).

- 98 - Page 99 56th Meeting Sixth session

The Library would be international in scope and, in addition to providing bibliographic information, would also serve as a demonstration center for modern library techniques and, eventually, as a Medical Literature Analysis and Re- trieval System (MEDLARS) center for South America, utilizing electronic tapes containing most of the world's medical literature of the past five years. In due course literature search by machine would thus be one of the services provided by that Library. It would also provide training programs for senior librarians. Still pending was a decision on possible additional support from the Commonwealth Fund of New York, which had before it a proposal to participate in the project for the next three years.

Dr. HORWITZ (Director, PASB) noted that, as stated by Dr. Martin M. Cummings, Director of the National Library of Medicine (USA), of all requests for bibliographical information received by the Library, which contained a complete collection of the world's medical journals other than those published in the Cyrillic alphabet (i.e., more than 3,500 journals per year) more than 52 per cent came from Latin America. That was the reason for transferring that work to a location closer to the users and interested parties. As new schools of medicine, dentistry, nursing, and others were established in the United States of America, books and journals became less available for loan abroad. That fact had led to the submission of the project to the XVI Meeting of the Directing Council. It could not then be put into practice because the Bureau's idea had always been that it should be financed primarily by grants, with as little help as possible from the regular budget. The purpose of the project was not so much the furtherance of research as the improvement of the quality of instruction in all health fields. The program was closely connected with the project for the supply of textbooks for medical students. It was hoped that within three or foeur years the Library would have become very active and would be up to date on all important advances in medical and health problems and be able to offer solutions to teachers in the Hemisphere and, through them to students, with the result that the content of the medical course would be continuously renewed. That was not an unattainable ideal, but a perfectly feasible program.

The main thing was to establish the Library. An item of $25,000 had therefore been included for that purpose in the regular budget, and the Commonwealth Fund would, it was hoped, approve a request for funds to cover that allotment.

The CHAIRMAN stated that the National Library of Medicine (USA) was going to make its services available to Panama, where with the Gorgas Memorial Insti- tute it would cooperate in establishing the regional-library of Panama to serve the Central American countries and the Caribbean area. For that purpose the Government of Panama had recently ceded a highly valuable tract of land in Panama City next to Santo Tomás Hospital, which was used by the Medical School. The Gorgas Memorial Institute was currently negotiating the financing of the construction of the building. It was therefore very likely that the second project for a regional reference library, under the National Library of Medicine of the U.S.A. would be carried out, thereby providing a most important educational tool for the entire region of Central America and the Caribbean area, including Colom- bia and Venezuela. When the budget for 1968 and the one for 1969 were taken up, the Organization should be aware of those plans and participate in a project of that kind which would benefit many of the countries. Page 100 Sixth session 561h Meeting

Dr. BLOOD (United States of America) asked whether the amount budgeted was a single or a continuing commitment and whether it was possible to forecast future commitments.

Dr. MARTINS DA SILVA (Chief, Office of Research Coordination, PASB) said the budget represented planning for three years. Six months before the end of the three-year period, an appraisal would be undertaken and the question of continued support resolved. A sum would be budgeted in each of the next three years.

Dr. ACOSTA-BORRERO (Colombia), referring to the project Brazil-0200 (Mala- ria Eradication), asked for information on the progress made in implementing the recommendations of the PASB seminars on the coordination of the malaria eradication programs with the general health services.

Dr. LYNCH (Regional Adviser in Public Health/Malaria Eradication Programs, PASB) said that the problem of coordination had been discussed at the international seminars held in Poços de Caldas (;Brazil) in 1964 and at Cuernavaca (Mexico) early in 1965, and that certain conclusions were reached. 2/ The coordination program itself began in May 1966, and a number of local seminars either had been or were about to be held: one in Trujillo (Peru); two more to be held in 1967 in Colombia; a second seminar in Arequipa (Peru), also in 1967; another in North- eastern Brazil; and one more in Honduras. What was involved was a series of local seminars that would examine the problem and decide how to solve it locally, on a different level from that of the international seminars. It was hoped that the seminars would be immediately followed by the launching of local programs providing for the increasingly active participation of the general health services in malaria eradication campaigns. Once that was done, further measures would be necessary to ensure maximum coverage of malarious areas, especially during the maintenance phase, as well as adequate epidemiological surveillance. In addition to his own services at Headquarters, a consultant assigned to the Zone IV Office in Lima was assisting with the projects.

Dr. ORELLANA (Venezuela) requested information on project Brazil-6700 (Bio- statistics Education and Population Dynamics) and wanted to know if it was related to interzone project AMRO-6700 bearing the same title.

Dr. PUFFER (Chief, Health Statistics Branch, PASB) said that Dr. Villarreal had referred to the postgraduate training centers and Dr. Martins da Silva to Brazil-6221. The purpose of both Brazil-6700 and AMRO-6700 was to provide postgraduate training in biostatistics and in population dynamics and demography. The center in Brazil was to be devoted primarily to the training of professional personnel. A sociologist had been employed and was being trained in demography; an economist was being trained at Princeton University, and a medical demographer- pediatrician was being trained at the University of Michigan. Thus the faculty was being prepared. It would be a center for the study of population problems and would provide courses in the field.

The first course was tentatively scheduled for October-December 1967. Dr. Irene Taeuber, an outstanding demographer, was rendering consultant services

2/ Published in Spanish in Scientific Publication PAHO 118. Page 101 56th Meeting Sixth session in the project and it was expected that she would assist in the planning of the first course, which would be given as soon as the faculty returned to Sao Paulo.

By 1968 it was expected that one-year courses would be available. Students would be university graduates and it was expected that many would be physicians from departments of preventive medicine. They would receive training in population and biostatistics, so that they would understand population growth and the interrelations between birth and death rates and socioeconomic factors. The aim was to bring into focus the relationship between population growth and the mul- tiple factors involved in population changes.

The CHAIRMAN said it would be advisable to specify whether the project, which was for the benefit of all the Latin American countries, should be carried as a country or interzonal project.

Dr. ORELLANA (Venezuela) said that Dr. Puffer's explanation was satisfactory as far as the nature of the Brazil project went, but that its relationship with project AMRO-6709 (Research Training Programs in Health and Population Dy- namics) should be clarified. If it was a project to expand training facilities, then it would be proper to consider it as interzonal. It should also be borne in mind that Brazil was both a country and a Zone, a coincidence that also posed a problem.

Dr. PUFFER (Chief, Health Statistics Branch, PASB) said that it was a very important question. Though Brazil-6700 was an international training project, it had been felt that a country the size of Brazil certainly needed a center and would provide training for a good number of Brazilians also. Project AMRO- 6700 might possibly be divided, for budgetary purposes, into a part for Chile and one for AMRO. That would have to be decided because there was going to be an increasing number of centers and the whole question of the development of the centers which Dr. Villarreal had spoken of would be dealt with later in the meeting. It was hoped to expand training projects in biostatistics education and population to as many as six, so as to strengthen medical research in the countries. Whether they should be country projects or international AMRO projects was a decision for others to make.

Dr. HORWITZ (Director, PASB) said that, considering the purposes of those projects, the time would come when at least one university in every country in the Hemisphere would have to include that type of instruction in its curriculum. Both centers had been planned with the idea that Governments could train a group of technicians in different disciplines who, on returning to their respective countries, would organize centers for population studies within the ministry or agency designated by the Government concerned. To be able to frame a sound population policy, the Governments had continuously to study the relationship between the growth of the economy as a whole and that of the population, and to give special attention to the structure rather than to the absolute value of those variables. In the debate on the relationship of population to development, which happily was no longer described as a mystery, as was done only recently, voices were being heard to the effect that, in establishing a population policy, attention should be paid to the future, and the immediate future was the next 20 or 30 years. The Americas had no technicians qualified to undertake that kind of study, and it was the purpose of the first two centers to provide them; they Page 102 Sixth session 56th Meeting had not yet done so because they had only begun to operate. In the next four or five months, biologists, economists, sosiologists, clergymen, and others would meet to examine the problem as a whole so as to be able to go on studying it when they returned to their own countries. Otherwise, nobody knew how the Governments were going to formulate a population policy. There was no one population policy and to frame the appropriate policy the current lack of information would have to be overcome.

Dr. BLOOD (United States of America) asked what was the status of schistosomiasis which had been described as one of the major health problems of Brazil and some of its neighbors, and what the future held for the solution of the problem.

Dr. OLIVIER (Regional Adviser in Parasitology, PASB) said that the Organ- ization.had been very interested in the work on schistosomiasis in Brazil, where good progress had been made.

Recently the Government of that country had become interested in expanding the national program and had made a plan for the development of studies in four pilot control areas, under the direction of the National Institute of Rural Endemic Diseases, with headquarters in Rio de Janeiro and laboratories in Recife and Minas Gerais. It would be an operational research project, the intent of which was to determine the efficacy of various control measures and to assess probable costs. It would provide the pattern for control work in the rest of the country as time went on and also, of course, provide an opportunity for the training of personnel for an expanding program.

The Government of Brazil had made an arrangement with the Peace Corps and with the Agency for International Development (USA) in Brazil. An interesting aspect was that the Peace Corps had agreed to train about 30 volunteers to take part in the project. In other words, they would become part of it in the sense that the Peace Corps volunteers would serve under the direction of the national technical authorities. It was an interesting proposition because if such an arrangement were to succeed, it would offer opportunities for collaborative work of that type in other fields. PAHO's participation in the Brazil project was that of assisting with the national plan and cooperating in promoting the project; it also hoped to provide technical services for the evaluation of the project.

The CHAIRMAN noted that the problem was continental in scope and that it might perhaps be best to view it as a whole when the meeting took up the proper item on the agenda. He added that the meeting would discuss the Zone IV projects, starting with those of Argentina.

Dr. AGUILAR HERRERA (Guatemala) asked why the Pan American Zoonoses Center was shown as an Argentina project and also as an AMRO project. Such duplication was possibly due to the fact that the Center served Argentina and the other countries in the region. He noted that, as a country project (Argentina-6700, Pan American Zoonoses Center), the revised PAHO budget had assigned it an item of $105,501, which was not shown in the provisional draft budget estimates in Offi- cial Document 67. On the other hand, under project AMRO-0700, also for the Center, the item of $108,557 charged to PAHO in the provisional draft, had been Page 103 56th Meeting Sixth session

reduced to $25,322. However, by adding the allotments for the country and AMRO projects it came to a sizable and satisfactory amount, but he would like an explanation of the reasons for the changes.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) recalled that in 1966 the Government of Argentina had submitted to the United Nations Develop- ment Program (UNDP) a project for strengthening the activities of the Pan American Zoonoses Center. The project, which was a national one, showed the contributions of the Government of Argentina and of the Organization as complementary to the resources requested from the UNDP. The project was approved by the Program, entrusted its execution to WHO, and, by extension, to its Regional Office for the Americas, and classified as country project Argentina-0700. As a condition for the approval of national projects, the UNDP required a contribution from the interested country either in local currency or in works, suppliest or services. Since it was a tripartite project in which PAHO participated, it had been decided, for accounting purposes, to transfer to the national project the funds de- ducted from project AMRO-0700 plus the supplementary funds established in the Plan of Operations signed on 5 September 1966 between the Government of Argentina, WHO, and the UNDP. The project had therefore been presented as AMRO as well as Argentina-0700 because, in keeping with the conditions of the United Nations grant, it always had to be shown as a national project even though it had regional purposes.

Dr. AGUILAR HERRERA (Guatemala) asked why in Official Document 67 the contribution of the Government for 1968 was considerably smaller than in 1967.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) explained that Official Document 67 did not show the contribution actually approved by the Government of Argentina under the new Plan of Operations (September 1966), by which time that document had already been printed, but it would appear in the next budget document showing the new estimates approved for the Center.

Dr. BLOOD (United States of America) asked whether full information on funds from all sources showing staff, personnel, etc., could be found in a single presentation. He found it difficult to visualize it as broken down in Official Document 67.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) added that the document on the new plan to strengthen the activities of the Pan American Zoonoses Center contained all the details on the project. He invited Dr. Blood to consult that document in the Bureau's files.

Dr. HORWITZ (Director, PASB) added that, if the members so desired, the document could be distributed to them.

Dr. ORELLANA (Venezuela) brought out the fact that project Argentina-4 803 (Latin American Center for Medical Administration) was not shown in Official Document 67 and appeared for the first time in Document CE56/5. The total allotment for it was $37,267.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) explained that, although the project was only just getting under way, it had long been under Page 104 Sixth session 56th Meeting negotiation. The Government of Argentina, Columbia University, and the W. K. Kellogg Foundation had had it under study for three or four years. It had been put into effect because the Government of Argentina had shown special interest in having it go into operation at the earliest possible moment. After the elimination of a few minor difficulties in the manner of presentation of the projects to be conducted by the Center, the Director of the Bureau signed the agreement establishing the Center on 7 April 1967 as one of the ceremonies commemo- rative of World Health Day.

The essential purpose of the Center was practical research in aspects of medical administration, and the training of senior staff, i.e., those who were to occupy high medical and nonmedical posts in the administration of hospitals and medical services. The staff of the Center would be composed of both Argen- tine and international staff and in the first few years would render services primarily to Argentina; later it would extend its training and research activities and services to other countries in Latin America. Then, hospitals or health regions would be entitled to ask the Center to conduct surveys on manpower resources, demand for medical care, service costs, etc., and the Center could undertake for countries or institutions that requested them studies of their problems in terms of specific local conditions. The agreement provided for contributions from countries other than Argentina to the financial support of the Center as well as for cooperation with it to be repaid in the form of services they themselves needed.

Columbia University, of New York, was participating, not financially, but by providing teaching staff. For example, the Director of the School of Public Health and Administrative Medicine of that University had already agreed to go to Buenos Aires in the following month and to stay there as long as necessary to draw up the curriculum and plans for operational research to be conducted by the Center in its first stage. Later on other professors would spend brief periods there. Moreover, Columbia University had offered to reserve a certain number of places in its courses for fellowship holders sent by the Organization for training as teaching and research staff for the Center.

Finally, the W. K. Kellogg Foundation had also expressed a keen interest, since it was one of the fields of its special concern. In the past the Founda- tion had helped similar centers in the United States of America, and would very probably cooperate at a later stage. For the time being, the staff of the Center would consist of a medical director, a secretary, international staff, and short-term consultants, and the supplementary secretarial and administrative personnel provided by the University of Buenos Aires or the Ministry of Public Health of the Government of Argentina, as appropriate. There were also sufficient funds to award four academic fellowships for the training of the personnel who would subsequently be responsible for the operation of the Center. When the Kellogg Foundation began its cooperation, which might be in 1968, sociologists, anthropologists, economists, planners, and professionals in the different specialties would, it was hoped, become available for the conduct of the manpower surveys, operational research, and other activities relating to the purposes of the Center.

Dr. ORELLANA (Venezuela) stated that he had two comments to make. First, he referred to the project entitled "Latin American Center for Medical Adminis- tration" which appeared as a country project; second, Official Document 67 Page 105 56th Meeting Sixth session showed no project 4803 for Argentina, whereas Document CE56/5 indicated that there was one, with an allocation of $15,600, charged to PAHO, which was later revised and increased to $28,267.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) explained that the discrepancy was due to the fact that the project was originally designated as Argentina-6101 (Center on Administrative Medicine). Later, when more emphasis was placed on medical administration, it was given a number in the 4800 series, which was used for medical projects.

Dr. BLOOD (United States of America), referring to Argentina-2200 (Water Supplies), said that apparently the Organization had provided some staff for that project. There seemed to have been considerable activity in the development of water supplies throughout the country and it might be very interesting to know how the Organization's assistance had contributed to it, and just how the whole operation functioned.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said the water problem in Argentina was, of course, particularly important in the smaller rural communities. Two organizations within the country had had somewhat similar responsibilities for urban and rural projects but that question had finally been resolved. The Government had obtained a sizable loan from the Inter-American Development Bank (IDB) and had organized a major water supply effort aimed specifically at the smaller cities and the rural towns and villages. PAHO's support had been generated by the need to develop not only the professional but, more importantly, the subprofessional personnel required to manage operations. There was also the problem of financing, of establishing water rate structures geared to economic conditions in the areas concerned. One interesting point that had emerged was that the traditional system of charges was being somewhat reversed, in that a minimum sum was being charged for the first few thousand gallons, which should favor the lower income group, and that charges then levelled off at a higher rate per thousand gallons as quantities used increased. It was a very practical way of meeting the problem in Argentina. The project also included short-term training courses, and an effort to put the development and construction of water systems on an assembly-line basis, by the grouping of communities. For example, in areas where well-drilling equipment was involved, the work was undertaken not project by project, but by drilling a series of wells in the same area through the organization of communities.

Dr. BLOOD (United States of America) asked what the role of the Organiza- tion had been in working with Argentina and the IDB in obtaining funds. He had the impression that often the Organization played a catalytic role that was unique, and he was wondering if that was so in the Argentina project.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that, in the case of Argentina, the Ministry had specifically requested the Director to assist not only in the preparation of the project, but also in the initial approach to and subsequent negotiations with the IDB. The Director had himself accompanied the Minister to the Bank on one occasion and after the initial presentation, PASB technical personnel in the country had, on two occasions, participated in the negotiations to work out the details of the loan. Page 106 Sixth session 56th Meeting

In the past; few days there had been a joint release by the Department of State and Department of the Interior of the United States of America, which would provide background information for the International Conference on Water for Peace, which would be held in Washington from 23-31 May 1967. That global document, which dealt with the water programs of the entire world, had highlighted the fact that the water program of Latin America provided an outstanding example of the catalytic function of an international agency, namely PAHO/WHO, in working with the international lending agencies, for the most part the Inter-American Development Bank, in developing sound projects and in carrying them through the loan stage to implementation. The document included the Organization's chart on the water supply development program in Latin America, and certain tabulations. He mentioned it because it reflected what one heard from many quarters, that the world in general was looking to development in Latin America as an example of what could be done and of experiences that could be used throughout the world.

Dr. BLOOD (United States of America) asked whether the provisions in the 1968 budget were sufficient to further the work of attaining the water supply goal of the Americas.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that at the current work level there were not enough resources to do what one would like to do, but the fundamental aim of the water program was to develop the capacity and competence of the countries to do the job. A billion dollar commitment for water supply was a very large commitment and certainly unprecedented in the world, but the real story lay in the development of capacity of Latin American countries to do the water job themselves. The recent training course in El Salvador mentioned by Dr. Portner in connection with administrative activity had been conducted entirely by experts from Latin America, and had been one of the most successful. Actually, PAHO did not have sufficient resources to carry out a program which involved the expenditure of billions of dollars. It was grateful for the assistance the Agency for international Development (AID) of the United States of America had given in recent years in supplementing those resources and was frankly distressed that it was to end in 1967. It would be most helpful if it could be continued for another year or two. Thus the resources were insufficient but they were going right ahead with the program.

The CHAIRMAN noted that the external financing agencies, especially AID and the IDB, could usefully regard PAHO as the proper catalyst in matters of technical decisions relating to loans in order to expedite the process of obtaining funds for the conduct of soundly conceived projects. With the technical assistance of the Organization, the Governments would be spared many difficulties in securing the endorsement of credit institutions, most specifically AID, IDB, and the World Bank. The great force of PAHO was not really being utilized. The Executive Committee should make it clear that PASB was the indicated teclinical agency to decide finally on the provision of funds for the execution of projects in the health field.

ur. ORELLANA (Venezuela) stated that various Argentina projects showed lump s-migrants and asked whether those grants were for special annual activities or for the actual operation of the projects. His reason for that observation was his concern that grants provided with no specific purpose were later treated as part of the budget of the national service itself, which made it difficult to Page 107 56th Meeting Sixth session match them with contributions from the countries themselves. It was his understanding that the work of the Organization was basically promotional and that, therefore, its assistance ought to be discontinued at some given point in a project or any other activity. Permanent grants might imply a commitment that a Government would be unable to fulfill when they stopped. The problem was not changed by making grants from funds other than those from the regular budget.

Finally he would like to know the reason for those lump-sum items in the form of grants. He added that there were grants in four of the Argentina projects, in one of them from extrabudgetary sources, in a second from WHO, and in the last two from PAHO. That kind of arrangement was to be noted throughout the budget for all projects, and not exclusively for those of Argentina. He would therefore like to know how funds received as grants were used.

Dr. HORWITZ (Director, PASB) explained that grants from institutions were for very specific purposes and, therefore, specifically earmarked for a given project. For example, on that very day he had been talking with the representative of the Research Foundation (formerly the Williams-Waterman Fund) about a relatively sizable contribution of US$100,000 to the Caribbean Food and Nutrition Institute. The Institute earmarked contributions for well-defined purposes, occasionally operational purposes, and it was only natural that it should receive guarantees that when any capital contribution was exhausted, steps would be taken to ensure the continuity of the project through contributions from other sources.

The question of Dr. Orellana concerned grants from WHO or PAHO, in which it was also appropriate to draw a distinction. Some were made essentially for research projects for specific purposes and stipulated periods, e.g., the Inter- American Investigation of Mortality. That Investigation concluded that, unless there were full-time personnel for the selection of death certificates and their exhaustive analysis in accordance with established procedures, the project was unlikely to be conducted in a satisfactory manner. Thus, there might be investigations which were operational because they were deliberately designed as such. There were a few other cases, most of them relating to institutions of learning, in which grants had been made for the introduction of certain aspects of teaching which the institution concerned was unable to finance and which the Organiza- tion regarded as important for the fellowship holders who would be attending those institutions. Occasionally the grants were also for operational purposes in that they facilitated the educational process.

There were also a few grants to defray the expenses of certain international conferences to be attended by professors and technicians from countries whose Governments could not assign funds for the purpose, so that the grants benefited the projects and, by extension, the participants and the Organization.

A careful study of each particular case in its own context and, especially, relating it to new activities or new fields within traditional activities, showed that the system was inevitable and was bound to expand rather than diminish. Except for groups of experts or reference centers for certain problems, the entire research program of WHO was carried out to a greater or lesser extent by means of grants to establishments or institutions as support for highly specific studies. When applied with care and in clearly defined cases, the technique for international collaboration was valuable and would increase in the years ahead. Page 108 Sixth session 56th Meeting

Dr. WEDDERBURN (Jamaica) requested information on the item Argentina-3107 (Research in Public Health). Apparently provision for three years had been intended but there seemed to be no allocation of funds for the continuation of the project, which had apparently been designed to establish priorities with respect to certain diseases.

Dr. HORWITZ (Director, PASB) said that the project in question had been requested by the Ministry of Public Health of Argentina during the previous administration. The central idea of Dr. O:iativia, who was the Minister at that time, was to set up in the Ministry a department of operational research, particularly in matters of health. In Argentina Professor Bernardo A. Houssay headed what was perhaps a model agency coordinating all kinds of scientific-- and hence fundamental--research. The Ministry wanted to have a similar institution, but focused basically on health, and it had therefore earmarked a sizable allotment for it and requested aid from the Organization, which in response provided two experts: Dr. Robert Dyar, Director of the Research Department of the California State Department of Health, and Professor Morris Schaefer, Profes- sor of Public Administration at New York State University in Albany. They trav- elled twice to Argentina, but on their f:irst visit advised the Minister that operational research could not be carried out unless the structure of the Minis- try and the quality of administration in it were improved. The Minister accepted that advice and began to take the appropriate steps.

The current administration had vigorously continued the reorganization of the Ministry and was so convinced of its success that it had requested the return of Professor Schaefer, who was currently in Argentina reviewing the progress made in the first stage of a truly far-reaching reform of the Ministry. Dr. Horwitz said that when he went to Buenos Aires recently for the purpose of signing the agreement on the Latin American Center for Medical Administration, both the Minister and the Secretary and Under-Secretary of Public Health restated to him their intention to set health research in motion again.

Dr. AGUILAR HERRERA (Guatemala) wanted to know what had happened to project Argentina-3104 (Health Services in Cuyo Region), which apparently had been eliminated.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) said that he was glad that Dr. Aguilar Herrera had asked the question immediately after the Director's explanation of what had happened to the health research project because it was precisely after Drs. Dyar and Schaefer submitted their report that the restructuring of the Ministry was begun. At that time there were only two general public health programs under way in Argentina. The one in the Cuyo Region, which originally covered only Mendoza andc San Juan and had since been extended to San Luis, and the one for services in the northwest, with headquarters in Tucumán. A program on the national or central level was organized immediately following the report.

Argentina was a federal republic with ministries of public health in its provinces. Hence, a project at the naticnal level was organized--Argentina- 3100--and since then the trend had been to gradually merge all provincial projects into the national one, from which to serve the provinces as circumstances permitted. The Cuyo program would be continued. What had happened was that Page 109 56th Meeting Sixth session projects Argentina-3102 (Health Services in the Northwest) and -3104 were to be merged into a single project under the title "Provincial Health Services." Since negotiations with the Government were still in progress, the headquarters of the provincial health services had not yet been decided; it was highly probable that it would be Buenos Aires and that the provinces interested would be served from there. Thus, although it would appear that the project had been eliminated, it was really being merged with another one for the sake of a more orderly arrangement. He added that the allocations for projects Argentina-3100 (National Health Services) and -3102 had been increased; under the latter the contribution from the United Nations Development Program had been increased from $17,913 to $33,400 in order to broaden the services to the provinces.

The CHAIRMAN announced that the meeting would take up the projects for Chile and, in regard to project Chile-0600 (Venereal Disease Control), asked whether venereal disease control was to be reincorporated into public health projects. Official Document 67 mentioned an increase in the incidence of those diseases in Chile. Nevertheless it would appear that they must have been very much reduced if the project had been eliminated.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that not only was the incidence of venereal diseases not diminishing, but it had been on the rise in all countries since 1957. That was why the Bureau was giving more attention to the problem and had organized a seminar _/ to study it and examine new control methods. After the seminar, several countries evinced renewed interest and Chile immediately requested aid for a course in the laboratory diagnosis of syphilis and other venereal diseases. The course was held, and the Government then asked for further help in a control program. Unfortunately, internal difficulties prevented the Government from obtaining all the funds it needed, and the Organi- zation transferred the sum earmarked for project AMRO-0600 (Yaws Eradication and Venereal Disease Control), a regional project, together with a certain number of additional consultants. If the Government were again to express interest in 1967 by providing the necessary resources, it would be possible to furnish the three months of short-term consultants and the two short-term fellowships that had been frozen.

The CHAIRMAN asked for information on project Chile-4802 (Cancer).

Dr. DROBNY (Chief, Health Promotion Branch, PASB) explained that it was a modest project started in 1965. It consisted in the organization of a Center sponsored by the School of Medicine of the University of Chile with the cooperation of the National Health Service and the National Medical Service for Em- ployees, for the purpose of establishing a cervico-uterine cytology department. The service was free to the public, in particular to patients referred by hospitals and physicians. Moreover, the department intended to train personnel so as to make the program nation-wide. The services had been steadily expanded and training was being given to several provincial technicians, one from Concep- ción, one from Valparaíso, and another would come from Antofagasta, for the purpose of setting up similar services in the provinces.

3/ Published in Spanish in Scientific Publication PAHO 137. Page 110 Sixth session 56th Meeting

Dr. BLOOD (United States of America) requested an explanation of the item Chile-3301 (Microbiology Center). The title of the project seemed a little strange because from the description given it was apparently designed to rein- force the Bacteriological Institute in doing what he believed was its basic function in any event. He failed to see how the creation of the Center within the Institute would serve that particular purpose.

Dr. HORWITZ (Director, PASB) said that the idea behind the project, conceived two years ago, was that an agreement could be reached to change the salaries of the staff of the Bacteriological Institute, which were very low and could not be raised under the legislation in force. At that time the idea had been to sign an agreement with the Organization under which the Ministry of Public Health might request that the personnel of the Institute be accorded the benefits of the legislation covering employees of private enterprises. That would have made it possible to pay much better salaries and acquire the services of technicians in other, and not necessarily medical, disciplines. Unfor- tunately the plan had not prospered and recently the Government, concerned over the situation of the Institute, had requested a very high-level consultant. Efforts were in progress to obtain the services of Dr. G. D. Cummings, of Lansing, Michigan, who had previously visited Chile to make a study of the situation and propose a definite project to the Government. He felt that the name of the project would eventually have to be changed, since the plan as conceived no longer seemed likely to succeed. Some agreements signed by the Organization with other Governments were used by them as a basis for legal measures to favor both the solution of certain problems and the technicians working in the activities concerned.

The session was suspended at 4:10 p.m. and resumed at 4:35 p.m.

Dr. AGUILAR HERRERA (Guatemala) asked why the item for project Chile-4300 (Mental Health) had been reduced from $7,500 to $5,000.

Dr. GONZALEZ (Regional Adviser in Mental Health, PASB) reported that the project was implemented in keeping with the guidelines laid down in earlier resolutions of the Governing Bodies, advocating the epidemiological study of the incidence and prevalence of mental illnesses, especially alcoholism and epilepsy, 4/ a highly costly effort since the study on epilepsy particularly required the acquisition of mobile equipment for use in rural as well as urban areas. For two years a grant was provided for the acquisition of that equipment and for the partial payment of some staff members handling the equipment.

Beginning in 1967, the project had been altered by converting it into one with short-term consultants, visiting professors, and fellowships, the purpose being both epidemiological field work and education. As a result, in addition to carrying out research and training personnel in a field as specialized as the epidemiology of those diseases, the University and the National Health Service had designated one of the four special professors of psychiatry of the Univer- sity of Chile to organize a demonstration area in which both types of work would be done.

4/ Official Document PAHO 58, 58-59. Page 111 56th Meeting Sixth session

It was his view that, if that activity was continued, the number of professors increased, and more experience acquired, the project could be transformed and constitute the basis for an excellent center for the training of psychia- trists, or rather of public health workers specializing in psychiatry or the epidemiology of mental illnesses. That was thereason for the existence of the project and why a grant-in-aid had become a project which, with the approval of the Government of Chile, would last for five years.

Dr. ORELLANA (Venezuela), referring to project Uruguay-4801 (Chronic Dis- eases), which appeared in Official Document 67 with an appropriation that had since been eliminated, asked what had happened to the project and what had been its nature, purposes, etc.

Dr. DROBNY (Chief, Health Promotion Branch, PASB) pointed out that the project had been in the budget of the Organization for several years. It was begun in response to the request of the Government of Uruguay for a study of cardiovascular diseases and cancer aimed at determining precisely what kind of project could be developed. In 1963, and again in 1964, short-term consultants visited Uruguay and made certain proposals, but the project could not be maintained for lack of administrative machinery in the Ministry of Public Health of that country, and it ceased to operate in 1966.

When the Government was askedwhether the project should be confirmed for 1968, the authorities replied that it would be better to make a complete study of the situation of health projects in the country. The project was related to Uruguay-3100 (National Health Services), under which an increase of $27,512 was assigned to those services to enable them to provide a physician who would handle all health problems at the national level and who would again study, with the competent authorities, outstanding problems and the projects that should best be conducted in the country.

He added for information purposes that at Headquarters of the Bureau there was an official whose position was included in project AMRO-4810 (Chronic Dis- eases) and who was exclusively engaged in studying cardiovascular diseases: namely, Dr. G. Wynne Griffith, who until recently had been working with Dr. Puffer on the Inter-American Investigation of Mortality but was currently examining the chronic disease situation. Those diseases were increasing in importance in the Latin American countries; many of them were leading causes of death, but there was a conviction that they could be prevented. Dr. Griffith was in touch with the United States Public Health Service, especially with the national agencies engaged in the control of cancer and the cardiovascular diseases, in order to determine what possibilities there were for developing operational research programs in the countries of Latin America.

Dr. ORELLANA (Venezuela) pointed out that it was very likely that the Organization would begin to receive requests for general advisory services in the field of the chronic diseases, inasmuch as they were being brought into increasing prominence by advances in preventive medicine. In a few years the Organization would also have to concern itself actively with the problems of old age and accident prevention. In Venezuela it had been possible to organize a department for the study of chronic diseases and a network of services for the early diagnosis and treatment of cancer. He noted that in the entire PAHO budget for 1967 there Page 112 Sixth session 56th Meeting was only one project for chronic diseases (Uruguay-4801), and that even that had disappeared from the budget for 1968. Dr. Orellana expressed his confidence that the study and care of those diseases would shortly become a new field of action for the Bureau.

Dr. BLOOD (United States of America) noted that the project on Chagas' disease in Uruguay was not to be continued in 1968. In view of the importance of the problem there, lhe wondered whether it was just a question of priority and whether there was some other way in which the work was to be done.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that Chagas' disease remained a serious problem for Uruguay. In that regard the Bureau had assisted the Government of that country a short time ago by providing a short- term consultant, Dr. Pedreira de Freitas, who died in 1966 and had been succeeded by Dr. Tulio Pizzi. Between them they liad prepared the program for the control of the disease all over the country, but difficulties were encountered in obtaining enough resources to execute it, so that the activity was postponed until those difficulties could be overcome. A staff member of the Bureau Dr. Solón Verfssimo, had been appointed to prepare a plan of activities, which would go into execution as soon as the necesary equipment and supplies, especially the proper vehicles, became available, as the project had been given priority.

Dr. AGUILAR HERRERA (Guatemala) asked for information on project AMRO-0506 Leprosy Control) for Zone VI.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) replied that leprosy was a problem in all the countries of the ¿Zone, with the possible exception of Chile, where the very few victims were now isolated on Easter Island. The Bureau was assisting by sending a consultant to study the problem. There was no real knowledge of the situation in Uruguay. In Paraguay the project had developed very actively, especially up to the time of the departure of the Director of the executive agency; since then efficiency liad declined although the Bureau was cooperating by sending consultants. The only country in the Zone where considerable progress had been made in the campaign against leprosy was Argentina. Following the seminar held in Belo Horizonte 2/ and that held later in Cuerna- vaca, 6/ attitudes toward the project in Argentina changed completely. The project was progressing very well there, with the assistance of a consultant from the Organization and the application of modern administrative methods. It would be one of three projects to be examined in the Seminar on Leprosy to be held in 1968.

Dr. Orellana (Venezuela) took the Chair.

The CHAIRMAN referred to the projects for Canada and pointed out that they were not being financed with funds from the PAHO regular budget but from WHO funds since Canada was not a member of the Pan American Health Organization. He then submitted for consideration the projects for the United States of America.

Dr. BLOOD (United States of America).j referring to the item United States of America-2300 (Aedes aegypti Eradication), said that it provided for two months

/ Scientific Publication PAHO 41, 1959. 6/ Scientific Publication PAHO 5-, 1963. Page 113 56th Meeting Sixth session of consultant services in 1967 and 1968. He was very pleased to mention that the Government of his country was making renewed and much more intensive efforts toward the eradication of Aedes aegypti and he expected that it would seek greater consultant assistance and guidance than was currently provided for.

The CHAIRMAN expressed his conviction that the Organization would do everything possible to meet the request made by the Representative of the United States of America.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that, in addition to the services of short-term consultants for two months, there were also those of the regional consultant.

Dr. AGUILAR HERRERA (Guatemala) requested clarification of certain points about the fellowship program. Project United States of America-3101 (Fellow- ships for Health Services) had the same number as that for the other countries, but in addition there was another project (3103) with the same title for the same country. It would appear that the funds shown in the PAHO regular budget had been transferred to project United States of America-3103, perhaps for the purpose of leaving just one project. He asked why the transfer had not been done in reverse so that all the countries could have the same number.

Dr. PORTNER (Chief of Administration, PASB) said that, as Dr. Aguilar Herrera had indicated, an effort had been made to consolidate the two items in one project, the WHO regular fellowships and PAHO regular funded fellowships-- an effort at consolidation and simplification that could well be followed in other cases.

The CHAIRMAN referred to project United States of America-3102 (Medical and Public Health Training) described in Official Document 67 (p. 105). Accord- ing to the text, the purpose of the project was to help officials of the United States Public Health Service, in particular of the Office of International Health, to visit the countries of origin of fellows studying in the United States of America. In his opinion, that purpose was highly praiseworthy and of primary importance for the countries of those fellows, since the flow of students from Latin American countries to the United States of America might well have been hampered by a variety of difficulties. Dr. Orellana stressed that he had upheld the need to train that personnel outside the Latin American countries, and especially in the United States of America, where they enjoyed the collateral advantage of learning English. He asked whether the project was being carried out and what results had been achieved.

Dr. CHARNES (Chief, Fellowships Branch, PASB) said that the project had been under way for several years and was initiated precisely to enable the faculty of the schools where the fellows were studying to become acquainted with the problems in the countries of origin of their students. The project had made satisfactory progress and so far no problems had been encountered.

The CHAIRMAN emphasized that it was a highly meaningful program which benefited fellows from the Latin American countries. He hoped that it would increasingly give the young public health physicians of Latin America access to the knowledge and experience of the United States of America. Page 114 Sixth session 56th Meeting

He announced that the Committee would take up the interzonal projects which began on page 44 of Document CE56/5..

Dr. BLOOD (United States of America) said that the parasitic diseases which so far had not been mentioned were of interest to all, and it would be most enlightening to know what was the international approach now deemed most productive in dealing with them.

Dr. OLIVIER (Regional Adviser in Parasitology, PASB) said that the general aim of PAHO was, of course, to assist the countries in their research and control programs. Of greatest help would seem to be assistance in the development of standard techniques so there would be comparability between data from one country and another, and thus a more logical and valuable approach to the problems. PAHO also hoped to be of some assistance in promoting closer contacts between the workers in the various countries. Often communication was not very rapid. Com- munication by means of publications was relatively slow and stimulus was sometimes given simply by assisting in the dissemination of information. Finally, it was hoped to help countries with parasitic diseases in common to cooperate in programs and perhaps exchange skilled personnel, to consult one another on planning, so that each could take advantage of the progress made by the others. In connection with the Sixth Meeting of the P?AHO Advisory Committee on Medical Re- search, there would be a special session dealing with immunological aspects of parasitic infections. It was very appropriate that it had been selected as the special topic because parasitic infections certainly required a great deal of attention in the Hemisphere. It was hoped that the intensive discussion of immunological problems would be very valuable, not only from the fundamental points of view in which there was much interest, but because progress in fundamental studies in immunology would eventually mean progress in controlling those diseases.

Dr. da SILVA (Chief, Malaria Eradication Branch, PASB) referred to the projects relating to campaigns against parasitic diseases, presented in Document CE56/5 (p. 44). They were shown separately because certain investigations and tasks relating to each of them were to be carried out in different countries and by different specialized staff. As an example he cited project AMRO-0200 (Malaria Technical Advisory Services), which was partially funded by the PAHO regular budget, and under which advisory services were provided at the country level.

In the specific case of Central America, because of the importance of problems there, a Zone-level advisory group had been established; and under project AMRO-0209 (Insecticide Testing Teams) new insecticides were being tested for their suitability in areas where the vector had shown resistance to chlorinated insecticides. The project was financed w:ith WHO funds and was being conducted in El Salvador. Moreover, studies were nearing completion on an insecticide produced by Bayer which it was hoped to offer to the countries for general use.

Project AMRO-0210 (Malaria Eradicat:ion Epidemiology Teams) was also funded by WHO and was providing specialists in the epidemiology of malaria to study special cases of persistent transmission. The project was functioning most actively in Mexico. The aim of project AMRO-0214 (Advanced Courses in Malaria Epi- demiology) was to provide advanced training for local physicians in charge of the Page 115 56th Meeting Sixth session

epidemiology sections of malaria programs. The first course had already been conducted in Venezuela. Since it was the first course, it was decided to confine it to the training of Bureau personnel engaged in the epidemiology of malaria, but subsequent courses would be for local personnel.

Project AMRO-0216 (Research in Epidemiology of Malaria Eradication in Prob- lem Areas), which also included investigations in the epidemiology of malaria, was shown separately from AMRO-0210 because it concerned work in problem areas and was financed by PAHO, whereas AMRO-0210 (Malaria Eradication Epidemiology Teams) was financed by WHO. The purpose of AMRO-0217 was to study different' methods of mass treatment in areas where malaria transmission persisted. The Bureau was conducting trials with different combinations of drugs, using the funds earmarked for the purpose.

Finally, the purpose of project AMRO-0218 (General Health Services and Malaria Eradication) was the maintenance of the necessary surveillance in the various areas so as to ensure that achievements of the campaign would not be lost.

Dr. BLOOD (United States of America) asked what advanced courses in malaria epidemiology were planned for the immediate future. In regard to AMRO-0217 (Field Investigation of Mass Drug Treatment), he would like to know something of the grant program, and whether it included the work he had heard of recently in Panama. He would be very much interested in Dr. da Silva's impression of the results being obtained.

Dr. da SILVA [Chief, Malaria Eradication Branch, PASB), replying to Dr. Blood's first question, said that the commitment to conduct the course in advanced epidemiology could not be met because of lack of time to plan it, but everything possible would be done to hold it either in 1967 or at the beginning of 1968.

As for mass malaria treatment, project AMRO-0217 was contributing to the local costs of a study on a combination of primaquine and pyrimethamine for malaria eradication on the Sambú River in Panama, under a program being carried out by specialized staff of the Gorgas Memorial Institute together with the Director of the National Malaria Eradication Service of that country. One of the advantages of the mixture of those two products was that it did not generate secondary effects as did chloroquine, which many people refused to take for fear to those effects. Also, the mixture did not have a disagreeable taste.

The first year of study was nearing completion, and the first survey of the entire working area had shown that about 17 per cent of all persons infected were positive for P. falciparum and P. vivax. But in the last report received, which referred to the third quarter, that figure had already fallen to 0.8 per cent. The Bureau was negotiating the extension of the study for one more year because a highly interesting phase was about to begin, i.e., the painstaking epidemiological study of each case to determine the real situation. Every 15 days a record was made of movement of persons into and from the area and also of house-to-house visits to administer the drug to the inhabitants. There was evidence that transmission had not been interrupted in the area; in the third quarter, for example, an infant who had started to receive the medication after Page 116 Sixth session 56th Meeting

the launching of the program because he had become six months old, was found to be infected, thus demonstrating that the disease was being transmitted..

Dr. AGUILAR HERRERA (Guatemala) said that he was struck by the existence of two rabies control programs, and asked what the reasons were for having included a new project on the Mexico-United States border. He asked whether it was due to the emergence of some special :problem or simply because of a desire to wage a more energetic campaign in that region.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) said that currently rabies could best be described as an urban problem, with the dog as the principal vector; the United States of America was the only possible exception to that rule because within its borders the disease affected only wildlife. A statistical study covering the previous 10 years indicated that cases of the disease in both man and animals were growing increasingly frequent in the countries. According to the official reports of the Governments to the Organization, there had been an average of 60 to 70 human cases over the previous five years, with the greatest incidence in Argentina, Brazil, Mexico, Peru, Uruguay, and Venezuela. The disease was introduced into Uruguay in 1964 after almost 20 years of immunity, and the only country where no cases of human rabies had been reported was Canada. In the United States of America there was only one case in 1966.

Rabies control programs were practically limited to vaccination of dogs and, in some cities, to control of stray animals by trapping or poisoning. As a rule health services earmarked very small sums for rabies control programs and activities were limited to accasional vaccination and destruction of animals.

There was a scarcity of vaccine for both veterinary and human use although the Organization had been assisting the countries through the Pan American Zoonoses Center by training personnel chiefly in diagnosis and in the control and production of vaccines. One of the most important recent successes in vaccine production was its production in unweaned mice, a procedure developed by Drs. Fuensalida and Palacios a few years ago at the Bacteriological Inr;titute of Chile. Production had already been started on an experimental basis in several South American countries, including Argentina, Colombia, Mexico, Peru, Uruguay, and Venezuela. More than 90,000 vaccinations had been administered and, at least among those given in South America, there had not been a single complication.

As to vaccine for use in animals, some institutes in the Region were producing it, especially live modified virus in chicken embryo, but output was quite limited; in point of fact, the 9,000,000 doses produced in 1966 in the United States of America were only enough to meet the national demand.

The Organization's activities in the control program had consisted in giving advisory services to Governments and, in emergencies, in supplying materials such as vaccine and poison for destruction programs, but it had also organized (although it was not shown under :project AMRO-0709 for 1967) a Regional Seminar on Rabies, to be held next September in Argentina. That Seminar would, he was convinced, encourage the Governments to allot more money and assign more staff to rabies control, inasmuch as the :problem was growing. Page 117 56th Meeting Sixth session

In response to Dr. Aguilar Herrera's question on project AMRO-0710 (Rabies Control--Mexico-United States of America Border), Dr. Acha pointed out that at the meeting of the United States-Mexico Border Public Health Association in 1965, the Secretary of Health and Welfare of Mexico, the Surgeon General of the United States Public Health Service, and the Director of the Bureau had agreed to step up rabies control activities along the border, especially in the northwestern border of Mexico where the incidence of the disease among dogs and wild animals was rather high. The Organization had signed an agreement with Mexico for the conduct of a program which had been launched in September 1966 in Tijuana, Ense- nada, San Luis, Río Colorado, Mexicali, and Nogales and which it was proposed to extend in 1967 to the other border towns, mainly Ciudad Juarez, Reinosa, and Matamoros. For the program, the Organization had received a grant from the United States Public Health Service, which had also seconded advisory personnel to the Bureau. The funds budgeted were for the veterinarian stationed in Tijuana who was in charge of the field operations.

Dr. WEDDERBURN (Jamaica) said that Dr. Acha had mentioned other selvatic animals, but he wondered whether in any of the other countries the mongoose was the reservoir of rabies, as it was in Grenada where the mongoose population had once been estimated at 25,000 but which by a systematic campaign some 15,000 had been destroyed. Apparently the mongoose was a prolific breeder.

Fortunately, only about three cases of human rabies had been encountered there in a number of years. He had just attended a meeting at the Trinidad Regional Virus Laboratory which did the work of isolating the organism from the brain of the mongoose and he could say that those involved were extremely concerned about it. He wondered whether the Organization had any experience with that type of reservoir in other territories and, if so, whether there was any effective means of dealing with it.

Dr. ACHA (Regional Adviser in Veterinary Public Health,PASB) said that for several years the problem of rabies in the mongoose on Grenada had been of concern to the Organization and for the previous three years had been taking action in collaboration with the Government of Grenada; those were included under project AMRO-0701 (Rabies, Zone I). An expert was assigned to try to determine the exact mongoose population on the island as a preliminary to undertaking mongoose control by poisoning, vaccination of dogs, and diagnostic services which were carried out with the help of the Trinidad laboratory. The consultant had twice visited Grenada to study and evaluate the results of the poison. Two poisons-- zinc and sodium fluoroacetate--were used to control the mongoose population not only near inhabited areas, but also in the deserted part of the island, where those animals reproduced more rapidly. The mongoose was also found in Puerto Rico and Cuba. The Organization had requested the necessary equipment for the Diagnosis Section of the Department of Public Health of Grenada and had awarded a fellowship to a laboratory assistant from Grenada to work with Dr. Epstein in Trinidad on the diagnostic aspects; at the same time, poisons and supplies had been acquired and delivered to the Government of Grenada for control purposes. In his opinion, the program was perhaps one of the most advanced as far as the control of rabies in wild animals was concerned.

The session rose at 5:30 p.m. SEVENTH PLENARY SESSION Saturday, 29 April 1967, at 9:10 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM AND BUDGET EST2EIATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN declared the session open and announced that the review of the proposed program and budget estimates would continue.

Dr. BLOOD (United States of America) said that, if he did not ask about the Zoonoses Center his silence might be interpreted as lack of interest. He would like very much to know how that activity was developing with the new resources available. Doubtless, one of the greatest problems was that of recruiting staff with which to assume the new, increased, role.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) said that in September 1966 part of the Pan American Zoonoses Center was transferred to new premises provided by the Government of Argentina and that in that same month a Plan of Operations, whose cost was estimated at approximately $1,672,000, was signed with the United Nations Development Program and that Government for a five-year project to strengthen the activities of the Center. The Center had used those funds to expand its four laboratories: one each for bacteriology, virology, parasitology, and food microbiology, which were doing research on the four zoonoses covered in the Plan of Operations: rabies, brucellosis, bovine tuberculosis, and hydatidosis. The Center had also set up a technical assistance department to assist the countries and provide personnel training through courses and fellowships.

As to staff, those funds had made it possible to add nine new professionals to the established staff of the Center, despite the difficulty of recruiting personnel of that type.

Dr. ACOSTA-BORRERO (Colombia) asked whether the fellowships for veterinary medicine were included in the country or in the intercountry projects, and whether personnel training in the special fields mentioned was to be continued.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) said that the fellowships provided under project AMRO-6500 (Veterinary Medicine Education) were for the training of faculty members of schools of veterinary medicine, which in some instances might be provided at the Center; many of the fellowships were for regular academic courses in public health, microbiology, or other subjects.

Dr. BLOOD (United States of America) said it was certainly gratifying to learn that the increased resources made available to the Center were being

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translated into both equipment and personnel. He would like to know whether the staff available, or soon to be available, would be utilized for field consultation, and whether or not that activity was to receive increased attention. For example, he did not know whether or not during the recent outbreak of rabies in Ecuador a request had been made to the Organization for consultative services, but he would like to know if the Center would be prepared in the future to respond to such requests with the utmost speed.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) said that, since the Center had more resources and personnel, it would be able to respond more rapidly to the varied requests from Governments for advisory services, such as those on leptospirosis submitted by the Governments of Chile and Uruguay, for which advisory services had been rendered.

Under the plan drawn up, the Governments were to be given broader and more complete assistance. It would not be limited to occasional consultations or simply to the planning of activities, but would also include the formulation and implementation of effective disease control programs.

Dr. AGUILAR HERRERA (Guatemala) asked, in connection with project AMRO- 0901 (Schistosomiasis), what the situation was and what possibilities there were for the control of the disease, which, in his opinion, was becoming more important, as reflected in the growth of the funds assigned to the project.

Dr. OLIVIER (Regional Adviser in Parasitology, PASB) said that he could best answer the question as to the status of schistosomiasis by saying that, owing largely to the efforts of both PAHO and WHO, the information available on the subject had increased so greatly in the last 10 years, that the point had been reached where in some of the countries and in some endemic areas it was already possible to do a very effective job of control. In some parts of the world, notably Venezuela and Japan, effective control work had been done, but in the remainder of the world's endemic areas, there had not been very effective control. The experience of Venezuela would be useful in establishing control programs in the other endemic areas of the Hemisphere. Therefore, the funds under project AMRO-0901 would be used largely to study the situation and needs in the remaining endemic areas of the Hemisphere, such as in Surinam and the islands of the Caribbean, so they would be in a better position to plan control programs when the resources to do the work became available.

Dr. ORELLANA (Venezuela) suggested that a detailed review be made of activities under project AMRO-0800 (Pan American Foot-and-Mouth Disease Center) and especially of the scope of the project and the administrative changes that had been made in it. The proposed budget estimates for 1968 included an item of $1,202,836 for that project, which was more than the $926,285 shown in Official Document 67.

Dr. BLOOD (United States of America) suggested that consideration of the item be postponed until early in the following week, since by then his country's Delegation might well be in possession of information that would facilitate the discussion.

It was so agreed. Page 120 Seventh session 56th Meeting

Dr. ACOSTA-BORRERO (Colombia) requested some general informat:ion on public health training and on the educational procedures employed in the many projects for that purpose, notably AMRO-6100 (Schools of Public Health) and AMRO-6110 (Continuing Education in Public Health).

Dr. DIAZ-COLLER (Chief, Professional Education Branch, PASB) said that it was the continuing purpose of the Organization's projects to improve teaching methods and to foster greater exchanges between the various schools in Latin America. To that end, conferences were held every two years for the directors and faculty members of those schools at which they discussed subjects selected at earlier meetings and reported on new developments in teaching methods. The subjects already covered included biostatistics, the teaching of health administration, and the teaching of epidemiology. The subject of the Fifth Conference of Deans of Schools of Public Health, to be held in Buenos Aires, Argentina,in November 1967, would be the teaching of medical care.

As for the travelling seminars, three had been held so far. At the most recent one held in April, the deans of schools of public health in the United States of America and Canada had visited the schools of public health of Mexico, Chile, and Brazil. The seminars had been highly successful from the standpoint of exchanges not only between the participants and the faculty of the schools visited, but also between the participants themselves.

The purpose of the small sum provided under project AMRO-6100 was to help both those schools that had no specific program, by providing them with supplies and materials, and those that had no budgetary funds with which to obtain them.

Dr. HORWITZ (Director, PASB), referring to the measures which, in his view, the Organization should take to implement the decisions of the American Chiefs of State l/ at Punta del Este in health matters, said that the Bureau would be inviting all the public health schools in the Hemisphere to examine the decisions taken at that meeting with regard to education, science, and technology in order to determine whether the education they offered was as it should be. Clearly, if the experts in the Hemisphere did not adapt their thinking and action to the new currents of development, they would be out of step.

The Organization's assistance in the teaching of public health would probably have to be revised in the light of the review that every teaching establishment, from Canada to the southern tip, would have to make, inasmuch as fellowship holders came from every school in the Americas.

Dr. ORELLANA (Venezuela) pointed out, in connection with Dr. Horwitz's statement, that the most recent seminar on medical education, held in his country, had discussed, inter alia, the relationship between medical education and economic and social development, and had even made a recommendation similar to the suggestion of the Director of the Bureau. At that seminar, which was attended by economists and members of non-medical professions from the public sector, it was suggested that instruction in the fundamentals of development l/ OAS Official Records, OEA/Ser. C/IX.1, 1967. Page 121 56th Meeting Seventh session and its relationship to health should start at the undergraduate level so as to instill in the medical student from the very outset an awareness of the inter- dependence of those two broad sectors; important resolutions were adopted regarding the education not only of students but especially that of faculty members.

Dr. Orellana agreed with the Director on the need to revise the public health curriculum in the light of the Punta del Este decisions.

The CHAIRMAN felt that the subject should be urgently reviewed at the Hemisphere level because of the disparity between traditional public health and the content of postgraduate health studies. Not only had schools which offered the traditional one-year Máster's degree in public health been left behind, but the courses they offered no longer provided the training the public health specialist should have. Furthermore, some universities were expanding their curricula to include studies in preventive medicine and health as a whole.

As a former professor, he was particularly concerned about the scope of university education and the expansion of studies and expressed the hope that the Bureau would increasingly take independent action in that connection. He then asked Dr. Díaz-Coller if there was any correlation between the two levels of instruction, if consideration had oeen given to the matter of the requisite continuity in the training of a physician in public health, and whether thought had been given to lengthening the studies for a Master's degree.

Dr. DIAZ-COLLER (Chief, Professional Education Branch, PASB) explained that many schools had already upgraded their programs to the requisite level for training the personnel who would be in charge of public health activities at the national or provincial level. The medical schools would gradually have to include in their curricula the basic aspects of public health administration, epidemiology, biostatistics, and environmental sanitation so that students, when they became physicians, would be able to handle both public health activities at the municipal levels and clinical work. As to the problem of coordination, certain difficulties arose because of the fact that schools of public health, although of university level, came under the health ministries and not under the universities. Consequently, coordination of education in public health with medical education was not as close as it should be. The Bureau would have to chart new paths and study ways and means of establishing or strengthening that coordination. The administrative status of the public health schools had been of particular interest to the participants from the United States of America and Canada during the travelling seminar he had referred to earlier.

Dr. ORELLANA (Venezuela) said that in the medical schools of his country the integration plan comprised four stages: six years of training in preventive medicine and public health, during which there was as much horizontal integration as possible in each year, and vertical integration from the first to the sixth; the physician could work in the lower service levels upon graduation. Then the student took a four-month course in public health which qualified him for work in health centers a little more developed that those of the first phase; on completing that course the physician returned to a service and, shortly thereafter, could take the course for a Master's degree in public health. Upon completion of his training, the physician either went on to the higher levels or Page 122 Seventh session 56th Meeting remained at the Master's level or could take specialized courses in, for example, epidemiology or nutrition.

Although that plan was not limited to the classical one-year public health training and did ensure considerable coordination between university training and postgraduate studies, the constant and close rapprochement that should exist between medical and public health schools had not yet been achieved.

Dr. HORWITZ (Director, PASB) stated that in his view the correlation between undergraduate and postgraduate studies should not be confined to medicine, because there was so much striving, not to dissociate societies, but to plan integral development, i.e., to learn more about the relationships between functions that occurred spontaneously or were induced in the social milieu. That correlation should also be sought in sanitary engineering education in the context of the study of urbanization and industrialization; in the schools of architecture, in connection with the mental health aspects of housing, since it was often contend- ed that one should live underground if one wanted to concentrate. The subject should also be studied in schools of architecture and of veterinary medicine.

As to dentistry, three seminars had been held to review the entire curriculum and harmonize the preventive with the curative aspects. Schools of public health and of law did not teach the relationships between health and the law. The schools of public health and of administration did not teach the relationships between those disciplines and health administration and planning. Conse- quently, the universities were not in line with the recommendations of the American Chiefs of State.

Dr. Horwitz restated his opinion, expressed on several occasions, that the universities were not keeping abreast of modern developments and, what was worse, had made no progress in their proper function of advising the Governments on the basis of thorough studies of urgent social questions so that the political authorities might take the right decisions. In other words, they had not provided the facts, either directly as universities or through the proper training of professional and auxiliary personnel. Hence, a far-reaching review was needed, and the least that an agency such as the Pan American Health Organization could do was to bring the problem to the attention of the competent university authorities and to offer its assistance when the faculty had examined it.

Dr. SANTA MARIA (Observer, Chile) underscored the importance of the subject and attributed the problem to the fact that public health had been regarded as the exclusive province of the physicians, and that there had been no attempt to involve the other professions. That rather parochial attitude of the physician should be abandoned and health related to the other professions. A first step had been taken in Chile with the organization of a small committee in which health personnel joined with engineers from the School of Engineering, the Minis- try of Housing, and the Water and Sewerage Authority to determine what was needed and orient the programs accordingly. A similar effort had been made with dentists. In Chile the School of Public Iealth was part of the University and, as a matter of fact, some schools of the National Health Service were fully caught up in the activist spirit of the university. Page 123 56th Meeting Seventh session

Coordination of several schools, such as those of nutrition and nursing, was effected through the National Health Service, in which all services were represented, and the result was that in Chile there was high-level integration. What might perhaps have to be strengthened was the connection between health work and that of the other professions at the field level.

The CHAIRMAN found the problem posed by the Director very interesting; he was of the opinion that the universities of the Americas should take specific action, and that in the integration of university education the Bureau could take the initiative in all matters relating to health and welfare. He hoped that a meeting could be held in the near future on the coordination of undergraduate and postgraduate studies not only in the medical field but also in that of other health disciplines. The Chairman then invited Dr. López-Vidal to report on project AMRO-6110 (Continuing Education in Public Health).

Dr. LOPEZ-VIDAL (Regional Adviser in Personnel Training, PASB) explained that the aim of that project was to update the knowledge of physicians not only about classical medicine, based on diagnosis and treatment, but also of preventive and social medicine. It focused chiefly on physicians who would be facing the difficult problems of the rural environment.

That updating work had to be done jointly by the university, the ministry of public health, and the school of public health. Instruction had to be emi- nently practical and motivated, i.e., "operational" in nature, related to the problems confronting physicians. The idea was to bring the physicians in one area together to discuss the problems they faced. Those problems, which shared a common epidemiological and ecological basis, because they arose in the same environment, could constitute the main justification for the courses. The university would participate in the instruction which would be provided by the professor of the subject concerned. For example, if the problem of infant diarrheas were chosen, the professor of pediatrics would be called upon, and would take charge of the clinical part. The work of that professor would be supplemented by that of a specialist in epidemiology or health administration, attached to the school of public health or the ministry or, if that specialist were unavailable, by a short-term consultant.

But the updating of instruction in the basic disciplines that the physician needed, especially in statistics, epidemiology, and health administration, would always hinge on the given motivation, without forgetting that the latter made itself felt in, for example, the need to improve environmental sanitation, while at the same time stressing the influence of the social conditions that generated or perpetuated those diseases, or weakened resistance to them. In short, the idea was to devise a brief, intensive,and comprehensive course. Another example would be a case of chronic tuberculosis, which would lend itself to a discussion by physicians of the problem of ambulatory vis-a-vis hospital treatment, after which the local public health administrator would discuss, with those in charge of the work, whether ambulatory treatment or therapy in a sana- torium were advisable.

The material presented by the physician could also be used to motivate the teaching of the statistician and to make him understand that he must provide the data without which there could be no planning or even any evaluation of the work done. Page 124 Seventh session 56th Meeting

Dr. ORELLANA (Venezuela) asked for information on projects AMRO-3300 (Lab- oratory Services) and AMRO-3311 (Training of Laboratory Personnel), since it was his impression that that was one of the fields where the greatest difficulty was being experienced in the Hemisphere, and particularly in Latin America. He emphasized the scarcity of well-trained laboratory personnel for diagnostic purposes and even for research in public health and in medicine as a whole. It was his understanding that the Latin American countries had not yet reached any agreement on the professional and subprofessional categories of technical laboratory personnel, and he was interested to hear the viewpoint of the Bureau. With regard to project AMRO-3308 (Seminar on Laboratory Services), shown in Official Document 67, Dr. Orellana asked whether the seminar was held in 1966 and, if so, what its results were.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said that, despite recent progress in developing laboratory services in some Latin American countries, many had not reached the requisite level of efficiency in diagnosis, research, testing of biological products, etc. Aware that the effectiveness of laboratory services was a prime factor in the proper functioning of health services, the Bureau had long been giving special attention to the problem. Thus, at the regional level, there were three laboratory projects, and there were others at the national and Zone level, too.

PAHO had assisted the Governments in organizing and improving health laboratory services. That assistance took the form of services by short- and long- term consultants, and by Zone and Headquarters personnel. Another important activity was assistance to the countries with personnel training, particularly through fellowships. Efforts were being made to supplement those activities by organizing courses such as the one on the laboratory diagnosis of smallpox conducted in 1966 in Sao Paulo, Brazil, and courses on laboratory techniques (sero- logy of syphilis) and one on the microbiology of tuberculosis which was held also in 1966 in collaboration with the Government of Venezuela and was to be repeated in 1968.

The initial purpose of project AMRO-3311 was to organize four courses: one each on enteric bacteriology, immunofluorescence techniques, mycobacteriology, and tissue culture. Budgetary considerations reduced the number of courses to two, the one on enteric bacteriology and the one on mycobacteriology. It was hoped that the courses on tissue culture and immunofluorescence techniques could be held in 1968. The costs of the courses on the laboratory diagnosis of smallpox to be offered in 1967 would be defrayed with funds assigned to the smallpox eradication program. Another important Bureau activity was the supply of biological reagents, many of which were obtained under an agreement with the Nation- al Communicable Disease Center of the United States of America. The National Institutes of Health of that country were also cooperating.

The other- project that complemented those activities was AMRO-3307 (Vac- cine Production and Testing). The purpose of that project was to encourage the national laboratories to use the most modern standards and techniques in the production and control of biological products. Under that project the countries were being supplied with reagents and strains for the preparation of the biological products as well as with the services of short-term consultants in Page 125 56th Meeting Seventh session specified fields and of reference laboratories. Although it was a rather old project, it was not being fully used by the Governments despite the importance of the services.

In conclusion, he referred to project AMRO-3308 (Seminar on Laboratory Services), which had been scheduled for 1966, but which had had to be postponed until 1967, mainly for administrative reasons.

Dr. AGUILAR HERRERA (Guatemala) agreed with Dr. Bica on the scanty use being made of the services offered by project AMRO-3307 and thought that it would be worth while urging the Governments to make as much use of it as possible and so maintain the quality of the products of national laboratories at the highest possible level.

Dr. BLOOD (United States of America) said it was very important to give further consideration to the question of laboratory services, not only because of their basic significance to the health services of individual countries, but because they struck at the root of some international health problems. He was referring specifically to the follow-up services on eradication programs for epidemic diseases. The importance of the maintenance phase had been mentioned. During that period and later, when some countries were free of a given disease while others were still fighting it, the importance of effective surveillance services was evident. But one could not develop a surveillance system without a good diagnostic system; there could be no reporting of disease until it had been diagnosed. Hence the need for laboratory services, which were really non- existent in many parts of the Americas. He hoped that they could perhaps be strengthened more in the future than was evident in the budget for the coming year. He noted that the position established at Headquarters had been vacant for some months, and wondered whether there was any chance that it would be filled soon.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) explained that the post had already been announced and that the deadline for applications was 15 May. Project AMRO-3307 (Vaccine Production and Testing) did not include the testing of smallpox vaccine because it was not allowed to enter the United States of America. Hence, an agreement had been reached with the Serum Insti- tute of Copenhagen, Denmark,and, more recently, with the Connaught Laborato- ries at Toronto University, in Canada. That was yet another service that the Governments were not using to full effect. Under the agreement with the Connaught Laboratories the Bureau could send two experts on periodic visits to laboratories producing smallpox vaccine.

Dr. SANTA MARIA (Observer, Chile) asked whether the Bureau intended to train medical laboratory personnel.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) replied that the course was designed primarily for physicians, since it was thought best to train auxiliaries in their own countries.

Dr. SANTA MARIA (Observer, Chile) explained that he was not referring to auxiliary personnel, but to professional laboratory workers from the old schools of pharmacology, currently known as schools of chemistry, because, in Page 126 Seventh session 56th Meeting his judgment, the physician who had studied anatomy and gynecology, etc., should be reserved for functions that he alone could perform, whereas in public health advantage should be taken of professionals trained in other than medical schools.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) agreed with the Ob- server of Chile and remarked that the training was open not only to physicians but to pharmacologists and biochemists as well.

The session was suspended at 10:40 a.m. and resumed at 11:00 a. m.

Dr. AGUILAR HERRERA (Guatemala), referring to project AMRO-311C) (Coordina- tion of International Research), asked for information on the work done by the Office of Research Coordination, established in 1961, and by the PAHO Advisory Committee on Medical Research.

Dr. MARTINS DA SILVA (Chief, Office of Research Coordination, PASB) said that the program of coordination of research, as an identified activity of the Organization, was about five years old. It had been begun with a grant in 1961 from the National Institutes of Health of the United States Public Health Service for the study and definition of the role that the Organization should or could play in stimulating, coordinating, and promoting biomedical research in the Americas.

The initial steps had consisted of the appointment of an Advisory Commit- tee on Medical Research composed of 15 members. Seven were from Latin America and and the remainder from the United States of America and other countries. The Committee functioned in an advisory capacity to the Director, more in connection with the policy and priority aspects of the program than with detailed technical aspects. From the beginning, the objective of the program had been to look into needs and opportunities for research in Latin America, in the program areas of interest of the Organization. PAHO wanted to know what gaps there were in the knowledge on any field, what reseairch was proceeding, or proposed, particularly in Latin America, and which projects lent themselves to multinational, multicoun- try, or multilaboratory effort. Once that was known, it would also like to know where and by whom the needed research work could best be undertaken, what it would cost, and what outside assistance would be required.

To ascertain that, the Organization had used a large number of consultants, about 200 over the five-year period, principally from among persons already engaged in the actual field concerned, and knowledgeable about problems in Latin America. The only funds available within the Organization were those for the planning of the program. Often just one consultant had been used, sometimes three, sometimes a scientific group in a particular field. In almost all cases the consultants had, before submitting their report, made visits to areas in the Americas where the activity was known to exist, in order to appraise the manpower, equipment, and other resources. The reports had been presented to the Advisory Com- mittee on Medical Research which met, usually for a week, in Washington in June. The Sixth Meeting would take place 12-16 June 1967. One day of the meeting was customarily devoted to examining in dept:h research needs and opportun:ities, especially in Latin America, in specific fields that the Committee felt needed Page 127 56th Meeting Seventh session evaluation. Those special sessions had been devoted to tuberculosis, environmental determinants of community well-being, deprivation in psychobiological development, and life at high altitudes. Where possible, Committee members worked with the staff of the Office of Research Coordination in setting up the sessions, to which were invited the best consultants available anywhere, in or outside of the Region, and a whole day was devoted for the chosen topic, ample time being allowed for discussion. The proceedings were published in the Scientific Publications Series, the last one within 90 days of the closing of the meeting.

Also, at the suggestion of the Advisory Committee, other activities had been undertaken, such as the study on science policy in Latin America, which had subsequently been published. 2/ Out of that study had come another, on the migration from Latin America of scientific personnel in the health field, the so- called "brain drain." 3/ Currently, in following up those two studies, a proposal would be submitted in detail to the XVII Meeting of the Directing Council in October for the establishment in Latin America of multinational centers for research and training in the life sciences and medicine, already alluded to by different staff members and by the Director. Such a proposal had been included in the agenda of the Meeting of the American Chiefs of State in Punta del Este and a preliminary report on it would be reviewed in June by the Advisory Com- mittee on Medical Research.

The funds available to the Office of Research Coordination were for planning only and the item in the budget referred specifically to the servicing of the Advisory Committee meeting once a year, and cost of the equivalent of nine months of consultant services. As mentioned, there were no funds for special projects, with some exceptions, such as the malaria program. The XVII Pan American Sanitary Conference, in reviewing the five years' activity,had created a Special Fund for Research 4/ within the budgetary mechanism of the Organiza- tion and so far three countries had pledged money to open the account. When developed, the Fund would be invaluable in giving the Organization a mechanism with which to finance specific research projects of high priority and sound technical design, when such priority did not coincide with the priorities of other granting agencies. He had in mind projects which, in the last five years, it had been difficult to fund from the usual sources. It would also allow the Organization to develop programs of research training, a project related to multinational centers, about which very little had been done to date because of lack of funds.

To sum up, the research activity had had a high level review mechanism through the Advisory Committee on Medical Research and through the recruitment of consultants to help develop the program. If the Special Fund for Research could be built up through voluntary contributions concerning which the Director had approached all Governments, as requested by the XVII Pan American Sanitary Conference, the research program could branch out and effect a better coordination between PAHO priorities and those of other granting agencies. The existing research program of the Organization was not small, involving as it did some

/ Science Policy in Latin America. Scientific Publication PAHO, 119, 1965. Migration of Health Personnel, Scientists, and Engineers from Latin America. Scientific Publication PAHO 142, 1966. / Official Document PAHO 74, 72-74. Page 128 Seventh session 56th Meeting

$2,500,000, but most of the funding was from possibly 12 or 15 outside sources. As mentioned earlier, the special subject for discussion by the Advisory Com- mittee in 1967 was to be the immunological aspects of parasitic diseases, notably Chagas' disease and schistosomiasis.

Dr. AGUILAR HERRERA (Guatemala) expressed his thanks for the information supplied on the work being done in coordinating research activities, and said that in his view they should be pursued as vigorously as possible.

Dr. SANTA MARiA (Observer, Chile) announced that in his country a Re- search Coordinating Committee had been established in the National Planning Of- fice, at the presidential level, so that Chile was also contributing to that Fund for Research which was regarded as cf the utmost importance for the Americas and which deserved more generous budgetary allocations in the future.

Dr. PEREZ RUEDA (Ecuador) asked for information on water supply and water fluoridation projects and studies and research on water resources.

Dr. HOTLLS (Chief, Environmental Sanitation Branch, PASB) replied that the whole field of community water supply was receiving major emphasis throughout the Americas, as he had already reported in general terms. The progress made had been not merely substantial but almost phenomenal, certainly with respect to urban areas and, in the last two years, in rural areas also. A whole group of interzone projects were related to the broad field of community water supply development.

As Dr. Portner had pointed out in his comments on administration and organization, highly-trained teams had been developed to comply with requests of Governments and render special service, reviewing the total organizational structure of the country's water supply activity and producing realistic programs of water rates and water tariffs. In additLon, PAHO had set up a network of short- course training programs to update professional staffs in the water field, and train the subprofessionals in the operatJ on, maintenance, and management of water supply systems. The development of a network of university-based training programs provided a very good foundation on which to develop some rather simple, but much-needed applied research. That item was included among the interzone projects, under AMRO-2215 (Applied Research on Water Supplies).

Another interesting development concerned water fluoridation, which was covered by two items, AMRO-2208 and AMRO-4409. It was not necessary to comment on the value of using a public water supply as a means of applying proper amounts of fluoride salts as an aid to public dental health, but would like to emphasize that it was a very effective, safe, and cheap method. But in order to launch a fluoridation program, on a continental or regional basis, it was first necessary to build within the countries the structure and competence to handle the basic water supply systems. The fact that tha-t had been done over the years made it very practical, timely, and proper to launch the water fluoridation program.

Again, in view of PAHO's limited resources, the Director had negotiated a grant from the W. K. Kellogg Foundation and under a joint agreement with the Foundation, PAHO was initiating a water fluoridation program on a continental basis in 1967. Most of the funds were coming from the Kellogg Foundation, but Page 129 56th Meeting Seventh session the Organization was providing funds for consultant services and meeting part of the total cost. The project came under PASB's Health Promotion Branch, but it was one of the many projects in which that Branch and the Environmental Sanita- tion Branch worked very closely together. He believed that the approach adopted made sense, since it recognized the limitations in funds and made the best use of the grant money from the Kellogg Foundation.

To carry out the program on fluoridation, it was proposed first to train PAHO's Zone engineers, senior staff, and other engineers assigned to the water program. The major training course would be given in July 1967. The training program would subsequently be extended rapidly, through organized courses for key water engineers in the various countries. It was felt that by the use of Kellogg Foundation funds a nucleus of well-trained people would be trained to carry on the fluoridation program throughout the Americas. An additional item under the program was aimed at developing local production of fluoride materials for use in such programs. Part of the funds would be devoted to it.

Project AMRO-2400, while concerned with housing and urbanization, also bore a relation to the problem. Because of the rapid expansion of the cities of Latin America and, as a part of the urbanization process, the water supply service, with the accompanying need to keep pollution within bounds, was closely related to sewage disposal and the treatment of industrial waste, and formed part of the whole group of related projects.

Dr. Hollis recalled that at the recent Meeting of the Presidents of America at Punta del Este there had been a very pointed and strong statement in the report urging action on the matter of water supplies in small towns and villages and, specifically,reference to the development of a practical financing mechanism that would establish a sound and sustained program, namely the development of revolving funds.

The Director had, three years earlier, advanced a proposal in that sense which was endorsed by the XIV Meeting of the Directing Council ~/ and subsequently at the Second Annual Meetings of the Inter-American Economic and Social Council. 6/ Thus a stage had been reached in Latin America in the development of sanitary engineering, particularly in the water field, where all the foundations had been laid. There was no longer any need to convince anyone of the significance of community water supplies to the health, economic, and social betterment of the people--that was accepted. The task was to pinpoint their efforts in some of these special areas of need, and he would place special emphasis on rural water development, particularly since it had received recognition at such high levels. He was sure that, with the funds available, attention would be focused even more sharply on developing rural water supplies through a financing mechanism that would be self-sustaining beyond the period of international loans and could be used, hopefully, in time for other health projects, namely a revolving fund.

5/ Official Document PAHO 54, 15-16. 6/ OAS Official Records, OEA/Ser.H/XII.6 (Eng.), pp. 32-33. Page 130 Seventh session 56th Meeting

The CHAIRMAN said he was sure he spoke for all the Governments in thanking the W. K. KeLlogg Foundation for its constant and generous aid.

Dr. SANTA MARIA (Observer, Chile) asked whether projects AMRO-2208 (Water Fluoridation) and AMRO-4409 (Fluoridation) were complementary.

Dr. HOLLIS (Chief, Environmental Sanitation Branch, PASB) said that the two projects were complementary in that they were actually operated as a joint project. AMRO-2208 provided consultants that were budgeted under Environmental Health and the 4409 series under Promotion of Health.

Dr. BLOOD (United States of America), referring to AMRO-3100 (Planning), said he had noticed several other projects in the budget devoted to planning. He would like to learn how all were tiedL together as an activity, and what was the real international role of planning. He suspected that much more of the budget could be said to be devoted to planning, but he would like some indication of the truly international role that the Organization was expected to play or should play in that process.

Dr. McKENZIE-1OLLOCK (Chief, Office of National Health Planning, PASB) said that the budget provision was primarily for Headquarters activity in planning, plus the international courses in that subject. Each Zone had a planning activity, and many countries had planning activities that were coordinated through the headquarters office.

An attempt was made through the Office of National Health Planning at Headquarters to represent the health sector in the international development fra- ternity. Health planning was a very new thing; to a certain extent it was an educational process whereby attempts were made to get development planners to understand the meaning of the health sector and how it should form a part of total development planning. A tremendous amount of external international activity was carried out by that Office, which represented the Organization at meetings of the Inter-American Committee on the Alliance for Progress (CIAP) and helped the CIAP subcommittees to appraise the various health development plans for the countries each year. That was one area where there was a tremendous amount of inter-sectoral negotiations, liaison, and mutual understanding.

As for planning as a means of obtaining better coordination of intra-sectoral activities within the Hemisphere, he would say that the preparation of national health plans within the countries was becoming more and more! the logical point for the technical coordination of the over-all development effort, both national and international.

Dr. BLOOD (United States of America) asked what percentage of the total budget was specifically devoted to planning.

Dr. McKENZIE-POLLOCK (Chief, Office of National Health Planning, PASB) said that his closest estimate, for it was a rather spread out activity, was that about US$200,000 were spent annually on Headquarters, country, and Zone activity in planning, or about 1 per cent of the budget. However, every discipline was involved in the planning business, so an exact figure could never be given. Page 131 56th Meeting Seventh session

Dr. HORWITZ (Director, PASB) thought that the question presented by Dr. Blood was very pertinent and said that he had already suggested the advisability of a program-by-program review of the categories on the budget and of adding new ones, such as Planning and Population Dynamics, so that the Committee might have that information at hand. Enlarging on the information provided by Dr. Mc- Kenzie-Pollock, he said that since 14 April planning had become an obligation, because at the Meeting of the American Chiefs of State an agreement had been reached that national health plans should be formulated in the context of development planning. But it should be borne in mind that the idea of the Presidents referred to the health sector as a whole, and not only to that part of the sector which was the responsibility of the ministries, which in some Latin American countries accounted for an investment smaller than that of all other public and private institutions which directly or indirectly contributed to the health of the population.

Two years earlier the Bureau had decided that the time had come to insti- tutionalize the planning function, and thus recommended the establishment of a Pan American Center for Health Planning in cooperation with the Latin American Institute for Economic and Social Planning. It had been suggested to the host Government of the Institute, namely Chile, that it submit such a proposal to the United Nations Development Program tUNDP) and it did so in due course. The persons in charge of the UNDP pointed out in reply that, since the project would be a regional one, it was very important to obtain the support of the Governments, not only for the idea, but for actual contributions as well. Negotiations had been undertaken and so far 10 Governments had agreed to contribute more than one million dollars for the project, which together would amount to an investment of about US$7,000,000 in five years. PAHO and WHO had indicated that they would continue their current arrangements.

It was a matter of regret that the UNDP had not yet taken a decision, but pressure was being exerted to have the proposal considered at the meeting of its Governing Council in January 1968. If the Committee thought it worth while, it might especially cite the importance of institutionalizing planning in terms of the Declaration of the Presidents. The basic functions of the Center would consist in strengthening the training of personnel, studies to improve planning methodology, and direct advisory services to the Governments to enable them to achieve the goal of having their first national health plans drafted by 1970, or of making the appropriate adjustment for the period that would have elapsed between the formulation of the first national plan and 1970.

He concluded by saying that planning was an essential or at least an appropriate tool for achieving a better correlation between needs and resources at any given moment in the history of each country.

Dr. AGUILAR HERRERA (Guatemala) proposed that, as suggested by the Direc- tor, the Committee make a recommendation, which could later be considered by the Directing Council, on the advisability of institutionalizing planning in the form of the Center in Chile.

Dr. ORELLANA (Venezuela) suggested that any such recommendation be postponed until agenda Item 21 (Intensification of Health Programs--Decisions Taken at the Meeting of American Chiefs of State) was discussed. Page 132 Seventh session 56th Meeting

Dr. AGUILAR HERRERA (Guatemala), referring to project AMRO-4225 (Graduate Course in Public Health Nutrition), asked how it differed from those that had been conducted by the Institute of Nutrition of Central America and Panama (INCAP).

Dr. BEGHIN (Regional Adviser in Nutrition, PASB) said it was hoped that the graduate course in public health nultrition would start in 1968; however, it did not yet appear in the budget. The basic idea was that there was in Latin America a great need for highly qualified persons in public health nutrition. So far there was no center teaching in Spanish or Portuguese and offering a course of a year's duration, especially for physicians. Most of the Latin American physicians specializing in nutrition had received their training in the United States of America. However, there were very good and qualified public health physicians, as well as biochemists and others, who,because they did not know enough English were barred from going to the United States of America for such training. It was a good idea to have people trained, wherever possible, in their own cultural environment, so the Organization was hoping to organize such a center, which would provide the equivalent of a Master's degree in nutrition. No decision had been taken so far as to location.

INCAP was now training physicians in a lO0-week summer course, but there was also a need for a course which was connected with a school of public health and which would follow a more general approach concerned with the overall public health aspect, as distinct from INCAP's quite special short course. Essentially, the aim was to try to repeat, in an environment more adapted to the needs of Latin America, the Master's degree courses given in a few public health schools in the United States of America, Canada, and the United Kingdom.

Dr. SANTA MARIA (Observer, Chile) expressed interest in that aspect of health activities and noted the need to apply scientific concepts where the problems arose. The provision of training in countries where malnutrition existed was much more useful than sending a physician or other members of the health team to countries with resources beyond the means of other less privileged countries. Very useful work could be done if those training activities were started in any of the Latin American countries and supplemented by seminars on nutrition and emphasis on the need to introduce scientific and biological concepts into the nutrition policies of the countries, as was obviously contemplated in project AMRO-4221 (Seminar on Nutrition in Food and Health Policies). He also attached great importance to the evaluation of what had so far been done.

The CHAIRMAN suggested that the progress made in evaluating the applied nutrition programs and the views of the Bureau on nutrition education in medical schools be discussed, even if only briefly.

Dr. BLOOD (United States of America) said he could not quite distinguish the purpose of that project from that which he understood was in the process of development in INCAP, in collaboration with the National and Autonomous Univer- sity of San Carlos, in Guatemala, to do exactly what was proposed, to give graduate nutrition instruction in Spanish. .He understood that the INCAP courses were bilingual and could be given either in Ehglish or Spanish. At the same time, he wished to reiterate the interest of the University of Puerto Rico in that field. His question was intended, not to detract from the proposal, but simply to clarify it in his own mind. Page 133 56th Meeting Seventh session

Dr. BEGHIN (Regional Adviser in Nutrition, PASB) said that INCAP's major training course was that of its School of Nutrition and Dietetics, which followed the pattern agreed upon at the Conference on the Training of Public Health Nutritionists-Dietitians which was held in Caracas, Venezuela, in 1966. It was a four-year course given in conjunction with the University of San Carlos in Guatemala. It trained multipurpose public health nutritionists who worked in the programs of the countries. He added that Dr. Bosley would be glad to answer any questions on the details of the training and background.

AMRO-4225 would train very high-level nutritionists who would work at the planning level of ministries of health and teach nutrition in schools of public health and schools of medicine. Preference would be given to medical doctors because the greatest need was there. In many countries PAHO's work was restricted by a lack of sufficient high-level personnel to participate in planning and teaching. Therefore, it was essential to have a good school of public health where such a training course could be held. The school of the University of Puerto Rico was one of the places under consideration. Unfortunately, there was no school of public health in Guatemala, and INCAP, though rich in nutrition resources, could not provide the kind of interdisciplinary approach needed for the training of such personnel. The report of INCAP activities that had been requested by Dr. Blood had not yet been completed but would be distributed shortly.

Dr. BLOOD (United States of America) appreciated the information given but said that he did not wish to be misunderstood. His purpose was to give to the many countries interested in INCAP, and contributing to it, directly or indirectly, evidence of the benefits they were receiving from it. He was referring not to the founder countries, but to those which were now contributing through the regular budget of the Organization, to the extent of something like $400,000 a year.

Dr. HORWITZ (Director, PASB) said that a preliminary report would be prepared but that INCAPARINA was being sold in very large quantities in Colombia. Other countries in Latin America were also contemplating its production, so that he felt that the INCAP studies of locally available vegetable proteins had stimulated several other Governments to explore possibilities in their own countries and had led to the discovery of several new mixtures. How INCAP trainees had fared and what role they were playing in their own countries could also be investigated. Some Governments were known to have developed important nutrition programs around technicians trained in the Institute. He reiterated that the report mentioned by Dr. Beghin was a preliminary one, but that the XVII Meeting of the Directing Council would receive a detailed report.

Dr. SANTA MARIA (Observer, Chile), while recognizing the work of INCAP in the scientific and research aspects of nutrition, noted that its effective direct action beyond the Isthmus had been more limited. The Organization should directly or indirectly promote the expansion of that multinational work. The production of protein concentrates should be fostered in other regions on, perhaps, a different basis and in accordance with the resources of each country.

Furthermore, nutrition courses should be conducted in Latin America not only for physicians, but in the schools of agronomy and veterinary medicine as well, so that members of those professions might learn that what had to be Page 134 Seventh session 56th Meeting

produced was not meat for export but proteins for internal consumption. In his experience physicians and biologists were clearly aware of the importance of nutrition, but the health services also needed agronomists and veterinarians who understood that animals and plants were intended for human consumption and were not merely products for international trade. Furthermore, nutrition education should be guided by the principle that nutrition was a biochemical concept while feeding was a social concept. Hence, the courses should be multidisciplinary.

It was a matter of regret that INCAP had acted directly or indirectly only in Ecuador, and perhaps to some extent in Peru. Much remained to be done and it was clear that the work of PAHO in nutrition should be better coordinated with the international activities of the Food and Agriculture Organization of the United Nations (FAO).

Dr. BOSLEY (Nutrition Adviser, PASB) said that a year earlier each of the 16 countries with applied nutrition programs (cooperative programs with agriculture, education, and health) had been asked to evaluate their programs. A guide developed by representatives of several of the countries with that type of program was provided to help the countries identify particular nutrition and operational problems, indicate the methods being used to meet those problems and the effectiveness with which they believed the problems were being solved.

In November 1966 a seminar was held in Popayán, Colombia, under the auspices of FAO and PAHO/WHO on the planning and evaluation of applied nutrition programs. It was attended by representatives of the agriculture, education, and health services in each of the countries carrying on applied nutrition. There were extensive discussions of the types of plans needed for effective applied nutrition programs, at the community level, with the incorporation of a system of evaluation. The countries that had evaluated their programs before the meeting prepared a planning guide which they believed would be useful in the promotion and evaluation of those programs at the local level. A detailed schedule for use in evaluation, year by year for five years, was also agreed upon.

In addition to the self-evaluation by the countries, the programs in Colombia and Trinidad were reviewed by an expert from WHO, FAO, and the United Nations Children's Fund (UNICEF), Dr. James Hundley. He evaluated programs in five of the countries in various parts of the world carrying out applied nutrition programs. Dr. Hundley was one of the originators of those programs during the time he was a staff member of UNICEF. He was scheduled to make his report on the programs in the five countries to the UNICEF Executive Board meeting in June. In a sense, therefore, there had been two kinds of evaluations conducted in the Hemisphere. PAHO was particular]y pleased with the efforts made by the countries in evaluating their nutrition programs. It should be emphasized that the applied nutrition programs were envisioned not as isolated programs, but as a specific part of the regular ongoing programs in health, education, and agriculture.

One of the major problems revealed by the evaluation was the lack of adequately trained personnel to carry out the programs at regional, national, or local levels. The Conference on the Training of Public Health Nutritionists- Dietitians referred to by Dr. Beghin discussed the curriculum and training required for personnel qualified to work in integrated health services, namely the nutritionist-dietitian, a polyvalent person. Page 135 56th Meeting Seventh session

As the Observer of Chile had mentioned, separate training for public health and hospital services was not practical. Polyvalent persons should be trained to work in both hospital and public health projects. Hopefully, therefore, with the schools of nutrition and dietetics instituting a four-year university training program for those working at the operational level of applied nutrition programs, it would be possible to integrate more effectively those programs into the total ongoing programs in agriculture, education, and health.

Dr. SANTA MARIA (Observer, Chile) said he would like to add something on national evaluation in the hope that it might prove useful to other countries operating applied nutrition projects. In addition to the limiting factor of personnel, referred to by Dr. Bosley, which was evident, there was another, namely the fact that those projects came into being outside the general framework of health activities, a circumstance that prevented them from developing around efforts already instituted in the countries. However good it might be, every vertical program later tended to get lost in the welter of projects and to lose the support of leaders. In Chile, the serving of breakfast and lunch to school- children was begun as an isolated vertical program to promote its growth, but, later, in order to obtain satisfactory results, was absorbed into the other programs.

With respect to personnel training, some Latin American countries, unfortunately, taking what was done in the United States of America as a model, eliminated the course on food and nutrition from the curriculum of their medical schools. However, those subjects were much more important than a special class on cancerogenic food additives. Before cancer could be caused by an additive, the individual had to eat; the priorities were clearly different. Courses on nutrition and, above all, on food, should be restored to the curricula of the medical schools in Latin America. Polyvalent personnel were also needed. In countries with meager resources it was not practical to have both public health nutritionists and hospital dietitians, especially in small towns where hospitals had to make the best possible use of their resources. It should again be pointed out that, while the United States patterns were good, they were not the only ones. There were other solutions, such as polyvalence, and that approach was proving increasingly necessary in Chile.

Dr. BOSLEY (Nutrition Adviser, PASB) added that the April 1967 issue of the Boletín of PASB contained a report of the Conference on the Training of Public Health Nutritionists-Dietitians which described the broad areas of studies involved in the preparation of the polyvalent nutritionist-dietitian, as distinct from the medical personnel mentioned by the Observer of Chile.

Dr. BLOOD (United States of America) asked how the services mentioned in AMRO-3400 (Health Education) were to be used. He understood that there was to be a meeting in Argentina, perhaps in 1968, of the International Union of Health Education of the Public, and it had been reported that there would be a meeting sponsored jointly by PAHO/WHO in that connection. It did not seem to be covered by the document before the Committee.

Dr. VALLEJO (Health Educator, PASB) stated that the First Inter-Regional Conference on Postgraduate Health Education Training of Health Personnel was held in Philadelphia (USA) in 1962. Some years had passed since then and it was again Page 136 Seventh session 56th Meeting necessary to ascertain what the recommendations of that Conference, and of the meetings of the WHO Expert Committees had led to. In 1968 it was proposed to hold another such meeting to discuss the progress made in the health education training of public health personnel and other related personnel.

In public health in general there was a great demand for community education designed to enlist support for health programs. Consequently, personnel had to be trained in new approaches in accordance with advances in the behav- ioral sciences,in particular motivation and the application of the social sciences in the health field, so as to be able to secure not only the acceptance of, but also the active participation of the community in, health programs. Those activities were being encouraged all over the world, and WHO was in the forefront in training health personnel and incorporating health education activities into the so-called community development programs. The Conference had been planned by WIHO and, consequently, by the Regional Office, and it was felt that preferential attention should be given to it because its purpose was to examine the problem of personnel training, which merited the highest priority.

Dr. BLOOD (United States of America) asked whether the item had anything to do with the meeting of the International Union for Health Education of the Public. He understood there was some connection between the two and would therefore like to know whether it was a new activity for 1968 that had not been incorporated in the documentation.

Dr. VALLEJO (Health Educator, PASB) pointed out that two meetings were scheduled for 1968: one was an international or interregional seminar which was separated from the Conference on Health and Health Education sponsored by the International Union for the Health Education of the Public. The seminar was included in the budget estimates for 1968 as project AMRO-3408 (Conference on Postgraduate Training in Health Education).

The CHAIRMAN asked for information on project AMRO-6216 (Preventive Med- icine Education) in particular the participation of the Milbank Memorial Fund. He also wanted to know whether preventive medicine was covered in the medical education program and whether consideration had been given to the need to make medical sociology a principal component of instruction in the latter discipline.

Dr. GARCIA (Medical Officer, Medical Education Branch, PASB) pointed out that the Bureau was planning a study on the teaching of preventive medicine in the schools of medicine. A group of experts in preventive and social medicine was convened by the Organization in 1964 to plan a study on the teaching of that subject, with particular reference to the two seminars on the teaching of preventive medicine in the medical schools that were held in 1955 and 1956, also under PASB sponsorship. The group of experts recommended that an evaluation be made and, accordingly, in 1966, a survey was prepared and the instruments devised for it were tested in 15 nedical schools. The results and the general plan were presented to a PAHO Advisory Committee on the Teaching of Preven- tive and Social Medicine in Latin America in March 1967. The objectives of that study were: to obtain a detailed description of the teaching of the preventive and social aspects of medicine and to investigate the factors which led to or delayed the introduction of innovations, changes, and improvements in that instruction; to determine the immediate needs of the schools and to supply them Page 137 56th Meeting Seventh session through the ordinary facilities of the Bureau; to investigate the factors impeding or conducive to the development of the aptitudes and knowledge of students in the field of preventive and social medicine; and to furnish the Organ- ization and other interested institutions with background information that would be of help in improving the planning of assistance and advisory services in preventive and social medicine.

That study was more explanatory than descriptive, and covered the medical school as a whole rather than concentrating on departments of preventive medicine. Visits would be made and various questionnaires submitted to the 122 existing schools in Latin America, as recommended by the Advisory Committee, under agreements signed with the national associations of medical schools. In addition, a special sample of medical students would be studied to learn which factors were impeding or making for better acquisition of knowledge and skills in preventive medicine. In all those activities the assistance of the Milbank Memorial Fund, which was providing the necessary financial support for the survey had been fundamental.

As to the earlier survey of 15 medical schools (five in Venezuela, four in Brazil, two in Chile, one in Honduras, and three in Ecuador), the general results indicated a very wide diversity in the teaching of preventive medicine. The most notorious shortcoming was in the teaching of the social sciences and epidemiology, and the best feature, the course to which well-trained teachers give the most hours, was perhaps statistics. In general, the schools lacked good statistical information on hours of instruction, students, and professors; the study would attempt to improve the administrative aspect of the schools, especially their accounting procedures.

Some of the teachers at the schools appeared to be changing their attitude toward preventive medicine, and a more favorable attitude toward the introduction of new subjects and new courses was emerging. At many schools preventive medicine was still not taught throughout the curriculum, and at only half the schools visited was any instruction given in the social sciences. That instruction seemed likely to be greatly expanded in the coming years, and one of the conclusions of the study might be that the Organization would have to gird itself to respond to all the requests that would be made in that connection.

The CHAIRMAN wanted to know how the sample was designed, since the distribution of the schools--five in one country, three in another, four in another-- and the fact that there were countries in broad areas in which no schools were represented, seemed somewhat unusual.

Dr. GARCIA (Medical Officer, Medical Education Branch, PASB) pointed out that the intention was not to obtain a representative sample, but to test the instruments, to find out whether they worked properly, and whether the questions had been correctly framed. The schools were selected for their variation in order to test the flexibility and suitability of the instruments. That was why the results were not conclusive and could not be generalized; the full-scale survey would be launched in June 1967 and the first results would probably be available in April 1968.

The CHAIRMAN asked whether the proposed evaluation seminar to be held in 1968 would bear on the information gathered in the survey. Page 138 Seventh session 56th Meeting

Dr. GARCIA (Medical Officer, Medical Education Branch, PASB) replied that one of the objectives of the study was to awaken interest in the preventive and social aspects of medicine through seminars in which the results would be evaluated with faculty members from the different schools, probably in late 1968 or 1969.

Dr. HORWITZ (Director, PASB) said he wished to enlarge on one item of information furnished by Dr. Garcia. The idea was not so much to visit the 122 medical schools in Latin America as to help them find out what had happened in the 10 years since the first two seminars were held (1955 and 1956) and, at the same time, in the light of the findings, to ascertain the attitudes of students and faculty members to the teaching of preventive medicine. As Dr. García had said, the study was not to be centered on one discipline, but on the institution as a whole, including its administration and organization if any; in other words, a global study of medical education, with concentration on preventive medicine.

It was proposed to carry it out with joint contributions from the Organ- ization and the Milbank Memorial Fund which, meanwhile, had already begun to provide support for those activities. Dr. García was himself an example of such support. But the important point was to ensure that the teaching of that discipline was modernized, as much as possible, on the basis of the specific ideas advocated by the experts in the subject.

Supplementary information on the project as a whole would be provided when the Committee discussed the item on the program of textbooks for medical students.

The CHAIRMAN underscored the enormous disparities in regard to the teaching of preventive medicine that existed in the Hemisphere. In his view, no one really knew how preventive medicine and social medicine were being taught in the Hemisphere. Those disparities were a matter of great concern to him since he spoke from personal knowledge having held a post in that field for many years, and was therefore extremely interested in a survey of that kind. The (Organiza- tion should take the initiative firmly and quickly in both the subject discussed previously, the teaching of public health in general (or of social medicine at the postgraduate level) as well as undergraduate education, both of which were highly important.

Dr. ORELLANA (Venezuela) reiterated his interest in the project, with which he had been acquainted since its beginnings in Venezuela, four schools in his country having been included as initial respondents to the questionnaire. The Director had pointed out that the survey covered not only the teaching of preventive medicine at the departmental level but also at that of the medical school itself; that it was concurrently exploring the teaching of school organization and administration, a field in which further study was greatly needed in the Americas. There were medical schools with a long tradition, excellently organized, and structured on very sound classical lines, but there were also recently founded schools which began with great enthusiasm but which had not yet achieved a proper organization, a proper structure.

Moreover, there were great variations from one country to another which should be studied to determine how they turned the entire range of their Page 139 56th Meeting Seventh session

instruction to account. Since the departments were set up and reorganized in Venezuela in 1960, with the aid of the Ministry of Health and Social Welfare, a meeting had been held annually to review and evaluate the curricula. At the most recent meeting it was agreed to make a study in depth of a minimum program for every department of each of the seven medical schools. The study would focus on instruction in four broad fields: the social sciences, statistics, epidemiology, and administration. It was entrusted to the Venezuelan Association of Medical Schools, which had already embarked on it. The information being gathered would probably be submitted to the seventh meeting of departments of preventive and social medicine to be held in August or September 1967.

The CHAIRMAN asked the Director of the Bureau how many sociologists or high-level social workers the Bureau had who could advise on medical sociology and social pathology, which he regarded as highly interesting aspects and which had been given scant attention.

Dr. HORWITZ (Director, PASB) said that the Organization had technicians to advise in economics, health education, and sociology, but not for what was usually referred to as social work, including social work in cooperation with the medical services, which was a distinct discipline in some countries and whose techniques were individual social work, group social work, and community organization to assist health programs. Before the Organization could enter that field, it would have to resolve questions of relationships with the Organ- ization of American States, within the Inter-American System, and with the U.N. Department of Economic and Social Affairs, within the United Nations system. That would require the Governing Bodies of PAHO to lay down the necessary guidelines and, to begin with, they would have to be asked whether they wanted the Organization to go into that aspect, particularly in countries where the ministries of health were also ministries of social welfare or included social welfare departments. Furthermore, UNICEF earmarked part of its funds for what it called direct social welfare projects.

Dr. BLOOD (United States of America), referring to the new project AMRO- 4815 (Training for Medical Care and Hospital Administration) asked whether it contemplated doing anything about the apparently great shortage of medical record librarians or technicians.

Dr. BRAVO (Chief, Medical Care Administration Branch, PASB) said that the purpose of project AMRO-4815 was the training of hospital directors and administrators and of the hospital management team, and that it fell specifically within the province of the Health Statistics Branch.

Dr. BLOOD (United States of America) said he had understood that AMRO- 6207 (Training of Medical Librarians) was for librarians per se, working in the traditional library sense. He had really been thinking about what he believed were termed medical record librarians or technicians.

Dr. PUFFER (Chief, Health Statistics Branch, PASB) said that medical record librarians were covered in AMRO-6708 (Training Program in Hospital Statis- tics), which was concerned with both medical records and hospital statistics. That project was being expanded and had received financial suport from the W.K. Kellogg Foundation for the past year. The recruiting of medical record Page 140 Seventh session 56th Meeting librarians was very difficult because in Latin America very little had been done to create such a profession. Consequently, recruitment of staff from the United States of America and Canada was necessary. However, the project was very popu- lar and great interest in it had been expressed throughout Latin America. Train- ing was being given in the schools of public health at the technical level. They, in turn, were giving training at the auxiliary level. Two weeks earlier, when she had been in Argentina, interest had been expressed in the training of personnel at the professional level, the leaders, as well as those at the other two levels. She believed the time would come when training would be given at the level of that offered in the United States of America where the university graduate was trained to give assistance in the field of medical records. The project was creating great interest and only that morning her Branch had been arranging to keep a short-term consultant in medical records in Haiti 'because of the interest expressed by the Minister of Public Health.

Dr. SANTA MARIA (Observer, Chile) said that he regarded the training of auxiliary statistical personnel as fundamental; but he could not go along with what Dr. Puffer had said about the training of professional personnel because, in his view, certain stages should be observed. There were still no hospital administrators in Latin America, and many years would pass before there was any need for file clerks who knew more than how to read, write, and enter numbers correctly. So long as the director of a hospital was not sufficiently qualified, he was not going to make use of such auxiliary personnel. In many hospitals the records were kept by the accountant, who often had other duties as well. Pro- gress should be made by stages, and the project, which was praiseworthy, could perhaps be postponed and instead more resources devoted to the training of administrators. Project AMRO-4815 (Training for Medical Care and Hospital Ad- ministration) should therefore be coordinated with AMRO-4813 (Hospital Planning and Administration) and even more with AMRO-3600 (Administrative Methods and Practices in Public Health) because intra- or extra-hospital administration was a universally applicable science. He would like to know how those three projects were coordinated to the end of training those who were primarily needed, namely hospital administrators.

Dr. HORWITZ (Director, PASB) said that Dr. Puffer had perhaps oversimpli- fied her explanation of project AMRO-6708. In actual fact, what the Observer of Chile had urged was being done. Great importance was attached, from the outset, to the training of statisticians, even of university staff, and to that of intermediate technicians. A review of the Annual Report of the Director 2/for 1965 would show that more than 150 middle-level statisticians had been trained at various universities, and the work was still going on. No special effort had been made to promote the training of the persons Dr. Santa María had described, i.e., persons responsible for the initial recording of data. The training of middle level technicians had begun two or three years ago. The 1966 Director's Report 8/ described the various courses conducted by the Organization with the aid of short-term consultants, in which about 900 had received training. The scheme adopted in Chile was different; there it had been decided to train instructors of the persons who would train the auxiliary personnel.

Official Document PAHO 70. Official Document PAHO 78. Page 141 56th Meeting Seventh session

The Executive Committee should bear in mind that when a hospital dis- charged a university or regional function, the entire process leading up to the preparation of a clinical history, the records of diagnosis, therapy, and course of the illness, had to be the responsibility of a professional trained for that specific purpose; so far that type of staff did not exist in Latin America today. It was to that staff that Dr. Puffer referred when she said that Latin America needed centers for the training of the directors of medical records departments, of people who understood the language of the surgeon and could give a brief description of the intervention, knew the language of the pathologist and could record data about the autopsy or biopsy in the medical history, which, as its name indicated, should be a comprehensive document of historical value.

The Organization was doing both things: in the first stage it was fostering the training of staff who were recording the basic data, but was well aware that there had to be a high-level group. It was the same process that was being carried out on three levels in the various health disciplines, and the one that was perhaps slightly underemphasized in view of the enormous advances of science and technique was the higher, not the lower one.

Dr. ORELLANA (Venezuela) reported that for several years a one-year course for medical record librarians had been offered in his country and attended by persons from other countries under fellowships provided by PAHO. They were not high-level personnel, but they were meeting the fundamental need of gathering hospital statistics in the best possible way. In addition, shorter courses were also conducted for the assistants of that personnel. Lastly, and also with the assistance of the Organization, an international course was recently conducted for instructors of medical record librarians.

The CHAIRMAN said that he disagreed entirely with the Observer of Chile and thought that, in view of the great shortage of statistical personnel in the Latin American countries, education and training was needed at all levels: university, intermediate, and auxiliary. He felt that his view was solidly grounded in the conclusions of the Technical Conference held two years ago by the Bureau.

Dr. SANTA MARIA (Observer, Chile) explained that he had perhaps misinter- preted the term "profesional universitario," which had a different meaning in his country. Perhaps it was merely a problem of semantics, and the personnel trained in the courses in Venezuela were not faculty members of a university, but university-trained professionals, a denotation which had a certain social significance. If that were so, the speaker was in full agreement with the Director of the Bureau and with what the Chairman had just said.

Dr. AGUILAR HERRERA (Guatemala) asked for information on another subject relating to the teaching of medicine, project AMRO-6210 (Teaching Methods and Administrative Organization of Medical Schools), which in his opinion was closely related to the previously discussed projects. In his opinion, it was lack of funds that prevented some medical schools from maintaining as many full-time teachers as they should have, and their faculty did not have enough time to review their teaching methods and improve their application. Nor did they have the educational materials they needed. He would therefore like to know whether it was the purpose of the project to solve those problems. Page 142 Seventh session 56th Meeting

Dr. VILLARPEAL (Chief, Medical Education Branch, PASB) said that the project referred to teaching methods and administration at medical schools, and collaborated with the countries in two aspects that had been shown to be two of the urgent needs of the medical schools, and in which they had most insistently asked for help in recent years.

There were 122 medical schools in Iatin America, many of which had been established in the previous 10 years. They had repeatedly expressed their need for assistance in improving their teaching methods and administration. For the past three years, therefore, the Bureau had tried to attack the first problem, assistance to the medical schools in improving their teaching methods, chiefly by trying to apply modern pedagogical techniques to the teaching of medicine. Dr. Edward M. Bridge had been recruited and had helped medical schools organize human relations and medical education laboratories, in an attempt to find, with members of the school's faculty, ways; to improve relations between teachers and students and to improve the learning process. So far those laboratories had been attended by 155 faculty members of medical schools. The idea was that each medical school, or at least each country, should take over that work on its own. Perhaps through the national medical school associations that initiative would gradually develop into a continuing activity of those schools. That was the only area in which a beginning had been made so far, but thought had also been given to, and bibliographical information supplied on, other subjects. For example, a book on the teaching of medicine--by Dr. Bridge, by the way-- had been published 2/ and distributed to all medical schools. It had been very well received and had had to be reprirted.,

In addition, a selection of bibliographical references from other journals had been prepared and was being published in the Boletin; they might also be published separately. That selection also bore on other aspects of methods of teaching or of using other devices to improve teaching. A move into the field in which more and more requests for assistance were being received, namely administration, was being considered. Since many medical schools were genuine institutions that were handling complex machinery in connection with personnel and resources, there was increasing need for assistance from the Bureau in that respect.

Specifically, the deans of the Central American medical schools had requested the organization of a small meeting at which to discuss those aspects. A seminar might possibly be organized in 1967 with the collaboration of Valle University in Colombia (not only its School of Medicine, but the School of Administration and other university bodies as well) to discuss the various administrative procedures. Two years prev:iously a seminar held at the Medical School of the University of Buffalo in the United States of America had dealt with the organizational aspects of the medical school within the university context. It was proposed to expand advisory services in that area, too, in response to the need expressed by various universities for changes in medical education itself and to take up the entire subject of the teaching of the health sciences within the university organization. Several attempts were already

2/ Published in Spanish as Scientific Publication PAHO 122, 1965. Page 143 56th Meeting Seventh session made in that direction in Colombia and in Mexico also specific steps were being taken to organize schools of health sciences in which the medical school and other university divisions in charge of training personnel in that field were unified and administered jointly.

The CHAIRMAN proposed that a working party be established to examine the resolution on the item under examination and to present it at a later session, as well as to formulate recommendations regarding the Pan American Foot- and-Mouth Disease Center. He suggested that that group consist of Dr. Aguilar Herrera, Dr. Acosta-Borrero, and Dr. Blood.

It was so agreed.

The session rose at 1:25 p.m. EIGHTH PLENARY SESSION Monday, 1 May 1967, at 9:15 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 3: AMENDMENTS TO THE RULES OF PROCEDURE OF THE EXECUTIVE COMMITTEE (conclusion)

The CHAIRMAN declared the session open and announced that, as agreed at the first plenary session, l/ the Committee would consider the revised text of Rule 27 of its Rules of Procedure proposed by the Representatives of Colombia and Venezuela.

Dr. SUTTER (Assistant Director, PASB) read the amended text as follows:

The Executive Committee shall normally vote by show of hands, except that any representative may request a roll-call vote; in that event the Government to vote first shall be determined by lot and thereafter the vote shall be taken in the alphabetical order of the names of the Governments represented as expressed in the language of the country in which the meeting is held. The vote of each representative participating in any roll-call vote shall be inserted in the record of the session.

The CHAIRMAN submitted the proposed text of Rule 27 for consideration, which was approved.

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item:

THE EXECUTIVE COMMITTEE,

Having considered the amendrrients to the Rules of Procedure proposed by the Director and conteined in the Annex to Document CE56/7; and

Considering that the adoption of the rules proposed in that document would facilitate the condLuct of business,

RESC>LVES:

To incorporate the amendments proposed by the Director into the Rules of Procedure, which will then read as shown in the Ad- dendum to Document CE56/7. l/ See p. 18. - 144 - Page 145 56th Meeting Eighth session

Decision: The draft resolution was unanimously approved. 2/

ITEM 6: FINANCIAL REPORT OF THE DIRECTOR AND REPORT OF THE EXTERNAL AUDITOR FOR 1966 (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item:

THE EXECUTIVE COMMITTEE,

Having examined the Financial Report of the Director and the Report of the External Auditor for the fiscal year 1966 (Official Document 75);

Noting that the Organization continues to be in sound financial condition, and that during 1966 quota collections were higher, the level of the Working Capital Fund was increased, and there were increases in the reserves to meet termination costs;

Recognizing that, although the number of Governments in arrears more than two years had dropped to two at the date of the Pan American Sanitary Conference, this number had increased to five when on 31 December the unpaid quotas for 1966 became classified as "arrears;" and

Observing that the expenditures for the program recommended in the authorized budget are necessary in order to attain the established objectives of improving the health of the people of the Americas and promoting economic and social development,

RESOLVES:

1. To take note of the Financial Report of the Director and the Report of the External Auditor for the fiscal year 1966 (Offi- cial Document 75) and transmit them to the XVII Meeting of the Directing Council.

2. To again draw the attention of the Governments to the need for quotas to be paid as soon as possible, within the course of each financial year.

3. To commend the Director for having achieved a sound financial condition through the consistent application over the years of the policies for maintaining budgetary expenditures within income, building up the Working Capital Fund, and creating reserves to meet termination costs.

Decision: The draft resolution was unanimously approved. 3/

2/ Resolution III. Official Document PAHO 79, 31-32. / Resolucion IV. Official Document PAHO 79, 32-33. Page 146 Eighth session 56th Meeting

ITEM 20: REQUEST OF THE GOVERNMENT OF BAREADOS FOR ADMISSION IN THE PAN AMERICAN HEALTH ORGANIZATION (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the subject:

THE EXECUTIVE COMMITTEE,

Having examined the application of the Government of Barbados for membership in the Pan American Health Organization, contained in a letter dated 5 April 1967 from Mr. F. L. Cozier, Permanent Secretary, Ministry of External Affairs, to the Director of the Pan American Sanitary Bureau,

RESOLVES:

1. To take note of the application of the Government of Barbados for membership in the Pan American Health Organization, and to instruct the Director of the Pan American Sanitary Bureau to transmit it to the XVII Meeting of the Directing Council.

2. To recommend to the Council that it give favorable consideration to the application of the Government of Barbados for membership in the Pan American Health Organization.

Decision: The draft resolution was unanimously approved. 4/

ITEM 14: SUPPLY OF TEXTBOOKS FOR MEDICAL STUDENTS

Dr. VILLARREAL (Chief, Medical Education Branch, PASB), introducing Docu- ment CE56/11 5/ on the subject, recalled that the program in question had been studied for the past two years by the Organization and that Resolution XV 6/ of the XVII Pan American Sanitary Conference recognized the usefulness of the program, gave it unanimous support, and authorized the Director of the Bureau to continue negotiations for its financing. The idea was to supply reasonably priced modern textbooks that medical students could either borrow or purchase, and to do so through existing editorial facilities.

After the Conference, the Bureau got in touch with the ministries of health and the rectors, deans, and faculty members of medical schools concerning ways of implementing the program. Consultants of the Organization had visited various countries and consulted several publishing houses on the problem, and in some countries the experts who were to select the most urgently needed medical textbooks had already been designated. Several alternatives had also been considered

4/ Resolution II. Official Document PAHO 79, 31. 5/ Mimeographed document. 6/ Official Document PAHO 74, 71-72. Page 147 56th Meeting Eighth session as to the languages in which the books were to be published, and the possibility had been envisaged of preparing a special edition with a large pressrun, which would reduce the cost of the books, and of thus opening up a new market for the ordinary edition among practicing physicians.

With respect to the financing of the program, negotiations with the Inter- American Development Bank (IDB) had led that agency to establish a Study Com- mittee to analyze the program and enable the Bank to come to a decision on the matter. The continuity of the program would be maintained by setting up a revolving fund-in PAHO and in the medical schools whereby the income from the sale or rent of books could be used to finance subsequent editions. That system had already been introduced at many schools and was gradually coming into widespread use in the countries.

PASB was aware of the efforts of other public and private organizations to strengthen its editorial services and to improve the situation of the medical libraries in the countries of America. The Organization had followed with interest the Franklin Book Program which, in collaboration with the W. K. Kellogg Foundation and the Commonwealth Fund, proposed to improve the medical libraries, and had contacted those institutions. However, while their programs related to a specific field of medicine, that of the Organization was aimed at providing the student with one basic reference work in each subject. The Bureau intended to coordinate its program with those of other agencies in regard to resources for its execution, and the publishing resources could be used for the textbook program for medical students.

Dr. AGUILAR HERRERA (Guatemala) expressed his pleasure at the satisfactory progress made in implementing the program and regarded as highly encouraging the way it had been welcomed by Governments, medical schools, and faculties. He also viewed with approval the steps taken to coordinate it with the plans of other agencies, as their expert committeees would be able to advise on the most suitable and necessary books. He asked for further details on the progress being made in the negotiations with the IDB.

Dr. ACOSTA-BORRERO (Colombia) asked how the proposed revolving fund would operate because he attached great importance not only to obtaining the initial loans, but also to the continuity of the program, which should be ensured by a soundly established system.

Dr. ORELLANA (Venezuela) requested clarification on the following points: (1) how could the program of the Organization be coordinated with that of the Agency for International Development (AID), of the United States of America, and duplication thus be avoided; (2) to what extent could those programs be combined, since the general publications program had no commercial purpose; and (3) to what extent had the cost estimates shown in the document under consideration been revised, since although the undertaking of the Organization was a non-profit venture, the commercial aspect, i.e., possible losses, should be considered.

Dr. SANTA MARIA (Observer, Chile) said that the Government of his country had undertaken to collaborate in the program and he felt that, in view of its scope and interest, there would be no difficulty in finding a favorable solution to the financial problem. Page 148 Eighth session 56th Meeting

Mrs. ELDRIDCtE (Observer, OAS) said she had wished merely to convey a suggestion from technical staff of the library of the Pan American Union, which for some time had worked with considerable success in the field of library development in Latin America. In effect, the suggestion was included in the document on the item, and she wished to lend support to it. It was that an adv:isory group might be useful. The staff of the library of the Pan American Un:ion had suggested Mrs. Carolina Amor de Fournier of Mexico, a person whom she understood Dr. Villarreal had already consulted, as one who could be of great help.

Dr. ORELLANA (Venezuela) said he was under the impression that the AID program was very extensive and aimed at the university schools in general, and that its purposes were identical with those of the Organization's program, namely, to provide reasonably priced textbooks under a reimbursement system. He felt that, to avoid duplication, AID would perhaps want to cooperate in that aspect of the Organization's program.

Dr. AGUILAR HERRERA (Guatemala) asked whether thought had been given to the possibility that publishing houses might be overloaded with work, and requested information on the time required for printing the textbooks.

The CHAIRMAN suggested that cost-per-book studies should be made.

Dr. ORELLANA (Venezuela) thought it was important to study the profit- and-loss aspect. He noted that Table 5 of the document in question showed an item for adjustments, contingencies, etc., which might be used to cover losses.

Dr. SANTA MARIA (Observer, Chile) asked whether the possibility had been considered of publishing the books in Latin America and European countries, where some costs would be lower, and whether the cost estimates allowed for the payment of interest on loans, administrative expenses, and other outlays.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB), referring to the proposed revolving fund, said that the purpose was to obtain an initial contribution with which to buy books and supply them to the medical schools so that they could offer them to their students for sale or rental. With respect to the production cost figures, they were averages and constituted estimates prepared by experts and large publishing houses in several countries, among them Mexico.

In reply to Dr. Aguilar Herrera's question, he said that the publishing time would depend on the book selected. As to adjustments and contingencies, a margin of 30 per cent had been allowed.

Finally, the possibility had indeed been considered of publishing the textbooks in other countries with the best publishing facilities, such as Argentina, Colombia, Chile, Mexico, Spain, and the United States of America, and it had been ascertained that there were no great differences in cost. The possibility had even been considered of preparing the plates in one country and having the printing done in another. The final decision on those matters was up to the Selection Committee, which would be given all the pertinent information.

Dr. HORWITZ (Director, PASB) said that, since the XVII Pan American Sanitary Conference, representatives of the Bureau had attended meetings of the Page 149 56th Meeting Eighth session

Board of Executive Directors of the Inter-American Development Bank at the invitation of its President. At one of those meetings the need to improve the quality of medical education in Latin America had been emphasized. In that connection, importance was attached to supplying textbooks, equipment, and essential facilities for basic and clinical instruction as a primary condition for improving teaching.

At a second meeting with the Board of Executive Directors of the Bank he and Drs. Villarreal and Jiménez Arango had participated in an examination of the feasibility of the program. The Bank had already named what was known as a Study Committee and the final decision of the Board would depend on the report of that Committee.

The Organization's funds had been invested in an understanding by the President of the Bank that they would be reimbursed if the loan were approved. The assent of the President of the Bank was received in writing, and the investments made so far were shown in the report. The launching of the program was waiting on the Bank's final decision. The Organization was also considering various ways and means of implementing the decisions of the Bank and was exploring other possible sources of financing.

Mr. CALDERWOOD (United States of America) said that the Government of his country had already expressed its support for the program that would provide the medical schools in Latin America with medical textbooks at a reasonable cost so that students and teachers might derive full benefit from it. However, the Government of the United States of America had been concerned, as had the XVII Pan American Sanitary Conference, about the financing of the project. He would like to know how many copies of a particular textbook would have to be sold in order to make it possible to keep the revolving fund going at an effective level.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that the estimates were based on a printing of 20,000 copies of each textbook, bearing in mind that there were 122 medical schools. It had been envisaged that each edition would last for three years, and that some of the textbooks would be rented, others sold and repurchased by the school under arrangements that were already in operation at some schools. The number sold would vary from one institution to another, but a figure of 70 to 80 per cent had been considered.

Dr. HORWITZ (Director, PASB) stated that the books would be sold or rented, or else the Governments would donate them to students and bear the cost themselves. Judging from information supplied by the schools where the procedure was already in effect, from 70 to 80 per cent of the books would be bought by them and about 20 per cent would be rented and passed on to other students in the succeeding year.

Mr. CALDERWOOD (United States of America) said that whether the program could be kept going would depend, obviously, on whether the textbooks produced were sold. Almost all the countries and universities visited had said that they would like to see the project launched, but it was being held up because as yet no loan agreement had been concluded. Perhaps before the XVII Meeting of the Directing Council attention might be given to some of the questions that had been raised, including those by the Chairman and Dr. Orellana, on whether the proposed figure was adequate to meet the need. Page 150 Eighth session 56th Meeting

The document before the Committee indicated that current prices of textbooks were far too high for most students, which was why the project was being supported. It was also stated that many of the textbooks existed only in languages that the students did not understand, and that others were out of date, did not deal with the most pressing problems in the country, or were of little educational value.

According to information received from one who made a visit to the Latin American countries in February, there were 53 medical titles, published by 13 different publishers, on the market in Spanish or Portuguese. They covered every subject offered in the first three years of the typical medical school in Latin America, and provided at least four titles in every major subject. That information seemed to contradict the statement that an inadequate number of books were available in translation. The matter needed clarification. Perhaps the high price was the reason why the available books were not being used. If so, it would be necessary to consider the price at which it would be possible for students to purchase and make use of them. Since the funds with which to launch the program were not yet available, those matters could be explored before the Directing Council meeting. If the Council were as enthusiastic about the project as had been the Conference, it would want to know what progress had been made in trying to obtain the funds, and if the point had not been reached where the program could be launched, it might wish to consider alternatives. But in order to do so, answers should be provided to the questions posed, including those he had raised because of the contradictory information that had come to his attention.

Therefore, it would be very useful to ask the Director, while continuing his negotiations with the IDB or other financing agencies, to ascertain what textbooks were available, their price and whether their high price was the reason the books were not being sold. He felt that it would be very helpful information for the Directing Council to have when considering the whole problem.

The CHAIRMAN said that the Director of the Bureau and Dr. Villarreal had answered the questions of the Representative of the United States of America and that, therefore, the inquiry did not need to be pursued. The real problem was not whether there were books in Spanish or how many titles were available to students, but the high cost of those books. The matter of quality had also been investigated by the Bureau, as had the feasibility of the program; it was merely a question of setting the system in motion so that it could be implemented in full.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) reiterated the remarks of the Chairman and said that the problem, especially the need for medical textbooks, had been examined from every angle. Bureau consultants initially visited 45 medical schools and had found opinion unanimously in favor. The Pan American Federation of Associations of Medical Schools, which embraced all the educators on the Continent, was consulted next. More recently visits had been made to Brazil, Colombia, Mexico,and Venezuela, which had 78 schools, and to 15 more in Zone VI. The six in Central America were being visited, so that a total of 99 schools had confirmed that there was an urgent need for the program.

Dr. HORWITZ (Director, PASB) thought that further inquiries were not needed since the administrative and teaching staffs of the medical schools had already Page 151 56th Meeting Eighth session been consulted. In reply to Mr. Calderwood, he said that the problem was not of a lack of textbooks in Spanish, but the fact that the students could not use them because most of them could not afford them, or there were not enough copies available in the school libraries. What the world publishing industry was interested in was getting students into the habit of reading, a habit they did not have because society had given them no opportunity to acquire it.

Leaving aside the matter of the quality of the books, Dr. Horwitz stated that the catalog of one of the largest publishing houses in Latin America, the "Fondo de Cultura Econ6mica," contained a large number of titles, but the prices were prohibitive. For example, Cecil's work on internal medicine cost 30 dollars, and Brentano's on pharmacology probably 20 dollars or more. Clearly students were in no position to buy them, even on easy terms.

He stated that the Organization was opening up a market that had never existed because books in Spanish were expensive. For that reason the program was undoubtedly of interest to the publishing industry of the Hemisphere and of the world. There was also the entirely unexplored market of books written for practicing physicians, especially country physicians, who also did not buy books because the university had not encouraged the reading habit in them.

The Bureau was willing to follow the instructions of the Committee, but he felt that nothing was to be gained from further consultations and that the only thing to do was to start the program experimentally with three to five books. He recalled that in 1963, at the XIV Meeting of the Directing Council, it was thought that the rural water supply project would prove impractical because no one would contribute to the Rural Welfare Fund. Exactly the opposite occurred in less than three years. The same thing would happen with the textbook program because the students needed those books urgently and the interested sectors would make their contribution for the purpose. In that connection Dr. Horwitz announced that he had received the moving news that the Government of Haiti had collected $4,000 in contributions from students to start the program.

Mr. CALDERWOOD (United States of America) said he would like to make clear that the Government of his country did not question the need for the program. He had merely indicated that the information he had received was not the same as that furnished by the Bureau. The latter might well be accurate and the information that had come to his attention entirely wrong, but since the Bureau did not yet have the funds to finance the project, it had seemed to him that they might well be better prepared, when the Directing Council met in October, to answer all the questions raised. He did not think it necessary to go back to the universities. Such information as they could give was already at hand. It might be helpful, however, to talk to the publishers, some of whom would be issuing the textbooks. He understood that the Organization was not proposing to do so itself. It might be possible, in that way, to refine the information available. He did not question the integrity of the Bureau's staff, but doubt had been expressed as to whether the books could be published at the price quoted, even with a pressrun of 20,000 copies. Both the Chairman and Dr. Orellana had raised the matter of price. Perhaps that should be reviewed. It might be necessary to raise the price 50 cents or more. His Govern- ment was entirely in sympathy with the project and with meeting the need, but he felt something should be done about the questions that had been raised. Page 152 Eighth session 56th Meeting

The Committee might well recommend to the Directing Council, if the project discussed at the XVII Pan American Sanitary Conference was not proving work- able, that it authorize the Director to try to find some other method of financing or that the Conimittee itself authorize some other method. The Director had been authorized to seek a loan through the IDB or some other agency and present the loan agreement to the Executive Committee for action. No such agreement was before the Committee, hence the project in accordance with the Conference resolution could not be launched.

Dr. HORWITZ (Director, PASB) felt that there was no contradiction between the information supplied by Mr. Calderwood and that presented by the Bureau. The Organization was well aware that medical texts were available; what was of concern to it was that the students could not use them, and it hoped to help them build'their own libraries and acquire the habit of reading from the time of their admission to the university, and not only medical texts. Although there might be room for doubt about the quality of the textbooks, it was for a committee of experts to examine them and advise on the matter.

As to the financing, the program might be launched with funds of the Organization and, if the loan was approved, those funds would be reimbursed. Page 21 of Official Document 75 (Financial Report of the Director and Report of the External Auditor) showed that there was a balance of $344,000 in the Special Fund for Health Promotion, which could be used as a kind of advance to start the program since, by agreement with the Kellogg Peundation, the Fund could be used for activities in sanitation, nutrition, or education. That sum would be later reimbursed from the IDB loan, if granted, from funds from any other source of financing, or through the Organization's own Emergency Revolving Fund if, following the suggestions of the Chairman and of Drs. Orellana and Santa María, it were deemed necessary to raise slightly the unit cost of the textbooks. But none of that would be possible unless the system was tried with at least three books.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) reiterated that inquiries with six or seven of the major publishing houses showed that differences in cost were not great. It amounted to $1.00 or $1.20 per unit, not including the cost of translation and author's royalties. He emphasized that the cost estimates presented were realistic.

Dr. PEREZ RUEDA (Ecuador) expressed the hope, on behalf of his country, that the program would be put into effect as soon as possible. He asked whether the expert committees had already been selected and whether thought had been given to the possibility of extending the program to practicing physicians.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) said that the deans and professors of the medical schools had been asked to nominate candidates for appointment to the expert committees and that about 75 replies had been received, many of which also mentioned works deemed useful as references for those committees. As to the possibility of extending the program to physicians, the Bureau had made provision for a pressrun of 200 copies for each medical school, which could be increased to extend the program to practicing physicians.

Dr. ACOSTA-BORRERO (Colombia) said that in his view enough information had been obtained on the subject and that the Governments had unanimously decided to Page 153 56th Meeting Eighth session

put the program into practice. The negotiations with the IDB provided a good indication of the feasibility of the program. He therefore believed that the Executive Committee should recommend that the Bureau be authorized to start it using the funds to which the Director had specifically referred. He proposed that a working party be designated to draft a resolution to that effect so that the program could be launched as soon as possible.

Dr. AGUILAR HERRERA (Guatemala), referring to Dr. Orellana's question regarding the ordinary edition, was under the impression that the low-cost edition would be the one envisaged in the program and the ordinary edition the one which authors arranged for with the publishers, which would be a more finished and expensive edition. The latter could be purchased by practicing physicians, as suggested by Dr. Pérez Rueda.

Dr. SANTA MARIA (Observer, Chile) believed that the small surcharge on the textbooks intended for physicians could defray part of the costs, which were not yet known in detail.

The CHAIRMAN emphasized that the aim of the program was to provide textbooks for medical students only, and not for medical practitioners; the supply of books for the medical profession was a problem for private industry.

Dr. VILLARREAL (Chief, Medical Education Branch, PASB) confirmed that the aim of the program was to provide low-cost textbooks for medical students and that the ordinary edition would be the one on sale and could also be of use to physicians in practice.

The CHAIRMAN designated Mr. Calderwood (United States of America), Dr. Acosta-Borrero (Colombia), and Dr. Orellana (Venezuela) as the members of the working party entrusted with drafting a resolution on the subject.

The session was suspended at 11:00 a.m. and resumed at 11:20 a.m.

ITEM 16: AMENDMENT TO THE FINANCIAL RULES OF THE PAN AMERICAN HEALTH ORGANIZATION

Dr. PORTNER (Chief of Administration, PASB) said that the Committee was being asked to confirm the amendment to the Financial Rules of the Pan American Health Organization, in accordance with Rule 101.3 thereof, which provided that all modifications would become effective from the date of issue by the Director, subject to confirmation by the Executive Committee.

The change proposed was relatively minor and would facilitate operations. The reason for the proposed change was that in the execution of the Organiza- tion's program it often occurred that short-term consultants planned for a particular year were not available until too late to complete their services before the end of the calendar year. A budgetary problem was thereby created since the budgeted funds were not utilized as planned and in the following year the budget might not make provision for continuation of the consultant services. The amendment would permit the charging of the service provided, even if it continued beyond the end of the financial year. Page 154 Eighth session 56th Meeting

Dr. Portner then presented the following draft resolution for the Commit- tee's recommendation:

THE EXECUT:VE COMMITTEE,

Recognizing the importance of assuring that short-term consultant services, planned as a part of the program of the Organ- ization, should be provided in full, even when the period of assignment has not been completed by the end of the financial year; and

Desiring to follow the practice of the World Health Organ- ization with respect to obligations covering short-term consultants,

RESOLVES:

1. To confirm the amendment to the Financial Rules of the Pan American Health Organization which adds the following sub- paragraph to Article III, paragraph 103.2:

(c) the entire costs relating to short-term consultants whose period of assignment may not have been completed by the end of the financial year.

2. To request the Director to report this amendment to the XVII Meeting of the Directing Council.

Dr. AGUILAR HERRERA (Guatemala) agreed with the amendment since it would make the services by short-term consultants more readily available.

The CHAIRMAN submitted the draft resolution to a vote.

Decision: The draft resolution was unanimously approved. 7/

ITEM 19: RESIGNATION OF THE EXTERNAL AUI)ITOR

Dr. PORTNER (Chief of Administration, PASB) said that at each meeting of the Governing Bodies a report was made on the financial state of the Organization. That report usually covered two items, the Financial Report of the Director and the Report of the External Auditor. During the past 16 years the Organization had been privileged to have with them the Auditor General of Sweden as External Auditor of the Organization. He had also served as the External Auditor of the World Health Organization. Recently, Mr,, Uno Brunskog had indicated to the Director that, because of his advanced age, he regretted that he had to relin- quish his position.

2/ Resolution V. Official Document PAH() 79, 33. Page 155 56th Meeting Eighth session

The members of the Committee had acknowledged again and again the invaluable contribution of the External Auditor not only in the review of the accounts of the Organization but, perhaps even more meaningfully, in the development of many innovations in its financial structure, processes, and techniques. It was therefore with great regret that he had to announce the resignation of Mr. Brunskog. The Director and staff of PAHO wished to pay tribute to his very fine assistance over many years.

WHO had, of course, had the same problem to face and, after a thorough survey of the external auditors of noted competence in the field, the World Health Assembly had appointed the Auditor General of Norway, Mr. Lars Breie, as the External Auditor of the WHO. In keeping with tradition, the Director was recommending that Mr. Lars Breie be named as successor to Mr. Uno Brunskog so that, in effect, the External Auditor of WHO would once again serve as the External Auditor of PAHO beginning on 1 January 1968. Mr. Lars Breie had been approached and had indicated his interest and enthusiasm in serving in that capacity. Definitive action would have to be taken by the Directing Council, but the matter was presented to the Executive Committee for information and recommendation as it saw fit. Accordingly, the following resolution was offered for consideration:

THE EXECUTIVE COMMITTEE,

Having been informed of the resignation of Mr. Uno Brunskog, External Auditor of the Pan American Health Organization, to be effective 1 January 1968; and

Bearing in mind that it has been the practice of the Pan American Health Organization and the World Health Organization to have the same External Auditor and that Mr. Lars Breie, the Ex- ternal Auditor of WHO has expressed his willingness to serve as the External Auditor of PAHO,

RESOLVES:

1. To note with regret the resignation of Mr. Uno Brunskog as External Auditor of the Pan American Health Organization, for reasons of age.

2. To express its thanks to Mr. Brunskog for his conscien- tious services and his many valuable recommendations on the Organ- ization's financial policy.

3. To recommend to the Directing Council that it appoint Mr. Lars Breie, External Auditor of the World Health Organization, as External Auditor of the Pan American Health Organization.

Mr. CALDERWOOD (United States of America) said the Delegation of his country wished to endorse strongly the commendation by Dr. Portner of the services rendered by Mr. Brunskog. He wondered whether the actual recommendation should Page 156 Eighth session 56th Meeting

not include an expression of thanks, as well as a reference to the appointment of the new auditor, so that it would in turn be expressed by the Directing Council. Perhaps it would be more appropriate for that suggested modification to come from the Directing Council itself.

Dr. PORTNER (Chief of Administration, PASB) said that the entire resolution, if approved, would go to the Directing Council, and the second paragraph was explicit in regard to the Committee's expression of thanks for the con- scientious services and many valuable recommendations made by Mr. Brunskog. Ac- cordingly, he wondered if it would not be redundant to repeat it in the third paragraph. The Directing Council, in its resolution, would doubtless take up the expression of thanks made in the second paragraph.

The CHAIRMAN submitted the draft resolution to a vote.

Decision: The draft resolution was unanimously approved. 8/

ITEM 13: AMENDMENTS TO THE STAFF RULES OF THE PAN AMERICAN SANITARY BUREAU

Dr. PORTNER (Chief of Administration, PASB), in presenting Document CE56/6, 2/ said that at each spring meeting of the Committee, amendments to the Staff Rules were submitted for its information and confirmation. The amendments presented were essentially of two types. A number of them were basically editorial in nature, but a major change was proposed concerning staff pensions under Rule 730.

The changes proposed were already in effect for staff members funded from the WHO funds, and had been adopted by the WHO Executive Board at its Thirty- ninth Session held in January 1967.

The major change proposed was that concerning the Staff Pension Fund. That particular change had gone through the entire sequence of development in the United Nations system. It had been taken up on the initiative of one of the Specialized Agencies at the Advisory Committee on Administrative and Budgetary Questions; from there it had gone to the! International Civil Service Advisory Board, had been taken up by the General Assembly of the United Nations, had been passed there, and had gone on to the WHO Executive Board where it was accepted in January. Therefore, it had been approved at four levels in the UN system and its application to PASB staff was being sought.

Basically, the change was to give to persons on contracts of one year and more, but less than five years, the Pension Fund coverage heretofore given only to persons with five-year contracts, or a four-year contract with a renewal of one or more years. The coverage it gave the staff members with a one-year contract was different from his previous coverage, which had been mainly for death and disability. Its purpose was, first, to give additional protection to staff members; second, to stabilize the funding of the Pension Fund, which had been

/ Resolution VI. Official Document PAHO 79, 33-34. 9/ Mimeographed document. Page 157 56th Meeting Eighth session incurring a loss in its coverage for death and disability of persons who were on only the one-year contract basis. Therefore, its meaning was twofold: to give better conditions of employment and to give financial stability to the Pension Fund.

Dr. AGUILAR HERRERA (Guatemala) said that in his opinion the amendments were justified and he therefore proposed that the Committee approve them.

Dr. WEDDERBURN (Jamaica) said that since members would obviously approve the recommendations he would propose the following resolution:

THE EXECUTIVE COMMITTEE,

Having considered the amendments to the Staff Rules of the Pan American Sanitary Bureau, contained in Annex to Document CE56/6 submitted by the Director; and

Bearing in mind the provisions of Staff Rule 030,

RESOLVES:

To approve the amendments to the Staff Rules of the Pan American Sanitary Bureau, submitted by the Director of the Pan American Sanitary Bureau in Annex to Document CE56/6, to be effective as from 1 January 1967.

Decision: The draft resolution was unanimously approved. 1f/

ITEM 8: ARRANGEMENTS FOR THE XVII MEETING OF THE DIRECTING COUNCIL, XIX MEETING OF THE REGIONAL COMMITTEE OF WHO FOR THE AMERICAS

Dr. PORTNER (Chief of Administration, PASB) said that arrangements were in progress for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas. It would be recalled that the XVII Pan American Sanitary Conference had received an invitation from the Government of Trinidad and Tobago to hold the 1967 Council Meeting in Port of Spain. Reso- lution XL i1/ of that Conference had thanked the Government of Trinidad and Tobago for its generous offer, and accepted the invitation.

Since that date numerous conversations had been held with representatives of that Government both in Port of Spain and in Washington. The Government had designated a Committee under the chairmanship of the Permanent Secretary of the Ministry of Health and Housing, Mr. Gerald Chen, and the group had worked very closely with the Organization on the arrangements. It was planned to hold the meeting at the Trinidad Hilton Hotel, which had the necessary facilities and

10/ Resolution VII. Official Document PAHO 79, 34. 11/ Official Document PAHO 74, 100-101. Page 158 Eighth session 56th Meeting acommodation for both the representatives and the staff of the Bureau. Arrange- ments were also advanced for moving supplies, material, equipment, and manpower. The date of the meeting, 2-13 October, had been established in agreement with the Host Government.

Dr. PEREZ RUEDA (Ecuador) submitted the following draft resolution:

THE EXECUTIVE COMMITTEE,

Having considered the report submitted by the Director of the Pan American Sanitary Bureau (Document CE56/10) on the arrangements for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of the World Health Organization for the Americas, and for the 57th Meeting of the Executive Committee,

RESOLVES:

1. To take note of the report submitted by the Director on the arrangements made for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of the World Health Organiza- tion for the Americas, and for the 57th Meeting of the Executive Committee.

2. To approve the arrangements made by the Director and to authorize him to convene the meeting of the Council from 2 to 13 October 1967 in Port of Spain, Trinidad.

Decision: The draft resolution was unanimously approved. 12/

The session rose at 12:10 p.m.

l2/ Resolution VIII. Official Document PAHO 79, 35. NINTH PLENARY SESSION Monday, 1 May 1967, at 2:40 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 15: STATUS OF SMALLPOX ERADICATION IN THE AMERICAS

The CHAIRMAN opened the session and announced that the first order of business was Item 15.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) presented Document CE56/14 1/ and said that since 1949 the Governing Bodies of the Organization, in 15 resolutions adopted in successive years, had expressed their concern over the problem of smallpox in the Americas and their desire to eradicate the disease from the Western Hemisphere.

In compliance with the instructions of the Governing Bodies, the Bureau, since 1950, had been actively engaged in a hemisphere-wide program of smallpox eradication to the extent permitted by available resources. It had been assisting the Governments in planning, executing, and evaluating smallpox eradication programs based on vaccination campaigns which, at the proper time, could be incorporated into the general health services of the countries. That aid had consisted in technical advisory services, training local personnel, and supplying equipment for the production of freeze-dried vaccine. In other cases assistance had been furnished in purchasing vaccine ready for use, and fellowships had been granted for training local personnel in the organization of vaccination campaigns.

The Organization had also made available to the Governments the services of an officially accredited laboratory for the purity and potency testing of smallpox vaccine prepared by the national laboratories. That work had been done at the Serum Institute of Copenhagen, Denmark, and more recently, another had been used, at the University of Toronto, by virtue of an agreement with that University.

Steady progress had been made since 1950 in the eradication of smallpox, but with varying results in each country. Some countries had already managed to eliminate the disease, others were approaching that goal, and still others had yet to enter the final stage of eradication.

The remaining foci were not only a problem for the countries where they existed, but also a threat and a cause of concern to those which were free of the disease and were obliged to continue their activities in order to maintain a high level of immunity in their population, which was a costly matter. The actual or threatened reintroduction of smallpox had obliged some countries already free of the disease to repeat their mass vaccination campaigns.

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Experience had shown that the disease could be quickly eliminated through the intensification of systematic vaccination programs using highly active vaccines. No insurmountable difficulties had arisen in that connection. The fact that some countries had not been able to conduct programs and that others had met with difficulties in achieving eradication was primarily due to the lack of the funds needed to obtain personnel and supplies, or to shortcomings in the conduct of vaccination campaigns, or failure to establish proper surveillance or maintenance services.

In order to determine the kind and extent of international assistance the countries needed for eradicating smallpox from the Hemisphere, the Organization, acting in accordance with Resolution XXX, 2 approved by the Directing Council at its XVI Meeting (Washington, D.C., 1965), had made a careful evaluation of the status of smallpox in the countries of the Region. The report on the findings of the study was presented 3/ to the XVII Pan American Sanitary Conference. That document indicated the kind of international assistance that the countries required of PAHO/WHO for the study, organization, execution, and evaluation of the smallpox eradication program, national smallpox vaccination programs, maintenance programs, and programs for the organization of epidemiological surveillance services.

On that basis, a comprehensive eradication plan was submitted to the XVII Pan American Sanitary Conference. The plan consisted of the following points: vaccination of the population in countries where smallpox existed (Argentina, Brazil, Colombia, Paraguay, and Peru and also Bolivia, where an eradication program was under way, and Uruguay, where cases were reported in 1964 and which was located between countries where smallpox was endemic); continuation or organization, as the case might be, of maintenance and epidemiological surveillance programs in countries where the disease had been eliminated as a result of successful smallpox vaccination programs but which bordered on others where smallpox still existed (Chile, Ecuador, and Venezuela were in that group); and, finally, for smallpox-free countries, other than those in the latter group, the adoption of safety measures to prevent the introduction and spread of the disease in the event that the population was exposed to the risk of infection. It would be advisable for that group of countries to make efforts to raise the proportion of their inhabitants protected against smallpox, preferably through the national health services and as part of broader immunization programs.

In order of priority, international assistance should be concentrated, first of all, on countries where smallpox existed and then, on those where maintenance programs were under way. The attack phase of the smallpox eradication programs should last not more than four years, at the end of which the disease should be eliminated and the programs of maintenance and epidemiological surveillance should be in full operation and cover the entire area of a country. It was important that the programs in the different countries be properly synchronized.

The Conference had taken note 4/ of the document on the status of smallpox eradication and its estimated requirements and had instructed the Director of the

2/ Official Document PAHO 66, 81-82. 3/ Official Document PAHO 77, pp. 548-568. 4/ Resolution XVIII. Official Document PAHO 74, 75-76. Page 161 56th Meeting Ninth session

Bureau to provide material assistance to the countries subject to budgetary limitations and in the form required by each Government as the national programs pro- gressed through each successive stage.

The Nineteenth World Health Assembly, 2/ recognizing the need to increase the resources available for the campaign and the importance of approaching the problem in a comprehensive way and with proper coordination, had decided to include in the regular budget of the Organization the expenses required for the participation of WHO in the program of smallpox eradication and had urged those countries that were planning to organize or strengthen their smallpox eradication programs to take the necessary action to do so as soon as possible. The regular budget of WHO included $2,674,000 for the 1967 program and an allocation of $2,820,000 had been proposed for the continuation and strengthening of those activities in 1968. Of the $2,674,000 for 1967, $670,000 was earmarked for the Region of the Americas, and of the allocation for 1968, $695,000 was so earmarked.

Dr. Bica emphasized that, in compliance with that resolution, the Organ- ization, in consultation with the Governments concerned, had begun to plan the details of the program and other preliminary work so that the Organization could make the best possible use of the funds approved. Thus, in March 1967, a Region- al Smallpox Adviser had been appointed to supervise the eradication program in the Americas. The Organization was also in the process of recruiting personnel for the posts of medical officer and statistician to be assigned to Zones IV and VI.

The Regional Adviser for the Americas recently took part in a meeting in Alexandria, Egypt, in which all the regional advisers, in cooperation with members of the headquarters staff of WHO, made a thorough examination of a manual of smallpox eradication, a rather comprehensive text that was revised and would be translated and published and which, once adapted to conditions in each Region, could serve as a guide for eradication programs in any part of the world. Three medical officers and a statistician had also been designated to collaborate with the public health authorities of Brazil in the national eradication program.

Dr. Bica announced that a third course on the laboratory diagnosis of smallpox would be held in Sao Paulo, Brazil, in October 1967. He recalled that two similar courses, sponsored by the Organization in cooperation with the National Communicable Disease Center of the United States Public Health Service and the Adolfo Lutz Institute of Sao Paulo, Brazil, had been conducted from 16 to 29 October 1966. They were attended by 15 experts, including three from Argentina, and one each from Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, Mexico, Peru, and Venezuela.

The training program for those courses was based primarily on simple, practical methods that could be used by any reasonably well organized laboratory without resorting to any difficult or complicated method. Emphasis was placed on the two methods most commonly used, namely, the method of cultivation in eggs, which required at least three days, and the agar-gel test, which could provide a diagnosis in 4 to 24 hours. Other, more complicated procedures were also reviewed:

2/ Resolution WnHA19.16. Off. Rec. Wld Hlth Org. 151, 8-9. Page 162 Ninth session 56th Meeting for example, electronic microscopy, fluorescent microscopy, and serological methods such as hemagglutination and complement fixation.

Dr. Bica then reported that the Bureau had signed an agreement with Argen- tina for an eradication campaign, would soon conclude one with Colombia, and was considering similar agreements with Paraguay and Uruguay, which would complete the coverage of all the countries where the disease still existed. The Govern- ment of Chile had also signed an agreement with the Organization to conduct a program of maintenance and epidemiological surveillance against smallpox.

He stressed that one of the most important aspects of the eradication program was the provision of an adequate supply of stable, high quality freeze-dried smallpox vaccine. In recent years the Bureau had actively promoted the establishment of vaccine production facilities in various countries. With the assistance of the Organization (consultant services, fellowships for training in the manufacture of vaccines, and provision of supplies and equipment), various countries were producing sufficient vaccine to meet their own requirements and supply non- producing countries.

In general, the countries were not making sufficient use of the services offered them to test the vaccines produced in the national laboratories, and some were having difficulties in preparing their vaccine, as evidenced by the fact that certain batches were not meeting the minimum requirements of WHO in regard to activity, innocuity, and stability. To produce a vaccine of consistently high quality, those countries would have to test their product systematically. The Organization was prepared to cooperate in ensuring sound operation of the laboratories producing smallpox vaccine and, to that end, had made arrangements for the University of Toronto to provide the services of the Connaught Medical Re- search Laboratories, which would offer advice and cooperation in the production and testing of smallpox vaccine, including the training of medical and para- medical personnel. Experts from the Connaught Laboratories would visit the vaccine production centers in the Region periodically to evaluate existing facilities and personnel and recommend the necessary changes. The laboratories currently being visited by those experts included those of the Oswaldo Cruz Insti- tute and the laboratory of the State of Rio Grande do Sul, which were equipped by the Bureau, and that of the Butantan Institute, which had not received such cooperation but which produced freeze-dried vaccine. The next laboratories scheduled to be visited were those of Argentina, Chile, and Peru.

Toward the end of 1966 the Bureau furnished equipment to the laboratory of the National Institute of Microbiology in Buenos Aires, which reported that Argentina would soon be able to produce 18,000,000 doses, which, when added to the 27,000,000 doses produced by Brazil, would be more than sufficient. The use of the jet injector made it possible to dilute the vaccine, and thereby substantially increase the available amount. Nevertheless, it would still be necessary to maintain at least two laboratories in order to produce the amount currently required and to provide for emergencies. For example, the Government of Brazil had the necessary capacity to produce 27,000,000 doses, which appeared to be ample to cover all needs, but recent problems, arising from the floods in that country, reduced the capacity of the Oswaldo Cruz Institute from 27,000,000 doses a year to 9,000,000. Page 163 56th Meeting Ninth session

Referring to the manual 6/ prepared by the National Communicable Disease Center of the United States of America on the use and repair of the jet injector, Dr. Bica said it would be used extensively in the eradication programs. The Portuguese version would be widely distributed among the personnel engaged in the campaign in Brazil. Jet injectors could be employed in the urban areas, where they could be used to maximum capacity. Certain problems had arisen, but were expected to be solved in the near future. In conclusion, Dr. Bica requested the representatives to read the summary appearing in the final pages of Docu- ment CE56/14.

Dr. PEREZ RUEDA (Ecuador) said that he was highly pleased with the document presented, which showed the need to increase the resources available for the smallpox eradication program.

He then submitted the following draft resolution to the Executive Commit- tee for consideration:

THE EXECUTIVE COMMITTEE,

Having considered the report of the Director of the Bureau on the status of smallpox eradication in the Americas (Document CE56/14 );

Bearing in mind the importance of the smallpox problem in the Americas and the repeatedly expressed wish of the Governments that this disease be eradicated;

Considering that the World Health Organization has assigned for 1967 the amount of $670,000 for the smallpox eradication program in the Americas; that for 1968 the Director-General of WHO has requested $695,000 for the Region of the Americas for the same purpose; that the estimate of the sum contributed by international agencies to the countries of the Americas for the eradication of smallpox, made by the Pan American Sanitary Bureau, shows that the amount of $1,556,280 will be needed for the first year and $446,940 for the second year; and that these figures show that there will be a shortfall of $638,220 for the first two years of the smallpox eradication program;

Mindful that the smallpox eradication program in the Americas will have to be carried out within a period of less than five years and that lack of funds will mean an unexpected prolongation of the campaign whose consequences can be very serious,

RESOLVES:

1. To take note of the report of the Director of the Bureau (Document CE56/14).

6/ Ped-O-Jet--Operation, Maintenance, and Minor Repair Guide, Model POJ. Pub- lished in Spanish and Portuguese as Scientific Publication PAHO 148, 1967. Page 164 Ninth session 56th Meeting

2. To recommend to the XVII Meeting of the Directing Council that it consider the possibility of including in the budget of the Pan American Health Organization for 1968 an additional amount of $638,220 for smallpox eradication.

3. To request the Director of the Bureau to undertake the necessary studies and to submit to the XVII Meeting of the Directing Council a proposal for implementing the recommendation contained in the immediately foregoing paragraph.

Dr. AGUILAR HERRERA (Guatemala) expressed his support for the draft resolution presented and said that while the documentation on the subject submitted to the 54th Meeting of the Executive Committee in 1966 had not been sufficient, the one submitted to the present meeting was satisfactory in terms of every requirement. He therefore considered that progress had been made in the summary presentation of the plan and in the description of available resources to enable them to be used in accordance with a proper scale of priorities. He also agreed with the total amounts and also with their distribution in accordance with the needs of the countries.

Dr. SANTA MARIA (Observer, Chile) called attention to the effort his country was making to conduct vaccination programs not only against smallpox but also against all other diseases that could be eradicated or at least controlled through the use of vaccines. He asked if the Bureau could prepare a general program of immunization to be conducted on a continuing basis and tied in concurrently with campaigns against specific diseases. He suggested that, if possible, the Bureau study that possibility, availing itself of financial cooperation from agencies such as UNICEF and providing the technical assistance itself. He considered that there were countries such as Chile that, if able to reduce their anti-smallpox activities, would be in a position to launch other public health campaigns.

Dr. BANTA (United States of America) said that his country's Delegation wished to express its full approval of the steps being taken to launch the full- scale program for eradication of smallpox in the Americas, and considered the program to be of the highest priority and a very important part of the global eradication program of WHO. It expected that the program would be given the operational priority and support requiretl to meet the objective of eradication by 1970. Obviously,until there was hemisphere-wide eradication, smallpox remained a threat to all. In that connection it was, of course, important that surveillance and assessment be built into the program, to ensure maintenance of an adequate level of immunity. He would like to have an opportunity to study the resolution introduced by Dr. Pérez Rueda. It seemed excellent but he would appreciate the opportunity to consider it in detail.

Dr. ORELLANA (Venezuela) said that the very fact that the resolution on smallpox submitted for approval by the Executive Committee would be the sixteenth on that matter was clear evidence of the importance of the problem and the difficulties constantly encountered in resolving it. Any decision adopted should be a practical one that woilld lead to definite progress toward smallpox eradication. In that respect, he agreed with the Representative of the United States Page 165 56th Meeting Ninth session of America that the draft resolution presented should be carefully examined. He then requested more precise information concerning the proposal, particularly as to whether or not the amount requested was additional to that proposed in Official Document 67, because it appeared inadvisable to request the Directing Council to approve the amount of $638,000 when an item of $766,353 was already allocated for 1968.

He then referred to the difficulties the countries had encountered in developing their smallpox immunization programs; they were not technical but rather economic and administrative problems affecting the general framework of the programs. Many countries had organized their smallpox programs along vertical lines, rather than incorporating them into the regular programs of general health services and a controversy had arisen in his country as to which of the two alternatives available to the Governments should be followed in organizing the smallpox program in Venezuela. Despite the arguments usually presented for making the general health services responsible and thus maintaining the smallpox campaign at a high level of organization, it had to be recognized that the same results had been achieved in Venezuela, and probably other countries, by means of vertical campaigns. The manual referred to by Dr. Bica seemed extremely useful and interesting and deserved wide distribution.

Dr. Orellana was disappointed that a disease as easy to combat, both from a technical and practical standpoint, as smallpox had not been eradicated and wondered if it was due to financial or administrative shortcomings. In any event, the eradication of a disease was a relative concept if considered from the geographic point of view. He believed that eradication should be conceived in terms of broad future results stemming from a single campaign to be conducted simultaneously everywhere, with no country lagging behind. He felt that the plan proposed by the Bureau was the most reasonable one, since it provided for concentrating the greatest efforts in countries most sorely affected while also maintaining the work of immunization in the other countries. Dr. Orellana said that he intended to vote in favor of the draft resolution submitted, after it had been carefully examined and the other representatives had expressed their opinions.

The CHAIRMAN said that it was clearly incumbent on the Executive Committee to forward to the Directing Council a resolution expressing a dynamic view of the program. Despite the fact that a method for eradicating smallpox had been available for almost 170 years, the problem continued to be debated. The time had come for showing the world that the goal, the elimination of the disease, was an undertaking that could be accomplished in the Hemisphere in a short time. The greatest problem was that of diagnosis; smallpox was sometimes confused with alastrim and it was therefore of the utmost importance to distinguish the two. That was the case in Brazil, where most of the cases were alastrim.

Dr. BICA (Chief, Communicable Diseases Branch, PASB), replying to Dr. Santa Maria, said that in Chile smallpox vaccination was part of a general immunization program that would be administered along with other immunizations, through the public health units. An agreement to that effect had already been signed, and the necessary material was being procured. The first quarter of 1968 would probably be devoted to the preparatory phase, which was perhaps the most difficult, since it involved examining the entire scope of the problem, determining what Page 166 Ninth session 56th Meeting

resources were available for the training of personnel and, finally, organizing the campaign. He emphasized that the distinction between alastrim and smallpox was made in the laboratories and was not too difficult because the lesions caused by alastrim were superficial and those of smallpox were relatively deep. The electron microscope offered the simplest procedure for differential diagnosis, but the cost of that method was high.

Referring to the manual on smallpox eradication being prepared, Dr. Bica said he was sure it could be distributed within approximately one year and that it was a highly useful text.

Dr. HORWITZ (Director, PASB), referring to the intervention of the Ob- server of Chile, said that careful examination of Document CE56/14 and of the volume of vaccination in the countries in 1966 would show that in the vast majority of the countries the immunity level was below what it should be. A country that indicated that it had eliminated the disease or reduced its incidence to a number of sporadic cases was still under an obligation to immunize all new inhabitants, whether newborn infants or immigrants, and to revaccinate at least 20 per cent of the pre-existing population. If that proportion were accepted, it would have to be said that most of the countries had not complied with that requirement in 1966. It would thus appear that in the preparation of the 1966 programs no consideration was given to what might be termed the "useful level" for maintaining a level of immunity sufficient to prevent the re-entry of the disease.

A list which Dr. Bica had provided him with confirmed that fact even more conclusively and showed that only a few countries had reached that "useful level."

The same was true of all immunizations, which raised the question of why there was still diphtheria in Latin America, why there was whooping cough, why there was so much tetanus neonatorum, and why, after the tremendous effort made 10 years ago with BCG, immunity remained well below useful levels. The answer to all those questions was that the programs had not been based on the attainment of useful levels in each community. Dr. Horwitz then referred to the various recommendations made on the preparation of biological products, and said there was no coordination between productive activities and the requirements of an immunization program for a given year. That was serious because both the producer of the vaccine and the agency that was to use it needed to know well in advance what the health service proposed to do in a given area. Even with the money in hand it was impossible to procure vaccine overnight. That was a problem for the Organization, despite the efforts made by the Governments of the producing countries to expedite the shipment of immunization agents.

Finally, he believed that the resolution under consideration, although dealing exclusively with smallpox, should be taken as an opportunity to express an opinion on the general problem, as that could be kept in mind when planning the control and eradication of communicable diseases through immunization methods.

Dr. SANTA MARIA (Observer, Chile) said that he was grateful that his comments had been taken into account and that Dr. Horwitz had placed them in the Page 167 56th Meeting Ninth session proper context by examining them as part of the general problem of communicable diseases. He referred to the decision recently adopted by the Meeting of Amer- ican Chiefs of State in Punta del Este, in which the importance of communicable diseases was recognized. He added that, even if the rightful priority were accorded to smallpox eradication and a substantially greater effort were made in those countries where the infection still had the highest incidence, it would be useful, for the future, to consider the possibility that the Director of the Bureau study how general immunization campaigns could be carried out either through the Organization itself or in conjunction with other agencies. Such a decision would be welcomed by the Government of Chile, and would also serve to interpret the practical meaning of the decisions of Punta del Este.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) agreed with the comments made by Dr. Santa Maria and announced that the Bureau proposed to organize in 1968 a seminar on combined immunizations which would deal not only with the vaccines that should be used but also with the best ways of using them and why those available were not being utilized. That activity, based on a proposal by Dr. F. Salveraglio of Uruguay, would afford an opportunity to examine the reasons why the available vaccines were not being properly utilized.

The CHAIRMAN proposed that a working party composed of Dr. Pérez Rueda, (Ecuador), Dr. Banta (United States of America), and Dr. Orellana (Venezuela) be appointed to revise the draft resolution presented by Dr. Pérez Rueda in the light of the views expressed.

It was so agreed.

The session was suspended at 3:40 p.m. and resumed at 4:00 p.m.

ITEM 18: APPOINTMENT OF THE DEPUTY DIRECTOR AND OF THE ASSISTANT DIRECTOR OF THE PAN AMERICAN SANITARY BUREAU

Dr. HORWITZ (Director, PASB), in presenting Document CE56/9 7/ on the item, said that the text of the document was a clear expression of the feeling of all those concerned, since it seldom happened that a document was written under the pressure of sentiments so clearly opposed as those on which the document submitted to the Executive Committee were based. The Deputy Director, Dr. Cutler, had long since informed the Director of his desire to enter the teaching field, having received a specific proposal, which he finally accepted, to serve as Director of the Population Division of the Graduate School and, at the same time, as Professor of International Public Health in the School of Public Health of the University of Pittsburgh. Dr. Sutter, who in the course of his long and distinguished career of more than 20 years in international public health, had served as Assistant Director-General of the World Health Organization, Minister of Public Health of his country, and Assistant Director of the Pan American Sanitary Bureau, planned to return to his country, El Salva- dor, where it was devoutly hoped he would continue to cooperate with the Organ- ization in the various posts his Government had offered him.

2/ Mimeographed document. Page 168 Ninth session 56th Meeting

As all those present were well aware that the only solace in such circumstances was the knowledge that the departure of a distinguished official could in no way impair the ties of friendship and warm regard established over the period in which they served the Organization so effectively and brilliantly. And that was precisely the case, for Dr. Cutler and Dr. Sutter, in entering upon their new assignments, would retain the friendships formed in so many years of joint activity and had offered to continue to cooperate, even more intensively if possible, in whatever the Organization proposed to do.

The Director then announced that the Organization had been fortunate in persuading two other outstanding officials to succeed Dr. Cutler and Dr. Sutter: Dr. Charles L. Williams, Jr., as Deputy Director, and Dr. Alfredo Arreaza Guzmán, as Assistant Director. Dr. Williams was currently Director of the Office of International Affairs of the United States Public Health Service, with the rank of Deputy Surgeon General.

Dr. Arreaza Guzmán had been active in international health affairs since 1947 and, in his own country, had held the post of Director of the School of Public Health, Director General of Health., and Minister of Health and Social Welfare. It was confidently expected, said Dr. Horwitz, that Dr. Williams and Dr. Arreaza Guzmán would perform their duties with the same efficiency and devo- tion displayed by Drs. Cutler and Sutter, to whom the Bureau wished to pay grateful tribute.

Dr. ORELLANA (Venezuela), speaking for the Executive Committee and confident of voicing the sentiments of all the Governments of the Organization, expressed his deep regret at the departure of Dr. Cutler and Dr. Sutter. In the Bureau, as in the countries, both were familiar figures to all concerned, known for their unceasing efforts on behalf of health in the Hemisphere and the world. Everyone knew them for their arduous yet cordial approach to the delicate tasks involved in their dealings with Governments and individuals. All the participants in the Meeting, he said, knew from their own experience what an international position implied. An international official often had to divest himself of his national feelings and act exclusively in an international capacity so that he could put together a program based on international or regional interests, which were broader than those of a single country. Dr. Cutler and Dr. Sutter had performed those functions admirably. If other commitments were taking them from the Organization, it was comforting to know that they would continue to work in the public health field. The experience they had gained would benefit their own countries and others as well. In matters of health there were no frontiers to the diffusion of knowledge or to the use of services. Everyone was saddened by the departure of those eminent servants of the Organization. The straight and restless figure of Dr. Cutler and the smiling and gracious countenance of Dr. Sutter were images that the public health workers of the Continent would long remember.

The members of the Executive Committee accorded Dr. Cutler and Dr. Sutter a standing ovation.

Dr. CUTLER (Deputy Director, PASB) stated that it was always exceedingly difficult to find oneself in a position such as he was. First, there was the prospect of making a change from an association and a post that one had enjoyed Page 169 56th Meeting Ninth session for many years, leaving with regret the association and the friendships that one had formed. He would like to take the opportunity to say several things. First, in a very personal way, he wished to thank Dr. Horwitz for the privilege of having been associated and working with him. It had been a wonderful experience and he was proud to have had the opportunity to serve under his leadership. He trusted he had been able to make some small contribution to the outstanding direction that Dr. Horwitz had given to the work of the Organization, and for that privilege he would like to thank him.

He also wished to mention his sadness at leaving his other colleagues in the Organization, notably Dr. Sutter. He would not mention the rest, but he felt a distinct sense of pride and privilege in having been associated with such an outstanding group of colleagues and friends, all of whom, he believed, joined him in taking real satisfaction in the thought that possibly, through their cooperation with the Governments, they might have been able to play some small role in achieving the objective of better health for the Americas.

He would like to thank each of the representatives of the Governments; for a long time they had been working together in one way or another, in meetings, sometimes as staff for a committee, at other times at various international meetings, and again it had been a distinct pleasure and privilege.

He felt as though he were saying goodbye to a very close and warm group of friends, and deeply appreciated the privilege of having been associated with them. He should not really use the word goodbye because he thought of it as being merely a sort of change in chairs that all of them had had at one time or another in moving from Organization to Government, to university, and so on. In the post which he was assuming he looked forward to being of use to the Organization and the Governments in any way it was possible for a professor of international health in a university to contribute in furthering the improvement of health in the Americas, and in working so as to be able to make a contribution in the field of population. He would like to pledge to Dr. Horwitz and the members of the Execu- tive Committee his complete support for their efforts to promote and improve the health of the Americas, an ideal and goal to which he was deeply dedicated. He would like to express his deepest thanks to them all.

Dr. SUTTER (Assistant Director, PASB) said that he was too deeply moved to find appropriate words to convey his emotions. He accepted the tribute, though doubting that he deserved it, as an expression of mutual friendship maintained over many years.

Dr. WEDDERBURN (Jamaica) supported what had been said about both Dr. Cutler and Dr. Sutter, but said he felt one aspect had not been mentioned. He had been attending meetings of the Organization for a number of years, and quite apart from the friendship and assistance in technical matters he had received from both of them, he had personally enjoyed the benefit of their guidance on administrative matters. Though delegates serving on committees were invariably supposed to be responsible for what emanated from working parties, they all knew only too well that a good deal of the useful product that emerged was the brain child of either Dr. Sutter of Dr. Cutler. He personally had learned a lot in that way, and apart from their competence, of which a good deal had been said, he would like to record that other aspect of the assistance which delegates had received from both of them over the years. Page 170 Ninth session 56th Meeting

Therefore he would like to propose the following resolution:

THE EXECUTIVE COMMITTEE,

Considering that, for professional and personal reasons, Dr. John C. Cutler, Deputy Director, and Dr. Víctor A. Sutter, Assistant Director, are unable to continue the valuable services they have performed in those posts for several years in the Pan American Sanitary Bureau;

Having been informed that the Director of the Bureau, using the powers conferred on him by Article 21-B of the Consti- tution, has appointed Dr. Charles L. Williams, Jr., to the post of Deputy Director, and Dr. Alfredo Arreaza Guzmán to the post of Assistant Director;

Considering that, in accordance with the above-mentioned Article 21-B of the Constitution, the appointment of officers to these posts must be approved by t;he Executive Committee; and

Considering that, in the opinion of the Committee, the persons appointed are suitable to discharge the functions assigned to them,

RESOLirES:

1. To approve the appointment of Dr. Charles L. Williams, Jr., to the post of Deputy Director, and that of Dr. Alfredo Arreaza Guzmán to the post of Assistant Director of the Pan American Sanitary Bureau.

2. To express its profound thanks to Dr. John C. Cutler and Dr. Víctor A. Sutter for the work they have carried out so zealously and competently in the service of the Organization.

The CHAIRMAN proposed that the draft resolution presented be amended to convey with more feeling the deep appreciation of the Executive Committee. For that purpose, he suggested that paragraph 2 of the operative part be changed to read: "To express its profound thanks to Dr. John C. Cutler and Dr. Víctor A. Sutter for the work they have carried out so zealously and competently for the benefit of the health of the peoples of the Americas."

Decision: The draft resolution as amended was unanimously approved. 8

8/ Resolution IX. Official Document PAHO 79, 35-36. Page 171 56th Meeting Ninth session

ITEM 9: REPRESENTATION OF THE EXECUTIVE COMMITTEE AT THE XVII MEETING OF THE DIRECTING COUNCIL, XIX MEETING OF THE REGIONAL COMMITTEE OF WHO FOR THE AMERICAS

Dr. PORTNER (Chief of Administration, PASB), in introducing Document CE56/3 9/ on the item, said it would be recalled that the XVI Meeting of the Di- recting Council had adopted a resolution l_/ in which it resolved to provide that the Executive Committee be officially represented by its Chairman, or any other member designated by the Committee, at the meetings of the Directing Council of PAHO and the Pan American Sanitary Conference.

It was therefore incumbent upon the Committee to designate a person who would officially represent them at the meeting of the Directing Council in Port of Spain, Trinidad, in October.

Dr. WEDDERBURN (Jamaica) proposed that the Chairman of the Executive Com- meettee, Dr. Calvo, be its official representative at the Directing Council Meeting.

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item:

THE EXECUTIVE COMMITTEE,

Considering that the Directing Council, in Resolution XXIII adopted at its XVI Meeting, decided that the Executive Committee should be officially represented by its Chairman, or by any other member that the Committee might designate, at future meetings of the Directing Council and the Pan American Sanitary Conference,

RESOLVES:

To appoint Dr. Alberto E. Calvo, Chairman of the Executive Committee, as its official representative at the XVII Meeting of the Directing Council.

Decision: The draft resolution was unanimously approved. IL/

The CHAIRMAN pointed out that it might be advisable to appoint a possible alternate and proposed that, should the need arise, Dr. Orellana serve as alternate.

It was so agreed.

9/ Mimeographed document. 10/ Resolution XXIII. Official Document PAHO 66, 76-77. 11/ Resolution X. Official Document PAHO 79, 36. Page 172 Ninth session 56th Meeting

ITEM 5: REPORT ON THE COLLECTION OF QUOTA CONTRIBUTIONS

Dr. PORTNER (Chief of Administration, PASB), in presenting Document CE56/17, 121 stated that in accordance with the recommendations of the Govering Bodies, the Bureau had made every effort to keep the collection of quotas as current as possible. There had been a steady improvement in the collection of quotas both current and those in arrears.

At the beginning of 1966 five Governments were in arrears more than two years, but at the date of the XVII Pan American Sanitary Conference, only two Governments were in arrears more than two years. Those Governments had adopted a plan of payment to bring their quotas up to date within a specified period of time. By the end of 1966, however, when the 1966 quotas were classified as arrears, the number owing more than two years had increased to five.

The collections thus far during 1967 were below the unusually high level attained in 1966 for the same period. Though it was still too early in the year to make a definite projection, there was an indication that it would be difficult to match the high level of quota collections in 1966, especially with respect to arrears.

Dr. BANTA (United States of America) congratulated and commended the Di- rector on his efforts and also those of the countries that had met their individual quotas. He hoped that the countries whose quotas were in' arrears would be able to meet their payments at least by the time of the Directing Council meeting.

Dr. AGUILAR HERRERA (Guatemala) expressed satisfaction with the financial position reported, which was actually a result of commendable efforts by the Governing Bodies and the Bureau to have the quotas paid as promptly as possible so that the Organization could carry out its entire program without problems or difficulties. He thought it advisable for the Committee to adopt a resolution expressing the comments of the Representative of the United States of America, with which he agreed. In that connection, he proposed a draft resolution on the item for consideration by the Committee.

Dr. PEREZ RUEDA (Ecuador) asked to have the text of the draft resolution distributed so that it could be studied before a final decision was taken on the matter.

It was so agreed.

ITEM 10: REPORT ON BUILDINGS AND INSTALLATIONS

Dr. PORTNER (Chief of Administration, PASB), in introducing Document CE56/12 and Addendum, l_/ said that at each meeting of the Governing Bodies a report was made by the Director on that item. The headquarters building had been occupied for 20 months and the trial period, when very close review was

12/ Mimeographed document. 13_/ Mimeographed document. Page 173 56th Meeting Ninth session made to determine faults in construction, was already over. The building had been found remarkably free of major defects. The air-conditioning and heating system which had been mentioned in the past had been adjusted, apparently to the satisfaction of nearly all. Otherwise, the building continued to be not only esthetically the subject of favorable comment by all who saw it inside or out, but also a building which had been identified as one in the community that should be studied for its maximum space utilization.

Recently, the Chairman of the Permanent Subcommittee on Buildings and In- stallations had raised the question of the need for additional space. It had been explained that there were currently 332 persons in the building, and that, at an estimated rate of increase of headquarters staff of approximately 10 per annum, additional space would not be required until 1975-1976. Current plans for space utilized included the conversion of two areas for documents and stock into 12 additional offices.

The planning of space for the Organization was a clear need both for it and for the Governing Bodies to which it reported. It would be recalled that, following action taken in 1951 not to accept a certain site offered by the Government of the United States of America, there had been a lull of perhaps four years before new efforts had been undertaken to obtain a site for Head- quarters. It had taken from 1955 to 1965, when the present building was occupied, to progress through the process of obtaining land, holding a contest for the building design, undertaking the detailed architectural plans, initiating or completing construction, and occupying the building.

In building as in financial matters, prudence had been one of the Organ- ization's guides to action. Accordingly, it might be well for the matter of future space needs at Headquarters to be thought of at the present time--action taken on future needs. It had been felt that critical planning for that purpose for some eight or nine years ahead should be undertaken not later than the end of 1968. It might take the better part of the period 1968-1975 to develop plans and to move through the various stages of the process through occupation of new space.

Dr. Portner stated that the reason he emphasized those facts so much was that the headquarters building was located in an area where land was rapidly becoming difficult to obtain. It had been difficult enough when the site had been selected, but immediately opposite to it the Columbia Plaza development was rising and would be fully occupied during 1968. There were very few other vacant spaces in the immediate vicinity of the building. Further land values in the area had increased dramatically and doubtless would in the near future. It was therefore a matter of prudence that the estimated need, even nine years ahead, be established and plans developed and action taken to meet that need.

Annexed to Document CE56/12 were details concerning not only the headquarters building but also the Zone Offices and the Pan American Foot-and-Mouth Disease Center, the Institute of Nutrition of Central America and Panama, and the Pan American Zoonoses Center.

At the XVII Pan American Sanitary Conference in 1966, mention had been made of the purchase of a property in Lima to house the Zone Office in that city. Page 174 Ninth session 56th Meeting

At that time, the Director was authorized l4/ to go ahead with plans for the purchase. The purchase price had increased somewhat since then from $79,000 to $100,000, but the need was still felt to be an acute one and it was planned to go ahead with the acquisition of the property.

In due course, the needs of other locations would be reported, but, as could been seen from the document, space was being rented at several locations and the entire matter of the rental impact over a decade as against the cost of purchase and maintenance had been studied in order to ensure that a prudent financial policy was followed.

In regard to donations of works of art, the Organization had been the recipient of the generous gifts of the Government of Jamaica in the form of the painting and the Spanish urn.

In summary, the headquarters building continued to give excellent service and depreciation was being met by an effort at preventive maintenance. He believed that a visual appreciation by each of the representatives was sufficient evidence of the state of the structure.

Mr. CALDERWOOD (United States of America) said that both the Permanent Subcommittee on Buildings and Installations and the staff deserved the thanks of the Committee for having made even the one settlement reported, by which the Organization, instead of paying 100 per cent of the cost of a change order under a particular contract, had been required to pay only 33-1/3 per cent.

The rate of growth of the staff was worthy of note at a time when the population explosion was a matter of concern generally. Attempts were being made to try to curb that trend, but the growth rate at Headquarters appeared to be increasing instead of decreasing. He hoped that during the next 10-year period, while the question was being investigated, some means would be found of curbing the growth rate at Headquarters as well.

He stated that he had a draft resolution to propose, although he was not absolutely sure whether or not paragraph 4 should be made the subject of a separate resolution. He then read the following resolution:

THE EXECUTIVE COMMITTEE,

Having considered the report of the Director on buildings and installations (Document CE56/12);

Noting the developments in the utilization of the headquarters building and in housing PAHO/WHO staff at the Zone Of- fices; and

Noting the need for prudent advance planning of future buildings and installations,

4/ Resolution XXVIII. Official Document PAHO 74, 85-86. Page 175 56th Meeting Ninth session

RESOLVES:

1. To take note of the report of the Director on buildings and installations (Document CE56/12).

2. To express its appreciation to the members of the Permanent Subcommittee on Buildings and Installations for their continued assistance in these matters.

3. To request the Director of the Bureau to report to the XVII Meeting of the Directing Council on short- and long- range plans for buildings and installations.

4. To thank the Government of Jamaica for the works of art it has donated to the headquarters building.

Dr. PORTNER (Chief of Administration, PASB) said that a paragraph similar to paragraph 4 of the draft resolution had been included in other resolutions on several occasions in the past.

The CHAIRMAN explained that the report included an appendix describing the premises belonging to the Organization throughout the Hemisphere. In that appendix it was to be noted that in some Zones the offices were housed in very economical quarters. As a result of negotiations, the Organization had managed to find the necessary financing in some countries to establish permanent quarters, which in the long run were much more economical for the Organization. However, some offices were still located in leased quarters. He specifically referred to the Zone III Office, whose cost per square foot was much higher than that for the Zone II Office in Mexico--where for a much smaller sum, almost the same area in square feet was occupied--and to the Zone IV Office in Peru, where the cost per square foot of leased space was lower.

Accordingly, since the appendix was to be brought to the attention of the Directing Council, some reference should be made to it in the resolution in order to make it clear that the installations of the Zone Offices, and not only those at Headquarters, were a matter of concern. The Chairman therefore proposed that a new paragraph be included in the operative part of the proposed resolution, requesting the Director of the Bureau to continue his efforts to obtain financing, on favorable terms, to enable the Organization to acquire suitable quarters for its Zone Offices. In Zone III, for instance, the Government of Guatemala was prepared to assist the Organization along very generous terms. The annual rental was $7,488. A loan could be negotiated to finance permanent quarters in Guate- mala City. Paragraph.2 of the operative part, which read as follows: "To express its appreciation to the members of the Permanent Subcommittee on Buildings and Installations for their continued assistance in these matters," did not make it clear that the members of the Subcommittee had protected the interests of the Organization. He therefore suggested that paragraph 2 should end with the following words: "for their continued assistance in safeguarding the interests of the Organization in these matters." Page 176 Ninth session 56th Meeting

Dr. AGUILAR HERRERA (Guatemala) said he considered the comments of the Chairman very much to the point and was somewhat ashamed that the Office of Zone III, in Guatemala, should be one of the few that was leased. While it was true that the Government of Guatemala was trying to provide badly-needed additional space for the Institute of Nutrition of Central America and Panama, the Zone Of- fice was also in need of space and it would be very desirable to place it on an equal footing with offices in other Zones that had their own quarters.

Dr. ACOSTA-BORRERO (Colombia), noting that the report said that the cost of constructing the headquarters building was financed partly by subsidies and partly through the sale of properties formerly owned by the Organization, asked how much was realized from the sale of the properties in which the former Washington Headquarters of the Organization were housed.

Dr. PORTNER (Chief of Administration, PASB) said the sale of the Organ- ization's former property in Washington had brought in $1,125,000.

Dr. HORWITZ (Director, PASB) said it was also important to note that the buildings had cost about $300,000 in 1951 and had been sold on cash terms. He added that those figures appeared in the Financial Report of the Director and Report of the External Auditor (Official Document 75) and, if the Executive Com- mittee so wished, they could be included in the appendix.

Dr. AGUILAR HERRERA (Guatemala) proposed that, since amendments had been proposed to the draft resolution, they should be put in writing and presented to the Committee at a subsequent session. For that purpose, he recommended that a working party be appointed.

Dr. HORWITZ (Director, PASB) said he was pleased that the discussion had taken a turn which gave him an opportunity to show how prudently and carefully the funds of the Organization were managed. To sell the buildings a public auction was called. The experts had reported that the minimum price should be $1,000,000. Three companies submitted bids, the highest being for $890,000. In view of that, the auction was declared inoperative, with deep concern because there was a risk that subsequent bids would be even lower. Later a $1,000,000 proposal, with political backing, was received, but at the same time a proposal came from the American Council on Education, a very important institution in the United States of America, which expressed an interest in the buildings and, after negotiations, offered $1,125,000 and full payment in cash.

The CHAIRMAN announced that the draft resolution presented by the Repre- sentative of the United States of America, with all the proposed amendments, would be submitted at a later session. He proposed that Mr. Calderwood and Dr. Aguilar Herrera be asked to prepare the final draft.

It was so agreed.

Dr. ORELLANA (Venezuela) apologized for returning to a subject already examined, in whose discussion he had not been able to participate for reasons beyond his control. Referring to the quarters of the Zone I Office, he remarked that they were smaller than those in other Zones. It was his understanding that an amount could be made available in those cases from the Building Fund, Page 177 56th Meeting Ninth session and he thought that perhaps the Director had already considered the need to provide suitable quarters for the Zone I Office. He added that the Government of his country was prepared to assist in meeting the cost of leasing such quarters for as long as necessary.

ITEM 7: PROVISIONAL AGENDA FOR THE XVII MEETING OF THE DIRECTING COUNCIL, XIX MEETING OF THE REGIONAL COMMITTEE OF WHO FOR THE AMERICAS

Dr. PORTNER (Chief of Administration, PASB), in introducing Document CE56/15, 15/ said that arrangements for the XVII Meeting of the Directing Coun- cil in October had been reviewed. As was the custom at the spring meeting, the Director was presenting the provisional agenda to the Executive Committee for approval. The first five of the 31 items suggested were traditionally included and referred to the organization of the meeting and set the pattern for the discussion and action on items of substance. Item 6 related to the request of the Government of Guyana for admission to membership in PAHO. The request of the Government of Barbados had come to the attention of the Director after the provisional agenda was prepared. Accordingly, it was for the meeting to decide whether or not to include it as an item.

Dr. ORELLANA (Venezuela) expressed the opinion that in that case, as in previous ones, the Executive Committee should bear in mind the provisions of the Rules of Procedure of the Directing Council to the effect that the approval by the Committee on such occasions was only tentative. The Director was authorized to include additional items, and the Governments could propose new items. Dr. Orellana added that, in order to comply with the requirements in those Rules of Procedure that the documents be distributed well in advance of each meeting, everything possible should be done to ensure the documents would be ready 30 days before the opening date of the Directing Council meeting, namely, 2 September 1967. He therefore believed there was not much ground for discussion and that the draft resolution appearing in the document presented should be considered forthwith.

The CHAIRMAN felt that the members of the Committee should be given the opportunity to submit any specific items to the Committee for consideration. For example, the Chairman himself wished to ask the Director to include as one of the major items of the agenda the document signed by the Chiefs of State at the recent meeting in Punta del Este.

Dr. SUTTER (Assistant Director, PASB) read a draft resolution on the item.

The CHAIRMAN pointed out that the additions proposed by the Executive Committee should be mentioned in the operative part of the draft resolution.

Dr. PORTNER (Chief of Administration, PASB) said that the inclusion of additional items derived from resolutions adopted by the Committee would be in order.

The CHAIRMAN proposed that the vote on the draft resolution be postponed until a later session, since other amendments might be presented.

It was so agreed.

The session rose at 5:30 p.m. I5_/ Mimeographed document. TENTH PLENARY SESSION Tuesday, 2 May 1967, at 9:15 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (continuation)

The CHAIRMAN called the session to order and announced that the next item of business was project AMRO-0800 (Pan American Foot-and-Mouth Disease Center), the examination of which had been postponed from the seventh plenary session.

Dr. ACHA (Regional Adviser in Veterinary Public Health, PASB) stated that the Pan American Foot-and-Mouth Disease Center, which had been establishéd at the beginning of 1951, as a joint project of the Pan American Sanitary Bureau and the Inter-American Institute of Agricultural Sciences, and had been financed with funds from the Program of Technical Cooperation of the Organization of American States (OAS), had been assisting the countries of the Hemisphere in foot-and- mouth disease control and prevention activities.

The Center, which was situated in Rio de Janeiro, Brazil, was the only one of its kind in Latin America and was one of the world's reference centers for foot-and-mouth disease. It had been fulfilling its purposes through the following activities: research, diagnosis, personnel training, and technical advisory services to national foot-and-mouth disease control services. In the 16 years since it was established, about 490 scientists had been trained in short courses or on fellowships and, as a result, nearly all the countries of South America currently had laboratories for the diagnosis and typing of foot-and-mouth disease virus.

The Center had been a forerunner in the production of modified live virus vaccines, and several South American countries were currently using the methods and strains recommended by the Center for vaccine production. The personnel training activities of the Center were also highly important, since it was the only such Center that could offer those facilities.

With respect to advisory services it was thanks to those activities that it had been possible to conduct foot-and-mouth disease control campaigns in a number of countries. The Center had also assisted with the preparation of national plans and of loan applications for submission to international lending agencies. At the Third Annual Meetings of the Inter-American Economic and Social Council (IA-ECOSOC), held in 1964, those agencies, in particular the Inter- American Development Bank (IDB) and the International Bank for Reconstruction and Development (World Bank), had expressed their willingness to assist the countries with foot-and-mouth disease control campaigns, provided they were multinational campaigns. The successful coordination of those campaigns depended on

- 178 - Page 179 56th Meeting Tenth session the Pan American Foot-and-Mouth Disease Center being provided with the necessary financial support.

At the Fourth Annual Meetings of the IA-ECOSOC (Buenos Aires, 1966), the budget of the Center had been considerably reduced, and that situation had been further complicated by an increase in the cost of living in the country in which the Center was situated. In view of those circumstances it became clear to IA- ECOSOC, and the persons in charge of the Program of Technical Cooperation of the OAS, that the budget was totally inadequate. In July 1966, the OAS announced that the approved budget ceiling was $640,000, which was hardly enough to cover operating costs at the 1965 level. That decision, together with a change in the budgetary system of the OAS, resulted in the funds for the operation of the Center being less than those voted in 1964. As a result it became necessary to reduce the staff to the indispensable minimum; nevertheless, it had been possible to provide countries with assistance in emergencies although not exactly as the Center might have wished.

The research program was being continued although in a rather limited way, but as a result of a grant from the United States Agency for International Development (AID) a study was initiated at the beginning of 1967 on the use of vaccines in other animal species, in particular sheep and hogs.

Dr. HORWITZ (Director, PASB) drew attention to the resolution l/ adopted by the Fourth Annual Meetings of IA-ECOSOC, which stated that the Secretary General of the OAS and the Director of PASB should prepare a report to be submitted to the Inter-American Committee on the Alliance for Progress (CIAP) and at the same time explore arrangements for the stable financing of the Center.

The above-mentioned study had been prepared and, in addition, it was suggested to the Secretary General of the OAS that, in view of the importance of the foot-and-mouth disease problem for the Americas, both from the financial and social as well as the nutritional point of view, a top level mission should visit all the Governments to discuss with them the actual magnitude and consequences of the problem, particularly at that point in time and, in the course of those discussions to emphasize the work of the Center,and especially the part it had to play in the process of economic integration which was taking place in Latin America and the other countries of the Hemisphere. At the same time the mission should attempt to make arrangements for the stable financing of the Center, patterned on the international financing arrangements of the Inter-American System; in other words, the system of assessments which the Organization of American States applied to its Member Governments.

The Director emphasized the excellent relationships the Bureau maintained with the OAS, and in particular with the Secretary General, Dr. José A. Mora, who had accepted that suggestion enthusiastically.

By common agreement it was suggested to Mr. Edgardo Seoane, Vice-President of Peru, not in his capacity as Vice-President but as an agronomist with 40 years experience in the field, that he might be good enough to head the Mission mentioned above. Mr. Seoane accepted to do so and he undertook the Mission together with

_/ Resolution 34-M/66. OAS Official Records,OEA/Ser. H/XII.11 (Eng.), pp. 70-71. Page 180 Tenth session 56th Meeting

Dr. Carlos Palacios, the Director of the Pan American Foot-and-Mouth Disease Center. They visited the countries of the affected areas, i.e., the South American countries as well as a large part of the disease-free countries, i.e., those of Central America, Panama, Mexico, the United States of America, and Canada. Because of official duties the Mission was unable to visit the countries in the Caribbean area but a special mission would do so shortly.

The result of those strenuous efforts was to be found in the document presented by Mr. Seoane and Dr. Palacios entitled "Report on Foot-and-Mouth Dis- ease, Present and Future Problems on the American Continent, and the Importance of the Pan American Foot-and-Mouth Disease Center." 2/ The report had been warmly welcomed by the countries and showed that there was an awareness of the importance of the problem for the national economies not only in those countries in which the disease was prevalent but aLso in the disease-free countries which should be protected against the introduction of the disease.

A number of countries had accepted the idea of financing an initial budget of $1,200,000 as from 1968, on the basis of the scale of assessments of the OAS.

The Director said he had had the honor to accompany Mr. Seoane and Dr. Mora on their visit to Mr. Lincoln Gordon, Assistant Secretary of State for Latin American Affairs of the U.S. Department of State. His own impression was that Mr. Gordon thought the idea was a reasonable one, although he was of the opinion that arrangements should be made for the contributions of the Governments to be paid directly to the Pan American Health Organization and that the Governing Bodies of PAHO should take the necessary steps to make it quite clear that the Center would be administered by the Organization and financed by the Governments in accordance with the scale of assessments established and with an initial budget of a little over $1,200,000.

The report of the Seoane-Palacios Mission pointed out that both the IDB and the World Bank were ready to extend their credit policy to cover well-organized and intensive vaccination programs against foot-and-mouth disease, currently in cattle and, in the future, in sheep and other animal species. The Mission had also made a number of very interesting suggestions, foremost among which was an agreement between the disease-free countries, from Panama to the United States of America, and Colombia concerning the application of the same measures as were being applied in the United States of America and Mexico to prevent penetration of the disease from South America. That agreement would of course have to be signed by the Government of Colombia, since that country was the immediate focus of the disease, in particular the Department of Choc¿. That meant that the Organization would need to undertake in Central America and Panama a very thorough study of the situation with a view to the application of the above-mentioned measures and, having obtained the agreement of all the affected countries to coordinate their efforts through the instrumentality of the Pan American Foot-and-Mouth Disease Center, to undertake systematic activities to gradually reduce the incidence of the disease.

Mr. Seoane had emphasized the statement of Dr. Carlos Lleras Restrepo, President of the Republic of Colombia, to the effect that his country would not

2/ Mimeographed document. Page 181 56th Meeting Tenth session pursue any livestock activities in the Chocó region which might be harmful to the disease-free countries; and also spoke of the foot-and-mouth disease control program in the states on the Atlantic Coast of that country. Mr. Seoane also drew attention to the concern of the authorities in all disease-free countries over the danger of the spread of the disease.

Under those circumstances, the Executive Committee should take a stand on the report it was examining and make it clear that the moment had come for the Center to definitively be an agency administered by the Pan American Health Organ- ization, that its finances should be stabilized along the lines suggested by the Seoane-Palacios Mission, and that its role should acquire a new dimension as a result of the possibility of financing a large-scale immunization campaign. However, it should not underrate the critical situation involved in the immediate financing of the Center, which was in danger of being closed down. It had been necessary to take an advance from the Working Capital Fund because it was more economical to maintain the Center in operation than to pay the staff their ter- minal payments. It would be paradoxical at that point in the life of the Hemi- sphere when the nutritional problem was so serious and animal proteins were in short supply and when the ideas of integration were making headway not to continue to expand activities which in those circumstances were so essential.

Mr. CALDERWOOD (United States of America) expressed his appreciation of the Committee's patience with those who had requested a postponement of consideration of the item. Unfortunately, he was still not in a position to make a statement--as the Delegation of his country had hoped--in regard to a means of settling the immediate financial problem that had arisen from the need to maintain the services of the Center, in the absence of adequate funds from the OAS Program of Technical Cooperation, at the level of operations of the past several years. He would like to express the views of his country's Government with respect to the Center and the program which the Center was carrying out, in fairly general terms. He would also avoid dealing with the technical operations on which others were better qualified to speak.

The Delegation of the United States of America considered it important that the Center be continued and its operations maintained at a level sufficient to enable it to provide Governments with scientific information and technical advice in the planning and execution of national control programs. The current financial position did.not permit those services to be provided adequately. He regretted very much that the IA-ECOSOC had found it necessary to reduce its contribution, necessitating action by the Bureau. Unfortunately, that action was somewhat questionable in view of the resolution 3/ adopted by the XIII Pan American Sanitary Conference in 1950 when the Organization accepted the responsibility of managing the Center.

He hoped the Director would continue to collaborate with the Secretary General of the OAS in an effort to find funds, so that the activities of the Center could be maintained at a level consistent with program plans, and in accordance with the need of countries for its technical support. Because of the reduction in funds provided by the OAS Program of Technical Cooperation there was a deficit, and there would be an additional deficit in 1968 unless funds were

S/ Resolution XX. PAHO Publication 257, 18-19. Page 182 Tenth session 56th Meeting

forthcoming. As he understood it, the IA-ECOSOC wished, after mid-1969, to have no further responsibility for financing the Center. It was the view of the Government of his country that until that time, the IA-ECOSOC had the responsibility for maintaining the Center, and that it should be maintained at least at the level existing at the time the decision of that body had been taken. He would hope that the Director would impress that fact upon the Secretary General of the OAS, so that IA-ECOSOC might take appropriate action at its Fifth Meetings to be held in June, to provide adequate financing for the Center until the time came when it turned the responsibility over to some other agency.

He assumed that there would be some responsibility, certainly in the immediate future, to be assumed by PAHO. He was in accord with the view that it was probably desirable that, in the future, the Center should be financed in the same manner as other operations in the Inter-American System, under a scale of assessments which would apply to all the countries of the Americas, not only to those that were members of the Organization of American States. The other countries, he believed, should be invited to participate in the program.

Until the question of adequate funding had been fully explored with the OAS, the Government of the United States of America would have to reserve its position; it also felt that the action of the Organization should be limited to maintaining the present level of operations in 1968. Any financial support from PAHO, in view of the resolution adopted in 1950, would require the approval of the Directing Council. Therefore, he would again express the hope that the IA- ECOSOC would provide adequate funds and he would hope that that point would be made clear to that agency before it met in June. If that was not to be the case, it was the view of his country's Government that the activity of the Center, to the extent that it was dependent upon PAEO funds, might have to be suspended, and necessary adjustments made in the program.

Dr. CARVAJAL (Ecuador) said that his country wanted to see the program put into effect as soon as possible and in the best possible way. He suggested that every effort be made to strengthen the activities of the Pan American Foot-and- Mouth Disease Center, to provide for its stable financing, and to obtain the necessary funds for its activities.

Dr. HORWITZ (Director, PASB), referring to the statement of the Represent- ative of the United States of America, said that, in the first place, the IA- ECOSOC had decided to continue the financing of the Center through the Program of Technical Cooperation of the OAS up to June 1969; second, in recent years, in a series of letters sent to the Secretary General of the OAS and in statements made at meetings of the PAHO Governing Bodies, he had drawn attention to the situation of the Center as well as to what might happen if that situation did not improve. The position adopted by PAHO was that it was up to the Program of Tech- nical Cooperation to maintain its contribution to the Center at the agreed level.

Nevertheless, the results had not been satisfactory. There had been an adjustment in the Center's program and staff, particularly its administrative staff, which had been reduced to the indispensable minimum. The moment had come when reductions had to be made in technical personnel, which were already in short supply and extremely difficult to recruit. Page 183 56th Meeting Tenth session

As to the future of the Center, Mr. Calderwood had not spoken in very precise terms about the advisability of the Center continuing to be part of the activities of the Pan American Health Organization. In that connection, he would like to recall what he said on another occasion to the Committee: that the problem was not only a biological one which had many aspects to be elucidated but also an administrative one. For example, a program of systematic immunization with live virus vaccine, which could be carried out thanks to the activities of the Center, among other institutes in the world, was in no way different from the other immunization programs which were part of the activities of the Organization. If in addition to that the moral argument was added, namely that since 1950 the Organization had been responsible for the installation and development of the Center, it was logical that at a time when the financing of the Center could be stabilized--because the credit policy of the development banks had been extended to cover vaccination against foot-and-mouth disease--the Center should remain under the aegis of PAHO.

As for the statement of Mr. Calderwood that if it was not possible to obtain funds for the minimum program of the Center, the program should continue to be reduced, he pointed out that that would entail the closing of the institution, and that it would be an extremely serious decision if the Executive Committee were to recommend it to the Directing Council and he himself would be very un- happy to see it made.

The CHAIRMAN emphasized the importance of the points raised, namely the permanent financing of the Center and the Organization it should be attached to, and underlined both the interest and the desire of most of the Governments to contribute the quotas assessed to them and to cooperate in the activities of the Center. He cited the example of his own country which, as a result of strenuous efforts, had prevented foot-and-mouth disease from being introduced from Colombia.

The session was suspended at 10:05 a.m. and resumed at 11:00 a.m.

Dr. ORELLANA (Venezuela) stressed the importance of the item and of any decision that the Executive Committee might adopt in the matter, since it was a special problem in the history of the Organization and perhaps in the Inter- American System; the fact was that the Pan American Foot-and-Mouth Disease Center, established as part of the Program of Technical Cooperation of the OAS and administered technically by PAHO, would shortly cease to have the financial support of the OAS, and would be under the threat of not being able to continue its activities.

In his opinion the activities of that Center had been placed under the administration of PAHO for very cogent reasons: some were administrative since there was no other agency within the Inter-American System devoted especially to problems of agriculture and the breeding of livestock; others were technical, and the Director of the Bureau had already referred to them, namely, that the control of foot-and-mouth disease was an epidemiological program similar to any of the eradication campaigns the countries were carrying out. So far epidemiology had been a medical matter and zoonoses were also a medical matter. In that connection, he recalled that, when foot-and-mouth disease appeared in his country in 1949, the first problem to arise was not a financial one but an administrative one: namely, Page 184 Tenth session 56th Meeting who would be responsible for the foot-and-mouth disease control campaign. In effect, the Ministry of Health and Social Welfare had been given that responsibility.

In view of what Dr. Acha had said about the work of the Center and the report of the Seoane-Palacios Mission, he was of the opinion that there was no doubt about the need not only to continue the program but also to expand it. In addition, the Center should remain part of the Organization as it had been since its beginning in 1951, not only for historical reasons--the fact that it was already part of it--but also for technical reasons, because there was no other organization within the Inter-American System that could assume that responsibility. In the countries the programs had been entrusted to the departments of agriculture, but at the international level programs had so far been the responsibility of the Organization. Time would tell whether it was necessary to establish another type of coordination with the ministries of agriculture and to hold the meetings that had been recommended.

With respect to the problem of financing, he would like to know why the OAS had suddenly decided to suppress the funds earmarked for the Center as from June 1969. That decision might possibly have been taken because of administrative reasons or because the necessary financial support in the form of voluntary contributions had not been forthcoming. On the other hand, as a result of the Seoane-Palacios Mission, the countries of the Americas had offered to contribute to the financing of the Center, and arrangements had been made, namely, a system of quotas identical with that of the Organization itself. In other words, the Governments wished to maintain the Center and intended to finance it. That was a fact which should not be overlooked; it meant that funds would be available when needed and he suggested that the Organization might be able to find administrative means enabling it to advance funds for the operation of the Center until such time as the quotas offered were received.

With respect to the attitude of the Government of the United States of America, he pointed out that the report of the Seoane-Palacios Mission contained a paragraph from the Message of President Johnson to Congress in 1966, an extremely important statement which read as follows: "I am requesting funds to support the Pan American Health Organization in developing and testing vaccines against rabies and foot-and-mouth disease. In addition, we will support the Pan American Health Organization, as it initiates and expands control measures against foot-and-mouth disease in several Latin Armerican countries." Consequently, there was no doubt that the Government of the United States of America supported the program, as did the other countries.

For those reasons Dr. Orellana suggested that the Bureau should study the possibility of advancing funds to ensure the survival of the Center until such time as the financial arrangements recommended by the Mission were made.

Dr. AGUILAR HERRERA (Guatemala) endorsed the views of the Representative of Venezuela and emphasized the advisability of the Pan American Foot-and-Mouth Disease Center remaining a part of the Organization since it had been very efficiently administered by the Bureau for many years, with optimum benefits for the countries of the Americas. The ministries of agriculture of the various Latin American countries were also of that opinion and, in that connection, he cited Page 185 56th Meeting Tenth session the following paragraph from the report of the Seoane-Palacios Mission: "The countries visited have indicated that they would be pleased to see the Pan Amer- ican Foot-and-Mouth Disease Center continue under the technical and administrative supervision of the Pan American Health Organization, in this way assuring themselves of the valuable cooperation they have been receiving from these institutions over the last 16 years."

As for financing, it was urgently necessary to take a decision to enable the Center to continue to operate fully because, as Dr. Horwitz had explained, rather than reduce its activities it would be better to close it. In view of the offers made by almost all the countries of Latin America to contribute to the financing of the Center as from 1968, Dr. Aguilar Herrera proposed that the Governments be urged to advance those quota payments and, if possible, to pay them in 1967. The Inter-American Committee on the Alliance for Progress (CIAP) at its Eleventh Meeting (Washington, D.C., 27-31 March 1967), had called on all the countries in the Inter-American System to provide the Center with sufficient funds as soon as possible. He was therefore of the opinion that the Executive Committee should endorse the statement of CIAP in order to help solve the problem.

Dr. ACOSTA-BORRERO (Colombia) said that the Representatives of Venezuela and Guatemala had very ably dealt with the two basic aspects of the problem. The Center should remain under the supervision of PAHO for administrative, technical, and scientific reasons and also because of the interest of the Bureau in the program which it had carried out so satisfactorily for 16 years. It had done so because that task had been entrusted to it by the OAS.

With respect to the financing of the Center and the reservations of the Delegation of the United States of America, he was of the opinion that the Bureau had given proof of its efficient administration and had reported that all possible reductions had been made. As for the permanent financing of the Center, he thought the suggestion of the Representative of Guatemala very germane and stated that the Government of Colombia would be in a position to pay its 1968 quota in advance so that it would be used in 1967. Although he realized that the small amomnt of funds his country contributed would not make it possible to solve so great a problem, that contribution was not being made solely for practical reasons but as a demonstration of continental solidarity.

He invited the Representative of the United States of America to again look at the problem from both the theoretical and practical standpoint in the light of that new approach. He was certain that, in the Organization of American States or at the meeting of ministers of agriculture, which might possibly be held in the near future perhaps in Bogotá, the Government of Colombia would urge on the countries of the Hemisphere that the Center needed to increase its activities and that the necessary funds for maintaining its program should be found. He hoped that the Directing Council would support any decision the Committee might adopt along those lines.

Dr. WEDDERBURN (Jamaica) said he had not heard any clear statement as to why the present form of financing had failed or was proving inadequate. The emphasis had been on the reason why PAHO should take over the financing of the Center, but the other reasons were not clear. Page 186 Tenth session 56th Meeting

Dr. SANTA MARIA (Observer, Chile) stated that the subject was worthy of comment by all the countries, even though they were very ably represented by the Executive Committee. He emphasized the need for the Center to continue its activities in view of its efficiency and to remain part of the Organization.

As to contributions toward the financing of the Center, there should be only one system for all the countries, regardless of the solution adopted.

The Government of Chile was ready, in view of the importance of the problem, to make that additional contribution for the good of the health of the peoples of the Americas, because it believed that the Organization was doing a very efficient job. He hoped that the Fbcecutive Committee would adopt the necessary measures to enable the Organization to continue that work.

The CHAIPMAN, speaking as the Representative of Panama, stated that, with the assistance of the Representative of Guatemala, the problem would be submitted to the XII Meeting of Ministers of Public Health of Central America and Panama to be held in El Salvador in August, who would be called upon to take a definite decision about the financing of the Center. He was sure that at that meeting the necessary financial support would be forthcoming, in the sense that the quotas which they had promised to pay as from 1968 would be advanced.

Mr. SALZMAN (Observer, OAS) recalled that the Center began to operate in 1951 under the Program of Technical Cooperation of the OAS, which in 1950 had been funded by voluntary contributions from the American countries. It had as its purpose the establishment of training centers on a regional scale in special- ities in which there were no technical institutions capable of providing that type of training at that time. The original idea had been to encourage the establishment of stable and permanent centers, both national and international, and to finance them for a maximum period of five years. Although the Pan Amer- ican Foot-and-Mouth Disease Center had originally been intended for five years, the truth was that it had been mostly financed with OAS funds since 1951.

He explained that the Program of Technical Cooperation, which had a stable financial basis, had in 1964 undergone a substantial cut as far as finance was concerned, in that it had been incorporated into the new Special Development Assistance Fund established by the IA-ECOSOC. At the same time the major con- tributor to the program of the OAS for that type of activities had reduced its contribution by 50 per cent, which had affected the financial basis of all the technical assistance programs. In addit-ion the Program of Technical Cooperation, on becoming part of the Special Development Assistance Fund, had entered into competition with a series of other training programs, and even research programs, in the economic and social field.

The total funds bf the Program of Technical Cooperation had amounted to about $3,200,000 and were currently at a level of $2,464,680. Apart from that, in 1965 there had been a change in the basis of the financial year from the calendar to the fiscal year, and the representatives of the countries in IA-ECOSOC pointed out that the budget for 12 months was sufficient for 15 months. That meant a reduction of 25 per cent in the budgets of all programs. Page 187 56th Meeting Tenth session

The result had been that the contributions offered by the Member Countries of OAS to the Special Development Assistance Fund were not even sufficient for the 12 months budget and, consequently, the funds available for the programs and the Pan American Foot-and-Mouth Disease Center had been reduced by about 38 per cent.

In reply to Dr. Orellana, he would like to say that the situation led CIAP to adopt a decision to try to find a more stable basis for financing the Pan American Foot-and-Mouth Disease Center. Furthermore, in reply to Dr. Wedderburn, he would like to say that the remainder of the projects which were not primarily research or technical assistance projects were shorter in duration and could be terminated at any given moment.

He emphasized that the work o.f the Center had suffered as a result of those changes and, in addition, of the fact that the prices and costs had increased rapidly and that the United Nations had decided to change the salaries and remu- neration of its local and international personnel. Under those circumstances, CIAP took the decision to fix a date on which the financial support of OAS would be withdrawn from the Pan American Foot-and-Mouth Disease Center, and had done so, in his opinion, in order to force a decision on the part of the American States to find a more stable and more permanent basis in accordance with the purposes of the Center. At no time had the efficiency of the Center, which was one of the finest scientific institutions in the world, been called into question.

Finally, the declaration of CIAP and the report of the Seoane-Palacios Mission would be submitted to the Fifth Annual Meetings of the IA-ECOSOC to be held in Viña del Mar, Chile, in June 1967, and it was expected that support would be given to a draft resolution endorsing the recommendation that PAHO should continue to administer the Center. In his opinion the immediate financial question was an unsolvable problem because, despite the Punta del Este recommendations, there was no great hope of increasing funds.

Mr. CALDERWOOD (United States of America) said he was sure they were all very grateful to the Observer of the OAS for clarifying certain points, and he was certainly grateful to members of the Committee for expressing so frankly their views on the question of what should be done in the future. He would like to add to his previous statements on the immediate financial problem, the long- term financial problem, and the question of the management of the Center.

What he had said earlier was that it seemed to him that until the date arrived when the OAS responsibility for financing the Center was to end, the responsibility indeed lay with the OAS. They had been told of that Organization's difficulty in meeting all their financial requirements, but PAHO had an equally difficult problem in trying to decide what activities should be supported since it could not support all the requests received from the countries.

It was quite true that funds came from the Governments of the United States of America and the Latin American countries, and that they used various channels in distributing them for the purpose of different activities. However, the members of the Executive Committee had to decide what could be done under the terms of reference of PAHO. Page 188 Tenth session 56th Meeting

The immediate financial problem had been discussed by the Government of his country. At the time of the meeting to which reference had already been made, the Assistant Secretary of State, Mr. Lincoln Gordon, had referred to the financing of the Center. He had indicated that the amount involved did not present any particular problem, but that the contribution of the United States of America would have to be made in appropriate form so that it could be handled under existing administrative procedures. He had further said that he and his staff had been giving considerable thought to it and were continuing to do so with a view to reaching an appropriate and rapid solution that would obviate any administrative complication. He added that the Government of his country had not yet found a solution, but was seeking one. Hence, he certainly could not now take any position on the budget of the Center for 1968. An increase of $1,200,000 had been suggested, and that the whole amount be raised by a quota system and be PAHO's responsibility. That would actually mean adding $1,200,000 to the proposed budget for 1968, or taking something out of the proposed PAHO 1968 budget in order to allocate that amount to the Center. He had no authority from his country's Govern- ment to agree to an increase in the budget for 1968 to that extent; it was considering the Seoane-Palacios report with a view to reaching a position on it before the XVII Meeting of the Directing Council.

With reference to the management of the Center, he thought it should remain under the present management pending a solution of the permanent financial problem, at which time a decision could be made on whether that was the best arrangement. He was not questioning it, but had some personal views on the subject. The Government of the United States of America had not yet reached a conclusion on it. It might be felt desirable to keep the management within PAHO, but some modifications might be sought as to the manner in which it should be done.

Reference had been made to the interest of the ministries of agriculture in the activity. No one could deny that they were interested in any program for the prevention of the spread of foot-and--mouth disease, which certainly was a matter of interest to those in the field of agriculture. There might be some way of bringing them into the picture. Those were all things that had not yet been resolved.

It could be hoped that the report of the representatives of CIAP to the IA-ECOSOC might impress on that body at its June meeting the importance which was attached to the Center and of maintaining it at the current level of activity. He had not given up hope that the IA-ECOSOC could find a way to provide more funds; or, to put it in another way, that, in talking to their Governments after the current meeting, members of the Executive Committee could persuade them to put more money into that particular channel so that the Center could be financed pending the time when a long-range solution was found. He felt that any such long-range solution should involve regular contributions on the basis of a scale of assessments. He could already state that that was the position of the Govern- ment of the United States of America.

However, he did not think that such a scale could come into effect immediately. It might well do so when the responsibility of the OAS was relinquished and PAHO took it over. There was the additional question of maintaining the level of activity. That might have to receive the serious consideration of Governments Page 189 56th Meeting Tenth session

of PAHO if IA-ECOSOC should, at its June meeting, fail to make adequate provision for it; but so far it was the responsibility of that agency.

He therefore hoped that, before a recommendation was made to begin to provide for the financing of the Center as of 1 January 1968, as suggested, the question of how the funds were to be raised, and what the implications were for the Bureau as a whole would be carefully examined. He would like to know whether such a recommendation implied the addition of $1,200,000 to the 1968 budget or the withdrawal of certain projects in order to offset that addition.

He believed the report before the Committee should be referred to the XVII Meeting of the Directing Council for serious consideration, just as was being done by the Government of his country, pending the meeting of the IA-ECOSOC in June. He hoped at least a partial solution to the immediate financial problem could be found and that the Directing Council in October, after considering the report of the Seoane-Palacios Mission and the outcome of the IA-ECOSOC meeting, might be able to find a solution or at least make recommendations to the Govern- ments on a long-range solution. He hoped that by that time the Government of the United States of America would also have decided on what channel it wanted to use to support such activities.

Dr. HORWITZ (Director, PASB) said that it was not possible to separate the problem of immediate financing and therefore of the current year, from that of the stable financing of the Center. The Organization had shown great administrative prudence and a very good foresight in having given warning for more than two years what was going to happen and of having adopted specific measures to guarantee, in agreement with the Secretary General of the OAS, the financial stability of the Center.

He therefore requested the working party which was going to prepare the draft resolution and the Committee as a whole to bear in mind those two aspects that could not be dissociated. He reminded Mr. Calderwood that there were letters and decrees of Governments which stated that they would begin to contribute funds through their ministries of agriculture as from 1 January 1968 and that the Organization would begin to collect them in agreement with the OAS. In that respect he considered the attitude of the President of the Republic of Colombia to be highly laudable in the sense that the Government of that country was ready to make available in 1967 the contribution which it would have to pay under the new scale of quotas. Furthermore, in his opinion, the quotas which would be collected in 1968 would make it possible to zover the shortfall due to the reduction in funds of the OA.S Program of Technical Cooperation. He therefore believed that the whole item of $1,200,000 could be guaranteed for 1968 especially if the Government of the United States of America agreed, as Mr. Gordon had said, to make its contribution together with the other Governments in the Hemisphere.

The Executive Committee was facing the serious responsibility of having to decide whether or not it was going to recommend to the Directing Council that it close the Center, since the Committee had very clear responsibilities under the Constitution. It was not only a static instrument which carried out the instructions given to it by the Directing Council or the Conference; it was a dynamic body with its own point of view, which it submitted to the Council or the Page 190 Tenth session 56th Meeting

Conference when necessary, but it should express its point of view in the name of all the Governments which had assigned it that responsibility.

Consequently, he called upon the Committee to take a single decision covering the liquidation of the deficit as well as the stable financing of the Center and the organization it would come under in the future. He emphasized that the last-mentioned connection posed very serious problems since the future of the technical personnel of the Center was at stake. Un behalf of those officials and bearing in mind the technical quality of the Center, recognized, among others, by the CIAP mission and by the Argentine--United States Joint Committee for Stud- ies in Tierra del Fuego which visited the Center, he called upon the Committee to take a clearcut decision on the problem.

The CHAIRMAN requested the working party responsible for preparing the draft resolution on the item to take into cons-ideration the views expressed and the fact that there was complete agreement with the Director of the Bureau that the two aspects were closely linked: the permanent financing of the Pan American Foot-and- Mouth Disease Center, and the financing of its current deficit.

ITEM 11: STATUS OF AEDES AEGYPTI ERADICATION IN THE AMERICAS

Dr. MUSA (Regional Adviser in Aedes aegypti Eradication, PASB) introduced Document CE56/8 §/on the item, which summarized the present status of the continental program for the eradication of A. aegypti. The Aedes aegypti problem continued to exist in the northern part of South America, El Salvador, the United States of America, and the Caribbean area. The continued existence of the vector in those areas not only posed the threat of urban yellow fever and other diseases transmitted by Aedes aegypti to the countries and territories infested but had also been the cause of the frequent re-infestation in the Americas which threatened the success of the continental program.

Despite repeated appeals to the countries and territories still infested to complete eradication of the vector as soon as possible, the campaign in recent years had made progress in only very limited areas; in several others the situation had substantially worsened. In that connection he drew attention to Resolu- tion XIX 5/ of the XVII Pan American Sanitary Conference in compliance with which the Director had convened the Conference on Aedes aegypti jradication in the Americas (3-5 April.1967); following that a Study Group on the same subject had met (6-12 April). The reports of those two meetings were being submitted to the Committee for consideration.

The Study Group recognized that the Pan American Sanitary Bureau had been playing a decisive role in the A. aegypti eradication program in the Americas as a result of the stimulated assistance received from it in the form of supplies or equipment and, in some cases, financial support. In its opinion it was of vital importance to the Americas that the Governments of the countries still infested should accelerate their campaigns so that erradication of the vector in the Hemisphere could be achieved as soon as possible. That final effort would

4/ Mimeographed document. 5/ Official Document PAHO 74, 76-77. Page 191 56th Meeting Tenth session be successful only if the Bureau took an active part in it. That participation would comprise: (1) negotiations with the Governments to convince them to give the highest possible priority to the program. It was suggested that for that purpose the Director of the Bureau get into direct touch with the highest governmental authorities; (2) energetic and broad assistance to the still infested countries and territories in conducting their campaigns. That assistance should cover all aspects of the program, financial assistance in the form of supplies and equipment and, in special cases, at the request of those Governments, the direct participation of the Bureau in the program; and (3) coordination of eradication programs in order to solve the problem of re-infestations in the Hemisphere.

So far 17 countries and territories had completed their eradication campaigns against A. aegypti, and were regarded as free of the vector. Of those countries, some were currently maintaining satisfactory vigilance services, others were carrying out insufficient activities, and some were not carrying out any vigilance activities at all. In view of the importance of those activities to the success of the continental program it was recommended that the Bureau assist (1) the Governments that maintained vigilance services in making periodic evaluations of those services for the purpose of correcting any shortcomings that might exist in them, and (2) the countries and territories which were already free of the vector but which did not have any vigilance services in organizing and maintaining appropriate vigilance.

If the Bureau was to be able to fulfill the role expected of it in accel- erating the continental program it would have to have more funds, and it was therefore recommended that the Director study the possibility of establishing a special fund for the eradication of the vector. Furthermore, lack of sufficient local funds had been at the root of many of the failures in the campaign in the Hemisphere. In that connection the Study Group recommended: (1) that the Govern- ments bring their influence to bear in international agencies to have them enlarge their credit policy to include the grant of loans for A. aegypti eradication; and (2) that the Pan American Sanitary Bureau provide the Governments with advisory services in obtaining bilateral or multilateral funds to supplement their own earmarkings for the eradication of the vector.

Dr. BLOOD (United States of America) said it had been his pleasure earlier in the meeting to refer to the A. aegypti eradication program in his own country. He would like to go back to that point and mention the recent developments in the United States of America that had made it possible to proceed with the program with renewed vigor and achieve the goal of eradication with the least possible delay. As mentioned earlier, the Government of the United States of America looked to the Organization for technical guidance on whatever steps were necessary to reorganize or reorient activities.

It was certainly most encouraging to hear the reports of the Conference and of the Study Group on the Eradication of Aedes aegypti. He had been struck particularly by the recommendation insisting on the active participation of the Organization, to the fullest possible extent, in the continental program, and by the three points made in that connection: high priority for each of the national programs; assistance and advice on the development of the programs; and international coordination, above all, to avoid re-infectation. Page 192 Tenth session 56th Meeting

There was not the slightest doubt that the eradication of A. aegypti was a feasible goal; many countries had already completed the task. It was in the interest of all that the remaining countries should complete it as soon as possible. He would like to suggest that the Organization include in its regular budget the necessary funds to fulfill its part in that international endeavor. It was interesting to note in going back over the record, that there had never been a refusal of funds to the Director of the Bureau for A. aegypti eradication. If more were needed, he was sure more would be forthcoming, because the role of the Organization was fundamental and would be even more so as eradication came closer. Whether or not the Organization could, upon the request of Governments, take an active operational part in those final'stages, might be explored for such action would be to the direct benefit of all concerhed.

Dr. ORELLANA (Venezuela) asked why the United States of America was not included in Table 1 of the report of the Study Group and what the estimated cost of the campaign in that country was.

Dr. MUSA (Regional Adviser in Aedes aegypti Eradication, PASB) explained that the purpose of the table was to show the total cost of the campaign in those countries that might need financial assistance from sources other than their own national budget; it was for that reason that the cost of the campaign in the United States of America was not included.

Dr. AGUILAR HERRERA (Guatemala) asked whether the estimated cost of the campaigns also included what was going to be contributed or what could be contributed by each Government; in other words, whether the table represented a budget which included both national and international funds.

Dr. MUSA (Regional Adviser in Aedes aegypti Eradication, PASB) explained that the estimates represented the total cost of the campaign, including the cost of personnel, equipment, supplies, insecticides as well as all local costs, but that they did not include the cost to PASB for the provision of technical guidance to the program or any other type of assistance, personnel training, research, etc.

Dr. ORELLANA (Venezuela) noted that Table 2 showed the number of PASB staff needed for advising, coordinating, and evaluating the campaign, but asked whether the total annual cost of $926,913 was for the total duration of all the campaigns or only for a short period.

Dr. MUSA (Regional Adviser in Aedes aegypti Eradication, PASB) replied that the annual cost was the cost to PASB if its personnel were to work in the campaign throughout the year. The Study Group had discussed two alternative methods of coordinating the programs to prevent re-infestations: to carry out the campaign in all the countries simultaneously, in which case the total personnel indicated would be that which the Organization would need to provide technical advisory services, consultant services, etc.; the second alternative proposed by the Study Group was to carry out the campaign by stages in order to eradicate the mosquito from the Americas. PASB personnel needed each year to assist the Governments would thus depend upon the strategy adopted.

In reply to the question of the Representative of Venezuela concerning the estimated cost of the campaign in the United States of America, Dr. Musa explained Page 193 56th Meeting Tenth session

that its Representative had told the Study Group that, for administrative reasons, it was not possible to submit a budget showing the total cost of the campaign since the budget of that country was examined and approved on an annual basis by Congress.

The CHAIRMAN asked the Representative of the United States of America whether he could give the Committee an approximate idea of the cost of that campaign.

Dr. BLOOD (United States of America) said that unfortunately he was not in a position to do so simply because he did not have the information available. It could be obtained rather rapidly if it was of special interest to members of the Committee. However, as Dr. Musa had pointed out, to anticipate the cost of the program would be to anticipate the will of Congress, which had to appropriate the funds.

The CHAIRMAN said that it was understood that the budget of the United States of America for the A. aegypti eradication campaign was US$70 million, so that about $150 million would be needed to eradicate the mosquito from the Americas.

Dr. ACOSTA-BORRERO (Colombia) asked whether the recommendation of the Study Group on the personnel required for the coordination of the program at the continental level had been taken into account in the proposed budget and, if not, whether there was any possibility of putting it into practice in the near future.

Dr. HORWITZ (Director, PASB), replying to Dr. Acosta-Borrero, said that Of- ficial Document 67 showed that between 1966 and 1968 there had been an increase of $80,000 in the amount earmarked for A. aegypti eradication; in other words there had been an increase in PASB funds in relation to national funds. He reminded the Committee that, when discussing the projects for the Dominican Republic, it had been pointed out that an item of about $27,000 had been suppressed. It had been explained that, in the light of latest information, it appeared that the Government of the Dominican Republic was not going to set aside the corresponding amount in its national budget and that the Organization had therefore considered it prudent not to keep those funds frozen. The Director hoped that the Executive Committee as well as the Directing Council would endorse the decision that the Organization should increase its coordinating efforts until the campaign was completed. Representatives of the Bureau would visit each of the countries and territories of the area still infested or recently re-infested, as was the case of El Salvador, in order to discuss with each Government what the status of the problem was. He hoped that it would be possible to submit to the XVII Meeting of the Directing Council a much more specific report on the situation. In the light of that information, some changes might be introduced into the proposed figure for costs, but that it would not be advisable to change it without ascertaining the opinion of the Governments. If the Governments of the infested countries decided to embark' on their campaigns simultaneously, funds would have to be obtained for financing them. it was his impression that it might be possible to solve the resistance problem by means of organophosphorus insecticides sprayed every two months, so that that problem should not constitute a negative factor in Page 194 Tenth session 56th Meeting the decision of the Governments. It was essential to approach bilateral lending agencies to induce ther, to give the program the same treatment they gave to malaria eradication.

Dr. AGUILAR HERERA (Guatemala) said that the problem should be given urgent attention, especially since in his country the situation was critical owing to the re-infestation that had occurred in El Salvador and threatened the neighboring countries. Consequently, it would be advisable to draft a resolution based on the opinions expressed in the Committee and on the recommendations of the Study Group and the Conference on the Eradication of Aedes aegypti.

The CHAIRMAN invited Dr. Fred L. Soper, Director Emeritus and Consultant of the Bureau to speak on the item under discussion.

Dr. SOPER (Director Emeritus and Consultant, PASB) said that he had had the privilege of attending the meetings of the recent Conference and Study Group and was naturally very pleased with the attention that was being given to the problem, which he believed to be much more serious than many people realized. Some of those present had lived long enough to know that they were currently deriving the benefits of the yellow fever eradication program that the Rockefeller Foundation had carried out between 1915 and 1934. The last center of aegypti-man-aegypti transmitted yellow fever had disappeared in 1934 in northeast Brazil. It was in that year that the eradication of A. aegypti had become possible and it was then initiated as the only possible answer to the discovery of jungle yellow fever which, incidentally, had come at the same time.

The program for the eradication of A. aegypti approved at the I Meeting of the Directing Council in 1947 6/ had not been suggested with the idea in mind that it would be easy of accomplishment. Dr. Waldemar de Sá Antunes, Director of the National Yellow Fever Service of Brazil, who had made the proposal, had been working with A. aegypti for much of his lifetime. The speaker had first met him in 1920 when he had been working on the program for the eradication of yellow fever, organized by the Government of Brazil. Dr. de Sá Antunes, already an experienced worker, had then gone through the experience of the epidemic of Rio de Janeiro in 1928 and 1929, and was Assistant Director of the National Service when it had been amalgamated with the Rockefeller Foundation in 1932.

When the first proposal had been made to eradicate A. aegypti in Brazil, Dr. de Sá Antunes had been among those who doubted whether it was possible, and yet he lived through the experience of seeing other cities re-infested with jungle yellow fever, and saw the eradication activities develop gradually from the cleaning of a few cities into a national program.

In 1947 the frontiers of Brazil were clean but Dr. de Sá Antunes had seen that Brazil could not maintain its program unless the other countries were cleaned up also. He had not made the recommendations at the Directing Council meeting in the belief that they would be easy of accomplishment, and they were not, but he knew that the defense against jungle yellow fever depended upon keeping the cities and towns close to the forest clear of A. aegypti.

6/ PAHO Publication 247, 3. Page 195 56th Meeting Tenth session

In the last 25 years, since the interior cities and towns of the Hemisphere had been cleared, there had been threats of re-infestation of urban areas only where the cities and towns close to the jungle were still infested. In 1954 both Port of Spain, Trinidad, and Caracas, Venezuela, received a case of yellow fever coming from a distance and by air. Probably it had been only through the emergency measures taken at that time that another Rio de Janeiro experience had been avoided.

Since then, yellow fever had been kept well out of the cities, with the exception of the recent experience in Venezuela when yellow fever cases were again found in contact with areas where A. aegypti was present. Again an emergency service had been called into action which, with the intensified use of insecticides, vaccines, and so on, apparently had been able to control the situation.

Dr. Soper emphasized that on looking back one had to realize that the current situation was not the result of the campaign since 1947, but of the campaign that the Rockefeller Foundation had started in 1915. If the Hemisphere was allowed to be reinfested with A. aegypti the situation could return, not to what it was in 1947, but to what it had been 40 or 50 years before. That was what was at stake.

With regard to expenditure, there was currently a tremendous expenditure even in the countries that had eradicated A. aegypti. One usually talked about expense in terms of dollars, but the dollar of today was quite different from that of yesterday. One figure that he would like to give was that presented by the Delegate of Brazil to the XV Pan American Sanitary Conference, in 1958, when Brazil had been finally declared free of A. aegypti. 2/ The figure had applied not only to the period during which work had been done against yellow fever, but also to that which had been carried out since the amalgamation of the services in Brazil in 1931. From 1931 until A. aegypti had been declared eradicated in Brazil, records had been kept of 617,000,000 house visits, required to do the job under the conditions they had worked under at that time. At current prices, that surely represented an investment of at least $200,000,000, probably more. Moreover, it was not generally recognized that the situation was getting worse instead of better. The cities were becoming larger, the number of artificial disposable water containers, which permitted A. aegypti breeding, were increasing in use and in number, and the available means of transportation into jungle areas and out of the cities were increasing.

Therefore, the reinfestation of South America with A. aegypti would neces- sitate a much greater effort to achieve elimination than had been necessary initially.

He wished to congratulate the Organization on the drive that had begun with the resolutions of the XVII Pan American Sanitary Conference, and he believed the time had come for a final drive to eradicate A. aegypti from the Hemisphere.

The session rose at 12:55 p.m.

2/ Resolution XXXV. Official Document PAHO 27, 40. ELEVENTH PIENARY SESSION Tuesday, 2 May 1967, at 2:40 p.m. Chairman: DR. ALBERITO E. CALVO (Panama) Later: DR. DANIEL ORELLANA (Venezuela)

ITEM 17: FELLOWSHIP PROGRAM

The CHAIRMAN called the session to order and announced that the next item of business was the Organization's fellowship program.

Dr. CHARNES (Chief, Fellowships Branch, PASB), introducing Document CE56/13 _/ on the item, recalled that, at the XVII Pan American Sanitary Confer- ence, the Government of Chile had proposed that a review be made of the fellowship program 2/ with a view to the possible introduction of changes into its administration. The proposal had been subsequently withdrawn and the Delegate of Chile had suggested that the matter be taken up by the Executive Committee. In compliance with that suggestion, the afore-mentioned document had been prepared to provide the Committee with the necessary information.

The fellowship program was, and had been, one of the most effective means for strengthening and developing national health services; promoting improved standards of teaching and training in medicine and the related sciences; and encouraging cooperation among scientific and professional groups and the exchange of scientific information on health activities.

To achieve those aims the program provided opportunities and the necessary facilities for studies abroad in academic courses leading to a diploma, a Master's degree, or a certificate in some special health field; short courses, generally sponsored by the Organization, on specific aspects such as those relating to population dynamics or environmental sanitation; and, lastly, observation visits (travel grants).

Everything possible was being done to make fellowships an integral part of national health programs in operation or about to be started. Preference was therefore being given to candidates participating or working in programs being conducted with the assistance of the Organization or holding key posts in the health services. High priority was also assigned to faculty members engaged in the preparation of professional and auxiliary personnel. The order of priorities was influenced by the lack of local training facilities, the need for qualified personnel, and, especially, the assurance given by the Government concerned that the candidate's absence during his study would not adversely affect his security, salary, and other rights, and that the allotments necessary to ensure that use was made of fellows on their return home would be available.

_/ Mimeographed document. _/ Document CSP17/30 (mimeographed). - 196 - Page 197 56th Meeting Eleventh session

Because of the steady expansion of the national health services in the countries and the inadequacy of local training facilities, international assistance was still needed to enable the countries to satisfy the normal requirements in health services and teaching personnel. Thus the number of fellowships awarded in 1959 and in 1966 had increased by 69 per cent, from 505 to 854. The selection of fellows was unquestionably the most important aspect of the entire process of awarding a fellowship and in the effective conduct of the program. Ex- perience had shown that conditions for the selection of applicants were best in those countries in which a special committee had been set up for the purpose. Hence, the Organization was encouraging the establishment of such committees.

Another aspect just as important as the preceding was the choice of the place of study. It was greatly facilitated by the active assistance and good will of Governments and the willingness of universities to accept fellows of the Organization. That had undoubtedly contributed to the success of the program. The prevailing policy was to choose a place of study that had the equipment, facilities, and instructors commensurate with the specific needs of each fellow. As far as possible, however, efforts were made to ensure that fellows pursued their studies in an environment where the standard of living and health problems most closely resembled those of their countries of origen. By so doing, many frustrations had been avoided and fellows were able to readjust more quickly on their return home. Moreover, such studies were more fruitful and effective because the language of instruction was the fellow's mother tongue.

As pointed out in Document CE56/13, the fellowship program was strongly influenced by how the parties concerned honored the commitments inherent in the award of the fellowship, i.e., the Government had to certify that the studies to be made and the fellowship were necessary for the strengthening of the national health service, that full use would be made of the fellow in the field covered by the fellowship on his return home, and that his salary and other rights would not be adversely affected by his absence. The fellow undertook to return home and continue to discharge the functions assigned to him for at least three years; and, lastly, the commitment of the Organization was to provide financial assistance and technical supervision to ensure that the fellow got the greatest benefit from his studies and pursued them in the most appropriate places.

The vast majority of commitments were being met but, in some exceptional instances, the Governments had not continued to pay the salary of their fellows or to utilize their services on their return. The difficulties that might arise were obvious and had led the Governing Bodies of the Organization to pass several resolutions urging the countries to honor their commitments.

Fellowships were normally awarded for not less than two months and not more than one year. Exceptions to that rule were specific short courses that might last for up to a week or studies of more than a year's duration.

The Organization defrayed all expenses directly related to the studies to be pursued; namely, the international travel and travel in the country of study plus the cost of excess baggage when the fellowship was for more than two months; tuition fees and a book grant the amount of which varied according to the length of the fellowship and the nature of the studies; and a monthly stipend which was paid in the currency of the country of study and which varied in amount from one Page 198 Eleventh session 56th Meeting country to another, according to the determinations of a special committee composed of representatives of all the specialized agencies of the United Nations.

The monthly stipend was of two kinds: one was paid to fellows who remained less than 30 days in one place, termed a "travel stipend," and the other, known as a "resident stipend," was for those staying longer than 30 days. All the fellows received the travel stipend in the first month in order to help them settle down in the place of study.

As stated in the brochures distributed to the Committee members, "a stipend is not a salary or an honorariumn; it is an allowance for room, board, and incidentals paid to the fellow while on official assignment for study abroad." It was not supposed to cover the fellow's routine expenses at home for himself or his family and should, therefore, not be regarded as a substitute for any salary paid to him at home. That underscored the importance of the Governments continuing to pay the salaries of fellows while absent abroad, since the monthly stipend only covered the expenses of one person. That subject had been discussed at several meetings of the Governing Bodies of PAHO. It had been suggested that different stipends be established for different classes of fellows. Every specialized agency of the United Nations which awarded fellowships had rejected the measure whenever it was suggested because of the psychological and administrative difficulties and complicat;ions to which it would lead.

It would be inconsistent to set up a special system for fellowships funded by PAHO since those funded by WHO and the United Nations had to conform to the regulations of those agencies. llence, the entire program was being administered under one set of regulations that was the same for all the agencies. Any increase in the cost of each fellowship would immediately affect the number of fellowships awarded annually because the funds for the program were not un- limited.

It followed that the conduct of the fellowship program demanded considerable efforts from all parties. Moreover, the cost of the program claimed a very substantial share of the budget of the Organization, which was, therefore, keenly interested in knowing what results were being obtained. To that end, questionnaires had been sent to the Governments and former fellows to learn how their services were being used. The replies indicated that the services of many former fellows were indeed being properly used. However, in many cases no reply had been received, so that the studies were based on a relatively small number of replies.

In view of the current status of the program, thought had been given to the advisability of making a thorough evaluation of it in 1968 through personal interviews with former fellows since, in his view, that was the most effective way of arriving at valid conclusions.

Dr. SANTA MARIA (Observer, Chile) expressed his satisfaction with the fact that it had been the Chilean Delegate who, at the XVII Pan American Sanitary Conference, had proposed the inclusion of the item in the agenda of the current meeting. In his opinion, it was a matter of major interest to the Organization, since one of the factors limiting activity in the field of health was the lack of qualified personnel and they could be trained under fellowships. Page 199 56th Meeting Eleventh session

Although the benefits obtained with the program were known, it was interesting to compare ideas on the selection of candidates and on the extent to which the services of fellows were used. Chile had established a selection committee composed of representatives of the Ministry of Public Health, the schools of medicine, and other entities, and was responsible for establishing the necessary priorities. The Committee was selecting not only the applicants for PASB fellowships, but also those who were to receive fellowships under similar programs sponsored by other international, governmental, and even private institutions, which made for more effective utilization of the diverse resources available for the same purposes. The best way to make optimum use of fellows was to select them without bias or discrimination. The amount of a fellowship stipend should be larger for a young man than for an established professional health worker, who generally had means of his own. Fellowship stipends should cover the needs of the fellow only during the academic course he was to attend; teacher training and advanced studies in certain basic sciences were different matters and in those instances the fellowships should be for longer periods.

His impression was that the Organization's fellowship program was progressing satisfactorily, but he suggested that consideration be given to the recommendations of the Government of Chile in the draft resolution presented in Docu- ment CSP17/30, namely that steps be taken to improve procedures for applying for fellowships and travel grants through the proper selection of recipients so that the training they were given might be determined chiefly by national health plans, and that an evaluation of the results of the fellowships be undertaken. Although a complex process, the evaluation should be made in such a way as to yield more than the mere fact that the Bureau had awarded 6,757 fellowships between 1954 and 1966. In his opinion, the evaluation procedure could perhaps be improved by asking more specific questions on the forms to be returned by fellows and studies could be made within the Bureau to determine the situation of the fellow on his return home.

Studies along those lines made in Chile revealed that only one third of the fellowships awarded were really useful; another third of the fellows had made only slight progress; and in the remainder the efforts of the Government or the sponsoring agencies had proved sterile.

It would be worth while to submit to the XVII Meeting of the Directing Council a draft resolution establishing a good procedure for fellowship evaluation. The Bureau might review the administrative machinery for the awarding of fellowships with a view to introducing changes to improve it.

Dr. BLOOD (United States of America) said the report was very interesting and certainly deserved more attention than he had been able to give to it.

He recalled that, at certain times in the past, some of the countries had felt the need for more fellowships than the Organization was able to provide and had advanced what he believed were called "funds in trust," through which fellowships could be funded. He wondered whether that was a general practice and what the current status was of the coordination mechanism with other agencies. He believed that PAHO had been the one to take the initiative in acting as the coordinating body for international fellowships in the health field. He would therefore like to know whether that was still in operation and how effective it was. Page 200 Eleventh session 56th Meeting

Dr. CARVAJAL (Ecuador) said that his country was especially interested in the fellowship program because the Ten-Year Health Program, which had been under way for a long time in Ecuador, made it necessary to send many professional health workers abroad for specialized training so that they might subsequently work in the different health regions into which the country was divided. A small number of fellowships was available for physicians but the problem was worse for nurses because of academic difficulties, even though fellowships were available for them. Owing to differences in the curricula of the countries, the nurses of Ecuador lacked the necessary academic qualifications. He asked the Bureau to assist in the matter so that Ecuadorian nurses might be placed on an equal footing with those of other countries. However, Ecuadorian nurses, especially those from Guayas University, in Guayaquil, were employed in their profession in the United States of America.

Dr. ORELLANA (Venezuela) said that he had felt drawn to the Bureau's fellowship program since it began because he regarded it as one of the most effective of such programs. He had had occasion since then to participate very actively in the selection of fellows from Venezuela. In his opinion, the program was increasing in importance since it afforded the Governments additional ways of obtaining assistance from the Bureau in such an essential matter. How- ever, it suffered from natural limitations which posed real problems at times.

As an example, he cited the question of the value of the fellowship, noting that in the course of a year the established stipend could become quite insufficient for the needs of a fellow, particularly because of the instability of exchange rates, which could change from one month to the next. The stipend would always be insufficient because it did not replace salary or cover all the expenses of the fellow, but was merely an allowance to defray certain expenses. Another problem was language; in public health as in other fields, English was a working tool and, as such, also merited attention, though the fellowship program made no provision for the cost of language instruction, which was borne by the candidate or the Government that sponsored him.

In regard to the choice of training centers, the interests of the country and fellow sometimes conflicted with the recommendations of the Organization, and a prospective fellow was hard to convince that the best school was the one recommended by the Organization and not the one he might have selected on advice given him in his own country. Those conflicts were generally not serious and did not lead to termination of the fellowship.

He emphasized the importance of the commitments assumed by a Government when requesting a fellowship and sent out a fellow and he noted that, as Dr. Charnes had pointed out, the salary of the fellow should be continued for the duration of his absence, a matter which posed problems, particularly in organizations that were not closely connected to the health ministries, which were the agencies that made the most use of fellowiships. That situation could arise if the recipient belonged to an autonomous institution or to one not subject to Government regulations. It should be avoided at all costs because a fellowship stipend was not enough to support a health worker abroad, although it was not the responsibility of the Organization. 'The employer of the fellow should undertake to continue his salary during his absence and to employ him on his return. Page 201 56th Meeting Eleventh session

As for the limited duration of fellowships under the program, it was impossible to continue them for more than a year because it was necessary to expand the program to allow the largest possible number of persons to benefit from it. However, some basic subjects could not be covered in that time, such as pathological anatomy, anesthesiology, and other fields in which training lasted longer than one year and had to be financed.

Evaluation was very important and, in spite of the difficulties involved, the problem had to be solved and the procedure improved. The Bureau used reports from the fellows themselves, which many of them were sending, as well as the two-year follow-up reports by both the Government and the fellow which served to measure the benefit derived from the fellowship, although he felt that no evaluation system could really convey the benefit of the program.

In his opinion, the personal interview method proposed in the report might turn out to be the best. The performance and results obtained by 50 fellows selected at random could be ascertained in a careful sampling two, three, or four years after their fellowships.

He drew attention to the last paragraph of the document which, in his view, betrayed unnecessary modesty. The fellowship program was not, in his view, in need of guidance because it was developing in excellent fashion and deserved only praise and encouragement from the Committee.

Dr. CHARNES (Chief, Fellowships Branch, PASB), replying to the question of the Observer of Chile on the duration of fellowships, said that, as a rule, they were not longer than one year, but that exceptions confirmed the rule, particularly in the case of teacher training. Great importance had been given in recent years to the training of teachers for schools of medicine and public health and that 186, or almost 20 per cent, of 854 fellowships awarded in 1966, went to such teachers.

In the specific case of basic science teachers who required more training, there never had been, and never would be any difficulty in increasing the number of fellowships in response to requirements. The Bureau did not want to award fellowships of longer than two years' duration because of some unpleasant experiences it had had. The Bureau was only granting one-year fellowships, although it might later extend them in accordance with recommendations from the institutions in which the fellows were studying.

In reply to Dr. Blood, he said that the Bureau was cooperating with the countries and with other international agencies with some of which it had established very close coordination with regard to their fellowship programs, in particular the OAS. The Bureau maintained an advisory committee for the program of that Organization, the purpose being to examine and advise on all applications received by the OAS for fellowships in the health field; later, a member of the committee sat on the Advisory Board of the OAS program and made appropriate recommendations. The Bureau was also giving technical advisory services to countries with their own fellowship programs, such as Venezuela, in which it was giving technical guidance to Venezuelans studying on fellowships in the United States of America, Canada, or several Latin American countries. In addition, there was a Medical Education Information Center (MEIC) supported by all the Page 202 Eleventh session 56th Meeting international agencies providing educational assistance. The members of MEIC, who generally met once a year under Bureau auspices, reported on their work and were helping to publicize the activities of the Bureau in the fields of medical education and the basic sciences. Certain countries had sometimes made the Organization the depositary of fellowship funds and had requested it to administer them.

Clarifying some of the points raised by Dr. Carvajal, Dr. Charnes said that the Bureau relied on the cooperation and good will of the universities, training schools, and Governments to accept the fellows it sent them and that, therefore, those institutions followed their own internal regulations and applied their own principles in according recognition to studies pursued or degrees conferred in a given country. The case of the Ecuadorian nurses referred to by Dr. Carvajal was not unique; the same difficulties were being encountered by nurses from other countries who had graduated from schools that universities did not regard as of univers:ity standing and who, therefore, could not be granted the diploma or a degree simnilar to that of Master in public health, but just a certificate of competence. In those circumstances, the only solution was for those schools to raise the standard of training to university level so that other universities could accept the degrees they conferred. The same applied to health educators, whose degrees had no standing from the university standpoint.

As for the matter of stipends raised by Dr. Orellana, they were subject to continual review. They were generally based on the studies made by the representatives of the United Nations Development Program in each country, and there were special forms establishing prices in hotels, boarding houses, res- taurants, etc.; there was also a form which was given to each fellow on which he had to record all his expenses. It was on those data that the amount of the stipend was based, and the dollar exchange rate had nothing to do with its determination because the fellowship funds were provided in the currency of the host country. What the Bureau was concerned about was the high cost of living in countries such as Brazil and Chile where it had created difficulties because of inflationary trends.

As to the evaluation, some attempts based on both questionnaires and on personal interviews had been made. The replies to questionnaires did not convey an accurate picture of the situation and an evaluation based on a sampling might perhaps be the best procedure.

Dr. CARVAJAL (Ecuador) asked the Bureau to take some action, as considered appropriate, to try to solve the problem of the Ecuadorian nurses he had referred to earlier.

Dr. CHARNES (Chief, Fellowships Branch, PASB) promised that he would comply with Dr. Carvajal's request and review the Bureau's policy on the matter.

Dr. AGUILAR HERRERA (Guatemala) expressed his satisfaction with the operation of the Bureau's fellowship program in spite of its shortcomings, which, he hoped, would be rectified in time. He then said that Dr. Acosta-Borrero of Colombia, who had been called away by urgent matters, had asked him to present to the Committee for consideration a draft. resolution which he proceeded to read. Page 203 56th Meeting Eleventh session

'Dr. SANTA MARIA (Observer, Chile) endorsed the draft resolution, but suggested that it might be advisable to include in the preamble a reference to the priority that should be given to the training of health service personnel, since the recent Meeting of the American Chiefs of State at Punta del Este had recognized its importance.

Increased efforts should be made to coordinate the work of the different international agencies granting fellowships in the health sector so as to make their respective programs more effective; and that point might also be covered in some way in the draft resolution.

The CHAIRMAN announced that the draft resolution would be distributed to the representatives for study and possible amendment.

The session was suspended at 4:00 p.m. and resumed at 4:30 p.m.

Dr. Orellana (Venezuela) then took the Chair.

ITEM 21: INTENSIFICATION OF HEALTH PROGRAMS--DECISIONS TAKEN AT THE MEETING OF AMERICAN CHIEFS OF STATE

Dr. HORWITZ (Director, PASB), introducing Document CE56/19 3/ on the item, recalled a remark of Dr. Orellana's bringing out the importance of the sequence in which the meeting held by the so-called "Group of 21" of the Inter-American Economic and Social Council at Buenos Aires in April 1959, was followed by the Act of Bogotá in 1960, the Punta del Este Meeting in August 1961, and the Decla- ration of the Presidents of America, the document signed by the Presidents of 18 American Republics and the Prime Minister of Trinidad and Tobago. From the standpoint of the Pan American Health Organization, that sequence had tended, on the one hand, to highlight individual and collective, physical, spiritual, and social health and, on the other hand, to make health activities part of economic and social development activities.

The Government of Panama had proposed the inclusion of the item in the agenda of the meeting and, for that reason, and to facilitate the discussion of it, the Bureau had prepared the afore-mentioned document. It was, to a certain extent, historical in character, since it contained a detailed account of the efforts of the Pan American Sanitary Bureau to implement Resolution XXX 4/ of the XVII Pan American Sanitary Conference. That resolution specifically instructed the Director of the Bureau to take steps to include in the agenda of the Meeting of Chiefs of American States those health problems which because of their characteristics and scope called for solutions at the highest level.

Much work had been done since that Conference decision. Particular mention should be made of the kind understanding evinced at all times by the Secre- tary General of the OAS, who had always been convinced of the fundamental

3 Mimeographed document. Official Document PAHO 74, 90-91. Page 204 Eleventh session 56th Meeting

importance of health for economic and social development, and had welcomed the ideas presented to him by PAHO in a letter dated 31 October 1966 (annex to Document CE56/19), in which four basic topics were suggested: improvement of the living conditions of more than 100 million people in rural areas for which a comprehensive approach was needed; higher education through which modern science and technology might be absorbed without impairing the cultural integrity of any society; reaffirmation of the objectives and goals of the Ten- Year Public Health Program in the Charter of Punta del Este based on the balance sheet drawn up by the Organization five years after its signature, and, lastly, reaffirmation by the Presidents of the American Republics that the principle that health was a basic component of development should find a practical expression in the inclusion of measures for the prevention and cure of diseases into every national or international development project.

Four documents dealing in detail with those proposals had been sent to the Secretary General of the OAS on 18 January and he had been kind enough to endorse them and forward them to the Preparatory Commission of the Meeting of Presidents, which was actually the Council of the Organization of American States. The document, which had been prepared in connection with the first of the four proposals, was entitled "Community Water Supplies--A Discussion of Financing," and the ideas contained in it had been reflected in the Declaration signed by the Presidents. That document appeared in Annex 3. A second document, bearing the title "Devel- opment of the Biomedical Sciences and of Education in Latin America--Definition and Role of Multinational Centers," and dealing with higher education, had been prepared with the help of a group of experts headed by Dr. Charles V. Kidd. With regard to the third proposal, which had also been embodied in the Declaration of the Presidents, it had been supported by Facts on Progress--Health Goals in the Charter of Punta del Este, 5/ a publication that had become a bestseller in the health field.

The fourth proposal referred in essence to a decision the Chiefs of State were asked to take which would serve as a basis for a rule, a practice to be followed, whenever a development project was being prepared in the Americas. Indeed, the effect of death, disease, and disability on output and productivity, whatever the nature of the economic development program, was beyond discussion, as was the importance of improving the physical environment for the exploitation of natural wealth. By extension, similar arguments were in order when talking about industrialization, agricultural development, and urbanization. It was clear that, in the preinvestment phase of any project that was a part of such activities, health services had to be regarded as a social service, and that was not happening today. That was the reason for the proposal that the Chiefs of State establish it as an inescapable principle, a rule, that would generate a habit in the Governments, the credit institutions, and the international organizations advising them.

The document described the history of those and other proposals and the highly effective collaboration of the health experts of the Governments who had been designated for the Eleventh Meeting of Consultation of Ministers of Foreign Affairs of the Hemisphere, the meeting of the Special Committee of Personal

5/ Miscellaneous Publication PAHO 81. Page 205 56th Meeting Eleventh session

Representatives of the Chiefs of State, and, finally, at the meeting of Minis- ters of Foreign Affairs that preceded that of the American Presidents. Each phrase was the object of lengthy discussions, editing, and amendment, and the result was to be seen in the Declaration of the Presidents of America. 6/

Through the kindness of the Organization of American States, the original document, just as it emerged from the Meeting, had been placed at the disposal of the Committee, and he would like to comment or it briefly. The central theme of the entire meeting was the economic integration of Latin America, the establishment of a commoin market, of a genuine economic community that could offer broader prospects to the population of each country and of the Region as a whole vis-a-vis the technologically advanced nations in the Americas and other regions of the world. Integration was the core, the backbone of the document, which had to be examined chapter by chapter from the standpoint of the economic community. The first chapter referred especially to the economic integration and complete industrial development of Latin America, in regard to which PAHO could be properly asked whether it had any part to play either during the organization of that economic community or when it had become fully operational and thereafter, a point that merited careful consideration.

Chapter II dealt with multilateral action for infrastructure projects and mentioned the undertakings involved, as given on page 12 (Items 2, 3, and 4): the Pan American Highway, construction of the Bolivarian Highway and its junc- tion with the Trans-Chaco Highway, new highway systems that would join groups of countries of continental and insular Latir America, and the basic works required for the development of multinational water and air transport and the corresponding operational systems. The document then mentioned projects for the development of watersheds such as that already launched for the development of the River Plate Basin, and that relating to the Gulf of Fonseca. He announced that the Organization had already been advised that the Inter-American Development Bank (IDB), the financing agency for the preinvestment studies on the projects for development of the Plate Basin, had issued a special invitation to the Bureau to participate, from the outset, in its preinvestment studies, which would cover all aspects of a great many health problems. In Buenos Aires recently he had had occasion to get in touch with the chairman of the Advisory Group of the five participating Governments, which had agreed that it would first be necessary to define the borders of that watershed so that the Bureau could determine which health problems would have to be taken into consideration.

As stated in paragraph 4 of Chapter II, sufficient resources were being allocated to the IDB's Preinvestment Fund for Latin American Integration to enable it to conduct studies that would make it possible to identify and prepare multinational projects in all fields, including, in Dr. Horwitz's view, health projects which might be of importance in promoting regional integration. Regard- less of how that or any other watershed was defined, it would contain centers of population with problems to be solved; there were also watersheds that were entirely unpopulated and blanketed in jungle in which the potential problems and dangers would have to be examined, i.e., for which all kinds of studies would have to be made, including so-called immunological profiles to determine the species present there that could cause known or unknown diseases.

6/ OAS Official Records, OEA/Ser.C/IX.l, 1967. Page 206 Eleventh session 56th Meeting

With respect to Chapter III, which discussed ways of improving international trade conditions in Latin America, it was clear that in the food trade, for example, the role of the Organization was to test foodstuffs, to establish reference laboratories, and to train technicians in order to prevent difficulties or disagreements between Governments over the importation or exportation of foodstuffs that had not been subjected to minimal tests, not only during production but when finished, and also of many other products traded within the Region.

In the subject dealt with in Chapter IV, namely modernization of rural life and increase in agricultural productivity, principally of food, the Organ- ization had a part to play. That chapter recommended the substantial expansion of specialized education and research and of agricultural extension programs in order to improve the training of the rural worker and the education of technical and professional personnel, and, also, to intensify animal and plant health campaigns. The Bureau had striven to have foot-and-mouth disease specifically mentioned, but it seemed there was a deliberate intent to couch the document in terms of broad principles, guidelines, and lines of action. However, it was generally understood that, when animal health campaigns were mentioned, foot- and-mouth disease, paralytic rabies, bovine tuberculosis, brucellosis, and others which were of interest to health, from the ecological standpoint, were implied. That was why the Bureau wanted the Pan American Foot-and-Mouth Disease Center to be administered by PAHO.

The modernization of rural life could, of course, not be accomplished solely in economic terms, but also had to be undertaken in social terms. In his view, integrated projects to improve rural life would have to make suitable provision for health services and be financed within the limits of the domestic resources and foreign capital required by each specific program.

The work of the Organization was specifically described in Chapter V "Educational, Technological, and Scientific Development and the Intensification of Health Programs."

The section on "Education and Culture," especially the part on multinational efforts (pp. 19-20), were-related directly to the Organization's higher education activities, as was the subsection on science and technology. The subject was covered in detail in the document prepared by the Bureau which dealt with advanced training and research centers and how to make them into international centers for the education of graduates, both teachers and non-teachers, from countries of the Hemisphere, through the linking of research and training.

The subchapter on multinational efforts proposed the establishment of a Regional Scientific and Technological Development Program designed to advance science and technology to a position where they could substantially contribute to the acceleration of the economic development and the welfare of the peoples and make it possible to engage in pure and applied scientific research of the highest possible quality; the program would complement the Latin American national programs in the areas of science and technology and would take special account of the characteristics of each of the countries. As part of the program, the Presidents proposed that multinational tecinological and scientific training and research institutions at the postgraduate :!evel be established and that intitu- tions of that nature already existing in Latin America be strengthened. Page 207 56th Meeting Eleventh session

It was substantially the proposal made by the Bureau and to put it into practice the Presidents proposed that a group, composed of high-level, qualified persons experienced in science, technology, and university education be established to make recommendations to the Inter-American Council for Education, Science, and Culture (the Inter-American Cultural Council) on the nature of such multinational institutions, including such matters as their organization, characteristics of their multinational administration, financing, location, coordination of their activities among themselves and with those of pertinent national institutions, and other aspects of their operation. That group, selected and convoked by the above-mentioned Council or in default thereof by CIAP,would meet within 120 days after the close of the Meeting of the Presidents.

Dr. Horwitz said he was thinking of asking the Secretary General of the OAS to consider the possibility of the Organization being represented at meetings of the group in order to explain what had been done and what it was proposed to do, according to the report he was discussing, in the field of biology, medicine, and the social sciences in relation to health.

The chapter on health was, he thought, quite well conceived, although it made no reference to either housing or social security of the urban or rural population, or to social welfare in general. He felt, therefore, that the Organ- ization should broaden its responsibilities in those areas.

He emphasized that the American Chiefs of State recognized that the improvement of health conditions was fundamental to the economic and social development of Latin America, which was the strongest possible endorsement the basic policy of the Organization could have obtained. The intention was to fulfill the goals of the Charter of Punta del Este, which was why they had been reaffirmed, i.e., the need had been reasserted of continuing to work of controlling communicable diseases and of eradicating those against which proven countermeasures were available, under international coordination whenever necessary.

Paragraph (b) mentioned the importance of programs for providing drinking- water supplies, sewerage, and other services essential to environmental sanitation in urban and rural areas, preference being given to lower-income groups, and recognized the advisability of using national revolving funds to assure the continuity of the programs--something the Organization had been urging for the previous three years. That policy had thus become an obligation for the Governments and their advisory agencies if the primary purpose was to accelerate the improvement of rural welfare.

It was urgently necessary to improve the nutrition of the neediest groups of the population and for that purpose to take advantage of all possibilities offered by national effort and international cooperation. It was essential to adopt an agricultural policy, under which the biological needs of the population were truly harmonized with those of the export economy, as a basis for improvement of the human diet. It was also urgent to promote intensive mother and child welfare programs and educational programs on comprehensive family guidance methods, an initiative of PAHO that would give a more modern dimension to mother and child care. It would be up to each Government to interpret that policy in the light of its own population standards. Page 208 Eleventh session 56th Meeting

Priority should also be given to basic education and training of professional, technical, administrative, and auxiliary personnel, and support to basic and applied research. To that end, the national and regional health programs would have to become part of general development plans as early as the preinvestment phases. The decisions to be taken would be to expand, within the framework of general planning, the preparation and implementation of national plans that would strengthen the health infrastructure and to mobilize internal and external resources to finance those plans.

The aim of the Organization, said the Director, was to ensure that external funds for financing health activities be obtained on the same credit conditions as funds for other social programs; while that aim had not yet been achieved, it should continue to be advocated in agencies such as CIAP, so that, when they studied health plans as part of national development plans, they might bear in mind the objectives and needs stated in that chapter of the Declaration. Lastly, the document he was discussing called upon PAHO to assist the Govern- ments in the preparation of the specific programs aimed at those objectives. His impression was that the Bureau was the only specialized agency in the Inter- American System to which the Presidents had assigned a very clearly defined function, and he therefore felt that the discussion of the document presented should focus on that point.

He closed by asking what the Pan Anerican Health Organization should do to assist in the preparation of specific programs for those purposes. As the Organization analyzed each facet of the chapter on health, it would have to answer the central question relating to the document as a whole: Did the Bureau have a part to play in the organization and development of an economic community? What was the nature of that role? How should that responsibility be fulfilled? The Secretariat was at the service of the Committee and awaited such decisions as it might choose to take.

The CHAIRMAN stressed the scope of the subject discussed by the Director, the importance of the Declaration of the American Chiefs of State, and the part to be played by the Organization in the great economic and social development programs of the American countries. in his view, the two last questions asked by the Director could be answered in the affirmative. The Organization had a most important part to play in that effort. As to point 3, the last one in Chapter V of the Declaration, in which the Presidents called upon the Organiza- tion to assist the Governments in the preparation of the appropriate specific programs, the Chairman felt that the Organization had been rendering such assistance for a long time, and that all that could be done was to further increase it.

Dr. BLOOD (United States of America) said that a document so complete and well assembled was very hard to reduce to its component parts in order for one to determine without a good deal of study what really could be done in the way of implementation. He doubted that the Committee could look at the various alternatives and recommend one over another. The Chiefs of State of the different countries had agreed upon a plan of action. Even if they wanted to, he did not see how members of the Committee could criticize such an excellent document. Page 209 56th Meeting Eleventh session

Certainly, he would agree with the Chairman that the third point showed clearly the way for PAHO to move into action. It provided an opening for it to collaborate with the countries in developing plans to achieve those goals.

However, he felt that the Committee needed more time and an opportunity to consider additional choices, before it could discuss the document as fully as it deserved. He was very appreciative of the fact that it had been brought to the attention of the Committee and was sure the Governments would be giving it much more attention between then and the XVII Meeting of the Directing Council. The Delegation of his country was unable to offer specific plans or proposals for the Organization at that particular time.

Dr. SANTA MARIA (Observer, Chile) was of the view that the document submitted for consideration amounted almost to a directive that the Organization collaborate--within its field--in the accomplishment of the general purposes enumerated in it. 'the first thing for the Committee to do was to put it on record that the Organization had been doing that for a long time.

In the second place, it should specify that planning and programs for the humanitarian ends envisaged in the document had been going on in the health field long before they were started in other sectors. He agreed with the Representa- tive of the United States of America that it was difficult to establish, in a few hours, and for so many problems, the specific priorities, the procedures, the goals, the technology, the personnel, etc., especially since the health sector had to compete with what the Governments wished to do in other sectors. Spe- cial studies might therefore be needed, but it would be well if they were undertaken soon. He suggested that the Committee appoint a working party to prepare, on the basis of the Director's document, somewhat more specific projects for presentation, as an item of primary importance and not as recommendations, to the next meeting of the Directing Council at Port of Spain.

Dr. AGUILAR HERRERA (Guatemala) agreed with Dr. Blood and Dr. Santa María that there was very little time in which to deal with the item, which actually deserved the most careful study possible by expert committees, before it was brought up for final and comprehensive consideration by the Directing Council.

The CHAIRMAN said that all present were impressed with the importance of the document and a little overwhelmed at having to consider the Declaration of the American Chiefs of State. Nevertheless, a decision had to be taken. He recommended that the item be submitted to the XVII Meeting of the Directing Council in terms that would express first, the Committee's appreciation of the Director's efforts to sustain an unflagging interest in high-level political and economic circles of the Hemisphere, in the execution of health programs as part of development programs, and, second, that the Committee request the Council to authorize the Director to take the necessary measures to comply with the mandate of the American Chiefs of State to the Organization to assist the C-overnments in the programming and conduct of health activities.

Mrs. ELDRIDGE (Observer, OAS) said that, on behalf of the Secretary Gener- al of the OAS, she wished to express her gratitude to the Government of Panama for its initiative in asking that the item be included in the agenda of the meeting, in advance of the Directing Council Meeting in Port of Spain. It had Page 210 Eleventh session 56th Meeting clearly afforded an opportunity for informing the Committee members on the Meet- ing of the American Chiefs of State.

She further wished to convey the thanks of the Secretary General of the OAS for the dedicated interest and careful attention given by the Director of PASB to that Meeting and the support provided by the detailed documentation on health matters.

The CHAIRMAN announced that the Secretariat would prepare, as quickly as possible, a draft resolution embodying the ideas presented and which could be summarized in two specific points: appreciation of the efforts made by the Di- rector, and adoption of the necessary measures to comply with the mandate given by the Declaration of the Chiefs of State.,

Dr. SANTA MARIA (Observer, Chile) pointed out that it would perhaps be advisable to draft the resolution in such a way as to authorize the Director to initiate specific measures immediately, without waiting for authorization from the Directing Council.

Dr. HORWITZ (Director, PASB) recalled what had happened at the signing of the Charter of Punta del Este in August 1961. At that time, Resolution A.4 of the Charter recommended specifically: "That the task force on health, organized through.the Pan American banitary Bureau, appraise prevalent problems and suggest general lines of action of immediate effect relating to: the control or eradication of communicable diseases; sanitation, particularly water supply and sewage disposal; reduction of infant mortality, especially among the newborn; and improvement of nutrition; and that it also recommend actions for education and training of personnel and improvement of health services."

In compliance with that decision, the Task Force on Health was held in April 1963; from its decisions emerged the policy of PAHO and WHO in the Americas, which was still in force. The Director asked whether it might not be advisable to hold another meeting of the Task Force to discuss the decisions of the American Chiefs of State in terms of concrete programs for a specified period and, at the same time, to determine the specific role that an international agency such as the Bureau should play in the process of organizing and developing the Latin American Common Market.

If the Executive Committee felt that the idea was worth considering, it would be necessary to carefully study the organization of such a meeting, the necessary documentation, the funds needed, and the most appropriate date.

The CHAIRMAN was of the view that the proposal suggested by the Director could be included in the operative part of the Committee's resolution by requesting the Director to study and propose to -the Directing Council the measures he deemed necessary to implement the mandate given at the Meeting of American Chiefs of State. By that time the Director could develop more specific plans for a possible Meeting of Ministers of Health or of a Task Eorce.

It was so agreed. Page 211 56th Meeting Eleventh session

ITEM 5: REPORT ON THE COLLECTION OF QUOTA CONTRIBUTIONS (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item, submitted by the Representative of Guatemala:

THE EXECUTIVE COMMITTEE,

Taking into account the report of the Director on the collection of quota contributions (Document CE56/17);

Having noted the information and comments on quotas contained in the Financial Report of the Director and the Report of the External Auditor (Official Document 75);

Considering that the collection of quotas, although it has improved, is still a problem in that arrears are still unpaid; and

Considering the importance of prompt and full payment of quota contributions to assure financial support for the entire approved program,

RESOLVES:

1. To take note of the report on the collection of quota contributions (Document CE56/17).

2. To commend the Director on his efforts to solve the problem of outstanding arrearages.

3. To commend the Governments for the efforts they made in 1966 to pay quotas in arrears and to increase the percentage of the current quotas paid.

4. To express its concern, nevertheless, especially over the arrearages of more than two years' standing.

5. To request the Director to continue to submit full reports to the Governments on the status of the collection of quotas and the consequences that failure to pay them has on the execution of the program of the Organization.

6. To recommend that the Governments which have outstanding quotas pay them as soon as possible, and that those whose quotas are two or more years in arrears put into operation their financial plans for the payment of those arrears within a definite period.

Decision: The draft resolution was unanimously approved. 2/

7/ Resolution XI. Official Document PAHO 79, 36-37. Page 212 Eleventh session 56th Meeting

Dr. Calvo (Panama) then took the Chair.

ITEM 7: PROVISIONAL AGENDA FOR THE XVII MEETING OF THE DIRECTING COUNCIL, XIX MEETING OF THE REGIONAL COMMITTEE OF WHO FOR THE AMERICAS (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item:

THE EXECUTIVE COMMITTEE,

Having examined the provisional agenda (Document CD17/l),prepared by the Director of the Pan American Sanitary Bureau for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of the World Health Organization for the Americas; and

Considering that Article 12-C of the Constitution pro- vides that "the provisional agenda. of the Council shall be prepared by the Director of the Bureau and submitted to the xcec- utive Committee for approval," and that pursuant to the rules of procedure in force the Governments may propose such items as in their opinion should be considered by the Council,

RESOLVES:

1. To approve the provisional agenda prepared by the Director (Document CD17/1) for the XVII Meeting of the Direct- ing Council, XIX Meeting of the Regional Committee of WHO for the Americas.

2. To authorize the Director to include in the provisional agenda such additional items derived from this meeting and those that may be proposed in. due time by the Governments and by those organizations entitled to propose agenda items.

Decision: The draft resolution was unanimously approved. 8/

ITEM 10: REPORT ON BUILDINGS AND INSTALLATIONS (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on Item 10 submitted by the Representatives of the United States of America and Panama:

THE EXECUTIVE COMMITTEE,

Having considered the report of the Director on buildings and installations (Document CE56/12);

_/ Resolution XII. Official Document PAHO 79, 37-38. Page 213 56th Meeting Eleventh session

Noting the developments in the utilization of the headquarters building and in housing PAHO/WHO staff at the Zone Offices; and

Noting the need for prudent advance planning of future buildings and installations,

RESOLVES:

1. To take note of the report of the Director on buildings and installations (Document CE56/12).

2. To express its appreciation to the members of the Permanent Subcommittee on Buildings and Installations for their continued assistance in safeguarding the interests of the Organization in these matters.

3. To instruct the Director to continue his efforts to obtain, on favorable terms, financial support to make it possible to acquire adequate installations for the Zone Offices.

4. To request the Director of the Bureau to report to the XVII Meeting of the Directing Council on short- and long- range plans for buildings and installations.

5. To thank the Government of Jamaica for the works of art it has donated to the headquarters building.

6. To request the Governments to continue to contribute works of art to the headquarters building.

Decision: The draft resolution was unanimously approved. 9/

ITEM 11: STATUS OF AEDES AEGYPTI ERADICATION IN THE AMERICAS (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item, submitted by the Representative of Guatemala:

THE EXECUTIVE COMMITTEE,

Having examined the report of the Director of the Bureau on the Aedes aegypti eradication program in the Americas (Docu- ment CE56/8);

Having also considered the reports of the Conference and the Study Group on the Eradication of Aedes aegypti in the Americas which were held under the auspices of the Pan American

9/ Resolution XIII. Official Document PAHO 79, 38-39. Page 214 Eleventh session 56th Meeting

Sanitary Bureau in Washington, D. C., from 3 to 5 and from 6 to 12 April 1967, respectively;

Considering that the vast areas still infested by A. aegypti in the Hemisphere constitute dangerous sources of reinfestation for the countries which have already eradicated the mosquito;

Recognizing that the frequent reinfestations which have been occurring in various areas jeopardize the success of the continental campaign;

Convinced that the success of that campaign can be ensured only of the above-mentioned sources of reinfestation are speedily eliminated;

Considering that administrat:ive and financial difficulties are at present the sole obstacles impeding the satisfactory conduct of the campaign in almost all the countries still infested by the vector; and

Bearing in mind that the XVII Pan American Sanitary Conference, in Resolution XIX, authorized the Director of the Pan American Sanitary Bureau to obtain funds to finance the prompt eradication of A. aegypti from the Americas,

RESOLVES:

1. To take note of the report of the Director of the Bureau and of the reports of the Conference and the Study Group on the Eradication of Aedes aegypti in the Americas.

2. To reaffirm the recommendation of the XVII Pan American Sanitary Conference that the Governments of the countries still infested by the vector take the necessary measures to overcome any administrative difficulties that may be hampering the progress of their campaigns, and that they give the highest priority to the provision of the funds, personnel, and supplies needed to complete those campaigns as soon as possible.

3. To congratulate the Director on the success of the Conference and the meeting of the Study Group on the eradication of the vector and to recommend that he continue his efforts to ensure that the eradication of the mosquito is carried out simultaneously and in a coordinated manner in all countries in which the problem sti]l exists.

4. To recommend to the Governments that they bring their influence to bear in international credit agencies to ensure the inclusion in their credit policy of the provision of loans for A. aegypti eradication campaigns. Page 215 56th Meeting Eleventh session

5. To recommend that the countries give one another reciprocal assistance either directly or through the Pan American Sanitary Bureau, such as the provision of loans or bilateral grants as well as supplies and equipment for A. aegypti eradication campaigns.

6. To request the Director to provide the countries with such assistance as they may need in order to put into effect the recommendations contained in paragraphs 4 and 5 of this resolution.

7. To recommend to the Director that he include in the budget of PAHO such supplementary allotments as are considered necessary for strengthening the assistance that the Pan American Sanitary Bureau has been giving to the Governments for the eradication of A. aegypti.

8. To recommend to the Director that he explore the possibility of establishing within the budget of PAHO a special A. aegypti eradication campaign account.

Decision: The draft resolution was unanimously approved. 10/

ITEM 17: FELLOWSHIP PROGRAM (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the fellowship program, submitted by the Representative of Colombia:

THE EXECUTIVE COMMITTEE,

Having examined the report of the Director of the Pan American Sanitary Bureau on the fellowship program (Docu- ment CE56/13) and the comments of the members of the Exec- utive Committee thereon,

RESOLVES:

To take note of the above-mentioned report with satisfaction and interest and to recommend to the XVII Meeting of the Directing Council that it consider and approve the following draft resolution:

"THE DIRECTING COUNCIL,

Bearing in mind the importance of the fellowship program for the education and training of the professional and

10/ Resolution XIV. Official Document PAHO 79, 39-40. Page 216 Eleventh session 56th Meeting

the auxiliary staff of national health services and for the faculty of schools of medicine and of related sciences;

Bearing in mind that full cooperation by the Govern- ments at all stages is essential to the success of the fellowship program;

Being of the opinion that it is highly advisable to maintain the existing coordination between the PAHO fellowship program, that of the World Health Organization, and those of other United Nations specialized agencies and the procedures common thereto, since a considerable number of fellowships are financed by funds from the World Health Organization and the United Nations Development Program; and

Bearing in mind the scope acquired by the fellowship program in recent years, which makes it necessary to intensify efforts to evaluate the results obtained,

RESOLVES:

1. To approve the report of the Director on the fellowship program.

2. To recommend that the Governments continue their efforts to improve their procedures for the selection of fellowship applicants, including, inter alia, the establishment of special selection committees.

3. To emphasize to the Governments the importance of making full use of the services of the Organization's fellows upon completion of their studies in their specialized field and in close relationship with national health plans.

4. To draw the attention of Governments to Resolution XIX of the IX Meeting of the Directing Council, which recommends that they continue to pay the salary and safeguard the seniority and other rights of officials pursuing fellowship studies abroad, since failure to do so is harmful to the selection of the best applicants, to the pursuit of their studies, and to the efficient conduct of the fellowship program.

5. To recommend that the Director continue to coordinate the fellowship program with those of the specialized agencies of the United Nations, the Inter-American System, and other agencies, in view of the satisfactory results obtained so far.

6. To instruct the Director to continue his efforts, in the way he considers most effective and in cooperation with the Governments, to make a complete evaluation of the fellowship program and to report his findings at a later date." Page 217 56th Meeting Eleventh session

Dr. SANTA MARIA (Observer, Chile), referring to paragraph 5 in the operative part of the resolution which dealt with coordination with the specialized agencies of the United Nations, asked whether it might not be well to include a reference to other agencies that awarded fellowships, such as the OAS, so as not to confine the coordination to the agencies of the United Nations alone.

Dr. HORWITZ (Director, PASB) explained that the fellowships of the OAS and those of the other international agencies were somewhat different as far as the Bureau was concerned. In his view, the central word in the paragraph referred to was "coordinate" because, while the Bureau and the specialized agencies of the United Nations followed the same procedures in giving effect to an approved fellowship, the procedures of the OAS were not exactly the same, and in that sense it was to be understood that coordination, in the fellowship program, did not refer exclusively to uniformity of procedures, including stipends.

Decision: The draft resolution was unanimously approved. LL/

ITEM 15: STATUS OF SMALLPOX ERADICATION IN THE AMERICAS (conclusion)

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on smallpox eradication, prepared by the working party composed of the Represent- atives of Ecuador, the United States of America, and Venezuela:

THE EXECUTIVE COMMITTEE,

Having examined the report of the Director of the Bureau on the status of smallpox eradication in the Americas (Docu- ment CE56/14);

Bearing in mind the importance of the smallpox problem in the Americas and the repeatedly expressed wish of the Govern- ments that this disease be eradicated;

Bearing in mind that the smallpox eradication program in the Americas is a pressing need that demands the attention of all the countries in the Americas;

Considering that the World Health Organization has assigned for 1967 the amount of $670,000 for the smallpox eradication program in the Americas; and that for 1968 the Director-General of WHO has requested $695,000 for the Region of the Americas for the same purpose; and

Considering that the XVII Pan American Sanitary Conference approved the continental plan for smallpox eradication proposed by the Director of the Pan American Sanitary Bureau, j4./ Resolution XV. Official Document PAHO 79, 40-41. Page 218 Eleventh session 56th Meeting

RESOLVES:

1. To recommend to the countries where smallpox still exists that they prepare national plans for the eradication of the disease.

2. To urge the Governments of the countries whose eradication programs are progressing slowly to adopt prompt measures to eliminate any administrative difficulties that may be hampering their campaigns, and to give the highest possible priority to the provision of funcs, personnel, and supplies needed to complete those campaigns as soon as possible.

3. To recommend to the Governments that special care be taken in the preparation of smallpox vaccines so as to ensure that it meets the standards for purity and potency established by WHO, and to urge them to make use of the reference laboratory services which PASB has established.

4. To recommend to the countries in which the disease has been eliminated that, until such time as smallpox no longer constitutes a continental problem they try to establish maintenance programs and epidemiological vigilance services.

5. To recommend to the Director that he take the necessary measures to intensify and accelerate the continental smallpox eradication plan approved by the XVII Pan American Sanitary Conference; that the co-untries be given the technical advisory services and material assistance they need, subject to the availability of budgetary funds; and that such assistance be provided to the Governments in accordance with the progress of their programs and the needs of each of the program stages, and the plans of operation established with the collaboration of PASB.

6. To urge the Governments of the countries that are free of smallpox but where the imrnunity level of the population is low, to initiate programs designed to rapidly raise the immunity level of the population.

Decision: The draft resolution was unanimously approved. 12/

Dr. BLOOD (United States of America) said that he had to depart for Geneva, but that he wished to thank the Chairman, the Director, and the staff of the Bureau, for the response that members of the Executive Committee had received in studying the proposed program and budget. To him it had been a most useful procedure, one that would enable all present, certainly his own Delegation, to defend

,/ Resolution XVI. Official Document PAHO 79, 42-43. Page 219 56th Meeting Eleventh session the budget and support it before their own Governments. The record of the explanation and background information provided during the discussion would be of inestimable value to all in securing the support that the program deserved. He was sure it would serve a useful purpose when members reported to the next Directing Council.

The CHAIRMAN excused himself for his absence during the discussion of the item on the Declaration of the Presidents of the American States at the Meeting of Punta del Este. That item had been introduced by the Government of his country, and he promised to discuss it at length when the relative draft resolution came up for approval. He had had to withdraw from the proceedings in response to a call from his Government in order to report on the problem of foot-and-mouth disease and, in that connection, he wished to announce that he had been authorized to advise the Executive Committee and the Director of the Bureau that his Government was prepared to pay its quota contribution immediately to the Pan American Foot-and-Mouth Disease Center.

The session rose at 6:20 p.m. 1 TWELFTH PLENARY SESSION Wednesday, 8 May 1967, at 8:40 a.m. Chairmnan: DR. ALBERTO E. CALVO (Panama)

ITEM 4: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION FOR 1968 (conclusion)

The CHAIRMAN called the session to order and asked Dr. Sutter to read the proposed resolution on the item.

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution:

THE EXECUTIVE COMMITTEE,

Having studied in detail the provisional draft of the Proposed Program and Budget of the Pan American Health Organ- ization for 1968 (Official Document 67) and the modifications thereto appearing in Document CE56/5 prepared by the Director;

Considering that the XVII Pan American Sanitary Confer- ence, in Resolution IX, noted that the afore-mentioned provisional draft comprised soundly conceived and much-needed public health projects;

Considering that the program modifications appearing in Document CE56/5 were made after consultation with each Govern- ment and reflect the latest known desires and requirements of Governments, with due regard to priorities of needs; and

Bearing in mind Article 14-C of the Constitution of the PAHO and Financial Regulations 3.5 and 3.6,

RESOLVES:

To commend to the XVII Meeting of the Directing Council for its favorable consideration the Proposed Program and Budg- et of the Pan American Health Organization for 1968 (Official Document 67) and the modifications thereto appearing in Document CE56/5 prepared by the Director, at the level of $10,190,000.

The CHAIRMAN asked if there were any comments on the draft resolution.

- 221 - Page 222 Twelfth session 56th Meeting

Mr. CALDER1WOOD (United States of America) said that he did not object to the proposed addition of the word "favorable," but that it should be clear that in approving the resolution on the proposed budget, he was merely agreeing to refer the budget to the Directing Council for review and adoption, according to the Constitution..

Decision: The draft resolution was approved.l_/

DRAFT RESOLUTION ON THE PAN AMERICAN FOOT-AND-MOUTH DISEASE CENTER

Dr. SUTTER (Asistant Director, PASB) read the following draft :resolution on the Pan American Foot-and-Mouth Disease Center:

THE EXECUTIVE COMMITTEE,

Being aware of the significance of foot-and-mouth disease with respect to both nutrition and economic development of the Americas and recognizing the valuable services of the Pan American Foot-and-Mouth Disease Center, under the direction of the Pan American Health Organization and supported by the Program of Tech- nical Cooperation of the Organization of American States;

Having noted that declaration of the Inter-American Commit- tee on the Alliance for Progress (CIAP), at its meeting in March 1967, which recommends that the countries contribute to the stable and permanent financing of the Center;

Having further noted the resolution of the Inter-American Economic and Social Council (IA-ECOSOC) with respect to future program and financing and the act:ion taken pursuant to the instruction that PAHO and the OAS submit a joint report to the Ninth Meeting of CIAP with respect to the status of the foot-and-mouth disease problems in the Americas, the functions and activities of the Pan American Foot-and-Mouth Disease Center, and its requirements in order to accomplish its task;

Having noted that in fulfillment of the IA-ECOSOC resolution the Secretary General of the OAS and the Director of PASB appointed as Special Representative of these Organizations His Excellency the Vice-President of Peru, Mr. Edgardo Seoane, to visit the countries of the Hemisphere accompanied by the Director of the Center, Dr. Carlos Palacios, to discuss with the Governments the foot-and- mouth disease problem and to recomnmend a program of action;

Having been informed of actions already taken by both the Inter-American Development Bank and the International Bank for Reconstruction and Development to support pre-investment studies l/ Resolution XVII. Official Document PAHO 79, 43. Page 223 56th Meeting Twelfth session

which are expected to lead to national and multinational programs, with external financial resources and requiring continuing technical services from the Center;

Having learned of the additional support of the Govern- ment of the United States of America to finance promising research on new control techniques;

Recognizing the need for and favorable possibilities of expansion of national and regional programs to cope with this problem and the necessary technical and coordinating role of the Center, in association with national programs of the international agencies, such as the Inter-American Development Bank, which may be expected to provide financial support; and

Taking note of Resolution XX of the XIII Pan American Sanitary Conference regarding the operations of the Pan Amer- ican Foot-and-Mouth Disease Center,

RESOLVES:

1. To reaffirm the importance of continuing the international and national efforts to control foot-and-mouth disease in the Americas.

2. To reiterate the great value of maintaining the activities of the Pan American Foot-and-Mouth Disease Center at a sufficient level and with stable long-term financing, to enable it to provide Governments with scientific cooperation and technical advice in planning and executing international and national foot-and-mouth disease programs.

3. To support the Director in his efforts to obtain funds from all possible sources for the purpose of providing adequate financial support that will enable the Pan American Foot-and-Mouth Disease Center to cooperate with Governments in their national programs.

4i To request the Inter-American Economic and Social Council to make provision for financing the activities of the Pan American Foot-and-Mouth Disease Center at an effective level during the period through 30 June 1969, in order to permit operation of the current program of the Center.

5. To note with satisfaction and to endorse the recommendations concerning the program and financing arrangements contained in the report of the mission of His Excellency the Vice-President of Peru and the Director of the Pan American Foot-and-Mouth Disease Center.

6. To request the Director to submit the report mentioned in paragraph 5 above to the XVII Meeting of the Page 224 Twelfth session 56th Meeting

Directing Council, with the recommendation of the Executive Com- mittee that it consider the report and that, pending a decision with respect to the recommendations therein, it provide for the continuation of the operations of the Center, under the administration of PAHO, at an effective level.

7. To authorize the Director to maintain the present level of operations of the Center by continuing to advance funds from the Working Capital Fund against reimbursement through contributions from Governments for this purpose and/or additional support from the IA-ECOSOC, subject to the decision of the XVII Meeting of the Directing Council on the operation of the Center.

8. To instruct the Director to report to the XVII Meeting of the Directing Council on the progress of the program of the Pan American Foot-and-Mouth Disease Center and of the efforts to arrange both long-term and short-term financing of the Center.

Mr. CALDERWOOD (United States of America) announced he had received word that the Government of his country was prepared to match the contributions which he understood some countries were willing to make to the aftosa program under the IA-ECOSOC resolution, on the usual two-to-one basis.

The CHAIRMAN, speaking on behalf of the Executive Committee, expressed its profound thanks to the Government of the United States of America for a further demonstration of cooperation in health activities in the Americas.

Mr. CALDERWOOD (United States of America) said he appreciated the comments on the announcement he had made. He understood that, on the basis of what the other countries were apparently prepared to contribute, the share of the United States of America would be approximately $140,000.

Dr. ORELLANA (Venezuela) proposed that paragraph 6 of the operative part of the resolution be amended to read as follows:

"To request the Director to submit the report mentioned in paragraph 5 above and the joint report to the Ninth Meeting of CIAP (CIAP/48) to the XVII Meeting of the Directing Council, with the recommendation that it consider the proposals therein and that it provide for the continuation of operations of the Center, under the administration of PAHO, at an effective level."

Mr. CALDERWOOD (United States of America) said that he understood that the amendment was intended to be a clarification of the language. The point of paragraph 6, as it appeared in the unamended form, was that the report was to be referred to the Directing Council with no recommendation, asking that the Council consider it and, if it did not come to a decision on the recommendations in the report that it provide for the continuation of the Center under the administration of PAHO provisionally at an effective level of activity or, at least, at the Page 225 56th Meeting Twelfth session current level. He assumed that IA-ECOSOC would continue to contribute some funds to the maintenance of the Center. That was its responsibility under its own earlier action, a responsibility not to be relinquished until the end of 1968 at the very earliest; so there should be some funds from that source to continue the operations of the Center in 1968. They were not enough to keep the Center going at an effective level, or at least at the current level; presumably the Directing Council would augment them. It was for that reason that the Committee was faced with the immediate financial problem.

He had received the translation of the Seoane-Palacios report a day or two before the Meeting. There had not been an opportunity to consider all of its implications, among them the recommendations for example, that the Center be placed permanently under the Bureau, and that the funds be increased beginning in 1968, a commitment that would add to the budget for 1968 the sum of about $1,200,000. The Delegation of his country could not approve of such an action at that juncture, but by the XVII Meeting of the Council the Governments would have had an opportunity to study the question. In short, the report should be referred to the Directing Council without a recommendation. He could accept Dr. Orellana's amendment on the understanding that its only purpose was clarification of language.

The CHAIRMAN considered that the observations of the Representative of the United States of America were already covered by the amendment proposed by Dr. Orellana. He himself proposed the addition of a paragraph drafted along the following lines:

"To express its thanks to the Organization of American States for the financial support it has been giving to the Pan American Foot-and-Mouth Disease Center, through the Program of Technical Cooperation."

Mr. CALDERWOOD (United States of America) said that he assumed that it was the hope of the Committee that the OAS would continue to provide such assistance.

Mr. SALZMAN (Observer, OAS) thanked the Committee for the recognition accorded the participation of the OAS in the program.

The CHAIRMAN asked Mr. Calderwood whether his observation was to be interpreted as an amendment.

Mr. CALDERWOOD (United States of America) said he was not proposing an amendment but felt that the statements should be consistent with the action of the OAS, since the date it had chosen for the termination of its responsibility was, at the earliest, the end of 1968 and, under certain interpretations, 30 June 1969. The resolution referred to the latter, so the hope of the Committee in that respect could be regarded as already expressed.

The CHAIRMAN put the draft resolution to the vote with the amendment proposed by the Representative of Venezuela and the addition suggested by himself. Page 226 Twelfth session 56th Meeting

Decision: The draft resolution was unanimously approved with the amendments proposed. 2/

ITEM 14: SUPPLY OF TEXTBOOKS FOR MEDICAI STUDENTS (conclusion)

Dr. ORELLANA (Venezuela) stated that the working party composed of the Representatives of Colombia, the United SRtates of America, and Venezuela, which had been entrusted with the preparation of a new draft resolution on the item, had been unable to reach agreement; consequently he believed that the Committee should examine the draft resolution as submitted originally.

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution on the item:

THE EXECUTIVE COMMITTEE,

Having examined the report of the Director on the program for the supply of textbooks for medical students (Document CE56/ll);

Bearing in mind that Resolution XV of the XVII Pan American Sanitary Conference acknowledged the urgent need for the program, whose purpose is to improve the quality of medical education and provide medical schools in Latin America with modern textbooks on terms suited to the financial possibilities of their students;

Considering that negotiations to obtain financial support for the program from international credit agencies are still pending;

Bearing in mind that any delay is contrary to the interest in and urgent need for this program repeatedly expressed by the Governments, by the universities and medical schools, and the Pan American Federation of Associations of Medical Schools; and

Mindful of Resolution XVII of the 54th Meeting of the Exec- utive Committee and Resolution XV of the XYII Pan American Sanitary Conference,

RESOLVES:

1. To reaffirm the importance, the interest, and the urgent need of the project for the medical education program, and to approve the steps taken so far.

2. To instruct the Director to continue negotiations with the Inter-American Development Bank (IDB) and other possible sources of financing for the program.

2/ Resolution XVIII. Official Document PAHO 79, 44-46. Page 227 56th Meeting Twelfth session

3. To take note of the tact that the IDB would be prepared to reimburse the funds invested in this program from 1 January 1967 as part of the loan, should the loan be approved by the Bank's Board of Directors.

4. To recommend to the Director that he gradually implement the program using existing funds, particularly those available in the Special Fund for Health Promotion.

5. To transmit the above-mentioned report (Document CE56/11) and this resolution to the XVII Meeting of the Directing Council and to instruct the Director to supplement the information contained in it with a further report on such activities as may be undertaken up to the date of the meeting.

Mr. CALDERWOOD (United States of America) recalled that he had earlier questioned the authcrity of the Executive Committee, under the current circumstances, to implement the project. The authority given by the XVII Pan American Sanitary Conference had been to approve, if the terms were satisfactory, a loan agreement negotiated by the Director with the IDB or some other agency. In the absence of such an agreement, the Committee would, he believed, be going beyond its authority in proceeding with a different method of financing.

With that in mind, and with a view to expediting matters, he would propose that paragraph 3, which he believed somewhat unnecessary, should be replaced and a new paragraph 4 added. Paragraph 3 would then read:

"To request the Director to continue to confer with publishers and others concerned with making textbooks available, especially textbooks in the scientific field, in the countries of the Americas, with a view to obtaining their cooperation in the effort to provide medical students with textbooks at a low cost."

Dr. Orellana and others had asked whether cooperation for that purpose was possible with other agencies and through other programs such as that of the Agency for International Development (AID). Paragraph 4 would read:

"To request the Director to continue his efforts to develop suitable draft agreements in order that the project may be promptly implemented when funds become available for this purpose."

Dr. SANTA MARIA (Observer, Chile) asked whether the amendment proposed by the Representative cf the United States of America meant that the reference to negotiations with the IDB would be eliminated.

The session was suspended at 10:10 a.m. and resumed at 10:40 a.m. Page 228 Twelfth session 56th Meeting

The CHAIRMAN submitted to the Committee the amendments to the draft resolution proposed by Mr. Calderwood.

Dr. AGUILAR HERRERA (Guatemala) proposed that the first amendment be included as an additional paragraph and that the original paragraph 3, as well as the original paragraph 4, be allowed to stand, since in his opinion the program should be continued. He therefore suggested the addition after the phrase "using existing funds" of the words "from the regular budget.- In his view the Executive Committee would not be overstepping its functions by authorizing the Director to use funds from that budget to ensure continuation of the program, pending a favorable decision from the IDB..

The CHAIRMAN proposed that the words "publishers and others concerned with making textbooks available" be replaced by the words "those in the field of textbook production and distribution" in order to eliminate any commercial implica- tion from the resolution. If it was necessary to be specific he suggested that the words "especially in the scientific f-Leld" be added after "distribution."

Dr. ACOSTA-BORRERO (Colombia) gave his full support to the proposals presented by the Representative of Guatemala and the Chairman.

Mr. CALDERWOOD (United States of Armerica) said that, as he understood it, what was proposed would omit the reference to publishers and others and require other changes in the original text. The paragraph, as revised, would then read:

"To request the Director to cortinue to confer with those in the field of textbook production and distribution, especially textbooks in the scientific field, in the countries of the Americas, with a view to obtaining cooperation in the effort to provide medical students with textbooks at low cost."

Dr. SANTA MARIA (Observer, Chile) considered that the proposal of the Rep- resentative of the United States of America was not necessary, since it was not the intention of the Organization to become a publishing house and it would not commit itself in any way by encouraging private industry to publish inexpensive books.

Dr. HORWlTZ (Director, PASB), replying to Dr. Santa María, said that there had never been any thought of the Organization becoming a publishing house and that the program would undoubtedly be a stimulus to publishing houses in the Hemisphere and possibly in other parts of the world, since it would open up a hitherto closed market. The Organization would deal with publishing houses when, for example, the book selected had already been published by one of them and, if it had not, as might happen in some cases, public bids would be called for in order to permit the selection of the publishing house offering the best terms. The bid would also cover the cost of distributing the textbooks in the same way as was done for some of the publications of the Organization; in other words, it would be done directly by the publishing house. Page 229 56th Meeting Twelfth session

Dr. Horwitz repeated that the Bureau had no interest in becoming a publishing house; on the other hand it was very interested in stimulating the production of textbocks at a price within the reach of the average student in Latin America, especially since sociological studies of certain medical schools had shown that the proportion of children of working class families who were going to the university was growing as was that of children from middle class families. That fact was closely related to the program being discussed, since it involved the capacity of the average student to purchase modern scientific books.

Dr. PEREZ RUEDA (Ecuador) said that his country was fully in agreement with the suggestions of the Representative of Guatemala concerning the amendment proposed by the Representative of the United States of America to the draft resolution on the item under discussion, provided certain minor editorial changes were made.

Dr. ORELLANA (Venezuela) said that in his opinion the original wording of paragraph 4 of the draft resolution was the most appropriate, since, if the sources of funds were specified, there was a danger of limiting the prospects for financing the program. He also asked whether the Representative of Guatemala would be prepared to withdraw his amendment.

Dr. AGUILAR HERRERA (Guatemala) accepted the suggestion of the Representa- tive of Venezuela to maintain the original wording of paragraph 4 and to withdraw his own amendment.

The CHAIRMAN put to the Committee the amendment proposed by the Represent- ative of the United States of America, with the amendment he himself had proposed. He explained that paragraph 4 of the original draft would be maintained and said that if there were no objections the amendment would be considered approved.

Approved.

The CHAIRMAN put to the vote the draft resolution as a whole, together with the amendment approved.

Decision: The draft resolution was approved.3/

Mr. CALDERWOOD (United States of America) registered dissent from the inclusion of the paragraph authorizing the Director to use funds from the Special Fund for Health Promotion for the financing of the proposed program. His reason, as stated earlier, was that the Committee was not authorized to do so under the terms of reference given to it by the Conference.

ITEM 21: INTENSIFICATION OF HEALTH PROGRAMS--DECISIONS TAKEN AT THE MEETING OF AMERICAN CHIEFS OF STATE (conclusion)

The CHAIRMAN emphasized the importance of the fact that the topic of health had been dealt with at the Meeting at Punta del Este and said that the draft resolution prepared was important in that it transmitted to the Directing Council the

3/1 Resolution XIX. Official Document PAHO 79, 46-47. Page 230 Twelfth session 56th Meeting views and remarks of the Committee so that that Governing Body could take them duly into consideration and decisions taken at the ministerial level. In that way the value of the health sector being made part of the great endeavor which had been undertaken in the Hemisphere, nsmely the economic and social development of the countries of the Americas, would be impressed upon lending agencies and the Governments. He then asked Dr. Sutter to read the draft resolution on the item:

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution:

THE EXECUTIVE COMMITTEE,

Bearing in mind that the XVII Pan American Sanitary Confer- ence instructed the Director to take steps to ensure that certa.in health problems which, because of their characteristics and scope, call for solutions at the highest level, be placed on the agenda of the meeting of the American Chiefs of State;

Considering that the Director took the appropriate steps as instructed, communicated with the Secretary General of the Organ- ization of American States, the Preparatory Commission of the Meeting of the Chiefs of State and the Group of Special Advisers appointed by it, the Eleventh Meeting of Consultation of Ministers of Foreign Affairs (Second and Third Sessions), and the Special Committee of Personal Representatives of the Chiefs of State, and that he attended the Meeting of the American Chiefs of State at Punta del Este;

Bearing in mind the report of the Director of the Pan Amer- ican Sanitary Bureau on the Meeting of the American Chiefs of State (Document CE56/19) and the comments made on the matter by the members of the Executive Committee during the present meeting;

Mindful that the Chiefs of State at the Punta del Este Meet- ing took decisions on the improvement of health conditions in the Hemisphere and its fundamental rol.e in the economic and social development of Latin America; and

Bearing in mind that the decisions on health matters contained in the "Declaration of the Presidents of America" endorse the policy of the Pan American Health Organization, a fact which light- ens the responsibility assigned to the Organization of cooperating with the Governments in the preparation of specific programs,

RESOLVES:

1. To take note of the report of the Director of the Bureau (Document CE56/19) and to commend him for carrying out the task entrusted to him in Resolution XXX of the XVII Pan American Sanitary Conference. Page 231 56th Meeting Twelfth session

2. To emphasize the importance of the decisions taken at Punta del Este for the health of the peoples and the development of the countries of the Americas.

3. To recommend that the Director, subject to the availability of funds, take such technical, administrative, and financial steps as may be necessary to carry out the instructions of the American Chiefs of State to the Pan American Health Organization, namely to cooperate with the Governments in the preparation of specific programs relating to the health objectives approved at Punta del Este.

4. To recommend to the Director that he consider the advisability of convening a meeting of health authorities at the highest level to draw up an action program for implementing the decisions of the American Chiefs of State.

5. To transmit this resolution and the report of the Director (Document CE56/19) to the XVII Meeting of the Direct- ing Council.

Mr. CALDERWOOD (United States of America) said it would seem that if the Director were to convene a meeting of the ministers of health to work out an action program, he would do so after considering what he was asked to consider under paragraph 3 and presumably after the discussions of the Directing Council in the fall. He asked whether he was correct in that assumption.

Dr. HORWITZ (Director, PASB) said that Mr. Calderwood was right in that it was first necessary to await the decision of the Directing Council. It should be borne in mind that not all the Governments of PAHO had attended the Punta del Este Meeting so that the Directing Council should first of all endorse, as the policy of PAHO, the decisions adopted there by the American Chiefs of State.

There was no doubt that the Council would do so, because, as was said in the draft resolution, the decisions on health matters taken at that meeting endorsed the policy of the Organization. Consequently, the Council should give instructions to the Secretariat on how to implement the third decision of the Chiefs of State, i.e., to urge the Pan American Health Organization to assist the Governments in preparing specific projects. One possibility might be for the Directing Council to decide to convene a meeting of the Task Force on Health to discuss the matter, as was done in April 1963. The Secretariat intended to submit to the meeting of the Council the necessary background information to enable it to take a decision with a full knowledge of the facts.

Decision: The draft resolution was unanimously approved.4/

4/ Resolution XX. Official Document PAHO 79, 47-48. Page 232 Twelfth session 56th Meeting

ITEM 22: OTHER MATTERS

Meetings of the Executive Committee

Dr. AGUILAR HERRERA (Guatemala) proposed that the Committee examine the advisability of holding two meetings, i.e., one a technical meeting at which the fullest possible information about the programs would be presented and one that would be concerned with financial matters and devoted to an examination of the proposed program and budget estimates. In his opinion, a further meeting should be held in 1967 to examine the WHO budget.

Mr. CALDERWOOD (United States of America), in supporting the suggestion of the Representative of Guatemala, said that under Article 17-A of the Constitution, the Director was authorized to convene a special meeting of the Executive Commit- tee on his own initiative, or at the request of three members thereof. An appropriate time for such a meeting would be just before the Directing Council met in the fall. The Director might be requested to give expression to the wish of the Committee that a special meeting be held at that time.

Dr. ORELLANA (Venezuela) said that in his opinion the meeting of the Execu- tive Committee at a date nearer the meeting of the Directing Council was justified, since, in the interval between the preparation of the budget document and its examination by the Council, a series of changes would necessarily be introduced into it. Therefore he agreed that the meeting which was to be held in April should be transferred to June or July; if that were done, the budget approved by WHO could be examined. Nevertheless, he suggested that in 1967 a meeting of the Committee be held immediately prior to the XVII Meeting of the Directing Council.

Dr. ACOSTA-BORRERO (Colombia) said that it was not necessary to hold two meetings, since in fact they both had the same purpose. On the other hand, he agreed that another meeting should be held in 1967 prior to that of the Directing Council and that it be stipulated that in the future the Executive Committee would meet at a date subsequent to the World Health Assembly.

The CHAIRMAN said he shared the view of Dr. Aguilar Herrera. In effect, the amount of information received was often so overwhelming, especially for new members of the Committee, that the matter might be resolved by holding two meetings.

Dr. AGUILAR HERRERA (Guatemala) added that it was one of the functions of the Executive Committee to facilitate the work of the Directing Council, or the Conference, and that the holding of two meetings would make it possible to have more time and provide those two Governing Bodies with better information since the documentation could be studied more leisurely.

Dr. ORELLANA (Venezuela) suggested that the Director or the Chief of Ad- ministration explain how a change could be introduced into the schedule of Execu- tive Committee meetings.

Mr. CALDERWOOD (United States of America) said that he had apparently misunderstood the proposal. He would agree with what had been said about the change Page 233 56th Meeting Twelfth session to June or July for the main meeting of the Executive Committee. He would also agree with the suggestion that a short meeting should be held before the Direc- ting Council meeting in Port of Spain, preferably immediately before. A two or three day meeting would enable the Executive Committee to look at the WHO budget for 1968, which it had not so far had occasion to do as well as at other matters. Whether it should be a meeting of a working party or of a full committee, where there was to be the full-fledged and very profitable discussion of the kind they had just had, did not need to be spelled out. If the main Execu- tive Committee meeting were held in June or July, there would probably be more time to review the proposed budget. After some experience with the short meeting before the meeting of the Directing Council, it could be determined more readily whether two meetings each year would suffice.

Dr. HORWITZ (Director, PASB) drew attention to Article 17 of the Constitu- tion which stated that the expenses of the representatives of the Ebecutive Com- mittee attending meetings concurrent with, immediately preceding, or immediately following those of the Council, or the Conference, would be borne by Member Governments. Therefore, the expenses of the meeting in Trinidad would be borne by the Governments. According to the Constitution the expenses of Representa- tives to other meetings of the Executive Committee or, in the event that a rep- esentative was unable to attend, of an alternate, would be paid by the Bureau. He pointed out that the cost of the current meeting was $30,000 ($19,000 had been budgeted plus $5,000 to $10,000 for special expenses), but if a performance budget was drawn up and the time of each official who attended the meeting was covered, the amount involved would be much more. In his opinion, it would be very advisable to change the date of the April meeting to June or July since the WHO budget would be already approved by that time and the amount allocated to the Region of the Americas would be known. The Bureau would do its best to prepare the definitive document, i.e., the one to be submitted to the Directing Council or the Conference.

Even before the current meeting at which so careful an examination had been made of the proposed program and budget estimates, it had been intended to suggest to the Committee some arrangement which would make it possible for it to make a study in depth of the program and budget estimates. For example, the Bureau would be very pleased if the Committee would choose one or two problems and instruct the Secretariat to prepare an account of the past, present, and future of the problems concerned, which would be included in the agenda as special items. The Committee could request more detailed information beforehand, such as new projects and others which it wished to study more thoroughly so as to facilitate the examination of the budget document. If that system were followed, it would mean that each year the Executive Committee would make a thorough analysis of the basic projects of the Organization.

With respect to the remarks of the Representative of Guatemala and the Chairman, he thought that it was not a good administrative principle to dissociate the technical from the budgetary aspects and suggested that all the necessary time be devoted to that meeting and it consider as a natural sequence the objective, the guidelines, the procedure, and the financing of each aspect of the Organization's activities.

He then referred to the meeting of the Committee following that of the Directing Council which was held for the purpose of electing new officers-- Page 234 Twelfth session 56th Meeting because the new members would have been elected--and, in principle, to review the decisions of the Council or the Conference and to decide which fell within the jurisdiction of the Executive Committee. In that respect, he stated that there was no reason why that Governing Body at its June meeting should not. indicate the special subjects which should be examined and thus make that meeting into a real working session. However, in 1967 it was advisable to hold a meeting prior to the Council since it had not been possible to examine the WHO budget in its final form.

Dr. AGUILAR HERRERA (Guatemala) said that the aim pursued could be achieved if the Director's suggestion was followed; in other words, the meeting held at the end of June would be a working meeting to make a thorough examination of the proposed program and budget estimates, irL particular to discuss the projects, and to submit to the Directing Council resolutions and well analyzed information. He also agreed that it was advisable that in 1967 a meeting be held prior to that of the Directing Cowuncil and thought Dr. Horwitz's suggestion very important, namely that the Executive Committee examine the need to deal with specific items in even greater detail.

The CHAIRMAN said that with the assistance of Dr. Aguilar Herrera a draft resolution on the item had been prepared and asked Dr. Sutter to read it.

Dr. SUTTER (Assistant Director, PASB) read the following draft resolution:

THE EXECUTIVE COMMITTEE,

Bearing in mind that, pursuant to Article 14-C of the Consti- tution, the Executive Committee is required to consider and submit to the Conference or to the Council the proposed program and budget prepared by the Director of the Bureau, with such recommendations as it deems advisable;

Considering that the proposed program and budget could be more appropriately considered after the World Health Assembly has approved the WHO budget for the fo:Llowing financial year;

Considering that a detailed examination by the Executive Com- mittee of the agenda items to be submitted to the Directing Council or to the Conference, as the case rmay be, would facilitate the work of those Governing Bodies; and

Mindful of Article 17 of the Constitution of the Pan American Health Organization,

RESOLVES:

1. To hold one regular meeting of the Executive Committee each year at the Headquarters of the Organization, subsequent to the meeting of the World Health Assembly and on a date to be fixed by the Chairman of the Executive Committee in agreement with the Director of the Bureau. Page 235 56th Meeting Twelfth session

2. To authorize the Director of the Bureau to convene a meeting of the Ebcecutive Committee immediately prior to the XVII Meeting of the Directing Council.

Decision: The draft resolution was unanimously approved. ~/

Dr. HORWITZ (Director, PASB) recalled that Dr. Blood, the Representative of the United States of America, had asked for information on the work of INCAP in countries outside Central America and Panama and stated that, in response to that request, the Secretariat had prepared a document from which he would like to cite certain details.

The information contained in that document included data on the number of fellows who had undergone training at INCAP up to the end of 1966, namely 634, of which only 258 had come from Central America and Panama. Ninety had come from the United States of America, 2 from Canada, and 52 from other Regions. Mention was also made of the amount of correspondence with other countries concerning INCAPARINA, which showed the interest of those countries in the product, and the number of leaflets on educational topics published and distributed by the Insti- tute both within and outside Central America and Panama. The Bureau would be very pleased to provide any other information which the representatives wished to obtain.

Dr. ORELLANA (Venezuela) expressed the appreciation of the members of the Executive Committee to the Chairman for the efficiency and competence with which he had directed the discussions. He also thanked the Secretariat for having efficiently provided the Committee with timely information; he had gained the impression of a strong and admirable team spirit which was an earnest that the program would be executed in a satisfactory manner. In his opinion the level of discussion had been higher than at previous meetings. He also expressed the thanks of the Committee to the interpreters, translators, the persons in charge of documents and, in general, of all the services that had so effectively contributed to the success of the meeting.

He suggested that in the future the proposed program and budget estimates include an organizational chart of the Secretariat so as to give a clear idea of the Organization's structure and thereby facilitate the study of it.

Dr. WEDDERBURN (Jamaica), in supporting the remarks of Dr. Orellana, expressed his thanks to the Chairman and the Director for meeting his convenience by arranging a late meeting date for the Committee. Having experienced the high quality of the presentations at the meeting, he would have hated to have missed the opportunity to participate in it, especially since it was the last occasion his country would be represented on the Executive Committee during the current period.

5/ Resolution XXI. Official Document PAHO 79, 48-49. Page 236 Twelfth session 56th Meeting

Dr. SANTA MARIA (Observer, Chile) said that as an Observer he would have great pleasure in informing the Government of his country about the high level of the discussions of the Committee meeting as well as of the seriousness and insight with which the agenda items were discussed. In his opinion the countries which were not members of the Committee could be sure that they were fully represented, given the international spirit wj-th which the problems had been examined.

The session rose at 11:40 a.m. CLOSING SESSION Wednesday, 3 May 1967, at 4:15 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

PRESENTATION AND SIGNATURE OF THE FINAL REPORT

The CHAIRMAN called the session to order and announced that it would proceed with the presentation and signature of the Final Report of the Meeting.

Dr. SUTTER (Assistant Director, PASB) presented the Final Report which included the 21 resolutions approved by the Executive Committee.

Dr. Alberto E. Calvo, Chairman of the 56th Meeting of the Executive Committee, and Dr. Abraham Horwitz, Director of the Pan American Sanitary Bureau and Secretary ex officio of the Committee, signed the Final Report. i/

TRIBUTE TO THE MEMORY OF DR. TOMAS PINEDA MARTINEZ, DIRECTOR GENERAL OF HEALTH OF EL SALVADOR

The CHAIRMAN asked for one minute of silence in tribute to the memory of Dr. Tomás Pineda Martínez, recently deceased, who had been the Director General of fealth of El Salvador and had rendered his country and the entire Hemisphere eminent services in the field of medicine.

All present stood for a minute of silence as a tribute to the memory of the deceased.

CLOSURE OF THE MEETING

Mr. CALDERWOOD (United States of America) said that his words of thanks would be in inverse proportion to the length of his speech. He wished to express his warm appreciation of the work of the Chairman and the work of the staff, including the interpreters, and to endorse fully the remarks made by Dr. Orellana at the previous session.

The CHAIRMAN thanked Dr. Orellana for his expression of appreciation at the twelfth plenary session and Mr. Calderwood for his, and congratulated the Director of the Bureau on his brilliant contributions to the discussions and his

1/ Official Document PAHO 79.

- 237 - Page 238 Closing session 56th Meeting constant assistance; he expressed his thanks to Dr. Orellana for his support as Vice-Chairman and to the other members of the Executive Committee, and commended the Secretariat for the competence, efficiency, and dedication t:hey had demonstrated. He then declared the 56th Meeting of the Executive Committee closed.

The session rose at 4:35 p.m. Annex 1 AGENDA OF THE 56th MEETING OF THE EXECUTIVE COMMITTEE

Item 1. Opening by the Chairman of the Executive Committee

2. Adoption of the Agenda (Document CE56/1, Rev. 3)

3. Amendments to the Rules of Procedure of the Executive Committee (Document CE56/7)

4. Proposed Program and Budget Estimates of the Pan American Health Organization for 1968 (Document CE56/5)

5. Report on the Collection of Quota Contributions (Docu- ment CE56/7)

6. Financial Report of the Director and Report of the External Auditor for 1966 (Official Document 75)

7. Provisional Agenda for the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas (Document CE56/15)

8. Arrangements for the XVII Meeting of the Directing *Council, XIX Meeting of the Regional Committee of WHO for the Americas (Document CE56/10)

9. Representation of the Executive Committee at the XVII Meeting of the Directing Council, XIX Meeting of the Regional Committee of WHO for the Americas (Document CE5 6/3)

10. Report on Buildings and Installatioñs (Document CE56/12, and Addendum I)

11. Status of Aedes aegypti Eradication in the Americas (Document CE56/8)

12. Request of the Government of Guyana for Admission in the Pan American Health Organization (Document CE56/4)

13. Amendments to the Staff Rules of the Pan American Sanitary Bureau (Document CE56/6)

- 239 - Page 240 Annex 1 56th Meeting

AGENDA (cont.)

Item 14. Supply of Textbooks for Medical Students (Document CE5 6/11)

15. Status of Smallpox Eradication in the Americas (Document CE56/14)

16. Amendment to the Financial Rules of the Pan American Health Organization (Document CE56/2)

17. Fellowship Program (Document CE56/13)

18. Appointment of the Deputy Director and of the Assistant Director of the Pan American Sanitary Bureau (Document CE56/9)

19. Resignation of the External Auditor (Document CE56/16)

20. Request of the Government of Barbados for Admission in the Pan American Health Organization (Document CE56/18)

21. Intensification of Health Programs--Decisions Taken at the Meeting of American Chiefs of State (Document CE56/19)

22. Other Matters Annex 2 LIST OF PARTICIPANTS OF THE 56th MEETING OF THE EXECUTIVE COMMITTEE

MEMBERS

COLOMBIA

Representative

Dr. Roberto Acosta-Borrero, Director, Ministry of Public Health, Bogota

ECUADOR

Representative

Dr. Alfredo Pérez Rueda, Under-Secretary of Health, Ministry of Social Welfare, Labor, and Health, Quito

Alternate

Dr. José Joaquín Carvajal Aragundi, Assistant Director General of Health, Ministry of Social Welfare, Labor, and Health, Guayaquil

GUATEMALA

Representative

Dr. Orlando Aguilar Herrera, Assistant Director General of Public Health, Ministry of Public Health and Social Welfare, Guatemala

JAMAICA

Representative

Dr. Charles C. Wedderburn, Chief Medical Officer, Ministry of Health, Kingston

Alternate

Mr. H. Dale Anderson, Third Secretary, Embassy of Jamaica, Washington, D. C.

- 241 - Page 242 Annex 2 56th Meeting

PANAMA

Representative

Dr. Alberto E. Calvo, Director General of Public Health, Ministry of Labor, Social W'elfare, and Public Health, Panama

UNITED STATES OF AMERICA

Representative

Dr. Benjamin D. Blood, Associate Director for International Organization Affairs, Public Health Service, Department of Health, Education, and Welfare, Washington, D. C.

Alternates

Dr. James E. Banta, Chief, Technical Resources Staff, Office of International Health, Public Health Service, Department of Health, Education, and Welfare, Washington, D. C.

Mr. Howard B. Calderwood, Office of International Economic and Social Affairs, Department of State, Washington, D.C.

Advisers

Mr. Edward Betzig, Office of Development Planning and Programs, Agency for International Development, Washington, D. C.

Mr. Simon N. Wilson, Bureau of Inter-American Affairs, Department of State, Washington, D. C.

VENEZUELA

Representative

Dr. Daniel Orellana, Chief, Office of International Public Health, Ministry of Health and Social Welfare, Caracas Page 243 56th Meeting Annex 2

Other Countries Represented

CHILE

Observers

Dr. Julio Santa Maria, Adviser, International Programs, Ministry of Public Health, Santiago

Dr. Raúl S. Orellana Ramírez, Third Secretary, Delegation of Chile to the Organization of American States, Washington, D. C.

FRANCE

Observer

Mr. André Cira, Second Secretary, French Embassy, Washington, D. C.

KINGDOM OF THE NETHERLANDS

Observers

Mr. W. Roosdorp, First Secretary, Embassy of the Netherlands, Washington, D. C.

Mr. J. B. Hoekman, Second Secretary, Embassy of the Netherlands, Washington, D. C.

Pan American Sanitary Bureau

Dr. Abraham Horwitz, Director, Member and Secretary ex officio of the Committee Dr. John C. Cutler, Deputy Director Dr. Víctor A. Sutter, Assistant Director Dr. Stuart Portner, Chief of Administration Dr. Pedro N. Acha, Regional Adviser in Veterinary Public Health Dr. Ivan Beghin, Regional Adviser in Nutrition Dr. Alfredo N. Bica, Chief, Communicable Diseases Branch Dr. Bertlyn Bosley, Nutrition Adviser Page 244 Annex 2 56th Meeting

Dr. Alfredo Leonardo Bravo, Chief, Medical Care Administration Branch Mr. Earl D. Brooks, Chief, Management and Personnel Branch Dr. Emilio Budnik, International Liaison Officer Miss Margaret C. Cammaert, Regional Adviser in Nursing Services Dr. Marcos Charnes, Chief, Fellowships Branch Dr. Carlos Díaz-Coller, Chief, Professional Education Branch Dr. Abraham Drobny, Chief, Health Promotion Branch Dr. César J. Garcia, Medical Officer, Medical Education Branch Dr. Rene González, Regional Adviser in Mental Health Dr. Mark D. Hollis, Chief, Environmental Sanitation Branch Dr. Emilio López-Vidal, Regional Adviser in Personnel Training Dr. Alfredo Lynch, Regional Adviser in Public Health/Malaria Eradica- tion Programs Dr. M. Martins da Silva, Chief, Office of Research Coordination Dr. James S. McKenzie-Pollock, Chief, Office of National Health Planning Mr. Clarence H. Moore, Chief, Budget and Finance Branch Dr. Vicente P. Musa, Regional Adviser in Aedes aegypti Eradication Dr. Louis J. Olivier, Regional Adviser in Parasitology Dr. Ruth R. Puffer, Chief, Health Statistics Branch Dr. José Quero Molares, External Relations Officer Dr. Bichat Rodrigues, Regional Adviser in Smallpox Dr. Oswaldo J. da Silva, Chief, Malaria Eradication Branch Dr. Nilo Vallejo, Health Educator Dr. Ramón Villarreal, Chief, Medical Education Branch Mr. Jose Rodriguez Olazábal, Chief, Secretariat Services Mr. Peter Ozorio, Office of Public Information

Observers

Organization of American States

Mr. O. Howard Salzman, Acting Director, Department of Technical Co- operation, Pan American Union, Washington, D. C.

Mrs. Alzora H. Eldridge, Liaison Officer, Executive Office of the Secretary General, Pan American Union, Washington, D. C. 57th MEETING OF THE EXECUTIVE COMMITTEE PRECIS MINUTES AND FINAL REPORT CONTENTS

Page

FIRST PLENARY SESSION (Thursday, 28 September 1967, at 9:10 a.m.)

Item 1: Opening of the Meeting ...... 247 Item 2: Adoption of the Agenda ...... 247 Item 3: Proposed Program and Budget Estimates of the Pan American Health Organization and of the World Health Organiza- tion, Region of the Americas, for 1969 ...... 248

SECOND PLENARY SESSION (Thursday, 28 September 1967, at 2:30 p.m.)

Item 3: Proposed Program and Budget Estimates of the Pan American Health Organization and of the World Health Organization, Region of the Americas, for 1969 (continuation) ...... 260 Item 4: Financing of the Pan American Foot-and-Mouth Disease Center ...... 271

THIRD PLENARY SESSION (Friday, 29 September 1967, at 9:10 a.m.)

Item 4: Financing of the Pan American Foot-and-Mouth Disease Center (continuation) ...... 279 Item 5: Resolutions of the Twentieth World Health Assembly of Interest to the Regional Committee ...... 281

FOURTH PLENARY SESSION (Friday, 29 September 1967, at 3:00 p.m.)

Item 5: Resolutions of the Twentieth World Health Assembly of Interest to the Regional Committee (conclusion) ...... 291 Item 3: Proposed Program and Budget Estimates of the Pan American Health Organization and of the World Health Organization, Region of the Americas, for 1969 (conclusion) ...... 295 Item 4: Financing of the Pan American Foot-and-Mouth Disease Center (conclusion) ...... 296 Item 6: Other Matters ...... 297 Travel Expenses of Members of the Executive Committee .. 297

FINAL REPORT ...... 299

- 246 FIRST PLENARY SESSION Thursday, 28 September 1967, at 9:10 a.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 1: OPENING OF THE MEETING

The CHAIRMAN opened the session and welcomed the members of the Commit- tee, observers, and other participants in the Meeting. Speaking for the Com- mittee, he thanked Dr. Leonard M. Comissiong, Chief Medical Officer of Trinidad and Tabago, for his presence, which indicated his country's great interest in the Pan American Health Organization.

He recalled that the Meeting had been scheduled in accordance with the decision of the 56th Meeting of the Executive Committee l/ to hold its regular meeting each year after the World Health Assembly to enable the Committee to examine the proposed program and budget of PAHO and consider the items to be submitted to the Council or the Conference in the light of the WHO program and budget approved by the Assembly. The Constitution contained certain provisions bearing on that matter, which he requested Dr. Horwitz to present in detail.

Dr. HORWITZ (Director, PASB) explained that under Article 14-D of the Constitution 2/ one of the duties of the Executive Committee was to advise the Conference or the Council regarding matters referred to it by those bodies or, on its own initiative, regarding other matters relating to the activities of the Conference, the Council, or the Bureau. The Committee's decision mentioned above was based on that provision of the Constitution. In addition, the Com- mittee's Rules of Procedure provided for special meetings, and the current meeting was unique in that it was the first special meeting to be held in the history of the Organization.

ITEM 2: ADOPTION OF THE AGENDA

Dr. ARREAZA GUZMAN (Assistant Director, PASB), before presenting the provisional agenda (Document CE57/1), 3/ read cables from the Governments of Guatemala and Ecuador advising that they would not be able to send a representative to the Meeting.

Dr. HORWITZ (Director, PASB) explained that, after studying the discussions leading to the adoption of Resolution XXI of the 56th Meeting of the Com- mittee, it had been decided that the Governments were primarily interested in l/ Resolution XXI. Official Document PAHO 79, 48-49. / Official Document PAHO 80, 15. y Mimeographed document.

- 247 - Page 248 First session 57th Meeting having an over-all view of the general program and budget estimates of PAHO, which should therefore describe all the funds that would be available in 1968, from both PAHO and WHO. In April 1967 the World Health Assembly had not yet decided on the amounts to be made available for the Region of the Americas in 1968 from the WHO regular budget and from other United Nations specialized agencies. For that reason, the Executive Committee had focused its attention on the PAHO regular budget. It was also considered advisable at the time to defer the future annual meetings devoted essentially to examining the PAHO program and budget estimates until after the World Health Assembly, and an item to that effect was therefore included in the agenda of the Meeting. Moreover, a number of developments relating to the stable financing of the Pan American Foot-and-Mouth Disease Center had taken place since April and deserved the attention of the Executive Committee.

The CHAIRMAN suggested that a new item "Resolutions of the Twentieth World Health Assembly of Interest to the Regional Committee," be included in the draft agenda since some of them could affect the programs of PAHO.

Dr. ACOSTA-BORRERO (Colombia) seconded the proposal by the Chairman.

Dr. BLOOD (United States of America) stated that, pursuant to the terms of the above-mentioned Resolution XXI, full advantage should be taken of the time available in order to assist the Council in its task. Though it was impossible to prejudge how the deliberations of the Council would be carried out, the Committee should do everything possible to advance the work of that body. In addition, he supported the Chairman's suggestion of taking up the resolutions of the Twentieth World Health Assembly of interest to the Regional Committee. Other Regions of WHO had no Executive Committee, which placed the Region of the Americas in a unique position. Therefore, as a study group or working party of the Regional Committee, it was important for the Executive Committee to study the items that had been taken up at the last World Health Assembly and to support the Regional Committee by advancing its work as much as possible.

Decision: The draft agenda contained in Document CE57/1 was unanimously adopted with the addition of the item suggested by the Chairman.

ITEM 3: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION AND OF THE WORLD HEALTH ORGANIZATION, REGION OF THE AMERICAS, FOR 1969

The CHAIRMAN expressed the Committee's satisfaction with the high technical quality of Official Document 76, which, from the standpoint of presentation was perhaps superior to the program and budget documents of any other international organization.

Dr. HORWITZ (Director, PASB), speaking for the entire staff of the Bureau, thanked the Chairman for his words of praise concerning Official Document 76. He explained that it represented a new stage in a process initiated several years ago in the preparation of a genuine program budget, i.e., a functional budget arrangement of highly complex international health activities. He believed the Page 249 57th Meeting First session

document to represent a further step toward the goal of offering the Governments more complete information on which to base their determination of the amounts needed to carry out health activities in the Region as a whole. That was, of course, a continuing process in which the program budget was gradually improved through experience, as envisaged some years ago.

Any examination of the program and budget estimates of an international organization, whatever its nature, inevitably raised the question of whether the budget reflected a plan that embraced the entire Region where the Organization performed its assigned responsibilities. In the case of health, the question was whether the document reflected the plan of work in that field in the Americas, in other words, whether it set forth the true order of priority of health problems. In his opinion, the question was pertinent and not inspired exclusively by philosophical or esoteric considerations.

If the decisions of the Chiefs of State, meeting in Punta del Este in April 1967, were put into practice, the Hemisphere would have a true common market, the success of which would requiere the firm support and encouragement of an intellectual community. The health program for the Americas would also have to become a reality, and the existence of an international organization with responsibilities transcending the limits of each nation would have to be considered within the institutional framework of that economico-intellectual community which was sought. The program and budget estimates, although still falling short of a health plan for the Americas, represented definite progress in that direction, as shown by the fact that, in addition to including projects of benefit to individual nations, it contained regional projects involving the participation of all the countries or of a given group.

In reading the document it should be borne in mind that health did not recognize frontiers and that, since movement in the Americas was and would continue to be intense, the solution of any problem was of common interest. The important thing was for each individual to have the greatest possible productive capacity and that the children have the best opportunities to grow and develop. He expressed the conviction that the time would come when the Govern- ments would call on the Organization to prepare a genuine health plan for the Americas considered as a single country. It was obvious that the program and budget document would be improved as the countries which had yet to begin the process of national planning embarked on that venture and as those which had done so improved their performance. As objectives were defined and placed in their proper priority, the ministers of health in each country would be able to determine more clearly which were the aspects in which they required international assistance. As a result, that assistance would be more effective, and that would, in turn, be reflected in the program and budget document.

The document was a hybrid in that it contained the priorities established by the Organization as a whole, those determined by the countries having health plans, and those requested by the ministers of health of countries which, while lacking such programs, agreed with the general policy aims of the Organization.

The Meeting would afford the Executive Committee an opportunity to perform the function for which it had been convened: to make a comprehensive Page 250 First session 57th Meeting

examination of the work and expenditures for 1968 and to give some indication of what could be done in 1969. It would also make it possible to determine what was actually spent in 1966, examine the Committee's recommendations in 1967, and ascertain what was being done by each country.

Dr. PORTNER (Chief of Administration, PASB) thanked the representatives for their comments on the document, prepared under his guidance and with a view to obtaining a deeper appreciation of the Organization's over-all program. It was a program budget designed to give a complete analysis of the major programs and perhaps to assist countries in the management of their own health establishments. It also sought to present PAHO's activities in various ways. It covered every phase from planning to operations at the country level, and presented a definitive analysis by object of expenditure, geographic area, organizational unit, and country. Excluded from the funds allotted to the various countries were several major centers, which was a problem still pending solution. An attempt had thus been made to present the total program in summary as well as in detail. In addition to general explanations, the document contained an introduction, the proposed appropriation resolution, the scale of assessments of the Member Governments and Participating Governments of PAHO, and the program analysis, followed by tables and summaries of major programs by fund. The greatest value of the presentation was to be found in Part III, especially when reference was made to any particular country. The narratives, formerly found in the front of the budget document, had been grouped together with financial and other details. An attempt had also been made to assign to the countries that portion of the intercountry projects applicable to each one. As in the past, the document contained a series of annexes on the method of preparation, personnel breakdown, summary of professional and local personnel, projects requested by Governments, to be implemented if funds became available, and the Building Fund.

Much of the administrative rationalization process was founded on the automatization of data, which had already been implemented and was going to be applied to other phases of the financial activities of the Organization. In closing, he called attention to the importance of the review and analysis process which was carried out in connection with the budget several times a year.

Dr. BLOOD (United States of Arnerica) praised the presentation of the budget document and stated that it clearly reflected the efforts made over the years to satisfy the wishes and hopes of the various countries; it was of value not only from the technical but also from the budgetary and fiscal aspects. He then requested clarification on the meaning of the four-year presentations: he understood that 1966 reflected what had actually been spent and that 1969 was a projection, but he wished to know how the figures for 1967 had been arrived at. He presumed also that the 1968 figures were those examined by the 56th Meeting of the Executive Committee, but asked for a confirmation of that fact.

Dr. PORTNER (Chief of Administration, PASB) said that the 1966 figures had been taken directly from the accounts and were given in much more detail than in the Financial Report of the Director and Report of the External Auditor for 1966. 4/ The figures for 1967 were based on the actual situation as of the spring, with the best estimate that could be made for the remainder of the year.

4/ Official Document PAHO 75. Page 251 57th Meeting First session

For 1968 there were variations between PAHO and WHO and changes had occurred since the previous Executive Committee meeting; they were very slight in the case of PAHO, but in the case of WHO there were numerous changes in recosting, though the amount was only about $24,000 lower than in April. For 1969, as indicated by Dr. Blood, the figures were merely estimates, calculated in the traditional fashion for PAHO and for WHO on the basis of a ceiling established by that Organization.

Dr. HORWITZ (Director, PASB) stated that the Annual Report of the Director for 1966, / which dealt with all the activities carried out, contained an account of 545 projects of extremely varied scope. He noted, however, that the importance of a program could not always be measured by the volume of expenditures. It sometimes happened that a single fellowship turned out to be more important to the health of a country than the investment of a million dollars in an institution. In other cases, technical assistance in the preparation of a project might have been largely instrumental in bringing about a decision by the Inter-American Development Bank to invest in the project.

The Director noted that not only the figures shown in the budget document should be taken into account, but also the matching investment by the country involved. When an organization which served in a technical advisory capacity and whose role was merely to supplement rather than to replace national efforts made an investment in a project originating with the Governments, it set in motion a process of matching investment by the Governments themselves. For instance, it was likely that some of the funds spent by the countries on the malaria campaign would not have been obtained had PAHO scientists not been participating in the program. In fact, that investment was obtained as a result of an agreement with the countries, which they had faithfully honored, save in exceptional circumstances. A comparison of the total expenditure submitted for the Committee's consideration with the total amount of national expenditures would indicate a ratio of 1 to 5 or perhaps 1 to 10. It would be extremely useful if the Governments could provide exact information on their own expenditures, since it would make it possible to determine more clearly the total investment in the projects.

Dr. Horwitz pointed out that without mechanization and electronic computers it would not have been possible to prepare the document in such great detail.

Dr. ORELLANA (Venezuela) said he was highly pleased with the manner in which the proposed program and budget estimates of the Organization had been prepared and that he realized that a great deal of work was involved in preparing such a document. He asked how much it cost to prepare the document with the help of automated procedures and how the cost of the AMRO projects had been allocated among the countries involved. He also asked for an explanation of the differences in the 1966 investments in the countries as shown in the Finan- cial Report of the Director and as shown in the document under examination.

The session was suspended at 10:15 a.m. and resumed at 10:45 a.m.

5/ Official Document PAHO 78. Page 252 First session 57th Meeting

Dr. PORTNER (Chief of Administration, PASB), replying to the three points raised by Dr. Orellana, stated that the first related to cost analysis and that the initial outlay, processing, and final product, including mailing of the document, totalled about $16,000 or $17,000 which would decrease as definitive computerization was available. The continuing additional cost of that process would probably be between $3,000 and $4,5(0, but those amounts were rather small compared to the value to be derived not only in future projections but also in evaluation of projects. Second, on the manner in which the AMRO's were calculated, several factors were taken into account. In the case of professional services, short-term consultants, and others, checks were made on the extent of actual travel and the time spent in countries, including waiting periods. Fel- lowship data were easily obtainable, as was participation in seminars, but it would take two or three years before it could be said that refined data had been obtained, and the figures for succeeding years would have to be adjusted on the basis of experience. As for the third point--the difference between the Finan- cial Report and the figures quoted in the budget document--there were none except where two projects were listed in the former and shown as a single project in the budget. Those were footnoted in the budget document.

Dr. HORWITZ (Director, PASB), enlarging on Dr. Portner's remarks from another point of view and referring to a previoLs observation commending the inclusion of estimates of amounts provided to individual countries under intercountry projects, said that that had been done because the Bureau had the impression that only the ministries had any idea of the assistance provided and that the assistance furnished by Zone staff was generally less well known and not thought of in terms of money. In order to assign a money value to the services provided to each country by the Zone staff, who were sometimes experts in disciplines not represented in the Zone, the Bureau had added a new chapter, "Portions of Intercountry Projects," which, as Dr. Portner said, presented only approximations. That technique would have to be improved by taking a larger sample than that currently being used and applying the conclusions to the Region as a whole.

With the program budget technique one ran the risk of over-analysis, which increased the cost without enriching the information. With the use of electronic computers it was possible to arrive at all the required analyses, but restraint was needed in order to avoid such over-analyses.

Dr. BLOOD (United States of America) was grateful for the explanations provided, but warned that caré should be taken not to exaggerate the analysis or to misuse and misinterpret what the machines were capable of doing. Though they could feed out information under the different categories and classifications, it was up to the persons involved to assign the values in accordance with reality. As an example he cited AMRO-3310 (International Conference on Vaccines against Viral and Rickettsial Diseases of Man), which he presumed was broken down according to the place where it was held or the country of origin of the participants. Though the value of the Conference was unquestionable, he wondered if it was a valid measure to have had the cost assigned to his country in terms of the value to be derived by the United States of America as compared to the rest of the world. He reiterated the danger of overeraphasizing the importance of mechanization and of assigning values that really did not exist. Page 253 57th Meeting First session

Dr. HORWITZ (Director, PASB) said that the Proceedings of the Conference on Vaccines against Viral and Rickettsial Diseases in Man / was actually the most up-to-date treatise on virology in existence. Apparently there was no more complete terminology available in any other source, and in expressing the Organ- ization's pride in that respect, he wished to commend the Office of Research Coordination and the Special Publications Unit for having published all the arti- cles on virology written by some 300 experts from throughout the world.

It was no one's fault that the United States of America was the world virology center and that the splendid coóperation of that country in organizing the Conference could certainly not be measured. As he had often pointed out, in those inflation-ridden times nothing was cheaper than talent, and the world was constantly deriving the benefit of free information. As an example, he cited the case of experts invited to serve on committees who, in the course of a few days, supplied the wisdom acquired in a lifetime of work. Economists, accustoned to assessing the value of activities in terms of money and not of actual worth, could not appreciate the enormous significance of contributions such as those.

Dr. ORELLANA (Venezuela) asked whether the Organization had considered translating the report of the Conference into Spanish.

Dr. HORWITZ (Director, PASB) replied that that possibility had not been considered and that funds would have to be budgeted if there were any interest in having that done.

The CHAIRMAN asked if any specific allotment was available in the budget for translating the volume.

Dr. HORWITZ (Director, PASB) replied that if the Executive Committee asked for the translation to be made the Bureau would study the possibility.

Dr. ORELLANA (Venezuela) pointed out that if that volume were translated into Spanish many more persons would benefit from it and also a greater amount of funds would be available as a result of its sale.

Dr. COMISSIONG (Observer, Trinidad and Tobago) thanked the Chairman for inviting him to participate in the discussion and his complementary remarks about him and his country. However, he merely wished to state that the budget document presentation was going to be of great value to countries such as his and to those responsible for its activities who would be able to see at a simple glance the exact contribution of the Organization to any particular country.

Dr. BLOOD (United States of America) referred to the listing of the AMRO projects that were of importance to each country and asked whether there was any danger of misinterpreting it and considering that the amounts given were a limit. While the information was of value to the health administrations, he asked whether there was a possibility that they would interpret the assignments as being definitive and would discourage them from requesting additional funds for projects.

6/ Scientific Publication PAHO 147. Page 254 First session 57th Meeting

Dr. HORWITZ (Director, PASB) said that, apart from any explanation Dr. Portner might give, the program was prepared in agreement with the Governments. They were consulted in advance about which projects should be continued, which should be started, and based on that first analysis the Bureau proceeded to draw up the budget. At that stage, the Governments were entirely free to present any problems of special interest to them. Contacts were then established at the Zone and local levels and with headquarters staff. It was not a question of applying a rigid procedure. What occurred was that the original proposals were gradually adjusted, which simply reflected the changing nature of international relations.

Dr. PORTNER (Chief of Administration, PASB) agreed that there was no explicit indication to that effect either in the reports to Governments or in the resolutions of the Governing Bodies. The concern had always been with the global figures and the establishment of ceilings at the country level, and the restric- tions were therefore at that level. However, they were known by all who worked on those matters, but long-range planning was made long in advance, kept up continuously with Governments, and adjusted accordingly. Though plans were made two years in advance, parts of the process would come up four times before the Gov- erning Bodies for review and adjustments.

The CHAIRMAN noted that the main purpose in reviewing the document was to consider the new contributions and the adjustments made in relation to the WHO regular budget, since the PAHO regular budget had been reviewed in April.

Referring to Table 1 of Official Document 76 (p. 6), which indicated the total amount allocated by WHO to PAHO--$55,400,000, or approximately 10 per cent of the WHO regular budget--he asked Dr. Portner what the actual percentage was and how that compared with allotments to other Regions, not in terms of the present situation but of future projections. An examination of yearly increases in the amount allotted to the Bureau (20.8 per cent in 1966, 21.0 per cent in 1967, and 22.3 per cent in 1968), indicated a rising growth rate. On the other hand, in terms of the total budget, the increase was 8.6 per cent between 1967 and 1968. The Chairman also noted the substantial differences in the appropriations from the United Nations Special Fund.

He thought the regular budget was perhaps a better measure of the dynamic health situation in Latin America, and therefore the contributions should be considered with an eye to the future. A 10 per cent increase for 1969 would only amount to some $500,000 above the 1968 allotment. Those increases were already ceiling figures imposed by the budgetary mechanism of the Organization and only minimal adjustments had been made since April within the ceiling of $5,400,000. He then requested Dr. Portner to explain the changes involved in the $24,000 reduction from the budget estimates originally presented.

Dr. PORTNER (Chief of Administrat:on, PASB), replying to the basic question raised by the Chairman, stated that the figure of over $5,400,000 for the Region of the Americas was the ceiling given to the Region by WHO from projects to be financed from its regular budget, and represented over 9.5 per cent of that budget for that year. If compared to other Regions, some received more, some less, but they were based on the Director-General's decision after making a detailed review of the country needs of the different Regions; the fact that PAHO Page 255 57th Meeting First session had funds was also a contributing factor. Changes were of course made depending on new needs, priorities, and programs, as was the case of malaria and smallpox activities whose allocations were included in the WHO regular budget.

As for that budget, an attempt had been made for the first time at the 56th Meeting of the Executive Committee to give the totality of the PAHO/WHO program. The process was a well-known one: detailed study, conversations with Governments, examination by the Executive Committee, transmittal to the Council, subsequent incorporation in the WHO budget, and assignment of a ceiling for the Region, which, as stated previously, was $24,000 less than the figure considered by the Executive Committee at its last meeting and reflected principally in recosting.

Dr. BLOOD (United States of America) asked whether there was any information available on the Region of the Americas, perhaps on a percentage basis, in relation to the rest of the world, with respect to WHO resources over the years.

Dr. HORWITZ (Director, PASB), referring to WHO Official Records 154 and the Summary of Regional Offices and Field Activities (without including those conducted at Headquarters), said that the WHO regular budget contained the following allocations for 1968 for the various Regions: $8,868,000 for Africa; $5,468,000 for the Americas; $6,249,000 for Southeast Asia; $3,224,000 for Europe; $5,761,000 for the Eastern Mediterranean; and $4,516,000 for the Western Pacific. The total amount of those allocations, including PAHO in 1967, but ex- cluding the UNICEF allocation for 1968, was $79,513,000, of which $25,256,000 (including UNICEF) was earmarked for the Americas. In other words, of the approximately $80,000,000 allocated for activities throughout the world in 1967, $25,000,000 was assigned to the Americas, including PAHO and UNICEF. That meant that the Region of the Americas received about a third of the total, exceeded only by the allocations for Europe and the Western Pacific. In recent years, Africa, Asia, and the Mediterranean seemed to be getting more attention than heretofore.

Turning again to Table 1 of Official Document 76, Dr. Horwitz noted that the allotment had risen from $4,086,922 in 1966 to $5,744,100 in 1968 and that, generally speaking, actual WHO expenditures were very close to appropriations, which was evidence of an equitable attitude on the part of the Director-General of WHO. In short, there were no valid grounds for asserting that the differences between regional allocations were prompted by the existence of PAHO.

The CHAIRMAN asked Dr. Portner if the amount assigned for 1969 was an unchangeable ceiling figure and if the Committee had to abide by the exact projection in the regular budget of WHO.

Dr. PORTNER (Chief of Administration, PASB) replied that the WHO administrative process assigned a ceiling to the Americas, with a specific dollar citation. There were subindications within the ceiling but the program did not go beyond that ceiling.

Dr. BLOOD (United States of America) also referred to Table 1 and pointed to an increase in the totals of 2.7 per cent in 1968 over 1967 and of 5.8 in 1969 over 1968. He requested additional information on that increase which was Page 256 First session 57th Meeting not evident from a study of the table. Though some projects showed negative funding it could have a marked influence on percentages. He therefore wondered if that was a regular budgetary procedure or whether there was some other explanation for that.

The CHAIRMAN said that he had asked the same question as Dr. Blood in Washington some days before and that the reply would undoubtedly be of interest to many others. He requested Dr. Portner to explain the matter of the adjustments, especially those where negative funding had been noted.

Dr. PORTNER (Chief of Administration, PASB) stated that the Represent- ative of the United States of America had touched on a point that was a source of preoccupation since it tended to give a distorted picture. There were indeed negative indicators, but the matter could perhaps be best explained by stating that there were a number of grants in operation that were due to terminate in 1967 or early in 1968. There was therefore a fall-off in funding areas and a decrease in projects funded from grants. There was, for example, a decrease of approximately $960,000 under other grants and contributions to PAHO, i.e., of 59 per cent, and a similar indication under the United Nations Special Fund of about 35.5 per cent. The reason, then, why there was a relative increase in 1969 was that that was an open estimating period.

Dr. HORWITZ (Director, PASB), enlarging on Dr. Portner's explanation, said that in Table 1, under the United Nations Special Fund, there was an item of $544,767 which pertained to the approved projects, such as the Pan American Zoonoses Center (the portion financed by the United Nations Development Program), the Venezuelan project for the teaching of sanitary engineering in four universities, the project of the School of Engineering in Rio de Janeiro for the same purpose, and at least four other projects being negotiated with the United Nations Development Program. One of those was the Pan American Center for Health Planning, a program already well advancedc which would be submitted in October to the Inter-Agency Consultative Board, headed by the United Nations Secretary General, and in January to the Governing Council of the Program. That was a proposal amounting to approximately $2,500,000 to be spent in five years. If approved, the relevant amounts, which were considerable, would have to be included in 1968. At the request of the Governiment of Venezuela, two other projects were being negotiated: the establishment of a Latin American Center on Mainte- nance of Hospital Equipment and a study of the environment in tropical regions.

Dr. Horwitz reported that Dr. C. A. Morrell of Canada was advising the Uruguayan Government in the organization of a center for the training of technicians in drug control and for research on simplified methods to be used for that purpose. The center would serve the South American countries. All those projects would raise the amount of that item, and it would be desirable if the corresponding amounts in the 1968 budget were much larger than the ones in the document under consideration. His purpose in presenting those figures was to indicate some of the increases and reductions in the various budget items which explained the differences noted, as stated by Dr. Portner.

Dr. ORELLANA (Venezuela) asked whether the technical assistance and the United Nations Special Fund appropriations had not been combined a year ago. He wondered if perhaps Dr. Portner could explain why they were listed separately. Page 257 57th Meeting First session

Dr. PORTNER (Chief of Administration, PASB) stated that Dr. Orellana was correct in indicating that that was now the United Nations Development Program; however, the listing was given separately depending on the origin of the project and the type of activity.

Dr. HORWITZ (Director, PASB), referring to Dr. Blood's observation, said that as a result of the poliomyelitis outbreak on the Pacific Coast of South America during the past four months, which had centered in Ecuador for several weeks, the Organization was trying to obtain between $40,000 and $50,000 from the Emergency Procurement Revolving Fund to meet a request of the Ecuadorian Government for the continuance of its nationwide immunization campaign. That figure was not shown in Official Document 76. Similar action was being taken in connection with the reintroduction of Aedes aegypti. In that case an allotment was being sought from the same Fund, at the request of the Governments concerned, to defray the costs of advisers, insecticides, and pumps.

Dr. BLOOD (United States of America) asked for a clarification of what action the Executive Committee was expected to take at that time. The program and budget had been examined in April, a resolution had been approved, Z/ and a recommendation had been made to the Directing Council. He therefore asked whether the Committee should again review the budget for 1968 or leave it as approved in April.

The CHAIRMAN said that the procedure would be for the Commnittee to inform the Directing Council that it had reviewed the entire document, including the figures, which were already available when the review was made last April, and to recommend its approval in total. That in regard to 1968. Concerning 1969, since that was the first time the Executive Committee had available the preliminary projection for the year, the appropriate action would be for the Committee to inform the Council that it had taken note of the projection. If any comment were to be made on the 1969 budget, the Committee would have to note that the increase in the projection for that year, 11.8 per cent, was in the same proportion as the increase between 1967 and 1968. In view of the quickening pace of health activities in the Americas, it would be advisable to state that the Organization aspired to a rising rate of increase in the budget, rather than the maintenance of the same level.

Dr. HORWITZ (Director, PASB) said that as a matter of principle the Bureau could accept any increase the Committee sought to recommend for 1969 because, as Dr. Portner had pointed out, the budget included projects requested by the Governments which amounted to more than $4,000,000 and for which no funds were yet available.

Dr. PORTNER (Chief of Administration, PASB) stated that he wished to call attention to the fact that $200,000 were being transferred to malaria eradication, the beginning of a five-year sequence whereby $1,000,000 would be moved under the PAHO regular budget. There would also be increases in commod- ities, personnel costs, etc., and though the gross increase would be 11.8 per cent, only 6.5 would be due to the transfers and other factors mentioned.

2/ Resolution XVII. Official Document PAHO 79, 43. Page 258 First session 57th Meeting

Dr. ORELLANA (Venezuela) said that as far as the proposed budget for 1968 was concerned, the resolution adopted in April was very clear and that the only action required vwas to recommend that the Directing Council approve the proposed budget in the amount of $10,190,000, which had not been altered since then. As for the preliminary budget estimates for 1969, the Committee had two alternatives: to simply take note of the document or not to mention it at all, since it would be examined by the Council. However, since that was a consolidated budget prepared and presented as such through a very complex process of planning, the preferable course of action would be for the Committee to simply take cognizance of the 1969 budget without indicating whether the proposed 11.8 per cent increase was small or large, since the proposed budget had not been subjected to any analysis in depth. The Council would undoubtedly refer the document to the Committee for study, which would offer the opportunity to increase or reduce the proposed amount. Dr. Orellana observed that the constant increase in the budgets of international organizations and, accordingly, in the country quotas, was a matter of serious concern to the countries.

The CHAIRtMAN pointed out that the Committee's current review of the proposed budget, despite the fact that a ceiling figure had been set, was based on a resolution adopted in April. He agreed with Dr. Orellana that the Committee should simply take note of the budget for 1969.

Dr. BLOOD (United States of America) said he was undecided as to what action the Committee should take with respect to the 1968 program and budget. The decision taken in April was final, though that did not prevent the Committee from discussing the 1968 budget further if it deemed it desirable.

The CHAIRMAN observed that a consensus had been reached as to procedure and that it was now only a question of drafting the operative part of the resolution. He wondered how the document should be designated in the text of the resolution, since the proposal examined in April was Official Document 67, while the one now being reviewed by the Committee for transmittal to the Directing Council was Official Document 76.

Dr. BLOOD (United States of America) said that the resolution of the 56th Meeting was taken after examining Document CE56/5. As he understood it, that document had now been combined with Official Document 76. Any additions to the resolution might be presented in the form of a footnote which the Secretariat could explain perfectly well.

The CHAIRMAN suggested that perhaps the matter could be explained in the Addendum to the report to the Directing Council.

Dr. BLOOD (United States of America) said that the Committee might find itself in the position of amending its own resolutions, which should be avoided.

Dr. HORWITZ (Director, PASB) said that while he realized that the Execu- tive Committee was perfectly free to do as it wished in that regard, he felt that, as a general rule, resolutions approved at a meeting of the Committee should not be amended at subsequent meetings, or even interpreted or explained. He considered, however, that something should be said in the minutes of the meeting to indicate that the document had been reviewed and that the Committee had expressed an opinion thereon. Page 259 57th Meeting First session

As to the manner in which the Committee should express its opinion on the proposed budget for 1969, he thought that could be done in a resolution to the effect that the Committee had reviewed the document as a whole and had simply taken note of the amount appropriated for the year, without expressing any opinion. If the Committee desired to express an opinion, it could say it was pleased that, in addition to the general order of magnitude, the document contained the details of programs on which the Directing Council was to take action.

Dr. ORELLANA (Venezuela) agreed with the Director that it was inadvisable to amend resolutions already approved and that what made it difficult to determine an appropriate procedure was the absence of precedence in that regard, since the Committee had never before been called into session to examine the budget of PAHO and of WHO after the latter's allotment to PAHO was a matter of record. Meanwhile there had been changes in Official Document 67, and the one to be submitted to the Council was Official Document 76, which had not been formally presented to the Committee. The resolution to be adopted should refer to Official Document 67, and the Council would understand that changes had been made in that document. Before confirming Resolution XVII, the Committee should take note of the new document presented.

The CHAIRMAN expressed the belief that the resolution the Committee had in mind was consonant with Dr. Horwitz's suggestions and that its text, which would be submitted to the Committee at the second plenary session, should reflect the terms used by the Director.

The meeting rose at 12:20 p.m. SECOND PLENARY SESSION Thursday, 28 September 1967, at 2:30 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 3: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION AND OF THE WORLD HEALTH ORGANIZATION, REGION OF THE AMERICAS, FOR 1969 (continuation)

The CHAIRMAN opened the session and said there were still some aspects of the item meriting examination and called for comments on the matter.

Dr. BLOOD (United States of America) stressed that the meeting offered one of the last opportunities to consider, before its submission to the Assembly, the proposed program and budget of WHO for 1969. Experience dictated that the Regional Committee would not be able to give that budget the thorough examination it merited, but rather would look to the Executive Committee for guidance. As far as was possible, therefore, they should try to understand what was proposed and be in a position to comment.

The CHAIRMAN stated that, in view of Dr. Blood's remarks, the Committee would examine the document at greater length, particularly the part concerning the ceiling fixed by WHO.

Dr. WEDDERBURN (Jamaica) asked what the practice had been in regard to the study of proposed PAHO allocations before they went before the Assembly for decision. He could not recall such a study ever having taken place. He was not suggesting that it should not, but wished to clarify his own thinking on the matter. Also, he wondered whether there was any possibility of effecting changes in the budget at that stage, and if so, whether that had ever been done.

Dr. HORWITZ (Director, PASB) replied that a ceiling figure, which reflected a certain percentage increase over that of the previous year, was first received from the Director-General. That indicated the framework within which part of the over-all activities of the Region should fall. The practice had been to prepare the proposed program of the Region for submission to the Directing Coun- cil which, upon approval, forwarded it to the Director-General for consideration when preparing his over-all budget.

The total activities of the Organization were presented, category by category, to the Directing Council, with an indication of the activity to be budgeted by WHO, so there was, indeed, prior examination of proposed allocations. There had not previously been an examination such as was now being conducted, nor had there been a detailed study of the proposed WHO budget: such as the one made in April of the PAHO regular budget.

Dr. ACOSTA-BORRERO (Colombia) referred to the statement in Official Docu- ment 76 (p. 4)' that the budget estimates for technical assistance reflected the

- 260 - Page 261 57th Meeting Second session probable distribution of expenditures in the 1967-1968 program and the estimates of requests for 1969. He believed that that study had been made too far in advance to be considered as a draft 1969 budget as far as the WHO funds were concerned. He understood that the Bureau fixed the amount of that budget on the basis of a quota previously assigned by the WHO and wondered if the projects requested by the Governments ard never sufficiently financed in previous years were being given priority by the Bureau.

He ther referred to the increase in the regular budget of the Organiza- tion, 11 per cent in 1968 and 1969 to meet increased costs, which averaged more than 4 per cent, leaving approximately 7 per cent for expanding the program. It would be useful to know what percentage was being devoted to projects for 1968, and particularly whether it represented a progressive increase rather than a steady increase each year.

Dr. ORELLANA (Venezuela) said that Dr. Blood's proposal that the Commit- tee examine the preliminary budget estimates of WHO for 1969, at least super- ficially, was a wise one. As for Dr. Wedderburn's query, he said that when the Council decided on the last year's portion of a proposed comprehensive program and budget, it simply took note of that portion and recommended that the Director- General report to the next World Health Assembly. Actually the Council did not discuss that part of the integrated budget in detail but only considered it as a whole.

Dr. BLOOD (United States of America) said that Dr. Orellana's remarks had really underlined his own view that if it was felt desirable to analyze in detail the WHO program and budget for 1969, that was the opportunity to do so. The budget for 1968 had already become part and parcel of the total program and budget of the Organization and could not be subjected to change of orientation by the XVII Meeting of the Directing Council. Any adjustment in the shape and profile of the WHO program and budget at the level of the Regional (;ommittee had to be made well in advance of the Assembly when final approval would be given. The 1969 WHO proposal would be considered by the Regional Committee the following week, and could not thereafter be considered by PAHO before the World Health Assembly met. The Executive Committee, under its new schedule, would not meet again until June or July 1968. However, such a meeting, coming as it would, after the Assembly, represented a logical sequence of events, and would make easier the consideration of future budgets. The Executive Committee should now be looking at the total program for 1968, but the present meeting would afford their best opportunity to consider the WHO proposals for 1969.

The CHAIRMAN agreed with Dr. Blood and said that there was still sufficient time to deal with the PAHO budget for 1969, which would not be prepared until the second half of 1968. In view of the large number of projects requested by the Governments, it would be wise for the Executive Committee to recommend to the Directing Council the adoption of a resolution requesting WHO to approve a more substantial allotment at its next assembly. To that end he believed it advisable to examine the proposed budget of WHO.

Dr. ORELLANA (Venezuela) said he believed it would be very laborious to make the study suggested in sufficient detail to determine what part of each project would be covered by its allotment. He referred, however, to Table 1 of Page 262 Second session 57th Meeting

Official Document 76, showing the WHO allotment, and requested Dr. Portner to provide a breakdown of the allotment.

Dr. PORTNER (Chief of Administration, PASB) said that the Secretariat would follow any course of action that the Committee desired. As Dr. Orellana had indicated, they were now considering an integrated budget, whose dimensions. had been indicated. The Committee could consider the financing or programming aspects, or pursue any other pattern of analysis it wished.

Table 1 of the integrated budget indicated a total figure for all funds of $26,216,527, reflecting an increase of $1,800,000, or 7.2 per cent. For the PAHO regular budget the movement was from $10,190,000 to $11,390,000, or an increase of 11.8 per cent. For the WHO regular budget, there was a movement upward of $542,000, or 10 per cent. The pattern of secondary funds would be delineated with equal facility.

Turning to the program budget, Table 2 set out, by type of program, the sums estimated to be needed, and the percentage they represented of the whole.

From Table 3 it was possible to obtain a breakdown of program expenditure into the three major areas: Advisory Services, Development of Human Resources, and Research.

Table 4 provided a personnel breakdown. For 1969 there were to be 16 additional regular posts, representing, as against the figure for 1968, an increase of a medical officer and four nurses, a decrease of one statistician, the addition of 10 other professionals, and the filling of two more local posts.

The table also provided comparative expenditures on fellowships, participants in seminars, and short-term consultants, with an indication of the state of balance of each particular project. The Committee would note that the number of short-term consultant months would increase from 962 in 1968 to 1,042 in 1969; that fellowships, academic and short-terr, would increase from 297 and 546 to 393 and 602, respectively, and that the number of participants in seminars and other meetings would increase from 320 to 414.

Table 5, Summary of Investment, provided a breakdown by object of expenditure, and by each of the 11 basic funds of the Organization.

Table 6 provided a summary of major programs by fund, if an examination of those was desired.

Dr. ORELLANA (Venezuela) requested information on the $5,987,000 WHO allocation for the Bureau. While he believed that that figure resulted from the consideration of projects presented by the countries and subjected to a process of planning by WHO for 1969, he said he would like more details on the subject.

Dr. HORWITZ (Director, PASB) said that the sum had been fixed by the Director-General of WHO after hearing the views of the Assembly. In that process, the Bureau received a ceiling figure to which it conformed in preparing its program and budget. The Director invited the Committee to once again examine Table 1 which showed the WHO allocations, including those of the Malaria Eradication Page 263 57th Meeting Second session

Special Account, which was woefully short of funds; the projects of the former Technical Assistance Program, the United Nations Special Fund, and other activities financed through the World Health Organization program. He underlined that a good portion of the total program was financed through WHO or the United Nations Development Program or represented the continuation of programs already established, such as malaria eradication, to which the smallpox eradication program had been added in 1966 as a result of an agreement to finance the world program through the WHO Special Account, with the assistance of PAHO funds in the Region of the Americas.

Dr. Horwitz added that the submission of the program for the Region of the Americas to be financed with WHO funds indicated that there was continuity of action and also that the system of assigning projects to specific United Nations agencies had been followed and new activities were the exception to the rule.

Replying to Dr. Acosta-Borrero's question concerning the budget items for "Administrative Direction" (Table 2, p. 7), Dr. Horwitz noted that according to that table the percentages allotted in the budgets for 1966-1969 to administrative services were very similar--5.8 per cent in 1966; 4.6 per cent in 1967; and 5.2 per cent in 1968 and 1969--which meant that the administrative expenses per se for operating the Bureau and the entire program had held rather steady.

Dr. BLOOD (United States of America) said that he would be happier if the proposed program and budget of WHO for 1969 were to be fully reviewed, as the PAHO budget for 1968 had been in April, but he was not sure that that was possible at the current meeting. If it was, it should be undertaken. Certainly, it would be desirable to provide the resources to enable that to be done for future WHO budgets.

At the Twentieth World Health Assembly, that Governing Body had, for the first time, concerned itself with proposing a general order of magnitude for the budget of the Organization almost two years in advance, and advised the Director- General on the percentage increase he should try to attain for 1969. It would be recalled that there had been much debate concerning not only the procedure itself but also the actual figure set, and that in the Committee on Program and Budget a 7 per cent figure had been agreed upon. Further, it came as a surprise to many when at the last plenary session of the Assembly the following day, a motion was been made to reopen the whole matter and the general order of magnitude for 1969 was then approved at 9 per cent. The Delegation of the United States of America first in the Committee on Program and Budget, and again in the plenary, pointed out that the general order of magnitude set was for guidance only and that its Government did not feel bound by any limitation over or under that figure; program needs and justifications would guide its vote on the proposed budget.

Therefore, the better the Regional Committee was prepared at the next Assembly to be able to say that the program and budget of the Region had been thoroughly reviewed by the Governments, and that it represented their decision, individually and collectively, the more strength it would have supporting it. Since they had before them an integrated budget, he seriously doubted whether an analysis of that kind was possible without an analysis also of the Page 264 Second session 57th Meeting

proposed program and budget of PAHO for 1969. Perhaps all they could do would be to study the program elements, by parts, and establish whether they represented the priorities in the judgment of the Committee. In that respect, the differing aims, priorities, and commitments of PAHO and WHO should be kept in mind. In general, both were directed to the promotion of health, yet each Organization had its own long-standing commitments. Unless the different parts of the integrated budget could be delineated, it would be impossible to say that the budget did, in fact, represent the a-ms, priorities, and commitments that the Governments had decided upon for the two organizations. Thus, though a detailed review of the 1969 WHO budget was probably impossible at the current meeting, they should consider its major elements and possibly seek a supplementary document that would provide information for consideration at the next meeting, to enable the Committee to see the elements of the budget in terms of sources of funds.

Dr. PORTNER (Chief of Administration, PASB) stated that the information would be made available at the earliest possible moment. He added that the integration over the last 15 years of the two separate presentations had tended to obscure their basic separateness. It was possible, however, to identify project expenditure by funds and to give the relative movements from year to year of each.

The CHAIRMAN asked the Director of the Bureau to furnish details concerning the projections for the 1969 proposed program and budget.

Dr. HORWITZ (Director, PASB) said that the analysis made in April covered not only the major categories of the PAHO regular budget but also details of the Bureau's activities. A special document had been devoted to expenditures, and various members of the Bureau's staff had described the different functions, relating them to the total program without specifying the source of the funds. That could be done any time that the members of the Committee so requested. Concerning WHO, the Bureau could prepare a similar working document setting forth each type of project within the various categories of the program budget. How- ever, a document such as that should not be included in the present proposed program and budget because what the Bureau sought at that time was an over-all program and budget. The important thing was to stress the scope and quality of the function and not the origin of the funds, whether they came from PAHO, Tech- nical Assistance, or any other source of financing.

The Director said that the Bureau was interested in having the Executive Committee review the tables in Official I)ocument 76 showing the activities programmed for 1969, including those to be financed by WHO, so that the Committee could give the Directing Council its opinion on the proposed order of magnitude and allocation of funds among the projects, and present any observations and comments it considered relevant. The Ececutive Committee might even inform the Council that it had studied the matter and, for future meetings, hoped to obtain more details that would enable it to make a better assessment of the document the Council was to submit to the Director-General of WHO.

Dr. Horwitz said that a specific proposal for the 1969 program and budget was being examnined. While the figures were subject to change, experience showed that the major aspects of those proposals followed a regular pattern. In drawing Page 265 57th Meeting Second session

up plans for the ensuing year, the Bureau did so in terms of projects rather than figures. What it produced was not a general order of magnitude but rather a program from which that could be deduced. The Executive Committee and Direct- ing Council were thus given some idea of the trend of the Bureau's activities and of the circumstances prevailing in each country, rather than a general figure. What the Executive Committee was now examining was the program of activities to be carried out, for which an over-all increase in funds was proposed.

The CHAIRMAN agreed with Dr. Horwitz and said that the Bureau, by providing a clearly-defined program, was justifying the financial support received from the World Health Organization.

Dr. BLOOD (United States of America) suggested that, for the moment, consideration be given only to programs clearly identifiable as of continental interest and for which WHO funds were committed. One financed especially by WHO was, of course, the smallpox eradication program. He asked whether the funds dedicated to that work for the next year or two would permit the dynamic leadership that would be required if the task were to be finished in the Americas by 1970 as many hoped it would be.

The world was looking to that particular focus of disease to be the first to be eradicated. There were three others, but he would certainly hope that PAHO could fulfill its part of the obligation in regard to smallpox within the next two years. That might provide a good starting point for their discussion.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) said it was somewhat difficult to reply to Dr. Blood's question, since some of the countries had delayed considerably in signing their agreements. Those with Argentina, Chile, Colombia, Ecuador, and Peru had already been signed, and the one with Uruguay was under negotiation. The agreement with Brazil was signed in 1965 but had not been implemented because there was no plan of operations and, according to the arrangement with WIiO, the Bureau 2ould not acquire the necessary equipment without such a plan. The plans of operations were already being received. The Brazilian plan had arrived 10 days before, the one from Colombia three days ago, and the one from Paraguay was still awaited. Procurement of the necessary equipment required larger amounts, which had been brought to the attention of WHO, although the lack of price information had made it impossible to specify the exact amount required, which it was hoped to do within two or three weeks. He regarded the amount available as inadequate, particularly because a considerable effort was being made, along with the field operations, to increase the production of vaccine and, especially, improve its quality. It had been necessary to procure new equipment for Argentina, Brazil, and Peru.

Dr. BLOOD (United States of America) asked whether the resources contemplated for 1968-1969 would prove adequate.

Dr. BICA (Chief, Communicable Diseases Branch, PASB) replied that in Brazil, for example, the smallpox eradication campaign had taken a new course and that the new authorities of the Smallpox Eradication Campaign were determined to follow a clearly defined plan of operations in regard to that problem. He said he believed that Brazil had the necessary resources for carrying out the 1968 program and only needed means of transportation, as did Argentina. Page 266 Second session 57th Meeting

Dr. BLOOD (United States of America) expressed his satisfaction that the resources available for Brazil appeared adequate. As he understocd the situation, that country presented the principal problem, epidemiologically, and he would assume its needs had top priority; that in an eradication programin, priority would be given to fighting the disease where the disease, in fact, was; and that if there were any surplus funds they would be used in support of programs elsewhere than in the area where thereal fight had to take place. He realized that many countries would like to have help in their immunization programs, lest smallpox cases should be brought in, by plane or otherwise, but the priority for that, he felt, would be lower than that assigned to the task of eliminating the source of infection, so that it would no longer be necessary to worry about such developments.

The campaign against malaria was probably another priority task in the Americas that the Committee might wish to discuss.

The CHAIRMAN said that the table relating to the proposed program and budget estimates showed practically no increase in the WHO funds for malaria for 1968 and 1969 and that since that program had high priority it would be necessary to apply for loans to external financing organizations.

Dr. HORWITZ (Director, PASB) recalled Dr. Portner's remarks at the first plenary session to the effect that during 1967 the first $200,000 from the PAHO Special Malaria Fund were being added to the PAHO regular budget. In the 1968 columns of Table 1 of Official Document 76 there was an item of $400,000 for malaria, which, together with $600,000 in the 1969 budget and $1,885,246 from the Special Fund made a total of slightly more than $2,400,000 in PAHO funds, plus the item of $600,000 appearirg under the WHO Malaria Eradication Special Account. The WHO contributions were tending to decline, which could cause a serious problem. The international allotments were based on the assumption that all the countries in the malarious area were concurrently carrying out their eradication programs according to the projected manner and schedule, but actually the opposite was more often than not the case and then the allotments could not be used in the projected amounts. That was impossible to foresee two years in advance. Despite that, the Bureau had the obligation to establish its budget on the assumption that all the Governments would advance their respective programs simultaneously. The decline in the PAHO Special Malaria Fund was offset by the resources included in the regular budget of the Organization according to the plan approved.

Dr. BLOOD (United States of America) asked whether the figures given indicated all sources of funds for the malaria campaign and whether they included special contributions, including research funds, for which there was perhaps as yet no firm commitment.

Dr. PORTNER (Chief of Administration, PASB) said that voluntary funds for the antimalaria campaign were estimated and specifically identified in the budget by fund.

Dr. BLOOD (United States of America) asked whether the program against malaria would have to be cut back because of the lack of adequate funds. He wished also to know whether the situation was cause for alarm or whether only a slight adjustment was involved and the program would call for a little less expenditure in 1968 or 1969. Page 267 57th Meeting Second session

Dr. PORTNER (Chief of Administration, PASB) said that the total of all funds for the eradication of malaria, in 1969, including voluntary contributions, aggregated $3,719,000. That was predicated on the expected continuation of funds from current sources. Any indication of a contraction in funds, such as had been given at Geneva, should act as a red alert that the item would be in question at some future date. One Government had made a generous voluntary contribution toward the activity, and hopefully that would continue. Should there be any question of that, the matter would warrant review. The need was identified as $3,752,000 for 1969 and to date there had been no indication that voluntary and related funds would be cut off for that year.

Dr. HORWITZ (Director, PASB) said that he preferred not to emphasize what Dr. Portner had just said and that judging by past experience there was little likelihood of a contraction of PAHO funds for malaria or of substantial changes in the WHO regular budget. On the other hand, there were some doubts concerning the funds from the Malaria Eradication Special Account of WHO since the voluntary contributions had been diminishing. It would probably be wise to adopt some decision at that time to meet that eventuality. However, the total malaria allocation proposed to the Executive Committee for 1969 had been budgeted on the basis of carrying out a continent-wide program, an assumption that was not materializing because in some countries the national programs were bogged down and there were areas in the consolidation phase that were returning to the attack phase. Some countries had obtained loans from the Agency for Interna- tional Development (AID) of the United States of America and had managed to maintain a sort of systematized control, but not eradication. If a Government did not make its entire counterpart investment in an eradication program, the Organization naturally found it difficult to maintain personnel in that country, since it would probably be more useful in other countries. During 1968 it would probably be possible to see if there was any reduction in the WHO malaria funds and if that required some adjustment in those of PAHO, in which event the Executive Committee might consider the matter at its meeting in 1968. He believed that the Executive Committee and the Directing Council should indicate the current needs of the malaria eradication campaign to the World Health Organization.

The CHAIRMAN asked Dr. Horwitz for information on the status of the Aedes aegypti eradication program and on the financial efforts by PAHO and WHO to advance that program.

Dr. HORWITZ (Director, PASB) replied that some of the A. aegypti eradication programs were financed with Technical Assistance funds and others with PAHO regular budget resources. The details for each country were shown in the document under consideration. The funds came from various sources and the amounts proposed reflected the present requirements. The Bureau had made an offer to the Governments of El Salvador, Guatemala, and Brazil to defray the cost of the necessary insecticides. In the case of Brazil, arrangements were being made to use Technical Assistance funds, which was also the intention in the case of El Salvador, especially to provide insecticides, pumps, other equipment and the services of consultants, with the understanding that the Govern- ments would provide the personnel for the spraying operations.

The Director said that it might be necessary to increase that item and, perhaps, provide more funds in the future, although the increase would not be Page 268 Second session 57th Meeting substantial. Reference would be made to that situation at the XVII Meeting of the Directing Council so that the Governments might decide if there was a need to assume a genuine commitment through an international instrument to eradicate the vector from the territory of the Americas.

Dr. ORELLANA (Venezuela) said that the major efforts being made on the international level to eradicate such diseases as malaria, smallpox, or yellow fever were often not matched by the Governments at the national level. In any eradication program a stage was eventually reached in which major prob:lems arose, with the result that the Governments and ministries of health were somewhat discouraged. At that moment it became increasingly difficult to finance the cost of the program and, even more so, to obtain an increase for the final eradication stages. Some countries had yet to launch a serious attack against malaria, while others, having reached the maintenance or consolidation stage, had not been able to achieve eradication for lack of funds.

The problem was more or less the samne in the case of A. aegypti, and even worse in some instances owing to the enormous technical difficulties involved in the eradication of that vector. Insofar as those two types of eradication activities were concerned, the proposed budget reflected a situation which was common to all the countries, and it was impossible to foresee what might happen in five or 10 years if eradication had not been achieved. The basic purpose of the Organization in investing in those programis was to encourage the Governments themselves to increase their contributions and prepare serious programs for eradication within a fixed period.

Dr. BLOOD (United States of America) said that the foregoing remarks of the Committee members were very important and made one wonder whether it would be wise to think in terms of providing additional sizable funds for those programs, if not for the years presently under consideration, for the following years, even to the extent of not increasing other activities, but rather finishing some of the tasks that had been started. Cost analysis studies of what that meant to the Hemisphere as a whole and to each individual country might already have been done, but he had no knowledge of them. His own country, for instance, benefited from the fact that Mexico did not have smallpox.

Improvement of the malaria situation in one country helped its neighbors also. In those eradication programs it was not a question of spending the Organ- ization's money in the countries that still had the problem to the benefit of those countries alone, and the fact that El Salvador, Guatemala, and Brazil now had A. aegypti again was of great concern to all. Probably, if it were known what had been invested already it would be apparent that the only course open was to go forward. After allowing for the effects of the inflation, it would be interesting to know what had been accomplished thus far, and what it would now cost if that work had to be done again. Consideration should also be given to the cost of allowing conditions to revert to their natural state. A. aegypti would eventually fill in the whole area of its natural habitat and spread to the point where it was contiguous with jungle yellow fever areas. There would be "spillouts" of jungle fever into the A. aegypti areas and urban populations, requiring the constant maintenance of vaccination programs.

He wondered what it would cost to vaccinate, and keep vaccinated, every person in the Americas if A. aegypti were to revert to all of its former natural Page 269 57th Meeting Second session boundaries. Such figures would be so emphatic that it might help many members to convince their Governments of the need to move ahead with all speed to eliminate the problem once and for all. He was not sure that such a study was something the Organization should undertake, but he would welcome comment on the possibility. It would be an exercise of great value to all of their countries.

Dr. HORWITZ (Director, PASB) said that the type of study mentioned by Dr. Blood was obviously very useful but that, in the case of A. aegypti the Bureau was obliged to meet a commitment assumed 20 years ago. In the A. aegypti eradication program in Brazil it was necessary to make more than 617 million house visits, and Dr. Fred L. Soper, who was then in charge of that work, estimated the cost of disinfection at $0.40 per house, which meant that Brazil had spent some $200 million in eliminating the vector. If by misfortune it should spread from Belém, where it was now found, the cost of eliminating it would undoubtedly be higher. An estimate of the cost, which would be useful for economic purposes, should lead to something more than further insistence on the need to take action as rapidly as possible to prevent the spread of the vector, since it was fully recognized by now that total eradication should be achieved as soon as possible. The Bureau had been repeating that resolution year after year. Some countries had not fulfilled their commitments, while a large number of countries and territories had done so, but unfortunately some of them had been reinfested precisely because the efforts had not proceeded concurrently.

Dr. Horwitz repeated that the task should be terminated and that since there were varying degrees of optimism, the temporary setback would probably serve a useful purpose by awakening the hemispheric concern so evident at the present meeting which was likely to make itself be felt even more at next week's meeting of the Directing Council. Under the circumstances, he wondered what was the proper role for the Organization. According to information available to the Bureau, $40'million were being spent each year on malaria eradication. The entire budget being examined by the Executive Committee would not be sufficient to meet that need, but would only cover a half or about 60 per cent. In that area, as in A. aegypti eradication, the task was essentially one for the Govern- ments, unless there was a sufficient amount to replace the national budgets. He believed that the Organization had been playing its proper role by providing technical advice, insecticides, and equipment of various kinds, helping to train technicians, etc. It was up to the national governments to provide the personnel, as they would otherwise not be meeting their responsibilities. The task of the Organization was to serve as a catalyst and a source of supplemental assistance, and the amounts invested had not been satisfactory. If at present all the countries where the vector was present were to provide the necessary funds, it would surely be possible to satisfy the international requirements by increasing the amounts currently devoted by the Organization to A. aegypti by 20 to 30 per cent, but the problem and the responsibility lay with the Govern- ments. It was they that should make the major investment.

Dr. BLOOD (United States of America) said he had a specific case in mind when he had asked for commrent, thinking that if it could be useful for his country it prcbably could be useful for others also. Those concerned with public health, though convinced of the need to fulfill commitments and move forward, sometimes lacked the documentation and eviderce with which to convince budget authorities of that need. An analysis of the kird he had suggested would be very helpful. Page 270 Second session 57th Meeting

Individual Governments could undertake the task, but any information made available by the Organization would be useful to all. Certainly, the Government of his ccuntry would be happy to collaborate in its preparation.

The session was suspended at 4:00 p.m. and resumed at 4:25 p.m.

Dr. HORWITZ (Director, PASB) observed that one of the Directing Council documents contained information on the amounts of investment required to eradicate malaria, and another on the requirements for eradicating A. aegypti. In both documents, the figures were such as to exceed any possibility of obtaining them through international investment.

In regard to A. aegypti, the Conference on the Eradication of Aedes aegypti in the Americas, held in Washington (3-5 April 1967) had estimated the total cost of eradicating the vector at $79,218,000, taking into consideration the countries and territories where it still existed; the number of houses in infested areas was almost 7 million;! the campaign would take from two to six years, depending on the country involved; and the amount for insecticides would be $1,541,000.

A 30 to 40 per cent increase over the present figures in the budget of the Organization would probably suffice, provided the Governments and territories made their required investment. Lik.ewise, in the case of malaria it would be necessary to invest a total of $301 million between 1967 and 1971. Of that amount, $283 million would come from the Governments and the remaining $18 million from the international organizations. The average over-all expenditure per year would therefore be $60 million, almost three times the total PAHO budget.

The problem was, therefore, national and not international, and, in Dr. Horwitz's opinion, the Bureau had acted prudently in assigning funds to those countries whose Governments had made the investments required to accelerate eradication of the disease, in the case of malaria, or the vector, in the case of Aedes aegypti.

Dr. BLOOD (United States of Almerica) said that there were high priority eradication programs which lent themselves to the kind of treatment the Commit- tee was able to give at the present meeting. He would be very much interested if consideration could be given to What might happen if either in the Regional Committee or in the World Health Assembly it was found difficult to obtain approval for everything that was listed in the budget. If the Assembly were not convinced that there was reason to increase the 1969 budget by more than the 9 per cent order of magnitude agreed upon earlier, presumably it would mean a reduction in the funds of most of tfe Regions, including perhaps the Americas. Assuming that there were certain priority and long-term commitments, he wondered whether it was possible at that stage to say what activities were most likely to be cut back. He could not imagine a general percentage decrease in every program. Undoubtedly, that process would be selective.

Dr. HORWITZ (Director, PASB) replied that the increase proposed in Table 1 of Official Document 76 (p. 6), under the WHO regular budget, was only 10 per cent and that the World Health Assembly had approved an increase of more than 9 per Page 271 57th Meeting Second session cent, so that the figures in Official Document 76 were very close to the increase approved by the Assembly.

In the event of a reduction it would be necessary to know the criterion of the Director-General as to the manner of reducing the total program. That criterion could be to maintain the field program intact and charge the entire reduction to Headquarters, a possibility that the Bureau would, of course, be glad to accept. But the Director-General's criterion might also be that of cutting back the entire program, including Headquarters, and the Regional Of- fices, and the projects. To show how the Organization would proceed in that case, the Director referred to Annex 4 (p. 539) entitled "Projects Requested by Governments To Be Implemented if Funds Become Available." There a number of projects were marked with an asterisk which indicated: "In addition to budgeted amounts." In other words, the Organization preferred in practice to carry out a large number of activities, including many if not all the activities requested by the Governments, instead of concentrating on a few programs. In view of the Region's stage of development in the field of health, it was difficult for the Governments to concentrate oh only a few activities. In the event of such a reduction, the Organization would obviously have to maintain such priority activities as smallpox or A. aeFypti eradication and would undoubtedly make a country-by-country study to determine those fields in which action was not absolutely essential and where a reduction could be made.

The CHAIRMAN expressed the hope that not only would no reduction take place but there would actually be an increase in 1969. It was that impression that should be conveyed to the WHO when the time came to defend the views of the Hemisphere in Geneva. The Chairman said that he also hoped that the sense of that discussion would be reflected in the resolution to be adopted on the budget for 1969.

Dr. BLOOD (United States of America) agreed that the resolution should mention that the Committee had looked into the content of the proposed 1969 WHO program and budget, in general terms. That would be quite consistent with leaving it to the Directing Council to refer the document back to the Committee for more detailed analysis later. The resolution should not address itself to the approval or disapproval of the Organization's presentation at that particular stage. He felt the Committee members were not in a position at that moment to pronounce themselves upon the detailed content of the proposed budget.

The CHAIRMAN said that if there was no further discussion a working party would be appointed to review the document on Item 16 of the Directing Council agenda, which was Item 5 of the agenda of the Executive Committee (Resolutions of the Twentieth World Health Assembly of Interest to the Regional Committee). The working party would be composed of Dr. Acosta-Borrero (Colombia) Dr. Calvo (Panama), Dr. Blood (United States of America), and Dr. Arreaza Guzmán (PASB).

ITEM 4: FINANCING OF THE PAN AMERICAN FOOT-AND-MOUTH DISEASE CENTER

Dr. ARREAZA GUZMAN (Assistant Director, PASB) introduced the item and referred to Document CE57/2, l/ prepared in compliance with Resolution XVIII_/ _/ Mimeographed document. 2/ Official Document PAHO 79, 44-46. Page 272 Second session 57th Meeting of the 56th Meeting of the Executive Committee. He explained that a number of important questions had arisen since that time. First, a project prepared jointly by the Secretariat of the OAS and the PASB referring, among other things, to the Executive Committee resolution and the need to establish a firm basis for financing the Pan American Foot-and-Mouth Disease Center had been submitted to the Fifth Annual Meetings of the Inter-Arierican Economic and Social Council (Viña del Mar, Chile, 12-24 June 1967). The IA-ECOSOC meeting approved a resolution / requesting PAHO to administer t;he Center and submit annual reports to IA-ECOSOC concerning the activities of the Center and its program and budget.

Second, the Inter-American Committee on the Alliance for Progress (CIAP) had been authorized to determine in final form at its Thirteenth Meeting, being held in Rio de Janeiro, Brazil (29 September-2 October), acting in conjunction with the OAS and PAHO, the system to be used in financing the Pan American Foot- and-Mouth Disease Center. That decision was based on the recommendations in the report of the Seoane-Palacios Mission, which was appended to Document CD17/19.4/ Because of the difficult financial situation of the Center, it was necessary to make an appeal for voluntary contributions by the countries. Those made it possible to cover at least the deficit for fiscal year 1966-1967, but the problem of course persisted with respect to the budget for 1967-1968. Meanwhile, IA- ECOSOC allotted $584,250 to the operation of the Center, but that amount had proved inadequate and a new deficit would arise during the year. There was no question of reducing the Center's activities even more because that would involve a risk of reducing its effectiveness, since its field services were already curtailed and a further reduction of activity would lead to the dispersal of a very high quality staff which would be d-fficult to replace at a given time.

Dr. Charles L. Williams, Jr. was attending the CIAP meeting as Deputy Director of PASB and would report to the Directing Council on the conclusions reached.

Dr. Arreaza Guzmán then read the following resolution of IA-ECOSOC:

"The Fifth Annual Meeting of the Inter-American Economic and Social Council at the Ministerial Level,

WHEREAS:

The "Report on the Study on the Stable and Permanent Financing of the Pan American Foot-and-Mouth Disease Center," carried out under Project 77 of the Program of TecIlaical Cooperation of the O.AS (Doc. CIES/1135, April 18, 1967), contains, in addition to a description of the national campaigns being carried out against foot-and-mouth disease in the Americas and of the Center's participation in these efforts, conclusions that make it clear that foot-and-mouth disease has serious effects on the economies of the American countries, and that consequently there is an urgent need to control the disease and to ensure the stable and permanent financing of the Center;

3 Resolution 12-M/67. OAS Official Records,OEA/Ser.H/XII.14 (Eng.), 42-44. J Mimeographed document. Page 273 57th Meeting Second session

Both the Inter-American Development Bank and the Inter- national Bank for Reconstruction and Development have taken measures to support with external financial resources, national and multinational programs requiring the continuing technical services of the Center;

The governments of countries both in the infected areas and in the area free of the disease have stated their decision to contribute to the stable and permanent financing of the Pan American Foot-and-Mouth Disease Center through specific contributions, irrespective of any other contributions from public or private agencies for specific activities,

RESOLVES:

1. To appeal to the governments of the countries affected by foot-and-mouth disease to take prompt action in their campaign against this disease, with a view to controlling and eliminating latent foci through the broadening and intensification of national campaigns, which must be coordinated at the inter-American level.

2. To request the Pan American Health Organization to continue to take technical and administrative responsibility for the Pan American Foot-and-Mouth Disease Center in accordance with the standards set by the IA-ECOSOC. Besides its program and budget, the Pan American Health Organization will present an annual report on the Center's activities to the IA-ECOSOC, through the regular channels.

3. To thank the governments that have agreed to cooperate in the permanent and stable financing of the Center, in accordance with the proposal made, and request that those governments that have not yet reconfirmed their support of this financing do so as soon as possible.

4. To authorize CIAP to determine at its next meeting, jointly with the Pan American Health Organization and the OAS Secretariat, and on the basis of the replies of the governments, the system of contributions for financing the Pan American Foot-and-Mouth Disease Center and the procedures for putting it into effect before July 1, 1968.

5. To ensure that the Center receives adequate assistance from the Special Development Assistance Fund until the new system goes into effect.

6. To urge the national and international lending institutions and the livestock industry in the various countries to continue providing financial support both to the Center and for the national and international programs being carried out for the control of foot-and-mouth disease. Page 274 Second session 57th Meeting

7. To request the Center to take the following criteria into consideration in carrying out its operations:

a. To make adequate provision in its program for the particular needs of each geographic area with respect to the prevention and eradication of foot-and-mouth disease, taking into account chiefly the impact of the disease on the economy of the countries.

b. To intensify the preparation, increase the effectiveness, and evaluate the effects of the biologicals used in the campaign against foot-and-mouth disease.

c. To present to the governments, before the next annual meeting of the IA-ECOSOC, a study that sets forth the technical criteria to be considered in determining when an area is free of foot-and-mouth disease.

8. To recommend that the Center encourage periodic regional meetings of the Ministers of Agriculture or their representatives in order to coordinate the campaigns being carried out in the respective countries against foot-and-mouth disease.

9. To congratulate the mission conducted by Edgardo Seoane and Carlos Palacios and their valuable contribution for the future development of the Center.

Dr. ACOSTA-BORRERO (Colombia) inquired what was the exact meaning of the expression "standards set by the IA-ECOSOC" in paragraph 2 of the resolution.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) said that to date the Center had been conducted in accordance with the general policy lines of PAHO. He believed that when the Organization presented its annual report to IA-ECOSOC, the latter would make appropriate observations that would enable the Center's program to be guided by those directives or "standards."

The CHAIRMAN said that if the Organization was to assume responsibility in accordance with those standards it would be well to know what they were and whether they had been more or less determined.

Dr. BLOOD (United States of America) said the English version did not present any difficulty, and seemed to read. logically: "To request the Pan American Health Organization to continue to take technical and administrative responsibility for the Pan American Foot-and-Mouth Disease Center in accordance with the standards set by the IA-ECOSOC."

Dr. PORTNER (Chief of Administration, PASB) pointed out that the supporting document contained the phrase: "IA-ECOSOC has established general policies governing the Program of Technical Cooperation and has approved the Budget of the Center as part of that program." Thie resolution was in line with what was indicated there. Page 275 57th Meeting Second session

Dr. BLOOD (United States of America) said he welcomed the continued interest of IA-ECOSOC in the Center because its members had economic responsibility in their respective countries, and the success of the Center would be in direct proportion to the number of national programs of control and event- ual eradication that would be developed. Those would be- very costly and would need the full approval of the national delegates in the IA-ECOSOC. As long as they were not dictating the technical activities of the Center, he would welcome their continued interest and would hope that they would be attracted to the Center's work.

The CHAIRMAN agreed with Dr. Acosta-Borrero that the expression "standards set by the IA-ECOSOC" implied the existence of a relationship between continued technical and administrative responsibility and certain directives presumably established beforehand, since the term "set" seemed to denote complete action.

Dr. ACOSTA-BORRERO (Colombia) said that that interpretation was supported by the fact that the Organization was required to submit periodic reports, which were almost always required for the purpose of verifying whether pre- existing standards had been met. He was also concerned by the technical aspect of the matter. The division of responsibility would, at a given time, permit IA-ECOSOC, whose objectives were almost directly opposed to those of PAHO, to lay down a series of technical standards for the Pan American Foot-and-Mouth Disease Center, through PAHO.

Dr. ARREAZA GUZMAN (Assistant Director, PASB),referring to Dr. Blood's remarks on IA-ECOSOC's interest in the Center, said that one of the decisions taken at Viña del Mar was that, because of the economic importance of the problem, it was incumbent on IA-ECOSOC to maintain its relationship with the Center and its activities, particularly in connection with the economic aspects.

Dr. HORWITZ (Director, PASB) said he was grateful to Dr. Acosta-Borrero for having drawn the attention of the Committee to the phrase, which had also caused some concern to the PASB representatives attending the meeting at Viña del Mar. They had, perhaps, related the phrase to paragraph 5 of the IA-ECOSOC resolution, which indicated that the Center was to receive adequate support from the Special Development Assistance Fund until the new system went into effect. Since the program and budget of the Special Fund were studied by CIAP and were approved in final form by IA-ECOSOC, the approval of the resolution meant that the activities of the Center would continue to be subject to the authority that now approved its budget. For that reason, the PASB representatives considered that phrase completely appropriate and in line with the regulations of CIAP that obliged the Organization to render an accounting of all its activities financed with those funds.

Dr. Horwitz observed that experience in the past 15 years showed that the organs of the Inter-American System concerned with that problem had always accepted the technical reports of the Organization and had never interfered with the development of the Center's activities. Three years ago the Special Develop- ment Assistance Fund had made an evaluation of the program through a group of outstanding experts. In his report to the Secretary General of the OAS, the head of the evaluation group had commended the work of the Pan American Foot-and-Mouth Page 276 Second session 57th Meeting

Disease Center. That was the only time in which the OAS, exercising its legiti- mate authority, had intervened in the work of the Center, and it had done so with very useful results. Therefore, until the system proposed by the Seoane-Palacios Mission was approved, and so long as PAHO had the administrative responsibility, that provision would remain in force. However, Dr. Horwitz agreed with Dr. Blood that even when the requirement no longer was operative, it would be very useful to keep the IA-ECOSOC well informed on the problem, which, by its very nature, greatly affected the general economy of the Region. Actually, as Dr. Arreaza Guzmán had said, the phrase did not concern, in the sense of preoccupy, the representatives of the Bureau, who had interpreted it in the straightforward sense.

Dr. ORELLANA (Venezuela) said that, notwithstanding the explanations given by Dr. Horwitz, he was still concerned regarding the relationship between the Center, CIAP, and IA-ECOSOC in the immediate future. Appendix 3 to Document CD17/19 (pp. 2-3) contained a definitive plan for financing the Center, as presented to the Directing Council. It was preceded by a draft resolution, in the body of the report, which established the quotas to be paid by the Governments. On further examination the plan of financing was found to be also a plan of operations. The plan stated that the Center would be administered by the Organ- ization and, in paragraph 4, that that administration would be conducted in accordance with standards already set or to be set in the future by IA-ECOSOC. Then, in paragraph 10, the plan provided that PAHO would submit annual reports to CIAP and IA-ECOSOC, through regular channels, on the activities of the Center and on its program and budget, and that CIAP would reserve the right to formulate observations on its activities.

Therefore, the actual decision was that although both CIAP and IA-ECOSOC would withdraw their financial support from the Center they would retain authority to give their opinion on its technical and administrative operation. If that program was carried out, the Center would become a technical and administrative dependency of the Organization. Dr. Orellana agreed with Dr. Blood that it would be useful for the group of economists in CIAP and IA-ECOSOC to remain informed and maintain a continuing interest; in an organization formerly under their authority, but he questioned the advisability of maintaining a continuing relationship after they ceased to be responsible for matters of finance and administration.

Dr. HORWITZ (Director, PASB) questioned whether the Executive Committee would want to include that consideration in the resolution to be approved on the item. He believed there would be sufficient time to revise the text of the resolution after the system of financing had been definitely established and the Organization was made entirely responsible for the Center.

Even if the expression "in accordance with the standards set by the IA- ECOSOC" were deleted, it would continue to be important for the organs of the Inter-American System to be informed of the status of the serious problem of foot-and-mouth disease.

Dr. ACOSTA-BORRERO (Colombia) asked what kind of information the Bureau provided to the OAS and whether that procedure referred only to the Pan American Foot-and-Mouth Disease Center or whether there was a continuing flow of Page 277 57th Meeting Second session

information and a regular exchange of views and evaluation with respect to other organizations as well.

Dr. HORWITZ (Director, PASB) said that the representatives of the Organ- ization of American States participated in all the meetings of PAHO and were therefore familiar with all the background material. Furthermore, a document summarizing the annual report to the Directing Council was submitted to the Secretary General of the OAS for inclusion in his own annual report on the activities of the Pan American Union. Naturally, the Secretary General could inquire at any time concerning any activity in which he was interested, including, of course, the Pan American Foot-and-Mouth Disease Center, which operated with OAS funds.

The report on the work accomplished had to be very carefully thought out if the purpose was to explain the reasons for requesting a given budgetary appropriation. In the case of the Center that had been particularly true in the last three or four years, when it had not been possible to obtain the entire amount of funds the Organization had requested from the Special Development Assistance Fund.

Dr. Horwitz observed that the relationships had been so cordial that no problems at all had arisen and, on the contrary, a harmonious and, in some cases, joint program had been accomplished. For instance, the efforts being made to achieve better coordination of social security benefits with those provided by the ministries of health were being advanced in close cooperation with the Depart- ment of Social Affairs of the Pan American Union.

Dr. BLOOD (United States of America) said that paragraph 5 of the resolution referred to the need to ensure "adequate" assistance for the Center. Dr. Orellana had indicated that it appeared the Center would not have sufficient funds for 1967-1968. The resolution called for the Special Development Assist- ance Fund to provide adequate assistance until the new system went into effect next year. He wondered whether the word "adequate" really meant adequate, or whether it meant "minimal." Also was there anything that the Organization could do in that respect even though only an interim period was involved. It would be helpful if "adequate" were to really mean what he understood it to mean.

Dr. HORWITZ (Director, PASB) replied that that question of "adequacy" had given rise to serious concern in the Bureau, so much so that the proposal submitted to CIAP was that the system of the Seoane-Palacios Mission be applied as of 1 January 1968, and that the OAS contribution be kept at its current level. That proposal was based on three arguments. The first was that the funds for 1968 would not be collected all at once, but rather in the course of the year; the second was that it was necessary to establish a Working Capital Fund; and the third was based on the importance of accumulating a reserve fund to cover the entitlements of the international staff, as in the case of PAHO and WHO. That proposal would have ensured proper protection for the entire system. Un- fortunately, one of the delegates felt that the proposal was probably based on an over-estimate. That was why the resolution had been drafted in its present form, which provided for the Center to operate with funds from the OAS Program of Technical Cooperation during the fiscal year 1967-1968 and in accordance with the plan proposed by the Seoane-Palacios viission beginning in July 1968. In Page 278 Second session 57th Meeting practice, any shortage of funds could be covered by appealing for voluntary contributions or making advances from the regular budget. That was actually done in the 1966-1967 fiscal year, when the Government of the United States of America generously announced at the 56th Meeting of the Executive Committee that it was prepared to make a contribution of $140,000 provided another $70,000 could be obtained from the Latin American Governments, which fortunately was received.

Mr. REY ALVAREZ (Observer, Inter-Ainerican Development Bank) reaffirmed the IDB's support for the Pan American Foot-and-Mouth Disease Center. That was one more field in which the interests of PAHO and the Bank coincided, as they did in the case of environmental sanitation and preventive medicine. The decisions taken by the IDB and the World Bank in support of preinvestment studies in that field were mentioned in Resolution XVIII of the 56th Executive Commit- tee Meeting and in the IA-ECOSOC resolution just read.

Mr. Rey Alvarez emphasized the interest of the IDB in the problem of foot- and-mouth disease control. In the first place, that activity should be viewed in the context of agricultural and livestock development, a matter given considerable prominence at the meeting of the Board of Governors of the Bank in April and known already as the "Assembly of Agriculture." That support by the Bank was also regarded as pertinent to the improvement of nutrition, particularly the intake of animal protein. Finally, in the broader action framework, foot-and- mouth disease control programs were a spur to integration. Foot-and-mouth disease was currently an obstacle to the development of agriculture and livestock. In its integration efforts, the Bank hoped, among other things, to aid in the elimination of frontiers. Those separating the countries where foot-and-mouth disease was prevalent from countries free of the disease had created some problems.

Mr. Rey Alvarez said there were three possible courses of action by the Bank in that matter. The first lay in the Bank's intention of applying the new system of preinvestment, for which two sources of financing were available, the Preinvestment Fund for Iatin American Integration, on the multinational level, and, on the national level, the funds being established in various countries such as Venezuela. The second course of action was to continue the policy agreed upon and coordinated.with CIAP, of which the Bank was an advisory member.

But the most effective course was the third, which was based on the moral persuasion the Bank could exert on the Govrernments when it received their applications for livestock development loans and was in a position to impose ccntract conditions relating to measures for the control of foot-and-mouth disease. One such condition could refer to the amount of the contribution the country in question would make for the operation of the Pan American Foot-and-Mouth Disease Center.

The session rose at 5:30 p.m. THIRD PLENARY SESSION Friday, 29 September 1967, at 9:10 a.m. Chairman: DR. ALBERTO E. CALVO (Panama) Later: DR. DANIEL ORELLANA (Venezuela)

ITEM 4: FINANCING OF THE PAN AMERICAN FOOT-AND-MOUTH DISEASE CENTER (continuation)

Dr. ACOSTA-BORRERO (Colombia) stated that, owing to the importance of the problem, the Executive Committee should not restrict itself to taking note of the resolution of the IA-ECOSOC on the Pan American Foot-and-Mouth Disease Center, but should recommend that the Directing Council study the matter in greater depth or adopt some specific measure.

The CHAIRMAN felt that the Committee could examine the problem more if it had detailed information on the response of the Governments concerning their quotas for financing the Center. He asked Dr. Arreaza Guzmán to report on the situation.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) said that the ietters from the Governments that had accepted the proposal of the Seoane-Palacios Mission were included in Document CD17/19.1/ He explained that the Governments of the Caribbean area had later adhered to the proposal and only the Governments of the United States of America and Mexico had yet to announce their decision.

The willingness of the countries to contribute on a continuing basis in the interest of financial stability for the Center was evidenced by the voluntary contributions made by a number of countries: Brasil, $40,000; Colombia, $3,750; Dominican Republic, $3,000; Panama, $3,750; the United States of America, $140,000, and Venezuela, $25,084.

Dr. ORELLANA (Venezuela) thought that the Excecutive Committee should recommend to the Directing Council the adoption of the plan contained in Annex III to Document CD17/19 for the financing of the Center.

Dr. BLOOD (United States of America) was pleased to have had the opportunity of being brought up to date on the situation of the future financing of the Center. The information provided would be of value prior to discussion in the Directing Council, but any action would have to come from the Council itself. However, that would depend in part on the decisions taken by CIAP at its Thir- teenth Meeting in Rio de Janeiro. In view of that, and because the Executive Committee had already acted on the matter at its 56th Meeting, ./ he suggested l/ Mimeographed document. 2/ Resolution XVIII. Official Document PAHO 79, 44-46

- 279 - Page 280 Third session 57th Meeting that note be taken of the report, without approving another resolution, though mention might be made of both the resolution and the results of the deliberations in the Chairman's report to the Council. The Government of the United States of America would prefer to wait for information on the decisions of the CIAP meeting.

The CHAIRMAN, referring to the IA-ECOSOC resolution, stressed the importance of the decision requesting PAHO to continue exercising technical and administrative responsibility for the Center. He believed that the Committee should find some way of expressing its satisfaction and bringing that decision to the attention of the Directing Council.

Dr. ORELLANA (Venezuela) inquired whether the plan currently being considered at the CIAP meeting was different from the one appearing in the afore- mentioned document.

Dr. ACOSTA-BORRERO (Colombia) requested information on the system of quotas referred to in the IA-ECOSOC resolution.

Dr. HORWITZ (Director, OSP) said that the Chairman of CIAP had agreed to make the topic of the Pan American Foot-and-Mouth Disease Center the first item of the agenda so that the PAHO Directing Council would know what decision had been taken when it examined the question. Furthermore, the PASB had sent representatives to the CIAP meeting to provide information on any matter regarding the Center.

The 11 items appearing in the document referred to were those which the three institutions had agreed to submit to CIAP for consideration. In regard to quotas, the scale was based on the proposal of the Seoane-Palacios Mission that the scale of quotas be in accord with the system used by the OAS, and that it cover an initial budget of $1,200,00C and a slightly higher budget for the period beginning in July 1968. As the Chairman and Dr. Arreaza Guzmán had pointed out, a large majority of the countries of the Hemisphere had accepted the system, some had already included appropriations in their 1968 budgets for that purpose, and others had generously provided voluntary contributions to cover the 1966-1967 deficit arising from the gradual diminution of the funds made available by the Program of Technical Cooperation of the OAS.

Referring to Dr. Blood's observations, the Director noted that it was traditional in the Organization to adopt a resolution expressing appreciation to countries making voluntary contributions, since the matter was of sufficient importance to be placed on record.

Dr. ORELLANA (Venezuela) asked if there was any possibility that CIAP would make substantial changes in the ll--point plan when it examined it. If such were the case, the Committee could not, at that time, express its support of the plan in a resolution addressed to the Directing Council.

Dr. HORWITZ (Director, PASB) was confident the plan would be approved but was in no position to offer assurances. In any case his confidence was justified by the importance given the problem, the repeated expressions of interest by the IDB, the public and private statements of senior officials of the International Page 281 57th Meeting Third session

Bank for Reconstruction and Development concerning possible loans for foot-and- mouth disease control programs and, particularly, by the urgent need to save the enormous amount of animal proteins lost in a region where 750,000 more children below age five died each year than in the United States of America and Canada, and where the vast majority of those deaths could be prevented through adequate nutrition. Considering those circumstances, the provision of $1,200,000 by 29 Governments would not appear to pose a tremendous problem. The Director hoped that those facts would be borne in mind by the members of CIAP and would lead them to adopt a resolution permitting PAHO to implement the decision taken by the 56th Meeting of the Executive Committee.

The CHAIRMAN said that the question of financing the Pan American Foot- and-Mouth Disease Center could not be regarded separately from the problem of the disease itself. His own country viewed that problem with serious concern and was using the Darien Gap as a buffer region to protect the spread of the disease in the Hemisphere. He believed the Excecutive Committee shared that concern and that that should be recorded in the minutes.

Dr. POITEVIN (Guatemala) said that the Government of his country was deeply aware of the need to attack the problem of foot-and-mouth disease. Although free of the disease, it was anxious to cooperate in the control activities because it needed to preserve the sources of nutrition, undernourishment being one of the major scourges in the country. Guatemala was therefore prepared to make its contribution to the program and the ministry of agriculture would include an allotment in its budget.

Dr. ORELLANA (Venezuela) regarded the solution submitted to CIAP as extremely satisfactory and was convinced that CIAP would approve the plan. He therefore felt that the Executive Committee, either in the report of its Chair- man or in a resolution, might appropriately submit a recommendation to the Directing Council on acceptance of the plan as presented.

Dr. BLOOD (United States of America) agreed with the Director's suggestion that special contributions of Governments be acknowledged in the form of a resolution. He asked whether the Committee could recommend that the plan of financing be transmitted to the Council for consideration, but that it take into account the decisions that might be taken by CIAP on the matter.

The CHAIRMAN said that the matter had been sufficiently discussed and appointed a working party composed of Dr. Blood (United States of America), Dr. Orellana (Venezuela), and Dr. Arreaza Guzman (PASB) to prepare a draft resolution.

ITEM 5: RESOLUTIONS OF THE TWENTIETH WORLD HEALTH ASSEMBLY OF INTEREST TO THE REGIONAL COMMITTEE (continuation)

The CHAIRMAN reported on the meeting of the working party established to study the document concerning the item and to prepare a recommendation with regard to their examination. The working party had concluded that some of the resolutions did not need to be examined by the Committee, which could simply Page 282 Third session 57th Session take note of them, but others would have to be considered. He requested the Secretariat to present a brief report before the discussion was opened.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) began by referring to Reso- lution WHA20.14 (Malaria Eradication Program) 3/ and describing its highlights. He attached particular importance to paragraph 7 of the operative part, where the Director-General was requested to determine the most suitable means of conducting a new study on the global strategy for malaria eradication and to report to the Twenty-First World Health Assembly on the matter. That was a point of special importance for the Hemisphere.

The CHAIRMAN referred to paragraph 4 of the operative part of the resolution regarding the support of the malaria eradication programs by the international organizations. He recalled that an attempt had been made at first to focus attention on the African programs but that, owing to statements by various delegates of American countries, the phrase "and all other areas where malaria retards the economic and social development" had been added.

Dr. BLOOD (United States of America) asked whether any decision had been taken by WHO Headquarters on the manner in which the evaluation and re-analysis of the global strategy was to take place.

Dr. HORWITZ (Director, PASB) said that while attending the Fourth Nation- al Health Conference in Brazil he had spoken with the WHO Director-General who was convoking meetings of experts in economy, sociology, general health administration, and malariology from various countries to lay the groundwork for a review of current global strategy for malaria eradication. He believed the report of those experts would be submitted to the Twenty-First World Health Assembly. The report was expected to lay down general basic research guidelines for the analysis by the experts, and as soon as the document was available the pertinent analyses would be made in the Americas.

Dr. ACOSTA-BORRERO (Colombia) thought that the document to be presented on the malaria problem would possibly clarify many of the doubtful points raised by the resolution and that the only thing to be done at that time was to review the resolution and report to the Directing Council.

Dr. HORWITZ (Director, PASB) emphasized that revising the strategy for a problem so complex as malaria eradication was a time-consuming task and that the efforts currently under way in the Americas could not be brought to a halt until the revision was completed. He had the :impression that where the transmission of the disease had not been stopped it was usually because certain circumstances prevented the Governments from using all their available knowledge. Those circumstances were largely of a financial rather than administrative nature-, i.e., they rose mainly from the impossibility of providing funds at the proper time, rather than from the quality and performance of the personnel. There had also been some biological problems. For that reason, it was hoped that the availability of foreign capital, a vital need in some countries, would provide a new and vigorous thrust to the efforts to solve the problem. A global strategy to assist in expediting malaria eradication would, of course, be welcomed.

3_/ See Off. Rec. Wld Hlth Org. 160 for all resolutions of the Assembly. Page 283 57th Meeting Third session

The CHAIRMAN attached great importance to the Director's observation con.cerning the danger of awaiting a decision on global strategy. That might lead to a diminution of current efforts or even certain reluctance on the part of the financial institutions, aware as they were that a re-analysis of strategy was being made. He felt that the problem should be brought to the attention of the Directing Council so that the Governments could be persuaded to continue their own activities and seek financing from domestic sources until the study was ccmpleted.

Dr. OPILLANA (Venezuela) agreed with the Chairman and the Director and expressed concern over the future of the world-wide malaria eradication program, which was tending to be less effective. He believed that the new strategy being ccnsidered should be based on administrative rather than technical measures. The participation of economists and sociologists in the study was an excellent idea and he expressed the hope that the study would emphasize sound administrative and financial practices.

Dr. ACOSTA-BORRERO (Colombia) shared the concern that the revision of malaria eradication strategy might somehow lead to a stoppage or diminution of work in the American countries. He suggested that the importance of the problem be stressed in the report of the Chairman of the Executive Committee.

The CHAIRMAN said that the Region of the Americas was possibly the one with most experience in malaria eradication problems and that he believed it was the consensus of the Committee that the Director of the Bureau should collaborate to the fullest possible extent in the study initiated by WHO.

Dr. ARREAZA GUZMLiN (Asistant Director, PASB) explained that the next Resolution of the Assembly was WHA20.15 (Smallpox Eradication Program) in which it noted the continued existence of smallpox in many parts of the world, recommended that the Governments give the required impetus to the smallpox eradication campaigns, and appealed to the vaccine-producing countries to provide assistance, especially by supplying good-quality vaccine. The resolution also requested the Organization to continue developing and implementing its plan and coordinate all international, bilateral, and national efforts to eradicate the disease.

Dr. BLOOD (United States of America) suggested that, in view of the discussion held at the second plenary session, there was probably no need to discuss the subject further at that time.

Dr. HORWITZ (Director, PASB) referred to a matter generally applicable to programs of immunization: the importance of having the ministries of health develop their programs on the basis of useful levels of immunization. Other- wise, there would continue to be outbreaks like the one of poliomyelitis on the Pacific Coast of South America, mentioned at an earlier session. The same held true for the smallpox programs, particularly in countries that had been free of the disease for a number of years. That explained the importance of having at least a system of programmed immunization in countries lacking a national plan. He thought it unseemly that in Latin America whooping cough should continue to have a high mortality rate in children between six months and five years of age though an effective immunization procedure was available, and that Page 284 Third session 57th Meeting there should still be cases of diptheria and tetanus neonatorum even though the children could be effectively immunized and the necessary vaccines and toxoids were produced in several countries. He believed that that could be attributed to the fact that no yearly determinations were made of the amount of biological preparations that had to be purchased or produced, depending on each country's situation, and no adequate provision was made in the budgets for the necessary professional and auxiliary personnel.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) read Resolution WHA20.18 (WHO Nomenclature Regulations, 1967), which reflected the Assembly's conviction that it was important to compile and publish comparable mortality and morbidity statistics. To promote that comparability the Assembly had adopted the latest revision of the International Classification of Diseases, Injuries, and Causes of Death and requested all the Members to compile and tabulate their mortality and morbidity statistics in accordance with the rules contained in that Clas- sification. That provision would be mandatory for the Region of the Americas beginning 1 January 1968, unless specific reservations were made. It was therefore incumbent upon PAHO to prepare the countries to comply with that requirement. To that end, a meeting on the new nomenclature had just been held in Washington, and plans had been made to conduct various activities at the country level in order to assist the countries and cooperate with them in the application of those important measures.

The session was suspended at 10:30 a.m. and resumed at 10:45 a.m.

Dr. Orellana (VenezueLa) then took the Chair.

Dr. CALVO (Panama) asked the Director how the Bureau proposed to assist the Governments to assume the very serious responsibility of putting the new Regulations into practice in the ministries of health. He believed the Execu- tive Committee should note the importance of the advisory services the Bureau could render in that regard.

Dr. HORWITZ (Director, PASB) said that the directors of the statistical services of almost all the countries had recently met in Washington to examine the Eighth Revision of the International Classification of Diseases, which represented a genuine nomenclature of common terms. The Bureau had collaborated actively in the revision of the chapters on nutritional and parasitic diseases and the final document contained a number of proposals by specialists of the Americas. As to the application of the Regulations, Dr. Horwitz reminded the Committee that the Iatin American Center for the Classification of Diseases had been operating for some time in Caracas under the joint auspices of the Minis- try of Health and Social Welfare of Venezuela and the Organization. The Center had provided courses, attended by more than 1,000 Latin American technicians, on the interpretation and application of the Classification and the international death certificate, a copy of which was contained in the document under examination. The Governments had been urged to use that certificate, which would make it possible to apply a common terminology. To facilitate that task, the Page 285 57th Meeting Third session proposed list for the tabulation of causes of disease and death had been restricted to 150 items representing the diseases most prevalent in the developing and highly developed countries alike. The Organization had achieved substantial progress in the use of the Classification thanks to the activity of the Center and the courses organized by schools and ministries of health, but it was important to continue the task until all physicians in every country were using the Classification.

Dr. Horwitz believed that the next step in applying the Regulations was to expand and improve the general and etiological diagnostic laboratories and foster the training of competent pathologists, not so much in morphological as in his histochemical and functional pathology, since the shortage of pathologists was even greater than that of laboratory workers.

In regard to the first problem, he cited the experience of Guatemala and Panama, where the number of general diagnostic laboratories had been increased, and he reported that an outstanding expert from the National Communi- cable Disease Center (USA) had just joined the Organization and would assume responsibility for improving those laboratories in the Americas. As to the training of pathologists, that work had been started in Colombia with the cooperation of four schools of medicine which were offering courses of one or two years' duration, depending on the previous training of the participants.

Finally, Dr. Horwitz mentioned the work of the Committee that had dealt with the subject of pathology for the first volume. That Committee had been requested to revise the pathology curriculum and the equipment and materials required for teaching that subject, and to select a textbook among the four or five suggested by the schools of medicine in a survey carried out by the Bureau. The textbook selected, which was written by four Latin American professors with the assistance of another 20 to 30, should soon be sent to the printers.

The CHAIRMAN said that under the system established for the nomenclature the various countries undertook to adopt certain measures to ensure sound statistical reports.

Dr. POITEVIN (Guatemala) stressed the importance of improving the laboratories in order to ensure more accurate diagnosis and end the chaotic conditions in the field of nomenclature. A recommendation to that effect might be made, in order to achieve universal application of the standard nomenclature.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) then presented Resolution WHA20.21 (Extension of the Use of the Russian and Spanish Languages), in which the Assembly agreed that both of those languages should be adopted as working languages for the Assembly and established certain arrangements to that end.

Dr. CALVO (Panama) felt that the Bureau should take the initiative so that Spanish would be a working language as soon as possible. Since that was a costly undertaking and was therefore programmed in various stages, the financial aspect should first be resolved. He added that Dr. Blood had some interesting ideas on the subject which would probably be useful to the Committee. Page 286 Third session 57th Meeting

Dr. BLOOD (United States of America) said that the subject had provoked a great deal of debate at the World Health Assembly and that even those delegates in favor of making Spanish one of the official languages of the Organiza- tion had expressed concern over the cost involved,since it meant that much less to be invested in health programs for the different countries. The cost for Span- ish and Russian liad been estimated at $500,000 a year, but would doubtless increase after a certain period in accordance with upward trends everywhere. The Chinese Delegation had warned that a proposal might be made to incorporate the use of Chinese; furthermore, several delegates from the Middle East had made their plenary session presentations in Arabic, so that it appeared to be only a question of time before others would be proposed as official languages. He therefore ventured to put forward a suggestion that the cost of adding any language might be borne by the Region primarily concerned, so that no Region would be paying for a language that was not of special interest or usefulness to that Region. Under such an arrangement, the Region for the Americas (PAHO) would pay costs for Spanish, and the WHO Region for Europe would finance the use of Russian. The idea was placed before the Committee merely as a suggestion and not a formal proposal.

The CHAIRMAN explained that, according to the resolution, the Director- General of WHO had already made provisions for financing the project in part. In addition to envisaging its application on a gradual scale, the resolution provided that the costs of the project were to be covered through the use of such income as might be available from time to time for the purpose, in order to avoid increasing the contributions of the Member States in the fiscal year 1968. While recognizing that Dr. Blood's suggestion was interesting, he thought it would be difficult to apply on a regional level since there was no Region which used only one language, even though one might be dominant. Perhaps the size of the population might be a sounder criterion.

Dr. CALVO (Panama) said it was important to consider the future implications of the project, since it involved substantial expenditures. Although he realized the importance of having Spanish adopted as a working language, each country concerned should seek the means of financing those costs directly so that they would not impinge on the operating budgets for health activities. Moreover, the problem of financing the adoption of the languages of certain countries or Regions as official languages would become even more complicated if at the next Assembly other countries expressed an interest in having their own languages so adopted.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) presented Resolution WHA20.22 (Decisions of the United Nations, the Specialized Agencies and the In- ternational Atomic Energy Agency affecting WHO's Activities: Administrative, Budgetary and Financial Matters). That resolution referred to the action taken by thé Special Committee of Experts charged with examining the finances of the United Nations and the specialized agencies. In order to ensure rapid implementation of the Special Committee's recommendations, the resolution urged that any measures that could be taken without amending the Constitution be adopted as soon as possible. It also recommended the participation of WHO in the joint inspection unit as soon as the United Nations organs and interagency groups had agreed to establish the service, and requested the Director-General to report Page 287 57th Meeting Third session on the results of subsequent interagency consultations and on the inspectors appointed pursuant to the terms of the resolution.

The CHAIRMAN asked Dr. Portner to explain what was meant by the "joint inspection unit."

Dr. PORTNER (Chief of Administration, PASB) stated that the item had an important significance for those responsible for the general management of international agencies. The major nations of the world had reached a point of considering that more intensive review was necessary of program planning and execution and that an effort should be made to look at the pattern of programs within the United Nations system. The Committee of Fourteen, a special group of experts representing 14 countries, had met for long periods and had presented a report in 1966 which, in effect, had created that group of eight inspectors. They were persons of an excellent administrative background who would be responsible for reviewing the utilization of resources from every aspect, not only the financial one.

Nominations had been requested from countries for the members of the group, which would be based in Geneva; it would be operating at the highest level, but, in the case of the specialized agencies, the extent of their functions and responsibilities would have to be approved by their Governing Bodies. All the agencies had agreed to the plan which was to review not only the activities of the United Nations but those of the World Health Organization as well. However, there were implications involved because of the structure of PAHO/WHO in the Western Hemisphere. Attention had been called to that fact and the autonomous nature of PAHO had been recognized in the report of the Committee of Fourteen.

Dr. CALVO (Panama) inquired whether the Bureau was prepared to submit to the inspection of its finances and programming ard if the Special Committee in question would have authority to review and inspect matters relating exclusively to the Hemisphere and unrelated to the contributions made by the United Nations through WHO. He believed it would be necessary to differenciate between PAHO's own funds and those provided by WHO for the financing of health programs and activities in the Hemisphere.

The CHAIRMAN pointed out that, as explained by Dr. Portner, the powers of the Committee were very broad, since the inspection would cover not only the use of funds but also the execution and evaluation of programs and even of planning and programming activities. The establishment of the inspection group might lead to the creation of an unwieldy superstructure like the Alliance for Progress Panel of Nine, which, while assisting the Governments with all good intention to evaluate their health plans, was sometimes unable to perform its planning functions at the national level. The Chairman wondered if Dr. Horwitz could shed some light on the authority of the new Committee with respect to PAHO, as an autonomous entity and with respect to the programming of the PAHO's health programs as a Regional Office of WHO.

Dr. HORWITZ (Director, PASB) said that the only information he had was that provided by Dr. Arreaza Guzmán and Dr. Portner, but that he thought the Bureau would follow the instructions of the Director-General in matters relating Page 288 Third session 57th Meeting

to WHO. As for differentiating between projects financed with PAHO funds and those financed with WHO funds, there were actually very few projects in which funds of both organizations were used.

In his opinion there would be no reason for reporting on PAIHO activities to the Special Committee, unless the Directing Council or the Conference, acting on a report of the Executive Committee, should so decide. On the other hand, there was nothing to hide, since the work being done was based on instructions from the Goverlnments and, like every human undertaking, had strong and weak points. The Director had the impression that the resolution referred to the United Nations System and not to the Inter-American Systemr, which, of course, had its own pace and autonomy.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) referred to Resolution WHA20.27 (Joint FAO/WHO Program on Food Standards: Amendments to the Statutes of the Codex Alimentarius Commission), which approved the amendments to the Statutes as adopted by the FAO Council at its forty-seventh session.

He then presented Resolution WHA20.34 (Quality Control of Pharmaceutical Preparations), stressing the timeliness and importance of that matter for the Region. In that resolution, the Assembly noted theat, despite repeated urgings to the various countries, some of them were still exporting pharmaceuticals without submitting them to the qualilty control required for the sale of those products in the country of origin. The Assembly also recommended that WHO set standards and procedures for the international inspection of pharmaceuticals and that the Regional Offices continue to help the Member States to establish laboratories or obtain access to those services, seeking the assistance of multilateral or bilateral agencies when needed.

Dr. POITEVIN (Guatemala) referred to the problem in the Central American countries, where a large number of locally manufactured drugs were being ship- ped from one country of the Region to ancther without any quality control. In order to solve that problem, it would be necessary to establish laboratories, which could not be done without foreign financial aid.

The CHAIRMAN, after noting the extremely rapid growth of the pharmaceutical industry, said that in his own country the pharmaceutical laboratories had far better equipment and much better trained personnel than the inspection service and could be asked to cooperate in the inspection of pharmaceutical products. The problem was especially serious because of the fact that some countries allowed the export of products that were not authorized for domestic sale, and he requested Dr. Horwitz to report on the work done on the problem by the Organization, particularly in the past four years.

Dr. HORWITZ (Director, PASB) said that the Organization had endeavored to comply with the relevant resolutions adopted by the Assembly, the Conference, and the Directing Council. It had collaborated with the Government of Panama, where, under an agreement with the Ministry of Health, Social Welfare, and Labor, the laboratory in the University had been designated by the Higher Public Health Coun- cil of Central America and Panama as a regional laboratory for all six countries and had been made responsible for inspecting the quality of pharmaceuticals submitted by their ministries of health. That Council also designated the INCAP Page 289 57th Meeting Third session laboratories as regional reference laboratories for quality control of food exports listed in the tariff of the Central American Common Market.

As to the South American countries, Dr. Horwitz reported that Dr. C. A. Morrell, of the Food and Drug Control Service of the Ministry of Health of Canada, was in Montevideo assisting in the formulation of a project to be submitted to the United Nations Development Program for the purpose of establishing a center in that city to train quality-control technicians on new or simplified methods and of creating reference centers for the products determined by the Governments.

Since the facilities and the training of personnel were a costly matter, primary attention was being devoted to improving and strengthening national laboratories in countries with a large population, or laboratories that could serve a group of countries, such as in Central America. The Organization had sent advisers to Argentina, Brazil, and Chile at the request of those Govern- ments and had received valuable assistance from the Food and Drug Administra- tion of the United States Public Health Service. An expert from that Adminis- tration with 30 years' experience in those matters would soon be added to the staff of the Organization.

Regarding quality control for drugs, Dr. Horwitz said that perhaps a supplementary procedure was needed, for example the inspection of the industry as such through the inspection of samples purchased in the ordinary course of trade, to see if the industry was controlling the quality of each batch. In that connection he pointed out that, while the Organization's activities for the training of technicians were essential, on the national level it might be advisable to combine those activities with studies of the pharmaceutical industry to determine what methods were used in regard to each product. That would make it possible to determine which were the truly responsible industries, i.e., which were controlling the quality of their products, and which were not, in order to eliminate those which were placing the health of the population in jeopardy.

Dr. CALVO (Panama), referring to Panama's experience not only with regard to inspection but also to the analysis of food and drugs in the laboratories said it was frequently necessary to re-examine the quality of products offered for public sale, and that the quality of a product certified as satisfactory was found to have deteriorated.

That problem did not arise in the large laboratories but only in the smaller ones, which were tending to multiply as a result of economic aid provided by the ministries of economy in an effort to encourage economic development. The problem was very complex since it involved not only the opening of new laboratories and the designing of programs for drug control and the training of personnel, but also the adoption of higher-level decisions which should be made known to the various Governments andregions.

Dr. POITEVIN (Guatemala) also referred to the seriousness of the situation and its national implications and said that measures should be taken to prevent the proliferation of laboratories producing low-quality drugs with no control whatsoever. The problem was made even worse by advertising campaigns Page 290 Third session 57th Meeting conducted through mass media such as radio and television, which advocated the use of poor-quality products, some of whizh were sold in greater quantity than those of good quality. He thought the problem should also be approached from the legislative end, through laws and regulations. His own country was considering a law to reduce the cost of drugs and improve quality controls. If approved, it would prevent the proliferation of laboratories so blinded by profit considerations that threatened the health of the population.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) cited the example of Ecuador, a country which had established a laboratory in Guayaquil--the Institute of Health--which was supported through a tax on pharmaceuticals, packaged foodstuffs, and cosmetics. That laboratory, which charged different rates for domestic products and imports, was conducting periodic inspections and its certificates were valid for five years at the most. The system was not perfect, as there was no quality control in the establishments where the products were manufactured, and other problems remained to be solved, but the situation had improved and the country had been greatly benefited.

Dr. BLOOD (United States of America) said that at the time the matter had been discussed at the World health Assembly the Delegation of the United States of America had expressed its great concern over the problem, not only because of national interest but because of international commitments as well. It had therefore offered every possible assistance to the countries and to the Organ- ization through advisory and testing services if some practicable international system could be developed under the aegis of the World Health Organization.

The session rose at 12:10 p.m. FOURTH PLENARY SESSION Friday, 29 September 1967, at 3:00 p.m. Chairman: DR. ALBERTO E. CALVO (Panama)

ITEM 5: RESOLUTIONS OF THE TWENTIETH WORLD HEALTH ASSEMBLY OF INTEREST TO THE REGIONAL COMMITTEE (conclusion)

The CHAIRMAN opened the session and, on behalf of the Executive Committee, extended a cordial welcome to Dr. Maxwell P. Awon, Minister of Health of Trinidad and Tobago, who was present at the meeting. He then announced that the Committee would continue to consider Item 5.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) said that Resolution WHA20.41 1/ (Public Health Aspects of Population Dynamics) was the third to be adopted on the matter by the Assembly and that it again mentioned the importance of stillbirth and the high maternal and infant mortality rates as public health problems. The resolution also stated that the organization of public health services was a matter of utmost importance to the success of any public health program, and recommended that WHO continue to develop its activities relating to the health aspects of population growth and that attention be given to requests for assistance in national research projects and the training of university professors and professional staff.

The CHAIRMAN noted that various countries of the Region had started programs of "family planning" without considering the importance of carrying them out through the Organization and with the cooperation of the national health services. He was concerned with the lack of coordination of efforts in that field and asked if the Bureau had received any request from the Governments concerning that type of program.

Dr. ORELLANA (Venezuela) said that the resolution added nothing important to the guidelines developed by WHO in connection with the problem. The recent Meeting on Population Policies in Relation to Development in Latin America, held in Caracas, had tried to establish the bases for a comprehensive population policy and determine the role that family planning programs could play therein. He stressed the medico-sanitary and social characteristics of such programs and the advisability of carefully examining those aspects. It was important not to confuse a family planning policy with a population policy related to long-term development. He believed family planning was based on an educational method of a medico-social type which took into account certain family needs and was broader in scope than population policy.

The CHAIRMAN said that the primary need was to establish a cohesive policy on population growth.

_/ See Off. Rec. Wld Hlth Org. 160.

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Dr. POITEVIN (Guatemala) stated that the problem was also of concern in his country, where an intensive publicity campaign was being carried out in behalf of family planning, although it had not been related to the health programs. He believed the Bureau should provide some guidance in that regard.

Dr. ACOSTA-BORRERO (Colombia) agreed with the views expressed and suggested that the Directing Council be asked to include the topic in the Techni- cal Discussions during its XVIII Meeting.

Dr. COMISSIONG (Observer, Trinidad and Tobago) said that those who attended the recent World Health Assembly had sensed a much more favorable climate of opinion on the subject, which was of particular importance to his country. The resolution had received the unanimous support of all but two Governments, which had abstained from voting because they considered it did not go far enough. The technical officers of the countries had favored pursuing a more vigorous policy but had been obliged to proceed cautiously and in accordance with the policies of their Governments. The resolution, though couched in somewhat vague language, did enable the Organization to indicate more difinitely the type of help it could give the countries. Trinidad and Tobago had been greatly heartened by the material assistance it had been promised in that regard recently by both WHO and PAHO.

Dr. ORELLANA (Venezuela) agreed that the Directing Council ought to include the topic in the Technical Discussions during its XVIII Meeting but thought it was not for the Executive Committee to make the recommendation at that time because the question was one for decision by the Directing Council.

Dr. BLOOD (United States of America) said that the Technical Discussions of the Regional Committee for the Western Pacific had that year been devoted to family planning in relation to maternal and child health services. He understood that they had been most successful, an indication perhaps that the topic might prove an interesting and useful one for the Region of the Americas to consider.

Dr. HORWITZ (Director, PASB) said that the three Assembly resolutions on family planning 2/ and those adopted by the XVII Pan American Sanitary Confer- ence 2/ and the XVI Meeting of the Directing Council 4/ of PAHO were the basis for the policy being followed in that regard. It was up to the Governments, acting independently, to establish a population policy, i.e., to express a desire to carry out a family planning policy. In the Declaration of the Pres- idents of America, 2/ the Chiefs of State had emphasized the need to give impetus to programs for the protection of mothers and children, including education in over-all family guidance. That, in his opinion, signified the intention of introducing family planning as part of the maternal and child care programs.

The Organization could not participate in any programs unrelated to the activities of the health ministries and services, which was where the task could

2/ Resolutions WHA18.49, WHA19.43, and WHA20.38. Off. Rec. Wld Hlth Org. 143, 35; 151, 20-21; and 160, 23-24. / Resolution XXII. Official Document PAHO 74, 81-82. Resolution IX. Official Document PAHO 66, 15-16. 5/ OAS Official Records, OAS/Ser. C/IX.l, 1967. Page 293 57th Meeting Fourth session best be accomplished. The decision as to the size of the family and frequency of birth was one that only the parents could properly make; therefore, it could scarcely take part in a program in which the Governments attempted to influence that decision in a given direction, or one whose objectives were so broad that, on analysis, it appeared to deprive the family of the opportunity of making that decision. In short, the Organization could not participate in any program in which the education of the family was not a clearly-defined factor and in which the family did not have the opportunity to select the method it considered best suited to its beliefs and other moral criteria.

Considered in that light, the action of the Organization was sufficiently well defined. However, it could collaborate with any Government requesting its assistance in preparing a plan of whatever scope it desired. It could also do so by furnishing advisers, especially for training purposes and for research on educational techniques.

The Organization was prepared to offer fellowships--indeed it had already offered them to one country, El Salvador--for the training of professionals abroad in the techniques involved in that new discipline of family planning. It was also prepared to cooperate with the Governments in epidemiological or operational research to facilitate the establishment of a policy of wider scope than the one in effect.

He recalled that the UNICEF Executive Board had agreed to develop a policy of that kind and was willing to offer equipment and supplies for that as for any other joint action program.

The Bureau had received requests from six Governments for advisory services in the establishment of a family planning policy and was already collaborating with one in the formulation of a national plan. It had alsc awarded fellowships for training abroad.

However, those activities required funds, and the work was generally centered in the rural areas, where the Governments had no resources for establishing even the most essential services. It had been proposed that those organizations wishing to advise, collaborate, or contribute to the development of those activities do so through the contribution of funds for the establishment of rural units where they were lacking. In order to develop a family planning program it would be necessary to devise a system for financing it on a nationwide basis through the ministries of health on a scale compatible with their budgets.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) said that Resolutions WHA20.42 and WHA20.43 of the World Health Assembly on the control of certain drugs, could be considered together. Among other things, the resolutions urged the Member States to take action as soon as possible to prohibit the sale of habit forming sedatives and stimulants without a doctor's prescription, to restrict the use of LSD and similar substances to special cases of medical interest and scientific research, and to make the competent public health authorities responsible for supervising their manufacture, distribution, and use. Page 294 Fourth session 57th Meeting

Dr. Arreaza Guzmán suggested that the Executive Committee restrict itself to taking note of Resolutions VTHA20.48 and WHA20.52. With respect to Reso- lution WHA20.53 (Health and Economic Development), he considered it further proof that the improvement of health conditions in the developing countries was regarded as an essential prerequisite to economic and social progress.

The resolution reflected the general concern over the reduction of public health appropriations within the United Nations Development Program and requested the Member States to take the necessary action to organize national public health plans and include them in the respective economic and social development programs. It also emphasized that the Governments should give special importance to assuring proper representation of health authorities in the national agencies responsible for the preparation and coordination of the economic and social development programs. Finally, i-t requested the Director-General to intensify the studies on economic matters related to public health action, thus fostering closer understanding between the economists and the public health authorities and, at the same time, improving the effectiveness of the program for training health administrators in matters of national public health planning, and particularly public health economy.

Dr. HORWITZ (Director, PASB) referred to the resolution on malaria examined by the Executive Committee at the third plenary session and stated that it would be extremely useful for the countries if research were to be conducted on the unfavorable fiscal implications of the failure to apply preventive measures, of applying them too late, or of delaying the treatment of patients which led to their death. He recalled an interview during the Assembly in Geneva with the Delegate of Roumania, Dr. M. Aldea, who had told him of the studies a ministry of health had made to convince the ministries of economy or finance that a given amount was needed to treat malaria patients, or simply cover the cost of their hospitalization.

Dr. Horwitz then cited some figures indicating the amounts spent in different countries for hospitalizing a malaria patient. In Latin America as a whole the actual expenditure per malaria patient was about $0.30, whereas the cost per hospital bed per day was about $4.00, rising in Chile to as much as $10.00 in general hospitals, although the daily cost in hospitals for chronic patients was about $4.00. If the economic cost of repeated absences of the worker from his job as a result of malaria and the effects of that absenteeism on output and productivity were estimated, the estimates would afford a better statistical basis than that now used to substantiate requests for national budgetary allocations for the health programs. It would be very useful if the ministers of health in conjunction with economists or specialists in the matter, could make an analysis such as that. The findings, in the Director's opinion, would be very valuable information for the discussions in the planning boards or cabinets when a decision was taken on the amounts to be spent on health vis-a-vis the other activities of the Governments.

While little had been published on that matter, there was a recent publication of the United States Public Health Service, written by Dr. Dorothy Rice, which examined medical care not only from the standpoint of direct cost but also of hidden costs in the case of the patients treated in various institutions in the United States of America. The Ministry of Health and Social Welfare of Mexico, Page 295 57th Meeting Fourth session

for its part, was carrying out, with financial assistance from the Bureau, a study on the effects of the antimalaria campaign in certain areas of the country now that the consolidation phase had been reached. In conclusion, Dr. Horwitz said it would be much more suitable to provide the appropriating agencies of the Governments with specific and clear information than to address them in medical and technical language.

Dr. POITEVIN (Guatemala) agreed with Dr. Horwitz and said that health investments were not only of primary importance but were also the most profitable type of investments that could be made, although certain economists had yet to be convinced of that fact. Some progress had been made, however, even if much remained to be done.

The session was suspended at 4:00 p.m. and resumed at 4:50 p.m.

ITEM 3: PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION AND OF THE WORLD HEALTH ORGANIZATION, REGION OF THE AMERICAS, FOR 1969 (conclusion)

Dr. ARREAZA GUZMAN (Assistant Director, PASB) read the following draft resolution:

THE EXECUTIVE COMMITTEE,

Having reviewed the Proposed Program and Budget Estimates presented in Official Document 76;

Considering that the Organization has continued to make progress in formulating in a single document budget estimates for a four-year projection by program, object of expenditure, budgetary allotment, organizational units, and geographic distribution; and

Having made a general review of the Proposed Program and Budget Estimates for 1969 to be submitted to the Regional Committee of the World Health Organization for the Americas,

RESOLVES:

1. To commend the Director for the excellent presentation of Official Document 76, which displays substantial progress in the formulation of a program budget, thereby facilitating a detailed examination of the whole range of activities of the Organization in relation to objectives and sources of funds.

2. To advise the XVII Meeting of the Directing Council that the Proposed Program and Budget Estimates for 1969 contain Page 296 Fourth session 57th Meeting

projects reflecting the general and specific activities of the Organization and showing their order of magnitude for that year.

3. To draw to the attention of the Directing Council that the Program and Budget Estimates for the Region of the Americas for 1969 provide for a series of activities which are part of the policy of the Organization and which are of great importance for the improvement of health in the countries in the Region.

Dr. BLOOD (United States of America) recalled that he had requested, for future meetings, supplementary information on sources of funds, by specific program elements. Thus, the phrase "and sources of funds" appearing at the end of the first operative paragraph was acceptable so long as it was understood as not closing the door to the provision of such information.

Dr. PORTNER (Chief of Administration, PASB) said that in the English version the phrase "a four-year projection" appearing in paragraph 2 of the preamble should be replaced by the phrase "for a four-year period."

Decision: The draft resolution was unanimously approved with the changes indicated above.

ITEM 4: FINANCING OF THE PAN AMERICAN FOOT-AND-MOUTH DISEASE CENTER (conclusion)

Dr. ARREAZA GUZMAN (Assistant Director, PASB) read the following draft resolution:

THE EXECUTIVE COMMITTEE,

Having noted the information contained in Documents CE57/2 and CD17/19 to the effect that voluntary contributions received from Governments slightly exceed the financial requirements ELS of 30 June and that additional arnounts have been pledged;

Being informed of the resolution approved by the Inter- American Economic and Social Cowicil at its Fifth Annual Meetings which, among other points, requested the Pan American Health Organization to continue to assune technical and administrative responsibility for the Pan American Foot-and-Mouth Disease Center, and delegated to the Inter-American Committee on the Alliance for Progress the authority to determine the system of financing of the Center in consultat .on with PAHO and the 'Secre- tariat of the Organization of American States; and

Bearing in mind, as expressed in Resolution XVIII of the 56th Meeting of the Executive Committee, the importance of the Pan American Foot-and-Mouth Disease Center to the health and economic development of the Americas, Page 297 57th Meeting Fourth session

RESOLVES:

1. To reiterate the interest of the Executive Committee in the prompt and definitive solution of the stable and permanent financing of the Pan American Foot-and-Mouth Disease Center as well as the recommendations contained in Resolution XVIII of its 56th Meeting.

2. To express its appreciation for the generous voluntary contributions of Brazil, Colombia, the Dominican Republic, Panama, the United States of America, and Venezuela.

3. To urge the Governments to make additional voluntary contributions to ensure the continued operation of the Center at not less than the current level until a stable system of financing can be put into effect.

4. To recommend to the Directing Council that it take appropriate action to ensure a system of stable financing at an adequate level in order to achieve the objectives of the Center in serving the Governments of the Americas, under the plan contained in the report of the Seoane-Palacios Mission.

Dr. BLOOD (United States of America) suggested the substitution, in paragraph 4,of the words "taking into consideration" for the word "under". The intention was that the plan should be examined closely but not necessarily followed in detail.

Dr. WEDDERBURN (Jamaica) suggested the insertion, in the second paragraph of the preamble of the word "which" before the words "delegated to the Inter- American Committee on the Alliance for Progress," to make it clear that both the request and the delegation had emanated from the Inter-American Economic and Social Council.

Decision: The draft resolution was unanimously approved with the changes indicated above.

ITEM 6: OTHER MATTERS

Travel Expenses of Members of the Executive Committee

Dr. ACOSTA-BORRERO (Colombia) called attention to the regrettable absence of the Representative of Ecuador, apparently for financial reasons. In, order to avoid future absences such as that, which impaired the Committee's work, he proposed that the Executive Committee take the necessary steps, even if they required amendments to the Constitution and the Rules of Procedure of the Committee, so that thereafter the expenses arising from the attendance of Executive Committe.e members at its meetings would be paid by the Bureau, regardless of the place and purpose of the meeting. Page 298 Fourth session 57th Meeting

In the ensuing discussion, Dr. Orellana (Venezuela), Dr. Poitevin (Guate- mala), and Dr. Blood (United States of Anerica) expressed their regret that no Representative was present from Ecuador and supported the proposal by Dr. Acosta- Borrero.

Dr. HORWITZ (Director, PASB) said that the proposal by Dr. Acosta-Borrero would undoubtedly require an amendment to the Constitution and would have to be processed in accordance with Article 28 of the Constitution which read as follows:

"Proposals to amend the Constitution shall be communicated to the Member Governments at least three months in advance of their consideration by the Conference or the Council. Amendments shall come into force for all Member Governments when adopted by the Conference by a two-thirds vote of the representatives of all Member Governments or when adopted by the Council by a two-thirds vote of those representatives."

He concluded that the proposal by Dr. Acosta-Borrero would not be eligible for consideration by the XVII Meeting of the Directing Council.

Dr. ACOSTA-BORRERO (Colombia) noted Article 28 of the Constitution and said that the Government of Colombia would formally present the matter at the proper time.

The CHAIRMAN informed the members of the Executive Committee that the discussion on Item 5 would be summarized in the Report of the Chairman of the Committee to be presented to the Directing Council.

He then proposed that, in closing the 57th Meeting, the Executive Com- mittee of PAHO observe a minute of silence in tribute to the memory of Dr. Santiago Renjifo Salcedo and that the Director send a message of sympathy to the family of that brilliant and cherished colleague, apprising them of the tribute.

The session rose as a body to observe a minute of silence in tribute to the memory of Dr. Santiago Renjifo Salcedo.

The session rose at 5:30 p.m. FINAL REPORT OF THE 57th MEETING OF THE EXECUTIVE COMMITTEE 1 Port of Spain, Trinidad and Tobago, 28-29 September 1967

Under the Chairmanship of Dr. Alberto E. Calvo (Panama) and the Vice- Chairmanship of Dr. Daniel Orellana (Venezuela), the 57th Meetirg of the Execu- tive Committee of the Pan American Health Organization was held at the Trinidad Hilton Hotel, Port of Spain, Trinidad, from 28 to 29 September 1967, as convened by the Director of the Pan American Sanitary Bureau pursuant to Resolution XXI 2/ of the 56th Meeting of the Executive Committee.

The following members of the Committee, observers, and officers of the Bureau attended the meeting:

Members:

Dr. Roberto Acosta-Borrero COLOMBIA Dr. Emilio Poitevin GUATEMALA Dr. Carlos A. Waldheim Dr. Charles C. Wedderburn JAMAICA Dr. Alberto E. Calvo PANAMA Dr. Benjamin D. Blood UNITED STATES OF AMERICA Mr. Otis E. Mulliken Dr. Daniel Orellana VENEZUELA

Absent Member: ECUADOR

Member and Secretary ex officio of the Committee:

Dr. Abraham Horwitz, Director PAN AMERICAN SANITARY BUREAU Observers:

Dr. Maxwell P. Awon TRINIDAD AND TOBAGO Dr. Leonard M. Comissiong Dr. Elizabeth S. M. Quamina

Organization of American States:

Mrs. Alzora H. Eldridge

Inter-American Development Bank:

Mr. Raúl Rey Alvarez l_ Document CE57/4 (29 September 1967). 2/ Official Document PAHO 79, 48-49.

- 299 - Page 300 Final Report 57th Meeting

Advisers to the Director of the Pan American Sanitary Bureau:

Dr. Alfredo Arreaza Guzmán, Assistant Director Dr. Stuart Portner, Chief of Administration Dr. Alfredo N. Bica, Chief, Communicable Diseases Branch Dr. Abraham Drobny, Chief, Health Promotion Branch Dr. José L. Garcia Gutiérrez, Chief, Zone I Dr. Alfred N. Gerald, PAHO/WHO Representative, Trinidad and Tobago Dr. Mark D. Hollis, Chief, Environmental Sanitation Branch Mr. Clarence H. Moore, Chief, Budget and Finance Branch Dr. José Quero Molares, Legal Officer

Chief, Secretariat Services:

Mr. José Rodríguez Olazábal

Public Information:

Mr. Peter Ozorio

AGENDA

At the first plenary session held on 28 September 1967, the agenda appearing in Document CE57/1,3/ as amended, was approved.

DRAFTING COMMITTEE

Pursuant to Rule 14 ofthe Rules of Procedure of the Executive Committee, a drafting committee composed of the Chairman, Vice-Chairman, and the Secretary was established.

PLENARY SESSIONS

Four plenary sessions were held.

WORKING PARTIES

Two working parties were established: one composed of the Chairman, Dr. Alberto E. Calvo (Panama); Dr. Roberto Acosta-Borrero (Colombia); Dr. Benjamin D. Blood (United States of America); and Dr. Alfredo Arreaza Guzmán (Assistant Director, PASB) to draft a resolution on the Resolutions of the Twentieth World Health Assembly of Interest to the Regional Committee; and another, composed of Dr. Benjamin D. Blood (United States of America); Dr. Daniel Orellana (Venezuela), and Dr. Alfredo Arreaza Guzmán (Assistant Director, PASB) to draft a resolution on the Financing of the Pan American Foot-and-Mouth Disease Center.

3/ Mimeographed document. Page 301 57th Meeting Final Report

RESOLUTIONS APPROVED

In the course of the meeting of the Committee, the following resolutions were approved:

RESOLUTION I

PROPOSED PROGRAM AND BUDGET ESTIMATES OF THE PAN AMERICAN HEALTH ORGANIZATION AND OF THE WORLD HEALTH ORGANIZATION, REGION OF THE AMERICAS, FOR 1969

THE EXECUTIVE COMMITTEE,

Having reviewed the Proposed Program and Budget Estimates presented in Official Document 76;

Considering that the Organization has continued to make progress in formulating in a single document budget estimates for a four-year period by program, object of expenditure, budgetary allotment, organizational units, and geographic distribution; and

Having made a general review of the Proposed Program and Budget Estimates for 1969 to be submitted to the Regional Commit- tee of the World Health Organization for the Americas,

RESOLVES:

1. To commend the Director for the excellent presentation of Official Document 76, which displays substantial progress in the formulation of a program budget, thereby facilitating a detailed examination of the whole range of activities of the Organization in relation to objectives and sources of funds.

2. To advise the XVII Meeting of the Directing Council that the Proposed Program and Budget Estimates for 1969 contain projects reflecting the general and specific activities of the Organization and showing their order of magnitude for that year.

RESOLUTION II

PAN AMERICAN FOOT-AN)-MOUTH DISEASE CENTER

THE EXECUTIVE COMMITTEE,

Having noted the information contained in Documents CE57/2 and CD17/19 to the effect that voluntary contributions received from Governments slightly exceed thie financial requirements as of 30 June and. that additional amounts have been pledged;

Being informed of the resolution approved by the Inter- American Economic and Social Council at its Fifth Annual Meetings which, among other points, requested the Pan American Health Organization to continue to assume technical and administrative responsibility for the Pan American Foot-and-Mouth Disease Center, and which delegated to the Inter-American Committee on the Alliance for Progress the authority to determine the system of financing of the Center in consultation with PAHO and the Secre- tariat of the Organization of American States; and

RESOLVES:

1. To reiterate the interest of the Executive Committee in the prompt and definitive solution of the stable and permanent financing of the Pan American Foot-and-Mouth Disease Center as well as the recommendations contained in Resolution XVIII of its 56th Meeting.

2. To express its appreciation for the generous voluntary contributions of Brazil, Colombia, the Dominican Republic, Panama, the United States of America, and Venezuela.

4. To recommend to the Directing Council that it take appropriate action to ensure a system of stable financing at an adequate level in order to achieve the objectives of the Center in serving the Governments of the Americas, taking into consideration the plan contained in the report of the Seoane- Palacios Mission. Page 303 57th Meeting Final Report

IN WITNESS WHEREOF, the Chairman of the Executive Committee and the Di- rector of the Pan American Sanitary Bureau, Secretary ex officio, sign the present Final Report in the English and the Spanish languages, both texts being equally authentic.

DONE in Port of Spain, Trinidad, this twenty-ninth day of September, nineteen hundred and sixty-seven. The Secretary shall deposit the original texts in the archives of the Pan American Sanitary Bureau and shall send copies thereof to the Governments of the Organization.

ALBERTO E. CALVO Chairman of the Executive Committee Representative of Panama ABRAHAM HORWITZ Director of the Pan American Sanitary Bureau, Secretary ex officio of the Executive Committee

58th MEETING OF THE EXECUTIVE COMMITTEE PRECIS MINUTES AND FINAL REPORT CONTENTS

Page

SINGLE PLENARY SESSION (Thursday, 12 October 1967, at 3:15 p.m.)

Item 1: Opening of the Meeting ...... 307

Item 2: Establishment of the Executive Committee ...... 307

Item 3: Election of the Chairman and Vice-Chairman ..... 307 Item 4: Study of Resolutions of the XVII Meeting of the Directing Council of Interest to the Executive Committee ...... 308

Item 5: Date of the 59th Meeting of the Executive Com- mittee ...... 310

FINAL REPORT ...... 312 SINGLE PLENARY SESSION OF TIJE 58th MEETING OF THE EXECUTIVE COMMFITEE Thursday, 12 October 1967, at 3:15 p.m. Acting Chairman: DR. ALBERTO E. CALVO (Panama) Chairman: DR. ROBERTO ACOSTA-BORRERO (Colombia)

ITEM 1: OPENING OF THE MEETING

The ACTING CHAIRMAN opened the 58th Meeting of the Executive Committee and welcomed the members of the Committee, observers, and other participants.

ITEM 2: ESTABLISHMENT OF THE EXECUTIVE COMMITTEE

The ACTING CHAIRMAN welcomed the Representatives of Nicaragua, Trinidad and Tobago, and Uruguay who had been elected by the XVII Meeting of the Direct- ing Council on the termination of the periods of office of Jamaica, Panama, and Venezuela.

ITEM 3: ELECTION OF THE CHAIRMAN AND VICE-CHAIRMAN

The ACTING CHAIRMAN announced that the meeting would proceed to elect the Chairman and Vice-Chairman.

Dr. ARREAZA GUZMAN (Assistant Director, PASB) read Article 9 of the Rules of Procedure of the Committee governing the election of officers.

Dr. BLOOD (United States of America) proposed Dr. Roberto Acosta-Borrero, Representative of Colombia, as Chairman.

Dr. WALDHEIM (Guatemala), Dr. AVILES (Nicaragua), Dr. COMISSIONG (Trinidad and Tobago), and Dr. DICANCRO (Uruguay) seconded the proposal of the Represent- ative of the United States of America.

Decision: The Representative of Colombia, Dr. Roberto Acosta- Borrero, was unanimously elected Chairman of the Executive Committee.

Dr. Acosta-Borrero (Colombia) took the Chair.

The CHAIRMAN requested a vote of applause for his predecessor, Dr. Calvo, and expressed his gratitude for the election, offering to perform the duties of Chairman to the best of his ability and to collaborate with the officers of the Bureau in their activrities.

- 307 - Page 308 Single session 58th Meeting

Dr. AVILES (Nicaragua) proposed Dr. Carlos A. Waldheim (Guatemala) as Vice-Chairman. The proposal was seconded by Dr. Comissiong (Trinidad and Tobago), Dr. Blood (United States of America), and Ir. Dicancro (Uruguay).

Decision: The Representative of Guatemala, Dr. Carlos A. Waldheim, was unanimously elected Vice-Chairman of the Executive Committee.

Dr. WALDHEIM (Guatemala) thanked the Committee for electing him.

ITEM 4: STUDY OF RESOLUTIONS OF THE XVII MEETING OF THE DIRECTING COUNCIL OF INTEREST TO THE EXECUTIVE COMMITTEE

Dr. HORWITZ (Director, PASB) explained that in accordance with Resolution VIII l/ of the XVII Meeting of the Directing Council, concerning the PAHO program and budget estimates for 1969, it was incumnbent on the Executive Committee to examine that document in detail at its 59th Meeting and to make such recommendations as it deemed pertinent to the Directing Council at its XVIII Meeting. In drafting those recommendations, the Ececutive Committee should bear in mind any changes introduced by the World Health Assembly when it approved the regional budget, as well as those resulting from changes in the Bureau itself.

Dr. Horwitz then referred to Resolution XXV, 2/ which recommended that the Director "continue his efforts, in the way he deems most effective and in cooperation with the Executive Committee and the Governments, to carry out in the next two years an evaluation of the fellowship program and that he submit a preliminary report on his findings to the XVIII Meeting of the Directing Council." He stated that he intended to submit to the 59th Meeting of the Executive Committee an outline for a continuing evaluation scheme which was already being prepared with the assistance of the sociologist attached to the Organization.

Dr. AVILES (Nicaragua) inquired as to the purpose of the evaluation. He wondered whether it was a question of determining how the trainees were putting their newly-acquired knowledge to use on returning to their countries or of considering whether the selection of trainees should be improved.

Dr. HORWITZ (Director, PASB) answered that the intention at present was to submit an evaluation scheme to the Executive Committee which would cover such questions as those raised by the Representative of Nicaragua.

Dr. BLOOD (United States of America) said that in addition it might be useful to have a summary of what other institutions had done to evaluate their respective fellowship programs.

Dr. HORWITZ (Director, PASB) then referred to Resolution XXX Y on buildings and installations of the Organization. In accordance with that resolution, he would report any new developments to the 59th Meeting of the Executive Com- mittee.

Official Document PAHO 82, 61-62. Ibid., pp. 83-84. Ibid., pp. 87-88. Page 309 58th Meeting Single session

He then referred to Resolution XXXIII 4/ on the Technical Discussions to be held during the XVIII Meeting of the Directing Council. The resolution instructed the Executive Committee to review the Rules for Technical Discussions and submit relevant observations and proposals to the Council.

It would be advisable to re--examine the procedure for the selection of topics, the rules for the election of a Moderator, and other provisions of the Rules in which experience counseled the introduction of changes.

Dr. WALDHEIM (Guatemala) agreed with Dr. Horwitz and said that an effort should be made to avoid the selection of topics that were too broad. That would ensure more useful debates during the Technical Discussions.

Dr. COMISSIONG (Trinidad and Tobago) agreed with the suggestion put forth since at times the topics were too broad for any country to derive benefit from the debates. In preparing the guidelines for the Technical Discussions it might be well to keep that in mind.

The CHAIRMAN stressed the importance of revising the Rules for Technical Discussions, as pointed out, and said that in that and all other matters it was the duty of the Executive Committee to facilitate the work of the Directing Council.

Dr. AVILES (Nicaragua) said that the Technical Discussions were a useful means of providing information, scientific knowledge, and encouragement to the countries and he was pleased to see that they were being given more prominence.

Dr. DICANCRO (Uruguay) was in favor of selecting the Moderator as far in advance of the Technical Discussions as possible and said that the person chosen should be an expert in the topic selected.

Dr. HORWITZ (Director, PASB) called attention to Resolution XXXIV, 52 which instructed the Director to arrange for a comparative study of the Staff Rules of PASB and WHO, in order to correct the existing disparities.

Referring then to Resolution XXXVIII, 6/ on the proposal by the Repre- sentatives of Brazil and Nicaragua to amend Article 15-A of the Constitution to increase the number of members of the Executive Committee from seven to nine, he believed it would be useful for the Committee to examine the number of members to be elected each year after the total number was increased so that the Directing Council might take action as it deemed appropriate. He noted that proposals to amend the Constitution should be distributed three months in advance.

The CHAIRMAN, recalling a question raised at the 56th Meeting of the Executive Committee, asked if it would be possible to suggest another amendment to the Constitution to the effect that the Organization pay the expenses of representatives attending the meetings of the Directing Council.

5/ Ibid., pp. 89-90. /Ibid., p. 90. Ibid., pp. 93-94. Page 310 Single session 58th Meeging

Dr. HORWITZ (Director, PASB) replied that if the Bureau were requested to do so, it would transmit such a proposal to all the Governments to enable them to present their views to the Directing Council, which would decide on the matter.

ITEM 5: DATE OF THE 59th MEETING OF THE E{ECUTIVE COMMITTEE

The CHAIRMAN requested the Director of the Bureau to report on the item.

Dr. HORWITZ (Director, PASB) said that since WHO usually approved its budget late in May of each year, perhaps the next meeting of the Executive Com- mittee could be held in the first week of July. By that time, the Bureau would have been able to develop figures, prepare the program and budget document, and distribute it to the Governments, a task normally not completed before the month of June.

Dr. BLOOD (United States of America) suggested that, particularly because of the new timing, a tentative date be set, subject to readjustment later if necessary.

Dr. HORWITZ (Director, PASB) invited Dr. Portner to explain the procedures involved in developing the budget and the time required to prepare that document.

Dr. PORTNER (Chief of Administration, PASB) stated that the purpose was to present to the Executive Committee definite program and budget estimates that would then be transmitted to the Directing Council. The printed volume of the budget would be available after the World Health Assembly. The preparation of the book in itself was a tremendous task; in addition, it had to be ready for dispatch to the Governments three weeks before the meeting. To hold the meeting earlier than the second week in July would place too heavy a burden on the Secretariat and the preparation of another document, similar to that prepared in the past, would be an impossibility. Members should keep in mind that if eight sessions of the Committee were required the last time on an interim document, additional time would be required for a detailed examination of more than 500 projects and three budgets, not just the PAHO regular budget as was the case before.

The CFIAIRYAN suggested that, as on previous occasions, the Chairman of the Executive Committee and the Director of the Bureau be authorized to fix the date for the next meeting of the Committee.

Dr. BLOOD (United States of America) said the discussion had served the purpose he had in mind. The second week in July might be a target date, to be changed later depending on the circumstances.

Dr. PORTNER (Chief of Administration, PASB) reminded the members that scheduling had to be kept in mind since documentation had to be prepared for the World Health Assembly, for the Directing Council meeting, and for transmittal to WHO in October for discussion at the Executive Board at its meeting in January. Page 311 58th Meeting Single sessior

The CHAIRMAN said that the date for the 59th Meeting of the Executive Committee would be fixed at a later time. He then proposed that the Committee express its appreciation to the members who had completed their terms of office. He especially commended Dr. Calvo and Dr. Orellana, the outgoing Chairman and Vice-Chairman, for their brilliant leadership, and also the Representative of Jamaica whose term of office also expired that year.

Dr. BLOOD (United States of America) also wished to commend the Chairman and the Vice-Chairman for their leadership and guidance, and the Representative of Jamaica for the work accomplished.

The session rose at 4:40 p.m. FINAL REPORT OF THE 58th MEETING OF THE EXECUTIVE COMMITTEE 1 Port of Spain, Trinidad and Tobago, 12 October 1967

The 58th Meeting of the Executive Committee of the Pan American Health Organization was held in the Scarlet Ibis Room of the Trinidad Hilton Hotel, Port of Spain, Trinidad, on 12 October 1967, as convoked by the Director of the Pan American Sanitary Bureau. The following members of the Committee attended the single plenary session:

Members:

Dr. Roberto Acosta-Borrero COLOMBIA Dr. Carlos A. Waldheim GUATEMALA Dr. Orontes Avilés NICARAGUA Dr. Leonard M. Comissiong: TRINIDAD AND TOBAGO Dr. Benjamin D. Blood UNITED STATES OF AMERICA Dr. Miguel Dicancro URUGUAY

Absent Member: ECUADOR

Secretary ex officio:

Dr. Abraham Horwitz, Director PAN AMERICAN SANITARY BUREAU

NEW MEMBERS

The meeting was opened by the Acting Chairman, Dr. Alberto E. Calvo, (Panama), who welcomed the Representatives of Nicaragua, Trinidad and Tobago, and Uruguay, the countries elected by the XVII Meeting of the Directing Council to fill the vacancies that occurred on the termination of the periods of office of Jamaica, Panama, and Venezuela.

OFFICERS

At the proposal of the Representative of the United States of America, seconded by the Representatives of Guatemala, Nicaragua, Uruguay, and Trinidad and Tobago, Dr. Roberto Acosta-Borrero, Representative of Colombia, was unanimously elected Chairman of the Committee.

At the proposal of the Representative of Nicaragua, seconded by the Rep- resentatives of Trinidad and Tobago, the United States of America, and Uruguay,

2/ Document CE58/2 (19 December 1967).

- 312 - Page 313 58th Meeting Final Report

Dr. Carlos A. Waldheim, Representative of Guatemala, was unanimously elected Vice-Chairman of the Committee.

AGENDA

The agenda contained in Document AG/1 _/ was approved.

DECISIONS TAKEN

As the result of its deliberations the Executive Committee took the following decisions:

1. To include in the agenda of the 59th Meeting all the items arising out of the resolutions of the XVII Meeting of the Directing Council, which were of interest to the Executive Committee and to which the Director referred.

2. To hold the 59th Meeting on a date to be fixed by the Chairman of the Executive Committee in agreement with the Director of the Pan American Sanitary Bureau.

IN WITNESS WHEREOF, the Chairman of the Executive Committee and the Direc- tor of the Pan American Sanitary Bureau, Secretary ex officio, sign the present Final Report in the English and Spanish languages, both texts being equally authentic.

DONE in Port of Spain, Trinidad, this twelfth day of October, nineteen hundred and sixty-seven. The Secretary shall deposit the original texts in the archives of the Pan American Sanitary Bureau and shall send copies thereof to the Governments cf the Organization.

ROBERTO ACOSTA-BORRERO Chairman of the Executive Committee Colombia Representative of ABRAHAM HORWITZ Director of the Pan American Sanitary Bureau, Secretary ex officio of the Executive Committee

2/ Mimeographed document. INDEX

Acha, Pedro N. (PASB), 68, 69, 103, Assistant Director, PASB, appointment of, 116-117, 117, 118, 119, 178, 243 167-170 Acosta-Borrero, Roberto (Colombia), Auditor's report (see Financial Report) Chairman, 58th Meeting of the Exec- Avilés, Orontes (Nicaragua), 307, 308, utive Committee, 3, 7, 18, 20, 21, 309, 312 47, 48, 57, 58, 77, 86, 89, 94, Awon, Maxwell P. rObserver, Trinidad 100, 118, 120, 143, 147, 152-153, and Tobago), 299 153, 176, 185, 193, 228, 232, 241, 248, 260-261, 271, 274, 275, 276- 277, 279, 280, 282, 283, 292, 297- Bacteriological Institute (Chile), 88, 298, 298, 299, 300, 307, 309, 310, 110, 116 311, 312, 313 Banta, James E. (United States of Adolfo Lutz Institute (Brazil), 161 America), 164, 167, 172, 242 Aedes aegypti eradication, 190-195, Barbados, request for admission in 213-215 PAHO, 19-21, 146 Conference, 31, 190, 191, 194, ]3eghin, Ivan (PASB), 132, 133, 243 270 ]3etzig, Edward (United States of Study group, 47, 48, 190, 191, America), 242 192, 193 Bica, Alfredo N. (PASB), 47, 48, 49, Agency for International Development 55, 56, 76-77, 77, 86-87, 87, 89, (AID), 29, 63, 69, 102, 106, 147, 90, 93-94, 94, 96, 109, 112, 113, 148, 179, 267 124-125, 125, 126, 159-163, 165-166, Agenda, Executive Committee 167, 242, 265, 300 adoption Blood, Benjamin D. (United States of 55th Meeting, 3 America), 7, 15, 19, 20-21, 22, 23, 56th Meeting, 15 24, 40-41, 41, 43, 44, 45, 46, 47, 57th Meeting, 247-248 48, 51, 52, 54, 55, 55-56, 56, 59, Aguilar Herrera, Orlando (Guatemala), 61, 62, 63, 65-66, 66, 67, 68-69, 19, 20, 23, 46, 47, 49, 50, 51, 53, 73, 74, 76, 82-83, 85, 86, 87, 92, 56, 60, 61, 65, 66, 68, 70, 71, 76, 93, 94, 95, 96, 100, 102, 103, 105, 77, 84, 85, 86, 93, 94, 96, 102- 106, 110, 112, 112-113, 114, 115, 103, 103, 108, 110, 112, 113, 116, 118, 118-119, 119, 125, 130, 132, 119, 125, 126, 128, 131, 132, 141, 133, 135, 136, 139, 143, 191-192, 143, 147, 148, 153, 154, 157, 164, 193, 199-200, 208-209, 218-219, 242, 172, 176, 184-185, 192, 194, 202, 248, 250, 252, 253, 255, 255-256, 209, 228, 229, 232, 234, 241 257, 258, 260, 261, 263-264, 265, Alliance for Progress, 27, 35, 287 266, 268-269, 269-270, 270, 271, 274, American Public Health Association, 275, 277, 279-280, 281, 282, 283, 55 286, 290, 292, 296, 297, 298, 299, Anderson, H. Dale (Jamaica), 24, 241 300, 307, 308, 310, 311, 312 Andrade, Leoncio (Ecuador), 4, 7 Boletin (PASB), 135, 142 Arreaza Guzman, Alfredo (Assistant Book Exchange (USA), 98 Director, PASB), 168, 247, 271, Bosley, Bertlyn (PASB), 134-135, 135, 271-274, 274, 275, 279, 281, 282, 243 283, 284, 285, 286-287, 288, 290, Bravo, Alfredo Leonardo (PASB), 47, 58, 291, 293-294, 295-296, 296-297, 96-97, 97, 103-104, 105, 139, 244 300, 307 Brazil, observer, 7

- 314 - Page 315 Index

Brooks, Earl D. (PASB), 244 52, 120, 122, 127, 129, 131, 167, Butantan Institute (Brazil), 162 219, 249 Budnik, Emilio (PASB), 244 intensification of health pro- Building Fund (PAHO), 22, 176 grams, decisions taken at, 203- Buildings and installations, report on, 210, 229-231 172-177, 212-213 Chile, observer, 243 Permanent Subcommittee on, 173, Cira, André (Observer, France), 243 174, 175 Collection of quotas (see Quota contributions) Colombia, representative, 7, 241, 299, Calderwood, Howard B. (United States 312 of America), 149, 149-150, 151-152, Colombian Association of Medical 153, 155-156, 174-175, 181-182, 187- Schools, 51, 85 189, 222, 224, 224-225, 225, 228, Columbia University (USA), 104 229, 231, 232, 232-233, 237, 242 Comissiong, Ieonard M. (Trinidad and Calvo, Alberto E. (Panama), Chairman, Tobago), 253, 292, 299, 307, 308, 55th, 56th, and 57th Meetings of the 309, 312 Executive Committee, 3, 4, 7, 8, 15, Common Market, 27, 39, 40, 289 16, 18, 19, 20, 22, 23, 25, 39, 41, Commonwealth Fund, 99, 147 42, 43, 45, 46, 50, 61, 63-64, 65, Community Water Supply Fund, 22, 37, 67, 68, 69, 70, 73, 74, 75, 77, 79, 41, 42 82, 89, 96, 97, 98, 99, 101, 102, Conference on the Eradication of Aedes 106, 109, 118, 121, 123, 130, 132, aegypti (Washington, D.C.), 31, 190, 136, 137, 138, 139, 141, 143, 144, 191, 194, 270 148, 150, 153, 154, 156, 159, 165, Conference on the Training of Public 167, 170, 171, 175, 176, 177, 178, Health Nutritionists-Dietitians 183, 186, 190, 193, 194, 196, 203, (Venezuela), 133, 134, 135 212, 219, 221, 224, 225, 229, 229- Connaught Laboratories (Canada), 125, 230, 232, 234, 237, 237-238, 242, 159, 162 247, 248, 253, 254, 255, 256, 257, Cutler, John C. (Deputy Director, PASB), 258, 259, 260, 261, 264, 265, 266, 167-170, 243 267, 271, 274, 275, 279, 280, 281, 281-282, 282, 283, 284, 285, 286, 287, 289, 291, 298, 299, 300, 303, Declaration of Presidents of America, 307, 312 40, 40-41, 41, 131, 208, 209, 210, Cammaert, Margaret C. (PASB), 91, 92, 219, 292 92-93, 93, 244 Deputy Director, PASB, appointment of, Canadian Public Health Assóciation, 167-170 84 Díaz-Coller, Carlos (PASB), 54, 55, Caribbean Food and Nutrition Insti- 120, 121, 244 tute, 107 Dicancro, Miguel (Uruguay), 307, 308, Carvajal Aragundi, José Joaquin 309, 312 (Ecuador), 182, 200, 202, 241 Directing Council, PAHO, XVII Meeting Central American Advanced School of arrangements for, 157-158 Public Administration (ESAPAC), 81, provisional agenda, 177, 212 Central University of Venezuela, 54 Director, PASB (see Horwitz, Abraham) Charnes, Marcos (PASB), 85, 86, 113, Dominican Republic, observer, 7 196-198, 201-202, 244 Drobny, Abraham (PASB), 48, 49, 50, 67, Charter of Punta del Este, 82, 88, 78, 90, 108-109, 109, 111, 244, 300 204, 207, 210 Chiefs of State, Meeting of the American, 5, 25, 27, 32, 39,40, 41, Ecuador, representatives, 7, 241 Page 316 Index

Educación Médica y Salud, 54 the United Nations (FAO), 33, 78, Eldridge, Alzora H. (Observer, OAS), 7, 134, 288 148, 209-210, 2414, 299 Foot-and-Mouth Disease, Pan American Election of Chairman and Vice-Chairman Center, 5, 30-31, 119, 143, 173, (55th and 58th Meetings), 3-4, 307- 178-190, 219, 221-225, 271-278, 279- 308 281, 296-297, 300 Emergency Procurement Revolving Fund France, observer, 243 (PAHO), 22, 152, 257 Franklin Book Program, 147 External Auditor, resignation, 154-156 Executive Committee date of 56th Meeting, 6 García, César J. (PASB), 136-137, 137, date of 59th Meeting, 310-311 138, 244 Garcia Gutiérrez, 55th Meeting, 3-8 Jose L. (PASB), 300 Gerald, Alfred adoption of agenda, 3 N. (PASB), 300 election of Chairman and González, René (PASB), 51, 51-52, 74- 75, 75, Vice-Chairman, 3-4 90-91, 92, 110-111, 244 Gorgas Memorial Institute final report, 7-8 and Labora- single plenary session, 3-6 tory, 62, 99, 115 Guatemala, 56th Meeting, 15-243 representative, 241, 299,312 Guyana, request for agenda, 239-240 admission in PAHO, 18-19 adoption of, 15 list of participants, 241- 244 Higher Public Health Council of Central 57th Meeting, 247-303 America and Panama, 64, 65, 69, 74, adoption of the agenda, 247- 75, 76, 288 248 Hoekman, J. B. (Observer, Kingdom of final report, 299-303 the Netherlands), 243 58th Meeting, 307-313 Hollis, Mark D. (PASB), 49, 52, 57, 61, election of Chairman and 62, 66, 94-95, 95-96, 105, 105-106, Vice-Chairman, 307-308 106, 128-129, 130, 244, 300 final report, 312-313 Horwitz, Abraham (Director, PASB, Mem- single plenary session, 307- ber and Secretary ex officio of the 311 Committee), 4-6, 6, 7, 8, 17-18, 18, meetings of the, 232-235 19, 20, 25-35, 39-40, 41, 42, 45, 46, representation of, at meeting of 49, 52-53, 57-58, 58, 59, 60, 63, 64- Directing Council, 171 65, 66, 68, 70, 70-71, 71, 72-73, 73, travel expenses of members, 297-298 74, 75-76, 78, 83-84, 86, 87-88, 91, 99, 101-102, 103, 107, 108, 110, 120, 122, 131, 133, 138, 139, 140-141, Fellowship program, 196-203, 215-217 148-149, 149, 150-151, 152, 166, 167- Ferreira, Manoel José (Observer, 168, 176, 179-181, 182-183, 189-190, Brazil), Acting Chairman, 55th 193-194, 203-208, 210, 217, 228-229, Meeting of the Executive Committee, 231, 233-234, 235, 243, 247, 247-248, 3, 7 248-250, 251, 252, 253, 254, 255, 256, Financial Report of the Director and 257, 258-259, 260, 262-263, 264-265, Report of the External Auditor 266, 267, 267-268, 269, 270, 270-271, (1966), 21-24, 145 275-276, 276, 277, 277-278, 280, 280- Financial Rules of PAHO, amendment 281, 282, 283-284, 284-285, 287-288, to, 153-154 288-289, 292-293, 294-295, 298, 299, Food and Agriculture Organization of 303, 308, 308-309, 309, 310, 312,313 Page 317 Index

Institute of Nutrition of Central Latin American Center for Classifica- America and Panama (INCAP), 22, 33, tion of Diseases, 284-285 71, 72, 73, 74, 132, 133, 134, 173, Iatin American Center for Medical Ad- 176, 235, 288-289 ministration, 103-104, 104, 108 Institute of Occupational Health and Latin American Institute for Economic Air Pollution Research (Chile), 57 and Social Planning (Chile), 131 Institute of Organization and Adminis- Leopoldo Izquieta Pérez Institute tration (INSORA) (Chile), 81 (Ecuador), 91 Inter-American Association of Sanitary L¿pez-Vidal, Emilio (PASB), 123, 244 Engineering, 53 Lynch, Alfredo (PASB), 100, 244 Inter-American Committee on the Alliance for Progress (CIAP), 130, 179, 185, 187, 188, 190, 207, 224, Malaria eradication in the Americas 272, 275, 276, 277, 279, 280, 281, Advisory Committee on Malaria 297 Eradication (PAHO), 29 Inter-American Cultural Council, 207 Seminars on, 100 Inter-American Development Bank (IDB), Special Malaria rund (PAHO), 22, 5, 30, 61, 88, 96, 105, 106, 147, 37, 41, 42, 266 149, 150, 152, 153, 178, 180, 205, WHO Special Account, 38, 262-263, 227, 228, 251, 278, 280, 299 263, 266, 267 observer, 299 Malaria Eradication Service of the Inter-American Economic and Social Central American Isthmus, 64, 65 Council (IA-ECOSOC), 30, 129, .178, Martins da Silva, M. (PASB), 56-57, 179, 181, 182, 186, 187, 188, 189, 98-99, 100, 126, 244 203, 224, 225, 272, 274, 275, 276, Medical Education Information Center 278, 279, 280 (PAHO), 201-202 Inter-American Institute of Agricul- Mexican Social Security Institute, 58 tural Sciences, 178 Milbank Memorial Fund, 51, 136, 137, Inter-American Investigation of Mor- 138 tality, 107, 111 Ministers of Public Health of Central International Bank for Reconstruction America and Panama, Meetings, 63, and Developmert (World Bank), 30, 65, 74, 75, 80, 186 106, 178, 180, 280-281 Moore, Clarence H. (PASB), 244, 300 International Classification of Mulliken, Otis E. (United States of Diseases, 284 America), 299 International Conference on Health Musa, Vicente P. (PASB), 190-191, 192, Manpower and Medical Education, 192-193, 244 51 International Conference on Water for McKenzie-Pollock, James S. (PASB), 60, Peace, 106 130, 244 International Labour Office, 78 International Sanitary Regulations, 40 National Association for Retarded Children (USA), 90-91 National Communicable Disease Center Jamaica, representatives, 7, 241, 299 (USA), 62, 124, 161, 163, 285 National Engineering University (Peru), 94 Kellogg Foundation, W. K., 33, 42, 72, National Institute of Health (Colombia) 104, 128-129, 139-140, 147, 152 86, 87 Kingdom of the Netherlands, observers, National Institute of Health (Ecuador), 243 89-90, 91, 290 Page 318 Index

National Institute of Microbiology ;Panama, representative, 7, 242, 299 (Argentina), 162 Pan American Center for Health Planning, National Institute of Nutrition 131, 256 (Ecuador), 90 Pan American Federation of Associations National Institute of Rural Endemic of Medical Schools, 54, 150 Diseases (Brazil), 102 Pan American Foot-and-Mouth Disease National Institutes of Health (USA), Center, 5, 23, 30-31, 119, 143, 173, 34, 72, 124, 126 178-190, 206, 219, 222-226, 248, 271- National Library of Medicine (USA), 278, 279-281, 296-297, 300 98, 99 Pan American Zoonoses Center, 22, 33, 102- National University (Mexico), 59 103, 116, 118, 173 National University (Panama), 68, 69, Paulista School of Medicine (Brazil), 70, 71, 288 56, 98 Nicaragua, representative, 312 Pérez Rueda, Alfredo (Ecuador), 21, 89, Nomenclature Regulations, WHO, 284 89-90, 90, 91, 128, 152, 158, 163-164, 167, 172, 229, 241 Personnel, PASB, amendments to Staff Olivier, Louis J. (PASB), 102, 114, Rules, 156-157 119, 244 Pineda Martínez, Tomás, tribute to Orellana, Daniel (Venezuela), Vice- memory of, 237 Chairman, 55th, 56th, and 57th Poitevin, Emilio (Guatemala), 281, 285, Meetings of the Executive Committee, 288, 289-290, 292, 295, 298, 299 4, 6, 7, 8, 17, 18, 23, 39, 41, 43, Portner, Stuart (Chief of Administration, 48, 50, 52, 53-54, 55, 58, 62, 66- PASB), 16-17, 18, 21-22, 22-23, 23, 35- 67, 67, 71-72, 78, 79, 82, 85, 87, 38, 41-42, 42-43, 43, 43-44, 44, 45, 89, 96, 97, 98, 100, 101, 103, 104- 46, 47, 48, 50, 56, 60, 65, 73, 79-82, 105, 106-107, 111, l-112, 112, 83, 87, 92, 113, 153-154, 154-155, 156, 113, 113-114, 119, 120-121, 121-122, 156-157, 157-158, 171, 172, 172-174, 124, 131, 138-139, 141, 144, 147, 175, 176, 177, 243, 250, 250-251, 252, 148, 153, 164-165, 167, 168, 176- 254, 254-255, 255, 256, 257, 262, 264, 177, 177, 183-184, 192, 196, 200- 266, 267, 274, 287, 296, 300, 310 201, 203, 208, 209, 210, 224, 226, Program and Budget 229, 232, 235, 242, 251, 253, 256 PAHO, 1968 258, 259, 261, 261-262, 262, 268, discussion, 39-44, 45-60, 61- 276, 279, 280, 281, 283, 284, 285, 78, 79-97, 98-117, 118-143, 286, 287, 288, 291, 292, 298, 299, 178-190, 221-222 300 presentation by PASB, 25-38 Orellana Ramirez, Rail S. (Observer, PAHO, 1969 and WHO, 1969 Chile), 243 discussion, 250-271, 295-296 Organization of American States (OAS), presentation by PASB, 248-250 5, 7, 22, 31, 79, 139, 179, 182, Public Administration School (Paraguay), 185, 187, 188, 189, 201, 203, 204, 81 205, 207, 209-210, 217, 225, 272, Public Health School (Venezuela), 53-54, 276, 277, 278 55 observers, 7, 244, 299 Puffer, Ruth R. (PASB), 58, 100-101, 101, Technical Cooperation Program, 139-140, 244 22, 23, 30, 178, 179, 181, 182, 183, 186, 189, 274, 277, 280 Quamina, Elizabeth S. M. (Observer, Ortega Peguero, Miguel Antonio (Ob- Trinidad and Tobago), 299 server, Dominican Republic), 7 Quero Molares, José (PASB), 244, 300 Oswaldo Cruz Institute (Brazil), 86, Quota contributions, collection of, 87, 162 172, 211 Ozorio, Peter (PASB), 244, 300 (see also Financial Report) Page 319 Index

Regional Library of Medicine for South Special Development Assistance Fund, America, 98 186, 187, 275, 277 Renjifo Salcedo, Santiago, tributo to Special Fund for Health Promotion memory of, 298 (PAHO), 152, 229 Representatives and other participants, Special Fund for Research (PAHO), 37, 7, 254-257, 316-317, 328 127 Research Special Malaria Fund Advisory Committee on Medical Re- (see under Malaria) search (PAHO), 98, 114, 126-128 Specialized Analysis Laboratory Office of Research Coordination, (Panama), 68, 69, 288 34, 127, 253 Staff Rules, PASB, amendments to, 156- Special Fund for, 37, 127 157 Research Foundation (Williams-Waterman Sutter, Víctor A. (Assistant Director, Fund), 72, 107 PASB), 3, 15, 144, 145, 146, 167- Resolutions 170, 171, 177, 211, 212, 212-213, of the Conference, 4-6 213-215, 215-216, 217-218, 221, 222- of the Directing Council, 308-310 224, 226-227, 230-231, 234-235, 237, of the World Health Assembly, 248, 243 271, 281-290, 291-295 Rey Alvarez, Raúl (Observer, IDB), 278, 299 Teaching of Preventive and Social Rockefeller Foundation, 72, 85, 86 Medicine, Advisory Committee (PAHO), 194, 195 136-137 Rodrigues, Bichat (PASB), 244 Ten-Year Health Plan, Alliance for Rodriguez Olazabal, José (PASB), 244, Progress, 27, 35, 204 300 Textbooks, supply for medical students, Roosdorp, W. (Observer, Kingdom of the 146-153, 226-229 Netherlands), 243 Trinidad and Tobago, observers and Rules of Procedure, Executive Committee representative, 299, 312 amendments, 16-18, 144-145

United Nations, 35-36, 41, 78, 79, Salzman, O. Howard (Observer, OAS), 139, 156, 187, 198, 217, 286, 288 186-187, 225, 244 Committee of Fourteen, 35-36, Santa María, Julio (Observer, Chile), 287 122-123, 125, 125-126, 128, 130, Development Program, 30, 38, 48, 132, 133-134, 135, 140, 141, 147, 52, 57, 58, 66, 67, 78, 89, 148, 153, 164, 166-167, 186, 198- 96, 103, 109, 118, 131, 202, 199, 203, 209, 217, 228, 236, 243 256, 263, 289, 294 Seoane-Palacios Mission, 31, 179-181, Special Fund, 38, 254, 256, 263 184, 185, 188, 189, 225, 272, 277, Technical Assistance, 38, 66, 67, 279, 280 263, 267 Serum Institute, Copenhagen (Denmark), United Nations Children's Fund (UNICEF), 125, 159 33, 63, 92, 134, 139, 164, 255, 293 Silva, Oswaldo J. da (PASB), 59, 59- United Nations Educational, Scientific, 60, 62, 63, 114-115, 115-116, 244 and Cultural Organization (UNESCO),78 Smallpox, eradication of, 159-167, United States of America, representa- 217-219 tives, 7, 242, 299t 312 Soper, Fred L. (Director Emeritus, United States-Mexico Border Public PASB), 194-195 Health Association, 117 Páge 320 Index

University of Alabama (USA), 69, 70,71 Waldheim, Carlos A. (Guatemala), Vice- University of Brazil, 85 Chairman, 58th Meeting of the Exec- University of Buenos Aires, 104 utive Committee, 299, 307, 308, 309, University of Chile, 109, 110 312, 313 University of San Carlos (Guatemala), Wedderburn, Charles C. (Jamaica), 6, 132 7, 48, 91, 91-92, 108, 117, 157, University of San Marcos (Peru), 92 169-170, 171, 185, 235, 24-1, 260, University of the West Indies 297, 299 (Jamaica), 48, 55, 91-92 Williams, Charles L., Jr., 168, 272 Uruguay, representative, 312 Williams-Waterman Fund, 72, 107 Wilson, Simon N. (United States of America), 242 Vallejo, Nilo (PASB), 76, 135-136, W. K. Kellogg Foundation, 33, 42, 72, 136, 244 104, 128-129, 139-140, 147, 152 Venezuela, representative, 7, 242, 299 Working Capital Fund (PAHO), 21-22, Venezuelan Association of Medical 22-23, 29, 37, 181 Schools, 53, 139 Villarreal, Ram6n (PASB), 50, 50-51, 53, 54, 60, 70, 84-85, 85, 142, 146- Zoonoses, Pan American Center of, 33, 147, 148, 149, 150, 152, 153, 244 102, 103, 116, 173

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