Annual Report of the Director 1979 Cover Design by 1

,,,IS:- PAN AMERICAN HEALTH ORGANIZATION g_11, . 3 (;¿,N:I.( ) J1,1 LA,K-,j,. 1

annual report of the director 1979 Cover design by 1. Ellauri (Frontispiece photos- top row: World BankIR. Witlin, J. Martin, and E.G. Huffman; second row: World Bank/l. Pickerell and E.G. Huffman, PAHO/CFNI, and World BankiT. Sennett; third row: World BanklE.G. Huffman; bottom row: World Bank/I. Pickerell and 1. Martin) 4, PAHO/WHO INTEROFFICE MEMORANDUM Date: 4 May 1981

From: Herbert H. Ortega, Chief To: Those mentioned below* Information & Public Affairs Our Ref: IPA/057/81 Attention:

Your Ref: Subject: NCIH 1981 International Health Conferenc

Orígíinator:

I bring to your attention the attached pamphlet in regard to the above mentioned subject, which NCIH has requested that we make them available to our technical staff°

Please be informed that the following staff members will be participating:

Speaker Topic Date & Time

Ms. Janice Jaeger-Burns Case-Studies for Regular Jun.16/81 9;10:30 am In-Service Training

Dr. Jorge Osuna Technical Management and Jun.16/81 11-12:30 pm Supervision of Primary Health Care Workers

Dr. Ciro De Quadros Special Problems in the Jun.17/81 11-12:30 pm Supply of Vaccines for Control of Communicable Diseases

~. Att.

*Dr. Sumedhn Khannn, CUS Dr. Jorge Litvak, DPC Mr. Frank Butrico, EHP Dr. J. Roberto Ferreira, HRR Dr. Mario Fernandes, AH 1)r. José M. Salazar-Bucheli, LO

ce: D DD AD OM

annual report of the director 1979

Official Document No. 171 August 1980

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, U.S.A. ISBN 92 75 17171 8

Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation of PAHO publications, in part or in toto, application should be made to the Office of Publications, Pan American Health Organization, Washing- ton, D.C. The Pan American Health Organization welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the legal status of any country, territory, city, or area of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. CONTENTS

Introduction vii

1. GENERAL DIRECTION OF THE ORGANIZATION 1

Health for all by the year 2000 4 Study of WHO's structure in light of its functions 6 Governing Bodies 6 The Directing Council 7 The Executive Committee 10 Reorganization of the Pan American Sanitary Bureau 10 Relations with other organizations 13 PAHO and the international cooperation system 13 United Nations Development Program 13 United Nations Environment Program 14 United Nations Children's Fund 15 United Nations Fund for Population Activities 15 United Nations Disaster Relief Office 16 United Nations Economic Commission for Latin America 16 United Nations Food and Agriculture Organization 16 World Food Program 16 World Bank 17 League of Red Cross Societies 17 European Economic Community 17 PAHO and the inter-American system 17 Organization of American States 17 Inter-American Development Bank 18 Inter-American Institute of Agricultural Sciences 18 Subregional groups 19 Conference of Ministers Responsible for Health in the Caribbean 19 Caribbean Community 19 Caribbean Development Bank 19 Ministers of Health of Central America and Panama 19 Ministers of Health of the Andean Pact Countries 20 Bilateral agencies 20 Canadian International Development Agency 20 Canadian International Development Research Center 21 United States Agency for International Development 21 German Agency for Technical Cooperation 21 Swedish International Development Authority 21 Foundations 22 W. K. Kellogg Foundation 22

iii 2. DEVELOPMENT OF HEALTH SERVICE SYSTEMS 24

National policies and strategies 25 Planning 28 Medical care systems 30 Physical and financial resources 34 Maintenance of health care facilities 35 Rehabilitation services 37 Health education 38 Management systems 38 National health information systems 40 Maternal and child health and family planning 41 Latin American Center for Perinatology and Human Development 42 Nutrition 43 Caribbean Food and Nutrition Institute 44 Institute of Nutrition of Central America and Panama 46

3. HUMAN RESOURCES AND RESEARCH 48

Manpower planning and administration 49 Development of human resources 52 Technologic resources 62 Regional Library of Medicine and the Health Sciences 63 Educational technology 65 Latin American Centers for Health Education Technology 65 Educational technology in nursing 67 Fellowships 67 Research promotion and coordination 71 Research grants program 73 Advisory Committee on Medical Research 73 Fields of research 74

4. DISEASE CONTROL 83

Communicable diseases 87 Expanded program on immunization 87 Tuberculosis 92 Mycoses 93 Influenza 93 Diarrheal diseases 93 Rotaviruses 94 Leprosy 95 Sexually transmitted diseases 97 Hepatitis 97 Bacterial diseases 98 Prevention of blindness 98 Malaria 99 Other parasitic diseases 103 Chagas disease 104 Schistosomiasis 104 Filariasis 105 Leishmaniasis 105 Aedes aegypti eradication 106 Yellow fever 111 Dengue 111 Mental health 112 iv Dental health 113 Noncommunicable diseases 114 Cancer 114 Other noncommunicable diseases 115 Hospital infections 116 Laboratory services 116 Epidemiologic surveillance 118 Caribbean Epidemiology Center 118 Biologicals 120 Emergency preparedness and disaster relief coordination 124 5. ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 127

Environmental health 127 Water supply and basic sanitation 131 Solid wastes 133 Institutional development 134 Pan American Center for Sanitary Engineering and Environmental Sciences 135 Pan American Center for Human Ecology and Health 139 Radiation health 141 Fluoridation 142 Traffic accident prevention 143 Control of toxic substances 145 Food protection 145 Zoonoses and animal health 146 Foot-and-mouth disease and the Pan American Foot-and-Mouth Disease Center 148 Zoonoses and the Pan American Zoonoses Center 151 6. SUPPORTING SERVICES 155

Information collection and dissemination 155 Development of statistical methodology 156 International Classification of Diseases 156 Microcomputers in health 158 Health and biomedical publications 159 Periodical and special publications 159 Journals 159 Scientific publications and official documents 160 Distribution 163 Filmstrips 163 Visual aids 164 Public information 164 Expanded textbook and educational materials program 165 Bibliographic and health information office 166 7. ADMINISTRATION AND MANAGEMENT 168

American Region Programming and Evaluation System 169 Budget and finance 169 Procurement 171 Personnel 172 Conference services 172 Management and computer services 173 Index 175 Acronyms and Corresponding Bodies or Programs 188

v tif 0 :i

International Year of the Child 1

1 Introduction

As the 1970s drew to an end, so did the Ten-Year Health Plan for the Americas promul- gated at Santiago, Chile, in late 1972. Since 1975 the Plan, which has guided the activities of the Region's health ministries and the Pan American Health Organization, has emphasized specific improvements in health status and the delivery of health care as well as technical cooperation from international and bilateral agencies. In the middle and late 1970s the social and economic thinking of the Region's developing countries began to change. No longer could specific disease control programs go un- related and often in conflict with each other; no longer could events in the health sector be isolated from those in other developmental spheres; no longer could technical assistance from abroad be a satisfactory substitute for efforts by the developing countries individually and collectively. The need for change in the way the Region's countries try to advance their health status found ever clearer expression toward the end of the decade. This evolution in strategies for improving the health of the developing world culminated in the IV Special Meeting of Ministers of Health of the Americas in 1977 and the International Conference on Primary Health Care at Alma-Ata, U.S.S.R., the following year. Primary health care, as defined at the Conference, implies rnt merely basic health care but also technical cooperation among developing countries, community participation in health activities, the use of appropriate technology to achieve universal health care coverage, and articulation of health with other developmental sectors. Thus, health for all people by the year 2000 is now the fundamental goal of the Region's'nations. Technical cooperation means that the developing countries guide their own advance- ment in all spheres including health, instead of relying on the external guidance implicit in the now outdated concept of technical assistance. Community participation, which is the community-scale equivalent of technical cooperation among developing countries, expresses the new awareness of planners that progress in health cannot be decreed from above but will only come about if the citizens for whom health programs are designed willingly collaborate in their execution. The phrase "appropriate technology" expresses another fairly recent realization: that the health care technology of industrialized countries is often unsuited to developing nations, as a result of which other-and sometimes simpler-technologies must be devised or adapted for their use. The countries of Latin America and the Caribbean are unique in their political, economic, and social pluralism. Their very diversity might seem an obstacle to realizing the goal of health tor all by the end of this century, but the past has amply shown that they can cooperate in achieving common health goals. The Region of the Americas was the first to eradicate smallpox-one of the greatest accomplishments in the annals of public health-and there is no reason to doubt that similar collaborative efforts will bear their

vii own fruit. The task now before the Americas, then, is to create health conditions condu- cive to a socially and economically productive life for all their peoples. The role of the Pan American Health Organization in this massive endeavor is promotion, coordination, and technical cooperation. To prepare itself for that function, it has institutedb.ennial programming and budgeting and its secretariat, the Pan American Sanitary Bureau, undertook a major internalreorganization in 1979. In collaboration with its Member Countries, the Organization is now analyzing the gains made and strategies used during the Ten-Year Health Plan. From this analysis will result programs to advance health care in individual countries, groups of countries, and the Region as a whole. Priorities must be set and funding-often from extrabudgetary sources-arranged for these programs, but if the will and cooperation that have characterized the past continue, the people of the Americas will surely achieve health for all by the year 2000.

Héctor R. Acuñia Director

vii Chapter 1 GENERAL DIRECTION OF THE ORGANIZATION

For the Pan American Health Organiza- health one of the essential components of tion, the year 1979 was dominated by a well-being. Since the health sector ob- goal that had been forming little noticed viously cannot attain the goal alone, for two years before it suddenly matured: its efforts must be joined with those of health for all by the year 2000. other socioeconomic development sec- This goal derives from two statements tors. Governments must expressly include of purpose. In 1977 the World Health health policies in their 2eneral develop- Assembly resolved (WHA30.43) that the ment plannin. It is essential, therefore, main social target of governments and that the strategies of the various sectors WHO in the coming decades should be be coordinated and mutually supportive in "attainment by all citizens of the world order to attain the profiles of well-being, by the year 2000 of a level of health that including health, which each country de- will permit them to lead a socially and fines for its own society. economically productive life." The world's developing countries are A year later the Declaration of Alma- becoming increasingly conscious of the Ata, adopted at the International Con- need to adopt a change in development ference on Primary Health Care at Alma- style. As a result, many are trying innova- Ata, U.S.S.R., clearly stated that primary tive approaches-other than linear growth health care is the key to attaining health or sporadic bursts in applying resources- for all as part of overall development and that are expected to produce the necessary in the spirit of social justice. The Declara- impact, in line with the health-for-all goal. tion called on all governments to formulate The operational capacity of national national policies, strategies, and plans of health systems must be augmented through action to launch and sustain primary administrative development if efforts and health care as part of a comprehensive investments are to yield their expected national health system and in coordination benefits. This includes planning and pro- with other sectors. The Declaration also gramming, information services, and fi- called for urgent and effective interna- nancing mechanisms, as well as the de- tional-as well as national-action to velopment of manpower and appropriate develop and carry out primary health care technologies. Substantial support of pro- throughout the world, and particularly in grams to maintain health facilities and developing countries. equipment is also essential. The principal characteristic of the The principal innovations relate to the health-for-all goal is that it considers operational concepts of primary health

1 The XXVI Meeting of the PAHO Directing Council discussed strategies for achieving the goal of health for all by the year 2000 and adopted resolutions on priority health items.

A contract was signed with the Inter-American Development Bank, granting a loan for the PAHO textbook and educational materiais program in public health.

PAHO honored the W.K. Kellogg Foundation on its 50th anniversary by placing a plaque in the Headquarters rotunda commemorating the Foundation's achievements in health during its first half-century of existence. (Photos: PAHO/R. Molina and H. H. Jensen) GENERAL DIRECTION OF THE ORGANIZATION 3 care: community organization and partici- long underway in the Region to achieve pation; articulation of traditional and health for all. The first regional statement formal health systems; promotion of tech- of resolve to improve health and health nologies suitable to national conditions, care in the Hemisphere was the Charter of and efforts to implement the concept of Punta del Este, which was signed in August technical cooperation among developing 1961 and led to the Ten-Year Public Health countries in technologic development. The Program of the 1960s. The next was the application of these ideas is a breakthrough now-ending Ten-Year Health Plan for the in extension of coverage: health will no Americas (1971-80), which was drawn up at longer be a matter of giving service to the III Special Meeting of Ministers of passive recipients, and community involve- Health of the Americas at Santiago, Chile, ment in health activities-especially in in 1972. primary care-will have a multiplying The Ten-Year Health Plan has represented effect and a corresponding impact on the an effort to integrate and coordinate the development of health services. work of the countries to improve the health For the Americas the year 2000 goal rep- of their populations and has been directed resents an extension of collective efforts toward the development of health in the

Figure 1. Estimated population in three regions of the Americas, 1960-2000.

600 _ Latin America 500 - 400- 300 -

200 - Northern America

A 100: E

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lo -

Caribbeanal 4- 1 1 1 I I 1960 1970 1980 1990 2000 Year "Excludes: Cuba, Dominican Republic, Haiti, and Puerto Rico, which are included in Latin America. Source, World Population Trends and Prospects by Country, 1950-2000. New York, United Nations, 1979. 4 REPORT OF THE DIRECTOR

Hemisphere as a whole. The overall ap- analyzing and formulating national and re- proach is seen in the Plan's recommenda- gional health strategies for the next two tions, which cover almost all relevant decades. aspects of health. The Plan was included The need for a regional strategy to in PAHO's policy through a Directing Coun- achieve universal health coverage by the cil resolution. end of the century was discussed in detail in September and October at the XXVI Meeting of PAHO's Directing Council, where 20 countries reported on the steps Health for All by the Year 2000 they had taken to define the national goal of health for all by the year 2000 and draw up national strategies for attaining it. Rep- In May 1979, as a result of WHA30.43 and resentatives of several countries stated the Declaration of Alma-Ata, the World that their governments had already incor- Health Assembly urged (WHA32.30) Mem- porated similargoals in their national health ber Governments to formulate policies, plans or were in the process of doing so. strategies, and plans of action to attain In consequence of these national reports, health for all through primary care. the Council adopted a resolution (CD26.25) This subject was examined at the 82nd urging the countries and PAHO to further Meeting of PAHO's Executive Committee a the analysis of their health strategies to month later, and the Committee resolved achieve the health-for-all goal. (CE82.19) that evaluation of the Ten-Year Starting in September 1979 and continu- Health Plan, analysis of the health care ing into early 1980, each of PAHO's Mem- development strategies the countries used ber Governments will analyze its national during the 1970s, and formulation of na- health strategies and accomplishments tional and regional strategies for achieving under the Ten-Year Health Plan. On the health for all by the year 2000 should go basis of this analysis, governments will hand in hand. design their national strategies for achiev- To initiate these activities, PAHO staff ing health for all by the year 2000. began holding a series of meetings with PAHO will consolidate and integrate in- national officials in several countries in formation supplied by the governments August and September to brief them on the and prepare a draft compilation of national approaches to be followed and on proposed strategies used during the 1970s and those procedures. The immediate objective was proposed for the balance of this century. to reach a common understanding on the From this information, it will draw up a re- nature of the global goal and its implica- gional profile grouping countries with tions for the Region. Particular attention similar future priorities and strategies. This was given to considering health as but one document, together with information from component of the well-being level of each the evaluation of the Ten-Year Health community, and to consider that the goal Plan's accomplishments and the strategies is a dynamic tool to promote policy deci- used during the 1970s, will become the sions and health actions in integration with framework within which Member Govern- other socioeconomic sectors. ments will formulate their proposals for To facilitate the tasks defined in CE82.19, future regional strategies to be discussed the Secretariat prepared and distributed at the XXVII Meeting of the Directing to the countries copies of guidelines for Council in 1980. evaluating the Ten-Year Health Plan and Since intersectoral relationships and GENERAL DIRECTION OF THE ORGANIZATION 5

Figure 2. Estimates and projections of births, deaths, and excess of births over deaths per 1,000 population in three regions of the Americas, 1950-2000.

100- 90- 80- 70- 60- 50- 40- Births Births-

30- ,2 , 20- Excessq o 1 Births o o0 : 1 - Excess Deathsj lo-

cx -

Deaths] Deaths ] Excess

2- I 1I 1i 1I I í 1 1 1 1 I ,1 ,1 I¡ I1 1950 1960 1970 19S01990 1950 1960 1970 1980 1990 1950 1960 1970 1960 1990 -1960 -1970 -1980 -1990 -2000 -1960 -1970 -1980 -1990 -2000 -1960 -1970 -1980 -1990 -2000 Latin America Caribbeana Northern America a Excludes, Cuba, Dominican Republic, Haiti, and Puerto Rico, which are included in Latin America. Source= World Population Trends and Prospects by Country, 1950-2000. New York, United Nations, 1979.

particularly extrabudgetary financing will velopment Bank. Both are heavily involved be crucial factors in achieving the 2000 in and financially support other-and now goal, PAHO has entered into much closer related-areas of development in Latin relations in the past year or two with the America and the Caribbean. PAHO's rela- United Nations' Economic Commission for tions with them are described in detail later Latin America and the Inter-American De- in this chapter. 6 REPORT OF THE DIRECTOR

Study of WHO's Structure in Executive Committee's summary report to Light of its Functions the Directing Council in September, and later five more responses were submitted. After consideration by the Directing Coun- A topic discussed at the Directing Coun- cil, the report was transmitted to Geneva cil meeting and both meetings of the Execu- where it joined similar studies from WHO's tive Committee during 1979 was a study other five regions. The documents were the World Health Assembly requested in reviewed by WHO's Program Committee in 1978 (WHA31.27)of WHO's structure in light November and were to be further studied of its functions. The purpose of the re- by its Executive Board in January 1980. quested study is to prepare WHO as effec- A summary of the responses follows: tively as possible for carrying out its central role in achieving the goal of health for The governments considered the goal of all by the year 2000 and to find ways to in- health for all by the year 2000 realistic. At the crease its technical cooperation with Mem- global level a political role was envisaged for ber Countries. The study's results may have WHO to enhance its prestige, but it was felt that far-reaching effects on PAHO's structure PAHO should concentrate on the "technical aspects" of health. Changes in WHO's structure and functions. were not considered necessary to reach the As a result of the Assembly's resolution, health-for-all goal, but changes in philosophy the Director-General of WHO prepared a and orientation were thought desirable. document in 1978 entitied, "Study of WHO's There was a call for a compact, highly quali- Structures in the Light of its Functions," fied technical-managerial staff at WHO Head- quarters oriented along functional program which put forward many ideas and asked lines. The responses urged that country repre- numerous questions about WHO's future. sentatives' offices be strengthened and that Later that same year the XX Pan Amer- more programmatic and administrative and ican Sanitary Conference asked PAHO's financial authority be delegated to them. There Executive Committee to give special con- was also a feeling that national institutions and centers could and should be much more widely sideration to the document and to carry used. out the study in the Americas. At its 81st It was felt that country contributions to re- Meeting following the Sanitary Conference, gional and global policies could and should be the Executive Committee in turn charged enhanced through subregional groups, govern- the Governments of Ecuador, Trinidad and ing bodies, and task forces. At the same time, PAHO's resolutions were seen to be influencing Tobago, and the United States with co- national health policies and to be entering the ordinating the hemispheric study. planning systems of the countries in an increas- On the basis of the WHO study, the three- ingly formal, structured way. The benefits of nation working group drew up a detailed using PAHO for in-service training of key na- questionnaire which was sent to all of tionals were noted, and the governments said they were willing to make nationals available to PAHO's Member and Participating Govern- PAHO for consultation, programming, and opera- ments. Twelve completed questionnaires tional duties. were received in time to be included in the

GOVERNING BODIES

The Pan American Health Organization the World Health Organization (WHO) and, (PAHO) is one of six regional components of as such, a member of the United Nations GENERAL DIRECTION OF THE ORGANIZATION 7 family of specialized international agen- The Directing Council cies. It has served as WHO's Regional Office for the Americas since April 1949, though it was founded much earlier-in 1902. By an The XXVI Meeting of the Directing Coun- agreement concluded in May 1950, it is cil, which was also the XXXI Meeting of the also charged with advising the Organiza- WHO Regional Committee for the Americas, tion of American States on health matters was held from 24 September to 5 October in the Western Hemisphere. at Washington. It was attended by repre- All American States are entitled to belong sentatives of the 32 Member and Participat- to PAHO and take part in the affairs of its ing Governments. Governing Bodies, as are certain non- Also present were observers from four American countries with dependencies in United Nations agencies-the Develop- the Hemisphere. At the end of 1979, PAHO ment Program, Children's Fund, Food and was composed of 29 Member Govern- Agriculture Organization, and Economic ments* and three Participating Govern- Commission for Latin America-and the ments (France, the Netherlands, and the Organization of American States (OAS), United Kingdom) representing dependen- Inter-American Development Bank, Hipó- cies in the Americas which, together, had a lito Unanue Agreement (related to the population of 603 million people. Andean Pact), and 22 nongovernmental PAHO is constitutionally quadripartite. organizations. Its three Governing Bodies are the Pan The Council held an inaugural, 16 ple- American Sanitary Conference, which is nary, and a closing session and approved defined as its "supreme authority" and 39 resolutions on various subjects. The meets quadrennially; the Directing Coun- following were among its more important cil, which normally meets annually in those topics of discussion and resulting resolu- years when the Sanitary Conference does tions: not convene, and the Executive Commit- * The Council appropriated $86,833,774 tee, which meets for twice yearly and is charged PAHO, including $11.3 million for the staff's tax with organizing matters for consideration equalization fund, for the financial period 1980- by the Sanitary Conference and Directing 81 and approved WHO's revised program budget Council. Its Secretariat is the Pan American for the Region of the Americas for 1980-81 in Sanitary Bureau, whose Director is elected the amount of $37,457,000 (CD26.9 and 11). * Because extension at each Sanitary Conference of health service cover- and whose age to the entire population is a common goal of other officers and staff are appointed by theAmericas, theCouncil asked MemberGovern- the Director. ments to continue their evaluations of the Ten- As required by PAHO's constitution, two Year Health Plan for the Americas, to pursue of the Governing Bodies held meetings the formulation of national and regional strategies for during 1979, the Directing Council and attaining health for all by the year 2000, and to promote multisectoral activities to Executive Committee. achieve the community's well-being (CD26.25). * The Council also recognized that varied health-sector institutions-especially social security agencies and health ministries-will have *Argentina, Bahamas, Barbados, Bolivia, Brazil, to Canada, Chile, Colombia, Costa Rica, Cuba, Domini- coordinate their efforts to extend health can Republic, Ecuador, El Salvador, Grenada, Guate- service coverage in order to achieve the goal of mala, Guyana, Haiti, Honduras, Jamaica, Mexico, health for all by the year 2000 (CD26.32). Nicaragua, Panama, Paraguay, Peru, Suriname, Trini- * The serious socioeconomic and public dad and Tobago, United States of America, Uruguay, health problems of the peoples of Nicaragua, and Venezuela. now rebuilding their country, and of Dominica 8 REPORT OF THE DIRECTOR and the Dominican Republic following hurri- their program needs as much as possible; (5) canes David and Frederick, spurred the solidarity promote basic and operations research to im- of the Region's governments. The Council approve treatment and control; and (6) encourage proved a 1980-81 operating budget for aid in PAHO to deal with critical program needs and Nicaragua's reconstruction and special services consider reprogramming available country proj- to Dominica and the Dominican Republic ect funds to meet those needs (CD26.38). (CD26.7). * The world's four principal causes of blind- * After recognizing that the Expanded Pro- ness-infectious eye diseases, onchocerciasis, gram on Immunization (EPI) is among PAHO's xerophthalmia, and cataracts-are present in most important programs, particularly as the Latin America and the Caribbean, and to them entry point for primary health care and exten- must be added glaucoma and eye accidents as sion of health service coverage, the Council causes of blindness in the Region. WHO has urged Member Governments to strengthen their declared that preventing blindness is one of its own immunization activities and recommended priorities, and some American governments that they participate in the EPI revolving fund have formulated national programs for that pur- and bolster their epidemiologic surveillance pose. The Council asked the Director to support systems. It asked the Director to study the feasi- public and private efforts in this area, especially bility of reallocating funds to EPI, collaborate as to research, training, and program planning, with national health authorities in research and to establish a regional advisory group, and to resource development, and examine the possi- obtain necessary extrabudgetary funds (CD26.13). bility of establishing a regional focal point for * Noncommunicable or chronic diseases vaccine cold-chain equipment operations such as cancer, rheumatic fever, and diabetes (CD26.21). mellitus are becoming ever more important in * The Council gave high priority to promoting Latin America and the Caribbean because they and supporting malaria programs, particularly lead to much death, sickness, and disability. the formulation and strengthening of national The Council consequently resolved to discuss plans as well as a hemispheric plan, and the this topic at its next meeting so that policies, exploration of possible sources of funding for strategies, and action plans for PAHO's technical such programs (CD26.30). cooperation can be drawn up (CD26.18). * Because of Member Countries' growing * Recognizing the magnitude of the dental interest in tropical diseases and leprosy research caries problem, the lack of resources for dealing and control, the Council encouraged special with it, and the need for effective caries preven- efforts to solicit extrabudgetary funds for those tion programs reaching all people, the Council diseases, continuation and improvement of recommended that Member Governments con- advisory and training services, and development duct salt fluoridation programs and that PAHO of national laboratories. The Pan American undertake other necessary measures to promote Center for Research and Training in Leprosy and caries prevention (CD26.39). Tropical Diseases at Caracas, a Venezuelan * Energy-protein malnutrition and other nutri- institute which has been associated with PAHO tional deficiencies have devastating effects on since 1976, was singled out as an outstanding human development, and their incidence poses example of technical cooperation among de- a grave public health problem. In view of this, veloping countries (CD26.37). the Council asked the Director to prepare a * Diarrheal diseases pose especially serious document on malnutrition and deficiency-in- socioeconomic and public health problems in duced mental retardation in the Region and to Latin America and the Caribbean. As a result, include funds in the operating budget for studies the Council endorsed the new emphasis on di- to develop suitable control strategies (CD26.17). arrheal disease control and goal-oriented re- * Noting that the zoonoses and animal health search as well as on regional self-reliance in are matters of crucial concern to the one-third producing oral rehydration salts. It encouraged of a billion people in Latin America and the Member Governments to: (1) establish national Caribbean, the Council declared itself in favor diarrheal disease control programs in their of keeping the Pan American Foot-and-Mouth primary health care systems; (2) designate na- Disease Center (PANAFTOSA) at Rio de Janeiro tional program coordinators to serve as focal attached to PAHO as a regular program, in- points for these activities; (3) develop work plans structed the Director to give first priority for their national programs in collaboration with to a comprehensive external evaluation of PAHO; (4) reallocate national resources to meet PANAFTOSA and the Pan American Zoonoses ro~0 E 2_

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_ _ | _ _ _ I | I I I I E s | _ 10 REPORT OF THE DIRECTOR

Center (CEPANZO) at Ramos Mejía, Argentina, visional draft of the 1982-83 PAHO/WHO budget and approved a 1980 supplementary budget as a basis for preparing program and budget for those two Centers (CD26.26-28 and 31). estimates for that biennium. * Emergency situations caused by natural or * Member Governments were asked to pro- man-made disasters affect the health status of pose regional strategies for extending health the Region's countries. The Council recognized service coverage, and the Director to help in that PAHO's most valuable contribution to disas- their formulation, to achieve the goal of health ter recovery is the speedy provision of technical for all by the year 2000. cooperation, for which its emergency prepared- * The Director was asked to work with Mem- ness and disaster relief coordination program ber Countries to formulate a hemispheric plan was developed. It urged Member Governments for strategies to promote technical cooperation to establish a high-level, multisectoral coordinat- among developing countries. ing group for updating plans, training, and pro- * The Committee recommended that the moting research for the program, to contribute Directing Council ask the Director to draw up a to PAHO's national disaster relief voluntary plan to promote and support malaria control fund, and to facilitate postdisaster cooperation programs. through prior agreements. It also asked the * The Committee approved a model for Director to maintain contact with funding agen- evaluating PAHO's Pan American Centers. The cies so that assistance could be suitably chan- model was used during the year to evaluate the neled, strengthen PAHO's cooperation in this Caribbean Epidemiology Center at Port-of-Spain, program, and focus that cooperation on training Trinidad and Tobago. and coordination (CD26.36). The Committee also authorized official The Council's Technical Discussions working relations between PAHO and the were on "Strategies for Extending and Im- Latin American Federation of Hospitals proving Potable Water Supply and Excreta and the Inter-American Council of Psychi- Disposal Services during the Decade of the atric Associations. 80s," and the topic chosen for discussion in The Executive Committee held its 83rd 1981 was "Sanitary Control of Food." Meeting at Washington on 5 October. Present were representatives from the three countries (Chile, Guyana, and Mexico) The Executive Committee which replaced those whose periods of membership had expired (Ecuador, Para- PAHO's Executive Committee held its guay, and Trinidad and Tobago), in addi- 82nd Meeting at Washington from 25 June tion to the other Committee Members- to 3 July. The following were somne of the Brazil, Canada, Guatemala, Peru, United highlights of the Meeting's resolutions: States of America, and Venezuela. Representatives of several countries * It recommended a PAHO working budget of were elected to various committee and $75.5 million for 1980-81. The PAHO budget, subcommittee posts, and the Committee combined with additional funds from WHO and other sources, makes up PAHO's total budget for authorized PAHO to establish official work- health activities in the Americas. The Commit- ing relations with the Latin American Feder- tee also instructed the Director to use the pro- ation of the Pharmaceutical Industry.

REORGANIZATION OF THE PAN AMERICAN SANITARY BUREAU

It falis to PAHO's Secretariat, the Pan responsibilities that derive from new poli- American Sanitary Bureau, to shoulder the cies and strategies and ensure that the GENERAL DIRECTION OF THE ORGANIZATION 11 decisions taken are implemented as effec- and supervision of technical cooperation tively as possible. The obvious interrela- programs in the field whose execution is tionships of health activities compel the the direct responsibility of the Country and Bureau to adopt a multidisciplinary ap- Area Representatives; (d) orientation, pro- proach at all staff levels, and increasing gramming, technical supervision, and eval- emphasis must therefore be placed on uation of the activities of the Pan Ameri- multidisciplinary work throughout the can Centers supervised by the various Bureau. technical divisions; (e) participation, on a To implement these ideas, four major multidisciplinary and interdivisional basis, areas have been established within PASB: in long-term planning and in short- and decision- and policy-making, program de- medium-term programming through the velopment, program execution and evalua- headquarters program committee and other tion, and administrative support. mechanisms; and (f) multidivisional contri- Decision- and policy-making. This area butions in priority program areas. consists of the Office of the Director, and Program execution and evaluation. The its main functions are: (a) discharging PASB's Office of the Operations Manager has constitutional responsibilities; (b) interpret- been established to coordinate the execu- ing and implementing the global and re- tion and supervision of programs in the gional policies of the Governing Bodies; field. It guides and supports field offices (c) decision-making to carry out the Govern- in their implementation of PASB's technical ing Bodies' mandates; (d) maintaining rela- cooperation program. tions with WHO's global program commit- Its functions may be summarized as tee and the program development working follows: (a) provision of guidance and sup- group; (e) long-term planning; (f) providing port to field offices in carrying out the orientation of PAHO's short- and medium- policies and decisions of the Governing term programming; (g) formulating policy Bodies and the Office of the Director; (b) with respect to extrabudgetary resources, participation in long-term planning, short- including the development of ways to and medium-term programming, and evalu- identify them; and (h) carrying out inter- ation of PASB's technical cooperation; (c) agency relations and bilateral and private monitoring the administrative aspects of technical cooperation. field offices' programmed activities; (d) Program development. Country-level coordination of the technical and adminis- program development is the province of trative communications and actions re- the field offices, subject to the guidance quired of Headquarters to ensure that and coordination of the Director's Office. activities are carried out effectively and At the Headquarters level, the staff of the in a coordinated and timely manner; (e) technical divisions, the Special Program of mobilization of support provided by the Animal Health, and the Office of Adminis- divisions and the administration to field tration participate in program develop- offices in technical and administrative ment through: (a)development and delivery matters; (f) operation and evaluation of the of knowledge and technologies, including development of the American Region pro- training; (b) formulation, implementation, gramming and evaluation system (AMPES); technical support, and supervision of re- and (g) promotion of activities to stimulate gional AMRO programs in coordination technical cooperation among developing with PAHO/WHO Country and Area Repre- countries in close coordination with field sentatives; (c) participation in the formula- offices and Headquarters. tion, implementation, technical support, 12 REPORT OF THE DIRECTOR

Administrative support. The Office of and coordinates with WHO's legal office in Administration is adjusting its norms and Geneva. procedures in response to the needs of * The Assistant Director was given supervision of the collection and dissemination of statistical PASB's technical cooperation program. To information, disaster preparedness, and health support the effective execution of the pro- and biomedical publications. The last group of gram, these adjustments must be based on activities, which embraces publications, text- its development and evaluation. To this books, and public information, were merged end, the office is increasing its participa- into a new Office of Health and Biomedical Publications. tion in long-term planning and short- and * The Office of the Operations Manager, medium-term programming and evaluation. which is described in greater detail above, was The measures being implemented are established to coordinate technical cooperation designed to assure that requisite human, and administrative communications with Coun- material, and financial resources are pro- try, Area, and other.field offices and ensure implementation of technical cooperation provided when needed. A better definition of grams at country and subregional levels. AMPES, the particular characteristics of these re- which supports these activities, was reassigned sources will have to be provided by those to this office. in charge of the programs, with the co- An internal reform begun in 1975 was the operation of the field offices, technical concentration of country and regional proj- divisions, and Office of the Operations ects in major program areas. This led to the Manager. Finally, the Office of Administra- consolidation of 11 technical departments tion is also called on to cooperate with the into six technical divisions, and an attempt Office of the Operations Manager and the was made to remove Headquarters techni- technical divisions in the administrative cal divisions from direct management of control of field operations, and in furnish- field operations. In 1979 this reform was ing the information required by PAHO and carried further by restructuring the divisions its external auditors. to reduce their number to four and to Within this context of PASB's structural achieve greater balance in their resources policies, the following refinements were and activities through inter- and intradivi- made in its organization during 1979: sional functional realignments. The result of these changes was the disestablishment of the former Divisions of Family Health * Two new units were created within the and Supporting Services. The major changes One was a long-term Office of the Director. in Headquarters divisional organization planning office under the Director's immediate supervision, which was established to participate were as follows: in and coordinate analyses for and proposais to the Director about the various strategic and operational aspects of PAHO's long-term plan- * The Division of Comprehensive Health ning. It takes part in PAHO's cooperation with Services was strengthened to consolidate all Member Governments in formulating, evaluat- health service functions. These comprise nutri- ing, and adjusting national and regional priori- tion; maternal and child health, including health ties, goals, and strategies for achieving universal education; human reproduction, family plan- health and in necessary analyses and prepara- ning, and population dynamics; national health tions for the Region's contributions to global information systems activities; and those dealing strategies toward that end. It also takes part in with women in social and economic develop- evaluating PAHO's short- and medium-term pro- ment. The division was also given technical gramming in order to coordinate and adjust responsibility for the Latin American Center for long-term planning. The other unit was a legal Perinatology and Human Development at office, which provides advice to the Governing Montevideo, the Institute of Nutrition of Central Bodies and PASBon legal matters and cooperates America and Panama at Guatemala City, and GENERAL DIRECTION OF THE ORGANIZATION 13 the Caribbean Food and Nutrition Institute at 1979 at Mexico City and soon to be transferred Kingston. Organizationally, the division is to Toluca, and the Pan American Center for divided into three components: health service Sanitary Engineering and Environmental Sci- development, appropriate technology for ences (CEPIS)at Lima. health, and intersectoral activities. * The Division of Human Resources and Re- * The Division of Disease Prevention and search assumed responsibility for the Bureau's Control was consolidated into four major com- bibliographic information services and de- ponents-communicable disease control, para- velopment of a bibliographic information net- sitic diseases and vector control, noncommuni- work in the Region centered at the Regional cable diseases, and laboratory services and drug Library of Medicine and Health Sciences at control-and it assumed responsibility for Sáo Paulo. It is also technically responsible for mental, dental, and radiation health. This divi- the Latin American Centers for Educational sion is technically responsible for the Caribbean Technology in Health at Rio de Janeiro and Epidemiology Center at Port-of-Spain, Trinidad Mexico City. and Tobago. * A Special Program for Animal Health was * The Division of Environmental Health Pro- established to provide a focal point for the tection was expanded to include water fluorida- promotion of veterinary public health. This tion and food protection activities which for- program has technical responsibility for the merly belonged to other divisions. This division Pan American Foot-and-Mouth Disease Center has technical responsibility for the Pan American at Rio de Janeiro and the Pan American Zoonoses Center for Human Ecology and Health (ECO) in Center at Ramos Mejia, Argentina.

RELATIONS WITH OTHER ORGANIZATIONS

Several high-level meetings were held in vironmental health projects. A UNDP repre- Washington during the year with represen- sentative chairs the International Drinking tatives of United Nations agencies, de- Water Supply and Sanitation Decade's velopment banks, bilateral agencies, and interagency steering committee, and at foundations to discuss policy issues and country level UNDP resident representatives areas of common concern in health. More act as focal points for international co- clearly defined relationships and closer operation. collaboration between PAHO and the other UNDP financed water supply and sanita- bodies were the result. tion improvement projects for 10 medium- sized cities in Haiti (Service National d'Eau Potable) and a project to strengthen the Trinidad and Tobago water and sewerage PAHO and the International authority's training program, the latter in Cooperation System conjunction with the Inter-American De- velopment Bank. Negotiations were begun United Nations Development Program for a new project to develop water supply and sanitation services in the Turks and The United Nations Development Pro- Caicos Islands, and an agreement was gram (UNDP) continued to collaborate signed to strengthen the state water works actively with the Region's countries by in Uruguay institutionally. In El Salvador providing financial support to eight en- the rural water supply and sanitation proj- 14 REPORT OF THE DIRECTOR ect, financed in part by UNDP, continued Four new projects-one regional and three as planned. national-were approved and began oper- In other environmental health areas, ations during the year. In Guatemala a UNDP provided support to PAHO's projects UNDP-financed mission collaborated in to develop environmental control pro- developing a national drug control programs in Rio de Janeiro and Sáo Paulo gram. PAHO collaborated with the United States in Brazil and to strengthen the en- Nations Capital Development Fund in a vironmental research directorate in Vene- mission to Nicaragua to review and make zuela. The two Brazilian projects-that in recommendations about its malaria con- Rio de Janeiro State had been started in trol program. 1974 and received $1,235,000 from UNDP, The community health training program while that in Sáo Paulo State was begun in for Central America and Panama (PASSCAP) 1973 and received $1,223,000 from UNDP- is financed by UNDP as part of its sub- were completed during the year and pro- regional programs. For the period 1979- duced a wealth of information for more 81 the agency has awarded it a grant of comprehensive environmental manage- $400,000 which, together with PAHO's ment. The two national agencies that participation through assignments of per- operated the projects are now preparing sonnel, has enabled the program to ad- proposals for submission to international vance rapidly. financing agencies for environmental pollution control projects costing $300 million. The regional educational program for United Nations Environment Program animal health assistants (REPAHA), started in September 1975, is conducted at George- In collaboration with PAHO, the Regional town, Guyana. The program trains assistants Office for Latin America of the United in animal health and veterinary public Nations Environment Program (UNEP) or- health in a two-year course. UNDP provides ganized the Fifth Inter-Agency Consulta- technical assistance, PAHO acts as execut- tion on the Environment for Latin America ing agency, and 17 countries participate. and the Caribbean at Washington in Octo- When the third class ended in 1979, the ber. The meeting was attended by 30 par- number of graduates from the course grew ticipants representing United Nations, to 97 from 15 countries and territories. inter-American, and bilateral agencies. Since the program is to end in June 1980, Staff from PAHO's Headquarters, CEPIS, representatives of UNDP, PAHO, and par- and ECO participated and described PAHO's ticipating governments visited REPAHA's environmental health program, the im- facilities in Georgetown and several of the portance of the Water Decade, and the graduates' home countries and territories need to consider the environmental and in 1979. On the basis of their observations developmental aspects of the goal of health and suggestions made at various Caribbean for all by the year 2000. The conclusions health meetings during the year, they rec- were broad-reaching and covered principles ommended in their reports to PAHO and of environment and development, inter- UNDP that REPAHA be continued for four agency programming, environmental in- more years. A request for second-phase formation systems, river basin develop- assistance was submitted to UNDP as the ment, unconventional energy sources, and year drew to a close. environmental education. In the area of UNDP increased its support of health proj- information, it was noted that CEPIS's in- ects slightly in 1979 compared to 1978. formation and documentation network GENERAL DIRECTION OF THE ORGANIZATION 15

(REPIDISCA) can support environmental sanitation component. Experiences were information systems. also shared with UNICEF on programs in Several Member Countries are partici- Bolivia and Colombia. Such coordination pating in the air, water, and biologic moni- maximizes the results of both agencies' toring programs comprising the UNEP-WHO efforts and helps identify areas of need. Global Environment Monitoring System PAHO and UNICEF began planning a joint (GEMS). late 1980 workshop to train national and PAHO continued to collaborate in the agency staff how to develop and finance UNEP-United Nations Economic Commis- water supply projects for small villages sion for Latin America environmental man- and areas with dispersed population. agement project in the Caribbean. As part of its support, it prepared an "Overview of Environmental Health in the Wider Carib- bean" which presents part of the back- United Nations Fund for ground information needed for the expert Population Activities meeting in early 1980 to discuss the Carib- bean project's plan of action. In 1979, PAHO served as executing agency PAHO provided short-term consultation for maternal and child health/family plan- to Cuba in carrying out that country's ning projects funded by the United Nations marine pollution research and control Fund for Population Activities (UNFPA) in project, and to Jamaica and Cuba in 19 hemispheric countries: Antigua, Bolivia developing their solid waste manage- (whose project did not have a family plan- ment programs, all of which receive UNEP ning component), Cayman Islands, Chile, financing. Colombia, Cuba, Dominica, Ecuador, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Peru, St. Kitts-Nevis, St. Lucia, St. United Nations Children's Fund Vincent, and Uruguay. Financial assistance to country projects approved by UNFPA During 1979 PAHO cooperated with the totaled $6,955,179. The organization ap- United Nations Children's Fund (UNICEF) proved new projects in Anguilla and the in national maternal and child health pro- British Virgin Islands, to begin in 1980. grams and in all regional events celebrating In addition, PAHO also developed the fol- the International Year of the Child. lowing regional or subregional activities PAHO held a series of meetings with whose total cost of $1,236,790 UNFPA UNICEF staff at which joint environmental agreed to finance: family health and popu- health programs for Dominica, El Salvador, lation dynamics, health and youth, con- Guatemala, Jamaica, and Paraguay were tinuing education in family planning pro- discussed. Since unsanitary environmental gram administration, continuing education conditions affect children's health ad- in family health nursing, and an interagency versely, UNICEF has for many years pro- meeting on family life education in the vided funds for constructing latrines and English-speaking Caribbean. village and rural water supply systems Under a new policy to take effect in in the Region. 1980, UNFPA will gradually reduce its sup- The UNICEF Executive Board approved port of regional projects and concentrate the Dominica rural water supply project. more on country projects. This is as the The Jamaican project provides basic serv- result of a United Nations General Assem- ices for children and includes a major bly resolution that UNFPA spend no more 16 REPORT OF THE DIRECTOR than a quarter of its budget on regional PAHO also participated in the ECLA- projects. organized Latin American Conference on Human Settlements at Mexico City, as well as in the UNEP/ECLA Seminar on Styles of United Nations Disaster Relief Office Development and Environment at Santi- ago, Chile. Both meetings took place in The United Nations Disaster Relief Of- November. fice (UNDRO) greatly increased its coordi- PAHO was represented at the meeting of nation with PAHO in 1979. PAHO invited ECLA's Caribbean Development and Co- UNDRO representatives to attend and con- operation Committee(CDCC) at Paramaribo, tribute to staff training in disaster manage- Suriname, in March. It has helped CDCC in ment and the preparation of guides and preparing plans for the development of a manuals for Member Countries. During the network of health statistics units in the relief operations following hurricane David Caribbean first proposed in 1978 and in the Dominican Republic, PAHO staff sent cooperated with it and UNEP in the en- there were placed under the direct supervi- vironmental management project in the sion of the UNDRO coordinator. This effec- Caribbean. tive cooperation improved the accuracy of CDCC's main functions are to act as a health data sent to potential donors through coordinating body for whatever develop- UNDRO situation reports. As a result, ment and cooperation activities the Carib- the international community contributed bean countries may agree on and to pro- $65,000 to reestablish that country's water vide advice to the Executive Secretary of supply system. ECLA about Caribbean issues and circum- After the natural disasters in Colombia, stances. CDCC uses the staff of the ECLA Dominica, Dominican Republic, and St. office at Port-of-Spain, Trinidad and To- Vincent, PAHO engineers assessed the bago, as its secretariat. damage and helped disaster relief programs. A "Manual on Management of Environmental Health Resources After United Nations Food and Natural Disasters" and guidelines for the Agriculture Organization use of water disinfection tablets were prepared. PAHO collaborated with the Food and Agriculture Organization (FAO) by providing laboratory facilities at its Pan American United Nations Economic Commission for Foot-and-Mouth Disease Center in Rio de Latin America Janeiro for diagnosing African swine fever.

The Latin American Regional Committee on Water, which convened during the April World Food Program meeting of the United Nations Economic Commission for Latin America (ECLA), PAHO continued its support of health- adopted a work program including PAHO related projects carried out by the countries participation for its part in the International with aid from the World Food Program Drinking Water Supply and Sanitation (WFP), which provided food assistance to Decade. PAHO is now discussing followup 21 countries in the Region in 1979. PAHO activities with ECLA to implement the joint collaborated in carrying out and evaluat- program. ing approved projects and in drawing up GENERAL DIRECTION OF THE ORGANIZATION 17

new requests. Since 1975 the policy-making health and resulted in exchange of in- body of WFP, a program with United Na- formation and reports and consultative tions ties, has been the Committee on Food meetings between technical and adminis- Aid Policies and Programs, an intergovern- trative staff of the two organizations. mental organization which reports annually These activities were carried out on behalf to the United Nations Economic and Social of both PAHO and WHO. Council and the FAO Council. Fourteen of the 51 WFP projects now in operation provide supplementary food for League of Red Cross Societies mothers and preschool and primary school children, and two projects provide food for During 1979 PAHO cooperated closely hospital patients. Together the 16 projects with the League of Red Cross Societies by benefit three million people. Nine of 11 providing technical input to a disaster social and economic development projects relief seminar at Oaxtepec, Mexico, in contribute to integrated development of January, helping update emergency plans rural communities. Of 12 agricultural pro- in Costa Rica, and advising on how to im- duction projects, three are to improve milk prove health management in temporary and meat production. camps in Honduras for refugees.from Nica- WFP's aid in the Americas ($414 million) ragua's civil war. represented 10.2 per cent of its total world assistance during the year. Four-fifths of its aid was in the form of commodities; the European Economic Community remainder, in cash and services. National contributions to each WFP-assisted project PAHO strengthened its working relation- were three to four times greater than WFP's ship with the European Economic Com- contribution. munity (EEC), which began in 1977 with an EEC grant to INCAP. EEC expressed interest in supporting a proposal for an emergency World Bank preparedness project, and it is anticipated that it will approve funding for it in 1980. PAHO continued its formal cooperative AmeetingatWashingtonwithan EEC health program with the World Bank in Latin specialist and a short-term consultant gave American environmental sanitation studies. PAHO an opportunity to explore possi- Representatives of the two organizations bilities of future EEC support for health joined in several missions to prepare two projects. environmental pollution control project proposals in Brazil whose estimated cost is $300 million, for which it is anticipated the World Bank will provide two loans totaling PAHO and the Inter-American $100 million. System PAHO also provided technical assistance for World Bank-financed village water supply and sanitation projects in Haiti, Organization of American States Nicaragua, and Paraguay. The approximate cost of these projects is $15 million. PAHO was represented at the Ninth Close collaborative relations continued Regular Session of the Organization of with the World Bank in the broad field of American States (OAS) General Assembly 18 REPORT OF THE DIRECTOR

at La Paz in October and November and The new agreement provided for more took part in the Washington meetings of PAHO participation in the early planning the Inter-American Economic and Social stages of projects in which it is to act as Council (CIES) and Inter-American Council executing agency. This will eliminate infor Education, Science, and Culture(CIECC), consistencies between separate agree- and the Caracas meeting of the Pan Ameri- ments PAHO and IDB sign with countries can Highway Congress. in which IDB-financed projects are to take PAHO continued to collaborate with the place. It will also establish from the start Interagency Committee on Human Settle- the actual costs for which PAHO must be ments (Latin America) chaired by the OAS. reimbursed and will ensure that projects A meeting was held at Washington in April receive needed staffing on time. to exchange information about the activ- The agreement also noted that PAHO's ities undertaken by the six participating consultants and staff will serve in IDB agencies in relation to human settlements projects in accordance with PAHO condi- and to review activities of common interest tions of employment. It was further agreed resulting from OAS's new emphasis on rural that PAHO will provide its services at cost, development. including a more realistic amount for In addition, PAHO cooperated with the administrative overhead than was provided OAS in preparing Venezuela's solid waste for in the original exchange of letters. disposal program. The second meeting between IDB and Hurricanes David and Frederick in the PAHO to review major public health prob- Caribbean and the strife in Nicaragua lems in Latin America and the Caribbean resulted in close cooperation between was held at Washington in November. PAHO and the OAS's Inter-American Fund Significant agreement was reached on a for Assistance in Emergency Situations common approach to supporting the (FONDEM). PAHO compiled technical data countries in making needed improvements on these situations and supported FON- to extend their health services. Another DEM's efforts to monitor the international meeting was planned for early 1980 to assistance provided to the affected coun- discuss the implications of the technical tries to minimize counterproductive dupli- inputs needed in the Region. cations. IDB continued to support programs to extend health service coverage and promote animal health and environmental Inter-American Development Bank sanitation.

PAHO and the Inter-American Develop- ment Bank (IDB) signed a new letter of Inter-American Institute of agreement in March updating an exchange Agricultural Sciences of letters three years earlier that established the financial and administrative arrange- Senior officials from the Inter-American ments governing PAHO's role as executing Institute of Agricultural Sciences (IICA) agency in IDB-financed projects. Over the and PAHO met at Washington in May to past several years, PAHO has received more discuss agricultural chemical residuals, than $7 million for its services as executing animal health and meat production, and agency for components of IDB health integrated regional development. They projects. signed a memorandum of understanding GENERAL DIRECTION OF THE ORGANIZATION 19 on closer collaboration between the two Caribbean Development Bank agencies in rural development, food production, nutrition, and animal health. To assist in project preparation and financing in the Caribbean, PAHO conducted water supply and sanitation studies Subregional Groups in Antigua, British Virgin Islands, Grenada, and St. Kitts. The resulting reports were submitted to the Caribbean Development Conference of Ministers Responsible for Bank and to the authorities for comment Health in the Caribbean and followup. A 1980 training course for Caribbean water engineers and planners on The fifth meeting of Commonwealth project preparation and financing and the Caribbean health ministers was held in financing of a project to improve opera- Antigua in early July. PAHO sent repre- tion and maintenance in the water agencies sentatives to the meeting, one of whom of the Caribbean were also discussed. gave the main address. The areas discussed in which PAHO's technical cooperation would be important were occupational health, disaster prevention and preparedness, food and nutrition strategies, cancer Ministers of Health of Central America and chronic diseases, national health in- and Panama formation systems, and the training of allied health workers including animal The Director of PAHO addressed the health assistants. Ministers of Public Health and Social Wel- fare as well as the Directors-General of Health of Central America and Panama in Caribbean Community San Salvador in July. The following main subjects were discussed: solid waste dis- PAHO collaborated with the Caribbean posal, health service extension, the role of Community (CARICOM) in defining a strat- nurses in primary health care, basic en- egy to improve environmental health con- vironmental sanitation in rural areas, ex- ditions in the Caribbean. Assistance was tension of dental health services using given to CARICOM in conducting a feasi- simplified technology, and subregional pro- bility study for a proposed Caribbean en- duction of basic drugs and biologicals. vironmental health center, and through In response to resolutions by the minis- CEPIS in carrying out preliminary occupa- ters as well as those resulting from a meet- tional health surveys in Guyana and Trini- ing in Costa Rica of subregional drinking dad and Tobago and making preliminary water and sanitation agency managers, arrangements for a regional occupational PAHO worked with the countries to develop health workshop to be held in the Carib- a coordinated action plan for improving bean in 1980. the operation and maintenance of such In association with the U.S. Agency for agencies in Central America. Financing for International Development and CARICOM, this effort is being sought from the agencies PAHO collaborated in disaster prevention, themselves as well as from such sources as preparedness, and relief activities. UNDP and IDB. 20 REPORT OF THE DIRECTOR

Ministers of Health of the Andean Pact sis on trainer and management training. A Countries two-year extension to consolidate the development of the training system is under The Ninth Meeting of the Coordination negotiation with CIDA and the Netherlands. Committee and the Sixth Meeting of the CIDA provided $385,860 over a four-year Ministers of Health of the Andean Pact period for disaster preparedness activities Countries were held at Lima in June. The in the Region which included training pro- Director of PASB attended. The main health grams, health management following disas- topics were: occupational health; produc- ters, technical cooperation seminars, and tion, registration, and quality control of visual aids production. basic drugs and biologicais; environmental The program for education and training health; manpower development; equip- of auxiliary health workers, which is fi- ment maintenance and engineering in nanced byCIDA, UNDP, UNICEF, and Project health facilities; maternal and child health; HOPE and is to end in June 1980, success- technical cooperation among developing fully completed the second phase of its countries; the relationship between institu- activities. An evaluation mission, whose tional health and traditional community report was submitted to Caribbean health health systems; and family physician train- authorities and educational institutions, ing. The ministers approved a resolution concluded that it should be extended for creating an advisory commission on en- five more years. The area's current needs vironmental health. were set out in a document that will be the basis for a special meeting of representatives from participating agencies and others Bilateral Agencies interested in the program's activities to be held in January 1980. This program is one of the best examples of the strategy of tech- Canadian International Development nical cooperation and exchanges among Agency countries. The strengthening and use of local institutions to train auxiliary workers Early in 1979 an evaluation mission rep- from the various Caribbean countries and resenting the Canadian International De- territories has been a major factor in pre- velopmentAgency(CIDA), UNDP, and PAHO venting their emigration and at the same visited the Caribbean countries taking part time has stimulated the area's most de- in a veterinary laboratory service develop- veloped countries to cooperate with their ment project headquartered in Jamaica to less developed neighbors. see if it should be extended into a second In September 1978, CIDA and PAHO phase as the countries had asked. The cost signed an agreement to conduct a three- of the project, begun in 1976, was $158,104 year joint regional project for the continu- during its first phase. ing education of primary health care team Representatives of Jamaica, CIDA, CARI- members working in peripheral areas. The COM, and PAHO signed a memorandum of contributions of CIDA and PAHO are Can. understanding to develop a Caribbean drug $960,000 and US$380,672, respectively. In testing laboratory. 1979 PAHO signed agreements with Bolivia, CIDA continued its collaboration in the Colombia, Cuba, Ecuador, Guatemala, and Caribbean Basin water management project Honduras for carrying out the project's to develop manpower for water utilities in activities in those countries. Negotiations the eastern Caribbean, with special empha- are now underway for the Dominican Re- GENERAL DIRECTION OF THE ORGANIZATION 21 public and Nicaragua to participate in the tion was given were Guatemala and Pan- project. A joint CIDA-PAHO mission to ama. evaluate progress during the project's PAHO also participated with USAID in initial period is planned for early 1980. conducting field studies to develop basic environmental health programs including drinking water and basic sanitation in the Canadian International Development Caribbean. Research Center USAID provided a one-year, $129,260 grant to support regional training programs The Canadian International Develop- for emergency preparedness and health ment Research Center (IDRC) supported management following disasters and spon- CEPIS in designing the regional environmen- sored a Caribbean seminar on disaster tal engineering information and reference preparedness in Barbados in May in col- system and in developing the operating laboration with PAHO and CARICOM. manuals, microthesaurus, and an inventory of regional information sources and users for it. Representatives of the prospective German Agency for Technical Cooperation national collaborating centers approved and adopted these tools at a special meeting WHO and the Federal Republic of Ger- in July. IDRC's support of the project ended many, acting through its Gesellschaft fur in 1979, but a proposal for it to aid in de- Technische Zusammenarbeit (GTZ, or veloping the national collaborating centers Agency for Technical Cooperation), agreed was prepared and is now under negotiation. to support preparations for the Interna- IDRC also supported the development of tional Drinking Water and Sanitation Dec- a project to evaluate the efficiency of the ade in a selected group of nations. Five San Juan Stabilization Ponds, near Lima, American countries (Bolivia, El Salvador, in treating municipal wastewater. The proj- Haiti, Honduras, and Paraguay) participated ect, carried out by CEPIS with the collabor- in the first phase, identifying projects for ation of Peruvian institutions, was com- sector development. The second, two-year pleted and the technical report presented phase-national planning for the Water to IDRC. Decade in Bolivia, Haiti, and Paraguay- will start in 1980 and cost about $300,000. PAHO collaborated with the Municipality United States Agency for International of Lima in drawing up a preliminary pro- Development posal to GTZ to develop that city's solid waste management program institutionally As part of its efforts to strengthen the and technologically. national capabilities of Member Govern- ments, PAHO hosted a workshop on water and wastewater treatment methods at Swedish International Development Washington in October sponsored by the Authority U.S. Agency for International Development (USAID) and the University of Oklahoma. It In compliance with the Directing Coun- is coordinating a series of similar work- cil's policy of exploring new sources of shops to be held in Latin America and the extrabudgetary funding, PAHO has estab- Caribbean. Among the countries to which lished and strengthened contacts with the assistance in organizing and implementa- Swedish International Development Au- 22 REPORT OF THE DIRECTOR thority (SIDA). This agency is now reviewing W.K. Kellogg Foundation projects submitted by PAHO for emergency preparedness activities in the Caribbean PAHO honored the W.K. Kellogg Foun- and Central America. The Swedish U.N. dation on its 50th anniversary by placing a Standby Force's ability to assist Member plaque in the Headquarters rotunda com- Countries affected by disasters was as- memorating the Foundation's achieve- sessed. ments in health during its first half-century of operation. The first major PAHO/Kellogg activity Foundations was the joint sponsorship of INCAP, which was created in 1949. Since then, Kellogg The Pan American Health and Educa- has continued to play an important role in tion Foundation (PAHEF), a continuing developing PAHO's nutrition program. In PAHO partner, supported 49 projects with the past decade, Kellogg has expanded its $1,382,269 received from 29 public and activities with PAHO in the administration semipublic organizations, private founda- of health services and in the training of tions, corporations, and individuals. Train- health workers in medicine, nursing, and ing and education, mostly in dentistry, dental health, all of which contribute to accounted for 48 per cent of PAHEF's ex- the extension of health care coverage. penditures, while nutrition projects, mainly Kellogg's collaboration with PAHO is for research and applied nutrition at INCAP, most visible in PAHO's Headquarters in accounted for 34 per cent. The remainder Washington. The well-known building was were devoted largely to family health and largely builtwith a $5 million loan from the disease control. Foundation which is being repaid in the The PAHO/PAHEF medical textbook pro- form of expanded health programs for the gram continued its operation. The ex- Americas. panded program embracing textbooks and The Latin American Program for Educa- instructional materials for all health per- tional Development in Health, financed by sonnel began with the selection of text- the Foundation, was to end in January 1980 books for delivery in 1980. after four years of operation. In 1979 it Private organizations making grants to collaborated with national research and PAHEF included the W. K. Kellogg, Damien, development units in education and health Microbiology (Yale), Potts Memorial, and (NIDES) in Honduras, Mexico, Paraguay, Rockefeller Foundations and the Thrasher and Venezuela, thus rounding out its sup- Research Fund. The largest amount, port of 15 units identified in the program. $833,084, was from Kellogg, which also A special grant was awarded to the instruc- awarded $4.1 million in direct grants for tional resources unit of the University of education, nutrition, and child care projects the West Indies in Jamaica. Plans were to institutions in Latin America. made to hold a meeting in 1980 to review The Pan American Development Foun- NIDES experiences. dation (PADEF), an organization closely The Foundation approved a regional associated with the OAS, continued its program for developing human resources interest in health and its cooperation with and operations research in maternal and PAHO. Its health program consists pri- child health in Latin America for three marily of obtaining donations of used years with a budget of $4 million. hospital and dental equipment for coun- Kellogg also supports the project on edu- tries in Latin America and the Caribbean. cation in health administration in Latin GENERAL DIRECTION OF THE ORGANIZATION 23

America and the Caribbean (PROADSA). The education and appropriate educational project's ultimate purpose is to provide technology. access to basic health care for the entire Kellogg supports this project through a population through integrated and con- $450,000 grant to PAHO and direct grants tinuing health services whose quality and to the countries totaling $1,670,000. cost are geared to local socioeconomic A new agreement was signed to establish conditions. procedures governing cooperative proj- To achieve that goal, the essentially ects between PAHO and Kellogg. The need educational project promotes integration for such an agreement had been felt for between educational and service programs somrne time, and a recent change in U.S. by improving instructors' teaching skills tax law now makes it possible for organiza- and stimulating continuing education tions such as PAHO to receive grants directly and research. It also promotes the de- from private donors. Kellogg funding was velopment of an information and docu- previously channeled through PAHEF. mentation system for health administration

E E E Chapter 2

DEVELOPMENT OF HEALTH SERVICE SYSTEMS

Fulfilling the 1977 World Health ing specific strategies, is part of a greater Assembly goal of "the attainment by all whole and that dealing with the resulting citizens of the world by the year 2000 of a interrelationships requires considerable level of health that will permit them to synthesis. lead a socially and economically productive This implies the need to guide the pro- life" (WHA30.43) creates a need to for- cedures of health planning, which is not mulate appropriate national strategies and only a technique but also a continuous action plans as well as related interna- policy-making process whose technical, tional cooperation. methodologic, and administrative content PAHO's activities in the field of health is justified only to the extent that it leads or service systems are based on needs ex- contributes to the effectiveness of plan- pressed by its Member Countries. The ning in achieving the desired social objec- regional cooperation program to develop tives. In consequence, planning ceases be- health services that PAHO conducted in ing confined to the health sector and 1979 included the basic concepts of becomes multisectoral and multidisciplin- primary health care, community participa- ary. In it national and subsidiary economic tion, intersectoral articulation, technical and social policies are the preponderant cooperation among developing countries, factors in guaranteeing the basic condi- and appropriate technology. tions of well-being inherent in the concept Because PAHO's health service activities of health. are divided into three major areas of co- In putting the concept of intersectoral operation-intersectoral articulation, ap- articulation in primary health care into propriate technology, and development of operation, it is necessary to place health health services-it was considered essen- programs within the broad range of govern- tial to establish from the start that they mental policies dealing with the rights and would develop and function as an integral duties of citizens and the state's responsi- whole. This became possible by broadly in- bilities with respect thereto. Such policies terpreting primary health care as the pro- are translated into definitions of institu- duct of activities intended to meet the tional roles in solving specific problems as basic needs of personal well-being. It is well as the various processes of community clear that each of the areas mentioned, in participation. addition to having its own problems requir- In the same way, the development of

24 DEVELOPMENT OF HEALTH SERVICE SYSTEMS 25 health services to satisfy the goal of uni- PAHO's cooperation objectives cannot versal primary care requires that the mean- be distinct from those each country deter- ing be worked out of the goal as a policy mines are required for the development of expression of a national aim and as a com- its own health services. As a result, regional ponent of the process of change intended cooperation strategies reflect the need to to raise levels of well-being. The exact facilitate the orderly exchange of national definition of the goal is essentially ex- knowledge and experiences about the pressed in the way in which institutions various processes involved in developing comprising the health care system should health services. It is hoped that one of the be organized and the manner in which results of such communication will be health activities should be related to the greater orderliness in making existing or socioeconomic development of communi- foreseeable international technical and ties. financial resources available to support the The policy-making and administrative development of national health services. processes set out briefly above require that In this context, the following regional institutions adopt technologies of great ef- strategies are suggested: and cultural viability ficacy and economic * Documentation, followup, and character- and avail themselves of the community's ization of national health service experiences trained participation in using appropriate in order to disseminate and exchange informa- health technologies at different care levels. tion. Within the framework established in the . Detailed studies of selected national en- advanced the mandates of recent major international deavors that have significantly development of health services. health congresses (the International Con- * Promotion and execution of collaborative ference on Primary Health Care, World intercountry health service research. Health Assemblies, and the IV Special * Promotion of interagency cooperation in Meeting of Ministers of Health of the health matters, with special reference to the of cooperation policies, determi- Americas in September 1977) dealing with development nation of priorities, improvement of procedures, extension of health service coverage to the and provision of resources that are adequate in entire population, the problems and con- volume, allocation, and timeliness. straints that must be overcome are iden- * Development of human, technologic, and tified below, and suggestions for regional institutional resources to carry out PAHO/coun- projects to develop health serv- strategies are put forward. try cooperation cooperation ices. In view of the variety of existing re- * Methodologic development to implement sources, needs, and possible ways of meet- cooperation projects in specific areas of health ing them in different countries, an effort service administration. Examples are financing, should be made to make regional strate- programming, management, appropriate tech- to allow for nology, and training. gies as flexible as possible * Identification of new areas of cooperation their adjustment to particular national and definition of criteria for future analysis, pro- requirements. cessing, and development.

NATIONAL POLICIES AND STRATEGIES

The health policies and strategies for- 1979 generally fulfilled the recommenda- mulated and carried out by the Americas in tions of the IV Special Meeting of Ministers 26 REPORT OF THE DIRECTOR

m~C 71.i Amo~A'1 1 lMo 'l .lk~ flIOf',Kw %%WWW M-_~11 !iW*;-i -"--» WAWM

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Primary health care is the ultimate product of a broad spectrum of health service activities: community participation, appropriate technology utilization, family planning, nutrition, maternal and child health, and institutional development. (Photos: V. Santiago Melgarejo, Peru, and Governments of Cuba and Guatemala; opposite page: World Bank/ 1. Pickerell, World BanklJ. Martin, Government of Chile, and Inter-American Development Bank) 4 - SÑ

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A 28 REPORT OF THE DIRECTOR

of Health, the International Conference on * Policies oriented toward a single health Primary Health Care at Alma-Ata, U.S.S.R., system for the entire country. and meetings of PAHO's Governing Bodies. * Policies that make health ministries responsible for policy-making, In some countries the objectives and standard-setting, and health surveillance while giving social security strategies for achieving universal popula- agencies responsibility for providing personal tion coverage by the health services were health services. reoriented toward the goal of health for all * Policies that promote private initiative in by the year 2000 through greater emphasis providing services and family responsibility in on intersectoral activities, integrated de- choosing and paying for them in a mixed official, social security, and private system. velopment of national regions, and definition of well-being profi¡les. Another important aspect of national Most of the Region's countries have health policies in 1979 was the greater link- policy proposais for achieving greater serv- age and scope of subregional agreements ice coverage. Differences exist in the ways as an effective way to develop intercoun- in which that goal is being achieved, and try technical cooperation and produce the following major categories may be dis- goods and services. tinguished:

PLANNING

The activities of PAHO's technical co- The integration of planning activities operation program in planning health serv- with those of administrative development ice systems in 1979 occurred in three and maternal and child care services was areas: intensified, with gratifying results in greater efficiency in resource use and * Transmission of knowledge and experiences, chiefly through the 15-week Second greater efficacy in program outcomes. International Course on Planning and Ad- Regional activities focused on designing ministration of Health Systems at Mexico City models and guides for programming the ex- from August to December for 32 participants tension of services and formulating strat- from nine countries. egies of health for all by the year 2000. * Analysis of national planning experiences in order to increase knowledge and formulate In particular, activities that made signifi- models and guides for programming and cant progress during the year were: evaluating the extension of service coverage. * Direct collaboration with the countries in * The preparation of a guide for planning and formulating health plans (Dominica, Guatemala, programming the extension of health service Panama), carrying out extension coverage pro- coverage, the first edition of which was given to grams (almost all countries in the Region), plan- the countries in order to test its usefulness and ning extension projects to be carried out jointly enrich it with experiences resulting from its by health ministries and social security agencies adaptation to different national conditions. (Brazil, Chile, Colombia, Costa Rica, Panama, After the countries have considered it and the Peru), and locating or relocating health care changes and new knowledge they contribute units (Ecuador, El Salvador, Guatemala, Guy- have been included, it will be made available to ana, Jamaica, Nicaragua, Panama, Paraguay). all countries in the Region. DEVELOPMENT OF HEALTH SERVICE SYSTEMS 29

* Programs to extend health service coverage course for participants from all parts of the have been underway for several years in some country in which PAHO collaborated. countries, and thus a need has arisen to evaluate Brazil. As the result of joint efforts by the the planning process and its results. A document Ministries of Health and Social Welfare, it was entitled "Model for Identifying and Analyzing possible to establish a common goal, policy, Problems Affecting Health Service Systems in strategy, and program to cover the formerly Coverage Extension Situations" was tested in isolated and medically underserved population Guatemala, Honduras, and Panama to adjust it in the North and Northeast. Some evaluation in- to actual conditions there and improve it for struments were designed and began to be used. possible use in other countries. Chile. The Government continued organizing * As noted above, the curricular aspects of a national health service system, and as the year courses on administration and planning of ended it was anticipated that a law would shortly health services found their principal expression be enacted establishing its structure and opera- in the Second International Course held at Mex- tion. ico's School of Public Health. From the ex- Colombia. A national health plan began to be perience gained in that course, it was arranged formulated as part of the overall national devel- that the School of Public Health at Medellín, opment plan. It is hoped that the health plan will Colombia, would incorporate basic regional contribute effectively to consolidating the pro- policies (planning, programming, budgeting, ad- gramming of coverage extension at the local, de- ministration, human resource development, in- partmental, and national levels. Progress also formation systems, and health economics) in its continued in developing the main subsystems curriculum. (information, manpower development, general * Preliminary steps were taken to formulate administration, supply, personnel, and account- basic concepts of integrated national developing), and a control and evaluation model was ment in order to make general development ob- formulated. jectives compatible with health service goals. Dominican Republic. With PAHO's cooperation, the Government continued drawing up Planning activities in the countries ad- standards and procedures for consolidating the vanced in various ways, among which the regionalization scheme for extending services, a following may be noted: process that began in 1976. Special importance was attached to designing a national health Argentina. Health policies were formulated planning system and establishing regional health which specify that national health activities structures and operations. should only complement provincial and muni- El Salvador. The Government decided that cipal programs in accordance with the so-called necessary steps should be taken to establish a principle of "subsidiarity." The Government all single national health system and continued ex- but finished transferring its health services to the tending the eastern region's experiences to other provinces and municipalities and in doing so parts of the country with satisfactory results. turned over facilities and funds. It also provided Guatemala. In accordance with the 1978-82 training by conducting a basic planning course health plan, local programming activities in- and courses on planning techniques. The basic creased. The result was the formulation of an ac- course will teach students essential planning tion plan for each operational unit and the train- concepts as well as necessary skills in health ing of personnel for 23 health areas. administration, health economics, and related Guyana. Priority was given to the macro- fields. The courses on planning techniques will design of health service regionalization and the expose trainees to necessary working tools for improvement of intersectoral relations. programming, budgeting, evaluation, and invest- Haiti. The country continued reorganizing its ment project preparation. technical and administrative units to improve Bolivia. Major efforts were made to coor- the structure and operations of its health re- dinate the health sector's requirements in order gions. With certain limitations attributable to to achieve a single national health service. To- the nature of the country, the coverage exten- ward that end the Government created an inter- sion project, which is financed by the Inter- agency commission with representatives from American Development Bank (IDB), continued. the Ministries of Health, Planning, Finance, and The draft of the country's five-year health plan Education, the national medical association, was completed, and a planning and evaluation and the social security agency. The need for office was created in the Ministry of Health. trained manpower led to a 14-week planning Honduras. Coverage extension continued suc- 30 REPORT OF THE DIRECTOR

cessfully, modified by the formulation of the Uruguay. Studies continued of rehabilitating 1979-83 national health plan and the prepara- existing facilities and such functional alterna- tion of the 1979 operations plan. In addition, a tives as population groups to be covered, patient methodology for evaluating coverage extension flows, and activities to be performed in order to was tested with promising results. make the health care system more efficient. Panama. The Covernment drew up a prelimi- Overall goals and resources were quantified, nary draft of the 1980-84 health sector plan cov- and necessary adjustments were made between ering the activities of the Health Ministry and levels and areas. social security agency in order to achieve Venezuela. Strengthening health care units universal health care coverage by 1984. Ninety and the organization and operations of the na- per cent of the population is already covered. tional health service was the basic concern of The Torrijos-Carter Agreement was of major sig- the sectoral committee, which made a diagnosis nificance because of its consequences for and defined preliminary policies and strategies health service planning in the Canal Zone. for the sixth national plan to start in 1980. Peru. A national health service system In general, the Region's countries was created by Decree-Law 22365, and seven national health council advisory committees showed a clear commitment to achieving began work. Coverage extension was programmed the extension of health care coverage. The in the Cuzco, Huancayo, Iquitos, Piura, Puno, list above is not exhaustive, but rather pro- and Tarapoto health regions, which together vides examples in order to document the have a population of 1 million people. Because effort being made to accomplish the cover- of the participation of education, agriculture, and housing officials, such programming is age extension goal. multisectoral.

MEDICAL CARE SYSTEMS

Making health care coverage universal Developing institutional resources. A by the year 2000 implies the need for major considerable number of the Region's coun- changes in both the organization and tradi- tries have undertaken specific actions to tional patterns of health services. expand their existing health care capacity Within this general orientation, PAHO's through projects financed by national and activities to develop medical care systems international lending agencies and espe- were aimed at cooperating with the coun- cially IDB. To rationalize such investments tries in four basic areas: (1) developing and so multiply various kinds of operating institutional resources and widening the units, the countries have felt the need to availability of services; (2) improving the carry out high-priority activities to improve accessibility and quality of care; (3) stimu- functional planning, architectural design, lating ambulatory care and emergency and the construction and equipping of medical services; and (4) strengthening co- health facilities. ordination between health ministries and In response to this need, PAHO helped social security agencies. prepare an Andean subregional project for DEVELOPMENT OF HEALTH SERVICE SYSTEMS 31

United Nations Development Program such services in the Region will be ana- (UNDP) financing, which will amount to $3 lyzed and the potential they offer as forms million over four years. Preparations were of efficient and effective care in dealing made for a seminar to be held during the with the problems of extending coverage in first quarter of 1980 to define the project's metropolitan areas will be explored. activities, which will consist of training, Strengthening coordination between technical cooperation among the five par- health ministries and social security agen- ticipating countries, research in areas of cies. This is essential for putting to use all common interest, and exchanges of techni- national resources to benefit the least pro- cal information. The chief purposes are to tected population groups. PAHO continued develop technical planning, design, construc- collaborating with social security agencies, tion, equipment, and maintenance standards which have been defining and applying for health facilities that match the coun- coverage extension policies to include care tries' socioeconomic contexts and to train of such groups in their systems. personnel in these disciplines. Social security has great potential for ex- PAHO also cooperated with Ecuador, tending health coverage both because it is Guatemala, Guyana, Paraguay, and Trinidad a health care financing mechanism and be- and Tobago in preparing investment proj- cause of its important role as a provider of ects with national and foreign financing to health services to the population. Recog- rehabilitate and develop health service nizing the activities that social security physical facilities. agencies have been carrying out in this Improving the accessibility and quality of sense, the Directing Council in 1979 approved care. PAHO's principal efforts in this area a resolution (CD26.32) providing for in- were aimed at promoting and stimulating creased PAHO cooperation with such application of the concept of care levels, agencies. giving priority to determining and designing To apply the resolution, PAHO extended the operational content of the basic com- a cooperation agreement with the Ecuadorian munity and next higher levels. In this re- Health Ministry involving that country's spect PAHO cooperated in designing and social security agency and initiated discus- carrying out health planning activities in sions toward the same end with the social Colombia, Dominican Republic, Ecuador, security agencies of Colombia and Peru. Panama, and Peru. PAHO also continued collaborating in the Information on the concepts of health extension of joint services by the Health service regionalization and the definition Ministry and social security system of and establishment of adequate levels of Panama and took part in several regional care within the context of the primary social security meetings devoted to discus- health care strategy was updated through sing policies and the technical aspects of participation in programs to train health their application. Particularly noteworthy service administrators in Brazil, Colombia, was PAHO's participation in the Inter- and Mexico. American Social Security Conference at Stimulating ambulatory care and emer- Ottawa in May and in working committees gency medical services. PAHO continued in various countries on the actuarial and promoting the development of schemes to occupational health aspects of social better organize ambulatory (or outpatient) security. As has become traditional, PAHO care and emergency medical services. also participated in the May course on ad- Two meetings were planned for 1980 at ministration of social security medical which the nature of the organization of services, which is held annually at the In- 32 REPORT OF THE DIRECTOR ter-American Center for Social Security At the same time, work was begun to Studies in Mexico City. develop a data base for compiling a direc- Administration of health care institutions. tory of hemispheric health care institutions In addition to the four fields of direct ac- as a general reference tool. tivity noted above, PAHO paid special at- Because of the importance that decisions tention to hospital administration and train- by executives have in institutional perfor- ing in medical care administration. mance, a study was designed and begun on According to the latest available infor- the functions and performance of health mation, hospitals in Latin America and the sector executives in Chile. The investiga- Caribbean provided 223,684,650 medical tion is being carried out in collaboration visits and discharged 6,251,449 patients an- with that country's Health Ministry and the nually in the mid-1970s. The capacity of University of Chile's Faculty of Economics ambulatory care institutions such as health and Administration. It is aimed at support- centers and posts, clinics, and dispensaries ing the educational decisions of health ex- has not been determined regionally. ecutives. The hospital bed-to-population ratio Since 1975, PAHO has been active in varies among the Region's countries from helping to create new executive training 0.8 to 8.7 and averages 3.0 beds per 1,000 programs in Brazil and Colombia, support- population. The 13,127 hospitals in Latin ing existing programs and developing a col- America and the Caribbean have 920,366 laborative network to exchange informa- beds, of which 63.5 per cent are in Argen- tion, upgrading faculty, developing educa- tina, Brazil, and Mexico. The owners of this tional materials, and conducting col- considerable investment are health minis- laborative research. In 1978 work was tries (32.8 per cent), other public authorities begun on compiling data on the status of (23.2 per cent), social security agencies (6.9 education in health care administration in per cent), and the private sector (37.1 per Latin America and the Caribbean; it is ex- cent). The public sector thus owns 62.9 per pected that the resultant study will be cent of the available beds. published. It will be the basis for the sec- PAHO's technical cooperation in this vast ond phase of the regional project, whose and complex area is oriented toward im- financing was approved by the W.K. Kellogg proving institutional performance, extend- Foundation. ing the services' coverage, rationalizing the Also in order to improve the performance use of technology, and optimizing resource of health care institutions and their ex- use. ecutives, PAHO began to support the pro- Emphasis was placed on improving insti- duction and dissemination of scientific in- tutional performance. Toward that end a formation about health care and hospital method was developed for classifying administration. In May a committee of rep- hospitals in order to create homogeneous resentatives from Argentina, Brazil, Chile, groups and analyze multiple production, Colombia, Mexico, Puerto Rico, and Vene- process, and resource variables. To apply zuela met for the first time to recommend this method, information about the produc- textbooks on health care administration for tion of hospital services in Ecuador was inclusion in PAHO's textbook program. processed, and similar data were gathered Toward the same end, the advanced pro- about Honduras. The methodology was per- gram on hospital and health systems ad- fected in successive comparative studies in ministration (PROAHA) at Sáo Paulo as- order to make it a tool for evaluating sumed responsibility for translating and hospitals comparatively. publishing a standard text on hospital ad- DEVELOPMENT OF HEALTH SERVICE SYSTEMS 33

Figure 4. Visits per 100 population in health establishments with outpatient services, around 1977.

Visits per I00 population 0 100 200 300 400 500 600 I I1 1 I i I Cuba a 532.61 Costa Rica b 402.4 I! Panama 170.81 Bahamas 153.6 Chile 129.7 Barbados 123.61 Brazil1 80.2

Venezuelaa 73.8 ' El Salvadors 50.91 Honduras 50.6 Colombia 39.2 I' Paraguay 1-- 27.6 i.e--1980 Goal Haiti 1_21.0 a Provisional data. b Includes Social Security visits.

ministration and another on hospital finan- effort was complemented by a directory of cial management. 275 periodical publications dealing with In this effort at cooperation among hospital administration. For review pur- countries, the Center for Education in poses, the directory was sent to the coun- Health Care Administration in Colombia tries for completion; it will be published in began a series of translations of selected 1980. To support hospital libraries and articles on primary health care which will educational programs, a list of books on be put into circulation in 1980. hospital administration grouped in 15 cate- Together with the Costa Rican Hospital gories was prepared. This reference docu- Association, the journal Hospitales de ment was preliminarily distributed to the Costa Rica conducted a study of its Region's educational programs in health publishing practices, financing, distribu- care administration. tion, and readership in order to improve PAHO also prepared a bank of manage- the publication. The results of this study ment cases for educational use and a case will be useful to other hospital journals catalogue. contemplating similar investigations. This The role of the hospital in extending coy- 34 REPORT OF THE DIRECTOR

erage began to receive attention, particu- Hospital in Panama, the development of larly with respect to patient referral and Honduras' central hospital and health flow problems. As this area of research sciences school, the opening of the José broadened, the first working protocol on María Cabral y Báez Hospital and the es- ways in which hospitais and health centers tablishment of a regional hospital adminis- should support primary health services was tration center at Santiago, Dominican drawn up. The programmed activities will Republic, and development of an indepen- be carried out in 1980. dent-study program in hospital administra- In order to inaugurate the José Maria tion education in Guyana. Cabral y Báez Hospital in the Dominican PAHO's varied research, development, Republic and the administrative develop- education, and dissemination activities are ment programs in Colombia and Jamaica, being integrated around these four objec- PAHO collaborated in rationalizing various tives in an effort to create networks of col- technologies. laborating institutions in different coun- The production and processing of mate- tries. rials in hospital laundries and sterilization PAHO has been organizing a network of centers received attention through a com- basic and advanced programs in health ad- parative study in 25 Colombian hospitals. ministration education since 1975. This This diagnosis resulted in the preparation task culminated in the approval of a large of a work plan for developing standards, project which will be financed by the W.K. formulating training, and designing mainte- Kellogg Foundation. The network of 45 nance activities. educational programs has gradually become A similar study was made of hospital for- an effective infrastructure of technical mula rooms which culminated in a series of cooperation among the Region's countries. seminars and a publication on that subject PAHO's interaction with the network has by Colombia's Center for Education in allowed new projects to be formulated Health Care Administration. which integrate educational, continuing In the Dominican Republic, PAHO co- education, scientific information, research, operated in designing sterilization center and advisory activities. More specific col- and accounting systems. In the latter area laboration is realized in seminars, confer- it collaborated with Jamaica in designing ences, publication of a hospital administra- and installing a hospital cost-control tion manual and a series of translations of system. primary health care articles, design of pro- Collaboration in optimizing the produc- tocols on central sterile supply and laundry tion and use of financial and real resources services, development of methodologies, was focused on supporting the program- and instructor training. ming and remodeling of the Santo Tomás

PHYSICAL AND FINANCIAL RESOURCES

One of the greatest limitations on pro- funds. It is estimated that, as part of the grams to extend the coverage of health goal of health for all by the year 2000, be- services is the lack of capital and operating tween $3 and $4 billion will be required DEVELOPMENT OF HEALTH SERVICE SYSTEMS 35 for developing the physical infrastructure pacity of health agencies have been one of of services, while yearly operation of new the most significant efforts to enhance the services may cost between 20 and 70 per financial and physical growth of health cent of initial investment. In a Region services. The effect of institutional develop- where about four-tenths of the population ment is twofold. First, it helps improve the lacks adequate health care, the financial planning capacity and the quality of devel- effort in achieving the year 2000 goal must opment decisions, lowers costs, and opti- be immense and will have to be carried out mizes the use of resources. And second, a with unprecedented vigor. health ministry's competence in carrying PAHO cooperated with 10 countries in out such projects improves its relations project identification, investment plan with external financing agencies with re- drafting, and loan request preparation in spect to current and future grants or loans. order to facilitate and expedite the negoti- PAHO participated in integrated institu- ation of credits abroad. These activities are tional development projects in 10 countries. directly related to the rapid increase of fi- PAHO was also active in promoting, iden- nancial and physical growth in health serv- tifying, and organizing subregional techni- ices because it is recognized that technical cal and financial cooperation projects. The soundness in investment plans and appro- subregional approach to development proj- priateness in handling loan requests are ects ensures that national efforts are mul- vital elements in securing external loans or tiplied, results in economies of scale in grants. costly undertakings, enhances cooperation An important factor in successfully exe- among countries, and limits reliance on ex- cuting a grant or loan is the effective ternal sources of aid. In this area PAHO organization and functioning of the unit helped organize several projects related to responsible for programming and manag- the development of health services' physical ing construction and financial projects infrastructure. funded by such credits. PAHO provided PAHO has also been helping prepare a re- technical cooperation to the implementa- gional project to assist the countries in in- tion units of seven health ministries in this corporating economic studies and finan- respect. cial projections in planning medium- and Institutional development projects to long-term development programs to fulfill upgrade the planning and operational ca- the health for all by the year 2000 goal.

MAINTENANCE OF HEALTH CARE FACILITIES

Continued health facilities construction levels to ensure trained manpower. Until has resulted in ever greater emphasis on equipment and spare parts importation can training and operations to maintain health be reduced, technical expertise in any par- care plant and equipment. ticular country will be required in depth. In Experience throughout the Region shows the operational area, PAHO has aided the a continuing need to upgrade teaching countries in developing national mainte- skills at both the university and vocational nance systems and programs. The main op- 36 REPORT OF THE DIRECTOR

erations problem continues to be insuffi- program. The facilities of French and Cana- cient funding. Though the minimum fiscal dian vocational schools and the University requirement should be 2.5 to 5.0 per cent of Haiti are being used to train Haitian of construction and installation costs, bud- electronic engineers for the health sciences. gets generally amount to less than 0.5 per Mention should also be made of PAHO's cent of such costs and so maintenance is support of existing institutions to train per- often simply crisis repair. sonnel from other countries in the Region To cooperate with the countries in their in health facilities maintenance. The insti- search for solutions to these problems, tutions being used for this purpose are PAHO undertook several actions. Among Venezuela's and Colombia's centers for them, specific mention should be made of health facilities maintenance and engineer- the enlistment of UNDP's collaboration in ing at Caracas and Bogotá, the conserva- evaluating hospital maintenance and re- tion division of Mexico's National Social lated problem areas in the English-speaking Security Institute at Mexico City, and Costa Caribbean countries. The results of this Rica's social security institute at San José. study and action proposals were submitted South American students supported by to all the countries in question and UNDP Venezuela have received training in bio- itself. medical engineering at Simón Bolívar Uni- In the maintenance area, sharing tech- versity in Caracas, while the Universities of nology among countries is a prime con- Panama and Rio de Janeiro, and, in the cern. PAHO, with the support of the In- United States, the Florida Institute of Tech- ternational Federation of Hospital En- nology, Johns Hopkins University, Georgia gineering, American Society of Hospital Institute of Technology, George Washing- Engineering, American Hospital Associa- ton University, and University of Michigan tion, and two private U.S. organizations, have developed similar programs to help Partners of the Americas and the Scientific train engineers. Apparatus Makers Association, encouraged Although no Member Government has the countries to prepare information and so far committed itself to a national policy technical data which could be used to of reclaiming silver from X-ray films and identify areas of mutual cooperation. solutions, PAHO continued to encourage PAHO and the organizations noted above the adoption of such policies. Recovery will sponsor an international hospital engi- equipment suitable for a 300-bed hospital neering congress at Washington in July 1980. could be purchased for as little as $265 in PAHO also cooperated with Panama in mid-1979, and experience in hospitals using preparing plans for modifications and al- such devices has shown that silver worth terations of the 1,000-bed Santo Tomás dozens or hundreds of times the initial in- Hospital at Panama City. To this end use stallation cost can be reclaimed during the has been made of the University of Panama's first year of operation. engineering faculty and the U.S. Veterans As a result of cooperative efforts stimu- Administration. As a further example of lated during the 1970s there are now 13 na- this type of technologic exchange, solu- tional programs with a maintenance input. tions developed by the U.S. National Insti- Fourteen countries have already trained tutes of Health's biomedical engineering nationals in maintenance, and eight have and instrumentation branch program in developed a basic training capability. Egypt are being adapted to Haiti's program Despite these achievements, national to develop resources for an integrated policies on maintaining health care facilities medical equipment repair and maintenance must be drawn up in all the countries. Such DEVELOPMENT OF HEALTH SERVICE SYSTEMS 37 policies should be the basis for national dards and specifications need to be devel- maintenance systems, formal budgets, and oped to ensure warranties and manufacturers' standard operating procedures. Programs compliance and the availability of perfor training hospital engineers and compre- tinent maintenance, repair, and collabora- hensive programs to train technicians in tion manuals. Spare parts availability various disciplines are required before they should be improved. More repair shops, can be asked to assume responsibility for more private contracts for repair, and more health facilities. Systems of inspection training programs are required if present need to be developed that ensure medical plant and equipment investments are to equipment reliability at the time of pur- fulfill the Region's health care goals. chase and when in use. Inspection stan-

REHABILITATION SERVICES

PAHO's major activity in this area during per cent). the year was continuation of research in WHO sponsored an international meet- and around Toluca, Mexico, on simplified, ing in Mexico City in November attended community-based rehabilitation tech- by representatives from 12 countries to dis- niques. The study is to last at least four cuss the draft of a manual on training the years. Surveys were conducted in 14 com- disabled in the community. The manual munities of between 400 and 600 house- contained suggestions for community lead- holds each, three of which were house by ers, local health workers, and school teach- house. ers, and training booklets for those who Two hundred eighty-one disabled peo- have disabilities requiring assistance. It is ple-about 5 per cent of the population in proposed to adapt the draft for the use of the communities surveyed-were individu- the Region's countries and carry out field ally assessed for problems of movement, tests of the efficiency and suitability of the learning difficulties, and behavioral or technology. Once established as useful, mental changes. They were grouped into these activities will be proposed for inclu- those who could probably live reasonably sion in health care financing projects so normal lives without any assistance (29 per that efficient disability prevention and recent), those who would benefit from assis- habilitation can be carried out. tance from community health workers (41 During the year PAHO also continued its per cent), those who required more profes- training programs for doctors and therapists sional aid from doctors or therapists (18 per in Colombia, El Salvador, Guyana, Mexico, cent), and those who could not be expected Peru, and Venezuela. to improve without institutional care (12 38 REPORT OF THE DIRECTOR

HEALTH EDUCATION

Health education has been an essential under the sponsorship of their governments component of programs to promote health in cooperation with UNFPA. in the Region's countries through extension PAHO worked closely with United Na- of primary care services. As an integral part tions agencies, the Organization of Amer- of programs to reduce and prevent health ican States, the International Planned risks, health education efforts were strength- Parenthood Federation, the private and ened in programs to improve the health of voluntary Regional Committee for Sex Ed- mothers and children. Since the 1978 Inter- ucation in Latin America and the Carib- national Conference on Primary Health bean at Bogotá, and subregional groupings Care at Alma-Ata, U.S.S.R., educational ef- such as the Andean Pact and the Caribbean forts have increasingly striven to involve Community to promote better coordina- the community in promoting primary tion in all educational activities and infor- health care. mation dissemination. Of special note was The health education component was an interagency FLE meeting held in the developed and educational activities were Caribbean to coordinate efforts among 39 implemented in major maternal and child governmental and nongovernmental agen- health/family planning projects supported cies working in this field. by the United Nations Fund for Population Continual changes in socioeconomic Activities (UNFPA) in Cuba, Dominican Re- and associated health conditions will lead public, Ecuador, Mexico, and Panama. to reorientation of policies and strategies Family life education (FLE)-which is to meet each country's special require- both a process and content through which ments. Educational activities will continue opportunities are provided in the home, at to be geared toward achieving health for school, and in the community for family all by the year 2000. To reaffirm the crucial members to improve their living conditions role of health information and education in and well-being-has acquired special im- attaining that goal and to increase aware- portance in the English-speaking Carib- ness among American governments that bean, where educational strategies and primary health care cannot be achieved curricula were developed for the schools without adequate health education, PAHO's and FLE is being made an integral part of Directing Council decided to begin the new primary education. Of particular note dur- decade by devoting its 1980 Technical Dis- ing the year were the training of family life cussions to "Community Health Education: educators and the development of youth Evaluation of Present Programs, New Ap- and FLE centers in Antigua and St. Kitts proaches and Strategies."

MANAGEMENT SYSTEMS

Difficulties in management, organiza- quate use of existing resources are among tion, planning, decision-making, and ade- the most fundamental problems facing the DEVELOPMENT OF HEALTH SERVICE SYSTEMS 39

Region's health services. Furthermore, the use of microcomputers to streamline health countries have recognized the implications ministry and hospital management prac- of the gap between needs and resources, tices. Guatemala's management develop- which is caused by the absolute scarcity or ment project, financed by IDB, ended dur- the misapplication and maldistribution of ing the year after having surpassed the resources. goals originally set for it. In Panama, na- Adoption of the goal of health for all by tional health authorities and representatives the year 2000 has not only highlighted of the U.S. Agency for International Devel- these problems but has stimulated initia- opment (USAID) concluded an agreement tives to find ways of overcoming them in a under which USAID will grant the country relatively short time. These initiatives have $240,000 for a two-year management im- produced basic strategies for redressing provement project in which PAHO will act the balance between health needs and re- as executing agency. sources. All of the strategies depend on im- In Colombia quite satisfactory progress proving the management of health services. is being made in the fields of personnel, Responding to increasing requests, PAHO supply, and finance which are a basis for continued cooperating with the countries guiding programs in other countries. to improve the organization and manage- In the area of training, PAHO helped ment of their health services by providing organize local courses on health service advice, local and regional courses and administration in the Bahamas, Colombia, seminars, publications, efforts to develop Costa Rica, Dominican Republic, El Sal- appropriate technology, and mechanisms vador, Guatemala, Honduras, and Jamaica. for exchanging experiences. It also assisted in preparing the 15-week In the English-speaking Caribbean, col- Second International Course on Planning laboration continued with Antigua, Ba- and Administration of Health Service Sys- hamas, and Barbados in the areas of health tems at Mexico City, which was attended service organization, supply, and account- by 32 participants from nine countries. The ing. Major cooperation was provided to theme of the XVI Regional Seminar on Dominica in the reconstruction projects it Health Services Administration at Mérida, started following hurricanes David and Mexico, which was attended by 79 repre- Frederick. Jamaica made progress in reor- sentatives from 19 countries, was "Admin- ganizing its Ministry of Health, and satis- istrative Processes and Regional Health factory results are being achieved in the Goals for the Year 2000." The seminar's personnel, budget, and supply areas. final report was distributed to all Member PAHO's cooperative activities were Countries. strengthened in Central America, where ef- In the area of legislation, PAHO col- forts were begun to promote technical co- laborated closely with WHO Headquarters operation among that subregion's coun- in evaluating the contributions to the Inter- tries. In Costa Rica, PAHO collaborated in national Digest of Health Legislation. A the national health services administrative short-term consultant visited Brazil, Canada, development program, whose experiences and Colombia and submitted a report, to are being documented for the benefit of be ready for distribution in early 1980, on other national programs. In El Salvador, it legislative developments and possible ac- continued its earlier management advisory tivities in this area in the immediate future. activities and injected a new element, the 40 REPORT OF THE DIRECTOR

NATIONAL HEALTH INFORMATION SYSTEMS

In this area PAHO continues to enhance programs in operation in Chile, Colombia, the importance of health information as an Costa Rica, Honduras, and Paraguay ma- input into and component of health activ- tured, especially in Costa Rica where the ities planning, programming, and manage- three once separate information systems ment. Experience is being gained in projects for rural, periurban, and nutrition service at different levels in several countries in extension are now integrated and share a broadening the field of health statistics to common data base. In Guatemala a new cover all health information systems, design was adopted to replace the earlier which also include data processing tech- one, which had been found unsatisfactory. nology and indicators generated for plan- In Nicaragua a start was made at formulat- ning, programming, management, and ing a new health information system em- evaluation. bracing the entire health sector, something Information systems activities fall into that is also contemplated in Uruguay. In four major areas: (1) strengthening conven- Paraguay an information system for periph- tional health statistics and medical records eral health services was completed, and in infrastructures; (2) redesigning health in- Argentina the national strategy was reori- formation systems; (3) strengthening infor- ented toward strengthening the manage- mation systems already in operation; and ment of provincial health services, a pro- (4) training. cess that began in two provinces. Chile and In the first area, PAHO cooperated with Peru continued strengthening their health the Dominican Republic, Honduras, and statistics and data processing infrastruc- Nicaragua in organizing medical records tures, and both countries have begun and statistics departments. Costa Rica, testing their information systems-for Honduras, and Panama requested PAHO's auditing performed activities in Chile and help in developing medical records forms the basic medicines program in Peru. for perinatal care. Cuba was assisted in Future development will consist of the developing national chronic disease regis- gradual growth of national information ters. systems. This will require that enough per- Colombia's seven-year-old national proj- sonnel for all levels be trained and that cur- ect to develop medical records standards ricula be strengthened in the area of health and forms for use at all health care levels, information systems. which will be a basis for a national health Toward that end, broad studies were con- information system, was discussed and re- ducted in Costa Rica and Cuba of require- viewed. ments for statistical and medical records In the area of redesigning information personnel at the auxiliary, intermediate, systems, the strategy of total redesign is be- and professional levels. Both countries ing carried out in Colombia and Honduras decided to revise their present auxiliary and of partial redesign and modular growth and intermediate-level courses. The inter- in Costa Rica and Paraguay. mediate course will continue to be the en- At the regional level, implementation tryway for people starting in the field. In and evaluation of national health informa- Costa Rica a second phase was added to tion systems continued to advance. The the present intermediate-level course DEVELOPMENT OF HEALTH SERVICE SYSTEMS 41 which can be offered to graduates of pre- by WHO and PAHO was held in Costa Rica vious courses and will satisfy the new at which general criteria for all other needs of the country's health systems and regions of the world were considered. Fol- their information subsystems. PAHO col- lowing the second seminar, a traveling laborated with Cuba in drawing up a pre- seminar organized in the same manner liminary plan to be submitted to the min- demonstrated what had been achieved in istry of education for training medical the Americas through field visits to Colom- records workers at the professional level. bia, Costa Rica, and Honduras. In El Salvador, it assisted in designing the In summary, the concept of health infor- first intermediate-level course, and in Peru mation systems is being promoted and ex- it took part in training activities. In Venezu- tended throughout the Region. Training ela plans were made to analyze the three materials were prepared which include courses offered in that country for training such features as national health informa- health records and statistical workers. The tion systems, strategies for their modular curriculum of the medical records and sta- development, control and evolution indi- tistics course in Jamaica was reviewed. cators, and computerized data banks. The A seminar for PAHO's divisions and cen- health information systems of Guyana, Ja- ters was held in February on concepts of maica, Nicaragua, and Panama will begin national health information systems, and to be reorganized in 1980 on the basis of an interregional seminar organized jointly these materials.

MATERNAL AND CHILD HEALTH AND FAMILY PLANNING

PAHO served as executing agency for Evaluations of MCH/FP projects were maternal and child health/family planning conducted in Chile, Ecuador, Honduras, (MCH/FP) programs financed by UNFPA in 19 and St. Vincent to assess progress and countries and territories in the Region. make recommendations for future action. They were Antigua, Bolivia, Cayman Islands, A joint PAHO/USAID mission visited Haiti to Chile, Colombia, Cuba, Dominica, Ecuador, make a detailed evaluation of that coun- Haiti, Honduras, Jamaica, Mexico, Nicara- try's MCH/FP program. Assistance was pro- gua, Panama, Peru, St. Kitts-Nevis, St. vided to Trinidad and Tobago in evaluating Lucia, St. Vincent, and Uruguay. New proj- its national family planning program; ects in Anguilla and the British Virgin analysis of data will be completed during Islands were approved, to begin in 1980. 1980. Formal recommendations were sub- PAHO staff provided technical and man- mitted to the Governments of St. Kitts- agement support during the year to all Nevis and St. Vincent for improving their countries developing or conducting UNFPA- family planning programs' statistical sys- funded MCH/FP projects. tems. For St. Lucia, PAHO provided data 42 REPORT OF THE DIRECTOR

processing assistance and a computerized UNFPA approved financial assistance for retrieval of literature citations on the ade- a Caribbean continuing and postbasic edu- quacy of nurses' diagnosis and treatment cation program in advanced family health of primary health care patients. nursing. Continuing education in family The health of adolescents received sig- health service management was initiated in nificant attention during the year because St. Kitts. Health professionals from the par- of their special psychosocial needs and the ticipating countries and PAHO staff met to lack of specific health services for them. develop curricula for the family nurse In honor of the United Nations' Interna- practitioner program, to begin in St. Vin- tional Year of the Child-proclaimed by cent in early 1980. the United Nations General Assembly in To improve the delivery and quality of December 1976 to stimulate child welfare MCH/FP services, PAHO undertook opera- programs-"health and youth" meetings tional research activities in collaboration were held in nine English-speaking Carib- with national program personnel. During bean countries and territories (Antigua, the year the following studies were con- Barbados, Belize, British Virgin Islands, ducted: national family planning program Grenada, Guyana, Montserrat, St. Kitts- dropout studies in St. Kitts-Nevis and St. Nevis, and St. Lucia) during the first half of Vincent; a WHO study of traditional birth the year. The goal of these meetings was to attendants in Ecuador and Honduras; an maximize the participation of young peo- evaluation of the training provided to rural ple in identifying problems related to their voluntary workers in Ecuador; a study of health and designing ways to overcome them. maternal and child mortality and morbidity In mid-July a subregional meeting was held in Uruguay;.and a survey of contraceptive in Barbados attended by technical resource use, infant mortality, and the use of MCH personnel and youths chosen at the prelim- services in Mexico. inary national workshops. Its purpose was A workshop to formulate methods for de- to discuss strategies, sources of funding, veloping MCH care standards was held in technical cooperation, and followup mech- Cuba for 37 physicians and nurses from anisms for developing and carrying out ac- Cuba, Dominican Republic, Mexico, Nica- tion programs to improve the health of ragua, Panama, Peru, and Venezuela. children and adolescents in the English- speaking Caribbean. Also in celebration of the International Year of the Child, PAHO prepared a publi- Latin American Center for cation in Spanish on health conditions of Perinatology and Human children in the Americas containing up-to- Development date information on the health status of mothers and children in Latin America and the Caribbean and innovative MCH pro- This world-renowned institute in Monte- grams in various countries of the Region. video joined PAHO's family of regional cen- Regional seminars on pediatric health ters in 1970. It has conducted significant were conducted in Argentina, Brazil, and perinatal research, specialized training, Uruguay. A training course on primary and advisory activities in the field of fetal health care for adolescents was held at and neonatal care. Santiago, Chile, for 30 national participants. In accordance with the policies estab- Assistance was provided to Brazil, Chile, lished by PAHO's Governing Bodies, the and Colombia in developing adolescent Center's research has been oriented toward health services. simplifying, reducing costs, and developing DEVELOPMENT OF HEALTH SERVICE SYSTEMS 43 appropriate technologies for perinatal scientific fundamentais of integrated ma- care. Appropriate technology has war- ternal, fetal, and newborn care. Nineteen ranted special attention in the form of col- fellowship holders from several countries laborative'investigations that help extend attended, and at the request of their gov- the coverage of perinatal and maternal and ernments two extended their training into child care. The diagnosis and treatment another year to become expert in perinatal standardization program for maternity cen- research. ters in Latin America has been widely and Also held was a two-week course on public well accepted and has now been used for health and perinatology attended by 72 more than 100,000 births at 40 institutions professionals occupying supervisory posts in 14 of the Region's countries. in maternal and child care in 14 Latin Amer- Preparation was completed of the regional ican countries. A short course was also perinatal and maternal and child care pro- held on appropriate technologies for peri- gram, which emphasizes primary care of natal care by risk level. Professionals from the nuclear family. The program was ap- seven of the Region's countries attended. proved by the PAHO project review group Extensive technical cooperation involv- and presented to the W.K. Kellogg Foun- ing more than 400 consultant-days of work dation for financing. by international and Center experts was In the training area, the Center con- provided to 15 of the Region's countries. ducted its annual nine-month course on the

NUTRITION

PAHO conducted regional, subregional, PIA/PNAN assistance. The organization's and country nutrition activities in 1979. board of directors met at Santiago in March The Institute of Nutrition of Central Amer- to review its activities and program of ica and Panama (INCAP), the Caribbean work. In addition to discussing future activ- Food and Nutrition Institute (CFNI) in ities, the group considered a document pre- Jamaica, and the Inter-Agency Project for pared by PAHO on the goal of health for ali the Promotion of National Food and Nutri- by the year 2000 through intersectoral co- tion Policies (PIA/PNAN) in Chile helped ordination of national development. carry out this responsibility. PAHO intensified its collaboration with PIA/PNAN is a joint undertaking of PAHO the World Food Program, UNDP, FAO, and four United Nations agencies, the Eco- ECLA, UNESCO, and UNICEF; bilateral assis- nomic Commission for Latin America (ECLA), tance agencies such as the Canadian In- Food and Agriculture Organization (FAO), ternational Development Agency, Euro- Educational, Scientific, and Cultural Or- pean Economic Community, and USAID, ganization (UNESCO), and Children's Fund and foundations such as W.K. Kellogg and (UNICEF). In 1979 the Project covered Bo- Ford and the Canadian International De- livia, Chile, the Dominican Republic, and velopment Research Center. It also took Haiti, though in earlier years five other further steps to identify food and nutrition hemispheric countries had also received activities to be carried out with IDB and the 44 REPORT OF THE DIRECTOR

World Bank. meetings: International Conference on Maternal PAHO's nutrition program consists of Nutrition (Guatemala, March); Regional Work- (Barbados, March); sub- (1) investigation of shop on Breastfeeding three main activities: committee on international nutrition of the U.S. nutritional problems and their causes and National Academy of Sciences (Washington, possible solutions; (2) training of general April); Second National Workshop on Food and public health and specialized nutrition Nutrition (Dominican Republic, May); ACMR's workers in the health and other develop- working group considering WHO's nutrition research program and PAHO's possible participa- to the mental sectors; and (3) direct service tion in it (Washington, June); International Con- countries in planning, carrying out, and ference on the Prevention of Blindness (Wash- evaluating food and nutrition policies, pro- ington, September); Joint WHO/UNICEF Meeting grams, and projects. on Infant and Young Child Feeding (Geneva, Oc- The following are some of the food and tober); International Consultative Group on Nutritional Anemias (Cairo, October); the PAHO- nutrition activities in which PAHO collabor- IDB meeting on joint cooperation (Washington, ated with Member Governments during November); the CFNI policy advisory commit- 1979: tee (Suriname, November); and the meeting of the PIA/PNAN governing board (Santiago, * Establishment of systems for monitoring December). the food and nutrition status of the most vulnerable groups in the population to detect, prevent, and treat major nutritional deficiencies such as energy-protein malnutrition, iron-deficiency ane- Caribbean Food and mias, hypovitaminosis A and xerophthalmia, Institute and endemic goiter. Nutrition * Development of intersectoral food and nutritional planning methods, with special em- The Caribbean Food and Nutrition Insti- phasis on the role of the health sector in promoting, formulating, and executing policies and tute at Kingston, Jamaica, which became programs. associated with PAHO in 1967, has had * Integration of basic nutrition activities in eight basic program objectives since 1973. the health services, stressing primary care and Over the years they have been modified effective community participation, to oversee slightly in light of CFNI's staffing pattern, pre- and postnatal care, infant growth and development, and nutritional education and current trends, and future needs within the food supplementation for mothers and children. total Caribbean food and nutrition situa- * Prevention and control of specific deficien- tion. cies by developing and applying appropriate Those objectives consist of: (1) establish- technologies for fortifying foods with nutrients ment and implementation of food and nu- they lack in specific countries or subregions. Ex- amples are vitamin A and iron fortification of trition policies and programs in Member sugar and iodization of salt. Countries; (2) diagnosis of the food and nu- * Support of nutrition and dietetic schools in trition situation in each country to formu- collaboration with the Commission on Aca- late, monitor, and evaluate food and nutri- in Latin demic Nutrition and Dietetic Programs tion programs and policies; (3) establishment America, and development of models of integrated nutrition teaching and care in regional- and strengthening of technical nutrition ized health services. units and support of national and regional * Support and coordination of nutrition and nutrition programs; (4) improvement of nu- food research activities at INCAP, CFNI, and the trition education and training at all levels Latin American Center for Perinatology and of health and related services; (5) improve- Human Development at Montevideo and by PAHO's Advisory Committee on Medical Re- ment in the standards of diagnosis, preven- search (ACMR). tion, and treatment of nutritional diseases * Participation in the following scientific according to each country's needs and re- DEVELOPMENT OF HEALTH SERVICE SYSTEMS 45

sources; (6) strengthening of institutional and Procedure Manual for Dietetic Serv- food services; (7) preparation, publication, ices in Small Hospitais." The "Regional and dissemination of educational materiais Diet Manual for the Caribbean" is a guide to support the foregoing objectives and im- for physicians in prescribing modified diets provement of communication skills in nu- and for dietitians and nutritionists in filling trition; and (8) operations research to sup- such prescriptions. port objectives 1 through 7. Breastfeeding is a high priority in the CFNI's efforts to promote national food Caribbean. A technical group on new tech- and nutrition policies reached the consoli- niques to promote successful breast- dation stage. Several countries have estab- feeding and infant nutrition met in Bar- lished or restructured their food and nutri- bados in late May and wrote relevant tion councils, and CFNI's collaboration guidelines. Seminars for the purpose of for- with them will continue in 1980. mulating national strategies to promote A most important area of nutritional breastfeeding followed; the first took place concern is the link between production or in Montserrat in November. Breastfeeding importation and consumption of foods- was further promoted by the production of the area of distribution and marketing. Pro- a teaching package, underwritten by duction and distribution of nutrient-cost UNICEF, comprising slides, cassettes, and users' reference tables was initiated, and teaching notes entitied "Breastfeeding quarterly production of nutrient-cost tables Your Baby." for each of the countries continued. CFNI recently turned its attention to dia- Because of the importance of middle- betes mellitus and high blood pressure. It level personnel in carrying out food and first tried to develop an understanding of nutrition programs, CNFI began the first in a the problem and its relation to nutrition; series of intensive courses to improve the second, developed a teaching aid entitled ability of participants to do so. These "Meal Planning for Diabetics" in 1978; and, courses are designed to fit the needs of per- third, sponsored a series of national sons supervising field or community workers meetings on dietary management of dia- in projects with a food and nutrition com- betes and cardiovascular diseases. In ponent. The first three-month course was November, nutritionists and dietitians met held in March. to review recent developments in this area Food and nutrition surveillance has in- so that the countries could improve their creased in importance in CFNI's program. efforts in it. Most member countries are developing sys- Anemia is prevalent in the Caribbean. tems for monitoring nutritional status using Care is needed to ensure that programs to clinic and hospital records. The UNICEF- deal with it are safe and cost-effective, assisted surveillance project in Anguilla which means that data on the extent of the and St. Kitts-Nevis reached the data problem, its causes, and functional conse- analysis stage in 1979. quences must be gathered. CFNI is collect- The latest in a series of manuals to ing such data for a control program in strengthen dietetic services in the English- all the countries, including anemia-screen- speaking Caribbean were produced in 1979. ing methods through the primary health "Job Descriptions for Nutrition and Di- care system. This follows up 1977-78 etetic Personnel" clarifies the roles and studies of the copper sulfate method responsibilities of the varied nutrition and of screening anemia and the effectiveness dietetic personnel now at work in the sub- of varying doses of iron supplementation region. Another publication was a "Policy in prenatal clinics. 46 REPORT OF THE DIRECTOR

Education is an essential part of almost and Panama. These investigations enabled all nutritional programs and activities. Fol- improved varieties to be chosen for com- lowing the recruitment of a nutrition edu- munity promotion. The search for new cator in 1978, CFNI has been developing a products that can be used as human or strategy to strengthen both formal and in- animal foods continued, during which it formal nutrition education in all the coun- was possible to begin converting coffee tries, producing resource materiais, and by-products into animal fodder. It was also training nutrition educators. possible to develop appropriate technolo- A series of nutrition modules for use in gies for preventing or reducing the harden- basic nursing schools was developed. Na- ing of legumes (beans) during long storage tional workshops began to be held in 1979 as well as simplified, inexpensive proce- on nutrition education techniques and con- dures for dehydrating vegetables in com- tent for government technical personnel, munities or cooperatives. Operational field including primary health care workers. research was carried out to test various Two new staff members, a public health systems that might be used in the intensive nutritionist and an applied nutritionist, production of foods of animal origin. were recruited during the year. These ap- Research on the relationship between pointments enhanced CFNI's cooperation nutrition and infection continued. Efforts with individual countries in infrastructure were made to clarify the epidemiology of development and training. the most prevalent communicable diseases in Central America and Panama by quanti- fying their extent, causes, and significance and identifying ways to strengthen host de- Institute of Nutrition of fense mechanisms. Of special importance Central America and Panama in this area were studies to measure the benefits of breastfeeding and the influence The Institute of Nutrition of Central of biologic and social factors in order to America and Panama (INCAP) at Guatemala develop an adequate basis for promoting City continued performing the research and that practice. teaching activities and providing the tech- Investigators also continued studying nical advice required by the programs and the physiologic and metabolic mechanisms projects it conducts in cooperation with involved in malnutrition. Among them was countries it serves. In doing so it received research to determine the relationship be- financial support from the W.K. Kellogg, tween proteins and energy in the diet in Ford, and Rockefeller Foundations, Food order better to define nutritional require- and Nutrition Foundation of Central Amer- ments. Part of this investigation was a ica and Panama, U.S. National Science study of the energy cost of the daily ac- Foundation, USAID, Canadian Interna- tivities of rural men and women. tional Development Research Center, United Studies of specific nutrients were ex- Kingdom, European Economic Community, tended to include essential fatty acids and FAO, UNFPA, and PAHO/WHO. certain trace elements. INCAP continued In the food area, INCAP's research con- collaborating with the governments in eval- tinued to elucidate the effect of agri- uating the operation and impact of fortify- cultural and genetic environmental facing sugar with vitamin A and salt with tors on the chemical composition and potassium iodide to control hypovitamin- nutritive value of cereals and legumes, osis A and goiter, respectively. Tests also which are staple foods in Central America continued in rural communities to deter- DEVELOPMENT OF HEALTH SERVICE SYSTEMS 47 mine the effectiveness of fortifying sugar and characterization of appropriate indica- with NaFe EDTA to prevent the iron defi- tors, and it paid special attention to pro- ciency prevalent in the Central American ducing food balance sheets in the coun- isthmus. tries by collaborating with national coun- The effect of different nutritional inter- terparts in standardizing that process. ventions on infant physical growth, mor- INCAP's technical cooperation in the bidity, and mental development was inves- training areas was carried out through ex- tigated in large rural areas. With the direct isting academic programs and tutorial and participation of the health services in one in-service training. Fourteen nutritionists of the countries, a system integrating graduated from its nutrition school, which primary health care and nutrition in rural brings to 111 the number graduated since areas was evaluated. Both the evaluation the school's founding. The postgraduate methods used in these studies and the course in public health with emphasis on results they produced can be immediately nutrition trained 15 professionals for mas- applied, and several of the countries have ter's degrees. The number of graduates begun or will shortly begin using such in- from the postgraduate course on food sci- terventions. Complementary information ences and technology and animal nutrition from these studies will be useful in achiev- increased to 33, all of whom are now oc- ing a better understanding of the effects of cupying important planning and evaluation social variables on health and nutrition. positions in governmental, academic, or in- INCAP also promoted and cooperated in dustrial organizations. Sixty-nine students further developing the countries' institu- received specialized tutorial training in tional capacity to formulate national mul- nutrition and food sciences. Advanced tu- tisectoral food and nutrition plans which torial training was given to 17 professionals effectively help improve the nutritional through the United Nations University/INCAP conditions of the population. One of the program to prepare them for teaching, re- countries has already drawn up a national search, or service activities through integral plan which identifies projects and is ready and direct participation in projects INCAP to begin putting them into effect in priority conducts which are part of the university's order, and two other countries have fin- war-on-hunger program. ished defining their plans. Finally, plans began to be formulated at Such plans have been worked out with- the beginning of the year to start an inte- out neglecting specific problems identified grated nutrition education program using by national authorities in areas in which modern techniques and varied communica- INCAP is competent. It thus cooperated tions media and providing facilities for specifically with the health sector in reor- training in this field. As the first step, re- ganizing hospital food services and pro- sources available at PAHO Headquarters vided support in planning and incorporat- will be transferred to INCAP to speed the ing nutrition activities in the health sector. process and draw up the specific proposals In the field of food and nutrition surveil- required to obtain the necessary financial lance, it continued promoting the creation support. of multisectoral systems and the search for

[] [ [] Chapter 3

HUMAN RESOURCES AND RESEARCH

As a result of the IV Special Meeting of workers per 10,000 population during the Ministers of Health of the Americas in seven years. This leads us to believe that September 1977 and the International Con- the two areas had 1,050,000 health workers ference on Primary Health Care at Alma- in 1979. Ata, U.S.S.R., a year later, plans were de- It can thus be assumed that there is veloped in 1979 to bring health care to and probably no general shortage of health improve the living conditions of all people personnel but rather shortages in certain during the next two decades. Thus, at the categories and imbalances in the se same time changes and ;mprovements oc-cuationat structure. I he table below were being made in health systems, the shows- he --istributon of and changes in Region's educational institutions were health workers by major categories. being organized to train the needed num- Although some variations in the statistics bers and kinds of health personnel for are due to better registration, different carrying out the mission of health for all classification criteria, and the inclusion of by the year 2000. certain technical groups in the professional Available information indicates that category, the changes during the 1970s Latin America and the Caribbean had demonstrate without doubt a serious short- 580,000 health workers in 1970 and 977,000 ageof middle-Ievel technical workers and in 1977, an increase of 20.6 to 28.7 health a continued increase in protessional per-

1968 1974 1977 Number % Number % Number %

Personnel with university or higher training 254,000 47 509,000 63 616,000 63 Technical workers 62,000 11 41,000 / 59 43,000 ¿43 Auxiliary workers 224,000 42 266,000 32 318,000 33 540,000 100 816,000 100 977,000 100

48 HUMAN RESOURCES AND RESEARCH 49

sonnel. require a billion dollars during the coming / Both of these facts indicate that the poli- decade. cies of giving priority to training technical It should be stressed, however, that the and auxiliary workers have still not been basic problem will be not the initial cost of put into force or that such workers cannot training the additional workers but the be used fully in the health services as they/ecurring costs of their later employment now exist. /and ad"equate compensation. Recurring Calculations in 1977 of the personnel costs create problems for national institu- required to staff new health care units in tions, and it is necessary to ensure suffi- future years show that more than a million cient national financing-or, in its absence, additional health workers will be needed external financing-so that recurring costs by 1990. This does not mean that the health can be absorbed by the countries them- care labor force should double between selves. 1979 and 1990, which is quite unlikely, but As to quality, the new personnel should rather that the ever-expanding network of be trained to work in health systems in service units will absorb a million more which the emphasis will be on primary workers. Among them will be 139,000 pro- care. Still, in the face of pressing immediate fessionals, 239,000 technical workers, and needs, special care should be taken to pro- 661,000 auxiliaries. As is easily seen, most vide these workers basic training that will future demand will be for auxiliary workers, later enable them to specialize and be re- followed by technical personnel and to a trained in other areas. lesserextentprofessionals. Estimates of the personnel required for In this regard it should be noted that developinghealthservicesduringthe1990s mostof the countries now have satisfactory will depend on the coverage achieved, university-level training and that in most development of the primary care strategy, ~health servcspvice sion-thoug gener- success in controlling communicable -ally inadequate-is made for training diseases, and changes in pathology during auxiliaries. But there is a grave shortage of the 1980s. Nevertheless, it is important to facilities for training middle-level technical bear in mind that in the year 2000-even 'worer is requires urgent revision of assuming a decline in the present rate of 'present policies. increase-the number of health workers in --For Latin America and the Caribbean Latin America and the Caribbean will ap- together, it has been reckoned that the cost proach 2 million. of training these additional personnel will

MANPOWER PLANNING AND ADMINN Ti

Manpower Planning personnel and formulatina de elopmen--e p a It also sponsored a Cari - manpower planning seminar PAHO collaborated with the Ministry of attended by representatives of the Baha- Health of the Bahamas in censusin_healtJ mas, Barbados, Grenada, Guyana, Jamaica, F P

.- ", 11-00 -,ii %W,---or- 41

algo V-111-1 HUMAN RESOURCES AND RESEARCH 51

Trinidad and Tobago, and the University bia, Costa Rica, Cuba, Jamaica, Mexico, of the West Indies. An integrated health Peru, Puerto Rico, and Venezuela and the personnel planning program was approved services and institutions composing the for the English-speaking Caribbean. health systems in those countries. It co- In the Andean subregion, PAHO provided operated in the following activities: advice to Bolivia, Chile, Colombia, Ecua- dor, Peru, and- Venezuela in designing * Redesigning the courses' curricula with health worker information systems and emphasis on behavioral objectives and an ade- organizing health ministry manpower units. quate balance between theory and practice; * Promoting the training of instructors, both In collaboration with the Colombian Minis- to update their knowledge and skills in specific try of Health, PAHO prepared and organized subjects and to improve their teaching skills; the second international course on man- * Coordinating continuing education for a power planning for participants from 15 critical mass of senior and middle-level adminis- countries in the Region. This course was trators; * Promoting interest in and capacity for carry- postponed until the beginning of 1980. ing on research on problems of health service production and quality; * Developing systems of information and communication among education programs in Education and Training in Health 22 countries; and * Creating new advanced study programs in Care Administration Mexico and Central America which, together with existing programs at Rio de Janeiro and Sáao Paulo in Brazil and at Cali in Colombia, will PAHO helped to improve interaction form a Latin American network to meet the demand for instructor training and research in among 45 health care administration health service administration. courses in Argentina, Brazil, Chile, Colom-

It helped complete the chapters on administration and management, health serv- 4-;' ice administration, hospital administration, and public health administration in the PAHO/WHO directory of training programs in Latin America and the Caribbean, which will be an information instrument of extraordinary usefulness for health authorities and fellowship holders. It began the followup phase of the program for coordinating and supporting education in health care administration in Latin America and the Caribbean with generous financial support from the W.K. Kellogg Foundation. This includes coopera- The needed numbers and kinds of health tion in evaluating the overall program, workers to provide health for all by the end developing effective information and of this century will require the planning, communication systems, improving the administration, and development of human, educational process, establishing continu- technologic, and educational resources. (Photos: University of the West Indies, Jamaica, ing education programs for executives at and Inter-American Development Bank) various levels, and developing models for 52 REPORT OF THE DIRECTOR delivering health services in order to inte- sion of equipment and materials. It also grate teaching with services and develop aided the health ministries of Chile, Do- applied research on health care problems. minican Republic, Jamaica, Nicaragua, Peru, and Venezuela in planning national programs and their future participation in the hemispheric program. Continuing Education The Headquarters of the Region of the Americas was the seat of an international seminar on continuing education in which PAHO collaborated with the countries in other WHO regions took part. Seminar developing continuing education programs participants agreed on the activities the for health workers, giving priority to the hemispheric project will undertake and health teams that provide primary care in discussed possible cooperation among peripheral areas. WHO's various regions in continuing educa- During the year Bolivia, Colombia, Ecua- tion. dor, and Guatemala began participating in Supporting national activities, PAHO the hemispheric continuing education sponsored a workshop at San José, Costa project sponsored jointly by the Canadian Rica, on continuing and adult education International Development Agency. It also techniques attended by participants from prepared a plan of operations for the 12 of the Region's countries. Dominican Republic's participation in To exchange experiences among the the project. It collaborated with the par- Latin American countries, PAHO published ticipating countries in elaborating opera- and disseminated a guide on organizing tional plans and in carrying out national continuing education programs as well as projects through advice, fellowships, na- various technical documents. tional courses and seminars, and the provi-

DEVELOPMENT OF HUMAN RESOURCES

Institutional and Program the Inter-American Development Bank Development (IDB), United Nations Development Pro- gram (UNDP), or foundations supporting PAHO cooperated with the countries the health sector. in integrating their health care schools In the Dominican Republic, PAHO and through programs that include plant con- the Ministry of Public Health. and Social struction or modernization, equipment Welfare continued reorganizing the admin- purchases, administrative and academic istrative, teaching, and service structure changes, and training of professional, of the Faculty of Health Sciences and the technical, and auxiliary personnel. These Center for Biomedical and Operations Re- activities were almost always carried out search at the Catholic University at Santi- as part of projects in which PAHO serves ago as part of the IDB-financed project as executing agency that are financed by there. HUMAN RESOURCES AND RESEARCH 53

In Nicaragua, PAHO acted as IDB's ex- the West Indies at Kingston, Jamaica, on ecuting agency in helping modernize the technologic resources for education. The León medical campus and the structure of coordinators of the units met four times to the National University's medical, dental, exchange experiences and develop a mech- pharmacy, and medical technology facul- anism for continuing exchanges and con- ties. Activities included curriculum review, sultation. A final meeting is planned for definition of levels of teaching-care coordi- the beginning of 1980. nation, and establishment of bases for organizing biomedical information, research and educational development, and drug production units. IDB agreed to post- Medical Education pone completion of the project to 1980 because of the civil war that occurred in Nicaragua during 1979. PAHO has concentrated its medical education activities in three principal areas: improving instruction, updating curricula, and strengthening community-oriented programs. Educational Development Improving the instruction given in the in Health Region's medical schools was carried out by training instructors in special courses, awarding fellowships for visits to more In 1976, with a grant from the W.K. Kel- advanced programs in other countries, and logg Foundation and the Pan American disseminating bibliographies and materials Health and Education Foundation, PAHO on health sciences teaching. As in previous began the Latin American Program for Edu- years, PAHO staff and consultants helped cational Development in Health (PLADES) analyze, reorganize, and update educa- by creating research and development tional programs. units in education and health (NIDES). This Teaching programs-chiefly through program brought together personnel from departments of preventive and social medi- health teaching and service institutions. cine-continued to be oriented toward ac- Relying on the principle of integrated work tivities in health care services and com- and teaching, it sought to overcome the munities. In some cases, an effort was lack of coordination that had existed be- made to reorient the overall curriculum tween health and education systems, the toward the community. In June, in col- duplication of activities in the various in- laboration with WHO's manpower develop- stitutions comprising those systems, and ment division, representatives of several the inevitable obstacles to training health institutions met in Jamaica to review the manpower. During its four years of opera- experiences of community-oriented pro- tion, the program became one of the prime grams and discuss expanded exchanges examples of PAHO's new strategy of techni- among institutions so oriented. The meet- cal cooperation. ing was attended by participants from In 1979 PLADES comprised 15 NIDES units Brazil, Canada, Colombia, Cuba, Jamaica, in Bolivia, Brazil, Costa Rica, Dominican Mexico, United States, and Venezuela as Republic, Ecuador, Honduras, Mexico, well as extraregional countries-Australia, Nicaragua, Paraguay, Peru, and Venezuela. Cameroon, Iran, Israel, Nepal, Netherlands, It also cooperated with the University of Nigeria, Philippines, and the U.S.S.R. 54 REPORT OF THE DIRECTOR

Several medical education activities ate public health and social medicine pro- were carried out, some in collaboration grams in several universities which have with the Pan American Federation of Medi- been conducting research in those fields. cal School Associations or national med- PAHO stimulated these programs as well ical school associations. Specific seminars as the development or consolidation of discussed the teaching programs in Argen- departments of preventive and social medi- tina, Chile, and Paraguay. cine which, in addition to their undergradu- PAHO provided technical assistance in ate activities, have undertaken postgradu- relation to plans and programs in the health ate education and health research. When sciences for the Universities of the West possible, these activities have been carried and Midwest in Venezuela and to medical out in close contact with the Latin American training programs in Bolivia, Chile, Colom- Association of Public Health Schools, bia, Ecuador, and Peru. In Bolivia activi- which embraces postgraduate programs in ties were oriented toward carrying out the public health in Latin America and the programs of the health sciences faculties Caribbean. at La Paz, Cochabamba, and Sucre, where The X Conference of Public Health meetings were held to follow up the first Schools was held in Venezuela in April national workshop on health sciences edu- and was attended by 51 representatives cation at Coroico in December 1978. The from 25 programs in Argentina, Brazil, activities in Ecuador and Peru were carried Canada, Chile, Colombia, Cuba, Mexico, out with the medical school or academic Netherlands, Peru, United States, and program associations and directly with Venezuela offering master's degrees in some schools such as the Faculty of Medi- public health and preventive and social cine of the Catholic University of Guaya- medicine. Its theme was applied health quil, where the curriculum was completely service research, and participants reported restructu red. on their experiences in the field. Experi- In Costa Rica the Faculty of Medicine ences were exchanged in relation to re- strengthened its coordination with the na- search methods, goals, the uses to which tional social security agency and carried research findings can be put, and the infra- out intense community health care activi- structure necessary to carry out applied ties, as did Guatemala, where work-educa- health service research. tion programs are quite advanced. PAHO also cooperated with specific pro- In Mexico several national and local grams and courses in Brazil, Chile, Mexico, meetings were held to discuss various Peru, and Venezuela. New public health aspects of the educational process, and training programs based on service needs advice was provided to teaching institu- were planned in Bolivia, the English-speak- tions such as the National Autonomous ing Caribbean, Paraguay, and Uruguay. University of Mexico and the Faculty of Medicine of the Autonomous University of Guadalajara. Nursing Education

Education in Public Health and PAHO's emphasis in nursing education is Social Medicine on primary care concepts in teaching and services. It recognizes that nursing school The schools of public health in Latin programs must be relevant to the health America were strengthened by postgradu- needs and demands of the community, and HUMAN RESOURCES AND RESEARCH 55 every attempt has been made to assist the were on epidemiology, diagnosis, primary schools in designing programs that reflect care of mothers and children, and care in those needs. Some recommendations being high-risk perinatal and neonatal cases. made are that programs include courses in In Peru, PAHO helped train traditional, epidemiology, sociology, change theory, community-chosen midwives in order to and operations research, that the commu- standardize the criteria, methods, and nity itself be used more for teaching and procedures such practitioners use. Thirty- learning, and that community members seven nurses and midwives from Arequipa, participate in programs for providing their Cajamarca, Iquitos, Lima, Moquegua, own care. Piura, Tacna, and Tumbes participated. PAHO sponsored a traveling seminar on With PAHO's cooperation, programs to primary care for nurses in the Andean train auxiliary nurses and community volun- countries in which 20 professionals from teers in caring for mothers and children Bolivia, Colombia, Ecuador, Peru, and continued in Colombia, Ecuador, Haiti, Venezuela took part. The group observed Honduras, Mexico, and Peru using learning and analyzed coverage extension and com- methods that enable such workers to de- munity participation programs now being velop their skills and expand their primary carried on in parts of Colombia and Peru. care functions. In Costa Rica, PAHO collaborated with PAHO proceeded with advisory services the social security agency in training 25 for the continuing education project in nurses in ambulatory care of adults with nursing and family health service adminis- uncomplicated chronic hypertension or tration in the English-speaking Caribbean. diabetes. Two meetings were held that permitted At the Catholic University of Santiago, analysis of the nursing education situation Dominican Republic, PAHO provided tech- in those countries and a basic nursing pro- nical advice on training 20 teaching and gram to be developed beginning in early service nurses in diagnosis. This allowed 1980 in St. Vincent. that component to be integrated with the The first was that of a working group basic nurse training curriculum as well as which met in St. Lucia in November to con- the use of nurses in maternal and child tinue revising the curricula of basic schools health care management and adult am- of nursing. Thirty-eight professional service bulatory care with emphasis on primary and education nurses from 13 English- care. speaking countries took part. It is antici- In Ecuador, PAHO provided technical pated that the nursing curricula will reflect advice on the maternal and child health a more comprehensive approach to the component of the nursing schools in Ma- health care needs of the English-speaking nabí Province, Guayaquil, and Quito. Caribbean as a result of this workshop. In Honduras, with PAHO technical ad- The second was a seminar on continuing vice, a second course on maternal and education in administration of family health child health care for service and teaching services in St. Kitts in late November and nurses was held. New instructional methods early December. Twenty-two health pro- were used, and an attempt was made to fessionals from eight English-speaking develop the students' skills and deepen Caribbean islands attended. their knowledge of adult and child physical An interdisciplinary workshop (medicine, examinations. nursing, sanitary engineering) was held in At Panama's school of nursing, PAHO Panama in November to discuss primary helped design a postbasic course in ma- care strategies. Forty professionals from ternal and pediatric nursing. Its emphases Costa Rica, El Salvador, Guatemala, Hon- 56 REPORT OF THE DIRECTOR

duras, Nicaragua, and Panama participated, sources development rather than merely and a report is being prepared for presenta- manpower training. Foremost among these tion to the health ministers of Central activities were: America and Panama. * A course on the operation and maintenance Sponsored by PAHO, a two-week work- of water supply systems jointly organized by shop on methods to standardize maternal PAHO and the College of Arts, Science and and child health care was held in Novem- Technology (CAST) in Jamaica, which was at- ber at Havana. It was attended by 37 nurses tended by 40 Caribbean participants. and physicians from Cuba, Dominican Re- * A May workshop in San José on the operation and maintenance of water supply systems public, Mexico, Nicaragua, Panama, and jointly sponsored by the Costa Rican Ministry of Venezuela. Public Health and water supply and sewerage To meet the need for current informa- authority, PAHO, and the Inter-American Associ- tion on nursing education and care trends ation of Sanitary and Environmental Engineering in Latin America, PAHO brought together (AIDIS). The workshop represented an integrated approach by the Central American countries and 14 nursing experts in Washington in July to Panama to all the problems of each country and prepare an anthology on nursing education an expression of their determination to seek in Latin America. The first volume of the concerted solutions to these problems. It was anthology was published in the last num- followed by a meeting of the managers of water ber of 1979 of Educación médica y salud, supply systems in Central America and Panama. The latter suggested, among other things, the and the second will appear in the first establishment of a subregional multidisciplinary number of 1980. working group which should be responsible for A workshop to follow up a 1978 course preparing a staged, long-term action plan for in Colombia on nursing research was held operatingand maintainingwatersupplysystems. at Washington in October and November * A course on street cleaning in Buenos Aires in November which is by now a well-organ- for nine nursing professionals from Brazil, ized yearly event that continues to attract par- Colombia, and Ecuador. Plans and pro- ticipants from several of the Region's countries. grams for future nursing research in the As in previous years, the 1979 discussions ranged participating countries were designed. far beyond street cleaning to cover solid waste management in general. PAHO's Pan American Center for Sanitary Education in Engineering and Engineering and Environmental Sciences (CEPIS) at Lima continued to fulfill one of Environmental Sciences the functions for which it was originally established, training. Of particular im- PAHO gave fewer of its national short portance was an August symposium on the courses conducted in cooperation with operation and maintenance of water supply local universities and engineering schools and wastewater systems, within the frame- in 1979 than in previous years. Instead, work of the $1.3 million water supply and increased attention was paid to regional sanitation project in Peru financed by that and subregional activities, most of which country and IDB. The 36 Latin American were oriented to the goals of the Interna- professionals attending recommended the tional Drinking Water Supply and Sanita- formulation of training programs for sys- tion Decade. This change in emphasis was tem operations, continuous training activi- designed to achieve three purposes: obtain ties, and the preparation of job-oriented an objective measurement of the impact training manuals. of training, restructure the personnel sys- The Caribbean Basin water management tem rationally, and focus on human re- project has now completed its fourth year. HUMAN RESOURCES AND RESEARCH 57

PAHO is the executing agency for this proj- Dental Education ect, which is jointly financed by the Cana- dian International Development Agency and 10 eastern Caribbean countries. It sprang from the realization that previous As part of its continuing effort to help training efforts in the Caribbean water dental schools in Latin America and the works industry had not kept pace with Caribbean improve their ability to provide professional manpower requirements and appropriate manpower for dental services, that the training of supporting subprofes- PAHO provided technical cooperation to sional personnel had too often been ne- institutions training dental personnel in glected. In addition to the publication of Brazil, Colombia, Dominican Republic, an English-language manual called Training Ecuador, and Mexico. Courses on the use of Trainers, which has gained wide accep- and preparation of audiovisual materials tance in and outside the Region, project were conducted at the Federal University staff are actively preparing training manu- of RioGrandedo Sul, Brazil, and in Panama. als which are job-oriented and break each PAHO assisted Bolivia, Panama, and Peru job down into specific tasks and step-by- in developing joint programs between step performance components. dental educational institutions and local The highlight of PAHO's activity in this authorities to extend dental services to field was a November symposium on en- additional sectors of the population. New vironmental manpower development at programs involving joint activities between Rio de Janeiro in collaboration with Brazil dental schools and local health authorities and the cooperation of the Brazilian Na- were established in Colombia, Paraguay, tional Housing Bank and Brazilian Associ- and Uruguay. A course on dental equip- ation of Sanitary Engineers. During the ment maintenance was conducted in Peru. week-long meeting a multidisciplinary Courses on dental equipment mainte- group of 40 professionals from hemispheric nance were also conducted in Barbados for countries discussed the three basic aspects personnel from Antigua, Dominica, Gre- of human resources planning, manpower nada, Montserrat, St. Kitts-Nevis, St. Lucia, education and training, and manpower Suriname, and Trinidad and Tobago, most utilization including personnel manage- of whom had PAHO fellowships. Dental ment. Representatives of the World Bank, auxiliary programs in the English-speaking IDB, the United Nations Children's Fund Caribbean, Cuba, and Suriname continued, (UNICEF), AIDIS, and the National Water and the first group of students graduated Council of England attended the sym- from the school in Trinidad and Tobago. posium, the proceedings of which will be The targets set by the Ten-Year Health Plan published in 1980 as a manual to be widely for the Americas (1971-80) for training distributed in the countries. Besides those auxiliary dental workers have been met in directly concerned with manpower plan- Cuba, Guyana, Jamaica, and. Suriname. ning, training, and management, it is ex- Dentists from the less developed countries pected that decision- and policy-makers, and territories of the Caribbean in addition sanitary and environmental engineers and to dentists from Barbados, Guyana, Ja- sanitary technicians at the executive and maica, Suriname, and Trinidad and Tobago operational level, and officials in environ- participated in a short course at PAHO's mental agencies and services will find the Caribbean Epidemiology Center (CAREC) at manual relevant to some of the problems Port-of-Spain, Trinidad, in May. Also in- confronting them. cluded were auxiliary personnel who were 58 REPORT OF THE DIRECTOR trained in simplified epidemiology for criteria forstandardizing curricula in Mem- dental health assessment. ber Countries' schools of veterinary medi- The joint PAHO-W.K. Kellogg Foundation cine. The three veterinary schools in Chile program on innovations in dental educa- held meetings to establish such criteria. tion and the provision of dental services Brazil's Ministries of Health and Educa- completed its third year. The project has tion and Culture appointed a standing involved 17 dental schools in Latin Amer- committee to organize and establish a ica, and during the three-year period of the minimal program for education in veteri- project approximately 15 institutions in nary medicine. This program has been drawn Brazil, Colombia, Costa Rica, Mexico, up and approved, and is ready to be imple- Panama, Paraguay, and Uruguay have re- mented. With PAHO's technical advice, ceived awards totaling more than $2 mil- several schools of veterinary medicine lion. During 1979 educational institutions introduced basic courses on veterinary in Colombia, Paraguay, and Uruguay public health in their curricula. Among joined the project. such schools-in addition to those that The third annual meeting of this program had taken that step in previous years- was held at Maracaibo and Coro, Vene- were those at Botucatú, Sáo Paulo, Salva- zuela, in November in collaboration with dor, Recife, and Londrina in Brazil. Venezuela's Health Ministry, Falcón and The third seminar on education in veter- Zulia State health authorities, and the inary medicine in the Americas was held at University of Zulia. A significant feature of the Faculty of Veterinary Medicine of the the meeting was a demonstration of the Southern University of Chile at Valdivia working relationship between the Uni- in November. Twenty-three deans or direc- versity of Zulia dental faculty and state tors of veterinary medicine schools in health authorities in establishing effective Latin America took part. Special attention dental programs for children and rural was given to criteria for standardizing populations. The meeting ended in Coro, curricula in veterinary schools in the Re- where existing barriers to more extensive gion and recommendations toward that care were identified and strategies were end, which PAHO will publish, were drawn developed to further improve the relation- up. The need to reactivate the general ship between the manpower-providing in- secretariat of the Latin American Federa- stitutions and those responsible for provid- tion of National Associations of Veterinary ing services. Medicine Schools created in 1972 at the second seminar at Belo Horizonte, Brazil, was recognized at the meeting. The offer of the National Autonomous University of Veterinary Education Mexico to house the federation's offices was accepted. The first meeting of a committee to During the past decade there has been choose veterinary medicine textbooks notable progress in veterinary education in was held in November at Washington. The Latin America: the number of schools or 10 professors from hemispheric veterinary faculties-now 91 -has doubled and the medicine schools taking part made rec- production and quality of veterinarians ommendations about the priorities PAHO have increased proportionately. should adhere to in establishing its text- In 1979 PAHO's collaboration focused book program in Latin American veterinary chiefly on stimulating the definition of medicine schools. HUMAN RESOURCES AND RESEARCH 59

Mental Health Education and on those topics on the occasion of the Cen- Training ter's designation. Fellowships were awarded to seven physicians and nurses from the English- A seminar on psychiatric epidemiology speaking Caribbean to participate in a was held at Lima in October. Two short course organized by the Caribbean Al- courses on the same subject were held at coholism Institute at Charlotte Amalie, Maceió, Brazil, and Caracas. Also held St. Thomas, U.S. Virgin Islands. at Lima was a workshop on mental health research methodology, which was attended by psychiatrists, psychologists, and general physicians. Training of Technicians and Short courses on basic child psychiatry Auxi l iaries were organized at Lima and Barquisimeto, Venezuela, with the assistance of local To extend health care coverage and health ministries and pediatric associa- primary care, PAHO intensified its col- tions. Training general physicians in the laboration with programs to train technical management of psychiatric emergencies, and auxiliary health workers. patient followup, and basic psychiatric Intermediate-level technical health treatment continued in Brazil and Peru as workers initially supported doctors in part of previous cooperation programs. hospitals when they first appeared more Strengthening education in psychiatry than 20 years ago and later extended their and mental health in nursing schools and activities to disease prevention, health continuing education and postbasic train- care, statistical operations, and health ing programs received special attention service administration. during 1979 in Colombia, Peru, and Vene- The reorganization of health services to zuela, countries with which PAHO coop- extend coverage has created the need for erated by sending consultants and tech- a new kind of intermediate-level technical nical materials. health worker trained to carry out innova- In the field of alcoholism and drug tions in health practices, perform institu- dependence control, PAHO collaborated tional work, and operate in marginal urban with Argentina, Ecuador, El Salvador, and rural areas. Honduras, and Peru in holding courses and In 1979 PAHO cooperated with the coun- seminars, two of which were international tries to obtain a better understanding of in nature. the problems in training such workers, the Advisory services were provided in nature of centers training them, and their designing and carrying out alcoholism working conditions, legal responsibilities, and drug dependence epidemiologic and occupational levels as well as to define studies in Ecuador, Honduras, and Peru. criteria and alternatives for carrying out An international seminar was held in the hemispheric, intercountry, and national last country on cocaine use and coca leaf programs. chewing. Because policies and rationalized sys- The Mexican Center for Mental Health tems for training such workers are lacking Research at Mexico City was designated in most countries, no registry of technical a WHO collaborative center for training and auxiliary training programs could be and research in alcoholism and drug depen- maintained nor could the production of dence, and PAHO helped organize a seminar such workers be standardized. Although 60 REPORT OF THE DIRECTOR

various kinds of auxiliary personnel entered Brazil. The health worker training program the health system, there was no basic pro- (PPREPS), a major effort of the Brazilian Health gramming and often the educational pro- Ministry in collaboration with the Ministry of Education and Culture and with support from grams did not meet the real needs of the PAHO since 1975, promoted health worker community and the educational process. training geared to service needs through gradual PAHO continued its collaboration ir integration of training and service. Its objectives training instructors and producing teach- are mass training of intermediate-level tech- ing materiais for the various auxiliary nical and auxiliary as well as basic health workers, the organization of health training and education programs. It was recognized, service areas as a coverage extension strategy, however, that it is necessary to concentrate and supporting the establishment of systems efforts on better programming in both for developing manpower integrated with the teaching and services in order to train the states' sectoral planning systems. The state necessary numbers and kinds of auxiliary health secretariats are the basis of the program. PAHO provided a special technical group (a workers and at the rate required for ex- coordinator and four consultants) who worked tending services. closely with state health secretariats and train- Cooperation was provided to the in- ing institutions. Similar projects are in opera- termediate-level medical training direction in different parts of the country with fi- torate in Cuba's Ministry of Public Health nancial support from the national Health Min- istry's Oswaldo Cruz Foundation. in the early operational stages of the na- When the project's activities as agreed on tional system of intermediate-level teach- between PAHO and Brazil terminated in De- ing started in 1976. cember 1978, Brazil extended the project. The PAHO participated in organizing a proj- technical group provided by PAHO was reorganized during 1979. ect in the Dominican Republic's first and Caribbean. In collaboration with the English- second health regions to train professional, speaking Caribbean countries and with UNDP technical, and auxiliary health workers funds, PAHO tried to expand the existing re- jointly. sources and establish a hemispheric system In Mexico, support was given to the to train auxiliary health personnel. The project, Ministry of Public Education and the which is based on a network of educational institutions in the Caribbean, is aimed at train- Ministry of Health and Welfare's plan- ing the personnel shown by previous man- ning subsecretariat in formulating a na- power studies to be needed. The first phase of tional project to train multiskilled inter- the project was completed in 1976, and the mediate-level technicians in social health. second will end in mid-1980. The project is also intended to help raise The collaboration of UNICEF in the project allowed the centers to improve their equipment health standards in medically underserved and hold seminars and meetings in which alter- areas of the country in coordination with native models for developing manpower and other higher and intermediate-level profes- health services were discussed. A contribution sionals. from Canada permitted fellowships to be of- Together with the secretariat of the fered for training candidates from the less developed Caribbean countries. Project HOPE Andean Pact and the manpower directorate collaborated with the project continuously, of Venezuela's Ministry of Health and So- particularly by providing consultant services for cial Welfare, activities were initiated to the tutor program. train intermediate-level health workers in During 1979 the project was carefully eval- the Andean countries. uated through interviews with more than 200 persons who had graduated from its courses The three largest programs in this field and supervisors in various Caribbean coun- were in Brazil, the English-speaking Car- tries. The evaluation indicated that the project ibbean, and Central America and Panama: should be extended for five more years because HUMAN RESOURCES AND RESEARCH 61

of the great need to train auxiliary and technical ties with universities, social security agencies, and workers for the Caribbean. other organizations participating in national develop- Because of the importance of the project's ment. fellowship component, PAHO established its * PASCCAP should support the countries' efforts to own decentralized system for the Caribbean, define new strategies for the next 10 years. which has led to greater flexibility and ef- The functions of the national units were not ficiency. Better implementation of this decen- discussed concretely, but the council agreed tralization based on the evaluation will start that the program will operate on the basis of in 1980. coordinated and integrated effort among the Central America and Panama. A program to countries with the support of the central nucleus. train community health workers for Central It supported a proposal submitted by PASCCAP's America and Panama (PASCCAP) started opera- coordinator and central group to integrate the tion at the end of March with the designation countries' network of institutional resources, of a PAHO-provided coordinator based at San subject to the approval of national authorities. José, Costa Rica. The program is the result of a proposal Costa Rica made at the 1976 meeting of PAHO's Directing Council in Mexico City to create a community health worker training Training in Supervision and center at San José and a subregional net- Consultation in Local Health Care work of specialized training units which the Central American countries and Panama could Units share on the principle of technical cooperation among developing countries. The Directing This project, which PAHO's Directing Council approved the proposal at its Mexico Council approved in 1977 and whose ob- City meeting (CD24.9). jectives are to train or reorient local health A first-year plan of operations was worked out unit supervisors and consultants in the and used to support the request for financing participating countries, entered the second that PAHO presented to UNDP. The program is to have a technical advisory council which will phase of its activities in 1979. In Central meet twice yearly consisting of the coordinators America it was brought under the control of the national training units in each of the sub- of PASCCAP. region's countries. The council's functions are The Central American countries began to advise on the adoption of working policies their local educational activities using and define areas and subprograms that meet the needs of the health ministries in the context the programs established during the proj- within which PASCCAP was conceived. ect's initial workshop at the Latin Amer- The council held its first meeting at San ican Center for Educational Technology in José in September. It agreed that: Health in Rio de Janeiro (CLATES-Rio) in * PASCCAP should not be merely a traditional October and November 1978. These pro- training center but also an instrument the health grams were modified to some extent, es- ministries can use to carry out detailed research on pecially as to operational plans and su- the operational and socioepidemiologic problems that impede the development of health plans. The pervision models which, in some countries, council agreed on proposed research areas, especially had not been defined or were being reor- operational ones, and on starting research activities ganized. by training national workers in research methods. * Training efforts should go hand in hand with In October a PASCCAP-organized meet- research activities. ing to coordinate the Central American * Activities should be carried out not only at the and Panamanian national groups was held headquarters but in all six of the subregion's countries. * The basis of all activities should be primary at Tegucigalpa. A workshop on supervi- care, preferably including community participation sion as an administrative and teaching since that is basic to all health care and coverage process and the program for 1980 were extension. * Although the national coordinating units will be prepared at this meeting. located in health ministries, they should have ciose A seminar was held at Alajuela, Costa 62 REPORT OF THE DIRECTOR

Rica, to train 53 supervisors from the Health cluded a conceptual framework and ac- Ministry's operations division and other tivities and instruments to allow super- components. The system of supervision to visory activities to be carried out. The be used in the country was worked out at educational activities for the year were the seminar. In addition, five seminars in reorganized accordingly. The Honduran which 180 persons took part were held for program trained around 300 persons work- regional personnel. In all, 233 Costa Rican ing in the country's various health regions officials were trained in the conceptual in supervision. and methodologic aspects of supervision An educational technology workshop during 1979. was held in Nicaragua for 30 health min- Educational activities began in El Sal- istry officials. A departmental-level work- vador with a seminar for 50 people. A basic shop-course was conducted on the meth- course on supervision was also given in odologic and administrative aspects of the central, paracentral, western, and supervision in which 40 persons partici- eastern regions of the country which 34 pated. Under the new Government, the persons attended. An additional course at program was reorganized at the beginning the end of the year for those supervisors of 1979. The program for departmental had 33 participants, and a short followup chiefs and their immediate subordinates course had 33. A total of 150 persons re- was put into effect at a six-day workshop ceived training during the year. in November at which activities for 1980 Several educational activities were were defined. carried out in Guatemala such as the first Three new countries-Bolivia, Brazil, workshop to evaluate educational material and Peru-joined the project. They or- on supervision in which 25 division and ganized their national coordinating groups departmental chiefs participated. Also and began investigating their needs for held were five workshops with 35 partici- training in supervision in the programs to pants each to train local health area teams extend health care coverage they have in supervision. A total of 200 Guatemalans been carrying out. The first meeting to received training in supervision. A study coordinate these groups was held at Lima was made of training needs, and support in October. The work carried out up to then was given to the development of a system was evaluated and the program of the of self-instruction in supervision as a new international workshop on training in super- educational technique. vision for those groups was outlined at the The program coordinating group in the meeting. Honduran Health Ministry's manpower In all, eight countries now belong to the division was broadened to include the program, and two more-the Dominican ministry's planning division. It prepared Republic and Panama-will start their a national supervision model which in- activities during 1980.

TECHNOLOGIC RESOURCES

The basic activity of PAHO's technologic within PAHO's various technical divisions. resources program was supporting work In addition, other manpower development HUMAN RESOURCES AND RESEARCH 63 programs were assisted, particularly those this, it conducted 25 service, teaching, carried out through project networks in research, and training activities in 1979. the countries. Direct service to users, interlibrary loans, This interdivisional methodologic sup- compilation of bibliographies, instruction, port was best seen in the joint work by the strengthening the Brazilian biomedical Expanded Program on Immunization (EPI) library network and support of the bio- in preparing, conducting, and evaluating medical libraries in other Latin American EPI educational activities as well as the countries, selective information dissemina- preparation of necessary self-instruction tion programs, and efforts to automate modules and audiovisual aids. These work routines were some of the most im- modules will soon be incorporated in portant day-to-day activities at RLM. PAHO's expanded program to distribute Interlibrary loans and local service. and make textbooks more widely used. During the year the library fulfilled 40,000 PAHO also began planning and develop- requests (15,000 from outside Brazil) for ing a basic epidemiology course stressing photocopies of journal articles and served surveillance for local health workers. 50,000 local users. Relevant instructional modules are being Bibliographic searches. RLM continued to prepared and will be tested in courses to process MEDLINE computerized biblio- be given in the countries during 1980. graphic search requests through terminals Following testing and final modifications, at four Brazilian medical schools (Sáo the modules will also be included in the Paulo, Rio de Janeiro, Salvador, and Belo expanded textbook program. PAHO Head- Horizonte) and the mails for the rest of quarters staff and epidemiologists from Brazil and other Latin American countries. Brazil, Mexico, Peru, and Uruguay took The number of MEDLINE searches made part in this work. during the year was 2,751, of which ap- In response to a 1978 recommendation proximately 800 were from other Latin by the committee on nutrition textbooks, American countries. preparation also began of a textbook on Bibliographic series. Number 5 in RLM's nutrition and public health with the par- bibliography series, Chagas' Disease, was ticipation of PAHO's Institute of Nutrition published to mark the centennial of the of Central America and Panama and na- birth of Carlos Chagas, who first charac- tional officials. terized the malady in 1907. Of the 1,000 copies printed, 600 were distributed at the International Chagas' Disease Congress at Rio de Janeiro in August at the request of its organizers. Regional Library of Medicine Teaching activity. RLM gave two six- and the Health Sciences week courses to upgrade the skills of biomedical librarians and updated the course's curriculum. Nineteen professionals-10 from Brazil and nine from The basic objective of the Regional Li- Spanish-speaking countries-attended. brary of Medicine and the Health Sciences A plan to create a nondegree post- (RLM) at Sáo Paulo is to provide informa- graduate medical librarianship course was tion and documentation rapidly to sup- presented through the Paulista School port the health programs of Brazil and the of Medicine to Brazil's senior personnel Region's other countries. To accomplish training directorate, which approved it 64 REPORT OF THE DIRECTOR for 1980. It will be the first course of this At its meeting in May, RLM's scientific type in Latin America and will meet a advisory committee approved the creation strongly felt need. of a working group to make a detailed Promotion of national centers. Expe- study of the Region's health information rience with the difficulties of developing needs and alternatives for meeting them efficiently operating national health infor- during the next decade. The working group mation centers led to a detailed analysis held the first of a series of meetings in of the various economic and technical Brasilia at the end of November to analyze factors that have so far constrained such Brazil's experience and RLM's activity centers. Based on this analysis, a strategy during the last 10 years. Representatives for developing a Latin American health of teaching and health care as well as information network was worked out and information and documentation institu- presented to and approved by RLM's scien- tions participated. tific advisory committee. It is realistic and The sequence of these meetings is im- inexpensive and, it is hoped, will be put portant in view of the various fields and into effect once the necessary funds for disciplines comprising the program. A the development of national centers be- meeting was to be held at Washington come available. Also in this area, RLM in January 1980 devoted to the technologic advised Ecuador and Nicaragua on de- aspects of information and its future in veloping health information centers to the Region's countries. Another will be meet their teaching, research, and medical held the following April at Mexico City care needs. on the health information needs of teach- Selective information dissemination. ing, research, and health care programs. This program was particularly stressed In May 1980, RLM's scientific advisory during the year since it provides users committee will draw up suggestions for selected information especially helpful to the Director of PAHO based on informa- them. As part of the LACRIP cancer infor- tion and recommendations from these mation program, specialized information meetings. was sent to 2,782 oncologists (1,855 in Information research. The need for Brazil and 927 in other Latin American detailed understanding of health informa- countries). More than 12,000 reprints and tion supply and demand, the lack of sys- almost 25,000 photocopies of journal tematic studies in this area, the imperative articles were sent out on request, more of providing information for meetings of than half to countries other than Brazil. the working group mentioned above, and Latin American Index Medicus. In ac- a desire to rationalize RLM's holdings in cordance with 1978 plans, Volume 1, No. 1, view of the growing cost of publications of the Latin American Index Medicus was led the library to undertake bibliographic published in 1979. Its appearance fulfilled research. a long-standing aspiration of the Region's This began with a study of the demands scientific community. By indexing Latin on RLM as a local library and as the center America's biomedical journals semian- of the Brazilian and Latin American inter- nually, the new reference work will make library loan network. Given the enormous that literature more widely known. Five number of publications now flooding the hundred copies of the first issue were dis- health sciences, the RLM study is contributed without charge among the Re- sidered the first step in analyzing the gion's medical libraries. Volume 1, No. 2, origins of demand in order to rationalize is to be published at the beginning of 1980. them. Working group on long-term programs. At the same time, professors at the HUMAN RESOURCES AND RESEARCH 65

Paulista School of Medicine were surveyed by the Sáo Paulo school's requirements. to determine which publications they Rather, it will produce concrete informa- thought are essential to their respective tion to fashion methods for determining desciplines. The findings from this survey what each medical school's basic collec- do not mean that RLM will recommend tion should be. RLM's role is to promote that the basic subscriptions of Latin Amer- and cooperate in this type of research and ica's medical school libraries be governed develop methods to carry it out.

EDUCATIONAL TECHNOLOGY

The Latin American Centers for Educa- edgucat et in May, concluded that tional Technology in Health (CLATES) at its program was satisfactory, and made Rio de Janeiro and Mexico City continued recommendations that will enable its supporting the development of such tech- activities to be increased. nology in the Region's countries in order to One of CLATES' most important activ- rationalize the teaching-learning process ities is giving instructors training in teach- by orienting it to the requirements of ing methods at the Center itself, where 20 coverage extension programs. The nursing courses were held for a total of 381 par- and dental educational technology pro- ticipants, including 95 from Latin Amer- grams and PASCCAP, through its educa- ican countries other than Brazil and 1 from tional development component, also par- Canada. This program's numerical figures ticipated actively in this field. show the importance of PAHO's collaboration in training Latin America's professors and instructors. Latin American Center for Outside Rio de Janeiro, CLATES' staff took part in the following activities: Educational Technology in * It supported the Faculty of Medical Sci- Health (CLATES-Rio) ences of the University of San Simón at Cocha- bamba, Bolivia, in designing a documentation CLATES-Rio made significant progress in center and audiovisual aids library. instructor training, research, data process- * Together with Brazil's National Social Security Institute, it developed training pro- ing, and audiovisual aids. Two new inter- grams for nursing auxiliaries in maternal and national professional positions were added child health, sterilization and surgical centers, to the staff of the Center, which is located an -- syLi ,-ubuiatory, primary, 'and at the Federal University of Rio de Janeiro4 emergency care. It also conducted didactic and has a total complement of 50 persons. training for university professors in Belem, Maceió, and Manaus, in conjunction with Members of the professional staff attended Brazil's education ministry. meetings and courses planned by Brazil, * It provided advice to the medical faculty Canada, Costa Rica, Dominican Republic, of the University of Sherbrooke in Quebec, Ecuador, Haiti, Paraguay, Peru, and Uru- Canada, on evaluating computerized training guay in addition to those held at PAHO programs. o It gave a course on teaching for 27 health Headquarters for hemispheric programs. professionals at the request of the Colombian CLATES' scientific advisory committee, Health Ministry. composed of specialists in health and * At the request of the Health Ministry of 66 REPORT OF THE DIRECTOR

the Dominican Republic, advice was provided financial goals for 1979 were determined. to its division of human resources on creating Three non-Mexican Latin American ex- a documentation, information, and audiovisual perts in health sciences education took aids center for the use of the ministry's health staff. part for the first time in order to provide * A seminar on teaching and care integration hemispheric representation. was given for 18 professors at the request of CLATES-Mexico carried out seven basic the Ecuadorian Association of Medical Facul- programs in 1979: manpower training, ties. As a continuation of this seminar, a course institutional improvement, educational. was given on teaching for 41 professors from Ecuador's medical, nursing, veterinary, and information, computerized administrative v dental schools. training, personnel functions research, * In collaboration with the Organization of learning research, and support services. American States, advice was given on develop- Two warrant special note: ing the new medical center at the University of Haiti. o The manpower training program com- * A health sciences teaching seminar was prised the following subprograms carried on held for 34 participants from Nicaragua's Health at CLATES-Mexico: master's degree in health Ministry. education planning and administration awarded * A seminar was conducted on curriculum by the National Autonomous University of planning at the Faculty of Medical Sciences Mexico; educational technologist training, of the University of Asunción in Paraguay for which comprises 27 activities in 10 modular 26 health sciences professors. units and 17 workshops with a capacity for * A teaching skills course was given at the 486 professors; administrative cadre training, request of Venezuela's School of Nutrition for which comprises six workshops with a capacity 18 instructors. for 74 persons; special didactic training, which comprises four workshops (two on teaching-care Generally speaking, CLATES-Rio also integration, one on basic sciences teaching, and supported the supervision training offered one on clinical sciences teaching); and internal by PASCCAP and PLADES and laid plans for development, which comprises the management joint activities with the Latin American of national fellowships abroad, seminars, work- Center for Perinatology and Human De- shops, and courses at the Center and the interaction of staff within the institution. velopment at Montevideo. Finally, CLATES- * The learning research program's purpose Rio's research activities included projects is to create a basis for a learning technology on diagnosis and communication, sociol- to improve students' study habits and thinking. ogy of communication, educational psy- A protocol, evaluation instruments, student chology, learning, visual images in instruc- population samples, and analytic tables to determine the learning algorithms predominat- tion, the use of games in learning, and ing among health sciences licentiate students teaching-care integration. were developed.

In the various countries CLATES-Mexico served, a course was given on modular teaching and didactic techniques at Cocha- Latin American Center for bamba, Bolivia, for personnel from that Educational Technology in Health country's Ministry of Health. Advice was (CLAT ES-Mexico) also given to the Catholic University at Santiago, Dominican Republic, on developing the university's audiovisual depart- The year began with the meeting of the ment. A seminar on educational method- CLATES-Mexico scientific advisory com- ologies and evaluation of clinical teaching mittee in which PAHO's Director par- was organized for professors at the Uni- ticipated and the Center's technical and versity of Panama's Faculty of Medicine. HUMAN RESOURCES AND RESEARCH 67

In addition to Mexican participants, five minican Republic, but they were not estab- professors from Ecuador, two from Vene- lished because the project's W.K. Kellogg zuela, and one each from Nicaragua Foundation financing was about to expire. and Uruguay attended CLATES-Mexico's A meeting was held in Chile to coordinate courses and short courses. The Center also the activities of the subcenters. supported dentistry teaching by produc- Advice was given to the National Nurs- ing or reproducing specific audiovisual ing Congress in Ecuador and the Brazilian materials. Nursing Education Association's seminar. PAHO also continued training professors for the future subcenters in Argentina, Dominican Republic, and Peru at CLATES- Educational Technology Rio. in Nursing The project was evaluated by the directors of the participating schools and This program, which is headquartered coordinating centers and PAHO and CLATES at CLATES-Rio and began with a W.K. Kel- staff. They concluded that CLATES partici- logg Foundation grant, is designed to ini- pation in planning local resources and tiate or strengthen the use of educational administrative and technical support were technology in Latin America's nursing factors in the project's success and that schools. Its activities are conducted through it should be extended to other countries. a network of 10 subcenters in various coun- They also found obstacles to the project's tries. PAHO cooperated in developing the greater development, including the in- 10 subcenters operating in Brazil (3), Chile, stability of the directing bodies of the Colombia (2), Costa Rica, Ecuador, Mexico, universities and in some cases insufficient and Venezuela, and added a new sub- support. center in Peru comprising the nursing Up to now the project's primary in- school at the Children's Hospital in Lima, fluence has been on formal instruction the Peruvian Health Ministry, and the in nursing schools. In the future it would J academic nursing program of the Uni- be desirable to emphasize learning from versity of San Marcos. Preliminary con- nursing students' experiences in the ser- tacts were initiated for the possible creation vices at different care levels within a true of subcenters in Argentina and the Do- framework of teaching-care integration.

FELLOWSHIPS

PAHO's fellowships operation reached 2). In addition to the above combined total an all-time high in 1979 in both the num- of 1,529 fellowships processed in 1979, 390 ber of awards (1,289) and the funds ob- fellows who had begun their studies in ligated ($4,400,865) (Table 1). earlier years continued them in 1979, thus Over and above the 1,289 awards granted giving PAHO administrative and technical in the Americas, arrangements for study supervision of a grand total of 1,919 fel- programs in this hemisphere were made for lows. This represented a 29 per cent in- 240 persons from other WHO regions (Table crease over 1978. 68 REPORT OF THE DIRECTOR

During 1979, 1,536 requests for fellow- from PAHO funds ($2,332,039), 444 from ships were received from countries in the WHO funds ($1,475,059), 220 from other Americas, of which 1,289 (84 per cent) funds ($593,767), and 31 from interregional were satisifed, as compared with 77 per funds. cent in 1978. Of these, 594 were granted Responding to the Member Govern-

Table 1. Fellowships awarded in the Americas, by country of origin and type of training, 1979.

Type of training

PAHO/WHO- organized Country of origin or -assisted Long-term Short-term of fellows group courses fellowships fellowships Total

Argentina 20 7 84 111 Bahamas 4 3 6 13 Barbados 3 14 13 30 Belize 1 6 1 8 Bolivia 11 2 11 24 Brazil 50 15 49 114 Canada 10 10 Chile 8 2 50 60 Colombia 12 3 43 58 Costa Rica 14 27 39 80 Cuba 9 18 13 40 Dominica 1 6 1 8 Dominican Republic 8 7 19 34 Ecuador 11 14 6 31 El Salvador 3 9 6 18 Guatemala 12 14 26 52 Guyana 6 3 16 25 Haiti 3 13 15 31 Honduras 7 34 22 63 Jamaica 8 14 31 53 Mexico 27 21 42 90 Nicaragua 9 5 14 Panama 3 20 11 34 Paraguay 2 3 8 13 Peru 12 1 31 44 St. Lucia 4 7 2 13 Suriname and the Netherlands Antilles 1 4 3 8 Trinidad and Tobago 9 5 2 16 United States of America 21 21 Uruguay 1 4 10 15 Venezuela 24 12 48 84 British territories 30 25 18 73 French territories 1 1

Total 304 322 663 1,289 Total 304 322 663 1,289 HUMAN RESOURCES AND RESEARCH 69

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Figure 5. Fellowships awarded in the short-term awards (19 per cent). The ef- Americas, by type of training, 1979. fects of inflation were seen mostly in long- term awards, the average cost of which rose from $8,905 to $9,448 in the United States and Canada and from $5,276 to $5,970 in Latin America. The average cost of short-term fellowships rose from $2,572 to $2,650 in the United States and Canada and from $1,859 to $1,927 in Latin America. 0 Consistent with PAHO's policy of placing fellows in areas whose environment, 61 language, and health conditions are similar (5%) to those of their own countries, most fel- 230 lows from Spanish-speaking countries were placed in Latin America (69 per cent), 15 per cent in the United States and Canada, (9%.) % (10%)(,0%S)- 9 per cent in the English-speaking Carib- Health administration bean, and 7 per cent in other regions of the world. Communicable diseases To bring fellowship operations closer to \ Medical education and related sciences fellows' home environments and enhance Sanitation the relevance of their programs, PAHO Maternal and child health decentralized its fellowship activities covering the English- and Dutch-speaking R Nursing Caribbean from Headquarters to Barbados W Other health services in late 1979. As part of the effort to train people from that area as close to their homes as possible, 142 of the 223 fellowships awarded to Caribbean nationals during the year were for study in the same geographic area and the remainder were for study in the United States, Canada, or ments' expressed needs, the distribution of other parts of the world. In 1980 all fellow- the 1,289 awards by field of study was as ships for study in the Caribbean will be follows: 24 per cent were in public health awarded and administered from the Car- administration, 25 per cent in other health ibbean Program Coordinator's office in E services, 18 per cent in communicable Barbados. diseases, 10 per cent in medical education Computer terminal operations were and related sciences, 9 per cent in maternal expanded to include on-line retrieval of and child health, 9 per cent in sanitation, updated information from the Directory of 5 per cent in nursing (Figure 5). Except for Training Programs in Latin America and maternal and child health awards, which the Caribbean. The final draft of the Di- rose from 63 to 119-an increase of 88 per rectory was completed for distribution in cent-there were no significant changes the Region. The design of a computerized from the previous year. continuing evaluation system was similarly The overall increase in the fellowships completed for implementation during the program was due mostly to the rise in first quarter of 1980. HUMAN RESOURCES AND RESEARCH 71

RESEARCH PROMOTION AND COORDINATION

PAHO's research coordination and pro- and information-gathering about their motion program has sought in recent years activities in the Region was improved. to stimulate Member Countries to adopt It is useful to stress that the task of in- research promotion policies since re- stitution strengthening carried out by the search is essential to achieving better Special Program for Research and Train- knowledge of a country's health problems, ing in Tropical Diseases with PAHO's col- showing the best way to solve them, and laboration has resulted in channeling major evaluating the impact of health care meas- resources into improving the level of re- ures. In this context, research has been search at centers in Argentina, Bolivia, considered an essential component of Brazil, Cuba, Peru, and Venezuela as well health service programs, and it is neces- as the support of 193 individual projects sary that every country, however modest in the Region. its resources, have the minimal facilities PAHO's participation in identifying, and manpower to carry out the studies its designating, and renewing agreements service programs require. Most of PAHO's with WHO's collaborative centers con- research activities are directed toward tinued. PAHO furthered these centers' train- strengthening research in and the research ing activities by helping to organize courses capabilities of Member Countries and on immunology, mycology, and enteric providing them the resources they do not bacteriology and supporting individual have individually through technical coop- investigators in training at them. eration with other developing countries. PAHO continued examining the impact PAHO's resources allowed it to continue of research on the health field, a study the programs started in 1977 and 1978. begun in late 1977. The data so far col- There was a greater contribution from lected were codified and preliminarily WHO's special programs, particularly that analyzed. This analysis enabled gaps in the for Research and Training in Tropical information to be identified and thus Diseases, whose expenditures in the Region necessary measures to be taken to round exceeded $6.5 million, and that for Human out the data in the nine countries-Co- Reproduction. The latter supported in- lombia, Costa Rica, Ecuador, El Salvador, vestigators and research centers in Ar- Guatemala, Honduras, Mexico, Panama, gentina, Brazil, Canada, Chile, Colombia, and Peru-where the study was begun. Cuba, Ecuador, El Salvador, Guatemala, Contacts were made to extend the study Mexico, Paraguay, Panama, Peru, and the to the remaining countries of Latin Amer- United States. PAHO participated in design- ica. At the same time, analysis was started ing new global programs such as research of the information on the social history in diarrheal diseases, health services, and of public-sector medicine and research nutrition on the basis of the Region's most institutes. pressing needs and the contributions it In intimate relationship with the study, can make to greater knowledge of the various activities were undertaken to problems related to these programs. Re- develop research units in health institu- lationships between PAHO and the leaders tions and ministries. Cooperation was of the global programs were better defined, extended to Cuba, Dominican Republic, -~~~~~~~~~~~~~~~~~~~~~~~~ 4

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Ecuador, Honduras, and Mexico in this tions in Latin America and the Caribbean, regard, and preparation of a manual on the PAHO awarded 37 grants totaling about subject was begun. $200,000 to investigators in 10 Latin Amer- Two meetings were held to discuss na- ican countries and three to investigators in tional health research policies in Argen- the United States who submitted proposals tina and Chile. That at Buenos Aires in for projects to be carried out in Chile and November brought together representa- Panama. The investigators who received tives of all centers in the country taking these grants work at centers in Argentina, part in health research and involved three Bolivia, Brazil, Chile, Colombia, Costa ministries and many universities. A doc- Rica, Cuba, Jamaica, Mexico, Peru, Trin- ument was prepared which, because of its idad and Tobago, and Uruguay. Since the importance, PAHO and the secretariat of program stressed grants furthering inves- health will jointly publish. It will be the tigator training, 65 per cent were awarded basic Argentine document presented to the for that purpose. subregional meeting on national health The six-year-old PAHO, University of research policies in Southern Cone coun- Bahia, and Harvard University cooperative tries to be held at Punta del Este, Uruguay, research project financed by the U.S. Na- in April 1980. A similar Chilean document tional Institutes of Health's Fogarty Center was drawn up at the meeting in Santiago. was renewed. The subject of the project is tropical diseases, chiefly schistosomiasis and Chagas' disease. The cooperative Research Grants Program arbovirus study being conducted by Cor- nell University at Ithaca, New York, and Continuing its policy of devoting most of Guatemala's health service, which is also its research funds to stimulating investiga- six years old, continued.

Advisory Committee on Medical Research

PAHO's 18-member Advisory Committee on Medical Research (ACMR) entered a period of great activity in which its annual meeting was complemented by the work of several subcommittees created to examine specific problems. The subcommittees that met during the year were those on research in diarrheal diseases; Research activities in such fields as malaria, leishmaniasis, vector biology and control, health service research; social indicators health services, and animal health lead to in health service research, and research the understanding and solution of countries' ethics, which was coordinated by two health problems as well as to the evaluation ACMR members who presented suggestions of measures to overcome them. (Photos: PAHO/ for modifying the composition and op- J. Moquillaza, Government Information Service of Barbados, Inter-American eration of PAHO's research ethics review Development Bank, and PAHOIM. Moro) committee. REPORT OF THE DIRECTOR

ACMR held its 18th meetingatWashington Member Governments and PAHO have in June. In addition to reviewing the rec- given high priority to the search for possible ommendations and programs of the various solutions. Two principal objectives have subcommittees, it heard a report on the governed PAHO's malaria research. One is Caribbean Epidemiology Center's research development of the most effective meth- activities and contributions to Caribbean ods for solving problems in areas with health programs, a followup to the ACMR's specific local conditions, and the other is recommendations on nutrition problems, promotion of research to deal with com- and a report on progress in the hospital in- mon hemispheric problems. fection control program. Another useful To attain the first objective, PAHO es- aspect of the program was the presenta- tablished a research project at Tapachula, tions by Brazil, Cuba, and Colombia on Chiapas, in 1979 in collaboration with their national experiences in research Mexico's national malaria eradication serv- training. Also discussed was a plan for ice whose principal task is to study vector managing research in WHO drawn up in resistance, principally of multiresistant mid-1978. anophelines and secondarily of mosquitoes ACMR's vice chairman delivered a report such as Aedes aegypti that vector other on current research activities to PAHO's diseases. Most of the work in the project Directing Council and represented the will be along the Pacific coast of southern Committee at the annual meeting of Mexico, but it will cooperate with similar the WHO Advisory Committee on Medi- studies in Central America. In collabora- cal Research in Geneva, where he reported tion with the communicable disease branch on research activities in the Western of Brazil's Health Ministry, PAHO estab- Hemisphere. lished another field research project at Belem to study the complex of vector biology and human migration in forest areas now under colonization and to test Fields of Research various control measures in order to find the most effective for controlling malaria Malaria in the Amazon Basin. To accomplish the second objective, By the end of 1979, malaria eradication PAHO has been promoting and taking active was achieved in areas with 112,257,000 part in the following research activities: inhabitants or 49.6 per cent of the popula- Malaria immunology studies. The Na- tion in originally malarious areas. In additional Institute of Health at Bogotá is pro- tion, malaria transmission was interrupted ducing and purifying Plasmodium fal- in areas with 58,132,000 inhabitants. ciparum merozoite antigens to prepare In the remaining areas with 55,976,000 immunizing agents for the Aotus trivirgatus inhabitants, however, transmission still griceimembra experimental monkey model. exists and the traditional insecticide and In collaboration with Colombia's Malaria antimalarial attack measures are deemed Service and Military Hospital, the Institute largely inadequate to achieve further prog- is now technically and administratively ress, especially where vectors are resis- able to conduct immunologic studies in tant to insecticides. There is no single rodent and nonhuman primate models. solution to the complex of problems that Immunization experiments will be started has interfered with normal progress in at the end of February 1980 to compare malaria eradication. In the last five years, different erythrocytic plasmodial antigens HUMAN RESOURCES AND RESEARCH 75 with various adjuvants. Studies will also be Haiti, Honduras, Mexico, Nicaragua, Pan- made to assess human immune response to ama, Paraguay, Peru, and Venezuela) naturally acquired malaria infections in were trained during the second half of severe or complicated cases, mainly pa- 1978 in field testing techniques for meas- tients at the Military Hospital. With the uring P. falciparum susceptibility to anti- collaboration of the Malaria Service, the malaria drugs in vitro. antigenic characterization of different Distribution of WHO standard kits for in strains of P. falciparum, its susceptibility to vitro testing of P. falciparum susceptibility antimalarial drugs, and immunologic to chloroquine was completed. Brazil and profiles of human populations will be Colombia were provided with WHO kits to investigated. This research project has perform mefloquine susceptibility tests been supported by the U.S. Agency for in vitro. Brazil, Colombia, and El Salvador International Development and assisted initiated their studies of the distribution of technically and administratively by PAHO resistant P. falciparum strains. It is expected and the University of New Mexico. that all 19 countries where P. falciparum Malaria chemotherapy. The health sec- has been reported will carry out the study. retariat of Pará, Brazil, and Barros Bar- The results may enable hemispheric map- reto Hospital in Belem, in collaboration ping of the distribution of P. falciparum with the Brazilian Health Ministry and susceptibility to chloroquine and even- PAHO and with technical and financial tually other antimalarials. support from WHO's Special Program for Following a P. falciparum in vitro cul- Research and Training in Tropical Dis- tivation course organized in Panama by eases, have started clinical trials with the the Gorgas Memorial Laboratory and PAHO new and promising antimalarial meflo- and sponsored by the WHO Special Pro- quine. The objective of this project is to gram, the in vitro cultivation technique is compare the agent's pharmacodynamics, now in use in Brazil, Colombia, Mexico, tolerance, and efficacy with the present and Panama. This will facilitate studies of standard combined regimen of sulfadoxine parasite sensitivity to antimalarial drugs, and pyrimethamine against chloroquine- antigenicity, and pathogenicity. resistant P. falciparum malaria in Pará. Evaluation of insecticides. Chlorphoxim In November, the steering committee of was tested in Guatemala and Nicaragua in the WHO Special Program's malaria chem- stages III to V against multiresistant Ano- otherapy scientific working group met at pheles albimanus. In localities where the Belem. Taking advantage of the presence vector is highly resistant to propoxur and of officials from the Brazilian Health fenitrothion, it also showed high resis- Ministry and PAHO malaria advisers, a tance to chlorphoxim. Stage III and IV malaria chemotherapy seminar was or- tests with pyrethroids, permethrin, and ganized to review recent advances and decamethrin were carried out in Guate- new approaches to the treatment of malar- mala and Nicaragua. In Guatemala, prom- ial infections. ising residual spraying results were ob- Hemispheric studies of P. falciparum tained with decamethrin at 0.05 mg/m2. susceptibility to antimalarials. With WHO Fenitrothion was used in household residual Special Program financial support, 35 spraying in Guatemala with good results officials from 19 countries (Argentina, in the north where the vector is suscep- Bolivia, Brazil, Colombia, Costa Rica, tible to propoxur, but results were poor in Dominican Republic, Ecuador, El Sal- the south where the vector is multiply vador, French Guiana, Guatemala, Guyana, resistant. Fenitrothion was also tried in 76 REPORT OF THE DIRECTOR

Haiti and Ecuador with satisfactory results, sília, which will be used to evaluate new but its high cost limited its wide applica- compounds and regimens in collaborating tion. In Haiti, a comparative field trial with leishmaniasis treatment centers in Central DDT, malathion, and fenitrothion was and South America. planned for 1980. Studies were initiated on diffuse cutaneous leishmaniasis (DCL), a rare manifestation which usually is completely refractory Leishmaniasis to standard treatment. In a PAHO-coordinated collaborative study by the Der- Specific treatment for American cuta- matologic Institute at Santo Domingo, neous/mucocutaneous leishmaniasis is Dominican Republic, and the U.S. National now limited to antimony compounds, which Institutes of Health, four DCL patients are not always effective and often have were brought to the United States for adverse side-effects. An additional dis- treatment and study, and valuable infor- advantage is that they must be given in mation regarding the relationship of the daily injections over 10 to 20 days, which patients' immunologic status to treatment makes them impractical because most response was obtained. patients live in remote and inaccessible The first cases of visceral leishmaniasis areas. The cost of hospitalization for such in Honduras were encountered in 1975. a time is likewise prohibitively expensive, The disease continues to cause high mor- and in many cases patients could not afford tality in small children there, but its dis- to leave their work or farms for an ex- tribution, prevalence, reservoirs, and tended period. For these reasons improved vectors remain unknown. A plan for a treatment for the tens of thousands of nationwide epidemiologic study of the existing cases is a priority research goal. disease was drawn up, and the WHO Special Last year saw the first organized and Program agreed to support it. structured effort to develop new drugs- In other PAHO investigations of leish- from initial screening to human trials- maniasis epidemiology, a seroepidemio- against this disease. Significant progress logic survey in Panama revealed an ap- was achieved with PAHO/WHO coordina- parent focus of leishmaniasis transmission tion, support, and participation. Allopuri- where no clinical infections could be found. nol, a compound which can be administered Completely subclinical leishmaniasis has orally and has already been cleared for never been encountered before and will be use in humans against other conditions, of great scientific interest if confirmed. was shown to have significant antileish- Such findings might be important to vac- manial activity and some of the mech- cine development. anisms of that activity were worked out in vitro. Testing in animal model systems is being coordinated, and a PAHO investi- Vector Biology and Control gator at the Gorgas Memorial Laboratory in Panama showed the compound to have The Research and Reference Center on a pronounced curative effect against ex- Vector Biology and Control at Maracay, perimental infections in monkeys. A clinical Venezuela, operated jointly by PAHO and trial protocol was drawn up by a group of Venezuela since 1976, has been conduct- experts attending a workshop sponsored ing studies with support from the Edna by the WHO Special Program for Research McConnell Clark Foundation on better and Training in Tropical Diseases in Bra- household vector control methods. Studies HUMAN RESOURCES AND RESEARCH 77 in both Maracay and Brazil indicate that on the socioeconomic effects of housing improvements in housing and the use of improvement. A review and planning meet- alternative construction materiais may ing was held in June in the city of Trujillo offer the best opportunities for effective to delineate the Center's future house control. modification research. Although the natural history and control Evaluation of insecticides and equip- of Chagas' disease continued to be the ment continued. A protocol was developed Center's most important function, studies for testing vector control equipment, and on rodent biology and control and the techniques were recommended for deter- natural history of dengue and jungle yellow mining the lethal dosage of insecticides fever were begun. against triatomes. Twenty-two insecticides The Center provided individual training were tested using this technique. The sus- for scientists from Bolivia, Brazil, Colom- ceptibility to dieldrin of Rhodnius pro- bia, Ecuador, and Paraguay and in May lixus, perhaps the principal reduviid bug hosted a two-week hemispheric course vectoring T. cruzi, was determined in 11 on the epidemiology of Chagas' disease for Venezuelan states and of Triatoma macu- medical officers from 10 countries. In lata, another reduviid, in eight states. addition, staff members took part in spe- The field study of R. prolixus' life table cialized courses at Mexico's school of continued in Cojedes State, Venezuela. A public health and Venezuela's malariology comparison is being made of two different school and visited six countries for brief ecologic situations using experimental consultations. houses. Different construction materials A group from the University of llinois are used in the houses to compare vector and the State of Florida's Vero Beach population growth rates. Laboratory undertook a study of the iso- Epidemiologic studies were expanded enzymes and cytogenetics of anopheline to include an evaluation of different para- mosquitoes and conducted training at sitology diagnostic techniques, including Maracay for professionals from three artificial xenodiagnosis. An epidemiologic countries. study of Chagas' disease was completed Chagas' disease. Progress continued in in an area under malaria control and a the Center's study of the impact of house serologic survey was made in Barinas State. modification on the transmission of Try- A cooperative study among cardiopath- panosoma cruzi, the parasite causing Cha- ology investigators in Brazil, Venezuela, gas' disease. The five-year study is sup- and the Center was begun. ported in part by a grant of more than The strain bank of T. cruzi from humans $400,000 from the Edna McConnell Clark with and without cardiopathology and Foundation which began in January. Ex- from sylvatic and domestic vectors and perimental houses were used to test the reservoirs has grown to more than 50 iso- vector and weather resistance of construc- lates. A study to compare five different tion materials, and epidemiologic evalu- techniques of T. cruzi preservation began. ation of a study area in Trujillo State where The Center and the Central University of Venezuela has provided new and modified Venezuela began a joint investigation of houses continued. The Pan American Cen- the biochemical and physiologic properties ter for Research and Training in Leprosy of the strains. Another study with Brazilian and Tropical Diseases at Caracas coopera- investigators has shown that Venezuelan ted in the clinical and pathologic aspects T. cruzi strains have a predominance of of the study and the University of Carabobo zymodeme 1. (A zymodeme is a distinct 78 REPORT OF THE DIRECTOR combination of specific isoenzyme pat- Health Services Research terns.) Additional studies are progressing to interpret the absence of zymodeme 2. In recent years PAHO has given high The Center has provided 62 strains from priority to operations research on primary El Salvador, Panama, Peru, and Venezuela care, community participation, appropriate for this study. technology, and technical cooperation Other vectors and reservoirs. A laboratory among developing countries in order to was created at the Maracay center to achieve the goals of coverage extension monitor warfarin resistance in commensal and health for all by the year 2000. rodents and screen new rodenticides for In agreement with the strategies formu- use against commensal rodents and res- lated at the International Conference on ervoirs. Two workshops were held, one Primary Health Care at Alma-Ata, U.S.S.R., in Brazil and the other in Venezuela, in 1978, PAHO conducted activities of to study the taxonomic problems of Si- major significance in this field during 1979. muliidae of medical importance in South ACMR devoted a special session at its an- America. The Center continued to class- nual meeting to analyzing and discussing ify and study arthropods and mammals various topics related to health service of importance in the natural history of research. To deal with specific aspects of jungle yellow fever, leishmaniasis, and health service research in greater detail onchocerciasis. in the future, the committee reorganized A workshop was given in Colombia to and broadened two of its working groups. interest scientists in biologic control meth- The first deals with conceptual aspects ods. Participants were taught to collect and definition of health service research and identify pathogens and predators of fields, and the second with the develop- mosquitoes and principles of their labora- ment of social indicators. tory breeding. An interdivisional consulting group To obtain more knowledge and better was created within PAHO to act as a chan- resources for A. aegypti control and eradi- nel for communication and interaction cation, PAHO, with the cooperation of between ACMR and PAHO and to promote the Colombian and Venezuelan Ministries and support health service research ac- of Health, conducted research on biology, tivities within the countries and PAHO ecology, and control methods including itself. urban aerial insecticiding, which is valu- As a result of the work of these groups, able in emergencies. Colombian health health service research activities as set authorities and PAHO were considering forth in the document, "General Bases an operational study of juvenile hormones for a Regional Health Services Research to modify the growth of A. aegypti larvae. Program," were formulated for the Re- PAHO and Mexico established a joint gion. "General Bases" notes the nature, project at Tapachula, near Mexico's south- orientation, purposes, and objectives of ern Pacific coast, to investigate insecticide such research in the context of hemispheric resistance and new vector control meth- health care goals and proposes an action ods. Since malaria is recrudescent in the plan comprising promotion, institutional Tapachula area and farther south in Central strengthening and development, and spe- America's Pacific coastal areas, the proj- cific project support activities. ect's emphasis will be on anopheline The plan stresses the adoption of na- resistance, but it will give some attention tional health service research policies, to vectors of other diseases such as A. formulates strategies for supporting the aegypti. countries' efforts to develop national HUMAN RESOURCES AND RESEARCH 79 capacity, and proposes mechanisms to formulating proposals for locating new encourage the inclusion of research com- facilities. In this field PAHO collaborated ponents in coverage extension projects. directly with Ecuador in formulating a Among the strategies proposed for car- model of a health service geographic ac- rying out these activities are the for- cessibility model, and with Guatemala and mation of multidisciplinary working groups Guyana in drawing up hospital service on specific facets of health service re- projects for submission to IDB. search; stimulating and supporting the During the year technical cooperation training of national investigators in vari- was provided to the Health Ministry of ous research fields, particularly research Barbados in identifying problem areas managers; disseminating the results of for operations research in its national studies carried out in the countries; and drug supply plan and new health service promoting and supporting the exchange of system. national experiences and research coop- In Colombia, PAHO collaborated with eration among countries. These activities the Health Ministry and the Xaverian Uni- are to be part of a 1980-83 hemispheric versity at Bogotá in reviewing the univer- health service research program which sity's master degree curriculum in health will begin in October 1980. administration with emphasis on opera- PAHO also took part in several national tions research. and intercountry meetings to promote In Nicaragua it helped simplify the model this type of research as a basic mechanism for evaluating the maternal and child health for improving service planning, organiza- care service's referral system. tion, and management. In the health care administration area, Another health service research activity it should be noted that Latin America and was a hemispheric seminar on operations the Caribbean have 13,127 hospitals with research at Washington in November. 920,360 beds and an unknown number of Participating in the seminar were Latin health centers and similar facilities. This in- American operations researchers who have frastructure represents a major investment been working in the field for several years, and a considerable operational expendi- health ministry executives interested in ture. To obtain adequate knowledge of this promoting such research, and U.S. health institutional universe, PAHO began a hemi- service researchers. spheric investigation of the production, The seminar offered opportunities for cost, and productivity of hospital serv- exchanging experiences in this field of ices starting with an exploratory study investigation in the United States and in Ecuador. This investigation will enable Latin America and for identifying prob- scattered information to be compiled, the lem areas for research. As its final product, hospital situation in various countries to the seminar group made specific recom- be described, and methods for comparative mendations about the conceptual frame- analysis to be formulated. work and conduct of operations research, including methodologies, training, basic information, dissemination of research Zoonoses and Animal Health results, required financial resources, and relations between investigators and politi- PAHO continued carrying out and sup- cal leaders. porting a large number of investigations Of special importance was PAHO's de- in zoonoses and animal health in 1979. velopment of concepts and models of serv- Most of the research dealt with diag- ice geographic accessibility as a basis for nostic and reference techniques, improve- 80 REPORT OF THE DIRECTOR

ments in vaccine production and control, in man, design of a model for eradicating epidemiology including information sys- brucellosis on large cattle ranches, and tems, program evaluation, animal losses improvement and evaluation of brucellosis due to foot-and-mouth disease, and re- diagnostic tests. Other projects were an search collaboration with the South Amer- investigation of the advantages of using ican countries to develop systems for B. melitensis type 1 vaccine against epi- conserving and reproducing primates used didymitis in sheep, a study of brucellosis in biomedical research. Most of the studies in wild animals in Argentina, an investiga- were conducted by the Pan American tion of brucellosis phase R antibodies in Zoonoses Center (CEPANZO) and the Pan reference sera and persons exposed to American Foot-and-Mouth Disease Center risk, studies of sheep infected by B. abortus (PANAFTOSA), which have scientific advi- type 2 and of meat by B. suis, and a search sory committees that review their research for B. canis in selected parts of Argentina. programs every two years. Hydatidosis. Among CEPANZO's con- Bovine tuberculosis. CEPANZO continuing projects dealing with this disease tinued developing a model for eradicating were a study of various drugs for treating bovine tuberculosis on large cattle ranches Enchinococcus granulosus in dogs, deter- and studies to determine the relationships mination of the ovicidal and scolicidal between viral and experimental tuber- properties of several chemical agents, an culosis infections. Final reports were com- investigation of the therapeutic properties pleted on the tuberculin response of cattle of several drugs in treating hydatid cysts, to foot-and-mouth disease and rabies vac- and improving knowledge of the various cines, Mycobacterium africanum virulence aspects of the life cycle of E. granulosus. in cattle, M. tuberculosis resistance to In collaboration with Uruguay's Hydatido- streptomycin, and the caudal fold and sis Control Commission, CEPANZO also con- neck tests with bovine PPD in naturally tinued its investigation to determine the infected cattle. economic losses caused by hydatidosis in Investigations continued on the im- sheep, and in cooperation with the Pasteur munoelectrophoresis of PPD tuberculin Institute of Lille, France, its project to antigens, the potency and specificity of develop immunity against E. granulosus in PPD tuberculins for use in cattle and hu- dogs using purified antigen. mans, the identification of mycobacteria Leptospirosis. Among CEPANZO's lepto- in cerebrospinal and pleural fluids by cul- spirosis research projects in 1979 were the ture in synthetic media, the real etiology development of a simplified method for of macroscopic lesions in cattle that can identifying leptospiras, evaluation of the be confused with tuberculosis, and tuber- external capsule antigen of the Fort Bragg culin testing in naturally infected cattie leptospira serotype as a hamster vaccine, in Uruguay. a study of the prevalence of leptospiral Brucellosis. Among the research projects antibodies in apparently healthy rural CEPANZO conducted in 1979 were a study inhabitants in Argentina and other hemi- of factors affecting the preservation of spheric countries, and determination of lyophilized brucellosis vaccines, tests of leptospirosis prevalence in dogs in Sáo the potency of Brucella abortus strain 19 Paulo and Buenos Aires and in wild ani- vaccines produced in Latin America, eval- mals in Argentina. uations of the use of the B. melitensis type Rabies. CEPANZO completed reports 1 vaccine to immunize cattle, a comparison on its investigations of abbreviated rabies of serologic tests for diagnosing brucellosis vaccination for exposed persons and the HUMAN RESOURCES AND RESEARCH 81 duration of immunity in dogs conferred paigns; development of attenuated live by tissue culture rabies vaccine. A pre- virus FMD vaccines; studies to improve liminary report on rabies virus typing by FMD control methods through better un- immunofiltration was also completed, derstanding of the disease's epidemiology and a report on the duration of immunity and transmission; determination of the to rabies in cattle conferred by suckling risks of FMD spread through milk and milk mouse-brain (SMB) vaccine was near com- by-products; and adaptability of FMD labo- pletion. Studies to determine the stability ratory techniques to national control cam- of SMB vaccines at different temperatures paign needs in South America. and to establish a method for detecting Among PANAFTOSA's most important antibiotics in such vaccines also continued. investigations were those of oil-adjuvant In association with the Johns Hopkins vaccines producing longer immunity than Hospital in Baltimore, Maryland, U.S.A., the ones now in general use in South Amer- and the Faculty of Pharmacy and Biochem- ica. A large step forward in controlling and istry of the University of Buenos Aires, eradicating FMD will be taken when oil- PAHO is carrying on a project to identify adjuvant vaccines against that disease the basic protein in mouse myelin in SMB come into general use. vaccines. Food microbiology. CEPANZO finished Within the framework of vampire bat- drawing up microbiologic criteria for transmitted rabies studies and in collabora- cheese inspection in Argentina, and its tion with Argentina's animal health service final reports on the development of mi- and the Argentine Association of Zebu crobiologic criteria for controlling curds Cattle Breeders, PAHO continued investigat- produced in Argentina and on the survey ing the etiology of the so-called "disease of of pathogenic enterobacteria in wild ani- Aguapey," which causes high mortality in mals were drafted. Its studies to determine cattle in Latin America's subtropical areas, the presence of "stressed" Staphylococcus and major advances were made. aureus in processed food samples and to Vesicular diseases. Investigations PANAF- evaluate the efficacy of various culturing TOSA carried out in 1979 were the iden- media in isolating S. aureus in dehydrated tification and classification of agents milk continued. causing vesicular diseases in animals and Primate production. PAHO collaborated provision of relevant reference biologicals; with Brazil, Colombia, and Peru in their selection of foot-and-mouth disease (FMD) programs to conserve and reproduce non- virus strains well related immunologically human primates. These programs are to field strains for later use in vaccine pro- largely financed through a grant from the duction; determination of the optimal U.S. National Institutes of Health. conditions for producing, purifying, con- Brazil began building monkey shelters centrating, and stabilizing FMD vaccines; at its Belem primate center at the end of development of cattle and hog FMD vac- December. During the year its national cines of high potency, long duration and primatology program was conducted in immunity, and without undesirable side-ef- states other than Pará, of which Belem is fects; development of methods to control the capital, because of the special interest FMD vaccines using methods compatible in it of the Federal Universities of Brasilia, with the infrastructures existing in South Natal, and Fortaleza. America; determination of the advantages Colombia's NationalInstitute of Health and disadvantages of large-scale use of oil- will be responsible for that country's adjuvant vaccines in FMD control cam- primate center when it is established at 82 REPORT OF THE DIRECTOR

Armero, a town of 18,000 in the Upper munity-squirrel monkeys (Saimiri sci- Magdalena River valley four hours from ureus), moustached tamarins (Saguinus Bogotá by car where the Institute now mystax), pygmy marmosets (Cebuella pyg- has a snake venom production station. maea), and owl monkeys. The squirrel During the center's first phase, shelters monkeys reproduce quite well, and the will be built for the owl monkeys (Aotus tamarins and marmosets have begun to re- trivirgatus) used in malaria research. Field produce. At the end of the year the center studies have already been carried out to began to breed red-chested tamarins determine the best places for obtaining (Saguinus labiatus), a primate widely used animals for the center. in human hepatitis research. The primate conservation and reproduc- A registry is maintained at the center tion center at Iquitos, Peru, which is ad- of the various studies in progress on pri- ministered by San Marcos University, is mate reproduction, nutrition, diseases, funded by PAHO and the U.S. National and management techniques. The center Institutes of Health. During 1979 it finished also conducts field investigations of popu- installing most of its laboratory and clinical lation dynamics and various aspects of equipment and personnel facilities. The primate management and conservation station now has four large shelters and a on Amazon River islands and in protected few small pens to house more than 600 ecology areas along the Pacaya and Samiria primates belonging to species in great Rivers in Peru. demand by the world's scientific com-

[ 1 E] Chapter 4

DISEASE CONTROL

During 1979 the emphasis in PAHO's program is to obtain more information communicable disease control program about their magnitude and nature. In addi- was on its Expanded Program on Immuni- tion, an attempt is being made through zation (EPI) against diphtheria, whooping intercountry projects to demonstrate the cough, tetanus, measles, poliomyelitis, and efficacy of various preventive and thera- tuberculosis. EPI's long-term goals are peutic measures in order to apply them basically two: to reduce the morbidity and more widely and regularly through estab- mortality caused by these diseases, and to lished health services. And because they help Member Countries incorporate inte- are a growing problem, accidents-partic- grated national vaccination programs in ularly traffic accidents-are being given their regular health services and pro- ever greater attention. duce and control the quality of necessary In the field of mental health, PAHO vaccines. cooperated with the governments in iden- Other diseases that received major at- tifying high-risk groups in order to tention were gastroenteritis and diarrheal strengthen mental health services and de- diseases in general, tuberculosis and acute velop programs to control alcoholism and respiratory diseases, leprosy, sexually drug dependence. Most of PAHO's dental transmitted diseases, hepatitis, blindness, disease prevention activities were carried and hospital infections. out in programs to fluoridate water and Malaria control continued to be the salt. Through its epidemiologic sur- most important program in the area of veillance program, PAHO cooperated with parasitic diseases and vector control. PAHO Member Governments in organizing na- continued cooperating with the countries tional information systems on the occur- in carrying out epidemiologic studies in rence and distribution of diseases and problem areas, applying the best possible immunity levels in the population, particu- strategies in each area, conducting clinical larly for those diseases included in the In- trials of new drugs, and training workers ternational Health Regulations and EPI. in the latest research and operational Attention was also given to networks of techniques. national diagnostic and biological produc- Noncommunicable diseases are becom- tion and control laboratories, to food pro- ing ever more important in most of the tection, and to drug regulation to make ba- Region's countries. Since there are few sic drugs of good quality and reasonable data available about their prevalence, cost available for primary health care pro- however, one of the objectives of PAHO's grams. regional noncommunicable disease control One event and one program of particular

83 84 REPORT OF THE DIRECTOR

s,!0

J; 1

A Increasingly more importance is being given to ,k prevention of blindness through the inclusion 1: of general eye care in primary health L' programs. (Photo: PAHO¡Costa Rica) DISEASE CONTROL 85

importance in 1979 merit special attention. achievement yet in the annals of public The event was WHO's certification of the health. worldwide eradication of smallpox, one of As a disease, smallpox had a long and mankind's oldest scourges. The program eventful history. It may have existed in was WHO's Special Program for Research classical times-some paleopathologists and Training in Tropical Diseases, which in believe the mummy of Rameses V, an essence seeks to cause the disappearance Egyptian pharaoh who lived in the 12th of six communicable diseases, other than century B.C., has facial scars like those that those being attacked through EPI, which re- smallpox causes-and it was first accu- main of vast importance to the world's rately described in A.D. 910 by the Persian public health. physician Abu Bakr Muhammad ibn Smallpox eradication. On 26 October Zakariya al-Razi. By the Middle Ages 1979, WHO certified the eradication of smallpox was firmly lodged in Europe, naturally occurring smallpox in the Horn of whence it spread to the New World Africa, its last stronghold, and two months through Spanish conquistadors, African later a technical commission recommended slaves, and French and English colonists. that WHO certify the world eradication of Lacking any acquired immunity to the the disease, which it is likely to do during disease, tens of thousands of American the World Health Assembly in May 1980. natives who camrne in contact with the Euro- Though the events of October and pean and African arrivals died quickly. But December received relatively scant notice their deaths were merely a tiny fraction of from a world beset by other problems, they the grand toll, for it can safely be said that signaled the global demise of smallpox as a smallpox killed hundreds of millions of disease-perhaps the most significant people around the world during the two or three millennia of its known existence. Smallpox was unlike many other communicable diseases in that its causative virus has no known reservoirs other than man, can only infect through personal transmission, is short-lived outside the human body, and its infection confers lasting immunity on those who survive it. These peculiarities made smallpox more susceptible than other contagious diseases to attack and, ultimately, eradication. Edward Jenner, an English country doc- tor, took the first step toward eradication in 1796 when he inoculated material from a dairymaid's cowpox lesion into the arm of an eight-year-old boy who later proved im- Disease control activities include campaigns mune to challenge by smallpox virus. Jen- aimed against parasitic and viral infections ner called his procedure "vaccination," a such as malaria and yellow fever. (Photos: word he derived from the Latin for "cow" PAHO/J. Moquillaza) since that animal was the source of his primitive vaccine, and accurately pre- dicted that "the annihilation of smallpox must be the final result of this practice." 86 REPORT OF THE DIRECTOR

A century and a half passed during found no further cases and then declared which methods of producing, preserving, the Western Hemisphere rid of the disease. and administering smallpox vaccine slowly When WHO certified smallpox eradica- improved. By 1950 they were advanced tion in the Americas in 1973, only five enough to make the first attempt at countries continued to report the disease. eradicating the disease in a major portion Smallpox succumbed in Nepal and Paki- of the world-the Americas. It fell to PAHO stan the following year and in India and to coordinate the effort. Within a decade Bangladesh in 1975. Only Ethiopia re- smallpox had effectively disappeared from mained, and it reported its last case in all the hemisphere's countries except August 1977. For several weeks WHO Argentina, Bolivia, Brazil, Colombia, and thought smallpox might at last have been Ecuador. conquered, but in September it began to Heartened by the results PAHO's pro- receive reports of a cluster of cases in gram showed were possible, the World Somalia which had been imported from Health Assembly voted in 1966 to begin a Ethiopia's harsh Ogaden desert region. global eradication campaign the following Emergency measures were set in train. year. In January 1967, when WHO started As a result, the world's last known case of its world campaign, smallpox was con- naturally occurring smallpox was diag- sidered endemic in 33 countries (among nosed on 26 October 1977 in a 23-year-old which Brazil was by then the only one in hospital cook at Merka, Somalia, who the Americas) and subject to sporadic im- subsequently recovered. portation in 11 others. Though the young cook was the final Several administrative and technologic naturally occurring case of the disease, advances helped bring WHO's campaign to smallpox has claimed at least one life since a successful close over the decade that then: in September 1978 a 40-year-old followed. One was the development of bet- medical photographer died after acciden- ter case reporting procedures; another was tal exposure to the virus in a British the tactic of containment vaccination to in- research laboratory. terrupt person-to-person virus transmission That tragedy underscores the world's by vaccinating all contacts of newly need for continuing watchfulness against discovered cases. Still others were the ma- any recurrences of the once-and still- jor improvement in vaccine preservation dread disease. WHO's Executive Board has resulting from Iyophilization, or freeze- resolved that 200 million doses of smallpox drying, and the introduction of a small, vaccine should be stored in refrigerated two-pronged needle costing only a penny depots in two countries, together with which made house-to-house vaccination stocks of bifurcated needies, to guard practicable in even the remotest areas. against any unforeseen outbreaks, and that The carefully organized campaign WHO the number of laboratories holding the and its Member Countries conducted virus for research purposes should be began to produce results. The last case in reduced to a handful. In the Western the Americas occurred in April 1971 when Hemisphere, only two laboratories stocked an 18-year-old man hospitalized in Rio de the virus at the end of 1979, the U.S. Center Janeiro for another illness contracted for Disease Control (CDC) at Atlanta, smallpox from a fellow patient and sur- Georgia, and the U.S. Army Medical vived. Following its established pro- Research Institute for Infectious Diseases cedures, WHO waited for two years to at Frederick, Maryland. The latter is to make sure that Brazil's health authorities transfer its stock to CDC in 1980. DISEASE CONTROL 87

WHO's Special Program. The WHO Spe- is its executing agency, and because of that cial Program for Research and Training in PAHO is responsible for coordinating its ac- Tropical Diseases was of great importance tivities in the Western Hemisphere. WHO to PAHO's communicable disease preven- Headquarters in Geneva oversees the pro- tion and control activities during the year. gram's global organization, which largely The program, or TDR as it is often called consists of scientific working groups (some for convenience, was initiated in 1974 in of the six diseases have one, others more response to a World Health Assembly than one) whose work is reviewed by a resolution (WHA27.52) expressing concern WHO scientific technical and advisory about lagging global efforts to control the committee, which in turn reports to a joint major tropical diseases and the need to coordinating board of representatives from develop better control methods. By 1976, the three cosponsoring organizations. when plans for the program had been com- As its name implies, the program sponsors pleted and the World Health Assembly ap- and coordinates studies related to its six proved its progress to date (WHA29.71), it target diseases and also promotes the train- was focusing on the six diseases with which ing of investigators for such research at it still deals-malaria, schistosomiasis, fil- designated centers. The program is partly ariasis (including onchocerciasis), try- financed from the regular budgets of WHO, panosomiasis (which in the Americas UNDP, and the World Bank, but most of its means Chagas' disease), leprosy, and leish- operating funds come from special contri- maniasis. butions by national governments and foun- Originally sponsored by WHO and the dations. Between 1975 and June 1979 it in- United Nations Development Program vested $6,547,000 in 195 research projects- (UNDP), the program gained a new cospon- mostly dealing with leprosy, malaria, and sor in 1978, the World Bank. WHO was and Chagas' disease- in the Americas.

COMMUNICABLE DISEASES

Expanded Program through immunization. The resolutions call on Immunization on Member Countries to expand their immunization programs and formulate spe- The Expanded Program on Immuniza- cific plans for developing or maintaining tion (EPI) in the Americas fulfilis resolutions immunization activities through their adopted by the World Health Assembly primary health care systems, particularly (WHA30.54) and the PAHO Directing Council maternal and child health services. (CD25.27) in 1977. These resolutions note EPI is concentrating on six diseases ini- that, of the more than 80 million children tially-diphtheria, pertussis (whooping born in the developing world each year, cough), tetanus, measles, poliomyelitis, about five million die of the common con- and tuberculosis-to reduce the morbidity tagious childhood diseases, largely because and mortality they cause to a level at less than 10 per cent of them are protected which they cease to be of public health 88 REPORT OF THE DIRECTOR

significance. The program's goal is to pro- The last EPI workshop in 1979, in St. Kitts vide immunization services to all children in December, was attended by 35 nurses at risk of the six diseases by 1990. from eight Caribbean countries. The Immunization activities have lagged workshop was notable in that it marked in developing countries because present PAHO's first attempt to integrate EPI train- knowledge has been inadequately applied. ing activities into broader continuing Although gaps do exist in some technical health education. It was the second session and operational areas and research will be of a two-week continuing nursing educa- necessary to answer some questions, the tion workshop which was part of a program most important concern is training national financed by UNFPA. The costs of preparing staffs in already available knowledge and the English-language curriculum for the skills to bring about improved program workshop were borne by PAHO's textbook planning and expanded operations. Pro- program, which will also underwrite the gram evaluation will also assume increased training materials used in future EPI importance as operations increase. It will workshops. provide planning guidelines and identify The basic workshop structure is divided areas requiring additional operations re- into five modules (EPI diseases, vaccines, search. the cold chain, programming, and evalua- The EPI plan of action which PAHO tion), which are further divided into units. developed for the Americas in 1978 has The text is designed for self-instruction, five major components: training; operation after which workshop participants meet in of a revolving fund to buy vaccines and small groups to discuss their answers and related supplies to meet country needs; exchange ideas and experiences. Par- development and testing of cold-chain ticipants are asked to answer a series of equipment suitable for country operations; written questions before and after the support of operations and applied re- workshop in order to measure their general search, and dissemination of information. knowledge about the development and Training. A hemispheric workshop on im- operation of an immunization program. munization programs, planning, adminis- The same test is given to participants im- tration, and evaluation was held at Lima mediately after the workshop, and scores in January for participants from all the from it are compared with those from the South American countries. This workshop earlier test. Results from the St. Kitts completed the first phase of EPI training ac- workshop showed that the average propor- tivities which started with the hemispheric tion of correct answers rose from 36 per EPI workshop held at San José, Costa Rica, cent before to 72 per cent after the in July 1978. The two workshops were workshop. After training materials have mainly for senior public health officials been adapted to each country's require- responsible for national immunization ac- ments, national workshop participants will tivities. organize local workshops. The second phase of training activities, EPI Revolving Fund. The revolving fund aimed at middle-level supervisory person- for vaccine purchases was authorized by nel charged with day-to-day EPI manage- the Pan American Sanitary Conference in ment, started in February. In all, seven 1978 with an initial capitalization of $1 countries (Bolivia, Colombia, Ecuador, million. All Member Countries are eligible Guatemala, Honduras, Peru, and St. Kitts- to participate in the fund provided they Nevis) held national EPI workshops during meet its five operating criteria. These the year, with a total of 388 participants. criteria include the appointment of a na- DISEASE CONTROL 89 tional program manager with authority to cedures are being developed to reduce the develop and carry out the program and the billing time for 1980 orders. establishment of adequate vaccine cold Of approximately 200 shipments in 1979, storage facilities: Twenty-three countries only two were lost en route to their con- and territories decided to participate in the signees. Both lost shipments were destined fund in 1979. to small islands in the Caribbean where PAHO awarded annual contracts for 1979 communications are difficult. To avoid in December 1978 based on sealed bids similar problems in the future, it has been submitted by suppliers worldwide that suggested that the total annual vaccine re- meet WHO vaccine production standards. quirements of the small Caribbean islands The final 1979 tally shows that more than 40 be sent in a single shipment during the first million doses of vaccine costing over $2.1 quarter of 1980. This possibility is now be- million were bought through the fund during discussed with the appropriate health ing its first year of operation. This ministries. represents three million more doses than Most vaccines ordered through the fund early 1979 estimates forecast would be have been delivered on or ahead of needed, but the fund was able to meet all schedule. In some cases vaccine deliveries vaccine requirements despite difficulties in were expedited to meet emergencies or maintaining adequate capitalization. special requests. For example, Honduras The Netherlands' donation of $500,000 asked that its first quarter 1980 require- and the September decision by the Direct- ment be shipped in the last quarter of 1979. ing Council to transfer $800,000 from the This rapid handling of urgent orders was holding account to the revolving fund were aided by PAHO's contractual relationship of major importance in enabling the latter with the various suppliers. fund to meet the 1979 vaccine re- The countries participating in the fund quirements of all participating national EPI and their 1979 vaccine requirements are programs. Estimates show that vaccine re- shown in Table 3. quirements will increase by 17 per cent, or Twenty-seven countries and territories 6.8 million doses, in 1980, which means chose to buy their 1980 EPI vaccines that at 1979 prices an additional $1.7 through the revolving fund and submitted million will be needed for efficient opera- their orders by the end of 1979. They will tions in 1980. More importantly, the in- total 42 million doses at a cost of $3.1 creased demands on the revolving fund million, including freight. will require that participating countries PAHO was able to extend the contracts reimburse promptly to ensure that suffi- for EPI vaccines until July 1980. cient monies are available for each Development and testing of cold-chain quarter. equipment. The cold chain is a vital link in Overall, participating countries' repay- any immunization program. The best ments to the fund were satisfactory in organized field program, reaching a high 1979, but there were some delinquencies percentage of the target population, is all and certain countries accumulated arrears for naught if the vaccine is not potent for of as much as $200,000. Another problem want of proper refrigeration somewhere causing delays in the flow of monies back between manufacturer and consumer. to the fund was the excessive time-an The cold chain refers not only to equip- average of five weeks-between shipment ment but also to the people and pro- of vaccine orders to countries and final cedures that move and monitor the vac- billing by vaccine suppliers. New pro- cine. If a refrigerator runs out of kerosene 90 REPORT OF THE DIRECTOR

Table 3. Number and cost of vaccine orders submitted by the countries and territories participating in the EPI Revolving Fund, 1979. (In thousands of doses and US dollars)

Country DPT Polio Measles BCG Tetanus Total

Anguilla 2.0 2.0 .6 Antigua 12.0 6.0 0.2 10.0 Argentina 1,000.0 3,500.0 1,000.0 2,000.0 625.0 Bahamas 34.2 26.3 8.0 7.0 5.3 Barbados 18.0 20.0 8.0 10.0 12.4 Belize 6.0 14.0 60.0 Bolivia 200.0 565.0 40.0 Cayman Islands 2.4 1.2 1.6 1.0 1.6 Colombia 4,500.0 5,648.0 2,200.0 500.0 Costa Rica 100.0 20.0 Dominica 3.0 5.0 Dominican Republic 600.0 800.0 400.0 a 200.0 300.0 Ecuador 1,500.0 500:0 300.0 Cuyana 264.2 233.76 10.0 17.15 Haiti b b b 225.o 22.15b 325.0o 232. 5b Honduras 375.0c 50.0 50.0 180.0 Nicaragua 267.o b 998.Oa 11 3.0 b 107.0b 87.0 b Panama 200.0 1,175.0 180.0 a 60.0 190.0 Paraguay 1,479.05 5.0b Peru 1,100.0 2,000.0 840.0a 1,750.0 St. Vincent 58.22 39.66 19.4 22.4 22.2 Turks and Caicos Islands 0.8 0.4 0.3 0.4 0.4 Uruguay 600.0 Total doses 8,861.82 18,744.37 5,413.5 5,486.45 1,569.15 Cost of EPI vaccines (US$) 317.0 317.5 1,269.4 206.0 32.4 2,142.3

3% Administrative charge plus shipping cost 371.2 Subtotal 2,513.5

Cost of other EPI-related vaccines 243.0 Total cost in 1979 2,756.5

aRequirement partially procured with non-EPI funds. bTotal requirement procured with non-EPI funds. c First quarter 1980 requirement procured during fourth quarter 1979.

and the rise in temperature is not detected In the field of cold-chain equipment, because of a worker's error, the resulting PAHO has encouraged research and devel- loss of vaccine is just as serious as if the opment of new types of refrigerators and equipment had failed. The techniques for vaccine carriers for the Region's immuniza- training, stimulating, and supervising work- tion programs. Research is proceeding on ers at all levels of the cold chain are just as the prototype of a 30-liter refrigerator for important as choosing the right type of health center use which will be produced equipment. in a number of the countries. A portable DISEASE CONTROL 91 vaccine carrier developed in conjunction ment at Cali to establish such a regional with PAHO which is capable of maintaining center. This project aims to ensure that all vaccines for up to 48 hours after they are hemispheric EPI programs, and particularly taken out of the refrigerator is already be- Colombia's, use cold-chain equipment that ing used in several countries. meets their common needs. The agreement WHO and the United Nations Children's establishes the following objectives: (1) Fund (UNICEF) are now preparing specifica- cooperation between the Center and tions for converting domestic, top-opening EPI/Colombia; (2) constant attention to the chest freezers into vaccine refrigerators needs of other EPI programs in the Region; designed to operate where electricity is er- (3) careful evaluation of the possibilities ratic. Two advantages of the chest freezer for Latin American manufacture of EPI are that it requires less energy to keep the equipment; (4) rigorous laboratory testing vaccine between 4° and 8°C because heat of equipment before it is mass produced; extraction is more efficient than in a refrig- and (5) constant evaluation of equipment erator and that, by opening at the top widely used in the field. rather than at the sides, it saves energy Support of operations and applied re- since less cold air escapes each time the search. The EPI demonstration areas that door is opened. When completed, the were established by the Ecuadorian Minis- specifications will be sent, along with a let- try of Health in 1978 provided experience ter explaining the importance of the pro- for drawing up program strategies and ex- ject, to selected chest freezer manufac- panding immunization activities to other turers. parts of that country. The experience gained WHO and UNICEF have also designed an showed that expansion of immunization ice lining for use with the converted chest services should be started in existing health freezer. The ice lining, consisting of water- services, then be extended to their out- filled plastic tubes which fit around the reach units, and finally be made to cover sides of the chest, is frozen when the chest populations that cannot be reached from is connected to an electrical supply. The present facilities. device can then maintain temperatures of The operations research to determine 4 ° to 8°C without further energy input. It the seroconversion to measles vaccination was found that test freezers fitted with this in children 6 to 12 months old in which ice lining required only 8 hours of electric- Brazil, Chile, Costa Rica, and Ecuador are ity a day to maintain adequate storage collaboratively participating completed temperatures. the field work phase, and laboratory work WHO and UNICEF periodically prepared started at the end of the year. Results from cold-chain product information sheets giv- this investigation are expected in the first ing specifications and prices of equipment quarter of 1980, and the information ob- available on the world market and distrib- tained, together with data from the uted them to all countries in the Region. epidemiologic surveillance of measles, will In the fall the Directing Council asked allow the optimal age for measles vaccina- the Director (CD26.21) to study the possibil- tion in the Region to be determined. ity of establishing a hemispheric focal Dissemination of information. New pro- point for cold-chain equipment develop- cedures and techniques are constantly ment and testing. To fulfill this request, being developed in the various disciplines PAHO signed an agreement with the Colom- involved in the EPI. As yet there are no bian Ministry of Health and the Center for universal answers to many problems en- Multidisciplinary Studies in Rural Develop- countered by field staff. Solutions applied 92 REPORT OF THE DIRECTOR

to cold-chain or community participation tion of sputa from patients with respiratory problems in some countries may not be symptoms. applicable elsewhere, for example. (3) Neutralizing discovered sources of infection through ambulatory chemotherapy. To create a flow of information in the Region about such aspects of EPI, PAHO These activities should be permanent started a bimonthly publication called EPI and integrated in general health services. Newsletter in May. Four issues covering all Advances in scientific knowledge have pro- program areas from disease epidemiology duced certain important changes in the to practical, day-to-day problems in run- strategy for controlling the problem: (1) in- ning an immunization campaign were creased stress on finding and treating widely distributed throughout the Region. sources of infection (pulmonary tuberculosis cases that are positive on direct microscopic examination of sputum samples); (2) the feasibility of brief (six- to nine- Tuberculosis month) treatment in countries that have sufficient resources to use new and more expensive drugs; and (3) the major role that Tuberculosis is still an important prob- BCG vaccine plays in preventing childhood lem in the United States and Canada and tuberculosis and its slight value as a way to one of vast significance for the countries of interrupt the chain of transmission. Latin America. It occupies a significant During 1979 the third hemispheric tuber- place among the causes of death in many culosis seminar, at Washington, was de- of the Region's countries, but in most there voted to chemotherapy, and the feasibility has been a tendency for it to decline by and usefulness of short-term treatment about 5 per cent annually. Although the were analyzed. number of tuberculosis cases is also Epidemiologic and operational studies decreasing gradually, advances in health continued in Argentina and Colombia, and care coverage resulting from the pro- new studies were started in Brazil and Mex- gressive integration of diagnosis and treat- ico. PAHO cooperated with national pro- ment activities lead to increased reporting grams by sending consultants to 10 coun- in some countries. In others, such as the tries and awarding fellowships to nationals United States, population migration from of 10 countries for training. International high prevalence areas tends to stabilize the courses on epidemiology and control were annual number of new cases. held in Argentina, Chile, and Cuba, and a The general policy on control and the hemispheric course on tuberculosis bac- goals to be achieved during the 1970s were teriology was held at the Pan American approved by the Ministers of Health at Zoonoses Center in Argentina. PAHO also their III Special Meeting at Santiago, Chile, collaborated in national courses, and in 1972. Control is based on the application technical information continued to be of several (rather than merely one) ac- disseminated in Spanish through the tivities: quarterly Boletín de Tuberculosis. In two seminars held at the Caribbean (1) Increasing biologic resistance to the infec- Epidemiology Center (CAREC) at Port-of- tion in the population than 15 less years old by Spain, Trinidad and Tobago, one on achieving and maintaining high BCG immunization coverage. epidemiology and the other specifically on (2) Localizing the main sources of infection in tuberculosis, the problem in the Caribbean the population through bacteriologic examina- countries was reviewed, and a project was DISEASE CONTROL 93

begun to improve the control program in During 1979 the Spanish translation of the area. the quarterly newsletter of the Medical Several countries have followed the Mycology Society of the Americas was model advocated by WHO and PAHO of published and distributed, and research broadening their tuberculosis control pro- was continued in Magdalena Department, grams to include other acute and chronic Colombia, on a combined mycosis, tuber- respiratory infections. culosis, and leprosy control program. The respiratory disease control project, with emphasis on pneumonias, in response to WHO's sixth working program and a 1979 World Health Assembly resolution Influenza (WHA32.33), will increase in importance beginning in 1980 because of the high mortality from acute respiratory infections and The world suffered relatively little in- especially pneumonias-which is partic- fluenza during the 1978-79 season. A ularly grave in children-and the gradual remarkable feature of the disease's decrease in tuberculosis. During 1979 epidemiologic picture since 1977 has been PAHO organized a seminar at Caracas on the simultaneous circulation of two legionnaire's disease in collaboration with distinct influenza A virus subtypes. An in- the U.S. Center for Disease Control for fluenza A strain isolated in Brazil in 1978, representatives from nine countries. The A/Brazil/11/78, was the most common A preparation of national epidemiologic, virus circulating in the Western Hemi- clinical, and operational studies on the sphere during 1979. Influenza B viruses problem of acute respiratory infections also circulated, producing moderate out- was stimulated. breaks in some countries. In June and July, the Influenza Center of Argentina identified a new variant of influenza B which was designated B/Buenos Mycoses Aires/37/79. It showed a major degree of antigenic drift from B/Hong Kong/72, which In 1976 the Twenty-ninth World Health is the strain used in present influenza vac- Assembly reviewed the world mycoses cines. situation and called attention to their im- The National Influenza Center Network portance, recommending that PAHO col- in Latin America once again showed effi- laborate with the countries in training, ciency and sensitivity in detecting new epidemiologic evaluation, and research. strains of influenza virus. Fungal infections constitute a high proportion of human pathology in both temperate and tropical parts of the Region. Cutaneous mycoses are extremely com- Diarrheal Diseases mon, while deep or systemic mycotic infections, which are usually contracted through spore inhalation, are more serious Diarrheal diseases are the leading cause and often confused with other pulmonary of childhood morbidity and infant mortal- diseases. Laboratory diagnostic capacity is ity in the Americas. Field data from several *very limited in almost all the Region's countries indicate that the typical child countries. below 5 years of age experiences an 94 REPORT OF THE DIRECTOR average of four to eight diarrheal episodes ing diarrheal disease case fatality rates to annually. In some countries up to 45 per less than 1 per cent should be the overall cent of all hospital consultations during medium-term goal of national ORT pro- the months of highest diarrhea prevalence grams. are due to childhood diarrhea, and case As of March 1980, 27 of the Region's fatality rates as high as 30 per cent have countries and territories will have taken been recorded. part in subregional ORT workshops. Of Given the problem's magnitude and these, seven have organized and executed complexity, PAHO has developed a multi- followup national workshops, and five faceted attack on the problem of child- more are planned for 1980. hood diarrheal diseases. Though program Applied research in diarrheal diseases in- strategies call for efforts to improve epi- tensified in the Region during 1979. With demiologic surveillance, environmental PAHO support, six clinical studies on the sanitation, personal hygiene, health educa- use of simple salt/sugar solutions, sub- tion, and maternal and child nutrition, the stituting sucrose for glucose, and the use of central strategy is the provision of oral antiemetics were conducted in four rehydration therapy (ORT) to treat child- Member Countries during the year. Plans hood diarrheas early. were made to carry out five more investiga- A now classic innovation in "appropriate tions during 1980. These and earlier studies technology," ORT was initially developed have greatly increased hemispheric re- in the early 1960s in response to massive, search expertise. Two subregional enteric recurrent cholera epidemics in southern disease research and training centers, Asia. Careful biochemical and clinical Children's Hospital at San José, Costa Rica, research since then has led to the formula- and Bustamante Hospital for Children at tion of a single glucose-electrolyte solution Kingston, Jamaica, will be designated in (ORS) that is effective for all types of diar- 1980 and partially supported by PAHO. rhea and can be safely and easily administered by health workers and mothers in the home. Eleven Member Countries are now pro- Rotaviruses ducing and three more are planning to produce ORS by 1981. In collaboration with UNICEF, PAHO is now cooperating in Rotaviruses were first detected in strengthening ORS quality control pro- humans in Australia in 1973 and shortly cedures in national production facilities. afterwards in Canada, England, and the To ensure that the medium-term goal of United States. The viruses derive their regional self-reliance in ORS production is name from the Latin word rota, a wheel, achieved, PAHO will continue to provide which they resemble under the electron technical cooperation to interested coun- microscope. Surveys have been made in tries in all aspects of ORS production. Argentina, Costa Rica, Guatemala, Mexico, In response to PAHO's efforts, 15 Trinidad and Tobago, and Venezuela Member Countries have initiated national which produced results similar to those in ORT programs. Ten countries are now con- other developing countries. Rotavirus is ducting ORS operational trials, and seven detected in approximately half of child- have planned health manpower training hood diarrhea cases, sometimes with programs to integrate ORT activities with seasonal variations. Data from a study in a their primary health care systems. Reduc- Guatemalan community indicated that DISEASE CONTROL 95 rotavirus accounted for 10 to 20 per centof the International Leprosy Association (ILA), all diarrhea there. either directly to the countries or through Because of the growing importance of funds provided to PAHO. rotaviruses and other viral diarrheas, a The general policy for controlling the subsection of the WHO scientific working disease was laid down at the III Special group on epidemiology and etiology met at Meeting of Ministers of Health at Santiago, Washington in March. It produced a report Chile, in 1972, which urged governments to on rotaviruses and other viral diarrheas and "reduce the incidence and prevalence of recommended further epidemiologic, clini- leprosy, with a view to the consequent de- cal, and basic research. The major objec- crease in disabilities resulting therefrom" tive is to develop a vaccine for humans through: similar to that now being developed and (1) Reformulation and implementation of used to control rotavirus diarrhea in control programs to include improvements in animals. diagnostic services and patient treatment and Two PAHO centers have pioneered in adequate training of those carrying out planned rotavirus research. The Institute of Nutri- activities. tion of Central America and Panama (2) Integration of control activities in general health services in order to increase coverage and (INCAP), in Guatemala, in conjunction with reduce costs. the U.S. National Institutes of Health (NIH), (3) Development of applied research pro- has carried out extensive surveys in grams in order to achieve greater efficiency and Guatemalan villages, while CAREC, in con- efficacy in control methods. The hemispheric junction with the University of Toronto, center that would be the focus of such research would also provide advanced training. has carried out a two-year study in Guyana, St. Vincent, and Trinidad and Tobago. These directives have been repeated in PAHO entered into a contract with NIH in resolutions by World Health Assemblies 1979 to produce rotavirus reagents for use (WHA29.70 and WHA32.39) and PAHO's in the enzyme-linked immunosorbent Directing Council (CD26.37). assay. These reagents will greatly facilitate The recommendations in the Fifth laboratory and field studies as recom- Report of the WHO Expert Committee on mended by the WHO scientific working Leprosy were adopted. The chief recom- group's subsection in March. mendation was for the use of bactericidal agents and treatment regimens employing two or more drugs for infectious cases. Following is a summary of some of the Leprosy main activities carried out in various of the Region's countries in 1979: Argentina. The national leprosy control pro- Leprosy continues to be a major public gram was reorganized and its headquarters health problem in Latin America and the transferred to Resistencia, Chaco Territory, Caribbean. As a reflection of the countries' which has resulted in better supervision of operations. Eighteen mobile teams diagnosed renewed interest in controlling this en- 875 new cases between July 1978 and June 1979. demic disease, 20,000 new cases were PAHO provided the country a short-term adviser diagnosed in the Region in 1979, 60 per and drugs and equipment contributed by the cent of them in Brazil. Order of Malta and the British Leprosy Relief The increase in activities against leprosy Association through ILA. Bolivia. The control programs in Chuquisaca was due in great part to financial support and Santa Cruz Departments continued their ac- provided by the relief societies composing tivities with financial aid provided through ILA 96 REPORT OF THE DIRECTOR

from the German Leprosy Relief Association and Institute, a private organization. PAHO assisted the Damien Foundation in Belgium. PAHO in planning activities for the period 1979-83, in helped formulate a control program in El Beni setting up a computerized registration system, and Pando Departments in the Amazonian part and in drawing up a combined tuberculosis and of the country through a short-term consultant leprosy control program in one of the country's and Japanese Shipbuilding Industry Foundation health areas with the help of ILA and the Damien (JSIF) drugs and funds for hiring field personnel. Foundation of Belgium. Brazil. The leprosy control programs in the Mexico. PAHO assisted Mexico with funds pro- various states continued to extend their vided by JSIF to increase supervision of the coverage along with the health services and to leprosy control activities being carried out by conduct extensive training programs for health the general public health services. workers. PAHO collaborated with advice on stan- Paraguay. The national leprosy control pro- dardizing nursing services in leprosy control ac- gram, partially financed through ILA by the Ger- tivities, fellowships for doctors and nurses for man Leprosy Relief Association and JSIF, training in prevention and treatment of dis- continued expanding its patient detection and abilities, and formulation of a leprosy control treatment activities. PAHO provided aid by sup- plan for the Amazonian and central regions to plying motorcycles for auxiliary field workers. be supported by the British Leprosy Relief The WHO Special Program for Research and Association. In the area of research, the Training in Tropical Diseases aided the leprosy facilities of the Oswaldo Cruz Foundation in Rio department in maintaining an armadillo colony de Janeiro were remodeled for conducting drug and research on the experimental transmission resistance tests, and leprosy was experimentally of leprosy. transmitted to armadillos (Dasypus novemcinc- Uruguay. A control program for the country's tus) at the Lauro Souza Lima Sanitarium at endemic departments was drawn up with PAHO Baurú, Sáo Paulo State. PAHO also channeled cooperation, and it should be put into operation JSIF funds to Pará State for hiring leprosy field during 1980 with aid from the Order of Malta workers in areas not effectively covered by the through ILA. regular health services. Venezuela. During 1979 new case-finding Caribbean. PAHO provided advice to the methods based on intensive epidemiologic Caribbean's less developed countries and ter- investigation around index cases, supervised pa- ritories for an evaluation of their leprosy situa- tient treatment with combinations of specific tion and reformulation of control programs. Two drugs, and the development of an extensive meetings were held at CAREC to discuss leprosy program to prevent disabilities through simple research problems in the area and establish a techniques were created in several sectional control policy. These activities received support services. from ILA, JSIF, Emaus Swiss, Guyana, Trinidad and Tobago, and WHO's Special Program for During 1979 the Pan American Center for Research and Training in Tropical Diseases Research and Training in Leprosy and Central America and Panama. PAHO and the Tropical Diseases at Caracas, a Venezuelan Damien Foundation of Belgium helped organize institute which has been associated with a Central American leprosy control workshop at which the disease's endemicity in the isthmus PAHO since 1976: (1) enlarged its armadillo was analyzed and recommendations were drawn house and built special facilities for up for formulating and carrying out adequate reproducing this animal in captivity; (2) control measures. purified Mycobacterium leprae from in- Colombia. PAHO and Colombia signed an fected armadillo tissues; (3) prepared M. agreement for a combined tuberculosis and leprosy control program in Norte de Santander Ieprae protein antigen derivatives; (4) con- Department and Arauca Commissary which ducted field studies of leprosy infection; (5) started with training general health service undertook preliminary clinical trials to workers. Similar programs made progress in San- determine the efficacy of leprosy vaccina- tander and Tolima Departments. Both projects tion; and (6) prepared protocols for testing were partially financed by JSIF and the German Leprosy Relief Association. a leprosy prevention vaccine. Dominican Republic. Leprosy control in this The Center conducted two international country is the responsibility of the Dermatologic public health dermatology courses at- DISEASE CONTROL 97 tended by nine fellowship holders from six and avarietyof neonatal disorders including countries and a course on the prevention ophthalmia, pneumonitis, and otitis media. and treatment of leprosy-caused disabil- Within the Americas, penicillinase-pro- ities for 11 nurses and physicians in Brazil. ducing Neisseria gonorrheae have so far been It also collaborated in providing advanced reported only from Argentina, Canada, training to several Latin American in- Mexico, and the United States. Importation vestigators. PAHO assisted the Center by of these strains elsewhere in the Region is supplying equipment and material as well anticipated. as advice on microbiology and biochem- With the exception of Cuba's syphilis istry. program, no country in Latin America has a well-organized STD control effort. Such programs as exist are found in large cities. In the English-speaking Caribbean, services Sexually Transmitted Diseases are breaking down under the stress of heavy caseloads and declining budgets. PAHO's approach to STD control is It is estimated that one Latin American through primary health care. Its basic adult in 50 is infected with at least one sex- allocation for venereal disease control is ually transmitted disease (STD) each year. slightly less than $10,000 a year, but this is Reported morbidity rates for gonorrhea in regularly augmented by other program and Latin American countries reflect only a country monies which may bring the total fraction of the actual numbers infected. In to $100,000. This is less than $0.20 per 1,000 some countries it is estimated that only population per year. Plans are underway one case in 10 is reported. Reported for the preparation and distribution at pri- syphilis in the Region is in the range. of mary health care facilities of health educa- 150,000 cases annually. This is estimated to tion materials encouraging early atten- be about one-quarter of the real total. dance at clinics, contact tracing, and the Reporting from the Caribbean indicates adoption of appropriate diagnostic tech- that syphilis and gonorrhea are widely nology in primary health care facilities. prevalent there. In one of the largest Carib- bean islands, with a population of 2 million, both diseases are described as epidemic. Hepatitis In the worldwide rise in gonorrhea rates during the last 20 years, pelvic inflammatory disease (PID) has become common. Viral hepatitis is highly prevalent in Latin In one Caribbean hospital, 8 per cent of the America where, in general, environmental women admitted for gynecologic problems and sanitary conditions are such as to en- were found to have PID. hance the disease's spread. It is estimated Nongonococcal urethritis (NGU) is in- that between 1.2 and 1.5 million cases of creasingly recognized. In some areas of type A hepatitis and nearly 500,000 cases Canada and the United States it is more of type B hepatitis occur yearly. At least common in men than gonorrhea. Many one-quarter of those occurs in persons over cases are due to Chlamydia trachomatis, 19 years of age. which can be found in the cervix of half of In a study of blood donors in 13 Latin the sex partners of men with NGU. C. tracho- American countries, the prevalence of anti- matis is now recognized as a cause of PID hepatitis A virus antibodies ranged be- 98 REPORT OF THE DIRECTOR

tween 82 and 99 per cent. Hepatitis B sur- gional plague reference laboratory at Piura, face antigen (HBsAg) detected by radio- Peru, which besides diagnosis offers train- immunoassay was found in 0.6 to 4.1 per ing to laboratory workers from neighboring cent. The predominant subtype of hepatitis Bolivia, Brazil, and Ecuador where plague B surface antigen is adw. is endemic. There are 18 national virus laboratories PAHO continued to support a large oral in the Americas outside the United States typhoid vaccine trial underway in Chile and Canada which provide some kind of and assisted in training qualified national routine testing for HBsAg. A survey of these investigators in the laboratory diagnosis of laboratories in 1979 showed that seven typhoid. Guidelines were developed to were routinely performing counter im- standardize the clinical diagnosis and re- munoelectrophoresis, five the reverse pas- porting of typhoid and will be incorporated sive hemagglutination test, four the radio- in future national typhoid control pro- immunoassay, and one the enzyme-linked grams. immunosorbent assay. Availability and cost PAHO continued to provide essential of reagents are major constraints in using technical assistance and supplies for men- the more elaborate tests. ingitis outbreak investigations, including A major resource for the hepatitis pro- meningococcal meningitis vaccine. gram in the Americas is Peru's primate cen- Other activities included assistance in ter at Iquitos. It is a potential source of mar- translating and disseminating a manual on moset liver reagents for hepatitis laborato- waterborne gastroenteritis outbreaks, a ries throughout Central and South America. training program in the clinical diagnosis and management of botulism to be undertaken in Argentina, and the provision of emergency assistance in epidemic situa- Bacterial Diseases tions to Member Countries when needed.

The bacterial diseases on which PAHO focuses are plague, typhoid fever, and meningococcal meningitis. In 1979 its ac- Prevention of Blindness tivities ranged from collaborative research and support for training activities to technical cooperation in epidemic in- In 1975 the World Health Assembly ap- vestigations. proved a resolution which requested An endemic disease in at least five WHO's Director General to stimulate the Member Countries, enzootic plague con- development of national programs to pre- tinued to cause sporadic human cases. A vent blindness, especially that caused by PAHO expert working group simplified sur- trachoma, xerophthalmia, onchocerciasis, veillance procedures recently developed glaucoma, cataracts, and traumatic eye in- as an adjunct to the WHO Plague Manual juries. It is estimated that there are be- published in 1976. They will be field-tested tween 20 and 40 million blind in the world, and revised throughout 1980 as part of four-fifths of whom are in developing coun- periodic national training activities for tries. Two-thirds of the causes of blindness which PAHO will continue to provide are preventable, and one-fifth of the technical assistance. Other activities in- world's blind can be cured. cluded development and support of a re- Fortunately, blindness is not as serious DISEASE CONTROL 99

a problem in the Americas as in other parts extrabudgetary resources for implementing of the world. Nevertheless, all of the six the resolution. blinding conditions identified by WHO as In October a training workshop was held important targets exist in the Americas, in Mexico on the treatment of ocular and estimates of the proportion of blind in onchocerciasis. Eye specialists from five national populations vary from 0.1 per cent countries received instruction in the latest in Brazil to 1.3 per cent in Haiti. treatment procedures from ophthalmolo- To develop a program for the Americas, gists working in the West African oncho- PAHO convened a planning group in cerciasis program. Washington in September. Participating were 23 representatives from 10 Member Countries, six representatives from international voluntary organizations and bi- Malaria lateral governmental organizations, and 10 PAHO staff members. A comprehensive report was prepared for the Director and No significant changes were observed in circulated to all Member Countries. It sug- the Region's malaria situation in 1979. The gested that PAHO's major function is to total number of cases reported during the promote not autonomous blindness pro- year was 452,216, although figures from grams but rather the integration of preven- seven countries are not complete for the tion activities in general health services whole year. This figure compares to and especially in primary health care ac- 405,958 cases reported in 1978 for the same tivities. The report also recommended that period and same countries from which in- PAHO encourage the exchange of national formation is available about 1979. The technical resources to aid or strengthen total number of cases in 1978 was 464,755, neighboring countries' programs according as shown in Table 4. to the principle of technical cooperation. The Third Meeting of Directors of Na- Eye care should be considered a part of the tional Malaria Eradication Services of the extension of primary health care. Americas was held at Oaxtepec, Morelos, The group reviewed the existing pro- Mexico, in March. The participants re- grams in the 10 countries represented at viewed program developments, evaluated the meeting and made recommendations the progress achieved in each country and for further national programming activi- in the Region as a whole, and, in order to ties. These include methods for epidemio- comply with a XX Pan American Sanitary logic assessment of the prevalence of Conference resolution in 1978, reviewed * avoidable blindness, training eye care the strategy of malaria control and laid the workers at all three levels within a country, groundwork for developing a new hemi- and research which could be carried out spheric plan of action against malaria. At with the abundant resources available in the meetings of PAHO's Executive Commit- the Americas. tee in June-July 1977 and its Directing After reviewing the group's report, the Council in September-October 1979, the PAHO Directing Council adopted a resolu- Director was asked to draw up a plan for tion (CD26.13) asking the Director to give all strengthening malaria programs in each possible support to program development country in collaboration with their govern- within the countries, establish a regional ments. Thus, in 1979, PAHO and national advisory group on blindness prevention, technical staff reviewed the malaria pro- strengthen technical assistance, and seek grams in and drew up national action plans 100 REPORT OF THE DIRECTOR

Table 4. Reported cases of malaria, 1976-1979.

Population in Cases reported originally Group malarious areas 1979 (in thousands) 1976 1977 1978 1979

Group I 12 countries or territories in which malaria eradication has been certified 72,847 424 531 718 1,034

Group II Argentina 3,276 70 463 325 936 Belize 158 199 894 1,218 1,391 Costa Rica 624 473 217 313 307 Dominican Republic 5,241 586 745 1,531 3,080 French Guiana 58 394 488 266 604 Guyana 899 4,642 1,563 927 2,294 Panama 1,811 727 674 263 316 Panama Canal Zone 45 7 4 5 0 Paraguay 2,487 140 156 156 109 a

Subtotal 14,599 7,238 5,204 5,004 9,037

Group ¡II b Brazil 48,427 89,959 104,436 121,577 10 3,27 3 Ecuador 4,712 10,974 11,275 9,815 8,207 Mexico 34,809 18,153 18,851 19,080 17,181c Suriname 287 537 993 876 903 Venezuela 10,076 4,768 5,304 5,065 4,403a

Subtotal 98,311 124,391 140,859 156,413 133,967

Group IV Bolivia 1,961 6,714 10,106 10,897 14,712 Colombia 16,212 39,022 63,888 53,412 60,957 El Salvador 4,020 83,290 32,243 52,521 77,976 Guatemala 2,644 9,616 34,907 59,755 69,039 Haiti 4,271 15,087 27,679 60,472 34,753a Honduras 3,267 48,804 39,414 34,554 19,383c Nicaragua 2,518 26,228 11,584 10,633 18,418 Peru 5,715 18,462 32,410 20,376 1 2,9 40 b

Subtotal 40,608 247,223 252,231 302,620 308,178

Total 226,365 379,276 398,825 464,755 452,216

aUp to November. bUp to September. 'Up to October. DISEASE CONTROL 101 for Colombia, Dominican Republic, Haiti, malarious areas (18.0 per cent of the total). Honduras, and Nicaragua. Although the ultimate goal of their programs is The Region's malaria situation in 1979 eradication, their immediate objectives are to reduce malaria mortality and morbidity in areas can be categorized as follows: with persistent disease transmission and to prevent resurgence of malaria in areas where Group I. Twelve countries or territories had transmission has been interrupted. Bolivia eradicated the disease (Chile, Cuba, Dominica, returned to the attack phase all areas of the Grenada and Carriacou, Guadeloupe, Jamaica, country previously in the consolidation phase. Martinique, St. Lucia, Trinidad and Tobago, PAHO reviewed the programs in Colombia, Haiti, mainland United States, and Puerto Rico and the Honduras, and Nicaragua and helped national Virgin Islands). This group has a population of authorities there draw up plans of operation 72.8 million in originally malarious areas (32.2 geared to local epidemiologic conditions. Hon- per cent of the total population in originally duras and Peru decided to conduct malaria con- malarious areas in the Americas). No major trol activities within their general health problems were encountered during the year in services, while in the other countries malaria maintaining malaria eradication, although im- control was pursued by autonomous malaria ported cases continue to be recorded in these eradication services. As a result of ad- countries and territories. ministrative problems stemming from organiza- Group II. Eight countries or territories had in- tional changes, case-finding and control ac- terrupted or almost eliminated malaria transmis- tivities in Honduras and Peru declined and thus sion (Argentina, Belize, Costa Rica, Dominican proper evaluation of the malaria situation in Republic, French Guiana, Guyana, Panama in- those countries became difficult. During 1979, cluding the Canal Zone, and Paraguay). This the countries in this group reported 308,178 group has a population of 14.6 million in cases or 68.2 per cent of the total registered in originally malarious areas (6.4 per cent of the the Region. total) and recorded 9,037 cases of malaria in 1979. In many there was an increase over 1978. Of the 226,365,000 people living in In some the number of imported cases mounted because of increased population exchanges with the Region's originally malarious areas at other countries, while in others operational and the end of 1979,112,257,000 (49.6 per cent) surveillance funds were inadequate or not pro- were in areas where malaria had been erad- vided on time and so caused program reductions icated (maintenance phase), 58,132,000 or delays in applying remedial measures. The (25.7 per cent) lived in areas where malaria epidemiologic situation deteriorated in Argen- tina, Belize, Dominican Republic, French transmission had been interrupted (con- Guiana, and Guyana during the year. solidation phase), and 55,967,000 (24.7 per Group III. Five countries vigorously pursued cent) were in areas where transmission still malaria eradication with adequate ad- occurred (attack phase). ministrative and financial support (Brazil, The physiologic resistance of malaria Ecuador, Mexico, Suriname, and Venezuela). This group has a population of 98.3 million in vectors to insecticides is by far the most originally malarious areas (43.4 per cent of the serious technical problem confronting the total) and registered 133,967 cases of malaria in Region's malariologists and one to which 1979. During the year, Mexico transferred an 2 there is no easy solution. This problem area of 190,952 km with 5.3 million inhabitants is most acute along the Pacific coast of from the consolidation to the maintenance phase and another of 178,873 km2 with 2.0 El Salvador, Guatemala, Honduras, and million inhabitants from the attack to the con- Nicaragua where insecticides are being ap- solidation phase. Brazil, Ecuador, and Vene- plied in ever-greater quantities and wider zuela continued their steady progress, while areas to increase cotton production. Vec- Suriname did not advance significantly in 1979. tors in these areas have been found resis- Group IV. The remaining eight countries (Bolivia, Colombia, El Salvador, Guatemala, tant to all the common insecticides used Haiti, Honduras, Nicaragua, and Peru) had a against them. Larviciding, drug distribu- total population of 40.6 million in originally tion, and biologic control measures had to 102 REPORT OF THE DIRECTOR

Figure 6. Status of the malaria program in the Americas, 31 December 1979.

4 3 - \ ~~~~~~~~~~~States ~nhted01 iAneinc

M exico < A a

" baDminica?. n Rep

i'irc SgUf J ramaica C o ico

Bejue 1,..,d.d and 1rh:r HondurasGvn iB \giuatemn iW bcia Panama,....

Gu Elr .~alv ado~ ~ ~ ~ ~XC ~ .,

N.¢aragua

lnctudingd

Aras in rih malaria has lappeared ntigua. Bahamas., Barbados. arbuda. Bermuda. S. Kitt-NevisAinguilla. St. Vincent. =or no- r oitOed T|uriksand Cacos Islands. Virgn Islands (UK)

I Are-s where malaria Dominica. Grenada. Guadeloupe. Marrsque. St. Lucia. Trinidad and lobago. has been eradlcated Maoinenancepla~el Virgin Islands iUS) - lI consoildation phase

= Inattack phase DISEASE CONTROL 103 be used in areas with vector multiple because they are endemic rather than resistance; as alternatives, they resulted in epidemic and tend to disable and in- more expensive field operations and capacitate rather than kill, they have usu- limited coverage. Epidemiologic studies ally received less attention than those were intensified during the year to stratify diseases that arouse public awareness by the malarious areas and apply the con- dramatic outbreaks. They have thus often trol measures best suited to local epide- been assigned priorities lower than they miologic conditions, the given area's merit in public health programs, consider- socioeconomic importance, and availabil- ing the significant economic loss and im- ity of control funds. To collaborate with measurable human suffering they cause. Mexico and the Central American coun- For many reasons, parasitic diseases re- tries, PAHO established a research project main among the least understood and most at Tapachula, Chiapas, Mexico to search poorly controlled of all infectious diseases. for solutions to the technical problems that Some parasites have complex life cycles have plagued their programs, particularly and the details of their existence outside that of vector resistance to insecticides. the human body are incompletely known. In many countries, administrative and Diagnosis is often possible only with the financial problems impeded effective ex- aid of relatively sophisticated laboratory ecution of malaria programs. Inadequate facilities which generally are least avail- budgets, shortages of trained professionals, able in the areas of greatest need. Even labor problems among field workers, and when a diagnosis can be made, there are no shortages of vehicles in good working con- requirements for reporting parasitic dis- dition, drugs, insecticides, and other essen- eases and no surveillance systems are in tials were common reasons for delaying or operation. The result, with few exceptions, suspending field operations. The result was is that little or no reliable epidemiologic in- epidemiologic deterioration. These prob- formation is available and even basic lems were thóroughly discussed during the knowledge concerning infection preva- year by PAHO's Executive Committee and lence and distribution is lacking. Several Directing Council, which approved resolu- diseases have exaggerated significance tions urging the countries to give high because no effective or satisfactory treat- priority to financing and carrying out na- ment for them exists. tional malaria eradication plans and re- Foremost among these parasitic diseases questing the Director and Member Govern- are Chagas' disease, schistosomiasis, fil- ments to explore all possible sources of ariasis, and leishmaniasis, which have all funds to support national and hemispheric received special notice from PAHO's malaria control activities. Governing Bodies in a series of resolutions in recent years. All four diseases in this group are vector-borne and, along with malaria and leprosy (which is nonparasitic), Other Parasitic Diseases occur primarily in the tropics. As such they were chosen as the initial targets of the WHO Special Program for Research and Several parasitic diseases other than Training in Tropical Diseases. In common malaria are significant public health prob- with the Special Program, PAHO's ap- lems in Latin America and the Caribbean. proach to these diseases is based on the Parasitic infections are incredibly prev- recognition that new technology and in- alent in most developing countries, but creased study are necessary to gain basic 104 REPORT OF THE DIRECTOR

information with which to devise effective The causative parasite, Trypanosoma measures for controlling them. cruzi, occurs in about 150 mammalian host and 36 insect vector species. The disease's Chagas' Disease epidemiology is varied and governed by complex factors: vector and reservoir Interest in Chagas' disease was high in species and climatic and socioeconomic 1979 because of the many events com- conditions, particularly housing types, pro- memorating the 100th anniversary of the foundly affect the patterns of this prin- birth of Carlos Chagas of Brazil. These ac- cipally zoonotic infection. tivities nurtured further cooperation in find- The best protection against such infec- ing ways to prevent and control the disease tion is obviously prevention, and ac- he first characterized in 1907. tive-though slow and very costly-vector Chagas' disease in man extends from control programs using chemicals have the United States to Argentina and Chile. been instituted in Brazil and Venezuela. Between 10 and 15 million people are be- Argentina, Bolivia, and Paraguay are lieved to be infected, chiefly in Brazil and developing or expanding their control pro- Venezuela. Millions more in South grams. America, Panama, Central America, and Knowledge of the disease's distribution Mexico are threatened. For those who suf- and epidemiology is still inadequate, how- fer from the disease the consequences ever. The WHO Special Program for range from a complete lack of symptoms in Research and Training in Tropical Diseases, the majority to prostration during the PAHO, and scientists in Latin America are chronic phase or even death. producing guidelines to standardize epi- In most places where Chagas' disease oc- demiology in countries where programs are curs it is considered a rural malady as- lacking and are developing training pro- sociated with reduviid bug infestation of grams in clinical epidemiology in Brazil. houses. In addition to the classical means of transmission through insect contamina- Schistosomiasis tion in the home, two other modes of spread are becoming increasingly com- Schistosomiasis is a disease caused by mon: inoculation by blood transfusion and small flukes. They have a complex life cy- transplacental infection. In both of the lat- cle involving an intermediate snail host ter the consequences tend to be serious and an immature stage that can penetrate because the infection is established in a the unbroken skin of persons exposed to host who is particularly susceptible owing the snails in water, after which they to debilitation or immaturity. develop into adult worms in the human Little can be done for the patient once host's bloodstream. Of the three major beyond the acute phase of the disease, species that occur widely in many tropical since no drug exists that is very efficacious and subtropical parts of the world, only against the intracellular parasite. One one, Schistosoma mansoni, occurs in the drug, Nifurtimox, has been reported to Western Hemisphere, where it was in- be quite effective in clearing free trypano- troduced from Africa. It is now established somes from the bloodstream, but often the in suitable molluscan hosts in more than severest harm-caused by irreversible half the states of Brazil, three districts in damage to the autonomic nervous Suriname, and parts of five Venezuelan system-may occur before a diagnosis can states. In the Caribbean, foci also occur in be made. the Dominican Republic, Guadeloupe, DISEASE CONTROL 105

Martinique, Puerto Rico, St. Lucia, and St. held at the same time which emphasized Martin. Control measures designed to the diagnosis and clinical management of break the man-snail-man transmission cy- ocular onchocerciasis and trachoma. cle were continued in countries where the Bancroftian filariasis was also intro- disease is endemic, but no major foci were duced from Africa and can be transmitted eliminated in 1979. by several species of mosquito including The WHO Special Program for Research the most common household pest mos- and Training in Tropical Diseases has quito. In the New World it is widely undertaken several activities to advance distributed in the coastal areas of Central knowledge and develop new and improved and South America and particularly in the control methods in endemic areas. During Caribbean. The extent and intensity of in- the year PAHO collaborated with WHO in a fection are known but poorly, and in many seminar in St. Lucia on human water con- instances the sheer magnitude of the prob- tact as a factor in the transmission of lem probably discourages national control schistosomiasis. efforts. Representatives from the Rockefeller Foundation met with PAHO officials during Leishmaniasis the year to discuss possible future uses for a Rockefeller-funded schistosomiasis con- Due to the variety of clinical manifesta- trol institute in St. Lucia. The institute will tions of infections by protozoans of the be ending its present functions in late 1980. genus Leishmania, there has been a growing tendency to refer to them collectively as the leishmaniases. Because of the seri- Filariasis ousness of some of these clinical forms and the widespread distribution of leishmania- Human filariasis is caused by several sis, which is transmitted by the bite of a species of nematode worms transmitted by small phlebotomine sandfly, some author- the bite of an insect vector, but only two ities have recently stated that this is un- worms-Wuchereria bancrofti and On- doubtedly the most important protozoan chocerca volvulus-are considered public infection after malaria in man today. In the health problems warranting control ac- Americas leishmanial infections have been tivities in the Americas. Onchocerciasis is reported from the southern United States transmitted by black flies and occurs in to northern Argentina. only a few small, well-defined foci in The visceral form of disease causes very Brazil, Colombia, Guatemala, Mexico, and high mortality in young children and has Venezuela which have been intensively been reported from eight South American studied by several research teams. Gua- countries, although it is a significant public temalan surgical teams, which remove health problem only in northeastern Brazil. nodules to decrease microfilariae, have In Middle America it has been reported probably reduced the number of blind in from El Salvador, Guatemala, Mexico, and, that country greatly, but transmission of most recently, Honduras. In the last coun- the infection continues in the affected try clinical awareness and the establish- areas. ment of diagnostic facilities quickly In October, Mexico sponsored an inter- changed the disease from an academic national symposium on onchocerciasis at curiosity to one diagnosed more than once San Crist¿bal de las Casas, Chiapas. A a month on average. The discovery for the workshop on tropical ophthalmology was first time in 1979 of a case in Trinidad and 106 REPORT OF THE DIRECTOR

of canine transmission in the United States often because of dengue epidemics or with indicates that the parasite may be a view to preventing outbreaks of that spreading or at least be much more widely disease. distributed than formerly thought. PAHO staff continued to assist national Cutaneous/mucocutaneous leishmaniasis anti-A. aegypti programs by providing continues to be the most serious problem, technical cooperation and limited amounts and there have been significant increases of equipment and insecticides, in par- in the number of cases reported in several ticular to countries affected by dengue. A countries in the past year or two. Costa manual on controlling A. aegypti epidemic Rica, which has very complete coverage emergencies is being prepared, and the and reliable statistics, has reported 2,000 manual of operations used in national cases a year in a population of 2 million. anti-A. aegypti campaigns is being revised Cutaneous leishmaniasis seriously im- and updated. peded a Bolivian scheme to relocate peo- In recent years efforts to eradicate A. ple outside the overcrowded high plateau aegypti in the Americas have encountered region, since many of the colonists aban- serious difficulties because the priority doned their land and more than 60 per cent once assigned to vector eradication pro- of those who did said that leishmaniasis grams has been downgraded. In some was their reason for returning to the moun- countries, financing has been so inade- tains. It has also significantly hampered quate that it has not been possible to con- both oil exploration and road building in duct vector control operations. Other several Andean countries. countries, in addition to encountering ad- During the year PAHO and the Guate- ministrative difficulties in organizing and malan Ministry of Health conducted a conducting programs, face severe labor three-day workshop for physicians and aux- problems that interfere with program ex- iliary personnel in the Petén area on the ecution and hinder progress. Because of epidemiology, diagnosis, and treatment of dengue emergencies, ministries of health cutaneous leishmaniasis. Training in the had to carry out costly operations that did use of immunofluorescence as a diagnostic not always produce timely results and and epidemiologic tool was given at usually were not continuous enough to Gorgas Memorial Laboratory in Panama to benefit regular control or eradication professional or technical personnel from programs. four countries, and serodiagnosis reagents As with national malaria eradication ef- or reference sera were provided to nine forts, A. aegypti eradication programs re- countries in the Region. Consultation visits quire technical personnel specially trained on problems related to leishmaniasis were to undertake anti-A. aegypti activities. In made to Costa Rica, Dominican Republic, most there is a lack of professional Guatemala, and Honduras. entomologists, a key discipline for planning and evaluating campaigns to control or eradicate vector mosquitoes. The WHO Special Program for Research and Training Aedes aegypti eradication in Tropical Diseases is supporting the establishment of a medical entomology master's degree course at the University of In 1979 a number of countries in the Carabobo in Venezuela, which should Region continued to step up their Aedes begin in 1981. aegypti eradication or control activities, New insecticiding technologies are being DISEASE CONTROL 107 used in the Region, especially ultra-low in Salvador in 1976. Infestation in Rio de Janeiro volume (ULV) spraying, but such equipment is widespread and includes most of the city's must be used correctly along with the more densely populated districts. Historically, Brazil has pursued the policy of eradicating the vector conventional technologies. Researchers in and has made resources for this purpose Colombia and Venezuela are cooperating available. The surveillance system, now in with PAHO in determining eradication or operation in vulnerable localities, ports, and air- control methods that are compatible with ports, was substantially strengthened. local environmental conditions. PAHO is Colombia. Jungle yellow fever continued to spread. During the second and third quarters of continuing to develop teaching aids and 1979, cases of jungle yellow fever were reported to provide on-the-spot training to satisfy in three rural areas near cities badly infested the needs produced by these new with A. aegypti. Yellow fever exists in Cesar, technologies. Magdalena, and Norte de Santander Depart- Argentina, Bolivia, Chile, the Panama ments as well as in the Sierra Nevada near Santa Marta. The national A. aegypti control program Canal Zone, and Paraguay are free of A. was strengthened, especially in the Cauca River aegypti. Aruba, Bermuda, Bonaire, Cayman valley and its main city, Cali, and in Santa Marta Islands, Ecuador, Panama, Saba, and St. and Valledupar in the northern part of the coun- Eustatius eliminated focal reinfestations try. This program consisted of ULV malathion and at the end of 1979 were in the con- spraying and focal temephos treatments. A. aegypti continues to spread into southern and solidation phase and A. aegypti-free. Pacific coastal areas. Manta, Ecuador, became reinfested in 1979 Costa Rica. The reinfestation discovered in but the focus was rapidly eliminated; the 1977 in Puntarenas Province continued to be at- fact that only two years earlier Manta had tacked through systematic operations that kept experienced and quickly eradicated A. aegypti under control. Cuba. A. aegypti control activities were another reinfestation shows the need for strengthened after the 1977 dengue epidemic, ceaseless surveillance and efficient anti-A. which showed that infestation was general aegypti measures. throughout the country. These included aerial The status of still-infested countries and and land ULV spraying with malathion, larvicidal territories was as follows: treatments with temephos, and health education through community organizations and the news media. Despite these activities, A. aegypti con- Bahamas. Following a dengue epidemic in the tinues to be a vector problem. previous year, the A. aegypti control program Dominican Republic. Control activities, car- was stepped up in 1978. Monthly inspections ried out for the most part in Santo Domingo and and treatments were carried out in four with limited resources, prevented the occur- localities in 1979. rence of a major dengue 1 epidemic. A small Barbados. A. aegypti eradication operations surveillance project began in various parts of have been underway throughout the island for the capital. Following hurricane David, more ex- several years and in 1979 succeeded in reducing tensive surveillance was started to monitor the the A. aegypti density below 1 per cent. This den- risk of increases in A. aegypti. sity rises slightly during the rainy season, which El Salvador. Reinfestation was apparent runs from August to November. Given addi- almost throughout the country, and A. aegypti tional effort and appropriate orientation, this indices were high, primarily in the capital. Dur- program may result in eradication of the vector. ing the first half of 1978 a dengue epidemic Belize. The reinfestation discovered in late struck several cities including Santa Ana and 1976 had spread to most of the country by the San Salvador, and cases continued throughout end of 1979. Limited control activities were be- 1979. Control activities were undertaken in the ing undertaken in the capital. principal infested cities. Brazil. A program to eliminate A. aegypti and French overseas departments. In French control its spread is being conducted in Bahia, Guiana the campaign continued to use com- Rio de Janeiro, Rio Grande do Sul, and Sergipe bined control methods which included focal, States as a result of the reinfestation discovered perifocal, and ULv ground applications. Regular 108 REPORT OF THE DIRECTOR

Figure 7. Status of the Aedes aegypti eradication campaign in the Americas, December 1979;

F a d ~~~~and

United Statesof America

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Mexicl s-

t°~ ° ~_ Dominican Rep. Belize Jamaica Ha- Puerto Rico

GuatemalaIjj- El Salvador' CanalZo Venezuela - Honduras "'a~ ZSZi 11 . - ''~Trinidad and Tobago N-caragua v CostaR ita ' L~ cyanaGu.IB Paainaa . .Suriname ~Coloi m/ ~b a... ~ irç ench Guiana

Ecuadoa

Pet

bolivia-'

Chi

- Parasuay

guay

rgentina

Countries which havecompleted Incuding, ¡ Aedea yp eradication* ['--- Areas in which Aedes aegypti Aruba. Bermuda, onaire.Caya lands is no longer found Aruba. emuda onaire Cayan land Areas reinfested (after completion of eradication)

Areas stillinfested or not yet inspected f Anguilla, Antigua and Barbuda, Bahamas. Barbados, ]Curanao, Dominica. Grenada. Grenadines. Guadeloupe. Martinique, Montserrat, St.Kitts-Nevis. St. Lucía.St. Vincent. Virgin Islands (UK), Virgin Islands (USA) Areas presumablynot infested *oradication carriedout accordingto the standards establishedby the PanAmerican Health Organization. DISEASE CONTROL 109 control operations continued in the French part United States of America. Extensive health of St. Martin. No information was available education aimed at source reduction was suc- about Martinique and Guadeloupe. cessful in decreasing A. aegypti in Puerto Rico. Grenada. A campaign using combined ULV ap- A. aegypti distribution was resurveyed in the 10 plications and perifocal treatments continued. A infested mainland states. With the cooperation treatment verification cycle was completed dur- of the U.S. Center for Disease Control at Atlanta, ing which 24,823 houses were inspected and Georgia, health departments and mosquito con- treated and 802 were found to be infested for a trol districts have been asked to update house infestation index of 3.23 per cent. surveillance for dengue and establish guidelines Guatemala. Following the 1978 dengue for A. aegypti control. A joint border meeting epidemic, control measures continued, espe- with Mexico was held at El Paso, Texas, late in cially in Coatepeque, Escuintla, Retalhuleu, and the year to discuss mutual vector control and Suchitepéquez Departments. dengue epidemiologic problems. Guyana. The A. aegypti program continued to Venezuela. Operations remained virtually the be limited to Georgetown and seven towns be- same as earlier. tween the Berbice and Courantyne Rivers in the east. Haiti. The country continued to be infested No notable changes in the A. aegypti and the last vector control campaign was in surveillance and control programs oc- 1973, but a small study of A. aegypti population curred in the Caribbean islands of Anguilla, densities was begun in Port-au-Prince. Antigua, British Virgin Islands, Dominica, Honduras. The A. aegypti control program was Montserrat, St. Kitts-Nevis, St. Lucia, St. reorganized early in 1979. Activities are confined largely to San Pedro Sula and Tegucigalpa. Vincent, and Turks and Caicos. These Jamaica. The country continued to be in- islands are infested, but they do not con- fested, and the A. aegypti control program was sider eradication a top health priority. deemphasized in 1979. PAHO's vector control program extends Mexico. The northern, southwestern, and well beyond A. aegypti. Other responsibili- southeastern parts of the country were infested. Studies to determine possible extension of A. ties include the vectors of malaria, Chagas' aegypti into uninfested areas were expanded. disease, schistosomiasis, leishmaniasis, fil- The 1978 dengue epidemic in Tapachula, ariases, and the arboviruses. A study to Chiapas, continued and extended along the Pan screen rodenticides against commensal American Highway into Veracruz State. Concern rodents and reservoirs was recently begun was voiced about further northward movement of dengue. Emergency control measures using in Venezuela. ULV malathion spraying and temephos lar- Two workshops on the taxonomic prob- viciding were stepped up in areas with dengue or lems of South American simuliids of potential high risk of it. medical importance were held, one in Netherlands Antilles. Curaçao and the Dutch Brazil and the other in Venezuela, as a part of St. Martin continued to have A. aegypti. Nicaragua. No new reinfestations were result of a grant from the WHO Special Pro- reported, and vector control programs began to gram for Research and Training in Tropical be reorganized. Diseases. Suriname. The new plan to modernize control A protocol for field-testing insecticiding activities by using ULV equipment underwent equipment was developed and testing some revision, and the A. aegypti campaign was expanded. began in Venezuela. Work began on a Trinidad and Tobago. As a result of an out- number of teaching aids on insecticide ap- break of yellow fever in humans and monkeys, it plication and evaluation. The testing of was necessary to institute a large yellow fever chemical and biologic control agents vaccination program and increased vector con- against important vectors in tropical areas trol activities. More ULV equipment was added and staff retraining begun. The number of staff of the Region is a continuing function of increased and was expected to reach the recom- the PAHO field units. These tests make it mended level by mid-1980. possible for PAHO to provide current infor- 110 REPORT OF THE DIRECTOR mation to countries about their insecticide series of visual aids about vector and ro- and equipment purchases. dent biology and control has begun and Training of vector control personnel is will be expanded. Brochures on the use of growing in importance. Production of a public health education in vector control

Figure 8. Reported cases of jungle yellow fever by major political division of each country, 1965-1979. DISEASE CONTROL 111 are being developed. National training vaccine production was adequate for courses and fellowships remain an essen- meeting any major outbreak that might oc- tial component of the program. cur in the Caribbean. At the time of the meeting, two million doses of vaccine were known to be available at the Oswaldo Cruz Yellow Fever Foundation in Rio de Janeiro and 400,000 doses at the National Institute of Health in Seven of the Region's countries-Bo- Bogotá. The group recommended that a livia, Brazil, Colombia, Ecuador, Peru, stockpile of not less than 10 million doses Trinidad and Tobago, and Venezuela-re- be available for possible emergencies. ported 192 cases of jungle yellow fever by the end of November, the first time in 20 years that the number of countries reporting the disease increased. Dengue Peru reported 97 cases, mostly in Junin (34) and Huánuco (24). Colombia, which The incidence of dengue in the Carib- had suffered a severe epidemic in 1978, bean during 1979 was much less than in the reported further outbreaks in 1979. Forty- previous two years. The dengue 1 epidemic five cases were reported through November: wave, which began in Jamaica in 1977, 27 from Magdalena, 12 from Cesar, 4 from moved into the northern countries of South Meta, and 2 from Santander Departments. and Central America and then extended The Cesar and Magdalena cases were farther northward into Mexico in 1978. The especially alarming in that they occurred in disease was reported in Barbados, Belize, areas heavily infested by Aedes aegypti. Cuba, Haiti, Jamaica, Puerto Rico, St. Kitts, Careful investigation by the Colombian St. Lucia, and Trinidad in 1979. authorities indicated no evidence of Aedes Dengue activity in Puerto Rico was transmission of yellow fever, however. markedly less than in 1978. The serotype Eighteen cases and seven deaths oc- circulating on the island was dengue type curred in Trinidad. All cases were of 1, which was first identified in December sylvatic origin, and there was no evidence 1977. Only serotypes 2 and 3 had previ- of urban transmission. Extensive A. aegypti ously been isolated in the Western Hemi- control and vaccination against yellow sphere. fever, in which 85 per cent of the popula- Dengue was first reported in Mexico tion was immunized, were carried out dur- near the Guatemalan border in late 1978. ing 1979. Last year it spread into Chiapas, Oaxaca, At the beginning of the year, Ecuador and Quintana Roo in the south, and 2,000 had an outbreak of 13 cases that was con- clinically diagnosed cases were reported trolled. Brazil had 10 cases in Goiás and by October. All confirmed cases of dengue Pará States and Rondonia Territory. Bolivia in Mexico were type 1. reported eight cases in La Paz and two in The risk of dengue spreading to the Santa Cruz. Venezuela reported three United States from Mexico is far higher cases in Mérida and Zulia States. than from the Caribbean because of the Since a sizable number of yellow fever much greater population exchange across cases were occurring in A. aegypti-infested the U.S.-Mexican border and the fact that areas, a group of experts met at Washing- the Mexican population that is affected or ton in July to discuss the subject. Their at risk by and large lives in conditions that principal conclusion was that yellow fever favor dengue transmission. All of the states 112 REPORT OF THE DIRECTOR of the southeastern United States are Rico, in February. A manual produced by known to be A. aegypti-infested. this workshop will be widely distributed to A workshop on the laboratory diagnosis laboratories throughout the Region. of dengue was held in San Juan, Puerto

MENTAL HEALTH

Mental illness, alcoholism, and drug social stimulation of high-risk children, dependence are quite prevalent in the promotion of manpower development Region and progressively increasing, par- through fellowships, consultancies, and the ticularly in the young adult population. organization of seminars and courses. Several governments have begun to assign Two consultants visited the Leeward higher priority to mental health activities, Islands in the Caribbean to advise on the including alcoholism and drug dependence development of mental health services in control, but in general the scope of such accordance with several resolutions ap- programs is limited. PAHO has encouraged proved by the Conference of Ministers the development of mental health pro- Responsible for Health in the Caribbean. grams which, in addition to psychiatric In Chile a national conference was held care, include activities to promote mental to develop a national mental health plan; health strictly speaking and the prevention recommendations were drawn up and of mental disorders within the framework transmitted to the government. PAHO and of general health services. the Inter-American Children's Institute at National mental health advisory coun- Montevideo, Organization of American cils were created in Costa Rica, Nicaragua, States, and Jamaica sponsored a regional and Venezuela to help those countries' conference on parental education at health services develop mental health pro- Kingston in November. grams. PAHO collaborated with health Singular importance has been attached authorities in Ecuador and El Salvador in to developing rehabilitation and occupa- analyzing the mental health situation in tional therapy programs, particularly in those countries in order to design programs large psychiatric hospitals with a high pro- and create specialized agencies. The men- portion of chronic patients. Toward this tal health departments of Argentina, Do- end PAHO cooperated with the mental minican Republic, Jamaica, Peru, and Vene- health departments of the Dominican zuela continued reorganizing their psychiatric Republic, Uruguay, and Venezuela in train- care systems. PAHO cooperated in this ac- ing auxiliary workers in occupational tivity by analyzing action plans, sending therapy and organizing hospital rehabilita- consultants, and supporting training. tion services. PAHO cooperated with Argentina, Chile, Almost all mental health departments in Colombia, Costa Rica, and Venezuela in the Region's ministries of health have in- organizing child mental health services. cluded in their plans the development of Activities included the establishment of community.mental health programs which linkages with maternal and child care serv- are integrated or coordinated with their ices, development of programs for psycho- general health services. PAHO collaborated DISEASE CONTROL 113 along these lines in 1979 with Brazil, Chile, After feasibility studies had been con- Colombia, Costa Rica, Cuba, Honduras, ducted in Argentina, Mexico, and Peru, a pro- and Jamaica in various ways such as send- gram to detect drug dependence through ing consultants, awarding fellowships, and case-finding in hospital emergency rooms was providing technical materials. adapted for Latin American countries. PAHO cooperated with Bolivia and Peru PAHO has promoted periodic evaluation in developing national drug dependence of national mental health services and in control programs in collaboration with 1979 cooperated with the health ministries the United Nations Fund for Drug Abuse of Chile and Jamaica in conducting such Control. analyses.

DENTAL HEALTH

During 1979 PAHO staff consulted on na- Guatemala, and Honduras extend their tional dental health programs with health dental health programs to larger sectors of ministry officials in Argentina, Brazil, Co- the population. lombia, Dominican Republic, Guyana, A review was made at the Caribbean Mexico, Panama, and Trinidad and Tobago. Atlantic Regional Dental Association Technical collaboration was provided to meeting in Antigua of progress toward the Mexico, Panama, and Venezuela in devel- dental health goals drawn up by the Con- oping dental service extension programs ference of Ministers Responsible for Health and providing administrative structures for in the Caribbean, held in St. Lucia in 1977. such services. It was evident from the presentations made The development of national and subre- that preventive programs are necessary gional strategies in dental health in accord- and are beginning to be put into effect in ance with World Health Assembly resolu- almost all the English-speaking Caribbean tions continued with a national meeting at countries and territories. Puerto Plata, Dominican Republic, to PAHO participated in many International develop such a strategy for that country Year of the Child activities to emphasize and a presentation on dental health for the need to increase children's training in discussion at the Meeting of Ministers of good oral health practices and to establish Health of Central America and Panama in preventive programs against the commonly El Salvador. As part of this effort, data occurring dental diseases. Bermuda's pre- began to be collected on the status of den- ventive dental project has involved more tal disease in some of the smaller islands than 90 per cent of the schoolchildren and territories of the English-speaking there through voluntary enrollment and Caribbean through a simplified method in- the collaboration of health and education volving tooth counting and determining authorities with good initial results. the presence or absence of caries by tooth In Cuba, the rural school dental care pro- type. Initial steps were taken to develop gram dramatically increased that country's strategies for the Andean Pact countries. ability to provide dental services to rural PAHO also helped the Bahamas, Bolivia, children through the use of teams of den- 114 REPORT OF THE DIRECTOR tists and auxiliaries. The increase in dental ily transportable equipment to reach such productivity was estimated at more than 90 populations. per cent in the program's first full year of A workshop of architects, engineers, operation. dentists, and dental auxiliaries from Can- Staff also participated in a meeting in ada, Dominican Republic, Jamaica, Mex- Milwaukee, Wisconsin, U.S.A., on dentistry ico, Peru, United Kingdom, and the United for isolated populations sponsored by the States met at PAHO Headquarters in American Red Cross, U.S. National Aero- December to discuss the effective design nautics and Space Administration, and of dental facilities. Special emphasis was Loyola University Dental School, Chicago. placed on the efficient use of space and Particular attention was paid to the need the design of facilities particularly applic- for applied and appropriate technology in able to programs in developing countries. developing and using simplified and read-

NONCOMMUNICABLE DISEASES

Noncommunicable diseases such as car- grams in certain communities on a re- diovascular disorders, diabetes mellitus, stricted scale to demonstrate the feasibility and cancer are among the principal causes and effectiveness of epidemiologic studies of death in most of the Region's countries. and preventive and therapeutic measures; This trend results principally from the (4) establishing information systems for gradual control of communicable diseases, monitoring the hemispheric situation and increases in life expectancy at birth, and identifying resources for collaborative ac- environmental changes. tivities in epidemiologic, basic, and clinical In response to the concerns expressed by research; and (5) seeking extrabudgetary its Governing Bodies, PAHO has in recent financing to support these activities. years considerably increased its coopera- PAHO's programs and activities focus mainly tion with Member Governments in devel- on cancer, arterial hypertension and oping criteria and planning adequate pro- rheumatic fever, chronic rheumatic diseases, grams to control noncommunicable and diabetes mellitus, and chronic allergic chronic diseases by: (1) developing diseases. epidemiologic studies to define the extent of the chronic disease problem and identify the risk factors involved in their pathogenesis; (2) providing technical Cancer cooperation in establishing noncommunicable disease units at the central health administration level as part of A significant portion of PAHO's activities regionalized national care systems; (3) pro- in support of cancer control programs is moting and coordinating intercountry pro- conducted through the Latin American DISEASE CONTROL 115

Cancer Research Information Project Other Noncommunicable Diseases (LACRIP). This joint PAHO-U.S. National Cancer Institute undertaking is financed Cardiovascular diseases (especially hy- largely from extrabudgetary resources. pertension and rheumatic heart disease), During 1979, LACRIP provided 881 cus- diabetes mellitus, and chronic rheumatic tom CANCERLINE bibliographic searches to diseases are being given high national pri- oncologists throughout Latin America and ority. At its September-October meeting, the Caribbean through the computer ter- PAHO's Directing Council resolved (CD26.18) minal at PAHO Headquarters. The services to review the noncommunicable disease of LACRIP's selective information dissemi- control program at its next meeting in order nation project, which is carried out in col- to assess PAHO's policies, strategies, and laboration with the Regional Library of action plans in this field. Medicine and the Health Sciences at Sao The PAHO working group on hyperten- Paulo and subcenters in Mexico and sion control, which has representatives from Venezuela, were extended to 2,782 Latin Argentina, Bolivia, Brazil, Chile, Colombia, American scientists. Cuba, Ecuador, Mexico, Peru, and Vene- Another LACRIP activity, the Collabora- zuela, met at Bogotá in November to discuss tive Cancer Treatment Research Program the results of the first three years of collab- (CCTRP), is conducted through nine centers orative studies and plan to integrate pro- in Latin America and six in the United grams to control cardiovascular diseases States. The countries participating were such as hypertension and rheumatic heart Argentina, Brazil, Chile, Colombia, Peru, disease. United States, and Uruguay. By the end of Representatives of the countries partici- the year, the program included the active pating in PAHO's program to prevent rheu- participation of 36 oncologic institutions in matic fever and rheumatic heart disease 27 protocols on breast cancer, head and (Argentina, Bolivia, Brazil, Chile, Ecuador, neck cancer, gynecologic malignancies, Peru, and Venezuela) met at Santiago, Chile, melanomas, sarcomas, lymphomas, leuke- in October to discuss the progress of the mia, and gastric cancer. Preliminary results collaborative study and review the final from these trials, which had a reported pa- draft of the operational standards for com- tient accrual of 750, were discussed at the munity prevention and control activities first principal investigators' meeting in which PAHO will propose to the countries in Miami in June. Throughout the year, the 1980. CCTRP also supported three-month training The PAHO chronic rheumatic disease visits by eight Latin American junior physi- study group in which Argentina, Brazil, cians and nurses to participating U.S. in- Chile, Mexico, Uruguay, and Venezuela are stitutions as well as the exchange of 15 participating held its second meeting at principal investigators. In addition to drugs Washington in August to analyze the re- required for treating patients, the nine sults of the first year of study and plan the Latin American centers received annual followup of selected diagnoses in order to research grants ranging from $6,000 to assess changes in incapacity and depen- $14,000. dency due to those diseases. Other technical cooperation activities Centers in Argentina, Brazil, Chile, Co- were hospital-based cancer registries and lombia, Mexico, Peru, Uruguay, and Vene- comprehensive cervical cancer control zuela initiated a joint study on chronic programs. allergic diseases. 116 REPORT OF THE DIRECTOR

HOSPITAL INFECTIONS

An international meeting on hospital community, and can put epidemiologic infection control attended by 19 repre- principles and methods into regular sentatives from 10 countries was held in practice. Such programs are also useful Guatemala in September. The participants in developing standards for patient care, sent the Director recommendations pre- identifying needs for general policies and pared by the participating countries on the procedures in other areas of the hospital, future development of hospital infection and improving the coordination of hospital control programs. administration, medical records keeping, Among these recommendations was the and laboratories. During 1979 the regional observation that epidemiology is basic to hospital infection consultant made visits to the development of such programs. The initiate or continue programs in Barbados, hospital is a microcosm of public health ac- Colombia, Costa Rica, Ecuador, El Salva- tivities, is able to serve as a channel of in- dor, Guatemala, Panama, Peru, and Vene- formation and communication with the zuela.

LABORATORY SERVICES

Carrying out public health and medical laboratory network for the smaller English- care programs requires laboratories which speaking Caribbean islands, which was pro- are able to provide precision services. posed to UNDP in 1977. The three-year, Without such laboratories, adequate drink- $400,000 project, which will upgrade existing water, food, and drug control, epidemi- ing laboratories, train personnel, provide ologic surveillance, and medical care are for equipment maintenance and repair, impossible. The problems that exist in and include research on pathology in the establishing laboratory programs meeting area, is expected to begin in May 1980. It national needs are universal, but they are will be headquartered in Barbados. especially serious in developing countries. Chile continued successfully carrying Still, there has been a growing awareness out a program begun in 1973 to strengthen of laboratories' support role in national and expand its national laboratory system health plans, and this has enabled their with PAHO and UNDP help. The project in- development to be furthered in several cludes bettering diagnostic standards, im- countries. proving the quality and increasing the PAHO has cooperated with the countries quantity of biologicais produced in the in formulating projects and arranging the country, and improving the quality control financing to carry them out. Among the of foodstuffs, drugs, and biologicais. Col- projects PAHO is helping is a diagnostic laboration was also provided to the Do- DISEASE CONTROL 117 minican Republic in preparing a laboratory Streptococcus pneumoniae in 10 countries. project for submission to UNDP. By the end of the year this study, whose PAHO cooperated with Mexico in draw- purpose is to identify the most frequently ing up a plan to designate three central lab- occurring pneumococcal strains in the oratories as reference centers and make 14 Region for incorporation in future vaccines, regional laboratories responsible for pro- led to the identification of 332 strains cedure standardization, quality assurance, whose antigenic behavior differs from proficiency testing, and supervision of those in current vaccines. other laboratories in their areas. Uruguay asked PAHO's technical cooperation in forming its. central laboratory, 24 departmental laboratories, and 20 other laboratories into a national laboratory network Immunology Laboratories which, with UNDP collaboration, will meet the growing demands of that country's health services. Venezuela was provided The explosive growth of immunology in the services of a short-term consultant in recent years has made it preeminent among extending its laboratory system to the laboratory disciplines. The important role health program covering the country. of the field in the diagnosis of communi- The growing demand for laboratory cable diseases, studies of the pathogenesis services has also resulted in a greater need of various illnesses, and the treatment of to train manpower to meet the demand. certain diseases has increased interest in PAHO has continued its efforts to establish establishing laboratories able to examine centers to train workers in laboratory sci- factors underlying immunity. ences, microbiology, laboratory manage- In cooperation with the Netherlands, ment, and biomedical equipment mainte- PAHO is helping to create a network of nance and repair. In cooperation with national immunology laboratories which Argentina and the U.S. Center for Disease began in 1977 in the Caribbean. Jamaica Control (CDC) at Atlanta, Georgia, PAHO and Suriname signed the tripartite agree- held a two-week course at Mar del Plata, in ment with PAHO and Dutch authorities in October and November, on clinical chem- 1978 and Cuba in 1979, while Trinidad and istry quality control for 28 participants Tobago joined the program informally last from 15 hemispheric countries. It is hoped year but by its end had not signed the agree- that this course will lead to the establishment. Costa Rica and Honduras applied ment of national quality control programs during the year for inclusion in the pro- which can effectively and efficiently sup- gram, and if the Netherlands accepts their port primary health care programs. applications the network will expand into PAHO continued its quality assurance Latin America. The purpose of the program projects in bacteriology in the Caribbean, is to create an immunology unit in each of in serology throughout the Region as part the participating countries to give them the of the syphilis serology evaluation program technologic ability to diagnose communi- conducted by CDC and in clinical chemistry cable diseases. The program has two stages. in Argentina, Chile, Panama, Uruguay, and The first consists of training national staff Venezuela. at Amsterdam and providing laboratory PAHO also coordinated a cooperative equipment and supplies paid for by the project financed by Merck, Sharpe, and Netherlands, and the second is beginning Dohme to determine the prevalent types of each national laboratory's activities. Cuba, 118 REPORT OF THE DIRECTOR

Jamaica, and Suriname have completed Twenty-five scientists from Cuba (10), Ja- the initial stage, and the first two countries maica (9), Suriname (5), and Trinidad and have entered the second. Tobago (1) have so far been trained in the Training workers to staff these services is 14-month course, which leads to a master's carried out at the Immunology Training degree in immunology from the University and Research Center at Amsterdam. of Amsterdam.

EPIDEMIOLOGIC SURVEILLANCE

Among the diseases subject to the Inter- ing epidemiology educational materials national Health Regulations, yellow fever and organizing a basic epidemiologic sur- was the chief threat to health in the Region veillance course for professional personnel during 1979. Seven countries (Bolivia, in peripheral health service units. Brazil, Colombia, Ecuador, Peru, Trinidad The eighth regional course on communi- and Tobago, and Venezuela) reported cable disease epidemiologic surveillance cases, all of jungle origin. and control was held at Caracas under the During the year PAHO updated the col- sponsorship of PAHO and Venezuela's Min- lection frequency and type of data required istry of Public Health and Welfare and for epidemiologic surveillance in accor- School of Public Health. It lasted four dance with the expressed needs of the vari- months and was attended by seven fellow- ous disease control programs of which ship holders from Latin America. epidemiologic surveillance is a part. The necessary technical studies were carried out to begin publication of PAHO's new bimonthly Epidemiological Bulletin in Caribbean Epidemiology Center separate English and Spanish editions to replace the bilingual Weekly Epidemiologi- cal Report, which ceased publication in PAHO's Caribbean Epidemiology Center January. (CAREC) at Port-of-Spain, Trinidad and To- During 1979 PAHO received information bago, was founded in January 1975 after about 36 varied epidemic outbreaks. At the having been operated by the Rockefeller request of Member Governments, it collab- Foundation and the University of the West orated with them in investigating the out- Indies as the Trinidad Regional Virus Labo- breaks and initiating control activities. ratory. At the end of 1979, its staff included Preliminary steps were completed in 15 professionals, most of whom were PAHO/ preparing epidemiologic surveillance WHO employees. guides which will allow different working Since CAREC was founded, one of its criteria to be adapted according to the chief programs has been to develop na- nature and development of the control tional disease surveillance systems in the programs in the Member Countries. Caribbean as part of a subregionwide sur- Special emphasis was placed on produc- veillance network. An earlier grant from DISEASE CONTROL 119 the U.S. Center for Disease Control at At- island governments in attracting and re- lanta, Georgia, to support the network's taining qualified pathologists, microbiolo- development expired in 1978, and in May gists, and senior laboratory staff. of last year the U.S. Agency for Inter- Other elements of the program include national Development (USAID) awarded a the provision of cold-chain equipment to new three-year, $1,160,000 grant to CAREC the countries of the area to ensure that to support surveillance activities and train vaccines retain their potency during ship- health workers to carry them out. In addi- ment to outlying areas. In addition, a data tion to the USAID funds, PAHO will con- processing and information system will be tribute $418,577 to the program, represent- established at CAREC. ing PAHO-funded staff time and resources. CAREC conducted training for medical The principal part of the USAID-funded and graduate students in Barbados and program will consist of training activities Jamaica, and in Trinidad gave a two-week conducted by the CAREC staff. Included microbiology clerkship for medical stu- will be: (1) the creation of a three-person dents. Courses for laboratory technicians training unit at CAREC; (2) traineeships in on new hepatitis techniques and general surveillance for country nationals em- microbiology took place in Trinidad. In- ployed by ministries of health or enrolled country training of public health inspectors in medical schools; (3) surveillance training and nurses took place in Anguilla, Ba- courses for epidemiologists, statistical hamas, Barbados, Cayman Islands, Do- officers, and primary health care workers; minica, Jamaica, Montserrat, Suriname, (4) courses for laboratory technicians and and Trinidad and Tobago. The deputy des- directors; and (5) the strengthening of lab- ignated epidemiologist course in Septem- oratory management and techniques in the ber was attended by 10 public health in- countries. spectors, nurses, and veterinary assistants To complement the training activities, a and one medical officer of health. proficiency testing program in bacteriology In addition to its training activities, and parasitology was established to assess CAREC also aided Caribbean countries the capabilities of the subregion's labora- and territories in carrying out various tech- tories to handle routine diagnostic speci- nical investigations. Using the insect cell mens. At the end of the year, the bacteriol- line and other methods, it was directly ogy and parasitology program involved 31 involved in controlling the yellow fever laboratories, all but one of which were outbreak and the continuing endemic den- making regular returns. The parasitology gue in Trinidad. A major study of gastro- program brought to light severe deficien- enteritis in Guyana and Trinidad using cies in the ability of the participating lab- funds from Canada's International De- oratories to recognize malaria parasites, velopment Research Center was completed and a number of courses were planned for and showed a high prevalence of rota- 1980 to remedy this. viruses. The laboratory obtained facilities Special care was taken to design the for hepatitis radioimmunoassay during the USAID/PAHO-supported training program in year. It is hoped that hepatitis testing such a way as to encourage the technicians will become routine in all blood banks to remain in the Caribbean, and not con- throughout the area. The first malaria anti- tribute to the already severe "brain drain" body tests were undertaken in Dominica problem there. A major constraint to con- and Grenada. Surveys for intestinal para- trolling communicable diseases in the Ca- sites were carried out in Belize, Dominica, ribbean has been the difficulty of the small and St. Vincent, and a special survey of 120 REPORT OF THE DIRECTOR

schistosomiasis was made in Montserrat. and council reviewed its program for 1979- Some preliminary work on Chagas' disease 80 in detail in March. The resulting report zoology in Trinidad also began. At the re- was presented and discussed at the Con- quest of Trinidad and Tobago, CAREC conference of Ministers Responsible for Health tinued to monitor Aedes aegypti at Piarco in the Caribbean held in Antigua in July. International Airport near Port-of-Spain France, which had earlier considered join- and on Tobago. Hospital infection studies ing the council, decided not to become a began in Barbados and Trinidad, and a member. request for similar help was received from In response to a XX Pan American Sani- Grenada. Research continued in strepto- tary Conference resolution (CSP20.31), an coccal disease, filariasis, and ischemic evaluation team was appointed to advise heart disease in Trinidad and Tobago. the Director on the review process for the Leptospirosis research was largely trans- 10 Pan American Centers and develop a ferred to Barbados. model procedure which might be used in The CAREC Surveillance Report was pub- evaluating them over the next five years. lished monthly with a circulation of 2,500. The model procedure, based on a self-audit During the year CAREC acted as host for by each Center's director and staff, was and participated in Caribbean meetings to first field-tested at CAREC to coincide with develop tuberculosis and leprosy control the five-year review of that Center required and veterinary public health strategies. In in the original multilateral agreement be- addition, it hosted a meeting on dental tween PAHO and the Caribbean govern- epidemiology. ments participating in CAREC's operation CAREC's scientific advisory committee during the decade beginning in 1975.

BIOLOGICALS

Biologicais are produced in 14 Latin polio, measles, and rabies vaccines will American countries by 28 government lab- more than double the country's present. oratories, only a few of which use rea- DPT production capacity within two years sonably modern equipment and effective of their inauguration in the near future, production methods and are economically and enough polio and freeze-dried atten- sound. Restrictions on the budgets of uated measles vaccines will be produced vaccine-producing laboratories have ham- to meet national immunization program pered the importation of the expen- requirements. sive equipment needed to meet the stan- In Chile, the Institute of Public Health dards recommended by WHO. Despite established a new pertussis department these difficulties, a few countries have and the existing equipment was being made genuine efforts to modernize their adapted for fermentation technology. laboratories. PAHO provided technical assistance in DPT Typical in this regard is Mexico. Its two and BCG vaccine production. new laboratories for producing DPT and A baseline survey of vaccine production DISEASE CONTROL 121

and control laboratories was undertaken it urges national vaccine producers to sub- in all five Andean Pact countries. At a mit their production and control protocols November meeting in Bogotá, Andean for auditing and their vaccines for testing experts recommended to their ministers of to one of four reference laboratories desig- health that national laboratories be nated by PAHO. These are the National strengthened and that a subregional bio- Virology Institute in Mexico for polio and logicais production laboratory for Pact measles vaccines, PAHO's Pan American countries be established with PAHO's co- Zoonoses Center in Argentina for rabies operation. and BCG vaccines, and two laboratories of Following an evaluation of the present the U.S. Food and Drug Administration's and future capacity'of the yellow fever Bureau of Biologics at Bethesda, Maryland, vaccine-producing Oswaldo Cruz Founda- for yellow fever and DPT vaccines. By com- tion at Rio de Janeiro and the National paring their results with those of the ref- Institute of Health at Bogotá, action was erence laboratory, national controllers initiated to step up production in the Re- have an excellent opportunity to improve gion through closer cooperation between their testing ability and establish self-confi- the two laboratories. dence in verifying the potency of vaccines. Lack of satisfactory government support From January to August, the reference lab- for improving control of the vaccines pro- oratory in Mexico tested 28 vaccine lots duced by national laboratories is a serious (14 polio and 14 measles), most of them shortcoming. Though the situation has im- referred from the field by EPI programs, proved over the past two years, a much while the U.S. Food and Drug Administra- greatereffortwill be required if Latin Amer- tion provided DPT reference services to ica is to become self-reliant in producing Colombia, Ecuador, Peru, and Venezuela the vaccines required for the Expanded during the year. With the establishment of Program on Immunization (EPI). Argentina, the yellow fever vaccine reference labora- Chile, and Mexico significantly improved tory, the quality of the seed used in Co- their controls. In Argentina, the depart- lombia to manufacture yellow fever vac- ment of control of the Carlos Malbrán Mi- cine could be ascertained. A stock of 20,000 crobiology Institute at Buenos Aires was doses of yellow fever vaccine donated by refurbished and a new wing was added to Trinidad and Tobago to CAREC was revali- accommodate laboratories for in vivo test- dated for six more months since on retitra- ing of bacterial and viral vaccines. In Chile, tion it was found to have maintained its small laboratory animal breeding was in- initial potency. tensified in better premises at the Institute To facilitate understanding of the im- of Public Health in Santiago, and the effi- portance of control, UNDP funds made it ciency of DPT vaccine production and possible to hold a course in Buenos Aires control operations began to be monitored. on viral vaccine titration for 12 participants At the National Health Laboratory in Mex- from Argentina, Brazil, Honduras, Jamaica, ico City, new sections were commissioned Mexico, Panama, and Venezuela. Two sim- and staffed. With the specific pathogen- ilar courses had been held in Mexico in free laboratory animal facility, they consti- 1978, and the 1979 course brought to 53 tute the National Biologics Control Labora- the total number of scientists trained in tory, which controls DPT, poliomyelitis, vaccine testing. and other vaccines. Reagents and international standards At the same time that PAHO helps in were sent to requesting laboratories. Two strengthening national control capabilities, preparations produced by an Austrian com- 122 REPORT OF THE DIRECTOR merical firm, an adsorbed diphtheria toxoid staff and industry representatives, held in and an adsorbed tetanus toxoid, which July, will be followed by additional consul- satisfied potency and stability require- tations to propose specific initiatives. ments, were distributed as PAHO working The recent stress on the economic im- references to national vaccine production pact of drug expenditures has not dimin- and control laboratories. ished PAHO's concern for assuring the Four WHO laboratory manuals-on the quality and safety of the products avail- production and control of diphtheria, tet- able in the Region. anus, and pertussis vaccines and laboratory In collaboration with the U.S. Food and design-were distributed to the Region's Drug Administration, PAHO sponsored the DPT manufacturers and controllers. First Inter-American Working Group on Drug Control at Washington in May to provide responsible government officials a forum for discussing experiences and identifying areas requiring international collabo- Quality Control of Drugs ration. Attending the meeting were specialists from 12 hemispheric nations, an Andean Pact representative, and observers from The expansion of health care coverage the drug industry. must be accompanied by ever-available The workshop recommended that PAHO drugs relevant to the needs of the popula- should: (1) collaborate with its Member tion. To satisfy growing requirements within Governments in increasing activities to budgetary limits, Member Governments train personnel to staff drug control pro- are recognizing, and PAHO is promoting, grams; (2) step up transfer of information the importance of carrying out compre- in its drug control program; and (3) bring to hensive national drug policies to rational- the attention of the international drug in- ize pharmaceutical supply at all levels- dustry the conclusion of the working group from the selection of basic drugs and assess- that an international code of ethics is ment of their quality to their distribution needed for all aspects of drug promotion. and use. The increasing number of national In November a working group on refer- formularies and interest in subregional ence standards in Latin America organized formularies are significant developments by the Drug Quality Institute (DQI) at Sáo in this respect. Paulo recommended the establishment of During the year PAHO initiated dis- hemispheric reference standards through cussions with representatives of the Latin technical collaboration among interested American pharmaceutical industry to de- countries as a strategy for ensuring the fine the areas in and conditions under availability of these important substances which manufacturers can contribute to the in official and private quality control lab- public health sector's expanding activities. oratories. The discussions were planned in response During the year PAHO distributed two to a XX Pan American Sanitary Conference pilot issues of a pharmacologic newsletter resolution in 1978 which requested PAHO in Spanish to help satisfy the urgent need to strengthen relations with the pharma- of government officials in Latin America ceutical industry in order to identify areas responsible for drug registration and con- for cooperation with countries' health pro- trol for up-to-date information on drug grams. The initial meeting between PAHO safety and efficacy. To expand readership, DISEASE CONTROL 123 the information on drugs will appear quar- difficulties in recruiting professional staff. terly as a special eight-page section of the Under the agreement establishing the lab- Boletin de la Oficina Sanitaria Panameri- oratory, PAHO will provide advisory serv- cana. ices, fellowships for training scientists DQI and two universities in Brazil have assigned to the laboratory's permanent begun a program to develop national stan- staff, and a grant to finance the salaries of dards, and DQI is expected to have a sig- the professional complement. Jamaica will nificant role in coordinating hemispheric provide the laboratory's building and oper- activities in this area. ating costs. CIDA will furnish equipment In 1979, DQI undertook extensive training and supplies. The CARICOM member coun- and advisory activities to strengthen the tries will recruit the laboratory's profes- managerial and technical capabilities of sional staff and assess contributions from the national agencies responsible for ap- the participating countries for operating proving and controlling drugs. Of special expenses. note were its first seminar on pharmaceutical legislation with government, university, and industry participation and its continued collaboration in reorganizing the Blood Banks federal drug control laboratory at the Os- waldo Cruz Foundation in Rio de Janeiro. A UNDP-financed mission collaborated The Region's blood transfusion services with Guatemala's authorities in evaluating are developing slowly. Though the pro- the need and developing a work plan for portion of blood supplied by replacement an effective national drug control program. donation has assuredly increased over the In Panama, a study of the national labora- past few years, the quality of blood remains tory confirmed its potential as a sub- in doubt since only a few central labora- regional training center for pharmaceutical tories carry out quality assurance. More analysis. countries are passing regulations which PAHO collaborated in the series of semi- need to be implemented. In Trinidad and nars organized by the Institute of Pharma- Tobago a national blood bank committee cology and Nutrition in Argentina and in a was established in 1979, and with PAHO's regional clinical pharmacy course held at technical cooperation a plan is being drawn the University of Chile in August. up for a central blood bank which may be- At the end of the year Jamaica finished come a focus for a national service. PAHO building the Caribbean Regional Drug Test- continued its cooperation with the Ameri- ing Laboratory (CRDTL), a joint venture of can Red Cross, the League of Red Cross the Caribbean Community (CARICOM), the Societies, and the International Society of Caribbean English-speaking countries, Blood Transfusion by participating in their PAHO, and the Canadian International De- activities and sponsoring scientists from velopment Agency (CIDA), but inauguration the Region to attend their meetings. of the laboratory was delayed because of 124 REPORT OF THE DIRECTOR

EMERGENCY PREPAREDNESS AND DISASTER RELIEF COORDINATION

The vulnerability of Member Countries and travel were required to stimulate the and their health services to natural and interest of agencies that have traditionally man-caused disasters increased in 1979. supported PAHO's activities as well as or- Volcanic eruption in St. Vincent; floods in ganizations that have not funded PAHO Bolivia, Brazil, Jamaica, Nicaragua, and programs in the past. Paraguay; earthquakes and tidal waves in Negotiations were successfully com- Colombia, Mexico, and Peru; civil dis- pleted in 1979 with CIDA and USAID. CIDA turbances in Central America; hurricanes approved a four-year, $385,860 grant to David and Frederick in Dominica, the Do- PAHO to fund activities to promote emer- minican Republic, and Haiti-all caused gency preparedness in countries of the great loss of life and had long-term effects Americas prone to natural disasters. The on the countries' progress toward better Canadian contribution will pay for con- health and primary care. sultants who will help refine the health Most countries in the Region still lack component of their plans and institutions health sector foci and programs to prepare that deal with emergencies. The new funds or update disaster plans and train necessary will also be used for producing technical health personnel, and their absence in the guides and field manuals on public health immediate aftermath of disasters has been management in disaster situations, and for felt severely. Manuals, guides, and training training selected high-level officials. Also aids on disaster management are still either included in the program are local training lacking or inapplicable to the specific con- courses on emergency relief for staff mem- ditions of most of the countries. bers and nationals, as well as other semi- Recent disasters and PAHO's sustained nars. USAID will contribute $129,260 to efforts to prepare for catastrophes have re- PAHO for one year to support the develop- sulted in much greater political awareness ment of a continuous training program in of the need for an emergency preparedness emergency preparedness and health man- program in each country. Several Latin agement following disasters. Additional sup- American countries have designated an port was being negotiated with the Swedish official to be responsible for such programs International Development Authority and or as a focal point in case of disaster. In the European Economic Community. October the Directing Council adopted a Compilation of a roster of emergency resolution (CD26.36) urging the countries to experts who could be available on short establish high-level multisectoral groups to notice was begun in 1977. More than 150 coordinate all relief measures and con- persons in Member Countries were re- tinuous programs to update emergency quested to provide biographic data. A low plans, train health personnel, and promote response rate and the prerequisite of ex- research and case studies to improve disas- tensive experience in disaster management ter management. prevented satisfactory extension of the Because PAHO's regular budget is not roster. large enough to support a full emergency A list of essential drugs to be stockpiled, preparedness program at the level required requested, or donated in case of natural for rapid progress in this area, much time disasters was prepared and circulated to

126 REPORT OF THE DIRECTOR

A major constraint on PAHO's coopera- PAHO's future activities in this area will tion after disasters is budget. Besides the include: (1) strengthening local technical reallocation of country program funds, cooperation through extrabudgetary fund- the only source of funding is the Natural ing of advisers' posts and activities; (2) Disaster Relief Voluntary Fund, which was promotion and support of a permanent initially created with $100,000 in 1977. No focal unit in each health ministry; (3) for- contribution was received in 1979, which mulation of plans to fly selected senior of- severely curtailed PAHO's ability to provide ficials of disaster-prone countries to other additional relief supplies to disaster- countries in the Region experiencing disas- affected countries, and informal contacts ters to acquire indispensable, first-hand with other agencies and governments to experience during emergency situations and spur donations did not meet with great aid PAHO in its local recovery assistance success, largely because they prefer to efforts; (4) organization of six-day hemi- make direct donations. Such agencies and spheric courses in Spanish and English on governments did show interest in support- disaster management for high-level relief ing PAHO's technical cooperation in disas- coordinators and health administrators; ter management, and negotiations with and (5) development of PAHO's ability to them for funds to assess needs and dis- provide immediate cooperation and assess tribute technical information promised to health needs after disasters. be successful.

[] E[ Chapter 5 ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS

ENVIRONMENTAL HEALTH

Urbanization and industrialization con- still a main cause of infant and child mor- tinue to increase at an accelerated pace tality, particularly in areas in many coun- in Latin America and the Caribbean. The tries lacking adequate potable water sup- population projected for the Region in the plies, basic sanitation, or both. year 2000 is more than 600 million, or The International Drinking Water Supply double that of 1970. The continued mas- and Sanitation Decade (1981-90), it is sive shift from rural to urban areas means hoped, will provide these basic needs to that 76 per cent of the Region's total the rural and urban poor. The Water Dec- population will live in communities of ade, as this endeavor is often called for more than 20,000 at the beginning of the short, grew out of the United Nations next century. Industrialization is increas- Water Conference at Mar del Plata, Argen- ing, and it has been estimated that the po- tina, in March 1977, and is a globally co- tential for development is several times ordinated effort to ensure that all the present levels. Thus, population growth, world's peoples have adequate drinking the shift to urban areas, and increased in- water and basic sanitation by 1990. As dustrialization characterize and accentu- emphasized in the Technical Discussions ate environmental health concerns in the at the Directing Council meeting in Sep- Americas. tember 1979, however, the major con- Water supply and sanitation continued straints of the past will have to be solved to tobe a major problem in most countries bring about rapid progress in this area. during 1979. At the end of 1978,155 million Solid waste management, despite the people had house connections or easy concern of health and other authorities, access to water supply systems and 84 mil- continues to be a growing problem. Large lion had access to sewerage systems in metropolitan areas are particularly sus- urban areas. In rural areas only 43 million ceptible to crises in solid waste collection, had house connections or easy access to as was the case in 1979 in two Latin Ameri- water supply systems and three million had can capitals where emergency measures access to sewerage systems or sanitary had to be taken to avert major environ- excreta disposal. Intestinal diseases were mental disasters. The countries now have

127

130 REPORT OF THE DIRECTOR

a greater understanding of the problem Many Member Governments have taken and are initiating solid waste management or are about to take measures to assess plans or preparing them for national or pollution levels and establish controls. international financing. The energy crisis, which now affects many Air, water, and soil pollution and food of the countries, may nevertheless delay contamination are becoming increasingly such actions or may force reassessment conspicuous in many urban areas, espe- and adjustment of present plans. cially in the more industrialized countries. As more information becomes available,

Figure 9. Urban and rural population served by water supply and sewerage systems, Latin America and subregions, 1978 or latest year.

Population (míiíons) Served Not served 200 150 100 50 100 150 I' lI i Latín America

Continental Middle Americaa

Caribbean b

Tropical South Americac d TemperateI SouthI America

t~~~~~~~~~

Latin America

Z --Urban population Rural population

a Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Parms bBahamas, Barbados, Cuba, Dominica, Dominican Republic. Guadeloupe, Haiti, Jamaica, Montserrat, St. Kitts, Trinidad and Tobago, Virgin lslands (UK) c Bolivia, Brazil, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Venezuela

dArgentina, Chile, Uruguay ENVIRONMENTAL AND ANIMAL HEALTH PROCRAMS 131

very high occupational disease and ac- and improving potable water supply and cident rates are confirmed and Mem- excreta disposal services during the 1980s. ber Governments are becoming aware of Briefly these include: obtaining support at their importance not only as health prob- the highest governmental levels for ex- lems but also as impediments to increased panding basic sanitation services as an production. essential component of national develop- PAHO's areas of cooperation in the en- ment plans; collecting, analyzing, and dis- vironmental sphere are water supply and seminating detailed information about the basic sanitation, solid waste management, water supply and sanitation sector for the institutional development, environmental preparation of plans, programs, and pro- and other health hazards and pollution ject development; overcoming institu- control, occupational health, radiation tional weaknesses at all levels; improving health, and fluoridation. the coordination of responsibilities among agencies; developing national training systems for manpower development; and overcoming economic and financial con- Water Supply and Basic Sanitation straints. PAHO's water supply and sanitation pro- The need to extend water supply and gram in 1979 was oriented to immediate sanitation services has been a constant and short-term needs as well as to provid- concern of the Region's health authorities ing support for medium- and long-term de- for many years. In 1961 the Charter of velopment within the framework of the Punta del Este, and in 1972 the Ten-Year International Drinking Water Supply and Health Plan for the Americas, recom- Sanitation Decade. mended water supply and sanitation serv- To strengthen national capacities for ice goals. Despite the progress made, 120 identifying and developing projects meet- million people were still without house ing the requirements of national and in- connections or easy access to water sup- ternational financing agencies for support, plies and 228 million without sewerage or PAHO and the World Bank conducted sec- excreta disposal facilities in Latin America tor surveys of the water supply and sanita- and the Caribbean at the end of 1978. tion situation and needs in Argentina, Bra- The goal of providing drinking water zil, Colombia, Costa Rica, El Salvador, and sanitation services to as many people Haiti, Honduras, Nicaragua, Panama, Para- as possible by 1990, stressed at the United guay, and Venezuela. With support from Nations Water Conference of 1977, pro- the Federal Republic of Germany's Gesell- jects the expectation that most of the 335 schaft fur Technische Zusammenarbeit million people in urban and 146 million (GTZ, or Agency for Technical Coopera- people in rural areas will have adequate tion), under its collaborative agreement water supply and sewerage or excreta dis- with WHO, project identification missions posal facilities by 1990. But major progress were sent to Bolivia, El Salvador, Haiti, and will depend on overcoming some of the Honduras. Similar missions were carried same constraints encountered during the out with support from the Caribbean De- past two decades. velopment Bank for the British Virgin The Technical Discussions at the Sep- Islands and St. Kitts-Nevis. It is expected tember meeting of PAHO's Directing Coun- that by early 1980, 18 country surveys cil recommended strategies for extending covering 97 per cent of the population of

134 REPORT OF THE DIRECTOR

Institutional Development to run it. To assist in the transition phase, Brazil requested and PAHO agreed to support the project for six additional months. A sound sector infrastructure is recog- The first year of Chile's National Sani- nized as an important element in improving tary Works Service projec.t was completed. the planning, construction, operation, and A PAHO staff member and three short-term management of environmental health serv- consultants helped implement the project, ices. PAHO collaborated with 13 Member whose entire financing is domestic. Because Governments in establishing and strength- of limitations in obtaining external support ening the national institutions responsible to continue the project, the agreement for providing water supply and sanitation signed with PAHO was terminated at Chile's services at various levels. These projects request. are financed through international finance A project to assist Guatemala's rural organizations such as IDB, the World Bank, water supply and sanitation program en- UNDP, and bilateral agencies, or are funded tered the phase of carrying out recom- directly by the water authorities and other mendations and adjusting the organiza- national institutions. PAHO consultants tional structure. cooperated by providing advisory services In Haiti, PAHO helped implement the in varied administrative and managerial Central Autonome Métropolitaine d'Eau areas including training. Potable (CAMEP) project begun at the end In Barbados, PAHO cooperated with na- of 1976, which is to provide water for Port- tional authorities in carrying out compre- au-Prince, assisted in designing CAMEP's hensive administrative studies for a new legal framework and organization, and ad- national water and sewerage authority. vised on improving commercial operations The institutional development project and technical services. Technical and ad- started by Brazil's National Housing Bank ministrative advice was also provided to with PAHO's cooperation in 1974 for the the Service National d'Eau Potable (SNEP), state water and sewerage authorities will started in October 1977, on developing end in January 1980. During its five years water supplies for Haiti's 10 next largest the project completed most of its scheduled towns during the period 1978-81. The $6.6 preliminary investigations, institutional million loan from the World Bank Group's evaluations, information analyses, and soft loan agency, the International De- preparation of institutional models. In 1979 velopment Association, includes technical efforts centered on completing the institu- cooperation to strengthen SNEP. PAHO co- tional models and applying them to the 21 operated in developing guidelines for bid- participating state water and sanitation ding and contracting, standards develop- authorities. Designed to establish or im- ment, community operation development, prove the managerial functions of planning, and training. commercial operation, finance, and admin- As a further step in the institutional de- istrative support, the models may be ap- velopment of Uruguay's sanitation service, plicable to institutions in other countries. the national authorities signed an agree- A proposal to adapt the models for such ment with UNDP in May to carry out a tech- use is under development. As a result of its nical cooperation program to strengthen final evaluation, the National Housing the service's finance and accounting units Bank has incorporated the project among and prepare a plan for improving Mon- its regular programs and has created a unit tevideo's water supply system. PAHO is the ENVIRONMENTAL AND ANIMAL HEALTH PROCRAMS 135 executing agency for the two-year, $300,000 ical Control of Water and Wastewater UNDP-supported project. Uruguay's con- Laboratories (PRELAB); and the Pan Amer- tribution is estimated at $485,000. ican Environmental Engineering and Sci- ences Information and Documentation Network (REPIDISCA). During 1979 CEPIS collaborated in the Pan American Center for research activities of nine institutions in Sanitary Engineering and five countries covering such topics as low- cost water supply and wastewater disposal Environmental Sciences technology, wastewater characteristics and treatability, and the health aspects of The Pan American Center for Sanitary wastewater reuse in agriculture. An intra- Engineering and Environmental Sciences mural research project on rural modular (CEPIS) was founded in Lima in 1967 with treatment plants, financed by WHO, was the cooperation and financial assistance of completed in 1979 and a draft final report Peru. It functions as a technology transfer was distributed for comment. The project point in the specialized areas of commu- resulted in the proposal of nine modular nitywatersupply and quality control, waste- plant designs and three pretreatment alter- water disposal, air and water pollution con- natives suitable to communities of 500 to trol, solid waste management, industrial 20,000 inhabitants. Investigations of water hygiene and occupational health, environ- pretreatment have permitted the developmental systems analysis, laboratories, and ment of models of slow sand filtration technical information. plants for treating water with high turbidity Within the framework of the environ- without the use of coagulants by employ- mental health protection program de- ing gravel roughing filters. Additionally, in veloped by PAHO's Headquarters in close collaboration with the water authorities in collaboration with its field offices, CEPIS Paraná, Brazil, and Lima, a very efficient provides technical support in the four basic hydraulic flocculator using porous media areas of technical cooperation, research, has been developed. training, and information exchange. Also during the year, an evaluation of During 1979 CEPIS' consultants partici- the San Juan Stabilization Ponds near Lima pated in 38 service missions in 21 countries was completed in collaboration with sev- in the Region. These missions occupied a eral Peruvian institutions. (A stabilization quarter of the professional staff's time. pond is an oxidation lagoon for stabilizing CEPIS' technical cooperation activities sewage.) The final reports were sent to the also included coordination and develop- sponsoring agency, the International De- ment of seven regional or subregional pro- velopment Research Center (1DRC) of Can- jects: the two Global Environmental Moni- ada. The findings from this project point toring Systems (GEMS/WATER and GEMS/ out the importance of taking into account AIR) financed by the United Nations En- problems of pathogen and parasite survival vironment Program (UNEP) and the United in reused wastewater and provide design Nations Educational, Scientific, and Cul- criteria for stabilization ponds in develop- tural Organization (UNESCO); the Pan Amer- ing countries. An important by-product was ican Air Pollution Monitoring Network the development of procedures for study- (REDPANAIRE); the Andean and English- ing stabilization ponds in such countries. speaking Caribbean occupational health In the training area, CEPIS' consultants programs; the Regional Program for Analyt- collaborated in 12 national courses, which

138 REPORT OF THE DIRECTOR activities in primary health services and PAHO participated in a workshop on basic working environment sanitation pro- national occupational health standards grams, and the development of adequate sponsored by the U.S. Society for Occupa- preventive techniques and control activi- tional and Environmental Health's interna- ties in small industry, could significantly tional commission at Mont Ste. Marie, reduce the present high incidence of work- Quebec, in November. The workshop was related disability. Attention should also attended by 73 participants from industri- be paid to cancer-producing substances in alized and developing countries. the working environment which could re- Solid wastes. During the year, a solid sult in serious long-range health problems. waste management adviser joined CEPIS' Epidemiologic studies that would show staff and provided assistance to five coun- the importance of such substances should tries. Two types of activities were em- be undertaken in some Latin American phasized: planning, organization, and ad- countries. ministration of solid waste services, and CEPIS cooperated with the Andean Pact identification of technical problems in occupational health advisory commission solid waste management and their immedi- in developing its program, including the ate and long-term solutions. As examples, establishment of an occupational health Chile was advised on the establishment of information system. In Barbados, Jamaica, a national solid waste service beginning and St. Lucia, CEPIS made preparatory with a survey of present conditions. In Peru, arrangements to undertake a survey of Iquitos received help in evaluating its col- occupational health problems to be sub- lection and disposal methods, while insti- mitted to a May 1980 workshop at which tutional development and technical prob- an occupational health program will be lems were analyzed in Cuzco. developed for the English-speaking Carib- DTIAPA. In February the special three- bean countries. The International Labor year program DTIAPA project was begun to Organization provided similar assistance develop water supply and sewerage insti- to other Caribbean countries. The Carib- tutions technologically. It is based on an bean Community Secretariat coordinated agreement for nonreimbursable technical both efforts. cooperation between IDB and Peru in col- In all, PAHO gave advice on industrial laboration with PAHO, with CEPIS acting as hygiene and occupational health to 11 the executing agency. The total cost of the countries (Barbados, Chile, Colombia, program has been estimated at $1,780,000, Ecuador, Guyana, Jamaica, Mexico, Pan- of which IDB will contribute $1.3 million ama, St. Lucia, Trinidad and Tobago, and and PAHO and Peru the remainder. The pro- Venezuela). Apart from the activities listed gram places particular emphasis on im- above, emphasis was placed on planning, proving the operation and maintenance implementing, and evaluating industrial capabilities of water institutions, and its hygiene programs and training. A typical activities are organized like those of CEPIS: case was the technical assistance given to scientific and technical cooperation, train- Colombia's Health Ministry in formulating ing, research, and information. an integrated industrial sanitation program In the area of training, three meetings and preparing an evaluation of the effects were held during the year: a forum on tech- of occupational health problems on the nologic development of water supply agen- country. In Mexico, a course was given cies, a symposium on water supply and on safety in water supply and sewerage sewerage system operation and mainte- services. nance, and a workshop for operation and ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 139 maintenance engineers in water services. In the environmental and health impact In all, 77 professionals from 13 countries assessment area, ECO and other PAHO units attended these meetings. Two courses were cooperated with the Yacyretá authority, also held in coordination with Peru's na- which is responsible for the construction of tional industrial worker training service for a multibillion-dollardam atYacyretá Island supervisory water service personnel, with in the Paraná River between Argentina and 46 participants from 14 countries. Paraguay. Future construction there will Technical cooperation and research involve 12,000 workers, displace 45,000 activities were initiated in collaboration people, and inundate 80,000 hectares by with the Peruvian Health Ministry to evalu- the time the massive barrage, whose tur- ate the present state of rural water systems bines will generate 4,500MW, is completed. built by the ministry. At the request of the Argentine and Para- With regard to technical information ex- guayan Governments, a multidisciplinary change, a quarterly newsletter was started team from PAHO visited the Yacyretá area to report on project development and in October-November to analyze the pro- promote the use of appropriate technology. ject's likely impact on human health and The first issue appeared in June, and the the environment. After finishing its de- newsletter now has a pressrun of 4,000 tailed study, the team made two basic copies. Two articles on operation and recommendations: that the two govern- maintenance were also translated into ments strengthen basic health services in Spanish, printed, and widely distributed. districts adjacent to the future dam since Plans are being made to organize a na- its impact on the health status of the local tional REPIDISCA collaborating center population is expected to be both im- through the DTIAPA program. mediate and widespread, and that the dam construction authority reinforce its staff with public health experts to work with other health agencies in improving epidemiologic services in the area. Pan American Center for Human The Center continued its collaboration Ecology and Health with the Salto Grande Authority of Argen- tina, which with Uruguay completed construction of a $1.2 billion dam on the Uru- The Pan American Center for Human guay River during the year. The electricity Ecology and Health (ECO) in Mexico con- generated by the dam will increase Argen- tinued to develop as planned in the five- tina's power supply by half and double year program the Governing Bodies ap- Uruguay's. ECO's principal task was analysis proved for it in 1977. Progress was made to of the physical, mental, and social health the point where the emphasis of ECO's problems of the 8,000-person Salto Grande work changed from program development dam work force and their families; it also to implementation. The second phase will studied the health problems of the 10,000 be further accelerated in 1980 when ECO people displaced by the construction in moves to new facilities at Toluca and its Argentina. present complement of six professional ECO also provided technical advice to staff members increases to nine. the Bolivian national colonization institute ECO's activities during the year followed in evaluating the health aspects of a settle- the five main program areas in its original ment project at San Julián in northern program. Santa Cruz Department. The recommenda-

ENVIRONMENTAL AND ANIMAL HEALTH PROCRAMS 141

Radiation Health age, PAHO worked with national authorities and manufacturers to organize a clinical field trial of a basic radiology system Most of the population of Latin America which will take place in Colombia over and the Caribbean, particularly in rural about two years. The trial will include the areas, does not have access to radiodiag- training of operators, who should be pre- nostic services. Many hospitals in the Re- pared in three months and who preferably gion do not have basic diagnostic X-ray will be residents of the communities in equipment or professionals adequately which they are to work, and general med- trained to use it. This situation is aggravated ical staff, who should be prepared to evalu- by too few and relatively untrained techni- ate the most common radiographic pro- cians who often have to cope with over- cedures accurately. Special experimental elaborate equipment prone to breakdowns. prototypes of a simplified X-ray machine In most countries the medical student gets which has been developed according to no experience in radiologic services before PAHO specifications and is easily installed, beginning his career, while schools for operated, maintained, and able to perform X-ray technicians are few in number and well under adverse conditions will be used. vary greatly in quality. In the radiotherapy area, the program to In countries with well-developed cancer improve dosage accuracy through a ther- control programs it has been estimated moluminescent dosimeter intercomparison that about half of all patients receive radio- study was expanded to include high-energy therapy during the course of their iliness. linear accelerators. This is a comparison It is generally agreed that tumor doses between the expected or calculated radia- must have an accuracy of about 7 per cent tion output of a radiotherapy machine in for treatment to be effective. Yet in many a participating national center and the countries the required supporting staff and measured radiation dose received by a equipment for accurate dose delivery are thermoluminescent dosimeter placed in unavailable. In addition, there are extremes the radiation beam. The calculation is between the very modern and sophisticated performed by the participating center and equipment in the Region's relatively few the measurement by the International advanced centers and the obsolete equip- Atomic Energy Agency (IAEA) laboratory ment in other hospitals. at Vienna, Austria. Begun in 1970, the pro- Many patients, workers, and community gram is chiefly financed by IAEA, which members are exposed to unnecessarily high provides the necessary dosimeters and radiation doses, but radiation protection accessories, laboratory measuring equip- services have not been established in many ment, and technical laboratory staff. WHO countries and are rudimentary or have de- and PAHO cooperate by coordinating the teriorated in others. participation of national health authorities With the trend toward the ever-increas- and providing followup consultation. Dur- ing use of radiation in medicine and indus- ing the year, 34 centers in Canada, Chile, try, public health administrators urgently Colombia, Ecuador, El Salvador, Peru, require guidelines for rationally planning, United States, and Uruguay participated in building, staffing, and equipping all types the continuing study of cobalt-60 radio- of radiologic services. therapy units, while seven centers in Argen- Recognizing the essential need to con- tina, Brazil, Canada, and Mexico began tribute to the efficient operation of primary taking part in the pilot linear accelerator health services to extend health care cover- study. 142 REPORT OF THE DIRECTOR

Suriname was advised on ways to radiologic risks, development of national strengthen its radiotherapy services and regulations, and radiation protection activ- increase radiation safety. Consultation ities were provided through on-site collab- was provided concerning manpower and oration in Argentina, Bolivia, Ecuador, training requirements, equipment, record- Honduras, Mexico, and Peru. Legislatively, keeping, and procedures. radiation protection is fairly advanced in Quality assurance in radiation medicine Latin America and less so in the Caribbean; was stimulated through a nuclear imaging considerable gaps sometimes exist be- procedures workshop which PAHO and the tween expressed legislative intent and Latin American Association of Biology and effective enforcement, however. Nuclear Medicine Societies (ALASBIMN) Contact was maintained with the activi- organized. ALASBIMN, established in 1964, ties of various authoritative international now comprises 13 national or subregional organizations such as the International societies. Commission on Radiation Units and Meas- A survey whose results will be published urements and the International Commis- in 1980 was made of Spanish-language sion on Radiological Protection to assure teaching materials for X-ray technologists. relevance and uniformity in PAHO's efforts The Bibliography of Recent Publications to promote the use of internationally ac- containing author and titie entries from 16 cepted radiologic standards throughout journals was distributed monthly to radio- the Region. logic workers throughout the Region, as was ALASBIMN's newsletter. Additionally, technical publications, guides, and reports were disseminated to national radiologic Fluoridation institutions upon request or as the need was perceived. Invited by Argentina, Colombian and The incidence of dental caries is very Mexican experts collaborated with na- high in the Region. In one country, 98 per tional experts and PAHO to work on the cent of schoolage children in the capital second volume of a basic teaching and and 91 per cent of those in the surrounding reference manual on radiation protection. countryside were found to have cavities. Volume I of this manual is undergoing The situation is similar in other countries. final editorial revisions and is expected to The use of fluorides to prevent dental be published in 1980. In conjunction with caries has proved effective when adminis- work on the manual, the experts cooper- tered in different fluoridation vehicles. ated in presenting a basic course on radia- Drinking water and table salt fluoridation tion protection in October for 110 physi- are public health measures that are easy to cians and dentists, mostly from Argentina. carry out, inexpensive, and highly effective. A cooperative program to measure en- The use of fluoride tablets, solutions, gels, vironmental radiation exposure in eight and pediatric drops are urged in the absence participating countries (Argentina, Colom- of mass measures or as complementary bia, Ecuador, Guyana, Jamaica, Mexico, dental health measures. Peru, and Venezuela) using thermolumines- Drinking water is now fluoridated in 12 cent dosimeters was coordinated in con- countries, and will be in three more in junction with the public health school of 1980. The total population with access to the University of Texas at Houston. Techni- fluoridated water supplies in Latin America cal cooperation and guidance concerning and the Caribbean at the end of the year ENVIRONMENTAL AND ANIMAL HEALTH PROCRAMS 143 was almost 40 million. Water fluoridation, the fluoride is removed from water as a already a practice in many other major regular practice. The other countries voiced Latin American cities, was begun in De- interest in adopting this practice. cember at the Guandú plant serving Rio de The emphasis in PAHO's assistance in Janeiro. 1979 was on training professional and tech- Salt fluoridation has been studied in nical staff in standard fluoridation tech- Colombia, and plans are being laid for its niques. This included promotional activi- wide use there and in Mexico. This measure ties, preliminary studies, project prepara- will specially benefit rural areas and small tion and implementation, operation and communities where water fluoridation is maintenance of fluoridation systems, fluor- not practicable. Salt fluoridation was dis- idation research, and training other fluor- cussed at the Directing Council meeting in idation workers. Short courses conducted September. It was noted that, in addition to in Costa Rica, El Salvador, Guatemala, Colombia and Mexico, Anguilla and St. Panama, and Paraguay were attended by Lucia were actively considering salt fluori- about 150 participants. The development dation, and the resulting resolution en- and use of simply designed and inexpen- couraged other countries to weigh this sive dosing equipment was promoted and measure. information disseminated about it. PAHO Naturally overfluoridated drinking water also collaborated in research to determine is a serious problem in some parts of Argen- and control natural fluoride in water in the tina, El Salvador, Mexico, and Peru. Argen- four countries and provided laboratory tina is now the only country where part of equipment for fluoride analysis.

TRAFFIC ACCIDENT PREVENTION

Traffic accidents continued to increase to reduce the magnitude of the problem. in the Region during 1979. Among other During 1979 the following significant factors, this was due to population growth, events occurred in this area: the increase in the number of motor * PAHO contributed to WHO's global traffic vehicles in use, and the absence of accident prevention program. measures and programs to prevent and * WHO held interregional meetings at control accidents. These very facts have Copenhagen and Paris to plan a 1981 interna- stimulated interest in some countries such tional conference on traffic accident prevention as Mexico and those in the Caribbean. In in developing countries. The possibility is now being considered of holding the meeting in one Mexico, the subsecretariat of health and of the Americas. welfare launched a national traffic acci- * In preparation for the conference noted dent prevention program at the end of the above, a survey was carried out in the world's year. The Caribbean countries requested developing countries to determine the mag- PAHO's technical cooperation through nitude and nature of the accident problem. Ar- gentina, Chile, Colombia, Costa Rica, Ja- CARICOM in conducting a study of the traf- maica, Mexico, Peru, and Venezuela parti- fic accident situation and, on the basis of cipated. that analysis, in preparing action programs · A seminar jointly organized and financed 144 REPORT OF THE DIRECTOR

Figure 10. Deaths due to motor vehicle accidents per 100,000 population, by age and sex, in Northern America and Latin America, 1977 or latest year.

70- Males 60-

50- Malesj

40-

30- Femalesj o - Females o. 0 o. 20- o o 0 o o

" lo-

4 - 1 I 20I I 40 60 80 0 1 0 20 40 60 8o00 20 40 60 80 Age in years Northern America Latin America

by PAHO and the World Bank was held in June PAHO representative presented a paper on traf- on traffic accidents in developing countries. Its fic accidents in Latin America. final report contains useful suggestions to both * PAHO was represented at two meetings in organizations for promoting prevention ac- Washington organized by the Transportation tivities in interested countries. Operations Research Institute, a private or- * PAHO was invited to take part in the First ganization interested in promoting coordination International Seminar on Medicine and Traffic among agencies that in one way or another con- Accidents at Toluca, Mexico, in June, and a cern themselves with traffic accidents. ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 145

* In response to the interest shown by various policies and programs, supporting the countries, the Director decided to extend the training of professional and technical per- hemispheric program by assigning it additional sonnel, using comparable nomenclature funds in order to hire a full-time epidemiologist. and information systems, and dissemi- In the immediate future PAHO's efforts nating technical information on traffic will be aimed at promoting epidemiologic accidents and their prevention. research, helping to define prevention

CONTROL OF TOXIC SUBSTANCES

Human illness and death from ingestion materials in their attempts to resolve the of or contact with toxic substances con- problems associated with the continued in- tinue to increase in frequency and severity discriminate use of toxic substances. in the Region, but agriculture and health Technical advice on laboratory procedures authorities appear reluctant to establish and equipment was provided to the U.S. ministerial policies to bring these sub- treasury department for its surveillance of stances under effective control. pesticides in foreign and domestic al- PAHO gave Argentina, Barbados, Costa coholic beverages, and information was Rica, Ecuador, Mexico, and Trinidad and provided to the Michigan department of Tobago technical advice and reference agriculture.

FOOD PROTECTION

At the Conference of Ministers Responsi- Ministries of Ecuador and Peru develop na- ble for Health in the Caribbean, held in An- tional food protection programs for which tigua in July, a resolution was adopted call- it and the UNDP have provided financial ing for a food safety policy and strategy for support. Implementation will begin in the English-speaking Caribbean. This re- 1980. flects the growing interest of Member Guatemala's Ministry of Health has formu- Governments in improving food protection lated a national food protection program services. The increasing cost of food in with the technical cooperation of PAHO domestic and world commerce has led to consultants. The Unified Food Control awareness that reducing domestic food Laboratory will provide laboratory support losses could help a country's balance of for this project as well as Guatemala's drug payments and lower the expenses of control program. treating patients with food-borne infec- PAHO's adviser to the Guatemalan tions and intoxications. laboratory also collaborated with the PAHO helped the Health and Agriculture health authorities of Colombia in eval- 146 REPORT OF THE DIRECTOR uating their national, regional, and professionals and three national courses, local food control laboratories. two in Colombia and one in Peru, were con- The hemispheric educational program in ducted jointly with national authorities. food protection, in collaboration with the The national courses covered seafood and National School of Public Health at Me- poultry inspection and administration of dellín, Colombia, graduated 16 food inspec- food protection programs. A total of 62 tors from its 22-week course on food pro- professionals participated in the three tection. Three of the students were from courses. In September PAHO aided a na- other countries. tional course for food inspectors in Costa An international milk hygiene course for Rica.

ZOONOSES AND ANIMAL HEALTH

It has been estimated that by effectively American countries, Mexico, and Panama, controlling and eradicating foot-and- and its main objective is to prevent the in- mouth disease and the zoonoses, the troduction of exotic plant and animal amount of animal protein needed by man diseases into those countries; COSALFA, could be increased by 25 per cent without which meets once yearly and uses increasing livestock populations. More PANAFTOSA as its secretariat, comprises than 200 diseases transmissible from the South American countries. animais to man (zoonoses) are of major In Barbados, the veterinary services medical importance, especially to mar- undertook to develop an effective program ginal rural populations living in contact of zoonosis epidemiologic surveillance, with domestic animais and close to wild and a free bovine tuberculosis diagnosis animais. program for small livestock owners was of- For these reasons, PAHO has always fered for the first time. The rodent control assigned great importance to collaborating unit was reorganized and personnel were with the Region's countries in their pro- trained appropriately. grams to control these diseases. This is Veterinary public health programs were done at Headquarters, in the field, and at carried out normally during the year in the Pan American Zoonoses Center Bolivia, Colombia, Ecuador, and Peru. In (CEPANZO), Ramos Mejía, Buenos Aires Pro- Colombia, 200,000 horses were vaccinated vince, and the Pan American Foot-and- against Venezuelan equine encephalitis, Mouth Disease Center (PANAFTOSA), Rio de and a national brucellosis and food micro- Janeiro. In all animal health and veterinary biology program was begun. CEPANZO col- public health activities, close contact has laborated with Ecuador in modernizing and been maintained with WHO, FAO, UNDP, standardizing its milk inspection labora- the International Regional Plant and tories and in revising existing dairy product Animal Health Organization (OIRSA), the standards and regulations. South American Foot-and-Mouth Disease During 1979, most of Brazil's animal Control Commission (COSALFA), IDB, min- health resources were devoted to control- isters of health and agriculture, and indivi- ling African swine fever at the expense of dual programs and laboratories in the Re- other zoonosis control activities. The gion. OIRSA's members are the Central Brazilian animal health secretariat re- ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 147

Veterinary public health activities target zoonoses and infectious and parasitic diseases common to man and animais. (Photo: Inter-American Development Banki D. Mangurian)

The CenterPan American garners theFoot-and-Mouth latest epidemiologic Disease l [ X 0 000 t data through the use of computerized information systems. (Photo: PAHOIPANAFTOSA)

The purpose of cattle development programs is to increase and diversify livestock products for national and foreign markets. (Photo: World Bank/E. G. Huffman) 148 REPORT OF THE DIRECTOR quested and obtained greater assistance in several countries was the extension of from PAHO in its program to control bovine the information system to other diseases rabies and brucellosis by providing master and economic and production matters strains to laboratories producing and con- related to animal health. PANAFTOSA also trolling biologicals, and CEPANZO acted as placed special emphasis on studying the an international reference laboratory. The behavior of FMD in each country and its new state Urban Zoonoses Center at Sáo general manifestation in the affected area Paulo completed its initial phase and was of South America, examining its char- beginning to consolidate its activities by acteristics within the context of the dif- the end of the year. PAHO's collaboration ferent ecosystems resulting from socio- was directed toward supervising, revising, economic, biologic, and environmental and updating the methods the Center uses. factors. Its technical personnel received training on As the reference laboratory for FMD rodents, insects, and rabies. diagnosis and vaccine control in the Americas, PANAFTOSA provided basic laboratory services for epidemiologic surveillance and strengthened the quality con- Foot-and-Mouth Disease and the trol of FMD vaccines. It collaborated with Pan American Foot-and-Mouth the countries by providing technical advice Disease Center on their FMD prevention and control programs and by promoting joint efforts by na- During 1979 the Pan American Foot-and- tional groups to develop laboratory net- Mouth Disease Center (PANAFTOSA), at Rio works for the diagnosis, investigation, and de Janeiro, cooperated with almost all the development required to produce methods countries in different ways. Budget restric- and technologies relevant to hemispheric tions reduced some activities. Never- conditions and needs. It also promoted, theless, extrabudgetary funds received coordinated, and supported agreements from several countries allowed PANAFTOSA between adjacent countries for maintain- to collaborate with specialized national ing epidemiologic surveillance in disease- agencies in Argentina, Brazil, Colombia, free or low-risk areas; supported and co- and Uruguay in carrying out important pro- operated with COSALFA as an agency for jects such as the development of lab- hemispheric coordination and evaluation, oratories, oil-adjuvant vaccine field ac- and produced and disseminated technical tivities, and studies of cattle losses through and scientific information on health to sup- reduced production and productivity port the countries in their animal health caused by foot-and-mouth disease (FMD). programs. The FMD control programs in Bolivia, Chile, Despite budget reductions, PANAFTOSA Paraguay, and Peru satisfactorily com- continued carrying on its training activities, pleted their goals using funds provided by giving special attention to holding interna- IDB. tional seminars on topics of interest in the PANAFTOSA focused its activities in 1979 animal health programs of the countries. on consolidating national information Panama agreed to join the subregional systems and linking them to the interna- vesicular disease surveillance project fi- tional information network required be- nanced by UNDP, but by the end of the year cause of the epidemiologic characteristics construction of the vesicular disease and economic importance of FMD. One of diagnosis laboratory planned there still had the most significant changes that occurred not started. ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 149

Figure 11. Status of foot-and-mouth disease, South America, 1979.

fi ,

Endemic

Sporadic Absent

No information 150 REPORT OF THE DIRECTOR

PANAFTOSA actively took part in coor- duction of this type of vaccine by govern- dinating and carrying out training in the mental and private laboratories in some Bolivian and Ecuadorian programs fi- countries, and, finally, the decision by nanced by IDB. In accordance with project Uruguay to adopt an eradication policy in plans, it prepared programs for each fellow its FMD program, with the possibility that and solicited the cooperation of various similar policies would be adopted in at countries and agencies in order to carry out least the neighboring parts of Brazil and training in vaccine control, quarantine, Argentina. field sanitary measures, control of animais Among the restrictive factors in the in transit, and information services. To countries were the effects of the world facilitate the coordination of these pro- energy crisis, which affect field operations grams, a survey was made of the areas of in some countries; high inflation rates; specialization available in each country. policies of decreasing public sector expen- PANAFTOSA technical personnel par- ditures including salaries; and upheavals ticipated actively in the University of Belo resulting from administrative reforms. The Horizonte's postgraduate program. Staff program's prospects are good in that the members also took part in several interna- countries continue to be interested in com- tional seminars and international and na- bating FMD, especially because of its effect tional courses. on the international animal and animal During 1978-79 PANAFTOSA provided in- products market and because experience dividual training to 54 professionals from has shown that quite satisfactory control is 12 countries in vesicular disease diagnosis possible. In the animal health sector, FMD (11), FMD vaccine production and control control continues to be given high priority (4), FMD vaccine control (4), cell culturing in meat-exporting countries. (5), laboratory animal breeding and man- PANAFTOSA should intensify its present agement (5), immunodiffusion (1), epi- line of work, especially in preventing FMD demiology and information systems (12), and studying vesicular stomatitis in Central animal health programs (8), communi- America and Panama, consolidating the cation (1), photography and printing (1), eradication of FMD in Chile, orienting the vehicle maintenance (1), and laboratory programs in Peru and the Plate River area stores (1). toward eradication, and advancing control Significant positive events in 1979 were: activities in the rest of South America. recognition of PANAFTOSA as the regional Special emphasis must be placed on reference laboratory for FMD vaccine con- developing the infrastructure of veterinary trol in the Americas by the XII Inter- services, reformulating programs, and American Meeting at the Ministerial Level heightening community awareness. on Foot-and-Mouth Disease and Zoonoses The FMD situation in the Region during Control, associated with intensification of 1979 was as follows: pertinent activities in the countries, FMD-free countries: Canada, the United especially Argentina, Brazil, and Uruguay, States, Mexico, Central America, Panama, as a result of which there was significant French Guiana, Guyana, Suriname, and all the improvement in the quality of vaccine of- Caribbean countries continued to be completely fered on the market; extension of PANAF- free of FMD. Customary episodes of vesicular TOSA's demonstration programs for apply- stomatitis were recorded in Mexico, Central America, and Panama. The affected countries ing FMD oil-adjuvant vaccine in Argentina, and OIRSA accepted a PANAFTOSA plan for in- Bolivia, Brazil, Colombia, Paraguay, and vestigating this disease. At the same time the Uruguay and the start of experimental pro- Central American countries, Panama, and Cuba ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 151

began organizing themselves to install the by PANAFTOSA to alleviate this situation met the epidemiologic surveillance information system requirements of the Agriculture Ministry and the for vesicular and exotic diseases that PANAF- Colombian Agricultural and Livestock Institute TOSA coordinates. in an effective and timely manner. The north- Canada and the United States, which have no western part of Chocó Intendancy, which FMD, have highly developed prevention services. borders on Panama, remained free of FMD. PANAFTOSA's activities with respect to these PAHO aided Ecuador in preparing a proposal countries are to distribute epidemiologic infor- for a new IDB animal health loan which will be mation, provide consultation as necessary, and considered part of the national development promote the channeling of national resources plan. The country finished building and equip- available for cooperation with the Region's ping new FMD laboratories during 1979. other countries. In Venezuela, evaluations were made of the Panama belongs to that part of the Americas national FMD program on the basis of vaccina- free from FMD. Preventing the disease is the re- tions carried out and of the regionalized sponsibility of the veterinary service of the diagnostic laboratory program. Ministry of Agriculture through an agreement with the U.S. Department of Agriculture and with OIRSA collaboration. During the year PANAFTOSA examined biologic specimens which Panama sent to Rio de Janeiro. It is giving pri- Zoonoses and the Pan American ority to developing an information system for Zoonoses Center Panama for epidemiologic surveillance of vesicular stomatitis, other vesicular diseases, and perhaps eventually animal health in general. As a group, the zoonoses cause serious In Mexico, Central America, French Guiana, injury to human health, economic dete- Guyana, Suriname, and all the Caribbean coun- rioration, and slow-downs in programs to tries that belong to the FMD-free area, PANAF- increase meat and milk production in Latin TOSA distributed information about FMD and vesicular stomatitis, warned of possible emer- America. Since more than 200 diseases are gencies, and provided professional training. Dur- recognized as zoonoses, PAHO's Pan ing the year vesicular stomatitis specimens were American Zoonoses Center (CEPANZO) at sent to PANAFTOSA. Ramos Mejía has established priorities in its activities according to the impact the FMD-affected countries. In South America, diseases have on the health and economic Chile reported no case of FMD and extended its disease-free area, which at the end of the year well-being of the countries. covered approximately 85 per cent of all Chilean CEPANZO's program emphasizes bru- livestock. Advanced control was maintained in cellosis, rabies, tuberculosis, hydati- Argentina, Peru, Uruguay, and Rio Grande do dosis, leptospirosis, anthrax, cysticer- Sul State in Brazil. In the rest of Brazil and in cosis, equine encephalitis, food hygiene Colombia, Ecuador, and Paraguay there were epidemic outbreaks of varying intensity and ex- and microbiology, and laboratory animal tent. No changes were observed in Bolivia and breeding and management. Its purpose is Venezuela, where FMD is widely endemic. The to provide technical cooperation in prevent- South American countries affected by FMD ac- ing, controlling, and eradicating zoonoses complished the objectives of their border in Latin America and the Caribbean. It also agreements as to frontier patrolling, strict control, and joint meetings. These agreements were serves as a preinvestment agency by pro- coordinated by PAHO. viding the countries technical cooperation Argentina assigned resources for building a in preparing requests for national zoonosis new laboratory and starting an FMD control and control program loans. It pursues the long- eradication program in parts of Buenos Aires term goal of reducing zoonoses in man and Province and La Pampa Territory. There was little FMD vaccination in Colombia stemming the economic losses caused by during the year because of vaccine production zoonotic diseases. and control problems. Collaboration provided CEPANZO continued fulfilling its func- 152 REPORT OF THE DIRECTOR tions of training, technical cooperation, the immunodiagnosis of human hyda- laboratory services, technical information, tidosis, with the Dominican Republic in and research. biologicals control, with Ecuador in In the training area, it offered intra- and regulating dairies, with Honduras in design- extramural courses and individual training ing a project to control ticks and chiggers, to 57 fellowship holders. Courses offered with Jamaica and Panama in controlling included: animal health planning course (7 parasitic zoonoses, with Mexico in the months), production and control of rabies large-scale production of brucellosis an- vaccines (11 weeks), brucellosis laboratory tigens and vaccines, with Paraguay in con- techniques (3 months), standardization of trolling brucellosis, rabies, and tuber- rabies immunofluorescence methods (2 culosis, and with Peru in its pilot program weeks), immunodiagnosis of human hy- to control hydatidosis in the Sierra Central. datidosis (two courses lasting 2 weeks To meet the demand for reference bio- each), food protection (3 weeks), food pro- logicals, CEPANZO continued dis- tection for military veterinarians (2 weeks), tributing strains, antisera, antigens, con- parasitology (2 months), bacteriology of jugates, and tuberculins for the most com- microbacteria (4 weeks), and production mon zoonoses in the Region. Reference an- and control of PPD tuberculins (4 weeks). tigens and antisera were also provided for These courses were attended by 102 profes- human hydatidosis immunodiagnosis to sionals. laboratories in Greece, Poland, and Spain. In addition, CEPANZO collaborated in CEPANZO's laboratory animal production 1979 with academic institutions and other colony at Azul in Buenos Aires Province agencies in several of the Region's coun- continued producing various kinds of tries in carrying out 55 workshops, animals to meet CEPANZO's working needs seminars, courses, roundtables, congresses, and supply breeding stock for laboratories conferences, lectures, and special classes in countries requesting them and training in which 221 persons were trained. personnel in the breeding and management CEPANZO offered advisory services to of laboratory animals. This colony stocks animal health authorities in preventing and rats, hamsters, guinea pigs, mice, and controlling or eradicating the main zoo- rabbits. noses. It collaborated in designing and in- CEPANZO continued publishing its quar- itiating animal health statistical informa- terly journal Zoonosis, monthly rabies and tion systems in El Salvador and Guatemala equine encephalitis epidemiologic sur- and in making recommendations for veillance newsletters, monographs, and reorganizing the directorate general of technical notes. Lists of bibiographic livestock services in Guatemala's Ministry references about various subjects related of Agriculture. It provided advice to the na- to zoonosis control were prepared, and tional FMD, rabies, and brucellosis control studies conducted by CEPANZO specialists service in Bolivia on its brucellosis pro- were published in journals of recognized gram in Cochabamba and Santa Cruz scientific prestige. Departments. Specific aspects of the Region's prin- CEPANZO continued cooperating with cipal zoonoses in relation to CEPANZO's ac- Argentina in its pilot program to control tivities are described below. goat brucellosis in San Luis Province, with Brazil in controlling zoonoses in the Sáo Bovine tuberculosis. Bovine tuberculosis is in- Paulo area, with Colombia in its national fectious for man and causes major economic brucellosis control program, with Chile and losses in cattle and other livestock. Most of the Uruguay in the production of reagents for Latin American countries and particularly those ENVIRONMENTAL AND ANIMAL HEALTH PROGRAMS 153 in South America are affected by this disease. Republic, Ecuador, Mexico, Peru, United States, During a six-year period, 43 million kilograms of and Venezuela), while biotype 3 was isolated meat had to be destroyed and 14.5 million had only in the United States and biotype 4 in to be consigned to industrial processing because Canada. Biotype 2 had still not been isolated in of tuberculosis contamination in 15 Argentine the Americas. packing plants that slaughtered 21 million cattle Equine encephalitis. Venezuelan equine (72.5 per cent of which were young bulis). In a encephalitis has been a human and animal single year in the same country, 4.7 per cent of health problem since its discovery in 1938, and the cattle slaughtered were found to have tuber- severe outbreaks have occurred in the northern cular lesions, and 12 million kilograms of meat part of South America. In 1971 the disease had to be destroyed. spread from Central America to Mexico and the In 1979 CEPANZO cooperated with Mexico, United States, but no cases have been reported Paraguay, and Peru in producing PPD tuberculin since 1972 in the last two countries. and with Argentina's national tuberculosis com- The best way to control the disease is horse mission in human BCG vaccination, and col- vaccination. CEPANZO has therefore recom- laborated in designing a study of tuberculosis in mended that the governments actively vac- indigenous populations and domestic popula- cinate susceptible horses and establish epi- tions in Paraguay. demiologic surveillance services. In 1972 CEP- Brucellosis. This is one of the main zoonoses ANZO started epidemiologic surveillance of en- in Latin America, both because it is widespread cephalitides to obtain information rapidly about and because of the economic damage it causes. the occurrence of the disease in the Americas Bovine brucellosis is the most prevalent form, and thus be able to make timely recommenda- especially in South American dairy cattle. Goat tions as to the need to carry out mass vaccina- brucellosis is of public health importance in tion when necessary. Because of opportune Argentina, Mexico, and Peru. campaigns, outbreaks and reports of the disease In 1979 CEPANZO provided reference diag- have decreased. As a result CEPANZO decided to nosis services to official and private institu- suspend monthly publication of its Encephalitis tions in Argentina, Bolivia, Chile, and Paraguay Epidemiologic Surveillance Bulletin in 1979 and and reference antigen and vaccine control serv- instead begin publishing semiannual newsletters ices to official laboratories in Argentina, starting in 1980. Dominican Republic, Honduras, Panama, and In 1978, 35 cases of Venezuelan and eastern Paraguay. equine encephalitis occurred in horses in the Up to 1979 the following biotypes of Brucella area south of Lake Maracaibo, Venezuela. At abortus had been characterized at CEPANZO: the end of 1978 the disease reappeared in horses biotype 1 in 15 countries (Argentina, Brazil, in Carabobo, Cojedes, and Zulia States; of the 54 Chile, Colombia, Cuba, Ecuador, Guatemala, cases reported, 26 were Venezuelan and 28 were Honduras, Mexico, Nicaragua, Paraguay, Peru, eastern equine encephalitis. During the first United States, Uruguay, and Venezuela); biotype week of 1979, 11 horse deaths were reported in 2 in five countries (Argentina, Brazil, Colombia, Yaracuy State, and serologic examinations United States, and Venezuela); biotype 3 only in showed them to be due to eastern equine en- Brazil; biotype 4 in six countries (Argentina, cephalitis. Chile, Cuba, Ecuador, El Salvador, and the Hydatidosis. Hydatidosis is found chiefly in United States); and biotype 6 in Argentina and the southern part of the Americas and affects a Brazil only. Biotypes 5, 7, 8, and 9 had not been group of countries whose populations comprise isolated in any country. 56 per cent and whose livestock production B. canis had been isolated in seven American comprises 70 per cent of Latin America's. In countries as of 1979 (Argentina, Brazil, Chile, these areas the prevalence of Echinococcus Mexico, Peru, United States, and Venezuela). granulosus in dogs is between 30 and 60 per Biotype 1 of B. melitensis had been isolated up cent. In some areas, human hydatidosis rates are to 1979 in five countries (Argentina, Chile, Mex- as high as 84.3 per 100,000 population. ico, Peru, and the United States), while biotype 2 In man the disease causes major hospitaliza- had been isolated only in Chile and biotype 3 tion expenses, prolonged absenteeism, and fre- only in Mexico. quent relapses. Economic losses caused by Up to 1979 CEPANZO had characterized hydatidosis in animals are very high because of biotype 1 of B. suis in 11 countries (Argentina, the large numbers of sheep and cattle infected Brazil, Chile, Colombia, Cuba, Dominican and the resultant seizures of meat. 154 REPORT OF THE DIRECTOR

In 1979 CEPANZO continued cooperating with vectors of the disease, by the middle of the year. Argentina, Brazil, Chile, Peru, and Uruguay in Nevertheless, a case of rabies in a cow transmit- applying immunodiagnosis to human hy- ted by vampire bats was diagnosed in Alajuela datidosis and in serologic surveys to detect per- Province. sons with hydatid cysts. It also cooperated with In the Dominican Republic no case of human Argentina in developing laboratories for produc- rabies occurred nor were there any postvaccina- ing immunodiagnosis antigens and antisera and tion complications in 854 persons treated with with Peru in using immunodiagnosis in sero- complete antirabies vaccine series during the epidemiologic studies of human distomiasis year. Still, lack of funds for canine rabies vac- and cysticercosis. It also provided technical cination required that activities be confined to cooperation to Argentina, Chile, Guatemala, outbreaks and potential danger areas. This situa- Peru, and Uruguay in controlling hydatidosis, tion, which has gone on for two years, puts the and to Jamaica and Panama in controlling country in a preepidemic status since the dog parasitic zoonoses. population has very little or no protection Rabies. All countries affected by rabies car- against rabies. It is aggravated by the large ried on control programs in 1979 to reduce reser- mongoose (Herpestes sp.) population positive to voirs of this disease and thus eliminate sources rabies, which is increasing uncontrollably for of human infection. Activities were increased in lack of natural predators. Bolivia, Colombia, Ecuador, and Peru to control Although Grenada saw no rabies in humans or rabies. domestic animals during 1979, it is the only In Argentina the rabies epidemiologic situa- island in the Caribbean where the disease is tion continued to improve in Buenos Aires Prov- endemic. PAHO therefore recommended that it ince, where in the first half of 1979 there were increase its epidemiologic surveillance, diag- only two cases of rabies in humans and 355 in nosis, and control activities and begin canine animals, a sharp contrast to the 13 cases in rabies vaccination in the near future. humans and 1,655 in animals there in 1976. At the start of 1979 an outbreak of canine In Barbados, facilities for controlling stray rabies occurred in the metropolitan area of El dogs were completed and equipped and person- Paso, Texas, U.S.A., and Ciudad Jua'rez, Chi- nel trained. In the capital of Bridgetown 20,000 huahua, Mexico, and in adjacent Dona Ana dogs were vaccinated against rabies and County, New Mexico, which is part of the same registered. ecologic area. As of March, 21 cases of canine In Bolivia rabies continued to be very impor- rabies were reported. Energetic house-by-house tant, primarily in urban areas. In 1978, 11 cases measures were taken to vaccinate dogs and in humans were reported, 8 in urban and 3 in eliminate strays, and all exposed persons re- rural areas, and 4,135 persons were treated in ceived rabies treatment. The first case of human health centers for bites by animals-mostly rabies was confirmed in a child in Ciudad dogs-suspected of being rabid. There were no Juárez, and another case was later observed in a postvaccination complications among the 2,677 child in Piedras Negras. who were vaccinated. Three cases of human In Venezuela, canine rabies assumed epi- rabies were reported in Bolivia through August demic proportions in 1978, 80 per cent of the 1979, and the start of a mandatory reporting reported cases coming from western Barinas, system resulted in improved surveillance. Portuguesa, and Zulia States. The eight human The rabies control campaign continued to in- cases, which occurred against a background of tensify in Brazil, but 104 human cases were widespread canine rabies, were similarly dis- reported through August. In Colombia, 980,000 tributed. The situation improved in 1979 as a dogs were vaccinated against rabies. result of intense control measures, but six In Costa Rica no cases of rabies had been seen human rabies cases were reported by the end of in either humans or dogs, which are the chief August.

E E E Chapter 6

SUPPORTING SERVICES

PAHO's supporting services, as their dissemination, publishing, public informa- name implies, support its health programs tion, a textbook program, and the Head- and promote its educational activities. quarters bibliographic and health informa- They consist of information collection and tion office.

INFORMATION COLLECTION AND DISSEMINATION

PAHO continues to be the central collec- effort will require considerable staff time tion and distribution point for health infor- over the nextyear or two as well as increased mation in the Region, as mandated by the computer data processing. Pan American Sanitary Code. Data on Several meetings were held during the causes of death, morbidity from com- year with representatives of the United Na- municable diseases, vaccinations, man- tions and WHO statistical offices to discuss power, health establishments, population, ways to reduce the burden on Member and other health-related topics are col- Countries in reporting mortality by cause lected through PAHO/WHO questionnaires to both the United Nations and PAHO/ and complementary official sources. A WHO. It was decided that PAHO/WHO health statistics information system (HSIS) will collect data on causes of death developed over the years is available for and transmit them to the United Nations handling a steady flow of information re- Statistical Office for publication in the quests from government agencies, univer- annual Demographic Yearbook. A simi- sities, researchers, and industry as well as lar agreement was reached with the Ca- from PAHO itself. The data are also pub- ribbean Development and Cooperation lished in the World Health Statistics Annual Committee of the United Nations Eco- and in PAHO publications. nomic Commission for Latin America. It is In 1979 PAHO reviewed the existing HSIS felt that such coordination and collab- to define and make the changes needed in oration among international agencies are the information required for analysis of the highly desirable and better serve the coun- hemispheric health system as well as sur- tries. veillance of specific program areas. This Another coordination effort which be-

155 PAHO's health programs and educational activities are supported throtgh the information collection and dissemination, publications, public information, and bibliographic services. (Photos: PAHOIG. Khokhar and Ht. H. Tensen) SUPPORTING SERVICES 157 gan in 1979 relates to the work being done arterial hypertension control programs. In by several national and international agen- the former, begun in 1975, 2,546 patient in- cies to improve civil registration and vital itial and annual followup registry forms statistics. The groundwork was laid for were analyzed. The results were presented PAHO participation in courses for civil at the fifth meeting of the rheumatic fever registry workers that are being organized prevention working group in October. In by the civil registration and vital statistics the arterial hypertension study, begun in unit of the Inter-American Children's In- 1976, 4,500 patient initial and annual fol- stitute at Montevideo. One or more courses lowup registry forms were analyzed. The re- will be held in 1980 for senior civil regis- sults were presented at the fourth meet- try and health ministry staff in Latin Amer- ing of the arterial hypertension control ica. PAHO participation in the courses working group in November. PAHO also de- will involve teaching vital statistics and the veloped a computer-based information proper use of the International Classification system to process and control the data pro- of Diseases. duced in this five-year study.

Development of Statistical Methodology International Classification of Diseases

During 1979 PAHO developed an instruction unit for the South American workshop A new agreement was signed with Vene- on the Expanded Program on Immuniza- zuela governing the operation of the Vene- tion (EPI) at Lima in January. The unit dealt zuelan Center for the Classification of with a sample design for collecting data Diseases, which will act as WHO's Spanish- with which to evaluate immunization pro- language reference unit. Among the Center's grams. The sampling procedures, devel- responsibilities are publishing the Spanish oped primarily for use by nonstatisticians, version of the International Classification had been tested earlier in Costa Rica, Ecua- of Procedures in Medicine and other dor, and Peru with good results. supplementary classifications approved In another EPI area, PAHO prepared a by the World Health Assembly, prepar- sample design for use in determining the ing teaching materiais for national courses immunologic effectiveness of administer- for coders at various levels, conducting measles vaccine to children 6-12 ing international courses in Caracas, and months old and the optimal age for mea- promoting and collaborating in research sles vaccination in the Region. Brazil, on the application of the International Chile, Costa Rica, and Ecuador participated Classification of Diseases (ICD) in Spanish- in the study. Unexpected delays in data speaking countries and on medical termi- collection and laboratory serology caused nology. the postponement of data analysis, inter- Venezuela will significantly increase the pretation, and presentation of the results, Center's manpower and budget in 1980 to which were expected to be completed in enable it to fulfill its hemispheric respon- early 1980. sibilities. PAHO is contributing consultants PAHO also continued to support the and funds. regional rheumatic fever prevention and Steps continued to be made toward 158 REPORT OF THE DIRECTOR preparation of the Tenth Revision of the The two countries were El Salvador and ICD. Two major meetings were held for that Guatemala, where PAHO staff aided of- purpose, the first at Moscow in June and ficials from the Health Ministries in in- the second at Taormina in Sicily in Novem- troducing microcomputers in the day-tober. Two specialists represented the Region day management of several work areas. at the first meeting and three at the second. Three microcomputers were installed in El Several conclusions were reached at the Salvador's Health Ministry to support its two meetings which will affect the Ameri- administration as well as functions of cas. Among them was the need for the San Salvador's main hospital including in- ICD to serve as a meaningful tool in meas- ventory control of expendables, personnel suring progress by the Region and its coun- scheduling, and payroll accounting. For tries in achieving the goal of health for Guatemala, PAHO developed microcom- all by the year 2000, in planning, manag- puter programs dealing with personnel ing, and evaluating primary health care record-keeping and budget control. programs, and in developing health infor- After reviewing the preliminary micro- mation systems at all care levels. The em- computer work being done at PAHO Head- phasis in preparing the Tenth Revision will quarters, three other countries expressed be on making it relevant and applicable to active interest in developing micro- developing countries. computer programs that will increase The Spanish version of Volume 2 of the their ability to respond to domestic health ICD was completed and published. information and planning requests. PAHO The fourth meeting of the regional ad- advised all three on equipment options visory committee on the international and uses. classification of diseases took place at PAHO staff also began preparing a li- Washington in October. It reviewed the ac- brary of microcomputer software packages tivities conducted by the countries, that will be available to all the coun- reference centers, and PAHO and recom- tries. These programs, which will be pro- mended high-priority activities PAHO and vided without royalty arrangements and the centers should carry out to meet the may be modified to meet specific national countries' urgent needs in this area. requirements, are intended to meet the most pressing demands of the countries using them. Health ministries that com- puterize their routine record-keeping will Microcomputers in Health free their personnel for more productive tasks. As a by-product of the increasing avail- Microcomputer technology, while tre- ability of microcomputer-generated infor- mendously promising in a wide range of ap- mation to national health authorities, PAHO plications, is not an end in itself. It is a tool has been developing a system to facili- available to health professionals and must tate the exchange of data between its Head- be so evaluated. During 1979, PAHO work- quarters and stations in Member Coun- ed with two countries in applying such tries using compatible microcomputer technology to their immediate health care technology. As a starting point, it last year problems and began advising three others developed a microcomputer-based ver- on how it might be used to help solve sion of the AMPES cooperation program de- theirs. scribed in the following chapter. SUPPORTING SERVICES 159

HEALTH AND BIOMEDICAL PUBLICATIONS

PAHO's publications and information ac- WHO. In meeting its commitments, it edited tivities were consolidated into the Office and published six PAHO Scientific Pub- of Health and Biomedical Publications in lications and completed the translation of August. The new unit absorbed the office four WHO Technical Reports and two non- of publications, public information office, serial publications. textbook program, and visual aids unit at PAHO and WHO publications were pro- Headquarters and the publications and moted through four exhibits, in Mexico documentation service (SEPU) at Mexico City at the Meeting on Socioeconomic City. Determinants of Mortality and the World This reorganization fulfilled recommen- Congress on Environmental Sanitation in dations made at various times by the Development Planning, in New York at the PAHO/WHO publications policy and coor- annual meeting of the American Public dination committee and PAHO's own pub- Health Association, and at Tucson, Ari- lications committee and subcommittees zona, U.S.A., at the annual meeting of the urging that related but dispersed activi- American Society of Tropical Medicine and ties be grouped together. It was also in line Hygiene. Two other exhibits on the theme with suggestions resulting from a major of health for all by the year 2000 and on study of PAHO's publications program con- primary care activities in the Caribbean ducted in 1978. were produced for the Directing Council Although 1979 was a transition year meeting in September and October. requiring adjustments and consolidation, every effort was made to strengthen publications and related activities. Resources were pooled as needed to meet priorities Periodical and Special established by the Governing Bodies and Publications the Director. The working group of the PAHO/WHO publications policy and coordination com- Journals mittee, composed of PAHO Headquarters, SEPU, and WHO representatives, met for The PAHO publications committee's peri- the fifth consecutive year in December to odical publications subcommittee met in discuss mutual problems related to poli- July. Members discussed ways to improve cies, planning, and communications and the content of PAHO's journals and con- to draw up a work plan for 1980. One of the sidered subscription prices and distribution most important topics was the design and with a view to increasing the number of approval of a better scheme of com- paid subscribers. munications between Washington, Mex- The Boletín de la Oficina Sanitaria ico City, and Geneva to facilitate and ex- Panamericana appeared regularly in a pedite PAHO and WHO publishing. 96-page format with a monthly circulation In accordance with the objectives for of 13,600 copies. SEPU assumed full respon- which it was created, SEPU gradually in- sibility for editing, printing, and dis- creased its capacity to produce Spanish- tributing the journal from Mexico City. Ef- language publications chosen by PAHO and forts were made to cover as wide a range as 160 REPORT OF THE DIRECTOR possible of important public health topics concluded in the first (March) issue of 1980, in the 12 issues. The April issue contained and the articles in the two issues will later timely material about World Health Day be published in PAHO's Scientific Publica- and its theme, "A Healthy Child, A Sure tions series. The volume for 1979 totaled Future," and a sizable portion of the Oc- 466 pages and included a subject and tober issue was devoted to the Interna- author index. tional Year of the Child through articles on children, their health, and their care. Other articles were published during the year on Scientific Publications and Official perinatal care, ecology and environmental Documents health, communicable and noncommunicable diseases, chronic illnesses, animal PAHO's special publications comprise its health and zoonoses, nursing, and the Scientific Publications, Official Docu- Technical Discussions at the XX Pan Ameri- ments, and others. Production during the can Sanitary Conference in 1978. year was 44 volumes totaling 6,841 pages The quarterly Bulletin of PAHO entered and 89,010 copies. Table 5 lists all the its 13th year of publication, increasing tities published during the year. from 96 to 112 pages and averaging press- The proceedings of the Xl Inter-Ameri- runs of 5,400 copies. In addition to pub- can Meeting at the Ministerial Level on lishing translations of articles in Por- Foot-and-Mouth Disease and Zoonoses tuguese and Spanish, the Bulletin contained Control were issued in English and Spanish original papers in English. Subjects covered (Scientific Publication 374), as were the included: crosscultural communication, results of a major study by the Institute of childhood immunization, primary health Nutrition of Central America and Panama care, adolescent and young adult health in in 12 rural Guatemalan communities ap- Latin America and the Caribbean, popula- pearing under the title Evaluation of Sugar tion and nutrition planning, migrant health, Fortification with Vitamin A at the National nursing education, and patient main- Level (Scientific Publication 384). The pro- tenance, as well as special features, ab- ceedings of a workshop held in Jamaica to stracts, reports, news items, and book discuss the 1977-78 dengue pandemic- reviews. the largest ever recorded in that area- The health and medical education were published under the title Dengue in quarterly Educacion médica y salud also the Caribbean, 1977 (Scientific Publication completed its 13th year of publication. As 375). The Inter-American Investigation of its specialized field is health manpower Mortality in Childhood: Report on a development, its content was devoted to Household Sample likewise was issued education in medicine, sanitary engineer- (Scientific Publication 386). ing and environmental health, public health, An original monograph in Spanish on nutrition, and research and the train- craniofacial genetics was issued as Scien- ing of middle-level and auxiliary health tific Publication 378 to meet a dire need workers. The year's last number was devoted for literature on the subject in that lan- entirely to papers on nursing pre- guage. PAHO's contribution to the Inter- sented at a workshop on the profession, to national Year of the Child appeared in highlight nurses' major role in providing Spanish in a volume on health conditions health care and the broadening of their of children in the Americas (Scientific professional functions to extend health serv- Publication 381). Spanish editions of WHO ices. A report of the workshop is to be publications included Volumes 1 and 2 of SUPPORTING SERVICES 161

Table 5. PAHO Special Publications, 1979.

Serial Printed No. Titie pages Pressrun

Scientific Publications 355 Andanzas por el mundo de la salud-Memorias de Fred Lowe Soper, J. Duffy(ed.) ...... 403 2,000 373 Guide to the Chemotherapy of Human Malaria ...... 24 1,000 373 Orientaciones sobre quimioterapia de la malaria humana ...... 26 2,000 373 Orientaçóes sobre quimioterapia da malária humana ...... 26 1,000 374 Marketing of Animals and Their Products and Animal Health- Proceedings of the Xl Inter-American Meeting, at the Ministerial Level, on Foot-and-Mouth Disease and Zoonoses Control ...... 186 1,000 374 La comercialización de animales y sus productos y la salud animal-Documentos de la XI Reunión Interamericana, a Nivel Ministerial, sobre el Control de la Fiebre Aftosa y Otras Zoonosis 198 2,000 375 Dengue in the Caribbean, 1977 ...... 198 2,000 376 Control de tuberculosis en América Latina-Manual de normas y procedimientos para programas integrados ...... 238 4,000 377 Técnicas de aislamiento para uso en hospitales ...... 103 3,000 378 Genética craneofacial, C.F. Salinas (ed.) ...... 266 2,000 379 Criterios de planificación y diseño de instalaciones de atención de a salud en los países en desarrollo, Vol. 1. B.M. Kleczkowski and R. Piboleau (eds.) ...... 176 3,000 380 Animal Disease Prevention in Developing Countries: Its Relation- ship to Health, Nutrition, and Development ...... 62 2,000 381 Condiciones de salud del niño en las Américas ...... 238 3,000 382 Criterios de planificación y diseño de instalaciones de atención de la salud en los paises en desarrollo, Vol. 2. B.M. Kleczkowski and R. Piboleau (eds.) ...... 166 3,000 383 Four Decades of Advances in Health in the Commonwealth Carib- bean ...... 163 1,000 384 Evaluation of Sugar Fortification with Vitamin A at the National Level, by G. Arroyave, R. Aguilar, M. Flores, and M.A. Guzmán. . 87 2,000 384 Evaluación del programa nacional de fortificación de azúcar con vitamina A, por G. Arroyave, J.R. Aguilar, M. Flores y M.A. G u z m á n ...... 89 3,000 385 Normas para la erradicación de la carencia de vitamina A y la x ero fta lm ia ...... 73 3,000 386 Inter-American Investigation of Mortality: A Household Sample .. 150 2,000 387 Criterios de salud ambiental No. 2-Difenilos y trifenilos poli- clorados ...... 94 3,000 388 Criterios de salud ambiental No. 3-Plomo ...... 177 3,000 389 Criterios de salud ambiental No. 4-Oxidos de nitrógeno ...... 88 3,000 390 Strategies for Extending and Improving Potable Water Supply and Excreta Disposal Services during the Decade of the 1980s. Tech- nical Discussions of the XXVI Meeting of the Directing Council of PA H O ...... 50 3,000 390 Estrategias para la extensión y mejoramiento de los servicios de abastecimiento de agua potable y disposición de excretas para el decenio de 1980. Discusiones Técnicas de la XXVI Reunión del Consejo Directivo de la OPS ...... 55 5,000 162 REPORT OF THE DIRECTOR

Table 5. PAHO Special Publications, 1979 (cont.).

Serial Printed No. Titie pages Pressrun

Official Documents 160 Financial Report of the Director and Report of the External Audi- tor, 1978 ...... 133 330 160 Informe Financiero del Director e Informe del Auditor Externo, 1978 ...... 133 380 161 Proposed Program and Budget Estimates: PAHO, 1980-1981; WHO, Region of the Americas, 1982-1983; and PAHO, Provi- sional Draft,1982-1983 ...... 607 750 161 Proyecto de Programa y Presupuesto: OPS, 1980-1981; OMS, Región de las Américas, 1982-1983 y OPS, Anteproyecto, 1982-1983 ...... 607 550 162 Final Report, XX Pan American Sanitary Conference, XXX Meeting of the Regional Committee of WHO for the Americas (bilingual edi t ...... i o n ) ...... 103. 1,500 163 Documentos Básicos de la Organización Panamericana de la Salud, 13a ed ...... 130 1,000 163 Basic Documents of the Pan American Health Organization, 1 3th ed...... 130 1,000 164 Proceedings, XX Pan American Sanitary Conference, XXX Meeting of the Regional Committee of WHO for the Americas (multilingual edition) ...... 442 1,000 165 Informe Anual del Director, 1978 ...... 169 2,000 165 Annual Report of the Director, 1978 ...... 159 2,000 166 Proceedings, 81st and 82nd Meetings of the Executive Committee of PAHO(multilingual edition) ...... 327 500

Other Publications Handbook of Resolutions of the Governing Bodies of the Pan American Health Organization ...... 165 1,000 Manual de Resoluciones de los Cuerpos Directivos de la Organi- zación Panamericana de la Salud ...... 165 1,000 Human Resources Series 27-Pan American Seminar on Education and Health Care ...... 42 1,000 Newsletter on Dengue, Yellow Fever, and Aedes aegypti in the Americas (Nos. 1 and 2) ...... 30 1,000 Boletín informativo sobre el dengue, la fiebre amarilla y el Aedes aegypti (Nos.1 y 2) ...... 30 1,000 Catálogo de Publicaciones, Suplemento 1975-1978 ...... 34 10,000 Serie de Informes de Enfermeria 21 -Encuesta sobre la enseñanza de la tuberculosis en las escuelas de enfermería de América Latina, 1976 ...... 91 3,000 Caribbean Epidemiology Centre (CAREC) (Reprint) ...... 8 1,000 SUPPORTING SERVICES 163

Approaches to Planning and Design of for answering queries, and a standard letter Health Care Facilities in Developing Coun- for address clarification. tries, and Environmental Health Criteria A complete revision and reorganization Nos. 2, 3, and 4 (Polychlorinated Biphenyls of PAHO mailing lists was begun with the and Terphenyls, Lead, and Oxides of Ni- long-term purpose of compiling a single trogen). The final report and working docu- master computerized distribution list by ments of the Technical Discussions held specialized fields. The 58,000 addresses in during the 1979 meeting of the Directing the computer list will be subjected to very Council were issued at the end of the year careful study in collaboration with all in order to be available for distribution to PAHO list holders in order to streamline the Member Countries at the beginning of the operation and avoid duplications. International Drinking Water Supply and Attempts were made to increase the Sanitation Decade in 1980. The titie of this sales volume of PAHO publications and important publication was the topic of the obtain subscriptions to its journals through Technical Discussions: Strategies for Extend- reminder forms. Invoicing increased by ing and Improving Potable Water Supply about 32 per cent over 1978. and Excreta Disposal Services During the The numbers of publications distributed Decade of the 1980s (Scientific Publication during the year were: periodicals, 228,600; 390). Scientific Publications, 76,600; Official In the Official Documents series, a new Documents and other publications, 24,464; edition of the Basic Documents of PAHO and WHO publications, 5,215. The grand was issued in English and Spanish and the total was 336,879. Annual Report of the Director underwent a complete change in its method of preparation, thus enhancing its content and Filmstrips improving its format and presentation. An updated version of the Handbook of Res- The two most important filmstrips com- olutions of the Governing Bodies of PAHO pleted and issued during the year were on was also issued during the year. sanitation in hospital food services and preventable eye disorders in children, for which technical approval was obtained from the copyright-holding Trainex Cor- Distribution poration and the Children's Eye Care Foun- dation, respectively. The Latin American New administrative procedures and Centerfor Educational Technology in Health forms were developed in keeping with at Rio de Janeiro (CLATES-Rio) collab- recommendations made by the chief of orated in the first project by furnishing 24 WHO's publications distribution and sales photographs needed to complete the illus- office in Geneva in late 1978 after a month- trations. long study of PAHO's distribution practices. At the request of PAHO's Caribbean Food These included a multipurpose invoice and Nutrition Institute at Kingston, Ja- form designed to eliminate unnecessary maica, assistance was provided in repro- and time-consuming paper work, a new sys- ducing 2,820 color slides and 149 black tem for inventory movement to facilitate and white enlargements to be used in four record-keeping, a new form for standardiz- classes on breastfeeding for mothers who ing publication request procedures, changes cannot read or write. in the filing system, a standard reply form A project was initiated with the Interna- 164 REPORT OF THE DIRECTOR

tional Eye Foundation at Bethesda, Mary- pages of makeup. Photographic production land, U.S.A., to adapt two strips and an reached the highest level ever: 2,934 photo- instructional booklet into Spanish for use prints, 2,020 negatives, 10,392 slides, and in training health auxiliaries in primary eye 156 overhead projection slides. Photographs care. The booklet will be converted into were also taken during the meetings of the a filmstrip, and the Spanish version will be ExecutiveCommittee and DirectingCouncil used by the Foundation in its own health as well as at 32 other conferences, meet- activities. ings, and seminars. Included in the fore- CLATES-Rio also collaborated in prepar- going were photographic reproductions ing the original voice recording of guide of frames for the filmstrip program and Nos. 74 and 75 on slaughterhouse sanita- preparation or revision of 40 frames pro- tion. A special distribution of these two duced during the year. filmstrips and tape cassettes was made through PAHO's regional advisers in veterinary public health. Preliminary arrangements were made Public Information with PAHO's Pan American Center for Sanitary Engineering and the Environmen- tal Sciences at Lima to update and adapt The bimonthly PAHO Reports was in- six filmstrips prepared by the U.S. Public itiated in March to meet the need for a con- Health Service on different aspects of cise newsletter about PAHO activities. With water purification and excreta disposal. a pressrun of 700 copies each in Spanish Work was begun or finished on scripts and English, the newsletter was aimed at a for filmstrips on drug addiction, slaugh- select audience of senior government of- terhouse sanitation (third edition), and ficials, legislators, and top administrators primary health care, and preliminary plans in international and nongovernmental or- were made to adapt six classes on gyne- ganizations who must keep abreast of the cology and obstetrics and one or sev- programs and policies of PAHO. eral filmstrips on oral rehydration in chil- The information program in 1979 pro- dren and geriatric health problems. moted the theme of health for all by the A complete evaluation was made of the year 2000. Preparation began of a special results of a special filmstrip survey in- issue of Pan American Health magazine itiated in 1978 to update recipient lists, de- featuring relevant articles for distribution termine subjects of greatest interest to in 1980. users, and design methods for making the As usual, PAHO's information office also filmstrip program more effective. Distribu- answered public inquiries about PAHO and tion was made of 6,622 filmstrips, 4,329 of WHO. A large volume of written and tele- which were purchased by individuals. phoned requests for information on health- related subjects was received from students, health workers, private companies, Visual Aids government officials, and travelers. Other information activities included li- The visual aids unit provided a variety of aison with the news media, preparation of services which included preparation of 250 releases for distribution to news services charts, maps, and graphs; 372 designs, il- with subscribers throughout the Americas, lustrations, and covers; 744 signs and cap- and loans from the PAHO/WHO film and tions; 171 forms and pages ruled; and 20 photo libraries. SUPPOR TING SERVICES 165

World Health Day 1979 was celebrated reaching their goal of health services for all in the Americas with national and local the world's peoples by the end of this cen- events held to promote the theme of "A tury. IDB, along with other international Healthy Child, A Sure Future," and 17,000 lending agencies, has been increasingly ac- information kits on the subject were tive in funding programs designed to ex- distributed in English, Spanish, Portuguese, tend basic health services to the urban and and French to the media, schools, libraries, rural poor. From IDB's viewpoint, the United Nations Association chapters, govern- teaching materials to be produced and dis- ment agencies, and other groups and tributed under the joint PAHEF-PAHO pro- individuals throughout the Americas. The gram will play an important role in training print and electronic media used these ma- the personnel required to carry out these teriais as the basis for numerous fea- health care extension programs. tures and editoriais. The program will mark the first large- scale production of teaching materials designed especially for primary health care workers. Included are textbooks, manuals, Expanded Textbook and Educa- and self-instruction modules. They will be tional Materiais Program reasonably priced since most of the students, health service workers, and patients benefiting from them will be poor. Their The Pan American Health and Education focus will be on such priority areas as Foundation (PAHEF) and the Inter-American maternal and child health, basic health Development Bank (IDB) signed a $5 mil- care, nutrition, disease control, and en- lion loan agreement in February that environmental health. abled the textbook program to be ex- Fourteen of the 19 Spanish- and Por- panded to professional subjects other than tuguese-speaking countries in the Region medicine and nursing and to nonprofes- signed basic agreements covering parti- sional study areas. Agreements were also cipation in the expanded program, and in- signed between IDB and PAHO whereby the dividual institutions began to sign the re- latter will act as guarantor for the loan, and quired memoranda of understanding with between PAHO and PAHEF under which the PAHO permitting the program to start at former organization will act as executing each school. agency and contribute $1.5 million to the During the year committees met to textbook program over a five-year period. choose textbooks on health administration, Besides acting as loan guarantor, PAHO midwifery, and veterinary medicine; other will help finance the production of new committees had earlier selected textbooks teaching materials, provide technical and on dentistry, sanitary engineering, and nu- administrative supervision, and negotiate trition. At the end of the year, printing of the required agreements with governments four dentistry and two nutrition books had and educational institutions. The program almost been completed. Preparation of will be self-financing, the income from material for use by technicians and aux- sales being used to restore the cost of pur- iliaries also began, although the complex- chases to the revolving capital fund. ities of selection and development made it The new program will emphasize train- a slower process than the simple choice of ing primary health workers. PAHO and standard textbooks for professional stu- WHO in recent years have viewed primary dents. health care as the principal means for As a first step, PAHO retained two short- 166 REPORT OF THE DIRECTOR

term consultants with extensive experience creation of new medical schools in Mexico in health education to survey institutions in and elsewhere. Central America and the Andean countries training auxiliary health workers. On the basis of the data obtained, meetings of aux- Nursing Textbooks iliary trainers were scheduled in both areas in 1980. The consultants will advise PAHO Preliminary statistics indicated substan- on the preparation of innovative materials tial increases in sales of nursing textbooks including manuals, programmed instruc- over 1978, and total 1979 sales should tion modules, and audiovisual aids. reach 12,000. Distribution of three new titles began during 1979: Fitzpatrick-Reeder's Enfermería maternoinfantil, Travelbee's In- Medical Textbooks tervención en enfermería psiquiátrica, and Morgan and Moreno's La práctica de enfer- Sales of medical textbooks continued at mería de salud mental. approximately the same pace as in 1978 Program acceptance was strongest in -85,000 books. In addition to an Anat- Colombia and Peru. To make the program omy Atlas, a new titie in Spanish, the pro- more attractive to students in Brazil, Por- gram made arrangements when PAHO tuguese translations of program textbooks published the Spanish translation of the on medical-surgical and pediatric nursing American Public Health Association's Con- were contracted for delivery in early 1980. trol of Communicable Diseases in Man in its Scientific Publications series to buy 15,000 copies for use in teaching epidemiology, Medical Instrument Program public health, preventive medicine, and nursing. The program continued to provide steth- The program continued to be well ac- oscopes, sphygmomanometers, and diag- cepted in Colombia and Venezuela. Efforts nostic sets to students in 14 countries, with to strengthen its administrative structure in sales comparable to 1978. Colombia began the two main consumer countries, Brazil to participate for the first time in 1979. and Mexico, had a favorable effect on Late in the year the program was extended sales. The number of participating schools to allow nursing schools to participate, remained almost constant, but some ex- a measure made possible by the increased pansion is expected in 1980 owing to the funding available from the IDB loan.

BIBLIOGRAPHIC AND HEALTH INFORMATION OFFICE

This office continued carrying out the The strategy followed two basic lines: policy adopted at the end of 1978 of trans- development of an efficient information forming itself from a traditional library into retrieval system (PAHO Documentation and a bibliographic and documentation center Information System, or PAHODIS), and in- to support PAHO staff at Headquarters and teraction with the U.S. National Library of in the field. Medicine's Medical Literature Analysis and SUPPORTINC SERVICES 167

Retrieval System (MEDLARS) and the DIA- ganizations; and PAHOSTC, a similar index LOG Information Retrieval Service. MED- of PAHO short-term consultant reports. At LARS and DIALOG give PAHO access to more the end of the year PAHODIS had about than 100 different data banks. 7,000 records and was expected to grow by PAHODIS embraces three periodic pub- about 10,000 documents yearly. lications: TABCONT, a monthly in which In addition to acquiring and providing the titie pages and tables of content of books and journals, the office provided selected scientific and technical journals PAHO staff more than 5,000 photocopies of are reproduced; PAHODOC, a compu- scientific articles and compiled more than terized index of documents published by 700 bibliographies during 1979. PAHO, WHO, and other international or-

O [ E Chapter 7

ADMINISTRATION AND MANAGEMENT

During 1979 the major emphasis in * Continued decentralization of respon- PAHO's internal administration was on sibilities and authority to the extent that these increased productivity. This meant further can be exercised effectively within PAHO financial regulations. development of management and infor- * An extensive study by Member Covern- mation systems, improvements in analytic ments of "WHO's Structures in Light of its and monitoring methods, cost-benefit Functions" resulted in significant recommenda- savings in telecommunications and word tions for the Region of the Americas regarding processing, and organizational refinements PAHO's changing role and the needs of the countries. These will be acted on after the World for more effective management. Health Assembly and PAHO Directing Council Highlights of PAHO's internal administra- have considered them in 1980. tion in 1979 were: * Systematic quarterly procurement of vaccines to carry out the Expanded Program on * Consolidation of all publication units and Immunization (EPI) according to plans developed the public information office into a unified with and by the countries for their vaccine and Office of Health and Biomedical Publications. cold-chain requirements. This office will coordinate all of PAHO's health * Development of new operating manuals and biomedical publications and textbook for fellowship activities in the Caribbean. programs. * Development of criteria for the review, * Implementation of an advisory committee initial approval, and renewal of projects financed of international banking experts to guide the from extrabudgetary funds. PAHO investment committee and help maximize * Improvements in documentation and in- the return on investments and protection of formation services through the adoption of a funds invested. data bank and on-line computer system to * Development of an evaluation model of retrieve PAHO documents and short-term con- Pan American Centers to be put into effect in sultant reports. And the development of an 1980. This is part of a plan for systematically information tool called "TABCONT" which evaluating all 10 centers over a five-year period. provides the tables of contents of scientific This plan has been overtaken by events and and technical periodicais and publications for five centers will be in various phases of review circulation to Headquarters and field staff, during 1980. The emphasis is on the management thus permitting their access to Headquarters and technical activities of each center and their publications at significantly.lower cost. role within the appropriate PAHO program.

168 ADMINISTRATION AND MANAGEMENT 169

AMERICAN REGION PROGRAMMING AND EVALUATION SYSTEM

To improve its technical cooperation finance, budget, and procurement units. with the Region's countries, PAHO con- As planned, the hemispheric program tinued developing its American Region Pro- and country profile word-processing data gramming and Evaluation System (AMPES). base, including information about national The system, which in 1979 began its second programs in which PAHO collaborates, year of operation, was designed to for- was completed. Expanded hardware capa- mulate, carry out, and evaluate PAHO's bility has greatly facilitated the updating collaborative activities, either by providing and retrieval of this large volume of textual direct support to Member Governments in information in response to PAHO and Mem- their national health programs or by ful- ber Government needs. filling Governing Body resolutions mandat- The telecommunication link between ing hemispheric programs. PAHO's word-processing and computer Based on the experience gained in the systems was completed as scheduled. The initial operation, procedures were improved first use made of the link was to prepare a and revised. Preliminary analysis of 1978 report on discrepancies between activities programmed objectives and accom- programmed and those executed in 1979 to plishments indicated the need for planning search for problem clusters. Though the and scheduling improvements for 1980-81 report was not a detailed analysis, it helped and 1982-83 budget cycle programming. identify general information about what As part of the internal reorganization had caused most of the problems in this at PAHO Headquarters, AMPES was trans- area. ferred to the Office of the Operations Certain adjustments in AMPES have sped Manager in late 1979. An effort to stream- preparation of most periodic and special line procedures has begun to provide more reports on PAHO's cooperation activities, timely and effective support through but more expeditious methods were under AMPES. study. In addition, preliminary work was The new functions assigned to the sys- done during 1979 to introduce additional tem have led to increased use of PAHO's changes in AMPES' mechanics in 1980 such data processing services and close coor- as simplification of forms and updating dination with the Headquarters personnel, of the procedures manual.

BUDGET AND FINANCE

In 1978 the Governing Bodies adopted get became a reality when the Directing a biennial program and budget cycle, and Council approved the 1980-81 effective in October 1979 PAHO's first biennial bud- working budget. PAHO, WHO, and other 170 REPORT OF THE DIRECTOR international agencies had formerly had to conduct a comprehensive external eval- annual budget cycles. uation of the Centers and submit a report In addition to the PAHO regular biennial to the 84th Meeting of the Executive Com- effective working budget of $75,534,600, mittee in 1980. the Directing Council approved a $1,041,400 In response to recommendations by the supplementary budget for the Pan Amer- external auditors, a review was begun of ican Foot-and-Mouth Disease and Zoonoses PAHO's accounting and financial manage- Centers for 1980. This supplementary bud- ment system to effect improvements. get was needed so that current levels of Efforts to achieve a program classifica- operations could be maintained at the tion system compatible with that of WHO Centers. Their budget ceilings could not Headquarters were begun and will continue absorb the increasing costs of living in in 1980-81. their host countries and the higher salaries In 1978 the XX Pan American Sanitary and allowances for local staff computed Conference approved the general policy under the United Nations System. The of charging for program support costs to Directing Council instructed the Director reimburse PAHO for administering ex-

Table 6. Expenditures by source of funds.

Expenditures Per cent Source of funds 1978 1979 change

Pan American Health Organization Regular budget 31,177,890 33,672,095 8 Trust funds 7,496,187 7,897,102 5 Community Water Supply Fund 1,403,109 1,680,584 20 Revolving Fund: Expanded Program on Immunization - 2,291,110 100 Special fund: Health promotion 226,084 250,000 11 Special fund: Program support costs 145,146 749,020 416 Other funds 194,825 363,438 87 INCAPa Regular budget and trust funds 3,908,582 4,382,228 12 CARECb 771,984 914,315 18 CFNlc 317,916 450,032 42 PAHO total 45,641,723 52,649,924 15

World Health Organization Regular budget 14,562,002 16,406,000 13 United Nations Development Program 2,837,771 3,007,999 6 United Nations Fund for Population Activities 6,947,527 6,968,819 - Other 263,957 466,962 77 WHO total 24,611,257 26,849,780 9

Total 70,252,980 79,499,704 13

a Institute of Nutrition of Central America and Panama. bCaribbean Epidemiology Center. cCaribbean Food and Nutrition Institute. ADMINISTRATION AND MANACEMENT 171 trabudgetary funds. Considerable effort ments, increased from $1,039,402 in 1978. was devoted during 1979 to improving the The revolving fund for the Expanded management of extrabudgetary funds and Program on Immunization (EPI) was ini- formulating program support cost policies tially capitalized at $1 million. In 1979 the and rates. Particular emphasis was placed Directing Council approved a resolution on policies and guidelines governing reim- (CD26.16) authorizing a transfer of $800,000 bursements from donor agencies and from the holding account to the EPI revolv- refinancing activities to be supported from ingfund. Thesetwo amounts plus a$500,000 extrabudgetary funds. In 1979 extrabud- contribution from the Netherlands in- getary expenditures of $25,866,665 increased the EPI fund to $2.3 million at the creased 10 per cent over 1978, and amounts end of 1979. During the year $2,291,110 collected from program support costs was disbursed for vaccines on behalf of helped to defray the expenses of admin- 20 countries. These expenditures, plus un- istering these funds. liquidated obligations (commitments) of Expenditure data by fund, as noted in $1,453,725, reached a total of $3,744,835, the Financial Report of the Director and indicating that the revolving fund is not Report of the External Auditor (Official fully capitalized. Document 168), are shown in Table 6. The Financial Report shows that PAHO Total expenditures of all funds during maintained a sound financial position in 1979 amounted to $79,499,704, an increase 1979. The largest contributor's revised of 13 per cent over 1978 expenditures. method of forwarding quarterly install- Miscellaneous income of $1,415,485, which ments had a most favorable effect on includes $1,246,697 in interest on invest- PAHO's financial operations.

PROCUREMENT

PAHO bought a wide range of com- costing more than $2.1 million. Over 200 modities and services for Member Govern- vaccine shipments were made, and almost ments and in support of its own operations all were delivered on or ahead of schedule. and programs in 1979. One of the most The total value of procurements in- significant activities in PAHO's purchasing creased markedly, from $10.9 million to was the systematic procurement of vac- $15.8 million. Most of the $4.9 million cines for 24 Member Governments accord- increase was attributable to $2.6 million ing to a quarterly schedule. The govern- in vaccine purchases and $400,000 in ments determined their vaccine needs, insecticide purchases not made in previous which amounted to over 40 million doses years: 172 REPORT OF THE DIRECTOR

PERSONNEL

At the end of 1979, PAHO's staff num- staff benefits included changes in the bered 1,317 (including 36 temporary em- education grants policy to cover unmarried ployees), as compared with 1,328 (including children over the former age limit of 21 29 temporary employees) a year earlier. years who are undertaking postsecondary Of the 1,281 regular staff, 446 were as- studies and the once excluded costs of signed to Headquarters, 85 to Area and university-level studies in the country or field offices, 493 to intercountry projects, area of assignment. The new provisions and 257 to country projects. also allow reimbursement of special edu- During the year an updated PAHO clas- cational expenses for a staff member's sification system for general service posts physically or mentally disabled child. was established at Headquarters. Prelim- In the area of staff development and inary studies were made of similar posts at training, advanced management seminars the Pan American Centers and Area offices were held at Headquarters and Antigua, in order to develop classifications for the Guatemala, for professional staff, and field. office management workshops were con- A survey of the general service salary ducted for the general service staff at scale for Washington was conducted from Headquarters. Three management trainees August to October, and the result was a were appointed at Headquarters and will 10 per cent across-the-board increase to start work in January 1980 as part of PAHO's meet higher living costs. Assistance was management trainee program. given to the field offices in Argentina, A service award ceremony to honor 49 Barbados, Guatemala, Jamaica, Suriname, staff members who completed 10, 15, 20, and Trinidad and Tobago in reviewing and 25 years of service was held at Head- conditions of employment prevailing for quarters in April, followed by similar locally recruited staff. ceremonies for 62 staff members at field In June, following similar United Nations offices. Staff members who completed 25 and WHO decisions, the Executive Com- years of service received gold medallions mittee confirmed a number of changes in bearing the PAHO symbol. the Staff Rules. These improvements in

CONFERENCE SERVICES

The steady increase in conference sup- Complete staffing and documentation port services noted in recent years con- services were provided for the 82nd and tinued in 1979. Assistance was provided to 83rd Meetings of the Executive Committee 225 seminars and meetings at Headquarters and the XXVI Meeting of the Directing and in the various Member Countries. Council at Washington and the XII Inter- ADMINISTRATION AND MANAGEMENT 173

American Meeting at the Ministerial Level ington), Consultation Meeting on National on Foot-and-Mouth Disease and Zoonoses Health Information Systems (San José, Control at Willemstad, Curaçao. Costa Rica), Interregional Workshop on Advisory and administrative assistance Financing Health Services (Cocoyoc, was also supplied to the following other Mexico), and the XVI Regional Seminar meetings: III Regional Seminar on Tuber- on Health Services Administration (Mérida, culosis (Washington), Third Meeting of Mexico). Directors of National Malaria Eradica- The language services unit continued tion Services (Mexico City), XXXVII Annual to supply translations in response to re- Meeting of the U.S./Mexico Border Public quests from PAHO's Headquarters and field Health Association (San Diego, California), offices. Staff and contract translators Sixth Meeting of the Ministers of Health of produced 12,167 pages of translations in the Andean Region (Lima), International PAHO's four working languages: Spanish Congress on Alcoholism (Tegucigalpa), (49.8 per cent of the total production), Meeting of Ministers Responsible for Health English (37.6 per cent), Portuguese (10.3 per in the Caribbean (Antigua), PAHO Advisory cent), and French (2.3 per cent). Committee on Medical Research (Wash-

MANAGEMENT AND COMPUTER SERVICES

PAHO's management staff increased taken during the year of optical character its continuing review of PAHO activities recognition (OCR) equipment. Documents at Headquarters and in all field offices to typed on ordinary electric typewriters in ensure that good management practices an OCR typeface could be "read" and are followed. Another major effort was the automatically entered by an interface completion of a manual for decentralizing device into PAHO's word-processing and the administration and award of fellow- computer systems without the intervention ships for the English-speaking Caribbean. of a typist. The study showed that OCR This program will be operational by the technology is feasible and will provide end of 1980. cost savings to PAHO. Plans are being made Other management activities included to introduce the system at Headquarters. standardization of delegations of authority PAHO began implementing a computer- from the Director to various PAHO officials based information system to put timely in the Region. To realign technical and information in the hands of its decision administrative direction with the year's makers. The design criteria for the project reorganizational refinements, a revision anticipate a PAHO-wide pool of informa- of PAHO's program codification system tion which can be amalgamated or sum- was initiated. In addition, a complete up- marized to meet decision makers' indi- dating of PAHO and field operations manu- vidual needs. A primary part of the system als was undertaken. is a management data base that allows To speed paperwork, a study was under- easy interrelation of informational ele- 174 REPORT OF THE DIRECTOR

ments for specific uses. Terminal retrieval a computer-based Spanish-to-English ma- has been introduced to facilitate the presen- chine translation system. This technologic tation and opportune introduction of data improvement is based on a telecommuni- in PAHO's general computer system. Deci- cation link between PAHO's IBM 370 and sion makers will thus be substantially Wang word-processing equipment. Signifi- freed from piles of computer printout and cant time saving in translation, retyping, in the future will receive concise informa- and editing will eventually be achieved. tion on computer terminals in their own Because of these and other initiatives, offices. the normal workload of PAHO's computer To assist the technical divisions in their center and programming staff mounted. need for better analysis of the large and The number of computer hours used in increasingly complex volume of health 1979 increased approximately 50 per cent, statistics compiled by PAHO and countries, and the center's printed output almost two sophisticated computer software doubled over the previous year. The in- packages were purchased in 1979. This troduction of programming and better cost-effective measure will allow trained productivity aids allowed the increased statistics users to perform complex statisti- workload to be absorbed without additional cal tasks and improve productivity. staff. Other cost-benefit measures included

E E E INDEX

A hospitals, 32 Influenza Center, 93 information systems, health, 40 Accidents (see Traffic accident prevention) laboratories, 117 Administration, health care, 32-34 leprosy, 95 training in, 34, 49, 51-52 leptospirosis, 80 Adolescents, health of, 42 malaria research, 75 Aedes aegypti, 78, 106-111 maternal and child health/family planning, 42 Air pollution (see Pollution, air) medical education, 54 Alcoholism, 59, 112 nursing education, 67 Allergies, 115 rabies, 81, 154 Allopurinol, 76 research, biomedical, 73 Alma-Ata, Declaration of (see Primary Health Care, smallpox eradication, 86 International Conference on) Articulation, intersectoral, 24, 28 Ambulatory care, 31, 55 Auxiliaries, health, 59-61 American Hospital Association, 36 American Public Health Association, 166 American Red Cross, 114,123 American Region Programming and Evaluation Sys- B tem (AMPES), 158, 169 American Society of Hospital Engineering, 36 AMPES (see American Region Programming and Eval- Bacterial diseases, 98 uation System) Bahamas Andean Pact countries administration, health care, 39 auxiliary and technical health workers, 60 Aedes aegypti situation, 107 biologicals production and testing, 121 manpower planning, 49 health education, 38 Barbados health services, 30-31 administration, health care, 39 ministers of health, meeting of, 20, 173 Aedes aegypti situation, 107 occupational health, 138 breastfeeding, 44, 45 PAHO, relationship with, 7 dengue, 111 Anemia, iron-deficiency, 44, 45 health and youth, 42 Anguilla health service research, 79 maternal and child health/family planning, 41 rabies control, 154 nutrition and food, 45 veterinary services, 146 Animal health, 8,146-154 water and sewerage authority, 134 personnel, 14 Belize research, 79-82 Aedes aegypti situation, 107 Antigua dengue, 111 administration, health care, 39 health and youth, 42 education, family life, 38 Bermuda health and youth, 42 dental health, 113 maternal and child health/family planning, 41 Bibliographic and Health Information Office (PAHO), Argentina 166-167 administration, training in health care, 51 Biologicals, 120-123 alcoholism and drug dependence, 59 Blindness, prevention of, 8, 98-99 animal health, 80-81,151 Blood banks, 123 dams, health impact of Yacyretá, 139 pressure, high (see Hypertension) health services, 29 Boletin de la Oficina Sanitaria Panamericana, 159-160

175 176 REPORT OF THE DIRECTOR

Bolivia C animal health, 152 auxiliary and technical health workers, 62 colonization schemes, health impact of, 139-140 continuing education, 52 Canada dental education, 57 International Development Agency (CIDA), 20-21, disasters, 125 43, 52, 57, 123, 124, 132 Expanded Program on Immunization, 88 International Development Research Center (IDRC), health services, 29 21, 43, 46,119, 135 Latin American Program for Educational Develop- legislation, health, 39 ment in Health, 53 University of Sherbrooke, CLATES-Rio aid to, 65 leishmaniasis, 106 Cancer, 8, 114-115 leprosy, 95-96 CANCERLINE computerized bibliographic searches, 115 malaria, 101 Cardiovascular diseases, 115 research, 75 Caribbean, English-speaking manpower planning, 51 administration, health care, 39 maternal and child healthlfamily planning, 41 auxiliary and technical health workers, 21, 60-61 medical education, 54 Caribbean Regional Drug Testing Laboratory, 123 nutrition and food, 43 dental auxiliary training, 57 public health, education in, 54 dental health, 113 rabies control, 154 education, family life, 38 smallpox eradication, 86 emergency preparedness, 19, 20 University of San Simon, CLATES-Rio aid to, 65 environmental health, 19 yellow fever, 111 fellowships for the, 60, 70, 168, 173 Brazil food protection, 145 administration, training in health care, 51 health and youth, 42 Aedes aegypti situation, 107 hospital maintenance, 36 animal health programs, 80-82, 146-148 laboratories, 21, 116 auxiliary and technical health workers, 60, 62 leprosy, 96 biomedical engineering, training in, 36 manpower planning, 51 dental education, 57, 58 mental health care, 112 environmental health, 14 nursing and family health project, 55 executives, training of health care, 32 nutrition and food, 44-46 health services, 29 occupational health, 19, 137-138 health services extension, 28, 31 public health, education in, 54 hospitals, 32 schistosomiasis, 105 Latin American Program for Educational Develop- sexually transmitted diseases, 97 ment in Health, 53 traffic accident prevention, 143 leprosy, 95, 96 water management project, 19, 20, 56-57, 132 leptospirosis, 80 Caribbean Alcoholism Institute (Charlotte Amalie, libraries, biomedical, 63-65 U.S. Virgin Islands), 59 legislation, health, 39 Caribbean Community (CARICOM) malaria research, 75, 101 Caribbean Regional Drug Testing Laboratory, 123 maternal and child health/family planning, 42 health education, 38 mental health, 59 health ministers, meeting of, 19, 113, 120, 145, 173 nursing education, 67 occupational health, 19, 138 primate production, 81-82 traffic accident prevention, 143 public health, education in, 54 water supply systems, 19, 136 rabies control, 80, 154 Caribbean Development and Cooperation Committee schistosomiasis, 104 (ECLA), 16 smallpox eradication, 86 Caribbean Development Bank, 19, 131 Urban Zoonoses Center (Sao Paulo), 148 Caribbean Epidemiology Center (CAREC), 10, 57, 74, veterinary education, 58 92, 95, 96, 118-120, 121 water and sewerage, 134 Caribbean Food and Nutrition Institute (CFNI), 13, 43 yellow fever, 111 44-46, 163 Brazilian Association of Sanitary Engineers, 57 Caribbean Regional Drug Testing Laboratory, 123 Brazilian National Housing Bank, 57 Cataract (see Blindness, prevention of) Breastfeeding, 44-45 Cayman Islands British Leprosy Relief Association, 95 maternal and child health/family planning, 41 British Virgin Islands (see Virgin Islands, British) Center for Health Care Administration (Colombia), Brucellosis, 80, 153 33, 34 Budget (PAHO), 7, 10, 169-171 Center for Multidisciplinary Studies in Rural Develop- Bulletin of PAHO, 160 ment (Cali), 91 INDEX 177

Central America and Panama hospitals, 34 auxiliary and technical health workers, 60, 61 information systems, health, 40-41 community health training program, 14 legislation, health, 39 dental health, 113 leprosy, 96 Health Ministers, meeting of, 19, 113 malaria research, 74-75, 75, 101 leprosy, 96 manpower planning, 51 wastes, solid, 133 maternal and child healthlfamily planning, 41, 42 water supply systems, 56, 132 medical education, 54 CEPANZO (see Pan American Zoonoses Center) mycosis, tuberculosis, and leprosy control pro- CEPIS (see Pan American Center for Sanitary Engi- gram, combined, 93 neering and the Environmental Sciences) National Institute of Health, 111, 121, 145 CFNI (see Caribbean Food and Nutrition Institute) nursing education, 55, 67 Chagas, Carlos, 63, 104 planning, health, 29, 31 Chagas' disease, 63, 77-78, 87, 104, 140 primate production, 81-82 Children (see Maternal and child health/family plan- rehabilitation services, 37 ning) School of Public Health, Medellín, 29 Children's Eye Care Foundation, 163 smallpox eradication, 86 Chile social security agency, 31 administration, training in health care, 51 Venezuelan equine encephalitis, vaccination animal health, 151 against, 146 biologicais production and testing, 120 yellow fever, 111 continuing education, 52 Commission on Academic Nutrition and Dietetic health services, 29 Programs in Latin America, 44 health services extension, 28 Committee on Food Aid Policies and Programs (see hospitals, 32 United Nations, World Food Program) information systems, health, 40 Community participation in health, 24, 25, 78 laboratories, 116-117 Computers, 173-174 manpower planning, 51 (see also Microcomputers in health) maternal and child health/family planning, 41,42 Conference services (PAHO), 172-173 medical education, 54 COSALFA (see South American Foot-and-Mouth mental health care, 112 Disease Control Commission) nursing education, 67 Costa Rica nutrition and food, 43 administration, health care, 39 public health, education in, 54 training in, 51 research, biomedical, 73 Aedes aegypti situation, 107 typhoid fever, 98 auxiliary and technical health workers, 61 veterinary education, 58 continuing education, 52 water and sewerage, 134 dental education, 58 Clark Foundation, Edna McConnell, 76-77 Expanded Program on Immunization, 88 CLATES (see Latin American Center for Educational health services extension, 28 Technology in Health) hospitals, 33 Cold-chain vaccine equipment, 88-91, 119 information systems, health, 40-41 Collaborative Cancer Treatment Research Program, Latin American Program for Educational Develop- 115 ment in Health, 53 Colombia leishmaniasis, cutaneous/mucocutaneous, 106 administration, health care, 33, 39, 51 malaria research, 75 training in, 39 medical education, 54 Aedes aegypti situation, 107 nursing education, 55, 67 animal health, 151 rabies control, 154 auxiliary nurse training, 55 Courses (see Meetings and courses) Center for Education in Health Care Administra- Cuba tion, 33, 34 administration, training in health care, 51 Center for Multidisciplinary Studies in Rural De- Aedes aegypti situation, 107 velopment (Cali), 91 auxiliary and technical health workers, 60 continuing education, 52 dengue, 111 dental education, 57, 58 dental health, 113-114 disasters, 125 workers, 57 executives, training of health care, 32 immunology laboratories, 117 Expanded Program on Immunization, 88 information systems, health, 40-41 fluoridation, salt, 143 maternal and child health/family planning, 38, 41, health service research, 79 42 health services, 29 research, biomedical, 73 health services extension, 28, 31, 55 syphilis control program, 97 178 REPORT OF THE DIRECTOR

D Ecuador Aedes aegypti situation, 107 alcoholism and drug dependence, 59 Damien Foundation (Belgium), 22, 96 animal health, 151 Dams, health impact of, 139 auxiliary nurse training, 55 Declaration of Alma-Ata (see Primary Health Care, birth attendants, traditional, 42 International Conference on) continuing education, 52 Dengue, 111-112, 160 dental education, 57 Dengue in the Caribbean, 1977, 160 Expanded Program on Immunization, 88 Dental health, 8, 113-114 health care units, locating, 28 workers, 57 health service research, 79 Diabetes, 8, 45, 55 health services, 31 DIALOG Information Retrieval Service, 167 hospitals, 32 Diarrheal diseases, 8, 93-94 Latin American Program for Educational Develop- Diet (see Nutrition) ment in Health, 53 Diphtheria, 87 libraries, biomedical, 64 Directory of Training Programs in Latin America and malaria research, 75, 101 the Caribbean, 70 manpower planning, 51 Disaster relief (see Emergency preparedness and di- maternal and child health/family planning, 38, 41 saster relief) medical education, 54 Disease (see name of specific disease) milk inspection laboratories, modernization of, 146 Dominica nursing education, 55, 67 disasters, 125 planning, health, 31 health planning, 28 research, biomedical, 73 maternal and child health/family planning, 41 smallpox eradication, 86 PAHO Directing Council resolution on, 7-8 social security agency, 31 reconstruction projects, 39 yellow fever, 111 Dominican Republic Educación médica y salud, 160 administration, health care, 39 Education, continuing health worker, 52 Aedes aegypti situation, 107 Education, in auxiliary and technical health workers, 60, 62 dentistry, 57-58 continuing education, 52 engineering and environmental sciences, 56-57 dental education, 57 family life, 38 disasters, 125 health, 38 health services extension, 29 medicine, 53-54 hospitals, 34 mental health, 59 human resources institutional development, 52 nursing, 54-56, 67 information systems, health, 40 public health and social medicine, 29, 54 Latin American Program for Educational Develop- veterinary, 58 ment in Health, 53 Egypt, 36 leishmaniasis, 76 El Salvador leprosy, 96 administration, health care, 39 malaria research, 75 Aedes aegypti situation, 107 maternal and child health/family planning, 38, 42 alcoholism and drug dependence, 59 nursing education, 55, 67 auxiliary and technical health workers, 62 nutrition and food, 43 health care units, locating, 28 PAHO Directing Counci! resolution on, 8 health services, 29 planning, health, 29, 31' information systems, health, 41 rabies control, 154 leishmaniasis, 105 research, biomedical, 73 malaria research, 75, 101 schistosomiasis, 104 microcomputers in health, 158 Drug dependence, 59, 112 rehabilitation services, 37 Drug Quality Institute (Sao Paulo), 122 water and sewerage, 13-14 Drugs, quality control of, 122-123 Emaus Swiss, 96 DTIAPA (program to develop water supply and sewer- Emergency medical services, 31 age agencies technologically), 132, 138-139 Emergency preparedness and disaster relief, 10, 16, 17, 20, 22, 124-126 Encephalitis, equine, 153 Engineering and environmental sciences, education in, 56-57 E Environmental health, 127-143 EPI Newsletter, 92 ECO (see Pan American Center for Human Ecology and Epidemiological Bulletin, 118 Health) Equipment, health care, 35, 57 INDEX 179

European Economic Community, 17, 43, 46, 124 food protection, 145 Evaluation of Sugar Fortification with Vitamin A at health care units, locating, 28 the National Level, 160 health planning, 28 Executives, health care, 32-33 health service research, 79 Expanded Program on Immunization (EPI), 8, 63, 83, health services, 29, 31 87-92, 156, i68, 171 health services extension, 29 information systems, health, 40 Institute of Nutrition of Central America and Pan- ama, 12, 22, 43, 44, 46-47, 63, 95 F leishmaniasis, 105 malaria research, 75, 101 medical education, 54 Family life education (see Education, family life) microcomputers in health, 158 Fellowships (PAHO), 67-70 water and sewerage, 134 Caribbean, English-speaking, 60, 70, 168, 173 Guide to Emergency Health Management After Natural Filariasis, 87, 105 Disasters, 125 Filmstrips (PAHO), 163-164 Guyana Florida Institute of Technology (USA), 36 Aedes aegypti situation, 109 Fluoridation, 8, 142-143 animal health, 14 Food (see Nutrition) dental workers, 57 Food and Nutrition Foundation of Central America health and youth, 42 and Panama, 46 health care units, locating, 28 Food protection, 81-82, 145-146 health planning, 29 Foot-and-mouth disease, 148-151 health service research, 79 Ford Foundation, 43, 46 health services, 29, 31 Foundations, 22-23 hospitals, 34 French Guiana information systems, health, 41 Aedes aegypti situation, 107 malaria research, 75 malaria research, 75 rehabilitation services, 37 Fungal diseases (see Mycoses)

H G

Haiti GEMS (see Global Environmental Monitoring Systems) Aedes aegypti situation, 109 George Washington University (USA), 36 auxiliary nurse training, 55 Georgia Institute of Technology (USA), 36 dengue, 111 German Leprosy Relief Association, 96 health services, 29 Germany, Federal Republic of hospitals, 36 Gesellschaft fOr Technische Zusammenarbeit malaria research, 75, 101 (Agency for Technical Cooperation), 21, 131 maternal and child health/family planning, 41 wastes, solid, 21 nutrition and food, 43 Glaucoma (see Blindness, prevention of) planning, health, 29 Global Environmental Monitoring Systems (UNEP- University of, 36 66 UNESCO), 15, 135, 137 water and sewerage, 13, 134 Goiter, endemic, 44 Health, animal (see Animal health) Gonorrhea (see Sexually transmitted diseases) environmental (see Environmental health) Gorgas Memorial Laboratory (Panama), 75, 106 occupational (see Occupational health) Governing Bodies, 6-10 pediatric (see Maternal and child health/family Grenada planning) Aedes aegypti situation, 109 radiation (see Radiation health) health and youth, 42 Health care facilities, 28 rabies control, 154 maintenance, 35-37 Guatemala Health Conditions of Children in the Americas, 42 administration, health care, 39 Health for all by the year 2000 (WHA30.43), 1, 3, 4-5, 6, Aedes aegypti situation, 109 7, 10, 24, 28, 34, 38 auxiliary and technical health workers, 62 Health service research, 78-79 continuing education, 52 Health workers, professional drug control, 14 technical, 59-61 Expanded Program on Immunization, 88 Hepatitis, 82, 97-98 filariasis, 105 Hipólito Unanue Agreement, 7 18) REPORT OF THE DIRECTOR

Honduras Inter-American Center for Integrated Water and Land administration, health care, 39 Development (Mérida, Venezuela), 136 Aedes aegypti situation, 109 Inter-American Center for Social Security Studies alcoholism and drug dependence, 59 (Mexico City), 31-32 auxiliary and technical health workers, 62 Inter-American Children's Institute (Montevideo), 112, auxiliary nurse training, 55 156 birth attendants, traditional, 42 Inter-American Council for Education, Science, and disasters, 125 Culture (CIECC) (see Organization of American El Cajón dam, 140 States) Expanded Program on Immunization, 88, 89 Inter-American Council of Psychiatric Associations, 10 health services extension, 29, 30, 42 Inter-American Development Bank (IDB) hospitais, 32, 34 administration, health care, 39 information systems, health, 40-41 animal health, 146, 150, 151 Latin American Program for Educational Develop- DTIAPA (program to develop water supply and se- ment in Health, 53 werage agencies technologically), 138 leishmaniasis, visceral, 76, 105 environmental agencies, development of, 134 malaria research, 75, 101 health for all, 5 maternal and child health/family planning, 41 health service research, 79 nursing education, 55 health services extension projects, 29, 30 research, biomedical, 73 human resources institutional development, 52 HOPE, Project, 20, 60 nutrition and food, 43 Hospitales de Costa Rica, 33 PAHO, relations with, 7, 18 Hospitals, 32-34 textbook program, 165 infections, control of, 116 wastes, solid, 56, 133 maintenance, 36 water supply systems, 13, 56, 57, 132 Human Reproduction, WHO Special Program on (see Inter-American Economic and Social Council (CIES) World Health Organization) (see Organization of American States) Human resources, environmental, 56-57 Inter-American Fund for Assistance in Emergency health, 48-50 Situations (see Organization of American States) Hydatidosis, 80, 153-154 Inter-American Institute of Agricultural Sciences, Hypertension, 45, 55, 115, 156 18-19 Hypovitaminosis A, 44 Inter-American Investigation of Mortality in Child- hood: Report on a Household Sample, 160 Inter-American Meeting at the Ministerial Level on Foot-and-Mouth Disease and Zoonoses Control, 150, 160, 173 International Atomic Energy Agency (IAEA), 141 International Bank for Reconstruction and Develop- ment (see World Bank) Immunization (see Expanded Program on Immuniza- International Classification of Diseases, 156, 156-158 tion) International Classification of Procedures in Medicine, Immunology laboratories, 117-118 156 Immunology Training and Research Center (Am- International Commission on Radiation Units and sterdam), 118 Measurements, 142 INCAP (see Institute of Nutrition of Central America International Commission on Radiological Protec- and Panama) tion, 142 Infections, hospital, 116 International Conference on Primary Health Care (see Influenza, 93 Primary Health Care, International Conference Information, public (PAHO), 164-165 on) Information collection and dissemination (PAHO), International Development Association, 134 155-158 International Digest of Health Legislation, 39 Information systems, health, 40-41 International Drinking Water Supply and Sanitation Insecticides, 75-76, 77 Decade, 10, 13, 14, 16, 21, 56, 127, 132, 163 Institute of Nutrition of Central America and Panama International Eye Foundation (Bethesda, Maryland, (INCAP), 12, 22, 43, 44, 46-47, 63, 95 U.S.A.), 164-165 Institute of Pharmacology and Nutrition (Argentina), International Federation of Hospital Engineering, 36 123 International Leprosy Association, 95 Instruments, medical (PAHO program), 166 International Planned Parenthood Federation, 38 Inter-Agency Project for the Promotion of National International Reference Centre for Water Supply Food and Nutrition Policies (PIA/PNAN), 43 (WHO, The Hague), 136 Inter-American Association of Sanitary and Environ- international Regional Plant and Animal Health Or- mental Engineering (AIDIS), 56, 57 ganization (OIRSA), 146, 150 INDEX 181

International Society of Blood Transfusion, 123 Health, Rio de Janeiro (CLATES-Rio), 13, 61, International Society of Disaster Medicine, 125 65-66, 163 International Year of the Child (United Nations), 15, Latin American Center for Perinatology and Human 113, 160 Development (Montevideo), 12, 42-43, 44, 66 Latin American Federation of Hospitals, 10 Latin American Federation of National Associations of Veterinary Medicine Schools, 58 Latin American Federation of the Pharmaceutical In- dustry, 10 Latin American Index Medicus, 64 Latin American Program for Educational Development Jamaica in Health (PLADES), 22, 53 administration, health care, 39 League of Red Cross Societies, 17, 123, training in, 51 125 Legionnaire's Aedes aegypti situation, 109 disease, 93 Leishmaniasis, 105-106 Caribbean Food and Nutrition Institute, 44-46 research on, 87 Caribbean Regional Drug Testing Laboratory, 123 Leprosy, 8, 87, 95-97, 103 continuing education, 52 Leptospirosis, dengue, 111,160 76, 80 Libraries (see Regional Library of dental workers, 57 Medicine and the disasters, 125 Health Sciences) Loyola University (USA), 114 health care units, locating, 28 hospitals, 34 immunology laboratories, 117 information systems, health, 41 maternal and child health/family planning, 41 M Japanese Shipbuilding Industry Foundation, 96 Jenner, Edward, 85 Johns Hopkins University (USA), 36 Malaria, 8, 10, 99-103 research on, 74-76, 78, 87, 103 Malnutrition, energy-protein, 8, 44 Management, health care (see Administration, health K care) Manpower, dental, 57-58 environmental, 56-57 Kellogg, W. K. Foundation, 22-23 health 51-52 Maternal and child administration, health care, 32 health/family planning, 28, 41-43 training, 22-23, 34, 51 Measles, 87 Medical dental education, 58 education (see Education, medical) records (see education and health, 53 Information systems, health) Medical Literature Analysis and educational technology in nursing, 67 Retrieval System (MEDLARS), maternal and child health/family planning, 43 166-167 Medical Mycology nutrition and food, 43, 46 Society of the Americas, 93 MEDLINE computerized bibliographic searches, 63 Meetings and courses Alcoholism, International Congress on (Teguci- galpa), 173 1 Andean Region, Sixth Meeting of the Ministers of Health of the, 20, 173 Blindness, International Conference on the Preven- Laboratories, 116-118 tion of (Washington, June), 44 LACRIP (see Latin American Cancer Research Informa- Breastfeeding, Regional Workshop on (Barbados, tion Program) March), 44 Latin American Association of Biology and Nuclear Caribbean, Meeting of Ministers Responsible for Medicine Societies, 142 Health of the English-speaking, 19, 113, 120, Latin American Association of Public Health Schools, 145, 173 54 Chagas' Disease Congress, International (Rio de Latin American Cancer Research Information Pro- Janeiro, August), 63 gram (LACRIP), 64, 114-115 Development and Environment, Seminar on Styles Latin American Center for Educational Technology in of (Santiago), 16 Health, Mexico (CLATES-Mexico), 13, 66-67 Drug Control, I Inter-American Working Group on Latin American Center for Educational Technology in (Washington, May), 122 182 REPORT OF THE DIRECTOR

Environmental Engineering and Sciences, Fifth Peru- auxiliary and technical health workers, 60 vian Congress of, 136 auxiliary nurse training, 55 Environmental Sanitation in Development Planning, biologicais production and testing, 120 World Congress on (Mexico City, November), biomedical engineering, 36 140, 159 dengue, 111 Financing Health Services, Interregional Workshop dental education, 57, 58 on (Cocoyoc, Mexico), 173 fluoridation, salt, 143 Foot-and-Mouth Disease and Zoonoses Control, health services extension, 31, 42 Inter-American Meeting at the Ministerial hospitals, 32 Level on Inter-American Center for Social Security Studies XI Meeting, 160 (Mexico City), 31-32 XII Meeting, 150, 173 laboratories, 117 Health Information Systems, Consultation Meeting Latin American Program for Educational Develop- on National (San José), 173 ment in Health, 53 Health Services Administration, XVI Regional Se- leishmaniasis, 105 minar on (Mérida, Mexico), 39, 173 leprosy, 96 Health Systems, Second International Course on malaria, 74 Planning and Administration of (Mexico City, research, 75, 101 August-December), 28, 29, 39 maternal and child health/family planning, 38, 41, Human Settlements, Latin American Conference on 42 (Mexico City), 16 medical education, 54 Infant and Young Child Feeding, Joint WHO/UNICEF National Virology Institute, 121 Meeting on (Geneva, October), 44 nursing education, 67 Inter-Agency Consultation on the Environment for public health, education in, 54 Latin America and the Caribbean (Washington, rabies control, 154 D.C.), 14 rehabilitation services, 37 Inter-American Social Security Conference (Ottawa, research, biomedical, 73 May), 31 traffic accident prevention, 143 Medicine and Traffic Accidents, First International Microbiology Foundation, 22 Seminary on (Toluca, Mexico, June), 144 Microcomputers in health, 39, 158 National Malaria Eradication Services, Third Meet- Ministers of Health of the Americas ing of Directors of (Oaxtepec, Mexico, March), Fourth Special Meeting of (September 1977), 25, 28, 99 48 Nutrition, International Conference on Maternal Third Special Meeting of (September 1972), 3, 92, (Guatemala, March), 44 95 Nutritional Anemias, International Consultative Montserrat Group on (Cairo, October), 44 breastfeeding, 45 Public Health Association, American (New York), health and youth, 42 159 Mycoses, 93 Public Health Schools, X Conference of (Venezuela, April), 54 Sanitary and Environmental Engineering, XVII Inter- American Congress of (La Paz, July 1980), 136 N Socioeconomic Determinants of Mortality, Meet- ing on (Mexico City), 159 Tropical Medicine and Hygiene, American Society National Housing Bank (Brazil), 134 of (Tucson), 159 National Water Council (England), 57 Tuberculosis, III Regional Seminar on (Washington), Netherlands 92, 173 disaster relief, 125 U.S/Mexico Border Public Health Association (San Expanded Program on Immunization, donation to, Diego), 173 89, 171 Veterinary Medicine, Third Seminar in the Americas immunology laboratories, sponsors Caribbean net- (Valdivia, Chile), 58 work of, 117-118 Mefloquine, 75 water management, 20, 132 Meningococcal meningitis, 98 Netherlands Antilles Mental health, 59,112-113 Aedes aegypti situation, 109 education in (see Education, mental health) Nicaragua Mexican Center for Mental Health Research (Mexico Aedes aegypti situation, 109 City), 59 auxiliary and technical health workers, 62 Mexico continuing education, 52 administration, training in health care, 51 disasters, 125 Aedes aegypti situation, 109 health care units, locating, 28 INDEX 183

health service research, 79 'ironmental Sciences (CEPIS, Lima), 13, 14, 21, 56, human resources institutional development, 53 132, 135-139, 164 information systems, health, 40-41 Pan American Centers (PAHO) 10, 168, 170, 172 Latin American Program for Educational Develop- Pan American Development Foundation (PADEF), 22 ment in Health, 53 Pan American Environmental Engineering and Sciences libraries, biomedical, 64 Information and Documentation Network malaria (REPIDISCA), 14-15, 135, 140 control, 14, 101 Pan American Federation of Medical School Associa- research, 75 tions, 54 maternal and child health/family planning, 41, 42, Pan American Foot-and-Mouth Disease Center (PAN- 79 AFTOSA, Riode Janeiro), 8,13,16,80,146,148-151, PAHO Directing Council resolution on, 7-8 170 NIDES (see Nuclei of Research and Development in Pan American Health (PAHO magazine), 164 Education and Health) Pan American Health and Education Foundation Noncommunicable diseases, 114-115 (PAHEF), 22, 53, 165 Nongonococcal urethritis (see Sexually transmitted dis- Pan American Health Organization, 6 eases) Advisory Committee on Medical Research (ACMR), Nuclei of Research and Development in Education and 44, 73-74, 78, 179 Health (NIDES), 22 Caribbean Program Coordinator's office, 70 Nurses and nursing, 42, 46 Directing Council, 4, 7-10, 31, 38, 61, 74, 89, 91, 95, education (see Education, nursing) 99, 103, 115, 124, 127, 131, 143, 159, 164, Nutrition, 43-47 169-170 Executive Committee, 4, 7, 10, 99, 103, 164 Pan American Sanitary Bureau, reorganization of, 10-13 Pan American Sanitary Conference, 6, 7, 88, 99,119, o 122, 170-171 Regional Library of Medicine and the Health Sci- ences (see Regional Library of Medicine and Occupational health, 137-138 the Health Sciences) OIRSA (see International Regional Plant and Animal Textbook program (see Textbooks) Health Organization) Pan American Medical Association, 125 Optical character recognition (OCR) equipment, 173 Pan American Sanitary Bureau (see Pan American Oral rehydration therapy (ORT) (see Diarrheal dis- Health Organization) eases) Pan American Zoonoses Center (CEPANZO, Ramos Order of Malta, 95, 96 Mejía, Argentina), 8-10, 13, 80, 92, 121, 146, Onchocerciasis (see Blindness, prevention of) 151-154, 170 Organization of American States PANAFTOSA (see Pan American Foot-and-Mouth Dis- health education, 38 ease Center) PAHO, relationship with, 7, 17-18 Panama University of Haiti, advice to, 66 administration, health care, 39 wastes, solid, 133 animal health, 151 Oswaldo Cruz Foundation (Brazil), 60,96,111,121 auxiliary and technical health workers, 62 biomedical engineering, training in, 36 dental education, 57, 58 health care units, locating, 28 p health services extension, 28, 29, 30 hospitals, 34, 36 information systems, health, 40-41 PAHEF (see Pan American Health and Education Foun- leishmaniasis, 76 dation) malaria research, 75 PAHO Documentation and Information System (PAHODIS), maternal and child health/family planning, 38, 41, 166 42 PAHO Reports (newsletter), 164 nursing education, 55 Pan American Air Pollution Monitoring Network planning, health, 28, 30,31 (REDPANAIRE), 135, 137 social security agency, 31 Pan American Center for Human Ecology and Health University of, 36 (ECO), 13, 14, 139-140 Paraguay Pan American Center for Research and Training in Chagas' disease, 140 Leprosy and Tropical Diseases (Caracas), 8, 77, dam, health impact of Yacyretá, 139 96-97 dental education, 57, 58 Pan American Center for Sanitary Engineering and En- health care units, locating, 28 184 REPORT OF THE DIRECTOR

health services, 31 Primary Health Care, International Conference on information systems, health, 40 (Alma-Ata, U.S.S.R., September 1978), 1, 24, 28, Latin American Program for Educational Develop- 38, 78 ment in Health, 53 Primate production and centers, 81-82, 98 leprosy, 96 Procurement services (PAHO), 171 malaria research, 75 Psychiatry (see Mental Health) medical education, 54 Public health, education in, 29, 54 public health, education in, 54 information (PAHO) (see Information, public (PAHO)) Parasitic diseases, 103-106 Publications (PAHO), 159-164, 168 Partners of the Americas, 36 Puerto Rico PASCCAP (see Central America and Panama, auxiliary administration, training in health care, 51 and technical health workers) dengue, 111 Pasteur Institute (Lille, France), 80 schistosomiasis, 105 Pelvic inflammatory disease (see Sexually transmitted Punta del Este, Charter of (August 1961), 3, 131 diseases) Personnel (PAHO), 172 Pertussis, 87 Peru Q administration, training in health care, 51 alcoholism and drug dependence, 59 auxiliary and technical health workers, 62 Quality control of drugs, 122-123 auxiliary nurse training, 55 continuing education, 52 dental education, 57 DTIAPA (program to develop water supply and sew- R erage agencies technologically), 138 Expanded Program on Immunization, 88 health services extension, 28, 30, 55 Rabies, 80-81, 154 information systems, health, 40-41 Radiation health, 141-142 Latin American Program for Educational Develop- REDPANAIRE (see Pan American Air Pollution Monitor- ment in Health, 53 ing Network) malaria research, 75, 101 Regional Committee for Sex Education in Latin Amer- manpower planning, 48 ica and the Caribbean, 38 maternal and child health/family planning, 41, 42 Regional Library of Medicine and the Health Sciences medical education, 54 (Sao Paulo), 13, 63-65, 115 mental health, 59 Regional Program for Analytical Control of Water and nursing education, 55, 67 Wastewater Laboratories (PRELAB), 135, 137 plague reference laboratory, regional (Piura), 98 Rehabilitation services, 37 planning, health, 28, 31 REPIDISCA (see Pan American Environmental Engineer- primate production, 81-82 ing and Sciences Information and Documenta- public health, education in, 54 tion Network) rehabilitation services, 37 Research, 74-82 social security agency, 31 animal health, 79-82 water supply systems, 56 cancer, 114-115 yellow fever, 111 Expanded Program on Immunization, 91 PLADES (see Latin American Program for Educational grants (PAHO), 73 Development in Health) health services, 78-79 Plague, 98 impact on health, study of, 72-73 Planning, family (see Maternal and child healthlfamily leprosy, 95-96 planning) leptospirosis, 76 health, 24, 28-30 malaria, 74-76, 78, 103 manpower, 49, 51-52 mental health, 59 Pneumonia, 117 noncommunicable diseases, 114-115 Policies and strategies, national health, 27, 28 nursing, 56 Poliomyelitis, 87 parasitic diseases, 103-106 Pollution Research and Reference Center on Vector Biology and air, 135, 137 Control (Maracay, Venezuela) (see Vector Biology water, 135, 137 and Control Research and Reference Center) Potts Memorial Foundation, 22 Research and Training in Tropical Diseases, WHO PRELAB (see Regional Program for Analytical Control Special Program for (see World Health Organiza- of Water and Wastewater Laboratories) tion) Primary health care, 4, 20, 24, 31, 42, 48, 55, 78 Rheumatic fever, 8, 115, 156 INDEX 185

Rockefeller Foundation, 22, 46, 105, 118 T Rotaviruses, 94-95

TABCONT (PAHO monthly publication), 167, 168 S Technical cooperation among developing countries, 10, 24, 78 St. Kitts-Nevis Technology, appropriate, 24, 27, 78 dengue, 111 educational, 62-63, 65-67 education, family life, 38 Ten-Year Health Plan for the Americas (1971-80), 3, Expanded Program on Immunization, 88 7, 57, 131 health and youth, 42 Tetanus, 87 maternal and child health/family planning, 41, 42, Textbooks, 32, 165-166 55 Expanded Program on Immunization, 88 nursing education, 55 nutrition, 63 nutrition and food, 45 veterinary, 58 St. Lucia Thrasher Research Fund, 22 dengue, 111 Toxic substances, control of, 145 health and youth, 42 Trachoma (see Blindness, prevention of) maternal and child health/family planning, 41 Traffic accident prevention, 143-145 nursing education, 55 Trainex Corporation, 163 schistosomiasis, 105 Trinidad and Tobago St. Vincent Aedes aegypti situation, 109 disasters, 125 blood banks, 123 maternal and child health/family planning, 41, 42 dengue, 111 nursing education, 42, 55 health services, 31 Salto Grande Dam (Argentina-Uruguay), 139 immunology laboratories, 117 Schistosomiasis, 87, 104-105 leishmaniasis, 105-106 Scientific Apparatus Makers Association (USA), 36 maternal and child healthlfamily planning, 41 SEPU (PAHO/WHO publications and documentation water and sewerage, 13 service, Mexico City) (see Publications (PAHO)), yellow fever, 111 Services, health, 24 Tropical diseases, 8 cost, 34-35 Trypanosomiasis (see Chagas' disease) extension of, 25, 28, 33-34 Tuberculosis, bovine, 80, 152-153 Sexually transmitted diseases, 97 Tuberculosis, human, 87, 92-93 Silver, reclamation of x-ray, 36 Turks and Caicos Islands Simón Bolivar University (Venezuela), 36 water and sewerage, 13 Smallpox, 85-86 Typhoid fever, 98 Social security agencies, 7, 31 Society for Occupational and Environmental Health (USA), 138 Solid wastes (see Wastes, solid) U South American Foot-and-Mouth Disease Control Commission (COSALFA), 146, 148 Special Program for Animal Health, 13 United Kingdom, 46 Statistical methodology, 156 United Nations Statistics, health (see Information systems, health) Capital Development Fund, 14 Strategies for Extending and Improving Potable Water Children's Fund (UNICEF), 7, 15, 20, 43, 45, 57, 60, 91, Supply and Excreta Disposal Services During the 94, 132 Decade of the 1980s, 163 Development Program (UNDP), 7, 13-14, 20, 31, 36, Suriname 43, 52, 60, 61, 87, 116, 121, 123, 132, 133, Aedes aegypti situation, 109 134-135, 146, 148 dental workers, 57 Disaster Relief Office (UNDRO), 16, 125 immunology laboratories, 117 Economic Commission for Latin America (ECLA), 5, malaria, 101 7, 15, 16, 43, 133 radiation safety, 142 Caribbean Development and Cooperation Com- schistosomiasis, 104 mittee, 16, 155 Surveillance, epidemiologic, 63, 118-120 Educational, Scientific, and Cultural Organization Sweden (UNESCO), 43, 135 disaster relief, 22, 125 Environment Program (UNEP), 14-15, 135 International Development Authority (SIDA), 21-22, Food and Agriculture Organization (FAO), 7, 16, 124 43, 46, 146 Syphilis (see Sexually transmitted diseases) Fund for Drug Abuse Control, 113 186 REPORT OF THE DIRECTOR

Fund for Population Activities (UNFPA), 15-16, 38, Foundation for Community and Municipal Develop- 41, 42, 46, 88 ment, 133 International Labor Organization (ILO), 138 health services, 30 University, 47 hospitais, 36 Water Conference (Mar del Plata, Argentina, 1977), information systems, health, 41 127 Inter-American Center for Integrated Water and World Food Program, 16-17, 43 Land Development (Mérida), 136 United States Latin American Program for Educational Develop- Aedes aegypti situation, 109 ment in Health, 53 Agency for International Development, 21, 39, 41, leprosy, 96 43, 46, 75, 119, 124 malaria research, 75, 101 Army Medical Research Institute for Infectious manpower planning, 51 Diseases (Frederick, Maryland), 86 maternal and child health/family planning, 42 biomedical engineering, training in, 36 mental health, 59 Center for Disease Control (Atlanta, Georgia), 86, nursing education, 67 93, 109, 117, 119 public health, education in, 54 dengue, risk of, 111 rabies control, 154 disaster relief, 125 rehabilitation services, 37 Food and Drug Administration, 121, 122 schistosomiasis, 104 leishmaniasis, 106 Vector Biology and Control Research and Reference National Academy of Sciences, 44 Center (Maracay), 76-78, 140 National Aeronautics and Space Administration, yellow fever, 111 114 Vesicular diseases, 81 National Cancer Institute, 115 Veterinary education (see Education, veterinary) National Institutes of Health, 36, 73, 76, 95 Virgin Islands, British National Science Foundation, 46 health and youth, 42 rabies control, 154 maternal and child health/family planning, 41 Veterans Administration, 36 Visual aids (PAHO), 164 Uruguay dental education, 58 health services, 30 hydatidosis, 80 information systems, health, 40 laboratories, 117 W leprosy, 96 maternal and child health/family planning, 41, 42 public health, education in, 54 Wastes, solid, 21, 56, 127, 133, 138 tuberculosis, bovine, 80 Water pollution (see Pollution, water) water and sewerage, 13-14, 134-135 Water supply and sanitation systems, 21, 56-57, 127, 131-133, 136-137 Whooping cough (see Pertussis) World Bank El Cajón Dam, construction of, 140 V environmental agencies, development of, 134 environmental manpower, development, 57 nutrition and food, 44 Vaccines, 88-89 PAHO, relations with, 17 Vector biology and control, 76-78 pollution control, 137 Vector Biology and Control Research and Reference Special Program on Research and Training in Tropi- Center (Maracay, Venezuela), 76-78, 140 cal Diseases, 87 Venezuela traffic accident prevention, 144 Aedes aegypti situation, 109 wastes, solid, 133 administration, training in health care, 51 water supply systems, 131, 136 animal health, 151 World Food Program (see United Nations) biomedical engineering, 36 World Health Organization Center for the Classification of Diseases, 156 Advisory Committee on Medical Research, 74 continuing education, 52 collaborative centers, 72 dental services, 58 International Reference Centre for Water Supply encephalitis, equine, 153 (The Hague), 136 environmental health, 14 smallpox eradication campaign, 85-86 INDEX 187

Special Program for Research and Training in Tropi- X, Y, Z cal Diseases, 72, 75, 87, 96, 103-105, 106-109 Special Program on Human Reproduction, 72 "Structures in the Light of Functions" study, 6, X rays (see Radiation health) 168 Xerophthalmia, 44, 98 water supply and sanitation, 137 Yacyretá Dam (Argentina-Paraguay), 139 Yellow fever, 111, 118 Zoonoses (see Animal health) ACRONYMS AND CORRESPONDING BODIES OR PROGRAMS

ACMR PAHO Advisory Committee on Medical Research AIDIS Inter-American Association of Sanitary and Environmental Engi- neering CAREC Caribbean Epidemiology Center CARICOM Caribbean Community CDC Center for Disease Control (USA) CEPANZO Pan American Zoonoses Center CEPIALET Pan American Center for Research and Training in Leprosy and Tropical Diseases CEPIS Pan American Center for Sanitary Engineering and Environ- mental Sciences CFNI Caribbean Food and Nutrition Institute CIDA Canadian International DevelopmentAgency CLAP Latin American Center for Perinatology and Human Develop- ment CLATES Latin American Center for Educational Technology in Health COSALFA South American Foot-and-Mouth Disease Control Commission ECLA Economic Commission for Latin America (UN) ECO Pan American Center for Human Ecology and Health EPI Expanded Program on Immunization FAO Food and Agriculture Organization (UN) IBRD International Bank for Reconstruction and Development (World Bank) IDB Inter-American Development Bank IDRC International Development Research Center (Canada) IICA Inter-American Institute of Agricultural Sciences ILO International Labor Organization INCAP Institute of Nutrition of Central America and Panama KF W. K. Kellogg Foundation LACRIP Latin American Cancer Research Information Project NIH National Institutes of Health (USA) OAS Organization of American States OIRSA International Regional Organization for Health in Agriculture and Livestock PADEF Pan American Development Foundation PAHEF Pan American Health and Education Foundation PAHO Pan American Health Organization PANAFTOSA Pan American Foot-and-Mouth Disease Center PASB Pan American Sanitary Bureau PASSCAP Program on Health Training of the Community of Central America and Panama REDPANAIRE Pan American Air Pollution Sampling Network RF Rockefeller Foundation RLM Regional Library of Medicine and the Health Sciences UN United Nations UNDP United Nations Development Program UNDRO United Nations Office of the Disaster Relief Coordinator UNEP United Nations Environment Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund UNU United Nations University USAID U.S. Agency for International Development USPHS United States Public Health Service WFP World Food Program WHO World Health Organization PAN AMERICAN HEALTH ORGANIZATION Pan Amrnerican Sanitary Bureau E Regional Office of the WORLD HEALTH ORGANIZATION